that is available in san francisco. we provide to a high number of needs that are primarily med cal. this slide here is intended to show you just where our patients are coming from. the darker the area, the more densely is our patients. you can see that st. mary's really serves a lot of the patients in the western side of san francisco. st. mary's challenges. just like many other hospitals, st. mary's has faced unprecedented financial exactlies and -- challenges and pressure. in order for us to continue and do the best we can to deal with limited resources that are available to the hospital so that we can continue with our mission, which is to take care

of the community to advocate for them and also to provide care for everyone including those without the ability to pay. in this slide here i also showed to the hospital, we take care of a pretty high population together of medicare and med cal patients. as i mentioned, about half of our patients are med cal patients. at this point, i will turn it over to abby who will share a bit of the community bents that we provide. >> good afternoon commissioners. as you know st. mary's is long standing provider of community benefits in san francisco.

this was what was reported in fiscal year '14. you'll see this again shortly. closure of the skilled nursely facility at st. mary's as i think you understand has been a long arduous and a discerned commission on the part of st. mary's and sisters of mercy. skilled nursing unit at st. mary's is short term acute unit that provides physical rehab and rehabilitative care. many hospitals across the united

states pulled skilled nursing units within the four walls in their hospital. that has been the experience at st. mary's as well. the expenses for the required hospital based services to the skilled nursing unit is about $2 million on a direct cost bases. that's not charges. that's not including the overhead. as i said the leadership did a valued based decision which is where multiple stakeholders are called into the room to have a very deep thoughtful discussion based on values not necessarily on finances but on the values of the hospital and what the closure means to the hospital in the community and it was a unanimous decision that this was a necessary step it take. so the plans are under way to close the unit on the 21st of june. the unit is budgeted on a

historical average. it's capped because of the budget. in private healthcare most budgets are set based on historical averages. this unit is running average daily census about 70 patients. it is anticipated, since these are sort term patients, those patients will be placed in the community. i think that concludes our presentation. i know there are questions that you may have for us and for the department. >> thank you, commissioners. questions. perhaps from your last comment. you said that you could place in the community. does that mean the community still has a number of sniff beds? we heard sutter was doing sutter and not taking others.

>> right. there's 17 community skilled nursing facilities in san francisco that do take patients. kaiser using them routinely, st. francis uses them routinely. these patients will be discharged home should they be ready to go home or and that's more likely scenario. patients that will be discharged to skilled nursing from st. mary's would go into a community skilled nursing facility. >> commissioners questions? commissioner pating. >> i want to thank our staff for doing a wonderful report. congratulations. wonderful briefing document. i want to thank ms. chung for involvement in the program. i have four questions and i'll ask them one at a time.

the census of your sniff unit has a capacity of 32 can you explain the low utilization? >> if you look at the census, the census actually and the patients have dropped primarily in the last couple of years. it probably is a multifactorial kind of reason. a part of that is the changes in some of the practice of our physician. started about two years ago our program they have expanded the number of hospice. our hospice started to follow patients in facility.

that's one of the reasons where attending physicians and patients were receptive. they go to a skilled nursing facility where they can be followed by the same group of physicians. another thing is that one of our long standing physicians at st. mary's actually have become very active in one of the local sniffs and medical directors, they provide great rehabilitation services. our orthopedic has been very satisfied in the patient -- and the patients came back with great comments. we have another physician. started following some of the patients in the skilled nursing facility. he has been doing some of that

prior to then, he had been putting some of the parents at st. mary's and following them. we collaborate with community sniff. the physician would folsom of these patients up to sniff. if they need to come back or for placement, they would work with st. mary's and we would take care of these patients. it's probably a number of reasons that prompted some of the physicians of their referring physicians to have the patients be placed. >> thank you very much. looking at your hospital based sniff. if you come offline, we'll be losing hospital based beds. which is largely short term. my guess, is you're not offering acute care. there's no ventilator support. shading this side being a hospital service.

