Introduction

American Indian and Alaska Native (Native) Veterans enrolled in U.S. Department of Veterans Affairs (VA) benefits programs are far less likely than other racial/ethnic groups (22% v. 36%) to access health care [21]. While the difference is likely multifaceted, it is driven in part by an often distant, complex, and culturally unresponsive Veteran Health Administration (VHA) [12, 15]. To address this disparity, in 2020 the VHA’s Office of Rural Health initiated the development of a patient navigation program designed specifically for rural Native Veterans. The goal of patient navigation is to help patients navigate health care systems through assistance and patient education, care coordination, and access to resources. Patient navigation has been shown to increase patient access to health care and health outcomes, which improve a patient’s experience interacting with the health care system [3, 6, 8, 16, 18, 20, 23]. Patient navigation programs culturally tailored to specific populations have been shown to improve health care outcomes and experiences for underserved groups [19]. While VHA has included patient navigation in a number of disease-focused programs [1, 23, 27] and has recently initiated a pilot program to reduce mental health disparities among minoritized Veteran populations [4], no program adequately addresses the unique needs of rural Native Veterans—the most rural of Veteran groups—many of whom live in remote tribal reservations or Alaska Native villages [14].

Patient navigation program models are diverse with respect to scope, disease, population focus, setting, and integration with social determinants of health. Given this diversity no defined “ideal” or standard program exists [9, 10, 22, 25]. Similarly, no pre-determined set of characteristics for a patient navigator exists, despite its centrality to the success of the navigation program model and improved outcomes. The navigator may or may not come from the communities they serve, be a volunteer, or have formal training, but may have job duties that vary considerably from program to program [26]. For example, clinic or hospital-based navigators are typically focused on guiding patients through treatment regimens, while community-based navigators tend to handle social determinants of health issues that affect the patient’s health care.

Establishing the criteria for selecting someone to fill the patient navigator role is best informed by the context of the patient’s treatment and informed by an understanding of relevant social determinants of health [22]. Understanding patient and caregiver perspectives on patient navigation characteristics and tasks is vitally important to the development of a responsive and effective patient navigator program. Few studies on navigator programs have focused specifically on Native populations and none on rural Native Veterans. Rankin et al.’s [22] review of patient navigator programs for tribal citizens found that primary roles for patient navigators generally involved transportation arrangements, locating housing, helping with financial issues, arranging childcare, assisting with provider referrals, and scheduling appointments. Grimes et al. [9] examined patient navigation in tribal clinics where patients used a navigation program for referrals, scheduling, transportation, and other logistical facets of health care. These Native patients appreciated patient navigators’ communication, assistance with making decisions, and help dealing with psychological/emotional problems. Other studies emphasized the importance of cultural competency when assisting Native patients through patient navigation [5, 11]. Navigators were perceived as more respectful of Native cultural values than physicians, nurses, and other health care professionals [24]. This small but growing literature centers the desire for logistic support, emotional and psychological connection, and cultural respect.

VHA presently lacks the experience to guide the development of a Native Veteran patient navigation program model informed by Native Veterans, their families, and community advocates. Our project team prioritized formative work to ensure a program of this nature is culturally appropriate and incorporates the insights and perspectives of tribal partners. Here we discuss the results of interviews with rural Native Veterans and those who care for them, with special attention to their expectations of a patient navigator as well as navigator functions and characteristics best be suited for this role. These insights are critical to creating a program that can increase rural Native Veteran access to VHA services.

Methods

History

The project sought to collaborate with Veterans, their family members, and advocates in developing a patient navigator program for rural Native Veterans. Due to the COVID-19 pandemic, which had devastating and lasting effects in many Tribal communities, the original plan to conduct in-person focus groups with 3–4 tribes across the country was no longer possible [2]. An alternative approach was hence developed to collect perspectives via video and phone interviews with individuals from 10 to 12 tribes and 34 participants were interviewed (Study methods pertinent to this manuscript are provided below; for additional details see Jervis, et al., [13]). The team obtained VA IRB determination that this project did not involve human subjects research. Interviews were conducted from May 2021 through July 2022.

