Innovative SCOUTS program brings care to Veterans’ homes in New Mexico

In New Mexico, one third of the population lives in a rural area. Older New Mexican Veterans often need to travel long distances to receive needed services. However, innovations at VA New Mexico Health Care System have changed how hundreds of Veterans receive their care. Supporting Community Outpatient, Urgent care & Telehealth Services (SCOUTS) is a program that sends Intermediate Care Technicians (ICTs) to the homes of older or medically complex Veterans who have recently left the emergency department (ED) to provide follow-up care.

SCOUTS addresses health concerns before they can worsen while a Veteran waits for their next scheduled appointment at a VA Medical Center. This cuts down on wait times by providing faster care.

ICTs typically conduct a home visit between 48 and 72 hours after a Veteran has been discharged from the ED. ICTs check for situations where Veterans might require more assistance. They check for situations like a lack of internet access, geriatric syndromes such as dementia or malnutrition, and if the Veteran is having difficulty moving throughout their home. ICTs then facilitate a telehealth visit with the Veteran and a VA provider to check for risks that might lead to a repeat visit to the ED.

"Medicine is coming full circle now," said Albuquerque VA ICT Michael Anguti. "Home visits through ICTs are the future of care. Our ICTs coordinate with a provider, PT [physical therapy], OT [occupational therapy], to prevent falls, help Veterans move around the house, identify problems and address them. We keep Veterans on the radar and bring them in when need be."

From their first SCOUTS consultation in August 2023 to January 2025, the Albuquerque SCOUTS team has received more than 1,200 consultations. Since its first home visit in February 2024, they have completed over 230 home visits.

John Romero, an ICT who drives up to 12 hours a week for Veteran home visits, emphasized the preventative care benefits SCOUTS offers. "We are the ER plus," he said. "We go to the houses to provide wound care, draw blood, screen them with some questions to see if they need any additional services to make them less likely to return to ER."

The SCOUTS team also works to prevent first-time ED visits by providing proactive support. Gregory Sanford, another ICT on the Albuquerque team, explained how their team will call Veterans over the phone who are 75 years or older and have not been to a VA ED, to see if they have any unmet needs. By conducting these screenings, they can help Veterans stay out of the ED.

"Veterans feel they're worth somebody's time and are cared for in between appointments. There's mutual respect and appreciation," said Romero.

SCOUTS now operates out of 10 VA sites nationwide, and it will continue to diffuse across the country to other sites. To learn more about SCOUTS, visit its webpage on Diffusion Marketplace.