In the Past Three Years, Between 2,718 to 9,153, San Franciscans Were Discharged Out-of-County for Basic Skilled Nursing Care

City Health Department’s Missing Report Concealed Shameless Patient Dumping

Were 6,000 San Franciscans “Granny Dumped” in the Past Three Years?

by Patrick Monette-Shaw

• • • • • • • • • • July 10, 2024 • • • • • • • • • •

It is shocking that San Francisco cannot provide skilled nursing beds for its frail senior and disabled residents who can no longer take care of themselves. While the City’s Hospitals are required to supply the San Francisco Department of Public Health (SFDPH) with a list of such discharges—patients dumped out-of-county—understanding the obscure data is left to a few bureaucrats.

It’s scandalous that a required annual data report about out-of-county discharge data from all San Francisco hospitals during 2023, due to SFDPH by January 31, 2024, took until July 2 to be presented to the Health Commission. That left SFDPH and the Health Commission in the dark for five months.

Shockingly, two reports 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 around 6,000 San Franciscans because CPMC claims its electronic health records system — Epic — cannot track in-county vs. out-of-county discharge destination locations. That is complete rubbish because other hospitals using Epic are able to stratify discharges by county.

Because SFDPH’s 31-page report for 2021 and 2022 and its 31-page report for 2023 do not contain a separate table with a row showing totals across all of the hospitals listing each of San Francisco’s nine private-sector hospitals that are required by Ordinance 77-22 to report their annual out-of-county discharges and instead presents 18 or more separate tables for each of the nine hospitals, the Westside Observer created a table summarizing all of the City’s residents and non-residents transferred to out-of-county facilities for both standard SNF care and sub-acute care (which is for patients with higher disease acuity needing specialized SNF car. This table is available online for readers interested in seeing an expanded summary of the data.

For this article, a smaller graphic displaying data for only San Francisco residents discharged out-of-county for routine SNF level-of-care is summarized in Figure 1.

When the report on out-of-county discharges for 2023 was presented to the Commission on July 2, 2024, SFDPH staff were unable to answer—and didn’t have in their hip pocket—data on the number of SNF beds remaining in San Francisco in response to Health Commissioner Laurie Green’s astute but long-overdue oversight question. The lack of in-county SNF beds obviously impacts the total number of out-of-county discharges for patients requiring SNF level of care.

Most thought SFDPH’s Policy and Planning staff presenting its report would have been prepared to know the number of SNF beds in-county. They were wrong. They didn’t, and weren’t able to, answer Commissioner Green on the spot. Knowing the approximate number of remaining SNF beds in The City is critical.

The most recent data presented by SFDPH to the Health Commission in 2017 reported in September 2017 that there were 2,439 SNF beds in San Francisco. However, that was likely disinformation at the time because it relied on data from 2013 that was probably outdated. Nineteen months earlier, SFDPH reported to the Commission in February 2016 that The City had 2,542 SNF beds. It needs to be clarified how the City lost 103 SNF beds across those 19 months.

After all, to artificially fluff up its data, SFDPH included hospital-based SNF beds and short-term beds for inpatients who had moved to a hospital SNF unit for stabilization or for transitioning to other locations. These are not the long-term care SNF beds available to regular San Franciscans for post-acute SNF care following acute-hospital episodes. Essentially, short-term hospital-based SNF beds aren’t utilized to prevent permanent eviction and disenfranchisement via in-county or out-of-county discharges for long-term care.

SNF-Bed Capacity Has Plummeted

It’s been just eight years since SFDPH presented its “Framing San Francisco’s Post-Acute Care Challenge” report to the Health Commission in February 2016, documenting that San Francisco had a 43.3% decline in the number of hospital-based SNF beds between 2001 and 2015 alone, from 2,331 beds, to just 1,319 — a loss of 1,012 hospital-based SNF beds across those 14 years.

Tack on the loss of another 151 beds in “freestanding” (i.e., non-hospital-based) SNF beds, from 1,374 to 1,223 in the 12 years between 2002 and 2014, an additional 9% decline in SNF-bed capacity reported to the Health Commission in 2016.

