July/ August 2011

VOL. 84 NO. 6 JULY/AUGUST 2011

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

THE STATE OF SAN FRANCISCO

HOSPITALS

A Comprehensive Update from Each Hospital

SF GENERAL REBUILD The New Laguna Honda Plans for UCSF Mission Bay And More . . .

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

July/August 2011 · Volume 84, Number 6

The State of San Francisco Hospitals FEATURE ARTICLES

MONTHLY COLUMNS

10 San Francisco General Hospital: The Symbol of Changing Health Care in San Francisco Todd May, MD

4 Membership Matters

12 Laguna Honda Hospital: Choice and Community in a Natural Setting Marc Slavin, JD, MA 14 UCSF Medical Center: A Period of Growth and Opportunity Mark R. Laret

16 Saint Francis Memorial Hospital: Investing in the Future Patricia Galamba, MD 17 San Francisco VA Medical Center: Providing Quality Care for Veterans C. Diana Nicoll, MD, PhD, MPA 20 California Pacific Medical Center: Expanding to Better Serve San Francisco Michael Rokeach, MD, and Ed Kersh, MD 22 Kaiser Permanente San Francisco: Hospital Planning for the Future Craig Lubbock, MD 24 Chinese Hospital: A Resource for the Community Linda S. Schumacher 25 St. Mary’s Medical Center: Providing Exceptional Service to San Francisco Francis Charlton, MD 26 SF Community Clinic Consortium: An Update on San Francisco’s Community Clinics John Gressman, MSW, MA 29 Aspiring to Universal Access: Healthy San Francisco Doug Trapp

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

7 President’s Message George Fouras, MD 9 Editorial Gordon Fung, MD, PhD 30 Hospital News

MEMBERSHIP MATTERS A Sampling of Activities and Actions of Interest to SFMS Members

Change the World: Call for CMA/AMA Policy Proposals

2011 Ethnic Physician Leadership Conference

Any SFMS member has the opportunity to influence local, state, and even national policy on medical and public health issues via our elected SFMS delegation to the CMA and AMA. Our delegation, chaired by SFMS past-president Stephen Follansbee, MD, has a record of bringing successful ideas to the state and national levels, where they have been translated into professional policy and even legislation.

Resolutions adopted at past CMA and AMA sessions include reforming health care financing, encourage universal immunizations for children, and protecting the doctor-patient relationship. SFMS also effectively developed policy to curtail the overuse of antibiotics in agriculture that was adopted by the AMA and most recently by California Sen. Dianne Feinstein in the Preservation of Antibiotics for Medical Treatment Act of 2011 (S. 1211).

Please submit any issues or concerns and potential policy solutions we can bring to the table on your behalf by contacting Steve Heilig at heilig@sfms.org.

The CMA Foundation invites SFMS members to the 2011 Ethnic Physician Leadership Conference, scheduled for September 17-18 at the Hilton Hotel in San Jose. With a theme of “The Challenge of Health Care Reform,” the conference features a keynote address from Richard Figueroa, program director at the California Endowment. For conference details and registration information, please visit http://www. ethnicphysicians.org/. Limited scholarships are available for medical students; please contact Anna Gutierrez for details at (916) 779-6627 or agutierrez@thecmafoundation.org.

Young Physicians Social a Success

Residents, fellows, and recent residency graduates met and shared their experiences as emerging physicians at the SFMS Young Physicians Social on June 16. Attendees took advantage of the opportunity to connect with colleagues from the local community (business cards and e-mails were exchanged) in an intimate setting. With great attendance and positive feedback from all, SFMS plans to organize similar social networking events in the coming months. If you would like to get more involved on the local chapter level, or for information about upcoming SFMS events, please contact Jessica Kuo at jkuo@sfms.org or (415) 561-0850 extension 268.

SFMS General Meeting—All Members Welcome

RSVP today for SFMS’ General Meeting, September 12, from 6:00 p.m. to 7:00 p.m., at the Commodore Room inside the Golden Gate Yacht Club. Featured speakers include San Francisco Mayor Edwin Lee and CMA President James Hinsdale, MD. Members are also welcome to stay for the board meeting that immediately follows the General Meeting. This is a good opportunity both to meet with SFMS leadership and to learn first-hand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California.

Dinner will be provided. Please RSVP before September 5 to Posi Lyon at (415) 561-0850 extension 260.

Membership Desktop Reference

The 2011-2012 SFMS Membership Directory and Physician Desk Reference will be mailed out in July. The annual Directory is one of the most valued benefits of membership and is the only pictorial directory of physicians in San Francisco.

This resource is complimentary to all active SFMS members and is used throughout the year by physicians and their staff.

For questions or information about the Directory, please contact Jessica Kuo at (415) 561-0850 extension 268 or jkuo@ sfms.org.

CMS to Modify Medicare ePrescribing Penalty Program

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San Francisco Medicine july/august 2011

Under the Centers for Medicare & Medicaid Services (CMS) ePrescribing rule, physicians must issue at least ten electronic scripts (e-scripts) by June 30, 2011, to avoid an ePrescribing penalty that amounts to a 1 percent reduction from their total Medicare Part B allowable charges in 2012.

On May 26, CMS released a proposed rule that would allow physicians, if they qualify, to apply for one of several new www.sfms.org

July/August 2011 ePrescribing penalty exemptions through a Web-based portal that is still under construction. Physicians would have to apply for an exemption by October 1 to avoid the penalty.

CMS will finalize its changes to the ePrescribing penalty program sometime this summer. For the latest information about the ePrescribing requirements, please visit the SFMS blog at http://sfmedicalsociety. wordpress.com/.

CMA Preserves Corporate Bar

CMA has prevented two bills from advancing that would have altered California’s ban on the corporate practice of medicine. AB 824 (Chesbro) would have allowed rural hospitals to employ physicians through year 2022. Strong opposition by CMA and key allies forced the author to withdraw the bill from committee. AB 1360 (Swanson), a reintroduction of AB 646 from the 2009-2010 legislative session, which CMA defeated last year, would have created an expanded pilot program to allow eligible district hospitals throughout the state to hire up to five physicians. CMA convinced the author to amend the bill to require medical staff concurrence with hiring decisions, prompting the bill sponsors—the American Federation of State, County, and Municipal Employees and the California Hospital Association—to withdraw their sponsorship, which effectively killed their own legislation.

Help Preserve Care Not Cash

In 2002, San Franciscans recognized a problem existed in homelessness and came together to find a solution that made sense for all. By passing Care Not Cash, the City has stopped giving out cash grants to individuals claiming to be homeless and instead has used those resources to provide supportive housing and other services. Care Not Cash provides a path and incentive for homeless to get off the streets. Unfortunately, a proposition to repeal Care Not Cash was placed on the November ballot. If it passes, the measure will cause a major setback and turn back the clock on real progress on this issue. SFMS has been an advocate of the Care Not Cash program since its inception, and the Board voted to oppose the repeal of Care Not Cash at its July meeting. To learn more about the Keep Care Not Cash campaign and how you can help, please visit http://sfmedicalsociety. wordpress.com/2011/07/12/help-preserve-care-not-cash/.

SFMS On-Site Seminars

October 14: Creating a “Director of First Impressions”—Customer Service, Patient Relations and Telephone Techniques This half-day practice management seminar provides valuable training for both front and back office staff to handle patients and tasks both efficiently and professionally using superlative customer service skills. This seminar will provide your staff with the tools necessary for positive patient relations.

9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast). $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for nonmembers. Contact Posi Lyon, plyon@ sfms.org or (415) 561-0850 extension 260 for more information.

October 28: “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This seminar teaches the core business elements of managing a practice that physicians don’t receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/ CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers. Contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260 for more information. www.sfms.org

Volume 84, Number 6 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD

SFMS OFFICERS President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS EXECUTIVE STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon

BOARD OF DIRECTORS Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

Term: Jan 2009-Dec 2011 Jeffrey Beane, MD Andrew F. Calman, MD Lawrence Cheung, MD Roger Eng, MD Thomas H. Lee, MD Richard A. Podolin, MD Rodman S. Rogers, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

July/august 2011 San Francisco Medicine

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San Francisco Medicine july/august 2011

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PRESIDENT’S MESSAGE George Fouras, MD

Health Care Reform: Are We up for the Challenge?

Over the first weekend in June, the CMA held its annual Leadership Academy. The theme for this year was health care reform. I found one of the most interesting presentations to be that of Mark D. Smith, MD, MBA, president and CEO of the California HealthCare Foundation.

The title of his presentation was “Implementing Health Reform: Overview and Challenges.” Dr. Smith made some interesting points about health care reform and our willingness, as a profession, to adapt to the new environment that we find ourselves in.

The “take-home message” is this: health care as we have it now in the United States is unsustainable. His three major points: 1) The pressure to control costs will increase, 2) biochemical and IT innovation with continue, and 3) the demand for higher quality and transparency will continue to grow. He compared health care delivery to other industries, such as banking and research, noting that all have progressed, especially in regard to IT usage and implementation. In comparison, health care IT resists change. “We still use vegetable pigments on pressed wood fiber,” said Dr. Smith.

Here is another example. You can go to London, England, and, with a four-digit code, get cash out of a metal box. The bank that you have visited knows your entire banking situation. In contrast, you collapse on a street and the emergency room that you are transported to knows nothing about you.

In the field of medicine, we fight defensively and resist change. For an example, we don’t have to look back much further than the development of Medicare. When it was first proposed in Congress, the American Medical Association fought it tooth and nail. I can’t help but wonder what Medicare would look like today had we been able to sit at the table and participate in its development constructively. One can even wonder whether we would be dealing with the SGR problem today if we had. The message for medicine is clear: We need to change our paradigms.

Here is another example: In the past, the primary care physician would examine, test, and then diagnose strep throat in an office visit. Now a parent can do this at home, with a test strip bought at the local drugstore. One more example: In the nineteenth and twentieth centuries, we would listen for a heart murmur with a stethoscope. In the twenty-first century, we use an iPhone app. Yet some of our colleagues stubbornly cling to old ways of practice, insisting that the patient come

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into the office, or that a stethoscope is the only viable tool.

