The Open Door Project Task Force: A Qualitative Study on LGBT Aging

Abstract

This paper reports formative qualitative findings from the Open Door Project (ODP), a unique program created by the Lesbian, Gay, Bisexual and Transgender (LGBT) Aging Project. Data were collected from Open Door Task Force members (N = 34). This includes 4 focus groups that were held with a total of 22 participants; and key informant interviews that were conducted with 12 participants from 10 different agencies. Findings revealed that agencies took significant steps to make important and long-lasting structural changes, including changing their diversity and personnel policies, and intake forms to be LGBT inclusive; implementing ongoing staff training initiatives on LGBT issues; and actively involving leadership, including senior managers, executive directors, vendors, and Councils on Aging, in helping to create and sustain organizational change. The ODP is an effective model to increase cultural competence in working with aging LGBT communities.

KEYWORDS:

• LGBT
• aging
• Open Door Project
• cultural competence

INTRODUCTION

In the United States, the baby boom generation will begin to turn 65 in 2010 (U.S. Bureau of the Census, 2004). As demographic trends show that life expectancy rates continue to rise, it is estimated that by the year 2030 70 million older persons (age 65 and older) will be living in the United States, representing 20 percent of the U.S. population (Rice & Fineman, 2004). Importantly, these estimates include a significant number of lesbian, gay, bisexual, and transgender (LGBT) aging Americans who are also living longer. Recent estimates indicate that the number of older LGBT people is anywhere between 1.75 to 3.5 million, with approximately 500,000 gay men and lesbians turning 50 each year (McMahon, 2003). As the number of aging LGBT persons grows, so too does the need for culturally competent health care that addresses the unique health need of this population.

Although some aging issues facing older LGBTs are comparable to their heterosexual counterparts (such as income, unexpected debilitating illness, economic hardship, loss of friends and family, difficulties protecting oneself, proposed policy changes in Social Security or Medicare, autonomy, and health care access), LGBT seniors also face specific challenges that are directly related to their status as sexual minorities (Kehoe, 1986, 1988; Beeler, Rawls, Herdt, & Cohler, 1999; Quam and Whitford, 1992; Stevens, 1995; Wojciechochowski, 1998; Grossman, D’Augelli, & O’Connell, 2001; Schope, 2005; Poindexter & Emlet, 2006; Jones & Nystrom, 2002).

A fear shared by many aging persons is that of being institutionalized in a personal care facility or nursing home, should they become unable to care for themselves. LGBT older individuals, however, must cope with additional apprehension about living in a setting where sexual orientation is not accounted for, or where discrimination occurs due to one's being lesbian or gay (Claes & Moore, 2000). LGBT seniors have indicated a strong desire for the development of LGBT-friendly or LGBT-exclusive retirement care facilities (Johnson, Jackson, Arnette, & Koffman, 2005; Kehoe, 1986). Johnson and colleagues (2005) investigated attitudes among LGBT seniors (N = 127) with respect to aged-care or retirement care facilities. The study revealed that 73% of the respondents believed that discrimination against LGBT individuals occurs; 60% indicated that they did not believe they received health and social services comparable to those received by heterosexual residents; 74% believed that these facilities were not inclusive of sexual orientation in their anti-discrimination policies; and 34% said they would conceal their sexual orientation if moving into this type of environment. Administration, care staff, and residents of aged-care or retirement care facilities all represented potential sources of discrimination (Johnson et al., 2005), highlighting the need to train providers and agencies on awareness and acceptance of LGBT aging issues (Harrison, 1996).

While fear exists regarding discrimination in institutional care settings for the aged, some are also concerned with respect to the possibility of homophobic caretakers providing home-based services. Elders describe “de-gaying” their homes before allowing new caregivers into the home or refusing services for this reason (e.g., Claes & Moore, 2000).

Other aging concerns of LGBT persons are the impact of perceived and experienced discrimination (homophobia) in accessing needed health and social services, fear of negative responses from health care providers and agencies, and the impact of common heterosexual practices and assumptions guiding care, all of which jeopardize the quality of services they receive (Harrison, 1996; Harrison & Silenzio, 1996; Donahue & McDonald, 2005; Hinchcliff, Gott, & Galena, 2005; Muraco & Fredriksen-Goldsen, 2006; Richard & Hamilton Brown, 2006). Further issues include a lack of recognition of same-sex partners as next of kin, and difficulty accessing superannuation and health insurance benefits as same-sex couples. Compounding these issues is the fact that mainstream senior providers have limited information or training on how to appropriately work with and serve the diversity of LGBT communities (Murguia, 1999). Strategies are needed to assist health and human services workers in providing quality, culturally competent care for the aging LGBT population.

