Barriers and Facilitators to Cross-Institutional Referrals: System Configuration Analysis of VA Staff Experiences

Abstract

Background

In 2014 and 2018, respectively, Congress passed the Veterans Access, Choice, and Accountability Act (Choice Act) and the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded eligibility for and use of cross-institutional referrals among U.S. Veterans enrolled in the Veterans Health Administration.

Objective

To identify facilitators and barriers to patient information sharing for cross-institutional, outpatient referrals resulting from policy changes.

Design

Applying the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted work system and configural analyses of semi-structured interviews.

Participants

Clinical and administrative staff in six Department of Veterans Affairs (VA) facility community care liaison program offices.

Approach

Interviews focused on barriers and facilitators to sharing patients’ information across healthcare institutions. Transcripts were summarized by domain and coded to consensus, followed by directed content analysis and visualization using configural diagrams.

Key Results

From 19 interviews, we characterized a nine-step, ad hoc referral process. Barriers were reported in four of nine referral steps: scheduling, coordination, sending of pre-visit clinical records, and receipt of post-visit records. Low adoption of new technology, strained relationships with CCN clinicians, and inconsistent policies were commonly reported barriers. Largely, perceived barriers were classified as technology, people, or organization factors. The COVID-19 pandemic and a transition between third-party administrators were reported as notable environment factors.

Conclusions

VA staff perceived increases in patient care delays and staff workload associated with social and technical barriers to sharing patients’ information across healthcare institutions. In the cross-institutional referral process, we identified the primary configuration or combination of work system factors—technology, people, and organization— related to prevalent barriers. System-level interventions are needed to enhance relationships with clinicians across healthcare institutions, implement policies that guide patient information exchange, and design supportive technologies for efficient clinician communication during cross-institutional referrals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-025-09450-5.

BACKGROUND AND OBJECTIVE

For the U.S. Department of Veterans Affairs (VA) healthcare system, purchased “community” care referrals have increased rapidly and seem likely to persist.¹ VA’s use of community care referrals increased after publicized problems with wait times and access to VA-provided care.² Through the Choice Act passed in 2014 and the MISSION Act in 2018, VA was mandated to change and expand purchased community care for enrolled Veteran patients meeting certain eligibility criteria (e.g., under the MISSION Act, Veterans residing more than 30 min from their nearest VA facility are eligible for CCN primary care).^3,4 Since implementation of these legislated programs, about a third of all VA-enrolled Veterans have used community care referrals.⁵ For VA, community care accounts for 44% of services offered in both VA and non-VA settings and 25% of its medical budget.^6,7

To achieve timely and reliable cross-institutional referrals, there is a need for successful coordination across these settings and among VA clinicians and the non-VA clinicians constituting VA’s Community Care Network (CCN).^8,9 However, coordination between these groups has been difficult.¹⁰ For example, CCN clinicians and administrative staff have reported problems with responsibilities, processes, access to records, and communication.¹¹ In some cases, citing delays in authorization, scheduling, or payment, CCN clinicians have refused appointments with VA patients.¹² Despite the introduction of a VA-wide Referral Coordination Initiative, intended to establish local VA care teams to help Veterans make informed choices about care options in the referral process,¹³ the initiative’s implementation has varied across VA facilities^14–16 and has not affected wait times or referral rates.¹⁷

Although system-level oversight of the program is centralized (Office of Integrated Veteran Care, formerly Office of Community Care), day-to-day management of community referrals relies on staff at facility-level community care liaison offices.^9,18 Coordination of appointments and records has been particularly difficult.^11,19 Suspected and identified sources of coordination difficulty included scheduling of appointments via third-party administrators or understaffed VA community care liaison offices.^18,20 Multiple reports have noted technical and sociotechnical problems, including complex scheduling processes,²¹ lack of interoperability of clinical records systems,²² “glitches” in HealthShare Referral Manager (VA’s referral management web application),²³ and low completion of VA-offered military and Veteran cultural competency training among CCN clinicians and administrative staff.¹ Adverse outcomes associated with such problems may not be indicated by typical metrics.²⁴ Instead, a system-level perspective may be useful in understanding the current state of a process and how it differs from the prescribed state.²⁵ Specifically, tracking the flow (i.e., sharing) of patient information between healthcare institutions may show areas for process improvement for cross-institutional referrals at VA and non-VA healthcare systems.²⁶ Our objectives were to (1) describe the flow of patient information in VA’s process for community care referrals, and (2) identify facilitators and barriers perceived by VA staff.