We need to focus our talents on the future and abandon the notion that what we have “always done it this way” is thus the right way.

One thing that I find surprising—and this was visible during the Academy—is that we are even discussing the repeal of health care reform. Why would we want to go backward, as if that was somehow better? The political reality is that we have crossed the bridge. It is not feasible to repeal the law. It won’t happen at the federal level (not enough votes, and President Obama would most likely veto any legislation that did squeak through), and far too many states have passed legislation to implement the law to go back now. I don’t think anyone (and if I may be so presumptuous, that includes President Obama) thought that the health care reform bill was the last word. I would say that it was the beginning.

So how do we move forward? We need to be willing to change and to compromise. As Dr. Smith said in his address, “modern medicine is a team sport.” We need to resist the bunker mentality that we have had in the past and figure out how different groups can find common ground and alignment. As medical technology becomes more complex and innovative, we need to look hard at scope of practice issues, always keeping the best interest of the patient in mind. As in the strep example, we have to let go of doing the simple things and focus our energies and talents on managing the complexities of health care. We also have to be willing to become more transparent and improve our ability to report what we do to the public. This is already being done in other countries, and we can take their example. Hopefully we can learn from the past, and not repeat it.

July/august 2011 San Francisco Medicine

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Hill Physicians’ 3,600 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health San Francisco Medicine july/august 2011 www.sfms.org Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

EDITORIAL Gordon Fung, MD, PhD

San Francisco Hospitals: Past, Present, and Future This month, San Francisco Medicine’s theme addresses doctors’ main health care provider partners—namely, the hospitals and the public health clinic consortia.

A few decades ago, one of our SFMS presidents, Lawrence White, predicted that in the future (that is, now) there would be only a few surviving hospitals. He was considered a visionary to foresee a time when the numerous smaller hospitals, such as Ralph K. Davies, Marshall Hale, Mount Zion, French, and many more, would be bought up and merged into part of larger hospital systems. This has left the public hospitals SFGH and UCSF, along with hospitals run by health care systems: Kaiser, Sutter Health, and CHW. Through all of this consolidation and merging, there was the only community private hospital that was able to stay afloat and independent—Chinese Hospital.

Over the past several decades, there have been significant changes in the way health care is delivered. We physicians spent the bulk of our undergraduate and graduate medical training in hospitals, where we learned how to care for patients. We learned to work in medical care teams with nurses, pharmacists, and therapists. Now we have moved away from hospital care, for reasons of expense and evolving medical practice that has allowed more outpatient diagnosis and management. The movement from incident-based care to prevention and management of chronic diseases has seen a significant shift away from acute in-hospital management. The main thrust of in-hospital care now is to provide acute care to the sickest patients in a high-quality and efficient manner. Many of us continue to practice in hospitals as primary care physicians, hospitalists, surgeons, pathologists, medicine subspecialists, and radiologists, working at the interface with emergency medicine specialists. And we expect hospitals to have the latest and greatest equipment to assist us in diagnosis as well as management of everything from surgery to complex medical care in the ICUs. The best hospitals are not able to be the best without the thoughtful collaboration of physicians. Physicians need to be aware of some of the issues facing hospitals, from cost of equipment to human resources to complying with regulatory organizations and dealing with the labor unions, in order to understand and participate in discussions of how to provide

www.sfms.org

the best care to our community.

What are some of the values that hospitals provide to medical care delivery? Even though in-hospital care accounts for some of the most expensive aspects of medical care, it is the focus of many quality-improvement activities to provide the best and most efficient care with the least amount of harm.

With all of systems and personnel required to coordinate, deliver, measure, and continuously improve this care, the price tag is growing. Regulatory and reimbursement agencies increasingly demand integrated systems to transition care of patients to the community of providers, from skilled nursing facilities to home health care teams to community physicians.

Kathleen Sebelius, director of U.S. Health and Human Services, recently commented on the outstanding efforts of San Francisco General Hospital to help patients discharged from the hospital for heart failure to receive a specific low-salt diet, new medications, and outpatient physician follow-up within a few days, with demonstrated outcomes of reducing readmission to the hospital in the first month (a key quality-improvement measure that includes penalties for failure).

Another aspect of in-hospital care is the requirement of providing 24/7/365 care of the same quality, regardless of time of day/week or location in the hospital. For many hospitals this is not possible, so they have to make tough decisions about which services they can provide, then coordinate with EMS to bring patients to those centers (such as stroke centers, burn centers, or acute cardiac syndrome centers) that can provide the appropriate care. Countywide, we need to monitor and continually review the situation as a whole and determine if the services are adequate for the entire population in case of disasters or epidemics. We hope you enjoy reading and learn from these articles.

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

San Francisco General Hospital The Symbol of Changing Health Care in San Francisco Todd May, MD

The future San Francisco General Hospital San Francisco General Hospital and Trauma Center has had a tradition of providing quality health care to our community since 1872, and a central part

of this tradition has been our ability to adapt to the changing health care needs of our population. As our health care delivery system changes nationally, the role of hospitals is evolving as well. What better time than now to rebuild San Francisco General Hospital and transform the physical environment in which health care delivery takes place?

As the only trauma center serving San Francisco and northern San Mateo counties, San Francisco General Hospital serves as the safety net for our city, receiving around 30 percent of the city’s ambulances and providing cost-effective and culturally competent care to a diverse community of patients, regardless of their ability to pay.

San Francisco residents clearly value the service that our hospital provides to the community, and in November of 2008, 84 percent of voters supported Proposition A, approving an $887 million bond for the hospital rebuild. The bond 10 San 11 SanFrancisco FranciscoMedicine Medicine july/august july/august2011 2011

will allow us to construct a new acute-care facility at San Francisco General Hospital and Trauma Center that will meet the seismic safety standards required in Senate Bill 1953.

We see our new hospital as symbolic of changing health care nationally but also locally, as we grow into our expanding role as an active member of our community. We are identifying ways to reach out to our neighborhood partners to improve health outcomes by connecting the needs of patients with wellness resources and ensuring that our presence has a positive impact on the health of our community.

Expanding Our Capacity

The new nine-story hospital building is being constructed on our campus in the Mission and Potrero Hill neighborhoods. It will be located just west of the existing main hospital building and is slated for completion in 2015. Two stories of the new building will be basement levels, seven will be above ground, and pedestrian bridges will provide connections to the existing building. Throughout construction, the existing www.sfms.org

hospital building will remain fully operational with no reduction in inpatient, outpatient, or emergency services. Upon completion, all nonambulatory acute-care services will transition over into the new facility while the current hospital will continue operating for nonacute patient care, with the exception of acute psychiatric services.

The 453,000-square-foot hospital will significantly expand our acute-care beds, operating rooms, emergency department, and other services, and the community will benefit greatly from our increased capacity to serve our patients. The emergency department size will increase from twenty-seven to sixty beds, operating rooms will increase from ten to fourteen, and we will have 284 acute-care beds, thirty-two more than in our current hospital.

Responding to Emergencies

As communities across America have experienced a dramatic increase in the number of emergency rooms closures in the last twenty years, the demand for San Francisco General’s emergency services has remained steady. And our role will grow as our new hospital houses the Department of Public Health’s Departmental Operations Center, making it the hub of San Francisco’s health care emergency response.

Our emergency department is the heart of our hospital and the main artery through which patients are admitted. We are central in responding to the majority of the city’s car accidents, violent crimes, disasters, and workplace accidents. For these patients, time is critical. The current emergency department has four rooms fully equipped to meet the needs of trauma patients. In our new facility we will be better prepared for multicasualty incidents with six trauma rooms plus two CT scanners dedicated exclusively to trauma patients. Having accelerated access to the right room and the right tests can mean the difference between life and death.

Today San Francisco General’s emergency department treats about 55,000 patients each year, and we currently have an average diversion rate of 25 percent. By more than doubling the number of emergency department beds, the new facility will be able to treat up to 100,000 patients annually and will eliminate the need to divert patients to other hospitals.

Furthermore, in a disaster situation, the emergency department will be equipped to surge up to 120 beds.

Prepared to Serve after Catastrophe

Should a major disaster impact our city, the new San Francisco General Hospital will be equipped to remain open and serve a central role as we partner with other community hospitals to care for our residents. The new facility will be constructed using a base-isolated foundation, the most earthquake-resistant design known today. The base isolators can freely move 30 inches in any direction, greatly reducing seismic impact on the building. This technology provides the best opportunity for the hospital to remain operational even after a major seismic event. The campus power plant will have upgraded emergency back-up power and the campus will have two underground 50,000-gallon potable water tanks, two 25,000-gallon sanitary waste tanks, and one 6,000-gallon decontamination tank. These features are designed to allow www.sfms.org

the campus to be self-sustaining for seventy-two hours in the event that city utilities are unavailable due to a major catastrophe.

A Hospital Designed for Our Community

The San Francisco General Rebuild has been a communitydriven effort from the beginning. The input from doctors and nurses helped us plan a facility that best meets the needs of staff and patients. The rounded exterior of the building reflects the interior design of the curved nurses’ stations that enhance the working environment and improve visibility of patient rooms for clinicians. More than 90 percent of rooms in the new hospital will be private and patients will benefit from an abundance of natural lighting.

The design of the new hospital is consistent with the City and County of San Francisco’s objectives for sustainable municipal buildings by striving to achieve a Gold Leadership in Energy and Environmental Design (LEED) certification rating. Patients and staff will benefit from the use of no or low-volatile organic compound (VOC) materials, furniture, paint, and adhesives. Our carbon footprint will become much smaller as our energy consumption is reduced by 21 percent and water consumption reduced by 40 percent.

The seventh floor of the building will include a rooftop therapy garden for patients and a public garden for staff and visitors. Not only will this benefit the health and recovery of our patients but it also will reduce storm water runoff and the heat island effect of the building.

