One all right. Thank you. I have a couple of questions. You said we have 782 skilled nug beds at laguna honda. Do we have any capacity there fa execute beds . And when we did laguna honda Ann Francisco general, why did we nt include subacute beds . It seems as though these are pre hospitals are owned hospital fas where we have an opportunity ase building and remodeling and sins has been a problem, why didnt d some . I believe its the cost in tf the number ever bed of beds we f money. The psyche beds never went intoe building because of cost factor. I can take that responsibility s of the fact that we did not buit for subacute beds within zuckerg general and some of that was ban the amount of space that we had between if you see where zucg is, it was a challenging new spr us to put a new hospital there e of the things have to stay behi. No, we did not plan for that ane did not have installers for that laguna honda. I know that when i first s appointed to the board, the thig i think i voted on was a parkind Research Facility at zuckerberg hospital. Im wondering if we had if we any space, could we create one . If it wasnt i understand ths cost. There is a cost not to have the. Absolutely. I think to put them on privae hospitals, youre right, it is o put it it all on cpmc, we shoule some responsibility as a city ay to have some of the beds also. Are we able to create at General Hospital now any beds for acute . Please stand by. Do we have a number that all the hospitals that could have beds. Or to be relicensed to have beds or do we have a number or report about where were at now and if any hospitals could be relicensed to have these beds. That is part of the extra edge tooic plan that were doing and right now were working on the short term plan with st. Marys, knowing they have subacute space today. Ok. So, do you so youre preparing that report. You dont have those figures now. Even not just with st. Marys, but for long range so we can get a larger picture of what were dealing with here. That is part of your extra edge tooic plan . Your extra edge tooic plan . Your Strategic Plan . Thats right. And one of the reasons were building New Buildings there like the search sfrr is because all the other buildings are very safe and so its a host issue regarding building more subacute beds on the campus. But that would be a bond issue for us to discuss for the future in terms of how we do that, if we wanted to do that. So, thats clearly another option. It would feel to me a little more expensive than trying to look at the other spaces that we have in the community. Sure. I think that the whole way i think that we can also its great that were part of this hospitals council, quite frankly. But this is something that we should really be looking at. If the city is i mean, if he know that there is a shortage of subacute beds everywhere and that we hold the value that patients or families of subacute patients, we want them to be close to their loved ones, then i think that we should be looking at what that cost would be to to remodel or renovate, whatever, those older buildings so they could be subacute beds and how many beds could there be . Theres also a shortage, im assuming im hearing now and ive heard before through this other presentation weve had before on Skilled Nursing facilities. And so could we do more subacute and Skilled Nursing facilities at the hospital if we were to renovate some of those buildings . I think it would be very cost prohibitive from the research that ive done on this campus. As an example. It would be much more expensive to do that than other locations. Let me finish. Sure. Would you have a nonprofit provider in the community who does have acreage and land that theyre willing to use in these facilities. Its part of the plan and will include the departments responsibility as well. And i think if we can do that in the most affordable way, support some of the groups that the nonprofit groups that are willing to do that. We do have lands in laguna. There has been discussion about assisted living on that campus. That was one of the first plans that was not being we could not put that into the bond. When laguna honda was rebuilt. We dont exclude ourselves from the solution to the problem. And so we would be part of that solution in terms of that. But trying to do it in a costly and the most effective way possible, it would be the trajectory that i would put through. And do we have any relationship to the Veterans Hospital . We do not. And thats were a difficult group because it is a federal hospital, but clearly we can work with them as well. Because they also have a lot of land up there. Yes. Thats right. Average 22 acres that is there. So, again, going back to this issue, though, its always a shortterm need that we have to have. We have somewhat of a focus on st. Marys. And then theres the longer term issue because if you ask me to build something today on the campus, it would take me five to seven years to get that completed plus million and millions of dollars for seismic upgrades because there is historical buildings, which is why we did not rebuild those to build zuckerberg general. So i think there are more effective ways and more cost through the artists, costly to meet the same need. I just think that this is a population that will grow in our city and i think that it is a population, especially the Skilled Nursing beds also. Subacute also, but Skilled Nursing beds and since there is a shortage already, and there is a shortage regionally and even statewide, subacute beds, i think that were always going to have the need. And i think that as the city and county of San Francisco, that we should be leading sort of the capacity for this because actually i would love to see the cost analysis of how many patients we pay for and [inaudible]. And the cost of at this time and i just think that this is a problem. And i get that were doing shortterm. But actually id love to see longterm planning. Because if we discussed this