This paper reports qualitative findings from an evaluation of the Open Door Project (ODP), a unique program created by the Lesbian, Gay, Bisexual and Transgender (LGBT) Aging Project that represents a collaborative effort of 14 Aging Service Access Points (ASAPs) in Massachusetts to support and participate in training activities intended to increase their cultural competence with respect to meeting the needs of LGBT seniors. The goals of this qualitative research were twofold. First, as a novel and innovative project, the team sought to learn as much as possible about the ODP's strengths and challenges to allow for further refinement and improvement of the program. Toward this end, it was hoped that the assessment would lead to the development of measures for a new program that had not previously been evaluated. Second, the qualitative research was conducted with the goal of advocating for the LGBT aging community. Documenting the ODP and its accomplishments and disseminating information more generally may encourage the creation of similar programs in other states.

MATERIALS AND METHODS

Participants and Procedures

The mission of the Open Door Project (ODP), an initiative of the LGBT Aging Project, is to ensure that LGBT elders have equal access to the life-prolonging benefits, protections, services, and institutions that their heterosexual neighbors may take for granted. The purpose of the ODP is to train the state's aging network staff on how to effectively work with LGBT clients and to increase the overall sensitivity and professional competence of providers statewide on issues of LGBT aging. More information about the elements of the training program can be obtained through the LGBT Aging Project's Web site under “Services and Programs” (www.lgbtagingproject.org/). The suggested curriculum for the Task Force included topics such as internal review (internal policies and procedures), external review (how are internal policies communicated to external world), client-centered work, transgender issues, and working with community partners.

The Massachusetts Home Care association for 27 Area Agencies on Aging (AAAs) and Aging Services Area Providers (ASAPs) supported this innovative project and 14 of these organizations across Massachusetts enrolled in and contributed financially to the program.

Open Door Task Forces (ODTFs) were formed at participating agencies with a plan to meet 10 times. Some of the agencies agreed to a monthly schedule and others agreed to a bi-monthly schedule. From spring 2005 through fall 2007, qualitative data were collected from ODTF members (N = 34; 22 participants in four focus groups; 12 key informant interviews that included both open- and closed-ended questions). Of the 14 participating agencies, 4 did not sufficiently complete the program in time for this evaluation. The lack of completion reflected lack of commitment to the program (one agency), a need to focus on other issues (two agencies), and a decision that the training wasn't needed due to sufficient in-house skills (one agency).

Data Sources

There were two primary sources of data. First, focus groups were conducted with ODTF participants. Twenty-two agency staff members based at four agencies were interviewed in four groups. A moderator's guide was developed (see Focus Group Facilitation Guide in Appendix) utilizing the objectives from the ODP curriculum as a guide for topic areas. Participants varied in age, gender, sexual orientation, and role within the agency. Focus groups were conducted halfway through the project and were therefore formative in nature. That is, the focus groups explored themes based on the ODP curriculum, and findings from these groups were used to hone questions for the key informant interviews.

The second source of data came from key informant interviews. A total of 12 key informant interviews were completed at 10 agencies, most held with senior managers or executive directors at agencies that had completed the ODP. Themes from the focus groups guided the development of open-ended and closed-ended questions for the key informant interview guide (see Interview Questions for Open Door Project Participants in Appendix). The key informant interviews built upon themes that were articulated at focus group discussions, including policy development, provider knowledge and program effectiveness, leadership, and sustainability. The closed-ended questions represented an attempt to collect some quantitative data and to provide information on development of useful measures by which to evaluate the program.

Data Analysis

Qualitative data from this study were analyzed using content analysis (Strauss & Corbin, 1997). After transcripts were reviewed for errors and omissions, we used NVIVO software to thematically organize transcripts. NVIVO software aided with the coding, organization, and searching of narrative sections from each interview, as well as facilitated the systematic comparison and analysis of themes across interviews. The Principal Investigator (PI) then reviewed the coded transcripts and reviewed the themes and findings with the ODP director. Data were re-examined through ongoing discussion between the PI and ODP director and the fidelity of the findings was “tested” by assessing the qualitative research findings through the lens of the experience of the ODP director in program implementation.

