Coordinating Specialty Care Across Health Systems: Primary Care Provider Survey

ABSTRACT

Objectives: Specialty care coordination is particularly challenging across health systems. The Veterans Health Administration (VHA) has implemented several measures to support coordination between VHA and VHA-paid community care. The objective of this study is to examine how within-system specialty care coordination compares with cross-system coordination with an array of organizational supports in place.

Study Design: Cross-sectional online survey of VHA primary care providers (PCPs) who placed referrals for specialty care.

Methods: We administered the Coordination of Specialty Care–Primary Care Provider survey, which comprises 1 item about overall coordination (0 [worst] to 10 [best]) and 6 multi-item scales measuring coordination subdomains: relationships and collaboration, communication, data transfer, role clarity, role agreement, and making referrals.

Results: Responses were from 351 PCPs about within-system and 226 PCPs about cross-system specialty care coordination. Overall coordination was higher for within-system than cross-system care (mean [SD] score, 7.01 [2.33] vs 6.22 [2.64]; P = .002). All scale scores were higher for within-system care. Cross-system respondents commonly lacked experience directly interacting with specialists. In both settings, the strongest association with overall coordination was with relationships and collaboration (within-system: standardized beta coefficient [β] = 0.45; P < .0001; cross-system: β = 0.69; P < .0001). Relationships and collaboration was a greater contributor to overall coordination for cross-system than within-system care.

Conclusions: Specialty care coordination is worse in cross-system care than in within-system care, even with significant organizational investment in structures and processes to coordinate across systems. Strategies to support direct clinician-clinician interactions could be particularly impactful for cross-system care.

Am J Manag Care. 2026;32(3):e83-e91. https://doi.org/10.37765/ajmc.2026.89900

Takeaway Points

Coordinating care between primary care providers (PCPs) and specialists is critical to optimizing patient health, system costs, and patient and clinician satisfaction. The Veterans Health Administration (VHA) has implemented new structures and processes to support coordination between VHA and non-VHA clinicians.

• VHA PCPs reported in a national survey that coordination remains worse for cross-system vs within-system care.
• In both settings, relationships between PCPs and specialists were the strongest contributors to coordination success.
• Strategies to support direct clinician-clinician interactions could be particularly impactful for cross-system care.

Coordinating care between primary care providers (PCPs) and specialists is challenging. Adverse clinical, cost, and satisfaction outcomes from poor coordination are well documented¹ and explained by inadequate referral tracking,² lack of timely communication,³ incomplete transfer of data between clinicians,³ and insufficient clarity about roles and responsibilities.⁴ Patients with more chronic illnesses have higher risks when care is fragmented across multiple specialists.⁵ PCPs are often responsible for coordinating specialty care, but many barriers are outside of PCP influence, warranting organizational support.

Integrated health systems can ameliorate many coordination challenges. In these systems, clinicians caring for a population of patients work under the same organizational structure and share practice guidelines and electronic health records (EHRs).⁶ Referrals are tracked, and clinic notes are immediately available in the EHR. A defined network of providers can readily interact electronically or in person, providing the opportunity to develop working relationships over time. All these features are effective in supporting specialty care coordination.^7-10 However, patient sharing across health systems—cross-system care—remains common.¹¹ Inadequate cross-system care coordination leads to worse chronic disease management¹² and more emergency department visits and hospitalizations.^13,14 Thus, it is important to understand the features of effective coordination in both scenarios to inform improvements and advance care quality.

The Veterans Health Administration (VHA) is the nation’s largest integrated health system. A massive challenge to coordinated care in the VHA was introduced with passage of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018.¹⁵ Under the MISSION Act, veterans can be referred to VHA-purchased community care (CC) for health services. Although CC may improve access to care, studies prior to the MISSION Act showed that veterans’ receipt of both VHA and non-VHA care increased risks of poor coordination and related outcomes, including hospitalization for ambulatory-sensitive conditions, overtesting,¹⁶ prescriptions for high-risk medications,¹⁷ and death from opioid overdose.¹⁸ To avoid these problems under the MISSION Act, the VHA has implemented several organizational structures to support cross-system clinical coordination, including dedicated teams to handle referrals,¹⁹ standardized referral processes,¹⁹ an online referral system,²⁰ and a health information exchange (see Setting subsection for details).²⁰

