Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center

J Behav Health Serv Res. 2022 Jan;49(1):50-60. doi: 10.1007/s11414-021-09758-0. Epub 2021 May 25.


Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran's preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.

Keywords: Access to care; Care coordination; Community care; Rural health; Veterans.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Health Services Accessibility
  • Humans
  • Mass Screening
  • Rural Population
  • United States
  • United States Department of Veterans Affairs
  • Veterans Health
  • Veterans*

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