RESULTS

Findings from Focus Groups

The following findings came from mid-project focus groups with four ODTFs. The purpose of these focus groups was to provide key themes for development of a key informant interview guide to be administered at each of the Open Door Project's participating agencies. Findings from the focus groups are condensed into five areas: Goals, Policy Development and Dissemination, Provider Knowledge and Program Effectiveness, Leadership, and Sustainability.

Goals

When asked how they would describe the goals of the ODP, most focus group participants identified two areas: first, educating themselves on how to better understand and serve the LGBT population; and second, supporting and instituting training to teach others (colleagues, new staff, vendor agencies, councils on aging, etc.) to understand these issues.

Policy Development and Dissemination

Every agency had new diversity or mission statements that were inclusive of sexual orientation and gender identity directly due to the effort of the ODP. However, dissemination of positive messages was not equally successful across all agencies. In some cases, the diversity statement was added to a publication or brochure. However, many agencies were concerned about “how to get the message out” and felt that even as better policies were established, neither staff nor the public were particularly well-informed about them.

Provider Knowledge and Program Effectiveness

All agencies found that the greater the knowledge about LGBT issues among providers, the greater the capacity to serve clients effectively. Participants strongly believed that the information that was provided in Task Force meetings was important in helping them provide culturally competent services to LGBT clients. Specifically, the group sessions included role plays and in-depth discussions of how to recognize and work with a situation in which it was possible that the client or caregiver was LGBT.

In terms of identifying when a client might be part of a sexual minority, there was an awareness of words that the client might use (spouse, partner, friend) or not use (husband, wife); observation of who else was present in the home; observation of pictures or other materials that might identify a significant same-sex companion; and other indications. The discussions also provided information on how the service provider could avoid using non-inclusive terms (husband or wife) exclusively when trying to identify the significant persons in a client's life.

Leadership

Leadership participation was considered to be crucial, but was not always present for each Task Force. All participants agreed on the importance of having leadership at the table to achieve significant agency changes. At two of the agencies it was agreed that senior management currently participated in the Task Force and clearly supported the effort. Communication was facilitated by this participation and the group felt empowered as it moved forward with its activities. Conversely, two of the agencies felt that although senior management was supportive of the ODP, they had become somewhat disconnected from the process. The lack of ongoing presence of the senior management team led Task Force members to feel that the LGBT community was no longer a priority population.

Sustainability

The issue of greatest concern to Task Force focus group members was the sustainability of the messages promoted by the ODP and the dissemination of the work that is being done. There were four aspects of concern related to sustainability and dissemination: (1) the size of the Task Force was small relative to overall staff; (2) what would happen when the Task Force ended; (3) the training of new staff and/or vendors; (4) whether ODTFs could lead to or link to broader diversity and advocacy efforts. Many of these questions were addressed and answered through the key informant interviews.

Findings from Key Informant Interviews

The following findings reflect information from 12 key informant interviews. Additional detail was obtained with respect to the themes from the focus groups, including how to sustain the information learned through ODP, how to engage leadership, and how to effectively train staff. In addition, the informants addressed several structural issues that they were aware of as institutional leaders that affected the ability of each organization to implement the ODP.

Each key informant interview also included closed-ended questions to reflect the themes raised in the focus groups. Table 1 summarizes findings from the closed-ended questions.

TABLE 1 Responses to Closed-Ended Questions

Measure	Response Category/Scale
Has a new diversity policy been established as a result of the Open Door Project (can include diversity statement, revised mission statement, etc.)?	0% No0% It has been drafted but approval is not complete89% It has been drafted and approved by the organization11% Not applicable; policy already inclusive
Have you made changes to policies and procedures or the personnel manual regarding benefits, leave, etc.?	11% No0% It has been drafted but approval is not complete44% It has been drafted and approved by the organization44% Not applicable; policy already inclusive
Have changes been made to internal agency intake forms to make them more inclusive of LGBT persons (marital status, gender, who client lives with)?	56% No0% Changes have been proposed, but have not been finalized33% Changes have been proposed and finalized11% Not applicable; forms already inclusive
Due to the Open Door Project, is information about local or regional LGBT resources now readily available to agency's staff, providers, and clients?	33% No22% In process33% Yes11% Not applicable; a list of LGBT resources was available prior to the Open Door Project
As part of the Open Door Project, has a strategy for ongoing training of agency staff on working with LGBT clients been planned?	22% No78% Yes0% Unsure
If ongoing training of agency staff has been planned, has it been executed?	22% None has been planned22% No56% Yes0% Unsure
Please indicate the extent to which you agree
or disagree with the following statements.			Neither
Each statement refers to the impact of the			Agree
Open Door Project on your agency:	Strongly		nor		Strongly
	Disagree	Disagree	Disagree	Agree	Agree
1. Our agency has increased its capacity to work effectively with LGBT clients.	0%	0%	0%	90%	10%
2. Discussion of LGBT issues in our agency has become “normalized” or “de-stigmatized.”	0%	0%	20%	60%	20%
3. All staff members understand it is their professional obligation to provide culturally competent services to LGBT clients regardless of their personal stance on LGBT issues.	0%	0%	10%	30%	60%
4. Leadership within our organization has been supportive of the Open Door Project.	0%	0%	0%	11%	89%
5. Leadership has actively participated in the Open Door Project.	0%	0%	0%	40%	60%
6. The impact of the Open Door Project will be felt long after the completion of the Task Force meetings.	0%	0%	20%	70%	10%
Note: Where more than one person was interviewed from an agency, responses were compared for the first six questions. There was agreement between those individuals, providing a small measure of validation of the questions. Since there was agreement, only one response per agency was included in the final tabulation to ensure that the results represented agencies, not individuals.

