A Geriatric Opinion
By Teresa Palmer, M.D., Family Medicine / Geriatrics
Editor’s Note: Teresa Palmer, M.D., will be joining us for our December meeting. She has invited some Laguna Honda staff to help provide updates and answer questions
On a walk around the Haight Ashbury, the Panhandle, and environs I see a yearly increase in aging people who are, like me, past 70. As a prelude to discussion at the HANC meeting on December 11 2025, I am presenting my subjective version of a glossary for folks who may need long term care someday. About 50% of elders need nursing home care at some point in their lives. Optimal nursing home care occurs in a high-quality facility in San Francisco so family and friends can keep tabs on your care. Knowing the vocabulary is part of getting what you want!
Glossary: In regard to long-term care vocabulary there are very specific financial definitions by insurance companies: if you or your family uses these terms in a medical setting—be sure to understand the implications, given our broken health care system! We can discuss this more at the meeting!
Skilled nursing facility (SNF): A licensed nursing home able to do post-acute (after hospital discharge) rehabilitation. There are different types of “rehab”. Being at an “SNF” specifically for rehab is different from living in one indefinitely. The facility may also be certified to do “Custodial” or long-term care.
Custodial or Long-Term Care (Nursing Home/NH care): The facility is “home” for those who need more nursing and less medical attention without daily “skilled rehab.” While there is periodic attention from a rehab professional, care is overseen by licensed nurses. A doctor or equivalent is required to visit every 30-45 days.
Medical insurance does not pay for “custodial” patients-- except for MediCal or long-term care insurance.
A Skilled Nursing Facility (SNF) is not the same as a custodial or long-term care facility (Nursing Home/NH), though the terms are often used interchangeably. Some facilities (like Laguna Honda or SF Jewish Home) are dual-certified to offer both services. The key difference is the type of care provided: NH/long-term care facilities (unlike SNFs) focus on the ongoing patient need for assistance with “Activities of Daily living.” NH care gets lower reimbursement from Medi-Cal, and is not covered by Medicare—although some bills- doctor and pharmacy- will still be paid by Medicare (part B). Medicare and private insurance does not pay the rent which can be 8-15,000 dollars a month.
“Acute (Hospital) Rehab” is done in an acute hospital, gets paid by insurance (if approved), and requires the patient to be strong enough to need AND tolerate a very intensive, short-term program with at least three hours of therapy per day. Acute hospital rehab provides 24/7 physician oversight.
Acute “SNF” rehab is less intensive, with one to two hours of therapy per day. It occurs in either a freestanding “SNF” or an SNF that is part of a hospital campus. “SNF rehab” is funded by Medicare, MediCal, or private insurance for patients who have been discharged from acute hospital after at least a 3 day stay. Frequent physician visits are not required. A facility that advertises itself as a “skilled nursing facility” or “rehab facility” should have rehabilitation professionals (Occupational, Physical and Speech Therapy) and “rehab gyms” on site. However, some SNFs bring in contract staff who are there only for limited hours and have very limited facilities/equipment such as gym & exercise machines. Best to ask and get someone to inspect the facility.
Licensed Nurses: are Registered Nurse (RN) or Licensed Vocational Nurse (LVN--LPN in other states). Only RNs are trained to do the skilled clinical assessment that a medically fragile patient needs; LVNs are not. LVNs are generally trained to give medications and take vital signs but must report any problems on to an RN. Objective studies show that an adequate quantity of RN staffing and generous “licensed” staffing (RNs and LVNs) lowers the death rate in SNFs or NHs.
Who do you see in the hallways when you visit? Look at their name tags.
Bedside care in SNFs/Nursing Homes: is generally done by unlicensed staff, who must report any “change in condition” to licensed staff, who in turn must report it to the primary care provider (physician or equivalent). Do not rely on overworked unlicensed staff to report a new problem higher up: ask to speak to RN or LVN. If one doesn’t appear, call the nursing supervisor on duty for the facility. Keep at it. You have the right to insist on speaking to a doctor. In understaffed nursing homes, training is poor (because that takes workers away from the bedside), overwork is exhausting, and supervision by licensed staff is poor (too few RNs/LVNs or poorly trained), and the doc is nowhere to be found. This is all going to get worse with exclusion of immigrant workers, who often come from cultures that care about the elderly.
Understaffing and Poor training is the Capitalist way: Payroll is the biggest expense in ALL long-term care. Low quality SNFs/nursing homes are understaffed. They skimp on licensed staff, rely far more on LVNs than RNs to supervise (unlicensed) Certified Nursing Assistants(CNAs) and less skilled assistants. Turnover is high (although fragile patients do best with staff that knows them). When calculating “hours per patient day (HPPD)” for staff, there are “industry guidelines” on how to lie about these ratios. Understaffing and Undertraining, keep the budget trim and the care bad! The saved revenue gets vacuumed elsewhere & disappeared. Of course this is true in hospitals too: Mismanagement, undertraining, poor staffing and overpaid zombie administrators…..
Residents’ Legal Rights in a Nursing Home or SNF: The Omnibus Budget Reconciliation Act of 1987 (OBRA '87) established a foundational principle that residents receive care that allows them to "attain and maintain their highest practicable physical, mental, and psycho-social well-being". This has been translated into regulations. However, in California, the inspectors/regulators are underfunded and overworked-worse than most states except for the deep south. Our governor and state elected reps listen to a lot of “industry” lobbies -profit over people! An assertive significant other visiting you frequently is your best bet for a good experience in a nursing home.
