Veterans Affairs Clinical Resource Hubs and Rates of Mental Health Community Care Referrals.

Importance: In an effort to increase access to care, the US Department of Veterans Affairs (VA) has created 2 additional pathways for veterans to receive mental health (MH) services: regional VA Clinical Resource Hubs (CRHs) and VA-purchased community care (CC). Previous studies have found that veterans rate their satisfaction with VA MH care, including via CRHs, higher than CC. It is unclear whether increased CRH use decreases referrals to CC. Objective: To determine whether clinics with higher CRH utilization have fewer CC referrals or, alternatively, whether clinics with local care shortages rely on both CRH and CC at similar levels to ensure adequate access to MH care. Design, Setting, and Participants: This longitudinal cohort study included all veterans with at least 1 outpatient MH encounter between 2018 and 2019 in 1149 MH clinics within the VA. The study evaluated changes in CC referral rates at clinics with and without CRH visits between baseline and post-CRH implementation (October 1, 2017, through September 30, 2023). In addition, CC referral rates at clinics with higher use of CRH were compared with clinics with lower CRH utilization. Data were analyzed from August 20, 2024, to July 25, 2025. Exposures: Clinics were classified based on whether they had any CRH utilization, as well as whether their per-patient rate of CRH visits fell in the top 25% (high penetration) or bottom 25% (low penetration). Main Outcomes and Measures: The main outcome was the number of CC referrals per 1000 patients. Difference-in-differences (DID) analyses were used. Results: The sample included 1 120 250 patients (mean [SD] age, 60.04 [15.38] years; 15.99% female). Clinics with any CRH utilization showed a slight but statistically significant increase in CC referrals in the post-CRH implementation period compared with clinics with no CRH utilization (DID, 0.525; 95% CI, 0.181-0.868; P = .003). However, clinics with high penetration of CRH had fewer CC referrals per month compared with low-penetration clinics at the end of the CRH implementation period (DID, -20.00 referrals; 95% CI, -21.90 to -18.20; P < .001). Conclusions and Relevance: In this cohort study of VA MH clinics, successful CRH implementation was associated with fewer CC referrals, suggesting that clinics with higher CRH utilization were less reliant on VA-purchased CC. Results underscore the importance of developing strong CRH infrastructures to ensure veteran access to high-quality MH care.