Nursing Careplans

- as the affordable careact begins its second year in major outreach effort isfocused on the lgbt population. how our healthcare providersmaking the transition from coverage of lgbt patients to care. kellen baker is a nationally known expert on trans in the lgbt health care. he will share insightsalong with barbara warren who directs mount sinai bethisrael's lgbt health services. kellen, barbara.

(audience applauding) - thank you. fabulous. good morning everybody. thank you for taking thetime to attend this session. as you heard, my name is kellen baker. i'm with the center for american progress which is i think tankbased in washington, d.c. i'm based here in new york

and i do a lot of travelingaround the country to talk about lgbthealth and in particular the affordable care act and some of the changesthat the law is making with regard to lgbt populations. first of this morningthough, i know many of you in this room do this work already, however there is a lot ofterminology that gets used and i know that folks may not be familiar

with what seems to bethe latest and greatest. all those words that keepgetting tossed around in the new york timesarticle's about how children are thinking about changing their gender. how young people aretransitioning and how older folks, has anyone seen transparent? come on, nobody? you've heard of it? it's really good and i don't watch tv,

so that's a ringing endorsement. just to make sure we'reall in the same page. lgbt stands for lesbian gaybisexual and transgender. sexual orientation, lesbian, gay, bisexual and to be honest, straightis not just about sexuality or who you're attracted to. it's about who you love,who you make a family with and who you consider your support system especially in a contextlike a healthcare setting.

gender identity is aperson's internal sense of being male, female or another gender. just like sexual orientation, everyone has a gender identity regardless of whether or notyou identify as transgender, you do have a gender identity, and regardless of whetheror not you identify as lesbian, gay or bisexual, you do have a sexual orientation.

gender expression is themanner in which a person represents or expresses theirgender identity to others. that's your hair, yourclothing, your mannerisms, your name, et cetera. transgender terminology because i know that this is something that people frequentlyfind fairly confusing. transgender refers toa person who's identity or expression is differentfrom what's typically

associated with theirassigned sex of birth. assigned sex of birth just means the sex that's on theiroriginal birth certificate. how many in here havemet a transgender person? look at you all, all right. that means i don't even have to come out to give the rest ofyou a bump up and over. (audience laughing) transgender people might be somebody

that you could see clearlywalking down the street or they could look like me and you may not know unless they tell you that they actually are transgender. a trans man like me issomeone who is assigned the female sex of birth but lives and identifies as a man. people may change different documents. they may have documents that say f on one

and m on another that have different names and different photos. for lucky people like me who have a lot of socioeconomic privilege, i've been able to changemy driver's license, my passport, my social security record and my birth certificate. most transgender peopleare not that lucky. a trans woman is a person who is assigned

the male sex of birth but who lives and identifies as a woman. talking about how manylgbt people there are because we frequently hear that this is something of a numbers game. there have to be enough of us in order to justify some focus on us. i would dispute the premise of that because i think we're all important.

each of us has our ownindividual experiences and identity and it's important to take that into considerationno matter who we are but it is pretty interestingthat my phone is now going off because that's incredibly rude of me. thank you, barbara. it is pretty interestingthough that if you look at what are the most recent andmost conservative estimates, these are the smallest possible estimates

that we're working with right now, at least eight millionpeople identify as lg or b and at least 700,000identifies transgender. that means that again, according to the mostconservative estimates, there are at least ninemillion lgbt people living in every corner of this country and for context, ninemillion lgbt americans. my wife was just calling,

her ears must have been burning. she's from new jersey and nine million people is just about the size of the population of new jersey. looking at the experiences of lgbt people, unfortunately we know that being lgbt is frequently associatedwith various disparities. some of the ones thatwe know the most about include higher rates of tobacco

and other substance use. higher rates of mental healthconcerns such as depression and suicidal ideation especially for transgender people. certain cancers such as breast cancer are more common in the lgbt population. experiences of bullying and violence whether in the home, atschool, at the workplace or even while walking down the street

and of course the continuedburden of the hiv/aids epidemic on the lgbt population particularly among gay and bisexual men, and other men who have sex with men, as well as transgender women of color. some of the reasons for theselgbt health disparities, they don't just come out of nowhere, they are unfortunately the products of factors that are builtinto the very foundations