Developing Cultural Competency Specific to LGBT Elders

For many participants, the question was raised within agencies, “Why so much emphasis on LGBT elders and not other groups?” For many organizations, the answer was some variation of “because they are here” or “because they asked first.” However, organizations were able to link the ODP's focus on LGBT elders to other minority groups in various ways. Several agencies used the discussions around LGBT elders as a model for how to think about improving services to other populations. Other agencies embedded the LGBT aging work into a broader diversity committee and found this work supported efforts to serve other types of diverse clients whether they are LGBT, Somali, blind, or mentally challenged.

Another respondent talked about the extent to which antigay bias was still a problem. The respondent said, “There is still confusion about asking about sexual orientation. Normalization of LGBTs will take decades. People still don't want to reveal information due to old homophobia. With [legalization of] marriage things may change, but the homophobia is still so great.”

Structural-Level Changes and Policy Development

The ODTF model produced structural-level agency changes. New diversity or mission statements were developed at all of the agencies (except one, whose statement was already inclusive) as a direct result of the project. Personnel policies were reviewed and improved at many of the agencies to become more LGBT friendly. This included clarification of applicability of the Family and Medical Leave Act (FMLA) and assuring that sick and bereavement leave applied equally to LGBT families. In some agencies, the adjustment of personnel policies seemed to be an agency function beyond the scope of the ODTF. Also, the issue of same-sex marriage further clouded some of the issues around benefits. Some agencies were abandoning domestic partner benefits since same-sex couples could now marry. However, at one agency, there was a re-affirmation of domestic partner benefits in a post-same-sex marriage era with the benefit accruing to both same-sex and heterosexual unmarried domestic partners.

Most of the agencies understood that the forms used for their programs were determined by state and federal officials and therefore could not be adapted by individual agencies. As one put it,

The whole gay marriage issue made this very real to board and staff. It did coincide in a way that came back to the agency in a real way. A lot of procedures are set up by the state and there haven't been any changes at that level. We have no place—if someone wants to be out—there's no place in our computerized record system to track this. Now that we could have married couples there is no way to track it.

However, they also learned that they had an opportunity to adapt some internal forms, including hiring forms, emergency contact information for employees, etc., to be more LGBT-inclusive. Moreover, several individuals were interested in working collectively with leadership at other agencies to change forms at the state level so that they would be inclusive of LGBT persons and relationships.

Dissemination of Policies

Informants’ responses indicated that various agencies disseminated their policies to a greater and lesser extent. Some agencies had gone to great lengths to include their diversity statement on all agency brochures, newsletters, and Web sites, as well as posted in visible places at the agency. In a few agencies, there was concern that the diversity statement was not as widely disseminated as it could be. This was seen as extremely important because dissemination of the diversity policy makes the public face of the agency more clearly LGBT-friendly to the community. For example, in one agency, the new policy statement about inclusion and diversity was posted on one bulletin board in the agency's building lobby and nowhere else. This was seen as insufficient to promote widespread awareness and knowledge of a policy that supported the inclusion and respect for LGBT clients, caretakers, and staff.

In agencies that had prepared lists of LGBT resources to assist staff and clients, differences in how they were used existed. For the most part, these guides were used internally, so staff would have access to them. They were also likely to have been given to clients who disclosed that they were part of the LGBT community. In general, however, these guides were not distributed to all clients, being seen as “too out front.” One practical solution was the inclusion of a smaller set of LGBT resources in the broader resource guide most agencies prepare and distribute to clients.

