Long-Term Care Equality Index 2023

Messages from HRC Foundation President
and SAGE Chief Executive Officer

A Growing Population

As the American public ages, it is also diversifying. Now, more than ever, the U.S. older adult population consists of many racial identities, ethnicities, faith traditions, sexual orientations, and gender identities.² By 2030, studies project the population of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people over 50 to reach 7 million.³ Despite the older members of the LGBTQ+ community growing in visibility and size, LGBTQ+ elders have historically been invisible to aging service providers, policymakers, and researchers.⁴

The Need for Care

No one should fear rejection or discrimination when seeking the care they need.

The Human Rights Campaign Foundation, and SAGE believe that most long-term care and senior housing communities do not want LGBTQ+ older people to hide their identity, face discrimination or worry about the care they will receive. But long-term care communities and senior housing providers may be unsure how to protect their LGBTQ+ residents from discrimination or develop gender-affirming policies. Long-term care and senior housing, service providers, older people, and their care partners now have a tool to address these concerns and provide inclusive care: The Long-Term Care Equality Index.

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1} AARP. (2020). Maintaining Dignity: Understanding and responding to the challenges facing older LGBT Americans. AARP Research. Retrieved from https://www.aarp.org/content/dam/aarp/research/surveys_statistics/life-leisure/2020/maintaining-dignity-lgbt-reformatted.doi.10.26419-2Fres.00217.006.pdf

² Administration on Aging (2022). 2021 Profile of Older Americans. U.S. Department of Health and Human Services. Retrieved from https://acl.gov/sites/default/files/Profile%20of%20OA/2021%20Profile%20of%20OA/2021ProfileOlderAmericans_508.pdf

³ SAGE & National Resource Center on LGBT Aging. (2021). Facts on LGBT Aging. Retrieved from https://www.sageusa.org/wp-content/uploads/2021/03/sage-lgbt-aging-facts-final.pdf

⁴ Fredriksen-Goldsen, K. I. (2023). Blueprint for Future Research Advancing the Study of Sexuality, Gender, and Equiuty in Later Life. The Gerontologist, 63(2), 373-381, https://doi.org/10.1093/geront/gnac146

⁵ Hyun-Jun, K., Jen, S., & Fredriksen-Goldsen K. (2017). Race/Ethnicity and Health-Related Quality of Life Among LGBT Older Adults. The Gerontologist, 57(Suppl 1), S30-S39. https://doi.org/10.1093/geront/gnw172

The Long-Term Care Equality Index (LEI) promotes LGBTQ+ inclusive policies and practices in long-term care and senior housing communities and formally recognizes those communities that lead the field in LGBTQ+ inclusion. Through LEI tools and resources such as the LEI biennial survey, LEI webinar series, and technical assistance calls, the LEI helps long-term care and senior housing communities adopt policies and best practices that provide culturally competent care to LGBTQ+ older people. Modeled after the successful Healthcare Equality Index, the LEI measures the following policy and practice areas as benchmarks of LGBTQ+ inclusion in senior housing settings.

3 Tiers of Recognition

LEI participating communities have the opportunity to achieve one of three Tiers of Recognition based on the extent in which they’ve implemented best practices set by the LEI 2023 Criteria. All communities that have foundational LGBTQ+ inclusive policies and practices (Criteria 1) are eligible for a tier of recognition. See below for more information about each of the three LEI tiers of recognition.

Executive Summary

The LEI 2023 represents the first validated survey on LGBTQ+ inclusion in long-term care and senior housing communities.The Human Rights Campaign Foundation and SAGE are excited to present this report on the 200 communities from 34 states that actively participated in the LEI 2023 survey.

LEI 2023 Participants at a Glance

23K+ residents

17K+ employees

Unapologetically Inclusive

United Church Homes (UCH) provides housing and healthcare for older people through more than 90 senior living communities across 15 states and in two Native American nations. These include independent living, assisted living, memory care, skilled nursing, and rehabilitation along with affordable housing. With roots in the early part of the last century, UCH remains deeply connected to the United Church of Christ (UUC). The current President and CEO, Rev. Kenneth V. Daniel, is an ordained UCC minister and 75 percent of UCH’s board must be UCC members.

