aware that it makes me feel like i've got my hands tied behind my back in the work that i'm doing. >> commissioner? >> thanks. first in the adults and hhs system, are those -- [ inaudible ] -- or is that by service that they're given or is it both? >> which number are you looking at? >> i'm looking at the 11,115. >> that's unduplicated people served in the health department. so the 15,000 is an estimate from the homeless department, presumably, the 11,000 would be part of that 15,000, but because i'm not sure, i mean, we'll find out. you know, when you look at the numbers here of two -- just one

year, so we don't know yet, to be honest. >> do we know in terms of the population of seniors who are medically compromised and might be a part of the system and/or people of color who might be part of the system, particularly when you look at the over population of blacks and latinos in san francisco and go in and out of jails and will be a part of system, but then will lose their access when they are incarcerated. >> right. we have a lot of data. i'm happy to share that with you of the population that we serve in the health department. so the idea is with whole person care is that every homeless person will have a health record, meaning, they will have been assessed, and every homeless person will have a housing assessment record. so the goal for whole person care is that 100% of the homeless people are both known to the health department and to the homeless department. but i do have a lot of information about the 11,000

that i'm happy to share with you. >> i look forward to that. >> and a very high percentage of african americans in the long-term homeless. >> thank you very much. this is a very clear and well cart claytoned report that you guys have pyou -- articulated report that you guys have put together today. >> commissioner chow: any further questions? seeing none, thank you for your presentation, and we look forward to a report at the -- i guess this is on a yearly basis that you are doing it. >> we can do it however often you want to hear from us. >> commissioner chow: well, i think you noted that as you were putting this together, it'll take about another year for you to come up with meaningful data, and i think that would be very hope that we'll do a full up in a year. >> okay. great. thank you so much for your time. >> commissioner chow: and thank you for your work. thank you. >> next item is item eight, and post acute care update.

>> good afternoon, commissioners. my name is snehapatil, and today i wanted to present to you some of the information about post acute care and the need for these services in our city. additionally, we have the post acute care collaborative here that was sponsored by the hospital council of northern and central california that are here to share the -- their final reports and recommended

solutions. so a little bit of background. in recent years, the commission has held several hearings on closures of hospital based skilled nursing facilities under proposition q. proposition q requires private hospitals in san francisco to provide public notice before closing an inpatient or outpatient facility or before eliminating services. since 2014, we have seen a reduction in more than 200 licensed hospital based skilled nursing beds, and most recently, the commission heard about the planned closure of cpmc st. luke's skilled nursing unit, and the commission heard this under proposition q in august of 2017. so just as an update, cpmc -- there are currently 17 remaining patients in sub acute patients in cpmc st. luke's, and they are planning to

transfer them to the davies campus this summer. so optimally, we know that post acute care is provided in home and community based setting whenever possible. there are several policies that recognize the importance of ageing in place to maximize an individual's independance and to provide care in the least restrictive setting. we also know that the vast majority of patients are discharged home after a hospital stay. however, some patients who cannot be safely discharged home do rely on stillkilled nug facilities for post acute care. you can see on that slide about 9% of all hospital discharges are to skilled nursing facilities, and less than half a prs of all hospital discharges are for patients who

needsub acute care. so i wanted to take just a minute to describe some of the types of facilities that provide care for seniors and adults with disabilities. so starting from the lowest level of care to the highest level of care. so residential care facilities for the elderly, which are also known as assisted living or boarding care primarily provide assistance with activities of daily living, which include bathing, eating, dressing, feeding, etcetera. skilled nursing facilities provide -- can provide short-term rehabilitation such as occupational therapy, physical therapy, speech therapy or skilled services, such as wound care. and skilled nursing facilities can also provide long-term care, which is primarily when someone considers a skilled nursing facility their residence, their home, and patients primarily need help with activities of daily living. finally, sub acute care is for

patients who are medically fragile and require specialized care, such as patients who might tube feed or patients who use a ventilator, and so this care can be provided in a sub acute mursing facility, and in another type of facility called a long-term care hospital. so there are several factors that influence the post acute care landscape. so on the federal and state level, several policy regulations and agencies such as centers for medicare and medicaid services, the california department of public services, and california department of public health have a large role in overseeing facilities. in terms of health plans and health cares, this can really determine if a patient has access to facilities. so for example, medicare will cover a patient's stay in a skilled nursing facility for up to 100 days, and medi-cal will

