Accepted for/Published in: JMIR Formative Research
Date Submitted: Jul 16, 2025
Open Peer Review Period: Jul 16, 2025 - Sep 10, 2025
Date Accepted: Oct 17, 2025
(closed for review but you can still tweet)
VetCoor: Developing a Community of Practice to Provide Care Coordination and Address Health-Related Social Needs for Veterans Receiving Care in Community-Based Settings
ABSTRACT
Background:
Between 26.5% and 49.7% of US Veterans receive care outside of Veterans Administration (VA) facilities—a proportion expected to rise due to the PACT Act and expanded use of VA-purchased community care.
Objective:
This paper describes the structure and impact of the VetCoor Program (Veterans Care Coordination in Community Settings). VetCoor was implemented in two non-VA community health centers, and we explored setting, staffing, and treatment targets to enhance Veteran care and to inform broader dissemination.
Methods:
VetCoor embedded a coordinator within community-based, non-VA healthcare settings to improve Veteran identification, address unmet medical needs, and facilitate VA-purchased care. Coordinators, including licensed and non-licensed professionals, connected Veterans to VA and local resources addressing health related social needs (HRSN).
Results:
From May 2021 to September 2023, 220 Veterans participated, engaging in 773 sessions. Seventy-three (33%) received VA enrollment assistance; 54 (25%) were referred for medical care; and 82 (37%) received care coordination, including medication reconciliation. HRSN assistance included: transportation (46; 21%), nutrition/food access (42; 19%), housing/repair (42; 19%), and utility payment support (31; 14%). Two case vignettes illustrate impact: one Veteran received help with medical debt, food insecurity, and employment; another was identified as at risk for suicide and connected to intensive care.
Conclusions:
VetCoor supported rural Veterans’ healthcare and HRSN needs using dedicated coordinators. This scalable model addresses resource gaps, fosters VA–community collaboration, and aligns with VA’s expanding benefits under the PACT Act.
Citation
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Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.