Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website
Publication Briefs

Study Shows Referral Coordination Team Improves Timeliness of VA Specialty Care Delivery and Patient Experience

Providing access to specialty care is a major challenge for large health systems due to a paucity of available specialists, compounded by inefficient staff utilization. For example, nationwide, approximately 1.3 million Veterans in the VA system suffer from obstructive sleep apnea and 4.5 million are at high risk; however, there are only about 300 providers specializing in sleep in the VA system—a mismatch that reduces the timeliness of care. In 2018, the Office of Veterans Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team to manage new referrals in sleep medicine. From May 2018 through December 2019, the referral coordination team completed consults alongside the traditional specialist-led system. The referral coordination team redesigned the initial sleep medicine consultation process by shifting the work from specialist providers (physicians and advanced practice providers) to registered nurses — and integrated administrative support staff within the team to increase service timeliness and continuity. Investigators then compared the referral coordination team and the traditional specialist-led method in terms of timeliness and community care referrals.


  • The referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost.
  • Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%).
  • Each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, valued at $420,368.
  • Although referrals to community care were low among patients in both groups, patients whose consults had been managed by the referral coordination team were slightly less likely to be referred outside of VA to community care, consistent with more timely service delivery (2% vs. 3%).


  • Informed by these results, national VA partners, including OVAC and the Office of Specialty Care, are working to disseminate referral coordination to other specialties nationwide.


  • The long-term impact on downstream patient outcomes was not assessed.

This evaluation was funded and supported by the Office of Veterans Access to Care, HSR&D, the VA Collaborative Evaluation Center, and the VA Puget Sound Health Care System. Dr. Donovan is supported by an HSR&D Career Development Award (CDA 18-187) and is part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA and Aurora, CO.

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: Innovations in Care Delivery. February 2021;2(2).

Related Briefs

» next 101 Access Briefs...

What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.