As our nation embarks on a new chapter in health care history with the Affordable Care Act, the construction of our new hospital is symbolic of an increasingly accessible, effective, and efficient health care system. We look forward to continuing our mission to provide quality health care and trauma services with compassion and respect and to expanding our role as partners in the health of San Francisco communities.

Dr. Todd May is chief medical officer at San Francisco General Hospital (SFGH) and a professor of Family and Community Medicine at the University of California, San Francisco. He is the outgoing chief of medical staff and has been a core faculty member in the Family Medicine residency program at SFGH for nearly fifteen years.

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

Laguna Honda Hospital Choice and Community in a Natural Setting Marc Slavin, JD, MA San Francisco’s new Laguna Honda Hospital and Rehabilitation Center opened in December 2010, establishing it as the country’s most modern center for skilled nursing and rehabilitation.

The hospital, owned and operated by the San Francisco Department of Public Health, provides long-term care and rehabilitation services to a safety-net population of 780 seniors and adults with disabilities. It is located on a sixty-two-acre campus west of Twin Peaks.

The new Laguna Honda is California’s first LEED-certified hospital. The U.S. Green Building Council’s Leadership in Energy and Environmental Design program, the national standard for designating green buildings, awarded Laguna Honda silver certification in June 2010.

The three new buildings on the Laguna Honda campus, which replace the hospital’s 1920s-era Florence Nightingalestyle open dormitories, are designed to foster choice and independence for the people who live at the hospital. They are a centerpiece of the hospital’s transition from institutionalized care to individualized care, which emphasizes the unique needs and preferences of each person being cared for.

The service priority in the new Laguna Honda is to assist residents to achieve their highest level of functional capacity, whether they remain on the Laguna Honda campus or complete a program of rehabilitation and move to a lower level of care or independent living elsewhere in the community. The restorative care program at Laguna Honda was the recipient of a 2007 best practice award from the California Hospital Association.

The new buildings themselves have therapeutic value. They were designed to bring the outdoors in, and they’re suffused with natural light. The materials used to construct the buildings are virtually free of volatile organic compounds. The buildings contain eleven therapeutic gardens, including secured outdoor spaces that allow people with advanced dementia to enjoy the therapeutic effects of the hospital’s natural environment without risk.

Most residents live in single bedrooms in suites of two or three rooms. Some share a room with one or two other 12 13

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people. The rooms are arranged in households of fifteen people, each with its own living room. Every four households are grouped on a single floor around a central great room where meals are served and daily activities take place, making up a sixty-person neighborhood.

Each neighborhood is home to a specialized nursing program, allowing Laguna Honda to provide the personal care possible in small-scale nursing facilities while at the same time maintaining the efficiencies of an integrated 780-resident hospital.

The hospital provides a wide range of specialized services to meet the needs of a highly diverse service population.

These services include acute care for hospital residents; the Bay Area’s only HIV/AIDS skilled nursing program; monolingual care in Spanish and Chinese; a safe and comfortable environment for people with Alzheimer’s and other dementias; rehabilitation services that include physical therapy, occupational therapy, speech therapy and audiology; programming for adults with developmental disabilities; an in-house hospice operated with the Zen Hospice Project of San Francisco; and care that combines medical and social support for people coping with the effects of stroke, traumatic brain injury, and multiple sclerosis.

At the center of the new facility is a wide indoor boulevard named the Louise H. Renne Esplanade, after the former San Francisco city attorney who put together the financing package for the new hospital, which included funds from the settlement of the city’s consumer-protection lawsuits against tobacco companies. Voters approved use of the tobacco settlement funds to rebuild Laguna Honda in 1999.

The esplanade serves as a main street for the hospital community. Arranged along the esplanade are the kinds of amenities one might find on the main street of a small town, www.sfms.org

including a community theater; a beauty salon and barber shop; a library; a general store; a café; and an art studio for the hospital’s many resident painters and sculptors, participants in the Art with Elders program offered in conjunction with Eldergivers, a San Francisco nonprofit, and classes provided on campus by City College of San Francisco.

During their day, Laguna Honda residents can choose to meet with friends in the living room of their household, gather for activities in the neighborhood great room, venture to the community center on the esplanade, or retire to their room for a bit of privacy.

They can also enjoy the outdoors in one of the gardens or in the Clarendon Valley, the hospital’s backyard, formerly the site of its maintenance services and now restored to its natural state. The valley is designed to offer possibilities for outdoor recreation. It contains raised planting beds accessible to people in wheelchairs; a small orchard, a petting zoo that is home to the hospital’s animal-assisted therapy program; a half-basketball court for wheelchair basketball (70 percent of residents are wheelchair users); and the Betty Sutro Meadow, named after a longtime benefactor of the hospital.

A central therapeutic element of the new facility is nearly $4 million in public art curated by the San Francisco Arts Commission. Funded by the city’s Two Percent for Art program, which sets aside a portion of the capital costs of new construction for artwork, each sculpture, painting, mosaic, or work in mixed media on the new campus is designed to stimulate memory and cognitive development and to add to the comfort of life.

The new Laguna Honda opens another chapter in the nearly 150-year history of a civic icon that opened in 1866 to care for one of the first generations of San Franciscans, the Gold Rush pioneers. Today’s hospital refashions a tradition of service to meet the changing health care needs of seniors and disabled adults.

Marc Slavin, JD, MA, is a former San Francisco deputy city attorney and is currently the community relations director for Laguna Honda.

Photos: Laguna Honda’s exterior is pictured on the opposite page. On the right, top to bottom: The “household living room” with large windows; Planting beds with new growth; The lobby with an Owen Smith mosaic; Ads displayed around San Francisco advertising the new Laguna Honda.

www.sfms.org

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

UCSF Medical Center A Period of Growth and Opportunity Mark R. Laret

UCSF Mission Bay Campus We are experiencing a period like no other in the history of UCSF Medical Center and UCSF Benioff Children’s Hospital. It is a period marked by change and

challenges. But most of all, it is a period marked by tremendous opportunity.

Today, vital efforts are underway to ensure that the quality of the patient experience consistently matches the clinical excellence for which we’re nationally and internationally known. We’ve been working hard to maintain and enhance a “culture of excellence” throughout the medical center by listening to our patients, improving their experience, and executing our vision to be the best provider of health care.

To meet that goal, we’ve implemented important initiatives to enhance patient satisfaction. These include instituting hourly rounds by nurses; requiring all clinical staff to wear uniforms with labels that clearly identify their roles; introducing more comfortable patient gowns; installing whiteboards in patient hospital rooms to facilitate and improve communication; and initiating post-discharge phone

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calls, which help ensure continuity of care. Later this year, we’re launching an electronic medical record, called APeX, which will put a wealth of information at the fingertips of our clinical staff and make our already comprehensive diagnosis and treatment even better. We’ve also instituted the Pathway patient wayfinding system and a state-of-the-art medication management system in the new robotic pharmacy operation at Mission Bay. In terms of our facilities, we have new ambulatory clinic space in the Osher Center for Integrative Medicine building on the Mount Zion campus and in the Cardiovascular Care and Prevention Center in the new Smith Cardiovascular Research Building at Mission Bay.

The most momentous milestone of the past year, however, was the start of construction of our new children’s, women’s specialty, and cancer hospitals at Mission Bay. www.sfms.org

The groundbreaking in October was the culmination of nearly a decade of work by UCSF faculty, staff, donors, and community advisory groups who together are bringing San Francisco its first completely new hospital in thirty years. Piles were drilled this past spring to support the foundations and last month steel began rising from the ground.

The new medical center’s location at Mission Bay will bring UCSF’s renowned research facilities and its world-class patient care together, shrinking the distance between scientists, physicians, and other health care professionals. Research, clinical care, and biotech are coming together to advance clinical care worldwide, and the new medical center is a model of modern healing. It will be a place of exceptional advanced technology where the next lifesaving techniques, such as fetal surgery, will be introduced.

Emphasizing comfort and community, and including patient-centric private rooms filled with natural light and surrounded by gardens, these hospitals will engage entire families in the healing process. Incorporating the highest standards of energy efficiency, seismic safety, and sustainability, Mission Bay hospitals will set new benchmarks for twenty-firstcentury health care enterprises. These new facilities will also give us room to evolve. In fact, the excitement for this project is matched only by the planning underway to imagine the best uses of vacated space at our Mount Zion and Parnassus hospital spaces when the new hospitals open in late 2014.

This new facility would not be possible without the generous gifts from its community of donors. San Francisco resi-

dents Lynne and Marc Benioff donated $100 million toward the now-named UCSF Benioff Children’s Hospital. Atlantic Philanthropies and its founder Charles F. Feeney made a $125 million matching gift and two additional anonymous pledges of $25 million each were also made. These gifts bring the total raised to $375 million—nearly two-thirds of the fund-raising goal of $600 million.

Finally, the impact of these three new hospitals will be felt beyond UCSF. Already a magnet for biotech enterprises looking to partner with UCSF’s research labs, Mission Bay will continue its transformation into a vital hub of health care, business, and technology, enriching local and regional economies and improving the quality of life for our neighbors.

Mark R. Laret is the chief executive officer of UCSF Medical Center and UCSF Benioff Children’s Hospital.

Past SFMS President Named ChairElect of AMA Council H. Hugh Vincent, MD, AMA delegate and past SFMS president, was named chair-elect of the AMA Council on Long Range Planning and Development (CLRPD). The CLRPD is charged with indentifying and making recommendations to the AMA board regarding important strategic issues and directions related to the AMA’s vision and goals. SFMS extend our most sincere congratulations to Dr. Vincent.

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July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

Saint Francis Memorial Hospital Investing in the Future Patricia Galamba, MD Before sitting down to write this article, I took the

opportunity to meet with our president, Tom Hennessy, to reflect on where we are and where we are going. We discussed the many challenges we face as health care providers in San Francisco and California, and certainly they seem daunting at times. However, we remain hopeful and proud of our community hospital on the hill.