cover the entire stay. hospital discharges take into account several factors when determining what an appropriate placement is for a patient, including what their insurance status is, what level of support that they have, and their medical and nonmedical needs. and so additionally, over the past several decades in general, we know that ageing has moved away from institutional care towards community based living. so one, we know that individuals prefer to live at home whenever possible, and two, there have been several course cases such as olmstead which was a extreme court case, and here locally, chambers versus san francisco, and both of these cases found that unnecessary institutionalization of individuals with disabilities might be considered discrimination if there are appropriate options for care in

a lower level. so giving changing demographics, health care financing trends, and the high cost of doing business, san francisco is facing several challenges. so first, we know we have a growing vulnerable population. our population 65 and older is growing rapidly. it's currently 14%, and this will grow to 21% of our population by 2030. additionally, we have a shrinking supply of skilled nursing beds, and we also have seen a more recent trend of closures of smaller boarding care operators. and finally, we know that there are limited options for individuals who are lower limited income, and especially if they need long-term care or if they have behavioral health challenges. for example we know that skilled nursing facilities which are predominantly and for profit private businesses may limit the amount of patients that they accept to have

medi-cal due to low reimbursement. and so while skilled nursing facilities are a very important health care resource for our community, we do need a multipartner and multipronged approach to address this need that both prioritizes home and community based care, but also supports access to beds in skilled nursing facilities and residential care facilities. and so the department is recommending a few strategies to address this need to better doeth upstream and drown stream, so thinking about it upstream, we really want to prevent the need for institutionalization, and looking at it downstream, thinking about the actual creation of it. so our first strategy is around prioritizing ageing in place to maximize independance and support care in the least restrictive setting.

so this is the idea that we want to ensure that our vulnerable populations can get care at home in had supportive living environments whenever possible. so the first strategy, 1-a is really about supporting the work of the department of ageing and adult services, which is already currently engaged in several programs and initiatives that really support older adults and adults with disabilities, as well as help bridge the gap from acute care settings to community based settings. the second strategy is around improving access to medi-cal's home and community based alternatives waiver. so under this waiver, residents who are currently in skilled nursing facilities or residents who might be as risk of being institutionalized can receive wraparound services in their home as opposed to being institutionalized. so historically this waiver was administered at the state level, and going forward later

this year in 2019, it will be administered by a local agency which will hopefully increase access. and there might be opportunities for us to engage in stayed advocacy around this. the third strategy is a recommendation of the post acute care collaborative, which is to support placement of nonacute patients into the community such as boarding care homes, by either subside gees or wraparound services and supports. the next strategy is around improving discharge planning. so from the acute care setting to lower levels of care. and again, both of these strategies are recommendations of the post acute care collaborative, which you'll hear from in a minute, so i won't go into a lot of detail, but the first is essentially supporting a citywide assessment tool so we are able to capture standardized data across all of our hospital systems about what type of care patients need. the second is around developing

a citywide roving placement team who would have the ability to determine assessments and what appropriate placements are. so our third recommendation is really around preserving the facilities that we have here today. as i mentioned, i know we are losing facilities rapidly, and we want to make sure that if we are able to step in and help, that we are engaged in efforts to do that. so the first, 3(a) is around collaborating with the office of workforce development to look at potential local incentives for facilities that are closing, in particular boarding care homes. so this might include helping with mer mit processing, potentially business grants, maybe workforce development, so just the beginning of having those conversations. another strategy that we're pursuing with the planning department through a separate

initiative called the health care services master plan is looking at our zoning codes to make sure that we are removing bare jerz for these facilities if they do want to open up in the city so it's not as burdensome. the thirt strategy is explor g exploring -- third strategy is exploring a creation of permitting process. as i mentioned since many of these businesses are predominantly private and for profit, we -- there's no systematic way for us to know when they are shutting down in the city, so there might be opportunities to create that legislatively. the fourth strategy is incorporating residential care facilities into the city's housing trends. so we would like to work with city agencies and think about housing strategies and goals and in a way that accommodates

