Nursing Bj redo assignment

Enhancing Referral Follow-Through for Veterans in Outpatient Mental Health Care

The Description of the Problem (Final)

Beverly Jordan

Herzing University

NU820 Project Residency

July 2026

Introduction

Mental health disorders remain among the most significant health concerns affecting United States veterans. Many veterans experience post-traumatic stress disorder (PTSD), depression, anxiety, substance use disorders, and increased suicide risk following military service. While the Department of Veterans Affairs (VA) has expanded access to behavioral health services, referral completion continues to be a significant challenge. Simply generating a referral does not ensure that a veteran receives the recommended treatment. Failure to complete referrals delays care, worsens psychiatric symptoms, and contributes to unnecessary healthcare utilization.

Improving referral follow-through is consistent with national quality initiatives focused on care coordination, patient engagement, and timely access to behavioral health services. Continuity of care is essential because untreated mental illness negatively affects physical health, family relationships, employment, housing stability, and overall quality of life. Veterans often experience multiple chronic medical and psychiatric conditions simultaneously, making coordinated outpatient services essential for successful long-term management.

Doctor of Nursing Practice (DNP)-prepared nurses are equipped to lead evidence-based quality improvement initiatives that improve healthcare systems. Through leadership, data analysis, implementation science, and interdisciplinary collaboration, DNP-prepared nurses identify barriers, implement sustainable interventions, and evaluate outcomes. This quality improvement project seeks to improve referral completion rates among veterans receiving outpatient mental health care by implementing standardized patient education, reminder systems, referral tracking, and nurse follow-up.

Description of the Problem

Review of organizational data at the practicum site demonstrated that more than 20% of veterans referred for outpatient mental health services did not complete their appointments within the recommended timeframe. Missed referrals interrupt continuity of care, delay treatment initiation, and contribute to worsening psychiatric symptoms. Veterans who fail to engage in treatment are at increased risk for emergency department utilization, psychiatric hospitalization, substance use relapse, and suicide-related crises. This practice gap represents an important opportunity for quality improvement.

Several patient, provider, and organizational-level factors contribute to poor referral follow-through. Veterans may encounter transportation difficulties, financial concerns, work or caregiving responsibilities, technology limitations, stigma related to mental health treatment, or a limited understanding of referral instructions. Organizational barriers include inconsistent scheduling practices, delayed appointment availability, inadequate communication between providers, the absence of standardized reminder systems, and limited follow-up after missed appointments. Together, these barriers create fragmented care that reduces treatment effectiveness.

Current evidence supports multifaceted interventions that improve appointment adherence. Telephone reminders, text messaging, electronic patient portals, telehealth appointments, nurse navigators, and standardized referral-tracking systems have consistently improved attendance rates. Early follow-up with veterans who miss appointments also increases the likelihood of rescheduling while strengthening therapeutic relationships. These interventions support patient-centered care by reducing barriers and improving communication throughout the referral process (Agency for Healthcare Research and Quality [AHRQ], 2024; Resnik et al., 2024; Shekelle et al., 2024).

The proposed DNP project will implement a standardized referral management process that includes patient education during the referral visit, automated reminder calls or text messages before appointments, electronic monitoring of referral completion through a tracking dashboard, and timely outreach by nursing staff following missed appointments. Interprofessional collaboration among primary care providers, behavioral health clinicians, nurses, schedulers, and administrative staff will be essential for successful implementation and sustainability.

Expected outcomes include improved referral completion rates, increased patient engagement, reduced missed appointments, enhanced continuity of care, and better mental health outcomes for veterans. In addition, improving referral follow-through supports organizational goals related to quality improvement, patient satisfaction, and efficient resource utilization. The project aligns with the AACN DNP Essentials by emphasizing systems leadership, evidence-based practice, quality improvement, informatics, and population health (American Association of Colleges of Nursing [AACN], 2021). If successful, this initiative may serve as a sustainable model for improving referral management at additional outpatient specialty clinics that care for veteran populations.

Evidence demonstrates that coordinated care, timely follow-up, telehealth access, and standardized referral management improve outpatient mental health engagement among veterans while reducing missed appointments and improving continuity of care (Ackland et al., 2023; AHRQ, 2024; Resnik et al., 2024; Shekelle et al., 2024).

References

Ackland, P. E., Koffel, E., Goldsmith, E. S., Ullman, K., Miller, W. A., Landsteiner, A., Stroebel, B., Hill, J., Wilt, T. J., & Duan-Porter, W. (2023). Implementation of evidence-based psychotherapies for posttraumatic stress disorder: A systematic review. Administration and Policy in Mental Health and Mental Health Services Research, 50(5), 792–812 . https://doi.org/10.1007/s10488-023-01279-6

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf

Agency for Healthcare Research and Quality. (2024). Care coordination. https://www.ahrq.gov/ncepcr/care/coordination.html

Resnik, J., Miller, C. J., Roth, C. E., Burns, K., & Bovin, M. J. (2024). A systematic review of Department of Veterans Affairs mental health-care access interventions for veterans with posttraumatic stress disorder. Military Medicine, 189(5–6), 1303–1311. https://doi.org/10.1093/milmed/usad376

Shekelle, P. G., Begashaw, M. M., De Vries, G., & Miake-Lye, I. M. (2024). Integrated mental and behavioral health care: A systematic review. U.S. Department of Veterans Affairs, Evidence Synthesis Program. https://www.hsrd.research.va.gov/publications/esp/integrated-mental-behavioral-health.cfm