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Background: Impoverished African Americans (AA) with hypertension face poor health outcomes., Purpose: To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension., Methods: We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months., Results: We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000., Limitations: The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms., Conclusions: This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Alyssa Adams - None. Muna Anabtawi, DDS – None. Lynn Andreae, PhD – None. Elizabeth Baquero, EDD – chair of education advisory board of MedExplain, Inc., a company commercializing a patient education platform based on the Patient Activated Learning System (palsforhealth.com). Joanna Bryan, MS – None. Andrea Cherrington, MD, MPH – None. Debra Clark, MPH – None. Doyle Cummings, PharmD – None. Jacqueline Halladay, MD, MPH - None. James Hollenberg, MD – None. Ethel Johnson – None. Suzanne Oparil – research funding from CinCor Pharma Inc. (site PI for a primary aldosterone study), George Clinical Pty (site PI for GMRx2 treatment of hypertension), and Higi (site PI for a blood pressure validation study); advisory roles for CinCor Pharma Inc. (Scientific Advisory Board for primary aldosteronism and hypertension) and Preventric Diagnostics, LLC (Chair of the Medical and Technology Committee, 2019–2022); and Editor-in-Chief of Current Hypertension Reports (Springer Science Business Media LLC) until 12/2023. Erica Richman, PhD - None. Joshua Richman, PhD, MD – None. Monika Safford, MD – owner of MedExplain, Inc., a company commercializing a patient education platform based on the Patient Activated Learning System (palsforhealth.com). James Shikany, Dr.P·H - None. Orysya Soroka, PhD – None. James Tillman – None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)