people who are ageing in place. finally, supervisor yee has been very interested in residential care facilities, and he recently announced a work group that both the department of ageing and adult services and the department of public health will participate in. so again look at tools and promote sustainability of businesses. and so our final strategy is real ae looking at unused health care facility space in the city that might provide opportunities to create new beds. so the first strategy that we have here is collaborating with st. mary's medical center to talk about the possibility of developing a skilled nursing and sub acute unit. we know there are no longer any sub acute units in san francisco, so this is a priority for the city. so -- and currently as saint mary's medical center,

kentfield owns and operates a long-term acute care hospital, so there might be an interest for expanding care for those patients. additionally, chinese hospital has a 23 bed unit that's unlicensed, but we are currently working with them to help get it licensed. that process can take quite sometime, so we are working with the mayor's office and looking at options to help expedite that process. the third objective, which is more longer term is to look at the potential expansion of our existing residential care facility at our behavioral health center located at san francisco general hospital, and the final strategy is to explore the development of additional post acute care and senior living housing services at the jewish home campus. so all of those things that i've just discussed, you know, will take at least a couple of

year yea years before they can be fully implemented. so the things that i just mention does, and we want to continue to have conversationed with the hospitals i mentioned to help bring services on-line as quickly as possible, and we will be participating in supervisor yee's work group which will hopefully get off the ground in the next couple of months. so with that, i'm done, and i would like to introduce daniel ruth who is the chairman of the jewish nursing home, and who would like to come and talk to you about the collaborative. >> commissioner chow: thank

you. >> sorry. i'm a mac guy, so using a pc is a bit of a problem. president chow, members of the health commission, director garcia, and to the public, my name's daniel ruth, and i'm the president and ceo of the san francisco campus for jewish living, formerly the jewish home of san francisco. i would like to thank you for permitting us to share with you today the report and solutions of the post acute care collaborative, otherwise known as the p.a.c.c. i had the honor to serve as a cochair for the p.a.c.c., along with kelly hiromodo, your extraordinary director of san francisco health net work transitions. the p.a.c.c. included some of the finest health and care coordination experts in the city of san francisco, both from the public and private sectors, representing a true partnership and collaboration.

some of them are here this afternoon, and i would like to recognize them. nivic hirosz who is the director of laguna honda hospital center, elizabeth pollock, who ais the director f patients and transition management at ucsf, and molly shane assistant director of management at ucsf, margaret williams, continuity of care service director at kaiser permanente greater san francisco, and ruth simon who is the post acute manager for the san francisco bay area for dignity health. we were greatly supported on the p.a.c.c. project team, which consisted of our

consultant, monique parrish, sneha patil at dph, we also brought in adjunct members to assist and support us with discreet issues as they occurred throughout the process. commissioners, it is my understanding that you should have a copy of the report. i want to take this opportunity to highlight just some of the important elements of our delivery process that led to the recommended conclusions that my fellow cochair kelly will cuss discuss in a few mom. as you may know in february of 2016, the commission adopted a report as part of the san francisco post acute care

project, and one of the recommendations was the recommendation of the post acute care collaborative. at that time, the san francisco section of the hospital council that comprises ceo's of the 11 public and private hospitals in the city agreed to sponsor the p.a.c.c. effort. our mission was to implement financially sustainable solutions to the post acute care challenge for high risk individuals in san francisco, and our corresponding vision was to empower individuals and families through strengthened social supports, collaboration and partnership. the p.a.c.c. affirmed that placing post acute care patients in the right setting

at the right time would positively affect patient outcomes, and needless to say, it is the right best thing to do in the best interests of those patients. as a result, we began work in march of 2017. it was a facilitated, deliberative and data driven process, and there are just two points that i would like to make note of. there are key informational interviews between april and june of 2017. project team members conducted extensive key informed interviews and site visits. interviews were conducted with a broad range of post acute care stakeholders. site visits were conducted at leading post acute care programs. and finally, there were -- there was a point in time survey in april of 2017, the p.a.c.c. completed a point in

