>> good morning, everyone. the meet being will come to order. welcome to the november 29, 2017 special meeting of the public safety and neighborhood services committee. i am hillary ronen. to my left is supervisor sandra fewer supervisor sheehy who is a regular member of this committee is homesick. so i will be making a motion to excuse him in a moment. we have supervisor ahsha safai sitting in for supervisor sheehy to my right.

mr. clerk, do you have any announcements? >> clerk: please make sure to silence all cell phones and electronic devices. part of the files should be submitted to the clerk. this will appear on the board of supervisors agenda unless otherwise stated. >> i wanted to thank sfgovtv for covering this meeting. first i'm going to make a motion to excuse supervisor sheehy, can i take that without objection? >> yes. >> that motion passes without objection. mr. clerk, please call item number one. >> clerk: item one the hearing to discuss the closing of the subacute nursing unit at st. luke's hospital.fo >> and i will make some statements after we hear from our presenters in public comment, but i want to turn this hearing over to the main sponsor supervisor

safai to start us off. >> supervisor safai: thank you. so many in the awed p audience know but maybe you don't supervisor and i came together on this issue. st. luke's hospital is an important life line to our communities. i think the vast majority of the patients that use that facility are both from district 9 and district 11. and so when this came to our attention a few months ago, we came together and decided this was essentially when we heard that cpmc was talking about shutting down the sub-acute unit, this was creating a public health crises for the respective communities and city and county of san francisco. i did not know thawch about subacute

care when this -- know that much about subacute care but quowt these beds, there are 40 licensed beds, those are the only subacute beds in the city and county of san francisco. we have the department of pun lick health here today and they'll give us a presentation on post-acute and sub-acute care. we have a list of speakers. i want to thank super supervisor ronen for working in partnership with my office. gairlen guzzen and sue have been amazing in leading this along with the coalition of advocates and family add advocates here in the audience today that we'll hear from. we're happy at the last hearing we held at cpmc, changed this decision and has knew agreed to in -- as long as the patients need that care, we'll be

providing sub-acute care for the existing and i believe it's 22 patients that are there now. we've had some good conversations with the department of public health barbara garcia and her staff they've been educating me and my team and others on what this means and what it means for the city and county of san francisco. for today's hearing, i'd like to accomplish a couple of things. we want to definitely focus on st. luke's hospital. we'd like to get an update from cpmc on their plans for permanent and where they're going to transfer the patients in county as they've committed. i'll call dr. warner brown to give us an update on that. then i'd like to talk with dph and allow them to do their presentation about sub-ra cute carea keupt care on how we're going to ensure that we're not the only county

in the entire bay area that doesn't have subacute care. dr. brown is working aggressively, but we want to invite cpmc to be part of that o solution. that solution. we're happy and excited to provide the care, but we need a long term solution on subacute care in the city and kowrchty of sancountyof san francisco. we hope they'll commit to permanent beds and supervisor ronen and i will push on that front. we have other hospitals that need to step up. the entire network of care, hopefully that can be part of the conversation. before we take public comment, we have a list of a few speakers i would like to call up. and then we'll get into the presentation from the department public health. the first person i'd like to ask come

up we'll limit this to no more than five minutes, then we'll take public comment after that. that would be -- let's hear from raquel rivera. is raquel in the room? please come up. >> good afternoon. thank you supervisors for taking the time today to meet with us. our mission today is to discuss a solution that encompasses the quality of it care and inadequate care at st. luke's hospital. cpmc is not utilizing all their licensed beds and is only intensifying the city-wide crisis. these problems were brought to cpmc's

attention in a letter dated october 20th, 2017. we responded to the esker e-mail on november third stating that they remain committed to the staffing levels and that their own risk management department was investigating and reviewing the claims referenced in our letter. cpmc found no fault in their internal investigation. they mentioned that once we have more information on which campus the unit will move to we'll share would your patients, family and family council. the family council was not informed. on november 27th two days before this hearing, cpmc announced at st. luke's hospital providing individual family meetings on that same day&on the 28th rashing the transition to davies campus. they're again communicating and working with the families.

