colleagues for the hard-fought work that we did to ensure that these beds would remain open, for remaining engaged. and then we will -- i'm going to pass it over to supervisor ronen would like to say some words as well. i just want to quickly go over the run of show today and who is going to present. we're going to do something a little bit out of order, is that okay, chair? >> can i do a couple of housekeeping itemness. we have spanish-language translation available. maybe you could come up an make and announcement. [speaking spanish] >> chair: thank you. and then my other housekeeping item, i noticed that the caption for this item is incorrect on the sfgov tv.

maybe we could fix that. back to you, supervisor safai. >> supervisor safai: thank you. we're going to call up kelly here in a moment. she'll have an opportunity to speak and play out a plan. we want to allow gloria and raquel, one of the families that are currently in sub-acute care to come up and speak about their experiences and their conditions their sister. then we will ask san francisco for health care housing, jobs and justice coalition mark erickson, salini-- am i saying that right? salini. and then from the california nurses' association c.n.a. and then we're going to ask benson nadal from the long-term care ombudsman program and we'll open it up for public comment. so again i just want to end with it's -- this is -- this is gut-wrenching. this is heartbreaking to see the conditions, to see the

individuals living and trying to survive and again this is something i have never experienced. and i understand that it's -- it is heart-wrenching to experience that type of circumstances with the family member. and just want to be sensitive to that. and really appreciate the families for inviting us down there to, to let us experience that with them. and know we're here to continue to advocate and push and demand the highest level of care in the city and county of san francisco. so just want to hand it over to -- i know you want to say something, supervisor ronen. >> supervisor ronen: yes, thank you, supervisor safai, for calling this hearing. you know, it is a shame that the city of san francisco, city and county of san francisco doesn't have, other than the few beds that are left at davies, a single sub-acute unit in the county. that is wrong and we need to fix that.

having -- i'm looking forward to hearing from the department of health about what the concrete plans are to do that. having said that, i also visited the davies campus, i would say it's about a month ago. and i was frankly shocked to see the conditions that i saw when i was there. i immediately called warren browner, the c.e.o. of cpmcand had a discussion with him. i know he went to the unit shortly after i called him that same day. and i talked to him a couple days ago and he assured me -- what he told me, let me say it this way was contrary to what i witnessed with my own eyes. so i'm not sure exactly what's going on. and i'm also looking forward to hearing from cpmc. when i went to the sub-acute unit, there were not very many

staff on the unit. in fact, i think i saw two people the entire time i was there. when i walked in, there was a light going off, you know, indicating that a patient needed staff, that i didn't see turned off for at least 15 to 20 minutes. when i was in the room visiting a patient, with her family, at one point she wasn't breathing well because her breathing machine was clogged. and she had pressed the button. and there was nobody coming to respond for quite some time to that -- to that linking button. eventually the group that i was with, someone went over to the one staffer that we saw in the area and asked him to come help. and he was sort of clueless as to the needs.

he said, oh, i didn't see that button. and the light flashing. oh, i'm helping this patient, but let me -- yeah, i'll go over there when i can. it was so casual and didn't lack -- it didn't exhibit sort of the urgency you would expect to make sure at least that the patient wasn't in serious trouble and then maybe multi-task to get them the things that needed to be done. it was not the level of care that i would hope for my family member, if that was me or my family member in that unit. in my subsequent discussions with warren browner, he told me that there is an off-site monitor that monitors the time between when a light goes off and when it's responded to by a staffer.

and that he didn't find anything unusual in terms of the time that it took. again i can only attest to what i saw with my own eyes. and it was worrisome. so, you know, this is not a hearing to beat up on cpmc sutter. this is the only hospital currently with any sub-acute beds. they were hard fought for to keep them at cpmc sutter. but the hospital did make that agreement and that was appreciated. i do want to hear from you and have some concerns about the level of care that is being provided at that facility. but this is more importantly or equally -- i should say not more importantly, but equally importantly about the fact that we do not have these services in the city and county of san francisco. and that that is unacceptable.