time survey across the hospitals to add critical data about the numbers, needs, and the characteristics of patients waiting for post acute care placement. the interviews, the survey, and the p.a.c.c. deliberation informed our next steps. so at this point, it's my pleasure to have kelly come up and -- to do the presentation. >> thank you, daniel. thank you, commissioners. the -- this was actually really a perfect group to work with. everybody was really committed to trying to tackle the issue at hand, and we worked very good together, so thank you to the team. jumping to the key findings of the survey, we did a point in time survey because an he can

dotally jucan -- anecdotally, just talking to the hospitals, they were behind, so try to get some data to really identify who was actually found to be long staying at the hospital, so we can two point in time surveys. those surveys found 117 patients were waiting for post acute care placement across the different eight acute hospitals that we surveyed. most had medi-cal, and half required post acute custodial care or 24 hour supervision. that's not a skilled nursing care, but activities with daily living, and not an actual skilled clinical need. many of them presented with behavioral challenges, some due to behavioral health challenges, some with ongoing dementias. some had substance abuse issues, and some had mental

health issues. so with that and furthering our discussion, we were able to identify populations that are high risk post acute care patients that are really the ones seeming to need the assistance and attention to try and move along to get into right level of care. so the primary populations that were identified for the -- from the group to really focus our work on were two similar but a little bit different populations. the first are people who predominantly cognitively impaired. these were people who were post acute care patients that impaired 24-7 supervision and were unable to manage their activities of daily living and otherwise manage their care. the second group of people were more the presenting feature were people who were very behaviorally challenged, and these post acute care patients

were people who either were experiencing a traumatic brain injury deficit. a cognizant impairment from dementia, substance abuse disorder or hypoxia, either a psychosis or mood personality, and/or substance use disorder that was manifesting in behavioral health -- acting out behaviors. so an analysis of their needs in recognizing they primarily comprised of people with low income and limited social support. it was clear that support settings were more appropriate than a skilled nurtsing facility were what needed to be identified. so we continued to work and develop some solutions to address gap in care for both of the populations, those that are cognitively impaired and those that are behaviorally challenged. we came up with three solutions. the first was to adopt a standardized post acute care assessment tool.

we identified the locus, which is the level of care utilization care systems. it's one of the tools for mental care placement. the second was to establish a citywide roving team, and the third was to find placement alternatives. the locate us, currently hospital use -- [ inaudible ] >> -- by using locate us, hospitals would share a level of care assessment tool that would facilitate treatment planning and would allow the hospitals to talk a common language around when they're identifying a right level of care. so it will also allow us the opportunity to collect aggregate data that would allow us to collect the data in the

level of care postulation. citywide roving placement team. [ inaudible ] >> hospitals have to have access to expertise and access assessing behaviorally challenging patients waiting for post acute care placement and a roving team would allow us to provide an assessment that would identify strengths, limitations, and appropriate level of care for placement. it would also give us the opportunity to do consultation, so we could provide behavioral and medication management recommendations. there are a group of people that if we intervened sooner and early on when an admission into hospital happened in an acute care stay, we would be able to preserve the housing where the person came from or allow them to return back home to their families, and some of that is just knowing right resources and how to being

assess them quickly and also managing care for a person in an acute care setting that could be duplicated when someone steps down into the community care setting. so an example would not be prescribing a medication regimen that doesn't work when you're in a hospital but works when you're discharged out to the community. there are also some interventions that are used in hospitals that can't be duplicated in the community setting that we could work with teams early on. the last, we would promote patient flow in hospitals and nonskilled facilities -- [ inaudible ] >> -- in order to help do that, it would be helpful to fund subsidies and residential care -- [ inaudible ] >> -- for those who could live supported in the community. and then, the last would be

expanding the residential care facilities in the mayor's housing initiative. there are quite a few boarding homes that are closing their doors, particularly small homes that are operated by small operators. so those are the three recommendations that we've landed at in a nutshell, and so thank you for your time and now the vice president of the hospital council, so... >> good afternoon, commissioners. david surano-sul, the director of hospital council of northern and central california. good afternoon. you have the report in front of you in your packet. we didn't include it in the slide presentation, but page four is an infographic, and that just really outlines everything that daniel and kelly just spoke of, and that is sort of the process that p.a.c.c. went through through most of 2017.