of our society and the way that our systems assignvalue to different people. some of the reasons forlgbt health disparities include anti-lgbt bias and discrimination. that can be overt in aperson to person encounter or it can be systemic, againbuilt-in to the foundations of how our systems interact with different groups of people. some other ones that iwant to point out to you

include poverty, contraryto popular stereotypes, lgbt people are actually more likely than the general populationto be living in poverty. this is particularly truefor parents, for women, for lgbt people of colorand for transgender people. transgender people in particular are four times as likelyas the general population to have incomes under $10,000 a year. another reason that i'm going to talk

a little bit more about islack of insurance coverage and down there on the bottom right, a lack of lgbt cultural competence. looking at some of the experiences that lgbt people havein healthcare settings, this is from a study that was done in 2009 by lambda legal. it's called, when healthcare isn't caring. you can see here some of the experiences

of lesbian, gay, and bisexualpeople, the blue bars, transgender people, the yellow bars and people living with hiv, the gray bars. across the board, highrates of people reporting, i was refused the healthcare that i needed because of who i am. health care professionalsrefuse to touch me or use excessive precautions. health care professionals used harsh

or abusive language and even health care professionals were physically rough or abusive. you can see there fortransgender people in particular, almost 8% reporting that they encountered overt violence in a healthcare setting because of who they are. looking again in a little bit more, focus on anti-transgender discrimination,

the blue bars here are transgenderand gender nonconforming, so folks who for whatever reason look like they are either transgender or for some reason donot accord with the norms of masculinity or femininitythat folks would expect from what's on their id card. you can see my provider wasunaware of my health needs, clinical competence inworking with lgbt people. more than 65% of trans peoplesaid that their provider

didn't know what to do with them. you can see all the way down,treating me differently, providing me with worstcare, refusing care. again, harsh language, blame for why you need health care today or even physically rough treatment. looking at insurancecoverage in particular, i had mentioned this earlieras one of the drivers of lgbt disparities.

this is from some research that we did at the center for americanprogress last year. in 2013, this is lookingat folks with incomes under 400% of the federal poverty level. those who are eligiblefor financial assistance to get coverage underthe affordable care act. 15% on medicaid, 12% on medicare, only 29% with employer sponsored coverage. that's compared to 58%employer sponsored coverage

for non-lgbt people. over there, the big red wedge, 34% of these lgbt people are uninsured. some of the reasons whypeople are uninsured or some of the reasonswhy people stay away from health care, theseare from some focus groups that we did associated with this research. a transgender man saying,"you can't be healthy "if you have to hide who you are

"or if you think youhave to hide who you are "because you don't know if it's safe." from a transgender woman talking about health care providers, "we are the group thatthey don't talk about "or the group that theydon't want to talk about." fortunately there's a lot happening on the national policy level in particular that's giving us a lot oftools to start addressing

lgbt health disparities andstart making the experience of getting covered and getting health care better for lgbt people. some of these i apologizethat they're so small because actually this, i would hope is a very useful slide for many of you who may be familiar with some of these national policy initiativesbut perhaps not all. healthy people 2020 which came out in 2010

includes an entire topicarea on lgbt health. a great resource for information about some of the basic disparities that lgbt people encounter. the institute of medicinehas done two reports over the last four years on lgbt health. one, about lgbt healthdisparities generally and the second aboutelectronic health records and the collection of lgbt data.

the joint commissionpublished a monograph in 2011 that talks about patient centered care for lgbt people and their families. it's available online at thejoint commission's website. samhsa, the substance abuse in mental health services administration which was the first division of the us department ofhealth and human services to put out a comprehensive resource,

addressing lgbt disparities and the agency for healthcare research and quality puts out its annualhealthcare disparities report which a couple of yearsago started including data on lgbt disparities as well. the national lgbt health education center based at the fenway institute in boston provides technical assistanceto health care facilities, particularly community health centers

wanting to work better with lgbt patients and the new class standards. are folks familiar with the class? any hands, folks familiar,know what we're talking about with the class standards. okay, so the classstandards are the culturally and linguistically appropriateservices standards. they're published by the usoffice of minority health. they serve as the federalgovernment's guidelines

for cultural competency. the class standardsthemselves are about 13 or 14 bullet points talkingabout how to make sure that care is patient centered especially for folks coming from various diverse backgrounds. in 2013, hhs updated the class standards and included sexualorientation and gender identity as aspects of patientidentity and experience

that need to be taken into account by facilities implementingthe class standards and providing care todiverse groups of patients. those are also availableonline at the office of minority health website. of course i would be remissif i didn't talk about what you may all have come here to hear me talk expressly about which is the affordable care act.

