ABSTRACT
Purpose
Veteran use of Veteran Health Administration (VHA)‐purchased community care (CC) for mental health has accelerated at a faster pace compared to both primary care and emergency services. Few studies have conducted an in‐depth exploration of rural Veteran experience using community mental health. This paper focuses on the voices of rural Veterans, with the aim of exploring advantages and disadvantages for Veterans receiving mental health services through CC.
Methods
We conducted interviews with rural Veterans, using purposive sampling to identify Veterans through the Integrated Veteran Care Consolidated Data Sets who were enrolled in VHA medical centers in the southcentral United States, had received CC for mental health, and were living in a rural area. Interviews asked Veterans about their experience with receiving community mental health care. We used thematic analysis to organize quotes and present salient themes from interviews.
Findings
We interviewed 30 Veterans. We highlight four findings: (1) Most Veterans were pleased with the mental health care they received through the community. (2) Some Veterans reported instances of unprofessionalism and recognized a lack of military expertise among community providers. (3) Rural Veterans continue to face access barriers and noted limited availability of community mental health providers. (4) Difficulty with navigating multiple health systems impacted some rural Veterans’ continuity of care.
Conclusions
While CC has improved access to mental health care for Veterans, there are concerns related to the quality of care and continuity gaps for rural Veterans.
Keywords: community care, mental health, patient experience, qualitative methods, Veterans
1. Introduction
Millions of U.S. Veterans are eligible to receive Veteran Health Administration (VHA)‐purchased community care (CC): care delivered by facilities or providers outside the VHA. Veteran access to CC was first expanded with the 2014 Veterans Access, Choice, & Accountability Act (Choice Act) and then again in 2018 with the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act [1, 2]. The Choice and MISSION acts sought to address travel and geographic burdens for Veterans seeking care [3]. At time of interviews, the MISSION act stipulated that Veterans eligible for CC must meet one of the following criteria: live 40 miles or more away from a VHA medical facility, live in a state or territory without a full‐service VHA facility, have over 60 min in average drive time away from specialty care, or require CC because it is deemed in their best medical interest [4].
CC has particular implications for rural Veterans, as many are eligible for CC based solely on distance [5, 6]. Furthermore, rural Veterans represent a sizeable proportion of patients served by VHA, as nearly one third of the 9.1 million VHA‐enrolled Veterans live in rural or highly rural areas [7, 8, 9]. Although use of CC has increased for all Veterans, rural Veterans are significantly more likely to use CC compared to their urban counterparts [10, 11, 12, 13].
As CC has expanded, studies have sought to understand Veteran experience with CC across a range of health care services. For CC‐delivered primary care and specialty care, issues related to care coordination, information sharing across different health systems, and scheduling and billing stand out as a particularly troubled aspect of care [14, 15, 16, 17, 18]. As well, Veterans rate communication in CC facilities less favorably than VHA [19, 20].
Notably, the increase in Veterans’ utilization of CC for mental health services has outpaced the increase in utilization of CC for primary care and emergency services across the country [21]. For rural Veterans, engagement in mental health services through CC doubled from 2017 to 2019 [22]. Studies have found that Veterans rate VHA and CC similarly in terms of access to mental health services [23]. Additionally, patient‐reported mental health outcomes are comparable across VHA and non‐VHA health systems [24]. However, a majority of Veterans using CC for Post Traumatic Stress Disorder (PTSD) treatment do not appear to receive evidence‐based psychotherapy and suicide risk assessment [25]. As seen in other services, mental health providers (both VHA and CC) who serve rural Veterans indicate pervasive communication and coordination problems [26].
Despite the growing literature on Veterans’ use of CC for a range of services and outcomes, limited research exists on their personal experiences—what they thought went well or not during care, whether mental health treatment through CC was helpful (or not), and why. Indeed, no studies to date have centered on rural Veterans’ voices to understand experience at the point of care when using CC for mental health services. This paper addresses this gap in the literature by focusing on the voices of rural Veterans, with the aim of exploring advantages and disadvantages for Veterans receiving mental health services through CC.
