Westside Observer
October 2009, at

Laguna Honda’s Unkindest Cut
by Patrick Monette-Shaw

Efforts underway to de-skill Laguna Honda Hospital’s (LHH) doctors and certified nursing assistants is the unkindest cut of all: Cutting medical care. De-skilling nursing home staff often precipitates a slide into substandard healthcare.

When newspapers reported the tragic murder–suicide at Oakland Springs Health Care Center nursing home involving a mother in failing health killing her brain-injured daughter, I was reminded of the Observer’s September staff report about LHH’s identity crisis and the so-called “Ja report” — which recommends replacing LHH’s doctors with nurses, psychologists, and social workers in order to increase mental health and substance abuse services at LHH.

Diana Harden had filed a series of complaints over the care of her daughter Yvette at Oakland Springs, which unlike Laguna Honda is a “free-standing” nursing home (one not affiliated with a hospital). But like LHH, Oakland Springs has had more than its share of complaints lodged with the State. Among the 152 complaints against Oakland Springs in the past five years, several involved residents waiting days or weeks to receive medical care. A common thread linking the two stories is the need for sufficient in-house physician staffing in nursing homes.

“Traveling” doctors serving free-standing nursing homes like Oakland Springs are only authorized to visit patients monthly, or every 60 days, unless patients have a documented medical necessity. Traveling MDs carry huge case loads, often covering more than one free-standing nursing facility.

By contrast, LHH has a staff of in-house MDs with relatively manageable case loads. LHH’s consistent physician staffing provides clinically-meaningful relationships with patients. LHH, to its credit, has never received licensing complaints involving residents having to wait weeks to receive medical care. At LHH, Yvette Harden would have been referred to its traumatic brain injury program.

The Ja report suggests replacing in a cost-neutral way supposedly “higher salaried” physicians with (ostensibly lower-paid) nurses, psychologists, and social workers, but fails to discuss how this will be done cost neutrally.

Salary data from the City Controller shows that in 2008, LHH had 21 physicians on staff involved in direct patient care, paid $2.9 million in total pay. By contrast, LHH had 37 nurse managers, clinical nurse specialist’s and nursing supervisors not involved in direct patient care, paid $5.2 million in total pay. The highest paid clinicians were three psychiatrists paid $600,000 in total pay, including $173,000 in “other pay” for carrying pagers as on-call staff; one of them is only a half-time psychiatrist, despite his pay. Only nine physicians earned more than $150,000; all three psychiatrists and 23 of the nurses did, due to overtime and “other” pay. Ja’s assertion LHH physicians are higher paid is erroneous.

In March 2009, the professional journal Annals of Internal Medicine published a peer-reviewed article about nursing home physician specialists, in which it noted that the quality of care in nursing homes is directly linked to physician practice, particularly for nursing home residents who have complex, multiple, comorbid conditions; chronic illnesses; and functional limitations. The article acknowledged a direct association between having physicians on staff, and the enhanced quality of care provided to residents, resulting, in part, from physicians knowledgeable about long-term care practice. Ja mentions none of this.

The Ja report recommends increasing LHH’s SATS (Substance Abuse Treatment Services) staffing, but presents scant evidence of need. It notes there were 348 SATS referrals between April 2006 and December 2008, but didn’t analyze the significance. Assuming a constant rate of referrals, the total is approximately 130 SATS referrals annually. During Ja’s study period, LHH had four SATS staff members; this translates to approximately 32 referrals per SATS staff annually. How does this compare to benchmark caseloads at similar facilities? Is it a valid rationale for Ja’s recommendation to increase behavioral staffing while cutting physicians? Does Oakland Springs employ SATS staff, whether “traveling” or otherwise?

Nowhere in the Ja report is there any analysis of caseloads for either physician or “behavioral health” staff, as if this wasn’t even considered before recommending reducing medical staff and increasing behavioral staff. From a Human Resources perspective, it’s inconceivable caseload benchmark levels at comparable facilities wasn’t evaluated.

Similarly, Ja presents no data whatsoever about the volume of services provided by physicians to the 1,263 residents in LHH’s medically-ill “control group” before recommending doctor positions be reduced. If one goal of Ja’s report was to assess capacity and needs at LHH and in the community that either discipline is able to provide, an impartial analysis of quantitative data regarding volumes of workloads in both disciplines is missing from the Ja report.

The Ja report wrongly claims LHH certified nursing assistants (CNAs) have not received training on de-escalating behavioral problems; he apparently wasn’t told CNAs already receive SMART and specialized dementia training, but he recommends increasing CNAs skills even though their pay is being drastically cut. The City has issued layoff notices effective November 15 to 289 CNAs, almost all of them at LHH. An unknown number of new “Patient Care Assistant” positions paid 20 percent less than CNAs will be created as part of the de-skilling of LHH staff. In addition, LHH has cut another 18 CNA positions and is replacing them with “Home Health Aides” paid 35 percent less. Some LHH residents have already voiced concern about how this may affect their quality of care.

Among Ja’s “study group” of patients with behavioral health needs, 31 percent died; among the “control group” of people with chronic illnesses, 45 percent died. Across the two groups, nearly 40 percent died either at LHH or post-discharge. This suggests both groups were severely medically ill and in need of medical care, which Ja all but ignores, since he didn’t discuss the medical reasons patients are admitted to LHH. He also failed discussing how either group is to access both medical and behavioral care post-discharge.

Rather than recommending augmenting existing medical staff at LHH by adding behavioral health staff, the Ja report recommended a “replacement” approach to subtract medical staff and shift resources from medical services to behavioral services in order to remain “cost neutral.” This is poppy-cock, and may involve actual, or perceived, conflicts of interest from not adequately acknowledging his personal relationships with staff employed by the City’s Community Behavioral Health Services department which commissioned the Ja study.

Insufficient availability of medical care at Oakland Springs Health Care led to a tragic murder–suicide. Subtracting physicians and certified nursing assistants at LHH — both of whom provide direct patient care — is not the answer, and may lead to increased rates of premature mortality. Is this really what we want for San Franciscans who rely on LHH for part of their medical care?

Twenty LHH physicians signed a resolution rejecting the Ja report’s recommendation to reduce physician staffing, due to Ja’s bias, inadequate data, flawed methodology, and lack of professional qualifications to assess physician services at LHH. You can join them by contacting Mayor Gavin Newsom and Supervisor Sean Elsbernd and urging them to reject the Ja Report recommendations.

Patrick Monette-Shaw

Monette-Shaw, an accountability watchdog, operates



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