that's the responsibility of health department and the entire medical community to remedy that fact. and so that's why i'm here. and that's what i'm interested in talking about today. i want to just say to the family members that are here that, you know, thank you for taking me around and showing me the circumstances for myself. i had never been in the sub-acute unit before. so it was very eye-opening for me. and, you know, i can say from what i witnessed that day, that i understand at another level the concerns that the family members have been bringing up in these hearings. and so i'm looking forward to hopefully getting some of those questions answered today. thank you. >> chair: supervisor fewer. >> supervisor fewer: thank you very much, supervisor safai, for having this hearing. i am also concerned that we don't have a sub-acute facility

in the city and county of san francisco dedicated just for that care. but i also just want to emphasize that it is not -- it's not a question of whether or not sub-acute or skilled nursing beds, because we need both. and so i am looking forward to the hearing today to find out what our current situation is, because i know, through various hearings we've had together, that there's also a shortage of skilled nursing beds. and so i don't think that we should be substituting one for the other. quite frankly there is high need for both. so thank you for calling this hearing. and i hope to learn a lot today and be part of a solution to i i think are this population that is going to need this care, currently needs this care. so they don't have to be pushed out of san francisco. thank you. >> chair: thank you, supervisor fewer. that's a very good point. that's a good transition. so i think we'll call up kelly. why don't you go over -- have an opportunity to give your presentation. >> okay.

thank you. good morning, supervisors. my name is kel request. i'm a project manager with san francisco department of public health. i'm here today to do the introduction for the update on sub-acute skilled nursing care. just kind of overview. supervisor safai did a good overview of reminding everyone what this level of care actually is. sub-acute skilled nursing is provided to medically fragile individuals. and this is to distinguish from some confusion that some folks may have around the beds that we currently have at st. mary's, which is also known as sub-acute, but it is more for mental health, individuals and not for those having medical compromises. today we're talking about people who need sub-acute care. and that is a level of their is when you're no longer in an acute crisis, meaning to be in an acute care hospital, but not well enough or stable enough to go back to a community setting, such as a home or an apartment. there are individuals who need

ongoing 24-hour care, as the supervisor mentioned. these are folks who require very specialty care, skilled nursing services, such as inhalation therapy, tracheotomy care, tube feedings, very complex on-care management, generally are the individuals that you'll find in these facilities. broadly speaking the department recognizes that optimally post-acute care would be provided in a home or community-based setting. that's most people who enter into hospitals get care and treatment. and then are able to go back home and finish recuperating. but there is the segment of folks that that is not possible. they are people who cannot be discharged home, either because they don't have a home or they don't have a home that can accommodate the specialty equipment. and these are folks that need to go to skilled nursing facilities for what we would call sub-acute care. and what brought us here today, in 2018, cpmc transferred at

that time 17 patients from st. luke's sub-acute to their davies campus. and the agreement at that time was that these individuals would be cared for, no new patients would be admitted and we are aware that today the census is eight. in the fall of 2018, the department of public health began a process to identify a consultant to help conduct an environmental scan to bring it to current -- the last time we did our environmental scan was several years ago. we also wanted somebody who would help us manage the project selection and implementation, so that we could bring new sub-acute skilled nursing beds online as quickly as possible. and we worked in conjunction with the controller's office. in june of 2019, we selected milliman inc., they are a health care and finance expert consultant. and we've invited milliman to give an update on the work that they've done to date. and i'll be able to answer

questions following. i'd like to introduce -- >> you said they're going to present on what they've done today? >> they did the environmental scan and they'll update. >> yeah. it would be good for you to come back. >> exactly. we'll follow through. >> thank you. >> i'm going to introduce you to the senior principal consultant. >> through the chair, what is an environmental scan? >> i'm sorry? >> supervisor ronen: an environmental scan? >> how many beds do we have in the community currently. how many -- we did surveys in 2015, of how many patients are discharging with sub-acute need. we wanted to update that. is that number getting more, less, stable. we actually engaged milliman to make the outreaches and conduct those surveys, they're going to give us a summary of the report. they're also going to need an update from the participants we're work -- partners we're working with and going forward. welcome. >> okay. good morning, supervisors. my name is susan phillips,

senior health care management health care consultant with milliman. as kelly mentioned, i'm here to present today an update of the project to identify and develop opportunities for sub-acute care capacity for the city and county of san francisco. so, first, just let me briefly introduce myself and milliman. milliman is an an ak due waral m created in 1947. we have a major office here in san francisco. our mission is to serve our clients to protect the health and financial well being of people everywhere. and that is our core mission and we take that mission very seriously. and strive towards that. we involve 3800 employees, including consultants that have extensive experience in supporting public sector clients. and i personally have 20 years of experience in working with public sector clients and working on various policy initiatives in terms of analysis development and supporting and

implementation. so as i mentioned why we're here today, is to give you a status update. and in terms of the -- in terms of the purpose, we want to provide you, as i mentioned, a status update. we want to give you an outline of our next steps, in terms of generating options for expanding sub-acute care options and give you preliminary findings of what we have done so far. okay. i think supervisor safai did a very good job in providing an overview of what sub-acute care is. and in terms of the specific population, i did have a few slides to walk through that. in the interest of time, i might go through that fairly quickly. but, you know, i think the main thing that we wanted to highlight here is that, you know, this population again is medically frail, in need of special medical services.

