The sfgov tv. Maybe we could fix that. Back to you, supervisor safai. Supervisor safai thank you. Were going to call up kelly here in a moment. Shell have an opportunity to speak and play out a plan. We want to allow gloria and raquel, one of the families that are currently in subacute care to come up and speak about their experiences and their conditions their sister. Then we will ask San Francisco for health care housing, jobs and Justice Coalition mark erickson, salini am i saying that right . Salini. And then from the California Nurses Association c. N. A. And then were going to ask benson nadal from the longterm Care Ombudsman Program and well open it up for Public Comment. So again i just want to end with its this is this is gutwrenching. This is heartbreaking to see the conditions, to see the individuals living and trying to survive and again this is something i have never experienced. And i understand that its it is heartwrenching to experience that type of circumstances with the Family Member. And just want to be sensitive to that. And really appreciate the families for inviting us down there to, to let us experience that with them. And know were here to continue to advocate and push and demand the highest level of care in the city and county of San Francisco. So just want to hand it over to i know you want to say something, supervisor ronen. Supervisor ronen yes, thank you, supervisor safai, for calling this hearing. You know, it is a shame that the city of San Francisco, city and county of San Francisco doesnt have, other than the few beds that are left at davies, a single subacute unit in the county. That is wrong and we need to fix that. Having im looking forward to hearing from the department of health about what the concrete plans are to do that. Having said that, i also visited the davies campus, i would say its about a month ago. And i was frankly shocked to see the conditions that i saw when i was there. I immediately called warren browner, the c. E. O. Of cpmcand had a discussion with him. I know he went to the unit shortly after i called him that same day. And i talked to him a couple days ago and he assured me what he told me, let me say it this way was contrary to what i witnessed with my own eyes. So im not sure exactly whats going on. And im also looking forward to hearing from cpmc. When i went to the subacute unit, there were not very many staff on the unit. In fact, i think i saw two people the entire time i was there. When i walked in, there was a light going off, you know, indicating that a patient needed staff, that i didnt see turned off for at least 15 to 20 minutes. When i was in the room visiting a patient, with her family, at one point she wasnt breathing well because her breathing machine was clogged. And she had pressed the button. And there was nobody coming to respond for quite some time to that to that linking button. Eventually the group that i was with, someone went over to the one staffer that we saw in the area and asked him to come help. And he was sort of clueless as to the needs. He said, oh, i didnt see that button. And the light flashing. Oh, im helping this patient, but let me yeah, ill go over there when i can. It was so casual and didnt lack it didnt exhibit sort of the urgency you would expect to make sure at least that the patient wasnt in serious trouble and then maybe multitask to get them the things that needed to be done. It was not the level of care that i would hope for my Family Member, if that was me or my Family Member in that unit. In my subsequent discussions with warren browner, he told me that there is an offsite monitor that monitors the time between when a light goes off and when its responded to by a staffer. And that he didnt find anything unusual in terms of the time that it took. Again i can only attest to what i saw with my own eyes. And it was worrisome. So, you know, this is not a hearing to beat up on cpmc sutter. This is the only hospital currently with any subacute beds. They were hard fought for to keep them at cpmc sutter. But the hospital did make that agreement and that was appreciated. I do want to hear from you and have some concerns about the level of care that is being provided at that facility. But this is more importantly or equally i should say not more importantly, but equally importantly about the fact that we do not have these services in the city and county of San Francisco. And that that is unacceptable. Thats the responsibility of Health Department and the entire medical community to remedy that fact. And so thats why im here. And thats what im interested in talking about today. I want to just say to the Family Members that are here that, you know, thank you for taking me around and showing me the circumstances for myself. I had never been in the subacute unit before. So it was very eyeopening for me. And, you know, i can say from what i witnessed that day, that i understand at another level the concerns that the Family Members have been bringing up in these hearings. And so im looking forward to hopefully getting some of those questions answered today. Thank you. Chair supervisor fewer. Supervisor fewer thank you very much, supervisor safai, for having this hearing. I am also concerned that we dont have a subacute facility in the city and county of San Francisco dedicated just for that care. But i also just want to emphasize that it is not its not a question of whether or not subacute or Skilled Nursing beds, because we need both. And so i am looking forward to the hearing today to find out what our Current Situation is, because i know, through various hearings weve had together, that theres also a shortage of