SFDPH’s staff should have been able to answer Commissioner Green on July 2, from the “Framing the Challenge” report eight years ago in 2016. SFDPH reported — and reported again to the Health Commission in 2017, shown in Figure 2 — that the City had just 1,223 regular SNF level-of-care beds remaining in “freestanding” facilities. The “freestanding” facilities are those that are separate from hospital-based SNFs. The hospitals shed their in-county hospital-based SNF bed capacity in San Francisco’s so-called private sector hospitals (that claim to be “non-profit” organizations) en masse. In reality, they eliminated their SNF beds because that level of care was adversely affecting their bottom-line profits. (SFDPH’s “Framing the Challenge” report was a major work product.)

But that’s assuming that in the intervening eight years since February 2016, the City hasn’t lost even more “freestanding” SNF-bed capacity, which is highly unlikely. The reality is much grimmer, with even fewer SNF beds for San Franciscans needing long-term SNF care, particularly the elderly and disabled.

Unfortunately, a short look through a California Department of Public Health website database named “CalHealth Find,” performed on July 5, 2024, revealed the number of freestanding SNF beds in San Francisco appears to have suffered the loss of another 243 beds from 1,223 in 2016 and 2017 to just 980 seven years later in 2024 — excluding Laguna Honda Hospital and the Jewish Home that SFDPH apparently hadn’t considered to be “freestanding” skilled nursing facilities in 2016, but were considered “distinct-part” SNFs affiliated with hospital-based facilities.

It’s highly unlikely any new brick-and-mortar freestanding SNF capacity has been built out and brought online in San Francisco since 2016. The Health Commission and Board of Supervisors certainly have not advocated for, or helped procure, more SNF beds anywhere in San Francisco, over the past eight years.

Just as alarming, the “Framing the Challenge” report in 2016 reported a 1,745-bed gap for SNF beds in San Francisco by the year 2030, comparing the projected demand to the then-current licensed bed supply shown in Figure 3.

Given the loss of an additional 243 freestanding SNF beds between February 2016 and August 2017, as discussed above, the gap in projected demand has increased to a 1,988-SNF-bed gap.

But that doesn’t take into account the fact that Laguna Honda faces another potential loss of between 120 and 445 beds, discussed below. Adding a potential loss of 445 beds at LHH and reducing it to just 324 SNF beds would only exacerbate the 1,988-SNF-bed gap to a 2,433 gap between demand and supply for SNF beds just six short years from now in 2030.

After all, LHH formerly had 1,200 SNF beds before its rebuild in 2010 and eliminated 480 SNF beds, largely due to the $195 million in massive cost overruns largely caused by mid-construction “change orders” altering the scope of the rebuild project. Chopping it down now to only 324 SNF beds would border on criminal, particularly following the two-plus years of its totally preventable decertification that closed the hospital to new admissions for 26 months, forcing hundreds of San Franciscans needing SNF care into out-of-county facilities.

Laguna Honda’s At-Risk Bed Reduction

As if a probable 1,988-SNF-bed gap wasn’t already alarming enough, there’s a real possibility it could worsen by the potential loss of another 445 beds at Lagaun Honda Hospital.

That’s because San Francisco’s Health Commission has failed to address two issues facing LHH that could reduce LHH’s current 769-SNF bed capacity (plus 11 acute-care beds) to just 325 SNF beds from 769 beds — which would be catastrophic to the availability of in-county SNF-bed capaity and would only worsen more out-of-county discharges for standard SNF level-of-care. It’s a frightening possibility.

First, LHH provides about one-third of all SNF beds in San Francisco County. That points to the urgency of the Health Commission taking action to save 120 beds at risk of permanent loss at LHH. After LHH was decertified, CMS ordered LHH to close 120 beds in its three-person suites due to a rule change in 2016. LHH had constructed 120 three-person suites in 2010 when they were still allowed. The CMS rule change put those 120 beds at risk of permanent removal.