2. Methods
2.1. Sampling and Recruitment
This study employed purposive sampling to recruit Veterans who had used CC for mental health and were living in rural areas [27]. To identify Veterans for recruitment, the co‐author (C.S.E.) used the Integrated Veteran Care Consolidated Data Sets database [28]. This dataset contains referrals, claims, and payment data from Veterans who used a community (non‐VHA provider) for care and had that care paid for by the VHA. We drew on established protocols for identifying Veterans using outpatient or inpatient mental health services and used the same Current Procedure Terminology codes from previous studies to identify the sample [29].
The VHA Rural Urban Commuting Area system was used to identify those living in rural and highly rural areas at the time of utilization [30]. This system uses population density and community patterns to assign rurality designations to census tracts. Areas with a majority or 30%−49% of workers commuting to a larger urban core are scored urban: 1.0 or 1.1, respectively. Highly rural areas, with less than 10% of workers traveling to urbanized areas, are scored 10.0. Rural areas are scored between 1.2 and 10.0 [31, 32].
Rural Veterans with records indicating that the VHA had completed payment to a CC provider for mental health services within the study period of October 2022−September 2024 were drawn for recruitment. The function sample_n() from the dplyr package in the statistical software R was used to randomly select 1200 Veterans from all the Veterans who met our criteria at two VHA Medical Centers in the southcentral region of the United States [33].
Out of the list of 1200, 130 opt‐out letters with study details were sent to Veterans informing them about the study and providing an opportunity to call the study team to indicate whether they would like to participate. Twenty Veterans who were mailed a letter toward the end of the recruitment phase were not contacted further, because the study met its recruitment goal and thematic saturation after letters were sent (see details on saturation in the Interview section). Five Veterans initiated calls to the research coordinator to express interest and opt into the study. One hundred and five Veterans were called by the research coordinator for further recruitment. Forty‐four were either lost to follow‐up or did not respond. Thirty Veterans declined participation. Six were ineligible: either deceased or with reported cognitive difficulties. Thirty Veterans agreed to participate. For those willing to participate, the project coordinator reviewed study details over the phone. Verbal consent was obtained prior to interviews.
We mailed letters and used telephone‐based contact methods to increase remote outreach to Veterans and decrease participant burden that is normally associated with completion and return of written informed consent forms. Obtaining verbal consent reduced the number of contacts required to schedule interviews and reduced the wait time to participate in interviews after consent. The Institutional Review Board at the Baylor College of Medicine, a private medical institution and affiliate partner with the Michael E. Debakey VA Medical Center, approved this research.
2.2. Interviews
Semi‐structured interviews were informed by the Perceived Access Inventory, an index measuring Veterans’ perceptions of access to care, including items pertaining to logistics, culture, digital, systems of care, and experience of care [34]. Senior author (K.M.B.) drafted initial questions, which were then further reviewed and modified by other co‐authors (see Supplementary Appendix for full interview guide). Our study design focused on understanding Veterans’ decision‐making regarding why they chose CC, probing on any guidance or discussions they may have had with VHA staff or personnel. The interview also asked about Veterans’ experience in receiving CC and to compare their experiences in VHA and CC. Finally, we asked Veterans for their thoughts on telehealth, mental health and wellness apps, and support from nonlicensed professionals supporting mental health. While including results from these queries is beyond the scope of this manuscript, future manuscripts on these topics are in progress at the time of writing. Co‐authors P.V.C. and A.H.S. conducted one‐on‐one interviews from February 2025 through September 2025 with consenting Veterans using a secured teleconferencing system in private offices at their workplace. On average, interviews lasted 32 min. Veterans were compensated $50 for their time and participation in the study.
