March 12, 2006

To: Mr. Edward Harrington, San Francisco Controller
Linda S. Yeung, San Francisco Controllers Office

RE: Analysis of Dr. Mitchell Katz's memo of 3/2/06 "Analysis of Laguna Honda Hospital Zoning for Health Care Facilities"

Dear Mr. Harrington and Ms. Yeung,

I am a Board Certified Geriatrician with 18 years of experience in direct patient care at Laguna Honda Hospital (LHH) primarily as the Attending and Screening Physician on the Admissions Ward. Over these 18 years, I have admitted and cared for approximately 4800 patients. For the past 2 years, I have gone to SFGH to screen referrals several times a week. One of my areas of expertise is the management of behavioral disorders related to dementia.

In my professional opinion, Dr. Katz analysis is based on incorrectly applied data related to behavioral disturbances in Alzheimer's disease. His figures regarding the number of patients who would need to be discharged if the LHSUD Measure passes are inaccurate. While behavioral disturbances are common in dementias of all types and increase as the dementia progresses, depression and apathy are more common manifestations of late stage dementia than is aggression. Behavioral studies of Alzheimer patients refer to 'aggression' and 'agitation', nebulous terms that include behaviors that do not endanger others. Many dementia patients, particularly those with advanced disease, are frail and even if 'aggressive/agitated', do not pose a danger to themselves or others. Furthermore, there are effective ways of managing aggression in demented patients including behavioral approaches, psychosocial programs and medications. LHH has been successfully managing dementia patients with behavioral disturbances including 'aggression' for many decades. Our specialized expertise in caring for these patients prevents them from becoming a danger to themselves or others.

I cannot understand why Dr. Katz believes that a Ballot Initiative that reiterates Federal and State Law mandating a safe environment in Skilled Nursing Facilities would cause 300 patients to be discharged from LHH. I wonder how he arrives at this figure of 300 patients. In my experience, there is no basis for stating that patients with late-stage Alzheimer's disease, AIDS dementia and/or behavioral problems, psychiatric disorders and those with traumatic brain injuries would "need to be discharged". The only patients that need to be discharged are those who, despite our best efforts, are violent and endanger themselves or others, regardless of their underlying illness. All but a small minority of dementia patients can live at LHH without posing any danger to themselves or others. Linking end-stage Alzheimer's disease, AIDS dementia, psychiatric disorders and traumatic brain injuries only with aggression, tends to stigmatize these patients. Also, it gives the unrealistic impression that there are large numbers of dangerous patients at LHH.

The number of LHH patients who pose a danger to themselves or others is miniscule and few if any patients would need to be discharged. However, during the year of the "Flow Project" 3/04 to 2/05 (when the Mayor halted the project), I was pressured to accept patients that posed a significant risk of endangering themselves or others. Outside 'arbiters' and administrators were brought in to overrule experienced clinicians regarding admissions decisions. Doctors like myself, who admitted patients to Laguna Honda, were caught between the Department of Public Health's mandate to make our screening standards less stringent and accept more high-risk patients, and the State regulators who were telling us not to admit patients for whom we cannot provide safe and adequate care. This is one reason this ballot initiative is being brought before the voters.

There are a small number of patients who are referred to LHH that we cannot safely manage. During the last two years the number of patients I have denied due to behaviors we cannot safely manage are approximately one per month. It is unfair to these patients to place them at Laguna Honda where they cannot receive the care they need and where they may inadvertently harm others. It is our ethical obligation to place them in an appropriate facility that meets their needs. If we try to save money by placing these patients at LHH, regulatory agencies will penalize us for not providing adequate care, as they did in 2005 when $500,000 was withheld in payments by the Centers for Medicare and Medicaid.

This year, LHH did not pass the State and Federal survey, with altercations and abuse playing a major role. The law is clear in this area, a facility may only admit and retain those patients for whom they can provide safe and adequate care. Failure to do so creates negative publicity, undermines public confidence in the governance of the health care system and erodes essential public support for the work Laguna Honda has done so well for so long.

Laguna Honda Hospital is licensed as a Medical Skilled Nursing Facility. By law, we cannot admit patients whose diagnosis is primarily psychiatric. All patients must have a medical skilled nursing need as defined by Medicare and Medicaid; otherwise we will not be reimbursed. There are large numbers of patients at Laguna Honda with psychiatric disorders (upwards of 60% of the population), who also have medical skilled needs. As long as they have medical needs and they do not pose a danger to themselves or others, this Ballot Initiative will not exclude patients with psychiatric disorders from being admitted to Laguna Honda Hospital, nor does it discriminate against patients with psychiatric illnesses.

I understand that you are using a figure of 17 patients currently waiting at SFGH who were denied admission to LHH due to behavioral issues in your cost analysis. In my experience, there has never been anywhere near that many patients at SFGH denied admission to LHH at any given time. The vast majority of those who are denied admission do not qualify for skilled nursing care as defined by federal and state criteria, refuse to come to LHH, or reside out of San Francisco County. The number of 17 patients requires verification.

The Department of Justice and the settlement of the Davis Lawsuit has made it clear that persons with disabilities have the right to live in the most integrated setting, generally the community. Institutional care such as Laguna Honda should be a last resort. Many patients referred from SFGH have no need to live in an institutional skilled nursing facility. They need either community housing with support services or residential drug treatment programs. These types of housing are scarce, and so SFGH patients are referred to Laguna Honda to be sheltered until housing is available. Such patients are denied admission to Laguna Honda since they have no need for the skilled nursing care LHH is licensed to provide.

In my professional opinion, this ballot measure will be cost neutral to the CCSF and the DPH. There are perhaps 10 to 20 patients per year who will need to be "patched" to specialized facilities either because LHH cannot retain them or LHH cannot accept them from SFGH due to unmanageable behaviors. (Some of these patients can be placed at the City's Behavioral Health Center.) However, this number is offset by Laguna Honda's program for repatriating patients from out-of -county psychiatric facilities that no longer need those specialized services. We have repatriated approximately 5 patients per year in the last 2 years. Therefore, the total number of patients that we cannot accept or retain due to severe behavioral disorders is no more than 15 per year. This number will not change with the LHSUD Measure. This ballot initiative will also save money by reducing penalties from regulatory agencies and time spent responding to regulatory concerns. Most importantly, this will preserve Laguna Honda as a place where San Franciscans can send friends and loved ones without fear.

Please don't hesitate to contact me at the numbers below if I can be of further assistance. Thank you for your attention to my input.

Sincerely,

Maria V. Rivero, MD, FACGS
Diplomate American Board of Internal Medicine
Certificate of Added Qualifications in Geriatrics