seven years ago and had a plan, we might not be in this situation now. I was actually a little disappointed to hear that with laguna honda, there wasnt any remodeling for subacute beds. What was the decision that these Skilled Nursing beds i know that we need, but no subacute bed interests at laguna honda . That is a question i wouldnt be able to answer because i wasnt during that period of time as the director. But that is something we can definitely explore. At one point, laguna honda went down to 780 beds because of the amount of money we had to rebuild laguna honda. So, the Strategic Plan the sxhition asking to do a seven to 10year plan and we are looking at the future of skilled nurses facilities as well. We have a shortterm need, as you have outlined. But we also have a longterm need in terms of the future. Ok. And so you are working with labor and community groups, as was mentioned, on this longterm and shortterm plan. Thats right. From the last supervisor hearing that you had, we were asked to have meetings with both labor and patients and we showed that in the slide today and then weve had continued conversations with some of the providers who are willing to do some of this work along with the Supervisors Office to meet with the other providers interested in longterm projects. Actually, i think whats really important in this plan if i may say so is it mandates a minimum number of beds that we should have in the city and county of San Francisco, public and private. Just so that we know that what we can depend on, i think that when we hear this removal of subacute beds and then were rushing, where are they going to go what a disruptions to the families. But if we have actually a minimum of what were saying that we should have available in the city and county of San Francisco, i think that helps us to prepare and plan and actually for families to plan, too. So that we know this is how many we have. But i also think, as i mentioned again, it is a shared responsibility and it isnt just with private hospitals, but also with uls, too. Absoluteliful and we feel the same way. Thank you. I dont think i have anymore questions for you right now. But thank you for all your hard work on this. Well continue to work with your office to come up with a solutionage just to reiterate the Hospital Council has a whole host of different private hospitals that can be part of this conversation. Absolutely. Well get back to the supervisor regarding the dollars that the department spends on subacute beds. As soon as possible. Thank you. Doctor, can you come back up just for a few more questions, please . Thank you. I didnt realize until this slide was presented to me that there was even a subsection of subacute care. So short term and longterm. So, st. Lukes is the only right now, licensed facility thats designated subacute skilled facility. Not care, in the county. Is that correct . Yes. Thats correct. Its probably easier, supervisor, if you think of elpacs which are called longterm acute care, has really been more closely aligned with acute Care Hospitals. Thats why it is so confusing and goes acute, longterm acute, subacute, chronic subacute. So, it is better to think of them as part of an acute Care Hospital. So i heard people wanting to call director garcia dr. Garcia [laughter] i mean, she does have a ph. D. But director garcia, you know shes made a commitment and we talked about st. Marys, but there is this general desire of this board and body and i know specifically i feel that way and i know supervisor ronan shares that. We would like to see all the private hospitals be part of the conversation. I dont know how we got here because im just becoming part of this conversation. But i dont see how we, as a county, can be the only county in the bay area without subacute care and you are the only facility right now, you are the only facility that has that care thats licensed. So i imagine the reason why you cant move some of the patients tomorrow is because you have to do certain things to make it and then the state will come in and authorize you to have license it seems like you are going through a tremendous amount and we really appreciate that. But what i heard director garcia say is that we want cpmc to be part of the conversation and solution for a permanent subacute care in the city. Can you talk to that . Can you commit to that and can you what that would mean for your hospital. And if you cant, why cant you . Let me just begin by saying, i want to thank the supervisors for havinging this incredibly thoughtful discussion about a very important issue and really addressing it the way we need to do as a city that takes pride in providing care for the people who live and work here. You asked how we got to this place and i think the supervisor hit the nail on the head. We have not been doing the work we should be doing to anticipate the future needs. Direct to garcia is absolutely correct. Right now the limiting factories for [coughing] just has to do with available space. I would remind the supervisors that subacute beds are actually a subpart, sublicense of snf facilities and we shouldnt eliminate the possibility that these facilities in the city could also take on subacute responsibility. Even among those that arent attached to hospitals. Does that answer your question . Yeah. But you just made a good point because you said your current facility at davies is currently s. N. F. Facility. So well go through that trouble, why not then make that a permanent part of your delivery there . Because it solves one problem, potentially, while exacerbating another which is we also need those beds as ordinary s. N. F. Beds to take care of patients who are dischargeded from the hospital and snead s. N. F. But not subacute care. It is a very thorny problem and it is probably a more difficult problem that we can solve right here and right now. But certainly the hospital sill, which represents public and private hospitals, including the v. A. , includinging