The 2013 hospital seismic retrofit deadline is requiring many hospitals to build completely new facilities to meet the standards enacted by our state legislature. Since our main hospital campus is located on top of solid bedrock, we have been able to take a much more cost-effective approach by rebuilding

our hospital from the inside out. We are confident that we will be one of the first hospitals in the City to be seismically ready.

We began our seismic project in 2006 when we opened our completely remodeled and enlarged Emergency Department.

As the second busiest ER in town, we were considered small but mighty with only nine beds. Now we have a modern facility with a nineteen-bed capacity, enabling us to meet the increased demands of our downtown community for emergent and urgent care. The new Emergency Department has an ample triage area, many private rooms equipped with flat-screen TVs, and a large and comfortable waiting area.

Next we began the complete remodel of our Surgical Department. We expanded the number of operating rooms from six to nine; most rooms are super-sized to accommodate boom-mounted lights and monitors as well as the latest digital technology and equipment. We believe we have the most state-of-the-art operating rooms in the City. We expect this project to be complete within the next few months. We will make sure our Medical Society colleagues are invited for a tour and reception to see what we have accomplished. It is impressive.

We are now beginning the process of renovating and expanding one of our most important assets in the community, the Bothin Burn Center. Over the past several years, local hospitals in Northern California have closed their burn centers, because they’re difficult to manage and to fund. Saint Francis’ Foundation and Hospital Administration have made a long-term commitment to providing the best burn care for all of Northern California and beyond. The support remains as strong today as it did in 1967, when Saint Francis opened the first burn center west of the Rockies. The number of intensive-care burn beds will increase from ten to fourteen, all in private

Continued on page 19 . . .

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www.sfms.org

THE STATE OF SAN FRANCISCO HOSPITALS

San Francisco VA Medical Center Providing Quality Care for Veterans C. Diana Nicoll, MD, PhD, MPA The San Francisco VA Medical Center (SFVAMC), which was founded in 1934, has a long history of con-

ducting cutting-edge research, establishing innovative medical programs, and providing compassionate care to veterans.

The Medical Center has 104 operating beds and a 120-bed Community Living Center. Primary and mental health care is provided at outpatient clinics in Clearlake, Santa Rosa, Eureka, Ukiah, and San Bruno. There is also a specialized homeless veterans clinic in downtown San Francisco.

SFVAMC has several National Centers of Excellence in the areas of epilepsy treatment, cardiac surgery, posttraumatic stress disorder (PTSD), HIV, and renal dialysis. It has many other nationally recognized programs including the Parkinson’s Disease Research, Education, and Clinical Center; the Hepatitis C Research and Education Center; the Mental Illness Research & Education Clinical Center; and the Western Pacemaker and AICD Surveillance Program. The Medical Center was selected to head the Southwest Regional Epilepsy Center of Excellence. This center provides epilepsy care, supports the training and educational needs of the network, and manages a VA epilepsy registry. The Medical Center has recently been designated as one of only five VA Centers of Excellence in Primary Care Education and selected as a Community Resource and Referral Center, one of only twelve locations designed to serve homeless and at-risk-for-homeless veterans and their families.

SFVAMC is renowned for its state-of-the-art acute medical, neurological, surgical, and psychiatric care. It has outstanding programs in clinical areas such as cardiac and vascular surgery, interventional radiology, interventional cardiology, orthopedics, neurology and neurosurgery, ophthalmology, otolaryngology, urology, endocrinology and metabolism, hepatology, hematology/oncology, renal dialysis, and mental illness. Its intensive care unit was ranked number one in the VA system.

The Medical Center has been affiliated with the University of California, San Francisco (UCSF), School of Medicine for nearly fifty years, and the affiliation is strong. Annually, more than 700 UCSF trainees from thirty-four programs rotate through the Medical Center. At any one time, one-third of UCSF Medical students in their clinical years are at the VA, and the VA has 190 UCSF residency program positions paid for by the VA. All specialties are included except obstetrics, gynecology, pediatrics, and family medicine. In addition, all physicians are jointly recruited by the Medical Center and UCSF School of Medicine and hold dual appointments.

The Medical Center has the largest funded research program in the VA system, with $87 million in research expendiwww.sfms.org

tures. Research programs include seven core facilities: Clinical Research Center, Animal Care Facility, Cell Imaging Core, Molecular Core, Proteomics Core, Brain Imaging Center, Bone CT Core, and Echocardiography Core. Areas of particular interest are prostate cancer, aging, oncology, cardiovascular disease, hepatitis C, breast cancer, PTSD, sleep disorders, Gulf War illness, substance abuse, neurological diseases, health services research, and advanced medical imaging. The Medical Center has four Medical Science Research Enhancement Award Programs (REAP) in neurology research, rehabilitation, prostate cancer, and bone research; and one HSR&D REAP in aging research. The Medical Center is one of the few in the world equipped for studies using both whole-body magnetic resonance imaging (MRI) and spectroscopy, and it is the site of VA’s National Center for the Imaging of Neurodegenerative Diseases. The Center uses the most advanced brain imaging technology, especially MRI, to investigate the cause, progression, and effects of neurodegenerative diseases and to develop effective treatments, diagnoses, and methods for early detection and prevention.

In 1988, the Northern California Institute of Research and Education (NCIRE), a private, nonprofit research corporation, was set up to administer non-VA research funds for VA faculty.

Today it is the leading private nonprofit research institute in the United States devoted to veterans’ health.

With more than two million Americans serving or having served in the wars in Iraq and Afghanistan, hundreds of thousands will return with combat-related injuries requiring specialized care.

Continued on page 19 . . .

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San Francisco VA Medical Center Continued from page 17 . . .

Saint Francis Memorial Hospital Continued from page 16 . . .

In an effort to ensure that these men and women receive the care they deserve, great strides are being made to expand the service we provide not only at the Medical Center but also in our community-based outpatient clinics. In 2007, the Integrated Care Clinic was created specifically to meet the health care needs of the newest generation of veterans. This clinic colocates primary care, mental health, and social work services.

During the first visit, the patient meets with a primary care provider for a comprehensive health exam, a mental health professional to discuss readjustment, and a case manager to address other post-deployment issues. This type of care is also now provided at all of our community-based outpatient clinics, allowing for better coordination of care. We have expanded not only our post-traumatic stress and substance abuse treatment services and suicide prevention efforts but also our women’s programs, since approximately 15 percent of current veterans are now women (up from approximately 5 percent). Our primary care clinics now have a patient care team (consisting of a provider, RN, LVN, and clerk) for each veteran in order to increase the efficiency of care provision and timeliness of outpatient care given to veterans. Eightyeight percent of new veterans are now seen within fourteen days. We continue to expand our telemedicine, telehealth, and home-based primary care programs so that veterans can get care as close to home as possible.

rooms. The new unit will also include several step-down beds.

The Burn Center has its own separate operating room located within the unit. This will be expanded and modernized just as our operating suites have been. The Center will also include modernized outpatient reception and treatment areas to serve the continuum of care of our patients. When finished, not only will the Bothin Burn Center be the only verified burn center in the Bay Area but it will also be new and modern.

As part of our community outreach, the San Francisco VA Medical Center was one of the first VAs in the country to partner with a community college, in its unique partnership with City College of San Francisco (CCSF).

CCSF opened a newly modernized Veterans Resource Center with the mission to serve students who are veterans and to enhance their successful transition from military life into civilian careers. San Francisco VAMC mental health and outreach staff are on site five days per week to provide enrollment and mental health counseling services. CCSF estimates there are more than 900 veteran students currently enrolled.

As we move forward, we are building on our strong tradition of innovation and collaboration to improve the health care provided to veterans.

Diana Nicoll, MD, PhD, MPA, has been chief of staff at the San Francisco VA Medical Center and associate dean, University of California, San Francisco School of Medicine, since 1995.

Our next investment will be in our critical care area. With the generous support of our Foundation, we will combine our ICU and CCU into one large Critical Care Unit.

This will provide the patients, staff, and physicians with a state-of-the-art unit and work environment. We expect this to be completed in 2014.

We are currently putting the final touches on the plans for a beautiful new lobby and parking entrance. This change will update the look and comfort that our patients and visitors experience, and it will make it easier to valet park. In addition, we are making plans to create a complete floor of VIP suites; I hope to be able to share the details with you in a future column.

Our investments for the future are not only in infrastructure but also in the next generation of physicians. To meet the needs of the newly graduated physicians who want to focus on what they do best—provide patient care—we are collaborating with the CHW Medical Foundation to expand its clinic to San Francisco with two multispecialty clinics located at Saint Francis and St. Mary’s Medical Center. In addition, Saint Francis has contracted with a new radiology group and a new pathology team. These two teams have enhanced our radiology and pathology services immensely. Furthermore, we have brought on board new ENT specialists, urologists, and primary care physicians to take over the mantle of services from our retiring medical staff. These recruitment efforts will provide continued growth and renewal of our medical staff.

Finally, in order to meet the challenges of health care reform and the impact it will have on our finances, we have set up new centers of excellence that have the potential for growth: our Spine Care Institute, our Pain Center, and the expansion of our Total Joint Center. To this end we are partnering with St. Mary’s Medical Center in areas such as cancer care and acute rehabilitation, where we can share resources and costs.

With the commitment of our executive leadership, Catholic Healthcare West and the Saint Francis Foundation, we’re making the investments to secure and grow our future. We are confident that these efforts will ensure that our hospital continues as a strong, valued member of the health care delivery system in San Francisco.

Patricia Galamba, MD, is a board certified family practitioner, medical director of the Saint Francis Palliative Care Program and the chief of staff at Saint Francis Memorial Hospital.

www.sfms.org

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

California Pacific Medical Center Expanding to Better Serve San Francisco Michael Rokeach, MD, and Ed Kersh, MD For close to 150 years, California Pacific Medical Center, or CPMC, has been part of the fabric of San Francisco. Currently we are working hard to make sure we remain part of the City for the next 150 years, by building two new hospitals and retrofitting another of our campuses. It’s all part of our plan to completely reimagine the way we deliver health care to our patients.