The UCC denomination has a strong history of being open and affirming to LGBTQ+ people. And that became highly relevant when, during a 2010 UCH board strategic planning session, the consultant asked, “What makes you different from your competitors?” One answer immediately stood out as a powerful differentiator: “We’re open and affirming.” And that began the official process of UCH fully embracing LGBTQ+ inclusivity. In the 2011 search for a new leader, the search committee ensured that every candidate was fully supportive and by 2012, the UCH board unanimously voted to become “Open and Affirming.”

In 2012, UCH partnered with SAGE for an initial round of education of board and staff. They reintroduced SAGECare training in 2017 and eventually became the fourth multi-state organization to take part in the SAGECare certification process. Now there are different training modules in the electronic educational system that are designated for specific employee positions. The goal is to ensure that frontline staff, middle-management, and executive staff are trained, with executive staff completing a special four-hour in-person training.

UCH’s website makes the company’s commitment to LGBTQ+ inclusion crystal clear. Their website includes images of LGBTQ+ couples and the About Us section titled, “We Welcome Everyone” states in part, “We invite people to come as they are, providing a safe and welcoming environment that is open and affirming to anyone who walks through our doors. The communities of United Church Homes are open to everyone, regardless of race, gender expression or sexual identity…”

The UCH career website flat-out says, “We’re unapologetically inclusive. Deal with it.” The goal there is to attract millennial (and older) employees who fully expect to work at a place that affirms all sexual orientations and gender expressions. It works. UCH has seen an increase in the number of employees who say they were attracted to UCH because either they or a family member is gay.

The other affirming measures matter, too. A simple rainbow flag sticker on the front door let one resident know that this was the right place to choose, as it meant her gay son—her primary caregiver—would be welcome in her new home.

Then, there are stories like this one, that make it abundantly clear that these efforts have extraordinary and unexpected effects. In a rural community, a very reticent resident had been meeting regularly with the chaplain as his health declined. One day, the resident said, “I’m going to share something I have never told anyone. My son who died in the 1980s died of AIDS. No one in this town knows.” The father had been living in silence for 40 years with his grief. With this conversation he was able to receive affirmation that his son was loved and hear a blessing on their relationship.

UCH has dedicated over ten years to being an “Open and Affirming” community to older LGBTQ+ people through education, inclusive policy, and best practices. Now by participating in the Long-Term Care Equality Index (LEI), UCH has a tool to measure and strengthen their LGBTQ+ inclusion efforts over time. As shared by UCH Administrator, Jeremy Lemon, “participating in the LEI is important because it gives us the opportunity to gauge how well we are ‘walking the talk.’ While working through this process, it occurred to us that while we have been on this journey for years and have made great progress in serving LGBTQ+ older adults, family members of our residents who are part of the LGBTQ+ community, and our LGBTQ+ staff members as an open and affirming organization, that there was still work to be done. The LEI is an important measuring stick as well as a compass for us as we continue to improve our ability to care for this special population.”

Welcome Home

Jan Carver and Norma Long met in 1986 and have been together ever since. Starting off as a long-distance relationship, Jan and Norma drove every other weekend between Pittsburgh, PA and Towson, MD. When given the opportunity, Jan relocated to be closer to Norma. They married in June 2004 in Canada and for over 40 years, Jan and Norma have made Towson their home.

Like many people, Jan and Norma want to spend their retirement years near their friends and family while also making sure their future care needs are met. A former engineer and a retired academic, respectively, Jan and Norma took a methodical approach to choosing a senior living community. With a notebook, selection criteria, and 4-6 communities in mind, Jan and Norma took multiple tours and site visits across the area.

