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