is there an advantage of running a hospital-based sniff, this is a community-based sniff. is one higher level care or lower cost than the other. it sounds like you're moving your patients to community sniff. i assume there's a reason. >> hospital sniff certainly is a much higher cost than running in a community sniff. for the hospital sniff, we staff in a much higher ratio. also the wages are different. there are a number of reasons why hospital based skilled nursing more than a community sniff. >> last slide i see. when you come offline. the staff conclusion, there will be a detrimental impact on the residents of san francisco for long term care services, losing our sniff beds. i'm not sure i agree with the

conclusion as written. mostly because it's a question of what type of sniff beds are we talking about. is it detrimental impact in the short term beds or long term beds like laguna honda. i see them differently. is it impact like right now. it seems to me if you're actually having seven beds out of 32 there's not a lot of demand for it, i'm just wondering whether the loss of those beds will be a detrimental loss in the short term. >> our skilled nursing unit primarily takes care of very short term patients as was noted. we take care of some of the

rehabilitative patients. it's a very short term. it's designed to be a very short term skilled nursing facilities. >> you found better ways to deal with your own patients correct? >> correct. >> if we do support this idea of coming offline, is there a commitment from st. mary's that long term that would help us to solve the problem? we're going to have a long term problem of beds. we'll be looking to hospitals. you'll be needing to discharge to continuing shortage of beds yourselves. i think we looked to be a part of the solution if you're taking beds offline. >> i certainly think all2mñ?ñ?ñ the hospitals in san francisco are interested in solving this problem. it's not one that we can do online. i know two levels, one dignity health i spoke with our

strategy about this yesterday. it's been recently declared that this is supposed to acute care is a major priority for us. the whole bucket of services that comes into long term care it's quite complex. i do sit on long term care council. i think this skilled nursing area is one that nobody owns in san francisco. long term care council doesn't own it. health department doesn't own it. it's something i know. when i first went to the long term care, i asked thisc?ñ?ñ? question about what the capacity was. there wasn't any studies done at ñ?ñ? that time. we're looking into. all of us aging baby boomers are not looking forward to

institutionalized care. it's something that really needs to be questioned. certainly, i think there's ways i would encourage this department and long term care council commission on aging to really look together at how we have a community that has resources of those of us that choose to stay in this expensive city as we age >> that was my last question. i just want to conclude by saying, i'm not sure that hospitals is expensive than they were or the best place for immediate care services. i think long term we need to look probably at health ?ñ?upports and creative ways to build services. big problem for san francisco, the rent is high and it's hard to build community based program. i think it's taking seven or ten

beds offline nowpoñ?ñ? doesn't create the huge impact. longer term we'll be keep doing as a system. >> commissioner singer. >> i have a questionñ÷ñ?ñ? for 9jñ?ñ?dph staff. >> i just wanted to explore a couple of things. it seems like nationwide there's a move to kind of get a better handlemçñ?ñ? on post acute?ññ?ñ? care management. andv!ñ?ñ?év2.s(4wh2< u

wholisticly to get patients at the right care level and get them home as quickly as they can. they're assertion and data that backs it up that suggest that for reimbursment and incentive purposes people staying in sniffs in general longer than they might in a more rational managed system. i'm just wondering, since you're an expert you can talk a little bit about the context of that and what's going on. then let's talk about specific things. >> can you repeat thathñ?ñ?ñ question again? >> what's the rational place that the systems is moving in5çñ?ñ? terms of patients in sniff beds in generalsxñ?ñ?ñ versus home care or lessr÷ñ?ñ? intense care? >> rational. what i would?tñ? say is, i think -- i was happy to hear of ñ?ñ? st. mary's and direction they're going.