laguna honda, including the jewish home, were absolutely commited to working on this because the reality is, although this is a problem for the board of supervisors when you hold hearing it is a problem for those of us who take care of patients every single day. How many beds are you going to have at the new hospital at Cathedral Hill . We will not have any s. N. F. Beds at either new facilities. Theyre being built as acute care facilities. The licensing requirements and probably more importantly, as director garcia was implying, the seismic requirements for acute care beds are much higher than they are for s. N. F. Beds for subacute beds, for lpc beds or psychiatric beds. Higher on those end . Greater for acute care. Require stronger buildings, more service,etc. So, youll have acute care in the shortterm, in and out. Yes. Acute care. Where in your network ofment hos, do you have any s. N. F. . We currently have them on campus and a few at st. Lukes and then we, like almost every other hospital in San Francisco and throughout country contract with s. N. F. Providers in the community to provide beds for patients when theyre discharged from the hospital. [inaudible] seems like most hospitals are now contracting out into the community that level of service. Its probably appropriate. S. N. F. S care is probably best provided in designated units and facilities. Ok. So, i just just i understand it could be thorny and part of your overall number of bedsful were not asking you to take on that entire burden of 70 or 40, but you have an existing facility. You could potentially you have an existing, like say building that you either could convert into office space because the seismic requirements are different for subacute versus an entire hospital. That is correct. And we are our current plans are to keep the unit on 1 south as a combined s. N. F. And subacute facility. Those are our current plans. Where . At davies, at 1 south. At existing st. Lukes building. Ill remind the supervisor that once we move the acute care patients into the new hospital across the way, that building actually will be taken down. Being torn down. Yes. And you are going to build a new building there. That that acute Care Hospital requires additional medical office sfies take care of other needs that people in San Francisco have. Could you consider being part of the solution . I think we already are part of the solution and i will absolutely commit to being part of the solution. As i was saying, this is an incredibly difficult problem. The Health Commission has been struggling with it for years. I know that director garcia has been working on it diligently and if there was an easy, ready solution, i would be more than happy to offer it today but there isnt. Ok. Thank you. Do any of my colleagues have any questions . Hi, doctor. So sorry. I probably need further explanation. So, at the at the existing st. Lukes, clearing everybody out and rebuild that whole building and mraeen to rebuild that building without any Skilled Nursing beds, is that correct . Just acute care and medical offices. So im there are two there is a building going up on the campus fou that im happy to take you through that will be just for acute care. That is the 120bed acute Care Hospital that we committed to build during the discussions back in 2013 with the supervisors. Sure. Until part of that plan part of our plan for that campus involves building a medical Office Building where the current hospital is located. Ok. Can you give me an example . Im so sorry. Theres all these terms and, you know, ive only spaent short time in a hospital myself, goodness. Just wanted to know, like what kind of patients are we talking about when we talk 120 acute beds. So, acute care beds are used, for example, for patients with pneumonia, patients who have undergone surgery, women who have delivered babies, patients in intensive care units. What we call medical, surgical and o. B. Patients for the most part. And at the facility, what kind of beds do you have there . At the van ness facility yeah. We have 274 acute care beds. Again the same kinds of beds. Medicalsurgical bed, i. C. U. Beds, labor and delivery beds and that hospital also has a pediatrics unit. And you dont have any Skilled Nursing beds planned for the new cpmc . No, as i mentioned to supervisor safai, the seismic requirements for acute care beds are so high that it is just not fiscally possible to build subacute or s. N. F. Beds within an acute care facility. That is the reason. None of the new hospitals being built around the state will include any of those facilities. Ok. Is it the cost . Yes. So its the cost. Essentially, yes. To do for example, the building were building on the st. Lukes campus is a 600 Million Building for 120 beds. So when director garcia was talking about the costs of including or renovating buildings to accommodate s. N. F. Subacute bedses she is talking rather large numbers. And then just because its so confusing to me, the new cpmc on van ness is going to be 274 acute care beds and then you are also going to be having pediatrics there . Yes. Pediatrics acute care. Kids get sick as well. And are you having medical offices there, too . Not in the hospital, no. Ok. And so so it is the cost that prevents you from having Skilled Nursing beds. Ill answer on behalf of all the hospitals, including the Public Hospitals and say, yes. The cost of acute care beds to build them to be seismickically safe and to be compliant with all regulations, its prohibitive to also include s. N. F. Beds in that kind of a structure. Ok. So, i mean, so we made there is acute beds, theres subacute. Theres Skilled Nursing. So youre saying to me that the only ones that are affordable, not even affordable, i get the price tag, that you are able to because of finances are acute beds. You are not aable to put any skilleding beds in these facilities because the seismic upgrade for a Skilled Nursing bed would be cost prohibitive, is that correct . All of the