Abstract
Objective
To investigate provider and administrators' perspectives about the impact of the Department of Veterans Affairs' (VA) Community Care program on acute and residential mental health treatment of rural Veterans.
Data Sources and Study Setting
Primary data were collected from participants via interviews. Participants were employees of VA Healthcare Systems located in Northern New England, or employees of non‐VA mental health treatment settings affiliated with VA in Northern New England.
Study Design
This study was informed by the Consolidated Framework for Implementation Research (CFIR), with Community Care as the implemented program. Individual, semi‐structured interviews were conducted.
Data Collection/Extraction Methods
Individual interviews were transcribed, coded deductively using the CFIR, and inductively coded by locating themes.
Principal Findings
Twenty‐one people completed interviews. Commonly reported challenges included community programs not focused on Veterans' needs, poor coordination of care, communication challenges, and problems tracking Veteran care. Facilitators included increased access to care and strengthening coordination of care.
Conclusions
The VA's Community Care program can address the acute or residential mental health needs of Veterans in rural settings in some circumstances, however there are challenges to successful implementation.
Keywords: mental health, qualitative research, rural health, VA healthcare system
What is known on this topic
Because Veterans can encounter challenges in accessing healthcare, the Department of Veterans Affairs (VA) has implemented a Community Care program to improve care access.
Researchers and providers have raised concerns about the potential adverse impact of Community Care on Veteran mental healthcare and VA suicide prevention efforts.
Little is known about the impact of Community Care on the treatment of rural Veterans during high‐risk periods for suicide such as after a non‐VA psychiatric discharge.
What this study adds
VA and community providers can encounter challenges with coordinating care for rural Veterans who access acute or residential mental health treatment in non‐VA settings.
The VA Community Care program is an important resource for rural Veterans to obtain access to treatment during an acute mental health crisis.
There are opportunities for the VA to strengthen the VA Community Care program to better meet the needs of rural Veterans during an acute mental health crisis.
1. INTRODUCTION
Rural populations in the United States (US) are at high risk of suicide. 1 Patients are particularly vulnerable for suicidal behavior following an acute mental health stay, 2 and Britton et al. 3 found that risk of suicide after discharge was 20% greater in rural versus urban Veterans. While several factors may play a role in the risk of suicide, 4 researchers and policymakers stress that low engagement in care is a special concern in rural populations. 5 , 6 These observations have prompted healthcare systems to determine new ways to increase access to treatment in rural areas. 7 , 8
The Veterans Health Administration (VHA) has nine million enrollees and roughly 37% of these patients live in rural areas. 9 To increase Veterans' access to timely and high‐quality care, the US government has executed several policy changes. 8 In 2014, the U.S. Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to ensure that VHA enrollees who meet driving‐distance standards can receive VA‐purchased care in the community, 8 known as Community Care. In 2018, the VCP was replaced by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, which broadened the eligibility criteria for Community Care. 8 , 10 Because of the MISSION Act, at least 2 million VHA enrollees qualify for Community Care. 8 , 11
While the VHA has made critical strides to improving Veterans' access to care, there is controversy about whether this innovation has exposed new challenges to delivering care, especially to rural Veterans. 12 , 13 There are heightened concerns about the impact of Community Care on mental healthcare and the VA's suicide prevention efforts. 14 , 15 , 16 One study of suicide‐related safety events among Veterans who accessed non‐VA mental health treatment found that some reports cited inadequate treatment of symptoms. 17 In a survey of 522 community mental health professionals' readiness to treat Veteran and military populations, RAND Corporation found that less than 50% of respondents used validated instruments to screen for depression. Only 19% met criteria for high competency in military culture. 18 Few studies have explored the association between Community Care and Veteran mental health outcomes. 17 , 19 , 20 , 21 No study has looked at VA and community providers' perspectives on the potential impact of Community Care on rural Veterans discharged from non‐VA mental health treatment settings.
