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Laguna Honda Update

• • • • • • • • December 6, 2022 • • • • • • • •

Dr. Teresa Palmer
Dr. Teresa Palmer

Our City Attorney dropped his lawsuit defending Laguna Honda Hospital (LHH) in mid-October. In return, the Feds (Center for Medicare and Medicaid Services-CMS) agreed to delay defunding LHH until November of 2023 but to delay required discharges and closure only until February of 2023 (with the possibility of extension for good behavior).

This delay gives LHH time to meet Federal criteria to resume normal operations. Closure, discharges, and bed cuts are still very much on the table -despite the extreme shortage of safe nursing home beds for the poor everywhere.

Most disturbing, a "revised closure plan" to be shared between City and State (California Department of Public Health, an enforcement arm of CMS) is being kept secret illegally.

Normalization of operations at LHH must be de-coupled from closure, discharges & bed cuts. There has been enough stress, sickness and death from this cruel exercise! This insanity by all levels of government must stop!

The city is laudably doing a big share of the work by funding & overseeing the stabilization of LHH.

Part of this stabilization must include government funding of safe and local settings outside Laguna Honda for those with active substance use & unstable mental illness.


... the rights of nursing home residents is to promote autonomy. This is not compatible with the treatment of persons with unstable behavioral issues, which requires structure and agreement to "house rules." If LHH continues to violate legal admission criteria by admitting persons with active substance use or unstable mental illness, we will lose Laguna Honda.”

We must remember that the rights of nursing home residents is to promote autonomy. This is not compatible with the treatment of persons with unstable behavioral issues, which requires structure and agreement to "house rules." If LHH continues to violate legal admission criteria by admitting persons with active substance use or unstable mental illness, we will lose Laguna Honda.

Please speak out to save Laguna Honda with all of its beds intact and to fund alternatives for those who need care in other settings:

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.

December 30, 2022

Discharged patient
A discharged patient awaits transportation
How we got here — step-by-step — where we are now.


•••••••••• August 30, 2022 ••••••••••

Dr. Teresa Palmer and Mom
Dr. Teresa Palmer,
Geriatrician, with her
Mother Berenice

San Franciscans supported a significant bond issue in 1999 to rebuild the Laguna Honda Hospital and Rehabilitation Facility (LHH). Reminded that LHH is a critical safety net, the voters supported it.

Then our City leaders wanted less general fund money to go to LHH. The Mayor and the Health Department decided it would be most economical to use LHH beds (at the cost of a couple of hundred dollars a day) for patients who could not otherwise be safely discharged from San Francisco General Hospital (where beds cost over a thousand dollars a day). This would save money for the system as a whole.

Other San Franciscans who needed a nursing home bed found it almost impossible to get in.  

LHH management and staff learned that they would be replaced if they said no to the San Francisco General patient transfers. 


Laguna Honda Hospital.

LHH is in a crisis. CMS decertified the facility due to a handful of correctable issues forcing the relocation of around 700 vulnerable people.

NEXT PUBLIC HEARING The next hearings that the public can testify at are: Health Commission hearing on September 6 at 4 pm, and Full S.F. Board of Supervisors Hearing on September 13 at 2 pm.

LHH has always been a nursing home facility, has no locked beds and no licensing to take care of those whose primary problems are behavioral, substance abuse or mental illness. But other, more appropriate treatment programs do/did not exist or are/were full (another failure of the city family to plan). 

In early 2022, after overdose incidents, federal government inspectors from CMS—the Center for Medicare and Medicaid Services—warned Laguna Honda that serial inspections would ensue. (Medi-Cal is the California equivalent of Medicaid). No one in the line of command at LHH at that time was capable of preparing the institution for the predictable attention to detail that federal inspection would bring.

CMS’s main power is to stop Medi-Care and Medi-Cal from paying the bills, which is 80% of LHH revenue. CMS noticed the lack of preparedness. CMS threatened to stop funding, “de-certified” the facility, and insisted on a complex recertification process. Nothing close to this has ever happened before.

Alarmed, Department of Public Health hired consultants to thoroughly train staff at the cost of between 5 and 10 million dollars. This training is going on now. It is of note that much of the training is about federal nursing home standards that have been in place since at least 2017.

Medi-care (insurance for disabled and those over 65) only pays for short-term rehab at a nursing home. Most people who need long-term nursing home care end up on Medi-Cal as the payor unless they are fabulously wealthy; a nursing home costs about 12-18,000 dollars a month.

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LHH has always been a nursing home facility, has no locked beds and no licensing to take care of those whose primary problems are behavioral, substance abuse or mental illness.”

CMS’s original deadline to stop payment was September 13, 2022; as of mid-August, after City lawsuits, deaths of discharged patients, and a public outcry, that date has been extended to November 13. 

The California Department of Public Health, which works under CMS, and Laguna Honda managers together worked out a plan in April 2022 to discharge all residents and close. None of the government agencies involved has taken clear responsibility for this. Closing a facility that is in the process of being fixed implies that it will never be fixed.

Serial discharges up to the end of July resulted in at least nine deaths after 57 patient discharges. Laguna Honda patient representatives filed a class action suit from Louise Renne’s law firm to stop further discharges. It occurred around the same time CMS stopped discharges in late July due to the high death rate.

The City family is supporting an additional lawsuit against CMS (David Chiu, City Attorney) to keep LHH open. The point of the City's lawsuit is that the loss of recertification is arbitrary. However, at this time, forced relocations could resume at any time after November 13.

Furthermore, out of about 760 licensed beds, CMS demands a 120-bed cut (to maintain a two-patient-to-one bathroom ratio, which is a new requirement as of 2016). The reasoning by CMS is that LHH should be treated like a new facility since it has lost its certification, although the building is less than 15 years old.

What happened at LHH involves incompetence at all levels of government. Given the extreme shortage of Medi-cal nursing-home beds, shutting or downsizing this safety-net facility deprives San Franciscans, who may need a bed and punishes (and may kill many of) the most vulnerable current residents.

San Franciscans are an aging demographic. LHH must remain open — with all of its beds — and be the best it can be: a high quality public, unionized nursing home with life in its halls from residents, devoted staff and volunteers. 

The next hearings that the public can testify at are: Health Commission hearing on September 6 at 4 pm, and Full S.F. Board of Supervisors Heating on September 13 at 2 pm.

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.

September 2022

Bernice Palmer
Karen Klink comforts her mother, Cynthia Tachner
Family and Friends—It's What Care Homes Need


Dr. Teresa Palmer and Mom
Dr. Teresa Palmer,
Geriatrician and her
Mother Berenice

Who is the last to be considered in an emergency and the first to suffer and die? Folks who must live in long-term care facilities. A report, Not just COVID: Nursing home neglect deaths surge in shadows by Matt Sedensky and Bernard Condon estimated there were at least 40,000 excess deaths in nursing homes NOT attributable to COVID-19 as of November 2020. (AP. November 18, 2020)

Now there is legislation, House Resolution 3733, that could immediately help—the “Essential Caregiver’s Act

 This bill mandates the right to have a chosen friend or family be identified as an “Essential Caregiver.”  This bill has bipartisan support. It is national legislation that no one should object to. It is likely to relieve some excess deaths and a lot of suffering NOW. A broad array of respected organizations and advocates support this bill.

H.R. 3733 mandates that two chosen people, in a public health emergency, have access to a resident in long-term care 12 hours a day. These “Essential Caregivers” must be offered, and comply with, the same precautions and protections as staff.


It simply ensures that, in the event of a public health emergency, folks in long-term care have the right to have their chosen ones with them in person.”

This legislation was written to solve a specific problem in long-term care facilities. Unlike other proposed legislation, this does not “fix” how care homes are now funded and run. It also does not challenge the need for strict precautions in a public health emergency. It simply ensures that, in the event of a public health emergency, folks in long-term care have the right to have their chosen ones with them in person. However, it may save facilities money by letting family in to help.

Berenice Palmer
Berenice Palmer died 2 months after a Care Home
kept the family away from her for a year.
She never met her great-grandaughter.

In March of 2020, when visitors were first locked out of care homes, we knew so much less than we know now. The suspension of regulatory protections for the right of free association and freedom of movement, so critical in long-term care, seemed like the right thing to do.

After vaccination, improvements in PPE and infection control, we have had great hope that this inhumane “lockdown” would be ended. But the Delta variant is now upon us, and this is not to be. To make this worse, the shortage of staff in care homes is worse than ever, leaving our loved ones with the ongoing threat of both isolation and neglect.

I met with, along with other advocates, an aide of Nancy Pelosi, Daenuka Muraleetharan, PhD, on August 24, 2021. We wanted to clarify the need for strong democratic support of this legislation. This legislation will not cost any substantial money. This and the fact that it has bipartisan support means that it need not be passed by reconciliation. It should be presented and passed in the House and Senate as soon as possible.

As of now, the bill has stalled since June in two committees:  the House Energy and Commerce and the Ways and Means Committees.

The push for Democrats to pass the “American Jobs Plan” infrastructure bill right now is understandably eclipsing smaller legislation like HR3733. The need for broader legislation is dire, (specifically the $400 billion investment to expand access to care support workers in the caregiving sector, expand access to long-term care services through Medicaid, which would in turn support good-paying caregiving jobs). BUT, we must not forget the immediate solutions that HR 3733 offers to those who are isolated and neglected in long-term care facilities. Bipartisan support will allow this smaller bill to pass standing on its own.

Berenice Palmer
We can only wish she had met her Great Grandmother

A list of H.R. 3733 current supporters and sponsors is here: more are expected soon!

Any of us, including children, could end up in a long-term care facility of some kind—not just the elderly. Imagine having a new level of disability and being told you could only see your loved ones for ½ hour with 3 days’ notice. Or that you cannot have anyone at the bedside because you are not at “End of Life.” Imagine that, due to difficulty hiring nurses and nursing assistants, that no one answers your call bell for hours. That your food is repeatedly taken away uneaten because you are slow. Imagine being surrounded by overworked staff who have no time to explain anything to you. Imagine your loved ones getting this call from a facility: you are dying, you should just get “comfort care” … but your loved ones have not seen you for weeks & you seemed fine then ... this is happening now.

In the future, we will look back on the current conditions for folks in care homes in the same way we now look back on Japanese Internment Camps in World War 2, or to forced Boarding Schools for indigenous kids. Both caused massive suffering, dehumanization, and increased death.

Please call or email your congressperson: HR 3733 must be passed as soon as possible.

In addition, Senator Ron Wyden (Democrat, Oregon) has offered a nursing home reform bill “The Nursing Home Improvement and Accountability Act.”

This legislation, if it is not watered down, has the potential to really help nursing home residents and to improve how care is delivered. It uses a carrot and stick approach to make sure nursing homes improve staffing and care if they are to receive increased help from the feds. It also proposes a demonstration project which has been recommended by many experts: a trial of small (5-14 bed) nursing homes situated within the community, which can give the same care as larger institutions.

The New York Times recently ran an article titled “Nobody Wants to Live in a Nursing Home-Something Has to Give.

Something indeed has to give, and we are all getting older so—the sooner the better. Contact your Congressperson about HR 3733 today, and don’t stop there!

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.

August 2021

Bernice Palmer
Before her death last month, my Mother, Berenice Palmer suffered from shortfalls in the healthcare system that illustrate why we are not prepared to care for our aging population
What Mom taught me about needed fixes in Caring and Health Care
Dr. Teresa Palmer and Mom
Dr. Teresa Palmer,
Geriatrician and Berenice

My Mother, Berenice Palmer, just died at almost 104 years old. She was a vibrant and lively matriarch who kept our extended family in touch. She was a writer, a story teller and a poet, and nursed us when we were sick. She never met a doctor, or a good-looking man, she did not like.

Mom had two things going against her: she outlived her money, and in the last 20 years of her life, she had a combination of memory impairment and mental illness. With these, it is possible to be healthy and have a good quality of life if you get the right care. But in our current system the combination of poverty, mental illness, dementia and age is deadly. You have no easy access to needed care.

My Mom was lucky: she had an M.D. daughter and extended family with some financial reserves to look out for her. But there are so many that don’t.

For over 10 years, until she was 98, Berenice lived happily at a senior residential hotel in San Francisco, paid for by the San Francisco house she sold.

As her memory slowly failed, the cost of sending in caregivers to her senior hotel first depleted her savings and then cut into mine. I was not confident my family and I could meet her social needs in my own home.

In late 2015, she could not reliably take her medications or go to the hotel dining room for meals. We moved her into my kids’ old room at my house. At the time, her bipolar disease (diagnosed in her 70’s) was well controlled on lithium. She remained bright, walked well with a walker and was happy to join us at the table for meals.

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For over 10 years, until she was 98, Berenice lived happily at a senior residential hotel in San Francisco, paid for by the San Francisco house she sold. As her memory slowly failed, the cost of sending in caregivers to her senior hotel first depleted her savings and then cut into mine. I was not confident my family and I could meet her social needs in my own home.”

