is marilyn and (calling names) and those are the last 3 i have anyone else wishes to testify submit a form. >> eye hi, i'm marilyn i'm an r.n. r.n. pled since january of 1990 i've noticed a down ward trespassed of patient they're taking they're picking and chu's not patients who have no insurance or their insurance company has lapsed or not taking homeless or anyone with the drug decisions and trying to control the consensus and keeping it low and canceling the staff it's difficult they don't staff on seniority but they're keeping it

at 14 patients two rn that's busy and difficult when you have to do all the quality of care because you have the 7 patient and something happens i don't staff for that. i think like i don't understand i thought there was supposed to do charity case but in my experience they try not to keep the patients too long based their financial status but some of the patients that went out to the community had to come back because of our care. i definitely urge you to pass the resolution because it will harm the community. people need those insufficient

beds i don't know they're trying to cut back their cutting back on the staffing it's definitely detrimental >> thank you. the next speaker as i said candy and john and others >> hi, i'm an rn that works at field nursing and it's going to close i have an internal ploy to read to you. it was written and july 9th it says hello all sharing with information i received at your post task force meeting we're on a pause for consolidating of the canvas to st. liking meaning holdings consolidation up to 4

months that brings us closer to the november date more like the end of the year it is due to the state working on and city health care hearing maybe insufficient consensus b will be held to 38 beds and the insufficient beds two 21 beds not opening up all the beds at st. luke's due to not enough staffing the insufficient beds are held to 16 beds we're asked to move staff over as itch as possible to the other canvases is not needed we are that told there this last week it was on pause and held at 15 beds for many, many most so

many of the staff has not worked may be one or two pay periods and now 15 beds we need to have 46 we used to have and now down to 15. so our patients that's it they're sick and minimal people there decreases have move forward along and physical therapists have moved on because they're closed. now we have hardly anyone in terms of support >> time. >> thank you. >> good evening. i'm a recommended nurse. i've been on the field nursing facility and i'm also on the bargaining team so i'm hoping to

work and find, you know, jobs for nurses within the medical center. so this is the first i've seen there will be no skilled nursing bed in the st. luke canvases i've been involved in this process for 8 or 9 years original we were committed to keeping one hundred beds plus open and now? wield down and no skilled beds in the canvas this is disturbing we have nurses thinking their jobs for them and now it looks like zero i feel terrible to my coworkers i've been telling them they're going to st. luke's and having a job interest and turn around and see zero, zero is really disturbing i want some transparent i have

coworkers their hours are cut or they have to move from, you know, like night shift to p.m. shift this is, you know, upsetting to them they've got 20 years at the medical center and don't feel there being a tread well, so trarnlts certainly in this process >> thank you. >> good afternoon from the nursing association i want to echo what the speaker said it's outstanding to us this the first we've heard they have actually some solid plan at insufficient at st. luke's everything we've

heard from sutter we're doing give me graphic research and so, now we have this hearing and all of a sudden they have an answer maybe we need to have a lot more hearing and got answers i don't know but we have been asking for the mixed services and their plans to the future of st. luke's we need to know that about cathedral hill for the nonprofit hospital for the being for the community having a policy they don't expect anyone outdoors of cpc if this is what 31 they do with their practice didn't make it okay. this hospital is supposed to have a responsibility to the community for them to go from 2

hundred and 12 insufficient beds to 38 insufficient beds that's a huge reduction and your own information is showing you you're going to need an increase of over a lot of beds from a huge hospital that is dedicated to insufficient so we're going to have to figure this out and work with the historic preservation commission to work this out because what sutter is doing is taking us in the wrong direction and as kim said another person they're making million dollars and statewide billions of in profit they're doing fine and to deny the veterans the services and the homeless or people that are lacking in their insurance even

though they have insurance and they're go to lapse so they don't want to cover them this is not what their supposed to be doing at the community hospital. we, you know, urge you to pass the resolution to say this is causing community harm and hope to work with you in the future too >> thank you very much. if there's no further public comment seeing none, public is closed commissioners, if you have any questions he at this point i was going to ask mr. veracruz if he could commercialism has i was looking at the number is it correct we currently have 99 insufficient beds i'm only looking at insufficient and that are staffed you're going to be proposed 75 staff but the ultimate license number you're

going to be asking post construction is only 38 >> that's post construction that's all consistent with what the report outlines. >> as our master plan. >> but i presume when 9 time comes how we'll handle the legacy services at st. luke's we'll have to go through the channels with public health but for clarification sake i heard there was a miss conception that the one hundred and 20 care beds we'll take the 79 and move them into them that's thoot not; correct this is the first day we're hearing about st. luke the director put out the report in 2008, and this is clearly outlined in the report.