To learn more from healthcare providers and administrative staff about their perceptions of the impact of the VA's Community Care program on the acute and residential mental health treatment of rural Veterans, we conducted semi‐structured qualitative interviews with both VA and non‐VA staff and leaders involved in processes of care for rural Veterans who access acute or residential care in non‐VA mental health treatment settings. Our findings may directly impact future VA and community mental health programing for rural Veterans.
2. METHODS
Our methods are detailed in the Appendix S1. This descriptive qualitative study was informed by the Consolidated Framework for Implementation Research (CFIR). 22 Study participants were required to be employees of VA Healthcare Systems (HCS) in Northern New England, or employees of non‐VA mental health treatment settings that treat patients affiliated with VA HCS in Northern New England. We used individual, semi‐structured interviews to collect data from enrolled subjects. Two study staff (NR, SS) with prior experience in qualitative research conducted interviews between November 2022 and June 2023. Quotes were sorted into CFIR domains and constructs and grouped by barriers and facilitators and themes located. We used a combination of directed content analysis 23 and inductive analysis to report on qualitative findings.
This study was guided by the Consolidated Criteria for Reporting Qualitative Studies (COREQ) which provides a guide for reporting necessary details of the study. 24
The Veteran's Institutional Review Board of Northern New England (VINNE) reviewed the study and determined that the study met exemption category #2 (ii) (iii).
3. RESULTS
Twenty‐one people were enrolled in this study including 11 participants from VA settings and 10 participants from community (i.e., non‐VA) settings (see Table 1). One of the states included in our study is one of few states without a full‐service VA facility and, therefore, may have increased referrals to Community Care. 25
TABLE 1.
Baseline characteristics of enrolled participants.
| n | % | |
|---|---|---|
| Description of subjects | ||
| Total enrolled | 21 | 100.0 |
| Setting | ||
| VA employment | 11 | 52.4 |
| Community employment | 10 | 47.6 |
| Primary position | ||
| Leadership position | 6 | 28.6 |
| Care coordinator | 7 | 33.3 |
| Registered nurse | 3 | 14.3 |
| Therapist/Prescriber | 5 | 23.8 |
| Primary role | ||
| Clinical only | 4 | 19.0 |
| Administrative only | 6 | 28.6 |
| Both clinical and administrative | 11 | 52.4 |
| Description of site of employment | ||
| Total sites represented | 12 | 100.0 |
| Site description | ||
| VA healthcare system | 3 | 25.0 |
| Community setting a | 9 | 36.0 |
| Description of community setting (N = 9) | ||
| Hospital or healthcare system a | 5 | 62.5 |
| State Psychiatric Hospital | 1 | 12.5 |
| Mental health crisis service b | 1 | 12.5 |
| Mental health residential program | 1 | 12.5 |
Abbreviation: VA, Department of Veterans Affairs.
Two interviewees were staff members of the same healthcare system.
Mental health crisis service delivers care in the outpatient setting as well as in the emergency room of the local hospital.
3.1. Barriers
Four significant themes related to barriers emerged from the interview content and analysis: Community Care not focused on the specific needs of Veterans, poor coordination of care, communication challenges, and problems tracking Veteran care (see Table 2). It appeared that communication challenges and problems tracking Veteran care were subthemes of the overall theme of poor coordination of care.
TABLE 2.
Barriers and facilitators to successful implementation of Community Care by the Department of Veterans Affairs (VA) to improve Veteran mental health.