Skilled Nursing beds. And so i dont think that we should be substituting one for the other. Quite frankly there is high need for both. So thank you for calling this hearing. And i hope to learn a lot today and be part of a solution to i i think are this population that is going to need this care, currently needs this care. So they dont have to be pushed out of San Francisco. Thank you. Chair thank you, supervisor fewer. Thats a very good point. Thats a good transition. So i think well call up kelly. Why dont you go over have an opportunity to give your presentation. Okay. Thank you. Good morning, supervisors. My name is kel request. Im a project manager with San Francisco department of Public Health. Im here today to do the introduction for the update on subacute Skilled Nursing care. Just kind of overview. Supervisor safai did a good overview of reminding everyone what this level of care actually is. Subacute Skilled Nursing is provided to medically fragile individuals. And this is to distinguish from some confusion that some folks may have around the beds that we currently have at st. Marys, which is also known as subacute, but it is more for mental health, individuals and not for those having medical compromises. Today were talking about people who need subacute care. And that is a level of their is when youre no longer in an acute crisis, meaning to be in an acute care hospital, but not well enough or stable enough to go back to a community setting, such as a home or an apartment. There are individuals who need ongoing 24hour care, as the supervisor mentioned. These are folks who require very specialty care, Skilled Nursing services, such as inhalation therapy, tracheotomy care, tube feedings, very complex onCare Management, generally are the individuals that youll find in these facilities. Broadly speaking the department recognizes that optimally postacute care would be provided in a home or communitybased setting. Thats most people who enter into hospitals get care and treatment. And then are able to go back home and finish recuperating. But there is the segment of folks that that is not possible. They are people who cannot be discharged home, either because they dont have a home or they dont have a home that can accommodate the specialty equipment. And these are folks that need to go to Skilled Nursing facilities for what we would call subacute care. And what brought us here today, in 2018, cpmc transferred at that time 17 patients from st. Lukes subacute to their davies campus. And the agreement at that time was that these individuals would be cared for, no new patients would be admitted and we are aware that today the census is eight. In the fall of 2018, the department of Public Health began a process to identify a consultant to help conduct an environmental scan to bring it to current the last time we did our environmental scan was several years ago. We also wanted somebody who would help us manage the project selection and implementation, so that we could bring new subacute Skilled Nursing beds online as quickly as possible. And we worked in conjunction with the controllers office. In june of 2019, we selected milliman inc. , they are a health care and finance expert consultant. And weve invited milliman to give an update on the work that theyve done to date. And ill be able to answer questions following. Id like to introduce you said theyre going to present on what theyve done today . They did the environmental scan and theyll update. Yeah. It would be good for you to come back. Exactly. Well follow through. Thank you. Im going to introduce you to the senior principal consultant. Through the chair, what is an environmental scan . Im sorry . Supervisor ronen an environmental scan . How many beds do we have in the community currently. How many we did surveys in 2015, of how many patients are discharging with subacute need. We wanted to update that. Is that number getting more, less, stable. We actually engaged milliman to make the outreaches and conduct those surveys, theyre going to give us a summary of the report. Theyre also going to need an update from the participants were Work Partners were working with and going forward. Welcome. Okay. Good morning, supervisors. My name is susan phillips, Senior HealthCare ManagementHealth Care Consultant with milliman. As kelly mentioned, im here to present today an update of the project to identify and develop opportunities for subacute Care Capacity for the city and county of San Francisco. So, first, just let me briefly introduce myself and milliman. Milliman is an an ak due waral m created in 1947. We have a major office here in San Francisco. Our mission is to serve our clients to protect the health and financial well being of people everywhere. And that is our core mission and we take that mission very seriously. And strive towards that. We involve 3800 employees, including consultants that have extensive experience in supporting Public Sector clients. And i personally have 20 years of experience in working with Public Sector clients and working on various policy initiatives in terms of Analysis Development and supporting and implementation. So as i mentioned why were here today, is to give you a status update. And in terms of the in terms of the purpose, we want to provide you, as i mentioned, a status update. We want to give you an outline of our next steps, in terms of generating options for expanding subacute care options and give you preliminary findings of what we have done so far. Okay. I think supervisor safai did a very good job in providing an overview of what subacute care is. And in terms of the specific population, i did have a few slides to