Laguna Honda Hospital and Rehab center (LHH) is a rare public City and County SNF. Has 780 beds; currently 120 of them are closed indefinitely by the feds. LHH is fully up and recertified and admitting new patients. (LHH is defined in the original San Francisco Charter as being an entirely separate public facility from the public county hospital. Per the original City and County charter, it is open to San Francisco residents over 16 who need nursing facility care.) LHH is one of the few “SNF” facilities in San Francisco not on a primary hospital campus that offers both “Acute Hospital” and Acute “SNF” rehab: this is because Laguna Honda has an 11 bed “Acute” hospital. It also has and 769 “SNF” and “custodial(NH)” beds. As of Nov 2025, about 557 of the 649 available SNF/NH beds were filled. So almost 100 empty beds remain to be filled.
San Francisco Health Network (SFHN): Essentially a health maintenance organization for San Franciscans who use public clinics and our county hospital. LHH has been arbitrarily defined as “part of SFHN.” “SFHN” patients have priority for LHH’s beds despite LHH’s separate mission and funding. 80% of LHH’s funding comes, when admissions are normal, from insurance and not from the San Francisco’s general fund. Under “SFHN” management, LHH patients, staffing and management were neglected for years-until LHH was decertified by regulators in 2022, with new admissions stopped until mid 2024. The local excuse was that SFHN managers “did not understand” how to run a nursing home(!) Hopefully this has (at great expense) been fixed, but vigilance is a good idea!
Activities of Daily Living (“ADLs”): Dependence on assistance for at least two of these is required for insurance to pay for a SNF or nursing home (legally defined as “medical” facilities). “ADLS” = bathing and hygiene, dressing, eating, toileting or incontinence care, and mobility (moving around, such as transferring, walking, or using a bed). “Instrumental” ADLs (“IADLS”) are more complex activities BUT assistance with IADLS can occur in a non-medical (residential) facility: using the phone, cooking, shopping or ordering food, paying bills etc. "Wayfinding" (not getting lost) affects functional independence and can be classified as an activity of daily living (ADL) or instrumental activity of daily living (IADL).
Hospice: BEWARE the “H” word-originally defined as a philosophy of appropriate and sensitive care at the end of life, a hospice “contract” has become a way of saving money for insurance companies who pay a flat monthly rate for all “Hospice Team” services. Beware of being asked to sign a “Hospice Contract” (saying you could die in 6 months) just to get nursing services when you are really NOT ready to die/ not “end of life.” A “Hospice Team” can supervise your care at home but also in a SNF, nursing home, or a residential care/assisted living facility. You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
Hospice care is managed by an R.N. who does not visit daily and focusses on “comfort” with narcotics and sedatives. Even when pain is not well controlled, you are discouraged from going to the emergency room. A doctor is usually only peripherally involved, mainly with signing paperwork to get the hospice team paid by insurance. At home, hospice provides a few hours (or less) of daily home care-often by an unlicensed aide. So if you do not have family or paid help at home to care for you 24/7, you must get your hospice team to move you to a facility or just lie there by yourself for many hours a day. You will “break” the hospice contract if you go to the emergency room. Some hospice providers are better than others—close attention to the limits of hospice care is important!
Palliative Care: Insurance definition: Hospice lite. Saves money. Insurance pays for a team to come to your home, or a “palliative care” consultant comes by the bed and advises your facility caregivers. The hope is you will stay out (or get out) of the acute hospital or rehab facility and cost your insurance less. Some palliative care consultants (MDs or Nurse Practitioners) are ethical and conscientious. However, many consultants are dependent financially on the facility and do not listen to the nuanced needs and wishes of the patient and loved ones. This can be due to lack of time. When you are asked to make a decision about any “withholding or withdrawal” of life-prolonging medical care, assertively refuse to budge until you get a consultant or hospitalist who actually TAKES SOME TIME. They should interview and observe the patient and the people that love them. They should be easily available to answer questions. Laguna Honda Hospital has a palliative care ward.
Assisted Living/Residential Care/Memory Care: The décor in the lobby is usually great. These are, by legal definition, non-medical care facilities which may increase their charges to you if more care is needed. Some are covered by government assistance; most are not and are for profit. The facility often does not increase trained or licensed staff even when they charge for “more care”. Commonly, although the facility charges more because the patients’ care needs have increased, there is no increase in poorly trained and poorly supervised staff (no profit in that)! Your doctor will not go there. Some facilities have a “Hospice Waiver” to allow end of life care by a visiting Hospice team. There are some good and adequately staffed “residential” and “memory care” facilities in San Francisco, but beware. Many of these facilities, despite being very expensive, will not say that a patient is too ill for the facility to handle, and it is up to the family to call 911 or arrange for a nursing home transfer.
Comfort Care: Means different things to different professionals and caregivers. Depends on who is at the bedside and who is writing the medical and nursing orders. Often, “comfort care,” in practice, becomes medical abandonment. It may not bring either comfort or better care! Beware of what you ask for-when you use the term “Comfort Care” in our current system. You should agree that, if your oxygen falls off tonight, death is ok. A common problem is that a hospitalist or palliative care consultant comes to the bedside unannounced and takes direction from a patient who lacks situational awareness. Loved ones are not included in the dialogue. Orders are written for “comfort care” or “discharge to hospice care” and loved ones are told by staff that this is a done deal.
Join us on Thursday, December 11, beginning at 7:00 pm, at the Park Branch Library or online for what promises to be an informative meeting. See the accompanying “How to Join” article for details about joining our meeting.