Community Care Consultations for Veterans with Diabetic Foot Ulcers | AJMC

The American Journal of Managed Care

- September 2026

- Volume 32

- Issue 9

Community Care Consultations for Veterans with Diabetic Foot Ulcers

These findings demonstrate substantial but variable use of community care consultations for specialty care among patients with diabetic foot ulcers within the Veterans Health Administration.

ABSTRACT

Objectives: To quantify community care consultations for patients with newly diagnosed diabetic foot ulcers (DFUs), identify associated patient- and facility-level characteristics, and measure time to specialty care within and outside the Veterans Health Administration (VHA).

Study Design: A retrospective cohort study.

Methods: This study included patients 65 years and older with newly diagnosed DFUs who received specialty care between 2019 and 2023. Data were sourced from the VHA Corporate Data Warehouse and linked Medicare data. Community care consultation was defined as receiving specialized consultations (ie, podiatry, vascular surgery, infectious disease, endocrinology) at a community health care system within 1 year of DFU diagnosis. Patient demographics, comorbidities, and facility characteristics were analyzed with multivariable mixed-effects logistic regression models to assess factors associated with community care consultation while controlling for facility-level clustering.

Results: A total of 60,121 patients with a new diagnosis of DFU were included. Of these, 29.2% had a community care consultation. Those receiving community care were more often older, White, living in a rural area, and cared for in lower-complexity facilities. Patients were more frequently referred to community care for vascular surgery, infectious disease, and endocrinology consultations than for podiatry. For all specialties, the time to a new consultation was longer for community care than for a consultation within the VHA.

Conclusions: Community care consultations for patients with DFUs in the VHA system were substantial but varied significantly across facilities. Rural and lower-complexity facilities relied more on community care, particularly for vascular surgery, infectious disease, and endocrinology. Future research should explore the impact of community care on DFU outcomes and strategies to enhance multidisciplinary care coordination.

Am J Manag Care. 2026;32(9):e309-e315.

doi:10.37765/ajmc.2026.90009

Takeaway Points

- This retrospective cohort study of patients with newly diagnosed diabetic foot ulcers within the Veterans Health Administration found substantial but variable use of community care consultations for specialty care (podiatry, vascular surgery, infectious disease, endocrinology).

- Community care consultations were more often used by smaller and rural facilities.

- The time to a new consultation for all specialties was significantly longer for a community care consultation vs a consultation within the Veterans Health Administration.

- Future research is needed to further assess the impact of community care consultation on the outcomes of these patients and to identify strategies for optimizing multidisciplinary diabetic foot ulcer care across various health care settings.

A diabetic foot ulcer (DFU) occurs in up to 34% of patients with diabetes. Approximately 50% to 60% of these ulcers become infected, and within 5 years, up to 30% of affected patients will undergo lower limb amputation (LLA), which is a serious life event.1

We recently reported a 12-fold difference across Veterans Health Administration (VHA) facilities in the proportion of patients with newly diagnosed DFUs between 2016 and 2021 who underwent major LLA within 1 year, even after adjusting for patient-level factors.2 We hypothesized that facility-level variation in LLA is mainly driven by interfacility differences in DFU-specific care, particularly in the coordination of care across disciplines. A multidisciplinary team approach is considered standard of care for patients with a DFU. Within the VHA system, the Prevention of Amputation in Veterans Everywhere program has provided a model of DFU care, including multidisciplinary teams, to all VHA facilities since 1983.3 However, some VHA facilities may be more successful than others at implementing these teams. For example, small and rural facilities may not be able to assemble a multidisciplinary team due to the lack of specialists, resulting in more specialty consultations at community hospitals.

The increasing use of community outpatient care among VHA enrollees through the Veterans Choice Program4 and Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 20185 may further complicate the multidisciplinary management of DFUs.6-8 Although community care could improve veterans’ access to necessary care, a major concern is that veterans who use both the VHA and community health care systems may experience poor care coordination between their providers.

Disconnected care, in turn, can lead to worse outcomes and care experiences.9-11 The challenges for coordinated care may be much greater in patients with complicated chronic diseases like DFU because care coordination is not only needed between VHA primary care physicians and community-based specialists but also between VHA specialists (eg, podiatrists) and community-based specialists (eg, infectious disease [ID] specialists).

To date, no study has described how often VHA patients with DFUs were referred to a community care health care system to receive specialty care. To begin understanding these needs and improve care coordination across systems, we aimed to (1) quantify community care consultations for veterans with DFUs, (2) identify patient- and facility-level characteristics associated with community care consultation, and (3) measure time to specialty care within and outside the VHA. Our data may be useful when designing future interventions and policies to improve care coordination and resource allocation for these patients and others with complex chronic diseases.

METHODS

Study Cohort

We conducted a retrospective cohort study of patients 65 years and older who were newly diagnosed with DFUs in the VHA and received specialty care (ie, podiatry, vascular surgery, ID, or endocrinology) between 2019 and 2023 using the VHA Corporate Data Warehouse, including inpatient and outpatient encounter files, and linked Medicare data. The cohort was limited to those 65 years and older because most of these individuals are enrolled in Medicare, thereby providing data on care not paid for by the VHA. We also limited the cohort to veterans who received any VHA care within the 2 years prior to their DFU diagnosis to ensure adequate capture of previous diagnoses and medical services. The diagnosis of DFU was identified using validated International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes for DFU (eAppendix [available at ajmc.com]). We excluded veterans who had ICD-10 codes for DFU in 2018 to ensure that only new DFU diagnoses were included in the study.

Variables

Additional patient-level variables collected included patient demographics (age, sex, race, and ethnicity), Social Vulnerability Index (SVI), rurality (urban or rural/highly rural), drive time to the nearest VHA tertiary hospital, comorbidities, and complicated DFU at the time of diagnosis. The SVI was obtained from the CDC home page and was used as an area-level measure of socioeconomic disadvantage and linked to patient records by the census tract of residence.12 Rurality was determined by the geocoded location of residence.13 Patients were considered as having a complicated DFU if they had an ICD-10 code for osteomyelitis or gangrene within 2 weeks before or 1 week after the DFU diagnosis (eAppendix); otherwise, they were considered as having an uncomplicated DFU. In addition to patient-level variables, we collected facility complexity—a rating based on health services provided, patient population served, and the teach