this did not give ample time for family members to coordinate their work schedules and other commitments to be present at the hospital on the same day notice. cpmc didn't inform the family council like they said they would in their letter. cpmc not including the family members in the family process. they didn't coordinate with the family members so they could obtain feedback from family members as they stated in their past meeting. that they would communicate and inform the families as the plans continue to develop, yet they waited to make their decisions. this seems to be a pattern with cpmc they are a not building truss and workingworking with -- trust in working with the families. we ask that they transfer them to the mission vernal campus. they had said they didn't have the specifications or licensing, neither

does davies campus. this was discussed in the meeting stating that the trants transportation will be difficult for most family members since they live within the vicinity of the hospital. cpmc ignores our request and does the complete opposite. we have asked to keep our family members together. we side of letter two days before this hearing that my sister, who is special needs, would be transferred to a room alone in complete isolation. the opposite of what we have discussed and requested. this is another tactic to cause transfer trauma and depression to the subacute patientses which cause a short life. cpmc has terminated most of the 1256 staff and replaced with travelers and floarts. cpmc continues to pressure current

staff members of the subacute unit with positions on other floors and say if they don't accept another position, they may not have a job when the subacute unit is moved. theycpmc said it is something that has to be requested from the actual patient. they have not been contacted by any former patients. how are any former patients going to know that they can be readmitted if they have not been informed? they refuse to contact the former patients letting them know their right to return because they don't want to increase the number of subacute patients which would require increased taxing. cpmc has denied accepting new patients stating they'll only take care of the subacute patients they currently have and once they pass, they'll close

that bed permanently. the solution for the problem is to require that cpmc fill all 3040 of the licensed beds for subacute care. this will address the inadequate staffing levels and quality of care issues. ened most importantly start the foundation for fixing the city-wide issue. san francisco is a city with diversity and heart. let's keep our patients who reside in san francisco, stay in san francisco where they belong. thank you. >> supervisor safai: thank you very much. we'll call the next speaker, dr. ken barnes representing the san franciscans for healthcare housing, jobs and justice. >> one thing before i start, we were told that it was up to seven minutes. i geared my comments to seven minutes. is it possible?

>> supervisor safai: do your best because we have a couple of long items on today. do your best. >> okay. i'm kevin barnes i'm a physician that worked at st. luke's for 30 years including working at the subacute and skilled nursing facility. plus ithus i have a lot of experience in working with subacute patients. in the last several years, i've been working with san franciscans for healthcare housing, jobs and justice as we have fought together for the right of all san franciscans to the healthcare we all deserve. while we were happy that cpmc has agreed to keeping this unit open and transferring it to the castro campus, we have great concerns about the viability as it exists and viability into the future. we have concerns about the quality of care provided for these fragile and

vul vulnerable patients and concern for the subacute care for the future of san francisco. let me give you an idea of the demographics of the patients in the subacute. 53% have been there for over two years. 76% are on ventilators. 96% are over the age of 40 and 40% are over 60. contrary to to what people normally think, people are discharged from the subacute. people, for example come in with strokes, they initially, perhaps, maybe unconscious, they go to the subacute, they wake up and given physical therapy and go home. there is also the patient for whom the family is not ready to let go.

and the patient will go to the subacute and allow the family to grieve and let go as the patient dies. there are also the long term patients who are federally dependent often having neuromuscular diseases like als or muscular dis strovey problem and there for a long time. they're loved by their families. cpmc has not admitted new patients since 2012. this means that the patients who need this type of care are being transferred out of county. the human side of this means that patients and families are separated depriving the patients of their support system. beyond that the lack of admissions has meant a gradual attrition of pab patients.

when i was working there, there were 40 patients, now there are 20 to 22 patients. this refusal to admit new patients has considerable consequences. families have and will attest to the decline and quality of care that has already occurred. one aspect of this is when it was announced that they were going to close the subacute unit, many of the staff or significant number of staff, decided to transfer o to another unit or took a severance package. as a result, what happened is the staff that is there now are trying the hardest they can but they don't have the experience of dealing with the fragile patients. it's part of the public health survey of discharges in san francisco. for the year -- it was a recent year

that they looked at it, there were 52000 discharges. and the estimate was 20 to 30 needed subacute care. if these patients didn't have subacute care available to them then they were -- the only thing we can sur smiez that they were said to go out of the county. further more, the numbers we think are low. it is well-known that hospitals often discharge people to a lower level of care than is actually need. additionally, we have strong reason to believe that patients at subacute level are discharged to skilled nursing facilities and in san francisco and out of county. in california, there are 4700 subacute beds.

