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Takeaway: VA social workers play a critical role in bridging gaps in clinical care, with particularly strong benefits for rural, high-risk, and other vulnerable Veteran populations. Among other benefits, the integration of social workers in primary care teams has reduced hospital admissions and emergency visits, and doubled palliative care utilization among Veteran patients. These results underscore the importance of social workers in expanding access to clinical care, including mental health care; in addressing social determinants of health; and in improving care coordination for rural Veterans, who often face complex medical needs and geographical barriers to care.
Social workers have been caring for and supporting Veterans in the VA system since 1926, and today VA is the largest employer of social workers in the nation, with about 21,000 master’s-level social workers. Because more than a third of Veterans enrolled in VA care live in rural areas, and a small but significant percentage of them are “highly rural”—from counties with fewer than seven people per square mile—VA’s National Social Work Program has long focused on overcoming the challenges associated with providing clinical and social services to these Veterans.
Rural Veterans typically live a considerable distance away from available healthcare resources. Compounding this problem is the fact that rural Veterans enrolled in VA care are more likely to need these resources: they’re slightly older than urban Veterans overall, and 15 years older, on average, than other rural Americans. They also tend to be medically complex, with higher rates of chronic conditions requiring frequent, ongoing care and services.
In 2006, when Congress established the Office of Rural Health (ORH), VA Social Work expanded to include a new Social Work Rural Health Program, aimed specifically at addressing the needs of rural Veterans and providing access to services through dedicated staffing in rural VA medical centers and clinics. These efforts were bolstered by Veteran-centric Patient-Aligned Care Teams (PACTs), introduced in 2010 to transform VA’s primary care system into a team-based model in which comprehensive care is provided by PACTs consisting of doctors, nurses, social workers, and other healthcare professionals. VA’s THRIVE Center of Innovation (THRIVE COIN), established in 2011 at the Providence VA Medical Center, has been a key partner in these efforts, with its focus on understanding and promoting independence, social engagement, and access to care for older Veterans.
Social workers play a key role in PACTs, meeting with care providers to determine issues that can have a significant effect on health and well-being, such as food and housing security, economic distress, isolation, or other circumstances that aren’t typically the focus of primary care visits. Their expertise and placement make them especially helpful in identifying risk factors for depression and other mental health conditions.
After the PACT program’s first several years, many teams in rural areas were not fully staffed with social workers. In 2016, to fill this persistent gap in rural health care and service delivery, ORH implemented the Social Work PACT Staffing Program, which placed more master’s-level licensed social workers in PACTs at rural health centers. The goal of the program is to increase Veteran access to care.
Since the program’s inception, VA’s Office of Social Work has been working with THRIVE COIN experts to collect and disseminate a body of evidence for the value of social workers in rural health care. In September 2024, Dr. James Rudolph, Director of the THRIVE COIN, and Jennifer Silva, VA’s National Social Work Program Manager, presented results of the Social Work PACT Staffing program to the Geriatrics and Gerontology Advisory Committee (GGAC), a Congressionally mandated oversight body that reports to the VA Secretary.
Currently, ORH-funded social workers are engaging rural Veterans at 77 VA facilities. Recent evaluations of the Social Work PACT Staffing Program have revealed significant impacts on the health and well-being of rural Veterans:
These findings have profound implications for the way VA delivers care, particularly to rural Veterans. They reveal that investing in social workers is key to addressing social determinants of health and improving care coordination for high-risk populations. Veterans with complex care requirements may have significant unmet needs if social work staffing falls below recommended levels.
Particularly in hospital settings, social workers in primary care may expedite access to palliative care through patient education, care coordination, advanced care planning conversations, and addressing barriers that might prevent Veterans from taking advantage of these beneficial services. The new SOS could identify Veterans needing specialized post-hospital interventions, improve discharge and transitional care planning, and reduce rates of unplanned readmissions and emergency visits.
James Rudolph, MD, is a geriatric and palliative care physician and health services researcher at the Providence VA Medical Center and an associate professor of medicine at Brown University. At the Providence VAMC, he is Director of the THRIVE Center of Innovation, which conducts research aimed at understanding and promoting independence, social engagement, and access to care for older Veterans.
Honken AN, Halladay CW, Wootton LE, et al. Differential effects of a social work staffing intervention on social work access among rural and highly rural Veterans: A cohort study. Health Services Research. December 2024;59(S2):e14327.
Cornell PY, Halladay CW, Ader J, et al. Embedding Social Workers In Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits. Health Affairs (Millwood). April 2020;39(4):603-612.
Cornell PY, Halladay CW, Montano AR, et al. Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans. JAMA Network Open. January 3, 2023;6(1):e2249731.
Cornell PY, Hua CL, Buchalksi ZM, et al. Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans. Health Services Research. February 2025;60(1):e14353.