| Theme | Exemplar quote | Participant site |
|---|---|---|
| Barriers to successful implementation of Community Care | ||
| Community Care Programs Not Focused on Veteran Needs | “Sometimes we do encounter [Veterans] but we don't know that they are Veterans. It does not always come up and we don't ask.” (Participant E013) | Community Care |
| “Sometimes it's [Veteran status] not one of the first questions we ask. Being more upfront about asking because [we] don't connect early with VA and [we] could then connect.” (Participant E016) | Community Care | |
| “I think from baseline risk [Veterans] may be at higher risk and we are not necessarily geared on that population….we don't target the population.” (Participant E020) | Community Care | |
| [The participant mentioned it can be difficult for community providers to care for Veterans due to lack of clinical training in VA settings.] “It's harder for providers who did not have that experience.” (Participant E017) | Community Care | |
| “There are a bunch of Community Care we don't refer to, based in part of Veteran feedback.” (Participant E009) | VA | |
| Poor Coordination of Care | “It would be better to collaborate more fully with VA providers to make better discharge plans.” (Participant E013) | Community Care |
| “There's no follow up. We have a community care nurse in charge of getting them into to CC care but not back into the VA. That's the downside to sending to community care.” (Participant E006) | VA | |
| Communication Challenges | “Lots of patients go to community care sites….We would never know if a patient went there. Even patients in the Emergency Room (at a community site) who want to come here, and we don't have beds. I don't find out ever where they go. If we don't accept them, there is no communication to outside site to let a person over here know and we don't track those patients. This is a gap.” (Participant E001) | VA |
| Problems Tracking Veteran Care | “They go to these places, and they are just gone. They just fall off the radar.” (Participant E004) | VA |
| Facilitators of successful implementation of Community Care | ||
| Increased Access to Care | “We see 25–31 Veterans per month, we have a 35‐bed capacity….The Veterans are traveling to [our program] and traveling a fair distance.” (Participant E008) | Community Care |
| “Plenty of Veterans go to other hospitals….mostly ER. Most places have mental health units that can take them.” (Participant E001) | VA | |
| [The participant mentioned that if a Veteran cannot be safely managed on VA unit in accordance with Directive 1167, a Veteran may be referred instead to a non‐VA mental health unit.] “There are certain other reasons, acuity level, if we could not safely manage vet. If there was a wheelchair for instance, being in line of sight, depend[s] on number of staff.” (Participant E007) | VA | |
| Strengthening Coordination of Care | “I need the information right now, so we have a lot of collaborating and coordinating.” “I will get the mental health nurse to call the patient a day or two after discharge to keep them connected.” (Participant E011) | VA |
| “Yes. I will work with the [community] inpatient care managers. I try to reach out to them on day‐one of the patient's arrival.” (Participant E011) | VA | |
| “After a Veteran is discharged from whatever place they got treated, that facility would send records to the VA and those would be uploaded into a patient's chart.” (Participant E003) | VA | |
3.1.1. Community Care Programs Not Focused on Veteran Needs
Participants indicated that a key barrier to Community Care includes that most community sites do not have a standardized process to assess for Veteran status.
Three participants mentioned another barrier to Community Care included that non‐VA hospitals and programs are not adapted to meet the unique needs of Veteran populations which could contribute to inadequate care. One VA participant mentioned they do not refer Veterans to some community sites because of these concerns.
One community participant expressed concern that community programs do not focus on trauma which the participant thought Veterans often experience. The participant stated that many community providers do not complete any clinical training in a VA setting and are less familiar with Veteran concerns.
We observed that senior executives from large, community healthcare systems posed thought‐provoking questions about the overall role of community providers in meeting the needs of the VA HCS. One executive considered whether community providers can overcome the cultural differences and biases that might make it challenging for these individuals to provide Veteran‐centric care. Another executive pondered whether Community Care is the right solution to solve gaps in VA care, especially in rural settings where resources are limited.
3.1.2. Poor Coordination of Care
VA and Community Care participants often cited challenges with coordinating care when a Veteran transitions back to VA from a non‐VA treatment setting. For example, one community participant said inpatient staff commonly have limited or no information about the care Veterans receive in the VA. While staff will provide the best care possible to Veterans, this participant expressed concerns that community providers may not always make proper decisions due to the lack of care coordination.
3.1.3. Communication Challenges
Both Community Care and VA participants cited problems with communication. Nine participants stated that non‐VA hospitals or programs do not communicate with VA. One VA participant felt this was especially true when Veterans are treated in non‐VA emergency departments.
