PROJECT SUMMARY/ABSTRACT Societal systems of racism, segregation, and criminal justice practices have resulted in high rates of imprisonment of Black, Indigenous, and other People of Color (BIPOC) and represent structural racism and discrimination (SRD). Upon release from prison, people face further challenges influenced by SRD including policies, procedures and practices in the healthcare system that limit access and contribute to poor health. Compared to the general population, people released from prison have a higher prevalence of poor CV health, an increased risk of CV events, and higher cardiovascular (CV) mortality within 2 years of release. Access to healthcare following release from prison is key to preventing poor health outcomes in this population. Systematic investigation of SRD in diverse healthcare systems has not occurred, and the extent to which different organizational policies and practices limit or perpetuate disparities in access and health outcomes among people released from prison is unknown. We propose three specific aims to provide critical information on SRD in healthcare organizations and begin to address the problem. In Aim 1, using three diverse health systems, we will analyze system written materials and conduct interviews and focus groups with system leaders, frontline staff, and representatives of community-based organizations to measure policies, practices and attitudes around healthcare access, transition programs, culture, support of social determinants of health and specialized services for people released from prison. In Aim 2, leveraging a database of individuals released from Colorado state prisons (~400 a month), we will prospectively enroll 600 people recently released from prison into a longitudinal cohort study to assess their exposure to healthcare structural conditions following release. Using the all-payer claims database, we will examine the association between exposure to structural conditions and 12-month primary outcomes of healthcare utilization (clinic visits, emergency visits, hospitalization) and secondary outcomes of CV hospitalization and all-cause mortality. Race/ethnicity and baseline CV health will be examined as moderating variables because intersectional SRD may particularly disadvantage BIPOC individuals released from prison and those with poor CV health. In Aim 3, we will integrate results from Aims 1 and 2 to develop practice recommendations to improve health care access and outcomes for people released from prison. Recommendations will be iteratively revised with a community advisory board and finalized using a modified Delphi panel of national experts. Final recommendations will be assembled and broadly disseminated. Given the enormity of the population of individuals with a history of imprisonment, their significant burden of poor health including CV disease and the disproportionate imprisonment of BIPOC individuals, a critical goal of our research is to identify targets for future...