Good afternoon supervisors, with the department of Public Health. As supervisor yee mentioned, ill share this presentation with department of aging and hospital counsel of northern and Southern California. So, Residential Care facilities for the elderly provide an important level of care in between adults who can live safely at home and adults who need 24 7 medical care. We know that the as people age, the majority of people want to remain in homes, in their homes which is referred to as aging in place. As adults age, they may require a range of services and supports called longterm care. So Residential Care facilities provide longterm care for people who can no longer live safely at home and for patients or persons who need 24 7 supervision but dont require 24 7 medical care. I want to take a second to define terms we commonly use when talking about longterm care. So longterm care is defined as a variety of services that help meet medical and non medical needs of people with chronic illness or disability who cant care for themselves. These services can be provided at home or a facility. Post acute care is generally a range of medical services that support recovery from illness, following a hospitalization and can include Skilled Nursing services or rehabilitation services. Residential care facilities for the elderly are licensed by the California Department of social services and known as assisted living, or board and care homes. Typically board and care are smaller facilities with six or fewer beds and often Single Family homes in residential neighborhoods. Assisted living facilities are larger apartment style buildings and these facilities provide a range of services to help individuals support their activities of daily living. Skilled nursing facilities provide rehabilitation and assistance with activities of daily living and to define activities of daily living, these are the tasks we do every day, dressing, bathing, toileting, eating and transferring and grooming. So as i mentioned, longterm care is a provision of both medical and non medical services that can meet an individuals needs, so someone who is turning age 65 today has almost a 70 chance of needing some type of longterm Care Services in the remaining years. Some of the medical services that can be provided are listed here on the left side of the slide, i have already referenced many of them. I wont read through them. Some of the non medical services are on the right side of the slide, activities of daily living, meal delivery, transportation services, home repairs and modifications and financial and legal services. So longterm care can be provided in the home or in a facility, and this slide shows the different types of services by their location. So i wont read through all of this, but i wanted to note that someone can receive both medical and non medical services at home, but in general those are provided on a limited parttime basis. And the second thing to note, when we look at facility based care, Residential Care facilities, is that Residential Care facilities provide non medical care and Skilled Nursing facilities have medical and non medical care. So, also according to national data, about 37 of seniors are expected to receive care in a facility such as a Skilled Nursing facility or assisted living facility at some point in their lives for an average of one year. How is this care paid for . This figure shows the level of care, the duration of care needed and different pair Sources Associated with this. Starting at the top, if someone needs medical care for a short period of time. You can see most insurance plans can cover this. However, if they need longterm care, most people pay out of pocket unless they qualify for medical which is an Insurance Program for low income individuals. If someone is receiving care in a Residential Care facility, most of the residents pay out of pocket. Individuals eligible for Social Security can get a benefit that can be used to stay in a Residential Care facility, however there are very few facilities that will accept that benefit alone. So, we know that most patients who do receive care or who can discharge from a hospital to a sniff might be able to be supported in lower levels of care. So the post acute Care Collaborative conducted a point in time survey earlier this year to understand how many patients are waiting in acute Care Hospitals who needed placement in lower levels of care. What that survey found, about 50 of patients waiting to be placed in Skilled Nursing facilities primarily needed help with assistance of activities of daily living. Additionally about 24 of patients could be supported in lower levels of care. Meaning not a sniff. And so while many patients could be supported in a facility like a Residential Care facility, we know many patients wait for a Skilled Nursing facility because its covered by insurance. If you look at this from a cost perspective, it is significantly more expensive for someone to be in a Skilled Nursing facility than Residential Care facility. So what do we know about Residential Care facilities in San Francisco . So first we know that our senior population is growing. At the same time, this graph on the left indicates we have seen a reduction in Residential Care facilities in the past five years. It looks like the bed supply has remained relatively