walk through that. In the interest of time, i might go through that fairly quickly. But, you know, i think the main thing that we wanted to highlight here is that, you know, this population again is medically frail, in need of special medical services. And to serve medical beneficiaries, certain licensing requirements sustained by the state. For example, certain nursing staff requirements that have to be met. Ill get into that in a little more detail. So i did think it was important just to lay out again the subacute care is part of the full continuum of postacute care. You know, as a person leaving a hospital, you know, thankfully most patients, you know, dont need postacute care following a hospitalization. Obviously some do. The goal of any discharge from a hospital is to get the patient to the right care at the right time at the right place. And the place and the type of care thats appropriate is highly dependent on the patients condition. And the level of care that they need. So this is, you know, a full continuum of postacute care, you know, from the home to Skilled Nursing and then up to subacute care. So the next slide is really to illustrate the difference between subacute beds. Again as i mentioned, the key difference here as you see is services of subacute care can offer our ventilator care, complex wound Care Management, intravenous tube feeding. Now as you mentioned back in 2018, cpmc had a 17 subacute care patients transferred to davies. And now the remaining eight patients, based on cpmcs report of current bed census. And based on 2018 data, the total count of general sniff beds is 2,227. And this does include freestanding facilities, as well as hospitalbased facilities. So its the total general sniff bed count. Excuse me. Do you have a breakdown of that 2,227 freestanding and which hospitals are doing what . Yeah. So we have 901 at freestanding. And 1,326 hospitalbased. Okay. Okay. I did just want to take a second to provide an illustration of people who need subacute care. Again we did speak about this. But i thought it was important to take a second to kind of walk through a couple of patient profiles of two different people. You know, we have one patient who is older, another one thats younger. Both of these individuals here have had serious medical crisis. And theyre both in need of ventilator care for a long time. And possibly, you know, for the rest of their lives. On this slide, you know, we see that the 45yearold might, who was in otherwise good health, prior to the medical crisis, may be in need of subacute care for decades. So i think this is just important to keep in mind. Okay. So switching to the project. The project objectives, as we said, are to support d. H. P. , plan for and implement expansion of capacity for subacute care beds in San Francisco. Our approach is to can you go back to that slide for a second. Sure. Sometimes you guys say things and do things that make sense to you. Okay. Yeah. And anyone thats might be in the industry. Sure. But when i read that, the first thing that jumps out to me is why is the medical beneficiaries an important part of that statement . Well, so i think that is a population that has, after longterm, medical is a primary payer. What if someone needs subacute care, thats not medical . So if they have medicare and commercial, there are other payers. But its true in terms of capacity, theyre facing the same issues. And thats where we consider them part of the vulnerable population. Okay. Thank you. So our approach is to try to take although wouldnt the vast majority of people in that situation be on medical, if were talking about yeah. If were talking about over 100 days, yeah. If theyre medicareeligible, if were talking about an older person, over 100 days, medicare does pay for the first 100 days. But then after 100 days, then the primary payer would be medical. Youd have to youd have to be either extraordinarily, incredibly wealthy or youre on medical. Right. Because this is longterm care. And thats a major issue in terms of just covering for longterm care in this country. That was my point. My point was to kind of clarify to the general public, but also for my own etfication since im not in the industry. Great. Thank you. Thanks for that question. Okay. So in terms of our approach, what were trying to do is again take a comprehensive view of the potential needs in the city and identify an array of options to address those needs. You know, our goal is to try to make sure that were bringing as many options as possible for your consideration, as appropriate. And as we mentioned right now, were in the mid of this environmental scan. And what were doing as part of that is to collect information from potential partners and stakeholders in San Francisco. So what we have done is conducted a series of interviews, with Hospital Systems and we have asked for data. And im going to get into, you know, our initial findings, based on that. The next phase is what were calling project selection, which we are starting very soon. Were starting by first identifying potential partners, who are interested in developing capacity in the city. And d. P. H. Is currently working directly to identify proposals. And once those proposals are submitted, we would review those proposals obviously. And then work to synthesize that and facilitate further dialogue among those stakeholders and we are would like to provide a framework for decisionmaking for d. P. H. And the board of supervisors and the city to, you know, consider those proposals. We plan to share our review. Were hoping to do so by november. And once the city and d. P. H. Have thought about this proposal and are