Must be enrolled to receive primary care at a VA Puget Sound Health Care System (VA PSHCS) hospital or clinic, have a VA primary care team, meet the eligibility criteria for home and community-based services as determined by the VA. To be considered in this category, a Veteran must have/be: -  Three or more activities of daily living (ADL) dependencies -  Significant cognitive impairment -  Receiving hospice services -  Two ADL dependencies and two or more of the following:         -  3 or more instrumental activities of daily living (IADL) dependencies          - Recently discharged from a nursing facility          - 75 years old or greater          - 3 hospitalizations or 12 outpatient clinics or emergency evaluations          - Clinically depressed          - Lives alone

M-F, 8am-5pm.