Miraloma Park Improvement Club Newsleter

January 2010

Published as "Questions Laguna Honda Needs to Answer"]
Westside Observer
February 2010 at

The full two-part article planned for the January 2010 and February 2010
Miraloma Park Improvement Club’s Newsletter is presented below.

Laguna Honda Hospital Policy Questions
by George Wooding

Policy decisions regarding Laguna Honda Hospital (LHH) are going on behind the scenes that Miraloma Park residents and the City’s voting public aren’t aware of, since the City doesn’t want to use the hospital for purposes presented to voters in 1999 to gain passage of the bond measure to rebuild LHH — and now doesn’t want to tell you about.

At its November 23 meeting, the West of Twin Peaks Central Council (WOTPCC) was presented with an update of Laguna Honda’s changing mission.

During the past ten years of planning and construction, LHH’s project scope has changed multiple times, including cutting 420 of LHH’s planned 1,200 beds, eliminating another 200 assisted living units for people needing a lower level of care, and chopping the Adult Day Health Center for elderly residents with dementias unsafe to stay in their own homes during the day, among other changes. Now, just four months before the new hospital is scheduled to open, LHH appears to be changing the type of patients it will serve, even though construction is all but complete. It’s not even clear whether LHH will continue to call itself a hospital, after spending almost $600 million to rebuild a facility with an initial $401 million budget.

When the City pitched the LHH rebuild bond in 1999, its entire advertising campaign claimed to be helping frail elderly and severely disabled San Franciscans. When 73% of voters passed Proposition A, they thought they were voting to rebuild a nursing home for indigent elderly and disabled San Franciscans. Now that the rebuilt hospital is almost completed, the Department of Public Health (DPH) is planning to add mental health and substance abuse patients at the eleventh hour.

LHH is not, and has never been, a psychiatric facility, and doesn’t have a psychiatric license. But DPH is actively planning to mix in a large number of younger, “behavioral health” patients with LHH’s current population of elderly adults with chronic, complex, and progressive medical conditions. (“Behavioral health” is defined as providing both mental health and substance abuse treatments).

Heretofore, LHH admitted patients with physical medical conditions needing medical and nursing treatment or rehabilitation. Patients with secondary psychiatric problems were also treated, but their primary diagnosis had to be medical in nature for admission. LHH is once again contemplating discarding its long-standing “medical model of care” and embracing a psychosocial rehab, or “social wellness,” model of healthcare (which was introduced in 2003, but failed miserably in 2004) that relies less on medical doctors and more on psychologists, social workers, and nurses. What we really don’t know is what a “social model” of care even is, which nobody seems capable of adequately defining. This is one of the jargon-war terms that DPH’s administrators throw around whenever they want to claim LHH’s model of care is too “medical,” asserting “medical” is bad but that they know what is good for us.

This is the second time LHH has tried to add psychosocial programming at the expense of the elderly. In 2003, Mitch Katz, the Director of Public Health, overrode LHH’s admissions policy by sending a variety of younger, ambulatory patients from San Francisco General Hospital (SFGH) to LHH. Katz claimed huge economic and political pressure to unload SFGH patients into LHH, dubbing the plan as a “flow project.” Back then, and still today, there has been stunning dishonesty with the public about the flow project, which “flow” appears to be a key component of Mayor Newsom’s “10-Year Plan to End Homelessness” by sweeping the homeless into LHH.

Many of the younger patients suffered from substance abuse or mental health issues, and elderly LHH patients were not only displaced out of the facility and dumped out-of-county, they were harassed and attacked by the behavioral patients. LHH staff were attacked, a wing of LHH was deliberately set on fire, and there was a fire set at the Laguna Honda reservoir. LHH was completely unprepared for these new patients, since staff had little training and LHH employed only two security guards. No resources were allocated to manage these behaviorally-troubled, younger, male patients dumped into LHH with nowhere else to go.

Hospital conditions were so disrupted the U.S. Department of Justice became involved, mandating specific types of patient care and treatment to prevent “institutionalizing” behavioral patients. LHH doctors and patient advocates reached out to community neighbors, and neighborhoods such as Miraloma Park became so vocal that Mayor Newsom ordered Dr. Katz to reinstate LHH’s pre-flow project admission policies, end the flow project, and resume LHH’s previous patient demographics, which the Board of Supervisors now monitors.

LHH is about to reinstate the 2003 flow project by adopting findings from DPH’s new “Ja Report,” which recommends rehabilitating behavioral health patients at LHH, reducing the number of LHH’s doctors, increasing behavioral health staffing, and expanding transitional behavioral health beds. The Ja Report states: “There is a great concern over patient and staff safety due to a mixing of high-level substance abuse and mental health patients with older lower-level patients in open units. We recommend some type of separation.”