thinking about which ones to potentially go with, well begin the process to partner with d. P. H. To further flesh out all of the incredible steps thats needed for implementation. Excuse me. Sure. Supervisor ronen, did you have your name on there . Supervisor ronen i had some questions about that. Chair just one second. Are you almost done with your presentation . No. I was going to provide findings. Chair okay. Go ahead, supervisor ronen. Supervisor ronen thank you. What does that mean that youre going to solicit proposals from potential partners . Can you talk a little bit more about who these partners are that youre expecting to receive proposals from and sort of the prework that goes into. Yeah. Sure. Its actually we wrap up with that. So if we could ask to finish the presentation. Chair sure. Thats why i asked. Some of the questions that we have might be answered in the presentation. They will be. Chair so if thats one of them, supervisor ronen, if you still have questions after theyre done, well come back to that. Supervisor ronen sure. Thank you. Ill get to the findings now. Chair thats fine. Okay. So in terms of the folks we talked to, here are the folks we talk to. We talked to seven Hospital Systems in the city. Again conducted interviews. The interviews include questions to gain understanding of what the subacute care needs are. We asked about placement barriers and interest in partnership. We also requested data to understand what the discharges currently ar to subacute care, what placement barriers there might be and the wait times. So all of these facilities generously provide their time and key staff involved in discharge planning and, you know, are involved in the care of their patients. So we really appreciate their time. We also gathered data from almost all of the facilities to the extent that they were able to do so. So im to provide what happened with kaiser . Going back there. So kaiser was not able to provide data, just in terms of the way they keep the data and thats essentially what they told us. What does that mean . How they maintain the data. Can you say it clear. They just didnt want to give the data . Well, they told us that they were not able to provide the data. Okay. So they didnt have the data. Okay. Thank you. What kind of data are you asking for . Sure. Yes. I will get into that. Actually i might just the kind of data real briefly. What we try to hone in is wait times for placeman and discharge. Seems pretty straightforward. Chair supervisor fewer. Supervisor fewer okay. You just ask for two things. Well, we ask for a few things. But those are the two key things that we wanted to distill, to give you a full sense of, you know, what are really the barriers for subacute care. And so that one specifically those two data points specifically, as ill get into, you know, kind of help paint a picture of, you know, who are these patients, how long are they waiting. And where are they how many of them are waiting for discharge. Supervisor fewer okay. When youre interviewing these seven facilities, youre not asking about capacity or are you . We did ask about capacity as well. That was part of our set of interviews. Yep. Supervisor fewer you asked for wait times, youre asking for waiting for discharge. Yep. We also asked about interest in partnerships. Supervisor fewer interest in partnerships. And did you ask about whether or not the facility is can take subacute patients and are licensed to take subacute patients . I mean, have everything in order to take them immediately. Yes. That was part of our capacity question. Right. So we did about that. And so i do have a slide that shows supervisor fewer yes. Okay. These are the things that kaiser couldnt give you data on, is that correct . Thats correct. Supervisor fewer im trying to find out what the questions were. They didnt seem that complex. Of course, im a lay person. Still. Sure. Chair thanks, supervisor. Okay. Chair please proceed. Okay. Thanks. You know, one thing i did want to mention, just to put this in context, there is a shortage of subacute beds in Northern California as a whole. In california, there are about 4,486 subacute care beds. About 70 of them are in Southern California. Among the bay area counties, there are about 514 beds. So, you know, theres just overall more in Southern California than there are in Northern California. I did also want to point out that right now patients who are ventilatordependent and in need of dialysis, must go to Southern California or outside of the state. So that is a real, you know, its these are rare circumstances, of course, where someone has a ventilator and dialysis. For a few patients that are in need of those services, there are none in Northern California. Chair supervisor stefani. Supervisor stefani yes. Thank you. I wanted to ask one more question what you were asking of the hospitals. Did you ask if they had the ability to provide subacute care . And later did not . We didnt get into their historical capacity. No, we just asked about where they were at that time. Supervisor stefani okay. Thank you. Okay. Okay. So based on the interviews, i did want to share qualitative findings. First, again to reiterate that, you know, the goals, of course, are to make sure patients are getting placement, the right place at the right time. We did hear again of this the need for custodial beds and that is also a shortage that the hospitals did share with us. I did want to make sure that that was highlighted and that is part of the overall postacute care placement challenges. Of course, there are major considerations for family, families that obviously keep part of the Caregiver Team to make