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Identifying implementation strategies that support the integration of services in different clinical settings is a necessary step for the efficient deployment of resources to improve outcomes. This study explores the implementation strategies used by six diverse California health systems to expand palliative care services, and the relationship between strategies and implementation outcomes and reach.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A longitudinal mixed methods study utilizing document review, key informant interviews, and program data to assess implementation and effectiveness was conducted using a convergent parallel design. A deductive content analysis and matrix analysis using the Expert Recommendations for Implementing Change (ERIC) framework to identify and compare strategies across sites was completed, along with a thematic analysis of the relationship between strategies and reach, feasibility, acceptability, adoption, and sustainability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      In total, 33 of the 73 discrete ERIC strategies were identified, spanning all nine strategy domains. Sites used between 11 and 23 implementation strategies for expanding palliative care programs. All six sites utilized financial strategies, evaluative and iterative strategies, supported clinicians, developed stakeholder interrelationships, and trained and educated stakeholders. We identified four themes that supported outcomes: (1)\n                      <jats:italic>establishing and sustaining a trained workforce<\/jats:italic>\n                      , particularly creating new clinical teams with physician leadership made service provision feasible and fostered acceptance and adoption; (2)\n                      <jats:italic>identifying cases<\/jats:italic>\n                      was important for referrals; (3)\n                      <jats:italic>engaging providers<\/jats:italic>\n                      through relationship development and education was crucial for acceptability, adoption and sustainability; and (4)\n                      <jats:italic>involving organizational leadership<\/jats:italic>\n                      , specifically active and enduring executive sponsorship, aided feasibility and sustainability.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Implementation strategies for expanding palliative care services focused on building a presence by establishing a trained workforce to provide the service, identifying cases and engaging providers to increase and sustain acceptability and adoption, involving organizational leadership for feasibility and sustainment, and securing financial support to feasibly launch the service. This study compares how different implementation strategies were used in different settings, and the impact. Palliative care programs looking to expand services should focus on these core strategies to maximize efforts, and reach more patients.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12904-026-02076-2","type":"journal-article","created":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T08:18:36Z","timestamp":1775031516000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Building a presence: implementation strategies used to expand palliative care services across six diverse health systems in a longitudinal mixed methods study"],"prefix":"10.1186","volume":"25","author":[{"given":"Heather Z.","family":"Mui","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura M.","family":"Holdsworth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karl A.","family":"Lorenz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcy","family":"Winget","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,1]]},"reference":[{"key":"2076_CR1","unstructured":"World Health Organization. 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The Stanford Institutional Review Board reviewed and approved the study, IRB#52693. The review board determined that the only involvement of human subjects in the research activities were in one or more of the categories that are exempt from the regulations at 45 CFR 46 or 21 CFR 56. The study did not involve experiments on humans or use of human tissue samples. All participants received written and oral information about the study\u2019s purpose, procedures, potential risks, and measures for maintaining confidentiality. All participants provided verbal informed consent for their voluntary participation in the interviews. All data was stored and maintained in an approved secure network to ensure confidentiality and protection of personal data.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"136"}}