Based on prevailing literature on saturation, the initial study plans set the goal for interview sample size at 30 [35]. After completing 30 interviews with Veterans, the primary interviewer, analyst, and first‐author (P.V.C.) determined that this sample size did indeed allow for saturation on themes. This determination was enabled through extensive experience in qualitative research and writing, as well as being embedded in the interview process. In addition to having information to produce a preliminary list of themes, this sample size provided sufficient information to organize Veterans’ varying experiences within different themes and show how different experiences related to each other.
A local transcription company was used to transcribe audio files. While the transcripts were not reviewed for accuracy prior to analysis, audio files were used to confirm and check text that was unclear or non sequitur. The need to confirm and check text during analysis was minimal.
2.3. Analysis
Thematic analysis informed our analytic approach [36]. To organize interview data and quotes, P.V.C. first coded interviews using atlas.ti software [37]. Coding followed an inductive approach: interview content drove the creation of code names. Broad descriptive names were used to categorize Veteran quotes into codes [38, 39]. After this initial coding was complete, quotes from different code categories were extracted. The code categories used for this paper included “CC Experience,” “CC Challenges,” “CC versus VA,” and “Approval Reapproval Process.” Extracted quotes were compiled into a table in Excel for further subcoding. The table was organized such that each quote had its own row, and columns indicated different subcodes. Quotes were reviewed and further categorized into subcodes. Examples of subcodes include: “CC Experience‐Rural: Few Providers Available”; CC versus VA: “Helpful Provider Rapport; Approval Reapproval Process: Back at the VA.”
The qualitative findings presented in this paper are the result of an iterative coding and review process. We followed thematic approaches, recognizing that the terms codes and themes are sometimes used interchangeably, and sometimes code names map onto subtheme titles [40]. In line with qualitative traditions that acknowledge the analyst as actively engaged in the construction of results [41], the organization and emphasis of topics emerged from both the participating Veterans and what they deemed as most relevant to their CC experience, as well as the primary analyst’s decision‐making during analysis and writing. The research team reviewed and discussed the findings throughout the development of this paper.
2.4. Reflexivity Statement
While a researcher’s positionality can be conceptualized in numerous ways, for this study, the authors consider professional position to be most salient when considering how researcher characteristics may have influenced data collection and analysis. The first author, who conducted most of the interviews and primary analysis for this paper, is a sociologist by training and a VHA employee. Several co‐authors are mental health professionals who, in addition to leading research on Veteran care, provide mental health care for Veterans at VHA medical centers. Additionally, all co‐authors live and work in urban areas.
As VHA employees, it is unlikely that any of the authors have strictly neutral opinions about CC. While recognizing our bias (in this case, for VHA care over CC), we nevertheless believe we have provided a balanced presentation of Veterans’ experiences, showing both positive and negative aspects of CC. The first author’s training in qualitative methods may have influenced the decision to focus more on the care experience, rather than the study’s question around why Veterans used CC. During interviews, Veterans had more to say about their experiences at the point of care, and this information proved more compelling for in‐depth analysis. As residents of urban areas, interviewers may not have been able to meaningfully connect with Veterans on living in a rural area. Nevertheless, Veterans did share some unique aspects of receiving CC in rural regions, which are presented below.
3. Results
We interviewed 30 Veterans living in the rural southcentral region of the United States. Two Veterans lived in a highly rural area. Twenty‐three identified as male, and seven identified as female. Twenty‐four identified as White, four as Black or African American, and two declined to answer their racial demographic (see Table 1).
TABLE 1.
Demographic characteristics of interview informants (n = 30).
Demographic data
n (%)
Rurality
Rural
28 (93.3)
Highly rural
2 (6.7)
Gender
Male
23 (77.7)
Female
7 (23.3)
Race
White
24 (80.0)
Black or African American
3 (10.0)
American Indian or Alaska Native
1 (3.3)
Declined to answer
2 (6.7)
The Veterans we interviewed shared a variety of care experiences with community mental health care, presented below. Table 2 provides a summary of themes and representative quotations.
TABLE 2.
Themes and representative quotes.