this is secretary sebeliusspeaking at the launch of the out and rollinitiative in september 2013 at the white house sayingthe affordable care act may represent the strongest foundation we've ever created to beginclosing lgbt health disparities. some of the reasons thatthe affordable care act is particularly usefulfor lgbt individuals include nondiscrimination. the affordable care act includes

a comprehensivenondiscrimination provision that at this pointincludes gender identity and sex stereotyping. it may soon include sexualorientation as well, the department is workingon those regulations and there are already regulations in place that mandatenondiscrimination on the basis of sexual orientation and gender identity in the marketplaces by insurers

and by anyone who's workingwith the marketplaces to help connect people with coverage, so navigators, in-person assisters, certified applicationcouncilors, et cetera. i will also give you a heads up that there are regulationscoming down from cms that are going toinclude this idea of lgbt inclusive nondiscriminationin all facilities that are accepting federal dollars,

so medicare and medicaid. this is also already a requirementby the joint commission as i'm sure many of you know. fair access to quality coverage, we all know that prior tothe affordable care act and even now it's still tough to say that insurance coverage really responds to the needs of people who have coverage and who need care.

under the affordable care act, there are a couple of requirements that seek to makeinsurance coverage better. no preexisting conditionexclusions, for one. you can no longer be denied coverage because you have preexisting condition such as cancer or hiv or even a transgender medical history. prior to the affordable care act,

my entire identity wasa preexisting condition. also under the affordable care act, no medical underwriting soyour premiums do not change on the basis of your health status. you cannot be charged more for needing insurance coverage more and the essential health benefits which require coverageacross 10 broad categories of care including somethat are really important

for addressing lgbt disparities such as prescription drug coverage and mental and behavioral health services. family coverage, people whoare in same sex relationships frequently have a very tough time getting insurance coverage. the affordable care actrequires that any plan no matter what state you're in, any plan that offers spousal coverage

has to make that coverage available to same sex spouses as well. if you live in kentucky, yougo to new york to get married. you go back to kentucky andyou're looking to buy a plan through kynect, the state'shealth insurance marketplace. if that plan offers spousal coverage, you and your same sex spouse cannot be denied coverage, that's huge. last, financial assistance.

there are a variety of mechanisms to provide people withfinancial assistance in getting coverage. for the folks with the lowest incomes, that was intended to bethe medicaid expansion that hasn't yet happened in all states but there is no expiration date. state should feel freeto opt-in at anytime and actually originallythe medicaid program

was not a requirement either. it took the last state 17 years after the enactment ofthe medicaid statute to join the program. in 1982, does anyone knowwhat state finally stepped up? nope, close though. come on. close. arizona.

arizona finally joined the program as the last state in 1982. for folks with higher incomes, subsidies available on a sliding scalethrough the marketplace so that they can purchasethe coverage that they need. the reason that i talk about all of this is because with thisexpansion of coverage, there are going to be a lot more people seeking health care on a regular basis.

among them will be many lgbt people. some of the basic guidelines or principles of lgbt patient centered care, i know dr. warren is going togo into this in more detail but just to run quickly through before i go to the last one which is where i will wrap up my remarks. creating a welcoming environment, lgbt people are accustomed to feeling

like we're not welcome. we are looking for signs,signals, language, stickers, newspapers that indicate that lgbt people are welcome here. not making assumptions, not going to put anybody on the spot but i sincerely doubt that if i'd walk up to anyone of you in a health care setting that anyone would have been able to guess

that i'm transgender. also that identify as bi and also that i'm married to a woman. i'm like the gift that keeps on giving like how deep is this rabbit hole but not making assumptionsis really important because you'll never knowwhere someone's coming from. using appropriate language. i was at a meeting recently

where somebody thought thatthey were going to have a real light bulb going over their head and they were like, "i get it. "so you're a woman who ..." "no, no actually, no i'm not." language is importantand people will turn off, they will walk out if they hear languagethat disrespects them or indicates that whothey are is not understood

or not welcome in the space. being familiar with lgbtquestions and concerns, we all know there's a lotof to keep abreast of, there's a lot of different news every day, something new happening but making sure that you have a basic idea of who lgbt people are andwhat some of the concerns that we may have is really important for forging those connectionsthat facilitate care.