daniel in his comments introduced the p.a.c.c. members that are here this afternoon. again, they met every month, lots of time and effort that was put into it, commissioners, and could not have done it without their incredible support. i don't know if they raised their hands, but hello. they're here. thank you, and so appreciate everything that they did. when we started this process, we couldn't have done it without two committed cochairs: kelly hiramoto and daniel arusz. they elevated the discussion at every step of the way. and when we provided updated to you, president chow and director garcia, you helped in that process, as well, so thank you very much. the first meeting of the san francisco section for this calendar year, as daniel noted, the report was done around november of last year, and we had to do some tidying up. so our first meeting was in february of this year, this

calendar year, and we had a full presentation and a formal adoption by the hospital council of the report. of course what's embedded in the report are what you have in front of you, the solutions, can we do something? and so we've begun a really robust dialogue around -- around -- particularly around solutions one and two, talking to nonprofit providers in the city. they're going to be meeting with us next week at our section meeting so we can get their thoughts on how we might implement some of these solutions because there's lots of getting into the weeding and mechanics of how you might go about contracting it, etcetera, etcetera. but there's a seriousness of purpose in this exploration, and so that is where we stand right now, and thank you. >> commissioner chow: thank you. it commissioners, we do have public comments.

we'll take those before we begin our own discussion. i'll call each of them. you can speak in any order that you wish. it will be ken barnes, mark aronson. looks like kim tavig-leon, melanie grossman, and vincent matic. each will have three minutes. speakers, i have an egg timer. when you start speaking, i start the timer. when the buzz buzzes, your time is up. dr. barnes, if you want to begin. >> my name is ken barnes, and i am a doctor who practiced at st. luke's for over 30 years, and i worked in the sub acute unit for 15 years. i'm going to limit my comments to mostly the issue of sub

acute. there's so much here that we could comment on. as you know, there is an acute shortage of sub acute beds in san francisco. at its peak, st. luke's had nearly 40 beds, and now it has 17. in 2012, sutter cpmc decided that only admissions from their hospitals could go into the sub acute unit. and then, in 2016, they decided that there would be no further admissions, so what's happened is that the number of patients have just been gradually falling. now, as i think was mentioned, the plan that cpmc has now is to transfer the 17 patients remaining to the davies campus,

and these beds that are being given to the sub acute are going to be placed in the skilled nursing facility, which has 38 beds now, and it'll go down to 21. and this is adding to another crisis that we have, and that is hospital-based snf beds, because the only snf beds that are hospital based in san francisco will be those 17 at davies. so what cpmc plans to do at davies is let the patients fade away by atrition, and this would mean at some point, there are no sub acute beds in san francisco. this is a vitally needed service, and not having it would interfere with patient and family choice, about whether their loved one should

live, and also be -- be nearby so that the families can visit them. the department of public health has estimated that at a minimum, there are -- there's a need for at least 70 sub acute beds in san francisco. dph 45z been working with ucsf, the st. mary's dignity and kentfield to discuss possibilities. as we understand it, noticeably absent from this discussion is cpmc, and what we're seeing is that cpmc sees itself as outside of this norm, much like the recent suit brought by the state of california. we are urge you to look at our proposal for a new sub acute unit and skilled nursing facility to be housed at the new medical office building being projected to be at the new mission bernal campus.

i have one sentence. >> commissioner chow: okay. one sentence. >> at this stage, floor or floors could be added to the building, and we urge you to strongly recommend that cpmc opened its current sub acute unit to new admissions and that they be part of the ongoing discussions with dph and other hospitals to find solutions to the sub acute and skilled nursing care crisis. >> thank you, dr. barnes, and you write very long last sentences. >> i did. >> please, next speaker, and if you'll all identify yourself. >> commissioners, i'm mark aronson. i'm an emeritus professor at uc hastings school of law. and i have been volunteering since 2013 around cpmc issues but also broadly issues affecting housing, health care

and jobs and justice in san francisco. dr. barnes is also appearing on behalf of this group. we have submitted to you a position paper and some proposals which complement and supplement what you were presented with today. i want to make two quick points. first is a process point, i want to emphasize the importance of having grassroots participation in these discussions with the department and with a group setup like the group that produced the p.a.c.c. report. we had a very constructive meeting from the coalition with zror garc drar garcia and her deputies on friday. we think grassroots involvement is important from people achkd in the community and labor unions from these discussions particularly around the kind of