Tribal Partners

Our team consulted with national and regional Native organizations and VA leadership, including VHA’s Office of Rural Health and VA’s Office of Tribal Government Relations, to generate a list of possible collaborating tribal communities reflecting wide geographic and cultural diversity. Eleven tribal communities were invited and agreed to participate in the formative work of developing a rural Native Veteran patient navigation program. At least one interview was conducted with one of the 9 tribes that ultimately participated in the project.

Interview Measures and Protocols

Separate interview guides were developed for Veterans, family members, and Veteran advocates; the format posed questions specific to each type of interviewee as well as similar questions. As potential clients of the navigator program, Veterans were interviewed to articulate their beliefs about how patient navigation should work and who should do the job. Family members of Veterans often play a large role in how the latter access health care, rendering their perspectives crucial to developing a Native Veteran patient navigator program model. Finally, Veteran advocates offered important insights into programming features, logistical assistance, and coordination with local health care systems and resources.

All interviewees were asked a series of demographic questions to determine age and past military service. A short vignette about a patient navigator at work with a Native Veteran was presented to all interviewees since some participants were not familiar with patient navigation, and was followed by a semi-structured set of questions. Follow-up questions asked interviewees about the type of person best be suited for a patient navigator role, past health care experiences within and outside of VHA relevant to understanding this role, challenges that a patient navigator as well as a Veteran may face in utilizing patient navigation, and the use of as well as recommendation for spiritual supports. Family interview questions additionally focused on the challenges of supporting health care for a Veteran family member. Questions specific to Veteran advocates explored existing programs for rural Native Veterans and best practices for rural Native Veteran outreach and engagement. Participants were offered $60 compensation for their time. All participants consented to being recorded; all interviews were conducted via phone by an experienced Native interviewer.

Data Analysis

Data analysis was conducted with the assistance of NVivo qualitative analysis software [17]. The project team collaboratively developed a coding scheme. Coding themes were built around similarity of responses to questions asked in interview guides. For example, interviewees discussed experiences with various medical systems 259 times across all interviews so the code “Medical System Experiences” was used to organize these responses. Within this parent code regarding medical system experiences, there was variety as to where these experiences took place so the sub-codes of “IHA, VA, and Other” were used to deepen the organization of data. This process was used to develop a coding scheme that was used to conduct all interview data analysis. Two team members coded interviews from each category of interviewees to achieve inter-coder reliability of nearly 90%. Upon completion of coding, code frequencies and correlations were analyzed and relationships among coding themes were identified.

Results

Of the 34 completed interviews, 19 were male and 15 were female (Table 1). Veteran interviewees were primarily male; family and advocates were primarily female. The average age for all interviewees was 60 years; average length of military service among those who served was 8 years; many of the Veterans were non-users of VHA. Interviewees came from tribes in the Pacific Northwest, Alaska, the Southwest, Southern Plains, and the Great Lakes regions.

Table 1 Sample Demographics
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Navigator Program Support

All participants considered a potential navigator program to be highly desirable. Many Veterans had not had positive experiences with VHA, referred to simply as VA in some quotes offered throughout this paper. Many of the problems underlying these negative experiences would be ideally addressed by a navigator program, as described by a 51-year-old male Veteran:

“I've been to the VA clinics wherever I've been located. I was in [state 1] and went to [nearby city], which was 45 minutes away. Now I'm in [state 2] and I actually work there, so it's a lot easier to get appointments. But like everything else, your appointments aren’t--you won't get it scheduled for like, maybe, my next one’s in June. Even after I did all the other requirements, blood work, CT scans, all that, the nerve test, I still can't get appointment until June. So that's the frustrating thing, and they're not giving me the medication that really helps. When I was in [state 1], I had a perfect medication, but they're unwilling to do it here. So I'm like starting all over again, which is kind of frustrating.”