The annual out-of-county discharge report presented on July 2 should lead the Health Commission to instruct LHH to immediately submit the simple waiver request to save and restore LHH’s 120 temporarily closed beds—which sit unused and without doors. The waiver involves a simple letter to Tomás Aragón, director of CDPH. CDPH grants waiver requests, and they don’t need CMS’s approval. We can’t afford to lose LHH’s 120 beds.

Second, the new annual report should guide the Health Commission’s decision on using LHH’s two separate patient towers to cohort traditional SNF patients in one Tower and behavioral health and mental health patients in the second Tower. In 2023, after LHH’s acting CEO, Roland Pickens, informed the Commission, another SFDPH workgroup was actively studying a proposal. Using one Tower for behavioral health programming for patients with a behavioral health primary diagnosis would necessarily reduce the number of beds for patients requiring traditional and standard SNF level of care. That report and potential recommendations has not yet been presented to the Health Commission for its consideration and required approval prior to changing the uses of LHH and its potential licensure.

If the potential plan to cohort the two different types of patients in LHH’s two separate Towers is enacted, it would simply rob Peter of SNF beds to pay Paul for greatly-needed behavioral health and mental health beds in San Francisco — also in gravely short supply. The two patient cohorts should not be pitted one against the other. Paul shouldn’t expect Peter to simply roll over and go along with the proposal to satisfy political pressure.

If LHH is reduced to 649 SNF beds by losing the 120 beds temporarily closed, converting half of the remaining 649 beds—approximately 325 beds in each Tower—into behavioral health beds would drastically reduce the total SNF bed capacity in the country. That would likely increase out-of-county discharges of San Franciscans, disenfranchising them of residency.

Losing 120 beds plus 325 beds at LHH would reduce the City’s SNF capacity by 445 in one fell swoop. The Health Commission must not allow this to occur.

Initial Canaries in the Coal Mine

There are another two cohorts of San Franciscans who were 1) Either discharged out-of-county prior to 2021 or 2) forced into out-of-county SNF facilities without first having been admitted to a facility in San Francisco, in addition to the probable 6,000 San Franciscans discharged from hospitals documented in the annual reports required by Ordinance #77-22.

First, there are San Franciscans who faced potential out-of-county discharge during the 26 months LHH was closed to new admissions between April 2022 when it was decertified and just this month, when LHH regained full Federal recertification.

Another analysis documents that — based on monthly data dating back ten calendar years to 2015 presented to the Health Commission’s LHH Joint Conference Committee (LHH-JCC) made up of Health Commissioners and senior staff of LHH — in the five years between 2015 and 2019 before COVID arrived in San Francisco in 2020, LHH had admitted an average of 496 patients annually, or 41.3 patients each month. Calculating 41.3 admissions monthly times the 26 months LHH was barred from admitting new patients, approximately 1,075 San Franciscans needing SNF level of care were forced into either other SNF facilities in-county or out-of-county. An unknown number of those 1,075 were likely forced into out-of-county SNF placements.

And, of those 1,075 forgone admissions, an estimated 209 would likely have expired (died) in-house at LHH had they gained admission to LHH. It’s not possible to estimate how many of them may have faced their end-of-life deaths in out-of-county facilities.

Another aggravating factor is that just after the onset of the COVID pandemic in May 2020, LHH’s admissions suddenly plummeted from 462 in 2019 to just 157 in 2020, also according to the monthly “State of the Hospital” reports to the LHH-JCC. Ostensibly, part of LHH’s touted “success” combating COVID in 2020 was due to having severely restricted admissions in 2020. That drop of 305 admissions to LHH across that one year probably resulted in an additional unknown number of San Franciscans who were discharged to out-of-county facilities.

Long before Ordinance #77-22 was enacted in 2022, the Westside Observer began its quest for out-of-county discharge data after badgering the LHH-JCC for months during 2012 and 2013 to release aggregate data on the number of LHH patients publicly discharged out-of-county.

The first trickle of data was for 28 LHH patients discharged out-of-county during FY 2013–2014. SFDPH eventually produced retrospective out-of-county discharge data going back to July 1, 2006, and continued providing periodic updates about out-of-county discharge data up until the end of 2019, just before COVID came along in March 2020. That’s when SFDPH and SFGH began claiming its $167.4 million Epic replacement EHR database could not track out-of-county discharges.

