Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website
Publication Briefs

Challenges and Strain on VA System Associated with VA-Funded Community Care for Veterans with Advanced Kidney Disease

Following the Choice and MISSION Acts, VA has been required to interact on an unprecedented scale with private health systems, many of which do not share its programmatic strengths or culture of providing lifelong care to Veterans. In 2021 alone, VA made more than 6 million referrals for non-VA care for eligible Veterans. Further, between 2014 and 2021, VA spending on non-VA care more than doubled, from $7.9 billion to $17.6 billion. This qualitative study sought to further the understanding of the internal challenges of cross-system healthcare use to the VA healthcare system and enrolled Veterans. Using VA data, investigators identified a national cohort of 1,000 randomly sampled Veterans alive on June 6, 2019 (starting date for MISSION Act implementation and establishment of the Community Care Program) with evidence of advanced kidney disease. Investigators searched VA's electronic health record for mentions of "community care," filtering out boilerplate text.


  • Three dominant themes pertaining to VA-financed community care were identified. Themes described VA as mothership, the hidden work of Veterans, and strain on the VA system.
    • ‘VA as mothership’ describes extensive care coordination by VA staff members and clinicians to facilitate care outside VA – and the tendency of Veterans and their non-VA clinicians to rely on VA to fill gaps in this care;
    • ‘Hidden work of Veterans’ refers to the efforts of Veterans and family members to navigate the referral process – and to serve as intermediaries between VA and non-VA clinicians; and
    • ‘Strain on the VA system’ refers to the challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes, particularly for social workers who often served as a point-of-contact for Veterans.
  • Overall, 607 (61%) members of the study cohort had at least one active or paid claim for VA-financed non-VA care during follow-up. 


  • Difficult-to-measure consequences associated with cross-system healthcare warrant consideration when budgeting, evaluating, and planning for VA-financed non-VA care for Veterans.


  • VA’s electronic health record does not directly or completely capture the experiences or perspectives of Veterans, family members, or VA staff and clinicians.
  • This study did not evaluate Veterans’ interactions with private health systems and clinicians or capture the experiences of non-VA staff and clinicians.

This study was funded by HSR&D (IIR 18-032). Drs. O’Hare, Butler, and Laundry are part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA and Denver, CO.

O’Hare A, Butler C, Laundry R, et al. Implications of Cross-System Use among US Veterans with Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Internal Medicine. Published online May 16, 2022.

Related Briefs

» next 101 Access Briefs...

» next 12 Kidney Disease Briefs...

What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.