Assembly Standing Committee on Health

These programs have been piloted throughout the United States since the 1990s and over the last few years in California. There's a growing interest in the hospital industry to expand these programs. This hearing will provide the Committee with an overview and background information on current programs and plans moving forward. I look forward to an interesting discussion. As other Members arrive, we'll try to squeeze in their opening comments in between. Want to thank you.

We'll have questions at the end of each panel, and then there will be an opportunity for public comment at the end of the hearing. So with that, we'll ask our first, as Dr. Weber is coming in, I will let her speak, but I'll ask our first panel to come up and be ready to go here.

So that's Dr. Bruce Leff, a Director of the Center for Transformative Geriatric Research from Johns Hopkins University School of Medicine Susanna Rustad, the Chief Procurement Office and Executive Director from Virtual Care at UC Irvine Health Chelsea Driscoll, the Public Policy and Prevention Division Chief, the Center for Healthcare Quality. So, please, everybody, very good. We're all there. So, Dr. Weber, would you like to make any opening comments?

Well, good afternoon, everyone. Thank you so much, Chair Wood and the Health Committee staff, for putting this very important session together today. I think hopefully all of us have one goal in mind, which is to create something that will have the best outcome for our patients as possible. And so I'm very much looking forward to all of the discussions from all of the different panels to see how we can work together to create something that is really transformative here in California. Thank you.

Thank you very much. And Dr. Rustad, Dr. Leff, excuse me. I'm going to blend everybody's name here. So, Dr. Leff, please, my apologies.

And the slides, please.

Got them there.

Okay. There we go. Well, thank you for the honor and privilege of having me here to participate in the hearing. Just a little bit about me. I'm a geriatrician and a health services researcher. I've been on the faculty of Johns Hopkins University School of Medicine since 1994, when I joined just after getting out of the Army. I see patients. I teach, and I conduct research mostly on home and community-based models of care for older adults.

You may ask why I got interested in hospital at home. When I was a resident, I started getting experience in doing home-based primary care, that is, for older adults who are too frail to come to our clinic. Our division would send out people to see them in the home and provide longitudinal care.

And it's in that experience that I really felt that I became a doctor, really learned how to talk to patients, collaborate with them, understand what mattered most to them, and really see them in their true living conditions. And you may ask, why. Hospital at home. So, hospital at home, which provides acute hospital-level care in the home as a substitute for what happens in the hospital, was really driven by our concerns as Geriatricians for the safety of our patients.

So in the mid 90s, there were a series of studies that documented adverse events in hospital care, high rates that launched the hospital safety movement. In a recent study on the slide here from this past January, those data were completely replicated, and we found that in about one of four admissions to hospital, there were adverse events. Nearly a quarter are reversible, are preventable, about a third result in serious harm, and 15% of those were associated with nursing care.

As a geriatrician, I'm particularly interested in older adults in the hospital. They are prone to additional complications, including delirium, acute confusional states, falls, immobility, disability, incontinence, adverse drug reactions, nosocomial infections, that is, infections that occur only in the hospital because you're exposed to the hospital and pressure sores, and this has somehow become normalized. We have renamed this as the hospital Associated Disability Syndrome. The gentleman on the right is an older patient of mine from years back. We were out making a house call one day.

He clearly had a pneumonia. We said, Walter, you need to go to the hospital. You're breathing rapidly, your oxygen levels are Low. And he looked at us and he know, I am so sick and tired of you geniuses from Hopkins. You're great doctors. You run a crappy hotel. I'm not going to the hospital. This is your problem. Do something about it. So we started to think about alternatives to care in the hospital.

So this is the overview of the basic model a patient comes to, usually the emergency room. That's where many hospital admissions come from. They're assessed. They absolutely must meet criteria for hospital admission. They can't be so sick that they need an ICU or cannot be cared for in the home with services provided in hospital. At home, they consent to treatment. They are taken home, usually in a medical transport, and then they get the care they would have gotten in the hospital.

Doctor visits, nurse visits, IV fluids, intravenous medicines, ultrasounds, X rays, blood tests, all of that they get at home, 24/7 coverage, and then they are discharged. Just to be clear of what we're talking about, hospital level care in the home. So it's an episode. Clear start and end date, provides everything folks need at home, 24/7 coverage. It's directed by hospital level staff and physicians. It meets regulatory and governance obligations of the hospital. It's consented to by patients.

And if someone's in hospital at home and they want to go back to the hospital, they whisper the words, I want to go to the hospital now, and they're back in the hospital. It's not outpatient antibiotic therapy or self directed IV therapy. It's not a chronic disease management program. It's not solely remote patient monitoring. It's not home based primary care, and it's not typical skilled home health care. Hospital at home has been around and studied for decades, since the 1970s.

Early studies done in the UK, Australia, New Zealand, France, Italy, starting in the 70s. We started working on this in the mid 1990s, developed the early theory of the model, how to choose the right patients, did studies on whether patients would want this kind of care, and did the first clinical pilots at Hopkins in the mid 1990s.

This was followed by a larger national demonstration study in several Medicare Advantage plans in a VA medical center in Oregon, and again proved out all the theory of the model, and I'll talk about those results in a moment. We did some early implementation of the model and several Medicare Advantage plans around the country in the VA, followed by a Center for Medicare and Medicaid Innovation study of the model at Mount Sinai in New York in the mid-2010s. Additional studies between 2018 and 2020.

In 2019, colleagues of mine and I established the Hospital at Home Users Group, which provides free technical assistance to help health systems get their programs up and going. In 2020, we had the federal waiver, and most recently that waiver was extended. So here's a summary of nearly 50 years of data on hospital at home, over 70 or 80 randomized controlled studies on the model. Care is super safe and high quality.

Fewer complications than what you see in the traditional hospital, lower rates of delirium and sedative use, and urinary catheters and nosocomial infections. Also mortality advantages. So in a meta-analysis, number needed to treat if you treat 50 people in hospital at home compared to the hospital, one more will be alive at six months alive. Better patient and caregiver experience, less caregiver stress. Providers like the model. Lower rates usually cut in half 30-day emergency department and hospital readmissions.

Low rates of skilled nursing facility admissions usually cut at least by 50%. Equitable care and this is stuff you can do in the rural settings. There was strong uptake with the federal waiver that occurred in the context of COVID You see a map here of the US and states that have the waiver. California was number three on the list at 20 hospitals that got the waiver. The waiver waiver waives only the requirement for 24/7 onsite nursing. All other hospital conditions of participation apply to these models.

So far, probably about 10,000 people have been cared for under the federal waiver. CMS published data on the first nearly 2000 patients and had very positive results. But as you know that the waiver must operate under state requirements as well. Interestingly, ironically, the waiver would not have happened, my sources at CMS tell me, had it not been for the input of the California Medicaid program. The waiver has been extended through September of 2024.

CMS has to submit a report to Congress in September of 24 and I'll just end with this. I honestly believe that California is in danger of becoming a laggard as opposed to a bellwether in the context of healthcare delivery. Hospital at home has been embraced around the US, around the world, and I don't think you can build yourself out of this situation. Real estate is too expensive, complicated approval processes to get hospitals built. You are probably among the most expensive states to capitalize a hospital bed.

Probably $4 million or so per bed. EMS in California is under major stress. Ambulance delays In Australia, they started paying for hospital at home in the mid 90 s at a rate similar to hospital. Their own health authority said that had they not done that, they would have had to have built a 500 bed hospital. So 500-500 times 4 million $2 billion.

I honestly believe that hospital home is a workforce retention strategy, especially for nursing, and I believe it aligns with the aims of medical and calam and the California Master Plan on Aging. And I would suggest that California citizens deserve equal access and opportunity to shape the model. The next 20 slides in the presentation just are references, very robust set of references and evidence on hospital at home. Thank you very much for this opportunity.

Thank you very much.

Good afternoon Honorable Assembly Members. My name is Susanna Rustad from the University of California Irvine Medical Center, here to provide a hospital health system perspective.

Could you pull that microphone closer to you?

Hopefully this is better. I am here before you today to urge you to consider the critical need for advanced hospital care at home for California's, which currently has no clear path forward. Despite the extensions provisions provided passed into federal law with the Consolidated Appropriations act and active programs in the majority of other US states as well as other countries, the pandemic has left lasting impacts to the health and well being of Californians. Hospitals are overcrowded.

Ours is patients are struggling to receive the access to the care that they need. We witness these conditions and constraints within our hospital's four walls. Our emergency Department and inpatients beds. They're packed to the brim. At our worst, we're resorting to hospital in the hallways where we're conducting hospital in the waiting room. In these instances, patients with limited mobility have had to use commode in the hallways. Can you imagine?

Frequently, we turn to diversion status, which means our no vacancy sign is switched on and we cannot accept ambulances or emergency patients due to capacity ceiling. And as the only tertiary, quaternary care level one trauma center in Orange County, we have over 300 patient transfer requests every month that we have to turn away in the patient's greatest time of need for the level of care that only we can provide. The picture I'm painting for you is stark and it's real.

Our hospital over 100% capacity at all times. And we have an incredible opportunity here before us with hospital at home, with a careful selection process that opens up a relief valve for the right patients to get the right care in the right setting with the right care team. I do believe there's some slides. Thank you. Thank you.

So we've spent thousands of hours collectively to work through the details of hospital at home with our multidisciplinary care team, with the patient in the center at the heart, surrounded by well orchestrated workflows, wraparound services, coordination of care, clear communications and handoffs. There is monitoring, and there's medical device technology that improves the patient oversight and enables our hospital staff to provide custom care and faster interventions. The care providers can assess in real time the patient status as well as the review of the vital sign trends.

And there's this actionable data stream that feeds into our mission control. We met CMS hospital conditions to participate, and we partnered with the California Department of Public Health for over one year to garner their confidence. And we really appreciated working with them to meet their conditions in adapting hospital Title 22 Regulations to the home setting. This is our comprehensive program and the team members that are out in the field in the home.

So our comprehensive program is focused on meeting and exceeding all aspects of hospital level care. There's rapid response nursing, pharmacy, phlebotomy, diagnostics. We have partners for medically tailored meals with patient selection choices, courier services, medical transport, durable medical equipment, and more. There are some fears that exist that hospital home sends patients home to be all alone with a reduction in services. We maintain all the resources here that you see are replicated in the home, and I assure you patients are safe at home.