APPROACH

Framework

The Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework provides a user-centered, systems-oriented view of the structure, processes, and outcomes in healthcare and their relationships.²⁷ SEIPS 2.0 describes healthcare work systems using factors belonging to five predefined components: person(s), tasks, environment (internal and external), tools and technology, and organization.²⁷ SEIPS 2.0 posits that the sociotechnical work system produces work processes, which then shape outcomes. Thus, work system factors can be qualified further as facilitators and barriers.²⁷ Existing health systems research studies have used SEIPS to identify work system facilitators and barriers from qualitative data.^27,28 SEIPS 2.0 introduced the concept of configurations, defined as “a finite number of relevant elements that interact to strongly shape the performance of [a] process.”²⁷ Diagramming the configurations of multiple related work systems can help in identifying persistent barriers and facilitators.²⁹

Recruitment and Setting

We interviewed VA community care liaison staff about VA’s cross-institutional referrals and conducted a work system configuration analysis.^27,28,30 We selected VA healthcare facilities with high and low volume of authorized referrals to CCN clinicians in VA’s CCN in fiscal year 2018 (i.e., October 1, 2017–September 30, 2018); these facilities were in the first three VA CCN regions with new third-party administrator contracts established by October 2020. Six sites were selected, two per region, with one facility from each region selected for its high volume of community care authorizations and the other for a low volume of authorizations (Table 1). At each study site, we contacted the hospital chief of staff or the chief or associate chief of the facility’s community care liaison program to introduce the study and to ask them to identify potential participants in their program, including both administrative and clinical staff. The study team (FW, AT, AS) planned to interview three to four individuals per study site.

Table 1.

Study Site Characteristics

Study site*	Community care referral authorizations**	Region	Date of contract deployment	Community care liaison staff (full-time equivalent)
1-H	491	1	9/17/2019	40
1-L	232	1	12/10/2019	60
2-L	367	2	10/8/2019	70
2-H	28,923	2	6/16/2020	95
3-L	7,905	3	7/21/2020	124
3-H	34,504	3	8/25/2020	115–120

^*Site names are pseudonyms

^**For 2018 fiscal year. Data are from the Veterans Health Administration Support Service Center

Interviews

We developed a semi-structured interview guide based on the prominent changes implemented and monitored for the Mission Act. These changes included (1) the working structure and process of the community care liaison program at each facility, (2) the relationship and structure of the CCN (including the role of the new third-party administrator), (3) the use of health information technologies to share between VA and CCN clinicians and staff, and (4) how the quality of community care is monitored. Because both the rollout of the new third-party administrator contracts and the timing of our interviews coincided with the COVID-19 pandemic, we also asked about how the pandemic affected the community care liaison program. Each of these topics had sub-questions and probes. The full interview guide is in Appendix A.

Interviews were conducted virtually using Microsoft Skype. Two members of the study team conducted the interviews: one served as the interviewer, and the other took detailed notes. The interviewers reviewed the notes after the interview was completed and made clarifying edits in cases of misunderstandings or misses by the notetaker. No identifiable information was retained in the coding documents. With verbal permission of the interviewees, interviews were recorded on an encrypted audio recorder. Audio recordings were used by coders to confirm statements and to clarify notes. Interview recordings were stored in US HIPAA (United States Health Insurance Portability and Accountability Act of 1996)-compliant secure files and were only available to research staff.

Ethics Statement

This project (#1375113) was reviewed and approved by the Edward Hines Jr. VA Hospital’s Institutional Review Board and the VA Research and Development Committee.

Data Coding and Analysis

We used a rapid approach to code and analyze the interview data.³¹ Interview topics served as the initial categories for coding responses. Data were organized by category and respondent type using a spreadsheet according to topic and subtopic. To refine our categories and subcategories of coding, three experienced coders (AS, AT, FW) coded the same two interviews. Results were compared and categories were fine-tuned following discussion among the coders. Additional codes were added to capture process steps, work system factors, barriers, and facilitators. A third interview was coded by all three members of the coding team using the refined categories, resulting in 100% agreement in the main categories and at least 80% agreement on subcategories. Following this, the coders individually coded the remaining interviews. To ensure internal reliability, two additional interviews were coded by all three coders, for a total of 26% of the interviews coded by the full coding team. High reliability was maintained in coding across these interviews through regularly scheduled consensus meetings.