Interestingly, the Ja Report didn’t consider the safety of surrounding neighborhoods. Its only mention of LHH’s surrounding neighborhoods was:  “The Ja report recognizes that local neighborhood and community concerns have been raised regarding the role of LHH with mental health and substance abuse patients. However, it is critical that the appropriate balance be struck between neighborhood concerns and the necessity for LHH to respond to the needs of the entire city and DPH as a whole.” Actually this statement is a lie. Virtually no one in the surrounding neighborhoods is aware of plans for the “new” LHH, since LHH hasn’t held a public meeting with any neighborhood organization about its potential population changes and probably won’t, unless they are pressured to do so. Instead, LHH offers tours of the new facility, but won’t hold town hall meetings to discuss substantive changes to its patient population or accountability of its bond expenditures.

The Ja report wrongly claims LHH needs to improve its interdisciplinary care. This recommendation is a red herring, since in 1986, then Mayor Dianne Feinstein’s Blue Ribbon Committee on LHH recommended changing from LHH’s old “nursing model of care,” by increasing the number of certified nursing assistants, doctors, social workers, and activity therapists working more collaboratively as an interdisciplinary team with the nurses, and adding an Ethics Committee and a hospice program. LHH has been using an interdisciplinary model of care for over two decades, utilizing medical doctors as a central component. Since 1999, LHH has added 20 new positions in its physical medicine rehabilitation department, including physical, occupational, and speech therapists, and restorative care aides. The bottom line? Now, in the absence of a new Blue Ribbon Committee on Laguna Honda, the Ja Report recommends LHH add psychologists and remove (fire) its medical doctors. This would be a step backward to the uni-disciplinary nursing model of care the DOJ objected to in 1998.

The Ja Report raises the possibility that LHH’s license will be changed to a hospital-based nursing home to formalize SFGH’s control over Laguna Honda’s mission, ending any possibility that Laguna Honda will serve the elderly from all over the City. Indeed there are some who believe the Ja report is designed to provide “cover” to allow Dr. Katz to unilaterally determine LHH’s role in providing behavioral health care, and once again change LHH’s mission using another flow project. This is something we all must watch out for and oppose.

San Francisco has inadequate discharge locations for behavioral health patients. In July 2004, DPH shut down San Francisco’s only long-term care psychiatric facility, the Mental Health Rehabilitation Facility (MHRF), closing 145 psychiatric beds. To defend its closure of the MHRF, DPH officials cited the 1999 U.S. Supreme Court’s Olmstead decision that “mental patients should be able to live in less restrictive community based settings, rather than in locked hospitals, if they are medically able to.”

The real challenge for DPH is the Chamber’s lawsuit settlement agreement. The 2007, Chamber’s agreement limits LHH to 780 beds (City officials deny this) and basically forces LHH to place residents back into the community as quickly as possible. The goal of the lawsuit is to keep patients from living in an institution, specifically not at LHH. Almost all of LHH’s behavioral health patients will come from SFGH. LHH, an institution which used to be autonomous, is now controlled by SFGH. Under Newsom, LHH has quickly become cheaper housing for indigent patients that SFGH needs to release but can’t place back in the community. Under terms of the Chamber’s settlement, many of these behavioral health problem patients should be placed directly back into the community and treated using community-based services. Unfortunately, the City has nowhere to house them and sends them to LHH, ostensibly for rehabilitative or “habilitative” treatment. After behavioral health patients have been “rehabilitated” at LHH, the City still has nowhere to place them in the community. Over time, LHH’s behavioral health population will expand at the expense of LHH’s geriatric patients too ill, demented, or recovering from strokes to be cared for at home.

The bed that once was used for grandma’s long-term care will now be filled by a behavioral health patient. Who will bring their mom or their grandma to LHH for stroke rehabilitation, when it becomes known that there are hundreds of younger, unruly substance abusers wandering around LHH’s campus?

As LHH stockpiles behavioral health patients, it will be in direct violation of the Chamber’s settlement agreement. LHH is becoming the safety valve for San Francisco’s indigent mental health and substance abuse patients. San Francisco voter’s never expected LHH would become a “behavioral health” hospital, and this isn’t why we voted for the LHH bond measure. What will happen to San Francisco’s geriatric and disabled patients needing long term care who can no longer be placed at the hospital and who can’t be cared for safely at home?

While City government has a strategic goal of increasing transparency and accountability, Mayor Newsom appears to be hiding behind the skirts of LHH’s new administrator, Mivic Hirose, who offers tours, but not answers to compelling questions about LHH’s mission, policies, or bond spending.

To be a good neighbor and a responsible institution, LHH needs to immediately start talking with its neighbors about LHH’s future patient population plans. We don’t know what population LHH intends to serve when it opens just four months from now, and whether LHH will be serving geriatric patients with chronic medical illness, or psychosocial patients with mental illness and substance abuse needs.

We don’t need more broken promises over how Laguna Honda bond money is being spent. We do need greater transparency — and a new Blue Ribbon Committee for LHH — to address Laguna Honda’s unanswered policy questions.

George Wooding
West of Twin Peaks Central Council



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