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