Terms of that transfer. Because part of the concern was when you move from, you know, a number of concerns, but when you move from sort of a Hospital Management of the service to the medical foundation, management of the service, does that change the nature of the services in such a way that it impacts the Patients Health . I dont think i have that data at this point in time. If youre referring to the diabetes, i can say with a lot more certainty that with the Breast Health center or with the noninvasive cardiology, its the exact same machine. Its read by the same radiologist or cardiologist. So i would have no doubt that should not have any significant impact. In terms of tracking diabetes before and after, because many of these are not necessarily Sutter Pacific medical foundation patients, so we dont necessarily have all of their medical record, access to them easily. And so especially before. And so its one of these things where it would be a little bit harder for me to i think think about if there are ways to do it. But at this point in time, that medical record data, because theyre not necessarily seen by our primaries or endo criologists per se. It would be helpful if there was sort of a way to observe or to analyze. And if you do, particularly for those patients who are sort of seen by the same provider, if theres a way. Because i think thats an important piece of just sort of considering, you know, these kinds of changes, whether its diabetes or others, that access is one thing. But were really concerned also about the impact on residents and patient health. We may have some data. But we can certainly look into that. Commissioner chow. Commissioner chow i was just also going to comment, im really pleased also that the institute of aging was able to actually complete their work in leasing over at the presidio. And that that seems to be really for that portion of that program and transferring it out of cpmc and then to i. O. A. And expanding it, i think has been a positive for us. And i hope that we will the minutes will reflect what the relationship so i. O. A. Other comments, questions . Also im sorry. If were going to we think that is a benefit to the city. Gotcha. Next item. Clerk item 7 is an action item. Its A Laguna Honda hospital and Rehabilitation Center medical staff bylaws and rules and regulation. Just a reminder, commissioner, they recommended that you that the full commission approve this document after review at the may 14th meeting. Thank you. Good afternoon, president loyce, members of the Health Commission and dr. Colfax. Im the c. E. O. At laguna hospital. On behalf of dr. S hathaway and dr. Mcshane. They have worked with the City Attorneys Office since august of 2018. And also worked to align the medical staff bylaws to align with the medical staff bylaws with the laguna honda bylaws revision. And a they have consulted with dr. Chow, as our resident bylaws consultant with the department. I am here to request your approval for the revisions of the laguna honda medical staff bylaws. Thank you. Theres no Public Comment request for this item. Because it comes from a committee, we dont need a motion, do we . Oh, actually youre correct. It usually is there usually is a motion here. You are correct. So we can just vote to adopt as a commission. So all those in favor of adopting adopting this report say aye. Aye. I say aye as well. All right. Thank you. Thank you very much. Thank you. Item 8 is the sfdph gender health s. F. Update. And please let me know if you need any help over there. Good afternoon, commissioners, my name is jenna rapues. Im the Program Director for sfdph. I want to thank you all for inviting us to provide an update of our program. Just a little bit about myself. So im actually joined by my colleagues as well, the medical director and the evaluator for our program. And just f. Y. I. , the pronoun used is she, her. As an information. All right. I live by myself, i am celebrating my oneyear in the program, actually as a Program Director, its been a wonderful experience to actually be involved in the program, that has actually centering the experiences and needs of trans folks in San Francisco, with regards to access and whatnot. My background basically is i before i joined general sfdph, i was doing with a threeyear with u. C. F. And i was doing capacitybuilding on a National Level and also at the time i had left, i was also the interim director for the center for Transgender Health and transitioned back to the program. So with that history, im interning in the department, prior to that working in Population Health and h. I. V. Prevention and research and whatnot. So with that i wanted to highlight i really wanted to first establish and show with you all that were celebrating today a major milestone in the program. We reached 1,000 surgery referrals in our program, which is a huge milestone. So we want to really honor that and really celebrate that and the work that weve done for the past i think seven years now. And well get a little bit more indepth about the data so far. Well talk about that more in terms of a Patient Population, but just wanted to share that. That is a huge milestone for the department to be able to move patients through, through surgeries. So sfdph navigates them surgeries, procedures and resources in order to help members of the transsexual, transgender and gender nonbinary people to achieve their hopes and dreams. We are a referralbased program in which patients, who require gender surgery are referred for education and preparation. And navigation and facilitation to getting steps