However I underestimated Mom’s need for frequent supervision and reassurance. I had so much stiffness and pain from years of Rheumatoid Arthritis that I could not care for her by myself. I had to work. Her caregivers were able to increase their hours. They learned to give her medications, take her to doctor’s appointments, walk with her in the neighborhood, and help her stay clean. And above all, converse with her.

When Personal Savings Run Out

After she ran out of money, my Mom was on Medi-Cal (in addition to Medi-care) and qualified for government-paid “In Home Supportive Services (IHSS)” and Veteran Administration “Aid and Attendance.” At times it seemed like I was paying caregivers just so I could spend time filling forms and being on phone hold to these agencies. But they covered less than half of the cost of her care.

“IHSS” did not provide us with enough caregiver hours to meet my Mom’s needs at my home, and did not pay the caregivers enough to make it worthwhile for them to stay. I added on hours of help but each day was a marathon.

In 2016, Mom’s neurologist advised us to begin a dementia medication. We later realized that this reduced her thirst and appetite. She gradually became dehydrated. Then she began to have a tremor, fearfulness and poor concentration. This, in late fall of 2016, was delirium from lithium toxicity. Lithium is a great drug for bipolar disease (“manic-depression”) but dehydration makes it toxic.

Mom’s psychiatrist had retired and it is almost impossible to find a psychiatrist who takes Medi-care if you are old and mentally ill. Luckily, my Mom was a World War II veteran. I remembered that the San Francisco V.A. Medical Center has a geropsychiatry service. From their emergency room she was admitted to hospital.

Mom was so terrified and disoriented that I had to sleep next to her hospital bed for some nights until she “came down.” Her lithium was discontinued. Back at my house, within a month, Mom cycled into mania. She tried to leave the house in a rainstorm at 5 in the morning saying, “Trees are falling on people and I have to warn them!”

Lithium was restarted during that second admission to V.A.M.C. With my urging, Mom was moved short term to the only remaining geropsychiatry unit in town: at the San Francisco Jewish Home (aka the San Francisco Campus for Jewish Living). Luckily I had been paying the bill for private Medicare add-on insurance, which improved her chances of getting in: we did not have to rely on Medi-Cal.

My Mom enjoyed the attention at the Acute Geropsychiatric Unit. Her psychiatrist advised me she was too isolated at home and would do better in a group living situation.

Home Care / Isolation

After she came home, we looked at the same Jewish Home campus' long term care (“skilled nursing”) facility. I saw a piano in every community room, gardens that the residents can walk to, and lots of fun activities.

My Mom had “skilled nursing needs” at 99, and qualified for a Medi-Cal long term Skilled Nursing (SNF) bed. Laguna Honda said she was qualified, but kept asking for more and more paperwork. A bed became available at Jewish Home. (Major medical insurance does not pay for long term care. Medicare only pays for short term nursing home rehab. For long term care, one pays with cash or Medi-Cal. Mom’s bed may have been offered sooner because of her age and my extreme familiarity with medical forms. Many Medi-Cal folks have a long wait.)

For the first three years at the Jewish Home, from March 2017 to March 2020, my Mom did well. Family and friends visited regularly and took her out. She walked all over the campus with her walker, knew everyone and never missed a concert. The nurses monitored her medication and her doctor did frequent labs tests to monitor her lithium. Of course, despite her evident good health, her dementia and frailty slowly progressed.

Covid Restrictions

Then, in March 2020, Covid slammed down and locked both me and Mom in. I sheltered at home, being an elder on immunosuppressive drugs for Rheumatoid Arthritis. And Berenice, at 102, was confined to her nursing home ward. Worse, for weeks at a time when a staff member exposed her to Covid, she was confined to her room. No more dinners out, family gatherings, sunsets at the beach.

We were lucky, overall: Mom did not die of Covid, or even get sick from it. She was in a non-profit nursing home that had higher standards than some others. But I and my family will never forget the suffering of this lost year.

Even post vaccination in early 2020, care home administrators and corporate lobbyists wanted to protect their reputations and bottom lines more than they wanted to ease the deadly isolation of their residents. This care home lockdown continues to some extent even to this day in California. Our isolated loved ones continue to fail and die in higher numbers even when we do not count Covid deaths.

I kept track of Mom by phone and Zoom, and made frequent calls to the nurses. In early March of 2021, Mom began to spend more and more time in bed and to say repeatedly she felt like she was dying. This had happened for a few days at a time previously—she would grow frustrated that her old body would not do her bidding. But this time it did not resolve. An abdominal “CT” scan made the diagnosis on March 14: Pancreatic Cancer.

Home and Hospice

I was told Mom had two months to live. I took her home and enrolled her in Hospice. Mom was terrified of dying, had to be cajoled to eat and drink, had no judgment about her fall risk, and did not want to be alone ever. She was too weak to walk.

Bernice Palmer in April
Bernice in April

Mom had an eight-week grace period at home: her extended family had time to say goodbye. She gained strength with our care, and for a time, resumed walking and joined us at the dinner table. At the end, there was a two week rapid decline and she slipped away on June 4.

She had not been as close to death as we thought when she left the nursing home: she was just profoundly malnourished.  In retrospect, the nursing home staff, all good people, simply did not have enough time to cater to Mom’s failing appetite, or to do the serial assessments that would have given me an earlier warning. I was locked out, unable to see for myself.

Nursing homes, as they are currently structured and run, even before Covid, do not give the staff enough time (or have enough staff) to be diligent in feeding those who are picky, or to thoroughly assess those who are failing. The tendency is to wait for a crisis.

But Home Hospice offers actual care for less than an hour a day. The hospice doctor never sees the patient. Nurses act as intermediaries and case managers. Hospice Staff can have a high “case load” and the hospice corporations are under financial pressure to keep the cost down: they get a flat monthly rate from Medicare.

I knew, when I brought her home that I had little time. I could not spend hours filling out paperwork and being on phone hold to get her back on IHSS and her VA benefits. These would only partially pay anyway.

I did have savings. So I called up my caregiver friends and hired them back. I found a caregiver to sleep over with her, and others to do daytime. The hospice team, all very caring and competent, trained us.

A living wage for 20 hours a day of caregivers is expensive, and Mom was a demanding patient. Even with this, family could not leave the house for long. After a year of being separated from family, she grew fearful when she did not see us. We had to give the caregivers breaks from her supervision and the repetitive reassurance she demanded: Mom needed someone to talk to unless she was asleep.

We Need Action to Fix Our System

My mother was lucky: she had a long and rich old age because she had owned her house, and she had an MD daughter to work the system, take her in, and to help when she ran out of money. In her last 10 weeks of life, that M.D. spent $30,000 for caregivers. Who else has that?

There is so much that is broken about both our care facilities and the system for supporting people at home. I am waiting, and working for the single payer health care system that we all need. Meanwhile, here are two incremental fixes to home and long-term care that we can support now:

  • No care home patient, in the event of a public health emergency, should be denied their right to family caregivers or equivalent. Good studies show that death rates during covid in care homes were high over and above Covid: our loved ones need our eyes, ears and hands. A bill is now before congress to put this into federal law:
    HR 3733. Read up about it and contact your congress person to get this passed. Support is bipartisan.
  • Long term care support and services (LTSS) must be reformed and funded. Home care should not only be for those who can pay. The Better Care, Better Care Jobs Act has been introduced to the senate (S2210). This plan includes improved funding for Home and Community Based Services (HCBS) that President Biden originally proposed in his infrastructure Plan. Investment in our care economy and support of caregivers is essential. If every Democrat in senate supports this bill, it may be passed by reconciliation. Let your senators know! (link to read about it.)
  • CARE CAN’T WAIT link: call to action

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.

July 2021

Ken Zhao
Years after a stroke in 2016, recently Ken requires a ventilator and waits to learn if there is a place for him in San Francisco
SF's Shameful Healthcare Gap

Exile from San Francisco for Subacute SNF Patients — a Continuing Reality

Kentfield demands $2400
In happier days Ken shows his dad how
to take a "selfie"

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.

Kentfield demands $2400
Kentifield Social Worker tells Mrs. Zhao by phone she may be liable for $2400 a day if Ken does not leave Kentfield hospital. The Zhaos had already exhausted their savings and legally Kentfield had no right to bill them-so Kentfield backed down once advocates got involved.

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.

The Zhao family
The Zhao family

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.

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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.

Sub Acute Care Chart
Source SF Dept. of Public Health

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.

Dr. Teresa Palmer
Dr. Teresa Palmer,

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

Visiting Mom
Visiting loved ones in nursing homes through a window.
Restricting Family Care at Long Term Care Homes: ISOLATION KILLS
Dr. Teresa Palmer
Dr. Teresa Palmer,

Currently, in San Francisco, almost every nursing-home resident and staff member who wants to be vaccinated has been. Testing and PPE is readily available. We have extensive knowledge of Covid-19 and infection control. This was not true in the beginning, but we have learned a lot.

Lockdown removes freedom of association and choice. It violates fundamental human rights- the rights of all kinds of people in all kinds of care facilities. This cuts across age. It tells long term care residents that they are low priority and not fully human. It makes them prisoners.

When I talk about “Long Term Care Facilities,” I include skilled nursing facilities, residential care facilities, assisted living facilities, halfway houses, mental health facilities and live-in treatment programs. I include anywhere where people must share space to get certain kinds of help. When I say “family,” I mean the people who care and give life meaning.

When Covid hit, overworked staff brought in and spread infection quickly. Patients were locked in.  Care home leaders and government rule-makers did not consider what families contribute and what happens when families are absent. We need to learn by these mistakes, however understandable they were a year ago.

Families augment care, observe, monitor, assist, stimulate their loved ones, and advise staff.
They maintain hope and personhood. They are not dispensable.

quote marks

From the frantically overworked staff’s point of view: the isolated resident, as they withdraw into depression and weakness, is quiet. Others are needy, there is always too much to do. Besides this resident is old, or has dementia, or are profoundly _________ (fill in the blank). When they cry out or kick, family should approve sedatives. Comfort is best, isn’t it?”

Care home staffing is chronically low.  Payroll is the biggest expense.  For skilled nursing facilities, “Patient centered care” to obtain “optimal function and independence” is, by regulation, the goal. However this is labor intensive and can interfere with profit. Or, for a non-profit facility-more labor interferes with “preservation of revenue.” Thus, staffing that is actually based on the needs of the residents does not occur, and cannot expand when there is more sickness.

Zoom Visit
Visiting with Mom on Zoom

Lockdown started a year ago: in San Francisco between March 10 and March 13, 2020. We know now that the toll has been unacceptable for those we were hoping to protect.

In my experience, families of long term care residents are not “Covid deniers.” They do not take their responsibility to protect their loved ones lightly. They are very willing to get tested, wear PPE, and get vaccinated (the same as health-workers) in order to care for their loved ones inside the facilities. They are willing to work in a flexible and creative manner.

There have been a number of deaths in the past year from “failure to thrive.” This is not always what the death certificate says. However, if you ask the family, the stories are similar. The resident eats too slowly, gets tired and so isn’t fed. The resident cannot get up and so they are not moved-and after days of this, they are too weak to be moved. The resident becomes too weak and too confused to initiate interaction, so no one speaks to them. A good nurse or assistant knows what she or he should do: but there is no time.

From the frantically overworked staff’s point of view: the isolated resident, as they withdraw into depression and weakness, is quiet. Others are needy, there is always too much to do. Besides this resident is old, or has dementia, or are profoundly _________ (fill in the blank). When they cry out or kick, family should approve sedatives. Comfort is best, isn’t it?

Families worry about being seen as “trouble makers.”  When a family realizes that their loved one will slip away and they better make some trouble or insist on a 911 call, it is often too late. You have read the stories.

During times of staff infection, many exposed staff can’t work. Staff shortages are worse. Residents curl up in their isolated rooms. Many of those who have not died will never be the same.

Much of the sickness, sadness and death that has occurred secondary to isolation does not show in the Covid statistics. Only some of these folks had Covid. The others are  “collateral damage.”

The toll has been higher in for-profit facilities, where there is more pressure to save on payroll. Also, the toll has been hidden in those facilities that are not as closely regulated by the state as “skilled nursing facilities.”

Care home experts say the problems were always there: Covid just unmasked how bad our system is. I agree that the changes that should occur are many. But today, I am focusing on the immediate relief of isolation from this lockdown. We must stop it now and have no repetition of it.

According to the State (California Department of Public Health), while San Francisco is “Purple” only brief window/outdoor visits can occur.  When our city turns “Red,” indoor visits with precautions may occur, but with strict limits on time, place and privacy.

The County of San Francisco (San Francisco Department of Public Health) by law, is free to be more restrictive than State/CDPH rules. SFDPH has consistently been more restrictive and inflexible on care home visitation.

SFDPH has been unresponsive to the concerns of families. Both SFDPH and our care home leaders have, far too often, denied or ignored the discretionary powers they have to make sure residents who are failing or distressed get visits.

In the future, this severe isolation of our loved ones must never happen again due to a public health emergency-or for any reason. Needing long term care should not turn you into a prisoner. The right to associate with someone you choose—someone who knows you as a person and not a resident—must be honored now.