“We wanted a database that we could search to find the information [HRC Foundation and SAGE] are beginning to put together. We had to do this [search for an inclusive community] “door-to-door” and there was no way we could get a sense without immersing ourselves in it…I’m glad that HRC is doing something that can help other people.”

Initially, Jan and Norma assumed they’d end up at a known LGBTQ+ inclusive community located outside of Baltimore. However, when visiting the campus, it was apparent that the sprawling layout, while beautiful, would be an additional challenge and barrier to navigate. Thinking of their current and future mobility needs, it was important to both women to have more direct access to the gym, dining room, and activities.

When visiting a friend at Edenwald, Norma suggested the two of them take a tour. When completing their resident interview with Diane, Director of Sales at Edenwald, Norma made a point to ask how LGBTQ+ friendly the organization was. She asked, “Will we become a problem? The fact that we are a couple, will that be a problem for Edenwald?” Quicky and emphatically Diane expressed, “absolutey not and if you ever, ever feel it becomes an issue let us know.”

After hours of visits, conversations, and pros and cons lists, Edenwald, a community located in the heart of Towson was the winner. “People are friendly, people are welcoming, people are accepting of who you are, where you came from, what your deal is. It feels very comfortable and it continues to feel that way,” shares Norma.

Edenwald is a vibrant retirement community located in the heart of Towson, Maryland, near Baltimore. Offering first-class residential living, services, and amenities, Edenwald provides additional care on-site such as assisted living, comprehensive nursing care, and memory care. Residents select from two types of contracts to cover their stay and care: Life Plan & fee-for-service.

A locally owned and operated not-for-profit, Edenwald’s history of caring goes back more than a century. Founded in June 1881 as the General German Aged People’s Home of Baltimore, and later the Greisenheim, the community was first known for providing quality care for older German citizens. As the aging population grew and diversified, so too did Edenwald’s resident population and campus. Moving to its current site in 1985, today, Edenwald is home to over 380 residents who are supported by over 300 staff members.

“At Edenwald, we are a family and we stand as a family. We will speak out against injustice and will ensure that our staff, our residents and anyone associated with our organization feels valued, respected and appreciated,” writes David Brown, Chief Information and Equity Officer. Over the past year, Edenwald has taken concrete steps towards equity through the formation of a Diversity, Equity, and Inclusion Committee, designation as a Baltimore County Policy Department’s “Safe Space for the LGBTQIA+ Community,” updated their guidelines and policies with inclusive language, and participated in the LEI.

David Brown began his work at Edenwald in the IT department over ten years ago. Today, he oversees the information and equity needs of Edenwald. DEI-Certified, David chairs the Diversity, Equity, and Inclusion Committee made up of Edenwald residents, staff members and board members.

Why is providing LGBTQ+ inclusive care important to Edenwad?

Providing LGBTQ+ inclusive care is important to Edenwald because it speaks to our organizational values of respecting all people and helping them to live their best lives, so whether it be the resident population we serve, or our team members who dedicate their lives to our mission, we want the services we deliver to speak loudly to what we stand for as an organization. We also understand the challenges and barriers the LGBTQ+ community can encounter when accessing care. LGBTQ+ inclusive care encompasses more than just health needs; we also focus on creating an environment that is respectful, understanding and accepting which improves the overall well-being of members in the LGBTQ+ community.

What are the benefits of providing an LGBTQ+ inclusive housing community?

Because we already serve the LGBTQ+ community, we knew that it was important to speak more directly to the importance of inclusive and supportive housing for this population. Providing LGBTQ+ inclusive housing benefits our residents and their families, team members, visitors and our surrounding community by showing that we are a safe, supportive and welcoming space, where everyone can live their lives authentically. At Edenwald, we want everyone to know that they belong, which helps to reduce isolation and feelings of loneliness.

Why is participating in the LEI important to your organization? What is the benefit?