Supplemental Process Analysis

We supplemented our rapid analysis with additional content analysis of unpublished and published VA documentation and reports.^18,21 This additional analysis enabled us to align our interpretations with formal and informal descriptions and terminology. In the case of discrepancies related to step definition or count, we chose the descriptions in our participant data. We modeled VA’s cross-institutional referral process using only the steps reported by interviewees.

Configuration Analysis

Two human factors experts (AS, HP) independently identified key characteristics that interviewees perceived as important workflow aspects, facilitators, or barriers. A consensus meeting was held to resolve differences and finalize the list. Together, they assigned one SEIPS factor to each characteristic, based on factor descriptions from SEIPS 2.0 and the SEIPS 101 supplement.^27,32 To illustrate the persistence of characteristics across referral steps and their designation as facilitators and barriers, the human factors experts drew configural diagrams of the overall process and selected steps. Starting with the overall diagram, each non-neutral characteristic (i.e., perceived facilitator or barrier) was put in a circle, with each of the five SEIPS factors represented by a cluster of circles. The size of each circle illustrates the persistence of the related work system characteristic across process steps, where the area increases proportionally with the number of process steps. The overall diagram served as a template for diagramming individual process steps, where color differentiates facilitators from barriers.

RESULTS

Participants

Nineteen individuals from the six VA facility community care liaison program offices completed interviews between February 2020 and March 2021. Interviewees included three chiefs, three associate or assistant chiefs, four nurse managers, one registered nurse supervisor, and eight medical support assistants.

Work-System Factors in Cross-Institutional Referrals

Table 2 presents the participant-reported work system factors in VA’s cross-institutional referrals.

Table 2.

Staff-Reported Work System Factors in Cross-Institutional Outpatient Referrals

Work system factor	Description
People	Community care liaison program chief Community care liaison program staff (including medical support assistants) CCN clinicians and staff Veteran patients and their families
Tools and technology	Software to access medical records Software to generate excerpt of medical record Software to exchange information (e.g., virtual fax server) Software to track community care appointments
External environment	Community clinics Transition to new third-party administrators Coronavirus-19 pandemic
Organization	Policies Veterans Choice Act MISSION Act Programs Referral Coordination Initiative HealthShare Referral Manager software training
Tasks	CCN clinician review of patient information before appointment VA community care liaison staff tracking appointment schedules Approval of additional community health services VA follow-up health care and coordination of care

VA, United States Department of Veterans Affairs; MISSION Act, VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018^9,33

People Factors

Each study site managed workload by dividing staff into teams, all of which included a nurse and multiple medical support assistants. Interviewees consistently included references to CCN clinicians, Veterans, and Veterans’ families in describing the cross-institutional referral process.

Tools and Technology Factors

Interviewees mentioned using many software applications in the cross-institutional referral process (Appendix B). Most of the technology focused on clinical information access (e.g., VA and non-VA electronic health record systems [EHRs]), report generation (e.g., Referral Documentation Tool), and information exchange (e.g., RightFax virtual faxing software), as well as appointment tracking.

Environmental Factors

Although SEIPS distinguishes between internal (i.e., physical) and external environment factors, interviewees reported only external environment factors. These included CCN clinics, the transition to a new third-party administrator, and the COVID-19 pandemic.

Organizational Factors

VA implementation policies and programs were the main factors.

Task Factors

Key task factors were coordination and communication efforts, including tracking appointments, reviewing patient information, approving of additional services, and conducting follow-up appointments.

Reported Process

Across the study sites, the described community care referral process included nine major steps (Fig. 1). The first five steps were internal to VA. Starting in Step 6, communication with CCN clinicians or staff was initiated to schedule the appointment. Steps 6B to 9 involved communications between VA and CCN clinics. Among the steps, steps 6B to 9 were described by interviewees as the most likely to be associated with communication breakdowns. Interviewees reported that issues or difficulties related to these steps increased workload and delays.

Figure 1.

Nominal cross-institutional referral process workflow.^9,33 Steps in shaded circles require cross-institution coordination. VA, United States Department of Veterans Affairs.