It is an urgent necessity to do what it takes to make family care safe and available in long term care facilities in all circumstances.

Long term care residents need to spend time with their families and loved ones. It is way  past time to vastly reduce Covid-related restrictions on residents of care homes:  for indoor visits, family assistance with care, and trips out.


This right to have designated caregivers and visitors must be encoded in both public health regulations, emergency regulations, and human rights regulations at local, state, and federal levels. Exceptions must be rare, and strictly time limited. We must learn by our mistakes.

Organizations that are helping with advocacy in California: California Advocates for Nursing Home Reform, Consumer Voice, Essential Caregivers Coalition.

On March 12, at 9am Pacific Time, National Consumer Voice will have a “Virtual Rally to Lift the Lockdown.” 

Long Term care Advocacy groups have put a website together: Isolation Kills.

Speak out.  As we approach a year of lockdown we must not collude with this ongoing cruelty.

Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at Laguna Honda Hospital, at UCSF and at On Lok, a program of all inclusive care for the elderly.

March 2021


Surviving the Pandemic:

Updated Strategies for the Next 4-6 Months
Dr. Teresa Palmer
Dr. Teresa Palmer,

65 or Older? Get the Vaccine Now!

Others stand by, keep these links and don't get discouraged yet!

There are A LOT of vaccine appointments for people 65 and older so please let your circles know. If you get a text notification, try to get an appointment right away as they may be exhausted later in the day.

If you do miss any given batch of appointments, know that you can also check this link each evening or morning and swoop cancellations!

The MRNA vaccines may be the most effective for elderly so best to go for it!

• GoHealth has opened a Vaccine Clinic at 1600 Market Street.Appointments are available.

Keep this link if you are <65 as it is likely to open up for other categories soon.

   I do not see anything on the link limiting eligibility to SF residents or even to first vaccines.  It helps to have a smart phone and download their app, but they have a phone number too: 415-746-1812.

  It is quite easy to book an appointment.

Location: Dignity GoHealth located at 1600 Market Street, San Francisco

  Scheduling Process:  

 To schedule an appointment, all they need is the person’s name and cell phone.  

Appointment Link: 

•    Currently shows availability for appointments today on

On-site Process:  

•    The eligible person needs to bring photo ID and insurance card (if they have insurance).  

•    Eligible persons will be asked to verify the information entered in the online registration process (or complete the registration process if there were difficulties prior to arrival), sign conditions of registration and vaccine consent – available in multiple languages: English, Spanish, Mandarin, Russian and Tagalog. Registration can happen onsite. 

•    There will be a full range of translation services available onsite via a translator phone line.  

quote marks

I am hearing some despondency among my elderly and high-risk friends about COVID variants. This is all the more reason for everyone, of every age to get vaccinated. A virus that does not replicate does not mutate. In general, vaccine immunity is stronger and lasts longer than disease-conferred immunity.”

This website contains multiple links so scroll down

If you don't live or work in SF:

Click Here

Vaccines are available to ages 65 and over if you call although this may not show online for Sutter patients.

Note: if you are in the next tier, keep all these links for when your turn comes.

Health Care System Links (“your provider”)

1. UCSF—must have been seen within 2-3 years, dental clinic alone does not count: Call 415 476 3307

2. Sutter Health: Call 844-987-6115.  Or go onto “My Health Online”. 

3. Kaiser should be doing better soon, please let us know if you hear.

4. As the Biden administration is going to release vaccines to pharmacies Feb 11, consider signing up with your nearby pharmacy chain (you can always unsubscribe after you get vaccinated). As of today health care/hospital systems and government links are a more dependable way to get appointments but this may change quickly. See #5

5. This website has variable reliability recently, look for the most recent updates it is good for pharmacy links.

6. Excluded from vaccine eligibility: this can change soon (Per the state -CDPH covid phone # 1 (833) 422-4255) current tier (over 65) that can now get vaccinated EXCLUDES “essential workers” except for health care workers.

Also, very high-risk folks under 65 are not being included, which is disturbing for those who are dependent on caregivers to come into their homes.

I have not seen any solutions for homebound, non-mobile seniors even though they are eligible.

However advocates are working hard and as more vaccine is released into the community, and eventually to local pharmacies,  I am hopeful that the pressure to vaccinate vulnerable people under 65 will be effective.

Caregiving family members of Developmentally Delayed patients of “Regional Centers” do have the option of getting vaccinated (HERE).


90% of people over 65 who have been vaccinated are white. I hope that is changing.

7. No Car? Getting vaccinated is an ongoing challenge for those without cars and low-tech folks. Fortunately,  more neighborhood walk-in locations such as the one now in the Mission are opening fast. Keep attuned to state and city links above.  To help your friends and neighbors, stay on top of  on-line links and offer to assist those who are lower tech with phone texting notifications and appointments and rides.

No Cell Phone or Internet?Seniors who can't access a cell phone or internet can call 311. They will get help reserving an appointment. As of this writing, the only phone # the 311 operator has is for Moscone Center Vaccine Site, which can also be called directly at 833-422-4255 (Mon-Fri 8a.m.-8p.m; Sat/Sun: 8 a.m-5p.m. Hopefully more options will be added.

Good advice about masking: Double Masking

Considering COVID Variants 

I am hearing some despondency among my elderly and high-risk friends about COVID variants. This is all the more reason for everyone, of every age to get vaccinated. A virus that does not replicate does not mutate. In general, vaccine immunity is stronger and lasts longer than disease-conferred immunity. 

As in flu vaccine, a schedule of yearly (or sooner) modified boosters will be made.

Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at Laguna Honda Hospital, at UCSF and at On Lok, a program of all inclusive care for the elderly.

Updated February 23, 2021

isolated person wearing mask

Surviving the Pandemic:

Strategies for the Next 4-6 Months
Dr. Teresa Palmer
Dr. Teresa Palmer,

Based on my review of the medical literature and the news, as of this writing, it looks like we have a ways to go and must continue vigilantly to protect ourselves, and our families and friends from the “Rona” and all of its complications.

Although our public health system in California and San Francisco is far from perfect, we are blessed, in San Francisco with good hospital capacity in relation to the numbers of folks who are infected. 

Here are my bullet points for family and friends: if any of you know more or would like to disagree, please let me know:

1. The best way to stay healthy is not to get infected. The aerosol borne virus does not listen to the Mayor or Governor about reopening: if you are too close to someone  not in your “pod” who is breathing, you can get infected. We all love to eat out, but is it worth dying for? The outdoor sidewalk arrangements do not look safe to me. Stick with take-out, or better yet, cook healthy food at home. Avoid groups of people on the sidewalk. Do not believe ANYONE who says you can be indoors safely IN ANY CAPACITY with people outside your "bubble." Be strict about who is allowed to be "in" your bubble even if it is socially awkward — this is about staying out of the hospital. Let the younger ones do the grocery shopping — and then carefully — at off hours with good mask and a lotta hand sanitizer. If you are desperate to see someone outside your bubble do a socially distanced walk with masks outside.


...if you or someone close to you does get infected: how you will isolate, and how you will be monitored? ”

2. Get your vaccine, any that is available,  as early as you can wangle it: for Pfizer/Moderna, you will not be protected after first shot but if your immune system is normal, you may get less severe illness. It takes 7-14 days after the second shot to be fully protected. Side effects are a good sign that your immune system is responding: better than getting covid. The newer vaccines coming down the road may not be as safe or as effective. A list of websites to check is below. 

As of this writing, only over 75s and health care workers can get an appointment, but this should liberalize to over 65s and essential public-facing workers soon.

Get on any email, online hospital or clinic/doctor system list that you can. If you are not high tech, or do not have cyber-access on smart phone or computer, ask others who are to register for you. Be prepared to be on hold if you call: have a good book or laundry to fold!

3. Had covid, and your immune system is normal? There is good evidence that if you have had covid, and your immune system is normal, you need not get vaccinated early, so you can wait until the supply is better.

4. Get a fingertip pulse oximeter Every household should have a fingertip pulse oximeter for monitoring once you are infected; best to know how to use it & know what level of oxygenation is normal for you in advance. It is best to buy the intermediate price range (30 to 50 dollars), no need for the really expensive ones. Mail order or get at pharmacy.

Fingertip Pulse Oximeter

While most healthy folks do fine with covid, best to have as much information as possible to avoid "denial" if you are going into complications—which generally occurs late in the first week or early in the second week of infection. By the time most folks get a positive test result they are in general entering the second week.

5. Have a game plan for if you or someone close to you does get infected: how you will isolate, and how you will be monitored? Inform your primary care doc immediately and seek advice. Practice on everyone in your “pod” with the fingertip pulse oximeter. Know what is normal for you. Get informed about public programs that will help if your income or housing is marginal. Your local district supervisor is a good source of information.

If your oxygenation starts to head to 92% or lower, or if you have any sign or symptoms of heart problems or blood clots: it is time to call 911. I advise ambulance to prevent uninfected people in your family from exposure while driving you, and to get the immediate attention you need in the emergency room. 


90% of people over 65 who have been vaccinated are white.

6. Contracted COVID? Early hospitalization is best if you are running into problems with Covid 19: aggressive treatment of early complications (lung inflammation or blood clots) will get you out of the hospital faster, prevent intensive care and invasive measures, and keep you hydrated—as many folks stop eating and drinking enough without realizing it. Our hospitals in San Francisco are now very good at what they do. Early hospitalization, both for the healthy with complications and for someone who is disabled with many risk factors, can be absolutely life-saving.

7. Paperwork Have your medical information and Advanced Care Documents (Physicians Orders for Life Sustaining Treatment; Durable Power of Attorney for Health Care, a list of your medications, diagnoses and doctors) easily accessible and ready to go. If you have not decided: full code and aggressive treatment is the default mode. Think about what you want. Review your directives with an eye to having COVID-19. 

Keep in mind, even if you wish to be “Do Not Rescusitate” and “Do not intubate” that life prolonging care can be done without this invasive care.  Intravenous fluids and medications, oxygen and close monitoring can save your life. Unless you are literally tired of living, make it clear to your medical providers and those that advocate for you that you want: “aggressive non-invasive treatment for potentially reversible or undiagnosed illness.” If going to the intensive care unit or a brief trial of invasive treatment (being on a ventilator) is okay with you, state this clearly.

8. Public facing job? If you cannot avoid working in a public facing job, get tested often. Remember, early warning is lifesaving. Continue this until at least two weeks after your second vaccine. At this point we will know more.

Links for vaccine appointments and information:

1.State sign up:
If you do not have a computer for sign upIt is for monitoring once you are infected; best to know how to use it & know what level of oxygenation is normal for you in advanceIt is for monitoring once you are infected; best to know how to use it & know what level of oxygenation is normal for you in advance you can call the CA COVID-19 hotline at 1-833-422-4255. This link will, according to the state, be fully functioning by mid February for those in our area, but you can try to sign up now.

2. SF City sign up

also, explore this website:

UCSF Health and the City of San Francisco have teamed up in a joint venture to administer Covid vaccinations to those 75 years old and older.  Presently, as of January 27 pm,  drive-through appointments are available for Friday, January 29 at this site:

Appointments fill up quickly.  There is a drop-down menu at the right to select a different date, but as of now, January 29 is the only date showing.

3.If you are a veteran:
My guess is that if you are a VA patient, you may get it faster than other places:

4. I found practical information on the CVS pharmacy website: it looks like CVS and the other big pharmacy chains will be taking appointments for vaccine as soon as they get the vaccines.

   There are very few contraindications to getting the MRNA vaccines (Pfizer/Moderna) other than a history of severe allergies, despite all the questions. 

If you have a lot of health problems, the main risk is that the vaccine will not be as effective, and you will have to depend on the immunity of those around you for protection.

5. Sutter facilities : They are only allowing Health Care Workers and people over 75 to sign up right now, but more to come soon they say so keep checking back.

website above contains a number to call for vaccine (long wait time) OR here is the online medical records place to sign up "My health online"--if you don't have an account you can create one NOW if your PCP is Sutter:

6. At Kaiser facilities:  there is a wait but keep trying; more to come when more vaccine is available.

Excerpt from website:
You needn't be a Kaiser member to get the vaccine from Kaiser if you're 65+.  Set up a Kaiser ID# at 1 800 464 4000 Secure the appointment at 866 454 8855
Note from Doc Palmer: appointments are currently limited by available vaccine supply. Keep checking this website for updates and upcoming ability to self-schedule an appointment online if you are in an eligible group. Currently over 75s and HCW are getting appointments, and appointments if Santa Clara and Contra Costa county may be more available than closer—so if you are willing to drive....
7.  This is an unoffical website - the authors try to keep up to date on local sources of vaccine.

Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at Laguna Honda Hospital, at UCSF and at On Lok, a program of all inclusive care for the elderly.