stable and the smaller and more are not as reliable. The table on the right shows the facilities we have on the bed side. About 60 are smaller facilities with 14 or fewer beds and recently the department of aging conducted a survey of our facilities and found there were about 93 occupied. With that im going to hand it to cindy to talk about some of the challenges. Thank you. Supervisors, the challenges we have seen in the residential facilities are really around accessibility. As pointed out in the previous slide, there are 19 fewer facilities in San Francisco now than in 2012. We work with many rcfes and in the conversations we have had with owners, reasons foreclosures included retirement with no interested Family Members to take over. The high cost of San Francisco and increased regulations making it hard for the smaller to make ends meet. And the smaller homes are closing their doors because financially its not feasible anymore. Some of the owners said their property was worth more than their business so they were opting to sell their home. The affordability of rcfes i think is the biggest barrier to low and middle income residents of San Francisco. 52,000 a year is the average with no type of assistance, making it essentially out of reach for any of the middle or low income families. Some longterm Care Insurance policies will cover a portion of rcfes but it depends on the policies and the number of people who can afford this type of insurance. And finally the limitations associated with facilities who have people with behavior or cognitive challenges, includes affordability and expertise. In order to work with the population, it takes additional staffing to ensure the residents are safe and staff who have been trained to work with this population in an effective way. There are challenges in finding and training the staff that are needed and then paying them a wage that compensates them for the work theyre actually doing. In addition to the high cost of rcfes, most of us want to remain in our homes. For the department of aging and Adult Services, this the services we support are to achieve these goals. Only Community Based care and Wraparound Services are essential to help adults maintain independence, prevent institutional care and support aging in place. The department of aging and Adult Services supports programs that bridge the gap between acute care pointed out in some of the slides and Community Based care settings through programs that include home Care Services, in our department includes in home supported services, a medical benefit offering personal care for people with functional impairments, meet criteria and can live in their own homes. Another program is supportive home, targeting middle income populations with financial and functional needs ineligible for iihs, Community Living fund or other wavered programs. Parameters include a sliding scale, an ability to pay as well as a cap of 15 hours per week. Funding for this pilot has been made possible by an add back from the board of supervisors. Case management which assists people in accessing coordinating needed services, home delivered meals, home delivered groceries, transportation and caregiver support are key items in helping people stay in their homes. The Community Living fund, the last item on the slide is slightly different. I would like to talk more about that program. This focuses on people with the next level of need, who want to live in the community and are able to do so, the supports are intensive Case Management and Purchase Services or items to help them remain in the community. The Community Living fund is considered the payer of last resort in the purchase of these goods. Just to give you an idea of the Community Living fund, it has a three pronged approach, one is transferring people from sniff back into the community and diverting people in hospitals or short term rehab stays to prevent them from longterm stays. As well as the community from going into longterm sniffs as well, an example of the community diverting someone in the community would be someone with dementia that needs 24hour care, they cant afford an rcfe and have to go into a sniff. Those are the populations that cls is trying to serve. This has been a very successful model in San Francisco, over 80 of the clients were stabilized in the community, which means they did not end up in laguna honda. They have purchased rcfe slots since 2007. During that time, the program has spent over 4 million on board and care patches on behalf of 67 clients. The Program Supports about 30 clients a year with an average subsidy of 2,400 a month. We have seen that patch grow rapidly in recent years. In 2014 it was closer to 2,000 a month. So i bring this up, and we have always thought there was a cost savings, it was better for the participants who were participating in cls but we couldnt show the cost savings because we didnt have all the data points. We contract out with the institute on aging, they took the program and replicated it by working with a county health plan. It is in essence the same program. The county organized Health System and so they were able to gather all the data points that includes hospitalizations, sniff utilization, Durable Medical Equipment and alike. They have shown in the tracking for the past three years, the drum roll please, a 50 per