facilities needed across the board is absolutely critical. the second point i want to make goes to both the short-term and midterm solution. one is to emphasize what dr. barnes said that cpmc has to be kept at the table. it should not be exiting from providing snf and sub acute care beds, and action has to be taken immediately. two proposals would be maintaining units at davies, and as dr. barnes suggested, using a new medical office building that's proposed on the mission bernal campus, to use some of those floors for snf and sub acute beds. that would be very important. and the second midterm to long-term solution that i would like to emphasize, we are all in favor of people coming voluntarily together and reaching joint private-public kinds of solutions, but we also are very fearful, and my account is based on many years

of experience working on behalf of community groups, but you also need some real teeth in the process, and we suggest, we urge that with the department, that we undertake a discussion and then coming up with legislative proposals that would provide greater certainty into meeting the kinds of needs we're talking about over the long run, in particular for sub acute care and also for some of the other kinds of facilities. just cooperative action is not likely to produce the kind of results we all want. we need some teeth, some legislative proposals, and i think it can be done at the local level as well as seeking federal and state help. thank you. >> thank you. next speaker, and we also have received a request from gloria simpson. >> kim cataloni, national union

of health care workers. i kind of feel like i got a report that says it's sunny outside today, and it's a beautiful day. these reports do nothing. it does nothing to add to the number of sub acute beds that are needed in this city today. their 17 filled beds that are declining rapidly. cpmc wishes nothing more than for these patients to go away. there are no more sub acute beds. this report doesn't add to that number. and essentially what it does it the hospital association essentially washes its hands clean of any responsibility for any future patients. there is no accounting for how many patients have been shipped out of the city. i personally believe that somebody needs to bring a lawsuit against the hospital association because i think this is intentional

discrimination against the elderly and disabled; that these folks are intentionally being shipped out of county and nobody has anywhere with all to stop it. and it's frightening, if that's the type of city that we want. it's frightening that nobody's standing up and saying, you know what hospital association? you know what, sutter? you're making millions of dollars off of our residents. you need to pony up. you need to put -- you need to keep these beds open. you need to have at least 40 other beds. whatever your market chair is, you've got to open up that many sub acute beds. not to mention you also need to pony up and start helping these rcfe's stay open because all this says is like we have a problem placing people, and these facilities are disappearing. yes, there's a log jam, and

until it reaches a crisis, nobody's going to do anything about it? the crisis is here. families have been tortured and torn apart, and nobody's speaking for them. i'm really appalled by the report that nothing is being done. it's like we're going to continue to study this until these patients die or just go away or they're shipped out of county. that's not an okay solution, and to accept a report like this is not fair to the families. it's not fair to the residents of san francisco, and the problem is going to get worse, and i think it -- we need something that says something like all the hospitals need to pony up. you need to do your fair share. you can't continue to ship these residents out of county, which is what they want to do, but they're all making profits. they're all pocketing tons and tons of money. and they're even gouging. the a.g. says they're gouging.

they need to come to the table and pony up the money. it's that simple. >> thank you. next speaker. >> hi. my name is medically grossman. and i am -- melanie grossman, and i'm a member of the older women's league. yeah, so i'm someone from the community. the older women's league advocates for older adults, but especially for older women. so i thought i agreed the report sounded extremely sunny, but in our experience, my experience, when a person needs to be discharged from the hospital, and i personally have been called for a friend to give her a ride home on christmas eve, and there's no discharge plan, there's -- you know, no services that are going to be available over a long weekend, you know, we have

a long way to go. it's easy to say improve discharge plans when the ones we have now really are inadequate. it's also easy to talk about an assessment tool, and there are human behavior, there are no tools to measure human behavior and human problems. and we certainly see them in our membership and in our neighborhoods. also, these wraparound teams, what are they exactly going to look like? supposedly that's for managing patients, but some of these behavioral problems are intractable, and they take weeks and months to work with, and these people are supposed to be managed at home? i don't think they're safe. i don't think the families will be safe. and then finally, i wanted to talk a little bit about the

wraparound services. what exactly would that look like? it sounds so great, let's have some wraparound services that's all cozy and snuggly. but are pima sessed in their home before they're discharged? has anyone checked out, is there safety there? is there a refrigerator that is working so that they have access to food? how long is the waiting list for meals on wheels? last time i checked, it was six weeks. so what is the discharge plan? go get a sandwich at walgreens? so i think it's easy to talk about all of these lovely tools and implementations, but for older people really struggling, sometimes they need a place to stay where they're not going to be pushed out, they need a place to stay where they can -- that they can depend on. some people just simply cannot be managed at home.

