PROJECT SUMMARY ABSTRACT Nearly 2 million Americans develop a diabetic foot ulcer each year. Dr. Brennan's research team and others documented a >50% mortality and 5% major amputation rate within 5-years of ulceration. Next, they determined that morbidity and mortality associated with ulcers disproportionately burdens rural patients, who have 50% higher odds of major amputation and 40% higher odds of death than urban patients. Dr. Brennan's long-term objective is to eliminate this rural disparity through interventions that improve the quality of diabetic foot ulcer care rural patients receive in the ambulatory setting. Over the past decade, many urban tertiary care centers have developed a model of integrated care for patients with diabetic foot ulcers. The integrated care model involves multiple specialists working side-by-side and following a care algorithm to address 4 precipitating physiologic factors in a coordinated manner: poor glycemic control, vascular disease, mechanical complications, and secondary infection. Dr. Brennan's systematic review found that 97% of these urban integrated care clinics reduced major amputation, with relative risk reductions ranging from 11 to 90%. However, this urban model is difficult to implement in the rural setting, where providers are scarce and geographically dispersed. Dr. Brennan's goal is to become an academic clinician-researcher in infectious disease leading an independent research program to improve care and outcomes of diabetic foot ulcers in rural settings. She proposes a 3-year K08 period with training in clinical trials, stakeholder engagement, systems engineering, implementation science, and advanced quantitative skills. Following her KL2 support, Dr. Brennan is well prepared for a successful K08 award period. Her focused training, expert mentorship, and research plan will catalyze her transition to independence. This proposal heralds her advancement from defining gaps in care to closing them. The primary objective of this proposal is to build and pilot an integrated care algorithm adapted to the rural setting. The proposed aims are to: 1) identify which specialists are associated with increased amputation-free survival, and the optimal timing of their involvement 2) co-design an integrated care algorithm and its implementation plan with rural healthcare systems, and 3) pilot the algorithm in the rural setting to maximize adoption and implementation. Upon completion of the proposed research and training, Dr. Brennan will be ideally poised to submit a competitive AHRQ R01 centered on testing the emerging intervention with an effectiveness-implementation study. Her current and future research aims will advance AHRQ's mission by focusing on a high-priority population (rural patients), problem (major amputation), and area of interest (ambulatory care).