
Unelected Commissioners Try Changing LHH’s Mission — Again
Good-Bye to Long-Term Care at Laguna Honda Hospital?
The Deception Behind the Attempt to Change Laguna Honda’s Mission

Monette-Shaw
• • • • • • • • • • December 2024 • • • • • • • • • •
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 clearly did not understand the depth of passion of San Franciscans.

Susan Belinda Christian, J.D.
Luckily, Health Commissioner Susan Belinda Christian, J.D., raised passionate testimony to her fellow Commissioners and announced during the December 3 meeting that 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 Bylaws for LHH resulted in continuing — postponing — the proposal to the Commission’s December 17 meeting, indicates that amendments will likely be made to clarify that LHH’s mission will continue to include the provision of long-term care and rehabilitation services.
Past Is Prologue — Again
Eternal vigilance over LHH’s mission must be sustained going forward. This is not the first or last time that SFDPH and LHH managers will keep periodically trying to eliminate 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 — in 2005, then-Mayor Gavin Newsom eventually ordered the then-Director of Public Health, Mitchell Katz, MD 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 San Franciscans who can speak out are watching them and will keep watching what they are trying to do to eliminate long-term care at LHH.
The immediate intervention and collaborative leadership skills of Mayor London Breed, President Aaron Peskin, and the other ten members of the Board of Supervisors have been completely missing in action. That leadership by actual elected public officials was urgently needed to prevent changing the mission of Laguna Honda Hospital that San Francisco’s unelected Health Commission considered on December 3, 2024.

The Mission Statement 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.”
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 that is welcoming, therapeutic, and rehabilitation services to a healing environment that promotes the health and well-being of a diverse population. 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 and 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 that residents come first, and it is a resident-centered care facility.
Mayor Breed’s Grandmother and Other Prominent LH 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 to 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.”
Why 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 that Commissioner Gray was appointed by Mayor Dianne Feinstein to San Francisco’s first-ever Health Commission in 1985. She 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.
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 drastically altering LHH’s mission and vision.
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 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. It was necessary to rebuild Laguna Honda Hospital with seismically safe structures that meet current standards to continue the City’s policy of providing high-quality long-term care into the 21st Century.
The “Master Plan” noted that in 1867, the site of the future Laguna Honda Hospital was acquired by San Francisco. In 1867, the City financed and constructed a shelter for the homeless on the site. The report noted LHH plays a vital role as the “provider of last resort” for long-term care and is the largest municipally owned long-term care institution in the nation. The “Master Plan” noted that the future of LHH must create the best “fit” between the long-term care needs of the residents of the City and the services to be provided by the Hospital.
Impact of Changing LHH’s Bylaws
What’s at stake involves the bylaws of LHH’s so-called “governing body,” the Health Commission. These changes eliminate providing both long-term care and rehabilitation services at Laguna Honda. Both are replaced by an ill-defined concept called “post-acute care,” but only for those who have “complex medical needs.”
The proposed changes redefine the mission as providing “post-acute care,” implying that only short-term care will be available. The proposed bylaws 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?
These changes would all but eliminate eligibility of patients being cared for at home without first requiring an acute-hospital admission, which may be unnecessary for those who need 24/7 skilled nursing and a 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 addition to patients needing physical medicine rehabilitation, given the deletion of rehabilitation services in the proposed bylaws changes.
That would 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 patients 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 the 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 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 after the rebuilt LHH opened in June 2010?
This massive back door betrayal deserves a 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 the door to revising LHH’s admission policies and admissions priority — to exclude patients who may need, and whose prognosis includes the necessity for long-term care. Will their need for long-term or physical medicine rehabilitation care become an automatic, disqualifying exclusion criterion preventing admission?
Out-of-County Patient Dumping Will Worsen
In 2022, then District 4 Supervisor Gordon Mar successfully introduced and passed Ordinance #77-22, requiring all San Francisco public and private-sector hospitals to report their out-of-county discharges to just sub-acute SNFs and regular SNFs to the Department of Public Health annually. Mar’s legislative intent: 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 of 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 probably 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 required placement in a facility for long-term skilled nursing level of care.
The proposed change to LHH’s bylaws to eliminate providing long-term care will almost certainly lead to additional San Franciscans being “granny dumped” out of county.
What Prompted Health Commission’s Sudden Bylaws Change

On November 22, Health Commission’s Executive Secretary Mark Morewitz announced a “Notice of Intent Regarding LHH Governing Body Bylaws” that would be considered by the full Health Commission to amend LHH’s bylaws during the full Health Commission’s December 3 meeting as part of its regular meeting agenda.
Morewitz’s e-mail indicated 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.
Asked to summarize the proposed bylaws changes, he said he saw the first draft several weeks ago, but his memory was they were minor changes — nothing “nefarious,” and said LHH leaders had asked for the review and potential revisions.
Why LHH’s leaders were involved? Morewitz said they wanted to ensure the bylaws align with federal and state regulatory requirements. What specific LHH policies were reviewed that might affect LHH’s admissions policies? Morewitz answered, “No,” and the bylaw revisions did not include any admissions processes.
Was Morewitz being disingenuous? At best.
It’s abundantly clear the bylaws changes are poised to drastically — and nefariously— alter LHH admissions, mission, and policies.
However, 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.
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 proposed changes. As indicated, Commissioner Christian opposed accepting the proposed Bylaws amendments.
Christian pointedly peppered LHH managers about why there was a push to amend the bylaws so rapidly.
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, claimed that LHH is facing an upcoming licensing survey inspection of it’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 stated that LHH last had an acute licensing survey in 2019, and the re-survey could happen any day now. He referred 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.
A Deputy City Attorney eventually reassured the Commissioners that continuing the agenda item to the Health Commission’s December 17 meeting was not a major concern.
Through Commissioner Christian’s astute line of questioning, it became clear the bylaw amendments 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 a pretext.
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 bylaws to focus on “post-acute care.” This was under the leadership of the Director of Public Health, Grant Colfax, and Health Commissioner Ed Chow.
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.
Thanks to the many members of the public who submitted oral and written testimony, the Health Commission finally agreed that the bylaws 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 care is part of LHH’s mission. Additional amendments to the proposed bylaws 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 starting in 2004, which eventually resulted in LHH’s decertification and halt of new admissions for 26 months 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. Do senior SFDPH managers 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 on 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 Bylaws” 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 valid reason for the “Governing Body Bylaws” not to apply to both LHH’s 769 SNF beds and its tiny 11-bed acute units. There’s no reason to have two sets of bylaws to comply with the artificial concerns SFHN’s Chief Quality Officer Troy Williams raised.
All the Commission needs to do is add appropriate sub-headings in the Bylaws document to point out to various inspection surveyors that a single “Governing Body Bylaws” 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. It’s simple secretarial and wordsmithing edits.
And suppose 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. In that case, 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 member of the California First Amendment Coalition (FAC) and the ACLU. He is a Childless (and catless) Cat Daddy, and voter for 50 years. He operates stopLHHdownsize.com. Contact him at monette-shaw@westsideobserver.com.
December 2024