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Publication Briefs

VA's Referral Coordination Initiative Does Not Measurably Affect VA or Community Care Wait Times or Community Care Referrals

VA launched the Referral Coordination Initiative (RCI) in 2019 to improve timeliness of appointments and Veterans’ choice of specialty care location. This study investigated whether the RCI was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. Investigators reviewed monthly facility-level VA data for 3,097,366 specialty care referrals for eight high-volume specialties (cardiology, dermatology, gastroenterology, neurology, ophthalmology, orthopedics, physical therapy, and podiatry) from 10/1/2019–05/30/2022. After aggregating the data to the facility-month level, investigators had 22,528 observations, ranging from 2,400 for podiatry to 3,264 for physical therapy. Facilities were dichotomized into high and low RCI use based on the proportion of total referrals for a specialty. Analysis was stratified by specialty and the staffing model that high RCI users adopted. Staffing model data was provided by the VA Office of Integrated Veteran Care. The primary outcome variables were monthly facility-level CC referral rates and mean wait times at VA and CC providers.


  • In the initial years of the RCI program, RCI implementation did not measurably affect CC referral rates or wait times at VA facilities or CC providers for most specialties.
  • Investigators did not find a strong association between RCI implementation and wait times at VA facilities for any of the specialties regardless of the type of staffing models the high RCI use facilities adopted. They also did not observe a significant relationship between RCI implementation and wait times at CC providers for most specialties, regardless of the staffing model.


  • The results do not support concerns that RCI might impede Veterans’ access to CC providers and suggest that VA carefully consider the value of RCI, given RCI’s use of scarce resources.


  • This study examined the time between when a consult was initiated and when it was completed. It can be argued that the wait time that referral teams affect most is the time it takes for an appointment to be scheduled. However, the data for this variable is unreliable.
  • Investigators did not use a formal procedure to select the threshold for dichotomizing facilities into high and low RCI use. However, they conducted additional analyses to demonstrate the robustness of their findings.
  • The study analyzed RCI’s effects during the early period of implementation, when implementation was unlikely to be standardized. This could mask heterogeneous effects across sites.

This study was funded by QUERI. Drs. Asfaw, Pizer, and Garrido are with QUERI’s Partnered Evidence-based Policy Resource Center (PEPReC).

Asfaw DA, Price M, Carvalho K, Pizer SD, Garrido MM. The Effects of the Veterans Health Administration’s Referral Coordination Initiative on Referral Patterns and Waiting Times for Specialty Care. Health Services Research. March 30, 2024;online ahead of print.

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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.

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