and to serve medi-cal beneficiaries, certain licensing requirements sustained by the state. for example, certain nursing staff requirements that have to be met. i'll get into that in a little more detail. so i did think it was important just to lay out again the sub-acute care is part of the full continuum of post-acute care. you know, as a person leaving a hospital, you know, thankfully most patients, you know, don't need post-acute care following a hospitalization. obviously some do. the goal of any discharge from a hospital is to get the patient to the right care at the right time at the right place. and the place and the type of care that's appropriate is highly dependent on the patient's condition. and the level of care that they need. so this is, you know, a full continuum of post-acute care, you know, from the home to

skilled nursing and then up to sub-acute care. so the next slide is really to illustrate the difference between sub-acute beds. again as i mentioned, the key difference here as you see is services of sub-acute care can offer our ventilator care, complex wound care management, intravenous tube feeding. now as you mentioned back in 2018, cpmc had a 17 sub-acute care patients transferred to davies. and now the remaining eight patients, based on cpmc's report of current bed census. and based on 2018 data, the total count of general sniff beds is 2,227. and this does include free-standing facilities, as well as hospital-based facilities. so it's the total general sniff

-- bed count. >> excuse me. do you have a breakdown of that 2,227 free-standing and which hospitals are doing what? >> yeah. so we have 901 at free-standing. and 1,326 hospital-based. okay. okay. i did just want to take a second to provide an illustration of people who need sub-acute care. again we did speak about this. but i thought it was important to take a second to kind of walk through a couple of patient profiles of two different people. you know, we have one patient who is older, another one that's younger. both of these individuals here have had serious medical crisis. and they're both in need of ventilator care for a long time. and possibly, you know, for the rest of their lives.

on this slide, you know, we see that the 45-year-old might, who was in otherwise good health, prior to the medical crisis, may be in need of sub-acute care for decades. so i think this is just important to keep in mind. okay. so switching to the project. the project objectives, as we said, are to support d.h.p., plan for and implement expansion of capacity for sub-acute care beds in san francisco. our approach is to -- >> can you go back to that slide for a second. >> sure. >> sometimes you guys say things and do things that make sense to you. >> okay. yeah. >> and anyone that's might be in the industry. >> sure. >> but when i read that, the first thing that jumps out to me is why is the medi-cal beneficiaries an important part of that statement? >> well, so i think that is a population that has, after long-term, medi-cal is a primary payer.

>> what if someone needs sub-acute care, that's not medi-cal? >> so if they have medicare and commercial, there are other payers. but it's true in terms of capacity, they're facing the same issues. and that's where we consider them part of the vulnerable population. >> okay. thank you. >> so our approach is to try to take -- >> although -- wouldn't the vast majority of people in that situation be on medi-cal, if we're talking about -- >> yeah. if we're talking about over 100 days, yeah. if they're medicare-eligible, if we're talking about an older person, over 100 days, medicare does pay for the first 100 days. but then after 100 days, then the primary payer would be medi-cal. you'd have to -- >> you'd have to be either extraordinarily, incredibly wealthy or you're on medi-cal.

>> right. because this is long-term care. and that's a major issue in terms of just covering for long-term care in this country. >> that was my point. my point was to kind of clarify to the general public, but also for my own etfication since i'm not in the industry. >> great. thank you. thanks for that question. okay. so in terms of our approach, what we're trying to do is again take a comprehensive view of the potential needs in the city and identify an array of options to address those needs. you know, our goal is to try to make sure that we're bringing as many options as possible for your consideration, as appropriate. and as we mentioned right now, we're in the mid of this environmental scan. and what we're doing as part of that is to collect information from potential partners and stakeholders in san francisco. so what we have done is conducted a series of interviews, with hospital

systems and we have asked for data. and i'm going to get into, you know, our initial findings, based on that. the next phase is what we're calling project selection, which we are starting very soon. we're starting by first identifying potential partners, who are interested in developing capacity in the city. and d.p.h. is currently working directly to identify proposals. and once those proposals are submitted, we would review those proposals obviously. and then work to synthesize that and facilitate further dialogue among those stakeholders and we are -- would like to provide a framework for decision-making for d.p.h. and the board of supervisors and the city to, you know, consider those proposals. we plan to share our review. we're hoping to do so by november. and once the city and d.p.h.