sure that the patient has Good Health Outcomes and they can be there as an advocate for their loved ones in the hospital. A couple of barriers we are heard were payment sources and payment rates. As mentioned, medical is the payer for longterm subacute care services. And per diem rates for subacute care are too low to cover the costs of San Francisco. Another hurdle weve heard is regulatory hurdles that could impact bed supply. Again there are issues in terms of licensing and staffing ratios that are required by the state, that are needed to set up subacute care beds. That were reportedly a barrier. So i think this is what you were looking for in terms of the initial findings. So well get into that. So the wait times for placement. Again these are difficult numbers, because were talking about very small population. So there is quite a wide range. But these are a couple of hewsful useful measures. We looked at wait time for placement and discharges from hospitals to subacute care. So, you know, its hard to speak about averages when theres such small numbers. So wanted to provide a range here. So while wait times for placements vary widely, the general average wait time for placement may be around 30 to 45 days. And then there are very extreme cases. Weve heard of wait times that are longer than even 500 days. So there are some pretty extreme cases. I did think it was important to note that a couple of facilities just said that they just havent been able to find placement at all. And so and you know, so folks are staying, you know, in the hospital. In terms of discharge, we do that means theyre looking in other counties, theyre looking around the state and theyre not able to find someone . Well, you know, theyre also trying to take into account family preferences and making sure that thats taken into account. So they might stay in the acute care facility. So in chair hold up. Supervisor stefani. Supervisor stefani back to page 19. Patients that are ventilatordependent and in need of dialysis, no subacute care options in Northern California and must go to Southern California or outside of the state. Im wondering what is that universe of patients . How many people is that . Yeah. I dont have a total count. What were hearing from facilities its about, you know, a couple a year. I mean, were not talking about a very large number. These are very, very rare circumstances. Supervisor stefani okay. Thank you. So in terms of discharges, we have a preliminary estimate of 49 discharges in 2018. And this is based on the hospital, acute care discharge estimates, as well as a rough estimate from facilities that talked about individuals that are waiting to be discharged, but couldnt find placements. Taking those two into account. You know, the bottom line is we think that these are pretty low estimates, because again there seems to be some challenges to track this data. One point that was made over and over again is that, you know, these patients are frail. And theyre you know, when theyre waiting for discharge, their status might change, right. Their condition might worsen, they might need to go back to the i. C. U. In that case theyre not necessarily picked up in the data there, in terms of their final, as they call it, discharge, disposition. So it wouldnt necessarily be picked up in the data there. So we do think that these that there could be a higher rate there. Okay. So in terms of the next steps. We are looking at options, hospitalbased distinct park facilities in San Francisco. As well as freestanding facilities in San Francisco. I did want to first speak about the hospitalbased subacute care beds. As we discussed, were exploring opportunities with the systems. As you mentioned, you were asking about the partners, right. So the two that we have identified, Chinese Hospital has identified 23 available beds that have been built out. And theyre interested in potentially designating these subacute care beds and working with the state to make that happen. Because they need to go through the state approval process. My understanding is that theyve been requested to support a proposal to d. P. H. Theyre in the process of doing so. The department of Public Health is also in conversation with dignity health. And theres a potential proposal that may be forthcoming in october. So thats another real potential. I did also want to highlight that kentfield, which currently operates a longterm care acute facility in st. Marys, on the 6th floor there on stanyon, they are interested in partnering with a hospital to really serve as the operator for subacute care unit. So they have experience in serving this population, because they serve people who are ventdependent and they have that experience now. So theyre interested in partnerships. In terms of next steps, we are planning at this point to conduct interviews with freestanding nursing home operators in the city. There are four right now, San Francisco health care, aspen Skilled Health care, providence group, Generation Health care. Initial conversations with these operators, theyve all expressed interest in potential partnerships and potential expansion. And really looking at all options. So they have all raised their hands and said that theyre interested in, you know, continuing a conversation. So we will plan to be conducting interviews with them over the next few weeks. Again as part of that, well be asking them about their current capacity. What their future capacity might be and shortterm, longterm. What, you know, potential barriers they have. What theyre considering is the implementation steps. And again their willingness to partner. Well also be asking them about other