Printer-friendly PDF fileDecember 8, 2024
Unelected Health Commissioners Tried Changing LHH’s Mission — Again
Say Good-Bye to Long-Term Care at Laguna Honda Hospital and Rehabilitation Center?
The Deception Behind Attempt to Change Laguna Honda’s Mission
by Patrick Monette-Shaw
On December 3, 2024 the seven-member Health Commission — who are not elected by the voters — tried again to change Laguna Honda Hospital’s mission by removing the reference to the facility providing both long-term care and rehabilitation services to San Franciscans.
It was a huge, pathetic miscalculation, borne of a misunderstanding of San Franciscans’ deep-seated belief in preserving the 150-year history and mission of Laguna Honda to provide San Franciscans who need long-term, and custodial, care at LHH.
The Commissioners had clearly not understood the depth of passion of San Franciscans.
Luckily, Health Commissioner Susan Belinda Christian, J.D. herself raised passionate testimony to her follow Commissioners, and announced during the December 3 meeting she would not vote to approve the mission change.
Christian is an Assistant District Attorney in San Francisco, and is the DA’s Managing Attorney for the Collaborative Courts and Mental Health Unit. She was appointed to the Health Commission in 2020.
Christian’s opposition to the proposal to change LHH’s mission statement in the Health Commission’s By-Laws for LHH resulted in continuing — postponing — the proposal to the Commission’s December 17 meeting, promising amendments will be made to clarify LHH’s mission will continue to include provision of long-term care and rehabilitation services.
Past Is Prologue — Again
Eternal vigilance over LHH’s mission must be sustained going forward, because this is not the first, or last, time that SFDPH and LHH managers will keep periodically trying to eliminate provision of long-term care at Laguna Honda.
Back in 2004, San Francisco’s Department of Public Health unilaterally changed Laguna Honda’s admission policy. Following a public outcry — and a year-long policy fight mounted by healthcare advocates and San Francisco residents — then-Mayor Gavin Newsom eventually ordered the then-Director of Public Health, Mitchell Katz, MD in 2005 to return the changed admission policy back to its pre-2004 version to preserve providing long-term care and custodial care.
Then, true to form, by June 2, 2007 Katz was back at it and changed LHH’s mission statement again, and specifically removed from the definition of “skilled nursing services” that it included long-term care for residents who cannot be cared for in the community and/or short-term care for those who can be rehabilitated and discharged to a lower level of care within the community.
Surely, SFDPH and LHH managers must know by now that those of us who can speak out are watching them, and will keep watching what they are trying to do to eliminate long-term care at LHH.
Unfortunately, eternal vigilance will apparently always need to remain on guard, because immediate intervention and collaborative leadership skills of Mayor London Breed, Board of Supervisors Aaron Peskin, and the other ten members of the Board of Supervisors has been completely missing in action. That leadership by actual elected public officials is urgently needed to stop the nefarious change to the mission of Laguna Honda Hospital and Rehabilitation being considered by San Francisco’s unelected Health Commission on December 3, 2024 proposing to eliminate providing both long-term care and rehabilitation from LHH’s mission.
Health Commission’s December 3 Flawed Proposal
Agenda Item # 6, “Amendments to the LHH Governing Bylaws” on the Health Commission’s December 3 meeting agenda proposed to make major changes to Laguna Honda’s mission and purpose. The principal changes were:
ARTICLE III: MISSION, VISION, AND VALUES OF THE HOSPITAL
Section 1. Mission and Purpose
The mission of the Hospital is to provide high quality, culturally competent long term care a welcoming, therapeutic. and rehabilitation services to healing environment that promotes the diverse population individual’s health and well-being. The purpose of San Francisco the hospital is to serve as a safety net for patients with complex medical needs who are low or very low income and often have no other options for care.
Section 2. Vision
The vision of the Hospital is to become a world class center of excellence build healthier lives as the leader in long term post-acute care and rehabilitation.
Section 3. Key Value
The key value of the Hospital is: Residents come first resident centered care.
The proposed nefarious by-laws changes were completely bonkers. It’s hard to know whether to laugh or cry.
Mayor Breed’s Grandmother and Other Prominent LHH Residents
As the San Francisco Examiner reported on August 16, 2023, Mayor London Breed's grandmother lived at Laguna Honda Hospital and Rehabilitation Center in San Francisco for almost 13 years. The Examiner quoted Breed as having said:
“My grandmother lived here for about close tauthoredo 13 years. To think that there are other people who couldn’t get this care was heartbreaking for me because this was a lifesaver for me personally, for me and my family.”