One suggestion was that a brief tri-fold brochure on LGBT issues be developed that could serve two purposes. It could be part of the materials given to new staff, so that part of their initial training and orientation to the agency would include some acknowledgment of LGBT issues. The same brochure (or a variant) could possibly be included in new packets for clients to inform them that the agency understood and was supportive of LGBT issues whether they were related to the client or the client's caregiver. Furthermore, such a brochure could document local resources (four to six key resources) that could help providers and clients seek out additional services as needed.

Participants found that inclusion of photos that represent visible members of the LGBT community give greater visibility to LGBT issues. Yet, this was not always an easy accomplishment. At one agency, an executive director looked at a brochure and when asked about including pictures of LGBT elders said, “I thought what we learned is that any of the elders already pictured in the brochure could be LGBT.” With some explanation, this individual agreed that having photos of identifiable LGBT persons was important. However, uncertainty remained about exactly what these images should look like and how to go about finding them.

Success in Learning to Work with LGBT Clients

Participating agencies reported success in learning how to work with LGBT clients and in clearly understanding that it was their professional responsibility to do so regardless of personal beliefs. Through role-play, empathy, discussion, and appreciation of the issues that affect older LGBT persons, respondents across agencies reported more specific understanding about how to work with LGBT elders. Moreover, individuals became aware of the issues involved in working with clients who might be LGBT, but may not be out or were unwilling to come forward with that information. People learned to understand the various ways that the agency could make clear to clients that it was open and inclusive and leave the door open for individuals to come out, without necessarily being intrusive. Most agencies have subsequently had at least a couple of clients come forward as gay or lesbian.

One agency leader spoke about how the Open Door Project affected her ability to address client complaints. She said,

I could pick out a handful of complaints that we've helped as elders that was intensified because of their [sexual] orientation. We haven't necessarily helped all of them, but every situation is different, and everyone isn't able to take the steps necessary. [Due to the Open Door Project,] we were better able to identify the problem and go back to the agency and see what could be done.

Distinguishing between personal beliefs and professional responsibility was a theme that emerged among key interviewees. Agency leadership was clear that staff needed to act in a way consistent with the “open and affirming” values that were put forth in the Open Door training and Task Force. While the ODP made it clear that it could not or should not be able to change every person's personal beliefs, it also made it clear that negative or discriminatory behavior toward LGBT persons have no place in the workplace. As one participant put it, “What you choose to think is your business, but what you choose to do here is our business.” In another example, when one respondent, a senior manager, was asked by a staff member who was not supportive of LGBT people, “Should I pretend that I think it's all right?” the informant answered “Yes, and with good grace.”

Institutionalizing Training on LGBT Issues

Several challenges arose in terms of ensuring clinical expertise could continue at the end of the ODTF. Due to relatively high turnover among agency staff, a clear need to develop a strategy for ongoing training emerged. Such strategies were developed at most agencies with varying degrees of independence and initiative separate from, but supported by, the LGBT Aging Project using fact sheets, videos, etc. For many of the agencies, this meant trying to conduct their own trainings of new staff. Several models were used, including incorporating LGBT work in annual mandatory training, conducting one-on-one training with new staff, conducting mini-training on the topic every six months, and bringing in ODP staff periodically.

Involvement of vendors and Councils on Aging (COA) was uneven, most likely reflecting the different relationships between each organization and their vendors. Some agencies invited vendors and COAs to their trainings. At one agency, a representative from a local COA spoke about his own transition as a result of gender reassignment surgery. This willingness to share led to a rich experience for the participants in this particular training. Other agencies have viewed this more as a contractual matter. In other words, treating LGBT clients in this manner is a standard they have set, and they expect all of their vendors to behave in a similar manner.

Dissemination of Task Force Knowledge and Activities

Some agencies found that members of the ODTF were unable to bring back their knowledge to their respective clinical departments. Some of the individuals selected to be on the Task Force did not have the interest, skill, or guidance to bring this information back to their respective departments. The solution to this problem at one agency was to replace some of the members with individuals with more seniority or better skills to carry back messages to their respective departments. At one agency, minutes from Task Force meetings were distributed to all agency staff. Although this may keep the Project visible, it may not necessarily represent the most effective means of transmitting detailed information. At the same agency, the individual who sent the minutes out could monitor whether individual staff actually opened the e-mail and the attached minutes or not.

