Why Are San Franciscans Dying in Substandard Out-of-County Nursing Homes?

Emergency: San Francisco’s Frail Elderly Need the Health Commission to Step Up to the Crisis

by Teresa Palmer, MD

• • • • • • • • November 2025 • • • • • • • •

None of us wants to think about spending time in a nursing home (Skilled nursing facility=SNF)—but humans are unpredictable, and the need can occur from complications of old age, progressive illness, or an accident.

Usually, we go to the emergency room first. After discharge from the hospital, we may need 24/7 nursing care for complete recovery. Seamless transfer to a quality Skilled Nursing Facility (SNF) can be lifesaving. But every year, hundreds of San Franciscans needing quality SNF care are transferred instead to low-quality, poorly staffed nursing homes in other counties. There, we receive poorer care, and our families and friends have great difficulty visiting to ensure we are getting the care we need.

Insurance companies, such as Kaiser and Blue Cross/Blue Shield, contract with many privately owned, low-quality SNFs that admit new patients even when their facilities are grossly understaffed. These “Medicare Advantage” and “Medi-Cal Managed Care” insurance plans do not contract with higher-quality San Francisco nursing homes, such as Laguna Honda, with few exceptions.

Help Keep Sick San Francisco Seniors Safe

Meeting of the Board of Supervisors is scheduled for Monday, November 18, at 2:00 p.m. Public Comment is last on the agenda best to be there/call in at 3 p.m.-if you wish to appear in person or give comment by phone. Agenda (with instructions for in person or phone testimony) will be out by Friday pm 11/14/25 at:

How can we stop these dangerous out-of-county transfers with little or no cost to taxpayers?

Laguna Honda Hospital and Rehab Facility (LHH), our public nursing home, has many empty beds. I am publicly requesting that the SF Department of Health, the SF Health Commission, and Laguna Honda leaders collaborate with the SF Health Service System to prevent the transfer of patients to out-of-county nursing homes and, whenever possible, transfer them to Laguna Honda instead.

The SF Health Service System (HSS) represents City retirees. It has the authority to determine which insurance companies will cover all retirees who have worked for the City of San Francisco. This gives CITY RETIREES REPRESENTED BY HSS formidable bargaining power to influence the behavior of insurance companies seeking to cover these retirees. The bargaining power of San Francisco City Retirees can be used to compel these large insurers to retain San Franciscans within their county.

We need a sure-fire, foolproof method to prevent the dangerous and heartbreaking transfer of San Francisco residents to out-of-county nursing homes. The existing provisions for San Francisco (including Laguna Honda) placement of nursing home patients with “exceptional” needs are NOT being used. More importantly, the need for decent nursing home care near your loved ones is a standard, not an exceptional, requirement.

How people are forced into out-of-county transfers and what happens

A typical scenario is an elderly City Retiree without an attentive family, who either owns or rents a home in SF. They have a limited fixed income. They are enrolled in an “HMO,” “PPO,” or “Advantage” Plan due to its lower cost. This person, perhaps an independent loner, begins to live in squalor (“self-neglect”) at home, due to lack of easily accessible home help or oversight. Their fear of being taken out of their home, as they weaken, leads to a downward spiral. If they or someone else calls 911 before they are dead, they end up hospitalized.

When they are deemed “ready” for hospital discharge, they are still too ill or weak to care for themselves in their home due to progressive health problems. They need stabilization in a nursing home. They are “SNF eligible:” -i.e., far too medically complicated to do well in a less intensive setting.

I recently advocated for such a person. Let’s call her Jane. Elderly friends did not realize how bad off frail Jane was in her SF home. A visit to Jane’s home led a friend to call 911. After less than three days of hospitalization in San Francisco, Jane was DUMPED (with encouragement from her insurance) to a nursing home in the East Bay known for poor care.

Jane and her friends were not told that she had the right to direct her SNF placement, and she was threatened with a hefty hospital bill if she did not immediately leave the hospital for this understaffed SNF in Oakland.

Jane’s friends did not know how to oversee, appeal, or obstruct a bad decision for discharge and “nursing home placement.” The hospital social worker and doctors, who are supposed to represent Jane, represented the financial incentives of the hospital. After all, she was a sick old lady who was “in denial.” (I quote the hospital discharge summary). The hospital team did not look at Jane’s high risk for re-hospitalization with this unwise discharge & Jane was too sick to understand, so Jane was rolled out the door.

Within 2 weeks, Jane’s elderly San Francisco friends had to go to the bedside at the Oakland nursing home, over an hour’s drive away. They insisted on a 911 for hospital transfer. Jane was obviously near death due to neglect and could not use the phone. Jane ultimately died in a nearby East Bay Hospital much sooner than she would have if decent care had been given. She had dehydration, malnutrition, new bedsores, and other treatable problems.

Elderly and frail San Franciscans, including City retirees, need more help from both their insurance and Laguna Honda Hospital admissions. I heard an LHH admitting representative say (about Jane): “We only take people on straight Medi-Cal,” and “we don’t contract to admit retirees on HMO or PPO or Advantage Medicare insurance plans.” No counseling was given about known strategies to make an exception for Jane.

During this second hospitalization, Jane’s supporters had an advocate: they were informed how to obstruct her discharge to an out-of-county nursing home until she died in the hospital. Jane considered staying in the hospital to be her chosen outcome after her nursing home nightmare. She lived for 22 days in this Oakland hospital and was constantly threatened with discharge back to an out-of-SF nursing home. Jane is no longer suffering, but her friends remain traumatized by the experience.

So, a frail person who is initially hospitalized has 2 to 3 days to assert themselves and navigate a highly complex system to stay in San Francisco. This is while they are sick in the hospital after a sudden decline. Predictably, this will fail, and that person will decline and/or die alone in a crappy nursing home out of county.

If SF Health Department/Laguna Honda leaders do not initiate a work group with our SF Health Service System to prevent out-of-county transfers of, at a minimum, City Retirees, both agencies are failing the people of San Francisco. City retirees can use their bargaining power to help all San Franciscans in need of a nursing home bed near their homes.

The next Laguna Honda Joint Conference Committee meeting of the San Francisco Health Commission is scheduled for Monday, November 10, at 4:00 p.m. (link). The next meeting of the Health Service System is Thursday, November 13, at 1:00 p.m. in City Hall Room 416 (link). Agendas are released about 3 days prior.

These agencies need to form a working group and listen to the people they claim to represent. We need to insist on BEING ON THE AGENDA and get this started! Let’s also tell the Mayor and District Supervisors that it is their job to support this process!

Teresa Palmer M.D. | Family Medicine/Geriatrics San Francisco | teresapalmer2014(at)gmail.com.

November 2025