But before SFDPH stopped voluntarily producing out-of-county discharge data in 2020, The Westwside Observer received data under public records requests documenting 1,746 out-of-county discharges between Fiscal Year 2005–2006 and Fiscal Year 2019–2020.

Those 1,746 San Franciscans dumped into out-of-county facility placements actually represented the first canaries in the coal mine.

We’re now seeing just the tip of a large out-of-county discharge iceberg submerged below the surface that leaks into the coal mine. The actual number is certainly likely far, far higher than the probable 6,000 in the last three years since 2021.

Without adequate reporting and repercussions and without a serious effort by San Francisco to build out additional SNF capacity, patient dumping following hospitalization is certain to continue.

The out-of-county discharge epidemic has grown severely, which is clearly a public health crisis in its own right. Suppose the Board of Supervisors and the Health Commission do not exert leadership soon enough to add additional in-county SNF bed capacity as San Francisco’s aging population increases. In that case, many more people will be simply evicted, exiled, and dumped out of the county.

Unexplained Excuses About “Limitations of the Data”

Both the Department of Public Health and each of the nine hospitals required to report their out-of-county discharge data do their damnedest to minimize the significance of the data.

For example, SFDPH claimed in the report for the 2023 data that:

“As with the prior report, reporting health facilities continued to use disparate record systems to collect the information required by the Ordinance. Due to the distinct hospital electronic health record (EHR) management and referral systems utilized by reporting health facilities, there was not a common methodology employed to collect the required data. This report is constrained to the facilities’ variable methodologies and does not provide a comparative or aggregate analysis.”

Surely, SFDPH staff is capable of aggregating data from the nine reporting hospitals, as shown in tables in its own reports.

SFDPH took it a step further claiming, “Hospital discharge records may not be complete for all skilled nursing discharges; not all hospitals are able to report discharge facility addresses; many discharge facilities have generic names or may have the same name, since the analysis did not include residential addresses of each SNF discharge, the data findings are only estimates; and without address information, these facilities could not be mapped” [to determine the mileage distance discharged to — which is not something required by Ordinance 77-22 and wasn’t of concern to the Board of Supervisors in 2022].

SFDPH claims that the actual discharge location may be embedded inside free-form text entries rather than being captured in a unique structured database field. [Note: Programmers know how to search for text inside of “free form” text entries.]

That’s because in the year 2024, EHR database systems are certainly robust enough to know the precise facility patients are discharged to if they are not discharged to their homes or previous housing situations. Many of these hospitals all use the “Epic” EHR database from Epic Systems Corporation.

That is essentially word salad, but SFDPH is a master at manufacturing “limitations” of data in its various reports.

Readers may recall that in February 2022, in an article disputing SFDPH’s false claims that it could not track SFGH and LHH out-of-county discharge destinations by the name of the facility or county discharged to due to its migration to Epic database in 2019.

That was pure nonsense because on June 16, 2021, Epic Systems Corporation’s Media Relations Department responded to a media inquiry placed for the Westside Observer. Epic’s Media Relations Department revealed that out-of-county discharge data that had been requested from DPH is, in fact, contained in structured database fields in Epic’s “Patient Flow” module. Epic’s standard configuration (i.e., its “base” enterprise package) includes discharge destinations/dispositions, including the name of the city discharged to in its “Patient Flow” module. (If the city discharged to is “San Francisco,” it’s not an out-of-county discharge.)

Any of the nine hospitals not using Epic and using a different EHR database platform surely should also be able to discern that if the city discharged to is not “San Francisco,” then it’s an out-of-county discharge. After all, logic tells you that there is only one City (named San Francisco) in San Francisco County — making it impossible to not be able to definitively identify out-of-county discharges easily and rapidly. This ain’t rocket science, after all!

