Laguna Honda Hospital Replacement Program

Meeting Minutes


Minutes from February 23, 1999 Meeting

MEMBERS PRESENT:  Joan Braconi, Dale Butler, Donna Calame, Adele Corvin, Larry Funk, Anne Hinton, David Ishida, Mitchell Katz, M.D. (Co-Chair), Susan Leal, Charles Levinson, Peter Mezey, Monique Moyer, Robert Neil, Louise Renne, J.D. (Chair), Roger Ridgway, Maria Rivero, M.D., Anthony Wagner.


Dr. Mitchell Katz (Co-Chair) announced that correspondence had been received by some groups asking additional membership be placed on the Planning Committee.  The Department of Public Health is on the process of responding to these letters to ensure that our planning process is inclusive. 

Review and Approval of February 9, 1999 Minutes

The minutes from the February 9, 1999 meeting were approved without modification.

General Overview of Laguna Honda Hospital Resident Population

Dr. Maria Rivero, Medical Director of Laguna Honda Hospital, provided background information on the residents at the Hospital. 

Laguna Honda Hospital's residents have changed significantly over the past decade.   In the past, Laguna Honda Hospital was primarily occupied by elderly individuals.   However, now, approximately 80% of the population is elderly and the remaining 20% are younger disabled persons.  In addition, within the last decade, there has been increased number of residents with medical problems, in addition to needing assistance with their activities of daily living.  It is estimated that approximately 40% of the population have psychiatric diagnoses, which while not being their principal ailment nonetheless is a compounding factor to their physical illness.  In response, the Hospital has attempted to develop new programs for this population.

There are currently 1,060 residents at Laguna Honda Hospital (this includes the main Hospital and Clarendon Hall).  At Clarendon Hall, the room configuration meets the federal standard of no more than four beds per room.  Clarendon Hall houses private and semi-private rooms.  It is designed for individuals who are more ambulatory and more independent.

Laguna Honda Hospital has several specialized units in order to address the needs of its population.  There is a Hospice Unit, a Rehabilitation Unit, two secured Dementia Locked Ward Units, and an AIDS Unit.  The AIDS Unit began nine years ago in response to ensuring that those with AIDS were cared in their end stages of life.  However, recent HIV/AIDS drug therapies has changed that nature of the disease and its progression.   As a result, the Hospital is now providing more sub-acute and terminal care in that unit.  Most of the patients in the AIDS Unit are younger.  Finally, the Hospital has an Admitting Unit for this skilled nursing care.  The Hospital tends to group residents by their level of alertness and care needs.

In recent years, substance abuse has become more a complicating factor for residents at the Hospital.  The Hospital does not have a residential substance abuse program per se, but is in the processing of developing a substance abuse treatment program.  It will utilize a consultation liaison model.  At this time, the Hospital does not have estimates on the number of Laguna Honda Hospital residents that may have substance abuse treatment needs.

The Hospital cohorting residents in certain units based on concerns from State and federal agencies that license the Hospital.  These agencies believe that it is appropriate to co-locate some individuals with behavioral problems together to reduce harm to those residents who do not have behavioral issues.  It was noted that this is unfortunate and that it can cause displacement for people who are in current parts of the Hospital to other areas.

Residents of Laguna Honda Hospital tend to stay in the facility for a very long period of time.  For patients who had been in the Hospital longer than six months, the average length of stay is five years.  For those who had been at the Hospital less than six months, the average length of stay is quite short.  It is estimated that one-third of the Hospital's residents eventually leave the facility.  These may be individuals who were placed in the Hospital for rehabilitation services.  It was noted that the number of individuals leaving Laguna Honda Hospital has been increasing over the last few years.  Approximately one-third of the patients who reside in Laguna Honda Hospital eventually die there.

Program Sub-Committee Report on Work Plan

The central issue for the Program Sub-Committee will be what type of services are necessary for the projected population at Laguna Honda Hospital and what opportunities exist on the campus to house those services.  The Sub-Committee spent a significant period of time discussing their need to determine what the future population for skilled nursing care will be in order to make programmatic recommendations.  The Program Sub-Committee work plan consists of: (1) developing principles to guide their response to the key questions, (2) predicting the population that will use Laguna Honda Hospital in the future, and (3) responding to the key programmatic questions.  The key questions relate to the size of the facility (number of beds), the array of services on the campus, the appropriateness of assisted living and the distribution and configuration or single, double and four beds in the Hospital.

