A Coordinated Transgender Person Care Pathway

Helping Patients Navigate Through Transitioning and Total Health

By Benjamin Seto
The Permanente Federation

As Kaiser Permanente worked over the years to establish care for transgender people, the Permanente physicians helping to shape the programs focused on ensuring the total health of the patient, inclusive of gender-affirming procedures, and on incorporating the patient’s voice in determining the most appropriate path to good health.

The Permanente physicians who provide care to Kaiser Permanente patients have worked collaboratively to develop and grow transgender services. A truly integrated and comprehensive program consists of general medical care, hormone therapy, behavioral health services, and several sub-specialized surgical services. The sustained commitment to developing the components of a comprehensive program in a collaborative, multidisciplinary, and culturally competent fashion is the hallmark of how the Kaiser Permanente community comes together to respond to a critical health care need.

In 2013 when the Kaiser Permanente Oakland Multi-Specialty Transitions Clinic was established, it was considered to be the first transgender person health clinic offering comprehensive services opened by a major U.S. health organization.

“This is a community that historically has faced tremendous barriers to accessing quality care,” says Stephen Parodi, MD, associate executive director at The Permanente Medical Group in Oakland, California, and one of the leaders of transgender care at Kaiser Permanente. “It was important to us to develop a program that’s based on state-of-the-art transgender medical and surgical therapy. Our multidisciplinary teams are deeply committed to providing the highest quality treatment and service to our patients.”

In Northern California, a cadre of surgeons led by Ali Salim, MD, chief of Plastic and Reconstructive Surgery at Kaiser Permanente San Francisco, provides several complex gender-affirming surgeries in-house. An expert microvascular surgeon, Dr. Salim learned phalloplasty and vaginoplasty procedures from surgical experts in Belgium, Serbia, and Amsterdam from 2014 through 2016, and now trains others in San Francisco.

Integrated Care Helps Navigation

The transgender patient care settings at Kaiser Permanente take a common approach to ensure coordinated care, reflecting the organization’s integrated care model. Key elements of Kaiser Permanente’s approach to caring for the transgender community include the following:

• Assigning a nurse navigator or case manager who helps the transgender member go through the process of transitioning, even if some of the surgeries are provided outside the system
• Adapting electronic health records to allow for fluidity in gender markers for transgender patients to accurately reflect the care prompts required for ongoing primary care
• Providing culturally responsive training and resources to physicians, other clinicians, and staff interacting with patients so a comfortable and welcoming environment is fostered, building trust between patient and provider
• Incorporating member feedback, whether through Transgender Member Patient Advisory Councils or by reaching out to community organizations to hear challenges the community faces and how the care experience can be improved

Several Kaiser Permanente regions include member advisory councils to incorporate patient feedback. In 2015, Kaiser Permanente launched a special project, known as “Lantern,” to conduct field work to understand how a transgender person might experience health and health care. The project, which included countless hours of member interviews, garnered Kaiser Permanente’s Innovation Consultancy a Design Value Award in 2016.

“It’s hard for us to put ourselves in the shoes of our patients,” says Stephanie Detlefsen, MD, physician lead of the Gender Pathways Clinic, which opened in January 2016 in Portland, Oregon, to provide care to transgender patients in Kaiser Permanente’s Northwest Region. “Member panels enlighten us to situations they’ve gone through that we may not have thought of. This helps us provide better care for this community.”

One of those voices belongs to Maggie Mae Pitchlynn, a Kaiser Permanente member in Southern California who is in the process of transitioning from male to female. She sits on the Behavioral Health Council as a patient adviser, providing input on both behavioral health services and transgender care. “I’m the only transgender person on the council,” she says, “and I look at that council as a way of giving my community a voice within Kaiser Permanente.”

Pitchlynn says it’s encouraging when the council makes suggestions and she can see changes implemented. Having member advisory councils shows that an organization “wants to improve how they treat their patients by listening to their patients’ requests. It makes me feel good that they’re willing to do that.”

Updating Electronic Health Records

Kaiser Permanente’s industry-leading electronic health record allows physicians and care team members to coordinate services, which is important for transgender patients who in smaller regions may have to receive certain surgeries in other Kaiser Permanente regions or from providers outside the system. Kaiser Permanente’s integrated care delivery system allows the care team to coordinate visits or consultations with mental health professionals, specialized social workers, endocrinologists, or surgeons.

“When people see our program, they tend to think it’s restrictive and don’t appreciate the integration at first,” says E.W. Emanuel, MD, associate medical director at the Mid-Atlantic Permanente Medical Group (MAPMG), who has oversight of transgender health services in Washington, DC; Virginia; and Maryland. “But then they’re wowed by all the information we have in one system, which allows us to collaborate and which leads to more efficiency and better outcomes.”

