QUERI – Quality Enhancement Research Initiative

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Social Work Effectiveness for Rural Veterans Evaluation (SERVE)

Providence, RI


Veterans with complex health conditions navigate an often-bewildering array of providers and supportive services. Those Veterans who live in rural areas often face additional challenges in getting the right care at the right time because providers may be unavailable in their vicinity or geographically dispersed. Social-work case management (SWCM) addresses the need for better access, coordination, and community support. Beginning in FY2016, the National Social Work Programs Office implemented a program called the “Rural Patient Aligned Care Team Social Work Staffing (Rural PACT SW) Initiative.” The program placed additional social workers in rural, VA-based, primary-care settings (PACTs).  

Social work case management addresses Veterans’ psychosocial needs and increases their access to needed care. For instance, a social worker might arrange transportation to appointments or in-home support for a Veteran with functional disability. Timely care and support ultimately reduce the need for unplanned hospital stays, emergency department use, and nursing home care, which are stressful for the Veteran and costly to the system. Social workers integrated within PACTs may be especially suited to identify risk factors for depression among older Veterans. Social-work case-managers spend more time meeting with caregivers and assessing issues that can have a profound effect on mental health, e.g., social support, social isolation, housing needs, and economic distress, that are often not the focus of a primary-care visit. Prior to the SERVE QUERI, however, no one has examined the impact of rural PACT social-work case-management on Veterans’ outcomes and access to care.

Project Aims

The SERVE QUERI project will evaluate the implementation and impact of the Rural PACT Social Work Staffing Initiative. Specific project aims include:

Assess implementation

  • Identify high- and low-performing sites using two measures of implementation: 1) social work services to high-risk Veterans, and 2) use of the case-management assessment tools.
  • Identify successful practices and barriers to full implementation of the SWCM model through semi-structured interviews with stakeholders.

Evaluate impact

  • Compare change in referral and healthcare use patterns before and after placement of a new social worker.
  • Evaluate the moderating effect of the rural context and use of case-management assessments on program outcomes.

Transform knowledge into action

  • Design a resource bundle to improve implementation of the social-work case-management model.
  • Provide feedback-and-audit reports to social-work teams about program implementation and impact.
  • Facilitate peer-to-peer coaching.
  • Evaluate the feasibility and impact of the resources bundle.

The SERVE QUERI addresses some of VA’s highest priorities: Connecting Veterans to their choice of providers and community resources, improving timeliness of care by addressing barriers to access in rural areas, and connecting high-risk Veterans with needed supportive and mental-health resources.


Interventions may need to be tailored to address specific local barriers. Thus, this QUERI project’s aims will be guided by the knowledge-to-action framework for program implementation (see figure below).

QUERI Evaluation in the Knowledge-to-Action Framework

Anticipated Impacts

Thus far, this QUERI project incorporates 12 VISNS, including VISNs 1,2,4,5,10,12,15,17,19,20,21, and 22, and incorporating 106 rural PACT sites. Moreover, 71 Rural PACT social workers (funded through this project) have helped treat 15,733 Veterans.

The product of the SERVE QUERI evaluation will be an in-depth appraisal of the Rural PACT SW Initiative. This evaluation will influence VA national practice by improving implementation of social-work case management; targeting high-risk Veterans through case finding with the Care Assessment Needs (CAN) score and evaluation using case-management tools; and by providing evidence of the impact of social work case-management on Veterans’ care.

Operations Partner: VA National Social Work Programs Office

Principal Investigator: Portia Y. Cornell, PhD; contact at Portia.Cornell@va.gov .