Clearly Laguna Honda Hospital provided long-term care to Mayor Breed’s grandmother for well over a decade. If they could provide that long-term care then, when can’t LHH continue providing that long-term care now?
Another prominent LHH resident was former Health Commissioner Naomi Gray. The San Francisco Chronicle reported Commissioner Gray was appointed by former San Francisco Mayor Dianne Feinstein to San Francisco’s first-ever Health Commission in 1985, and served two four-year terms on the Commission. Gray was considered among “the Who’s Who of strong black women” in the City.
In the summer of 2006, while a patient at Laguna Honda Hospital, Gray strongly supported the November 2006 ballot measure to protect Laguna Honda Hospital as a long-term skilled nursing facility in the citizen-led ballot effort to prevent then Director of Public Health Mitchell Katz, MD from turning LHH into a “psychosocial rehabilitation facility for the urban poor,” and turning LHH into a facility to replace the Mental Health Rehabilitation Facility (MHRF) on the campus of SFGH, which Katz had managed to close as a behavioral health facility. Katz had sought to turn LHH into a behavioral health facility, along with then Health Commissioners Jim Illig and Edward Chow’s support, not a long-term Skilled Nursing Facility (SNF) serving the elderly and disabled.
Now the Health Commission is at it again trying to eliminate long-term care and rehabilitation services at LHH. As they say, the past is often prologue.
Gray was 84 when she died on December 29, 2006 at Laguna Honda Hospital after a series of strokes. Had she lived, she would strongly oppose the current crop of Health Commissioners, led again, in part, by Commissioner Edward Chow, MD to drastically alter LHH’s mission and vision. Chow has served continuously for 35 years on the Health Commission since his appointment in 1989. Chow was a Commissioner when Katz tried to change LHH from a long-term care facility back in 2005 and 2006 to a “psychosocial rehabilitation facility for the urban poor.” Chow’s still there, repeating the past as prologue. Time he be replaced on the Health Commission!
LHH’s 1994 Institutional Master Plan
LHH has provided long-term care for over 150 years. A document titled “LHH Master Institutional Plan” authored in 1994 by San Francisco’s Department of Public Health was used, in part, as part of the original EIR (Environmental Impact Report) used to analyze the CEQA implications of the LHH rebuild project between 2007 and 2020, funded by the 1999 general obligation bond passed by voters. That report, and the 2016 report “Framing the Post-Acute Care Challenge” also authored by SFDPH, both recognized LHH’s decades long role in providing long-term care at LHH.
The “Mission Statement” section of the “Institutional Master Plan,” stated that for over 125 years, San Franciscans have relied on Laguna Honda Hospital as the main provider of the City’s long-term health care services. Committed to serving citizens regardless of their ability to pay, the Hospital has offered quality care and a source of security to generations of elderly and disabled. To continue the City’s policy of providing high quality long-term care into the 21st Century, it was necessary to rebuild Laguna Honda Hospital with seismically-safe structures that meet current standards.
The “Master Plan” noted that in 1867 the site of the future Laguna Honda Hospital had been acquired by San Francisco, and in 1867 a municipally financed shelter for the homeless was constructed on the site. The report noted LHH plays a vital role as the “provider of last resort” for long term care in San Francisco, and is the largest municipally owned long-term care institution in the nation. The “Master Plan” noted the plan for the future of LHH must create the best “fit” between the long-term care needs of the residents of the City and the services able to be provided by the Hospital.
Impact of Changing LHH’s By-Laws
What’s at stake involves the by-laws of LHH’s so-called “governing body,” the Health Commission. The Commission suddenly sprung these by-laws changes, which eliminates providing both long-term care and rehabilitation services at Laguna Honda. Both are being replaced by an ill-defined concept called “post-acute care,” but only for those who have “complex medical needs.”
The proposed by-laws changes being considered on December 3 redefines the mission of Laguna Honda Hospital and Rehabilitation Center as providing “post-acute care” — which implies that only short-term care will be available. The proposed by-laws repeatedly delete “long term (nursing home) care.”
