The narrowly averted closure of a special care facility at St. Luke’s hospital in San Francisco highlights a bigger problem in the region — and even statewide.
Activists have saved more than two-dozen medically fragile patients from being shipped out of San Francisco for lack of local beds. But there’s still a shrinking number of nursing care beds across the Bay Area, and throughout California.
If you get sick or are injured and go to the hospital, for most people, the expectation is that you get better and then go home.
But what happens if you’re not quite well enough to do that?
Patients with ongoing daily medical needs that aren’t an emergency but can’t be taken care of at home go to something called a skilled-nursing facility.
Yet around San Francisco and the Bay Area, those kinds of facilities have been disappearing.
Patients at St. Luke’s hospital in the Mission District recently scored a victory when hospital administrators changed their minds about shipping all the patients from a specialized nursing facility out of the county.
But local governments are still grappling with a thornier problem of what to do with patients who need serious long-term care.
Inside St. Luke’s
Irie Pushia, a local church organist, has been at St. Luke's for four years.
“She’s in a minimal vegetative state, she wakes up when she wants to, wake up, go back to sleep,” her daughter Marshia Pushia tells me. “She knows her children. She's not responsive, but she definitely knows her children.”
Pushia and the families of the other 23 patients in the unit, some of whom have been here a decade or longer, have been fighting to stay. These patients are a particularly fragile subset of skilled-nursing patients in an even more demanding level of care called sub-acute.
California Pacific Medical Center, which runs the hospital, was planning to close the skilled nursing and sub-acute facility there. Patients were looking at their relocation options, some of which were as far away as San Jose or even Los Angeles.
That was a huge shock for many families, some of whom visit their loved ones in the hospital several times a week.
Dr. Gary Birnbaum, the medical director of the unit that was going to be closed, was not optimistic about the fate of sub-acute patients who get were going to get sent far away from their loved ones.
“What happens to a sick person who suddenly can't have contact with their family? That's a no-brainer, they get depressed, they get sick, they die,” he said.
How long did he think that would take?
“Mmm, couple weeks,” he said.
The families were not having it. They organized press conferences and protests, and testified at hearing after hearing.
“She needs these services,” Pushia told me of her mother. “And if she do for the rest of her life, she need to be here in sub-acute ... I will do whatever I have to do to fight, but they are not gonna move my mom.”
After months of protest and pressure from city leaders, California Pacific Medical Center promised in early September to find room for the sub-acute patients in its San Francisco hospitals.
Supervisor Hillary Ronen counted it as a major win for patients.
“Make no mistake about this, this was a community victory,” she said at a Sept. 12 press conference in front of City Hall. “This was a community coming together and saying we are not going to accept profits over people, we’re not going to accept when you say no, we’re gonna fight until the moral and ethical thing is done and done correctly.”
But this reprieve is only for the patients currently getting this care. Once they’re gone, there is no commitment to new patients. Even with this change in plan, the city may be left with no sub acute beds at all.
A civic challenge
Why is San Francisco having such a hard time providing this kind of care?
“The financial incentives for companies to provide it in a high-cost city like ours are complicated,” says Colleen Chawla, deputy director of the San Francisco Department of Public Health.
“Medi-Cal is a low payer for this kind of service and it's also the primary payer … it pays more, a little bit, for sub-acute — but generally it doesn’t pay very well. And when you couple that with the high cost of living in San Francisco and the high cost of doing business in San Francisco, it's very difficult to locate in the city.”
That said, it’s not just happening in San Francisco. When families thought they needed to leave, they found their options limited, especially for the more complicated sub-acute patients. Alameda County has 149 sub-acute beds, Sacramento has 52. San Mateo has 44.
It’s a problem years in the making, as Supervisor Norman Yee pointed out at the City Hall press conference.
“We’ve been losing all kinds of health care facilities ... whether it is skilled nursing or just residential care facilities,” he said, “to the point where we can’t even serve our own residents anymore, and we have to deport them outta here to get in somewhere else, which means that the families can’t even visit them.”
Regionally and even nationally, sub-acute nursing beds are disappearing — especially from hospitals. Medi-Cal and Medicaid often don’t pay hospitals for the cost of this care very well, and regulations are stricter for facilities in hospitals than outside them.
So hospitals around the country are getting rid of them. For sub-acute patients, that’s not a good thing, according to Dr. Birnbaum. He says having patients at a hospital, where they’re close to intensive care, is crucial.
“I can show you pictures and videos of people not expected to walk out the door, who did,” Birnbaum said. When they deteriorated and needed resuscitation, he said, the appropriate staff was immediately available.
Sandy Rivera has been at St. Luke’s in the sub-acute unit for seven years. Her sister Raquel describes it as her home. They visit her regularly, and bring her stickers and coloring books. According to Raquel, Sandy is 53 years old, but due to a disability has the mind of a two-year-old.
“So she needs 24 hour care. She needs someone to help her bathe, brush her teeth, get dressed,” Rivera says.
But it’s not just round-the-clock care that’s so important for sub-acute patients. They also need skilled professionals on hand if something goes wrong.
During one of my visits, Sandy’s tracheostomy needed attention in order for her to breathe properly. Fortunately, a nurse was just a button-press away.
Before CPMC decided to keep the hospital open, Rivera’s family had heard they might have to consider a placement in Los Angeles.
“There's no beds available here in the Bay Area. Everything’s full. All the beds are taken,” Rivera says.
In the Bay Area, the average occupancy rate at sub-acute facilities is very close to full at 88 percent.
The broader category of skilled nursing facilities, which includes patients who are less medically fragile, has also decreased.
Statewide, the number of such facilities has dropped from 1,278 to 1,243 — a decline that also includes a 17.8 percent drop in hospital-based facilities.
A shortage of nursing care is a systemic problem. San Francisco’s health department estimates that if current trends of aging and population continue, the city will need 4,288 skilled nursing beds by 2030. Currently, It has 2,463 — a bit more than half that many.
A shortage like that means unnecessarily extended stays in acute hospital beds.
“It's not good for the patient, because they're in a more restrictive level of care ... it backs up the hospital with a patient who doesn't need to be there,” said Chawla from the Health Department. “So it's a whole-system issue.”
While San Francisco has been trying to figure out how to address this cycle, in the last couple years two similar facilities in the city were closed.
The best hope so far is for the city to find some kind of incentive to get providers to jump back in the skilled nursing and sub-acute game. That’s true not just for the city, but for the region and beyond.
“We've already initiated conversations with San Mateo County to see if we can come up with a regional approach ... that we can solve their problem and ours,” Chawla said. “The challenge is not just our problem, it's a nationwide issue.”
The national connection is not lost on Supervisor Ronen, who has made the St. Luke’s incident a rallying cry for single-payer healthcare.
“Ultimately, until we have a single-payer system, we are going to be fighting individual profit-making decision after individual profit-making decision,” she said.
As far as skilled-nursing care goes, it’s up to local and state governing bodies to ramp up their efforts to add beds.
One thing’s for sure — the families and activists at St. Luke’s have made a lasting impression.
Supervisor Ahsha Safai, who represents San Francisco’s District 11, asked the Department of Public Health if seats on the Post-Acute Care Collaborative, a regional working group tasked with making recommendations to the city for addressing the nursing-care shortage, can be opened up to relatives of skilled nursing patients.
The patients' families ended up not just protecting themselves — they may now get a chance to make sure families of sub-acute patients don’t have to do the same.
The Public Safety and Neighborhood Services committee of the San Francisco Board of Supervisors has committed to holding quarterly meetings on the topic of skilled nursing care from now on. You can find the agendas for those hearings online.