Edenwald’s participation in the LEI is important because it affirms our unwavering commitment to embrace every individual for who they are, regardless of sexual orientation or gender identity. The benefit of participating in the LEI is that our community knows that we have not only implemented policies, but we have taken actionable steps that are supportive of these policies, which reinforce and celebrate LGBTQ+ inclusion.

Advancing Health Equity

New York City is home to the largest LGBTQ+ population in the United States and NYC Health + Hospitals (NYC H+H) is the largest public health care delivery system in the United States. NYC H+H is dedicated to providing the highest quality health care services to all New Yorkers with compassion, dignity and respect, and regardless of immigration status or ability to pay. It is an integrated network of hospitals, community-based health centers, long-term care and rehabilitation facilities, home care services, correctional health services with a health plan, MetroPlus. Their diverse team of health care professionals – 45,000 strong – provide culturally responsive care to more than one million patients every year in more than 70 patient care locations across the five boroughs of New York City.

As a safety net health system, NYC Health + Hospitals is committed to making health care accessible and affordable. They focus on health and wellness with an emphasis on keeping communities healthy, not just treating injury or illness. They advance health equity by consistently addressing social determinants of health, ensuring workforce diversity and creating models of care that remove barriers for special populations experiencing a disproportionate burden of illness. Their skilled clinicians offer the full continuum of care including primary care, urgent care, behavioral health and specialty services in every area of medicine to improve the health of the communities served and help all New Yorkers live their healthiest life.

NYC Health + Hospitals was the first U.S. municipal health care system to mandate LGBTQ+ training for all staff members in 2011. Over a decade ago, NYC Health + Hospitals/Metropolitan became the first municipal hospital to open a health care center dedicated to the needs of LGBTQ+ patients. Today NYC H+H has seven of these Pride Health Centers. When the Office of Diversity and Inclusion was established in 2016, the LGBTQ+ portfolio was folded into the office to offer a centralized and coordinated approach to meet the needs of LGBTQ+ New Yorkers. At that time, the first Associate Director of Gender Equity was hired to focus on ensuring that the health system’s policies and practices are congruent with meeting the needs of, and creating affirming space for, members of the LGBTQ+ community.

As of 2022, all 18 of NYC Health + Hospitals’ eligible facilities have earned the Human Rights Campaign Foundation’s “Leader in LGBTQ Healthcare Equality” designation — a recognition they have received every year since 2015, so it was a natural progression for NYC H+H’s five long-term care facilities to participate in the first Long-Term Care Equality Index survey.

Throughout NYC Health + Hospitals, policies and procedures have been reviewed to make sure they are inclusive. The required staff training program is strong. Everyone, including long-term care staff, participates in annual training which incorporates LGBTQ+ best practices. In addition, there is a wide array of online training modules that staff can take in a self-directed fashion. If staff choose, they can even seek a Certificate of Advanced Training in LGBTQ+ Health Care, which is issued jointly between NYC Health + Hospitals and The Fenway Institute at Fenway Health (an LGBTQ+ health care, research, and advocacy organization headquartered in Boston). All of the trainings were developed in collaboration with subject matter experts and have been vetted by individuals with lived experience. NYC Health + Hospitals has been intentional about making sure those voices are embedded and heard in all training materials.

Ivelesse Mendez-Justiniano, Interim Chief Diversity & Inclusion Officer at NYC Health + Hospitals states, “the mission of NYC Health + Hospitals is to deliver high quality health care services to all New Yorkers with compassion, dignity, and respect, regardless of income, gender identity, or immigration status. To remain true to our mission we must ensure that we meet the needs of our LGBTQ+ patient population. This can be achieved via the provision of continuous education and increasing the levels of awareness for staff in areas such as Health Equity, Allyship, Inclusion, and Unconscious Bias. Staff at all levels need to join in the journey towards inclusivity. In support of this, the leadership at NYC Health and Hospitals is committed to providing our staff with the tools and learning needed to ensure our LGBTQ+ patient population receives an optimal patient experience every time they walk through our doors.”

