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Laguna Honda At Risk: SFMMS Meets with the Centers for Medicare and Medicaid Services About Certification of Laguna Honda Hospital
LAGUNA HONDA AT RISK:
SFMMS Meets with the Centers for Medicare & Medicaid Services About Certification of Laguna Honda Hospital
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On August 29th, 2022, the San Francisco Marin Medical Society (SFMMS) met with the Centers for Medicare & Medicaid Services (CMS) regarding ongoing issues related to the certification of the Laguna Honda Hospital and Rehabilitation Center (LHH), the deadline for which is now November,
2022. Approximately 700 patients with complex care needs receive care at LHH. It has long served an essential purpose in our community, serving as a care site for some of our most vulnerable citizens, most with no other options.
Of particular concern to SFMMS is that in order to attain certification, LHH must either expand its capacity to house patients or reduce the number of beds by approximately 120 before the November 2022 deadline for certification. Further deadline extensions or continuance of federal payments without certification are unlikely. Should LHH fail to attain certification, federal payments will cease, and the remainder of LHH patients would require transfer.
It is unclear how LHH can fund the transfer of patients should payments cease. There are insufficient beds in San Francisco, the Bay Area, or California to accommodate either 120 or 700 long-term patients, and their transfer may have drastic, negative effects that will ripple throughout San Francisco’s health care systems. “We understand that the standard for certification is a matter of statute, and CMS’ responsibility is to issue certification based on whether a hospital meets that standard. Those standards exist in order to ensure the safety of patients and quality of care,”said SFMMS President, Michael Schrader, MD.
“However, in order for LHH to meet those standards, it may be required to transfer patients on such a short timeline that it will result in harm to those patients. The removal of this hospital of last resort may also create failures that will cascade throughout the health care system.”
Background:
In April 2022, federal CMS decertified LHH following inspections from 2021-2022. The decertification ended Medicare and Medicaid payments, which constitute the vast majority of LHH’s revenue, requiring closure of the hospital and the transfer of approximately 700 medically fragile patients.
Patient transfers began in June 2022, following which, at least four patients died. Some of these medically fragile patients found themselves in homeless shelters. After outcry from the community, patient transfers were paused, payments resumed, and the deadline for certification was extended until November 2022.
The initial attempt to transfer patients from LHH laid bare the gaps in San Francisco’s delicate ecosystem of care and the devastating effects of transfers on some of the most complex patients in our community. Lack of access to LHH beds causes further gridlock in transferring appropriate patients out of our community hospitals, with adverse impacts for all concerned.
SFMMS is deeply concerned that it is not possible for LHH to attain certification without resuming transfer of patients that will again result in patient harm or deaths. SFMMS communicated these concerns to CMS, along with anecdotes collected from dozens of SFMMS’ physician members about the importance of LHH to their practice, their patients, and their community. We cannot let the “cure” become worse than the problem itself.
THE MANY BENEFITS OF LAGUNA HONDA
Victoria Sweet, MD
The following quotations from doctors who have taken care of LHH patients are especially notable for their emphasis on the
bilateral benefits of LHH. First, simply to the hospital system as a whole of San Francisco, because these patients are the most complex patients you can imagine, many of them acutely chronic, as it were, and if they don't go to LHH, then they jam up the acute hospitals, as one of these doctors notes. And jamming up other hospitals is terrible for all of us, especially as citizens and potential patients.
Then of course the second issue is to the humanity of the patients themselves and therefore to our own humanity.
And last perhaps, as I have often tried to emphasize, in the end the kind of care LHH gives that keeps these incredibly sick and complicated patients out of the acute hospital is cheaper. Think of a patient like the patient I called Terry Becker in “God's Hotel,” who had 28 admissions to the General following her transverse myelitis, including three failed skin grafts, although she took two and a half years to completely heal at LHH- she eventually did heal, and was never admitted to a hospital again as far as I know. So in the end LHH was—and is—not only better but cheaper. We are all suffering today across the country because of the lack of institutions that formerly provided places for people to go—state mental institutions, county hospitals, and almshouses like Laguna Honda.
Victoria Sweet, MD is an Associate Clinical Professor of Medicine at the University of California, San Francisco, and a prize-winning historian with a Ph.D. in history. She practiced medicine for over twenty years at Laguna Honda Hospital in San Francisco, where she began writing her book “God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine,” a highly-lauded bestseller.
Laguna Honda Stories from UCSF Residents
As a resident physician in San Francisco, I have cared for patients who are residents of Laguna Honda Hospital as well as patients who have benefited from their services while recovering from illness requiring hospital stays. This is particularly important for patients who are members of vulnerable populations, such as those who are elderly, have complex medical needs due to rare or debilitating medical conditions, or those who struggle with substance use or psychiatric disorders. For these patients, Laguna Honda has provided a place they can receive care outside of a general hospital setting, giving them the opportunity to lead a life outside of our hospital system.
When I have cared for patients who are residents of Laguna Honda, I am consistently struck by the complexity of their care and admiring of the Laguna Honda staff's ability to take care of them. When I am sending a patient to Laguna Honda to recover from illness, I feel confident that they are going to a place that gives them excellent support to continue their journey to recovery. Laguna Honda has become a haven for these folks, and its closing renders them without a place to go in a city that historically and presently struggles to house its citizens. It is essential to the health of the people of San Francisco that Laguna Honda Hospital remains open. As a resident physician in San Francisco, I have seen firsthand the benefit that Laguna Honda has on our patients. I cared for a gentleman early on in my first year of residency who presented after being found down in his home for many days, unable to care for himself and with no other options for places to go. He had no support network. Every other skilled nursing facility declined to accept him because of his substance use history and social vulnerability. Laguna Honda accepted him and our team as a whole felt so much relief, as the alternate was discharging him back home to continue to fail in the community.