Our beginnings stretch back to 1854, just five years after the Gold Rush that marked the rise of San Francisco, when Dr. Joseph Rausch founded the German General Benevolent Society, the precursor of CPMC’s Davies campus. In the early 1870s, St. Luke’s was founded, and that was followed by the building of hospitals that today are our California and Pacific campuses.

Individually, the different hospitals weathered earthquakes, fire, depression, and war. Now, collectively, we are building toward a new future, one in which technology plays an increasingly vital role, although the individual care providers remain the focal point of our patient-centric hospitals.

Laws passed in the aftermath of the 1994 Northridge earthquake in Southern California meant we had to rebuild or retrofit our existing acute-care facilities, and so for the past few years we have had design teams working to help us create a plan to deliver twenty-first-century care.

At our Davies campus in the Castro, we have already done extensive work to meet the higher seismic standards.

Our goal at Davies now is to create a new Neuroscience Institute to expand the range of services we offer for stroke care, brain tumors, and other neurologic diseases such as ALS (Lou Gehrig’s disease). We’re also working toward enhancing all of our physical medicine and rehabilitation services at Davies so that patients will receive all their treatment and follow-up care at the same location.

At our St. Luke’s campus in the Mission, our plans include a new, eighty-bed, state-of-the-art community hospital, one that will meet the current needs of our patients and allow for growth in the future; a hospital that will be able to withstand even a major earthquake and be able to continue to care for patients; inpatient medical care, surgical care, critical care, labor and delivery, and postpartum care; single-patient rooms that will improve both privacy and infection control; an expanded Emergency Department with 50 percent more space than the current one has; and a new Medical Office Building to attract a new generation of patients to the hospital.

In addition, St. Luke’s will support a network of clinics, outpatient facilities, and physician practices to deliver more of the health care services that the neighborhood actually needs. An example is our Bayview Child Health Center, which 20 San 21 SanFrancisco FranciscoMedicine Medicine july/august july/august2011 2011

Neuroscience Institute at CPMC Davies works to provide medical care for the children of the Bayview/Hunter’s Point community, one of the most medically underserved neighborhoods in the City.

Even before the new hospital is built, the people of the Mission will have access to a wide range of specialty services at St. Luke’s. In the past year, the hospital has added an orthopedic clinic that not only takes care of adult injuries but also has a pediatric specialist; a liver disease clinic to treat patients with Hep C, Hep B, and HIV/AIDS; two breast cancer surgeons; a neurologist; and acancer care specialist.

The plans represent a dramatic change in fortunes for St. Luke’s, which has been on the brink of closure several times in the past few decades. The new hospital means that the people of the Mission will continue to have a hospital that both matches and meets the diverse health care needs of the community.

The final element in the plan is our new campus at Van Ness and Geary. This will include a world-class, seismicallysafe, 555-bed hospital that will combine all our inpatient services from the Pacific and California campuses and accommodate future growth; inpatient medical care, surgical care, pediatrics, critical care, labor and delivery, and postpartum care, plus specialized programs such as organ transplantation, interventional cardiology, and newborn intensive care; an ED with dedicated treatment areas for triage, general acute www.sfms.org

care, pediatric care, and adult and pediatric critical care, plus a secure psychiatric treatment area staffed 24/7; a new medical office building directly across Van Ness Avenue from the hospital to allow doctors easy access to their hospital patients; a centrally located hospital with excellent public transportation access; and an architecturally stunning structure that will rejuvenate the Van Ness corridor and reinvigorate the local community.

These plans are important not just for CPMC but for all San Francisco citizens. We are envisioning a network of physicians’ offices, medical centers, and community clinics around the City to deliver care where people need it most—close to home—and to offer them world-class inpatient care when they need it. Our new hospitals will also double the number of earthquake-safe beds in San Francisco, inject $2.5 billion into a challenged economy, and create more than 1,500 new union construction jobs at a time of record high unemployment in that industry.

And the entire project is being done at no cost to San Francisco taxpayers.

For the past five years we have been working closely with the City to get the entitlements we need to turn those plans into reality. So far, they have been approved by the San Francisco Health Commission and are now being reviewed by the SF Planning Commission. We hope to get their approval by late summer so we can take the plans to the San Francisco Board of Supervisors for final approval. As soon as we get the green light, we will start building. Our goal is to have all three campuses up, open, and running by 2015.

There’s a lot at stake here. For the physicians and staff at CPMC, it means creating three hospitals that are able to take advantage of the most modern technology so we can continue to deliver the latest and best care possible. For our patients it means building hospitals that will be there when they need them most, even in the aftermath of a major disaster. The people of San Francisco deserve nothing less.

Michael Rokeach, MD, is the medical chief of staff at CPMC and has been with the hospital for more than 30 years. He is also a past-president of the SFMS. Ed Kersh, MD, is a nationally renowned cardiologist and the medical chief of staff at CPMC’s St. Luke’s Campus. www.sfms.org

The new St. Luke’s

New campus at Van Ness Ave. and Geary St.

SFMS Member Selected for Royer Award SFMS board member Donald C. Kitt, MD has been named the recipient of the 2010 Dr. J. Elliott Royer Award in Neurology for Community Excellence. The formal ceremony will take place at the Aird Professorship Lecture of the San Francisco Neurological Society in October. The Royer Award honors Bay Area physicians who have made significant contributions to the fields of psychiatry and neurology. Established in 1962 with an endowment from the late Oakland physician J. Elliott Royer, the award is bestowed in psychiatry and neurology in alternate years, naming one academician and one clinician. Please join the SFMS in congratulating Dr. Kitt on receiving this prestigious award.

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

Kaiser Permanente San Francisco Hospital Planning for the Future Craig Lubbock, MD

As we at Kaiser Permanente, San Francisco, look to the future, we are committed to our current hospital foot-

print as it meets seismic criteria through 2030. That being said, anticipated growth in both San Francisco-based primary inpatient care and tertiary care, including referrals from our sister Kaiser Permanente medical facilities in Northern California, forces us to look internally to meet our future hospital needs. One strategy we are exploring is to move appropriate services out of the hospital into our outpatient setting. Within our hospital, we will work to maximize use of our fixed-capital assets.

The “seven-days-a-week hospital operation” is beginning to take on reality, driven by demand and patient preference rather than medical necessity.

To pursue this, we continue to invest in our physical infrastructure, providing redundant systems to support and sustain 22 23

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our operations. We diligently pursue a safe work environment for our staff so they can provide outstanding care for our patients.

We have invested significantly in our IT systems to support our model of integrated care delivery. We have a fully implemented electronic medical record linking our inpatient and outpatient care. We continuously learn how our data can support our quality programs and operations to proactively promote safe and efficient care—essential elements of sustained capacity management. We are increasingly aggressive in response to this information, implementing programs and work flows to enhance both safe care delivery and appropriate throughput.

Currently, one of the most compelling areas of focus is reducing idle time in the pathway from diagnosis to treatment to discharge from the inpatient setting. To this end, we are working on a system that will allow us to “schedule” the patient’s hospital stay, providing a plan that will be transparent to the patient and the family throughout the process. We plan to be able to schedule all necessary aspects of the patient’s hospital experience—consult visits, ancillary and surgical procedures, teaching, and diswww.sfms.org

charge processes—so that all involved are aware of the next step.

This benefits the care delivery team and improves the care experience for the patient by dispelling any uncertainty. Of course, communication is a cornerstone of safe and efficient care, and we are looking forward to the addition of handheld devices to provide us with an enhanced communication tool to better integrate our care teams.

One of the tangible benefits of the electronic medical record is the recovery of space used to house the charts. Since the entire process of health information management can be executed remotely, we have freed up some valuable space within the hospital. We are eyeing this space to accommodate the growing number of hospital-based specialist (HBS) physicians who anchor the majority of our inpatient delivery teams. Along with our bedside nurses and our patient care coordinators, these are the professionals who drive inpatient care. We are fortunate that the HBS physicians have assumed partner leadership roles with nursing management on our med/surg care units to respond to patient and staff needs. HBS physicians provide a vital continuum of care between the emergency department and critical care, and they manage our post-cardiac surgery patients and our surgical specialty patients in conjunction with their surgeons.

We plan to remain committed to resident teaching as we have both freestanding and affiliated resident-training programs. As resident numbers, work hours, and educational goals have evolved, we continue to explore the appropriate integration of postgraduate training into our delivery model. Traditional assumptions of how residents might best learn and be taught are tested against the economic reality of an expectation of a more efficient inpatient stay. A sequential diagnostic and treatment process, like so much else in today’s world, is more of a multitasking exercise shared by a team and includes initiating discharge planning on admission.

ing to all digital mammography, 3-D reconstruction of our 64-slice CT scanner, special coils for our MRI, a new cardiac cath lab, and a GI ultrasound unit to support our tertiary program in hepatobiliary surgery. These enhancements will greatly increase our capacity to diagnose and ultimately treat patients within a remarkably faster time frame.

In May 2011, we opened a renovated, state-of-the-art operating room suite that incorporates IR imaging to support vascular surgeons in their endovascular work. This operating room will also provide capacity for interventional cardiologists and cardiac surgeons in the inauguration early next year of a new program to place aortic valves transcutaneously. Also anticipated is the equipping of another surgical suite with a robot to support specialists in gynecologic oncology and urology.

Finally, the exercise posed for this article begged for the bricksand-mortar answer to what lies ahead. How health care reform affects volume and care delivery systems remains to be seen. Improved health for our community and care for our patients remains our focus. While it is clear that information technology is the hard wiring that will link it all together, it is our people who will provide the energy and, as importantly, the caring. Our plans include continued investment in our people—engagement in our planning and work flow development, and education regarding our systems and technology. We need to create capacity to efficiently and effectively care for more patients with resources that will most likely grow more slowly in the future. We are presently working enthusiastically toward that end.