finally, collecting lgbt data. there's a lot of different data points that could be involved when you're talking about lgbt data in a clinical setting. some of them include sexualorientation identity. how do you identify, how would you name yoursexual orientation, your sexual attraction towhom are you attracted. not everyone acts on it

and then sexual behavior, related to that relationship status. we don't frequently thinkof relationship status as lgbt data but in fact it is because people who are insame sex relationships, that's part of being an lgbt person. transgender status, sex assigned at birth, that's important because eventhough i identify as a man, i may still need preventivecare in particular

that actually corresponds to the gender that was on my original birth certificate, so you'll never knowwhether a transgender person might need, for examplea mammogram, a pap test, a prostate exam to makesure that you're taking care of the whole person. current gender identity,this is really important. if somebody puts a recordin front of me that says sex assigned at birthfirst and it's a big f

and it's like that f is going to follow me all the way through. i'm going to go somewhere else because the importantthing to me is who i am in my body, in my day to day life. right now current gender identity is male. finally, preferred name and pronoun. i mentioned that noteveryone is able to change their documents so knowingwhat somebody prefers

to be called, whatpronoun they prefer to use and documenting that forall future encounters is really important. i will notice if i come inand the sex on my record has been changed to f. i mentioned the twoinstitute of medicine reports just quickly with regard to the data on sexual orientation andgender identity being collected. in electronic health records,

these again are bothavailable on the iom website for you perusal at your leisure. i warn you, the topone is like this thick. just put it under your pillow and just, it will sip in, it's what i do. why do these data matter? i already mentioned a little bit but these data actuallyhave a pretty wide range of utility in a clinical setting.

prevention of wellness i already mentioned making sure people get thescreenings that they need and that's not just transpeople, that's all people. sexual health, mentaland behavioral health, family support, again, sexual orientation is very much intertwined withwhat our families look like and our support systems look like. transgender status, quality control, and patient satisfaction, you can't know

how well your serving lgbt people unless you know where they arein your patient population. research, we've seenparticularly a number of places that are collecting lgbt data in their electronic health records, being able to look at those records for purposes of learningmore about lgbt patients and lgbt disparitieson a population level. meaningful use, i mentionednational policy initiatives.

are folks familiar with meaningful use? i see some nods. this may not be the most popular program in the entire world. it is the program providingfinancial incentives for practices to transitionfrom paper records to electronic records. there are three stages todate that are being over seen by hhs and just to give youa little bit of a heads up

of what may be coming down the pike. in march of 2014, thepreliminary recommendations for stage three indeedincluded that record systems that are certified under meaningful use have the capacity to collect and appropriately usedata on sexual orientation and gender identity. i think i've gone way over my time. i appreciate your patienceand will hand it now

over to dr. warren. we will be happy to answer questions after the end of dr.warren's presentation. thank you. (audience appluading) - [barbara] that's great, thanks. what do you press to move forward? - [kellen] that one there. - [barbara] that one there.

okay, great. thank you kellen. kellen and i have had thebenefit of being colleagues and friends for a long time now and every time i hear him speak, i actually learn something new and come away with itinspired, so i thank you kellen for your great work. what he didn't say isthat he's going to russia

on friday, to moscow where he has lived because he is coordinatingand implementing health conference for transgender people and providers of transgenderhealth care in russia that are coming from allover central asia and russia. there's about a hundred people coming to this event in moscow. it's really for folks inthat part of the world, some of you may be awarethere's a lot going on there

and there are a lot of prohibitions about even doing that work. i said to him before we start, i said, "are you sure you're going to be okay? "it's going to be safe,"but he's on a mission. his work has not only touched the lives of so many people in this country but he's really doingamazing work worldwide, so thank you kellen forall the work that you do,

you're incredible. he also set the stage for me and let me just take aminute because actually the credentials or my old credentials that were given at thebeginning of this talk. i've actually had it andyou'll see it on the slide. some of you might be a little bit familiar with mount sinai health system. we are now the largestprovider of health care

in the greater metropolitan area, the largest employer inhealth care in new york state. we have the largestresidency training program in the country. we have more medical residence now in our combined systemwhen mount sinai acquired what was continuum healthpartners a year ago. we are the largest providerof hiv/aids related care in the country right now,and we're in new york city.