We maintain these requirements of the hospital-level care you would expect. There's physician services, nursing, occupational, physical, speech therapies, registered dietitians. There's advanced wound care, nurses labs, imaging. And we layer in additional resources such as nurse practitioners and caregivers. In the home. There's no shortcuts. There is more FaceTime for the patients, and these are for patients that qualify and choose to enroll. So it's by patient choice. zero, shoot.

I'm sorry, this is the wrong deck or the updated version isn't here, but I guess I can just adlib this. So there's a slide that shows how we determine eligibility and it's on clear clinical criteria. So there's also a comprehensive home environment and social screening that happens and completed. And once that's conducted and it passes, then based on patient choice and if consented, our resource nurse readies the home and deploys the resources to the field.

The patient is provided with biometric devices and sensors that are enabled with Bluetooth technologies. They're trained on the very user-friendly monitoring and communications app. They're instructed what to expect with their daily check-ins, their symptom questionnaires, and prompts that are built into their care pathway. And this is med surge level of care. It's maintained with vitals monitoring, and the in-home nurse ratio remains equivalent to the hospital required ratios of one to five.

We see nurses as central and vital to optimal patient and program measures. We are committed to the nursing ratios. We are also powered by the University of California, our innovation institutes, our School of Medicine, our School of Nursing, and at the Medical center. We take great pride in our quality and safety ratings recognized by us News and World Report Leapfrog Magnet accreditation.

With our Vizient ratings, we have one of the lowest mortality percentages in the nation, and we only embark on programs that truly serve patients and our community. We would not pursue things that would put patients or a reputation in harm's way. I would also like to share with you my own experience with Healthcare, which has made me a strong advocate for hospital at home. Growing up, my family struggled to access adequate health care.

My parents, who immigrated to America in the 1970s, worked long hours to make ends meet, and as a result, we would put off seeking medical care until it was absolutely necessary. And for over a decade, I witnessed my grandparents age and their health care journeys were difficult, stressful, riddled with errors and mistakes. This experience has made lasting impression on me, and I realize that our health care system is fragile and it's failing us, especially those who are most vulnerable.

I have dedicated my career to healthcare and find great purpose in advocating for improved healthcare access and quality, particularly for those who are marginalized and underserved. In conclusion, I would urge you to consider the crucial need for hospital at home. For Californians and for our rapidly aging population. We have a duty to provide access to healthcare, and hospital at home is a critical step in that direction. Can we find a path to begin that important work in California?

There are many health systems in California that are willing to make the commitment and willing to make the investment. We need legislators and elected officials like yourself to be open to responsibly forging a path forward with innovative care models. Thank you for your time and consideration.

Thank you, Ms. Driscoll.

Good afternoon, Mr. Chair and Members. My name is Chelsea Driscoll, and I'm the Chief over the Public Policy and Prevention Division within the Center for Healthcare Quality at the Department of Public Health. I oversee the centralized program Flex Unit, and part of our responsibilities was to review and approve hospitals so that they could provide acute care at home to hospitals here in California during the public health emergency.

The reason that we were able to do this is because of expanded waiver authority that was provided to CDPH through the governor's executive orders, and then we were also able to have the flexibility from the CMS Waiver program which authorized this type of care. CDPH approved hospital-at-home concepts through the program flexibility process and worked with hospitals to find alternatives to meeting ways to meet the intent of the regulations.

For existing hospital regulations, each of the hospital concepts had to be reviewed on a case-by-case basis because each of the concepts were different, and they proposed different alternatives in order to meet those intended regulations. While CMS approved a larger number of hospitals in California to operate these programs, only 12 of them applied and were ultimately approved by CDPH to offer hospital-at-home programs, and seven of those actually provided care to patients in the home.

All of the hospital at home programs that had been operating in California, their program flexes expired February 20 eigth 2023 or earlier, and at this time, CDPH is not permitting any hospitals to provide hospital care at home. The seven hospitals that did participate were required to meet high quality standards and to prioritize and protect patient care.

Because of the variables of providing care to acute care patients outside of the hospital environment, we really think that separate regulations would be required in order to have some program going forward. Some of the regulatory challenges that we faced ranged in areas of pharmacy, dietary medical records, and monitoring staffing. When we're looking at the pharmacy service, some of the unique challenges were ensuring safe and accurate medication administration and maintaining drug integrity.

So moving forward, hospitals would need to have policies and procedures in place for safe drug Administration, and they would need the capacity for remote monitoring of viewing patients, taking medications, and protocols for only allowing licensed nurses or authorized persons to access those drugs. Hospitals would also need protocols to limit the mishandling or diversion of drugs, especially narcotics, during transportation and storage and disposition.

Additionally, hospitals would need methods for preserving drugs, as in storing them at the appropriate temperature and making sure that they were handled correctly during reconciliation and disposition as it pertains to dietary services. Challenges included ensuring that patients receive meals appropriate to their individual nutrition assessments. Existing requirements for dietary services require hospitals to consider the patient's preferences along with options for the patients to select for from each meal and to provide at will nutrients throughout the day.

Moving forward, dietitians would need real access to information on what the patient is eating, including the fluid intake and the nutritional values of each of the meals. While evaluating hospitals to participate in the program, CDPH completed two on-site inspections during the approval process. Because our oversight processes are designed for providing a survey within the hospital we face some unique challenges when evaluating the hospital at-home programs. For example, when we go to do a hospital on-site, we're there, everyone is accessible to us.

We can do patient reviews and documents and observe care very easily in that environment. However, when you move to an at-home model, you have to conduct a survey in multiple locations. So you would have to monitor care provided in the patient's home with that patient's consent. Then you would also need to go to the main hospital to verify information, as well as go to the site where the remote monitoring is taking place, just to make sure that everything is occurring as it should.

And so some of the challenges that we foresee in potentially monitoring this care going forward is being able to do those interviews and care observations in a way that we're able to determine the safety and quality of care that's being provided. CDPH's mission is to ensure the safe, quality care for patients, whether they're in a home setting or a facility setting. Particularly as our population ages, we want to continue to explore promising opportunities that support individuals' right to remain in the community with Independence, dignity, and support.

While there may be some statutory and regulatory hurdles in launching this program, we recognize the power of technology in the changing healthcare landscape. CDPH looks forward to working with the Legislature to ensure that Californians have safe access to appropriate health care. And I thank you so much for the opportunity to make this testimony and for listening to me today. I welcome any questions.

Great. Thank you very much. We'll bring it back to the Committee for questions. Go ahead, Dr. Weber.

Well, thank you all so much for being on this panel, and I have questions for each of you, but I will start with Ms. Driscoll first. So thank you for being here and presenting some of that information. So my first question is, do we need a State of emergency to actually have a hospital-at-home program with the federal waiver? Is that what we need? Since it expired in February,

I don't. Think that there's necessarily a need for a public health emergency, but there needs to be a regulatory structure for that service.

Okay, so I know you had talked about some of the things that need to be in there, some of the issues that you encountered as far as, like, pharmacy and dietary issues. Were there any other issues that you encountered with the programs? Who, the seven, I think you said that we had implemented during the State of Emergency.

Yes. I mean, I think there were concerns across the board in various areas that are required services for a hospital to provide, and I can certainly provide some additional details offline. If you need that.

Oh, that would be great. If you can send those to my office, I would love to have access.

Absolutely.

And one of the other questions that I had from some of the issues that I heard from different hospitals during this process when they could apply for it, is just the cumbersome nature of it and whether or not this is something that could be possibly streamlined if it were to be something that we opened up and offered in the future.

So I think the reason why the process was maybe more cumbersome was because the regulations that we were trying to bring the facility in line with are designed for care that's provided in a hospital setting. And so when you take care out of that setting, it's how do you provide those same protections in that other setting which they weren't necessarily designed for? So I think if there were specific requirements that were designed for this type of program, it would be a much easier process.

Right. Okay. And with the site visits that you were referring to and some of the challenges with having to go to multiple sites, I was just wondering Dr. Leff, I'm so sorry. Okay. Have you heard of those other challenges.

In other states in terms of survey process? Yeah, we really haven't. I think part of it is that under the federal waiver, I believe there was something of an understanding that this was being done in the context of the public health emergency. The goal was to help hospitals innovate quickly, to help decant hospitals and create bed capacity. In the context of the pandemic, it may be hard to kind of go back in time to the fall of 2020, but this is before vaccines.

This is when hospitals were desperate for space. So sort of the major survey process, the Joint Commission, I think they were held off at bay a little bit by the federal officials. I would say, though, that I think that state survey agencies have experience surveying skilled home health agencies, probably surveying home based primary care programs that exist within the context of a health system.

So some of the principles and approaches that are used in that context could probably be applied to the hospital at home use case, probably with some modification. And the survey process is absolutely needed. Absolutely needed.

Yeah. Thank you. No, I was just wondering, because I like, if something's already been done, then looking at it to see if we can model it and maybe tinker it a little bit to fit what we need here in California. So, Ms. Driscoll, I'm not sure, was there any discussion about looking at how other states may survey or looking at other models like nursing homes to help that process along? Because it's needed, and we definitely don't want it to be an extra layer of burden for the.

I think, you know, some of the hospitals that we worked with, shared with us, that had programs in other states said they told us, well, basically CMS said they were approved, so the state just stepped back and let them operate. So I don't know that they were put through a lot of rigor in other states. It's certainly a question that we can take back and talk to our national Association and find out what other states' experiences were in terms of monitoring.

Okay, thank you. So, essentially, when the other, however many states that did this, they just kind of went with the CMS waiver. There was no separate state oversight body that then went in and did some extra or had extra requirements. That's my understanding.

Okay, thank you. Can I keep going? Great. So I have some questions from the UCI. Sorry we couldn't get your slides up, but you were kind of talking about how hospitals vet patients to see if they're candidates. So not any and every patient that walks through the door is a candidate for this program. Correct.

Correct.

And then they have to agree to it.

Correct.

But you mentioned something about home checks.

