The hospital, with its big, open wards, sits on the western slope of Twin Peaks, more toward the ocean than the bay. Some 1,100 elderly people live here, in the biggest municipally run nursing home in the nation. On beds lined up one after another in long, straight rows, men and women lie with feeding tubes down their noses and throats, in that gray space between home and the grave. They are people other hospitals can't care for, or won't, and at any given time, 200 more like them wait on a list for a chance at Laguna Honda's care.
For 125 years, Laguna Honda Hospital has provided the far end of the dust-to-dust benevolence San Francisco prides itself on. But now Laguna Honda is outdated. Its buildings are as old as its residents, three-quarters of a century and counting. Its roofs are dilapidated, its emergency power systems don't meet current design standards, its open rooms -- housing 30 patients at a pop -- require constant waivers from state and federal regulators to stay in operation. And last year alone, Laguna Honda needed some $10 million from the city's General Revenue Fund just to keep its doors open, at a time when private hospitals throughout the city are cresting with vacant beds.
Simply put, it's a problem -- this physical and financial strain that Laguna Honda Hospital poses. But if the predicament is easy to identify, solutions are not. Hospital administrators propose spending $250 million to rebuild Laguna Honda; the San Francisco Health Commission has proposed cutting the hospital's budget to reduce the amount of taxpayer subsidies going to shore up its programs. And it's not just money that's at issue. It's what role, if any, the hospital will continue to play in San Francisco.
"These are long, difficult discussions," says Dr. Sandra Hernandez, director of health for the city of San Francisco. "I think there's a need for us to look at different kinds of long-term care."
"I think we need to look at all ways and not close doors on anything in terms of coming to what we know will be a problem," says Dr. Edward Chow, president of the San Francisco Health Commission. "There are many new ideas."
Since 1866, San Francisco has owned Laguna Honda's 62-acre site. By the 1880s, there were 580 patients on the property; by 1903, nearly 900 people called the place home. The present buildings were constructed beginning in 1926, and in 1928 and 1954 bond issues paid to build and renovate the hospital. These days, there are 1,172 operating beds at Laguna Honda -- mostly for elderly patients who need skilled nursing care. Services available to patients include dentistry, physical therapy, plastic surgery, neurology, radiology, and adult day health care. As of October 1993, the average age of Laguna Honda residents was 77 for women and 67 for men, and the vast majority of the residents are without the resources to pay for their care themselves and are covered by MediCal. In order to be admitted, all patients must be San Franciscans.
The question of what to do about Laguna Honda is not a new one. Chow himself chaired a commission eight years ago that probed the facility's fate. In 1992, city supervisors nearly put a $540 million bond proposal for the hospital on the ballot. And in 1994, Laguna Honda's institutional master plan -- devised with the help of an extensive community advisory group -- proposed a huge new building for the wooded Twin Peaks site.
The master plan envisioned spending some $486.1 million on a new 900,000-square-foot hospital, with just 60 additional patient beds and one new 50-unit residential care facility.
"Approximately three years would be required for planning, design, and mandated agency reviews," the master plan reads. "It is estimated that the construction of the project would then span the next seven years."
It was that dollar amount that "really made people stop and think, 'Is this really what we want to do for the future?' " Hernandez says.
Compounding things is the fact that Laguna Honda has required General Reserve Fund money to keep its doors open. Its annual budget of $120 million -- the figure given by Health Commission President Chow -- comes from MediCal reimbursements, with some money from the taxpayer-supported General Reserve Fund thrown in to make up the difference between costs and reimbursements. The budget works out to some $110,000 per patient per year. Between 1,400 and 1,500 people work at Laguna Honda, Hernandez says, a staff-to-patient ratio that's greater than 1-to-1. At smaller nursing homes with less acute patients, Hernandez says, the staffing ratio isn't as high; "That's what distinguishes us from many other smaller free-standing skilled-nursing facilities."
Now, city officials are re-evaluating staffing at the hospital -- as well as the hospital itself.
Last month, the Health Commission voted to approve a budget that cuts 70 full-time-equivalent positions from Laguna Honda for an annual savings of $5 million.
In addition, the Health Commission's budget report says, there are plans to save another $600,000 by reorganizing and consolidating the hospital's medical and central supply distribution systems, its radiology services, and its clerical functions, and by "adjusting the Hospital's workers compensation account to reflect actual expenditures."
And the hospital has backed away from its original half-billion-dollar bond issue proposal.
