Abstract
BACKGROUND: Approximately half of US veterans receive care outside of US Department of Veterans Affairs (VA) Veterans Health Administration facilities-a proportion expected to rise due to the Promise to Address Comprehensive Toxics Act and expanded use of VA-purchased community care. OBJECTIVE: This paper describes the structure and impact of the Veterans Care Coordination in Community Settings (VetCoor) program. VetCoor was implemented in 2 non-VA community health centers, and we explored setting, staffing, and treatment targets to enhance veteran care and inform broader dissemination. METHODS: VetCoor embedded a coordinator within community-based, non-VA health care settings to improve veteran identification and address unmet medical needs. Coordinators also connected veterans with VA and local resources addressing health-related social needs. VetCoor included training on veteran needs and military culture. It also held a monthly community of practice call where coordinators shared best practices and met with facility representatives to learn about VA services. RESULTS: From May 2021 to September 2023, a total of 220 veterans participated, engaging in 773 sessions. Of these 220 veterans, 73 (33.2%) received VA enrollment assistance; 54 (24.5%) were referred for medical care; and 82 (37.3%) received care coordination, including medication reconciliation assistance. They also received assistance with transportation (46/220, 20.9%) nutrition and food access (42/220, 19.1%), housing and repair (42/220, 19.1%), and utility payment support (31/220, 14.1%). Common barriers to veterans seeking care were perceptions that enrolling in the VA took resources from veterans more in need and confusion regarding discharge papers required for enrollment. CONCLUSIONS: VetCoor supported rural veterans' health care and health-related social needs using dedicated coordinators. This model addresses resource gaps, fosters VA-community collaboration, and aligns with the VA's expanding benefits under the Promise to Address Comprehensive Toxics Act.