Correct. So, environmental safety, we want to ensure that the patient is returning to a home that has proper equipment, has proper safety. So even if the rugs are trip hazard for fall safety or they don't have the right grab bars in the bathtub or in the bathroom area, these are all things that our program can outfit for the patient. And so there is a pre-visit to determine the needs and to ensure that the home is ready.

So how does that work in the scheme of things? So if a patient comes in through the emergency room, the provider does the evaluation deems that this patient may be eligible for this particular program. When does that home visit occur?

While the patient is waiting for in-hospital workups to be completed. So all major radiology orders are completed, lab results. So it could be the first day or two. So med surg level of care, they're already at the kind of General condition level versus telemetry is more serious and intermediate level versus ICU is the highest critical need. A patient who's unstable. So we're looking at a population and we're continue to refine and funnel the criteria.

They also would need to geographically live within 25 miles, so that if there's a need to be repatriated, some sort of escalation that we bring them back. We want that to be very swift. So based on our inclusion and exclusion criteria, from the very get-go. And then the time that we have them in the hospital to finish the sort of the heavy assets, things that are not available in the home, in the field, that's when the home would be inspected.

Okay, so the patient, what is usually normally initially admitted to the hospital?

Correct? Right. There are programs out there for ED to home. Where we wanted to start was the inpatient to home.

Okay. All right. I don't know if you know this, but do you know the current reimbursement cost of hospital to home compared to traditional care?

So, yes. Is that for me? Yeah. Okay. So the reimbursements are part of MS-DRG and APR DRG groupers for patients with like conditions and with sort of the considerations of what it normally takes in terms of utilization and resources for their care. This does not change with hospital at home in terms of the primary diagnoses and the patient's conditions really drive that one-time reimbursement. The reimbursement is not predicated off of the hospital costs.

So oftentimes it doesn't matter if we're spending more than the DRG indicates because that's what Medicare and insurance payers have determined is the appropriate amount to reimburse healthcare systems for that care, for that patient with that particular state. So this is a cost-neutral budget. Neutral. Ask initially upfront. We do have quite a bit of investment to make in order to start up hospital-at-home infrastructure. We're replicating so many of the resources. There's human capital, labor, there's equipment.

There's just a bunch of startup investment costs that we will be taking in addition to the reimbursements that are available.

And my final question for you is it deals around nursing and staffing. So what are the nursing staffing levels for acute care at home versus what we'd see like in a traditional hospital setting.

So in the acute hospital, there's depending on the level of care. So an ICU is a two-to-one nurse ratio, telementary. So it's two to 13 to 14 to one. The population, we're talking about medical, surgical, the General population. So they're not on continuous monitoring. Even in the hospital, they're on a Q-eight. So at episodic times intervals, the Clinicians go into the room to take their vitals on. That is a one-to-five ratio. And this is what we built our program on.

So it's the same ratio as the patient was in the hospital?

Correct.

Okay. All right. And I have a couple of questions for you, Dr. Leff. So I've read a lot of the articles, and thank you so much for being here. I've seen your name as either the primary author or one of the contributing author to many of the studies that have been published in very well-respected journals. And it looks as if patient outcomes in many aspects are improved at home. And you talked about things like nosocomial infection.

And I'm just wondering if you can elaborate on some of the potential negative outcomes you can have from a patient being admitted to the hospital, especially long term. And I know you specifically work in the geriatric population.

Yes. So thanks for that question. It's a very good question, and it was the real reason we got interested in thinking about developing the model. So some of the more awful adverse events that are common among older adults, I would say, number one, I think a lot about delirium. So that's a development of an acute confusional state. Right. All of you are sitting here. You're attentive and engaged and awake and alert. People who become acutely ill can develop acute confusion.

Their thinking changes, their level of consciousness changes, and those episodes can have long-term cognitive effects such that some people believe that incident delirium can be a contributing factor to conditions like Alzheimer's disease. So delirium, very important, very, very challenging for people to watch their loved one suffer with delirium, right? I can. A year or two ago, I was with my dad in the hospital after major surgery, he was delirious. No one in a major academic medical center in New York recognized it.

I had to be telling them that he was delirious. Disability, development of disability, and loss of functional capacity is another major. You know, commonly people in hospital are basically put to bed even if there's not a formal bed rest order, just because they're tethered with intravenous lines and urinary catheters, or it's an unfamiliar environment and they can't move about. If I were to put any of you to bed for a day, you lose about 1% of your muscle mass every day at bed rest.

So if you were functioning at a marginal level, above the level that you needed to go to a nursing home or needed more help at home, being put to bed for a few days can tip you over. So functional decline, delirium, adverse drug events, quite common. Probably more common in the hospital where people are dealing with more patients all at once. So those are some of the big ones.

Thank you for that. I know we always, in the hospital setting, try to safely, but get patients out as soon as possible, because we know the longer they stay, the more likelihood they are to get infections or adverse drug reactions, like you said. And the mobility factor is huge.

And if I may just to add one thing that hospital at home does, just to highlight. So reductions in readmission to hospital, reductions in the need for people to go to a skilled nursing facility at the end of a hospital admission. This interrupts the whole sort of set of transitions of care that people go through every time someone moves from one care setting to another care setting. That is a dangerous moment, a very dangerous moment in time.

The notion of reconciling medicines in the hospital, basically science fiction, right? People are just reciting lists and comparing lists as opposed to really understanding what the patient is taking. So the ability to interrupt that usual glide path, that easy glide path that we set up for patients to move through the system, actually ends up saving a ton of money, right? So you reduce skilled nursing facility admissions.

If you don't go to a skilled nursing facility, the odds of you ending up in a nursing home as a result of that hospitalization drop precipitously. And I know that the state's very appropriately, very concerned about Medicaid expenditures, as they should be.

I have some other questions dealing around social determinants of health, but I see you're on the panel for that later, so I will hold off on those. Thank you, Chair.

Thank you. Vice Chair Waldron.

Thank you, Mr. Chair. So just a little bit on the cost. I'll follow up on that. In my notes, it says that the hospital at home program may reduce the cost of care by approximately 30%. Is that basically because of the reduced readmissions and things like that, or as far as the patient care, direct patient care, how does that compare to in hospital?

So that's 20% to 30% number as high as 50% in other studies. That's the cost incurred during the acute admission. That does not include the savings incurred by reductions in readmissions, by reductions in Emergency Department visits at post-discharge, by the reduction in skilled nursing facility visits after discharge. That's just the hospital admission.

Is that just because they're not using a bed or room?

Well, the hotel cost of the hospital stay is rather substantial. I think another way to think about costs and what money goes towards a lot of the cost of a hospital stay when the hospital obtains that payment, say, from the Medicare program, much of that dollar, most of those dollars are going to pay for the fixed cost of the infrastructure, the buildings, the electricity, all of that in hospital, at home, the money is really going towards the variable cost of taking care, direct care of the patient. Right.

And to the extent that you're freeing up capacity for hospitals, you get to provide care to more patients. Instead of having patients sitting in the hallway and using the commode, they're actually being, actually being cared for.

As far as communication, which would obviously be needed between the home and whoever is the point person, I guess, must be a point person for each patient. How is that done? On demand. Remote audio. What does that mean?

Is that, yes and yes, all options. And I would say that remote patient monitoring and all of the televideo capacity has really just come online in the last few years. So just thinking back, hospital at home has been studied and implemented since the late 1970s. I can tell you when I did my first clinical trial, the most technology I had was the first generation cell phone. And I'm not talking about the big block thing, I'm talking about the thing I carried on my back.

And we thought it was a miracle. Right. You got a dial tone with something you were holding. So even without that technology, hospital at home was able to provide safe care through the use of telephone. Now pretty much all programs are using telemedicine enhancement, all sorts of redundant communication. Right. So now you have the ability to set up redundant hardened supply chain and logistics to support this care at home. Right.

20 years ago, none of us would probably have imagined that we would never go shopping again and that Amazon would keep dropping off boxes at our front door. And now that's the State of the world and that technology will get better. And the key point here, technology is only a tool. It is never ever the solution for patient care. It is just a tool, really important construct.

So it's like similar to, I don't want to say an app, but like an app, like a chat, live chat kind of a thing.

Yes. So the way most programs set this up, it is literally a one button push, and then instantly you get someone on the other line, quite honestly, much faster in many cases than in hospital.

Okay, so then as far as setting this up, I have some questions around that distance from the hospital to the patient's home, obviously is part of the consideration for response. Is there like a median amount of miles between the hospital and the home that can be done?

Great question and appreciate it. And the issue is really more time based than mileage-based. So, for instance, I once helped Presbyterian Health Systems in Albuquerque set up their program. They set up a 2500 square mile catchment area for their program because you can drive 80 miles an hour, and there's no traffic. And you can get from here to there like that.

When you're doing this in Manhattan or LA, you really have to think about traffic patterns in the context of distance, because the key thing is to be able to get to someone quickly if they need it. And quite honestly, it's a relatively rare event that they need urgent kind of care in that way while being cared for in hospital, at home, because programs are selecting people who need to be in the hospital, but are not so sick that they have a high likelihood of being unstable. So that's a key thing. But you need to create that as a safety mechanism.

Okay. Because what if an incident occurs? Obviously, they could call 911, but is there any link between some more localized services of people that could come in within five minutes instead of many programs.

Also, and this varies from state to state, and program to program will collaborate with community paramedicine and mobile integrated health. And we'll use that asset as a way to get to patients in the middle of the night should something happen or in an urgent situation. So that is another asset that's commonly.

Used, and it could be done even if the patient lives alone and doesn't have their family member.

It's really interesting. So I blew by a lot of the studies that we did. But in the study that we did, what we called our national demonstration study. So this is well before the federal waiver. This is in the early 2000s, we did this in three Medicare-managed care plans around the country. In a VA medical center. We did not require patients to have a caregiver, and about 2030% of our patients lived alone.

And in that case, if they needed someone to help with their activities of daily living, going to the toilet, transferring, we would supply a home health aid, right? A home health aid is a very inexpensive asset to put into someone's home compared to the cost of the hospital stay. And those folks did just fine. In fact, in our earliest clinical trial, our research board at Hopkins. So this is like, 1995 and hospital at home, that's insane.