The Long-Term Care Equality Index 2023 asked participants a series of questions about LGBTQ+ inclusive policies and practices in senior housing. Those questions are divided into four criteria sections.

• Criteria 1: Non-Discrimination and Staff Training
• Criteria 2: Resident Services and Support
• Criteria 3: Employee Benefits and Policies
• Criteria 4: Resident and Community Engagement

Responses to the criteria are reported in aggregate to indicate national trends and facilitate benchmarking. More information about how each participating community responded to these criteria can be found online in the LEI search tool.

Resident Non-Discrimination

The first section of the LEI Non-Discrimination and Staff Training criteria calls for a written resident non-discrimination policy (or residents’ bill of rights) that includes both “sexual orientation” and “gender identity.” LGBTQ+ people experience many forms of discrimination in senior housing care because of their sexual orientation and/or their gender identity or expression. An explicitly LGBTQ+ inclusive resident non-discrimination policy can do much to reduce the discrimination that LGBTQ+ residents experience and fear. Learn more about this criterion in the LEI Resource Guide.

96% of LEI participants with an LGBTQ+ inclusive resident non-discrimination policy documented that the policy is readily accessible and communicated to patients in at least two different ways and documented that the policy is readily accessible and communicated to staff in at least one way.

Equal Visitation

The second section of the LEI Non-Discrimination and Staff Training criteria calls for a written visitation non-discrimination policy or an equal visitation policy. The federal government requires that all long-term care communities that accept Medicare or Medicaid payments ensure that residents are granted certain rights and protections, including the right to spend time with visitors of their choice. Learn more about this criterion in the LEI Resource Guide.

82% of LEI participants with an equal visitation policy documented that the policy is readily accessible and communicated to patients in at least two different ways and documented that the policy is readily accessible and communicated to staff in at least one way.

Employment Non-Discrimination

The third section of the LEI Non-Discrimination and Staff Training criteria calls for an employment non-discrimination policy (or an equal employment opportunity policy) that includes both “sexual orientation” and “gender identity.” LGBTQ+ people continue to face discrimination in employment because of their sexual orientation and/or gender identity, creating a need for explicit non-discrimination policies. Learn more about this criterion in the LEI Resource Guide.

88% of LEI participants with an LGBTQ+ inclusive employee non-discrimination policy communicated the policy publicly.

Staff Training in LGBTQ+ Resident-Centered Care

The fourth section of the LEI Non-Discrimination and Staff Training criteria calls for key facility employees to receive expert training in LGBTQ+ resident-centered care. This criterion recognizes that training is critical for policies to be successful and for LGBTQ+ residents to feel welcome. Learn more about this criterion in the LEI Resource Guide.

There are also some policies and practices where there is significant room for growth. For example the following policies could be made LGBTQ+ inclusive with the thoughtful addition of sexual orientation and gender identity to the enumerated lists of protected residents.

For more information about best practices for care of transgender residents see the publication, Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, from HRC Foundation, Lambda Legal, and the LGBT Rights Committee of the New York City Bar Association. While created for hospitals, these sample policies can easily be adopted for any residential care setting.

Equal Benefits

Competitive employer-provided benefits packages are critical to attracting and retaining talent. Providing LGBTQ+ employees and their families with inclusive benefits, from healthcare coverage to retirement investments and more, is a low-cost, high-return proposition for businesses. HRC Foundation and SAGE strongly urge employers to maintain domestic partner benefits for their workers as a sign of sustained commitment to family diversity, inclusion and protection of LGBTQ+ employees whose rights outside the workplace are not guaranteed under law in many states. Domestic partner benefits ensure that all employees will be treated equally.

Other Support for LGBTQ+ Employees

In addition to providing equal benefits, there are a number of other ways that employers can be inclusive of and supportive of their LGBTQ+ employees.

Transition Guidelines

In addition to ensuring healthcare coverage for gender-affirming care, one of the most important policies an employer should have is a set of written gender transition guidelines that document the necessary policies and practices in place to support a respectful and successful workplace transition.

