Table 4.

Selected interview quotations on experiences and perceptions of Key Respondents in implementing HBPC on American Indian reservations, organized by CFIR domains and constructs and identifying respondent by HBPC as staff, clinician or VA leadership roles and by an anonymized facility identifier

DOMAIN & Construct	Themes	Representative Quotation from Key Respondent Interviews
INTERVENTION Complexity	Difficulty of working in rural areas: a) Hiring	“The biggest challenge … has been hiring. It’s really difficult to get good quality providers to go work in these rural areas. We get people in, and they’ll come and stay for a little while, and then they’ll move on somewhere else. It’s really difficult to keep good providers.” Leadership (2) “[I]t’s hard to find people that want to live in a rural area and work in a rural area. Because most of our tribal entities tend to be a lot further than an hour away from a medical center. And it’s hard to get staff who want to live in that general area that want to do the Home Based Primary Care.” Leadership (12)
	b) Distance and location	“The other issue to consider as well is that a number of reservations are very isolated. You’re talking about potentially huge tracts of land… it would take them forever to get there, to find this person in their home. …. I think that’s a really big barrier, is the fact that these reservations typically are very isolated. Leadership (9) “[Programs should] factor in [the fact that you’ll]… drive two hours to someone’s house. How many people can you see in a day when you’re taking two hours? So don’t try to overdo it… leave enough time to go, and to be with that Veteran as long as you need to be there, because you don’t want to have to go back.” HBPC Clinician (12) “Everybody up there is on a P.O. Box… there are no physical addresses. And that can be a real challenge. I mean, if you have somebody who has difficulty traveling, you have to get a relative to meet you at whatever dirt road turnoff and follow you in.” HBPC Staff (11)
	c) Reduced case load	“We hired a second nurse practitioner and a second RN, and… we had originally thought was that they could, between those two, they could case-manage 45 patients and it just turned out that that wasn’t really true. So the RN in particular just was drowning and said, “Really, I cannot manage more than 22 patients,” HBPC Staff (2) One of the challenges that we’ve had is a limited number of patients that we’ve been able to enroll on the program because of the extreme distance that we drive to see these patients and because every person on this program has a very significant collateral role with the team—so it really limits our ability to increase our numbers. HBPC Staff (12)
Cost	Sustainment potential	“The tribe is actually a fairly small percentage of the Veterans that we serve… never more than 20% have been Native.” HBPC Clinician (7) “[The proportion of American Indian patients is] fairly low, I’m thinking about 20%… the [total] census lists anywhere from 40 to 50 so we had… 10 or so Native Americans at any one time serviced. “HBPC Staff (8) “[T]here’s a lot of little communities that are scattered all over…but I would tend to say [the percentage of Native patients is] over 50%. HBPC Clinician (10)
OUTER SETTING: Cosmopolitan	Collaboration between VA and IHS/THP	“At [THP], if the social worker has a particular veteran that she knows will be getting equipment for the VA, the social worker will give us a call and kind of get an idea of what VA is providing in the home so they won’t duplicate any equipment or stuff.” HBPC Staff (3) “A lot of our Home Based Primary Care program veterans that are enrolled in our program actually have primary care locally. So there’s a lot of time and coordination needed to get results from the local hospital or local physician or local specialist.” HBPC Clinician (4) “… they gave us space at a [Tribal Health] office until our larger clinic was built … we created our office there and we were there for about two years. They didn’t renew the lease last fall and it was because they had begun to grow. So our challenge now is to stay connected because we’re about 25 miles apart now. So it’s different when you’re in the building right there with Tribal Health versus now being in a separate VA building a ways.” HBPC Staff (8)
	Ad hoc patient centered care	“[THP] provides primary care…more or less jointly with us, depending on the needs and desires of the patient. In some cases it may be a little bit more Home Based Primary Care doing that. In some cases it may be more [THP]…” HBPC Staff (2)
Patient Needs and Resources	Ad hoc patient centered care	“We look at, is there copays from the VA or not? Can we get the medications cheaper for them and have them directly mailed to their homes? So we really try to look at all of that. How can we save them on expenses as well as their healthcare?” HBPC Staff (9)
	Differences in VA and IHS/THP policy	“They receive free services from the Health Center and they don’t have any co-pays. So, it was a barrier for medications and other things that VA does have co-pays.” Leadership (4)
External policy	Differences in VA and IHS/THP policy	“It’s very hard to tell a [Native American] Veteran, “The VA’s going to charge you for this.” …because they don’t have to be charged in their system. So that’s a hindrance to recruiting some of our Native American Veterans, in that they have to pay for those services.” HBPC Staff (3)
		“The problem has been that we’ve gotten several referrals where we would have gladly provided the service, but the Veteran would have had a copay for the VA. Well, if I’m [Tribe B] and I have never paid a copay in my life for any medical service, I generally don’t like doing that.” HBPC Staff (2)
		“We went into this with some assumptions. …that the people on the reservation would socioeconomically be of a certain level. And we were incredibly surprised. Because while that was true for the most part, interestingly enough the veterans, who were a very tiny subgroup, were not always meeting the means test for the VA, which we were not allowed to waive.” Leadership (4)
