Healthy People 2030 supports improving the health and well-being of lesbian, gay, bisexual, transgender, and queer (also questioning) (LGBTQ+) individuals through a series of objectives that address issues with data collection, health behaviors, and systemic problems.(1)
Physician leaders have a significant role in facilitating and ensuring patient-centered, inclusive, and equitable programs that address the diverse needs of the communities they serve.(2) Further, there is a need to address healthcare disparities for specific patient populations, particularly those who are gender minorities, because they may have become disenfranchised and marginalized and lack gender-affirming care.
Addressing equity and disparities in care are central tenets of providing high-quality clinical programming in the modern era.(3) Organizations continue to struggle with how to facilitate gender-affirming care for a host of reasons, including a lack of training, the perception of system inertia among providers, other competing factors for funding, and staffing.
This article addresses how we have been able to implement gender-affirming care and continue to evolve our program to address the needs of these individuals with the aspirational goals of addressing disparities and ensuring equity.
CASE OVERVIEW
Gender-affirming care was not routinely available in our system, especially for patients seeking to initiate hormone therapy. Depending on age, patients accessed care through the departments of pediatrics or internal medicine with providers who were comfortable providing gender-affirming care, including emotional support, hormone therapy, and preventive care. When unique problems or concerns arose, referral and consultation were obtained. For gender-affirming surgical care, patients had to independently seek surgeons; they were often located outside of the state.
The problems with this approach were obvious.
First, the burden was often on the patient to identify where to access care.
Second, cross-coverage issues among providers led to patients being seen by different providers with varying degrees of comfort and competency in gender care.
Third, beyond the individual provider, there were inadequate support systems for follow-up because care was mainstreamed with care for patients who had a range of medical problems.
Fourth, the care was far from patient-centered because it failed to address the longitudinal issues that these patients often present as they progress in their gender-affirming journey.
Finally, there was concern that patients might be at risk if the approach to care was not changed. This concern arose from literature that demonstrates that transgender patients avoid routine and, in some cases, emergent care if gender-affirming care is not available in a safe and respectful environment.
BACKGROUND
In 2015, the single physician who provided gender-affirming care with hormone therapy decided to retire. This physician was serving a small cohort of patients in a large health system. One option was to assign these patients to other physicians who would be interested and comfortable in providing care. There clearly were challenges with this approach, including inconsistency in care because of a lack of guidelines, lack of experience, lack of interest among some providers, and concerns about where new patients would seek care.
PROGRAM IMPLEMENTATION
As with many clinical programs, leadership matters. One of the first and most important steps in establishing a gender-affirming care program was to assign a medical director who was interested in providing care and could maintain other clinical and administrative responsibilities, as there were few patients at initiation.
Formalizing this structure was important. The medical director, who regularly cared for patients with members of other departments, already knew who the subject matter experts were in other departments, and this made accessing referrals easier and more convenient. Further, the care for individuals became more integrated and less fragmented.
Next, policies and procedures that addressed everything from appointment scheduling to clinical protocols were instituted. This helped address the disparities in care and the problem with patient care during cross-coverage. A focus was placed on addressing barriers to access and improving the patient experience. This included providing patients with appointments without referrals, training staff in workflow, addressing pronouns, and involving technology services to change the electronic medical record (EMR) so the banner shows patients’ preferred names and pronouns.
Team-based care evolved next. Each month, a multidisciplinary team of professionals met to discuss particularly challenging cases. As the team matured, so did the clinical care and protocols.
A dedicated clinic time and space within the internal medicine department was created. This provided a “home” for patients who needed access to the expertise of these providers as well as a dedicated support staff to follow through on their individual care needs across disciplines.
Finally, the call center was informed and educated about this comprehensive care program for patients who needed gender care and subsequently made appointments at the clinic when patients inquired.
When taken together, these steps relieved the patients of the burden of coordinating their own care and applied it to an integrated and multidisciplinary clinical team.
OUTCOMES
As the program continues to evolve, so do the outcome data. Initially, when the program was small and dis-integrated, approximately 60 local patients received care that they accessed individually. Today, that number has grown to more than 300, and there is a greater regional distribution of the patient base.
The main factor contributing to this growth has been ease of access and a community-based referral network. When patients feel they are cared for in a comprehensive and caring way, they spread the word. Guidelines are set forth by the University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People and the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People.(4,5)
A gender clinic was integrated with the internal medicine clinic, which improved the efficiency of office space and staffing. The EMR was optimized to allow patients to use their preferred name and gender on the main banner and to allow physicians to document a patient’s gender and “organ inventory.”
Finally, staff satisfaction was not surveyed before and after implementation, but the volume growth would suggest that patients appreciate the dedicated expertise and space to care for them. The staff is passionate about the care they provide, appreciate the fact that it is standardized and “best practice,” and each day bears witness to the smiles and appreciation offered by patients and their families.
This program consistently gets the highest patient satisfaction ratings, which is a bonus to the satisfaction that the team gets in providing this service. This program also provides learning opportunities for medical students and residents from internal, family, and community medicine. The program also has enriched the organization academically by providing an opportunity to initiate prospective research to study mental health outcomes in patients starting hormone therapy.
NEXT STEPS
Despite tremendous success in this program, physician leaders should consider the next steps for program development. Continued and more focused expertise among providers is one such opportunity. While there are several continuing education programs, some insurers have responded to addressing these national priorities by helping clinicians achieve recognition for their expertise in culturally responsive care.(6)
For example, Aetna has provided three self-directed CME modules with an acknowledgment “badge” for the provider upon completion. The program addresses three important areas for clinicians: culturally responsive care, LGBTQ+ responsive care, and culturally responsive PCP behavioral healthcare. One provider in the program has already completed these modules.
Beyond individual enhancements, program metrics have become more formalized so that documentation of quality, efficiency, and clinical outcomes of performance are hardwired and care can be improved.
CONCLUSION
This programmatic approach to gender-affirming care addresses several important national priorities, including Healthy People 2030, patient-centered and equitable care, and disparities in care as suggested by the Institute of Medicine. More importantly, it addresses a community need, which is consistent with the organization’s mission as a not-for-profit healthcare organization. It improved the patients’ quality of care, access, and experience, and improved providers’ satisfaction with the care they delivered — a triple bottom-line improvement with minimal incremental costs.
References
U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. Accessed June 12, 2024. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt .
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001. https://doi.org/10.17226/10027 .
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2003. https://doi.org/10.17226/12875 .
Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, 2nd ed. University of California San Francisco; June 2016. https://transcare.ucsf.edu/guidelines
Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1): S1-S259. https://doi.org/10.1080/26895269.2022.2100644
Aetna Better Health of Florida. Care Champion Badges for Providers. Aetna Provider Bulletin, November 28, 2023. Accessed June 12, 2024. https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/florida/provider/pdf/ABHFL_Care_Champion_Provider_Communication_11.2023.pdf