Spending and programs are not tracked, nor coordinated -- creating a system seemingly ripe for waste and ineffectiveness.
When it comes to providing disabled, infirm, and elderly people with what they need to live at home instead of in an institution, San Francisco is extraordinarily generous. The city spent $736 million last year, up from $645 million the previous year, according to a recent Controller's report. Of that, $218 million comes from the city's general fund, with the rest routed through city programs from the federal and state government. This does not include the $160 million spent on long-term care services last year at Laguna Honda Hospital.
This money is spent to further the noble cause of helping people emulate normal lives as much as possible in spite of disabilities. But routing of taxpayer dollars to what are called community-based long-term care services is not routinely tracked by the city. Services are spread over multiple non-profit and city agencies with different missions and different criteria for accepting and serving patients. The city has spent the better part of a decade studying the issue of better coordinating these services; but public officials are still scratching their heads about how to get this done.
The report does not describe any waste or other failure associated with the lack of coordination. But experts told the Snitch that lack of coordination has been considered an important problem in government efforts to help the disabled live at home.
"What will happen is, well-intentioned people and good staff meet a niche need," said Donna Calame, executive director of the San Francisco In-Home Supportive Services Public Authority, which oversees a state program that pays for workers to help disabled people in their homes. "Then there got to be all these niche needs that arise over a period of years. And they stay separate out of a combination of inertia and institutional preservation."
According to the report:
But "the reality is these people need the same kind of service," Calame said. "A person in a wheelchair who cannot get out of bed, whether they're a 10 year-old with a developmental disability, or a person with HIV who's lost physical function, or an old person who's getting arthritis, they're all ending up with the need of someone who'll help them get out of bed, bathe, get dressed, and so on. But each of these people might be served by a different department, or a different funding mechanism, and it's all chopped up."
There exists no universal best practice, or consistent and fiscally measurable approach, to defining "long term care services." State and federal programs, academia, as well as the San Francisco Long Term Care Coordinating Council (LTCCC) employ different definitions for what comprises LTC services and populations, or they leave it broad and open to interpretation.
City departments use different methodologies for identifying LTC clients and services. City departments do not share the same eligibility criteria for LTC service provision. When departments made an effort to distinguish Immediate Need services from Continuum services, the methodologies differed as they were tailored to individual program eligibility criteria
The City's fiscal systems are not currently equipped to replicate this analysis. The City's budget documents and accounting system (FAMIS) are not currently designed to report this information. Department staff generated spending data for this analysis using their unique internal systems and recordkeeping efforts. This proved a time-consuming process - repeating this data collection and analysis would require an advance commitment of significant staff time from the departments involved, notably HSA and DPH.