INNER SETTING: Networks and Communications	Difficulty working in rural areas	“The problem is that connectivity can be really slow and a problem. So it can take you longer to do your documentation. We haven’t had a printer up until, I think we just got it so it now works but we’re talking for a year and a half we haven’t been able to print from there.” HBPC Staff (2)
Implementation climate: compatibility	Value of HBPC	“The providers in primary care have learned that if you’re having a problem trying to coordinate care in what’s happening to this patient, well, just get them enrolled in HBPC and it’ll happen magically. It isn’t real magic. It’s actually a lot of work. But that’s fine. I don’t mind that that’s part of our job, because it’s important.” HBPC Staff (9) “We see now a number of Native American veterans… [whose] lives … we are affecting, changing, making better. Changing their quality of life. You know, to me, that is value. “Leadership (12)
INDIVIDUALS: Knowledge and beliefs	Value of HBPC	“So the program itself is a huge benefit to everybody…because they’re so highly rural up there … our program can help them access the services to which they might otherwise not be able to access.” HBPC Clinician (9) “[The added value] for us it’s the variety of patients. For them, I think they get good care and some coordinated care within the realm of what they want.” HBPC Clinician (3) “I don’t know that anyone would have taken care of some of the people we take care of if we weren’t willing to kind of step out there a little bit.” Leadership (1)
	Value of working with new population to VA	“Our involvement with our Native American population has been a blessing to us… The fact that they allow us into their centers and their lives has, I think, enlightened and benefited everybody who works here in this HBPC program. …. So we are honored that they allow us to do this.” HBPC Staff (1) The last few years this project has kind of taken hold of my heart. I’ve met such great people and learned so much that it is important to me. HBPC Staff (9)
Other personal attributes	Experienced working with Tribes, IHS/THP	“I think having the inroads, having somebody familiar with the people there and somebody that the people there trusted I think made a lot of difference…” HBPC Clinician (3) “We couldn’t have done it without [an experienced American Indian health advocate] leading the way. Since she came to us from IHS, since she lived on the [local Tribe’s] Reservation…. They knew her already. They accepted her into their homes. And she was able to help convince them to accept the rest of us into their homes. So really, we couldn’t have done this without her. And we hadn’t done it prior to this.” HBPC Staff (12)
	Learning to work with Tribes IHS/THP	“Part of our goals that very first year was to become familiar with the system, to try to find a way to be able to address the leadership in the community. [A Tribal member] has been my liaison for the tribe since about day one. And has been just integral in helping me figure out what I need to do in a way that was respectful to the culture. So as a result, one of the things that I do every year with him is I go to all or most of the community clubs on the reservation… Because what we want to do is keep showing up in the different communities to let folks know that we’re really there, we want to continue to be there. As a result of that, a lot of things have really happened. One has been that there has been a slow acceptance of our members on the reservation and people have begun to recognize those folks.” HBPC Staff (2) “And we’re starting to see the fruits of [getting veterans signed up for benefits], in that people are coming up to us and thanking us for what we’ve done in that respect to help them. Takes a lot of time to do that process. And that’s extra. Me as a provider, that’s not counted on me seeing a patient and all that, doing that extra stuff for these veterans. It makes a difference.” HBPC Staff (3) “We spent a lot of time talking …, listening. And I think after several meetings where we really made it clear that we wanted to have an official relationship, we wanted to provide the kind of care that they wanted, that we wanted to be involved in their community, we got invited to a powwow, those of us that were reaching out. …. So I think showing that we were willing to step out of our comfort zone and go to them and do things within their culture really helped them to accept us as we started moving forward.” Leadership (1) “We do go to gatherings and represent the VA … especially when there’s a gathering American Indian Veterans. We …set up a little booth and we hand out flyers. And even on weekend or at night. We really try to be a positive presence at meetings. And we’ve had more people starting to stop by. First year there was almost nobody, and the last time we had more people, so that was nice. So I think getting out there and getting invited to community events is really important. “HBPC Staff (12)
PROCESS: Champions	Experienced working with Tribes, IHS/THP	My role is liaison in some ways between VA and the tribe, that’s kind of a grassroots level. …And so word gets around it’s a small community … I’m someone they know. And so I introduced the program to the community, letting them know we would be coming in and standing up this new project and kind of what our boundaries were.” HBPC Staff (11)
	Collaboration between VA and IHS/THP	“Many of the IHS staff I knew from before because I worked at Indian Health Service, so I knew a little how to negotiate their system.” HBPC Clinician (12)
Executing		“If IHS identifies somebody that’s having problems getting to a clinic or the Veterans’ Service Officer, the Tribal Veterans’ Service Officer can identify somebody with some transportation issues, health issues, any of those sorts of concerns that would make in-home health care advisable, then we’ll hear about it either from IHS or the VSO or sometimes the providers here in [Site I] or the CBOC, you know, if they recognize a need for home based we’ll get a referral.” HBPC Clinician (7) “Our referrals came directly from primary care at Tribal Health. So we tried to integrate ourselves by attending their meetings, giving presentations and just by physically being in their building, helped precipitate referrals. And then we attended their health fairs and a lot of veterans came up to our table that attended Tribal Health and also became our patients too. So there was a lot of working back and forth together in terms of health care.” HBPC Staff (8)