By definition, that means patients would first need to be admitted to an acute-care hospital before they could be eligible for admission to LHH. And if they don’t have complex medical needs, they may not be eligible for admission to LHH at all. How does this help patients struggling at home who used to be admitted for long-term care without having to go through an acute care hospitalization first?
This would all but eliminate patients being cared for at home for admissions eligibility, without first requiring an acute-hospital admission that may be unnecessary for those who need 24/7 skilled nursing and custodial level of care. By focusing only on “complex medical needs” patients, it could conceivably eliminate patients with palliative care, memory care, HIV/AIDS care, or “total support” chronic care needs, in additional to patients needing physical medicine rehabilitation, given the deletion of rehabilitation services in the proposed by-laws changes.
This will be a disaster for elderly or disabled San Franciscans who require a nursing home setting for safety and survival. In fact, a majority of residents of Laguna Honda at this time are long term nursing home patients, due to the long moratorium on new admissions and the slow rate of resuming admissions.
Presumably, when admissions to LHH were halted between April 14, 2022 and June 19, 2024 patients needing physical medicine rehabilitation admission to LHH’s 49-bed skilled nursing rehabilitation unit and its 5-bed acute rehabilitation unit had to go to an out-of-county rehabilitation facility for short-term rehabilitation, if they couldn’t locate a facility in San Francisco for rehabilitation admission.
LHH’s current census as of November 22 is just 425 patients occupying LHH’s 769-bed skilled nursing units. Despite the admissions of 28 new patients between July and October, LHH had a reduction of 22 residents during the same period (11 due to discharge from the facility, and 11 patient deaths in-house). That involved a net gain of just six residents over four months to a census of 423 patients. In November, LHH’s census increased two more to 425, which is 285 fewer residents than the 710 patients it had on October 14, 2021 prior to decertification.
As for LHH’s 11-bed acute care hospital units regulated by Title 22, on November 22 LHH had just two acute care patients, both in its six-bed medical acute unit and zero paients in its five-bed acute rehabilitation unit.
While short term “post-acute” care is an important function of the hospital, so too is long-term nursing home care for those who need to live for a long period, or permanently, in a skilled nursing home setting. At last official count, LHH provides approximately one-third of all Skilled Nursing Facility (SNF) nursing home beds in San Francisco.
But the “Framing the Post-Acute-Care Challenge” report authored by the San Francisco Department of Public Health issued in February 2016 documented that of the then mere 992 long-term care skilled nursing beds in San Francisco, LHH provides 67.4% (669) of the long-term care beds, while the Jewish Home provides the remaining 32.6% (323.)
No one wants to live in a nursing home who can do well elsewhere, but for some San Franciscans long-term nursing home residence is necessary for quality and length of life. It is unacceptable for unelected Health Commissioners — as an oversight body of our public nursing home — to approve a “mission statement” that may lead to rejecting admission of San Franciscans who might need to reside at LHH for long-term periods.
These Health Commissioners were not elected to change the 150-year-old mission of Laguna Honda Hospital — particularly without the consent of voters. After all, voters passed the LHH rebuild bond in 1999 with 73% of voter approval after specifically being told the rebuild of LHH authorized providing long-term care to San Franciscans. Was that a bait-and-switch ploy to get voters to pass the rebuild bond that can now be dispensed with? How dare this Commission change the will of the voters now, after the rebuilt LHH opened in June 2010!
This is a massive back door betrayal. It deserves a powerful, unified response from the community in opposition and outrage, in part because as an opening salvo of eliminating long-term care and rehabilitation care from LHH‘s mission statement it opens up the barn door to the Health Commission coming back in future months and revising LHH’s admission policies and admissions priority groupings based on a revised mission statement — to specifically exclude patients who may need, and a have a prognosis of needing, long-term care. Will their need for long-term, or physical medicine rehabilitation, care become an automatic, disqualifying exclusion criteria preventing admission? Don’t be fooled by this gambit!
Out-of-County Patient Dumping Will Worsen
As you may remember, in 2022 then District 4 Supervisor Gordon Mar successfully introduced and managed to get passed Ordinance #77-22 requiring all San Francisco public- and private-sector hospitals report their out-of-county discharges to just sub-acute SNF’s and regular SNF’s to San Francisco’s Department of Public Health annually. Mar’s legislative-intent with Ordinance #77-22 was that meaningful analysis of the out-of-county discharge data is critical and desperately needed to inform healthcare Master Planning citywide.