34% of those are in -- 46% of those are in los angeles and 11% are in the bay area. to put this into context, there are over 10 million people who live in los angeles and 8 million who live in the bay area. while 36% of the beds are located in a hospital, it is imperative that they all be located in the hospital because the patients are very fragile and often need immediate transfer to the icu. in 2019, a blue ribbon panel recommended that st. luke's stay open but recommended the creation of a city-wide task force to determine the future of subacute care. any real solution must involve a significant increase in the number of subacute beds in san francisco. key to the solution is that cpmc must use the 40-bed st. luke's license

at the castro campus where it plans to relocate the patients. cpmc must see this as a permanent contribution to a larger city-wide solution which meedz to be a public and private effort. this would mean to open the unit to the 40 beds admitting new patients and make the viability more certain. we believe that the department of public health has the ultimate responsibility for assuring the creation of such units in hospitals city-wide. since all hospitals have a need for such a unit, all hospitals must in some way accept a proportional share of the burden in providing space an financing. one last thing we've submitted to you a proposal statement by san franciscans for healthcare jobs and justice and we hope that you will consider it. thank you very much for your consideration and thank you for allowing me to finish. >> supervisor safai: thank you dr. barnes for all your work.

the next person identify a like to bring up is dr. warren browner from cpmc. >> good afternoon, supervisors and good afternoon supervisor sheehy in absentia if you're watching. thanks for the opportunity to talk to you today. i appreciate your on going interest in this issue and well-being of our patients and families. as of i've said before, we sthair that interest. our top priority is the quality of care reprovide to our patients at cpmc, while we haven't been perfect and this process hasn't been easy, i'm happy to report today that o we're in a bet -- that we're in a better place than we were

a few short months ago. we committed on going care to our subacute patients here in san francisco after the current facility at st. luke's closes. since that time we've been working on our plan consulting with state and local officials as well as meeting with patients and families. the best choice for continuing to serve our subacute patients together and in san francisco is to care for them at our cpmc davies campus. i'm pleased to report we're in the process of meeting with the families and letting them know what to expect in the coming months. we've been working hard to prepare the facility at davies to care for the patients. we anticipate that davies will be ready to accept the subacute patients as early as june of next year. when we have an exact date, we'll communicate that to everyone starting with the patients and families. we hope that this solution will give

families peace of mind knowing that their loved ones will receive the highest quality care here in san francisco where they can visit and support them. as you know our cpmc davies cam spus located two miles from the st. luke's campus on castro street right on the car line. now i want to address staffing levels briefly. staffing levels at the subacute facility at st. luke's have been higher than the level required by the department of public health. we share our staffing information monthly with cbph and that informations is always available. since announcing closure of the unit earlier this year, our staffing levels haven't changed. we've confirmed that information with the ombudsman office. it may seem there are fewer staff members but that is because there are fewer patients. the ratio of staff to patients remains above required levels.

i'm aware that questions have been raised about care quality, we take this seriously, supervisors, we pride ourselves on add adhering to the highest standards. after receiving the letter in october, we asked our risk management department to conduct an independent investigation. they found no changes to the quality of care since the original closure announced in june. moreover the california department of public health also visited the unit and cbph recorded no changes in quality of care which we'll continue to prior size. prioritize. we'll monitor and investigate any definitionsdeviations and take appropriate action. any timely, we recognize over the past several decades a shortage of post acute care has developed in san francisco. we'll continue to be part of the city's