The MISSION Act enables large-scale examination of how the organizational supports of an integrated health system¹⁹ may strengthen coordination across multiple private-sector clinicians (“cross-system care”) compared with coordination for within-system care. PCPs are at the crossroads, managing interactions with multiple clinicians for each patient. They are well positioned to report the direct effects of major system change on coordination. In this study, we used a previously developed survey on specialty care coordination²¹ to compare PCP experiences with within-system vs cross-system care under the MISSION Act. The overarching study goals were to understand the differences in specialty care coordination across systems vs within systems and to identify lessons applicable to both VHA and non-VHA settings. Our specific research questions were as follows:

1. How does within-system care coordination compare with cross-system care coordination overall?
2. How does cross-system care impact whether certain aspects of coordination occur at all?
3. What subdomains of coordination contribute most to any differences in overall coordination within system vs cross-system?

Answers to these questions can help determine where care coordination could be improved in each scenario.

METHODS

The study was approved by the Veterans Affairs (VA) Bedford Healthcare System Institutional Review Board.

Setting

Under the MISSION Act, VHA patients who meet newly expanded criteria may receive VHA-paid care in the community.²² VHA facility-based Offices of Community Care (OCCs) are the primary conduit for coordination. Local OCCs use standardized processes to manage cross-system referrals through the entire episode of care.¹⁹ Specialty care referrals are reviewed for CC eligibility by the local OCC. CC is available to patients who cannot access VHA services due to distance, wait times, or meeting other standards. OCC staff discuss options for VHA or CC referrals with patients. If a referral goes to CC, standardized episodes of care are used that include authorizations for a bundle of condition-specific services, including initial evaluation, treatment, testing, procedures, and follow-up.¹⁹ The local OCCs process CC referrals, organize clinical information, share data with CC providers via fax or online portal (HealthShare Referral Manager), and manage additional interactions such as return and scanning of CC records into the VHA EHR. CC providers may use HealthShare Referral Manager for referral documentation or the Veterans Health Information Exchange for records viewing, although use of these platforms is relatively low; use of fax or phone is more common. Contact information provided with the referral is usually for the OCC rather than for the referring clinic or clinician. Local OCCs do not mediate within-VHA coordination.

Measure

We used the Coordination of Specialty Care–Primary Care Provider survey (CSC-PCP) to examine PCPs’ experience of specialty care coordination.²¹ The CSC-PCP comprises 20 items across 6 scales that measure subdomains of care coordination as experienced by PCPs interacting with specialist consultants. The scales are (1) relationships and collaboration, (2) communication, (3) data transfer, (4) role clarity, (5) role agreement, (6) and making referrals. Scale scores were calculated for respondents who answered at least half of the items. Scores range from 1 (never) to 7 (always), except for the making referrals scale, which is on a 1 (strongly disagree) to 5 (strongly agree) scale.

The CSC-PCP was developed in the VHA, and we used it in its original form for the within-system (VHA-VHA) sample, with minor modifications to ensure relevance for the cross-system (VHA-CC) evaluation. We retained 4 scales comprising 15 items for VHA-CC and added 2 “not applicable” (NA) response options for items that interviewees deemed frequently irrelevant for cross-system care. Both survey versions included a single question about overall coordination with specialists in the assigned specialty (on a 0-10 scale from worst possible to best possible): “All things considered, how would you rate the overall quality of specialty care coordination between you and VHA clinicians in this specialty over the last 3 months?”

Survey Sample

VHA PCPs were eligible if they had placed at least 3 referrals to at least 1 VHA or CC medical specialty within the previous 3 months: cardiology, endocrinology, gastroenterology, hematology/oncology, nephrology, neurology, pulmonology, or rheumatology. PCPs with referrals to VHA and CC were randomly assigned to the VHA-VHA or the VHA-CC samples. Within the 2 samples, we assigned PCPs to 1 of 8 subgroups based on the specialty to which they most recently referred. Within each subgroup, we surveyed a random sample of 200 PCPs. PCPs were asked to respond in relation to their assigned subgroup. For example, PCPs assigned to the VHA cardiology group would answer questions related to VHA cardiologists, and PCPs assigned to the CC cardiology group answered questions related to CC cardiologists. We invited 1560 PCPs to complete the VHA-CC version and 1733 PCPs to complete the VHA-VHA version of the survey.

Data Collection

We administered surveys online using SurveyMonkey between April 2021 and December 2021. Recipients were emailed a link with an opt-out option and 2 reminders.