they haveí;ñ?ñ? continuity care. st. mary's has shown they've been able to manage the patients in lower levelsñ?ñ? of ca that continuityre by doing and that whole person view. you don't use the positions follow the patients from the hospital to community. i think they've done some pretty good direction. i think that's the direction we have to go. we had a paltive care report here showing the direction where we have to go. we're doing a numbers issue in termsnzñ?ñ? of the number of beds going without having the increases in those other services that we have to ramp up. i think that's the bequest that we would have of st. mary's to work with us along with cpmc. i do see that the financial piece of having sniff beds in hospitals is will'mñ?ñ be challenging. we have the same challenge within our own hospital. dr.chow from a longer term

perspective, we do have to get a little bit more serious about those other'rñ?ñ? options and start looking at[ññ?ñ? inhome health support. i think the models that st. mary's -- ithññ?ñ?ñ has a smaller number of patients from theóññ?ñ?ñr skilled nursing area to manage thepiñ?ñ? cost over head to have seven beds. it doesn't work for their financial plan. i do think we have a responsibility along with every other hospital to really work closely in looking how we're going to increase those supportive services in the community. from a numbers perspective there could be a detrimental impact. having all the bed closures and supportive services there is a gap there that we have to meet. i know that dignity is very supportive of looking at those. we are as well. we just need to get on a fast track with that so we can meet that need.

>> that's helpful, thank you. the second question i have is, is a question about whether i'm reading the data correctly. the data suggests that in the united states, five percent of sniff beds are in the acute care center. >> yes. >> what's that number in san francisco? >> well, we have six hospital based units. the chart i showed earlier showed the number of beds in our hospital units always been higher than the number of beds in our free standing facility. the proportion is higher in san francisco. >> the numbers you have suggested is well over 50% of the beds? >> yes. >> don't have 14 numbers but you

have four of the community, you have 13 numbers butzdñ?ñ? you have 1xñ?ñ?14 numbers. to me i'm ñ?ñ? trying to put all of these things together. in the context of where we'rerzñ?ñ? trying to get to. for sure we need as a city to make sure that we have those services as the world transitions to what i think is a completely more rational place. which is have better lower cost care better for the patients and better for the system. that seems completely rational to me. it seems that the proposal to close these beds is something you might or we would like to encourage as a system. these are extremely high cost beds. independent of the data that was presented, we know that already.

it doesn't make sense to me in a transitional time in healthcare to slow down a transition that we want to encourage because it is better patient care and it's more economic. that's something we need to celebrate. at the same time we need to make sure that we're able toézñ?ñ? receive and manage those patients outside of a hospital. i like commissioner pating don't really follow think that the data that you presented follows the conclusion on the first page that this is detrimental. i think on the nows is on us to make sure we have the services, we work with the providers to do that. i forone this is exactly what we need to encourage. we need healthy private systems in san francisco as well as healthy public systems.

i read the data and i concluded the opposite of what the department concluded. >> let me add one concern. i think is that, a reduction in short term beds means that patients needing short term care will be shifted to other facilities to meet their short term care needs. this may impact the availability of long term care beds which we have heard froms from doss that these beds are full and there's waiting list for people who need long term care. that's the only caveat i would add. >> i'm assuming there's data to back all of this up. that's absolutely right and that's the issue we need to focus on. not in my view not the rational behavior of folks in our city

that we want to keep healthy and vibrant and financially stable. i was just looking at some data. this was a good time to bring this up. i think there is as a department has indicated that there's reallial difference between the short term sniff and the long term sniff. this is a closure of short term sniff within the hospitals. the free standing really don't have short term sniff for the most part. >> they do. the majority -- >> one of the deficits from this data we don't know what the free standing short term sniff capacity is. it doesn't say what the capacity is of short term sniff. it says free standing sniff. >> we don't have data on that. >> you don't have the data on short term.

