Conducts comprehensive nursing assessments of patients with complex, chronic, serious, or advanced illness while identifying patients who may benefit from Advance Care Planning (ACP) services, including individuals with chronic illness, serious illness, advanced age, multiple hospitalizations, or complex healthcare needs. Collaborates proactively with providers, care managers, social workers, palliative care, Avera@Home, and interdisciplinary teams to identify patients who may benefit from Advance Care Planning services, particularly those with serious illness, chronic disease, or complex healthcare needs.