Supplemental Services and arrangements they might need, like Critical Care transport. And again well work with d. P. H. To obtain proposals. So that wraps up my points. Chair so what well do, because we have Family Members and other people from the community that want to come and theres some more of the presentation and some questions and Public Comment, i want to come back to the last two slides, because thats part of what i wanted to get on the record. We have Chinese Hospital thats willing to have this conversation. St. Marys is willing to have the conversation. We can dive into the residential, in the nursing home operators. I know supervisor mandelman and fewer have put forward a proposal about longterm care facilities. Using potentially small sites money for acquisition and preservation. So we have a whole bunch that we can talk about. We can come back to that. I want to be respectful for the people that have taken time off from work to come here and speak. So if my colleagues dont mind, well come back to the last two slides. I know we have a lot of comments and questions that we can add to that. So thank you. Please dont leave, because were going to come back to that portion. I would like to call up miss gloria and raquel to come speak. Two current Family Members with a sister in the davies facility. Good morning. My name is gloria rivera. Im the sister of sandra rivera. On behalf of the patients and families and ours, we thank you for taking the time to visit the subacute unit, to see with your own eyes what we have been encountering. We are here today because half of the 17 subacute patients, that were transferred from st. Lukes, died within one year. Cpmc has not been keeping their promises. They have not been providing the quality of care that they had assured us. Patients are being neglected due to lack of staffing. There is no urgency when answering patient call lights. They have inexperienced staff and floaters, who are not familiar with the patients and equipment. Patients are not being checked for suctioning. Something needs to be done now to make sure the remaining patients do not die from neglect. At this rate, there may be only four left by the time december comes. This is why we need the subacute unit reopened. These rooms have already been specifically retrofitted for the original 17 subacute patients that were transferred. In the best interest for cpmcs current patients and the community, cpmc should maintain and admit new patients, so that theres an adequate level of staffing and continuity of care at all times. How do you explain eight deaths in less than a year, soon after going to a new facility. Cpmc is working diligently to get rid of these sick patients, whether by transfer, sent home or by death. [bell dings] for example, one patient was convinced that she was well enough to go home, only within three months after being transferred to davies, released and then admitted back into a subacute facility out of county, all the way in sacramento. For another patient, which is my sister, who is developmentally disabled, cpmc contacted an agency without our knowledge, to find out the qualifications to have her transferred to a group home. [bell dings] and yet more recently another Family Member was told their sister was ready to go home, even though she still required much further rehabilitation. We have families grieving today because of cpmcs lack of care for subacute patients. They intentionally went against everything we stood for to cause havoc, depression, anxiety, financial hardship, whatever it took to tear us down and for the patients not to thrive. I asked how do eight patients die in less than one year. The very same patients who were at st. Lukes for many years. Supervisor ronen, do you recall the part of your visit when a patients alarm went off. The staff member who said he was from rehab did not know what the alarm was for or how to turn it off. How do you feel at that moment . Im sad to say this patient passed away in just a few weeks. I dont know how to turn this on. Fran, my friend. Supervisor stefani, how did you feel seeing how helpless these fragile patients are . The stories of how their lives once were and how their lives are now at the mercy of cpmc. Wasnt it hard when it was time to leave them. When supervisor yee and walton visited the unit, as you know, stefani, mr. Browner came to our group and totally dismissed the families and asked supervisor walton and yourself to step into an office with him, so he can talk privately with you. But supervisor walton refused his invitation and stated to browner, that whatever he has to say, he can say it in front of the families. Supervisor safai and stefani, just like youve seen how the staff was the day you both arrived, because they knew we were coming. Its how the subacute should have been staffed at all times. Where is the transparency and compassion for the families . In addition, inadequate staffing, the subacute patients are also not thriving because they are they do not have the designated activities coordinator to give them stimulation throughout the day. Because the activities coordinator is handling both the s. N. F. And subacute patients. The priority is given to the s. N. F. Patients who are more alert and mobile. The subacute patients had an outstanding designated activities coordinator at st. Lukes. She went above and beyond her duties and cared for them as if they were her own family, such as washing their hand, nail painting and helping the nurses. They should have a distinct or separate activities coordinator, just for the subacute. Questions to cpmc. Why have there been so many deaths . How many more deaths are