SFDPH’s 31-page report for 2021 and 2022 and its 31-page report or 2023 of the out-of-county discharge data revealed that somewhere between 2,518 and 9,153 San Franciscans were discharged across calendar years 2021, 2022, and 2023 to out-of-county facilities for routine Skilled Nursing Facility (SNF) level of care. The three-year total is more probably around 6,000 San Franciscans, because CPMC claims its electronic health records system — Epic — is unable to track in-county vs. out-of-county discharge destination locations. The reports do not break out how many of the San Franciscans discharged out of county had required placement in a facility for long-term skilled nursing level of care.
But with the Health Commission’s sudden proposed change to LHH’s by-laws to eliminate providing long-term care, it will almost certainly lead to additional San Franciscans being “granny dumped” out of county and will substantially worsen.
What Prompted Health Commission’s By-Laws Change
On November 22, Health Commission’s Executive Secretary Mark Morewitz pushed out an e-mail alert announcing a “Notice of Intent Regarding LHH Governing Body Bylaws” that would be considered by the full Health Commission to amend LHH’s by-laws during the full Health Commission’s December 3 meeting as part of its regular meeting agenda.
Morewitz’s e-mail alert indicated the proposed by-laws changes would become available for review on November 27, but if anyone “wishing to receive additional information” had questions they could call him. So, I called him on November 22.
I began by asking if Morewitz could summarize the proposed by-laws changes. He said he saw the first draft several weeks ago, but his memory was they were minor changes. He volunteered that there was nothing “nefarious” (his choice of words) with the changes, and said LHH leaders had asked for the review and potential revisions.
Naturally inquisitive, I asked why LHH’s leaders were involved. Mark said they wanted to ensure the by-laws as the governing body are refreshed and updated to align with regulatory requirements (meaning Federal and State regulations). So, then I specifically asked if there were specific LHH policies being reviewed, too, that might affect LHH’s admissions policies. Mark answered “No,” the by-laws revisions weren’t including any admissions processes.
While technically correct that no specific LHH policies were being considered on December 3, when the proposed by-laws changes were made public on November 27, turns out Morewitz was being disingenuous. At best.
It’s abundantly clear the by-laws changes are poised to drastically — and nefariously — alter LHH admissions, mission, and policies. Turns out they were nefarious, and not “minor” changes that may well change LHH’s admissions policies.
The Health Commission’s by-laws mission change was a nefarious pretext to eliminate providing long-term care and rehabilitation services at LHH. It’s a pretextual effort ostensibly aimed at ensuring the by-laws of LHH’s governing body are refreshed and updated to align with regulatory requirements (meaning Federal and State regulations).
But as it turns out, this is pretextual precisely because Federal and State regulations do not mandate or require that nursing homes cease providing long-term care to nursing home residents. It’s a complete ruse!
December 3 Proposal Punted to December 17 Meeting
During the hearing on December 3, various Commissioners thanked members of the public repeatedly for providing testimony opposing the By-Laws proposed changes. As indicated, Commissioner Christian was clearly adamantly opposed to accepting the proposed By-Laws amendments.
Christian pointedly peppered LHH managers about why there was a push to amend the By-Laws so rapidly.
Lamely, Troy Williams, a nurse by training who rose through the ranks of SFGH and the San Francisco Health Network (SFHN) management positions as the “Chief Nursing Officer” and “Chief Quality Officer” for SFHN, lamely claimed that LHH is facing an upcoming licensing survey inspection of LHH’s 11-bed acute hospital units — just a six -bed medical acute unit plus a five-bed “acute rehabilitation” unit. [Again, of those 11 acute-care beds there were just two patients in LHH’s acute medical unit on November 22, and zero patients in the acute rehab unit, compared to just 425 patients in LHH’s remaining 769 skilled nursing beds.] Williams appeared to be focused on just those two acute-care patients!
Williams — clearly unhappy with the potential delay in adopting the proposed By-Laws changes on the spot — stated that LHH last had an acute licensing survey in 2019, and the re-survey could happen any day now. Williams resorted to threats of survey “consequences,” stoking “they’re at the door” fears that there was “potential vulnerability” to passing the acute survey licensing if the amendments were postponed for a mere two weeks, or until the Health Commission’s January 7, 2025 meeting. It was a smokescreen that Commissioner Christian clearly wasn’t buying.