Craig Lubbock, MD, is the chief of staff for Kaiser Permanente San Francisco.

Tracy Zweig Associates

At present, we are extensively remodeling our maternal child health units as we provide high-risk obstetrical services and have a neonatal intensivecare nursery.

When this work is complete we will have enhanced labor and delivery capacity to support women who deliver at the San Francisco Medical Center, as well as those from our referring Kaiser Permanente medical centers. We will also have increased space per isolette in our nursery to provide a more satisfactory experience for our infants’ parents and our care staff.

No look into the future can ignore the march of technology. We continue to enhance the capability and capacity of our current imaging/diagnostic systems movwww.sfms.org

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tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

Chinese Hospital A Resource for the Community Linda S. Schumacher Chinese Hospital is a community-owned, not-forprofit organization with a long and rich history of provid-

ing culturally sensitive health care to its community. Founded in 1899 as the Tung Wah Dispensary, Chinese Hospital is the last independent hospital in San Francisco. The current hospital is licensed for fifty-four acute-care beds (predominantly in multibed rooms) with an intensive care unit, a medical/ surgical unit, and a telemetry unit. Other services include a twenty-four-hour Level IV emergency room, surgical services, radiology, and laboratory services. The hospital also operates three community clinics located offsite in the Sunset and Excelsior Districts and in Daly City.

More than 97 percent of the inpatients served at Chinese Hospital are of Asian ancestry, with an average age of 76 years.

They are predominantly monolingual and more than 90 percent are covered by Medicare and/or Medi-Cal. The outpatients cared for by Chinese Hospital are slightly younger, with an average age of 65, and they are more frequently bilingual.

Patients travel from all over the San Francisco Bay Area for services at Chinese Hospital because of the cultural uniqueness of the organization.

Chinese Hospital has been active in addressing many of the health disparities found among Asian-Pacific Islanders (API). The incidence of hepatitis B is nearly 10 percent in API and, as a result, Chinese Hospital has been actively involved in providing education and early screening for hepatitis B for the residents of Chinatown, and in offering more affordable vaccinations against the virus. One hundred percent of the physicians practicing at Chinese Hospital have stated their commitment to screening patients for hepatitis B. Last fall, the medical staff of Chinese Hospital honored Dr. Baruch Blumberg for his work in discovering the hepatitis B virus and developing the first vaccine. Dr. Blumberg and his team eventually donated their work to China so that all people could have access to the screening and vaccine. Because one in four people with the hepatitis B virus will develop either liver cancer or go into liver failure, this vaccine actually prevents cancer by preventing the infection.

Another health disparity facing the Chinese residents of San Francisco is what is generally called “metabolic syndrome.� There is a higher incidence of diabetes and high cholesterol among Chinese Americans, which leads to many other chronic conditions. As a result, members of the hospital team are focused on screening and educating the community on these diseases as well. Organizationally, the diabetes manage24 25

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ment programs are expanding to assist patients in managing their diseases more effective and improving their quality of life.

The future of Chinese Hospital is filled with exciting changes. In an effort to meet the health care needs of the community and the California State Law requiring seismic safety for all hospitals, Chinese Hospital is planning the construction of a new hospital. The new building will stand on the current campus in the space currently occupied by the 1925 Hospital building and the parking garage directly behind it. This new hospital will have fifty-four private acute-care patient rooms as well as twenty-two skilled-nursing beds. Other new, expanded, or improved services include an MRI and an all-new Radiology Department, three new surgical suites, a new Level IV emergency room with observation capability, and a dedicated radiology room, a new pharmacy, and cardiopulmonary unit. The hospital will also support the transition to electronic medical records. As part of the work to improve the services provided by Chinese Hospital, a new outpatient radiology service will open on Pacific Avenue in late 2011.

Chinese Hospital was created by the Chinese to provide health care to the Chinese community. The new hospital building will continue the legacy and provide the opportunity for Chinese Hospital to continue serving the residents of the San Francisco Bay Area.

Linda S. Schumacher is chief operating officer for Chinese Hospital.

www.sfms.org

THE STATE OF SAN FRANCISCO HOSPITALS

St. Mary’s Medical Center Providing Exceptional Service to San Francisco Francis Charlton, MD The St. Mary’s beehive is abuzz with new and ongoing patient-centric projects and activities. The

CHW Cancer Center at St. Mary’s opened this spring to fill the community’s need for a comprehensive, single-site outpatient cancer facility. The Center also provides patients with a dedicated, personal “Cancer Navigator” who will guide them throughout their trying journey from oncologic consultation to infusion services and radiation therapy and beyond.

The Infusion Center and Radiation Therapy Unit are spacious and state-of-the-art in all respects. Aligned with that is the Northern California Melanoma Center (NCMC), an on-site service that provides a multispecialty consulting panel of clinical experts in the field of melanoma. The NCMC offers therapeutic options for every stage of this devastating disease, from standard therapy to innovative treatments available only through clinical trials. The physicians at the NCMC have provided consultations to more than 5,000 patients from around the globe and their work has been published in many scientific journals.

Our orthopedic services are second to none. More than 10,000 total joint replacements have been performed at St. Mary’s over the past thirty-five years. Our Total Joint Center has superior outcomes, both short- and long-term, for many reasons.

Fellowship-trained, high-volume surgeons use innovative techniques to reduce dislocations and they have helped develop and design state-of-the-art, long-lasting implants, which may be customized individually based on patient anatomy and postsurgical physical demands. A multimodal pain protocol, rapid intensive rehab, and advanced cell technologies minimizing transfusion requirements all contribute to our success. Patients come from far and wide for both primary replacement and more complicated revision procedures, as evidenced by our Blue Distinction Center designation from Blue Shield of California for knee and hip replacement surgery.

Our spine surgery program has earned the same distinction.

St. Mary’s Spine Center is thirty years old and is the oldest continuously operating multidisciplinary spine center in the western United States. The Center offers a full spectrum of treatment modalities, and most spine patients can get treatment without surgery. When they do require surgery, the latest minimally invasive techniques are employed. The X-Stop® implant for spinal stenosis was invented by our surgeons and is now being used extensively worldwide. Additionally, we are the life-long home of the San Francisco Orthopedic Residency Program. While they cover and train at many Bay Area hospitals, residents come here to build the foundation of their skills and knowledge. The residents also learn advanced techniques as they work in our biomechanics lab. These skills will transform them into top-notch surgeons and innovators, like their teachers (many of whom prewww.sfms.org

ceded them in the same training program).

Cardiology services have long been a particular area of expertise at St. Mary’s. From the first percutaneous transluminal coronary angioplasty in the U.S. in 1979 to the first fully digital cardiac cath lab in the U.S. to the revolutionary percutaneous left atrial appendage ligation using the LARIAT suture procedure, we have long been at the cutting edge of cardiac care. Our average door-to-balloon time for Code STEMI is one hour, resulting in excellent outcomes for myocardial infarctions.

Our Emergency Department continues to triage patients and keep wait times under thirty minutes on average. Rapid ED care also accounts for our success in treating strokes. We are certified by the Joint Commission as a Primary Stroke Center, knowing that “time lost is brain lost.”

As soon as stroke is suspected, Code Stroke is called. Radiology, lab, a neurologist, and the stroke team are immediately notified. Stroke patients who suffer significant neurological deficits can be treated by our onsite acute rehab team.

St. Mary’s Acute Rehabilitation Center accepts patients with an enormous variety of functional impairments due to traumatic injuries or medical illnesses, such as stroke, and they are referred from all over northern California. Using a team-based approach and staffed by experienced physicians, nurses, and therapists, the multidisciplinary team tackles the most challenged patients and their many problems with such astounding persistence and caring that we can discharge three-

Continued on page 28 . . .

July/august 2011 San Francisco Medicine

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THE STATE OF SAN FRANCISCO HOSPITALS

SF Community Clinic Consortium An Update on San Francisco’s Community Clinics John Gressman, MSW, MA The community-based, nonprofit partner clinics of the San Francisco Community Clinic Consortium (SFCCC) are cornerstones in San Francisco’s health

care delivery system. From 1956 to 1992, these clinics were created in underserved neighborhoods to ensure that people who are at the greatest risk for poor health outcomes—due to such problems as lack of insurance, low income, or homelessness—did not continue to fall between the cracks in our health care system.

In 1982, a group of community-based, nonprofit health clinics, recognizing their shared values and concerns, came together to form the San Francisco Community Clinic Consortium (SFCCC).

The creation of SFCCC allowed these clinics to pool their collective resources, both financial and experiential, and it serves as a vehicle to address their needs and interests, and those of their patients, to local, state, and national policy makers.

The core mission of SFCCC is to preserve and promote community-based health care, and our objectives are to expand the delivery of primary health care services; support the partner health clinics to provide quality, cost-effective health care; strengthen the provider networks to enhance access to health care; and provide leadership in health policy and education. Last year our partner clinics provided quality culturally and linguistically sensitive primary health care services for more than 77,000 patients through more than 336,000 patient visits. The care ranges from prenatal care to geriatric care. Of our patients, 53 percent are Asian/Pacific Islander, 6 percent are black, 23 percent are Latino, 2 percent are Native American, 13 percent are white, and 3 percent are of unknown ethnicity/race. Sixty-four percent of our patients have incomes of less than 100 percent of the federal poverty level—about $10,000 for an individual and $22,000 for a family of four. A third of our patients have Medi-Cal and/or Medicare.

SFCCC works to lead and support the partnership in four core areas, each with distinct programs: access to care, workforce development, maximization of valuable resources, and health policy. While SFCCC partner health clinics focus on patient care, promoting individual health to preserve the well-being of the communities they serve, SFCCC promotes the health of our clinics, keeping them poised to adapt to a changing health care environment so that their long-standing tradition of community care is preserved.

