By Michael B. Garrett, MS, CCM, CVE, CPCHE
Introduction
June is pride month for the entire lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community and individuals. The LGBTQ+ community is aging along with the rest of the American population. This is a benchmark birthday year for me, since I turn 70 later this year. This led me to develop this blog on how case managers can better serve older LGBTQ+ individuals to achieve better outcomes. I will identify the challenges faced by LGBTQ+ individuals with healthcare and more broadly in society. I will then identify several strategies and tactics that case managers can use in addressing those barriers for enhanced healthcare access, experiences, and outcomes.
The Challenges
Higher Rates of Social Drivers of Health (SDOH): LGBTQ+ individuals are disproportionately impacted by SDOH issues, such as access to housing, transportation, and healthy, nutritious food. We know in case management practice, that these SDOH can and will negatively impact the ability to access care and adhere to care plans. Even when community-based organizations that provide necessary social and human services are identified, they may not provide LGBTQ+ inclusive services. This means case managers need to ensure that they consistently screen for SDOH needs, and then identify services that are LGBTQ+ inclusive.
Negative Encounters with Providers: It is truly unfortunate that LGBTQ+ individuals have experienced negative encounters with providers. This includes harsh and inappropriate language, refusal to acknowledge the family of choice, refusal to use the correct name and pronoun, and general lack of knowledge about caring for LGBTQ+ individuals. This likely results in distrust of providers and concerns about future encounters with new providers. It is important for the case manager to engage with clients to understand hesitations about visiting providers, and not reach a conclusion that the client is simply being non-adherent.
Higher rates of certain health conditions, especially chronic conditions: LGBTQ+ individuals may have higher rates of chronic health conditions due to a variety of factors, such as negative encounters with providers (described above), lack of insurance, financial constraints, lack of access to pharmacies or providers, and/or lack of awareness of the need to adhere to chronic care guidelines. Through the assessment process, the case manager can determine the reasons for lack of adherence, so that effective interventions can be implement to eliminate those barriers, if possible.
Higher rates of behavioral health conditions: The LGBTQ+ community experiences higher rates of depression, anxiety, substance use disorders, and other behavioral health conditions as compared to straight, cisgender communities. This makes it even more important for case managers to routinely assess for behavioral health conditions with LGBTQ+ clients, even though this should be happening with all clients. Then, if there is a positive screen, then the case manager needs to know if, how, and when to make appropriate referrals to behavioral health providers and services that are LGBTQ+ inclusive.
Stressors related to rejection by family and friends: LGBTQ+ individuals face rejection by family members and friends when someone’s sexual orientation and/or gender identity are discovered or revealed. This may then lead to rejection and shunning by a family of origin and friends. As a result, there can be increased stressors and health consequences. Also, there can be a decision to create and identify a family of choice. The case manager needs to assess who the client identifies as their family regardless of blood relation. The case manager also needs to be aware of who the client does not what you to communicate with, since the client may not want any information share with the family of origin.
Discrimination broadly in society as well as in health systems: LGBTQ+ individuals not only face discrimination and barriers within healthcare systems, but more broadly with society. This may involve challenges in finding housing, employment, schools, and other resources that are LGBTQ+ inclusive. As the case manager explores potential resources to meet the needs of the LGBTQ+ client, it is important to bear in mind that not all organizations are LGBTQ+ inclusive, so the case manager needs to be circumspect in making referrals.
Higher rates of poverty and economic insecurity: LGBTQ+ individuals may face a lifetime of disparities in building wealth and financial security. This leads to many negative consequences, such as housing instability, food insecurity, and inability to obtain necessary healthcare services and medications. These challenges need to be identified during the case management assessment process in order to develop effective strategies to diminish as much as possible the impact of these challenges.
The Opportunities
Use the Name and Pronouns the Client Uses: Some members of the LGBTQ+ community modify their names and pronouns to reflect their gender identity or to own a different identity than what was assigned at birth. In order to be inclusive and respectful, the case manager should acknowledge and use the name and pronouns that the client uses regardless of what is listed in the case management, patient profile, and/or eligibility systems.
Respect the Family and Caregivers the Client Identifies: As described above, some LGBTQ+ individuals may have been rejected by their family of origin and friends as well as by others, such as their faith community. The LGBTQ+ client may identify a chosen family or family of choice rather than the family of origin. This may be challenging for some case managers to understand, since they may have had positive experiences with their family of origin. However, the client gets to choose and identify who they consider to be their family, regardless of blood relation.
Assess and Address Behavioral Health and Social Drivers of Health (SDOH): The case manager should be assessing for behavioral health conditions and SDOH for every client. This is particularly important for the LGBTQ+ client, since it was described above how behavioral health and SDOH issues disproportionately impact the LGBTQ+ community. If there are positive screens for these issues, the case manager needs to be prepared to make referrals for behavioral health providers as well as for community-based organizations to address SDOH issues. There are LGBTQ+ community-based organizations that might be preferred by the LGBTQ+ client, and these are usually within or associated with LGBTQ+ centers. Of course, the client gets to decide who they prefer for providers and community-based organizations.