They thought, if you want to do a clinical pilot on this, you have to put a nurse in someone's home for 24 hours, at least for the first day. And for the most part, patients refused that because they said, it's going to be really weird to have someone in my home watching me sleep. And that made them very uneasy.

The other reason we took that very seriously is we started going to CMS as early as the mid-90s, and we told them about hospital, home, and they said, that's very interesting, but, you know, by the year 2000, everyone in America will be in a managed care plan. So that's why you should do your studies there. But they also warned us, they said, it sounds like here, that there's a risk that you're pushing the care that hospital staff do onto family.

So we would never ask family to provide any care. That was like, one of our prime directives. Family wants to be involved. We would educate them. We would tell them about things. But we never, ever expect family to monitor an IV or change a bandage or do anything. Not during a hospital, at home, stay.

Okay, just a quick. I know it would vary by hospital or by the program, but how many patients can a single hospital handle in a program like this?

Yeah, it's a great question. And even though it's been going on for almost 50 years, there's still a lot of work to do to scale many programs. But I can tell you, for instance, that Mass General Brigham is in the process now of planning a 200 to 250-bed hospital at home. Why? Because they literally cannot build another bed. They don't have the real estate, and Massachusetts won't let them.

So you can go big, but even a relatively small program can have significant impact in terms of saving hospital bed days and creating capacity within hospital. Right. So if someone goes from the emergency department home, the bed in the hospital is never occupied. If the person leaves the hospital a day or two or three early, you're creating more space so people can move from the emergency room to that bed upstairs.

Okay, I just have one more question for Department of Public Health. So we saw the Bill, AB 2092 before, and as far as you were talking about regulatory frameworks that might be needed, what's included in that legislation? What else would be needed? I mean, does Department of Public Health still retain oversight over the programs? Does Department of Public Health, can they still have penalty authority or licensing over these programs, or is it not, or is there anything else that we're not seeing? Know, you had mentioned we need a good regulatory framework.

So I'll confess it's been a while since I looked at that legislation. My recollection is that there was not sufficient detail to provide enough accountability to hold facilities accountable in that. So additional clarity would be needed as far as oversight. Right.

Okay. Just trying to figure out how these would be set up in light of. I guess they extended the waiver to 2024, according to my notes. But the way it would be set up, if this is something that we would be pursuing anyway.

Okay. Thank you.

Did you have a question or comment?

Just a point of clarification for Vice Chair. That Bill never moved. It was never heard in Committee.

If it ever comes back.

Did you have any questions, Ms. Aguiar-Curry? Ok, thank you. Thanks. So I have some questions and I'll try to be brief. Dr. Leff, how much would it cost to set up a hospital-at-home program, roughly? Do you have any ideas?

It's a great question, and it depends a bit on how big you're going to go, but it's usually an investment of a few $1.0 million for a health system to get this up and going. I mean, the key thing to keep in mind is you are building a virtual hospital.

Right.

You have to build the whole darn thing sort of like a hotel. You have to have the whole hotel and every system working before you could take care of your first guest. You have to have the whole thing.

Are any of the existing programs profitable?

I don't actually know the answer to that. I would think likely it takes a few years to scale up and probably even break even.

So I guess going back to, I think, Vice Chair, and I read some of the same information about that, some of the pilots have potentially achieved savings of 30%. You said up to 50%. Where do the savings go? Do they go to payers? Do they go to consumers? Because it sound like from Ms. Rustad that the fees are the same whether you're in the hospital or the hospital at home. So if there's.

Saving, the savings on the hospital admission would accrue to the clinical organization that's deploying the model. The savings on readmissions, the savings on 30 day readmissions and 30 day ED visits accrue to patients. It accrues to society. The savings on skilled nursing facility accrues to Medicare. The savings on nursing home admissions accrues to the state. The savings on avoided complications. That's priceless and that accrues to patients.

Thank you, Ms. Rustad. So UCSF Cedars Sinai, and Keck USC were all approved for the federal hospital at home waivers in March of this year. So will UC be applying to DPH for program flexibility prior to implementing these programs?

Yes. So you're referring to Francisco?

Well, any of the UCS, I mean, UCSF. There's the three is UCSF, Cedars Sinai and Keck USC have applied. So are they going to be applying to DPH for these flexibility waivers?

I can't speak to Cedars Sinai or USC.

I'm sorry, we can't hear you.

I can't speak to USC, Keck or Cedars Sinai as they're not part of our health system. But I do know that UC San Francisco, UC Irvine, and UC San Diego would like to proceed, and UC Irvine have applied for the CDPH waiver and were approved. However, it expired February 28th with the ending of the public health emergency.

Yeah. Okay. I don't know. Maybe this is a question for DPH. So the public health emergency allowed for the flexibility, is that what you're saying? So now without the public health emergency, why is DPH no longer allowing program flexibility?

So the way we were able to do it is because of the public health emergency waivers that were in place. Now that that waiver has gone away, there needs to be some other authority to authorize these programs going forward. That's sort of the struggle that we're in. We don't have the ability to approve these programs without some sort of structure in place.

But you still have program flex, though, do you not?

We still have program flexibility for our regulations, but they still have to meet the intent of the regulation. So many of the requirements were waived in their entirety in order to allow these programs to operate, so we wouldn't have the ability to waive those things going forward.

So essentially. Hang on, I got a train of thought here, and it's a short train and it can go off the tracks, really. So essentially, I guess what I'm hearing is that DPH is going to need some sort of legislation or authority or something to allow pilots to go forward. Is that a fair characterization?

Yes, that's fair.

Okay. Does will you need to have a different approval system, or will the, rather than the program flexibility form, which I'm gathering was pretty onerous, like really onerous?

I think that it depends on what the structure is. If the way that it's designed has enough clarity for us to be able to implement easily. It could be similar to submitting a regular licensing application and going through that process, but it really depends on how the system would be set up.

Do you know why all the Adventist Health pilots closed? Do you know why that happened?

I do not know why they all closed.

Yeah, there's a lot here, so I'm process assessing this, and there's a lot going on here, so I want to defer back to. Did you have a question? You got an answer? Okay, I guess we kind of got clarification there. Okay, question.

Legislation. Go ahead, please ask your question.

Yeah, so I'm just trying to figure out, because we keep talking about the waiver President Biden signed into law HR 27116 the Consolidated Appropriations act for Fiscal year 2023. And among other things, this legislation extended the hospital at home individual waiver to December 31, 2024. So, can we still do it or can we not do it in California? Or why wouldn't the federal law, this legislation, apply to us in California? I'm just trying to clarify that confusion that I'm seeing.

So I think that the federal waiver addresses the federal requirements. So the CMS certification requirements, there's still California licensing requirements that would have to be addressed in order for this type of service to be operational in California.

So my question is going to be, was it working in California during COVID Was this concept working well in California during COVID Yeah. Either of you.

I mean, I'm not a.

No, no. She know either of mean, was it working? We had waivers.

We had my senses from intelligence that I had that it was working.

Ms. Rustad.

So it took us a while to have the Department of Public Health Conversation. It took us over a year, and at which point the public health emergency was ending. The goal kept we actually, even though we had an approval, it had a very short term date, and so we did not turn on our program that we built.

So we got the waivers and the.

End of the PhD.

Kind of sounds like it failed to launch then, more or less.

What's that?

It failed to launch, I guess. Is that fair characterization?

We didn't have enough runway, so, yes, we failed to have the necessary.

But you went through a process of over a year, even with the waivers and even with the flexibility provided by the governor's office.

Correct.

Did you have a question, Dr. Weber?

And thank you so much for this line of questioning. I didn't realize that you all had gone through all of that work, invested all of that time and energy and resources, and then that was cut short here in California, unlike the other states that had received the waiver. Dr. Leif, you have helped implement these programs in other states. Just out of curiosity, have you ever seen the amount of pushback or the amount of issues that we seem to be having in California?

It's not always easy to compare, but I would say that you guys are having some pushback. And it's a little surprising, considering that I tend to think of California as sort of a bellwether of innovation and wanting to do well and think carefully about adopting new approaches, new technologies with the right kind of. You're. You're on the other side of the curve to be sure.

Okay. And one other question I want to follow up. So, you said at Brigham you guys are building out to a program that would allow for 250 at-home beds. A part of that program. Is that going to be hiring more nursing staff?

Yeah. Just to clarify, I'm not building that. Master General Brigham are building that. I take no credit for that. But of course, they will be hiring more staff to staff that hospital at home. It takes a village.

Including nursing staff.

Absolutely. Including nursing staff.

Critical component.

Okay.

Thank you.

Okay. Thank you. I think we're going to move on to our next panel. Dr. Lief, you're not going anywhere. I hope your seat's warm, because you're going to stay there for a little while, if you don't mind. Thank you very much. So, our second panel, Chris Nielsen, Assistant Director of Education for California Nurses Association, and Sandy Marquez, who, a nurse with UNAC and UHCP. So please come on forward. And Mr. Nielsen, you are up first. Thank you.

Okay. Good afternoon, and thank you very much, Chair Wood, and to the Committee Members for the invitation to join you today. On behalf of the California Nurses Association and the over 100,000 registered nurses that we represent across the state, I'd like to voice some of our serious concerns about the hospital home model.

We know that the hospital industry has been trying for a long time, decades, to cut labor and overhead costs through a combination of devaluing nursing care, deskilling nursing care, shifting services out of the hospital, among other things. And this hospital at home model continues this trend, I think, in ways that will degrade patient care, place undue burdens on family members, despite some of the reassurances that we've heard shrink our hospital infrastructure and potentially worsen health inequities in our communities.

As a result, the model radically redefines what constitutes a hospital. As we've heard, patients' homes are redefined as med surge units, basically, and what counts as acute patient care as well, the bedrock of which is 24/7 nursing care in the hospital. Under the CMS waivers that we've heard about, patients who would normally receive round the clock nursing care are diverted to their homes to be remotely monitored and to receive, under the requirement, a minimum of just two visits a day.

And outside of California, under the CMS waivers, those visits can be done by paramedics in place of nurses. Luckily, here in California, we have innovated the types of protections that would guard against that and safeguard effective patient care. So, some of the existing research that we've heard about on hospital at home, we believe is insufficient to support proponents claims about some of the benefits of the model. A lot of it is based on small sample sizes and single case studies.