have thought about this proposal and are thinking about which ones to potentially go with, we'll begin the process to partner with d.p.h. to further flesh out all of the incredible steps that's needed for implementation. >> excuse me. >> sure. >> supervisor ronen, did you have your name on there? >> supervisor ronen: i had some questions about that. >> chair: just one second. are you almost done with your presentation? >> no. i was going to provide findings. >> chair: okay. go ahead, supervisor ronen. >> supervisor ronen: thank you. what does that mean that you're going to solicit proposals from potential partners? can you talk a little bit more about who these partners are that you're expecting to receive proposals from and sort of the pre-work that goes into. >> yeah. sure. it's actually -- we wrap up with that. so if we could ask to finish the presentation. >> chair: sure. that's why i asked. some of the questions that we

have might be answered in the presentation. >> they will be. >> chair: so if that's one of them, supervisor ronen, if you still have questions after they're done, we'll come back to that. >> supervisor ronen: sure. thank you. >> i'll get to the findings now. >> chair: that's fine. >> okay. so in terms of the folks we talked to, here are the folks we talk to. we talked to seven hospital systems in the city. again conducted interviews. the interviews include questions to gain understanding of what the sub-acute care needs are. we asked about placement barriers and interest in partnership. we also requested data to understand what the discharges currently ar to sub-acute care, what placement barriers there might be and the wait times. so all of these facilities generously provide their time and key staff involved in discharge planning and, you know, are involved in the care of their patients.

so we really appreciate their time. we also gathered data from almost all of the facilities to the extent that they were able to do so. so i'm to provide -- >> what happened with kaiser? >> going back there. so kaiser was not able to provide data, just in terms of the way they keep the data and that's essentially what they told us. >> what does that mean? >> how they maintain the data. >> can you say it clear. they just didn't want to give the data? >> well, they told us that they were not able to provide the data. >> okay. so they didn't have the data. okay. thank you. >> what kind of data are you asking for? >> sure. yes. i will get into that. actually i might just -- the kind of data real briefly. what we try to hone in is wait

times for placeman and discharge. >> seems pretty straightforward. >> chair: supervisor fewer. >> supervisor fewer: okay. you just ask for two things. >> well, we ask for a few things. but those are the two key things that we wanted to distill, to give you a full sense of, you know, what are really the barriers for sub-acute care. and so that one specifically -- those two data points specifically, as i'll get into, you know, kind of help paint a picture of, you know, who are these patients, how long are they waiting. and where are they -- how many of them are waiting for discharge. >> supervisor fewer: okay. when you're interviewing these seven facilities, you're not asking about capacity or are you? >> we did ask about capacity as well. that was part of our set of interviews. yep.

>> supervisor fewer: you asked for wait times, you're asking for waiting for discharge. >> yep. we also asked about interest in partnerships. >> supervisor fewer: interest in partnerships. and did you ask about whether or not the facility is -- can take sub-acute patients and are licensed to take sub-acute patients? i mean, have everything in order to take them immediately. >> yes. that was part of our capacity question. right. so we did about that. and so i do have a slide that shows -- >> supervisor fewer: yes. okay. these are the things that kaiser couldn't give you data on, is that correct? >> that's correct. >> supervisor fewer: i'm trying to find out what the questions were. they didn't seem that complex. of course, i'm a lay person. still. >> sure. >> chair: thanks, supervisor. >> okay. >> chair: please proceed. >> okay. thanks. you know, one thing i did want to mention, just to put this in context, there is a shortage of

sub-acute beds in northern california as a whole. in california, there are about 4,486 sub-acute care beds. about 70% of them are in southern california. among the bay area counties, there are about 514 beds. so, you know, there's just overall more in southern california than there are in northern california. i did also want to point out that right now patients who are ventilator-dependent and in need of dialysis, must go to southern california or outside of the state. so that is a real, you know, it's -- these are rare circumstances, of course, where someone has a ventilator and dialysis. for a few patients that are in need of those services, there are none in northern california. >> chair: supervisor stefani. >> supervisor stefani: yes. thank you. i wanted to ask one more