Clinicians’ Experiences: Additional Tasks, Outcomes, and Implications

Interviewees described the required tasks and information not denoted in the designed (nominal) workflow (Fig. 1). Although information generation and review were consistent throughout the workflow, critical points of information flow were highlighted after scheduling the appointment and after the appointment occurred. Across sites, there was consensus on aspects of the workflow where information exchange between VA and CCN clinicians and staff was essential: (1) the CCN clinician’s review of patient information before the appointment, (2) VA community care liaison staff’s tracking of appointment scheduling, (3) VA’s approval of additional care services, and (4) VA’s follow-up health care and coordination of services. Interviewees described the information exchange between VA and CCN clinicians and staff as inefficient and frustrating.

Interviewees described the information essential to referral, which included a medical record excerpt, date and time of appointment, requests for additional services, and visit notes. Interviewees noted that VA initiates information exchange with CCN clinicians. The initial information exchange is required to support the CCN clinician’s review of patient health information before the appointment. VA staff generate a PDF excerpt of the patient’s medical record using web software called Referral Documentation Tool. The excerpt includes medical history, labs, and medications. After an appointment is scheduled, this excerpt is shared with the CCN clinician through HealthShare Referral Manager software application. Based on organizational policy, VA staff monitor the referral process, ensuring patients receive care within the allotted waiting period. However, after the patients are scheduled with a CCN clinician, VA must rely on the clinician or the patient to inform them if or when the appointment occurred. Interviewees indicated that VA typically initiates information exchange after the scheduled appointment date to request patient information, including the CCN clinician’s notes and orders. As an exception, when CCN clinicians want to request approval from VA to perform additional services, the clinicians may initiate communication and information exchange. Interviewees reported limited data interoperability between VA’s EHR and the EHRs at CCN facilities, which made it necessary to use multiple different information technology systems to exchange information.

Reported Process Facilitators and Barriers

Based on the interviews, the main facilitators and barriers for the process were identified (Table 3). There were four facilitators: (1) standard episodes of care, (2) VA’s Referral Coordination Initiative, (3) access credentials to multiple EHRs, and (4) telehealth services. The presence of these facilitators was not consistent across study sites. Where present, interviewees described benefits of each facilitator. Comparatively, there were more barriers, totaling six. Similar to facilitators, the presence of identified barriers was not consistent across study sites. One example of a perceived barrier was the need for both VA staff and CCN clinical and administrative staff to complete HealthShare Referral Manager training. Interviewees reported they did not have time to learn the new software, were frustrated by recurring changes to the software, and found it difficult to remember which software to use for a given task. According to interviewees, CCN clinicians who used HealthShare Referral Manager wanted to have their staff trained as well. These CCN staff told our interviewees that they were already using other health records software and did not want to learn a new system just for communication with VA. Learning to use HealthShare Referral Manager was not a simple process, although VA staff who mastered the training did comment on the value of the tool. Categorized as a facilitator and barrier, fax machines were the most used technology for obtaining information from CCN clinicians. As a result, information flow was largely a manual, laborious process that required notable amounts of time and repetitive steps. Collectively, interviewees reported that inefficient or ineffective health information technology was associated with an increased workload for CCN clinicians.

Table 3.

Summary of Interviewee-Reported Cross-Institutional Referral Process Facilitators and Barriers