And I think the crucial point is that they're mostly older programs, well-resourced programs, pilot studies that don't necessarily resemble the programs that we're seeing rolled out today in the current climate under the CMS waivers. So, these findings, I don't think, are necessarily generalizable. If the industry had found that evidence compelling, we heard that this model has been around for decades, one would think that they would have embraced the model sooner.

Instead, they waited for the CMS waiver program, which I think it's important to remember, was fast tracked at the 11th hour of the Trump Administration, in just eight days outside of the normal rulemaking process. And it was only when this program allowed these acute care at home services to be reimbursed at the same rate as inpatient services, including allowing hospitals to charge facility fees for this care happening outside of a brick-and-mortar hospital.

It was only then that we started to see an expansion of the model, and we also started to see a flood of venture capital and private equity investments into this space that's driven what some have called a hospital home gold rush since the beginning of the pandemic, or since late 2020, when this was passed.

The key feature, as we heard of these waivers, is the lifting of the normal requirement that hospitals provide nursing services, quote, on premises, 24 hours a day, seven days a week, and the immediate availability of a registered nurse for the care of any patient. That's the CMS conditions of participation. The industry's lobbying effort to make these waivers permanent is an attempt to make a virtue out of pandemic necessity, and it's one that will threaten the safety of patients.

Study after study demonstrates that the more nursing care that a patient receives in a hospital setting, the better their outcomes across a range of metrics. Just to cite one, we know that the risk of mortality increases by 7% for each additional patient that a nurse takes on above the California ratios that we have in our state, our safe nurse to patient ratios.

Now, again, this is in a hospital setting, the risk could be higher, with nurses monitoring patients from command centers across town or even across the country. One of the leading platforms for hospital home, medically home, has command centers operating across state lines. Again, most of the research done on hospital home is focused on programs where standards of care exceed what we're seeing under the current programs. That are being rolled out, the CMS approved programs.

So just as an example, the in person visits, rather than being done by a paramedic, they were done by physicians, or at the least by nurses, not by lesser licensed healthcare workers. So to give you a sense of what these programs can look like in the current context that we're seeing what they look like on the ground, I want to share the experience of a nurse who reached out to us from the Midwest and who asked to remain anonymous.

So this nurse with over 20 years of experience quit their hospital at home program after just two weeks because of how, in their words, dangerous and unethical it was in the program, which was run again by Medically Home, a leading venture capital backed platform that's partnered with Kaiser with other large hospital systems. I believe Dr. Lief is an advisor to medically home. Patients were sent home with nothing but a small iPad, and they were told, a smartwatch, but it's just a wrist-based call button.

Patients could go up to 16 hours without receiving an in person check in from a paramedic, and the nurses had to remotely monitor up to eight patients at a time from a command center that this nurse likened because of how hectic it was to an air traffic control center. Nurses had to also advocate for their patients and face managers who attempted regularly to override their clinical judgment.

For example, one example that the nurse gave was the manager refusing to readmit a patient with dangerously low oxygen levels, citing their readmission targets. So here in California, nurses tell us that patients are reluctant to participate in hospital at home. Patients go to the hospital because they want to be hospitalized. They understand the importance of receiving nursing care. This mirrors national trends we've seen. Studies show that a majority, upwards of 60% of patients that are pitched to these programs decide to opt out.

And hospitals, I think, in response, are adopting some slightly more aggressive sales tactics, approaching patients multiple times over the course of an inpatient stay, even after refusing the first time, telling patients that they'll be safer at home again because they'll be able to avoid exposure to COVID-19 or nosocomial infections. But instead of sending patients home to mitigate these risks, hospitals should be addressing their systemic causes. So when it comes to nosocomial infections, wouldn't it be easier to reinstate masking requirements?

Wouldn't it be more effective to adopt and implement permanent workplace safety standards for infectious diseases in our hospitals? So, nurses know that the hospital at home experiment again. In the current climate, we have to take these things in context.

I don't doubt the intentions of the academics and Clinicians who have developed this idea, but we have to understand how this idea will play out within the context of our corporate, market driven healthcare system, again, comparing to single payer countries where the findings are not generalizable to our context. Industry proponents, maybe less so today, but in other contexts and other settings, have been very straightforward about what their strategy is here. The hospital home users group that we heard about before is upfront about this.

In their materials, in their webinars, and elsewhere, they've explained that the quote value premise of these programs is capital avoidance and backfilling inpatient beds in the remaining hospitals with the highest acuity, patients know potentially more profitable patients as well. Dr. Lief himself has described a vision of the future in which hospitals are reduced to an ER, an, or an ICU, and everything else moves into the community or to the home. To quote Dr. Lief, maybe there are future uses for the leftover facilities.

Maybe some of them become condos, end quote. So, at a time when hospitals are being shuttered across the state, including in my hometown of Madera, California, which is now a hospital desert, about 30 minutes away from 20 to 30 minutes from the closest hospital, this is not the path forward. The industry should be investing in nurses and should be investing in inpatient facilities, in our hospital infrastructure here in California. And there's no reason they cannot do that. We heard about some of the costs.

Well, the hospital industry in California alone has made $46 billion in profits just over the last five years. I heard a $2 billion number cited for building out new inpatient hospitals facilities. All Californians, and this is really our core concern, deserve 24/7 hands on nursing care when they need it. And that's why we're calling on CMS at the federal level to discontinue the acute hospital care at home program.

And in the meantime, we urge lawmakers here in California to ensure that CDPH does not reinstate the authorization for the CMS waivers and that we maintain the protections that California has innovated to ensure the safe and effective care for patients in acute care settings. Thank you very much for hearing our concerns.

Thank you, Ms. Marquez.

Thank you. Good afternoon. Chairman Wood and the Members of the Committee on Behalf of the United Nurses Association of California Union of Healthcare Professionals, thank you for the opportunity to voice our concerns about the efforts to expand hospital care at home programs in California. My name is Sandy Marquez, and I have been an RN for approximately 39 years and have worked in different settings in predominantly Low income communities in Los Angeles County.

I have worked in the acute care medical surgical units, ICU, Cath lab, interventional radiology, and as a home health care nurse. Of all the settings I have worked in, home health care has been the most difficult and sad. In home health. You begin to see the social inequities that exist in our healthcare system, the lack of resources, and the negative impact on the family systems.

The sadness sinks in not because of the critical nature of the patients, but because of how patients are sent home with minimal to no resources. Minimal to no resources includes inadequate supplies, it includes inadequate living conditions, and it certainly includes lack of support. The proposed program expansion would negatively impact our most vulnerable populations, the elderly, low-income families, families with language barriers, and those who don't have a family.

Far too often, patients are released to home health and even hospice without regard to the patient's living situation and with the expectation that the patient and their family, if they have one, will provide or follow the recommended plan of care. To provide proper care at home by unlicensed individuals is unrealistic and unsafe. Acute hospital care at home is no different, and meeting minimal care requirements by hospitals at patients home still leaves unlicensed.

Individuals attempting to provide care to a patient and the licensed individuals available are on time restraints placed on them by the healthcare systems to promote profits, not quality care. Patients, even in the best home health care, hospital divisions, are sent home with instructions that they often have minimal understanding of because of language and age barriers and with the expectation that family and friends will be able to assist while working and caring for children.

Elderly patients with mobility issues and on medications that require frequent use of the bathroom are sent home with minimal to no assistance. Many are on continuous oxygen with extending tubing that also includes the chance of falls. Patients don't have help because they either outlived family or their family live in remote areas and or are unable to offer much assistance because they work. Forcing a family member to take leave will have severe economic impact, especially for low-income wage earners.

Ultimately, acute care demands care within the hospital by qualified personnel, and a patient deserves it. It's their right. And while some patients' goals are to be back in the comfort of their home, the reality is the necessary resources are not available, and expanding hospital care at home would overload a home-based healthcare system that is currently inadequate, unsafe, and unregulated. Moreover, only requiring a physician or a registered nurse to be available remotely and to visit infrequently is impractical.

For many of our patients, especially in the elderly community, they often cannot access the necessary technology reset something even simple like the WiFi monitors or simply just use basic technology. Having visits from RNs or integrated paramedics seems like it would work on paper. But what about the other hours? Who is going to provide the nursing care for the patients? Families are often placed in a non-sustainable situation in an attempt to maintain jobs, childcare and deliver the care expectations.

For example, my 70-year-old female patient with mobility issues was home alone during the day because a relative worked. She had bilateral lower extremity edema swelling with leg wounds. When I encountered her, she was soiled because she couldn't make it to the bathroom. Her wounds were seeping, and she was severely short of breath. Despite her saturation, which is your oxygen level being on the lower end, the evaluating physician refused to readmit her. I could not get her readmitted to the hospital.

That was the catalyst to my last home health care because I just couldn't bear seeing what we were sending these patients home with under the guise that they would be better at home. Hospital care at home also would require paramedics to be available to respond to an emergency. This just further impacts at least our area in southeast Los Angeles where I work, and paramedic response can sometimes take longer because of all the impacted calls that are coming in.

What's troubling about this program is not only the disregard for patients in the family unit, but the fact that it is consistent with the sad reality of our healthcare system. It's motivated by profits. Hospitals will be able to avoid regulatory oversight. Hospitals are constantly violating nurse to patient ratios and with this program they will not have to follow any ratio laws. In many hospitals, including my own, the chronic violation of Title 22 is becoming the norm. Hospitals will be able to avoid compliance with seismic standards.

Hospitals liabilities will decrease, but they will build the same. The program will increase the accountability gap for healthcare providers. Hospital utilization management, which is already aggressive in discharging patients who will need acute care, will continue to coerce patients and their families to accept hospital care at home.

In closing, I appreciate the effort to have a discussion about a program that was expanded during our worst health care crisis in our lifetime, which was used to address an immediate need due to COVID, the pandemic is over, and that need is no longer there. Taking advantage of the pandemic to implement programs to allow hospitals to make more profits while taking advantage of government programs such as Medi-Cal is irresponsible.

And I would like you to remember that in most cases people do not qualify for this assistance of a home health care aide. If you have even a small pension and Social Security, you do not qualify unless they change the regulations and at least start there, you're not going to get home assistance. Your home assistance is either kindly neighbors or family. We should be focused on resolving the staffing crisis and the hospital's intentional disregard for California staffing laws.