thank you. >> thank you. >> next speaker, please. >> president chow, commissioners, barbara garcia, my name is benson aidel, and i'm the director of the long-term care ombudsman program. we're authorized by federal and state law to basically troubleshoot licensed facilities, and i have many comments from reading the report, but there is an error on the report on page 19 where it gives a rather large figure for hospital based snf beds, and my understanding is there are not that many hospital based snf beds anymore unless the writers of report meant dp-snf. i'm not quite sure, but i want to drill down on custodial care in terms of the 117 from the october '17 snapshot.

custodial care really implies disability and then contra to custodial care implies chronic disease management, and i think we need to not use custodial care anymore, but talk about individuals with disability returning to the community, either successfully or not so successfully. when they're combined with comorbidity, then, it becomes complicated. now in the dph memo, in ab-940, chapter in law as of january '18, we receive all the discharge notices. not the involuntary one from all the snf's to our office, and these include people on medicare, people on long-term care. we're starting to collect all these notices. the first snf's to do a really good job were the city and county ones, laguna and general hospital, and the other community snf's have been kind

of slow in giving us the reports. it must be the required notice of transfer with all the details in federal law. this report really does ignore some of the regulations for the snf's in its report. there may be barriers, but the ombudsman expect a person-centered care plan where goals and objectives are in the first few days of admission, including those on medicare. what we're finding in experience is the big meeting occurs a few days before discharge. most of our complaints from the various post acute snf's have to do with unsafe discharges, people going home with no coordinated care, where case managers are confused with social workers. the only facility that does a good job is laguna honda, but they are working with a protracted period of planning because they're mostly on medi-cal, but when medicare has

a short and very fast moving progression, there must be some subscribing to the cms requirements, and we're not finding that in practice as witnessed by some of the unsafe discharges. and finally, the rcp's need to be scaled in this report by large versus small. title 22 boarding care homes, where you have six beds to 15 beds do not require adequate fte's to handle some of the comorbidities. >> your time is up, sir. >> so this report needs additional input. >> thank you. >> thank you. >> thank you for your input. and lastly was miss simpson. if anyone else wishes to testify, if you'll submit a speaker card, that would be fine. this is the last one i had. >> i'm gloria simpson. i'm with the family council at st. luke's hospital, and i'm speaking on behalf of the sub

acute issues, especially with the transfer of the patients going to davies. we sent out several questions to cpmc to answer, and they refused to answer the questions, and we also asked them to come to one of our family council meeting does, a -- meetings, and what they did, they planned or they met with the families individually, so we don't know exactly what was said to each family member. we're expressing the -- the stress that -- in regards to the transfer trauma that may happen with the patients. they're not given giving any incentive to the current staff to be transferred to cpmc. i requested to even have the

activity person transfer, who is nonunion, and they refused. so this is a great concern of mine because these poor patients who's been with the same staff for several years, they go into some sort of anxiety or depression, which will cause death, which is a goal, i believe, with the pmc since from the beginning, they've been wanting to eliminate the sub acute. so we're asking, then, pleading, if you can please open 70 beds to the city and county of san francisco. thank you. >> thank you. there is no other public testimony. commissioners, we're prepared for questions to the presenters and/or dialogue. any questions going for the --

yes, commissioner? >> i thank you for the report and thank you for spending the time to put this together. there are a couple of questions that i have. one is i don't really see the projections of the needs of the city in this report whatever. there's no predictions, you know, like how many of these, like, snf beds or sub acute beds that the city would need, you know, like, in five or ten years. we know that the baby boomers are getting older, right? and we know that the city is flaling, so we know that the need for this is rapidly increasing, so there's no -- [ inaudible ] >> -- and all the beds that have been closed so far.