Having a patient navigator for rural Native Veterans at VHA facilities is a needed service that would be welcomed to address challenges that Veterans have faced in accessing health care.

Ideal Navigator Characteristics and Activities

Rural Native Veterans interviewees described their expectations for and the importance of the roles, functions, and characteristics of a patient navigator (Table 2).

Table 2 Interviewee expectations for patient navigator, ordered by most frequently mentioned
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The most important characteristics of a navigator, according to participants, included good customer service and personality characteristics important to the job. Cultural competence, specific demographic characteristics, and background qualifications were also seen as important by many of the Native Veteran interviewees.

Ideal Navigator Characteristics and Activities: Customer service

Good customer service was the most frequently discussed feature of a good navigator. Given the problematic experiences dealing with VA that many Native Veteran participants had experienced, many Native Veteran participants were clearly looking for a better customer service experience. The following quote from a 79-year-old male Veteran illustrates the desire for good customer service:

“To me, they need to be knowledgeable or at least be able to admit that they don't have the answers that they need and that they are willing to research it and find out what [the answer] is, be it, whatever question would come up….Of course, [the navigator needs to] be polite and also be respectful to the people they are talking to but be able to stand up to other people….We want them to be a person who can get things done.”

Interviewees expressed the importance of consistency and stability among navigators. Native Veterans wanted connection and rapport with navigators. High turnover could derail the navigator program since it would damage efforts to build connection and rapport between rural Native Veterans and patient navigators. As this female family member described, avoiding high turnover is of utmost importance:

“You start up a new program and you go gung-ho for the first year or so, and people are learning about it, getting to use it, and then, all of a sudden, the person leaves and then you've got a vacant position and you can't get any help. And then you get someone in there just filling in. They don't know anything.”

One way to avoid high turnover in a patient navigator program is to ensure new hires have appropriate expectations of the job along with good training and support for their work. Interviewees also offered their insights into what type of person might be best suited for a patient navigator role.

Ideal Navigator Characteristics and Activities: Personality characteristics

Similar to good customer service, interviewees also wanted a navigator to possess a number of positive interpersonal qualities, including being caring, empathetic, patient, and a good listener. Not surprisingly, Veterans seek to interact with a navigator who is both pleasant and an effective advocate for their needs, as made clear by this 52-year-old male Veteran:

"They've got to be patient, kind of a happy person that's willing to explain, take the time to explain and listen to the patient, show compassion, [have] urgency to try to get their appointment. I would say those are the biggest things that we kind of look for."

Interviewees sought someone whose positivity can make an often otherwise somewhat difficult experience a more pleasant one, hence the desire for a “happy” person. Happiness was emphasized in this 51-year-old female advocate’s statement, along with several other key characteristics:

“Someone that's outgoing, motivated, like happy. There's lots of Veterans that have had lots of trauma, like PTSD issues. It has to be someone that's patient and a good listener.”

The desire among interviewees to interact with a patient navigator who is positive, happy, empathetic, and a good listener underscoring the importance of rapport and a navigator’s ability to engage patients on a personal level.

Ideal Navigator Characteristics and Activities: Cultural competence

Native Veterans indicated that patient navigators need to be culturally competent and/or tribal members themselves. Tribal members were thought to be better able to relate to Native Veterans and, if also a Veteran, they would be even more familiar with the issues this group faces. Thus, interviewees felt the navigator has understand the cultural and geographic context of those with whom they serve and work as well as VHA and IHS, as made clear by this 53-year-old male Veteran:

“I think if you are knowledgeable on [the VA and IHS] systems but also be knowledgeable on Indian country, and be able to converse on two fronts. I mean, Natives have a little bit of a unique sense of humor. You mix that in with a Native Vet, and your Veteran’s humor can come off as jaded, to say the least. It’s not crude. But that person has to be able to speak that jargon. I guess that’s the best way to say it.”