Acute care belongs in the acute care hospital setting, where patients and families can receive the appropriate care by professionals educated to deliver quality care. No one expects to be in this situation until they are. It's better we don't create this challenge moving forward. Thank you for your time.

Don't, sorry, we don't do that in our hearings. I appreciate that with no clapping or booing or anything like that. So, thank you, Dr. Lief.

Thanks. And the slides can come up. That would be great.

Thank you.

So, I've been asked to take a few minutes and talk about issues related to social determinants of health in hospital, at home. And I'd first start off by saying that to address social determinants of health, it's very important to be able to create trust. And in healthcare today, trust is in short supply sometimes, and I think at times it's well earned.

Hospitals and health systems have engaged in surprise billing and medical bankruptcy, the high drug prices, lack of access for many people, disparities and inequities, hard for patients to negotiate the healthcare system. Long waits and emergency departments, and then when they're hospitalized, their families have trouble. You would not believe how much I hear about the challenges of parking at the hospital when someone wants to visit their loved one. People often feel disrespected within the institution.

And I would say that providing care at home empowers patients, it empowers caregivers, and it changes the power equation between providers and patients. When I'm in someone's home doing a house call, I don't like to admit it, but I think I act a little bit better than when I'm seeing them in the hospital. I'm a guest in their home.

It's their turf. They have autonomy. The other critical item to think about is that in order to best address social determinants of health, direct observation is critical, right? There's a difference between getting a patient to answer a question, what's your house like? And actually, being in that environment and seeing it and getting direct observation of how they're using their medicines. What's the availability of food? Whenever I do a house call with permission, I do a refrigerator and a pantry biopsy.

What is sitting on the shelves, you get to see family and caregiver dynamics and the need for caregiver supports. You get to see how patients function in their home. So seeing someone maneuver in their home is different than a physical therapist doing that evaluation in the hospital. You get a sense of the patient's financial status, the safety of their home, and how people go about managing their chronic conditions.

So there have not been very many studies yet of equity and social determinants of health in hospital at home. Like a lot of areas, there's a lot of research getting started, but we were able to go back and look at the data from the Center for Medicare and Medicaid Innovation Study we did at Mount Sinai in the. We had indicators of socioeconomic status. We had patients Medicaid eligibility and Medicaid status.

And we also had their socioeconomic status by whether they lived in public housing or lived in a census block with high levels of deprivation. And what we found out is that the program was provided to people at equal rates, whether you were high or low socioeconomic status. So, in New York City, it's not as if you had to live on Park Avenue to get hospital at home.

Also, what we found actually is that if you were Medicaid eligible, you were less likely to have an Emergency Department visit in the first 30 days compared to those who are not Medicaid eligible. So if you have lower socioeconomic status, you actually seem to do better by that utilization metric. The other thing we looked at were the outcomes of hospital at home with and without high levels of social support.

And it turns out that people who received hospital at home, who opted in for hospital at home, had lower levels of social support than those who were taken care of in the hospital. However, the outcomes were exactly the same.

And the reason for that, I would hypothesize, is that folk, when you're taking care of someone in hospital at home, and a gap in a social determinant was identified, the program was able to address it and bring those resources to the home and give the social worker direct input on what needed to be addressed.

There's been some unpublished work that should be coming out soon in one of the larger hospital at home programs, looked at about 2000 admissions to their hospital at home program, compared it to about 20,000 similar patients admitted to their hospitals. And if you look at the distribution of the deprivation National Deprivation Index across the two groups, it was pretty much identical. So much more work needs to be done on this.

But I think hospital at home, at least early studies suggest that it's doing well in this context.

Thank you very much. Questions from the Committee? Questions or comments? Dr. Webber.

Thank you all so much for engaging in this conversation. I think it's important to hear everyone's concerns, the good, the bad, the ugly. I have, actually a lot of questions. I think I'll start with Sandy. Thank you so much for telling your story, especially your experience in the home.

And as you were talking, for those up here, know that I am a huge proponent of the social determinants of health, because that really impacts one's health and one's outcome more than whatever we can do when they come and see us, either in the clinic or in the hospital or in the operating room. And you being in that patient's home allowed you to see all of the societal factors that are impacting his or her health.

And that's one of my concerns with our healthcare system today, that we don't really dig deep into looking at our patients as a whole individual. So, whether they stay in the hospital for two days and then are discharged to a hospital at home program or stay in the hospital for five days and are discharged at home, those elements are still there.

And I think one of the reasons why we see readmission rates, or sometimes what we call frequent flyers, especially to the emergency room, is because we send patients out without really knowing what their home environment is like. And many years ago, when I was in med school, we used to talk about the non-compliant patient, and this was the patient that either didn't show up to appointments or we'd send them home on a regimen.

I'm an OBGYN, so if you have a gestational diabetic, you send them home on this regimen, and they either don't come back to their clinic appointment, or they come back and their sugars are all over the place, or the blood pressure is all over the place. And we just talk about this non-compliant patient without recognizing that this particular patient that we sent home doesn't have a refrigerator to put the insulin, to store the insulin in.

And so, when I started learning about this, one of the things, and that's why keyed in on the previous panel, what do you mean when you go home and you look at the environment to make sure that it's okay, because that's someone stepping into that environment to say, hey, you have fall risk here. You don't have a refrigerator, you don't have this, you don't have that. You claim to have food, but you don't. You live in an area where you live in a food desert.

So, as we counsel you on nutritional habits, right, you send someone to the nutritionist, and they come back and they're still the same weight or even worse. And it's because we don't know that as we're telling them, okay, eat your fruits and vegetables and this and that. That's not what they have. They have your Mcdonald's and your Burger King. And I'm in San Diego, so we have the best Mexican restaurants.

And you can find them on every corner in certain communities, like the one I represent, but not necessarily like your Whole Foods or your Mendocino Farms, where you find in more affluent areas. So, when you have that ability to go to someone's home, you are able to see what happens within their home and also within their environment.

And that allows them to be not only healed from whatever it is that they're dealing with at that time but helping them stay out of the hospital and realizing that your counseling methods and what you're recommending may have to be altered based on their environment. So, thank you so much for sharing your stories about what you saw at home, because it just really elaborates on the impact of the social determinants of health and whether they're in the hospital the whole time or not.

You have to evaluate what's going on at home if you really want those individuals to heal overall. So, I just really wanted to thank you for that, for my other questions. There is a packet from the National Nurses United, and it's all on Medicare's hospital and home program. So, I just have a couple of questions on this, and again, the introduction, to me, it just screams of social determinants of health.

It talks about the nursing profession, which we all respect, but it says it demands an ability to address the physical, psychological, and emotional needs of a patient with compassion, empathy, and advocacy to honor the dignity in all people. And again, that's just really getting down to that particular patient and their environment, also talking about racial and ethnically biased treatment methods. And again, it's really focusing on that particular person.

But one of the things you mentioned is that CMS has approved this program in 110 health systems with 245 hospitals in 36 states. Now, in our packet, we have lots of studies from very well respected journals, such as the Annals of Internal Medicine. I think we have something from JAMA as well, Geriatric Society. So, these are well respected publications and journals that we as healthcare providers, not just physicians, but healthcare providers in General, go to because they publish your evidence based randomized clinical control trials.

I am just wondering, because I couldn't see any in your biography, where is the data of harm? Since we have some of these things that have been rolled out and some of them that I guess have been in place for a while, do we have the data that shows harm?

Well, we are still collecting data, and that research is still in the process of being developed. We do have data, again, like I mentioned, on the strong correlations between the amount of nursing care, hands on, in person nursing care that patients, hospitalized patients receive and a variety of patient outcomes. And so we can make inferences from that in terms of how these types of programs would affect patients.

Again, in the real world, these are highly respected journals and studies that affirm the positive benefits in terms of patient care, in terms of costs. But again, the question is whether they're generalizable when the sample sizes, all of the sample sizes here in the studies that were included in the packets were fairly small. And again, the crucial difference here was that the standard of care in those programs significantly exceeded the standards of care allowed under the CMS waivers.

So, again, patients were receiving, in one study, 24 hours of in home nursing care for the first 24 hours. We're not seeing that today. They were having physicians visit them in the home. Nurses visit them in the home at a higher frequency than is allowed under the CMS waivers. So the question of applicability and generalizability there, I think, is really important, right?

No. And I think that it's always good to, when we assert something and say that there is going to be harm, that we actually have evidence that shows that if there are systems that are already in place that are currently doing what we say would harm someone. But to your point, I agree, some of these in these studies are very structured programs that may have accounted for their positive outcomes, at least that they reported in these studies.

And I think that if we were to move forward with something, then I think this is why it's important to have everybody agree to come to the table to participate in these conversations. So whatever we create here in California would be of the utmost quality to mirror some of these in the studies. On page three of your handout, you say that CMS does not require any additional in person registered nurse or Doctor visits with a patient.

Instead, the program requires just two in person patient visits a day with a community paramedic. Isn't that a nurse or community paramedic?

Yes.

Okay, so that's just a little typo right here.

No. Well, a paramedic could be substituted. And again, this is outside of California presumably.

Right.

And what we're seeing is that paramedics have been substituted regularly according to nurses that have been reaching out to us from other states.

I'm sorry. So, you said presumably outside of California.

So here in California, theoretically, the nursing services provided would fall outside of the scope of practice of a paramedic. Here in California.

Okay, so what you're saying is that here in California, a paramedic could not do this.

They should not.

Okay. So here in California, the only people who could actually go in, because in this document that, I guess this is the federal one, it says having two in person visits daily by either registered nurses, excuse me, or mobile integrated health paramedics. That's fertile. But here in California, those two in person visits daily would have to be a registered nurse. Based on our scope of practice confinements, they should be. zero, okay. Well, thank you for clearing that up for me. Okay.

Now, there was one study that you did cite in this package that talked about reviewing 50 patient charts. I know that's a very small sample size. When you were talking about adverse drug reactions in that study, how many of those reactions were severe?

I would have to follow up with you after. I don't recall the numbers there.