Statistical Analyses

Most facilities in the random sample had only a single PCP surveyed, so we did not adjust SEs for clustering by facility. We assessed differences in demographic and practice characteristics between the 2 survey cohorts (VHA-VHA and VHA-CC) using χ² tests. We examined means and distributions of individual survey items and multi-item scale scores.

To compare VHA-VHA and VHA-CC on overall coordination, we compared mean scores on the single item measuring overall coordination using a t test and calculated Cohen d as an estimate of effect size. We similarly compared scores on the 4 coordination subdomains common to the VHA-VHA and the VHA-CC surveys (relationships and collaboration, communication, data transfer, and role clarity). Two items (Q9 and Q19) were excluded from this analysis because response options were different (VHA-CC had an NA option; VHA-VHA did not). We examined how often specific aspects of specialty care coordination were missing for within-system and cross-system care by using χ² tests to compare 7 individual survey items with “NA” or “not sure” response options offered on the VHA-CC survey.

We examined which coordination domains were most strongly associated with overall coordination in each setting to help understand what aspects of care delivery in the 2 different contexts might serve as targets for quality improvement. We used hierarchical regressions with PCP characteristics (age, sex, location [VA medical center, community-based outpatient clinic, etc]) as control variables in the first step, then added the coordination scales in the second step. This allowed us to estimate the percentage of variance in overall coordination explained by the scale scores above and beyond any variance accounted for by PCP characteristics. To check whether any associations between scale scores and overall coordination differed across settings, we estimated a model using the combined data from all respondents (VHA-VHA and VHA-CC) with the scale scores, setting (VHA or CC), and their interactions as predictors. All analyses were conducted using Stata 17.0 (StataCorp LLC).

RESULTS

Overall, 351 PCPs responded to the VHA-VHA survey (20.3% response rate), and 226 responded to the VHA-CC survey (12.7% response rate). Among VHA-VHA respondents, 54.1% worked at VA medical centers and 40.8% at community-based outpatient clinics, whereas among VHA-CC respondents, only 21.7% worked at VA medical centers, with 71.2% at community-based outpatient clinics (Table 1). Survey items and scale scores were normally distributed.

Research Question 1: How Does Within-System Care Coordination Compare With Cross-System Care Coordination Overall?

Overall coordination was higher for VHA-VHA (mean [SD], 7.01 [2.33]) than VHA-CC (6.22 [2.64]). The mean difference (MD) between the 2 settings represented a small to moderate effect size (MD = 0.80; d = 0.32; P = .002). In addition, scale scores were higher for VHA-VHA vs VHA-CC on each scale compared (Table 2). The MD represented a moderate effect size for relationships and collaboration (MD = 0.44; d = 0.35; P < .001), a large effect size for data transfer (MD = 1.75; d = 1.45; P < .001), and a small effect size for role clarity (MD = 0.24; d = 0.24; P = .007). Among the smaller sample for whom the communication score could be calculated (respondents with responses on ≥ 2 of 3 items), MD was not statistically significant (P = .057).

Research Question 2: How Does Cross-System Care Impact Whether Certain Aspects of Coordination Occur at All?

On the 3 relationships and collaboration items with “NA” or “not sure” options, VHA-CC PCPs more often reported being unsure of whether specialists valued their contributions (27.3% vs 15.1% of VHA-VHA PCPs; P < .01) and more often reported not needing to work together with specialists in caring for patients (21.2% vs 6.9%, respectively; P < .001) (Table 3). On all 3 communication items, all with “NA” response options, VHA-CC respondents reported a lack of direct communication with specialists or their teams more often than respondents in the VHA-VHA group (all P < .001), as indicated by “NA” rates of more than 50% for VHA-CC.

Research Question 3: What Subdomains of Coordination Contribute Most to Any Differences in Overall Coordination Within System vs Cross-System?

The main models included the relationships and collaboration, data transfer, and role clarity scales. The communication scale was not included in the primary multivariable models due to the small sample available for multivariable regression analyses (n = 72; 31.9% of respondents). For VHA-VHA, the 3 scales uniquely explained 53.7% of the total variance in overall coordination after controlling for PCP characteristics (ie, change in R² from PCP characteristics–only model = 0.537; P < .001) (Table 4). For VHA-CC, the 3 scales uniquely explained 70.8% of the total variance in overall coordination after controlling for PCP characteristics.

