1. Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA.
2. Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
3. Mass General Brigham Home Care, Boston, Massachusetts, USA.
4. Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research (CHOIR), Massachusetts General Hospital, Boston, Massachusetts, USA.
5. Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
6. Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.
7. Department of Psychiatry, Massachusetts General Hospital,
8. Department of Orthopedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, USA.
9. Claude D. Pepper Older Americans Independence Center, Duke University School of Medicine, Durham, North Carolina, USA.