Abstract For most patients with end-stage kidney failure, kidney transplantation confers longer survival, better quality of life, and lower cost, relative to dialysis. Despite these benefits, too few patients make it through the complex transplant evaluation process, and long-standing racial and socioeconomic inequities exist in access to each transplant step, including referral, start and completion of the transplant evaluation, and placement on the waiting list. In 2010, with the explicit goal of improving equity in access to transplant in the US Southeastern region that includes Georgia, North Carolina, and South Carolina, we created the Southeastern Kidney Transplant Coalition, a community of transplant stakeholders, including patients, caregivers, medical professionals, patient advocacy groups, and health system administrators that encompasses all 10 transplant centers in these states and large dialysis organizations serving a population of >50,000 patients with kidney failure. Since its inception, our Coalition has conducted several pragmatic interventions of educational and quality improvement activities at the dialysis facility, provider, and patient levels, finding increased rates of referral and evaluation start, and reduced racial disparities in these outcomes among Black vs. White patients and those with lower vs. higher socioeconomic status. Unfortunately, health system barriers persist after referral and education: more than half of patients referred did not start the transplant evaluation, and 65% of those referred were never waitlisted. However, prior interventions were limited to interventions at the patient- and dialysis facility-levels and did not address the structural barriers in the complex process across the health systems that patients must navigate to get a transplant, including both dialysis facilities and transplant centers. In surveys of health system staff and a scoping review, we identified persistent health system barriers to transplant equity, including scheduling logistics, inadequate provider communication across health systems, and limited transplant provider awareness of inequities. In this proposed RaDIANT Health Systems intervention, we will leverage proven interventions from our research and use a community-based participatory research approach to adapt and enhance sustainability of the RaDIANT interventions targeting structural barriers to evaluation start at the health system level (Aim 1). We will then conduct a hybrid type 1 effectiveness-implementation quasi-experimental study of the RaDIANT Health System intervention among 4 Southeastern transplant centers and ~800 dialysis facilities in GA, NC, and SC with a goal of reducing racial and socioeconomic inequities in transplant access (Aim 2). Finally, we will conduct a process evaluation among the participating health systems to assess acceptability, usability, implementation, and sustainability of interventions (Aim 3). If successful, interventions coul...