Five Milestones to Addressing Rural Veteran Care Coordination, Care Management, and Case Management Needs: An...

Veterans often experience fragmented care across clinics and health systems, with rural veterans facing additional challenges such as navigating community care. To address these needs, the Veterans Health Administration (VHA) implemented Care Coordination and Integrated Case Management (CCICM), a standardized, clinical practice framework that assigns high-needs veterans a lead coordinator to assess needs, coordinate services, and reduce fragmentation. Evidence describing CCICM implementation in rural settings is limited. This project examined CCICM implementation across rural facilities.

This multi-methods project assessed CCICM implementation at six rural VHA facilities participating in an Office of Rural Health Enterprise-Wide Initiative (EWI) October 2024 through September 2025. Implementation proceeded through five milestones: (1) Leadership Awareness; (2) Facility Readiness; (3) Preparing to Implement; (4) Systems and Clinical Integration; and (5) Establishment of a Governance Structure. Structure and process evaluation used quantitative data and qualitative interviews, focus groups, and observations. VA Generative Pre-trained Transformer transcript summarization with human review supported rapid matrix content analysis.

All six sites achieved clinical integration; one site will not continue due to staffing constraints. Over 80% of veterans identified for care coordination had moderate or complex, most commonly medical or physical, needs. Veterans assigned a Lead Coordinator (n = 245) were predominantly older, male, White, and rural. Four elements associated with successful implementation were strong leadership, effective change-management, clear communication, and tailored veteran engagement. Enhanced EWI supports facilitated workflow alignment and sustainability planning.

Structured, leadership-supported system changes can improve rural veteran care coordination. CCICM offers a reproducible model for coordinated care across diverse settings.