Facilitator or barrier	Process aspect	Summary of interviewees’ comments
Facilitator	Standard episode of care	• These defined the care covered for a particular condition or treatment (e.g., knee replacement), including pre-operative imaging, surgery, and rehabilitation following surgery
Facilitator	Referral coordination initiative	• Interviewees reported their perception that the Referral Coordination Initiative intended to reduce the use of community care when VA is able to provide timely services in-house • If a Veteran was deemed eligible for referral, a nurse contacted the Veteran to educate them about options for care available through VA and Community Care
Facilitator	Credentials to multiple electronic health records systems	• Some VA community care liaison staff could log in to their academic-affiliated healthcare institution, using systems (e.g., Epic) in the same network as CCN clinicians, and directly access Veterans’ community care medical records • This type of access greatly streamlined information exchange and flow by circumventing repetitive telephone calls and the multiple steps to get information from the CCN clinician and into Veterans’ VA medical records • Interviewees described this type of information access as the ideal situation and noted a desire for direct access to other electronic health records systems
Facilitator	Telehealth	• There was a huge shift to telehealth during the pandemic, with all sites reporting increased use by both VA and CCN clinicians • While some of the older Veterans were reported to be more likely to want to see their doctors face to face, interviewees reported that younger Veterans liked using telehealth and the flexibility it provides • Respondents also stated that they felt that this was a “new paradigm” and that the use of telehealth was here to stay
Facilitator and Barrier	Fax machines	• Most often used technology for obtaining information from CCN clinicians • Largely a manual, laborious process that required notable amounts of time and repetitive steps   ◦ Requests could take 2–3 telephone call attempts spanning 2–3 weeks   ◦ When the request for the information was successful, CCN clinicians faxed patient information • Frequently, information sent was incomplete requiring additional communication back and forth
Barrier	HealthShare Referral Manager training	• Appropriate use of HealthShare Referral Manager software requires training for both VA staff and CCN clinicians • Most interviewees described the training as available but not feasible or effective • Interviewees’ workload did not permit enough time to participate in the training sessions • Interviewees cited the multiple changes in the referral processes and requirements/rules that occurred frequently as another barrier
Barrier	New third-party administrator contracts	• Most respondents felt that the transition to the new third-party administrator contract did not go smoothly, especially the adequacy of the network of CCN clinicians • Many CCN clinicians were unaware of changes associated with the transition • VA facilities lost vendors (CCN clinicians) because these clinicians did not want to agree to the terms set up with the new third-party administrator and/or they had not yet been paid for care provided to Veterans from the previous third-party administrator • Other vendors who did sign up in the months before the switch had still not been added to the list of approved clinicians at the time of our interviews • New contracts reportedly decreased use of Veteran Care Agreements, an alternative to the CCN that were still being used at sites with gaps in service or when clinicians were trying to get in-network
Barrier	Provider profile management system	• This software lists all the clinicians who had signed with the third-party administrator • Community care liaison staff use this tool to identify CCN clinicians near a Veteran’s home with the required services • Some respondents found the software difficult to use, in part because the National Provider Identifier is used, but VA billing uses other numbers to identify clinicians • Once a clinician is signed up, their information is locked in the database and is problematic to correct or change • Use of the software is difficult because it is not easy to search by location or clinician contact information
Barrier	Policy changes	• It is difficult for VA community care liaison staff to stay current with frequent policy changes by the head office, especially when these changes are not well or widely communicated • This also can cause confusion with patients and CCN clinicians • Mechanisms to communicate changes more rapidly and effectively are needed
Barrier	Requests for additional care	• The secondary authorization request is sent to the main fax line at the local VA community care liaison office • The secondary authorization request must include enough clinical information to show the patient is making progress and why an extension of the care is medically necessary; if not, the CCN clinician must resubmit the request with all necessary clinical information • After the request is reviewed by a community care liaison nurse, it is sent to an approving official • Requests that are not approved usually are denied due to either missing information that is needed to provide care, or because the required care can be provided by VA • Many interviewees felt that increased education of CCN clinicians would decrease secondary authorization requests that did not have the necessary information or were inappropriate
Barrier	COVID-19 pandemic	• The impacts from COVID-19 pandemic varied by site, partially due to differences in state laws and timing of CCN clinic closures • VA community care liaison offices were told to keep referrals open, creating a backlog of active referrals nationwide • During interviews, several sites were still trying to get through the backlog, as many Veterans preferred to wait until they could be seen in person by the CCN clinician

VA, United States Department of Veterans Affairs

Work-System Configurations

From the configural analysis, 23 work-system characteristics were identified (Fig. 2).

Figure 2.

Configural diagram and factor descriptions for the work system in referral steps 6–9. Each circle represents a work-system characteristic from Table 3. Circle area varies proportional to the number of process steps (1–4) in which the characteristic appears present in the referral process. VA, United States Department of Veterans Affairs.

Considering steps 6b–9, the characteristics varied by extent (affecting single or multiple steps) and facilitators or barriers (see Fig. 3).

Figure 3.

Visualization of impactful work system characteristics. In each step, characteristics were classified as facilitators, barriers, or neutral.

Regarding people factors, the relationships between VA staff and CCN clinicians and staff are highly influential across all steps. Interviewees described frustration from CCN clinicians whose reimbursement for past care was delayed or missing. This frustration appeared to decrease CCN clinicians’ motivation to dedicate the time needed for signing new contracts and completing training required for access to HealthShare Referral Manager.

Technology factors affected all steps. According to interviewees, technology supporting shared access to patient information or exchange of information among VA staff and CCN clinicians was a facilitator. For example, a limited number of VA clinicians were granted access to academic EHR systems where CCN clinicians worked. VA staff noted that they were able to go into the system and pull needed information. This method was perceived as decreasing workload, as it did not require multiple attempts to contact CCN clinicians. Yet, most of the characteristics associated with the technology factor were considered barriers because there was limited availability or adoption of the technology or shared privileges described above. HealthShare Referral Manager’s document storage feature allowed information to be exchanged among VA and CCN clinicians and staff efficiently; however, HealthShare Referral Manager required training, which was not feasible (or acceptable) for some VA and CCN staff.