Theme
Representative quotes
Getting preferred services through community care:
positive experiences
The first therapist I got who happened to be male was really, really good. He is the individual who started the CBT training with me. He was very attentive in terms of keeping up with, you know, they have the, they have the little questions, barometer that’s supposed to figure out how depressed you are or where your PTSD, figuring out my levels. (Study ID 29, Rural Male, White)
Getting preferred services through community care: direct access to providers
The other good thing with my provider is that if it’s in between our sessions, and something really goes awry on my end, I know I can text her, and you know, if she’s available that moment or shortly there around. She has called me, and we have talked through whatever was going on at that moment to be able to get re‐grounded and get the situation figured out and resolved. (Study ID 98, Highly Rural Male, White)
Community care falling short:
negative experiences
So it’s just really talking. You know, they don’t ever just talk to you like a normal person. It’s just when it comes to, and this is just my experience, well, and I’ve talked to other guys, too. It’s just they don’t talk to us like we’re just normal. They look at us like we’re, there’s something wrong with us. (Study ID 11, Rural Male, White)
Community care falling short:
lacking military expertise
So in the military, they know the experiences, so they can go deep when they are with you and you know they understand it. With the civilian one, it’s all speculation because most of them haven’t done it. But if they haven’t done it, it’s speculation.
Uniquely rural challenges:
limited provider availability
[Rural City] is a little small town anyhow. I don’t know if there are going to be many practices in town other than her. (Study ID 18, Rural Male, White)
Uniquely rural challenges:
distance to providers
It’s like a 45‐minute drive [to community care provider]… Because of distance, we just talk on the phone… I would have to make a special trip just to go out there. And that’s, it’s a bit of a distance, and frankly, the vehicle I’m driving has seen better days. So it is what it is. I may go out there. In fact, I should. I keep meaning to. (Study ID 42, Highly Rural Male, White)
Uniquely rural challenges:
rurality and culture
He started trying to recruit me to go to church. Which is not at all what I was there for…
I’m not happy with the community care… And I don’t know if this is just because I’m from (State). I’m in (State). I live in the Bible Belt. And that’s what, if that’s what every therapist is going to end up doing to me? (Study ID 60, Rural Male, White)
Community care and continuity gaps
I really enjoyed my time with my therapist. I did run into an issue when it came to… I guess I had so many sessions, and I was… that number came up, and she had put in paperwork to try and extend. And I talked to my psychiatrist at the same time, but it got denied. So now I’m having to start the process over again. (Study ID 10, Rural Female, White)
3.1. Theme 1: Getting Preferred Services Through CC
3.1.1. Subtheme 1A: Positive Experiences
Most Veterans spoke well of mental health care in the community. One shared how their community provider was “very personal… She listens to what I’ve got to say, and she asks the right questions, I guess, to get me talking” (Study ID 43, Rural, Female, White). Another Veteran similarly described how their community provider,
…Let me really vent and say everything that I needed to say. She was not asking the same questions or looking at the paper the whole time or the computer while they talk to you the whole time… I had more eye contact [and] acknowledgement that I’m there with her than at the VA. So I felt like that I was actually talking to a person, and she actually understood where I was coming from and everything. Not just there to file a piece of paper. (Study ID 24: Rural, Female, Black/African American)
The Veteran explicitly compares their experience to the VHA, sharing how they felt a deeper sense of “acknowledgment” and understanding from the community provider. In another interview, a Veteran shared their perception that the VHA was more likely to offer medication management, describing how, in contrast, Veterans using CC,
…Are going to actually get the help and resources that they need, and they have a higher success rate… The community is more likely to give them tools than to just throw pills at them… They teach you breathing techniques. They talk about what’s going on and how to work through a flashback, how to deal with situations that cause you anxiety. (Study ID 70, Rural, Female, Declined Race Information)
For another Veteran, the inability to receive medication management through the VHA was deeply frustrating:
They [the VHA] won’t prescribe. I went to a regular world doctor, [CC Facility], and they provided me all the medications that I needed. (Study ID 25, Rural, Male, White)
In contrast to the prior example, this Veteran viewed the VHA as unwilling to provide medication management. While these two Veterans appear to have conflicting perspectives on what treatments the VHA does or does not provide, both speak to receiving the services they needed through CC.
