Staff Experiences With Implementation of the Referral Coordination Initiative

Ashley C Mog; Anna Woolery; Kelty Fehling; Makkawi Makkawi; Colin I O'Donnell; Edward O'Brien; Paul L Hebert; Brian N Palen; David H Au; Lisa M Arfons; David Winchester; Lucas M Donovan

doi:10.1111/1475-6773.14654

Staff Experiences With Implementation of the Referral Coordination Initiative

Health Serv Res. 2025 Jun 9:e14654. doi: 10.1111/1475-6773.14654. Online ahead of print.

Authors

Ashley C Mog^{1

2

3}, Anna Woolery^{1

2

4}, Kelty Fehling^{1

2

4}, Makkawi Makkawi^{1

2

4}, Colin I O'Donnell^{1

2

4}, Edward O'Brien^{1

2

3}, Paul L Hebert^{1

2

3}, Brian N Palen⁵, David H Au^{3

5}, Lisa M Arfons⁶, David Winchester⁶, Lucas M Donovan^{1

2

3}

Affiliations

¹ VA Collaborative Evaluation Center (VACE), Veterans Health Administration, Seattle, Washington, USA.
² VA Collaborative Evaluation Center (VACE), Veterans Health Administration, Denver, Colorado, USA.
³ Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), Veterans Health Administration, Seattle, Washington, USA.
⁴ Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), Veterans Health Administration, Denver, Colorado, USA.
⁵ Department of Veterans Affairs, Center for Care and Payment Innovation, Washington, District of Columbia, USA.
⁶ U.S. Department of Veterans Affairs, Office of Integrated Veteran Care, Washington, District of Columbia, USA.

PMID: 40488258
DOI: 10.1111/1475-6773.14654

Abstract

Objective: To understand VHA staff experiences with the referral coordination initiative (RCI) following nationwide dissemination.

Study setting and design: RCI uses a team-based approach to improve the timeliness, efficiency, and patient-centeredness of specialty care referrals, while redistributing the time-intensive triage tasks from specialist providers to nurses. To assess frontline experiences with RCI, we purposively sampled four VHA sites for qualitative interviews, ensuring variability around the use of nurses in triage and the organization of scheduling staff within three high-volume specialties: cardiology, gastroenterology, and pulmonary. From May to December 2023, we conducted semi-structured interviews with 68 VHA staff members who engaged in various aspects of referral coordination, including interviews with nurses, schedulers, specialists, and referring providers.

Data sources and analytic sample: We asked staff about challenges and facilitators to RCI implementation and maintenance. If certain RCI elements (e.g., nurse triage) were not implemented, we asked about anticipated challenges and facilitators. We analyzed qualitative data concurrently with data collection using a rapid matrix analysis approach.

Principal findings: Staff expressed varying perceptions around the effects of RCI and its impacts on specialist burden and clinic staffing. We identified challenges to RCI, including (1) inconsistent staff perceptions around program goals, (2) mixed perceptions around the appropriateness of nurse triage, (3) lack of clear specialty-specific triage guidelines, and (4) limited coordination with schedulers. Key facilitators of RCI included (1) leveraging existing relationships and nurses with existing specialty-specific expertise, and (2) building relationships and clear triage guidelines with specialties.

Conclusions: To streamline patient-centered referrals, health systems should foster working relationships between referral management teams and specialties. While nurse-led triage can improve efficiency, concerted efforts are necessary to train nurses and develop clear triage criteria.

Keywords: VA healthcare system; program evaluation; referrals; specialty care; triage.

Published 2025. This article is a U.S. Government work and is in the public domain in the USA.

Abstract

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