This legislation directs the Center for Medicare and Medicaid Innovation (CMI) to establish and implement a new community-based palliative care model for high-risk Medicare beneficiaries. This five-year model aims to improve care outcomes, enhance patient experience, and reduce unnecessary emergency department visits and hospitalizations for individuals with serious illnesses, such as cancer or Alzheimer's, without excluding those with prior hospice care use. The model emphasizes a team-based approach , involving multi-disciplinary palliative care teams, home health agencies, and hospitals, working in co-management with primary and specialist care. Comprehensive services will cover pain and symptom management, advance care planning, mental health support, and family and caregiver assistance, delivered 24/7, including telehealth. Care can be furnished in various settings like a patient's home or an extended care facility, with a focus on equitable access for rural and underserved areas. The CMI will evaluate the model's effectiveness by comparing participants to non-participants, assessing healthcare utilization, hospice care election and duration, and the overall care experience for beneficiaries and their caregivers.