3.1.4. Problems Tracking Veteran Care
Several participants described that a barrier to Community Care includes problems with tracking Veterans' treatment when receiving care in the community. One VA participant mentioned that the tracking “has been a bit of a black hole.” As a result, VA providers are not always aware of the treatment Veterans are receiving in non‐VA settings. In general, participants felt that tracking care was a problem in acute inpatient or emergency department settings. One VA participant expressed concerns that despite the requirement to notify the VA within 72 h of community admission, 26 VA staff are not always promptly notified when a Veteran presents to a community hospital with suicidal behavior. Thus, the Veteran is less likely to receive timely follow‐up care.
3.2. Facilitators
While many participants pointed out barriers to Community Care, there were also some that highlighted facilitators, especially in the realm of increased access to care and strengthening coordination of care (see Table 2).
3.2.1. Increased Access to Care
Nine participants mentioned it is easier to care for Veterans in the community because VA policies can make it difficult to access VA care. One VA participant mentioned their standard is to refer Veterans to community residential programs if the Veteran's health status did not improve after multiple stays in a VA residential program. The participant felt this was in the best interest of the Veteran because a different program could be useful to the Veteran.
Several participants described that since the process or criteria for getting a Veteran admitted into a VA setting is complex, a non‐VA hospital or program may be the only available option. For example, if the VA unit is at full capacity, the Veteran would be admitted to a local community hospital. Another example from a VA participant is a request for VA admission may be declined if certain medical needs cannot be accommodated safely and in compliance with the VA environment of care Directive 1167. 27 VA units must adhere to this suicide prevention protocol, 27 , 28 (e.g., wheelchairs and oxygen tubing must be under constant observation by staff when accessible to the patient). While this protocol is well‐intentioned, the downside is the VA may decline admission of a Veteran during an acute mental health crisis if VA staff are unable to meet the requirements of the directive. Community Care can fill this gap.
3.2.2. Strengthening Coordination of Care
While most participants referenced barriers regarding coordination of care, some reported facilitators. For example, three people mentioned the VA has taken steps to promote continuity of care for Veterans treated in non‐VA settings.
Fifteen quotes referred to various staff from both within and outside the VA who help facilitate the coordination of care of Veterans who receive mental health treatment in the community. One VA participant stressed being responsible for coordinating care post‐discharge from a Community Care inpatient unit. Both sites described a robust relationship aimed at streamlining processes to connect Veterans back to VA care after discharge. This included having VA staff conduct on‐site visits.
Nine individuals cited key contacts within the VA, familiar with steps involved in caring for Veterans who received Community Care treatment in residential or inpatient settings.
4. DISCUSSION
We interviewed VA and community leaders and providers familiar with the VA's Community Care program and its role in meeting the acute mental health needs of Veterans in rural areas. Commonly reported challenges associated with Community Care included poor coordination of care, communication challenges, and problems tracking the care of Veterans. In addition, community hospitals and programs are not always focused on the distinct needs of Veterans, especially during an acute mental health crisis. Yet, community hospitals and programs fill a critical need in rural areas when VA acute or residential mental healthcare is not readily available or aligned with the needs of the Veteran.
Consistent with the literature, 29 some community participants mentioned that lack of knowledge of Veteran status is a barrier because their treatment approach is not informed by Veteran status. Most participants reported that their community site did not have a formal process to assess for Veteran status. There was one site, however, that had developed a standardized process to determine Veteran status and had used this information to coordinate care with the local VA and connect the patients to Veteran‐centric resources. The participant at this local VA reportedly conducted visits at the Community Care site to learn about processes of care and design a way to track care in real time. Both participants characterized the relationship as robust.
Participants stated they are worried whether community providers are insufficiently prepared to care for Veterans. Participants pointed out that treatment in non‐VA settings is not adapted for Veterans. Community providers may not have the skills and tools to work with Veterans. Owing to these observations, some participants perceived that Veterans may receive suboptimal care in non‐VA acute inpatient or residential mental health settings. Our results corroborate concerns that have been raised in the field about potential negative consequences of the VA's Community Care program on Veteran health. 14 , 15
Community providers may benefit from intensive support and training in military culture and suicide prevention. The VA and the Substance Abuse and Mental Health Services Administration (SAMHSA) have developed the Governor's and Mayor's Challenge to Prevent Suicide Among Service Members, Veterans, and their Families. 30 One of the goals of this multistate initiative is to equip states and communities with tools to prevent suicide among Veterans.
