Feature Article

Improving Efficiency in Care Coordination for Veterans

Why is efficiency in care coordination so important?

Many Veterans have multiple, complex chronic conditions for which they must visit a number of different specialty providers.1 They may also have service-connected disabilities or conditions , such as exposure to toxins or a history of traumatic brain injury, that require care from providers who are educated in military-related injuries and the specific medical needs of Veterans. Information sharing between providers is crucial to provide high-quality care.

Since 1945, the VA has collaborated with community partners on programs to enhance care options for Veterans. Thanks to the MISSION Act, VA Community Care has been fundamentally transformed into a singular program designed to be easier for all stakeholders to navigate. As the need to ensure that Veterans’ care will continue to be coordinated efficiently, data and information sharing will be crucial to modernizing and streamlining care coordination for our nation’s Veterans.


The role of the Mission Act in Coordinating Care

The VA oversees the provision of comprehensive health care services to Veterans within the its own network and through approved, non-VA medical providers, also referred to as community care providers.3 Each system of care has its own set of regulations, providers, and rules, which makes care coordination challenging.1

A Veteran may be eligible to seek care in the community if they meet certain eligibility criteria, such as wait or drive times that exceed VA established standards or if a service is not available at a VA medical facility.

When patients receive care in the community, they must undergo more transitions than patients seen solely by the VA, with ensuing risks that include missing appointments, lack of critical information shared with VA providers, and duplicate services. Communication and organization are key to avoiding poorly coordinated care, which can result in gaps in care and potentially, poor outcomes.3

Improving customer experience, and enhancing access and options to care, are among the top priorities for the VA.2 The MISSION Act, signed into law in June 2018, also aligns with the VA’s broader modernization efforts and aims to strengthen care delivery by improving access to care and their patient experience through a consolidated community care program.


Patient-centered care requires better and more efficient coordination

A patient-centered approach to care emphasizes shared decision-making between patients and providers. In the VA Community Care program, VHA works with Veterans and a network of community providers to coordinate referrals, records and payment. This enables access to private providers outside the VA system, while still ensuring the VA controls Veteran care and experience. Clear, comprehensive and immediate communication and seamless sharing of data between these providers is an essential part of coordination of care.3

For efficiency in care coordination, programs need to be easy for patients and their families to navigate. Wherever possible, this means consolidating programs that provide overlapping services into one program, such as the multiple legacy VA community care programs that were integrated into the Community Care program as part of the MISSION Act. The Community Care program should be easier and more streamlined for Veterans, their families, community providers, and VA employees to navigate.

Providing family support and caregiver services is another integral part of coordination of care. Eligibility for the Program of Comprehensive Assistance for Family Caregivers will be expanded to include eligible Veterans from all eras of service, so family caregivers will have greater access to needed supports.

The VA Community Care program aims to use technology to standardize coordination of care within the VA, and includes a Decision Support tool to determine if a Veteran is eligible to seek care in the community. A personalized care plan is developed by the Office of Community Care and is implemented by a professional healthcare team of multidisciplinary providers. The team must follow the Veteran through their episode of care. Interoperability of health information between community providers and the VA is key to improving patient safety and quality of care. The Care Coordination Review Team also ensures focus on high-risk Veterans receiving the right type and intensity of care coordination services.3


Efficient information sharing is key to care coordination

Spanning all these areas is the sharing of information and data. For VA and non-VA providers to coordinate a patient’s care, they must be able to share medical records and treatment data in a timely way. The VA must have line of sight across the data collected by multiple providers in different organizations and play an active role in the veteran's care journey.

There is also a critical need for longitudinal coordination across a single patient’s lifespan. Providers must know what the patient has been exposed to in their military service, what injuries they may have sustained in past service, and what their baseline was. This is especially important for non-VA providers as they may not intuit the unique risks and considerations facing this patient population. For example, a woman in her 30s, who may have been exposed to airborne toxins, may require an earlier baseline mammogram and more frequent screening.

Driving improvements in efficiency and coordination of care requires timely handling of complex data, the implementation of useful analytics, and artificial intelligence (AI). Care coordination software is a growing market, aided by innovative technologies including AI and blockchain. These technologies support data interoperability. Care coordination IT is expected to expand with both software and service solutions.5



  1. Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. Cordasco et al. Journal of General Internal Medicine. Last Accessed 1/17/20. https://link.springer.com/article/10.1007/s11606-019-04999-4#Sec4
  2. Department of Veterans Affairs FY 2018-2024 Strategic Plan. https://www.va.gov/oei/docs/VA2018-2024strategicPlan.pdf
  3. Standardizing Care Coordination Within the Department of Veterans Affairs. Greenstone et al. Journal of General Internal Medicine. Last Accessed 1/17/20. https://link.springer.com/article/10.1007/s11606-019-04997-6
  4. Patient-Centered Care and the Veteran Experience. Chapter 10, Evaluation of the Department of Veterans Affairs Mental Health Services. Last Accessed 1/17/20. https://www.ncbi.nlm.nih.gov/books/NBK499505/
  5. AI-powered Care Coordination Software Gives Vendors Competitive Edge in the Era of Personalized Healthcare. Frost & Sullivan. PRNewswire. Last Accessed 1/17/20. https://www.prnewswire.com/news-releases/ai-powered-care-coordination-software-gives-vendors-competitive-edge-in-the-era-of-personalized-healthcare-300829893.html