After consulting with its in-house subject-matter experts, Epic’s Media Relations Department also confirmed that the Patient Flow module includes database fields for “Discharge Disposition” — the broad category of where a patient is discharged to, e.g., returned to home vs. discharged to a skilled nursing facility, a rehabilitation facility, a Long-Term Care Acute Hospital (LTCAH), or perhaps a Residential Care Facility for the Elderly (RCFE) — and the actual discharge location (including the name, address and city, phone number, and type of facility).

As well, all EHR databases contain patient discharge instuctions plus physician orders allowing discharge from acute hospitals, which regularly contain information about both the discharge location and acuity level of the patients for use by the gaining facility patients are discharged to, along with hand-off notes from physicians and nurses to the gaining facilities. For that matter, the hand-off discharge notes should be able to indicate whether a patient being discharged (whether in-county or out-of-county) continues needing the sub-acute level of care interventions such as ventilators or frequent suctioning 24/7.

To her credit, Health Commissioner Suzanne Giraudo spoke out during the July 2 Health Commission meeting (when the annual discharge data report for 2023 was presented), suggesting SFDPH’s Chief Information Officer, Eric Raffin, contact Epic Corporation and request that Epic put a sub-acute facility discharge code into its EHR database. Raffin should have done so long ago without prompting from Giraudo. After all, if that code doesn’t already exist in Epic’s database look-up table for fields for “Discharge Disposition” containing the type of facility a patient is discharged to, it should be an easy fix to add and implement rapidly.

City Ordinance Requiring the Data Collection

Requests were submitted to then-Board of Supervisors President Norman Yee in 2018 to introduce legislation requiring private-sector and public-sector hospitals in the City, and also Residential Care Facilities for the Elderly (RCFEs), to submit out-of-county discharge information, including a limited amount of demographic data, to DPH annually going forward. Further, it was recommended that such legislation also require all hospitals to report annually their out-of-county discharges to the various types of long-term care facilities (including RCFEs and SNFs) listed in a table in a Health Management Associates report and additionally require them to report the number of out-of-county discharges to other acute-care hospitals and to sub-acute care facilities.

Yee did not sponsor such legislation.

It took until 2022 before District 4 Supervisor Gordon Mar successfully introduced and passed Ordinance #77-22, requiring all San Francisco private-sector hospitals to report their out-of-county discharges to just sub-acute SNFs and regular SNFs. Mar wasn’t allowed to require RCFEs licensed in San Francisco to also submit annual reports.

Advocacy requiring submission of this long overdue data about out-of-county discharges asserted the data should be used, in part, to guide policy on use of LHH as an in-county SNF, and used, in part, to guide healthcare Master Planning efforts to encourage the construction of additional brick-and-mortar skilled nursing facilities in-county to prevent massive disenfranchisement of San Franciscans to out-of-county facilities.

When Supervisor Gordon Mar steered Ordinance #77-22 through in 2022, his legislative-intent was that meaningful analysis of this data and accurate data submission is critical and desperately needed to inform healthcare Master Planning citywide.

A coalition of patient advocates had been asking members of the Board of Supervisors for over four years to introduce and pass an Ordinance requiring that all hospitals in the City report aggregate data annually to SFDPH about San Franciscans discharged out-of-county. The Public Safety and Neighborhood Services Committee of our Board of Supervisors held a hearing on the initial very limited and then inadequate draft Ordinance. The draft legislation initially required hospitals to report out-of-county discharges only for those needing sub-acute SNF care placement.

Many healthcare advocates insisted at the time that the proposed legislation must be amended to require reporting of all categories of out-of-county discharges, stratified by all types of facilities San Franciscans are discharged to, not just to sub-acute SNFs, among other sorely needed amendments. Mar was successful in ensuring the final Ordinance required reporting of discharge data to both regular and sub-acute SNFs, despite initial opposition by Supervisor Safai who only wanted the Ordinance to include reporting of discharges to sub-acute facilities.

Unfortunately, Mar lost his re-election. There doesn’t seem to be any interest among the Supervisors in pursuing this data. After all, former Supervisor David Campos, who had been deeply concerned about SNF issues, is no longer a supervisor. Norman Yee is long gone and hadn’t focused on SNF capacity planning anyway. Supervisor Ronen is termed out in November’s municipal election. Supervisors Safai and Peskin are too busy running to become San Francisco’s next Mayor to care about this issue any longer.