In both settings, the strongest association with overall coordination was for the relationships and collaborationscale (VHA-VHA: standardized beta coefficient [β] = 0.45; P < .0001; VHA-CC, β = 0.69; P < .0001), meaning that for every 1-SD increase in the relationships scale score, there was a 0.45-SD increase in the score for overall coordination in VHA-VHA and a 0.69-SD increase in the score for overall coordination in VHA-CC. The interaction term from a model with responses combined from both survey cohorts indicated that relationships and collaboration was a greater contributor to overall coordination for VHA-CC than for VHA-VHA (β = 0.60; P = .003).

DISCUSSION

The MISSION Act introduced cross-system specialty care for VHA patients on a huge scale. The VHA invested significantly in strategies to alleviate challenges to cross-system coordination. Thus, the VHA example serves as a best-case scenario in terms of organizational intentionality around cross-system coordination. Nonetheless, in this first-of-its-kind national survey of PCPs about specialty care coordination under the MISSION Act, overall coordination and every measured dimension of coordination were worse for VHA-CC care. We found that even with significant organizational commitment to coordination, achieving it is particularly difficult when patients’ care is delivered by separate health systems. Our findings offer insights applicable to the coordination of cross-system care both within and outside the VHA.

Scores for the relationships and collaboration and role clarity scales were lower for VHA-CC vs VHA-VHA care. Additionally, a high percentage of VHA-CC respondents reported that interclinician communication does not occur for VHA-CC care. Local OCCs are intermediaries that reduce clinician-clinician interactions. However, the very common absence of factors that are foundational to good clinical coordination in any health system^23-26 likely contributes to the lower overall coordination score for cross-system care.

The largest difference between VHA-VHA and VHA-CC coordination was observed on the data transfer scale; this is consistent with our prior work in the private sector, where a shared EHR strongly predicts higher scores in this domain.⁹ Qualitative studies document persistent difficulties in data availability for clinicians engaged in cross-system VHA care; VHA PCPs rely on records being returned and scanned into PDFs, which are not readily searchable.^27,28 These findings are concerning because access to clinical information is an essential condition for safe and effective health care. Incomplete data transfer is a widespread and central problem for successful cross-system care, such that health data systems interoperability is a key priority at the national level in the US and elsewhere.^29,30

In both settings, the relationships and collaboration scale was the strongest predictor of overall coordination. Data transfer was among the least strongly associated with overall coordination. This combination of findings is notable in that it underscores the relative power of clinician relationships to impact care coordination.⁷ It also suggests that provider judgments of overall coordination may not account adequately for the noninterpersonal elements of coordination (such as data transfer), such that assessing subscales is important to measuring presence of important coordination subdomains.

Notably, the relationships and collaboration scale was more strongly associated with overall coordination for cross-system than within-system care. Similarly, we previously found that the benefits of personal acquaintance are present when a shared EHR is present (eg, within-system care), but they are strongest in settings without a shared EHR (eg, cross-system care), where they positively impact every subdomain of coordination.⁹ Other studies have shown that, particularly in the face of structural shortcomings, personal relationships between clinicians are powerful enablers for overcoming coordination challenges and facilitating communication and collaboration that support successful coordination.^31-33

There are lessons from this study relevant to VHA but also non-VHA settings. Data platform sharing or interoperability is key. However, achieving this is often hindered by decentralized strategies, complex regulations, and the need for significant structural investment. Health systems should also prioritize cross-system mechanisms that permit clinicians to interact about individual patients’ care. Medical care frequently requires clinician-clinician conversations, sometimes time-sensitive, to ensure plans are safe, effective, and congruent with each other and the specific patients’ overall goals of care. The VHA example demonstrates that it is difficult to bypass clinician-clinician interactions with other mechanisms (eg, facility-level staff, standardized processes of care, or even an EHR) and still approximate coordinated care at levels that exist within-system.

Encouragingly, the VHA is actively addressing coordination barriers. For example, the organization recently launched the Veteran Interoperability Pledge,³⁴ which will improve data sharing with civilian-sector health system partners. The VHA could also require PCP and specialist email addresses as a field on clinical communications, facilitating relationships and better clinical care. Relationships could also be built in time-limited settings, for example, during learning events on veteran-specific care at which VHA and non-VHA clinicians are invited to interact.