Updated January 27, 2021

Delays in Testing Nursing Care "Invisibles"

Dr. Palmer with Mom is not disposable sign

I began to advocate for Covid 19 testing in nursing homes when I realized my vibrant 102 year-old Mother is at risk of dying from this virus. It was clear early on from the experience in Washington state, and the reports of patients found dead in their care home beds in Spain that the "cruise ship" like set-up of nursing homes could result in many deaths.

The need for universal testing in all group care facilities, where asymptomatic staff can begin a deadly outbreak, is now being publicly recognized. But it is slow to happen.

Given the horrific cost in lives we have already seen, there is no justification for further delay. But delays are ongoing.

Testing in care facilities is, understandably, labor AND resource intensive. And the last thing many of these (90% for-profit) facilities want to do is to divert more resources to their residents. Nothing will happen in any given location unless an outbreak forces the authorities to come in, or the government mandates it with substantial penalties.


People in care homes are “invisibles” unless one happens to be your relative. Their demographics intersect with those who are the least served in the best of times.

Governor Newsom and Mayor Breed are proud to announce testing sites for anyone who can walk or drive that has a runny nose . But we hear all about how difficult it is to test in nursing homes, and how the overstretched SF Department of Public Health is having to do the testing, and that the facilities just cannot do it themselves.

I do not understand why there are state and private contracts for testing all over California, but not for nursing homes, and similar care facilities-where residents are being held captive and are at such high risk of death.

Dr. Palmer with her Mother
Dr. Teresa Palmer and her Mother Berenice

BACKWARDS REASONING: We see hesitation to mandate routine testing because there is no safe space WITHIN THE FACILITY to put positives, and no staffing to care for them without cross contagion. This was actually candidly stated by Dr. Mark Ghaly, Secretary of the California Health and Human Services, when he was called on by Gov. Newsom at; press conference on May 12 (about 44 minutes). He actually stated that he had to figure out what the "right time" to test was. How about right now? This denial and delay of care is a guarantee that COVID will continue to kill.

We DO have places to safely put those who test positive: we have massive hospital “surge” capacity in California, and, for those who live outside of nursing homes, or who have family support, many empty hotel rooms. Yet those who live in group facilities are being denied entry.

Hospital beds must be made available to frail people at risk to themselves or others, even if they do not meet usual criteria for acute hospitalization.

There is no point in “saving” empty hospital beds when a conflagration of infection and death can be prevented in a care home by isolating a few frail folks in the hospital. These lives have value like any other (don’t they?).

The use of acute hospitals to isolate those who are contagious is not new: it has historically been done for those with active TB until treatment made them safe. So why not use acute hospitals for frail Covid positive folks who need close medical monitoring until a more long-term place can be found?

The only problem that I can see is that the reimbursement might not meet the hospital’s expectations.

The failure to use empty hotel rooms for those who are unsheltered or marginally sheltered and at risk is very parallel to the failures at nursing homes: unused resources are being “saved” due to a potential future loss of revenue, at the expense of life.

Another public failure is the local failure to publish transparent data about Covid infection in congregate facilities; Los Angeles has a wonderful site (Scroll down to the bottom of: San Francisco Board of Supervisors to passed a resolution to request a similar public “data set” in San Francisco on May 12, 2020. We haven’t seen a complete data set on the CDPH & DSS (state) websites and nothing on the SFDPH website yet. Note that if one does publish data, it becomes pretty obvious when one is not collecting it…….

Other scary developments include:  State of California being asked to offer immunity to the operators of Long Term Care facilities for bad COVID care (currently proposed by the “industry” & “providers”:

Most disturbing, the State also tried to provide guidelines justifying denial of care to some. This was in the name of theoretical shortages that we have not seen from the pandemic in California. But the website is now being modified due to an outcry of senior and disability advocates (#NoBodyIsDisposable) about its unethical and unnecessary suggestions for denying care.

The issues that COVID has unmasked are not new, and we need to go forward together and demand the care we all deserve. There will be many pressures to cut essential services under cover of “Covid” economic losses and we must all stand firm: the lives of people, all people, must be our priority.

May 2020

What is wrong with our priorities?

covid response chart

Our high-risk folks will pay the price

At the Health Commission meeting on April 21, Director Grant Colfax talked about problems with supply limiting the amount of tests that could be done on a daily basis.

Today I am hearing everywhere that these supply issues are being solved. What I see is that "guidelines" by various government agencies still state that testing cannot be done on those most likely to die, and those that care for them, unless they have symptoms.

For those living in congregate settings like nursing homes or similar care homes, this amounts to a death sentence.

quote marks

Nursing homes are like cruise ships, and the outbreak at Central Gardens, here in the Western Addition is illustrative. Staff who are pre-symptomatic or asymptomatic often bring the infection in the to site.

Director Grant Colfax
Director Grant Colfax

Nursing homes are like cruise ships, and the outbreak at Central Gardens, here in the Western Addition is illustrative. Staff who are pre-symptomatic or asymptomatic often bring the infection in the to site. Care home staff are often underpaid and overworked. So their ability to be fastidious about precautions, as they hurry to care for every resident, is impaired.

Central Gardens
Central Gardens

And the residents are getting understandably anxious from being shut in. Add lack of routine testing and lack of aggressive contact testing to the mix and we have rapid and massive spread. For those most likely to die from Covid 19, early diagnosis and close medical monitoring offers the best chance to survival.

This is just not happening — and our high risk folks will pay the price.Where are our priorities?

Teresa Palmer MD, Geriatrician

April-May 2020

Nursing Homes: Letter to Newsom, Chiu and Wiener

Dr. Palmer

Don't Abandon Our Nursing Homes, Keep Seniors Safe

Please do not allow COVID 19 positive patients to be transferred to existing nursing homes, and please offer nursing homes sufficient resources to test everyone, staff and patients and to get sufficient PPE.

At our own Laguna Honda hospital in San Francisco, staff does not have what they need to protect themselves, let alone the patients.

California’s Department of Public Health told the state’s nursing homes last week to prepare to accept patients with coronavirus. This must not go forward!

Our nursing homes are chronically understaffed as it is, and the prevention of visitors and volunteers, needed to prevent covid, makes caring for patients harder.

We know from what has happened in Washington State and Italy, that any exposure to COVID will result in a high death rate. This amounts to throwing our parents and their caregiver’s lives away due to poor planning.

Please stop this

Teresa Palmer MD, Geriatrician


April-May 2020

San Francisco and all Hospitals Need to Provide Subacute SNF Care for San Franciscans NOW

intensive care Doctor

Since at least 2016, any San Francisco resident who requires Subacute Skilled Nursing Care has to leave the county. Subacute Skilled Nursing Care is an intensive form of long term care for people who require ventilators and other forms of complex nursing care to survive. It is best done in a hospital setting, as those who need this care can get critically ill quickly and then need to go straight to an intensive care unit.

The last Subacute SNF in San Francisco was at St. Luke’s Hospital run by CPMC/Sutter. In 2012 the corporation shut down admissions from outside its hospitals for those needing subacute care. In 2016-2017 all new admissions stopped, and Subacute SNF and regular SNF patients were pressured to leave, as a prelude to total shutdown of these units, in anticipation of a new hospital that would not offer this service.


...the 17 remaining patients were transferred from St. Luke’s to Davies. Eight have now died, and one was discharged home The discharged patient required readmission to subacute SNF care, which CPMC/Davies refused to provide, and is now in Sacramento, the closest unit the family could find.”

In late 2017, CPMC/Sutter grudgingly agreed to care for remaining Subacute SNF patients at CPMC Davies (until they died or left) after an intense family/community outcry. In 2018, 17 spaces were retrofitted in the CPMC Davies SNF unit, and the 17 remaining patients were transferred from St. Luke’s to  Davies.  Eight have now died, and one was discharged home.  The discharged patient required readmission to subacute SNF care, which CPMC/Davies refused to provide, and is now in Sacramento, the closest unit the family could find.

Just this year, Department of Public Health has restarted an effort to identify and secure adequate numbers of Subacute SNF beds in San Francisco under public-private partnerships with facility and financial support proportionately provided and contributed by private sector entities. This has been a slow process with a delay due to the change in Medical Diretors at the Department of Public Health. This must go forward quickly. Co-operation from all hospitals, whose patients will use the service, is currently incomplete (thus the need for legislation and community pressure.)

By opening the total 70 Subacute SNF beds that San Franciscans need, we will prevent the dangerous exile from family and community in this most vulnerable part of a life journey. This has been going on since 2016.  Enough is enough.

The Board of Supervisors must generate and support legislation to force institutional co-operation with identifying and collecting data on all out-of-county transfers of San Franciscans from hospitals and post-acute setting (including SNFs, RCFES, SROs, and behavioral health acute, subacute and residential settings) due to inadequate availability of safe long-term care settings in San Francisco. This data is needed to determine the real gap in services in San Francisco to those in need.

PROFIT MOTIVE: At St. Luke’s, CPMC/Sutter shut down its Subacute SNF beds to increase its profit margin and serve fewer Medi-Cal patients. This had nothing to do with the need by people for such beds in San Francisco. Most long-term subacute care patients are on Medi-Cal.  Charity care reports show that CPMC’s Medi-Cal shortfall is less in 2017 compared to 2013, with the drop almost in half for St. Luke’s.  The drop in the Medi-Cal shortfall represents a reduction in the number of and services provided to Medi-Cal patients.  In 2016-2017, CPMC/Sutter stopped admitting new patients to the 40 bed Subacute SNF at St. Luke’s and began to push for transfers of these remaining very sick patients out-of-county since there was no in-county Subacute SNF elsewhere. NOTHING in the 2013 CPMC/Sutter development agreement required the shutdown of its hospital-based subacute SNF and other regular  SNFs, although CPMC/Sutter has repeatedly implied this.  The closures were a success financially, as CPMC/Sutter’s revenue has continually risen.  The move was purely to enhance profitability despite CPMC/Sutter’s nonprofit status.

HIGH DEATH RATE: It is important to ascertain that there is adequate and safe staffing at CPMC Davies Subacute SNF for those left alive.

It is of note that the initial plans for transfer from St. Luke’s to Davies in 2018 were so disorderly that the families had to call the State to mediate and make sure patient safety and family counseling and notification were adequate.

The death rate at CPMC/Davies is very high considering that many of these patients lived for many years at St. Luke›s hospital.  Aside from the reality of transfer trauma in these delicate people, quality of care at Davies is an issue. RNs at Davies are not unionized and so have limited whistleblower protections.  Families and skilled observers note that it is difficult to recruit LVNs and RNs for a temporary (but very skilled) placement like this. Staffing appears overly lean with very green licensed staff and a lot of discontinuity. Managerial staff have been unable to tell us what training the staff has been given.  There appear to be even more inadequate staff physically on the unit during breaks and hard-to-fill shifts.  As these patients live with tracheostomies, very frequent suctioning is needed. Alert patients have complained that the call bell is not answered, and those patients unable to call are at even higher risk.

At a minimum, CPMC/Sutter should obtain the licensing for and staff 17 permanent Subacute SNF beds at Davies.  The rooms already have been retrofitted.  Recruitment of permanent and well-trained dedicated staff will lower the death rate, increase patient safety, and prevent other San Franciscans from out-of-county transfer for this service. As the Department of Public Health estimates that 70 Subacute SNF beds are needed in San Francisco, this bed number is less than CPMC’s proportional share.

Unfortunately, due to profit-motivated shutdowns of hospital-based post acute SNFs (“rehab”) all over the city, these Subacute SNF beds are and will use a portion of the 38 remaining Hospital SNF beds left at Davies unless the hospital provides for more beds.

We have a long way to go in providing adequate longterm care for low-and moderate-income folks in San Francisco—but the least we could do is offer those who must live on life support a chance to live in their own city.

Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at Laguna Honda Hospital, at UCSF and at On Lok, a program of all inclusive care for the elderly.

October 2019

A Letter to Speaker Pelosi

Fix Long Term Care for Senior and Disabled People

Nancy Pelosi

Dear Madam Speaker,

The proposed Medicare for All Act is the first to include comprehensive provisions for Long Term Care (LTC). We would like to again thank you, Madam Speaker, for ensuring that the proposed bill has had committee hearings - a historic first for any single payer healthcare bill! We look forward to further hearings in the Energy and Commerce Committee and a mark-up in the Ways and Means Committee.

Madam Speaker, you have a great opportunity to speak out, raise awareness and explain to the public and congress how broken and wasteful our current Long Term Care system is. Everyone has or had a grandmother or grandfather, knows someone who is aging or disabled and faces these challenges – the need for comprehensive LTC coverage touches us all. The provision of long-term care (LTC) should be a priority for the Democratic Party, the party that historically has cared for vulnerable older adults and people with disabilities.

Dr. Tadepalli began by defining LTC as a spectrum of support services for activities of daily living such as managing and cueing medications, housekeeping, eating, toileting and bathing that can be delivered in the community, in assisted living facilities or nursing homes. She described her experience as a geriatrician coping with the complexities of qualifying for public funding for LTC services. In the current system she witnesses clients becoming impoverished as they spend down to meet qualification criteria for Medicaid and then consequently being left without any control or choice over their care. She explained the strain clients and their families experience because of this impoverishment and subsequent insecurities related to continuing care. She talked about the undue burden on family care givers, most of whom are women, and the toll this takes on mental and physical health.