Interviewees did not necessarily expect a patient navigator to be expert with respect to all tribes but wanted the navigator to be generally knowledgeable of Native Veteran tribal life as well as local circumstances, especially in rural areas, and to be sensitive to Native Veteran cultural norms and traditions.

Ideal Navigator Characteristics and Activities: Navigator Demographic Characteristics

As mentioned above, a number of interviewees believed that the navigator should be a tribal member and a Veteran. Interviewees also asserted that the navigator should be familiar with the geographic region(s) of the Veterans they are serving and the challenges faced by people who live in rural areas. A 71-year-old male Veteran illuminates this point:

"I would rather be talking to another [tribal community member from my region] because we have something similar. You know, I talk to somebody in New York and they’d be like, ‘Yeah, right, sure’. But you know, if I'm dealing with somebody who is [from my area], then there's that commonality."

A patient navigator who is aware of the realities of local rural life in the regions wherein Native Veterans are located is highly desired as such knowledge were believed to facilitate in-person visits and lend itself to more informed problem-solving than likely by a non-local patient navigator.

Ideal Navigator Characteristics and Activities: Background Qualifications

Participants clearly preferred that a navigator be a Native Veteran (or spouse of a Veteran). Should that not be possible, the second-best option would be a navigator from the local area. A caring manner and ability to help Veterans navigate the VHA system of care was greatly desired, as described by this 69-year-old male Veteran:

“I would say a Veteran or I would say, believe it or not, the wife of a Veteran. Or someone who has a big enough heart to understand that this Veteran has already paid the price. And their job is to make sure that Veteran gets the best care that he can. Not that [the navigator] just got a job. And the person that you just described helping those Veterans [in a vignette that was part of the interview] would be the type of person you would be looking for. Someone with a big heart and everything else, and realizing that the Veteran has already paid the price. And there’s the reason behind the headache, there’s a reason behind the backache. You can’t put twenty, eighty pounds on your back and clomp through the desert and not hurt yourself.”

If a hiring a Native, Veteran, local resident is not possible, participants stressed the importance of hiring a person who is empathetic, positive, and pleasant.

Perspectives on Navigator Roles or Tasks

Interviewees described many tasks the navigator could assume; navigating various aspects of VA bureaucracy, checking on Veterans’ status, explaining benefits, assisting with appointments, and arranging transportation were most frequently discussed.

Perspectives on Navigator Roles or Tasks: Navigate VA bureaucracy

VHA is a large, complex federal entity and many interviewees talked about the challenges of accessing medical care and how a navigator could help them in this regard. A 51-year-old female advocate spoke directly to this matter:

"...maybe explaining how things work within the VA, if [the Veteran] wanted to access care for any reason. Good contact numbers, providing numbers mostly, because I give out numbers a lot to staff, but I don't know if Veterans know those same numbers. Which would be good to have like a contact list for Veterans, on who to contact within the VA for what reason."

Managing and explaining VHA’s complexity in ways that provide Native Veterans clarity would be a critical task for the patient navigator.

Perspectives on Navigator Roles or Tasks: Veteran Check-ins

Many Veterans expressed a desire for a navigator to check regularly on their welfare and inquire about unmet needs. Interviewees felt that this should be a central part of the navigator’s responsibilities and would demonstrate often requested caring and concern for the Veteran. Toward this end, a 79-year-old male Veteran noted:

“Somebody having to call randomly, you know, and checking in, saying ‘How are you doing? Can we get you anything? Do you need anything?’ I think something like that would really be great. Especially, like I said, people who have...the depression from being in combat and stuff.”

Periodic check-ins with Veterans involved in a patient navigator program would help the navigator better understand what the Veteran needs in their interactions with VHA as well as understand what aspects of VA system the Veteran needs help with, such as understanding benefits.