The HRC Foundation’s Transgender Inclusion in the Workplace: A Toolkit for Employers is a comprehensive resource to guide employer transgender inclusion. The toolkit includes HRC’s best practice advice for implementing transgender-inclusive policies and practices (including sample policies) as well as guidance for implementing transgender-inclusive healthcare benefits.

While marketing and advertising to the LGBTQ+ community can be an important outreach tool, a long-term care or senior housing community should not do this without first ensuring that it has the foundational policies and practices in place for LGBTQ+ inclusion. During the LEI research and survey review process it was not uncommon to find that a senior housing community would include LGBTQ+ visual symbols like a pride flag on their website to indicate that they were inclusive, yet upon review of their non-discrimination policies we found that they had not been updated to be LGBTQ+ inclusive. We encourage older LGBTQ+ people or those caring for them to look beyond the website symbols and ask a community about the policies and practices that make them LGBTQ+ inclusive. Learn more in our consumer guide on Finding an LGBTQ+ Inclusive Long-Term Care Community.

The LEI Advisory Council

Members of the Long-Term Care Equality Index Advisory Council serve as key advisors in the development and implementation of the LEI. The Advisory Council is made up of a diverse selection of senior housing professionals, aging advocates and LGBTQ+ advocates from across the country.

The LEI Team would like to thank Jerry Brown, Joan Devine, Cassandra Leggett-Coulbourne, and Yasemin Washington for their past service to the LEI Advisory Council.

The LEI Team

The Long-Term Care Equality Index is a project of the Health & Aging Program at the Human Rights Campaign Foundation and Sage.

Special Thanks

Thank you to HRC Foundation Senior Vice President Jay Brown, HRC Foundation Senior Director, Programs and Corporate Advocacy, Eric Bloem, and Senior Director of Programs & Partnerships, Ellen Kahn, for their continued support and guidance.

Thank you to SAGE Chief Executive Officer Michael Adams, Executive Vice President, Lynn Faria, Chief Experience Officer, Christina Da Costa, and Acting Chief National Initiatives Officer, Hector Vargas, for your visionary leadership and guidance. A special thank you to the entire SAGECare team, Alex Kent, National Projects Coordinator, Karen Cushing, SAGECare Business Development Manager, Nicholas Watson, Managing Director of Social Enterprise, Nicole Paggett, Assistant Director of Data Strategy, and Sadiya Abjani, Director of Training and Instructional Design for their support in developing and hosting the LEI Executive Briefing and promotion of the LEI among SAGECare Credentialed Long-term Care Communities.

Thank you to the HRC’s Data and Analytics Team for all of the assistance in maintaining the LEI data with a special shout-out to Alec Carrasco, who always finds a way to make it work. Thanks to the team at Heller Consulting who built the database behind the LEI and continue to help us improve upon it.

Thank you to past SAGE and HRC Foundation interns and volunteers Morgan Van Vleck and Lillie Levin for their contributions.

Thank you to Robert Villaflor, Josette Matoto and Tarine Wright for design guidance and support.

The LEI 2023 was designed by Tony Frye Design.

Our Funders

The HRC Foundation and SAGE are grateful for the support of these funders.

Why Participate?

• Provide high-quality welcoming environments to LGBTQ+ residents and assurance to their care partners

• Public recognition as a leader in providing LGBTQ+ welcoming services

• Access to best practices for LGBTQ+ diversity, equity, and inclusion

• Access to education and resources for serving LGBTQ+ residents

• Technical assistance

• Improved ability to develop LGBTQ+ culturally appropriate marketing for future staff, clients, and funders

What Organizations are Eligible?

• Skilled Nursing Communities

• Assisted Living Communities

• Independent Living Communities

• Memory Care Communities

• Life Plan/Continuing Care Retirement Communities

• Free-standing Hospice Facilities

• Affordable Senior Housing

Steps to Participate in the LEI

Register to Participate