Leadership

Leadership was a critical component for program success. In most organizations, people look to leadership to decide if there is understanding and support for a controversial issue, such as working with LGBT clients. This tone helps determine how willing individuals are to participate in something like a Task Force, the level of importance assigned to Task Force meetings, and the sense that activities and ideas generated in the Task Force will be realized by the organization as a whole. Thus, supportive and active leadership was a necessary condition for success of the ODTF model.

In all of the agencies that implemented the full Task Force model, the executive director or another high-level individual had made a commitment to LGBT issues. Some of these commitments were based on personal reasons or identification with the issue; some were based on incidents that arose within the agency that made evident the need for this work to take place; and some had a combination of general commitment to diversity with support for a project that they had seen develop and move forward over time.

Building and maintaining support among the governing board is an important way to ensure long-term support of the ODP. One agency had decided, as a result of the ODP, to recruit an openly LGBT member for its board of directors.

DISCUSSION

This qualitative study of a unique model to improve delivery of services to LGBT elders in mainstream aging services organizations found informants reporting the model to be effective. Agency leaders were successful in understanding the concept and importance of establishing an open and affirming agency to LGBT issues and took concrete steps to move in that direction. ODTF agencies truly owned their commitment to internal transformation, to becoming an open and affirming environment, to training staff on an ongoing basis, to normalizing and de-stigmatizing discussion of LGBT issues, and ensuring that public statements, agency policies and procedures, and personnel manuals were open and affirming. Moreover, findings revealed important and useful information in moving forward as well as in the design of future programs advocating for LGBT seniors.

Policy and Procedural Changes

All agencies looked at their diversity policies and created new, fully inclusive ones. Leadership supported approval of new diversity statements at the organizational level so all of the new diversity statements became official agency policy. All agencies examined personnel policies and made adjustments where possible. Agencies became sensitized to the issue of the wording of forms and how wording could be made more inclusive of LGBT persons and families. Intake forms and interviewing skills were discussed as important tools to handle various situations in which a client might be LGBT, but not publicly out. These included specifics on how to determine whether to get the income of a partner as part of the household income assessment and deciding how to identify and characterize emergency contacts, such as when a son's male partner is the primary caregiver to a senior. Several Task Forces indicated that they were learning to use more gender-neutral terms such as “spouse” or “partner” instead of “husband” and “wife.” This is consistent with the American Psychological Association's published guidelines addressing heterosexism in language (American Psychological Association, 1991); however, for now these changes have not been made to institutional forms required by state agencies.

In general, respondents believed that the effective delivery of services to LGBT elders was enhanced with specific knowledge of their concerns. For some providers of care, this was accomplished by helping them separate their negative beliefs about homosexuality from their professional responsibility to provide quality and compassionate services to everyone. For others who did not hold negative feelings about LGBT persons, it was helping them overcome awkwardness in working with nontraditional families and learning how to use inclusive language and obtain needed information without necessarily asking intrusive questions.

At the same time, most participants agreed that it was the job of those providing home-based services to be prepared for anything and work with a variety of situations. Creating a supportive environment was seen as a useful skill and a way to encourage a senior or a senior's caretaker to feel more comfortable coming out to the provider. Continued efforts should be made to ensure widespread dissemination of diversity statements and policies. Additional engagement with leadership may be needed to fully empower ODTFs to address personnel policies. Bringing together representatives of agency ODTFs would help to address issues at a state level and to begin to identify best practices.

Need for Ongoing, Mandatory Training

Several challenges arose in terms of ensuring clinical expertise could continue at the end of the ODTF. Due to relatively high turnover among agency staff, a strategy for ongoing training needed to be developed. Several models were being used, including incorporating LGBT work in annual mandatory training, conducting one-on-one training with new staff, conducting mini-training on the topic every six-months, and bringing staff from the ODP in on a periodic basis. It was seen as particularly helpful to have someone come in from the outside to provide information on such a sensitive subject.

Cataloguing the various strategies for continuing training of new staff and highlighting mechanisms for sharing information among staff at department meetings, through role-plays, through newsletter articles, etc., are important strategies to consider. Importantly, boards of directors, Councils on Aging (COAs), and vendors should be included and offered all training components.

It was essential that individuals serving on the Task Force be selected carefully. Across the agencies some members volunteered and others were recruited. Neither mechanism necessarily made for a better Task Force member. One characteristic that was noted as important was the ability of Task Force members to communicate back to their department about what was learned, discussed, and planned at Task Force meetings. For this reason it was also important to recruit representatives from different departments in the agency (case management, home care, health services, caregiver support, and protective services), so all parts of the agency were represented. In selecting participants for the ODTF, it should be clear that they are responsible for reporting back activities of the group to their department. ODTF meetings should include an opportunity for members to report back to their peers on their dissemination of activities.