question what you were asking of the hospitals. did you ask if they had the ability to provide sub-acute care? and later did not? >> we didn't get into their historical capacity. no, we just asked about where they were at that time. >> supervisor stefani: okay. thank you. >> okay. okay. so based on the interviews, i did want to share qualitative findings. first, again to reiterate that, you know, the goals, of course, are to make sure patients are getting placement, the right place at the right time. we did hear again of this -- the need for custodial beds and that is also a shortage that the hospitals did share with us. i did want to make sure that that was highlighted and that is part of the overall post-acute care placement challenges. of course, there are major

considerations for family, families that obviously keep part of the caregiver team to make sure that the patient has good health outcomes and they can be there as an advocate for their loved ones in the hospital. a couple of barriers we are heard were payment sources and payment rates. as mentioned, medi-cal is the payer for long-term sub-acute care services. and per diem rates for sub-acute care are too low to cover the costs of san francisco. another hurdle we've heard is regulatory hurdles that could impact bed supply. again there are issues in terms of licensing and staffing ratios that are required by the state, that are needed to set up sub-acute care beds.

that were reportedly a barrier. so i think this is what you were looking for in terms of the initial findings. so we'll get into that. so the wait times for placement. again these are difficult numbers, because we're talking about very small population. so there is quite a wide range. but these are a couple of hewsful -- useful measures. we looked at wait time for placement and discharges from hospitals to sub-acute care. so, you know, it's hard to speak about averages when there's such small numbers. so wanted to provide a range here. so while wait times for placements vary widely, the general average wait time for placement may be around 30 to 45 days. and then there are very extreme cases. we've heard of wait times that are longer than even 500 days. so there are some pretty extreme cases. i did think it was important to note that a couple of facilities

just said that they just haven't been able to find placement at all. and so -- and you know, so folks are staying, you know, in the hospital. in terms of discharge, we do -- >> that means they're looking in other counties, they're looking around the state and they're not able to find someone? >> well, you know, they're also trying to take into account family preferences and making sure that that's taken into account. so they might stay in the acute care facility. so in -- >> chair: hold up. supervisor stefani. >> supervisor stefani: back to page 19. patients that are ventilator-dependent and in need of dialysis, no sub-acute care options in northern california and must go to southern california or outside of the state. i'm wondering what is that universe of patients? how many people is that? >> yeah. i don't have a total count. what we're hearing from facilities it's about, you know,

a couple a year. i mean, we're not talking about a very large number. these are very, very rare circumstances. >> supervisor stefani: okay. thank you. >> so in terms of discharges, we have a preliminary estimate of 49 discharges in 2018. and this is based on the hospital, acute care discharge estimates, as well as a rough estimate from facilities that talked about individuals that are waiting to be discharged, but couldn't find placements. taking those two into account. you know, the bottom line is we think that these are pretty low estimates, because again there seems to be some challenges to track this data. one point that was made over and over again is that, you know, these patients are frail. and they're -- you know, when they're waiting for discharge, their status might change, right. their condition might worsen, they might need to go back to

the i.c.u. in that case they're not necessarily picked up in the data there, in terms of their final, as they call it, discharge, disposition. so it wouldn't necessarily be picked up in the data there. so we do think that these -- that there could be a higher rate there. okay. so in terms of the next steps. we are looking at options, hospital-based distinct park facilities in san francisco. as well as free-standing facilities in san francisco. i did want to first speak about the hospital-based sub-acute care beds. as we discussed, we're exploring opportunities with the systems. as you mentioned, you were asking about the partners, right. so the two that we have identified, chinese hospital has identified 23 available beds that have been built out. and they're interested in

potentially designating these sub-acute care beds and working with the state to make that happen. because they need to go through the state approval process. my understanding is that they've been requested to support a proposal to d.p.h. they're in the process of doing so. the department of public health is also in conversation with dignity health. and there's a potential proposal that may be forthcoming in october. so that's another real potential. i did also want to highlight that kentfield, which currently operates a long-term care acute facility in st. mary's, on the 6th floor there on stanyon, they are interested in partnering with a hospital to really serve as the operator for sub-acute care unit. so they have experience in serving this population, because they serve people who are vent-dependent and they have that experience now. so they're interested in partnerships.