you all willing to sacrifice before a change is made . This is raymond. Our friend who had no family. Raymond was transferred out with no choice of his own. He was fighting that he didnt want to go. We were his only family. Because he was a religious man, they brought a priest to his room. And the priest told him if he does not leave, that he wont go to heaven. Raymond passed away a year later. Question, how many more deaths are you willing to sacrifice before a change is made. What would it take for cpmc to open this unit to new patients. What would they need what would they need to readmit the patient they discharged home. Shouldnt they be allowed to come back. How soon can we make this happen. What is the plan if and when there is no subacute left in San Francisco. Where is the director of nursing to answer our question, where is dr. Browner, how come no one from davies hospital is here to answer our questions. Heres a plan that we propose. Cpmc already retrofitted rooms specifically for subacute care for at least 17 patients. We can end this fight today if they are willing to keep these beds open for new subacute patients. When she was speaking on there are over 2,000s. N. F. Beds and eight subacute, thats less than 1 . Thank you. Chair thank you, ms. Rivera. Does your sister is your sister wanting to present or presenting for both . Im just the one presenter. And, as you know, the alarm that was going off for the patient, and as i mentioned, she passed away. Chair thank you. Im sorry to hear that. Okay. We will move to mark erickson. Its just about good afternoon, supervisors. Im mark erickson. Im an an emeritus professor of law at Hastings College for law. And for more than ten years now, our c. E. D. Clinic, our Community Economic development clinic, has worked with san franciscans for justice on cpmc and health care concerns. Generally in San Francisco. I want to address just two points today in terms of background for cpmc, as part of your larger discussion regarding the need for subacute care and a whole host of needs around postacute care in San Francisco. The first up with is to take off the table that the Development Agreement the city entered into a with cpmc, in 2013, in any way restricted cpmc from being a full participant in any program San Francisco wants to meet the needs for subacute care and other postacute care needs. The Development Agreement itself says that cpmc is to act in good faith to deal with the subacute care unit. It does explicitly not require cpmc to expend any funds or staffing. But most importantly, it does not limit or restrict in any way cpmc being a full participant and, in fact, providing subacute care facilities and other needs for lowincome and other people in San Francisco, in terms of health care issues. The second point i want to make goes to the most recent San Francisco charity care report for 2018. And it looks at hospitals in San Francisco in light of their charity care effort. And most strikingly is the comparison between 2013 and 2017. Chair thank you. Because of obamacare, the need for charity care, which in San Franciscos definition does not include medical recipients, has gone down at most at all hospitals. Theres more people now on medical, so the actual effort on charity care, which subsidizes or dismisses fees that may be due by nonmedicareeligible clients, has gone down. All other hospitals, however, except cpmc, what is most striking is that its medical shortfall also has gone down. Medical shortfall is the difference between medicare medical the medical reimbursement rate and the somewhat fictitious fees that the hospital largely carries. Its not a statistic i usually like to look to, because it overinflates what may be the Charitable Giving of hospitals. In this case its very striking, where other hospitals have, in fact, seen a rise in the medical shortfall, which means theyre providing more services, theyre spending more money in effect as they see it on their Balance Sheet on medical and poor recipients. And most people that are on longterm subacute care are on medical. That is just striking. Cpmc is not doing its fair share. Theres a real question whether, in fact, acting in good faith, despite the things that it did do largely due to the pressure that was applied by the board of supervisors in San Francisco. Now it has to be called to task. It does theres no legal document thats going to require them to do it. Unless theres new legislation thats somewhat difficult, but not impossible for San Francisco to pass. But it is important to hold them accountable publicly and to provide all reasonable pressure to get them to do what they should be doing in good faith on a voluntary basis. Thank you. Chair thank you. Seoni, if youre still here. Okay. Good. Seoni, is with the California Nurses Association. Good afternoon. I am a registered nurse. I work in the i. C. U. At mission burnell camps, formerly the st. Lukes hospital. Ive been working at this hospital over 40 years. Im also a proud member of the California Nurses Association. Im here today with my fellow nurses nurses from st. Lukes mission, who took care of the patients in the subacute unit for many years before cpmc closed the unit at our hospital. We joined with our Coalition Partners to demand that cpmc take its part to provide program, wellstaffed, subacute beds in San Francisco. In 2016, st. Lukes hospital had 40 licensed subacute beds. They were the only subacute beds in the city. Cpmc refused to take new patients into the unit, billowing the unit to shrink as patients passed away or were discharged. Cpmc began to pressure families to transfer patients out of the county. The nurses are a