Identifying and Building Services for LGBT Clients

Older LGBT persons have unique support needs that may not be met by either general services to the elderly or by gay organizations, which typically cater to younger individuals. Research with older LGBT persons has indicated that a robust social support network not only enables easier acclimation to the effects of aging on mental and physical health, but also provides a means of helping alleviate the stigmatization that LGBT persons experience because of their sexual orientation (Grossman, D’Augelli, & Hershberger, 2000). Support groups (Slusher, Mayer, & Dunkle, 1996) and community initiatives (Nystrom & Jones, 2003) among aging LGBT people are just one way of addressing the unique support needs of the community.

Agency attempts to organize LGBT elders in communities have met with mixed success. However, some efforts have been successful, and many organizations believe a meal site or support group would be effective ways to demonstrate their open and inclusive nature, as well as a way to let other members of the community see that they are committed to providing services to the LGBT seniors. One agency held a community meeting that was attended by 30 individuals from the LGBT community. They collected information about why people attended the meeting and what their concerns were as they aged. Other agencies have just begun organizing these types of events. Most organizations recognize that these types of events require community organizing that will take effort over time. Many of the agencies saw this work as a long-term investment. In other words, they anticipate that if they could build good relationships with members of the LGBT communities now (while these folks are in their forties, fifties, and early sixties), they would be more trusting and prepared to accept services as they age and have greater needs for professional services.

Limitations

Certain limitations are inherent in conducting a qualitative analysis. The evaluator tried to speak with a specific set of individuals whose feedback was presumed to give a wide range of thoughts and opinions on the program. However, in a few cases, agency staff redirected the evaluator to speak with the individual they felt was most appropriate to represent the opinions of the program. Moreover, as with all qualitative research, the information represents the perspective of the particular stakeholders who were interviewed. In this case, four agencies that initially planned to participate in ODP did not, and their exclusion from participation in the evaluation may represent failures of the ODP model that have not been identified.

Another potential limitation is that since the ODP is new, various aspects of the evaluation received greater or lesser attention based on such factors as lack of project resources and agency limitations to participate. In addition, this was formative research where part of the goal was to develop measures for a novel and innovative program that had not previously been assessed. Consequently, all measures utilized were themselves preliminary and untested.

In conclusion, the ODP was described by a majority of informants as an effective model to increase cultural competence in working with aging LGBT communities. Discrimination against LGBT persons takes various forms, from overt homophobia to more subtle heterosexism, and influences patterns of health-seeking behavior, health-risk factors, and specific aging-related health care issues. The Open Door Project provided training and expertise to 14 Massachusetts agencies, including specific knowledge about the issues faced by LGBT elders and how to address them, apparently improving their capacity to “open the door” and provide quality, compassionate, and competent care to these individuals. To measure the effectiveness of the Open Door program with greater rigor, a more expansive research design is needed to learn how many additional LGBT clients were served and whether they were provided with improved services, ideally, comparing agencies who had participated in ODP with some who had not.

APPENDIX

Focus Group Facilitation Guide

INTRODUCTION:

My name is Stewart Landers. I am a senior consultant working for JSI Research and Training Institute and have been hired as the program evaluator for the Open Door Project. I'd like to ask you a series of questions regarding the Project that will help us to measure the progress that is being made. All of your answers will remain confidential in that my report will not connect any individual names or names of individual Task Forces to responses. I will be spending the first 45 minutes or so of your session today obtaining this feedback. Do you have any questions before we start?

SECTION 1: Participation on the Task Force

1. How did you become a member of the Open Door Task Force?

2. What is your understanding of the goals of the Open Door Project?

   Probes: Do you think other agencies participating understand the goals in the same way?

3. How important is it that the Open Door Project addresses each of these challenges (note: only choose goals that task force members haven't already mentioned):

   • - Agency policies and procedures including benefits and staffing

   • - Internal training at agencies (including board, management, and staff)

   • - Training for vendors

   • - How agency communicates that it is gay friendly to its clients and partners

   • - Role of advocacy

   • - Assessment: How do we talk about LGBT issues with clients?