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San Francisco Medicine july/august 2011

SFCCC Partner Clinics CURRY SENIOR CENTER 333 Turk Street (between Hyde and Leavenworth) (415) 885-2274 main (415) 885-2344 fax www.curryseniorcenter.org Mission: Curry Senior Center is a joint project of San Francisco’s Department of Public Health and the private, nonprofit Curry Senior Services organization. From its key location in the Tenderloin, Curry Senior Services provides services to seniors that promote independent living while maintaining their dignity and self-esteem.

Services and Programs: Primary care, prevention services, case management, health education, home visits, blood pressure screening, podiatry, HIV testing, mental health consultation, substance abuse program, meal program, North and South of Market adult day health care, socialization services, community service programs, housing services, and translations services Target Population: Seniors, over fifty-five years old; 1,620 clients per year Languages Spoken: Spanish, Cantonese, Mandarin, Tagalog, Vietnamese, Cambodian, Laotian, and Russian

GLIDE HEALTH SERVICES 330 Ellis Street, 6th Floor (cross street: Taylor Street) (415) 674-6140 main (41) 673-1037 fax www.glide.org Mission: Glide Health Services is a core program of the Glide Foundation and Glide Memorial United Methodist Church, which has a forty-year history of service and advocacy on behalf of the poor, homeless, and disenfranchised in San Francisco’s Tenderloin District. Glide Health Services is a “gateway,” or point of initial contact, for many of the needy and homeless who come to Glide seeking services, such as Glide’s addiction recovery and empowerments programs.

Services and Programs: Primary care, adult urgent care, chronic disease management, case management, HIV testing and education, health screenings, health promotion and education, health and risk reduction counseling, psychiatric treatment, crisis intervention, individual therapy, supportive medications, psychoeducation groups, peer-facilitated “Recovery Circles,” substance abuse services, smoking cessation services, and acupuncture Target Population: Low-income and uninsured San Franciscans, who are generally between the ages of 18 to 64; www.sfms.org

2,904 clients per year Languages Spoken: English, Spanish, and Tagalog

HAIGHT ASHBURY FREE CLINICS, INC. 558 Clayton Street (cross street: Haight Street) (415) 746-1950 main (415) 431-9909 fax and 1735 Mission Street (cross street: Valencia Street) (415) 746-1940 main (415) 746-1068 fax www.hafci.org In May 2011, the board of directors of Haight Ashbury Free Clinics and Walden House voted to merge the two organizations. As a result, Haight Ashbury Free Clinics will be providing expanded services to our patients and clients in primary care, mental health, and substance abuse treatment services.

Mission: Our mission is to increase access to health care for all and improve the health and well-being of our clients. The Clinics provide free, high-quality, demystified and comprehensive health care that is culturally sensitive, nonjudgmental, and accessible to all.

Services and Programs: Primary care, specialty care, urgent care, chronic disease management, woman’s health services, HIV testing and services, mental health services, jail psychiatric services, substance abuse services, smoking cessation services, acupuncture, homeless services, and RockMed Target Population: Low-income and uninsured San Franciscans generally between ages of 17 and 64; all welcome; number of clients: 5,000 per year Languages Spoken: English, Spanish, and sign (by prior arrangement) LYON-MARTIN HEALTH SERVICES 1748 Market Street, Suite 201 (cross street: Valencia Street) (415) 565-7667 main (415) 252-7512 fax www.lyon-martin.org Mission: The mission of Lyon-Martin Health Services is to provide excellent health care to women and transgender people in a safe and compassionate environment with sensitivity to sexual and gender identity; services are provided regardless of ability to pay.

Services and Programs: Primary care, Breast Cancer Early Detection Program, gynecology, Health Care for the Homeless, comprehensive primary care and gender reassignment support for transgender people, substance abuse education and screening, transgender health care, advocacy, smoking cessation support, health screenings and education, chronic disease management, HIV and STD testing, mental health services, primary care for HIV+ women, group therapy Target Population: Women and transgender people (MTF and FTM) 18 and older, especially those who are lowincome, people of color, lesbian or bisexual, HIV-positive, and/ or older; number of clients: more than 4,000 per year Languages Spoken: Spanish and English

MISSION NEIGHBORHOOD HEALTH CENTER 240 Shotwell Street (cross street: 16th Street) (415) 552-3870 main (415) 431-3178 fax www.mnhc.org Mission: Mission Neighborhood Health Center is committed to compassionate, culturally competent, and comprehensive health care services. We strive to provide services for the medically underserved with a focus on the Latino/Hispanic Spanish-speaking community and its neighbors.

Services and Programs: Primary care, pediatric medicine, adolescent medicine, adult and senior medicine, Women’s Clinic, family planning and reproductive health, prenatal care, podiatry, preventative services, health education and nutrition, chronic disease management, HIV testing and services, homeless services, X-ray and lab, pharmacy Target Population: All populations served, with an emphasis on Latino clientele; bilingual, bicultural, Spanish/English providers are available; number of clients: 12,671 per year Languages spoken: Spanish and English; limited Tagalog and Cantonese interpretation also available NATIVE AMERICAN HEALTH CENTER 160 Capp Street (cross street: 16th Street) (415) 621-1170 main (415) 621-3985 fax www.nativehealth.org Mission: Provide health care to residents in San Francisco with respect for and promotion of American Indian culture, health, and well-being.

Services and Programs: Dental (adult and pediatric); preventative care; patient education services; HIV care and counseling; mental health services; substance abuse awareness and services; smoking prevention and cessation; Women, Infants, and Children (WIC); nutrition and physical fitness services; lab Target Population: Native Americans and the Mission district community; open to all San Franciscans; number of clients: 3,719 per year Languages Spoken: English, Spanish (dental only)

NORTH EAST MEDICAL SERVICES 1520 Stockton Street (cross street: Green Street) (415) 391-9686 main (408) 573-9686 main (415) 433-4726 fax www.nems.org Mission: North East Medical Services is a nonprofit community health center located in the San Francisco neighborhoods of Chinatown, Portola, Visitacion Valley, and the Sunset.

NEMS provides affordable, comprehensive, compassionate, and quality health care services in a linguistically competent and culturally sensitive manner to improve the health and well-being of our community.

Services and Programs: Primary care; specialty medical care; pediatric care; women’s health, family planning, and reproductive health; prenatal care; dental services; optometry; podiatry; HIV testing and services; X-ray and lab; pharmacy;

Continued on the following page . . .

www.sfms.org

July/august 2011 San Francisco Medicine

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mental and behavioral health services; preventative services; health education and nutrition; social services Target Population: The clinic serves the Asian community as well as individuals from a wide range of ethnic and cultural backgrounds; all welcome; number of clients: 49,436 per year Languages Spoken: Mandarin, Cantonese, Vietnamese, Korean, Burmese, Taiwanese, Toishan, Spanish, English

ST. ANTHONY FREE MEDICAL CLINIC 150 Golden Gate Avenue, 2nd Floor (cross street: Jones Street) (415) 241-8320 main (415) 2418322 fax www.stanthonysf.org Mission: In the spirit of the Gospel, our mission is to feed, heal, shelter, and clothe the needy; empower the homeless; and, together with those we serve, promote a social order in which all persons flourish.

Services and Programs: Primary care, urgent care, pediatrics, podiatry, chronic disease management, HIV testing and care, pregnancy testing, immunizations, health education and outreach, mental health services, therapy services, residential recovery program, smoking cessation, diet and nutrition counseling, dining room, social work center, senior outreach and supportive services, residence programs, clothing and furniture program, tech lab employment program, harsh weather drop-in Target Population: Homeless, low-income, uninsured, 55 and under, children, residents of San Francisco; all welcome; number of clients: 3,106 per year Languages Spoken: Spanish, Cantonese, Vietnamese, Lao, Mien, Thai, French, Russian, Hindi, Gujarat

SAN FRANCISCO FREE CLINIC 4900 California Street (cross street: 11th Avenue) (415) 750-9894 main (415) 750-1966 fax www.sfccc.org Mission: The mission of the San Francisco Free Clinic is to provide free, accessible medical treatment to those without health insurance and to advance the field of primary care by providing educational opportunities for future practitioners.

Services and Programs: Primary care, preventative health care, chronic disease management, screenings, immunizations, health education, nutritional counseling, family planning, pregnancy options counseling, yoga Target Populations: All uninsured welcome; number of clients: 1,642 per year Languages Spoken: Mandarin, Cantonese, Russian, Spanish

SOUTH OF MARKET HEALTH CENTER 229 7th Street (between Howard and Folsom Streets) (415) 503-6000 main (415) 503-6096 fax www.smhcsf.org Mission: South of Market Health Center is a comprehensive ambulatory medical clinic that provides affordable patient centered care, with emphasis on patient access, dignity, com-

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San Francisco Medicine july/august 2011

passion, and culturally-sensitive and quality medical services.

Services and Programs: Primary care, acute and chronic disease management, dental services, podiatry, women’s health care, family planning, prenatal care, HIV testing and services, chronic pain management, disease prevention and health maintenance services, lab and diagnostic services, pharmacy, care management Target Populations: Our services are available to all persons. Our health care program is designed to meet the special needs of poor, medically underserved, and low-income residents in the South of Market and Tenderloin areas. Number of clients: 6,140 per year Languages Spoken: We provide on-site access for Spanish, Mandarin, Cantonese, Tagalog-speaking clients, and for other non-English speaking clients we have electronic access to interpreting services.

John Gressman, MSW, MA, is the president and CEO of the San Francisco Community Clinic Consortium.

St. Mary’s Medical Center Continued from page 25 . . . quarters of patients directly to home, and virtually all of them highly recommend our unit.

The McAuley Institute continues to provide mental health treatment for adolescents, compassionate care for kids in crisis.

We offer the most comprehensive mental health assessment and treatment services for adolescents (twelve to eighteen years old) in the Bay Area, with the only dedicated adolescent inpatient program in San Francisco.