It was suggested that Laguna Honda Hospital have an opportunity to become more of a community resource as we look at rebuilding the campus.  Specifically, it was suggested that Laguna Honda Hospital be examined for its educational potential.  It would be ideal to develop training programs in the area of food, maintenance, and medical which can meet the needs of the community, as well as potentially bringing in a source of additional income to operate the Hospital.  It was further suggested that the Hospital examine the potential to provide rehabilitation to more people.  The Planning Committee asked the Program Sub-Committee to look at the recommendations of the Long Term Care Pilot Project Task Force with specific focus on the recommendations of the supportive housing design team.

Dr. Maria Romero provided a brief description on Eden Alternative.  Eden Alternative is a different model of providing long term care within skilled nursing facilities.  It is based on the assumption that what improves quality of life for persons residing in a skilled nursing facility are the same that improved quality of life for everyone else.  Therefore, it stresses how to ensure spontaneity, keep residents self-interested, promote companionship, and keep residents engaged in life.  It creates what is known as a human habitat by also having an intergenerational prospective (allowing adolescents and children to work with the elderly and disabled).  It also stresses the idea of companion-animal and that individuals in skilled nursing facilities can have access to individual relationships.  There are 87 facilities in the United States that have the Eden Alternative model.  There is a 7-minute video on the Eden Alternatives which will be shown at the Planning Committee next meeting.  It was noted that Laguna Honda Hospital currently has some of these characteristics in Clarendon Hall.  It is just that we need much more of this type of approach throughout the campus.  In response to the description, it was again noted that the Planning Committee should think about the appropriateness of placing a child care center for Laguna Honda Hospital employees on the campus, as well as looking at exploring the opportunity to have adolescents who are at the Youth Guidance Center volunteer time on the campus.   This intergenerational approach is also being supported by the federal Housing and Urban Development Department.  It is fostering this concept for senior housing as outlined in the President's proposed year 2000 budget.

It was asked whether this planning effort should look at housing issues beyond the campus of Laguna Honda Hospital (i.e., exploring other properties and looking outside the campus).  Dr. Katz indicated that the charge of this Committee is to develop a plan for rebuilding Laguna Honda Hospital.  If that plan includes the rebuilding of the Hospital and other options that related to housing that does not appear to be problematic.    However, if the Planning Committee focused on the housing issue and does not make recommendations on rebuilding the Hospital that would not be acceptable.  It is very appropriate, however, for us to look at other federal agencies that might assist us, particularly, in our effort to get assisted living on the campus and that should be folded into the recommendations.

Technical Build Sub-Committee Report on Work Plan

The Technical Build Sub-Committee has determined the need to expand its membership to include representatives from the surrounding neighborhood to provide prospective on how the technical build recommendations will impact residents and agencies in that area.   The neighborhood representative will be Pastor Roger Ridgway, who also was appointed to the Planning Committee.  The Technical Build Sub-Committee work plan consist of: (1) developing conceptualized design guidelines, (2) providing parameters to the site building to the Program Sub-Committee, (3) answering key questions and (4) developing a question and answer fact sheet on the technical issues.

The Committee recognizes that it will not, within the current timeframe, be able to do a complete analysis of the site.  Therefore, it will be looking at the work that has been previously done on past bond issues and determine whether or not the information should be revised and updated.  As a result, tomorrow's Sub-Committee meeting will focus on a presentation from the Department of Public Works on the previous rebuilding proposal of Laguna Honda Hospital.  The presentation will cover program analysis, cost estimate and escalation, a description of proposed construction schedule, previous analysis of alternatives and a summary site analysis.

The Sub-Committee felt that it was important to do a complete inventory of all potential questions that may be posed on the technical issues related to rebuilding the Hospital.  It was also announced that Anshen & Allen will provide pro-bono analysis for the Technical Build Sub-Committee.  Anshen & Allen will provide the following:  (1) analysis of the Laguna Honda Hospital options paper, (2) the conceptual idea of the rebuild environment, (3) review of the cost estimate and (4) product schedule with milestone.  This is scheduled for the March 3, 1999 meeting of the Technical Build Sub-Committee. 

It was stressed by the Planning Committee that there must be ongoing dialogue between the Technical Sub-Committee and the Financial Sub-Committee given the fact that their work overlaps extensively and the fact the Technical Sub-Committee will now be responsible for doing the cost construction estimates and not the Finance Sub-Committee.  It was noted that the Department of Public Health will be scheduling weekly meetings with the chairs of all the sub-committees to ensure that there is sufficient dialogue and discussion of overlapping issues between those sub-committees.  Information will be brought back to all sub-committee members.

