SF's Shameful Healthcare Gap
Exile from San Francisco for Subacute SNF Patients — a Continuing Reality
What happened to Ken Zhao is heartbreaking. At 39 he is alert, and understands what is going on around him, but he is paralyzed and dependent on a ventilator via a tracheostomy. He can understand English and Cantonese, but he cannot speak. He is, in essence, “locked in.” And now he has to leave San Francisco, and his loving elderly parents, in order to survive. He needs a “subacute skilled nursing facility (SNF).”
California Pacific Medical Center/Sutter (CPMC)announced the shut down of the only subacute SNF in San Francisco (at St. Luke’s hospital) in 2017. Families, patients and advocates organized to protest. Supervisor Ahsha Safai held hearings via the Public Safety and Neighborhood Services Committee, of which Supervisor Hilary Ronen was chair.
In 2018, at a hearing in front of the full Board of Supervisors, CPMC/Sutter, shamed by the publicity, agreed to keep the remaining St. Luke’s subacute SNF patients in county. CPMC would transfer those patients left in the 40-bed unit at St. Lukes to the SNF at CPMC Davies until they died.
The Zhaos are afraid that if they are not able to visit Ken very frequently to oversee his care and emotional health, that Ken will deteriorate again and potentially die. He is very vulnerable.”
CPMC's Profit Motivation
The CPMC Davies 38 bed SNF unit, which until then had not served subacute level patients, was retrofitted for the 17 remaining patients. Of course this displaced other patients who needed post-hospital SNF/rehab care. Also, to the horror of families and advocates, after transfer away from their stable team at St. Lukes in 2018, many subacute patients died in a short time. And no subacute SNF beds were left available in San Francisco for new admissions.
Ken’s situation illustrates how cruel and dangerous the absence of any sub-acute Skilled Nursing Facility (SNF) beds in San Francisco is. No progress has been made on this, despite a number of meetings with the Board of Supervisors, the Health Commission, and efforts by SFDPH, advocates and families between 2017 and January 2020.
Subacute Skilled Nursing Facility Care is a specialized and labor intensive form of long term care for those who require ventilators, tracheostomies with frequent suction, or other complex forms of care to stay alive. (This is an entirely different entity than subacute psychiatric care.) It is reimbursed, for those who are not able to pay, by “Medicaid” (Medi-Cal in California). This type of care is best done on a hospital campus with access to an Intensive Care Unit (ICU), as these patients can rapidly deteriorate and must then be cared for in an ICU. For the hospital, it does not generate as much revenue as short stay acute care.
Revenue driven decision making, not what the people of Northern California really need, has driven the Sutter empire to massive financial success. In San Francisco, the losers have been, among other services, post-acute hospital based SNF rehab, hospital based subacute SNF care, and acute inpatient psychiatric services. All have been cut on the SF-CPMC campuses.
St. Luke’s, historically a safety net hospital for the Mission and Excelsior, has been the recipient of one divestment of needed services after another, despite its rebuild and renaming as “Mission-Bernal.” Sutter did not want to rebuild or continue St. Luke’s, but the community insisted.
A regular nursing home (SNF), including Laguna Honda, offers post-hospital rehab (SNF) care, but does not have the capacity to offer subacute SNF care.
Those San Franciscans who must live on life support long-term deserve a chance to live in their own city, near those who love them. CPMC/Sutter’s closure of San Francisco’s only sub-acute SNF at St. Luke’s Hospital has made this impossible.
Ken Zhao's Story
In 2016, at 34, Ken had a sudden stroke that led to a coma. He was hospitalized at San Francisco General Hospital. After he emerged from a coma, Ken was quadriplegic, breathing through a tracheostomy, and could not speak. He was alert but “locked in.” An event like this could happen suddenly to any of us.
After he stabilized and could breathe without a ventilator, Ken was transferred to Laguna Honda Hospital (LHH) for skilled nursing care. At that point he was quadriplegic, and had a tracheostomy (opening in the neck to his airway). His elderly parents began to visit almost daily and assisted with exercise and suction of secretions from his mouth. He gained strength, developed some ability to move one arm, and the tracheostomy healed over.
Ken is an only child. His parents are 70 years old. He was the only English speaker, and the only member of the family who could drive.
His father, Ru Sen Zhao, is retired. Mr. and Mrs. Zhao only speak Cantonese. They are very low-income, and dependent on public transportation. Ken’s parents report that he was doing fine and even improving for years at LHH while his family came in to assist with care-giving and to cheer him on. Along came Covid-19, and in March 2020 all family visitation was shut down at LHH.
According to Ken’s parents, he deteriorated within half a year of Covid lockdown due to deficits in care. In addition to family being excluded, there were undoubtedly staff shortages from the ravages of Covid-and with no family to give early warning of a change in condition, things did not go well. This is a story that has been repeated in nursing homes all over the country during the pandemic, resulting in death rates that are not explained by Covid alone.
After eight months of family lockout, on November 15, 2020, Ken was transferred from Laguna Honda to UCSF Medical Center by ambulance. He had hypoxemic respiratory failure (not enough oxygen in his blood), urosepsis (sepsis caused by urinary tract infections), and pneumonia.