Coalition Partners and the families fought the decision as we knew, that pushing the patients away from the support systems would be a death sentence. We are proud that we won the fight to keep the patients in San Francisco. But more must be done. There are still patients in our hospital who need subacute care and have no place to go. In this i. C. U. I work, we have cared for patients for many months at a time, while waiting for discharge planners to find subacute bed placement for them out of the county, even as far as sacramento or los angeles. This patient should not be waiting for months in i. C. U. , which is designed for different level of care and does not have the resources appropriate for longterm patients. Of the 17 patients who moved to davies campus last year, fewer than half are alive today. Each time a patient passes away, cpmc decommissions the bed and takes it out of service for subacute patients. These are a terrible waste of resources, that are desperately needed in the city. We demand the cpmc maintain 17 permanent subacute beds open to new admissions. This is a small presentation of the need in San Francisco. It is well within cpmcs financial ability to provide for these beds. Thank you. Chair thank you. Next person were going to have present is the last one before Public Comment is mr. Benson nadal. You have five minutes to speak. Supervisors, good afternoon. It is afternoon. My name is benson nadal. Ive been the Program Director for the Ombudsman Office here in San Francisco since the end of 1986. So i take the long view and i dont live in the past, except to regret the loss of so many smallSkilled Nursing facilities throughout San Francisco. And so our focus, under federal and state law, is to visit and advocate for all of the residents and all of the Skilled Nursing facilities, all of the assisted living facilities and the board and care homes, which you know are hemorrhaging in terms of loss, not only for elderly, but people in the system. So our offices all over the place in terms of advocating for beds to be kept, but also more than counting beds, its the quality of the care that our office has always been focusing on. Our offices went to st. Lukes Skilled Nursing facility, as well as the subacute unit years ago, when there were almost 40 residents in the subacute unit, some with m. S. , some with a. L. S. , some on trach, all on vent, aroundtheclock, and the care was excellent. Weve absolutely presided over a funeral for one person, who decided with advanced a. L. S. He wants no more. So he went to the Catholic Church and went to a ceremony. It was very moving. The staff at st. Lukes subacute was incredible. Its my opinion, and i cant prove this, because ombudsman and forensic nurse investigators that had they had the patients not moved out of st. Lukes, into davies, there would be more alive today, because of continuity of staff, the incredible linchpin of carmen, the activity person. And when they moved into davies campus, it was a minor victory, not a major victory, because the staff did not follow the patients, the activity person did not follow the patients. They were merged into some more insidious Skilled Nursing care called postacute care. [ please stand by ] so you layer on that scarcity onto the disappearing 17 beds. We have a crisis in San Francisco. Again, my office is concerned not only about the quantity of beds that are disappearing, but also the quality of that care, as well. So what happened with the davies patients from st. Lukes, the quality was affected. What happened is was you have people dying when maybe they would not have died, and i cant judge that, i dont have any forensic capabilities had they remained at st. Lukes. Our office looks at the whole i dont call it an environmental scam, i call it a supply matched up with the demand, which needs better data, not only to subacute, but for care, longtermcare longterm care s. N. F. Beds, for all the people aging in the very various supervisorial districts. This is a citywide issue. Thank you very much. Thank you. We will go ahead and open it up to Public Comment. I wanted to ask if there are any additional Family Members of any subacute patients. I know some are here. I will ask her to come up and speak first, but anyone else that would like to speak in Public Comment, they can line up on the right. You can start the timer over, please. Is our translator here . He left about ten minutes ago i am trying to attack track him down. I think supervisor ronen can, if you are able to. It is my new job as translator. [speaking spanish] i want to say thank you. It is very hard for me to come up and share, but thank you so much for the time you are taking for us. Im here on behalf of my father. They translated him they transferred him to davies. My father is not the same. He smiled with us, and right now he is always lying on the bed, doesnt open his eyes, they are not open like before. We can see he is not the same. They only have a new nurse. They dont have any relationship with my father. My father is fighting with them because he doesnt want anybody touching because they dont recognize him. I dont know nobody over there because they never show up. Only the nurse. Anything happens to my father, we have to deal with the nurse because theres no dr. Around, only on the phone. That is why i am coming here to advocate because [indiscernible] my father still listens to us he puts his head on my chest like, you know, dont worry. I am just coming to advocate for him and for everybody because the care that they provide to him is not okay. They dont have nobody taking care of them. Today i want to the hospital with these photos