as kellen pointed out withthe increased visibility of lgbt patients and consumers and the fact that moreand more lgbt people have access to care throughthe affordable care act and that we are one ofthe largest providers of health care in new york city. we certainly knew awhile back that we were going to havelots of lgb and t patients coming to our doors

and that the great but small fairly qualified healthcenters in new york, particularly the callen-lorde center which is an lgbt specific center and a great, great colleaguepartner and resource in no way could handlethe healthcare needs of the entire lgbtpopulation or community. one of the challenges and one of the goals in our health care systemis to do what i call

mainstreaming lgbt health, it's the 21st century and it's really time to make any door that a patient and lgbt patient walks through a door where they can accesssensitive, affirmative and not only culturally competent but clinically competent health care to meet their needs. to that end, mount sinaihas started a new office

for diversity inclusion whereinboth the medical school, the icon school andmedicine at mount sinai and we are also in the direct care system. that's huge because as isaid we have eight hospitals, a huge primary ambulatory andsub specialty care system. we have a research instituteand we have an hiv institute. we're a pretty large mainstream system and many eyes are upon us. we're training a lot, a lot of residence

and a lot of fellows. the challenge is to make ourentire system lgbt culturally and clinically competent into increase people's access to competent care and to make the patient experience the lgbt patient experiencethe best experience for them in new york city. with that there are many challenges. we're basing on a model,we started at beth israel,

i came there three yearsago to start that project and you can read my bio but i have 30 years doing lgbt health. i was excited to finally, asan advocate, really excited and as a provider, i'm a psychologist. i was really, really excited to be able to implement it finally in the system and not just tell everybody else what they should bedoing from the outside.

kellen set us up, here's thewhy eliminate disparities, improve health outcomes isour ethical responsibility to provide competentcare to all the people that we serve and you'llsee that sexual orientation and gender identity are now written in to the ethical guidelinesand ethical principles of almost every major healthcare provider association whether you're talkingabout the ama, the apa, the american nursing association,

the national associationof social workers. you name it, they'rewriting in specifically that we have an ethical responsibility to provide care without discrimination and the best care tolgb and t populations. kellen also talked about some issues around legal compliance. some of you may be awarethat in new york state, we have a sexual orientationon discrimination act

and i don't know if you come from a state where you have equal protection under law for lgbt people but wedo in new york state. that means that we cannot treatanybody with discrimination and in new york city, we haveone of the most progressive gender identity and genderexpression protective laws in our human rights law in new york city. we cannot discriminate andwe have to treat everyone according to the genderthat they identify with

and the pronouns they want to use regardless of the sexassigned to them at birth and regardless of what their physical or genital anatomy might be. then finally just the business case and i think we heardabout that this morning. it's good business. we have many, many lgbt patients. many more of them now have access to care

because of the affordable care act. we want to increase our patient revenues and we also want to keep our cost down. if we are reaching outto the lgbt community, more and more lgbt peoplewill come into our system because they'll feel like it's not only an affirmative environment and a safe environment buta competent environment. if we give them competent care,

we'll decrease theiremergency room visits, we'll decrease their hospital stays, we'll increase their health and we need to really makeour primary care system completely lgbt competent and lgbt sensitive and affirmative. how do you do this in agiant system such as ours? well here's some of thelessons i'm going to share, lessons learned, some ofthe experiences we've had

and some of the challenges. leadership support, we heardall about that this morning, i won't reiterate it. i'm happy to say that in oursystem from the ceo down, we have incredible supportfor doing the lgbt work in our office of diversity inclusion. we also had to do a lotof work reaching out to leadership in differentparts of the hospital, in different divisionsin the medical school

and to sit down withpeople and talk to them about why they thought it was important, what they thought they could do. we also didn't make an assumption that everybody was coming from a deficit. we went in and said, "whatdo you already do well?" what are the resourcesyou already think you have around lgbt health,and where are the gaps, and how can we help you feel those gaps,