I have also cared for many patients brought into the hospital from Laguna Honda with acute medical needs. One patient was entirely dependent on others to care for him 24/7, requiring a feeding tube and hourly turning due to prior devastating spinal cord injuries. This patient was incredibly medically complex and many other SNFs in the area would have been unable to provide him with adequate care. LHH was a safe place for him to be. Otherwise, he would have remained in the hospital indefinitely, likely acquiring an infection or other adverse event that we know is so common for our vulnerable patients.
I hope that Laguna Honda will remain open so that our patients can continue to receive care that they otherwise would not.
Finally, the health of everyone in San Francisco is contingent on LHH remaining open. Often times we admit patients to the hospital who are too medically complex or whose families do not have sufficient funds to pay for a full time caregiver and they are not accepted at many other area SNFs. LHH provides a safe discharge option for these patients. If LHH closes, these patients will remain in the hospital, taking up valuable space in San Francisco's hospital for other acutely ill patients to receive medical care. It is essential that LHH remains open, for the health and safety of everyone in this city.
During a month of UCSF Parnassus medicine wards, I took care of a Laguna Honda Hospital resident who showed me how much she loved her living place. As a younger woman, she had attempted suicide and had been left paraplegic and wheelchair-bound. Now in her older age, without family support, she lived happily at Laguna Honda for many years with nursing support and loving caregivers—such that she did not develop any of the pressure sores so characteristic of bed-bound nursing home patients. Her hair was clean, her clothes were tidy, and she appeared well-fed; a stark contrast to similar patients coming from home or other facilities. Her hospitalization at Parnassus had unfortunately resulted in a tracheostomy placement which required frequent suctioning that was a barrier to discharging her back to Laguna Honda. Her number one goal was to get back to the place she loved and the place she felt safe—Laguna Hondao we worked with her every day to figure out how we could care for her tracheostomy more effectively. Laguna Honda meant everything to her, and it really showed me how much of an impact a place like LHH can have for vulnerable members of our community with challenging medical needs. If anything, we need MORE places like Laguna Honda to help those in need—prolong life, promote well-being for the chronically ill, and provide a secure, healing environment for people like my patient.
As a medical provider in San Francisco for the last 5 years, I often care for Laguna Honda patients in the hospital. I am always amazed at the complexity of Laguna Honda patients—all have several medical comorbidities—and marvel at the incredible job that Laguna Honda providers do. I remember having a patient with dementia who was non-verbal, on 18 medications, who's family remarked how cared for he was at LHH and how well his wounds were healing and weight was maintained. When I called his LHH provider they knew so much about his medical problems but also so much about him as a person.
When Laguna Honda is closed for any given reason, it is ALWAYS a disaster in the hospital. People live in the hospital for months or even years and it prevents us from caring for patients with acute needs. It is impossible to discharge patients in this city that already has so little housing for our elders. When Laguna Honda is open, we feel confident that our patients have a safe place to go. We are failing our elderly patients already. Please do not take away 780 beds. Keeping Laguna Honda open will allow us to provider better care for our community as a whole.
The last patient I took care of from LHH came to the hospital because she was having some issues with her heart (heart failure exacerbation). She was a lady also who needed assistance in transferring herself, cleaning herself and performing all the activities of daily living and then more recently, with a decline in mental status causing her to not be able to verbalize her wishes or preferences. She is also someone who was disconnected from her family and thus did not have a place to go to if she otherwise didn't have LHH to return to. During her hospital stay we needed to have a goals of care discussion regarding the next steps of her care and unfortunately was not able to have this conversation with the patient herself given her mental status. Thankfully her LHH doctor (who was the only person who has seen her consistently in the last 3 years as she had no close family) was able to advocate for what she was like as a person including her values and what she would want at the end of life. Thankfully, the patient was also able to return to LHH; it would have otherwise been very difficult to find her a new home as she had significant needs medically and nursing-wise. I wish there were more places like LHH that can take our most socially and medically vulnerable patients and provide an excellent continuity of care. For this reason it would be disastrous to go in the opposite direction and transfer patients out of LHH to an alternative place. I can't imagine this same patient surviving a transfer out of LHH as she would have lost the doctor that knew her values (prior to her mental status decline who could advocate for her) as well as the excellent nursing care provided at LHH.
I took care of an elderly woman who was a long-term LHH resident while she was hospitalized for respiratory distress. She slowly recovered to the point of being able to leave the hospital but unsafe to go home. Her son, her primary caregiver, was incredibly dedicated and at bedside daily advocating for his mother. He spoke of visiting his mother daily at LHH, knowing the staff there on a first name basis, and being actively engaged in her care while she resided at LHH. When this patient discharged back to LHH, we were confident as a medical team that this would be the best place for her care. Not only would she continue to receive excellent care from the LHH medical team that knew her well, but she would receive the additional loving support from her son who we were confident would remain actively involved in the care of his mother due to the collaborative spirit of the LHH staff.