Comprehensive Long Term Care in Germany is available to disabled people of all ages, assesses need by functional limitations and recognizes and financially supports informal care. LTC expenditure in 2008 was 1.3% of GDP.”

Dr. Palmer spoke about her own experience providing care for her mother, now a nursing home resident and 102 years of age, who has a history of mental health problems. Despite a long career as a geriatrician and extensive experience dealing with the complex needs of older adults, Dr. Palmer found navigating the LTC system and caring for her mother at home a hard burden to bear. She suffered mental, physical and marital strain related to the anxiety her mother’s care caused. Dr Palmer also spoke briefly about her work as a geriatric expert for lawsuits regarding abuse and neglect in nursing homes and assisted living. She highlighted the approach by certain facilities to encourage residents and families to opt for “comfort care” when completing the POLST (Physician’s Orders for Life-Sustaining Treatment) not because this was best for residents but because it suited the facility management who felt empowered to give minimal care once this was agreed.

Dr. Halifax agreed with the evidence given by Drs. Tadepalli and Palmer that the current US model for LTC provision is unsustainable. She gave examples of other countries that have introduced comprehensive LTC coverage: Austria (1993), Germany (1994), Japan (2000). These countries have used strategies that have included: covering all citizens (with no age restrictions); providing individual assessment for eligibility based on ability to function; combining provision of services and cash benefits to pay for formal and informal care; scrapping means tested services in favor of social equity and funding through mandatory social insurance payments. She argued that these models could be used to address the challenges of providing care that the US faces. She went on to describe the comprehensive care her mother had received both at home and in a nursing home in the UK following a diagnosis of dementia. She explained that her family had peace of mind that care would be provided and would be within their means, that they were able to continue working, support their own families and maintain healthy lives.

Comprehensive LTC in Germany is available to disabled people of all ages, assesses need by functional limitations and recognizes and financially supports informal care. LTC expenditure in 2008 was 1.3% of GDP. In the same year, US LTC expenditure was 1%, despite serving less of the population and providing limited services. We ask you to consider the contribution that marketization (profit taking) of nursing home care makes to LTC costs in the US.

In conclusion, the only bill in congress that comprehensively addresses a continuum of care for the disabled and for our seniors as they age is the Medicare for All Act of 2019, HR 1382. We ask that:

You as Speaker of the house, show that the Democratic party stands for care and compassion for our vulnerable older adults and people with disabilities.

You, as Speaker of the House use your skills to see that this bill goes through the Energy and Commerce Committee, the mark-up process in the Ways and Means Committee and gets to the floor of the House for a vote in a timely manner.

You, as Speaker of the House, speak positively and inclusively about those who support Medicare for All, knowing we are standing by to help the Democratic Party at election time.

Teresa Palmer MD, on behalf of Uma Tadepalli MD, Elizabeth Halifax, PhD, & Jeanne Crawford

Dr. Teresa Palmer is a geriatrician/family physician who has worked in San Francisco for over 30 years, including at Laguna Honda Hospital, at UCSF and at On Lok, a program of all inclusive care for the elderly(PACE). Due to her family and professional experience, she is especially concerned about the SNF bed shortage and the unmet need for high quality skilled nursing care in her own commmunity for moderate and low income people. In 2017 and 2018 she wrote a series of columns in the Westside Observer about the shortcomings in our ability to offer appropriate long term care to those in San Francisco who most need it.

Editor’s Note: This letter is excerpted. A complete Bio of Drs. Tadepalli and Halifax here.


Additional Services Won’t Magically Appear Without Funding

Local Politics: Voluntary vs. Involuntary Treatment and Housing — SB 1045 Analysis

State Senator Scott Wiener, with the support of now-Mayor London Breed, has created a plan for a new form of conservatorship for those who are both mentally ill and substance abusing. A group who “refuse services” would be conserved, which transfers the right to make decisions about placement and treatment to a “guardian.”

Wiener’s original idea about who should be conserved under the new law was so all inclusive that he was forced to improve the legislation by, among other things, stipulating that potential candidates had to be first offered a list of voluntary services, including “Assisted Outpatient Treatment.”

SB 1045 in its current form has been offered to three cities to implement: Los Angeles and San Diego both declined. A hearing is still to come up in San Francisco. The first step will be a hearing at the Rules Committee of the Board of Supervisors.

This law looks good to those who are concerned by seeing people on the street in bad shape, but the law will help few, if any. Distressingly, Supervisor Rafael Mandelman and Breed overlook the fact that resources will be diverted from actual services by the expensive additions to city bureaucracy that will be needed to support the implementation of SB 1045. And there is no evidence that involuntary services to treat substance abuse are effective.


… but the law will help few, if any … resources will be diverted from actual services by the expensive additions to city bureaucracy that will be needed to support the implementation of SB 1045.”

Some other disturbing aspects of SB 1045:

SB 1045 includes no funding to increase the quality and quantity of services, or to provide truly intensive “Case Management.” In San Francisco, two thirds of those who need case managers are on a waiting list for weeks or months. Caseloads are large. For the most part, case managers do not leave their offices and do not have after-hours availability.

Models of case management such as “Assertive Community Treatment” work to reduce hospitalizations. Case managers develop long-term relationships by going out to where their clients are and gaining their trust. They then offer services that will stabilize, such as housing, and continue going to the client to assist in the adjustment to “coming inside” and finding needed treatment. SB 1045 is not needed to offer this kind of case management, and San Francisco needs to offer it.

Services are overwhelmed. None of our street outreach teams are generously-enough staffed and funded to meet existing need. No way is substance abuse treatment available without a wait, if at all. The waiting lists for “Supportive Housing” are mostly closed, because there are too many folks waiting. There are not enough Navigation Centers and not enough long-term housing to follow a stay there.

A team for someone in crisis is usually unhelpful when all that can be offered is an insecure shelter bed, or a trip to an overwhelmed psychiatric ER. Typically, clients in the Psychiatric ER have to sit on chairs all night and just go back to the street in the morning.

Despite denials from SB 1045 supporters, many will suffer if services are reserved for a few without increasing funding for voluntary services for all who actually need them. In fact, it is illegal to implement this law if others will be displaced from services. And they most certainly will be.

A criterion to begin the conservation process is “Eight 5150s” in a year. A 5150 is, by legal definition: “A hold based on probable cause by a peace office or county authorized professional, allowing involuntary transport to an authorized facility for a period of up to 72 hours for assessment, evaluation and crisis intervention.”

The vast majority of “5150” holds are cancelled (usually in the emergency room) in less than 24 hours, as the person is assessed to be not “gravely disabled” or not a “danger to self or others.”

Many folks who are 5150’d would voluntarily accept appropriate housing and treatment but cannot access it. Many homeless refuse a shelter bed: They cannot bring in their survival gear, they risk assault and robbery, and they are pushed back to the street at 6:00 a.m. This is not to mention that it’s hard to make and keep appointments when you are homeless. They have not actually “refused services.” There are simply not enough accessible and integrated services — such as mental health treatment linked with stabilization housing that then goes on to long-term housing.

It’s unethical and violates human rights to use a 5150 evaluation requested by the police or a social worker as the criterion to say whose rights should be curtailed or removed.

Those who work on the front lines in San Francisco can tell you heart-breaking anecdotes about people who “refused services” until they died. But more services will not magically just appear if SB 1045 is implemented in San Francisco. And there are so many more stories about people who wanted services but couldn’t get them — until something terrible happened to them or they died.

We need more and better voluntary services, not more laws that take away people’s rights and make them fearful of getting help.

Los Angeles and San Diego took a pass on implementing SB 1045. San Francisco should take a pass on it, too!

Dr. Teresa Palmer was a Senior Physician Specialist in geriatrics at Laguna Honda Hospital for 15 years and has practiced medicine in San Francisco for 30 years. Dr. Allen Cooper is Emeritus Professor of Medicine at Stanford University. He has also worked for Healthright 360 and the UCSF Medical Student Homelessness Clinic at the 5th St. Shelter.

March 2019

Shame on San Francisco: Patient Dumping

The Homeless Nobody Talks About

Aging in Place is a popular term for supporting those who are elderly or disabled at home. There is a lot of effort locally, statewide, and even nationally on this. Helping someone frail stay healthy in their home environment is clearly cost effective and good for quality of life.

But what happens when you can no longer safely live at home despite maximal available support? "Homelessness" is another issue now finally getting attention and funding, and this is one variant of homelessness There are huge gaps in services to those who have lost their "place" in San Francisco specifically due to the gravity of their health problems and who are, therefore, functionally homeless.

In San Francisco, not all of these folks are desperately poor — some own homes, and many just don't have enough income to pay $4,000 to $15,000 monthly to residential care facilities and skilled nursing facilities (SNF's) for long-term care (LTC).

Due to "market driven" shifts in provision of healthcare San Francisco lost 1,012 hospital-based SNF beds (43.3%) between 2001 and 2015 and lost an additional 151 SNF beds in non-hospital freestanding SNF's. Many Residential Care Facilities have shut down. San Francisco lost 16 "board and care" facilities (a form of residential care) and 80 beds in Residential Care Facilities for the Elderly (RCFE's) in the five years between 2011 and 2015.

patient in wheelchair for relocation

This makes the "market" for long LTC services much more competitive. The availability of "beds" in facilities that accept Medi-cal or who charge lower fees are a vanishing breed. The result is that those who cannot pay, or who must "spend down" for Medi-cal, have to leave the county.

Traditional health insurance doesn't pay for LTC in either RCFE's or SNF's. Medi-Cal (Medicaid in other states) pays only for LTC SNF's. Medicare, which all seniors get, pays partially for 100 days of post-hospital rehabilitation only in SNF's. Because Medicare rehab pays more per day than Medi-cal LTC, SNF's want to convert as many beds as possible to short-term rehab and limit the number of Medi-cal LTC beds. This has resulted in the loss of LTC beds for those who need them most.


The availability of "beds" in facilities that accept Medi-cal or who charge lower fees are a vanishing breed. The result is that those who cannot pay, or who must "spend down" for Medi-cal, have to leave the county."

Many believe the definition of "Aging in Place" should include your own community. One's "place" in their community is a big part of what confers meaning and gives quality of life. It also means you are close to family and friends who support you. Medi-Cal and other services are apportioned by county: If you are low-income and have to move out-of-county, you have to enroll in a completely different set of healthcare and social services that may be less in other jurisdictions than in San Francisco.

Forcing physically frail elderly and disabled San Franciscans to leave the county is a sign of failure to care for our own.

Observers believe San Franciscans as a whole don't want to mistreat this subcategory of the "homeless" (which may include our own parents or spouses). But we are doing so. We have no idea how many folks in this category are forced from their long-time family and community support systems to leave the county in order to survive. How many others linger at home without adequate care, fearing out-of-county displacement?

San Franciscans need a plan for LTC. The last "Health Care Services Master Plan" completed by San Francisco's Department of Public Health (SFDPH) in October 2013 noted:

"San Francisco likely lacks sufficient long-term care capacity to accommodate its growing aging population … San Francisco's long-term care (LTC) bed occupancy rate is higher than that of the state, though San Francisco has fewer LTC beds per population."

Since then, many more beds have been lost, including beds caring for people with Alzheimer's in county.

One of the first steps to solve this is to begin to collect data. In 2017, the SFDPH asked private-sector hospitals to provide data on their out-of-county discharges. The data was incomplete because some hospitals simply ignored DPH's request and there was no mechanism to enforce it.

There are two categories of data on out of county discharges of San Francisco residents that need to be collected: 1) Discharges from an acute-care hospital who are transferred immediately out-of-county due to a lack of facilities, and 2) Discharges of San Franciscans who have been temporarily admitted to San Francisco skilled nursing or residential care facilities for convalescence/rehab who are later transferred out-of-county because they cannot find a facility to accommodate their need for ongoing LTC in county.

If collection of this data is legally mandated, as it should be, consideration should be given to offering San Franciscans discharged out-of-county some sort of "certificate of preference" so they can return as soon as possible.

We do know that at least 1,479 folks have been discharged out-of-county: 703 from SFGH and LHH combined, and at least 776 from just two private-sector hospitals, during different reporting periods. It hasn't been possible to obtain data from all acute-care hospitals, because four hospitals didn't respond.

Worsening out-of-county discharges was CPMC's closure of its sub-acute unit in June 2018 for patients who need ventilators, tracheostomy, and other forms of complex care to survive. There are no other sub-acute units in the City left. So if you have an illness that leaves you ventilator-dependent and you can't continue at home, there is no long-term bed in San Francisco for you.

It should not be difficult for the Mayor and the Board of Supervisors to require, through a legislative mandate, that our Health Department collect this out-of-county discharge data from private sector facilities. Data collection can then be enforced for those facilities that may be reluctant. Since this measures the care we give to the most vulnerable among us, once the legislation is proposed, it will be hard for any elected or appointed official to disagree with collecting it. What public officials don't measure, they can't fix.