Okay. Do you know, in that particular study, and that's, I believe, the Mount Sinai one, I think they looked at it from 2014, do you know what kind of provider went out to that home.

Every day in the Mount Sinai study? I believe it was a nurse or higher in terms of qualifications, like a Nurse or a physician.

Okay. And there were no severe adverse drug reactions, and it only looked at the first 50. That was one of the limitations that they mentioned in the study for Mount Sinai. Dr. Lee, I don't know why I keep messing that up. You were not the lead author, but you were one of the authors. I'm not sure if you are familiar with that, because this was 2014, and they looked at the first 50 that were enrolled. As far as, like, adverse drug reactions, do you know long term?

Yeah, long term. There were no long term adverse events. And again, I think that's an example of the field taking a very careful attitude towards safety and quality. And during that demonstration, I would say the rigor regarding medication Administration was lower than it is currently. So under the current CMS waiver, all drug Administration must be directly observed, either in person by a nurse or via video with someone on the staff for every single medication Administration.

To replicate the Safety and quality of medication Administration that occurs on the inpatient service. That is the standard now.

Okay. Thank you so much for that clarification. So it's not that a patient is just. Or their family Member is just giving it in the dark. They're actually being monitored or a nurse is doing it.

Correct.

Okay. Thank you for that. And I guess it talks about the evolution of this program, because this initial study was from 20141 of the concerns that I have heard a lot from nursing associations is that this might or this would be a job killer. And that is definitely not something that I or I think anybody wants. Well, there's only two of us here. Well, anyone in the Legislature, I'll talk about anybody in the Legislature would want is to kill jobs.

How many jobs have been lost due to hospital at home programs that have been implemented?

Again, we don't have any figures yet on that because of what an early stage these programs are in terms of their rollout in their current format under the CMS waivers.

Okay. I'm not sure. I know you're not.

This is, to my knowledge, no nursing jobs have been lost to hospital at home. I think it's important to think about this in the context of how care delivery within hospitals evolves over time. So I can remember when I was a wee intern admitting patients, if you needed a cardiac catheterization done, that was an overnight hospital admission back in the day. Right? Because we were concerned people would bleed out because their large arteries had been punctured during the know.

Now you would need an act of the Assembly or Congress to have someone stay overnight for routine cardiac calf. I can remember when I was eight or nine years old visiting my aunt at New York Ioner. She had cataract surgery. When you had cataract surgery back then, you were put in bed for a week blindfolded, because people were worried that if you moved your eyes, you would jeopardize the surgery.

Not knowing at that time that every night people went to sleep, they were having REM sleep and their eyes were just going a million miles an hour. So what we take care of in hospitals will continue to evolve for sure. And the flippant comment that I made that hospitals may turn into condos one day, that was flippant. But I think we saw glimpses early in the pandemic in certain cities of hospitals basically being converted to big eRs, ORs, and the whole building became ICUs.

That was all the New York City hospitals. That was mass General, Brigham. And I think that what we take care of in the hospitals in the future will change, and there will be a need to move things that happen in the hospital now to the community because there will never be enough beds. So I'm a geriatrician. By 203020% of the US population is going to be over the age of 65, including myself.

A lot of people, no matter how well we do with care, will end up getting hospitalized. We need to create capacity, and we can't build our way out of it. This is one of the tools, not the solution, but one of the tools to help get there.

Yeah, no, thank you for that. As I was looking through the CNA packet, you all talk about acute inpatient hospital capacity has declined in the number of beds. And I think there are so many different factors for that. To your point, when I started, most of our hysterectomies were open procedures, especially at Cook county, because everybody waited till last minute and you'd be in the hospital for 34 days plus. Now we do a lot of things via mis, minimally invasive surgery.

And so these patients that used to be admitted for 23 days are now going home the same day. So medicine, it is changing. I did a panel this past weekend in my area, and I was moderating a panel of nurses, and we talked about healthcare system and changing, especially like post COVID. And one of them, I asked a question about nurses shortage, and one of them gave an answer that was so profound. And he said, there is no shortage of nurses.

There is a shortage of nurses that want to work inpatient. And he said there are a million registered nursing licensed nationally, of nurses that are not practicing right now. And we talk about burnout within the health community. We talk about physician Burnout, we talk about nursing burnout. We talk about just the demands and the difficulty.

But also we have a new generation coming up who have a very different outlook on the balance of quality of life work versus life balance that many of us in previous generations didn't have. I wonder if there has been any discussion about the possibility that this could actually attract more nurses back into the profession because they don't have the demands that you see in the eight to 12 hour shifts, inpatient, in ICUs, in CCUs, that they could potentially have a little bit more flexibility.

So they can do inpatient for three months, and then there's home healthcare service for three months as a relief, so that we don't continue to bring people into this healthcare field, require so much of them, especially inpatient, when you see the sickest of the sickest, and sometimes it is a revolving door that this may help with their overall satisfaction within the profession. And that's not really a question, just like a thought that I had.

When could I offer a response? Yeah, I think that's a really important point. We have heard a lot from the industry, from the hospitals, about a nursing shortage. We have is a staffing crisis that the industry has engineered. It's been a self inflicted crisis because they have refused to staff adequately. For decades. We've seen intentional understaffing in our hospitals here in California and across the country for many, many years.

And these are the conditions that are driving nurses out of the hospitals and even out of the profession. We have over a million nurses who have active licenses who aren't currently working as nurses in the United States today. So there's no shortage of nurses. Now, we've heard that if there are hospital home programs that are rolled out, then we will simply hire more nurses. Well, hospitals are telling us they can't hire enough nurses already in the inpatient setting.

Again, really, they refuse to hire nurses and to provide the conditions that nurses are willing to work in. So that's where we should start. We should start by investing in nurses in the inpatient setting, in our General acute care hospitals, investing in them in the profession, and in that inpatient infrastructure, and that's how we can address these crises that nurses are facing today.

Yeah, thank you for that. And again, I think that's another plug to why everyone should come to the table, especially if a program like this is rolled out. I don't see it as two separate things. I think we should be able to address the issue of inpatient, but also potentially establish something outpatient, because those of us who are in the health profession, we know that being in the hospital is not necessarily the best place for everyone.

And we talk about it behind closed doors because of a variety of things that can possibly happen. But we want to make sure that we have the proper nursing, the proper nursing staff ratio to manage patients, whether they are inpatient or at home or in another kind of facility. And so I definitely encourage you to, if we choose to take this on as a legislative body, to continue the discussion and participation.

My final question for nursing is, I'm just wondering, have you all been in any discussions with any of the hospital associations or the hospital groups about this particular program?

We've made our position clear on the use of programs. We think that the model itself presents unacceptable risks to patients. We think that nationwide, it can degrade and devalue the nursing profession. And so that's where we stand on this.

And so just so I can understand, so if there is a discussion about this, you don't want to be a part of it.

We are advocating for these programs to be discontinued. We're advocating for the CMS waiver program to be discontinued, and we're advocating for investments to be made in our inpatient hospital infrastructure and in the nursing profession.

Okay. So I guess I take that as a no, you don't want to be a part of it. There was something that was stated that was a little concerning, and I don't understand it. Facility fees are included in the billing fees for these programs.

As I understand, hospitals are allowed to charge facility fees for these acute care services provided in the home. It's included in the.

It's not, they're not in the.

Correct.

So I don't understand.

I mean, the DRG is charged, so whatever's encumbered in the DRG is reimbursed because Medicare is reimbursing this under the DRG mechanism. But I don't believe there are any. So, for instance, when someone comes to see me in the outpatient clinic, in my clinic, there's a professional fee coming to see me, whatever that's worth, and then Hopkins charges an additional facility fee because they can. That additional fee I don't think is being charged in addition to a DRG. My understanding.

So I don't know that I agree with Mr. Nelson, but we can clarify that easily.

Yeah, I would like that clarify know thinking with surgery. Like if I do something in my clinic, because it's not in the hospital, the patient doesn't have that hospital fee attached to whatever other fees go along.

We can say in Maryland, and I don't know if it's true across the country, if the clinic is what's called, at least in our state, a regulated clinic, which has to exist under a higher standard of care, which ironically, sometimes does not actually translate. However, if it's a regulated clinic, then the health system has the option of charging an additional facility fee in addition to the professional fee and the usual fee for the clinic visit. That's my understanding, but we can clarify that.

That would be great if I could get that clarified. Thank you.

Okay, well, thank you. I have to admit, Dr. Weber asked a lot of the questions I had. So I appreciate that. And I just want to say I appreciate all the witnesses Being here Today. Thank you. Thank you very much. This is a complicated topic, and a procedure like this and informational hearing is not like our typical hearing, where we can actually have multiple witnesses for a lengthy period of time. We've had a Discussion for nearly 2 hours now.

Our typical Bill hearing is 10 or 15 minutes, and that's not a lot of time to really discuss issues, which is why we're doing this here today. I wish we could do this on every issue in healthcare, quite frankly, but this Is Something that Was certainly New to me. I've learned a lot here Today from both Sides of the issue. And I appreciate the opportunity to be able to Hear that.

I will say, while I appreciate that a representative from CNAS that believes that there is not a nursing shortage, there, at the very least is a maldistribution. Because I will tell you, in my district, we have a real challenge with nurses getting nurses getting doctors getting dentists to provide care. And so we're relying on locums, nurses and doctors to come in to communities like Eureka and other areas further north. And so you can Call it what you want.

In My Mind, it's a Shortage because we don't have them. And so that means that hospitals and others are paying a huge premium, which takes away from the ability to provide a lot of services, from my perspective. So we actually have a nursing program that's getting up and going in Humboldt County, which I think will be helpful, but it's going to take a while for that to happen.

And there's no guarantee that the nurses that are trained there will stay, because all these programs now have lottery systems to attract people. And nurses could come from anywhere or train from anywhere, and then leave the area, which will help with the larger pool, but not necessarily help with the local needs, so to speak. If anybody's got solutions for that, I am more than open, because we are really struggling in some of our rural areas, and that's just the coastal my area.

I know this is happening throughout other rural areas in the state. Looks like you wanted to say something there.

