As the home health industry has grown and become more competitive, it’s become increasingly important for providers to seek any means of differentiation.

For the Visiting Nurse Service of New York (VNSNY), that’s meant spearheading a rapidly growing program specifically designed for gender affirmation surgery patients.

Gender affirmation surgeries are procedures that transform individuals’ bodies to better align with the gender that they identify with. For some, those surgeries include vaginoplasty, a procedure to change genitals from male to female that requires substantial post-operative skilled care at home.

VNSNY launched a dedicated gender affirmation program in collaboration with Mount Sinai’s Center for Transgender Medicine and Surgery in 2016.

Since then, it has trained more than 150 of its clinicians, therapists and social workers on the cultural and medical nuances of post-op care for affirmation surgery patients.

“We basically built the program from scratch,” Shannon Whittington, a registered nurse and gender affirmation program director for VNSNY, told Home Health Care News. “It’s often a component that’s overlooked, but the home care piece is very important to helping transition patients and teach them how to take care of themselves.”

The nuances of care

Specialized training for VNSNY caregivers typically lasts between four to five hours, according to Whittington, who said a big chunk of that time is devoted to cultural sensitivity education and background on how appropriate language is important during interactions with gender affirmation surgery patients, particularly when it comes to pronouns.

“When a patient goes into surgery as ‘Johnny’ and comes out as ‘Janie,’ it’s very likely they want to be identified under a female pronoun, even if their insurance card or legal name may still reflect ‘Johnny,’” she said. “That lets a patient know we are sensitive to the topic, that we are trans-friendly and that we are culturally competent to care for these patients.”

In total, VNSNY has cared for about 225 transgender patients through its gender affirmation program. The majority of patients are referred to VNSNY from Mount Sinai, though some also come from NYU Langone and Montefiore Medical Center.

When VNSNY first launched its the program, it provided care for about one or two patients a week, according to Whittington. In 2018, that has jumped to about eight to 16 patients a week. Overall, clinicians have been “excited” for the opportunity to work with gender affirmation surgery patients, she said.

“Nurses are excited to have a new skill set,” Whittington said. “They learn a lot.”

Founded in 1893, VNSNY is the largest not-for-profit home- and community-based health care organization in the country, serving roughly 33,000 patients on any given day.

Earlier this year, the organization’s licensed home care services agency, Partners in Care, was awarded platinum-level certification from the LGBT advocacy group SAGE. VNSNY Hospice and Palliative Care and VNSNY Home Care have also been awarded SAGE certification.

‘Knocking down’ Mount Sinai’s door

Episodes of care for gender affirmation surgery patients usually last between two to four weeks.

In addition to focusing on cultural competency, VNSNY’s gender affirmation program also prepares clinicians for navigating the complex relationship with patients and their families, who may not always be on the same page at first.

“In home care, it’s very important we involve the family, whatever that support system is,” Whittington said. “But sometimes we have to support the support system because they don’t fully understand what’s going on with the patient.”

Zil Goldstein, a family nurse practitioner who has been working with transgender patients for more than a decade, is the clinical program director for Mount Sinai’s Center for Transgender Medicine and Surgery. Mount Sinai has performed hundreds of vaginoplasty surgeries in the past couple years, and VNSNY has been an essential part of positive health outcomes in those cases, Goldstein told HHCN.

“These are pretty unique procedures with some pretty unique after-care requirements,” Goldstein said. “There’s such a demand for these procedures and this kind of care—people have been knocking down our doors since the minute we opened them.”

VNSNY caregivers’ eagerness to learn is largely responsible for the success of its gender affirmation program, she said.

“They’ve been incredibly nimble in terms of adjusting to what we do,” Goldstein said.

For now, VNSNY sees itself as the home health industry’s clear-cut leader in providing post-surgical home care for gender affirmation surgery patients, Whittington said. The program has “absolutely” been a major differentiator from other home-based providers, she added.

VNSNY is likely to have more competition for that patient population moving forward, however, especially as more health systems start to make affirmation surgeries readily available to the estimated 1.4 million transgender adults living in the United States.

“I think we might be one of the only agencies that’s really focusing on this population,” Whittington said. “Prior, patients often had to leave the country to have these types of surgeries. I’m really pleased with the progress.”

Under federal and state laws, it is illegal for home health, insurance companies and health systems to discriminate against individuals who identify as transgender. Even with expanded protection under the Affordable Care Act, which prohibits sex and gender discrimination, many in the transgender community still face discrimination in health care and coverage, according to the National Center for Transgender Equality.

VNSNY and Mount Sinai’s care coordination for gender affirmation patients preaches the importance of cultural tolerance and education, but those lessons aren’t limited to providing care for transgender individuals, Goldstein said. In general, the demonstration serves as a solid building block for all home health providers looking to improve upon their caregiving capabilities for patients with sensitive or unique social standings.

“What has made this program successful is everyone’s flexibility and willingness to learn, and those are really the keys,” she said. “It’s all about being ready to do whatever it takes to create a good experience when you’re going into someone’s home.”

Written by Robert Holly