on going discussions on the issues. we work closely with the department of public health, other san francisco hospitals and healthcare partners in the community to conduct a post acute care it's assessment. we appreciate the leadership of dph on this issue as well as the other supervisors. thank you for your time. >> supervisor safai: i want to ask you a few questions because it's timely. a couple of things we've heard about cpmc choosing to bring in new staff in the subacute unit rather than using existing staff. you didn't address that in yr your remarks. the issue is that patients and families have existing relationships with the long term staff. can you talk about that a little bit? >> yes as you know, when we announced the closure of the unit, we had a commitment to our staff to assure that we treated them fairly. some elected to take severance packages,

many of them are still working on the unit and where necessary, we fill in to maintain adequate staffing levels. >> supervisor safai: because because of of the closure they received severance? did some have the option to stay? >> some had the option to go to different units to further crease and interests. >> supervisor safai: have any attempted to come back and say we'd rather be in the existing facility? >> i can't answer that. there might be somebody on my team here that can. >> supervisor safai: the other big thing that we've heard and i know you said you looked into it, we received a copy -- a letter from the family council speaking to infections, falls and bed sores. can you talk about that? they say there is an increase with the existing patients. >> i would respectfully disagree.

>> supervisor safai: so you've investigated that and there is no -- >> correct. >> supervisor safai: okay. and then the issue that miss raquel brought up earlier about keeping families and keeping the patients in the unit that they're housed together, is that the plan? what is the plan going to look like at davies? i know you haven't finalized it. i know you said it would be in june. but will they have the opportunity to be in the same area similar to now? >> yes, the plan is that it's the current smith unit, it will meet the additional requirements to become a subacute facility. when that happens, we'll begin transferring patients from st. st. luke's tost. luke's tothe same floor.

>> so it's on the same floor. any questions? >> i have a couple of questions. so could davies provide the 40-bed acute unit to increase the beds to the level of service that you had a few years ago? >> so i believe the unit that we are going to be using at davies is slightly smaller. but we need it and use it as a skilled nursing facility. >> so it's going to be both a subacute unit as a%!én?nnursing facility? >> subacute is a category within skilled nursing. >> supervisor safai: we'll get dph get into the weeds on that. >> i thought that was last night. >> so the unit will have how many beds in total? >> i believe it will have a total

of 30. it's an existing unit, we use it now. i believe it's 37 beds? 38? 38. i stand corrected. >> so this unit will be on going so even if one of these 20, 22 families that are able to leave the unit, then those beds will be maintained after they leave? >> that's our current plan. as sniff beds. >> as sniff. as the current subacute patients leave the facility, those beds will no longer then be subacute but sniff. >> our commitment is to the current patient in the unit at st. luke's as well as to work with the city that crafts additional solutions to address the post acute care crisis in san francisco which includes not just

subacute, not just sniff but patients with behavioral issues, etc. >> okay. and given that you had historically the subacute beds, what is it about these beds that make it possible for you to maintain and commitment to the snif beds but not the acute beds? >> we have need for all kinds of beds. we try to do the best we can considering all of our patients. >> okay. >> supervisor safai: dr. browner, we'll probably call you up for other questions. i just wanted to get a response on some of the things. i just want to ask the question again. will all the patients be transferred pretty much at the same time to the same facility and on the same floor? >> i can't answer at the same time because -- >> supervisor safai: i don't mean all on

the same day, but they won't be one month three people -- >> i anticipate that as -- once that unit meets the facility requirements and we have the correct staff in place and we get the correct licensing and crediting, we will -- accrediting we'll get in processes of process of moving the patients over. >> supervisor safai: just from a response from an individual who has a family member there, is there flexibility in that? i don't know your physical, you know the business, but is there flexibility in where patients can be located and can they be in the room with someone? >> the unit has private and semi-private beds. we're open to trying to accommodate patients.