The Sister Mary Philippa Clinic is at the core of community benefits, providing a coordinated program of outpatient health services. One-third of our 5,000 patients are uninsured and receive free care. The Clinic serves as the medical home to 1,285 patients who are members of Healthy San Francisco. Last year alone, we offered more than $8 million in charity care for those living in San Francisco. Patients are ethnically and socially diverse, many non-English speaking. The Clinic also serves as an ambulatory care training location for our internal medicine and orthopedic residents.

The University of San Francisco Student Health Clinic is onsite for our collegiate neighbors. The San Francisco Wound and Reconstructive Surgery Center offers multispecialty comprehensive care for both acute and chronic wounds, and the Vein Center provides a bevy of treatment options for varicose veins and vascular conditions. Occupational health services are rendered at our airport SFO Clinic, while travel medicine services may be obtained at SFO or on our main campus. The Primary Care Council has established personal care and men’s health programs. The Hospitalist Program is thriving and evolving to provide optimal patient care hand in hand with both attending physicians and house staff.

I wish you all good health, but should you want or need any of our exceptional services, come on by.

Francis Charlton, MD, is chief of staff at St. Mary’s Medical Center. Dr. Charlton is an internal medicine physician and native San Franciscan. He completed his residency at St. Mary’s and has been treating patients there ever since. www.sfms.org

PUBLIC HEALTH REPORT Doug Trapp

Aspiring to Universal Access: Healthy San Francisco The city’s four-year-old safety net initiative survived a legal challenge to become an urban test for improving care coordination under health reform.

Most large American cities have a safety net of community health centers, public health clinics and hospitals, and private physicians. But San Francisco has gone a step further—it has turned its safety net into a health network.

In 2007, the city launched Healthy San Francisco (HSF), a unique universal access program available to most city residents between eighteen- and sixty-four-years-old. The program provides primary care medical homes plus emergency and specialty care to anyone who earns less than 500% of the federal poverty level. Participants earning more also pay quarterly program fees, plus co-pays.

HSF is not health insurance, because it doesn’t pay for care outside its network, which ends at the city limits. Each participant chooses a primary care medical home from one of thirty-six public health clinics, community health centers, and physician practices.

“We have a large safety net, and this is filling in the gaps,” said Steve Heilig, MPH, director of public health and education for the San Francisco Medical Society. Heilig also served on a mayoral commission that helped create the program.

Care coordination is the key to HSF. The program’s centralized eligibility and enrollment system is available to all medical homes and all participating hospitals. Clinic physicians and hospital emergency departments can find out quickly which facility is a patient’s medical home by checking the enrollment system. Two-thirds of the city’s uninsured are in HSF; 80,000 residents have signed up since 2007 and 54,000 were enrolled at the end of April 2011.

The concept is having some success. Better coordination has reduced hospital admissions and duplicate care. HSF has encouraged the working poor and people who recently lost private health insurance to seek health care, physicians said.

“One of the biggest lessons is how much better we can do on a local level caring for uninsured persons if all of the providers who are caring for the uninsured work together,” said Mitch Katz, MD, former director of the San Francisco Department of Public Health, which runs the program. Another lesson is that employers can be compelled to help pay for their workers’ health costs. HSF was adopted at the same time as a requirement that most businesses spend a minimum level on employee health coverage or contribute to a fund that supports the program. A court challenge to the requirement by a local restaurant association ended with the U.S. Supreme Court declining to hear an appeal of a ruling upholding the employer mandate. www.sfms.org

The program has allowed early access to care for many people who will qualify for Medicaid under the national health reform law’s eligibility expansion starting in 2014. About 60 percent of program enrollees are expected to qualify for Medicaid or subsidized private insurance.

Access Not Always There

“The only way most clinics have been able to increase capacity is through adding hours,” said Hali Hammer, MD, of San Francisco General Hospital, one of the designated medical home sites. Many of HSF’s enrollees never had a steady source of health care. “There were amazing stories early on of people who lived in San Francisco their whole lives and never had access to health care,” Dr. Hammer said. People showed up with undiagnosed diabetes, high blood pressure or even metastatic cancers. Some women had never had a Pap smear, she said.

Some specialist access, including for mental health care, continues to be problematic. “We could certainly use some more,” said Albert Yu, MD, MPH, director of the Chinatown Public Health Center.

The new patient mix has impacted Potrero Hill Health Center; the center has been hiring more medical assistants, behaviorists, and clinical social workers. These changes are not directly due to HSF, but the program’s influx of new patients has encouraged clinics to try to use resources more judiciously, said Michael J. Drennan, MD, the clinic’s acting director.

Charity Care Still Plays Major Role

Healthy San Francisco is not a perfect reform test. For one thing, the initiative is still largely a charity care program.

The city clinics and San Francisco General Hospital receive no payment for the services they provide to enrollees. Non-cityowned clinics and private physician groups are paid on an annual capitated basis based on the number of enrollees for whom they provide medical homes.

City medical home payments are confidential, but physician leaders at those sites said they are relatively low. “We have to really watch our utilization to make sure we’re financially viable,” said Kenneth B. Tai, MD, medical director of North East Medical Services, the program’s largest medical home.

This article appeared originally in longer form in American Medical News, the newspaper of the AMA. For the original version, with charts and resources, see: http://www.ama-assn. org/amednews/2011/05/30/gvsa0530.htm.

July/august 2011 San Francisco Medicine

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HOSPITAL NEWS KAISER

Saint Francis

CPMC

Robert Mithun, MD

Patricia Galamba, MD

Michael Rokeach, MD

Providing services that enhance the patient experience at our hospitals is one of the ways we look to the future at Kaiser Permanente. When a patient arrives at our hospital, either for an elective procedure or due to an emergency, we hope to deliver care that helps the patient heal as soon as possible. To that end, we opened our unique on-unit stroke rehabilitation room for those who have suffered a stroke and require rehabilitation before they leave the hospital.

Chief of Neurology Kenneth Fox, MD, says, “We now know that early rehabilitation for stroke patients can mean all the difference in their recovery. So we developed the concept for our stroke rehabilitation room in the hospital to enhance their healing process.”

At this point, the Kaiser Permanente San Francisco Medical Center is the first Kaiser Permanente facility that uses such a room to help stroke patients prepare for the second phase of their rehab process. This second phase can include going to a certified rehabilitation center or directly home after discharge.

The room itself contains both physical and occupational therapy equipment, including parallel bars to aid movement and a faux kitchen for practicing food preparation. Another feature of the room is providing educational resources for family members through a fully functional stroke website that provides information about the rehabilitation process.

Both neurology and hospital-based medicine physicians and staff perform daily rounds through the room and use it as a conference room to provide patient and family education just steps away from hospital rooms.

For all members of a patient’s care team, the room provides not only therapeutic space for stroke patients but also educational space for everyone dedicated to the well-being of our patients.

30

Saint Francis is currently running an advertising campaign entitled “One Stop to Stop Pain.” The reason I mention this is because pain does stop at Saint Francis—we have just completed back-to-back surveys from the Centers for Medicare & Medical Services (CMS), including the Patient Safety Licensing Survey and the Joint Commission. It all began on May 9, when CMS arrived (unannounced of course), and they stayed with us through Monday, May 16. This was a full validation survey, and we were happy with the results.

There is always room for improvement, and they identified a few gaps in our processes.

On Tuesday, May 17, we thought we could take a breath, but CMS showed up again for the Life Safety portion of their survey to assure that we were in compliance with our environment of care. This group opened every door and cabinet in the hospital, and they left us on Friday, May 20. After ten days of surveyors walking, talking, and questioning every person they came into contact with, we were feeling confident, although maybe a little exhausted.

Monday rolled around and we were back to normal and back to our real jobs, but not for long: Tuesday, May 24 brought the surprise of the Joint Commission Survey. The Joint Commission confirmed the good care we provide. As is the practice, we spent hours discussing how we collaborate as a team and how we educate our patients and staff, and we shared all of our policies and procedures.

It has truly been a very long three weeks, but the uphill run has stopped! On behalf of my physician colleagues, I applaud the senior leadership and all the staff for their exemplary leadership, hard work, and dedication. You make Saint Francis shine.

San Francisco Medicine july/august 2011

Congratulations to Dr. Thomas Peitz, who was recently reappointed for a five-year term as chair of the Department of Emergency Medicine. Dr. Peitz will continue to serve as chair through 2016.

CPMC welcomes radiation oncology’s newest technology, the frameless, noninvasive SABR Knife radiosurgery. We are now able to treat brain, prostate, lung, spine, or pancreas cancers using the fastest stereotactic radiosurgery (SRS) treatments available.

With the ExacTrac® SABR Knife frameless radiosurgery treatments, using automatic setup and Trilogy’s delivery system, most patients are in and out of the treatment room within fifteen to twenty-five minutes, in one to five treatment sessions.

In addition to the tumors listed above, ExacTrac® Stereotactic Ablative Brain/Body Radiation (SABR Knife) Therapy is also available to treat your patients with AVM, trigeminal neuralgia, and acoustic neuroma. SABR Knife is a linear accelerator-based, noninvasive alternative to surgery for the treatment of both malignant and benign tumors anywhere in the body. Using real-time tracking and robotic couch, SABR Knife’s capabilities include intensity modulated radiosurgery (IMRS), the next evolution of IMRT. SABR Knife’s imageguided radiation therapy (IGRT) system provides greater accuracy in targeting tumors, allowing us to treat a greater range of conditions.

SABR Knife technology uses high-resolution X-rays to identify tumors seconds before treatment, automatically correcting patient positioning due to any tumor or patient movements. With this technology, we can deliver more precise, higher-treatment doses with submillimeter accuracy, significantly reducing the risk of radiation exposure to surrounding healthy tissue. For more information or to schedule a tour, contact radiation oncology at (415) 600-3600.

www.sfms.org

The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SFMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Endorsed by:

• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

Underwritten by:

Administered by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice.

51423 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544

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