Developing a Community of Practice to Provide Care Coordination and Address Health-Related Social Needs for Veterans Receiving Care in Community-Based Settings: Program Development and Survey Study

Carolyn Turvey; Natalie Suiter; Rhonda Fellows; Shawna Domeyer; Lindsey Fuhrmeister; Amanda Heeren; Kimberly McCoy; M Bryant Howren

doi:10.2196/80654

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Developing a Community of Practice to Provide Care Coordination and Address Health-Related Social Needs for Veterans Receiving Care in Community-Based Settings: Program Development and Survey Study

Journal article

Open access

Peer reviewed

Developing a Community of Practice to Provide Care Coordination and Address Health-Related Social Needs for Veterans Receiving Care in Community-Based Settings: Program Development and Survey Study

Carolyn Turvey, Natalie Suiter, Rhonda Fellows, Shawna Domeyer, Lindsey Fuhrmeister, Amanda Heeren, Kimberly McCoy and M Bryant Howren

JMIR formative research, Vol.9, e80654

10/31/2025

DOI: 10.2196/80654

PMCID: PMC12619014

PMID: 41172298

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Abstract

Approximately half of US veterans receive care outside of US Department of Veterans Affairs (VA) Veterans Health Administration facilities-a proportion expected to rise due to the Promise to Address Comprehensive Toxics Act and expanded use of VA-purchased community care. This paper describes the structure and impact of the Veterans Care Coordination in Community Settings (VetCoor) program. VetCoor was implemented in 2 non-VA community health centers, and we explored setting, staffing, and treatment targets to enhance veteran care and inform broader dissemination. VetCoor embedded a coordinator within community-based, non-VA health care settings to improve veteran identification and address unmet medical needs. Coordinators also connected veterans with VA and local resources addressing health-related social needs. VetCoor included training on veteran needs and military culture. It also held a monthly community of practice call where coordinators shared best practices and met with facility representatives to learn about VA services. From May 2021 to September 2023, a total of 220 veterans participated, engaging in 773 sessions. Of these 220 veterans, 73 (33.2%) received VA enrollment assistance; 54 (24.5%) were referred for medical care; and 82 (37.3%) received care coordination, including medication reconciliation assistance. They also received assistance with transportation (46/220, 20.9%) nutrition and food access (42/220, 19.1%), housing and repair (42/220, 19.1%), and utility payment support (31/220, 14.1%). Common barriers to veterans seeking care were perceptions that enrolling in the VA took resources from veterans more in need and confusion regarding discharge papers required for enrollment. VetCoor supported rural veterans' health care and health-related social needs using dedicated coordinators. This model addresses resource gaps, fosters VA-community collaboration, and aligns with the VA's expanding benefits under the Promise to Address Comprehensive Toxics Act.

United States

Community Health Services - organization & administration

Community of Practice

Female

Health Services Needs and Demand

Humans

Male

Middle Aged

Program Development

Surveys and Questionnaires

United States Department of Veterans Affairs - organization & administration

Veterans - statistics & numerical data

Veterans Health Services - organization & administration

Details

Title: Subtitle: Developing a Community of Practice to Provide Care Coordination and Address Health-Related Social Needs for Veterans Receiving Care in Community-Based Settings: Program Development and Survey Study
Creators: Carolyn Turvey - Iowa City VA Health Care System
Natalie Suiter - Iowa City VA Health Care System
Rhonda Fellows - Van Buren County Hospital, Keosauqua, IA, United States
Shawna Domeyer - Community Health Center
Lindsey Fuhrmeister - Iowa City VA Health Care System
Amanda Heeren - Iowa City VA Health Care System
Kimberly McCoy - Iowa City VA Health Care System
M Bryant Howren - Iowa City VA Health Care System
Resource Type: Journal article
Publication Details: JMIR formative research, Vol.9, e80654
DOI: 10.2196/80654
PMID: 41172298
PMCID: PMC12619014
NLM abbreviation: JMIR Form Res
ISSN: 2561-326X
eISSN: 2561-326X
Publisher: JMIR PUBLICATIONS, INC
Grant note: US Department of Veterans Affairs (VA) Office of Rural Health Veterans Rural Health Resource Center-Iowa City: PROJ-04143
Acknowledgments ChatGPT (OpenAI) was used to assist with grammar and language editing in early drafts. The final manuscript was reviewed and revised by all authors. This work was funded by the US Department of Veterans Affairs (VA) Office of Rural Health Veterans Rural Health Resource Center-Iowa City "Developing a Community of Practice between VA and Rural Community Health Centers to Enhance Coordinated Care for Rural Veterans" project (New Office of Rural Health Management and Analysis Database PROJ-04143) . The views expressed in this paper are those of the authors and do not necessarily reflect the position or policy of the VA or the US government.
Language: English
Date published: 10/31/2025
Academic Unit: Psychiatry; Epidemiology; School of Social Work; Internal Medicine
Record Identifier: 9985024146602771

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