Well, yeah, I agree. It is a crisis. It is a staffing crisis. And the question is whether the programs like hospital at home will ameliorate that crisis or exacerbate it. And if we're talking about a program that is intended to minimize, again, according to the hospital at Home Users Group, the Value strategy, the profit generation strategy of these programs, is to avoid further investments in capital, in hospital infrastructure, and to move as many services out into the home and into the community.

That just means fewer resources for hospitals that are already starved of resources that are already, especially in rural areas, unable to attract and retain nurses and contributing to the staffing crisis that you've just outlined.

Well, I appreciate your comments on that. I would just say that aside from this program, we still have a huge problem in my district. Take this program completely away from that. We still have a challenge getting doctors. We still have a challenge with all the allied health professions, nurses and dentists and so on. And so I'm still looking for solutions for that, quite frankly, and have been since the day I got here. Thank you for that.

With that, thank you to our panel once again, and I'd like to move on to public comment. Could I get an idea of roughly how many people would like to speak in public comment? Okay. And if we could keep a comment to a minute, and if someone has said substantially what you plan to say, if you could just say, I echo my previous speaker, we would appreciate that as so we have. Yeah, we'll have a minute here.

My name is Anna Sindelar. I've been a nurse, a registered nurse at UC San Diego Medical Center for four years, and I serve as a CNA nurse representative on my unit. Nurses know that positive health outcomes do not happen by chance. They are a result of quality, experienced care administered by trained professionals. I'm here today to share a cautionary tale about a personal experience with hospital at home.

A close family Member of mine with a pre existing lung condition was sent home from a hospital in Texas Overseen by their hospital after being diagnosed with pneumonia. She was told to monitor and report her own symptoms, her own vital signs. The machine that was supposed to ensure that she was receiving enough oxygen because she was on three liters when she was discharged or actually, when she was sent home on a hospital at home.

So she was still technically inpatient, was not installed correctly by the tech. She woke up in the middle of the night with a dangerously Low oxygen levels. Had she not herself been a registered nurse with a much deeper understanding of what could have gone wrong, she could have had devastating consequences, including respiratory failure. And one of the symptoms of hypoxia is confusion. So if you don't have someone there with you that knows that, it could cause you to get even worse.

In that moment, she belonged in a hospital under the watchful eye of trained doctors and nurses, not at home. With malfunctioning technology and little recourse, our patients and families deserve and require appropriate care inside of a hospital, not to be sent home all alone to fend for themselves. And one of my biggest concerns with this is the lack of FaceTime with nurses. Nurses are the eyes of the doctors in the hospital.

And if they're not right down the hall, you only get seen, what, once or twice a day by them. I was just in a code this week with a med search patient that was supposedly fine and stable, the nib coding, and intubated within 15 minutes. Thank you.

Thank you. That was two and a half minutes, so we're asking you to go. Just a minute, please.

Hi, my name is Michelle Santizo, and I'm an oncology nurse at UCLA Medical Center and a CNA nurse representative from my unit. I'm here speaking to you today because I fear the looming threat of a hospital at home program will significantly deepen the existing rift between those who receive a safe and appropriate level of care in the community that I serve and those who do not.

I have seen my own hospital ranked among the top in the nation remark about the supposed convenience of transitioning acute healthcare into a patient's home. But nurses know the reality that this program will only embolden a profit driven industry to determine who receives quality inpatient care and who is sent away. Hospital at home programs will exacerbate already widening health inequities by reducing acute care capacity across the state and incentivizing hospital closures, which already disproportionately affect communities of color and Low income communities.

We need to strive towards providing more hands on acute care facilities to the most vulnerable, nor further restricting access to quality health care by expanding the use of by expanding the use of home all alone programs.

Thank you. Good afternoon. Chair and Committee Members Vanessa Gonzalez with the California Hospital Association, representing over 400 hospitals and health systems throughout the state, really appreciate today's important discussion on hospital at home. California hospitals are committed to providing safe and effective care to all their patients, and many hospitals throughout the state are interested in implementing an acute hospital care at home program to extend their services and meet the needs of their communities.

With the extension of the federal waiver, many hospitals have already invested a lot of time and resources to develop safe and effective acute hospital care at home models. Unfortunately, there is currently not a pathway for California hospitals to implement this program in the state. It is important to note that hospital at home will not replace traditional hospitals in any way. This is an additional option for qualified patients who prefer to recover at home, and patients will always have the option to stay in the hospital.

Additionally, there is an important distinction between the acute hospital care at home model through the federal CMS waiver, which is what we're discussing here today, versus other programs like home health. These are separate and distinct programs and more of a reason for the state to set its standards and requirements. We look forward to continuing to work with the Legislature, CDPH, and other stakeholders to ensure a California model adheres to relevant state licensing standards like nurse staffing ratios. Thank you. Thank you.

My name is Kim Bransoforti. I work at UCSF Benioff Children's Hospital at Mission Bay, where I serve as CNA Nurse rep and co chair of our union's professional practice Committee. As nurse leaders who have witnessed firsthand the ways that health, safety and well being of our patients pale in comparison to the profits and prosperity of our employers, we have been bracing for the threat of outsourced nursing work to unlicensed personnel and patients'family Members.

For the past several months, I myself have sent patients home to manage their own central lines and chemotherapy at home. And I've had to look those patients and their family Members in the eye while they looked at me with fear, confusion and sorrow, unbelieving that they were being asked to do at home what I spent years pridefully going to school. And that parent, I'll never forget the sister of the patient, said, Isn't this your job? And I said, yes. So please, just let us keep doing our jobs. Thank you.

Hello. My name is Rachel Cohen Sepada. I've been a nurse since 1993, and I've worked at UCSF Medical center since 1998. I'm an RN. I work currently in acute psychiatry. And I would like to respond to some of the facts that Dr. Leaf has presented. One, in regards to delirium, it's true that delirium is a dangerous and potentially life threatening condition which is often caused by infection and medication.

A patient who becomes delirious at home would no longer be able to utilize the equipment that is being provided them. And if he said that the hospital his father was in didn't recognize delirium, how would a family Member or the patient themselves be able to recognize this?

Just one moment. I have to get my notes back. He mentioned that 15% of falls in the hospital were caused by nursing. In my long career, the falls are caused by lack of nurses. When patients can't get a nurse fast enough, they fall. Nurses don't throw patients down or trip them. So I feel that that fact was greatly misrepresented.

Thank you.

Also, we don't check our patients every 8 hours. We are constantly checking our patients. Vital signs may be ordered every 8 hours, but anytime a patient has a change in condition, we are constantly checking their vitals and reporting to them. Okay, thank you also.

Next speaker, please. Dr. Weber and Mr. Chairman, thank you for talking about the nursing shortage. And you asked for a solution. Ms. Ariane Marquez sat here and told you why nurses are leaving the industry and her concerns. I think nurses have been speaking up about what's needed, but they haven't been listened to. Just listen to us. We have the interests of the patients. We have the interests of the healthcare system. But I think oftentimes we're just not being listened to, listen to what she said, why she left the industry. So thank you. Thank you.

Hi, my name is Victoria. I work as a nurse in San Francisco. I've been a nurse for about nine years, which is not a long time. There's people who've been here for like 40 years or so. So I recently have left the ICU. I now work in a GI lab. It's a little less stressful, and I really feel the lack of quality of care stemming from hospital systems. And I don't think that I trust this home health system program in the way that it's implemented.

They're going to implement it. From what I've heard today and from the context that we're living in right now, just working the last few years in the ICU has been rough, and I think hospital systems have failed us. So I'm here to discuss, and I'm happy to be heard. So thank you.

Thank you. Hi. My name is Jeff Silau. I'm from Kaiser, San Francisco. I work on Medsurg. I just wanted to share my personal experience about telehealth, for example, the models of at home care. My dad, for example, had shingles. From the photo or from the video, it looks like a pimple. But had I not been there to tell the Doctor, hey, he's having all these other symptoms, they wouldn't have been able to diagnose shingles for my dad. And the technology and infrastructure, I feel is not there yet. That's all. Thank you. Thank you.

Hi. I'm sorry. I'm Deb Quinto. I'm a registered nurse from Kaiser San Francisco. We are not interested in surveilling patients via video monitors. We are here because we want to take care of our patients in person, and we are committed to protecting our patients, our community.

We share concerns with this program, and despite the assurances that you are giving us that they are going to be closely watched, we know that the patients need to be in the hospitals watched by a registered nurse, and we're able to provide real time interventions as needed should their condition change. And so we are here, all the nurses, because we're committed to protecting our patients, and we do not support hospital at home.

Thank you. Anyone else? Thank you very much. Bring it back. Do you have any closing remarks, Dr. Weber?

Well, first, I want to thank chair, Vice Chair, and this Committee for putting this informational hearing together and all of the information that you provided for us in advance. I want to thank everyone who participated in the panels to share your experiences your concerns, the possibilities of what health care may look like now or in the future.

And I really want to thank all those who came out, who drove down from the various areas where you are actually working to make sure that your voices are heard as well. And there are a lot of challenges within the healthcare system for those of us that actually work in there, we can attest there are a lot of challenges, and we need to do better for everyone who works in the healthcare system, and we need to do better for our patients as well in our communities.

And COVID was just an example of how we have not been doing right by our healthcare providers and our communities and our patients. And so as we continue in these discussions, it really is in the vein of how can we here in California do right by our workers, our patients, and all of those who live and visit this great state.

So I really appreciate everyone coming to the table and talking, and I really strongly recommend that everyone come to the table for future conversations that deal with health care, our communities, and our patients. So thank you.

I, too, want to say thank you to everybody who came here today. We appreciate that the panels as well as the discussion. For me, this was a great learning experience. I'm learning about something that I really didn't know a lot about prior to the background that had been put together here. And as I said, one of the reasons we do informational hearings is to dive deeper into subject matter that many people are not familiar with. And so appreciated that opportunity here today.

And I suspect there will be discussions in the future on this and a myriad of other things as we all strive to improve healthcare access and healthcare quality for all the people of California. So I want to say thank you again to those who came out, and I would encourage, if you have additional comments or information you'd like to pass on to us, to please submit that in writing.

We're happy to take that, and we go through everything that comes through our office and our happy to incorporate that into the record and use it for future reference with that. Thank you very much, and we stand adjourned. Okay.