The two most influential environment factors were the transition of third-party administrators and the COVID-19 pandemic. The third-party administrator transition included a new vendor serving CCN regions 1–3 and new contracts between the vendor and CCN clinicians. At the time of the study, the third-party administrator’s responsibilities included enrolling CCN clinicians into each region’s CCN and maintaining each region’s list of CCN clinicians. Interviewees identified problems with the accuracy of these lists, and they felt the new third-party administrator was not sufficiently responsive to their reports of accuracy issues. Interviewees described no other interactions with the third-party administrator during referrals. The third-party administrator transition itself was denoted as ambiguous (Table 3). In addition, there were some functionalities or capabilities that were not provided to VA staff with the new third-party administrator; for example, the new third-party administrator did not provide any means to report or track quality issues. Although interviewees described most Veteran encounters with CCN clinicians as a positive experience with high-quality care, there were instances where VA staff wanted to report quality issues but were unable to do so or were unable to track the issue to its resolution.

Regarding organization factors, the main characteristics described by interviewees were VA programs or initiatives created to support the implementation of the MISSION Act. Interviewees described the benefits of initiatives related to HealthShare Referral Manager training, informing Veterans of care options, and increasing availability of VA telehealth. These initiatives were described as facilitators in steps 6B to 9. Interviewees perceived those efforts related to increasing Veteran awareness of care options and telehealth options, thereby yielding a decrease in CCN appointments. These initiatives were not available at all VA sites. Additionally, interviewees described associated barriers to the implementation of these initiatives, such as frequent changes in the implementation of VA policies that were not communicated effectively or efficiently. Interviewees also mentioned the lack of incentives offered to VA and CCN staff for compliance.

When interviewees discussed responsibilities and the characteristics associated with the task factors, most of them were associated with barriers to community care referrals. Scheduling and requests for changes to standard episodes of care and secondary authorizations were among the most consistent characteristics described among interviewees. Scheduling was led by either VA staff or CCN staff, depending on the site. This lack of standardization caused confusion as patients received care across various VA and CCN clinics. Change requests for standard episodes of care often increased paperwork for VA staff. Additionally, these changes and secondary authorization requests were normally handled by VA nurses, which was perceived as additional workload; these changes often required more time from VA nurses.

CONCLUSIONS

Summary and Interpretation

This study explored cross-institutional, outpatient referrals from VA to CCN facilities and clinicians, focusing on VA community care liaison staff’s process workflows, information sharing, and supporting technology. Primary facilitators included telehealth visits and staff access to multiple EHR systems. In the cross-institutional referral process, VA staff perceived increases in workload and patient care delays related to specific configurations or combinations of organizational, people or role, and technological changes. Barriers included an insufficiently responsive new third-party administrator and underspecified secondary authorization requests from CCN clinicians and staff, stemming from several process-spanning work system factors: strained clinician relationships, low technology adoption, and inconsistent organizational policies. To our knowledge, this is one of the first studies to include a work system and configural analysis of the VA cross-institutional referral process.

Recent studies have shown the persistence of referral breakdowns and its exacerbation in cross-institutional referrals.^24,25 Analyzing the perceptions of VA staff at the system level enabled this study to advance our knowledge of the cross-institutional referral process. Previous research on closing the referral loop²⁴ and increasing access to primary care³⁴ demonstrates the importance of a system-level analysis in identifying facilitators and barriers. Some of the barriers identified in our study were similar to those noted recently within VA and non-VA health systems.^21,24,25 For instance, interpersonal relationships seem to be very important across internal and external referrals regardless of the institution. Moreover, our findings specifically illustrated the essential consideration of social and technological dependencies during the implementation of organizational policies.³⁵ Applying SEIPS 2.0’s system-level configural analysis to the VA community care process, our study translated reported experiences into visualizations of facilitators and barriers at various steps in the cross-institutional referral process.²⁷ These visualizations highlight the dynamic and interconnectedness of the work system and how experiences are shaped at each step. With these seemingly temporal depictions, the evolution and ripple effects of facilitators and barriers in the work system become apparent.

