Making Long-Term Care Communities More LGBTQ+ Welcoming

Ann Francis remembers vividly the time she and her partner Nancy Lombardi were searching for a life plan community they might live in, allowing them to get increasing levels of onsite long-term care if they ever needed it.

Francis, a former GM pipefitter and supervisor, and Lombardi, a one-time community college administrator and graphic designer, found one possibility. "And we just outright asked them, 'Would we be welcome? How would it be for us coming as out lesbians to your facility? Would people treat us right?'" Francis recalls. "'The woman said: 'Well, we have a policy to treat people right, but we cannot guarantee that our residents would treat you right."

The couple, who were Lansing, Michigan residents, didn't relocate there.

Instead, in 2015, they found a warm and welcoming, mission-driven life plan community in Ohio — Kendal at Oberlin, one mile from Oberlin College — and moved into one of its independent living cottages. "We were really looking for a place where we felt we would be supported," says Francis, 80. 

When Francis met with Kendal at Oberlin staff initially and was asked, "How do you want to be treated?" She answered simply: "'With respect.'' And people here do treat us respectfully."

She now helps run an LGBTQ+A (the A stands for Allies) interest group for residents and staff of Kendal at Oberlin, where the single-occupancy entry fee starts at $54,445 and the monthly cost ranges from $3,334 to $6,697.

"One of our goals was to make sure that Kendal not only said they were welcoming and affirming, but that we actually met the criteria for what it meant to be a welcoming and affirming community," says Francis.

The criteria is spelled out in the new and groundbreaking Long-Term Care Equality Index 2023, a report from SAGE (Advocacy & Services for LGBTQ+ Elders) and the Human Rights Campaign (HRC) modeled after HRC's Healthcare Equality Index for health care facilities. It's the first validated survey on LGBTQ+ inclusion in long-term care and senior housing communities.

"The goal is to ensure that LGBTQ older adults can access welcoming and respectful care wherever they live. In the United States, that's just not the case now," SAGE CEO Michael Adams told me at the American Society on Aging's On Aging 2023 conference in Atlanta in March.

A 2018 AARP study found that 70% of LGBTQ+ older people said they were concerned they'd have to hide their identity in a long-term care community. In 21 states, there are no explicit laws prohibiting housing discrimination on the basis of sexual orientation, gender identity or both.

The need for inclusivity is especially acute, Adams says in the SAGE/HRC report, for LGBTQ+ elders of color, transgender older people and LGBTQ+ elders living in rural areas who often face the greatest challenges.

For the Long-Term Care Equality Index report, SAGE and HRC invited skilled nursing, assisted living, independent living, life plan/continuing care retirement, memory care, free-standing hospice and senior housing communities to fill out their comprehensive survey to measure whether they met more than 60 benchmarks for LGBTQ+ inclusion in four key areas:

• Non-discrimination and staff training: ensuring legal protections for LGBTQ+ residents and staff along with staff training
• Resident services and support: demonstrating progress toward LGBTQ+ resident care and support
• Employee benefits and policies: assuring that LGBTQ+ employees receive equal treatment and access to health-related benefits and policies
• Resident and community engagement: best practices from communities to publicly demonstrate their commitment to the LGBTQ+ community

Just 200 long-term care and senior housing communities in 33 states and Washington, D.C. — a small fraction of the total number in America — participated in the survey, which was conducted during the depths of the pandemic.

Of those, only 13 (or about 7% of them) qualified as Long-Term Care Equality Leaders, the highest level of the report's three tiers. To reach it, the facility must offer at least one trans-inclusive health care plan.

Another 137 communities in the report (68%) were High Performers, eight (4%) were not as far along and deemed Builders. Another 42 (21%) didn't rise to any of the three tiers.

The three states with the highest number of communities participating in the study: Ohio, New York and California, in descending order. The 17 with zero participants: Alaska, Arkansas, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Maine, Montana, Nevada, New Hampshire, North Dakota, Oklahoma, South Carolina, South Dakota, Vermont and Wyoming.

Sherrill Wayland, SAGE's senior director of special initiatives and partnerships, believes that over time, long-term care communities and senior housing developments in all 50 states and in more rural areas will participate in the biannual survey.

"We recognize that in this industry, we are in the beginning stages" of LGBTQ+ inclusion, says Dan Stewart, associate director of the Human Rights Campaign Aging Equality Project and a gerontologist. "I think as time continues, individual institutions will see that not only is this the right thing to do, but it's smart business sense."