	Ad hoc patient centered care	“Usually referrals come from families, word of mouth. Somebody will say, “Hey, I know so-and-so. You might want to contact him,” or something like that.” HBPC Clinician (7) “…there has been a slow acceptance of our members on the reservation and people have begun to recognize those folks. And the other is that it is not uncommon for me to get a call from a family member or somebody that is caring for or involved with someone who needs our services to say, “What about Mr. So-and-so? Can you help him get enrolled in the system or figure out if he’s eligible for your service?” So I think that’s really one of the backbone pieces of how we’ve gotten to where we are.” HBPC Staff (2)
Reflecting	Image of VA	“But I think the path has been really increasing the positive image of the VA on the reservation and with the population. When we first went out there, there was a lot of reluctance from people in terms of letting us come in, especially those of us who were non-Native, with being able to come into their homes. And I think we’ve really found that that resistance has lessened pretty significantly over the last year or so, so that initial period with a little tough to convince people to let us in. They were waiting and seeing and making sure that we were still going to be around. And we don’t really have to sell the program like we used to, so I think that’s helping. We’re still expensive in terms of staffing and vehicle costs, certainly, but I think there are some intangible benefits that are certainly paying off for us.” HBPC Staff (12)
		[HBPC has] really opened the doors to us, in a way, to start the conversation about the agreement with [the Tribe]. We also had kind of an outreach event at [the Tribe]…to provide outreach and information to tribal veterans and their families …I think the fact that the HBPC programs and [HBPC Staff] in particular had been on the reservation for a couple years by then, meeting with people, talking with people, kind of being the face of the VA, and being okay—that they were trustworthy and had this relationship—it very well might be that if that hadn’t started, we may not have gotten that invitation to go there. “Leadership (9) “Because veterans who met HBPC enrollment criteria were too high income for the VA medical benefit, I was told that basically I lied, I didn’t tell them about this. The truth is, it was not a big highlight of our presentations over the preparations and months when we went into this. We, again, falsely assumed that this would not even come up. And we don’t own it. It’s a bigger VA regulation… I mean, talk about the mistrust, the miscalculation. I don’t think I ever really recovered completely from that. They still remind me of this.” Leadership (4)
	Building Relationship with Tribes, IHS/THP	“You know, just keep showing up. One of the things that [a Tribal member] told me in the beginning is that you can’t come out there and start a program and not keep showing up. If you really want this to work, you gotta keep showing up.” HBPC Staff (2) “Build relationships with both the Tribe and Indian Health Service because those are the folks that you really have to communicate with to keep all the resources flowing back and forth. Open communication is really important….They need to have input, and a stakeholder meeting before you start any program…and they can decide if they want to participate or not from day one.” Leadership (12) “…Make the Tribe or Tribes part of your planning process, get them involved in the planning and to define … catchment areas,…how many potential patients, a better demographic study…is the IHS facility aware that we are coming…what’s the process for getting them referred into our program and really have somebody that’s out front [as a point of contact].” Project Staff (1) “… every tribe is different. Every tribal leadership is different. The biggest thing is trust. And what you’re doing with a tribal organization is, they want to see you and they want to see you more than once. They want to see what you’re going to bring to them and what benefit they’re going to receive out of it. And they want to know you’re going to be there. … And so they want to make sure that it can be sustained. And they want to do it their way, too. “Leadership (12) The difficulty of establishing relationships with Tribal services [has] been a bit of a stumbling block. Although I think the fact that we’ve now kind of bypassed that by making our own relationships with veterans and have increased our profile on the reservation and have a more positive reputation is helping to alleviate that barrier a little bit.” HBPC Staff (11) “[This] is really a pretty small tribe… so… the numbers of folks that we have served ….are really small … It really is a relationship and the development of that relationship. And what I mean by that is trust. And our continued presence in that community. I think that’s why we are being successful. And having [VA staff] over there on the reservation, in the hospital forever, has been really helpful as well.” HBPC Staff (2)
	Opportunities for expansion	“But my idea of what would be ideal … [is] a full-time liaison that can work with the VA and IHS. And it would be a tremendous benefit if that person were Native and if the person were an RN. Because I can see this person working with all of the CHRs, all of the IHS providers, communicating directly …the VA provider—to the IHS provider. Kind of like the go-between” HBPC Clinician (10) “Have expanded contract services. Because there are agencies out there that are willing to go to these remote areas.” HBPC Clinician (10) “I would like to establish telehealth with tribal centers… [so when] issues occur with the Native American population that we can immediately respond.” HBPC Staff (2)