A big issue for a transgender patient is being misgendered. – Jennifer Slovis, MD, medical director, Oakland Multi-Specialty Transitions Clinic

All Kaiser Permanente regions are working with their physician partners to update the electronic health record system to allow for gender markers to indicate what primary care prompts should go with a patient’s record; many collect the SOGI (sexual orientation and gender identity) data outlined by recommendations of the GLMA, formerly the Gay and Lesbian Medical Association.

“You have to think beyond the typical preventive prompts that might tell you what services may be due,” says Jennifer Slovis, MD, medical director of the Oakland Multi-Specialty Transitions Clinic in Northern California. “A transgender woman who had gender-affirming surgery may still have a prostate and might need appropriate care. Those reminders may not show up in the medical record if she had her gender marker changed to female. … A big issue for a transgender patient is being misgendered.”

Creating a System of Trust

In an effort to improve the records, for example, the Southern California Permanente Medical Group (SCPMG) – through a grant from Kaiser Permanente’s Garfield Memorial Fund – is working with MAPMG colleagues on how to update the dashboard of the electronic health record to better address transgender patients’ needs, starting with transgender focus groups.

Sometimes the change in the electronic health record can be a simple first step to help get the patient’s name right and use preferred pronouns.

“It may be a simple thing, but calling people by their preferred name is one of the biggest thing you can do to build trust,” says Deb Friesen, MD, an internist and physician market leader for the Colorado Permanente Medical Group. Dr. Friesen has been a physician champion for transgender patients in the area for the last five years and says getting the name right is part of the organization’s “Know Me” tenets. “You can’t know someone if you don’t call someone by their right name.”

Education and training are common among health care organizations, but they still play a critical role in providing care to the transgender community. In 2016, the Gender Health Program at the Washington Permanente Medical Group offered an initial continuing medical education (CME) course on how clinicians can better meet the needs of transgender patients. The course included content about transition protocols, behavioral health, care management, and speech. Due to its popularity, the CME course was offered again later in the year and reached full registration.

“The popularity of these courses highlights the desire providers and staff have to offer the best quality of care for this population,” says Colin Fields, MD, Gender Health Program’s medical director.

It may be a simple thing, but calling people by their preferred name is one of the biggest thing you can do to build trust. – Deb Friesen, MD, physician market leader, Colorado Permanente Medical Group

Kaiser Permanente regions also follow guidelines from the World Professional Association for Transgender Health, which outlines services recommended for transgender patients. “The whole journey for a transgender patient is multifaceted,” says Kalvin Yu, MD, chief integration officer and physician lead and director of Transgender Care at SCPMG. “We educate front-line physicians and staff about the care we provide and how to initiate it so our transgender patients are knowledgeable of the services, too. We want to foster trust in the health care system from day one.”

In West Los Angeles, the program strives to provide most of the transitioning surgeries in house, adding vaginoplasty last April. As chief integration officer, Dr. Yu’s job is to ensure all the various services are coordinated and seamless. “We want to have a comprehensive service line where members are talking to all the clinicians they need access to. It’s truer to our mission when we can provide comprehensive care.”

Commitment to Change

Some regions have launched websites to better explain their services. And several have extended transgender care to pediatrics. “If we can care for these patients at an earlier age, ultimately we’ll be providing much better care down the line,” says Dr. Detlefsen.

With transgender patients, however, it’s important to remember that there is a broad spectrum of gender identities. “There isn’t any single correct destination or path,” says Erica Metz, MD, medical director of Transgender Health for The Permanente Medical Group in Northern California. “One of the crucial goals of transgender care is the need to be individualized to each person.”

Dr. Metz, who is also director of the Gender Pathways program at Kaiser Permanente San Francisco, says it’s an honor to help patients and guide them on their journey of becoming their true selves.

This represents Kaiser Permanente’s commitment to diversity and inclusion, which recognizes that high-quality care is provided to everyone, no matter a patient’s race, sex, age, sexual orientation, gender identity, faith, language, or economic background. Recently when the Department of Justice released guidelines that appeared to threaten the protections to access care for transgender people, Kaiser Permanente and the Permanente Medical Groups reaffirmed their commitment to providing care to all communities, including transgender people.

In staff training programs, reaffirming the organization’s mission is key to acceptance, says Kate Koplan, MD, associate medical director for Quality and Patient Safety, The Southeast Permanente Medical Group.

“We always harken back to Kaiser Permanente’s mission of providing affordable, non-discriminatory, high-quality care,” says Dr. Koplan, who oversees Kaiser Permanente Georgia’s transgender care program. “That’s our north star, and when we focus on that, we can rally the troops and be respectful of all voices.”

Many of the physicians interviewed talked about their own education and personal growth in working with their transgender patients and the community; many of them have been recognized by LGBTQ organizations as partners or allies, with several marching regularly in Pride parades.

“What amazing partners our members and patients have been,” says Dr. Friesen in Colorado. “How they have educated us, corrected us, really partnered with us to be better at delivering care to them. It’s really their courage, their patience, and their dignity through it all that has made us better.”