Explaining why her United Church Homes senior living facility in Beavercreek, Ohio takes LGBTQ+ inclusion so seriously (it's a designated Leader in the report), executive director Laura Farrell says: "United Church felt this was an underserved population in senior care and senior housing."

That's also the reason the nonprofit is developing a primarily LGBTQ+ independent living community in Dayton, Ohio, working with the city and planning commission. The goal: breaking ground at the end of 2023.

"One of the biggest concerns we continue to hear from our older LGBTQ+ people is, 'Should the time come when I need long-term care support, will I be able to find a place to live that supports me, that recognizes me, that treats me with dignity?' And that doesn't discriminate against me because I'm LGBTQ+,'" says Wayland.

The question comes from lived experience.

"Ten-plus years ago, [long-term care and senior housing] providers were adamantly saying, 'There are no LGBTQ elders that live here,'" says Stewart. "Thankfully, I believe we've now seen with growing awareness, growing social context and conversation and recognition that the LGBTQ community exists across all spectrums of identities and that includes age."

Stewart notes that although many Millennials, Gen Zers, Gen Xers and boomers have been out and open for decades, "some members of our community in their late 70s and 80s have a history that often led to them being in the closet, out of fear of receiving poor treatment and access to services."

Farrell says many in the LGBTQ+ generation who want to live in long-term care communities and senior housing are "pre-Stonewall and live a little bit in fear" after facing years of discrimination.

Wayland says SAGE has seen people being denied entrance into long-term care communities because they're gay, lesbian, bisexual or transgender.

"These are true concerns and at a time when people are needing support but sometimes don't have the ability to pick up and move to another area of the country where they may feel more supported," she adds. "There definitely are real challenges out there."

Farrell recalls a lesbian couple who lived in Beavercreek a few years ago: "One of them said it was the first time she was ever able to feel safe having a public relationship with her longtime partner. They could walk up and down the halls holding hands. For the first time in 60 years, they could be who they were."

In the Long-Term Care Equality Index 2023, 73% of participants said they have rooming policies that are inclusive of same-sex couples and 84% took part in or supported one or more LGBTQ+ related events or initiatives in their service area.

But just 14% have medical and comprehensive health benefits to domestic partners of benefits-eligible employees.

One reason older LGBTQ+ adults long for a welcoming environment in long-term care is that they're twice as likely to be single and live alone and four times less likely to have children than others their age. So, they have fewer family members who could offer social support and assistance when needed.

AARP's 2018 research found that 76% of LGBTQ+ adults age 45+ surveyed were concerned about having adequate social support to rely on as they age.

The most important sign of LGBTQ+ inclusivity in long-term care and senior housing, Stewart says, is whether the facility has a non-discrimination policy for residents.

Ninety percent of the communities participating in the SAGE/HRC study have updated their resident — and employee — non-discrimination policies to include protections based on sexual orientation and gender identity.

By contrast, when SAGE and HRC researched such policies for their 2021 report, only 18% of the communities had published such an enumerated resident non-discrimination policy and 36% had a written policy for employees.

You can search for each of the 200 communities that participated in the SAGE/HRC report and see how they fared by using the online Long-Term Care Equality Index search tool on the Human Rights Campaign site.

SAGE and HRC's free online guide, "Finding an LGBTQ+ Inclusive Long-Term Care Community," offers helpful suggestions on what to look for and questions to ask when comparing prospective long-term care communities and senior housing developments.

"One indication of a space not being welcoming is if there's no visibility for LGBTQ+ people," Adams told me. "It's as simple as when you walk into the lobby, what are the pictures you see on the wall? Do you see a Rainbow sticker anywhere?"

All the collateral materials for United Church Homes' Beavercreek community, for example, have Rainbow flags and their front door has a Rainbow sticker, says Farrell. "To signify to folks that we are a safe place that's inclusive, open and affirming," she notes.

Stewart believes most aging-service providers want to foster an environment that lets people be themselves. But Wayland says some long-term care providers don't know how to be more inclusive and welcoming to LGBTQ+ residents and staff. She hopes the SAGE/HRC report will give them answers.

"There's always room for improvement," says Wayland.

A follow-up survey from the two groups will open in Summer 2024; results will be released in 2025.

Richard Eisenberg is the former Senior Web Editor of the Money & Security and Work & Purpose channels of Next Avenue and former Managing Editor for the site. He is the author of "How to Avoid a Mid-Life Financial Crisis" and has been a personal finance editor at Money, Yahoo, Good Housekeeping, and CBS MoneyWatch. Read More