in terms of next steps, we are planning at this point to conduct interviews with free-standing nursing home operators in the city. there are four right now, san francisco health care, aspen skilled health care, providence group, generation health care. initial conversations with these operators, they've all expressed interest in potential partnerships and potential expansion. and really looking at all options. so they have all raised their hands and said that they're interested in, you know, continuing a conversation. so we will plan to be conducting interviews with them over the next few weeks. again as part of that, we'll be asking them about their current capacity. what their future capacity might be and short-term, long-term. what, you know, potential barriers they have. what they're considering is the implementation steps. and again their willingness to

partner. we'll also be asking them about other supplemental services and arrangements they might need, like critical care transport. and again we'll work with d.p.h. to obtain proposals. so that wraps up my points. >> chair: so what we'll do, because we have family members and other people from the community that want to come and -- there's some more of the presentation and some questions and public comment, i want to come back to the last two slides, because that's part of what i wanted to get on the record. we have chinese hospital that's willing to have this conversation. st. mary's is willing to have the conversation. we can dive into the residential, in the nursing home operators. i know supervisor mandelman and fewer have put forward a proposal about long-term care facilities. using potentially small sites money for acquisition and preservation. so we have a whole bunch that we can talk about. we can come back to that.

i want to be respectful for the people that have taken time off from work to come here and speak. so if my colleagues don't mind, we'll come back to the last two slides. i know we have a lot of comments and questions that we can add to that. so thank you. please don't leave, because we're going to come back to that portion. i would like to call up miss gloria and raquel to come speak. two current family members with a sister in the davies facility. >> good morning. my name is gloria rivera. i'm the sister of sandra rivera. on behalf of the patients and families and ours, we thank you for taking the time to visit the sub-acute unit, to see with your own eyes what we have been encountering. we are here today because half

of the 17 sub-acute patients, that were transferred from st. luke's, died within one year. cpmc has not been keeping their promises. they have not been providing the quality of care that they had assured us. patients are being neglected due to lack of staffing. there is no urgency when answering patient call lights. they have inexperienced staff and floaters, who are not familiar with the patients and equipment. patients are not being checked for suctioning. something needs to be done now to make sure the remaining patients do not die from neglect. at this rate, there may be only four left by the time december comes. this is why we need the sub-acute unit reopened. these rooms have already been specifically retrofitted for the original 17 sub-acute patients that were transferred. in the best interest for cpmc's current patients and the

community, cpmc should maintain and admit new patients, so that there's an adequate level of staffing and continuity of care at all times. how do you explain eight deaths in less than a year, soon after going to a new facility. cpmc is working diligently to get rid of these sick patients, whether by transfer, sent home or by death. [bell dings] for example, one patient was convinced that she was well enough to go home, only within three months after being transferred to davies, released and then admitted back into a sub-acute facility out of county, all the way in sacramento. for another patient, which is my sister, who is developmentally disabled, cpmc contacted an agency without our knowledge, to

find out the qualifications to have her transferred to a group home. [bell dings] and yet more recently another family member was told their sister was ready to go home, even though she still required much further rehabilitation. we have families grieving today because of cpmc's lack of care for sub-acute patients. they intentionally went against everything we stood for to cause havoc, depression, anxiety, financial hardship, whatever it took to tear us down and for the patients not to thrive. i asked how do eight patients die in less than one year. the very same patients who were at st. luke's for many years. supervisor ronen, do you recall the part of your visit when a patient's alarm went off. the staff member who said he was from rehab did not know what the alarm was for or how to turn it

off. how do you feel at that moment? i'm sad to say this patient passed away in just a few weeks. i don't know how to turn this on. fran, my friend. supervisor stefani, how did you feel seeing how helpless these fragile patients are? the stories of how their lives once were and how their lives are now at the mercy of cpmc. wasn't it hard when it was time to leave them. when supervisor yee and walton visited the unit, as you know, stefani, mr. browner came to our group and totally dismissed the families and asked supervisor walton and yourself to step into an office with him, so he can talk privately with you.

but supervisor walton refused his invitation and stated to browner, that whatever he has to say, he can say it in front of the families. supervisor safai and stefani, just like you've seen how the staff was the day you both arrived, because they knew we were coming. it's how the sub-acute should have been staffed at all times. where is the transparency and compassion for the families? in addition, inadequate staffing, the sub-acute patients are also not thriving because they are -- they do not have the designated activities coordinator to give them stimulation throughout the day. because the activities coordinator is handling both the s.n.f. and subacute patients. the priority is given to the s.n.f. patients who are more alert and mobile. the sub-acute patients had an

outstanding designated activities coordinator at st. luke's. she went above and beyond her duties and cared for them as if they were her own family, such as washing their hand, nail painting and helping the nurses. they should have a distinct or separate activities coordinator, just for the sub-acute. questions to cpmc. why have there been so many deaths? how many more deaths are you all willing to sacrifice before a change is made? this is raymond. our friend who had no family. raymond was transferred out with no choice of his own. he was fighting that he didn't want to go.

