Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population. METHODS: The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design. RESULTS: We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase). CONCLUSIONS: FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

Characteristics of HIV-Positive Transgender Men Receiving Medical Care: United States, 2009-2014.

OBJECTIVES: To present the first national estimate of the sociodemographic, clinical, and behavioral characteristics of HIV-positive transgender men receiving medical care in the United States. METHODS: This analysis included pooled interview and medical record data from the 2009 to 2014 cycles of the Medical Monitoring Project, which used a 3-stage, probability-proportional-to-size sampling methodology. RESULTS: Transgender men accounted for 0.16% of all adults and 11% of all transgender adults receiving HIV medical care in the United States from 2009 to 2014. Of these HIV-positive transgender men receiving medical care, approximately 47% lived in poverty, 69% had at least 1 unmet ancillary service need, 23% met criteria for depression, 69% were virally suppressed at their last test, and 60% had sustained viral suppression over the previous 12 months. CONCLUSIONS: Although they constitute a small proportion of all HIV-positive patients, more than 1 in 10 transgender HIV-positive patients were transgender men. Many experienced socioeconomic challenges, unmet needs for ancillary services, and suboptimal health outcomes. Attention to the challenges facing HIV-positive transgender men may be necessary to achieve the National HIV/AIDS Strategy goals of decreasing disparities and improving health outcomes among transgender persons.

Qualitative inquiry into barriers and facilitators to transforming primary care for lesbian, gay, bisexual and transgender people in US federally qualified health centres.

OBJECTIVES: Health systems must rapidly move knowledge into practice to address disparities impacting sexual and gender minority (SGM) patients. This qualitative study explores barriers and facilitators that arose during an initiative to improve care for SGM patients in federally qualified health centres (FQHCs) from the perspectives of FQHC staff. DESIGN: Cross-sectional qualitative content analysis, using a general inductive approach, of secondary data from transcripts of intervention events offered to FQHC staff and semistructured interviews with staff and FQHC leadership during the intervention. SETTING: 10 FQHCs from nine states in the USA. PARTICIPANTS: FQHC quality improvement (QI) and clinical care staff, and leaders at each FQHC. INTERVENTIONS: The transforming care for lesbian, gay, bisexual and transgender people QI initiative combined two evidence-based programmes, Learning Collaborative (LC) and Project Extension for Community Healthcare Outcomes (ECHO), to assist primary care health centres in developing capacity to identify SGM patients, monitor their health and care, and improve disparities. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was identification of barriers and facilitators to implementing initiatives to improve care for SGM patients. The secondary outcome was clarification of how intervention participants used Project ECHO sessions versus LC meetings to obtain information that influenced implementation of the initiative at their FQHC. RESULTS: Barriers and facilitators mapped to two major themes: 'Clinical' (patients' health, wellness, and available treatment) and Health Systems and Institutional Culture (FQHC operations, and customs and social institutions within the FQHCs and in the external environment). Common 'Clinical' inquiries were for assistance with behavioural health, pre-exposure prophylaxis and transgender hormone therapy. Prevalent facilitators included workflow change and staff training, while adapting electronic health records for data collection, decision support and data extraction was the most prevalent barrier. CONCLUSIONS: Project ECHO and LC provided complimentary forums to explore clinical and operational changes needed to improve care for SGM at FQHCs.