member per month cost savings and 40 reduction in total longterm care spends over the past three years. What theyre comparing to is preenrollment cost and utilization to the post enrollment cost and utilization. Which has shown improvement for the care to the clients as well as savings to the health plan. In addition to that, they have shown a 33 reduction in overall healthcare costs. Currently they plan to replicate this program in santa clara starting in 2018. All of these services allow people to remain living in the community for as long as possible while maintaining their cal quality of life. We recognize some people need a higher level of care. We believe it should be delivered in the least restrictive environment. There are many longterm care needs for the individuals, to speak of the post collaborative, i want to introduce the regional Vice President of the counsel of northern and Southern California hospitals. Supervisor yee, thank you for calling the hearing. And it was an honor to work for the city for 14 years and work with great Public Servants like the ones behind me. As was mentioned and i want to give a bit of background before getting to the recommendations that the post acute Care Collaborative put together. In february 2016, the department of Public Health engaged in a post acute care project report. And that was to provide an assessment of the post acute care landscape in the city and county of San Francisco. Identifying the high demand and supply tension, that report is robust, a lot of data and a lot of experts were on it and it made a few recommendations to the commission they adopted, one, ensure were meeting the high demand for the sniff bed situation in San Francisco and increase home and Community Based options and really something this committee is interested in right now, important aging in place options. So we engaged in that endeavor earlier this year, the post acute Care Collaborative. We were pleased that the countys department of transition, the cochair, it was a collection of Public People and private Hospital Leaders and healthcare leaders rolling up their sleeves, this is an Incredible Group of people, trying to zero in on its mission, which was to identify implementble, financially Sustainable Solutions to the post acute Care Challenge for high risk individuals in the city and county of San Francisco. Can you see this slide . Is it up or thank you. Referenced the collaborative did a lot of in time surveys, looking at the data, did a great survey, a deliberative data driven effort and we identified two population groups we thought we should focus on, one cognitively impaired and two behaviorally challenged. We thought we should come up with solutions applicable to each of those subpopulations is and thats what we did. You see that before you in its draft form. A standardize post acute care assessment tool, so all the hospitals can speak the same language and have the same assessment terminology. A great recommendation. A roving team to place patients in the right kind of care and access to the Residential Care facilities for elderly and independent housing with Wraparound Services. That has two elements, one, ensuring the partnership to increase these kinds of fundings and then secondly, advocate with the Mayors Office that his Housing Initiative include this element. Thank you. Thank you for your presentations. Any questions. I would like to maybe have Public Comment at this time. So im going to call up some names who have signed up for Public Comments. You have two minutes to speak, state your name and so forth, that would be great. Ken barns, i think. Benson nadel, anne lugwig. Go ahead and line up to that side. To my left or your right. My name is ken barns. Im a physician who worked at saint lukes for over 30 years, a hospice physician for eight years. I worked in rcfes, Skilled Nursing facilities, including saint lukes, visited patients in socalled memory units and for the past several years working for healthcare housing and jobs for justice as we fight for the right for good healthcare for all of San Francisco. As has been made abundantly claire, San Francisco is in the midst of a post acute care crisis, actually an emergency, in the aging community and those particularly who are most frail and vulnerable. This is about Human Dignity and caring for our elderly in a compassionate and respectful manner. Were at a point that cries out for action, not more study. There needs to be a plan to rapidly identify sniff and rcfe faults. We urge you to regulate solutions to give incentives of Residential Care to open new facilities and maintain a High Standard of training. Begin looking for land where they can be built, already existing buildingss to house new beds. And Dementia Care has to be a high priority. The program must remain open and not closed. Please dont lose sight of what we need to do on a deeper level. Unconditional love and compassion in our dangerously violent world. Our task is to genuinely care for others wellbeing and demonstrate the essential will for good. I have two documents here that represent thinking of San Francisco for healthcare housing jobs and justice and we wanted to share it with you. Thank you. Thank you very much. Supervisors yee and everyone, thank you for listening to this very important program. I have left copies of the list of