Background <p>Clinical champions are a known strategy for implementing evidence-based practices; however, their application in de-implementing potentially inappropriate medications (PIMs) among persons with dementia is underexplored. We conducted a pragmatic cluster-randomized clinical trial of a champion-led deprescribing intervention in accountable care organization (ACO) primary care settings.</p> Objective <p>To (1) understand clinical champions’ perspectives of their deprescribing projects and (2) identify key contextual factors that influenced champions’ deprescribing PIMs for persons with dementia within ACO primary care.</p> Design <p>A qualitative study guided by the de-implementation outcomes framework.</p> Participants <p>Clinician champions who engaged in deprescribing projects.</p> Approach <p>Data sources included transcripts from monthly learning calls and semi-structured interviews. All champions were invited to participate in learning calls and semi-structured interviews. The 30- to 60-min interviews were conducted using a semi-structured guide. We coded transcripts and performed thematic analysis to identify overarching themes.</p> Key Results <p>Eleven champions participated. Feasibility and fidelity of deprescribing were commonly undermined by external and organizational disruptions. Five contextual factors influenced champions’ experiences: limited organizational readiness, lack of information technology infrastructure to support data access and patient identification, the importance of relationship-building and care coordination, the dyadic nature of deprescribing involving care partners, and the pharmacist’s role as a multidisciplinary liaison. Champions employed adaptive, communication- and relationship-centered strategies to support deprescribing efforts.</p> Conclusions <p>Champion-led deprescribing for persons with dementia is shaped by key contextual factors within ACO primary care settings. Dementia-specific training helped clinicians tailor deprescribing to local needs, but sustained efforts require supportive organizational structures, including ongoing education, accessible clinical data, and multidisciplinary collaboration. Primary care clinicians are uniquely positioned to lead personalized deprescribing conversations while pharmacists serve as liaisons with providers, patients, and care partners to coordinate deprescribing. Interventions that align with value-based care principles may strengthen system-level coordination and promote safer medication management in dementia care.</p> Trial Registration <p>ClinicalTrials.gov ID: NCT05359679</p>