Limitations and Strengths

Low response rates raise concerns about nonresponse bias. Although the VHA-VHA response rate is similar to or better than other large surveys of VHA PCPs,^35,36 the response rate for VHA-CC was lower. Survey respondents may be motivated to report particularly high or low satisfaction with coordination, but this bias should manifest similarly for the 2 cohorts. Also, our findings of worse coordination for cross-system care are plausible given the structures of care under study and consistent with prior qualitative studies of cross-system coordination prior to and under the MISSION Act that describe problems transferring data, determining responsibility for veteran problems, and communicating with other clinicians.^28,37,38 We did not measure clinical, safety, satisfaction, or cost outcomes as part of this survey study. However, coordination is well established as an intermediate outcome that predicts all of these.^1,39,40

Our study also has strengths. There is no other large-scale PCP survey that measures coordination in detail post MISSION Act or that directly compares within- and cross-system care. We leveraged a rare opportunity to examine 2 linked but separate systems of care. This work offers lessons applicable to other settings and serves as a benchmark for studies of change as new ways to coordinate are introduced or refined.

Future studies can compare how coordination for within- and cross-system care may relate differently to outcomes. We used the CSC-PCP to examine a point in time. The companion CSC-Specialist^41,42 and CSC-Patient⁴³ surveys could be applied over time to obtain a holistic view of how cross-system care impacts how the “specialty care triad”²⁵ experiences coordination in relation to important outcomes. Development and testing of interventions are needed that complement existing efforts and enable direct clinician communication and relationship-building.

CONCLUSIONS

Cross-system coordination incurs challenges that are different from those in within-system care. They are difficult to overcome even with significant organizational effort. Direct clinician-clinician interactions are critical to coordination and are even more important when clinicians are in separate health systems. On top of technologic supports, care pathways, and dedicated coordination staff, health system leaders should facilitate opportunities for clinicians to communicate directly about patient care.

Disclaimer: The work contained herein does not represent the views of the VHA or the US government.

Author Affiliations: Center for Health Optimization and Implementation Research (CHOIR), VA Bedford Healthcare System (VGV, MSZ, JBW, KES, BGF), Bedford, MA; Section of Endocrinology, Diabetes and Metabolism, Boston University Chobanian & Avedisian School of Medicine (VGV), Boston, MA; Heller School for Social Policy and Management, Brandeis University (MSZ), Waltham, MA; Department of Psychology, University of New Hampshire (JBW), Durham, NH; VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID-10EA), Field-Based at the VA Bedford Healthcare System (MM), Bedford, MA; Department of Management, Policy, and Community Health, UTHealth Houston School of Public Health (JKB), Austin, TX; Department of Psychiatry and Behavioral Sciences, University of Texas at Austin Dell Medical School (JKB), Austin, TX; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (MPC), Boston, MA; Health Law, Policy, and Management Department, Boston University School of Public Health (MPC, BGF), Boston, MA; Department of Public Health, Center for Health Statistics and Biostatistics Core, University of Massachusetts (DB), Lowell, MA.

Source of Funding: The study was funded by Field-Originated Project #20-241 from the US Department of Veterans Affairs, Health Services Research and Development Service.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (VGV, KES, MM, DB, BGF); acquisition of data (VGV, KES, DB); analysis and interpretation of data (VGV, MSZ, JBW, KES, MM, JKB, MPC, DB, BGF); drafting of the manuscript (VGV, MSZ, JBW, MPC, BGF); critical revision of the manuscript for important intellectual content (VGV, MSZ, MM, JKB, MPC, DB, BGF); statistical analysis (MSZ, JBW); provision of patients or study materials (KES); obtaining funding (VGV, JKB, DB); administrative, technical, or logistic support (KES); and supervision (VGV).

Address Correspondence to: Varsha G. Vimalananda, MD, MPH, Center for Health Optimization and Implementation Research (CHOIR), VA Bedford Healthcare System, 200 Springs Rd (152), Bedford, MA 01730. Email: varsha.vimalananda@va.gov.

REFERENCES

1. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. The National Academies Press; 2001. Accessed November 29, 2022. https://www.ncbi.nlm.nih.gov/pubmed/25057539

2. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496. doi:10.7326/0003-4819-145-7-200610030-00006

3. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-631. doi:10.1046/j.1525-1497.2000.91119.x

4. Williams J, Palmes G, Klinepeter K, Pulley A, Foy JM. Referral by pediatricians of children with behavioral health disorders. Clin Pediatr (Phila). 2005;44(4):343-349. doi:10.1177/000992280504400410

5. Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356(11):1130-1139. doi:10.1056/NEJMsa063979

6. Charns MP, Smith Tewksbury LJ. Collaborative Management in Health Care: Implementing the Integrative Organization. Jossey-Bass; 1993.