With the understanding that a combination or subset of work system factors is associated with prominent process barriers, our findings support socio-technical approaches to the implementation of future policies or adaptations. Additionally, these findings have implications for program evaluations and organizational policies related to cross-institutional or external referrals among healthcare institutions that attempt to share patient information but do not share electronic health record systems, referral policies, or scheduling systems. Future work is needed to investigate associations and severities among system barriers across institutions, which potentially change among steps of the cross-institutional referrals. Future research should analyze the level of limitations for the development of adaptations across the different factors in the work system.²⁷ From our findings, the external environment factor highlighted a potential challenge for adaptations, which is not often emphasized in non-VA literature. Various intervention implementations could present challenges to referrals, without the presence of government mandates. Identifying those limitations early in intervention design can inform implementation and continuous improvement. Although healthcare systems are trying to reduce referral leakage,³⁶ this will not eliminate the need for improving cross-institutional referrals. For example, certain Kaiser Permanente health plans, which cover more than 12.5 million members in the USA, recently increased contracting with external clinicians, who may or may not share interoperable EHRs, to ensure members have adequate and timely access to mental health care.³⁷ Patients’ preferences or needs to seek specialty and other types of care across healthcare institutions will persist.³⁸

Since the time of our interviews, the VA has continued to make efforts to improve both Veterans’ and staff’s experience with the logistics of VA’s implementation of the community care program under the MISSION Act. As the growth of referrals for VA purchased community care continues and as other health systems continue to use cross-institutional referrals to meet the care needs of patients, the findings from this study apply to VA and non-VA clinicians and healthcare institutions. Increases in clinical and administrative workloads or delays in care at one institution can spread to other healthcare institutions as patients experience more cross-institutional care.

Study Limitations

Although the study had notable strengths, there were some limitations. Although we recruited from multiple VA sites across the country, our sample size was small. As we began conducting interviews during the height of the pandemic, recruitment of VA staff across institutions became extremely difficult, especially clinicians in smaller community healthcare facilities. The multiple VA sites did provide heterogeneity among participants’ experiences and interactions with various CCN clinicians. Future studies should interview patients and CCN clinicians to better understand their experiences with the community care process. This would provide more context for referrals work system, defining facilitators and barriers across various perspectives. Future work may also address the influence of new third-party administrators and telehealth services.

CONCLUSION

VA staff-reported prominent barriers among multiple steps of the cross-institutional referral process that increased staff workload and breakdowns in sharing patient information. For the MISSION Act, implementation of policy changes relied heavily on VA and CCN clinicians or staff adoption and use of new technology. However, the adoption of this technology was limited by strained relationships with CCN clinicians and insufficient technology training. Subsequently, barriers emerged delaying secondary authorizations, restricting access to health information technology, and complicating third-party administrator transitions. These prevalent barriers were attributed to organization, people, and technology work system factors. Prioritizing requirements related to the highlighted work system configuration (technology, people, and organization), human factors engineering or socio-technological approaches are warranted to improve the cross-institutional referrals process. Future efforts should be focused on system-level interventions to build relationships with clinicians across healthcare systems, creating policies that guide patient information exchange, and designing technologies to support efficient communication for cross-institutional referrals.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

VA

United States Department of Veterans Affairs

COVID-19

Coronavirus disease 2019

CCN

VA community care network

SEIPS

Systems Engineering Initiative for Patient Safety

EHR

Electronic health record

Funding

This work was funded by grants from the US Department of Veterans Affairs (VA), Veterans Health Administration, Office of Research and Development, Health Systems Research (formerly Health Services Research and Development; SDR 18–321 and SDR 17–155). Drs. Savoy and Patel were also supported by a Center of Innovation grant from VA Health Systems Research (VA CIN 13–416). Dr. Weaver was also supported by a Research Career Scientist award from VA Health Systems Research (RCS 98–354). Dr. Taylor was also supported by grants from VA Health Systems Research (TRA 01–001 and SDR 98–004). Dr. Govier was also supported by a Postdoctoral Fellowship award from VA Health Systems Research (TPH 98–000-02). Dr. Hynes was also supported by a Research Career Scientist award from VA Health Systems Research (RCS 21–136).

Data Availability

Interview prompts are included in Appendix A. To protect the confidentiality of participants’ personally identifiable information, datasets from the study will not be available, except as required under the Freedom of Information Act (5 U.S. Code § 552).

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily represent the views of the United States Department of Veterans Affairs or the United States Government.