>> supervisor safai: okay, great, we'll call you back up when we have more questions. thank you. next person i think this is a good opportunity to bring up the department of public health. >> snaha. >> she's with the department of public health. we'll -- we also have dr. bar bar barbara here that will address our concerns. dr. garcia. >> good afternoon supervisors. today i'll provide you with a brief overview of post acute care in san francisco. when patients need continued medical care after a hospitalization, post acute care is provided in the home and community-based settings.

home care we mow is preferred by all aging adults and supported by several national state and local policies that recognize aging in place so adults can maximize their independence. we know that the vast majority of patients discharged from hospital go home, however, some are not able to safely discharge home and they rely on skilled nursing facilities for post acute care. as our city's population ages, san francisco will need to rely on a multipronged and multipartner approach for post-acute bear that supports access to skilled -- care that supports access to skilled nursing care. as i mentioned, we see that the majority of patients do go home after a hospitalization. about 79% of discharges from san francisco hospitals are for patients who go home 64% go home without additional

services and 15% go home with home healthcare. about 9% of discharges are for patients that go to skilled nursing facilities and these are likely patients with complex compare needs or sometimes patients without family or care-giver support. less than half a percent are for patients who receive subacute care. so of the patients that do discharge home, how can we help them stay safely in their home? for many@shl>t patients, home and community-based care and wrap arounder services are essential to help adults nene their independence and support aging in place. residential care facilities for the elderly are a housing option in the community that provide 24/7 is up vietion and for24/7 care.we include

in-home support of certify services for persons aged blind or disairbled, we help low income county residents transition occupant of hospitals so they can live independently as well as case management home delivered meals, transportation and caregiver support. so what does post-acute care services provide? on the left of the slide is a general definition of post-acute care which is a raifng medical services that support an individual's recovery from illness they can be provided in a home or specialize the facility. the table on the slide shows different levels of post acute care and services available at each level. starting on the left, home health provides physical therapy as well as

skilled nursing care which includes i.v. injections. moving to the right, in addition to the serveservices provided to home health, they provide 2wu7 supervision including bathing eating, dressing and transferring. subacute care provides ventilator care and intravenous tube feeding for patients with serious illness. in addition to an individual's medical needs, there are several facts that are determine where patients receive care. including their insurance status and how long they need care for. on the left of the slide, this arrow indicates how they allow for greater independence and care in the least restrictive setting such as home healthcare and patients that receive post-acute care than subacute are

in more restrictive environments. on the right side, this table shows the relationship between the lifl of level of care and who pays for it. you can see that most health insurers pay for short term but in long term, the options are fewer. those are circled on the graph. if someone needs long-term care, medical ismedi-cal is the only plan that serves this kind of care or patients have to pay out of pocket. the previous slide shows that private insurance pay for short term care while medi-cal which is insurance for low income individuals is the only insurance that pays for long-term care. because medicare and private health insurance reimburse at higher rates and medi-cal reimburses at lower rates,

this incentivizes allows them to serve more short term patients and fewer long term patients. this leaves patients with medi-cal with fewer options. additionally if they have behavioral health needs or no home to discharge to, they're difficult to place in post acute care facilities because they tend to be reluctant to place those patients with those needs. now turning to focus specifically on skilled nursing beds, in san francisco we are experiencing a decline in our skilled nurs bed supply. this is also a national trend as the number of hospital-based skilled nursing facilities in the u.s. has fallen by 63% since 1999. in san francisco we've seen a similar decline, we've seen a reduction in skilled nursing beds by 30% since 2003 and consistent with national trends,

this is largely due to a 43% reduction in hospital-based skilled nursing beds. now turning to subacute care, subacute care can be provided in two types of facilities. many patients who need short term subacute care may receive care in what is called the long term acute care hospital, which i know sounds counterintuitive, but they're specialty care hospitals and provide treatment for 25 to 30 days. if patients need long-term and subacute care, they have a designation from medi-cal to provide this level of care. in san francisco we have one of each of the facilities. kentfield owns and operates an acute care hospital located at st. mary's hospital. cpmc has a 40-bed facility which is

slated to close. so while facilities are an important resource for san francisco, we need a hult pronged and multipartner approach to address the challenges. our health commission asked us to create a post-acute care strategic plan which we are in the process of developing. our initial objectives are here. the first is to maximize independence and support care in the least restrictive setting. the second objective is to incentivize residential care facilities for the elderly and skilled nurse providers to preserve the beds they have potentially create new beds. the others is to provide opportunities for new residential care facilities or skilled nursing facilities. so in developing this plan, we will be

doing several things, first is incorporating stakeholder feedback from patients in skilled nursing facilities and their family members. also engaging with labor to understand their approach and perspective about solutions. the plan will also align several related initiatives including the post-acute care collaborative which will be finalizing the report in december. the health care services master plan which is sa joint care between the department of health and planning department looking at healthcare capacity and city and makes policy recommendations. wie started to participate in regional conversations with san mateo county to talk about our shared needs and challenges in providing post-acute care. we continue to support implementation of medi-cal home and community-based waivers which allow for residents who are at risk of institutional care to receive care in home settings.

