BACKGROUND: Veteran enrollees of the Veterans Health Administration (VA) have increasing options for where and how to access health care, including within VA in person or virtually and through VA-purchased community care. To promote Veterans' informed choice and streamline access to appointments, VA initiated referral coordination, which entails clinical review and conversations with Veterans before scheduling all specialty care referrals.

OBJECTIVE: Identify how VA facilities implemented referral coordination and local contextual factors influencing the implementation.

RESEARCH DESIGN: Qualitative formative evaluation, using process maps to compare implementation approaches by hospital system and thematic analysis to identify contextual influences on implementation.

SUBJECTS: Between March and August 2022, we interviewed VA referral coordinators (n=27) for acupuncture, cardiology, endocrinology, and hematology/oncology at 8 VA hospital systems in a geographic region with urban and rural settings.

RESULTS: We identified 2 implementation approaches for referral coordination. Three facilities added clinical review to employees' existing responsibilities ("expanders"), and 5 created new roles dedicated to referral coordination ("creators"). "Expander" facilities relied minimally on VA-purchased care and received little implementation support from local leadership. "Creator" facilities relied heavily on VA-purchased care and local leadership was actively involved in implementation. The effort employees dedicated to referral coordination tasks varied according to other demands on their time.

CONCLUSIONS: This work provides an empirically grounded way to identify different implementation approaches (ie, expanders and creators), which we conceptualize as a framework for interpreting the outcomes of referral coordination on waiting times, utilization of different types of care, and Veterans' experiences seeking care.