That because, in part, there’s nothing in Ordinance #77-22 requiring that SFDPH transmit an annual report aggregating out-of-county data collected from the nine reporting hospitals, and no requirement that the Board of Supervisors hold a hearing annually of the out-of-county discharge data that is collected.

Without any SNF-bed champions remaining on the Board of Supervisors, you can almost predict that out-of-county discharges to skilled nursing facilities will increase in coming years, as the population of elderly San Franciscans soars before 2030.

About the Sub-Acute Patients

San Franciscans needing higher-acuity long-term “sub-acute” care 24/7 are a different matter. Sub-acute units are best situated in or adjacent to an acute-care hospital in case sub-acute patients need to be transported urgently to an ICU.

Wading through the 62-pages of the two annual discharge reports involved looking for the proverbial needle in a haystack. The expanded one-page summary of the out-of-county discharges revealed that in addition to the 2,718 to 9.153 San Franciscans discharged out-of-county between 2001 and 223, there were an additional 53 San Franciscans transferred to out-of-county sub-acute facilities across those three years.

Initially, Supervisor Asha Safai and other District Supervisors wanted to restrict Ordinance #77-22 in 2022 to private sector hospitals to only report their out-of-county discharges for just patients needing continuing sub-acute level of care.

As reported in my February 2019 article, Supervisor Ahsha Safai called for a hearing on closing CPMC’s skilled nursing and sub-acute units in St. Luke’s Hospital. That hearing was held on July 26, 2017, before the Board of Supervisors’ Public Safety and Neighborhood Services (PSNS) Committee. At the end of that hearing, the St. Luke’s closure was continued to the call of the Chair, where it languished in the PSNS Committee for months, essentially tabled. Supervisor Hillary Ronen was then chairperson of the Supervisors PSNS Committee.

The sub-acute SNF issue was pulled from the PSNS Committee when the full Board of Supervisors held a “Committee of the Whole” hearing on September 12, 2017. Safai clarified the hearing was specifically to be about “in-county, in-hospital [sub-acute] solutions for San Francisco.”

Safai also noted the lack of SNF and sub-acute care beds had been a “crisis in the making over the past decade … as we’ve seen a major, major decrease in the number of skilled nursing beds over the last ten to 15 years.”

Safai had thankfully managed to get SFDPH to admit in 2017, San Francisco needed to have a minimum of 70 sub-acute beds in hospital-based facilities. But sadly, zero sub-acute beds have been brought online in the City since CPMC shuttered its St. Luke’s sub-acute to any new admissions in 2012 from non-CPMC facilities, and Chinese Hospital is only committed to eventually hosting 23 sub-acute beds. That still leaves a massive gap in the sub-acute bed capacity San Francisco deserves.

For his part, then-Supervisor Jeff Sheehy noted that during the rebuild of Laguna Honda Hospital [during 2007 to 2010] “we knew then that [the City] was projecting a shortage [of] skilled nursing beds, and the reality is that instead of building [additional] capacity, we’ve been shrinking capacity.”

Unfortunately, Supervisor Norman Yee highjacked the September 12 hearing by wrongly claiming he had called for a hearing “on these issues” in June 2017, ostensibly referring to SNF and sub-acute SNF level of care facilities. Instead, Yee had called in June for a hearing regarding institutional housing, residential care facilities, and small facilities for elderly senior citizens, not regular or sub-acute SNFs.

A tug-of-war ensued, with Supervisors Safai and Ronen wanting to focus on the acute shortage of hospital-based and private-sector “freestanding” SNF and sub-acute facilities. On the other hand, Supervisor Yee wanted to focus primarily only on Residential Care Facilities for the Elderly (RCFEs) and assisted living facilities.

In the end, Yee essentially won, and Ronen and Safai essentially abandoned their quest to increase both standard SNF beds and sub-scute SNF beds. Safai resumed some interest in 2019.

