Project Description Reducing health inequities for sexual and gender minority (SGM) populations is a major public health priority. Compared to heterosexual, cisgender populations, SGM people are much more likely to suffer a variety of serious health conditions and are far less likely to access preventive services. Disparities are greater for SGM members of other health disparities populations (e.g., Hispanics/Latinos, Native Americans, socioeconomically disadvantaged people, and rural residents). Culturally- and medically-inappropriate services to SGMs in healthcare systems with a history of promoting stigma around sex and gender contribute to these disparities. Primary care is the frontline of vital prevention, screening, and healthcare delivery to patients across the life course. However, few primary care services have mechanisms to create practice milieus that are attentive to SGM patients. Insufficient SGM-specific cultural competence leads to patient dissatisfaction and subpar care. Use of guidelines promoting SGM cultural competence at the provider/staff, practice setting, andorganizational levels will help ameliorate these deficits in health care. Although current guidelines contain vital information about SGM patient-centered clinical environments and interactions, they tend to be fragmented and neglectful of population-based attributes (e.g., race/ethnicity, culture, and rurality) and input from SGM patients and providers/staff. They would benefit from further refinement and closer attention to the racial/ethnic, socioeconomic, and geographical diversity encountered in primary care settings. Research must also assess the extent to which the guidelines can be feasibly implemented and develop tailored implementation strategies to increase guideline adoption and sustainment. We will undertake focus group and nominal group technique activities in Federally Qualified Health Centers (FQHCs) that will yield data for grounding SGM practice guidelines within primary care venues and advancing theory-based implementation strategies to promote guideline adherence. We will then develop a toolkit to assist in guideline implementation and pilot it in four FQHCs. The Implementation of Change Model will shape data collection, guideline enhancements, and strategy development. The study has three aims: (1) prioritize existing SGM practice guidelines and adapt and develop implementation strategies for primary care settings with attention to the intersection of race/ethnicity, rurality, and economic conditions; (2) develop and refine a comprehensive toolkit of SGM practice guidelines and implementation strategies to provide FQHCs with resources to promote and evaluate SGM-specific competence at multiple service delivery levels; and (3) evaluate the implementation of the toolkit at the (a) individual provider/staff, (b) social/practice setting, and (c) organizational context levels in supporting SGM-specific primary care in FQHCs. This study responds to national research priorities to enhance SGM health in primary care where providers are stretched to form a healthcare safety net for socially diverse communities. This formative work will form the basis for an R01 application to deploy a rigorous type 2 hybrid effectiveness-implementation design to test both SGM practice guidelines and implementation strategies adapted or developed for primary care settings.