we were his only family. because he was a religious man, they brought a priest to his room. and the priest told him if he does not leave, that he won't go to heaven. raymond passed away a year later. question, how many more deaths are you willing to sacrifice before a change is made. what would it take for cpmc to open this unit to new patients. what would they need -- what would they need to readmit the patient they discharged home. shouldn't they be allowed to come back. how soon can we make this happen. what is the plan if and when there is no sub-acute left in san francisco. where is the director of nursing to answer our question, where is dr. browner, how come no one from davies hospital is here to answer our questions. here's a plan that we propose.

cpmc already retrofitted rooms specifically for sub-acute care for at least 17 patients. we can end this fight today if they are willing to keep these beds open for new sub-acute patients. when she was speaking on there are over 2,000s.n.f. beds and eight sub-acute, that's less than 1%. thank you. >> chair: thank you, ms. rivera. does your sister -- is your sister wanting to present or presenting for both? >> i'm just the one presenter. and, as you know, the alarm that was going off for the patient, and as i mentioned, she passed away. >> chair: thank you. i'm sorry to hear that. okay. we will move to mark erickson.

>> it's just about good afternoon, supervisors. i'm mark erickson. i'm an an emeritus professor of law at hastings college for law. and for more than ten years now, our c.e.d. clinic, our community economic development clinic, has worked with san franciscans for justice on cpmc and health care concerns. generally in san francisco. i want to address just two points today in terms of background for cpmc, as part of your larger discussion regarding the need for sub-acute care and a whole host of needs around post-acute care in san francisco. the first up with is to take off the table that the development agreement the city entered into a with cpmc, in 2013, in any way

restricted cpmc from being a full participant in any program san francisco wants to meet the needs for sub-acute care and other post-acute care needs. the development agreement itself says that cpmc is to act in good faith to deal with the sub-acute care unit. it does explicitly not require cpmc to expend any funds or staffing. but most importantly, it does not limit or restrict in any way cpmc being a full participant and, in fact, providing sub-acute care facilities and other needs for low-income and other people in san francisco, in terms of health care issues. the second point i want to make goes to the most recent san francisco charity care report for 2018. and it looks at hospitals in san francisco in light of their

charity care effort. and most strikingly is the comparison between 2013 and 2017. >> chair: thank you. >> because of obamacare, the need for charity care, which in san francisco's definition does not include medi-cal recipients, has gone down at most -- at all hospitals. there's more people now on medi-cal, so the actual effort on charity care, which subsidizes or dismisses fees that may be due by non-medicare-eligible clients, has gone down. all other hospitals, however, except cpmc, what is most striking is that it's medi-cal shortfall also has gone down. medi-cal shortfall is the difference between medicare -- medi-cal -- the medi-cal reimbursement rate and the

somewhat fictitious fees that the hospital largely carries. it's not a statistic i usually like to look to, because it overinflates what may be the charitable giving of hospitals. in this case it's very striking, where other hospitals have, in fact, seen a rise in the medi-cal shortfall, which means they're providing more services, they're spending more money in effect as they see it on their balance sheet on medi-cal and poor recipients. and most people that are on long-term sub-acute care are on medi-cal. that is just striking. cpmc is not doing its fair share. there's a real question whether, in fact, acting in good faith, despite the things that it did do largely due to the pressure that was applied by the board of supervisors in san francisco. now it has to be called to task. it does -- there's no legal document that's going to require them to do it. unless there's new legislation that's somewhat difficult, but

not impossible for san francisco to pass. but it is important to hold them accountable publicly and to provide all reasonable pressure to get them to do what they should be doing in good faith on a voluntary basis. thank you. >> chair: thank you. seoni, if you're still here. okay. good. seoni, is with the california nurses' association. >> good afternoon. i am a registered nurse. i work in the i.c.u. at mission burnell camps, formerly the st. luke's hospital. i've been working at this hospital over 40 years. i'm also a proud member of the california nurses' association. i'm here today with my fellow nurses nurses from st. luke's mission, who took care of the patients in the sub-acute unit for many years before cpmc closed the unit at our hospital.