>> i can address the need. i think when we think about the need for long-term care or skilled nursing care, there are several ways we can think about it. we can think about it in terms of ageing demographics, two, utilizing, and three looking at it with the current population of beds that we have right now. we know we have 20 beds per-1,000 adults 65 and older. but in terms of making a projection going forward, i think that that's a very difficult thing to assess, and we've reviewed literature that's out there, and we're not able to find, you know, a magic number in terms of how many beds the city needs. but we do know variation across

counties, and we can compare us to other counties. >> you have no projections of like, the graying of the city in five to ten years and what the median age -- >> when we did this, we brought it to you at the first report, and i believe that sneha -- i believe these are projections, and the thing about projections is as soon as we say the number, you're going to be asking me when we're going to fill those numbers, so i want to be real clear about projections because part of the way we're trying to make sure -- and i would want to comment on the fact that we do have -- you just heard a whole person care report about a very vulnerable population that probably wouldn't meet the guidelines in terms of a skilled nursing facility. so i do want to acknowledge that some people do need more intensive report. that's why in our report directly from the department, you saw two reports, one from the hospital, one from the department where we are trying to identify where we need those numbers. we're going to give you the number that we projected, but i

wanted to understand it's projections, and part of our goal is to try to get ahead of that to ensure that people age in place as much as possible. and as you remember, commissioners, we were brought under the homestead act as well as the other suit that we had to ensure that people were not institutionalized, so that's the balances that we're going to do. so sneha, why don't you talk a little bit about the numbers. >> yeah. to the projection that we had made previously, it was based on a ratio. so as i mentioned, we had 20 beds based on 1,000 people. based on our ageing population, if we wanted to maintain that same bed rate of 20 beds per-1,000 adults, we would need about 1600 beds by 2030, and that's again based on the assumption that what we have right now is an ideal number, and we're only able to do that based on our current ageing

population and the current bed supply we have now, so there's no current literature we would need based on the needs of older adults. there are also national statistics that say that 37% of adults over 65 are likely to need care in a residential care facility or skilled nursing facility at some point in their lives. >> if you were to look at the report that we did, we show you at least for today in the next five years what we think we could put on-line, and that does not reflect -- comes close to those numbers, and so i want to make sure we understand that this is going to be a big lift for us for the next decade. and i do think that all the hospitals, we all have to come together to try to figure this out. and also, the private sector who -- how can we make it more attractive for them to come back to san francisco, considering the cost of doing business in san francisco and

also availability of space and building. so we're trying to insert our ability to look at how can we make it in our master health plan in terms of permit streamlining and how -- and that's why we are engaged with some of the providers today who are providing skilled nursing facilities and see if we can really help in terms of providing those benefits to ensure that we keep the beds that we have, and how do we build more -- and whose responsibility is that? and i think it's a joint responsibility of all of us. and we are trying to lead the way in terms of the planning process and what the city's responsibility is to try to insert its power over trying to make sure that as we're doing affordable housing, we're also looking at residential care facilities and skilled nursing facility beds, but as you can see, depending on where the federal government goes with

reimbursements, it's how people are deciding whether to keep their beds in hospitals or not. and so there could be lots of different ways of looking at this and so we're doing our best in trying to identify at least for the next three to four years what we can do in terms of inserting our power to make it affordable and also attractive to bring people back into san francisco. we heard one of our labor member leaders talk about the fact that out of county is the only location we have for many of our transfers, so we do need to build upon that in terms of how do we build more capacity in the city. the department's committed to that, and we're trying to look at our own abilities, and so that's why we're trying to partner with ucsf to look at skilled nursing and acute beds, and you can see that in our report, but we're going to have a lot more to do as a city as a whole. >> thank you. i think it is important for us to also then refer back to our

previous reports on previous data. i think on also skilled nursing and as we're looking at numbers, there is that whole question of short-term skilled nursing versus long-term skilled nursing which is really important. and short-term skilled nursing and maybe that's more the hospital level responsibility than the long-term skilled nursing kind of gets into this whole issue of ageing in place and ageing where and what type of facilities. i think that also is part of our confusion when we look at gross numbers without looking at that type of division, and then, places may get all concerned about all of a sudden the undifferentiating numbers in which they themselves may have a limited responsibility as a post acute care type of service. and i know that where you have