Background: VA is tasked with providing timely, high-quality specialty care for nearly 3 million Veterans, yet faces unique challenges in doing so, including a large rural Veteran population and specialty provider shortages. These challenges are particularly evident for pulmonary hypertension (PH), a devastating and prevalent disease among Veterans with a median survival of only 3.9 years. Patients with PH require frequent access to PH experts and careful coordination across multidisciplinary teams and facilities to ensure high- quality care. Yet, VA has not taken a coordinated approach to PH care, and as a result there are wide gaps in PH care access and quality across VA. The redesign of VA PH care into a hub-and-spoke model is a guideline- recommended, evidence-based solution to improve PH care quality. The integration of telehealth technologies into this model, a “telehealth-enhanced hub-and-spoke model,” can advance this model to ensure every Veteran has equal access to state-of-the-art PH care. Yet, before this innovative solution can be implemented, several critical research and implementation questions must be addressed, including how to adapt other hub- and-spoke models to unique PH challenges, and which model components are key to improve outcomes. To address these knowledge gaps, this proposal will leverage survey data paired with in-depth qualitative analyses to understand provider and organizational characteristics of high-quality PH care within potential hub sites. This knowledge will inform the co-design of an implementation blueprint with stakeholder input that will be used to pilot test the telehealth-enhanced hub-and-spoke model in VISN 1. Significance/Impact: This research has the potential to improve the organization, access, quality, equity, and coordination of care for the more than 250,000 Veterans living with PH. Furthermore, by developing a process to design a telehealth-enhanced hub-and-spoke model that is driven by scientific hypotheses, grounded in theory, and integrates key stakeholder perspectives, this work will provide VA with key guidance to redesign specialty care for other specialty conditions. Innovation: The union of telehealth technologies with the organizational redesign of PH care into hub and spoke sites represents an innovative model of excellence for PH care to comprehensively address current gaps in PH care delivery across VA. Additionally, the integration of co-design with health services research and implementation science to develop a scalable solution to PH care delivery is an innovative approach that will ensure the solution is relevant and acceptable to key stakeholder groups while being rigorously evaluated for effectiveness and broader application to other complex redesign and implementation questions. Specific Aims: Aim 1: Characterize stakeholder perspectives on PH hub site care delivery through mixed methods. Aim 2: Co-design a blueprint for the reorganization of PH care into a telehealth-enh...