hospital affiliated ones are basically short term. we don't know what the other 1500 are so, how many really are short term. >> rake. >> if you go only on the short term, we're looking at about 180 short term hospital beds that then 32 in this case represents. the focus is really whether the loss of 32 or six operating beds. we also don't know how many are really operating the 180 or so that are licensed. we don't really know what percentage this really is of the total hospital level. it's 180 or so just for our commissioner's information. short term beds in acute care hospital affiliated. that affiliated with the hospital. maybe of the 179, maybe only 100

are really staffed or operating. we don't know that. >> no. >> it's very hard to say what percentage of the six out of x that this might represent. i heard this argument beginning and end. i'm not saying one or the other. we need to focus the issue if we're going to focus on the beds as sniff, although certainly as director garcia had said, my thought has also been that by itself a skilled nursing bed is only a skilled nursing bed whether it be short term or long term. where does it fit in the post acute phase of care? it's really hard to answer that as to whether or not it's going to be detrimental as we lose six

staff beds versus -- some of them were absolute whack -- back a year ago when we talked about the closure. they were much clearer about what they were doing, what they were moving around and the question then of what -- weeñ?ñ focused mostly on hospital based type care. this represents, i think, a progression ofñ?ñ? the dialogue looking beyond the six beds, which i think our commissioners brought to us. i want a clearness in our discussion about the fact that this is really talking about short term sniff beds being lost. commissioner karshmer. >> thank you st. mary's for this. it does raise a reallyezñ?ñ? interesting question. we're focused on short term beds. when i believe we should be talking about short term and

long term care. it's about the services that the patients and the familyñ?ñ? needs to recover or get to their highest level. what we've learned is this notion of lowest level of carry is what we want. missioner singer and pating comments were about this as well. it's about the services. i think we should be very worried in san francisco about the availability of skilled nursing care. not beds as much. i think that gets us confused that somehow the end point. as we think this through, we need to be very committed with doss, with this care group. what are the -- businesses is not as usual. it's not about sniff beds. what is the long term and short

term care of skilled nursing. we need to put our thinking caps off for creative approaches to say that this is going to be the model as opposed to reaction to numbers. >> commissioner chung has the floor next.eñ?ñ? >> first off, i want to say2wñ?ñ? that we really appreciate them as a partner in providing the passionate care to ourzdñ?ñ community and residents in san francisco. we don't want to sit here andççñ?ñ? say that you have to keep these beds open so you0vñ?ñ? lose money. it's also goes back to the principlesmwñ?ñ? what providing like compassionate healthcare is to our community. i appreciate that you have a system in place to follow them. my guess is to really8pñ?ñ? make sure

that we to the risk of hospitalization.ñ?ñ? that comes to the hint of data rñ?ñ -- point of data. to we have data aroundoqñ?ñ? someone who actually stay in acute&xñ?ñ? -- in hospital sniff versus someone who stays in a community sniff andanñ?ñ the rate of rehospital station. i think that'sgzñ?ñ? something that i'm more interested in.zññ?ñ?ñro% ñlj!pm8 v#'e&@3t%s07:dvíe?rf-á it's about improving outcomes of any of these patients. also, when we talk about placing them in communities, this actually happened to close friends of mine. she was placed in a community skilled nursing facility outside of san francisco. is that usual also?(uñ?ñ? in >> i can speak to the first question. i don't have data on

rehospitalization. for free standing sniff of patients that were discharged. a quarter of them was discharged back to the hospital. >> the second question is when you talk about free standing community sniffs and where we placing them, all of them within san francisco or some of them are outside of san francisco? >> we all do on education -- occasion have to place people outside of san francisco. we all know one of the things we all lack in healthcare is predictability and volume. there are times where all systems are full and we do place outside of san francisco. >> that comes to the questions of transportation. wouldn't that kind of add another layer of risk to

patients? >> it's definitely at the top of the list. there's all kinds of inconveniences for families etcetera. it's never a first choice to place people outside of san francisco. on the reahead mission -- readmission we develop a transition care program. one of the areas we did look at was the skilled nursing readmission. i know both st. mary's and st. francis as driven us to work closely with the skilled nursing facilities. >> i agree with