rcfes, the Demographic Data for each district and Additional Information if you wish to see it. I have also filed my testimony online. I run the unbutton program in San Francisco, i have been doing the program for like 30 years. I have a look back and a look forward in terms of forecasting a bleak picture for those individuals who might need around the clock care and supervision. I was on the discharging Planning Task force, dementia expert panel and longterm care coordinating counsel and this m Ombudsman Program is mentioned in the local ordinance. We get grievances and abuse reports on behalf of everyone in longterm care facilities from mandated reporters. We have been going into small board and care homes and large assisted living facilities and Skilled Nursing facilities. I cant possibly cover everything in a minute and a half. Was is happening in the system, the hospitals are now using Community BasedSkilled Nursing for medicare utilization and the Skilled Nursing facilities are pushing out those individuals eligible for medical into unknown destinations. The hospital is determining the policy for every constituent in San Francisco by being pushed out because the need to keep the medicare beds open. The destination would be naturally you step down unit for Residential Care but there are not any in the market place. Consequently, i want to ask the supervisors if the hospital needs are the driving force for creating longterm care policy based on forecasting and not reaction. Thank you. Mr. Benson, you dropped something. Next speaker. Good afternoon, im anne ludwig. My husband, a 79yearold advanced runner is now a victim of advanced alzheimers. What can Family Members do when this kind of disaster occurs. Three years ago it was impossible for carl to live and be cared for at home, we were so fortunate to move him to swindeles. They have extraordinary loving and expert caregivers, many of whom have worked there most of the 20 years of existence. They are our family now. The hospital counsel report recommends this type of care but the largest member is shutting down the facility, that should be expanded to meet a growing need. Some of us were told it would be moved to another campus when the current building is sold and demolished, but medicare and medical dont pay for this kind of care and suter decided were not profitable enough. Theyre letting it widther by atrition, shutting us down next year. We protest this decision that is wrong for our loved ones and our city. We have decided as a group, were not moving and you will hear from other members of our council. Thank you. Thank you. While the next speaker comes up, ill call a few more names. Come on up. Victoria claymen, dr. Teresa palmer. Im linda, the daughter of penny who is 103 yearsold. She has adjusted and being well cared for at the center. She sometimes sings, laughs with the staff. She has sun downers syndrome. Her nights and days are mixed up. Staff share meals with her so shes not alone at night. I am here to plea with you to not close the facility. I look at other facilities i cannot afford. At this time, my mother spent down her investment, granted a subsidy grant for 50 a year and a half ago. I am paying less than 3,000 a month, i am paying my moms care with her Social Security check and my pension now. I applied for medical, veterans, ssi, i have been approved for medical but it doesnt pay for assisted living. Im here for your help to find solutions to solve the situation and future problems with memory care, alzheimers care for assistance where its privately owned. Where will we go when we are in the situation . Will we be tossed in the street like homeless to care for ourselves since there will be no place to care for us. And become a problem for our family. Thank you. Thank you. I would like to thank you all for being here and especially thank norman yee, my supervisor. My mother was very angry, she didnt know she was losing her mind. Im a flight attendant. I cant take care of her. She needs 24hour supervision. I called around to many of the small homes, i called one and they said oh, will your mother watch tv . No, my mother wanders around. They said were a small facility and we need to keep her in her room to watch tv. At swindels, they have people who love the patient and families. We have at least six neuro science schools in San Francisco. They should be studying these models, they should be a part we get two interns each time and they are excited because there is trauma therapy, they sing together, i saw one uncommunicative person help my mother when she was trying to get up. These people are a family, they need to stop getting ready to close down the units, they dont paint the walls, the staff is worried because they love their patients and we love them. Please stop this unit from closing. Help cpmc, expand it for the city of San Francisco. Thank you so much. Thank you. Thank you all for the opportunity to speak. My name is victoria cleamen, my mother has been a resident at the residential memory care for nearly two years. I wish you could have known my mom, three and a half years ago before she had a massive stroke in the right frontal lobe of her brain. She was brilliant, adventurous, vital and engaged. Before coming to the facility she had many cognitive traumas at other facilities. I want to ask you to hold the person