ii think that answers your questions >> i thought we should get classification and any further reduction require a hearing under our current prospers recollections. and i was going to ask a clarification open the employees there's a various whether it's 19 or 4 are you relocating or offering them packages we're interested >> first and foremost we want to keep people in jobs and offer them alternatives one thing there are about 8 nursing physicians we've gun go going through troothd training to take care of cardiology patients a number of them have passes their

examines so people are qualified for those positions so my lastly number we're identified for everyone positions four ln positions we're looking for jobs and open positions to offer people all the way up until the consolidation. >> questions. >> go ahead. >> i wanted to ask co- lien some questions. >> okay. >> and understand a couple of things and sure. >> sure i'm sorry. and then i have a couple of questions for the gentleman as well. i'm trying to boil this down the employment issues aside what i'm trying to make sense is the supply and demand equation here

the demand for the services vs. the supply so start with the in an willful question the departments work the sites and insufficient beds per person in the city versus national for over the age of 24. the lou even report eyes over 65. look at the data who audio tapes those beds today in the city is primarily female and primarily over 65 a huge percentage but a larger percent female and as you think from a prospective what's the right gage for measuring the demand for those services which population co- inherit is the most vigorous to look at and i also that the reason there are a

couple different kinds of facility beds they can be after injury and don't necessarily have a pro documents for the patients long-term care besdz like 9 laguna honda will have elderly patient so i think it's a mixture of the two. the issue was removing skilled nursing beds that are short-term beds it puts greater pressures on the community to gill i fill the gaps for additional needs in the effect they're a full capacity at c mc you take care of the short-term rehabilitation needs and c pmc looks outside of their facility to support their needs to take beds from the city

that needs the long-term care beds those are the ones we're talking about being in greater shortage in the long term. but i would say about long term skilled nursing beds that's not the ideal place to provide care for our growing senior population there's a great effort put into aging in place and providing appropriate services to patient in the their home to allow them to live in their home and while certainly patients that are older he needs the skilled beds there will be a need for instill based care not the direction the industry is going. i don't know if i've directly answered 2 but there's a combination of things >> yeah.. so let me pickup on where you

left off this is my second question there's a huge demand i don't pvend prevented to be an expert but there's a national conversation boiled down and insurance reimbursement rates about the where we want to have incentive care not only for financial reasons for for better care and a rigorous findings of what's better and worse and so maybe you can educate the commission on what is going on nationally in insufficient beds and what's the world look like 5 or 10 years from now in terms of for a lack of a better word the eco system is growing to care for the patient in the most

appropriate place because we've spent a lot of time talking about real issues in san francisco but without the context of where the world is going i think we have a chance of making maybe a more short-sighted decision >> currently part of the reason that has obedience stated for the trend the transition from long-term care beds to short term rehabilitation beds relates to reimbursement. the medicare will reimburse on for a hundred days i think it is of skilled nursing facility care and that's the limit for any medicare beneficiary and medi-cal reimbursements separating for the care so pashlts with low income that's a benefit under medi-cal so medi-cal rates are lower in our

state we're range 49 or 50 in reimbursements so it makes sense it's a better business sense for a facility to use skilled nursing beds in a short term base for their medi-cal base hay and that's the need hospital based skilled nursing beds have not long term but short-term beds to step down from acute care until they're able to go into the community. on the medi-cal side increasing it naild we're looking at managed care right now in california the care is carved out of murder in the second degree care there's an increasing push towards managing care for patients, in fact, california has launched a demonstrates project including

long term services medi-cal duly eligible with is medi-cal that's a trend we're seeing expand and the idea is if you provide a person enough supports and services earlier in their life perhaps you'll achieve savings and you'll be motivated to do that as a provider so the trend is more towards managed care. i don't think it's going to avoid the need for skilled nursing care but make the financial decision more apparently >> so when you think let's take everyone at their word and assume those policies to sort manage care more holistically nationwide are from a liability point of view what do you think accident impact brown will be

the study was 09 that's 5 years ago what do i think 5 or 10 years from now our best guess is the projections we've seen for the demand for insufficient beds that will be what we think it is correct me if i am wrong they assume a constant reimbursement environment that exists today. and but people are trying to make our health care system for rational which everyone is for except it's hard when it touches the communicated today in the way people are comfortable with what's our guess 10 years from now how the projects will look.