7. Charns MP, Benzer JK, McIntosh NM, Mohr DC, Singer SJ, Gurewich D. A multi-site case study of care coordination between primary care and specialty care. Med Care. 2022;60(5):361-367. doi:10.1097/MLR.0000000000001704

8. Abdellatif B, Vimalananda VG. PRISMA-ScR-Checklist—endocrine econsults scoping review_2024.pdf. Figshare. doi:10.6084/m9.figshare.26860159

9. Vimalananda VG, Wormwood JB, Qian S, Meterko M, Sitter KE, Fincke BG. The effect of clinicians’ personal acquaintance on specialty care coordination as the sharing of an EHR increases. J Ambul Care Manage. 2021;44(3):227-236. doi:10.1097/JAC.0000000000000381

10. Vimalananda VG, Meterko M, Solch AK, et al. Coordination of care as experienced by the specialist: validation of the CSC-Specialist Survey in the private sector and the effect of a shared electronic health record. Med Care. 2020;58(12):1051-1058. doi:10.1097/MLR.0000000000001402

11. DuGoff EH, Fernandes-Taylor S, Weissman GE, Huntley JH, Pollack CE. A scoping review of patient-sharing network studies using administrative data. Transl Behav Med. 2018;8(4):598-625. doi:10.1093/tbm/ibx015

12. Colvin CL, Safford MM, Muntner P, Colantonio LD, Kern LM. Health care fragmentation and blood pressure control among adults taking antihypertensive medication. Am J Manag Care. 2022;28(3):108-115. doi:10.37765/ajmc.2022.88837

13. Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure. Am Heart J. 2016;174:157-163. doi:10.1016/j.ahj.2015.09.023

14. Chen CC, Cheng SH. Care continuity and care coordination: a preliminary examination of their effects on hospitalization. Med Care Res Rev. 2021;78(5):475-489. doi:10.1177/1077558720903882

15. VA MISSION Act of 2018, S 2372, 115th Cong (2018). Accessed November 1, 2024. https://www.congress.gov/bill/115th-congress/senate-bill/2372

16. Maciejewski ML, Wang V, Burgess JF Jr, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Med Care Res Rev. 2013;70(5):497-513. doi:10.1177/1077558713495454

17. Thorpe JM, Thorpe CT, Schleiden L, et al. Association between dual use of Department of Veterans Affairs and Medicare Part D drug benefits and potentially unsafe prescribing. JAMA Intern Med. 2019;179(11):1584-1586. doi:10.1001/jamainternmed.2019.2788

18. Moyo P, Zhao X, Thorpe CT, et al. Dual receipt of prescription opioids from the Department of Veterans Affairs and Medicare Part D and prescription opioid overdose death among veterans: a nested case-control study. Ann Intern Med. 2019;170(7):433-442. doi:10.7326/M18-2574

19. Greenstone CL, Peppiatt J, Cunningham K, et al. Standardizing care coordination within the Department of Veterans Affairs. J Gen Intern Med. 2019;34(suppl 1):4-6. doi:10.1007/s11606-019-04997-6

20. Community care: HealthShare Referral Manager. US Department of Veterans Affairs. Accessed November 1, 2024. https://www.va.gov/COMMUNITYCARE/providers/Care-Coordination.asp#HSRM

21. Vimalananda VG, Meterko M, Qian S, Wormwood JB, Solch A, Fincke BG. Development and psychometric analysis of the Coordination of Specialty Care – Primary Care Provider Survey (CSC-PCP). Health Serv Res. 2020;55(5):660-670.

22. Veteran community care eligibility. US Department of Veterans Affairs. August 30, 2019. Accessed February 25, 2025. https://www.va.gov/files/2024-12/VA-FS_CC-Eligibility.pdf

23. Outland BE, Greenlee CM, Vimalananda VG, Candler S, Bering H, Arbaje A. Beyond the referral: principles of effective, ongoing primary and specialty care collaboration. American College of Physicians. 2022. Accessed July 30, 2024. https://www.acponline.org/sites/default/files/acp-policy-library/policies/beyond_the_referral_position_paper_2022.pdf

24. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807-819. doi:10.1097/00005650-200008000-00005