you love most in the world in your minds eye. Imagine they cant speak, walk, give you a kiss or share a hug. Imagine you are no longer able to care for them at home and your finances are rapidly being devastated. Then all of a sudden, theres an answer to a prayer and called swindels residential. It has given my mom unparallel love and care by the staff who are angels. Lets realize how important it is to do the right thing. The inequality of races in our past and present is horrible. The treatment of our elderly currently is. Do the right thing. Do not allowed loved ones and future elderly citizens of San Francisco to be pushed aside, the ability to maintain dignity and their lives is in your hands. Thank you for your time, attention and compassion. Were all depending on you to do the right thing. Thank you so much. Thank you. Excuse me for a second before you come up. Is it okay to allow her to come first . Yeah. I am if its allowable, i intend to speak about the people who would otherwise be eligible for admission to shelters in the city of San Francisco. Something that would have to be built. They suggested that im raising is that they one of the city shelters, not the largest one, be a senior shelter, especially Senior Center. I have raised the idea with supervisor of district six and he was very enthusiastic about it. When i raised it about maybe two years ago. I didnt have to argue or across the street about half a block away on the other side is a Senior Center for activities and lunches, and its all flat area, so people dont have to hike up a hill or cross at a guarded street. Theres actually a crossing there on the street. And thats eight street, 201 sanctuary shelter. And it does need some renovations, like the people who are residents there need an elevator to the second floor to use the laundry room, it has been used for people to go up there from the first floor, which is the womens floor. Theres a second floor for mens floor. It might be a one gender shelter, but it operates as a two gender one right now. And my name is nancy cross, and lets see, what else did i want to say. I have been working on San Francisco for about three or four years, but not publicly. I mean thank you. Thank you. Can somebody help bring her walker closer. Hi everyone on the board. Im one of the caregivers that has been at the irene swindel alzheimers unit since it opened and we have several coworkers here. We wanted to express to the board that the whole department right now is like in a mourning state because of the fact of the closure and our patients is our pride and our joy. Its not just a job. And what our concern is is that say like for you and i, its easy for us to get up and relocate and deal with new faces. With our clients its not like that. It can be devastating and can even lead into death possibility, which we pray not, but this is our concern. Our clients have very challenging behaviors that we understand and our first step or recourse is not to medicate. We know how to interact or defuse their behavior and not allow them to get hurt and protect them. Everything that is very, very difficult for a Family Member to do, you need a team like the irene swindel center. We hope the board can review the track record of the center, which we were one of the leading models of the residential facility in the northern california. We had other facilities sending their clients to us. When they came to us, there was a drastic improvement in ways there wasnt at the other facility. I feel this is a facility that really, really needs to stay here in the city and the clients we had had are the state of the art people who build highrise buildings and other things here in the city. Thank you. Im going to call other names while the next speaker comes up. Hi, im teresa palmer, i work with San Francisco for healthcare jobs and justice. One of the things i wanted to point out, its on the c m. P. C california campus, it costs 6500 a month minimum to be there. It is a model facility and under the model of memory care, which is an enhanced form of Residential Care that is expensive to provide. It has increased nursing and staff training than most Residential Care facilities. Most facilities are decidedly non medical and do not do well when seriously ill patients are sent to them. The ombudsman has provided you with a list of Horror Stories that can happen when sick people are discharged to the hospital from an rcfe. And the Hospital Council is basically supporting a narrow focus on short stay acute care because that brings the most revenue. They want to discharge their problem patients to Residential Care because thats the cheapest thing for them to do. Low to moderate income cant find regular longterm care in San Francisco and community sniffs are using beds to provide post hospital rehab, that the hospital used to provide because it is funded by medicare and pays more than medical. Because the hospital industry will no longer provide post hospital sniff, sniff subacute and acute psychiatric care, they dont make enough of a profit on it, even though they dont pay taxes. This is pushing sicker and sicker people to Residential Care. Residential care should only be used for frail and ill people if it truly meets their needs. To meet the needs of a Residential Care patient, you have to have wraparound thank you. Whats your