the seven hundred bed projection was not from the aluminum even report but the chiropractors master plan and cited so it was more recent after the health care reform but a little bit of experience we have with health reform it's somewhere in the middle i think it would we need seven hundred beds in 2050 i hope not hopefully, there will be other alternatives that allow people to stay in a in their homes maybe we'll need more. >> thanks. i have a question for mr. veracruz. so thanks for coming here.

i don't think this is the most pleasant thing you've done all day. i could have not been listening carefully enough last night but where are you guys doing this >> the consolidation. >> no, no not the consolidation i get that but why are you reducing the amount of sniff beds your staffing in the city there's some data we just heard a more moderate view there's a huge demand our the supplier so help us in simple terms where c p pmc thinks this the good. >> we're providing a short term

sniff about 14 days as opposed to a much broad problem that we acknowledge exist i think the deputy director her comments we're talking about a boarder conversation so the judge is simple our demanded for those short time beds a has strurng slung their responding for to that we've had an upper 60s and low 70s thour now we're reducing to 17 we've seen that pattern there was five or six months of data trend we've had it mentioned 24 has to do with payers we know that's some of

the reason our consensus has dropped payers make decisions on a variety of reasons but that's effectively why. >> do you think in your experience in san francisco in terms of seeing less demand for those short time sniff beds if i follow you is gentle lists able to all health care or seeing some go up. >> the sum. >> i don't have insight we didn't investigate but really looking at our care delivery system. >> the thing i'm trying to figure out do having i have public comment that suggest the decrease has been carefully managed i'm not awe certified

anything and so one of the jobs for us is the hard job to figure out okay someone is inserting that is that what's happening and one way to do that will certainly help me to understand the issue to understand if your demand is going down is everyone's demand going on down this is the reality of, you know, one part of what's happening in the change of health care or not i don't know if anyone director garcia who can help us understand that it seems like that's one piece of data that unpacks some of the awe southerners were and we have to think about the networks particularly because we're a strong network the san francisco network one of the greatest concerns are the other networks

not going to do something we'll have to pickup for them. and you've heard the testimony. so one of the issues when reimbursements stop people stop doing the services this could be looked we don't get to have this choice in terms of public healthy health so there's a responsibility of the networks like c pmc to take care of not only their getting network but the opening needs of the community at large that's part of the issue i think we face with when we i sat in the negotiations over a year with c pmc we have an agreement that will be honored by city but there's a greater honor you have to hold c pmc to 38 and that's the community.

you've identified an area that if someone doesn't make money they'll make others pickup. i hold c pmc account to not only their network patient by the greater needs of the community we want them to be a better partner (clapping) >> i guess what i'm trying to - i disagree we're going to live up to our responsibility and obligations have we seen increased demand for those services. >> we consistently have demands in our community and i think that the other issue we're facing and you've heard pacific monaghan talk about this how do we inaccurately manage people

that are getting older we're going to have a larger older population in san francisco we have an obligation not to institutional lists individual we have to insure people at the right levels of care we have a responsibility to make sure that people are not snuldz in long term care beds so we have to look at ways to reducing the way even if people being institutional listed in terms of managing their care at home we have to make sure that people get the right care. but i'm concerned when networks start being driven by the reimbursement which i understand we face it we've got the opportunity to make the back fills to support that but we need to work together around

this piece of looking at how to keep people out of being institutional listed and but i think this may change in 5 years marching maybe 9 fact we're taking care of people at home and who knows what that we'll find in medical technology we account potentially reduce the needs but today is what we see for the future it's hard to predict >> that's the conclusion i'm coming to say that it's a little bit early to have too much confidence in your prediction of the demand for those beds you may be right but this is early so the shack up from health care reform. so i think as a commission that this if we're going to error

it's going to be on the side of m error we have to have a capacities in the city you guys are going to be here forever and probably prudent to see how the data shacks out i've not heard a convincing agreement argument with the supply of beds out weeks ago the demand >> director and director garcia i completely agree with you we're not not first and second ending and out it is brooklyn beyond the sniff beds but