Project Summary/Abstract This proposal describes a five-year research training program that will prepare Dr. McDaniel to achieve her long-term goal of becoming an independent physician-scientist dedicated to supporting the delivery of high- quality, equitable care to children hospitalized in rural settings. With more than 12 million children living in rural communities in the United States and with almost half of rural counties not providing definitive general pediatric inpatient care, children in rural areas experience both poorer health status and limited access to pediatric healthcare infrastructure and resources relative to children from urban areas. Addressing inequity in access for children in rural areas in the setting of scarce resources and limited infrastructure requires health policy change and innovative initiatives. Dr. McDaniel’s project goal is to establish system-level (e.g., provider, hospital, community) facilitators for the provision of pediatric care in rural hospitals that may improve access to and delivery of equitable inpatient care for children in rural communities In the first aim of this proposal, using a difference-in-differences approach, Dr. McDaniel will determine if there is an association between the state-level provision of cost-based reimbursement for critical access hospitals, a federal designation to promote the retention of services within rural communities, and the maintenance of pediatric services (1a). Then she will examine the hospital and system characteristics of rural hospitals associated with loss, gain, or sustained provision of general pediatric inpatient services across the US from 2010 to 2018 (1b). Together, these will identify these will identify hospital, county, and state-level characteristics associated with sustained provision of general pediatric inpatient services in rural counties over time. In the second aim, using a consensus methodology with key stakeholders from seven partnering rural hospitals, Dr. McDaniel will develop an intervention-bundle to support the provision of general pediatric inpatient care. The bundle will build off preliminary qualitative data identifying rural hospital strategies to support care and the contextual factors identified in Aim 1. In the third aim, Dr. McDaniel will conduct a pilot implementation trial at three rural hospitals of the developed intervention bundle. She will assess 4 primary implementation outcomes: acceptability, feasibility, appropriateness, and adoption. These will create a framework for future multi-site interventions evaluating the effectiveness of interventions to promote the sustained provision of high-quality general pediatric inpatient care. Dr. McDaniel’s research will be supported by an outstanding group of mentors with expertise in patient- centered outcomes research, rural healthcare disparities, qualitative and mixed-methods, and econometrics. Her mentors are dedicated to ensuring the success of this project and her developmen...