Luckily, a Deputy City Attorney providing advice to the Health Commissioners on December 3 eventually reassured the Commissioners that continuing the agenda item to the Health Commission’s November 17 meeting was no big deal, suggesting Williams had been crying wolf.
Only due to Commissioner Christian’s astute line of questioning on December 3 did it become clear the By-Laws amendments that apply to LHH’s entire facility were promulgated to focus only on the 11-bed acute hospital license, not LHH’s 769-bed skilled nursing facility license. The changes were driven by Title 22 regulations, when in fact, other Federal and State regulations apply to the 769 skilled nursing beds. Eliminating long-term care and rehabilitation services from the 11-bed acute hospital license to comply with Title 22 was ridiculous on its face and clearly a pretext.
During the December 3 meeting, the Health Commission was reminded that its acceptance of the Hospital Council of Northern and Central California’s “Post-Acute Care Challenge” report in February 2016 had led directly to the change in the by-laws to focus on “post-acute care.” This was under Director of Public Health, Grant Colfax and Health Commissioner Ed Chow’s so-called leadership!
They had removed nursing home care from LHH’s mission and vision statements in 2016, oblivious to San Franciscans who do, or may eventually, need long-term care in a nursing home. Their actions in 2016 had been a “bait and switch” that most San Franciscans didn’t even know had been foisted on them.
Thanks to the many members of the public who submitted oral and written testimony to the Health Commission on December 3, the Health Commission finally agreed that the by-laws presented for a vote needed to be clarified and improved, to reassure the public and to clarify to all that high quality long term nursing home care is part of LHH’s mission. Additional amendments to the proposed By-Laws language will be presented at the Tuesday, December 17 Health Commission meeting at 4:00 p.m.
Like the “flow project” of SFGH patients to LHH that started in 2004 that eventually resulted in LHH’s decertification and halt of new admissions for 26 months starting in April 2022, this is obviously the result of SFDPH bosses who think they know more about acute hospitals and revenue generation from Medicare (which pays for post acute care) than they do about skilled nursing facilities and long-term care and custodial care which is only reimbursed by Medi-Cal and cash. It’s almost as if senior SFDPH managers don’t care about elderly, medically complex, and poor disabled patients who need long-term care.
LHH Policy “#01-00, “Value(s), Mission, and Vision Statement,” also revised January 12, 2016 had removed “rehabilitation services” from LHH ‘s mission statement, in favor of the nebulous term “post-acute care.”
On January 17, this Health Commission should consider amendments both to the “LHH Governing Body By-Laws” policy and to Policy # 01-00, and mirror the language to include the expanded definition of “post-acute care” to specify it includes long term care, skilled nursing care, and rehabilitation services in both policies.
There is no good reason not to revise both policies concurrently in order to have them match one another.
In addition, there is no valid reason for the “Governing Body By-Laws” to not state explicitly for both acute licensure surveyors and Medicare/Medi-Cal (e.g., CMS and CDPH) surveyors that the Governing Body By-Laws apply to both LHH’s 769 SNF beds, and its tiny 11-bed acute units. There’s no reason to have to have two separate sets of by-laws to comply with the artificial concerns SFHN’s Chief Quality Officer Troy Williams raised on December 3 (clearly as misguided Zen and the Art of Motorcycle Maintenance “sand in the eyes of the bull”).
All the Health Commission needs to do is add appropriate sub-headings in the By-Laws document to point out to various inspection surveyors that a single “Governing Body By-Laws” applies to both LHH’s SNF bed mission and its acute-bed mission to satisfy both CMS/CDPH and Title 22 acute-care facilities legalese.
This isn’t rocket science, after all! It’s simple secretarial and wordsmithing edits to make.
And if Mayor Breed and Board President Aaron Peskin can’t use their political influence to get the Health Commission to do the right thing and restore “long-term care” to LHH’s mission statement by the end of 2024, then that should be the first order of business for Mayor-elect Daniel Lurie! He could start by replacing all seven Health Commissioners, if necessary.
Monette-Shaw is a columnist for San Francisco’s Westside Observer newspaper, and a retired City employee. He received a James Madison Freedom of Information Award in the “Advocacy” category from the Society of Professional Journalists–Northern California Chapter in 2012. He’s a member of the California First Amendment Coalition (FAC) and the ACLU. He’s a Childless (and catless) Cat Daddy, and voter for 50 years. Contact him at monette-shaw@westsideobserver.com.