Perspectives on Navigator Roles or Tasks: Explain benefits

Similar to many medical insurance plans, VA benefits can be complicated and Veterans are often confused about eligibility. Many interviewees felt strongly that the navigator must be well-versed in how VA benefits work and able to clearly explain eligibility and access to, or be prepared to refer them to a local enrollment specialist. This ability to help Veterans understand what they are entitled to within VA is important, as observed by this 58-year-old male advocate who is also a Veteran:

They come in for help. That's what they come in for is for help…Help them navigate healthcare. Help them navigate benefits, compensation, pensions. I mean, when people retire from the military, you would think after all those years they knew all the ins and outs about the VA and how to get all their benefits and their retirement pay and everything. I’ve had people that didn’t know boo about it. I mean, I’ve had to literally be on the phone almost every day with them.

Explaining benefits, or ability to assist the Veteran to obtain assistance with eligibility or enrollment information, is a major feature desired in a patient navigator.

Perspectives on Navigator Roles or Tasks: Assist with appointment reminders

Interviewees wanted navigators to send personal reminders to Veterans of their appointments at VHA, as stated by this 69-year-old female family member:

“It will be best to follow up, maybe weekly, doing reminder calls that the appointments are coming up and you need to follow up with this certain doctor or program. So, I know it’s a lot but sometimes these Veterans, they forget.”

This may be a service that VHA already provides for veterans, but if not, appointment reminders can serve as an opportunity for both the navigator and the Veteran to identify additional needs that help facilitate the Veteran’s VHA visit such as transportation or appointment coordination.

Perspectives on Navigator Roles or Tasks: Arrange Transportation

Interviewees would like the navigator to assist with arranging transportation for VHA appointments, especially for Veterans who may no longer drive or do not have reliable transportation. This is important for many Native Veterans as they may live in very rural locations that are quite distant from VHA facilities, especially Native Veterans who live in Alaska who often face long days riding “bush planes” to get to appointments. As described by this 70- year-old Veteran and this female Veteran, age 45, respectively:

“Coordinate the travel and appointments between the provider and the Veterans. Work out a system, a good system...”

“…[over 40] air miles. We have to do flight or in summertime we could use a boat or snow machine in the winter, but we fly in and out in little airplanes.”

For many rural Native Veterans, accessing VHA facilities can be a daunting task, as these facilities can be quite geographically distant from their homes. A patient navigator helping to arrange transportation may be an important aspect in facilitating a Native Veteran’s visit to VHA facilities.

Perspectives on Navigator Roles or Tasks: Emotional Support

Interviewees believed navigators must provide emotional support to Veterans, many of whom are lonely and socially and/or geographically isolated. Emotional support was seen as essential to building connection, rapport, and trust between the Veteran and the navigator, which would increase the former’s likelihood to follow-up on appointments and care instructions. This 51-year-old female advocate described her view on this:

"I think just to be able to open the door for them, to be able to engage with the Veteran, to make them realize that they’re not alone, to ensure that you’re there to help. So that the ball doesn’t drop, so that the Veteran doesn’t fail to follow-up. I think just establishing and maintaining that trust."

Providing emotional support can help Native Veterans better connect to the navigator as well as facilitating, by proxy, an overall better connection to VA.

Perspectives on Navigator Roles or Tasks: Navigate VA campus

Many Native Veterans come from smaller, rural communities and VA campuses can seem huge and overwhelming. A patient navigator that can provide directions to physically navigate VA campuses may be helpful for some Native Veterans. This family member described what she thought would be helpful in terms of physically navigating a VA campus:

“…[the navigator] could probably bring information or show them where to find things.”

Perspectives on Navigator Roles or Tasks: Connect with family

Some interviewees asserted that the navigator also needs to connect with the Veteran’s family, as many Veterans depend upon familial assistance with their appointments and health care needs. Connecting to a Native Veteran’s family may also establish rapport and trust between the Native Veteran and the patient navigator. This 56-year-old male Veteran thought contact with the family might help put the Veteran’s situation into perspective:

“…getting to know the family, I guess, the Veteran and the family. Find out what their needs are. I know it all relates to health but getting a little bit more information about the family, the family circumstances, some things that could be troubling, the reason why they might have back pain.”

