CULTURALLY COMPETENT CARE FOR OLDER SEXUAL MINORITY ADULTS: A SYSTEMATIC REVIEW FOR HEALTHCARE DELIVERY

Abstract Recent attention to culturally competent care has largely overlooked the needs of older LGB adults. To address this, we conducted a systematic literature review and make recommendations for how the healthcare workforce can reduce sexual-orientation-based disparities. We searched PubMed, PsycINFO & CINAHL for manuscripts 1/1/10-6/19/18 (n=799), deduplicating, dually-screening abstracts (n=80), reviewing full-text articles (n=44), and classifying relevant articles (n=27) into five domains of cultural competency and associated recommendations: 1) Physical environment: display pictures with older same-sex couples and LGB-identified symbols; 2) Education/staffing: expand to include older-specific LGB issues, especially for key conditions (e.g., cancer, dementia,) and hire LGB-identified administrative/clinical staff; 3) Inclusive language and communication: review terminology on forms, electronic health records, and used with patients to ensure a broad range of terms (e.g., partner/spouse) and note older LGB may have more limited understanding/comfort with terminologies (e.g., self-identify as ‘something else’ instead of ‘gay/lesbian’ or ‘bisexual’); 4) Patient histories: discuss how factors particular to their sexual orientation (e.g., level of outness) may affect their support networks; 5) Subgroup differences: consider specific health concerns by sexual minority subgroups (e.g., healthy weight for lesbian women, HIV for gay men, and negative health outcomes for bisexual adults related to their simultaneous isolation from sexual minority and heterosexual communities) and note additional challenges based on characteristics such as race/ethnicity and urbanicity. Cutting across these domains are the ways in which local and national policies affect healthcare access and surrogacy (e.g., legality of same-sex partners to obtain health insurance, participation in medical decision making/visitation).


IMPROVING HEALTH CARE OF LGBT OLDER ADULTS: INTERDISCIPLINARY PROJECT ENHANCES HEALTH OUTCOMES
Noell L. Rowan, 1 Stephanie D. Smith, 1 Tamatha Arms, 1 and Kris L. Hohn 1 , 1. University of North Carolina Wilmington, Wilmington, North Carolina, United States To date, there is a dearth of interdisciplinary simulation education and research that involves LGBT older adults within schools of social work and nursing. The purpose of this mixed method study was to examine the use of an intervention among social work and nursing students to determine if lecture and simulations impacted their health-related knowledge and cultural sensitivity/awareness of health provisions with LGBT older adults. Interprofessional faculty created lecture and interdisciplinary simulations with actual members of the older LGBT communities using simulation clinic/lab and health care scenarios. An adapted survey with permission from Grubb et al (2013) was used to include quantitative and qualitative measures of cultural awareness with LGBT populations. Pre-Post test data were analyzed using Generalized Linear Models in SAS software. Results indicated that the intervention positively changed perceptions and increased knowledge among (N=90; 32 social work; 58 nursing) allied health students. Statistically significant change experiences in their work with LGBT individuals were noted to positively alter their beliefs about sexuality, gender identity, and sexual development (Agree to Strongly Agree, X2(1)=26.51, p<0.001). Qualitative findings include four primary themes about how gender identity and sexual orientation influences health: (a) bias of health care providers, (b) access to quality care, (c) specific health care needs, and (d) health risks of LGBT older adults. As older adults continue to be the largest population needing health care, it is imperative that professionals are trained to give culturally sensitive health care and demonstrate this competency in their practice and interpersonal interactions with clients.
LGBT Older sexual and gender minority adults in rural communities face challenges in accessing formal health, mental health, and long-term care services (Butler, 2017;Koch & Knutson, 2016;Stein et al., 2010). Formal service providers in rural Southern Appalachia are more likely to have conservative values that are closely linked to their religious beliefs (Keefe, 2005). Some may be opposed to gender non-conformity and same-sex relationships or marriage, making it wise for LGBT older adults in rural contexts to carefully select formal service providers and settings (Willging et al., 2006). Barriers to accessing formal services for LGBT older adults residing in rural contexts include few LGBT-inclusive service providers and facilities, transportation, cost, and health insurance (Butler, 2017). When faced with the prospect of long-term care, older LGBT adults are more likely to conceal their sexual or gender identity due to fears of being mistreated (Brotman et al., 2003). This session will present results of a qualitative study examining experiences, concerns, and recommendations regarding formal services among 11 LGBT older adults residing in rural southern Appalachia. Several of the participants described experiencing discrimination from local service providers. A number of participants were fearful about the perceived lack of LGBT-inclusive services in the area and expressed that they would consider leaving the area if their own or their partner's health declined. Many participants expressed the need for local provider education about the needs of LGBT older adults. The presenters will discuss the implications for research and for health, social, and long-term care services.