name again . Teresa palmer. Thank you. Im michael lion, also with San Francisco for healthcare housing jobs and justice. Im on the board of the California Alliance for retired americans. Were working very hard to incorporate universal longterm care into the california Single Payer Health bill thats going on right now. As part of that, were working to remove the strong institutional bias and longterm care. But you have to consider whats going to be happening in 2013. Its only 13 years from now. In 2030. Its only 13 years from now this is when the baby boom wave is going to approach 85. So this is the elephant inside the snake is going to move to the point where the beginning of it is 85. Nationally in 2010, there was 11 Million People who were 85 and older. In 2030 it will be 18 million. In 2050, 35 million. In San Francisco 25,000 people in 2030. 50 of the 85 plus are expected to get dementia. The future 85 year olds are going to have much more chronic disease than the past 85 year olds. The future 85 year olds are going to have a lot less money than past 85 year olds. Something must be done to care for them and it cannot be simply Residential Care. There must be a continuum of all levels of care. We must remember that hurting any level of care is going to hurt other care. Thank you. Hello everyone. Im so happy to come here to talk about our residents, which means not like i mean, theyre like our family. Its not im talking about myself, im going to lose my job, its not that. Its our small community, we have high experience and i know how were going to deal with them, its good for our residents to stay the same place and then the same staff its a better place for them. Thank you. Thank you. A few more cards. Annie chung and katie owens. Im kim from the National Union of healthcare workers and i have a privilege of representing the workers at the facility. We have a real problem here. The people at the top of the food chain, the hospitals who are making millions and millions of dollars of profits pay no taxes and are shoving people out the doors. And are not doing their fair share at the other end of the spectrum. They apparently dont like seniors, primarily cpmc, theyre trying to throw out the swindel patients out. What we have here is pure profit and greed going on and we need to do something to change the dynamic. Its time, the hospitals that dont pay taxes, maybe we do some sort of surtax on every hospital bed, that money goes to a pool to try to create more beds. They need to do their fair share. Basically the post acute care, what is it, collaborative or whatever, collaborative was only amongst hospitals primarily. There was no like the people making the most money are not doing their fair share of the healthcare in San Francisco for the Residential Care, for the subacute care and Skilled Nursing beds. Theyre not doing their fair share. We need to come together and perhaps its time to create another dynamic where the Community Members come together and we sit dine and try to hash out a real solution and make them accountable. Make them accountable to the patients, make them accountable to the families, make them accountable to all of San Francisco. This is not fair. Good afternoon. Thank you for calling the hearing. Im katie owens from advanced approach to senior care. Essentially what we do is try to find housing, board and care, assisted living for all counties in northern california. The best way to describe it like a realtor but helping to find assisting care homes. On a daytoday basis i cant explain the stories that i hear, its overwhelming. Theres sadness underneath it. Right now i feel activism, a call to something more and im inspired by everyone here and im very sad to hear that the facility is closing. Even if you can imagine at 6,500, thats not inexpensive and people are paying 50 of that, thats amazing. Above and beyond that, its a specialized facility, so its not like you can say youre closing down, call katie owens and have you 3,000 and what can i find for you. What i can find for you may not be safe and i dont have the list of everything that the ombudsman gave you but if you have a moment ill take you on a tour and you can go into some of those, i guarantee you wouldnt want your Family Members to be living in a lot of those. Nothing about the business owners, thank you, theyre serving a population that needs to be served but not necessarily with frail and vulnerable. I wish i had a solution, i dont. A little bit comes down to money obviously. Were giving a lot of money to research, thats beautiful, but what can we do to solve this problem. Ill leave a thought, i got a call from a gentleman paying 10,000. He has a day in the city named after him that governor ed lee gave him and he cant afford to live where he lives anymore at the age of 99. Im kathy davis, we have no board and cares in our district in 94124 or 94107, the closest is age long and no one can afford to go to it. My concern and i want to thank you for just bringing up the topic supervisor yee. No one has thought about the idea that maybe every senior cant be in independent housing. Maybe we need other solutions and places for people to live. I appreciate the conversation but i think we need to go a step further. Having the discussions about Affordable Housing, we have to think of people aging in place in the Affordable