Connection with a Veteran’s family members provides critical context surrounding a Veteran’s needs and increases understanding of their needs within VHA.

Spiritual Services as Appropriate

Most interviewees saw referrals to spiritual supports as positive, if culturally appropriate and the navigator possesses relevant local knowledge. However, it was not seen as realistic for navigators to refer patients directly to local spiritual supports as there is often a specific protocol for contacting spiritual healers within a given community. Traditional spiritual healing is usually arranged on an individual basis. Some tribes arrange spiritual healing “among the men”, precluding the ability of a female navigator to do so. This 47-year-old female advocate explained:

"Well, we do like sweats and stuff like that, and a lot of it's more like on a personal level, like it's just more like a community thing and not like practitioner thing."

It is important to understand types of spiritual supports used vary from tribe to tribe, as this 78-year-old male Veteran explained:

"….one spiritual service doesn’t fit all…like the churches, there's so many different kinds…but some people don't know that. But maybe that's one of the maybe extra questions you can do with a vet when you’re providing services, to make sure that you know [what] the spiritual preference [should] be."

Thus, rather than direct referrals to local spiritual supports, a navigator should learn who is connected to spiritual supports in a Veteran’s community and refer Veterans to these local persons.

Navigation Practices to Avoid

Interviewees’ observations suggest they see the work of the navigator as occurring on-the-ground in a local tribal community, which is why the preferred person to fill this role was seen as a local tribal member. Participants prefer that the navigator work in-person, conducting face-to-face visits in the community. Such preference was attributed both to culture and generational position (older). A frequent example referred to pre-COVID times when local VA staff came into community and signed people up for benefits, reflecting personal investments of time and effort which were appreciated greatly by Veterans, as shared by this 47-year-old Veteran female advocate:

“With COVID, we kind of had to shut down. [Pre-Covid] We did a lot of conferences. We did a lot of get-togethers. We had information sessions, just meetings for [Veterans] to come see us if there's anything of importance they would like to talk about. And we'd put out information sessions like DIC [Dependency and Indemnity Compensation, for eligible survivors of service members or Veterans who died] information, what kind of benefits they could get through compensation. Just anything like that that deals with the VA and what they can provide if they are qualified.”

Telephone interactions, while not preferred, were generally acceptable as most Veterans have cell phones. However, many problems became apparent by relying exclusively on this approach, as many Veterans don’t have their voicemails set up, won’t answer calls from an unknown number, and/or have bad service or limited minutes on plans.

Veterans were clear that while telephone calls would be acceptable, videoconferencing could be a problematic mode of delivery for the navigator program. This was considered an absolute no for older people, although participants acknowledged that it might be acceptable for younger Veterans (e.g., 40s and younger). Participants opined that even if an older person has a home computer they most likely have trouble using it. As one 79-year-old male Veteran stated:

“And I can make a computer crash no matter what. I'm my own worst problem on them. I always say that it's self-inflicted when it crashes, and I have to go down and I call my gurus--the outfit that I get my computers at--they go through and fix them up for me.”

In addition, some Veterans lack internet/adequate internet, as described by this 56-year-old male Veteran:

“Yeah, the Internet, especially on cloudy days or in times of bad weather, the internet connectivity is down sometimes."

Telehealth was a highly unappealing option for most participants. Some participants had used telehealth and did not like it (e.g., trouble signing in, impersonal experiences with providers, etc.). While participants acknowledged that there may be Veterans who are more comfortable with telehealth technology, they believed those Veterans still did not like using it. This 56-year-old male Veteran described his preferences for connecting with a navigator:

“I think for Natives, being in-person is probably more beneficial than having a telephone conversation. Or, in some cases, they don't have computers in their home so that that might not be available. But I know with the cell phone, they probably can. But I think that most Veterans I talk with would prefer person-to-person interviews.”