3.1.2. Subtheme 1B: CC’s Unique Advantage: Direct Access to Providers
The ability to reach their mental health provider in emergency situations stood out as a unique advantage of CC. Several Veterans shared how they were able to contact their community provider directly if needed:
If I feel really bad, I can even just send him a text message or something and just be like, “Hey, I’m not feeling good. Can we talk or something”…Even sometimes when they’re in an appointment, they will take emergency calls (Study ID 22, Rural, Male, White)
Another Veteran mentioned the ability to contact their community provider outside regular business hours:
She’s been able to help me after hours on the weekends… There were times where I needed somebody besides my family beside me to, to help me get through a situation… Whether it’s a five‐minute conversation or an hour‐long conversation, we’ve been able to get, get things figured out. (Study ID 98, Highly Rural, Male, White)
While our findings do not show that after‐hours availability was universally available from all community providers, one Veteran contrasted the ease in reaching CC providers with the difficulty in reaching VHA providers:
I just have that confidence that she [CC Counselor] cares and she is available. The VA, I know they care, I know that they are available, but honestly, how would I get a hold of anybody at the VA? Dr. [VA Physician], I don’t know their number. I mean, I have a hard enough time getting hold of anybody at the VA. (Study ID 5, Rural, Male, Declined Race Information)
Easy access to the CC provider, via their direct contact information, increased the Veteran’s confidence in the community provider and was a meaningful indicator of care quality for him.
3.2. Theme 2: When CC Falls Short
3.2.1. Subtheme 2A: Negative Experiences With CC
Not all Veterans reported positive experiences with CC providers. Some described mixed experiences, such as the Veteran who said:
Hit or miss. Initially I got lucky. I found a great counselor… [At] The new place I moved to… the first counselor I spoke with was just missing appointments. Not very professional, and so I got rid of her. (Study ID 42, Highly Rural, Male, White)
Several other Veterans described disappointing or unhelpful experiences:
There felt like there was a complacency… And so the complacency of not keeping up with me, things felt like they were more of a casual conversation by the end of it as opposed to an actual therapy session…. I do think that the VA has a much more noticeable professional setting… In the community care process, there’s a lot of things where the rapport building feels like they’re trying to be your friend sometimes. And that’s a little off‐putting… I just felt like that wasn’t the purpose of me being there. (Study ID 29, Rural, Male, White)
Another Veteran recalled how their provider “liked to talk about herself; and so she spent more time talking about herself than basically she did listening to me, which I found very disappointing” (Study ID 84, Rural, Male, White). And yet another detailed how, in his experience with CC,
They never set plans and goals for the future. It was always just an, “Oh well, it seems like we need to look into this for this behavior. You might wanna learn how to do this. Try talking in this way. Try saying ‘I feel’ instead of ‘You’ to people around you.” Things like that. It was never a set goal kind of thing. (StudyID 99, Rural, Male, White)
Other Veterans also found their community provider’s responses to their mental health issue unhelpful. One Veteran recounted how their community provider intervened:
He started trying to recruit me to go to church. Which is not at all what I was there for. It was totally inappropriate…From our, like our third time we saw each other, he started bringing up religion and church. And I told him, ‘That’s not why I’m here. I don’t need help with that… My problems are physical and mental, not spiritual. And, and these are the things I have problems with. And I know that they can be fixed. And that’s why I’m here… He kept telling me I just need to go to church. (Study ID 60, Rural, Male, White)
A common thread among these stories was a shared experience of a community provider’s unprofessionalism. In this case, the Veteran shared that he felt the community provider not only acted inappropriately, but also that “It made my shit worse…it did not help me in any way whatsoever” (Study ID 60, same as above), underlining how the experience negatively impacted his mental health.