Dr. Teresa Palmer was a Senior Physician Specialist in geriatrics at Laguna Honda Hospital for 15 years and has practiced medicine in San Francisco for 30 years. Patrick Monette-Shaw contributed to this article.

December 2018


CPMC's decision to stop providing subacute skilled nursing services for San Francisco's most frail and vulnerable patients is the cruelest and most tragic example of what happens when a "non-profit" hospital corporation dominates a market, and then sheds services that yield less revenue.

Subacute skilled nursing facility care is long-term life support for those who choose to live on ventilators, or have other very complex care needs. It is called "subacute" because the patients are just stable enough to be moved out of the intensive care unit. No patient population is more delicate and more vulnerable to small changes in their quality of care. No patient population is more dependent on loving family members to watch and advocate for them on a daily basis.

In spite of all this, CPMC, which has the only subacute SNF (skilled nursing facility) in San Francisco, has refused to accept non-CPMC subacute patients since 2012, forcing them out of the City and away from their caring families. CPMC Subacute SNF, originally licensed for 40 beds, is at St. Luke's Hospital. Since 2016 CPMC has refused to accept ANY new subacute patients even as the remaining (now 17) die or leave the city. CPMC's plan will leave San Francisco as the only major city in the State without subacute skilled nursing beds, and the only city with a "Level 1" Trauma Unit without these beds.


In this geriatric doctor's opinion, the loss of subacute care in San Francisco is at a crisis stage and should be considered a public health emergency. It must be addressed by CPMC, by the City's private and public hospitals, by the City's government, and most of all, by the City's residents, whose power is needed to force a resolution.”

Intensive care unit

As a result of an outcry by families of these patients, the larger community, and public officials, CPMC has reluctantly agreed to continue treating the remaining 17 subacute patients, who are now endangered by staff instability. CPMC wants to transfer these 17 from St. Luke's to Davies Hospital on June 30, 2018, and no familiar staff will follow them. Moreover, at Davies, RNs (Registered Nurses) have no union to protect them when they advocate for their patients. As the patients die or leave and are not replaced there, this new subacute SNF will close and all the new staff will also lose their jobs.

What separates subacute patients, and the care they need, from other patients is the need for heroic measures to maintain life on a long-term basis, coupled with the need for exquisitely detailed attention to the other most basic aspects of care. Subacute patients often have multisystem failure, combined with problems communicating. They are mostly immobile, and many are totally dependent on others to monitor their nutrition, hydration, hygiene, and breathing. They are prone to sudden, overwhelming, and potentially fatal infections from skin breaks, as well as urinary tract infections and pneumonia. If they have a downturn, they must be quickly transferred out of the subacute SNF to the acute hospital's intensive care unit.

To prevent constant re-hospitalization and early death of these patients, the subacute care team (doctors, nurses, and aides) must be very well-trained, motivated to work flexibly, have excellent communication up and down the line of authority, and be led by experienced RNs and very accessible doctors. The team must all know what is "normal" for each patient to see early warnings of new illnesses, because, of course, any new illness can be catastrophic.

In this geriatric doctor's opinion, the loss of subacute care in San Francisco is at a crisis stage and should be considered a public health emergency. It must be addressed by CPMC, by the City's private and public hospitals, by the City's government, and most of all, by the City's residents, whose power is needed to force a resolution. Please tell your friends, your organizations, your representatives, and CPMC that CPMC must provide care for the 40 subacute patients they are licensed for, on a permanent basis.

Let me give an example of the level of detail that subacute patients require - details that touch their families, every member of the staff caring for them, and the doctors that have either short or long-term responsibility for them. Imagine the following:

A family member reports to the charge nurse that when they walked into the room, their sister was struggling to breathe through her tracheotomy tube and the front of her gown was wet with bubbling secretions coming from the tube.

The family member assumed that the patient had been neglected and called for suctioning, which relieved her situation in the moment. Her gown is changed and she is repositioned. The patient appears more confused than usual after an unknown amount of time in respiratory distress, and her ability to communicate detail is already poor.

On review, the staff reports routine frequent checks and suctioning, but cannot say whether episodes of becoming overwhelmed by secretions are becoming more frequent. Suppose the Aides, LVNs, and RNs who know this patient best are not present on the shift when this is reported. What could be happening with the patient?

There are many factors that can contribute to excessive and/or obstructive secretions in a patient who breathes through a tube. Among these are:

Under or over hydration; inadequate or infrequent suctioning (which is not pleasant, and unfamiliar staff may allow a patient to refuse it); lack of good oral and dental care; a heart that is subtly beginning to fail more than it already was; overly fast feeding by mouth or tube leading to reflux of stomach contents into the lungs; oxygen administration that is too high (leading to carbon dioxide accumulation and respiratory depression) or too low (leading to patient fatigue from the work of breathing); ventilator settings that need adjustment (when did the respiratory therapist last review them?); anything that can lead asthmatic spasm of the bronchial tubes, or to nausea and/or vomiting, or anything that can lead to periodic depression of consciousness; violation of dietary restrictions by families or staff that want to slip the patient a treat which then gets aspirated.

Are there new signs of pneumonia? Does the patient's history suggest that a new occult pneumonia is likely from what is known about past episodes? Is the current problem new or old, intermittent or progressive, and can the needed data be found, and is the patient exam at the moment typical or an exception to the usual state of things?

I give you this example to show the level of detail that a team caring for these patients must cope with. And remember, this is not an intensive care unit which has a very high staffing level and is designed for an acute, short-term stay. This is a long term care facility- a "SNF."

The care at the St. Luke's Subacute SNF has been excellent for many years, well above what is legally required. However, this excellence has broken down in recent months as the number of patients in the unit dwindled from the mid-20s to 17.

As the unit downsized, many staff accepted other work or termination agreements that allowed them to get on with their lives. There have been a number of days recently when more than one Certified Nursing Assistant (CNA) called in sick. Normally, another CNA or a Licensed Vocational Nurse could be substituted, but no qualified staff were found, and families were forced to notify each other to visit and monitor. Of course families should visit and monitor, but this is not a substitute for qualified staff.

Why is Sutter/CPMC so determined to stop subacute care services? Since it is long-term care, Medi-Cal pays hospitals less for subacute SNF patients (and all SNF patients) than for acute patients. So CPMC is maximizing its revenue by avoiding patients who bring in less revenue. Before moving to close subacute Care, CPMC closed 101 regular Skilled Nursing Facility beds on its California campus, which has been sold to a real estate developer for market-rate housing. CPMC is closing its 25 bed Swindells' Alzheimer's Center on the same campus, and closing 39 SNF beds at St. Lukes. CPMC closes low revenue units outright when possible, or incrementally strangles them by attrition if it cannot. Either way, it is their policy to maximize revenue rather than to fill San Francisco's healthcare needs.

Many people reading this may wonder why it is so important to keep these subacute patients alive, given that they are so frail, so expensive to care for, and that their autonomy and quality of life are so low. Many may feel that they themselves would not want to live in these circumstances. This is understandable. But people must have the right to choose. As a doctor who has practiced geriatrics for decades, I can assure you these decisions, either way, are highly personal, best reached in consultation with families and often with spiritual advisors. People must have the right to choose how they will live. It is not society's right to make that decision for them. And it is certainly not CPMC's right to make that decision for them, in order to maximize their revenues.

A brief history: CPMC, a multi-hospital chain in San Francisco, is the biggest and most profitable division of Sutter Health, a huge "non-profit" Northern California hospital chain. Sutter's domination of the Northern California market and its revenue-maximizing practices have raised Northern California hospital's prices far above Southern California hospital prices, to the point that the State of California has initiated an anti-trust suit against Sutter. Sutter's and CPMC's policy of avoiding less-profitable SNF care including Subacute Care, is part of this picture.

In 2001, CPMC bought St. Luke's Hospital with overt plans to shut it down and reduce competition to its own hospitals, but community resistance prevented the closure.

In 2012, CPMC began refusing to admit patients from other hospital systems into St. Luke's 40-bed subacute SNF as well as its 39-bed regular SNF, which treats less fragile patients after hospitalization.

In 2017, the families of the subacute patients were informed that the unit would close in late 2017 and they would need to find care for their family members outside San Francisco where many patients had lived for decades, and where their families lived. Many patients stayed, and the families organized and fought the eviction of their loved ones.

In September 2017, CPMC announced, at a Board of Supervisors hearing on this crisis, that it would care for the remaining 17 subacute patients in their SF facilities, but would complete the closure of St. Luke's subacute SNF and regular SNF by June of 2018, while not accepting any new patients.

CPMC has chosen to move the remaining 17 St. Luke's subacute patients into its Davies 38-bed regular SNF Unit in June 2018, displacing almost half of the Davies regular SNF patients from the CPMC system. San Francisco already has a severe shortage of regular SNF beds, due to the shutdown of hundreds of hospital based SNF beds since 2013. According to California law, Subacute SNF and regular SNF patients must have separate staff and space within the new Davies Unit. CPMC is implementing this unwieldy plan at Davies just until the Subacute patient numbers dwindle to the point of a complete subacute closure.

If CPMC truly cared about serving the most vulnerable San Franciscans (those who need subacute and regular SNF care) it would permanently resume care for the 40 Subacute SNF patients and 39 regular SNF patients, as they are licensed to do at St. Luke's. Space can certainly be found on its large campuses while St. Luke's campus is rebuilt. Additionally, CPMC should not reduce the existing 38 regular SNF beds at Davies.

Warren Browner, CEO of CPMC, says there is "no space" in the future for this chronic care in either its new St. Luke's or its new Cathedral Hill hospital, meaning all space must be used for acute care, which generates higher revenue. But even if space in the two new hospitals were reserved for acute care, as CPMC demands, CPMC could still accommodate subacute and regular skilled nursing care in their two planned medical office buildings next to their two new hospitals. Buildings with SNF care do not legally require the expensive level of retrofitting as an acute hospital. CPMC refuses to consider this.

Dr. Browner has implied that the 2013 Development Agreement, where the City authorized construction of a new CPMC Cathedral Hill hospital, forced CPMC to close St. Luke's Subacute and regular SNF. This is simply not true. Community advocates did, at the time, demand that CPMC continue adequate acute hospital services at St. Luke's. However the 2013 Development Agreement is silent on subacute and regular SNFs. CPMC has used this silence to betray an earlier agreement to maintain its skilled nursing facilities.

The SF Department of Public Health estimates a citywide need now for 70 Subacute SNF beds. This means even if CPMC re-opens its 40 licensed subacute SNF beds at St. Luke's, there will still be a deficit.

Due to the severe shortage, SF Department of Public Health is discussing a partnership with all local hospitals to re-open hospital-based regular and subacute SNF beds in San Francisco. The City will need to spend taxpayers' money to replace beds closed by CPMC, which is already subsidized by San Francisco because it does not pay taxes on the basis of being non-profit.

The public-private solution which SFDPH is discussing will take years, and meanwhile, all of those now choosing to live with a subacute SNF level of support will be forced to leave San Francisco, their home. Thus far, CPMC is absolutely unwilling to change its plans while the Department of Public Health works on a longer-term solution.

Since the advent of the Affordable Care Act, CPMC hospital revenues have increased in San Francisco, but the dollars spent on charity care have decreased, both in absolute terms and as a percentage of revenue. One would hope that this revenue would lead this tax-exempt corporation to re-open critically needed subacute and other SNF beds for the aging population of San Francisco, but this has not occurred.

Community and political pressure, and some new local, regional and/or state legislation is needed to prevent this disaster, and to pressure CPMC into maintaining permanent Subacute SNF beds.

I urge you to contact your community health advocacy organizations, Dr Warren Browner, CEO of CPMC, and Sarah Krevans, President and CEO of Sutter, your Supervisor, Mayor Farrell, and Barbara Garcia, Director of the Department of Public Health, to encourage CPMC to establish a permanent subacute skilled nursing unit on one of its campuses immediately until one can open at St. Luke's, and to re-engage, in general, in providing hospital-based SNF care in order to meet the needs of this aging community.

Teresa Palmer, MD, is a Geriatrician.She has provided a bibliograpy of her research. It is available on the website:


1.SFDPH Power Point Presentation: Prop Q: CPMC St. Luke's Skilled Nursing Facility& Subacute Unit Closure 9/5/17; Board of Supervisor's Presentation Sept 12 2017

2.SFDPH Power Point Presentation to Health Commission April 3 2018: Post Acute Care Update

3. Plans filed with SF for CPMC Van Ness Hospital; includes information on medical office building:

4. Plans filed with SF for St. Luke's campus, includes information on office building:

5.Addressing San Francisco's Vulnerable Post‐Acute Care Patients 2018 Analysis and Recommendations of the San Francisco Post Acute Care Collaborative By the Hospital Council of Northern and Central California

6. Charity Care Report Draft 2016:

a. Department of Public Health Power Point Summary: April 3 Health Commission

b. Draft SF Hospital's Charity Care Report

7. Sara Gaiser, Bay City News, July 26, 2017

8. Development Agreement between San Francisco and CPMC 2013

9. California Code of Regulations (CCR), Title 22 : Subacute Care Programs: Adult (subacut adu) - Medi-Cal

10. Attorney General Becerra Sues Sutter Health for Anti-competitive Practices that Increase Prices for California Families: Press Release March 30 2018

11. Halifax, E., Wallhagen M., & Miaskowski, C. (2018) Nursing Home Certified Nursing Assistants Understanding of Residents' Pain. Journal of Gerontological Nursing, 44(4), 29-36.

