PROJECT SUMMARY/ABSTRACT: PROJECT 2 (NELSON-BRANTELY) The U.S. population age 65 and over is projected to reach 94.7 million in 2060; presently, more than one-fifth of the nation’s elderly reside in rural America. Advance care planning (ACP) is a process of care that supports adults in sharing their values, life goals, and choices regarding future health care. ACP increases alignment of health care services with patients’ values, improves patient and family satisfaction, increases use of palliative care, and reduces costs. Despite global consensus that ACP should start early for older adults, ACP usually happens too late or not at all. Effective interventions to increase ACP exist, yet an extensive gap remains in translating the intervention into everyday practice. This is particularly true in rural primary care clinics. This project pilots the use of implementation facilitation (IF) for improving the uptake of ACP in rural primary care clinics. IF involves an integrated set of implementation strategies to promote adoption of an evidence- based practice—in this study, ACP. The IF strategies in the proposed study include Respecting Choices First Steps® ACP training, an ACP toolkit, and tele-mentoring for ongoing implementation and training support. The PrISM Core will assist with refining study procedures; the CEO Core with engaging clinic sites; and the HSR Core with securing final IRB approval for the study protocol. Develop a tailored ACP plan for implementing ACP into rural primary care clinics (Aim 1). We will use the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to ACP, conduct a needs assessment, and develop an ACP plan adapted to the local context of each clinic. Characterize the reach, estimated effect, adoption, and implementation using IF for implementing ACP (Aim 2). This study pilots a Hybrid Type 229 protocol, estimating both effectiveness and implementation outcomes. We will estimate effect size and associated variability, describe the reach, adoption, and implementation of ACP using IF, and descriptively compare IF to implementation as usual (IAU). Describe the costs and revenue generated from using IF for implementing ACP (Aim 3). Feasibility assessment of elements necessary for a definitive trial economic evaluation will be conducted. Costs will be captured through a clinic service receipt inventory and revenue through ACP billing codes. The project aligns with the goals of the proposed COBRE to improve health equity for rural populations and will advance the field of implementation science vertically by providing new knowledge of implementation strategies that work in rural primary care clinics. The outcomes of this study will provide an evidence base to support an R01 application testing the IF strategy on a larger scale. Ultimately, this research is expected to have a positive impact by expanding ACP to medically underserved rural areas and improving early ACP for older adults before they are no longer able to make their wishes known.