and how can we help you do it better. when we first did a needsassessment in beth israel as i start building thefoundation for this program. one of the things that wewent out and asked people was not "what are we doingwrong around lgbt patients?" but we asked them, "whatare we already doing right?" what are you doing well andhow could you do it better? that really changed the way people felt about wanting to be involved in the work

that we were doing. they didn't feel likethey were being accused or put on the spot. they were asked to becontributors, participants and to be able to do thework that they're doing even better than they already do it and that made a differencein how we approached people from the top down and from the bottom up. i don't know what i just did.

can somebody help me with this? there we go. funding, that's dedicatedfunding to the initiative. you can't do this withoutputting some resources. it's not good enough just toask everybody to volunteer and to ask when you have events or you need materials or resources to have to make them yourself and xerox them on a xerox machine.

you really need to havesome dedicated funding to this effort and ithink that's common sense. buy-in, i just talked aboutbuy-in from the top down and the bottom up and again,buy-in really is about asking people to make the system better, not accusing them of being deficit or accusing them of not wanting to do this or wanting to treat patients well. designated staff, that's me.

i hope i'm going to get a few more but i'm glad to say that iwork with a team of colleagues who are really helping and that there are people identified all across our system whohave made a commitment in time and effort tothe lgbt specific effort. to have a full time,at least one full time paid point person in the systemis really, really important. it's really hard to do it.

as a volunteer thing orget your erg to do it and while they're doing allthe other work they have to do. the use of the lgbt erg and allies and we heard a lot about that this morning so i don't have to go into that anymore. necessary elements, i thinkwhat was really important is to make these efforts visible in the lgbt communities that you serve. it's not good enough justto say, to look internally,

you also have to do someoutreach externally. one of the reasons theyhired me is i have 25 years particularly in new york city. i worked for the lgbt community center, in a leadership capacity. i've worked both statewide and nationally and internationally inlgbt health care equity. i'm known and i am credible but when i came intothe system originally,

when i came in to start lgbthealth services at beth israel. one of the things i said to them is, "what is your commitment "to making sure that when i go out there "and i outreach tocommunities and i use my name "and use my credibility to bring people in "that they're going to come through a door "where they're going toget the kind of services "that we want to provide

"and that i want to represent." we had to do a lot of work and there had to be areal sincere commitment. it's not good enough to invite. i always say, "don'tinvite people to dinner "and then give them food poisoning." don't invite lgbt people to come to care and then have them haveterrible experiences because that will be worse for you

than not doing anythingat all quite frankly. access to chronology btinformation and resources, you need to know what you don't know, you need to know how to get it and you need to reach out topeople experts like kellen. there's a tremendous wealth of resources. i won't go into all of them, kellen shared some of them with you. all you have to do is put lgbt health

into a web browser these days and you'll be amazed to see what comes up in terms of resources. web based in social media resources. not only reaching outto the ones that exist but using web based training,using web based resources. i'm going to show you atthe end of this little clip that we have online. welcoming patients toour lgbt family practice

in new york city which was the first lgbt family practice in new york city that was specific to lgbt families. legal and ethical protections both internal and external. the health equality index if you're not familiar with it and you haven't used it at the human rights campaign foundation,

go online, look it up,check it out, take it. it's an incredible instrument. it gives you access toall of the policy language you need to have internally. we did that but as weshared and as kellen shared there's external policiesboth government policies and legal policies now in many places and of course the joint commission, the field guide to lgbt health.

right now the lgbtanti-discrimination provisions and the joint commissionaccreditation review are mandatory but there'sa whole bunch of others that are recommendationsthat will be mandatory by 2017, so be prepared and get that joint commission field guide and look at some of those criteria. then there's mandatesboth political mandates and field mandates tobecome lgbt culturally

and clinically competentthat kellen has discussed. i just wanted to show you this. this is my [san antonio] office diversity and inclusion mission and focus. right there in the middleas a special focus, not a sub focus in anyof these other things is an lgbt specific focus. you'll notice that wedon't have other things that are specific suchas particular culture

or particular ethnic or racial identity because that cuts across all of that. we have one panel that saysethnicity and racial issues but lgbt has to be a separate focus because it's been so neglected for so long and it's been so invisible. if you really want to do justice to this, you have to make it a special focus area and mount sinai has done that.