Refer Clients to LGBTQ+ Inclusive Providers: In light of the negative encounters that some LGBTQ+ clients have experienced with providers, it may be the desire of the LGBTQ+ client to got to a provider who cultural competence and expertise in working with LGBTQ+ individuals. There are some resources available who have identified providers who attest to providing LGBTQ+ inclusive care. Examples of these resources include but are not limited to FOLX Health, Out Care, GLMA (Health Professionals Advancing LGBTQ+ Equality), and Plume Clinic. Some of these organizations conduct on-going evaluation of the providers in their network. And some of these organizations offer a wide range of providers (such as primary care, specialists, and behavioral health providers) whereas other only offer specific services (such as hormone replacement therapy).
Although this is not a guarantee of cultural competence in working with LGBTQ+ individuals, it is at least a way to potentially achieve positive healthcare experiences for the LGBTQ+ client. It is always important to confirm if any provider is within the client’s provider network in order to optimize benefit plan coverage.
Incorporate the Framework of an Age-Friendly Health System: The 4 M’s framework of the age-friendly health system identifies the core subject that should drive the care of older adults, including:
- What Matters: Know and align care with each older adult’s specific health outcomes goals and care preferences including, but not limited to, end of life care, and across settings of care
- Medication: If medication is necessary, use age-friendly medication that does not interfere with What matters to the older adult, Mobility, or Mentation across settings of care
- Mentation: Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care
- Mobility: Ensure that older adults move safely every day in order to maintain function and do What Matters.
Professional case managers can collaborate with the whole team in delivering age-friendly care by identifying any of these needs into the care plan.
Refer Clients to LGBTQ+ Inclusive Long-Term Care Facilities and Services: Older individuals are the major users of long-term care services and supports. It is important that these programs provide respectful and responsive services to all individuals, including members of the LGBGTQ+ community. The Long-Term Care Equality Index (LEI) voluntary surveys residential long-term care and senior housing communities for LGBTQ+ inclusiveness. This includes arrange of services and facilities, including life plan communities, skilled nursing facilities, assisted living communities, memory care unites, independent living facilities, affordable senior housing, and hospice. The Human Rights Campaign Foundation and SAGE developed the LEI to meet the needs of the entire LGBTQ+ communities. The LEI provides a roadmap for LGBTQ+ inclusiveness based on several criteria, including the following 2025 criteria:
- Non-discrimination and staff training: Ensuring legal protections for LGBTQ+ residents and staff along with staff training is a critical step in laying down the foundation for inclusivity
- Resident services and support: This section of the LEI asks about policies and practices that demonstrate progress toward LGBTQ+ resident care and support
- Employee benefits and policies: This section assess the equal treatment and access to health-related benefits and policies
- Resident and community engagement: This section asks about best practices a community takes to publicly demonstrate its commitment to the LGBTQ+ community
There are three tiers of recognition after the survey is completed and validated, including:
- LGBTQ+ long-term care equality builder (Bronze Level): Communities that are beginning their journey and have a solid foundation
- LGBTQ+ long-term care equality high performer (Silver Level): Communities are further along with their LGBTQ+ inclusion journey
- LGBTQ+ long-term care equality leader (Gold Level): These communities have made significant progress in their LGBTQ+ inclusion journey
In order to optimize benefit coverage, it is always important in referring clients for any services to check with their benefit plan for coverage as well as for criteria or requirements, such as prior authorization.
Conclusion
This blog has outlined the challenges that the LGBTQ+ community and individuals face not only in healthcare but also in the broader societal environment. It is critical that the case manager conduct a comprehensive assessment, so that all relevant issues and barriers are identified. Then, the case manager can collaborate with the client, and their identified family members and caregivers, in developing and implementing a care plan based on the client’s preferences, values, attitudes, beliefs, and behaviors. The case manager can be more effective in providing LGBTQ+ inclusive services, so that the client achieves the optimal healthcare access, experience, and outcome.
References:
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Bio: Michael Garrett possesses more than 30 years of progressively responsible experience in managed care, care/case management, utilization management and review, chronic condition management, health information technology, healthcare quality, and population health management services. He has served in operational management, business development, product development, and strategic planning roles. His experience includes developing and implementing value based care models, such as patient centered medical homes and accountable care organizations (ACOs). Michael has experience working in a range of benefit programs, including fully insured medical plans, self-funded health plans, workers' compensation, Medicaid, government employee plans, and long term disability. He served as the leader in the successful development, implementation, and on-going maintenance of quality management programs for care management programs He has also worked with health plans and healthcare providers in evaluating, improving, and optimizing health information technology and healthcare quality programs. His commitment to the healthcare industry is demonstrated by leadership roles in key organizations, including serving as a member and chair on the Commission for Case Manager Certification, a committee member and chair of URAC's clinical accreditation committee, and a member of the Case Management Society of America's Task Force for the Revision of the Standards of Practice for Case Management. He has served as an author, editor, and contributor on six case/care management books as well as the author of numerous journal articles in the field of care/case management. Michael's professional credentials include a Master of Science degree from the University of Idaho in clinical psychology and a Bachelor of Arts degree in psychology and religious studies from Gonzaga University. He is also a Certified Case Manager, Certified Vocational Evaluator, and a Certified Professional in Clinical Health Equity.