Housing and divert dollars for people to live in and work with nonprofits to provide the services. Im concerned about the population now. We have 120 unit Senior Housing and 3,000 people on the waiting list and as our seniors age in place in independent housing we place them in, where do they go . If you dont have a Family Member in San Francisco or person to advocate, youre not going to be in San Francisco. And its unfair to people who have lived here all their lives not to be able to figure out a solution for them. I feel theres a way to work with the Health Department and department of aging and homelessness and housing to address this issue together. Thanks. Thank you. Good afternoon. Im the president and ceo for the elderly. This is our 51st anniversary being a Community Based organization, mostly for low income and immigrant seniors, particularly asian seniors. We started to operate a small six bed in the Richmond District back in 1990. We accepted only ssi seniors in those days and when they get the ssi check, they take out 100 and the rest comes to operating. When the landlord raised the rent to double, we couldnt do it anymore. We bought a small row and run an 11 i think 12 bed rcfe, accepting half private pay and half ssi. But with all with the healthcare costs and increase of you know like the requirement by the rcfe operators, weve always for 30 years advocated for department of health to provide rcfe with facilities for the elderly, the same patch to Mental Health operators. Ev im here urging the supervisors and thank you for raising the issue and bringing the issue to rcfe. A lot of the seniors have run down their savings. I urge you to find solutions for the residents in the rcfe. Thank you. Any other Public Comments . I didnt hear my name called. I probably wasnt loud enough. Are you phil . Yeah. My wife and i moved here in 1971 and bought our house, really a flat, and decided thats where were going to live and well stay there until were carried out in fine boxes. Unfortunately marian developed alzheimers, i had day services for a while. And then it worked until marian developed a fear of going down stairs and our flat was two flights up. I would have had to have somebody there 24 7 to carry her up and down the stairs in an emergency and that was not practical. I looked around for a suitable place for her to go. I came across swindels for alzheimers patients. We were accepted and its been one of the greatest things thats happened for marian. Shes now totally wheelchair bound, doesnt speak, needs help with feeding her, dressing her, all of this. The wonderful staff, which several are here have taken great care of her. Im concerned if they close the facilities shes been there three years and if they she has become adjusted to the routine. It could be catastrophic if they close that facility. The staff knows her and how to work with her. And anticipate her needs. Thank you. Any other Public Comments . Seeing none, closing Public Comments. Public comments are closed. I guess i have a few questions. I want to thank the public for coming out and you see that the needs are varied and a variety of things we need to find solutions to. A few questions for clarification of staff that came up. How have the rising costs factored into basically the rcfe closures. Whats causing it to close . The rising cost factors . I shouldnt assume that. What are some of the factors causing the the closures . Yes. So part of in all honesty, this is antidotal, from conversations weve had with the various rcfes. In many instances, it is the cost of living in San Francisco is raised and i think annie spoke to it, a lot of these places have mortgages but its the other cost associated. I faux theres been labor costs that go up but also regulations around labor laws. With rcfes when you pray 24 7 care to make sure people have breaks and stuff like that, its been additional staff you have to add. Its those types of things. Theres regulatory requirements within the rcfes as well. They look at the business and its not sustainable anymore. These are things we have heard. Thank you. In the care report of this year, it mentioned the idea of equity and post acute care. It mentions how women and people of color are affected by lower quality of care of unlicensed facilities. How will data be addressed moving forward . Just to clarify, how will disparities be addressed Going Forward in the report or it talks about inequities but not having enough data. Maybe im making an assumption of inequity. Is there discussion of how its going to be addressed . In terms of disparities, the biggest is around affordability and income and being able to afford this level of care, when it comes to racial and ethnic disparities, this is something not looked at closely, especially for Residential Care facilities for the elderly. In general we dont have good data of who is being served in the facilities. Its hard to assess. It also suggested reaching out to the mayor to include rcfes as part of their initiative. Could someone talk about hospital post acute Care Collaborative have engaged with the Mayors Office of housing in this particular discussion so far. Thank you supervisor and thank you for taking the first question. Miss patel served as part of the team. To the advocacy question, that is something the Hospital Council and members are