While hospitals and health care systems work to provide equitable health care to all patients, LGBT individuals remain invisible to many health care providers. Collecting data, improving communication between clinicians and patients, and educating clinicians and staff about LGBT health issues will help to ensure high-quality care and better access for sexual and gender minorities.
In a recent Hospitals in Pursuit of Excellence webinar, Harvey Makadon, M.D., program director at the National LGBT Health Education Center at the Fenway Institute, Fenway Health, and a professor of medicine at Harvard Medical School, discussed the stigma that has contributed to health and health care inequities for LGBT individuals and action steps for providing equitable care. John Knudsen, M.D., medical director of the Clinical Practice Office of Health Equity and Inclusionat Mayo Clinic, shared what the Minnesota-based health system is doing to improve care for LGBT patients.
More Focus on LGBT Health Issues
Recent reports and initiatives are drawing more attention to the health issues of LGBT individuals. In 2011, the Institute of Medicine released “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding,” a report that examines the “unique health disparities” of sexual and gender minorities and includes recommendations for further research and understanding of LGBT health. Healthy People 2020 includes LGBT health as a topic area, with suggested interventions and resources to improve the “health, safety and well-being” of LGBT individuals.
Improving LGBT health care access is an important population health issue. Statistics show that LGBT youth have a higher rate of suicide and homelessness and a higher rate of tobacco, alcohol and other drug use. Gay men have a higher risk of HIV/AIDS and other sexually transmitted diseases. Lesbians are less likely to be screened for cancer. In addition, discriminatory practices have limited health care access and health insurance access for LGBT individuals.
An Inclusive, Affirming Environment for All
To provide equitable care, hospitals and health systems must increase awareness and education on LGBT issues. “Health organizations can do more to create a more inclusive, affirmative environment for LGBT individuals,” says Makadon. There is “too little training and attention” to create such an environment, he adds. According to Makadon, the four main challenges in providing equitable care to LGBT patients are: (1) data collection, (2) clinical education, (3) consumer education, and (4) patient-centered care.
The education center at Fenway Institute and the IOM recommend including information about a patient’s sexual orientation and gender identity in electronic health records. The education center suggests collecting this data along with information on the patient’s sex assigned at birth and preferred name/pronoun. Information about the patient’s sexual practice would best be collected as part of the patient’s medical history, Makadon recommends. This information is critical for population health management, he adds.
Improving provider-patient communication is also key. Anecdotally, about half of physicians ask patients about their sexual health, and very few physicians ask patients about their sexual orientation or gender identity, explainsMakadon. A recent study in the American Journal of Public Health found that 84 percent of physicians had discussed adherence to antiretroviral therapy with HIV-positive patients, but only 14 percent of physicians had discussed HIV transmission and/or risk reduction.
The education center has published “Ten Things: Creating Inclusive Health Care Environments for LGBT People,” which highlights 10 topics for health care organizations to consider, such as ensuring the hospital has a nondiscriminatory policy that includes sexual orientation, gender identity and sexual gender expression. “It’s one thing to have a policy and one thing to make it real,” Makadon says. Other topics include providing clinicians and staff with knowledge about the health needs of LGBT patients and ensuring that LGBT employees feel respected and safe in the workplace. The education center provides additional resources for hospitals, including “Do Ask, Do Tell” templates for creating posters and pamphlets that encourage patients to talk to their providers about being LGBT.
Culture Changes at Mayo Clinic
A presentation to leadership by an employee resource group helped to improve the care and climate for LGBT patients at Mayo Clinic, based in Rochester, Minn. The LGBT employee resource group shared compelling stories with clinical leaders about “incorrect assumptions, awkwardness, misunderstanding, suboptimal care and, even in some circumstances, hostility,” says Knudsen. In response, Mayo’s leadership established the Office of Health Equity and Inclusion, a “pivotal moment for our LGBT patients and other patients that face inequities of care,” Knudsen asserts.
Ensuring organizational readiness and handling competing priorities were two challenges at Mayo. “Some people didn’t know what LGBT stood for,” Knudsen says of the initial lack of exposure and awareness across the health care organization about LGBT health issues. In addition, with so many competing priorities, it’s imperative to make room at the table to discuss LGBT health, Knudsen says.
Key lessons learned at Mayo Clinic include:
· Getting leadership buy-in. Knudsen advises identifying a leadership champion in the health care organization and then not only providing needed support, but also understanding and helping to tackle the challenges ahead.
· Aligning with other efforts to eliminate disparities. Creating connections with other groups that experience care disparities and building alliances with other equity champions in the organization will be beneficial.
· Aligning health care equity with key strategic business priorities. Making the business case for health equity and linking equity to business performance contribute to achieving success, Knudsen says.
In the two years since Mayo Clinic established its equity and inclusion office, awareness and knowledge about LGBT health issues have increased. The health care organization now is including LGBT topics in grand rounds and continuing medical education conferences, expanding health coverage and services to transgender patients and families, and distributing an LGBT-friendly provider list. Knudsen says the work will lead to improved care and better outcomes. All these efforts are ending the invisibility of LGBT patients at the health care organization.
Visit the Hospitals in Pursuit of Excellence website for the webinar presentation and slides on “Ensuring Access and High-Quality Care for LGBT Patients.” The HRET Disparities Toolkit is available free of charge.
Cynthia Hedges Greisingis a communications specialist with the AHA’s Health Research & Educational Trust, Chicago.