Closing a Home-Based Primary Care Referral Gap: Development and System-Wide Adoption of an Interprofessional Screening Consult for High-Risk Veterans

Background: Home-based Primary Care (HBPC) programs serve older Veterans with complex, chronic conditions who cannot access clinic-based care, and delayed referrals result in potentially preventable hospitalizations. Despite VA Directive 1411 establishing eligibility criteria, a systematic search identified no published HBPC referral screening instrument designed for general, interprofessional referral decision-making. Objective: To develop, test, and refine a structured screening consult (SC) to improve timely HBPC referral identification at a rural VA primary care clinic. Methods: Guided by the Institute for Healthcare Improvement Model for Improvement, an SC incorporating the care Assessment Need (CAN) score and VA Directive 1411 eligibility criteria was developed and tested through 2 Plan-Do-Study-Act (PDSA) cycles at a rural geriatric primary care clinic within the South Texas Veterans Health Care System. Pareto analysis prioritized referral considerations, and weighted scoring thresholds were refined iteratively. Results: Across both cycles, 271 Veterans were screened (Cycle 1: n = 128; Cycle 2: n = 143); 124 qualified for HBPC referral, exceeding the goal of 50 by 148%. Cycle 1 (threshold ≥ 3) yielded 85 qualifying Veterans (66%), prompting greater specificity; cycle 2 (threshold ≥ 5) yielded 39 (27%), targeting highest-acuity Veterans. The SC was adopted system-wide, and its data supported 2 additional registered nurse case manager hires. Conclusions: An iteratively refined, electronic health record–integrated SC can close systematic HBPC referral gaps, streamline referral documentation, and generate objective data for home care workforce planning. The SC remains in active system-wide use 3 years post-implementation, demonstrating sustainability. The methodology is adaptable to non-VA home-based and community care programs.