There are currently 1.1 million LGBTQ+ Americans over the age of 65. By 2060, the number of LGBTQ+ adults over the age of 50 is expected to reach almost 5 million. Currently, about 5% of people living in long-term care communities identify as such, according to the Long-Term Care Equality Index (LEI). But for many, finding a long-term care provider that affirms their sexual orientation and/or gender identity is a challenge.

Many post-acute organizations already strive to provide patient-centered care, including equitable treatment of patients from diverse backgrounds. Yet it may not be clear to leaders how to practically translate this mission into an environment that makes all feel welcome, including LGBTQ+ residents.

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The same is often true for frontline staff, who may not have the knowledge, skills, and attitudes they need to provide identity-affirming care to LGBTQ+ residents. And for everyone, it's often hard to recognize common instances of unconscious bias—such as making assumptions about marital or family status.

How Hebrew SeniorLife created a safe space for LGBTQ+ seniors

Hebrew SeniorLife (HSL) is a nonprofit provider of senior care in the greater Boston area. Providing equitable care to residents of all faiths and backgrounds is a central part of HSL's mission. But in 2015, HSL leaders realized that they needed to go beyond the fundamentals of patient-centered care to recognize and honor the specific needs of LGBTQ+ residents. They did so in three ways:

1. HSL leaders first reviewed the organization's policies and procedures to ensure they were inclusive of all gender and sexual identities. In addition to their non-discrimination policy, HSL added an affirmation of welcome and inclusivity to LGBTQ+ people, as well as people of all faiths, races, and backgrounds. HR and admissions documents were also changed to be more inclusive.
2. In 2015, HSL started a program for chaplains to help them meet the spiritual care needs of the aging LGBTQ+ population. First, HSL spiritual leaders educate chaplains on topics relevant to the experiences of the LGBTQ+ population, including experiences with coming out, the history of the gay rights movement, and violence against LGBTQ+ seniors. Chaplains then have a community placement with a local LGBTQ+ organization to observe the needs of the community firsthand.
3. HSL also mandated that all employees attend workshops on how to provide culturally sensitive care for LGBTQ+ seniors. For example, attendees watch a documentary on LGBTQ+ residents who grapple with hiding their identity in the long-term health care system. Workshops also include an introduction to inclusive vocabulary, like pronouns and other key terms. Leaders receive additional training to prepare them for handling possible instances of discrimination.

To hold staff and teams accountable for maintaining an inclusive care environment and in response to missteps, any staff member may anonymously request additional LGBTQ+ education workshops for their department at any time. HSL also provides staff who complete the training with rainbow stickers and lanyards for their ID badge to signal to residents that they are in a supportive community.

Feedback indicates that LGBTQ+ residents who would have otherwise remained closeted in a long-term care facility now feel comfortable being open about their sexual and/or gender identity. The same is also true for visiting LGBTQ+ family members and HSL's own staff. In addition, HSL frequently receives referrals from LGBTQ+ community organizations in recognition that they are an industry leader in inclusive senior care.

3 things you need to know to make meaningful inclusivity changes

Three insights learned from HSL that post-acute organizations can adopt to make change.

Change starts with culture, not financial investment

One barrier preventing leaders from advancing inclusivity efforts is a perception that this work requires large financial investments. Make no mistake: this work warrants dedicated investment. But shifting the culture doesn't have to be prohibitively costly.

Instead, organizations should start by refining their mission to explicitly name honoring marginalized identities as a core value. Once defined, leaders should identify policy changes and other action steps to reinforce that value, depending on their community's needs and available resources. For example, the LEI recommends that organizations start by adopting a written resident nondiscrimination policy, visitation policy, and employee policy that explicitly includes "sexual orientation" and "gender identity."

We recommend that post-acute organizations participate in the LEI's benchmarks of LGBTQ+ inclusion and access their report for added guidance and scenario planning on inclusivity practices.

Implementation needs to involve both the front line and senior leadership

Change often starts at the executive level and trickles down to the front line for implementation. But to successfully implement inclusive policies and programs across post-acute systems, both the senior leaders and frontline staff must be engaged from the very beginning.

To sustain change long-term, organizations should convene a committee of individuals from across the system—at varying levels of seniority—to focus on efforts such as new campaigns and day-to-day change. For example, employees at all levels should be involved in developing inclusive policies and procedures, planning Pride events, and creating mechanisms to advertise and reinforce inclusive behavior, such as HSL's rainbow stickers.

Inclusivity efforts can accelerate other diversity, equity, and inclusion (DEI) work

Through a focus on LGBTQ+ residents, you can develop the structures and culture to take an intersectional approach to all DEI efforts. Creating a welcoming space for LGBTQ+ seniors is just the beginning of what long-term care organizations can and must do. But in addition to their intended impact, equity efforts create policies and accountability mechanisms—and the cultural buy-in ingrained across the system—that open the door for more transformational DEI efforts.

For example, HSL is furthering their work to honor marginalized identities by addressing racism that staff experience from patients and family members, rejecting the notion that it's an inevitable and excusable aspect of caring for seniors. Leaders attribute their relatively rapid progress to the culture and structures their LGBTQ+ equity work created, allowing the organization to quickly adopt new guidelines and protocols.