25. Vimalananda VG, Dvorin K, Fincke BG, Tardiff N, Bokhour BG. Patient, primary care provider, and specialist perspectives on specialty care coordination in an integrated health care system. J Ambul Care Manage. 2018;41(1):15-24. doi:10.1097/JAC.0000000000000219

26. Peterson K, Anderson J, Bourne D, et al. Health care coordination theoretical frameworks: a systematic scoping review to increase their understanding and use in practice. J Gen Intern Med. 2019;34(suppl 1):90-98. doi:10.1007/s11606-019-04966-z

27. Benzer JK, Gurewich D, Singer SJ, et al. A mixed methods study of the association of non-Veterans Affairs care with veterans’ and clinicians’ experiences of care coordination. Med Care. 2020;58(8):696-702. doi:10.1097/MLR.0000000000001338

28. Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-community dual care: veteran and clinician perspectives. J Community Health. 2020;45(4):795-802. doi:10.1007/s10900-020-00795-y

29. Global interoperability gaps revealed in 2025 healthcare connectivity rankings - Black Book. News release. ACCESS Newswire. Updated April 24, 2025. Accessed June 4, 2025. https://www.accessnewswire.com/newsroom/en/healthcare-and-pharmaceutical/global-interoperability-gaps-revealed-in-2025-healthcare-connectivity-1019025

30. Interoperability. Assistant Secretary for Technology Policy. Accessed June 4, 2025. https://www.healthit.gov/topic/interoperability

31. Zuchowski JL, Rose DE, Hamilton AB, et al. Challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med. 2015;30(3):305-311. doi:10.1007/s11606-014-3100-x

32. Anderson E, Solch AK, Fincke BG, Meterko M, Wormwood JB, Vimalananda VG. Concerns of primary care clinicians practicing in an integrated health system: a qualitative study. J Gen Intern Med. 2020;35(11):3218-3226. doi:10.1007/s11606-020-06193-3

33. DuGoff EH, Cho J, Si Y, Pollack CE. Geographic variations in physician relationships over time: implications for care coordination. Med Care Res Rev. 2018;75(5):586-611. doi:10.1177/1077558717697016

34. Veteran Interoperability Pledge. US Department of Veterans Affairs. Accessed December 10, 2024. https://www.va.gov/health/veteran-interoperability-pledge.asp

35. Linsky A, Simon SR, Stolzmann K, Bokhour BG, Meterko M. Prescribers’ perceptions of medication discontinuation: survey instrument development and validation. Am J Manag Care. 2016;22(11):747-754.

36. Apaydin EA, Rose DE, McClean MR, et al. Association between care coordination tasks with non-VA community care and VA PCP burnout: an analysis of a national, cross-sectional survey. BMC Health Serv Res. 2021;21(1):809. doi:10.1186/s12913-021-06769-7

37. Zuchowski JL, Chrystal JG, Hamilton AB, et al. Coordinating care across health care systems for veterans with gynecologic malignancies: a qualitative analysis. Med Care. 2017;55(7 suppl 1):S53-S60. doi:10.1097/mlr.0000000000000737

38. West AN, Charlton ME. Insured veterans’ use of VA and non-VA health care in a rural state. J Rural Health. 2016;32(4):387-396. doi:10.1111/jrh.12196

39. Hempstead K, Delia D, Cantor JC, Nguyen T, Brenner J. The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions. Med Care. 2014;52(suppl 3):S67-S74. doi:10.1097/MLR.0000000000000049

40. Tsai TC, Orav EJ, Jha AK. Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality. JAMA Surg. 2015;150(1):59-64. doi:10.1001/jamasurg.2014.2071

41. Vimalananda VG, Fincke BG, Qian S, Waring ME, Seibert RG, Meterko M. Development and psychometric assessment of a novel survey to measure care coordination from the specialist’s perspective. Health Serv Res. 2019;54(3):689-699. doi:10.1111/1475-6773.13148

42. Vimalananda VG, Meterko M, Solch AK, et al. Coordination of care as experienced by the specialist: validation of the CSC-Specialist survey in the private sector and the effect of a shared electronic health record. Med Care. 2020;58(12):1051-1058. doi:10.1097/MLR.0000000000001402

43. Vimalananda VG, Meterko M, Sitter KE, Qian S, Wormwood JB, Fincke BG. Patients’ experience of specialty care coordination: survey development and validation. J Patient Cent Res Rev. 2023;10(4):219-230. doi:10.17294/2330-0698.2027