May 2018

No Room at the InnDr. Teresa Palmer

Facing Our Long-Term Care and Post-Acute Care Issues

A s a "Silver Tsunami" of baby boomers and their elders emerges, a nationwide failure to cope is in process. Specific aspects of life in San Francisco, such as very high property costs, exacerbate our local failures. As residents, we must find a way to care for seniors, disabled people, and others who most need care. We do not wish to live in a walled fortress where all but the very well off are sent away, out of county.


Patient dumping at Brius Home
Are private out-of-county providers the best choice for our vulnerable populations?

Aging At-Risk and Underserved People Increase While Services Do Not

Predictable increases in aged, poor, sick, and homeless people are occurring in San Francisco, even as desperately needed services are shut down or remain too expensive for those in need. Given the increasing complexity of cognitive, medical, and psychiatric problems that occur with aging, especially aging in poverty, it is crucial to have appropriate medical, psychiatric, and social supervision for those who cannot be completely independent.

Our acute hospitals are excellent at performing "medical rescue" for a single acute illness, but what then? The long-term and post-acute care continuum ranges from a few hours of help at home by family or caregivers, all the way to 24/7 skilled nursing and medical care for chronic, ventilator-dependent patients in a Skilled Nursing Facility (SNF) sub-acute unit.


a. Rapidly aging population, with low proximity of caregiving family nearby.

b. 50% of those over age 85 develop Alzheimer's or similar memory issues.

c. Inequity between the cost of housing (both for people and care facilities) and income. While especially true for the Medi-Cal-eligible population, care and placement may not be entirely affordable even for those who earn $100,000 annually. Residential Care or 24-hour care at home costs a minimum of $2,500 to $6,500 a month (even with a minimum wage of $14 to $15 an hour and some unpaid help from family members). Many people need more than the minimum amount of care.

d. Medi-Cal, which pays for chronic care at Skilled Nursing Facilities (SNF), does not pay for residential care outside of a SNF. Medicare pays only for temporary rehab. Major medical insurance, like Medicare, does not pay for long-term care, only temporary rehab, unless people purchase separate and extremely expensive long-term-care insurance.

e. For the middle class, even Medi-Cal may not be available, due to the extremely strict limits on assets (less than $2,000 in savings). Due to its low reimbursement rate, most nursing homes limit the number of people on Medi-Cal that they admit, and ask for financial records to prove that a family can pay the monthly cost ($10,000 to $15,000 per month).

f. Those whose sole source of income is social security disability, often less than $1,000 per month, cannot even pay for a single room occupancy (SRO) hotel (now at least $1,400 per month), let alone the costs of residential care (over $2,500 per month).

g. Lack of accessibility to mental health services and treatment on demand for substance abuse has led to a chronically ill sub-population that is harder to treat and house. Advancing age, and age-related illness, add to the complexity.

h. Chronic brain disease/cognitive impairments such as Alzheimer's disease are not billable to insurance as a "psychiatric" diagnosis, even when the behavioral manifestations are extreme and require a level of care that is only available in an acute psychiatric unit. The only exception to this is for 72 hours, but only if the individual is considered an imminent threat or gravely disabled. However, discharge from the hospital without an effort to do highly individualized assessment and careful placement often leads to injury or death from falls, elopement, aggression to others, or self neglect.


Many in the disability/independent living community supported this (cuts), as promises were made about using the savings to increase care at home. Now we have shortages in both home-based care and SNF beds for low- and moderate-income people.”

Profits over Service

This has resulted in a narrow focus on short-stay acute care in the hospital, and a subsequent severe shortage/shut-down of hospital-based SNF's, and sub-acute SNF beds, as well as acute psychiatric beds.

Public sector: Funding instability and cuts have worsened poor integration of the existing rich, but overburdened, array of public services in San Francisco. To save money, public SNF beds (Laguna Honda Hospital) have been cut. Many in the disability/independent living community supported this, as promises were made about using the savings to increase care at home. Now we have shortages in both home-based care and SNF beds for low- and moderate-income people.


Everyone in the health care sector and public /nonprofit planning sector must do their share to provide needed services:

A. The Department of Public Health must exhibit leadership in planning for long-term and post-acute care needs of the sickest among us, and must be assertive with corporate providers of health care in the community.

B. Private-sector "non-profit" hospital corporations and health care foundations must prioritize the person in the community, and not prioritize the profit in it. In San Francisco, this clearly involves a commitment by all hospitals to fund hospital-based SNF units, sub-acute SNF units, and acute psychiatric beds in proportion to their acute care and community outpatient caseloads.

C. Land or space for Residential Care Facilities for the Elderly (RCFE's) and SNF's must be made available in every neighborhood. Seniors and others who most need care should be close to their families and their home neighborhood. Planning regulations must be changed to accomplish this.

D. A sufficient quantity of hospital-based sub-acute SNF beds must be opened. Currently, there are no sub-acute SNF units in San Francisco except for the remaining beds at CPMC–St. Luke's Hospital that will be shut down when the existing people in them leave or die. All others who need this care must leave the county.

E. Acute psychiatric beds must be re-opened, including gero-psychiatry. There is only one 12-bed acute gero- psychiatry unit in San Francisco at this time (at the Jewish Home SNF).

F. Local and state legislative solutions may include use of licensing authority; planning and building codes to reopen post-acute SNF and sub-acute SNF care units on hospital campuses; and to place chronic care sites in new buildings, available public spaces, and community centers.

G. Funding assistance for the housing costs of residential care providers must be found. Too many small providers have found that selling their property and leaving the business makes more sense than continuing.

H. The Board of Supervisors and our state representatives must work with the California Department of Public Health to assist in the existing, but underused, process to make waivers of Medicare and Medi-Cal dollars available for residential settings for those in need.

We Cannot Afford the Human or Ethical Cost of Funding One Type of Needed Care at the Expense of Another: All Are Needed.

Those proposals that pit funding for one aspect of the continuum of post-acute and long-term care against another are generally not person-centered, but are "industry-" or "profit-driven," with the ethically unacceptable goal of shifting responsibility for less profitable, more expensive services to someone else. To save money, especially for those who cannot pay, a lower level of care, inferior care, or care far out of town are offered instead. An example of this is CPMC Sutter's actions toward the patients at St. Luke Hospital's sub-acute SNF unit. Another example of this is displacement of long-term beds in nursing homes by more profitable (Medicare funded) short-stay rehab because hospitals have shut down their SNF rehab beds to make more profit from acute care.

Many studies that discuss the huge numbers of aging demented people now and in the future in San Francisco point out that "there will never be enough SNF beds for all of them." Then there is a discussion about why demented people should not go to SNF's (since they are "just demented," the logic goes, they will do fine in less medically skilled and expensive settings).

This is disingenuous, as dementia is a progressive disease that occurs in people who are aging and also getting more frail from other age-related conditions. As time goes on it takes more and more resources to maintain them at home (if they have one), and for many this becomes unsafe or impossible.

While it may be possible to delay the need to enter a nursing home by optimal support in the community, timely availability of an SNF bed is essential for the safety of those with advancing dementia.

We certainly need to get better at supporting the increasing number of people with these conditions (and their families) to live full and unrestricted lives outside of nursing homes as long as possible. But for many, a nursing home (SNF) will be the most humane placement toward the end of their journey.


A. People need different kinds of help as they age. "Too little, too late" is often the story for low-and moderate- income people. People who have hard lives may need more help. People who get services and support in a timely fashion retain their ability to live outside a nursing home longer. We must increase funding for adequate and timely services for the full continuum of care for low- and moderate-income people as they age.

B. Funding of adequate home and community health services must be increased for both low- and moderate- income people, but not at the expense of adequate SNF beds.

Lack of Support Is a Part of the Larger Picture of Economic Displacement

The egregious lack of care and placement options in San Francisco is very much a part of the larger issue of the displacement of all low- and moderate-income people in the City: If it is just not affordable to age in place, one must leave the county.

Levels of care that are needed for seniors and physically frail people:

a. Help at Home: For Medi-Cal eligible patients, "In Home Support Services" (IHSS) will provide up to 240 hours a month (8 hours a day) of assistance from an aide, who has limited training in performing personal care. IHSS caregivers make minimum wage, and many recipients "pad" the hourly wage (illegally) to keep a good worker. The system is chronically stressed, which results in persons in need getting awarded too few hours, and there is a chronic shortage of social workers to supervise the workers. Nurse visits are available for those meeting criteria.

Medicare and major medical insurance will only pay for very temporary nursing help at home after an illness. Private agencies generally charge at least $25 an hour for help at home. This leaves many low- and moderate- income people either totally dependent on family and friends, or dependent on "off the books" arrangements.

Other Funds/Services for Those at Home and in the Community: In general these programs are to support a person at home, although some are available to those in residential care facilities. The purpose is to prevent the need for either SNF care or Sub-acute SNF care. In general these programs provide "waivers" to allow the use of Medicare and/or Medi-Cal dollars. They are usually available only to people who are very low income. Names of these programs include: Medicare Shared Savings Program and/or Multipurpose Senior Services Waiver (MSSP); In-Home Operations Waiver (IHO); Home-and Community-Based Alternatives Waiver; Assisted Living Waiver; Community-Based Adult Day Services, and others. Transition to the home may be accomplished, for a new disability, by providing time in a Skilled Nursing Facility to stabilize the person, get equipment into the home, and train paid and unpaid caregivers.

b. Supportive Housing: These are individual residences such as Single Room Occupancy Hotels (SROs) which have a social worker, or at least a trained front desk person, on site during normal working hours. Medical clinic personnel are either nearby or do home visits during normal working hours. These are usually publicly funded. These units are usually full, and have waiting lists (often with long waits). Waiting lists in many of these are so long they are no longer open to new people.

c. Assisted Living: This is a general term, and in the private sector generally means minimal daily help with personal care and medications. Extra help with specific services can be offered, usually for an increased monthly cost. Example: assistance with medication, dressing, or bathing. These are usually private facilities and purchase of additional services can be expensive. Staff are often undertrained.

d. Residential Care Facilities for the Elderly (RCFE's): These facilities are not covered by medical insurance, including Medi-Cal. A Medi-Cal waiver with use of funds to cover some of the care is possible, as discussed above. The intensity of help with medications and personal care is greater than that in assisted living, but there is little or no skilled medical help (licensed vocational nurses or registered nurses). Facilities having less than six beds have less-stringent licensure requirements than facilities that have more than six beds. All are considered "non-medical" facilities, although for limited hours every day staff trained to administer oral medication and check vital signs are present.

A staff member must be present and awake at night, but the staffing ratios are low, especially after day shift, and on weekends and holidays. Residents are generally alone in their (often shared) rooms evenings and nights.

RCFE care can be enhanced to handle specialized subpopulations (such as dementia patients needing "memory care," or end-of-life patients needing hospice services) by offering specialized staff training, increased staff-to-patient ratios, and increased presence of licensed nursing and medical staff. The cost to the patient is increased. Insurance funding of hospice services is available, but not for dementia services.

In general, skilled or formal rehabilitation modalities, even supervised walking for exercise, are not offered at typical RCFE's, as there are no licensed, or even consistently responsible, staff present to supervise the patient in performing the exercises, or to even know whether exercises are being done.

e. Skilled Nursing Facilities (SNF's): Licensed nursing staff are present 24/7; and rehab, dietary, and activity therapists are available. A doctor must visit at least once a month and when patients are ill. Staffing ratios are higher and more skilled than RCFE's.

Hospital-based SNF's tend to have the most skilled and most available rehab, nursing, and medical teams.

To be eligible for a SNF, patients must need help with multiple Activities of Daily Living (ADLs), and must need attention from licensed nurses ("skilled care").

Hospital-based SNF's (and community-based "freestanding" SNF's with post-hospital "rehab" beds) accept people who need active rehab five days a week, or have a medical condition that requires intravenous treatment and/or extra care by licensed nurses. Medicare pays for this "skilled rehab" after hospitalization for up to 100 days.

People who need supervision 24/7, who do not need rehab, and only need a few hours of skilled care daily are called "custodial" or "long-term care" patients.

In general, there is more profit from (Medicare-funded) short-stay Post-Hospital Rehab than in (Medi-Cal or cash funded) long-term, or "custodial" SNF care. So, as hospital-based SNF beds are shut down, more community-based SNF's do short-stay post-hospital "rehab" — resulting in long-term care beds in the community being lost.