finally, we will a be collaborating with multiple partners such as department of aging and services who conducts an extensive needs assessment process with stakeholder input and provides the services i spoke about earlier. director garcia will continue to coordinate with healthcare partners on shared responsibility. we can't solve this alone and all providers in the community have a role inin contributing to solutions. we hope to finalize this plan in the spring of next year. thank you. >> supervisor safai: thank you. dr. garcia can you come forward? thank you for that. that was a great presentation. so dr. garcia, we've had a few conversations since our committee of the whole hearing when we had the great victory for the city and cpmc was

part of that of agreeing to keep this for the existing patients. from this slot on page -- on page 9 where it talks about twoeyqdj types ever subacute care. there is short short term and long term. the only beds that we have in the city right now, 40 beds for medi-cal designated subacute is the ones that are existing at st. luke's. what is the plan? i know we've talked about that, but what is the idea of how we're going to solve that? i see there will be a post care strategic plan, but there is the need today. what are the steps that we should be taking? >> first off director garcia, i'm not a physician. i have phd. but not a doctor. our subacute care capacity is clearly going to be a need for the future,

but we're looking at short term plans and long term plans. we're engaged in and you and i engaged with one of the providers, a nonprofit in the community. i've had conversations and will continue with st. mary's. they have some space on their campus. we're slg conversations and if we stick to the subacute i think that might be the best location for the future. >> supervisor safai: where? >> st. mary's. when you look at the percentage the least number of beds that we need. we can focus on those and i believe there could be a process of having a business conversation with st. mary's. the issue will be to work with each hospital to -- you have to remember that many of our hospital systems, regional hospitals. the fact that many of them have facilities outside of the county is

part of their regional approach to their care. particularly for specialty services. if you're kaiser members, you know that. i see some shaking heads of the supervisors. clearly, we need beds in the county as welt, and i agree with that. we'll -- as well. i will be looking at that. we'll look to others to see if we can get us together to try to provide some support for what they need in the county and if they can contribute towards some some -- as an example st. mary's. >> supervisor safai: so the post-acute strategic plan, is that part of this process? >> we look at short term and long term initiatives. on the short term, that's what i'm saying that we have in terms of potential space.

again, cph is not responsible to purchase the beds and provide those to the hospital, we have to work with each hospital to figure out their commitments and also -- including cpmc has 40 individuals of working with them and working with potentially st. mary's in the future to look at other beds. >> and just so i'm clear because i have this today, this was the first time i saw this long term versus short term. you're saying at st. mary's, are you talking about -- >> subacute. >> supervisor safai: is it long term? or short term? >> those are conversations that we're just having. >> supervisor safai: so they might be willing to do both? >> i haven't had that conversation but that's a conversation we'd look at. >> supervisor safai: my other question is do we as a a county or you as a

department, do we say to private hospitals that this is the level of care you have to provide in san francisco? >> each hospital system has a responsibility to their clients to provide a level of care. no, we do not have regulatory over that. some of it is due to their insurance and what they can provide. from a health department point of view, our job is to ensure that those services are available for individuals and the commission feels strongly that the subacute levels ever care should be presented to the community and we work with partners and many of the systems want these beds. they want people to stay in the community. and so i believe that we'll have some success in trying to keep some of these beds locally. >> supervisor safai: we don't have any real regulatory authority but we have the ability to negotiate with the private hospitals. >> for the best of the clients, absolutely.

