Q&A with Katie Fasullo: Needs of LGBTQ Older Adults and Long-Term Care

September 2021 | Katherine Fasullo

“Unfortunately, many long-term care facilities do not realize the importance of affirming LGBTQ identities. So, any facility that challenges the status quo and asks the question of whether they are inclusive to all sexual and gender identities in their facility has proven that they’re ready.”

Let's begin by telling our readers about yourself and research background.

My name is Katie Fasullo. I'm a Registered Nurse and a doctoral student at Rush University in the Advanced Public Health Nurse (APHN) Doctor of Nursing Practice (DNP) program. I have been a nurse for over 12 years in a variety of settings, and my passion is advancing the health and wellness of LGBTQ older adults. Throughout my DNP education, I’ve been able to deepen my understanding of the experiences of and best practices in serving LGBTQ older adults through the lenses of population health and programming. With regards to my research background, LGBTQ Older Adults in Long-Term Care Settings: An Integrative Review to Inform Best Practices is my first published work, but as an LGBTQ older adult scholar, I hope to continue to improve the treatment and outcomes of LGBTQ older adults through future publications.

What prompted you to research the experiences of LGBTQ people in long-term care?

As I learned more about the lived experiences of LGBTQ older adults, I became interested in the dynamics of entering long-term care. These settings are unique given that once an individual enters one, it quickly becomes both their new home and a place that they are reliant on for care. So, for LGBTQ older adults, entering these settings comes with a whole new set of challenges and fears about whether they can live openly within them. As I explored further, I found that there is so much great work being done around long-term care, but it isn’t uniform. Often the trainings being offered rely on long-term care facilities to initiate a desire for care that affirms the identities of LGBTQ residents/clients within them. What about those facilities that don’t see this need? I wanted to provide a review that looks at the best internationally peer-reviewed evidence that investigates this. What are LGBTQ older adults saying that they want? What are long-term care staff saying? Most importantly, how do these intersect to provide evidence towards best practice? My hope is that this work can be used as a foundation to make systemic policy and practice changes. 

Was there anything that surprised you in your findings?

I was not surprised to learn that if LGBTQ older adults entered long-term care, they strongly preferred that it be LGBTQ-specific or LGBTQ-friendly. I was surprised to learn that while gay men preferred living in LGBTQ-only spaces, women cared less about whether their housing was LGBTQ-specific and were more focused on it being women-only. This makes sense when framed that women often occupied women-only circles in their personal lives and feared unwanted advances from men. Unfortunately, the preferences of trans and gender-nonconforming older adults were underrepresented, so it’s not clear where they would fall.

It also surprised me that even in designated LGBTQ-friendly facilities, staff did not ask sexual orientation or gender identity questions, even if their forms included the questions, if it was not the norm in the facility. If leadership did not encourage and model the behavior, it was not done. This drove home the weight of how important leadership’s involvement is.

How would you assess the readiness of long-term care setting to support LGBTQ inclusivity and equity?

Unfortunately, many long-term care facilities do not realize the importance of affirming LGBTQ identities. So, any facility that challenges the status quo and asks the question of whether they are inclusive to all sexual and gender identities in their facility has proven that they’re ready. Fortunately, organizations like SAGE and the Human Rights Campaign have self-assessments that can help with these first steps as part of their Long-term care Equality Index (LEI). It allows long-term care facilities to take a “Commitment to Caring” pledge and offers self-assessments to gauge how inclusive their policies and practices are. After the self-assessment is complete, the LEI provides resources to improve policies and practices. Our study also offers evidence-based recommendations that facilities can use to ensure they are following best practices in providing an inclusive and equitable environment of care.

Based on your research, what recommendations do you have for long-term care settings?

Inclusivity starts with hiring and training staff to be affirming to all those in their settings, regardless of sexual orientation or gender identity. Facilities should partner with their Human Resources department to make sure that job descriptions outline the policies, mission, and vision of the organization, including statements about equity and inclusion of LGBTQ people. This will encourage individuals with aligned values to apply, including prospective LGBTQ applicants, which is great because representation matters! Staff at all levels should be trained on LGBTQ older adult issues and best practices in their care. Training should also include direct contact with LGBTQ older adults, like storytelling events. Staff should use gender neutral language and treat residents as unique.

It is also important to build a culture of inclusivity. As with most organizational changes, leadership involvement is key. They are integral to making sure that staff are held accountable for any discrimination and modeling inclusive behaviors. Leadership should ensure that forms and policies include sexual orientation and gender identity questions and that mission statements, confidentiality procedures, visitor policies, and values statements are revised to include the needs of LGBTQ older adults. Facilities should display signs of inclusion, like hanging a rainbow flag or allowing staff to wear rainbow pins and offer LGBTQ programming to residents. Beyond the involvement of leadership, it is essential that LGBTQ older adults have an opportunity to inform changes in long-term care like forming an LGBTQ advisory boards.

What recommendations do you have older LGBTQ people seeking inclusive long-term care services?

First, reach out to the local and national organizations doing work with LGBTQ older adults for resources. The Long-term care Equality Index (LEI) is a great database of facilities that have made a pledge to be affirming for LGBTQ individuals. Next, explore the facility’s website. Do they have images of same-sex couples and gender diverse individuals? Are there any signs of affirmations on the website, like a rainbow flag? Check their website to see if they display a SAGE Care emblem indicating that the facility has been trained in affirming LGBTQ older adults. If so, what level have they obtained? Platinum care certification (highest level) means that 80% of employees have completed a 1-hour LGBT aging training and 80% of leadership completed a 4-hour training. Read the facility’s mission and values statement. Does it align with your mission and values? Then, contact the facility. Ask for the facility’s visitation policies – does it allow for same-sex partner visitation? Ask the facility if they have an antidiscrimination policy. If so, does it include policies against discriminating based on sexual orientation or gender identity? Are same-sex partners allowed to room together? Finally, visit the facility. Are there gender neutral bathrooms? Do staff assume heterosexuality or gender identity? Or instead, do they use gender neutral language?

How can we learn more about this study?

If you're interested in learning more about this study, please feel free to reach out to me at katherine_fasullo@rush.edu.