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Health Services Research & Development

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HSR&D In Progress

In this issue: Advancing VA Telehealth and Virtual Care
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June 2021

Redesigning Virtual Sleep Care

Takeaway: This study is expected to streamline virtual e-consultation and virtual care services for Veterans referred to sleep medicine, thereby enhancing timeliness of care and reducing costs.  

Almost 50% of Veterans are at high risk for obstructive sleep apnea (OSA), and treatment is known to improve patients’ quality of life and wellbeing. However, VA has limited capacity to meet demands for OSA care with just more than 300 sleep providers nationwide. Further, specialists are concentrated in VA medical centers (VAMCs), which may be an inconvenient distance away from Veterans living in rural settings. VAMCs already incorporate E-consultation to improve the reach and capacity of VA sleep providers, but gaps in access remain and up to half of patients referred to these specialty care services do not receive them. While community care is often used to meet demand, there is growing interest in incorporating nurses into traditional specialist roles so that VA can grow its specialty care workforce.

Recently, the VA Office of Veterans Access to Care worked with VISN 20 (Northwest Network) to pioneer a novel team-based approach known as Referral Coordination, which aims to free specialists for in-person and virtual patient care by shifting the task of e-consultation to nurses provided with a decision support tool. Referral Coordination also integrates administrative support to streamline scheduling. However, the effectiveness of this approach was unclear relative to traditional practice. Starting in 2018, Referral Coordination was rolled out alongside the traditional specialist-led system. Supported by an HSR&D Career Development Award and the Office of Veterans Access to Care, this ongoing research (January 2020 – December 2024) evaluates the impact of nurse-led Referral Coordination on access, receipt of guideline-consistent sleep care, patient experiences, and costs.


Investigators planned propensity-matched analyses of patients receiving Referral Coordination versus Traditional Care to compare timeliness of scheduling and appointments and receipt of guideline-consistent sleep testing. Investigators also performed surveys to compare patients’ satisfaction with scheduling, and qualitative interviews to assess Veterans’ experiences with telehealth visits facilitated by the program. To understand impact on costs, investigators used administrative data to estimate direct costs for services – and staff surveys to assess time spent managing referrals. In the future, investigators plan to use qualitative methods to understand staff experiences with the new process of e-consult management.


In comparing Referral Coordination to Traditional Care, thus far, research has shown:

  • Nearly 7-fold greater odds of patients receiving specialty care in fewer than 28 days.
  • Greater quality of care, with 48% reduced risk of guideline discordant sleep testing.
  • Improved patient satisfaction.
  • Reduced referrals to community care.
  • For every 1,000 referrals, Referral Coordination frees specialists to complete 800 additional encounters with an estimated value of more than $70,000. 

Early findings also show that the arrangement of telehealth appointments led to favorable patient perceptions around access, personalization of care, and patient empowerment. However, findings also suggest that unmet needs remain.

Anticipated Impact

This study will inform the impact of nurse-led virtual e-consultation on patient access, quality, experience, and costs, while also identifying potential barriers to implementation.

Principal Investigator

Lucas Donovan, MD, MS, is past of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA and Denver, CO. Dr. Donovan is supported by an HSR&D Career Development Award.


Donovan L, Palen B, Fernandes L, et al. The Referral Coordination Team: A redesign of specialty care to enhance service delivery and value in sleep medicine. NEJM Catalyst. 2021;(2)5.

Donovan L, Palen B, Syed A, et al. Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study. BMJ Quality & Safety. December 22, 2020.

View study abstract

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