Veterans preferred to interact with the same navigator when accessing VA services. Interviewees, like the 47-year-old female Veteran below, believed Veterans would need to interact with one person consistently rather than a cadre of navigators, some of whom would be ignorant of critical elements of their situation:

“I think stability is important, too. And I know we deal with this…there’s always a lot of turnover and providers…when you build that trust with someone, it’s better to have someone that has longevity in their career than having a new navigator or somebody every couple of months or something.”

High turnover would require the Veteran to repeat their stories again and again, which they did not want to do. High turnover would also damage the ability for a patient navigator to build rapport with a Native Veteran and this rapport is vital towards Native Veteran patients having positive experiences accessing VHA services.

Discussion

Participants recognized that a rural Native Veteran patient navigator program housed within VHA could greatly improve rural Native Veteran access to VHA healthcare. Participants welcomed having a patient navigator for rural Native Veterans and felt it would be a very useful service. Interviewees offered several suggestions about the desirable characteristics and functions of a patient navigator.

Similar to other research findings, logistical support, cultural awareness and competence, and emotional or psychological support also surfaced as critical to this role. Interviewees emphasized the crucial contribution of VHA-specific knowledge and understanding the military experience as well local culture. Good customer service, including courtesy, knowledge of VA structure, protocols, and processes, and respect for the Veterans served frequently emerged as desirable traits. Participants described the importance of a positive personality, cultural competence and clear commitment as a tribal member, Veteran, or local resident. Interviewees stability and consistency are fundamental to patient navigator success.

Interviewees offered concrete suggestions for Native Veteran patient navigation. Checking-in regularly with Veterans, explaining VA benefits, and assisting with appointments, and facilitating transportation were deemed essential functions. Rather than directly arranging for local spiritual supports, participants suggested referring Veterans to appropriate community contacts familiar with the spiritual landscape and protocols for access.

Participants were not enthusiastic about more complicated, computer-based telehealth modalities, though telephone communication was acceptable. But they warned that even this could be challenging at times given inconsistent cell service and Veterans’ reluctance to answer calls from unknown numbers. In-person connection was greatly preferred. In-person navigation, yet can be challenging given Veteran’s rurality and resource limits within VHA. One possibility for balancing participant desires and resource challenges could be initial in-person connection with phone follow-up. Transparency in program constraints with the rural Native Veteran community is critical in setting expectations and delivering on promises.

Finally, connection, rapport, and emotional support were greatly desired by Native Veterans. One way this can be accomplished is through regular patient navigator “check-ins” with the Native Veterans they serve. Patient navigation has been described as needing an arc, i.e., the patient starts at point “a” and the navigator helps them get to point “b” [7]. Check-ins could help get to point b by building rapport between the navigator and their clients, a critical relational element valued in many tribal communities. Check-ins could also positively affect a Veteran’s perspective and willingness to use VHA. Finally, positive Veteran-navigator relationship building could generate goodwill across informal networks of Veterans and their caretakers in tribal communities, expanding interest and use in a navigation program. In short, while standard navigation programs strictly define a beginning and ending point for the navigator’s assistance, navigators in a program for rural Native Veterans may need to be flexible while on the path between typical navigation start and end point as a strict linear approach could be a turn-off to Veterans.

While this study reports the perspectives of Native Veterans, families, and advocates on preferred patient navigator characteristics and roles for a VHA program, they do not represent all tribes throughout the United States. Additionally, these interviews were conducted during the COVID-19 pandemic which may have influenced both participation in the project and the responses to the interview questions. In spite of these possible shortcomings, participants’ perspectives provided important insight from diverse cultural and geographic communities into navigator characteristics and roles valued by rural Native Veterans and those who care for them.

Conclusion

This paper examined Native perspectives on important characteristics and roles of a patient navigator in a VHA program designed specifically for rural Native Veterans. With the right planning, implementation, and transparency in program services, a patient navigator program for rural Native Veterans at VHA health care facilities would be a service that is welcome, needed, useful, and one that would help Native Veterans have the highest quality experience in accessing their health care at VHA.