3.2.2. Subtheme 2B: CC’s Unique Disadvantage: Lacking Military Expertise
Several Veterans also discussed, without prompting, how CC providers did not have military experience. For some Veterans, the lack of military expertise negatively impacted their care:
Like if I go to a public person, I have to go through a lot of history that I don’t really want to go through over and over. Where at the VA, I already have most of my stuff… It’s just easier with the VA to talk to those people because they… know military situations and stuff, and they’re just more understanding, I think. (Study ID 106, Rural, Female, White)
Here, the Veteran indicates that for her, the feeling of being known and understood is missing in CC. Another Veteran explained that:
They [the VHA] seem to be obviously well versed in… military issues. You don’t have to clarify a lot of things in terms of… what happens in war. And because it’s [the VHA’s] a much more professional setting, and they do have much more experience with Veterans, it feels easier to communicate with them (Study ID 29, Rural, Male, White)
While the Veteran is describing his experience getting VHA care, he is also speaking to a contrasting experience in CC: needing to clarify war experiences and greater difficulty communicating with community providers.
Not all Veterans viewed the lack of military expertise as a fatal flaw for CC. As one Veteran stated:
Civilian care wasn’t bad. They do their best and they do a good job. It’s like talking military stuff with your non‐military friends. They are cool, they are interested and
they kind of get it, but they don’t fully grasp what you’re saying or what you’re doing. But it’s not rude. They do their best and they are good at what they do. (Study ID 3, Rural, Male, White)
The Veteran still appreciates CC providers and is satisfied with them, regardless of their lack of military expertise.
3.3. Theme 3: Unique Challenges for Rural Veterans Persist
Veterans we spoke to also discussed unique barriers to receiving mental health care for rural residents.
3.3.1. Subtheme 3A: Limited Provider Availability
Veterans reported a shortage of mental health providers in rural regions. One mentioned how “Providers get thinner and thinner the further away that you get from the metropolitan center” (Study ID 25, Rural, Male, White). Another shared “I understand that there just aren’t a lot of providers out here where I live and not, on top of that, ones that work with the VHA and or have military experience, you know, working with military clients” (Study ID 10, Rural, Female, White). One Veteran who had lived in both a large city and then moved to a rural area compared the differences in provider availability:
Like out in (Urban City) it was easy to find a therapist that’ll fit…because there’s 8000 of them in the system already just waiting for us to show up. And I’m out here in (Rural State). I’m very limited on what’s available out here. It’s very, very limited. (Study ID 60, Rural, Male, White)
The Veteran highlights how provider scarcity intersects with mental health care, and how it impacts their ability to find care that meets their needs and preferences.
3.3.2. Subtheme 3B: Distance
Veterans also shared having to drive long distances to reach their providers. One Veteran who needed services from a neurologist commented:
Like the VA? The neurologist is gone. So we have to send you somewhere else. And then they gotta put you to the furthest place where you’re from, like an hour‐and‐a‐half to two hours to go talk to this doctor. (Study ID 11, Rural, Male, White)
The mental health provider shortage at the VHA, combined with long distances to community providers, was especially frustrating for this Veteran. Another Veteran who had hoped to see a provider in‐person and had opted to use CC specifically so they could do so, recounts how “When I looked up the distance from my house to her [CC provider] location, it was just too difficult for me to make it work on a weekly basis” (Study ID 10, Rural, Female, White). Whether receiving care through the VHA or in the community, this Veteran was also not able to receive preferred care due to long distances to any mental health providers.