Many participants articulated that poor communication and fragmented care are a central obstacle to implementing Community Care. VA staff may not be aware in real time about acute mental health treatment in the community. It is possible that some community providers do not know that VA policy 26 requires that the VA be notified of emergency care within 72 h. In a qualitative study of Veterans, VA and community staff involved in the transition between non‐VA hospital and VA primary care, participants cited issues with assessing for Veteran status, communication, follow‐up care, and prescribing. 31
It is worrisome that poor coordination of care is a barrier to using Community Care when treating Veterans with acute mental health needs in rural areas. Patients are at high risk of suicide after an acute 2 or residential stay. 32 In a retrospective study of suicide safety events in Veterans who accessed VA‐paid treatment in non‐VA settings, Riblet et al. 17 noted that a root cause included failure to arrange follow‐up care. Continuity of care is associated with risk of suicide. 33 The receipt of timely follow‐up care may prevent suicide. 34
Related to this concern, some participants questioned whether Community Care is the appropriate response to insufficiencies in VA care. Miller et al. 35 observed in a qualitative study of 57 VA and community providers that staff expressed concerns that rural settings are under‐resourced. Community Care may strain non‐VA healthcare systems that already lack capacity. Because resources are tight in rural areas, and the VA has an expertise in treating Veterans and suicide prevention, there may be precedent for the VA to increase its own capacity to treat Veterans in rural areas.
The most mentioned facilitator related to the theme of strengthening coordination of care. Several participants referenced key stakeholders at their site who facilitate the implementation of Community Care. The VA and its community partners should capitalize on these resources and reinforce collaboration across settings. Other studies have shown that interventions to strengthen care coordination between VA and Community Care sites may benefit Veterans in rural areas. 36 , 37 The VA has released a Veteran Community Partnership Toolkit to help VA and community partners enhance their collaboration. 38
Our study is novel because we examined the role of the VA's Community Care program in meeting the acute mental health needs of Veterans in rural settings. We used recommended approaches to conduct our qualitative analysis. A limitation of our work includes that our sample is limited to Northern New England. Providers from other regions or settings may have identified other barriers or facilitators to implementing the program. We did not interview Veterans and, thus, have no direct knowledge of their perspectives on the role of Community Care in meeting their acute mental health needs.
In conclusion, the VA's Community Care program can play an important role in addressing the acute mental health needs of Veterans in rural settings. The VA continues to be well positioned to meet the unique needs of the Veteran population, and non‐VA care remains a critical partner to close the gap when VA resources are exhausted in rural areas. There are challenges, however, in successfully implementing the program. The VA and community sites may overcome these challenges by streamlining processes and capitalizing on existing resources. Future studies should examine the Veterans' viewpoint on Community Care and incorporate these data into improvement efforts. Studies should also evaluate interventions to improve care transitions between settings.
FUNDING INFORMATION
This work was funded by the VA Office of Rural Health, Veterans Rural Health Resource Center, White River Junction VT.
CONFLICT OF INTEREST STATEMENT
The author declares no conflicts of interest.
Supporting information
Appendix S1. Supporting information.
ACKNOWLEDGMENTS
Thank you to all of our Veterans Affairs and Community Care participants who helped make this research possible. We appreciate your time and effort.
Kenneally L, Riblet N, Stevens S, Rice K, Scott R. Examining the impact of the veterans affairs community care program on mental healthcare in rural veterans: A qualitative study. Health Serv Res. 2025;60(2):e14405. doi: 10.1111/1475-6773.14405
Dr. Riblet has support from the VA Clinical Science Research & Development Career Development Award Program (IK2 CX001920). The supporters did not have a role in the design, analysis, interpretation, or publication of this study.
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Supplementary Materials
Appendix S1. Supporting information.