Seven years later, no additional sub-acute SNF beds have been brought online following CPMC’s closure of its sub-acute SNF unit at St. Luke’s Hospital in 2017. [Note: of the 20-plus sub-acute patients CPMC transferred to its Davies Hospital Campus, only four of those initial patients still remain, and no additional admissions have been allowed by CPMC.]

Director of Public Health, Barbara Garcia, testified during the Board of Supervisors hearing on September 12 that DPH was working with Dignity Health (not Sutter Health/CPMC) on trying to develop a sub-acute unit, but only for mental health patients. [Note: Dignity’s two hospitals were just acquired by UCSF. It’s highly unlikely UCSF will consider opening a long-term, sub-acute unit in either of Dignity’s two former hospitals.]

An e-mail from Chinese Hospital dated January 31, 2020, to DPH’s Kelly Hiramoto revealed that the hospital’s Board of Directors had agreed to host a sub-acute SNF.

That e-mail from Paul Ziegele, Chinese Hospital’s then-Interim Chief Financial Officer, indicated Chinese Hospital’s Board of Directors had met during the week of January 31, 2020 and its Board agreed to continue to explore a partnership with DPH for a subacute unit at Chinese Hospital. Ziegele indicated the basic terms its Board had endorsed included, 1) The sub-acute unit would be separately licensed and operated by an independent subacute provider, 2) Chinese Hospital would lease space to the subacute provider, and 3) Chinese Hospital would need an annual payment of $1.7 million, in addition to services provided in item #2.

Why, after over four years, is Chinese Hospital no closer to opening a subacute unit? They recently received a $5 million grant from the State of California to assist with opening SNF units due to the efforts of SF Assembly Member Phil Ting.

The new report SFDPH released containing the out-of-county discharge data for 2023 stated that SFDPH is still working with both a Chinese Hospital and another SNF facility — San Francisco Health Care — to open a sub-acute unit. Centers for Medicare and Medicaid Services (CMS) rate San Francisco Health Care a two-star SNF. San Francisco Health Care has been “working on” converting regular SNF beds to sub-acute care beds for six years, since 2018. The report seems to indicate Chinese Hospital will be lucky to open a sub-acute SNF at some point in 2025, but that DPH has paused contract negotiations to determine the impact of CalAIM and to identify a mechanism to support the cost of client care at. San Francisco Health Care.

Noted Geriatrician on Sub-Acute Care

In May 2018, the Westside Observer published an article by Dr. Teresa Palmer (“Why We Care About the Closure of St. Luke’s Subacute Unit”). Palmer, a noted geriatrician who worked at LHH for a decade, astutely noted:
“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 [an] intensive care unit.”

Palmer went on to note that “no patient population [other than sub-acute care patients] is more dependent on loving family members to watch and advocate for them on a daily basis.”

Palmer noted St. Luke’s sub-acute unit was the only sub-acute SNF in San Francisco. Still, it stopped accepting non-CPMC patients in 2012, forcing those patients out of the City. Then in 2016, CPMC stopped admitting any patients into St. Luke’s sub-acute unit, even if they were CPMC’s own patients from its other campuses. CPMC closed its St. Luke’s facility entirely in 2017. She noted that sub-acute patients need heroic measures to maintain their lives on a long-term basis, and these patients are prone to potentially fatal infections from skin breaks (bed sores), urinary tract infections, and pneumonia, and may need to be transferred quickly from a sub-acute SNF to an ICU in an acute-care hospital.

Epilogue

The Board of Supervisors should require that all hospitals in San Francisco provide data on all out-of-county discharges of San Francisco residents back to June 30, 2006, to gain a historical context of just how severe this problem has been.

They must also grow the funding pie to fund a range of facilities, including regular and sub-acute SNFs, RCFEs, ADHCs, and independent residential senior housing, not pit them one against each other — since all are critically-needed, urgent priorities the City should fund — to stop the plague of out-of-county discharges and patient dumping.

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 operates stopLHHdownsize.com. Contact him at monette-shaw@westsideobserver.com.