"Aging in place" or "Home- and Community-Based Care" are popular terms to describe care at home, in a residential setting, or anything other than a SNF. This is, in theory, less expensive than SNF care, and is what most people say they want. However, the enhancements needed at home or in an RCFE to adequately care for a demented person who is behaviorally disturbed with worsening cognition, or for a frail elderly or disabled person with multi-organ disease, may cost more than an SNF placement.

f. Sub-acute SNF Units: Specialized SNF units where patients with very complex skilled medical and nursing needs can stay either temporarily until they improve, or long term if they do not. Complex open wounds, need for IV nutrition, or breathing support from ventilators through a tracheostomy are some of the qualifying conditions.

Sub-acute SNF's located on a full-service hospital campus ("hospital-based" units) are best able to handle these complicated patients due to close proximity to all medical personnel and intensive care units (ICU's).


A. City leaders must assertively advocate for changes in state and federal laws about post-acute and long-term care funding for low- and moderate-income people for all aspects of the continuum of care. Even in the face of federal threats to health care, we must advocate and plan for what we need.

B. As ("non-profit") private and public hospitals seek to give priority to their (most profitable) acute services, public leverage (land use agreements, building codes, mitigation payments, organized community pressure) must enforce the provision of proportional hospital-based post-acute and long-term care services. This is part of public and corporate responsibility to the communities these entities are supposed to be serving.

C. Patch funding, land use agreements, and property/business tax codes need to be modified to help bring in providers of residential care.

D. More funds from waiver programs and non-profit foundations need to underwrite the monthly cost of residential care for both low- and moderate-income people.

E. Consideration should be given to re-opening an Adult Day Health Care (ADHC) unit at Laguna Honda Hospital which was prematurely and inappropriately closed in approximately 2008 that had predominantly served people with dementias.

F. The euphemism "Regional Solutions" is used by the Hospital Council and Health Commission to describe discharging patients out of county, especially when the care — such as hospital-based SNF and sub-acute SNF care — cuts into revenue streams of large hospitals. Forcing people to leave the county for needed care is unacceptable. There must be enough of each type of care available in-county, in a timely fashion, to serve each individual whose healthcare needs increase. Beware of this euphemism.

The PACC's draft final report recommended "creating a formal governance structure to oversee regional SNF patient placement practices and protocols" for those placed out-of-county for SNF and sub-acute care. The

PACC report also indicated San Franciscans "placed in regional SNF facilities should, however, be transferred back to a corresponding facility in San Francisco as space becomes available."

To facilitate return of San Franciscans as space becomes available, a formal "Certificate of Preference" system must be developed to give patients placed out of county preference for return to San Francisco-based facilities. Such a preference program should be prioritized for rapid development and implementation.

Importantly, since DAAS and DPH have jointly funded development of the SF GetCare database developed by RTZ Associates at a cost of millions of dollars, RTZ should be awarded a contract to enhance the SF GetCare database to track the Certificates of Preference, and each private-sector hospital in San Francisco should be given access to the database and be required to use it to track "regional" placements. DPH should be assigned as the lead agency to oversee governance of placement practices and protocols.

Consideration should be given to retroactively issuing "Certificates of Preference" to people previously discharged out-of-county from both our public hospitals, and private-sector hospitals, as an issue of equity.

Acute Hospitalization May Be an Opportunity to Reverse a Downward Spiral, and Superficial Care of Complex Patients Is a Missed Opportunity:

Not only does a narrow focus on short-stay acute care predispose to shorter hospital stays, the shut down of hospital-based SNF's and acute psychiatric units have led to a shortage of staff geriatricians and psychiatrists who are willing to consult on hospitalized patients.

Hospitalization is a seminal event in the life of a person, and premature discharge or discharge to an inappropriate setting can do more harm than good. In lay terms, if a person is discharged without totally understanding what went wrong and why it went wrong, a repeat hospitalization, death, or worsening illness is likely to ensue.

The transitional period between full acute hospitalization and return home or to another long-term location must be approached with a rich array of options. When needed, comprehensive assessment of the person, of their decision-making ability, and/or an array of specialty consultations takes time. For the elderly and chronically ill, healing takes time. A person's ability to recover function after an insult/hospitalization is not always immediately clear, especially when — as in the aged or mentally ill — pre-existing chronic illness and multiple organ systems are involved.

The need for emergent hospitalization is often a sign of needing more than one kind of help. If the need for acute hospitalization for treatment is brief, but a person is not at baseline or failing in their usual environment, the best way to do a full assessment and timely rehab is often to begin either during the acute stay or "in house" immediately upon discharge to the hospital-based SNF, the sub-acute SNF unit, or to an acute psychiatric unit.

The Hospital Council has recommended a "Roving Team" to compensate for shortages of comprehensive discharge planning, geriatric and psychiatric assessments, rehab and psychiatric care that the hospitals themselves have caused to preserve revenue. This proposed "Roving Team" would be staffed by public employees and would remove all responsibility from private-sector hospital's staff for discharge planning of "difficult" patients. In this scheme, frail cognitively-impaired patients are grouped with substance abusers and behaviorally-disturbed mentally ill people.

For those requiring it, a comprehensive assessment and consultation is not quickly available in the community after hospital discharge with some exceptions: A few geriatric clinics (which are generally full); some public mental health clinics (which are bursting at the seams); and PACE programs (Programs of All Inclusive Care for the Elderly), which have strict enrollment criteria.

In general, university and private (corporate, non-profit) health care providers avoid having overly large geriatric clinics, because Medicare limits the charges — and younger patients with major medical insurance brings in more revenue.

PACE can offer comprehensive assessments and wrap-around care immediately after hospital discharge. However, On Lok Lifeways here in San Francisco will, for the most complex patients, direct that a patient either spend additional days in the acute hospital or transfer to a hospital-based or rehab SNF until further stabilization. Also, On Lok Lifeways does not offer housing, does not enroll people who have active mental illness or substance abuse as a primary diagnosis, and only initially enrolls people who can live safely at home with the services the program provides.


A. Many hospital-based SNF, sub-acute SNF, and acute psychiatric beds (especially gero-psychiatry) must be re- opened. Timely use of these services allows frail people at risk of long-term nursing home care to remain in the community longer. Long-term SNF beds in the community also must increase; however, some beds (now being used for short-stay post-hospital rehab in community SNFs) will become available when hospital-based SNF's re-open.

B. Barriers to expanding PACE Programs, dedicated geriatric clinics, adult day health center, mental health centers with geriatric capability and comprehensive post-discharge care capability, and other models of care which offer "wrap around" services after hospitalization (or ideally, prevent hospitalization) to seniors and others who need care must be explored for both low- and moderate-income people.

Immediate Short-Term Post-Acute Care Must Be Person-Centered and Meet the Needs of Complex and Frail People. Residential Settings Should Only Be Used for Post-Acute Care When the Needs of the Person Can Be Met, and Not as a General Practice to Save Money:

Post-acute transitional care settings (i.e., care immediately after acute hospital discharge) must fully meet the needs of complex sick and/or elderly patients. Precipitous discharge from the hospital without adequate assessment and stabilization is unfortunately a common story.

Recently, the Hospital Council of Northern California "Post-Acute Care Collaborative" (PACC) recommended use of (typically understaffed and underfunded non-medical) residential settings to get people out of acute hospitals. The Hospital Council's PACC made these recommendations in order to avoid re-opening hospital- based SNF beds in favor of maintaining acute hospital beds to maximize revenue, and not to institute best practice models of care. Furthermore, they selected a screening tool (LOCUS), which has been validated only for psychiatrically ill patients, in spite of the increasing population of demented people who need nuanced discharge planning. An alternative assessment tool should be identified, and used instead of the LOCUS tool.

Widespread use of short-stay residential beds as a "holding place" for newly discharged hospital patients is likely to take needed beds away from those who need long-term care in these facilities.

There is a grave risk that patients discharged from hospitals who need more than a residential setting to stabilize medically and psychiatrically will be warehoused at this lower level of care, either to get sicker and return to the acute hospital, or die.

Furthermore, disaster often results from mixing younger and vigorous people who have behavioral disturbances with frail demented people who have no sense of personal space.

Multiple studies have documented that post-acute hospital-based SNF care — with a rich interdisciplinary team, immediate rehab activities, and easy access to re-hospitalization — is the needed level of care for those with complex neurologic insults such as strokes, and for frail elderly with multisystem disease. This provides both the family and the patient the optimal care while assessing what will be needed for safety and quality of life once stability is achieved and longer-term discharge is possible.

The ethical implications of differentially discharging low-income sick people to understaffed and under-skilled residential care facilities are chilling.


Although it may be "cost effective" on paper, using short-term residential placement as a general discharge plan for low-income people who get "stuck" in the acute hospital, or who do not wish to leave the county, may result in doing more harm than good. The most vociferous advocates of post-acute short-term residential placement are those who have profited by shutting down hospital-based SNF's, sub-acute SNF units, and acute psychiatric units, including gero-psychiatric units. We must beware of degrading or denying care to complex people who need more than a residential facility can provide.

Specialized Long-Term Residential Care Units Can Be a Boon to Dementia Patients, But Standards Must Be Strictly Maintained:

The need for specialized long-term residential settings for those who do not do well in a SNF environment, (specifically people with cognitive impairment/Alzheimer's with behavioral issues) is increasing as the population of San Francisco ages. "Memory Care" is the common term. Extra space, and ideally space outdoors to ambulate without getting lost, are ideal attributes of these settings.

Residential care can be set up for a "memory unit" by using visiting (or extra on-staff) licensed nurses, specially trained and supervised staff, and increased licensed staff on-site at all hours. Hospice care, permitted by hospice waivers in residential facilities, will bring in additional staff that can be used to allow a comfortable death in a person's familiar environment.

Again, this type of care approaches traditional SNF care in its cost and complexity, and is best suited for those people who do not do well in a SNF, and who are not medically complex (or at a minimum, whose medical conditions are under good control). Criteria for admission should include current physical stability while staff grows to understand each person's needs.

The Irene Swindells Alzheimer's Residential Care Program on the California Campus of CPMC/Sutter is an outstanding example of this type of unit, and derives benefit also from its hospital campus location and proximity to the full range of hospital services. However, Medi-Cal and other medical insurance does not pay the high monthly cost of this care — at minimum, $6,500 monthly — and some families are dependent on a non-profit foundation to assist with the monthly cost.

CPMC–Sutter has announced the planned closure of its Swindells facility in 2018 to make room for condominiums. New admissions to Swindells have been stopped, despite the demand. Sadly, many other residential care facilities in San Francisco that charge extra for "memory care" do not have this rich, well-trained array of staff, along with safe space for people to walk around outside.


A. CPMC/Sutter must not shut down its Swindells Alzheimer's Residential Care Program, which is a model facility.

B. Funding for state-of-the-art residential facilities that specialize in "memory care" for those who cannot pay must be made available in the form of non-profit foundation help, waivers for the monthly cost, and public and private donation of space.

Assistance to Home Care Entrepreneurs to Increase Long Term Residential Placements Is Needed:

Small-bed home care (e.g., "board-and-care") facilities are no longer a realistic business opportunity for San Francisco families, although an entrepreneurial, dedicated family is often able to offer the best and most personal care. The cost of housing and required renovations, and the cost of maintaining adequately-trained staff, is prohibitive when compared to the income of those that need the care most: Elderly and disabled moderate- and low-income people.

Multiple smaller residential care facilities have shut down in recent years, as the cost of doing business and following the many regulations outweighed the high value of residential property in San Francisco. So, properties were sold.

However, given the frailty and vulnerability seen in typical RCFE's, the need for strict regulations and monitoring

— including comprehensive and regular staff training — is unquestionable. There is limited or no access to licensed staff (registered nurses and licensed vocational nurses) to do skilled medical assessments of patients who appear ill or who are exhibiting new behavioral symptoms. Thus, the possibility of neglect, victimization, or abuse is huge without adequate staff training and oversight.


New programs of funding and support that could relieve the financial burdens of offering care in a home-like setting are needed. Standards of monitoring and staff training must be maintained. The "Silver Tsunami" of baby boomers with Alzheimer's Disease would ideally be served in home-like residential facilities near their families everywhere in the city.


A. Use of "below market rate" space in new buildings and grants to build out unused space in neighborhood and community centers;

B. "Tuition" stipends via increased funding for waivers and non-profit foundations.

C. Adjustment of land use regulations and property taxes to incentivize opening of home care businesses.

Selected References:

"Addressing San Francisco's Vulnerable Post-Acute Care Patients: Analysis and Recommendations of the San Francisco Post Acute Care Collaborative," final draft for December 2017; Hospital Council of Northern and Central California.

"20/20 Foresight: San Francisco's Strategy for Excellence in Dementia Care" (parts one and two), by Alzheimer's/Dementia Expert Panel for the Department of Aging and Adult Services, December 2009.

Teresa Palmer, MD, is a Geriatrician who formerly served at Laguna Honda Hospital

December 2017

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parking tickets for RVs on Winston

RV residents on Winston Drive face uncertain future

by Thomas K. Pendergast

A four-hour parking limit is going to make things even more difficult for RV residents.

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