then here are some of the things we did as the model at beth israel that now we're extending system wide. we did a needs assessment and we did it bothinternally and externally and again we did it ina very prescribed way. we didn't go in and justask people what was wrong or what the gaps are. we went in and we auditedour existing resources.

we asked people whatthey were doing right. then the way that we approached it again was how do we make and atthat time it was beth israel and now we're going to extend it to the mount sinai health system. how do we make beth israelthe best medical system for lgbt patients in new york city? we're inspiring people to ratchet it up as oppose to saying you'redoing something wrong

or these are the deficits or you better, and that made all the differencein the kind of interest in participation andenthusiasm that we got with employees across allthe different disciplines and functions of our institution. we met with other lgbtstakeholders including patients. new york's a big town, there's lots of lgbt best in interest. there are corporations whowant to be able to send

their lgbt employees tolgbt sensitive health care. there's lots of ways todo that kind of outreach. lgbt in particularityis the new black folks. some of you might be evenwatching orange is the new black but lgbt is the new black. there's lots of opportunities to partner with other organizationsand other stakeholders who want to do lgbt work. building system capacity.

i would have walked out of all of these if i didn't see a trueand ongoing commitment. we have a long way to go. we don't have all theanswers at mount sinai. we've learned a lot oflessons in the process and we're still working on it but we're getting there slowly but surely, and there is an ongoingcommitment to this. it's not like a one shot deal

and it's something we'dconstantly working on. employee and studenteducation and training, clearly i don't explainwhy that is really key. that's something that youhave to do in many ways and i say in every way possible. for example, we thoughtwe did a survey of folks and we ask them, thinkingthat web based training and stuff they could do at their own pace and access on their timewas going to be the best way

for people to get trainingbecause they're so busy and there are so many competing priorities in health care that peoplehave to learn and go to and trainings and grandruns and you name it. what we found out was thatpeople really wanted some in person opportunities to be trained because they had questionsthey wanted to ask and each concerns they wanted to address and issues they wanted to discuss.

we do multimodal training. resource and referral tools. lot of people don't knowother people in our system. we have 35,000 employees in our system, all kinds of expertise across the system. we're still finding out new people that can help us around lgbtspecific health care needs. people don't know each other, they don't know how torefer within the system.

that's where your ergs come in handy. also we are creating now aninternal lgbt referral system so anybody in any one of our hospitals in any one of our subspecialty areas in any one of our clinics, in any one of our community practices can find out where they can send somebody who's lgb or t to someoneelse in our system who has special expertise or capacity

or services that that patient might need. it's internal and it's also external. we have lgbt patient referral program. we're training our patient representatives to be able to refer people internally but also i do a little patient navigation and we're going to buildan lgbt patient navigate. lgbt specific patientnavigator program this year because people really need that.

i've done everything from handholding a transgender man that got gay bashed to our emergency room one night to making sure that people get, if people call up and theyreally want a gay physician to making sure that they get someone that openly identifies he's gay. it runs the gamete of what i've done and we now need to extend that system wide

and i can't be the one that's doing it if i'm doing everything else. there's some specialty capacity. i can't emphasize enough. this is not about just beingnice to the lgbt people, it's not good enough. it's not about being tolerant. it's not even about being sensitive. it's about being notjust culturally competent

but clinically competent. that means you need to train, particular our primary care providers had to screen peoplefor issues that may be of special concern tolgb and t populations and it's not all the same. it's different for lesbians. it could be differentfor lesbians of color. it could be different for trans men

as opposed to trans women, for people who arepre-transition or in transition. learning about this, the clinical issues and teaching the clinical issues particularly to ourresidence and our fellows and our students now aticon school of medicine is just so critical and inour nursing school as well. then there's huge opportunities for lgbt research and evaluation.

there are now, nih now has an lgbt pa. they've been complaining they don't have enough applications. they have money they want to give away for lgbt research. we know research drives alot of our institutions. there's huge opportunities folks. take a look at those pas,know who's in your system, know how to access those patients.