As he improved from this episode, it became clear, that Ken’s ability to breathe without a tracheostomy/oxygen/ventilator was now dangerously poor. He indicated that he didn’t want a tracheostomy or ventilator, but that he did want to receive on-going life prolonging care.
On January 3, 2021 following his nearly two month hospitalization at UCSF Medical Center, Ken was discharged to Kentfield Hospital on St. Mary’s San Francisco campus. A long-term acute care hospital (LTACH), Kentfield is a specialty facility designed to accommodate extended hospital needs of patients having complex medical issues, including patients with chronic respiratory failure.
While at Kentfield, Ken did agree to a tracheostomy and is now ventilator-dependent. He is alert, and communicates to a limited extent, using a letter board or gestures indicating “yes” or “no.” He needs a level of care that is only available at a facility like Kentfield, or for the long term, only at a sub-acute SNF.
Those San Franciscans who must live on life support long-term deserve a chance to live in their own city, near those who love them. CPMC/Sutter’s closure of San Francisco’s only sub-acute SNF at St. Luke’s Hospital has made this impossible.”
Ken and his parents had wanted him to return LHH where his parents could continue visiting, but they now understand his current needs will necessitate long-term placement in a sub-acute SNF.The Zhaos are afraid that if they are not able to visit Ken very frequently to oversee his care and emotional health, that Ken will deteriorate again and potentially die. He is very vulnerable.
Kentfield Puts the Squeeze on the Zhao Family
Kentfield informed the Zhao family, after 3 months, on April 9, 2021 that it wanted to quickly discharge Ken, now 39, to available sub-acute facilities in Sacramento or in Hayward. Ken’s parents would be unable to visit frequently or take care of Ken in Sacramento. Alternatively, although Hayward is accessible by BART, it would pose a long, costly ride and then walk for Ken’s elderly parents.
Mr. Zhao’s former employer reached out to a host of advocates for assistance on behalf of Ken. Unfortunately, the Zhao family’s first appeal to Medicare Quality Improvement of Ken’s impending discharge was denied. On April 13, the Zhao family’s second appeal was also denied. A Kentfield Social worker told Ken’s mother by phone after this (through a family friend who was translating,) that the Zhao parents could be liable for $2400 dollars a day if they did not agree to quick discharge.
The Zhaos had, by then been informed by their own advocates that they have the right to refuse inappropriate discharge placement. Also, they were informed that Ken’s continued stay at Kentfield, even once he had truly maximized the benefit of being there, would be covered by insurance during the wait for an appropriate SNF placement. Appropriate would mean that Ken would be near enough to allow frequent visits from his parents.
By April 15, a lawyer from California Advocates for Nursing Home Reform, a member of Pelosi’s staff, Supervisor Gordon Mar, and Adult Protective Services helped to advocate for keeping Ken at Kentfield until an appropriate sub-acute SNF could be found. On April 16, Kentfield agreed to honor Ken’s rights, and to delay discharge.
Daly City Beds Wait for Staffing
Seton Hospital (Daly City) sub-acute SNF, the closest to San Francisco, appears to have beds available, but it is closed to new admissions until Seton hires more staff. Supervisor Mar had attempted discussion in the past with San Francisco’s Department of Public Health about contracting for beds there for San Franciscans, at least until beds could be funded in San Francisco. Supervisor Mar has again been asked by Ken’s family to explore whether SFDPH could assist in admitting Ken to Seton’s sub-acute SNF.
However, in-county sub-acute SNF beds are really needed for San Franciscans. And even Seton would pose a longer public transportation commute for Ken’s elderly parents than an in-county facility.
Previous SFDPH director Barbara Garcia made efforts in 2017 and 2018 to look at available space at Chinese Hospital or St. Mary’s Hospital for some of San Francisco’s needed sub-acute beds. SFDPH made an estimate that 70 Subacute SNF beds are needed for all the city hospitals. Given that all hospitals would use these beds, all hospitals should assist in funding them. In June 2019 SFDPH hired consulting firm Milliman to manage the process of bringing new subacute SNF beds on line.
The last I have heard of the effort to re-institute subacute SNF beds in San Francisco was at a Public Services and Neighborhood Safety Committee in January 2020. There were no definitive commitments, and then Covid 19 hit.
In the face of a respiratory pandemic, it sure would be nice to have the extra ventilator capacity that an in-county sub-acute unit offers. The hospitals know how many folks they have sent out of county for sub-acute SNF care. Undoubtedly there were quite a number due to Covid 19. But the public has not been informed.
If these beds were in place now, Ken would have been able to move from Kentfield on St. Mary’s campus to either St. Mary’s or Chinese hospital for his long-term care.
Intense involvement from family, friends and advocates has now prevented Ken from being immediately transferred out-of-county. He can stay at his specialized acute facility in San Francisco, for now, but not for long.
Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at St. Luke’s Hospital, Laguna Honda Hospital, UCSF, and at On Lok, a program of all inclusive care for the elderly.
April 27, 2021