3.3.3. Subtheme 3C: Rurality and Culture
A few Veterans pointed to cultural factors as negatively impacting how they regarded their community mental health provider. One participant mused:
Maybe it’s just the area that people are a lot different here than where I’m used to… People in this area look at things a lot differently than I do. So it’s just … difference of community …It’s like they sometimes look down on you if you don’t live like they live… Or you don’t act like they think you should act. (Study ID 106, Rural, Female, White)
While this Veteran does not necessarily feel the community mental health provider looked down on her, her overall assessment of the rural community negatively impacted her ability to connect with a local provider. Another Veteran shared her frustration with a CC provider:
It seems like in (County name) where I live, the health care professionals don’t know how to like separate HIPAA from their personal life… The VA people are like just there to do their jobs with no extra emotional attachment for stuff that doesn’t have anything to do with me… In this county and like the city I live in and stuff, they talk about your stuff. People knew what medications I was taking and stuff like that. (Study ID 94, Rural Female, Black/African American)
Here, the Veteran posits that her local providers are not able to maintain patient privacy and suspects small‐town talk. She pointed to this as the underlying reason for her break with CC. While this may also be interpreted as an example of unprofessionalism, the Veteran attaches this form of unprofessionalism to her rural location.
3.4. Theme 4: CC and Continuity Gaps
Several of the Veterans we spoke to were experiencing unwanted interruptions in mental health care. This was often due to guidelines that required Veterans to seek reapproval to continue seeing community providers. One Veteran shared:
When I called about getting my mental health re‐upped, they [the VHA] told me, “Well, it’s been denied. You can redo it again, but most likely, you’ll be denied again. So we’d like you to come in and try with our [VHA] therapists.” And I explained to them… it’s kind of inconvenient because I just got comfortable with this therapist, and I felt more confident because… I feel like I’ve been making a lot of progress. (Study ID 24, Rural, Female, Black/African American)
Several other Veterans voiced similar sentiments of wanting to stay with their CC provider because “It took me a long time to build up a rapport like that with somebody” (Study ID 5, Rural, Male, Declined Race Information) and “because there’s still so much to do. We were just making progress and really getting into things” (Study ID 6, Rural, Male, White). Another Veteran recounted difficulty in getting any information from the VHA:
Once those [community care] sessions ended… I was going to ask for extended care and therapy. For whatever odd reason, that appointment [with a VHA provider to request an extension] was cancelled. I called in to see if I could schedule an appointment. I sent a note through the VA health care messaging system saying I needed an appointment… I didn’t hear back from any source… I just felt slightly discouraged … I just simply felt ignored. (Study ID 2, Rural, Male, Black/African American)
For this Veteran, reapproval guidelines intersected with gaps in VHA communication systems to result in their falling out of care completely.
4. Discussion
This study contributes to our understanding of Veterans’ experiences with receiving mental health care through CC. Psychotherapy entails repeated sessions, typically with the same provider, and leans heavily on therapeutic alliance for positive outcomes [42, 43]. However, in one commentary piece, a prominent VHA stakeholder surmised that, in general, CC may be best suited for “Highly technical, low volume services… one time procedures…” [44]. If true, mental health services may be the least suitable for CC.
However, the Veterans we interviewed detailed a range of experiences, some good, some bad. Previous studies have shown that when comparing patients who care receive through VHA versus CC facilities, patients report similar outcomes, and there are no clinically meaningful differences in terms of patient improvement for PTSD or depression. [24]. What our findings show is not necessarily that Veterans’ experiences in CC are similar to those in the VHA, but that Veterans have diverse experiences when receiving mental health care through CC. Furthermore, whether a Veteran is satisfied with their care, or perceives their care as high quality, appears highly contingent on their own preferences [45]. For some Veterans, having a provider who could listen and allow them to “vent” was important. Others preferred more structured and skill‐based sessions. Some Veterans wanted to be able to directly contact their provider during emergent situations, something which may only be possible through a community provider. As seen in other studies, having a provider who would be able to understand their military background was critical for many Veterans, which may represent a unique shortcoming for most CC providers [46].
Our findings also highlight the unique barriers that rural Veterans face when seeking care, including limited provider availability and distance [47]. A few Veterans also pointed to small‐town rural culture as hampering the receipt of professional care. For them, sharing rural embeddedness with their providers did not support better mental health care. This showcases locality as an important dimension of culture and cultural competency [48, 49]. Along with studies that advocate cultural competency training that is specific to localities of practice, training for mental health providers on navigating the complexities of treating rural patients in a close‐knit community could be helpful [50]. Additionally, Veterans in our study reiterated challenges related to coordination, continuity, and authorization processes that other studies have highlighted [16, 17, 51]. These problems may have a deeper impact on Veterans seeking mental health care. Limited provider availability in rural areas, heightened need for effective therapist−patient alliance in mental health, and mental health treatment protocols that require continuity of care for optimal outcomes can all intersect and lead to unsatisfactory or incomplete mental health care for rural Veterans using CC.