in order to do that, youhave to collect lgbt data in your electronic health record. it's absolutely imperative. we are not there yet at mount sinai but we are working on it. community relations, we do a lot of greatprograms in the community. one of them i always brag about, sage which is the lgbtnational senior organization

is headquartered in new york. the new york part ofsage has the very first lgbt senior center publicallyfunded in the country and we do a programthere called ask the docs where our providers come in every month on a different topic of concern to lgbt elders and older adults. we do a presentation, wedo a special screening. we actually have a health education nurse

that's stationed at sagethat does patient navigation and referral into our system. then they get to askour providers questions. it's been great on a couple of fronts, it's great community relations, it's great patient education and we've gotten tons ofreferrals into our system because they get to meetand know our providers, our nurses, our doctors,our pas, our social workers,

our psychologist have all come in. then they feel safe when they can go and make an appointment in our system. we sponsor lgbt communityevents and activities. we were at the sage gala and we bought a $50,000 table. that's putting our money where our mouth is supporting sage. dedicated mount sinai,

website which i'm going to show you. we do print media, we do web banner aids. if you build it, they won't come unless they know about it and i can tell you the nextthing we're going to do is we're going to dosome safe space training and do so safe space stickersin many of our facilities. when lgbt patients walk in, if they don't see something

that indicates that this is lgbt space and we have an lgbt rack card that we put in all ofour primary care sites, in our ambulatory caresites and in the hospital. that's an indication, "this may be a place "where i can be out." here's our lgbt rack card. we're actually retooling it now. this is a beth israel one,

we're retooling it for thewhole mount sinai system. it's also very important toput a number and a person. my name is on there, my number is on there because if anybody comes in and doesn't have the experiencewe want them to have, we tell them, "call meand i will make sure "it gets addressed." i will make sure yourindividual need gets addressed and we will make sure itgets addressed in the system.

we have been really good atfollowing through on that. we have a campaign called wetake pride in your health. we put images of our real patients that have volunteered to do that and we do take pride in folk's health and it's all over the place. we march the pride pray new york this year and we had those giant placards. the two women on the left there

are two very well knowntrans women activists who are also our patients and the two gay men withtheir baby on the right there are also our patients because we have an lgbt family practice. usually you see twolesbians holding the baby which i think is kind of sexist and bias. i really insisted when we were doing this, i want gay fathers in this picture,

her raising children as well. here are the challengesbecause i'm out of time and i want to show you the video. time for training andcompeting priorities, huge, huge challenge. that's why you have to makeit available multimodally. you have to tape everything you do so people could play it back later. i was astounded to findout in the medical school

that most of the studentsdon't go to the lecture. they watch it later becauseall the lectures are taped. i asked one of our coach hereof our lgbt student group at mount sinai medical school. i said, "does anyone ever go to class?" he said, "yeah, sure, people do go." he said, "but most of us, we were so busy, "we're doing so many things, we watch it." i said, "well, how do you know

"that you're learning anything?" he said, "because wehave to take the comps "and if we don't watchit, we'll fail the comps "which means we'll be kickedout of medical school." i said "yeah, i forgot about that." you'll set the managepatient expectations. we are an evolving system and sometimes people come in and their expectations arethat everybody they see

is going to be gay or that people sometimesmispronoun people. people make mistakes and one of the things that we really push people to do is and it's our responsibilityto let them know where they can report anyproblems that they're having. we really encourage them to do it, to put in writing because it helps me take it back to our system leadership

and make sure that we mediate those issues and that we make changes. it helps us when we have that. electronic health recordsand confidentiality. my biggest challenge in our system is getting sexual orientationand gender identity into our ehr and into our h caps. there is no reason why youcannot add sexual orientation and gender identity,demographics to the h caps.

there is no reason why youcan't add sexual orientation and gender identityquestions to the h caps in the demographic section. i'll say that one more time. i really want our institution to do that. how are we going toknow patient experience for lgb and t patients if wedon't ask those questions? we do have a lack of patient outcome data for monitoring and evaluation

and i think if we couldget pass that in our system and be a model in new york city because nobody else in newyork city is doing it either. the university of california, davis just instituted universal soji collection across their whole medical system and in their medical school. i'm working with ed callahan there and i'm looking forward to my colleagues

being able to show us their outcomes to present to our folks to show that it's going to bebetter for us network.