SOCIAL ISOLATION AMONG LGBT OLDER ADULTS: LESSONS LEARNED FROM A PILOT FRIENDLY-CALLER PROGRAM
Angie Perone, 1 Berit Ingersoll-Dayton, 1 and Keisha Watkins-Dukhie 2 , 1. University of Michigan, Ann Arbor,Ann Arbor,Michigan,United States,2. SAGE Metro Detroit,Detroit,Michigan,United States Lesbian, gay, bisexual, and transgender (LGBT) older adults face heightened risks of social isolation, given decades of discrimination. Research on telephone buddy programs with non-LGBT participants have proved predominantly unsuccessful at addressing social isolation and have found the greatest success with same-age matches. However, evidence suggests that LGBT adults may actually benefit from telephone buddy programs and in ways uniquely different from other groups. This article shares lessons learned from 30 participants across a 12-month pilot program that matched LGBT older adults to both LGBT and non-LGBT volunteer callers of various ages. One-third of participants identified as African American or Black. This project employed community-based participatory action research to identify, execute, and evaluate the program. Data includes information from questionnaires and telephone interviews prior to and during the program. In contrast to other research, data here revealed strong support for intergenerational matches.
LGBT older adults of color especially benefited from program referrals and matches with/from LGBT adults of color, regardless of age. While the project aimed to capture two groups (LGBT older adults experiencing isolation and volunteer callers), the project revealed a third group: LGBT adults at risk of social isolation. This third group usually emerged among the "volunteer" callers but also identified concerns and risk factors for social isolation. The program also revealed unexpected benefits to both LGBT and non-LGBT volunteers, including less loneliness and a stronger sense of community. This article concludes with recommendations for developing similar programs to reduce social isolation in the LGBT community.

THE MANIFESTATION OF MULTI-LEVEL STIGMA IN THE LIVED EXPERIENCES OF TRANSGENDER OLDER ADULTS
Vanessa Fabbre, 1 and Eleni Gaveras 1 , 1. Washington University in St. Louis, St. Louis, Missouri, United States Transgender and gender nonconforming (TGNC) older adults experience disparities in mental health outcomes when compared to non-TGNC sexual minority older adults. Stigmatizing experiences are thought to influence these outcomes, but little is known about this process. Recent conceptualizations of stigma draw attention to multiple levels -individual, interpersonal, and structural -experienced by TGNC people of all ages. To explore how multi-level stigma manifests in the lives of TGNC older adults, we conducted a two-phase qualitative content analysis of in-depth biographical interviews with 88 TGNC adults aged 50 and older, from across the United States. Data were obtained from the photography and interview project To Survive on This Shore. Our interpretive analyses suggest that TGNC older adults' development and well-being are impacted by multiple levels of stigma, which are dynamic and unpredictable, resulting in constant awareness of a changing social environment. Individual level stigma is experienced as ongoing vigilance about aspects of oneself that break gender norms, which is also marked by self-imposed social isolation and fears about accessing older adult services. At the interpersonal level, TGNC older adults navigate unpredictable interpersonal relationships, which manifest as fluctuating levels of love, acceptance, strain, and exclusion. Structural stigma manifests in the awareness of stigmatizing policies and systems but also in the conscious action of TGNC older adults to resist these structures. TGNC older adults promote supportive structural responses to stigma to both improve conditions for younger generations while also reducing experiences of individual and interpersonal stigma for themselves. Although several states have implemented Value Based Reimbursement (VBR) systems in long-term care; little is known of their impact. In 2016, Minnesota passed new VBR legislation to tie payment to quality with increased funding earmarked for nursing and other care-related services. We evaluated the effect of the policy change on care-related expenditures and measures of care quality. Data sources were cost reports and quality measures for the years 2013-2017 from 348 Minnesota nursing homes. Analysis consisted of descriptive tables, time plots, and linear growth curve modeling. We found increased expenditures for nursing and care-related services, particularly nursing assistants, during the first year; while quality metrics did not appear to be impacted by the policy change. Some differentiation was seen across facilities in their response to the policy change based on occupancy rate, rural-urban continuum code, attachment to a hospital, and resident acuity. The lack of an improvement in care quality might be attributable to VBR design as the quality incentive affected very few facilities. Additionally, there is the challenge of improving quality metrics even with additional resources. The legislature is currently considering changes to VBR policies in response to the report from this study.