Finance Sub-Committee Work Plan

The Finance Sub-Committee will be looking at a number of costs related to rebuilding the campus (including operational cost).  Specially, the Finance Sub-Committee will look at the initial planning cost, opportunity cost or saving (such as the cost of maintaining or contracting out laundry), assessment of equipment, and activation cost (whether they are part of capital or part of operating cost).  The Sub-Committee will make assumptions that the facility is less expensive to operate in the first two years than in the subsequent years.  The Sub-Committee will also look at whether an acute care license should be maintained on the campus or whether the Hospital should utilize acute care beds elsewhere in the Department of Public Health's delivery system.  The Finance Sub-Committee will look at the financing alternatives for the Hospital -- looking at federal funds, tobacco tax settlement revenue and State revenue.   The Finance Sub-Committee believes that it is important to retain a consultant to assist it in looking at the various financial issues. 

The Planning Committee asked whether the Finance Sub-Committee will be looking at the Long Term Care Pilot Project Concept Paper to understand the proposed financing of long term care under this proposal.  It was indicated that the Committee would be looking at future reimbursement issues based on whether or not long-term care is capitated or per diem or on another reimbursement mechanism.  The Planning Committee also asked whether the Finance Sub-Committee will be looking at additional usage for the land, such as residential or vicinity, etc.  It was noted that currently it was the understanding of the Finance Sub-Committee that the land at Laguna Honda Hospital cannot be sold.  The Finance Sub-Committee will doing an inventory of revenue to address the ongoing operational cost once the campus is re-built and will make recommendations with respect to how efficiencies can be gained.  There was a concern expressed about the appropriateness of the Finance Sub-Committee making programmatic recommendations (specifically, the contracting out of laundry).  Ken Jensen (Chair of Finance Sub-Committee) responded that it was important for the Finance Sub-Committee to look at the cost of rebuilding and operating the campus and that the laundry would be looked at from that vantage point.  It was mentioned that it would be important to look at the impact of rebuilding Laguna Honda Hospital on other facilities.  With the current reduction in census, several facilities have been impacted.  This should be taken into account in the cost estimation.  It was also suggested that the Finance Sub-Committee look at the cost of what happen if assisted living is not put on the campus.

It was emphasized that in San Francisco there is a need for not only skilled nursing beds but also assisted living given the overall aging of our population.  Therefore, this should not be a situation of either skilled nursing or assisted living, but of both.  

Coordination of Sub-Committee Work and Analysis

As noted before, the sub-committees are working in tandem and not sequentially.   This means that there must be an easy flow of communication between the sub-committees since their individual work is impacted and dependent upon the work of other sub-committees. 

The purpose of the Planning Committee is to provide guidance to the sub-committees on issues to explore and to ultimately review the recommendations from the sub-committees.   The Department will be scheduling weekly chair meetings to discuss common issues.   It was also indicated that a joint meeting may be necessary when issues are similar among the sub-committees.  It was also recommended that each sub-committee develop a timeline with dates for each of the critical components of its work plan that this information be placed on the Web site.

It was noted that if there are land-use constraints then this information should be brought to the Planning Committee soon and that this will appropriately provide the parameters for program, technical and finance.  It was further noted that there are some benefits with larger open wards and that as we look to replace Laguna Honda Hospital, those aspects should be preserved.

Revised Meeting Schedule

It was announced that the meeting times and locations had changed for two sub-committees.  The Program Sub-Committee, effective February 24, 1999, will meet from 10am – 12noon at Laguna Honda Hospital in Room B102.  Also, the Finance Sub-Committee will meet on Thursdays from 1pm – 3pm (excluding February 25, 1999 at which time will meet from 10am – 12noon).  There is a new revised meeting schedule which has been distributed and has also been posted on the Internet site.


Peter Mezey, Committee member, provided the Planning Committee with copies of a memo that he had done outlining key questions that it felt were relevant to answer during this planning process.  The questions were in the areas of :  (1) home care, (2) alternative sites, (3) staffing, (4) operational costs, (5) services, (6) technical build issues and (7) capital costs.  This information will be provided to the appropriate sub-committees for response. 

Next Meeting Agenda

The next meeting of the Planning Committee will be March 9, 1999, from 1:00 p.m. to 3:00 p.m. at 25 Van Ness, Room 330A. 

The agenda for that meeting will consist primarily of two presentations.  The first presentation will be on current land-use issues related to Laguna Honda Hospital.   The second presentation will address community life issues at Laguna Honda Hospital.  In addition, each sub-committee will discuss its work plan and progress to date.

At the March 23, 1999 meeting, there will be a presentation on the projection of the skilled nursing care population, assisted living and home care.  Other items may be calendared for this meeting.


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