>> supervisor safai: any questions supervisor ronen? >> supervisor ronen: just following up with supervisor safai's line of questions on how we're urging hospitals to provide the essential service even though the number of patients that need it are low, they're still patients who need it and, you know wpmc will not have, it sounds like in the future, that possibility in their hospital chain. so why would a st. mary's, for example be able to continue providing the service that cpmc couldn't? >> i can't speak for them. but i can tell you my perspective. for st. mary's as an example they've had empty space in their hospital for several years. many of our hospitals as an example for [inaudible] we clearly could purchase

some of the beds for our patients. and we have some of our patients out of county. i would want to bring the out -- i wouldn't want to bring the out of county back in because it doesn't grow the numbers. but i can and commit to our department for purchasing the beds. >> supervisor safai: what does that mean? >> a contract for a provider. to give you an example, we opened up 40 subacute but the mental health side of the house, which are different. in st. mary's, we have a pro p provider crestwood services that we're paying for crestwood to provide the service. we're in the midst of talking to some of the hospitals to see if they'd like to purchase some of the beds. as an example, st. mary's could have a provider we'd sit with some of the other hospitals and have them have contracts. many of the hospital systems have contracts with other providers for the sublevel of care.

some provide it themselves. when you look at the kaiser model, they may want to own that level of care. and cpmc would want to do the same as a way to control their costs and have the facilities. i do think that there is a potential having some additional subacute beds and then we have to work at -- because everybody is going to need those. we may have some other possibilities as we continue to do this work. i would say that i would like to see cpmc continue their responsibilities towards the subacute role and we'd like to help by ensuring that maybe they could do that with st. mary's as an example in the future. it's still not happened, but i'd like to ensure that we have subacute beds in the city. but again from a financial model, you have to remember that each of these entities are very different in their business plans. and it's our job both as a health

department and supervisors to encourage cajole, provide what you're doing to all the health systems to ensure there are levels of care pa available for people in our community to stay close to home. i think you've shown that in this pros wes cpmc. it's a business process. it's also a community responsibility that we should work for. it would be ucsf up here in the same conversation. we have to work as hospitals. this is one of the reasons we have a hospital council. and we have to put this in the front and center of our needs. remember that the subacute issue is a smaller one. for the families here today it's the biggest one for them and i recognize that. from an overall health planning responsibility we will be trying to show what -- there is no national standard for subacute, but we probably need some additional ones more than

40 for sure. we do have to work closely with all the systems. i do want to recognize that our system you asked why st. mary's have space. we're in a competitive system. for us, we're a medi-cal provider not a private insurance provider. so, but each hospital has that. st. mary's footprint for primary care is not as large as others. so the feeding of clients coming into the hospital is not as large as others. so now, they have some capacity. i want to support st. mary's to continue as an important institution. that is one of the reasons why we worked with them on the 40 beds for the mental health subacute level because of our need and their need. that's what you have to do with match needs with the community's needs. i appreciate what you're attempting to do and we have not only on the subacute

level, but we have to work on the skilled nursing facility level as well. we, the health department has 782 skilled nursing beds until laguna honda. that is a contributing factor to the support of skilled nursing needs in the city. but clearly, the data shows that we're going to need more. st sph i >> supervisor safai: i want to go tobacco to two other things you said. what is the number -- what is the right number of subacute for san francisco? >> there is no standard that we've been working off about 7 o beds. >> supervisor safai: 7 o. you said you'd like to work, i know i agree and supervisor ronen and dr. browner said, definitely want cpmc to be part of the conversation is and like them to make a commitment with permanent subacute beds along with

the other private hospitals in san francisco. we would work with cpmc -- >> and ucsf, kaiser, we all have the responsibility. i want to have that shared responsibility including what cpmc is doing. it's not fair for us to just put it on cpmc. they have capacity outside of this county and that's not going to work for this situation that we're in today. >> we're talking about san francisco. you said you would be -- maybe cpmc would could work with st. mary's. >> not just cpmc. >> supervisor safai: you were listing the entire network of hospitals. i'm exited exit committed to working with you on that. we'll find the right level of space for subacute care here in san francisco. mp thank you. >> supervisor safai: any other questions? if we do, we'll c