Table 2.

Summary of the Sequential, Multiple Assignment, Randomized Trial (SMART) design

Standard of Care	Multi-component health program
Aligned with patient-centered medical home components and quality-of-care measures	Community Weaver led Co-Creation Overarching strategy
Care coordination	mHealth Outreach
• Routine immunization efforts • Annual physical exam • Eligibility: defined medical conditions (e.g., uncontrolled diabetes, hypertension), high health services utilization (e.g., > 5 medications), social determinants of health and referred by care team	Community outreach led by Community Weavers via SMS and voice messages about COVID-19 vaccines (importance, reminders, how to access) and preventive services engagement (importance, reminders, how to access) in languages spoken by patients (i.e., Spanish, Arabic, Vietnamese)
	Care Coordination
	Inclusive of standard of care coordination with added focus on completing outstanding preventive services (e.g., HbA1c, blood pressure screenings, mammograms, colorectal cancer screening)