Differential effects of a social work staffing intervention on social work access among rural and highly rural Veterans: A cohort study

Objective: To evaluate the impact on rural Veterans' access to social work services of a Department of Veterans Affairs (VA) national program to increase social work staffing, by Veterans' rurality, race, and complex care needs.

Data sources and study setting: Data obtained from VA Corporate Data Warehouse, including sites that participated in the social work program between October 1, 2016 and September 30, 2021.

Study design: The study outcome was monthly number of Veterans per 1000 individuals with 1+ social work encounters. We used difference-in-differences to estimate the program effect on urban, rural, and highly rural Veterans. Among rural and highly rural Veterans, we stratified by race (American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and White) and complex care needs (homelessness, high hospitalization risk, and dementia).

Data collection: We defined a cohort of 740,669 Veterans (32,434,001 monthly observations) who received primary care at a participating site.

Principal findings: Average monthly social work use was 8.7 Veterans per 1000 individuals. The program increased access by 49% (4.3 per 1000; 95% confidence interval, 2.2-6.3). Rural Veterans' social work access increased by 57% (5.0; 3.6-6.3). Among rural/highly rural Veterans, the program increased social work access for those with high hospitalization risk by 63% (24.5; 18.2-30.9), and for Veterans experiencing homelessness, 35% (13.4; 5.2-21.7). By race, the program increased access for Black Veterans by 53% (6.1; 2.1-10.2) and for Asian Veterans by 82% (5.1; 2.2-7.9).

Conclusions: At rural VA primary care sites with social work staffing below recommended levels, Black and Asian Veterans and those experiencing homelessness and high hospitalization risk may have unmet needs warranting social work services.