Laguna Honda Hospital’s Identity CrisisA view of construction from patient quarters at Laguna Honda

Meanwhile, longtime frail San Franciscans in their 80’s with multiple medical problems or advanced dementia who need a facility like LHH cannot get in, and are being dumped out-of-county because LHH is busy delivering care to younger folks who need “behavioral” care.

Just four months before construction of Laguna Honda Hospital’s new buildings are scheduled to be completed, and just eight months before it’s scheduled to move into its new digs, LHH continues to face an unresolved identity crisis involving what services it will deliver (and to whom), and an elusive, evolving mission statement.

Shouldn’t this have been determined before construction began, nearly six years ago?

In November 2008, Wide Angle Communications conducted an assessment of LHH’s communications. This assessment noted LHH’s perception and credibility problems are rooted in competing visions of LHH’s future, and noted LHH’s inadequate communications strategies has affected the perception and image of LHH among its constituencies. The report claims LHH’s staff and supporters have a “misunderstanding and lack of information regarding the scope of Laguna Honda’s services and its mission,” due in part to LHH’s “failure to define itself.” The report noted neighbors retain lingering perceptions of “the so-called flow project,” which increased the flow of patients from San Francisco General Hospital (SFGH) to LHH.

This $42,000 consulting study recommended, among other things, consistent outreach to the surrounding community by publishing a newsletter three times a year for the community and holding quarterly forums with its neighbors. Nine months later, LHH hasn’t issued a neighborhood newsletter or held neighborhood meetings. The last neighborhood forum LHH held occurred a year ago, in September 2008. Meeting with the community to discuss LHH’s identity crisis and progress with the facility seems reasonable, but LHH’s failure to do so seems to be deliberately thumbing its nose, refusing to meet with taxpayers funding construction of the hospital.

Last March, the Mayor’s Long-Term Care Coordinating Council issued a revised Living With Dignity Strategic Plan, which indicates a priority objective for 2009 is to move LHH from a “medical model to an inter-disciplinary social-health model of care.”

In July, the Department of Public Health began seeking a new consultant for a $250,000 project to help LHH define its organizational identity and model of care based on “resident-centered care” principles. In addition to re-defining Laguna Honda’s model of care to include physical and social rehabilitation programs, another project goal is to develop new communications tools to define LHH’s “brand identity.” New skills will be developed and required for interdisciplinary staff providing direct patient care, particularly certified nursing assistants. The contract calls for revising LHH’s mission and vision statements, changing LHH’s functions, and helping staff understand LHH’s mission.

Also in July, another $49,000 consulting project released an assessment of “behavioral health” services at LHH. Behavioral health is a concept combining mental health and substance abuse services. The new Davis Ja and Associates report was contracted for by the Health Department’s Community Behavioral Health Services (CBHS) section, as part of the Chambers settlement agreement requiring assessment of behavioral health services at Laguna Honda, the patient flow, and linkages to behavioral health services following discharge to the community. The Ja report contains a number of flawed assumptions and startling admissions, but doesn’t assesses the availability of community linkages to behavioral health services following discharge.

The list of 41 people interviewed for the Ja report is top-heavy with fox-guarding-the-hen-house psychosocial professionals, including all of LHH’s behavioral health staff. Not one certified nursing assistant, licensed vocational nurse, front-line registered nurse, long-term care ward attending physician, or geriatrician providing direct patient care were interviewed. Only one LHH front-line social worker involved in discharge planning was interviewed. Of those interviewed, 14 (34%) were external to LHH; they may have little understanding of how medically ill LHH residents are.

The Ja report admits that staff external to LHH — presumably CBHS staff — expressed concern over “patient and staff safety due to the mixing of high-level substance abuse and mental health patients with older, lower-level patients in open wards,” given LHH’s inability to separate patients based on severity of diagnosis, and problems supporting both patient populations safely in open wards. This validates community concerns about the 2004 to 2005 “flow project” regarding patient safety that led to Proposition D being placed on the 2006 ballot. The Ja report recognizes local neighborhood concerns, but never addresses them, reminiscent of the 2005 flow project. The Ja report doesn’t address how changing from open wards to semi-private rooms in the new buildings will resolve the differently-diagnosed patient mix issue, or provide greater safety, if at all.

Although the Ja report notes LHH staff are concerned about SFGH patient referrals underestimating the degree of patient’s mental health and substance abuse issues, the report offers no recommendations about improving the patient referral process. Instead, the report recommends LHH’s mission statement should be reviewed.

Remarkably, the Ja report claims the greatest barrier to discharge of patients is due to LHH staff members misunderstanding LHH’s identity. The report claims staff doesn’t understand LHH’s identity, and improperly determine independently what services they should provide as their job duties and responsibilities, leading to inconsistent standards in providing patient care. Apparently, the Ja report’s authors were never told what staff have known for over a decade: The greatest barrier to discharge is the lack of appropriate housing, not staff confusion about LHH’s identity.

The Ja report wrongly blames the “professional dominance of [LHH’s] medical doctors” in positions of leadership as the reason LHH has not moved from a medical model of care to an “integrated” model of care providing medical, mental health, and substance abuse services, preventing patients from acquiring independent living skills in activities of daily living (bathing, dressing, etc.) necessary for independent living in the community. Not only are doctors blamed for this leading to improper “institutionalization,” they are blamed for nursing assistants not participating in interdisciplinary team meetings (which is untrue). If the Ja recommendation to replace doctors with registered nurses, social workers and psychologists is implemented, patient medical care will plummet.

This is silly. Ja ignores that LHH publicizes it has won awards for its restorative care programming focusing on teaching patients activities of daily living, and ignores that nursing assistants participate in team meetings on a regular basis on most wards. Senior nursing administrators are already disproportionally represented in executive-level decisions. If nursing assistants are excluded from key decision-making processes, it’s not by medical doctors, but by nursing administration.

In fact, the “medical model” of care has been in place because it’s the least expensive way of caring for patients, and it works well for the frail elderly, which is who the public was told would be cared for in LHH’s new buildings.

After scapegoating doctors and nursing assistants, the Ja report recommends creating two “behavioral health” units at LHH, one possibly for potential permanent placements for behavioral health clients. LHH has never been a permanent-placement location, for any patient population. The Ja report recommends increasing services for a comparatively smaller group of behavioral health clients, a group Ja’s own data shows already has a much higher rate of discharge to the community.

The Ja report doesn’t itemize a specific number of LHH’s beds that should be converted from long-term care to behavioral health care, worsening an already grave shortage of skilled nursing beds for elderly Alzheimer’s patients who are being dumped out of county.

Behavioral healthcare is more costly, and can’t be adequately funded by simply cutting LHH’s medical doctors. If Ja’s recommendations to replace doctors with nurses and psychologists is attempted, LHH will end up providing both mediocre behavioral health care, and bad medical care, to its residents. If behavioral health clients simply need housing and psychosocial care, why are they at LHH?

Meanwhile, longtime frail San Franciscans in their 80’s with multiple medical problems or advanced dementia who need a facility like LHH cannot get in, and are being dumped out-of-county because LHH is busy delivering care to younger folks who need “behavioral” care.

One question is whether these three consultant contracts totaling $350,000 seek to obscure re-defining Laguna Honda’s mission as a psychiatric facility treating behavioral patients.

Other questions are: Why can’t San Francisco find somewhere else for patients needing behavioral health care, and let the old folks stay in county? And have voters spent $594 million to build a facility having an identity crisis just before it opens?

September 2009