In the wake of President Obama’s recent order that hospitals extend visitation rights and advance directives to same-sex partners, a new report looks at how U.S. hospitals are doing so far at ensuring equal treatment for LGBT patients.

The Healthcare Equity Index, a Human Rights Campaign Study, found that while there have been improvements since they started doing the survey four years ago, many hospitals and clinics still lack clear policies regarding LGBT patients. The lack of a clear policy leaves same-sex partners at risk of being denied visitation or medical devision-making abilities.

Of the 200 hospitals studied, only 42 were rated as top performers. Until the new rules are implemented, it will be up to individual hospitals to decide what protections to extend to LGBT patients.

“The healthcare landscape for LGBT patients and their families is about to change dramatically,” said Joe Solmonese, president of the HRC Foundation. “We all know horror stories of loved ones torn apart, already heart-wrenching decisions made even harder, and basic human rights denied. Bold action by the President and the Joint Comission mean many of those stories will be a thing of the past – and not a moment too soon, because as of right now huge challenges remain on the books.”

Until the changes are put in place, it’s important for LGBT people to ensure they are prepared before tragedy occurs – particularly legal documentation like advance directives and visitation authorization forms.

It’s also important to note that the lack of written policy does not mean a hospital is actively discriminating against LGBT patients and families. “While many LGBT people may indeed have a positive experience in these hospitals, we believe that the standard for equality must be policies that are put in writing and carried out in practice,” said Solmonese.

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