   • - Transgender issues

   • - Linkages with partners in community including use of community forum

   • - Linkage to LGBT resources (local and statewide)

SECTION 2: Feedback on the Task Force Model

1. How well do you think the Task Force model is working? What are its strengths or weaknesses?

   • - How does the Task Force connect to the leadership (ED, senior management, board) of your agency?

   • - What, if anything, would you like to see happen at these meetings that is different from what is currently happening?

2. Does it make sense to continue the Task Force beyond its current schedule of meetings?(You are committed to a total of 10 meetings and have had X already.)

3. What other activities connected to the Open Door Project would you like to see happen?

SECTION 3: Overall Opinion of Program; Next Steps; Role of Respondent

1. Overall, how successful do you think the program has been to this point?

2. What do you think are the most important steps moving forward for its continued success?

3. How do you see your role in helping your agency to realize the goals of the Open Door Project outside of attending these meetings?

4. Is there anything you would like to add about the Open Door Project?

Thank you for meeting with me today!

Interview Questions for Open Door Project Participants

SECTION 1: Introduction of Program; Goals; Accomplishments

1. How did you become involved with the Open Door Project?

2. What has your role been with respect to the Open Door Project?

2a. When did you get involved?

3. What is your understanding of the goals of the Open Door Project?

3a. Do you think other agencies participating in the Open Door Project understand the goals in the same way?

3b. Did you ever talk to your colleagues at other agencies about this work?

4. What would you say are the main accomplishments of this program within your agency? If the program is just beginning at your agency, what are you hoping will be the main accomplishments of the Open Door Project at your agency?

5. The following outcome measures have been developed based on meetings with various Open Door Task Forces (see next page). Please think about the best response to each of the following potential outcome measurements:

Table

Outcome Measurement Form for Open Door Task Force
Measure	Response Category/Scale
Has a new diversity policy been established as a result of the Open Door Project (can include diversity statement, revised mission statement, etc.)?	□ No□ It has been drafted but approval is not complete□ It has been drafted and approved by the organization□ Not applicable; policy already inclusive
Have you made changes to policies and procedures or the personnel manual regarding benefits, leave, etc.?	□ No□ It has been drafted but approval is not complete□ It has been drafted and approved by the organization□ Not applicable; policy already inclusive
Have changes been made to internal agency intake forms to make them more inclusive of LGBT persons (marital status, gender, who client lives with)?	□ No□ Changes have been proposed, but have not been finalized□ Changes have been proposed and finalized□ Not applicable; forms already inclusive
Due to the Open Door Project, information about local or regional LGBT resources is now readily available to our agency's staff, providers, and clients.	□ No□ In process□ Yes□ Not applicable; a list of LGBT resources was available prior to the Open Door Project
As part of the Open Door Project, has a strategy for ongoing training of agency staff on working with LGBT clients been planned?	□ No□ Yes□ Unsure
If ongoing training of agency staff has been planned, has it been executed?	□ None has been planned□ No□ Yes□ Unsure
Please indicate the extent to which you
agree or disagree with the following
statements. Each statement refers to the			Neither
impact of the Open Door Project			nor
on your agency:	Strongly		Agree		Strongly
	Disagree	Disagree	Disagree	Agree	Agree
1. Our agency has increased its capacity to	□	□	□	□	□
work effectively with LGBT clients.	□	□	□	□	□
2. Discussion of LGBT issues in our agency has become “normalized” or “de-stigmatized.”	□	□	□	□	□
3. All staff members understand it is their professional obligation to provide culturally competent services to LGBT clients regardless of their personal stance on LGBT issues.	□	□	□	□	□
4. Leadership within our organization has been supportive of the Open Door Project.	□	□	□	□	□
5. Leadership has actively participated in the Open Door Project.	□	□	□	□	□
6. The impact of the Open Door Project will be felt long after the completion of the Task Force meetings.	□	□	□	□	□

SECTION 2: Feedback on the Task Force Model

6. Overall, how well do you think the Task Force model is working? What are its strengths or weaknesses?

7. How often have you met? Was the frequency and timing of meetings optimal?

7a. Were adjustments made to the schedule? Why, and was that helpful?

8. What factors influenced your ability to implement this program as expected?

9. What parts of the Open Door Project would you leave as is?

SECTION 3: Overall Opinion of Program; Next Steps

1. What do you think are the most important steps moving forward for the Open Door Project to be successful at your agency?

2. In your agency, who will be responsible for continuing this effort?

3. What role do you see yourself or your agency playing in this project as it moves forward?

4. How will you sustain this effort in your community?

5. Is there anything you would like to add about the Open Door Project?

Thank you for your time!