PROJECT SUMMARY The primary roles of the Implementation Core are to: 1) harmonize core functions and processes; 2) optimize and integrate clinical decision support; and 3) enable training and intervention fidelity across the three interventions. The Implementation Core Lead, Grudzen (mPI), and the Core Director will oversee harmonization, adaptation, and fidelity monitoring with input from the project leads (Chodosh, Brody, Shah), an implementation scientist (Mittman), qualitative methodologists (Dickson and Arbaje). They will oversee optimization of clinical decision support in collaboration with a lead informatician (Mann). These seasoned collaborators are supported by a rich research infrastructure and personnel with expertise in the implementation of complex health interventions across multiple settings in older adults with serious illness. NYU Grossman School of Medicine, NYU Rory Meyers College of Nursing, University of Wisconsin-Madison, Memorial Sloan Kettering, and the mPI team have substantial expertise in harmonizing core functions of complex interventions, enabling high fidelity across multi-site pragmatic trials in diverse settings, and tailoring usable clinical decision support tools across variable electronic health record (EHR) platforms. To ensure tailoring to local contextual factors across settings, the Implementation Core Steering Committee will engage the Lived Experience Panel and Lived Practice Panel to pre-specify allowable adaptations in form, including the mode of delivery, providers involved, materials or tools needed, dose, and frequency/intensity. Besides overseeing all aspects of the core, the Implementation Core Lead Grudzen and the Core Director will lead strategy to monitor and continually improve implementation. They will first conduct a needs assessment and assess readiness at each site to develop a tailored implementation blueprint. This will include detailed standard operating procedures that describe implementation strategies and how planned and unplanned adaptations will be managed, measured/documented, and reported over time. They will, in coordination with the Administrative Core, oversee the fidelity of each intervention to ensure all core functions are performed during the triadic encounters. Approaches to achieve high fidelity will include pilot testing at multiple sites; identifying nurse, physician, and social work champions at each ED; establishing peer-to-peer learning networks; and using evaluative and iterative tools until fidelity targets are met. Cyclical small tests of change during pilot testing will identify optimal implementation strategies. The lead informatician will direct the processes used to optimize the clinical decision support and ensure that documentation and communication between internal and external members of the care team are both compliant and seamless. A data manager will work with sites to establish their EHR builds and extraction methods. An informatics analyst will ensure...