we joined with our coalition partners to demand that cpmc take its part to provide program, well-staffed, sub-acute beds in san francisco. in 2016, st. luke's hospital had 40 licensed sub-acute beds. they were the only sub-acute beds in the city. cpmc refused to take new patients into the unit, billowing the unit to shrink as patients passed away or were discharged. cpmc began to pressure families to transfer patients out of the county. the nurses are a coalition partners and the families fought the decision as we knew, that pushing the patients away from the support systems would be a death sentence. we are proud that we won the fight to keep the patients in san francisco. but more must be done. there are still patients in our hospital who need sub-acute care and have no place to go. in this i.c.u. i work, we have cared for patients for many

months at a time, while waiting for discharge planners to find sub-acute bed placement for them out of the county, even as far as sacramento or los angeles. this patient should not be waiting for months in i.c.u., which is designed for different level of care and does not have the resources appropriate for long-term patients. of the 17 patients who moved to davies campus last year, fewer than half are alive today. each time a patient passes away, cpmc decommissions the bed and takes it out of service for sub-acute patients. these are a terrible waste of resources, that are desperately needed in the city. we demand the cpmc maintain 17 permanent sub-acute beds open to new admissions. this is a small presentation of the need in san francisco. it is well within cpmc's financial ability to provide for these beds. thank you. >> chair: thank you. next person we're going to have present is the last one before

public comment is mr. benson nadal. >> you have five minutes to speak. >> supervisors, good afternoon. it is afternoon. my name is benson nadal. i've been the program director for the ombudsman office here in san francisco since the end of 1986. so i take the long view and i don't live in the past, except to regret the loss of so many small-skilled nursing facilities throughout san francisco. and so our focus, under federal and state law, is to visit and advocate for all of the residents and all of the skilled nursing facilities, all of the assisted living facilities and the board and care homes, which you know are hemorrhaging in terms of loss, not only for elderly, but people in the system. so our offices all over the place in terms of advocating for beds to be kept, but also more

than counting beds, it's the quality of the care that our office has always been focusing on. our offices went to st. luke's skilled nursing facility, as well as the sub-acute unit years ago, when there were almost 40 residents in the sub-acute unit, some with m.s., some with a.l.s., some on trach, all on vent, around-the-clock, and the care was excellent. we've absolutely presided over a funeral for one person, who decided with advanced a.l.s. he wants no more. so he went to the catholic church and went to a ceremony. it was very moving. the staff at st. luke's sub-acute was incredible. it's my opinion, and i can't prove this, because ombudsman and forensic nurse investigators that had they -- had the patients not moved out of st. luke's, into davies, there would be more alive today, because of continuity of staff, the incredible linchpin of

carmen, the activity person. and when they moved into davies campus, it was a minor victory, not a major victory, because the staff did not follow the patients, the activity person did not follow the patients. they were merged into some more insidious skilled nursing care called post-acute care. [ please stand by ]

>> so you layer on that scarcity onto the disappearing 17 beds. we have a crisis in san francisco. again, my office is concerned not only about the quantity of beds that are disappearing, but also the quality of that care, as well. so what happened with the davies

patients from st. luke's, the quality was affected. what happened is was you have people dying when maybe they would not have died, and i can't judge that, i don't have any forensic capabilities had they remained at st. luke's. our office looks at the whole -- i don't call it an environmental scam, i call it a supply matched up with the demand, which needs better data, not only to subacute, but for care, long-term-care long-term care s.n.f. beds, for all the people aging in the very -- various supervisorial districts. this is a citywide issue. thank you very much. >> thank you. we will go ahead and open it up to public comment. i wanted to ask if there are any additional family members of any subacute patients. i know some are here.

i will ask her to come up and speak first, but anyone else that would like to speak in public comment, they can line up on the right. you can start the timer over, please. is our translator here? >> he left about ten minutes ago i am trying to attack -- track him down. >> i think supervisor ronen can, if you are able to. >> it is my new job as translator. [speaking spanish]

>> i want to say thank you. it is very hard for me to come up and share, but thank you so much for the time you are taking for us. i'm here on behalf of my father. they translated him -- they transferred him to davies. my father is not the same. he smiled with us, and right now he is always lying on the bed, doesn't open his eyes, they are not open like before. we can see he is not the same. they only have a new nurse. they don't have any relationship with my father. my father is fighting with them because he doesn't want anybody

touching because they don't recognize him. i don't know nobody over there because they never show up. only the nurse. anything happens to my father, we have to deal with the nurse because there's no dr. around, only on the phone. that is why i am coming here to advocate because -- [indiscernible] -- my father still listens to us he puts his head on my chest like, you know, don't worry. i am just coming to advocate for him and for everybody because the care that they provide to him is not okay. they don't have nobody taking care of them. today i want to the hospital with these photos. nobody is around. only two people who are talking