4.1. Limitations
Our study has several limitations. First, we only interviewed Veterans in the U.S. southcentral region. Experiences of Veterans in other rural regions may have more insights to offer and different ways their rural context impacts their experience with mental health care. Second, we did not design the study as a comparative analysis between VHA and CC. At the same time, when relevant, we do occasionally present Veterans’ experiences with VHA, because comparing CC to VHA was the lens by which many understood their CC experiences. Third, because our initial goal was to understand how and why Veterans opted to use CC, interviews did not probe deeply into the specific treatments Veterans may have received in care. However, the open‐ended nature of our interviews allowed Veterans to speak on experiences at the point of encounter. It became clear that the real topic of interest was not why they received CC but what happened once they were there.
4.2. Implications
We highlight two areas of concern from our findings that have direct bearing on mental health care quality for rural Veterans. First, several Veterans detailed experiences with providers who did not meet professional standards for patient care (not maintaining patient confidentiality, provider centering their own experiences during care, and proselytizing). Furthermore, we show how in rural communities, where residents often share close ties and overlapping relationships, the traditional boundaries between patients and providers may be more easily crossed. Given the potential for harm this can have on Veterans, conducting vetting processes with community providers would benefit rural Veterans. Additionally, we recommend that VHA medical centers proactively seek feedback from Veterans who are seeing a community provider for mental health care.
Second, for Veterans who have successfully established a therapeutic alliance with a community provider, ending sessions with their provider due to denial of reauthorization can be especially difficult. It constitutes a break in care and, according to many with whom we spoke, a break in their progress to better mental health. While the reasons for the denial of reauthorization vary, Veterans in this study expressed frustration and sometimes confusion about the process. In May 2025, VHA policies removed the need for secondary approval for CC, which may mitigate some continuity issues related to reauthorization [52]. VHA medical center staff could also address this issue by setting Veterans’ expectations in advance on the duration of care through CC and reauthorization criteria. Additionally, improving VHA communication systems to support Veterans’ return to and use of other VHA mental health services as appropriate may mitigate this issue.
4.3. Future Directions
Additional studies are needed to better understand the care experience at VA facilities compared to community facilities. While many Veterans we interviewed discussed mental health care they received at the VA, often comparing their experiences in VA with CC, the study was not designed to explicitly engage in this comparison, and this manuscript focuses on their CC experiences. Other comparative studies show that Veterans with behavioral health conditions rate their experiences using CC lower than Veterans without mental health care needs [53]. A future study could sample Veterans who have only used CC versus those who have only used VA for mental health care. A head‐to‐head comparison on services received, quality of care, and mental health outcomes in different care settings would be informative to policy makers and VA stakeholders working to optimize mental health care for Veterans.
4.4. Conclusions
CC has increased access to mental health care for rural Veterans, but rural Veterans interviewed in this study described variable experiences in care quality, continuing barriers to care, and concerning stories related to around continuity of care. While some progress in this area has been made, these stories may indicate that more can be done to improve mental health care for rural Veterans.
Funding
This work was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PROJFY 010902.
Disclosures
The authors have no relevant financial or nonfinancial interests to disclose.
Disclaimer
The contents do not represent the views of the Department of Veterans Affairs or the United States government.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Supporting File 1: jrh70151‐sup‐0001‐SuppMat.docx
Acknowledgments
We thank Armandina Garza and Hannah Simpson for their contributions to patient recruitment for this study.
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Supplementary Materials
Supporting File 1: jrh70151‐sup‐0001‐SuppMat.docx
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