we were established in 2013 by the department to provide access, again to gender referral surgeries. For those who are insured and eligible for our program. So currently sfdph provides a wide range of Health Services to transand nonbinary residents, such as primary care, be it for health, preventative care, hormone therapy and numerous other initiatives in the department, that really serves the population, which includes the Population Health and other initiatives that are within this department. I also wanted to note that we submitted some Supplemental Information that you all may have had, which speaks a little bit more about our basically [indiscernible] that really speaks to our program eligibility, our Insurance Coverage and navigation services, which is the core and the heart of our program. And also the history that speaks to a more contextual and detailed history of our program in the way in which serves different surgeries have actually become more available, rarely available over the time, so that theres a supplemental document that speaks to that. And also our staffing structure. But speaking to the Mission Statement, this is something that weve actually developed this year. And our Mission Statement basically is to increase access to Quality Health care for underserved trans and nonbinary people in San Francisco, regardless of immigration status and their lack of income. And the values that we hold true to our program, includes social justice, community investment, peerled harm reduction, wellness, advocacy, and compassion wholeperson care. Just a few milestones that i mentioned earlier, the information that really speaks to more detailed information around programs and milestones. But just a few milestones and i think the doctor may talk about this a little bit more later. But i think just i really want to frame the way in which weve had a really extensive collaboration and partnership with the Trans Community and the program really came out of that partnership, which really started in 2013, where the board of supervisor adapted a resolution that deemed these surgeries as medical necessity. So it really sparked the interest and the commitments from our department to really develop a program such as ours. And with the Health Commission actually approving surgery access for development in 2012, right. In 2013, the department managed health care, solutions were removed, which actually increased access and increased interest to get these surgeries for our Patient Population. So that expanded our program and enhanced also we launched at the time it was called Transgender Health services. I can recall back where transgender, just a small space. I think the doctor can talk about a space, which was in a closet at the c. I. V. , which really tells about where we came from and where were at now as a program. In 2017, my predecessor julie graham really zillion a lot of work to develop the program and expanding the services and actually expanding the capacity and staffing of our program. Where, you know, weve included weve hired more staff, included more Civil Service staff to really increase our capacity to respond to the need and demand. At the same time, too, in 2017 we moved from the closet here at the ivy to a space at cfhg. Ward 86 really has proven to be really Great Success in being able to serve the population through the work that were doing and really being developing programs in the department. And in 2017, we adapted a new program called gender health s. F. In 2018, i came on board to really come in with my experience, with the department, and also really kind of sparking interest and kind of taking on the next the next roles of our program and the next iteration of the program. Im going to turn it over to seth, who will talk a little bit more about our Patient Population, demographics and our metrics and outcomes. Thank you, commissioners, for having us here. My name is seth, and i [indiscernible] under the client demographics, im the lead for the Program Evaluation for gender health s. F. And the Program Evaluation began in 2016. As part of this Program Evaluation, we have a lot of indicators, many of which i will show you here. For the client demographics, through the end of calendaryear 2018, approximately just over 500 unique patients, threequarters of this population that we serve, through this program, are trans women, a majority of them are people of color, who are of early, middle age, between the ages of 25 to 44, with low education, 50 , some college and more a quarter unstably housed and a majority are unemployed or on some sort of public assistance. And this flag here shows how our primarily transgender and nonbinary sample compares to a 2015 National Survey of trans individuals and gender nonbinary individuals. This next slide that talks about some of the quantitative evaluation highlights shows the trend of referrals received. The blue line which has systematically gone up since the in 2013, were also on track, as jenna mentioned, to hit 200 referrals this year in 2019. Were about halfway there. Halfway through the year. And the orange line, insurgentries surgeries completed remained relatively flat since 2013. But what this suggests is the demand for the services are increasing, while our capacity to meet those needs are remaining relatively flat. For surgery wait time, if there are questions about this, i do have more information than what it presented on this slide. But generally speaking, were seeing a longer wait time for services that are heading out of network, which are primarily our genital surgeries, than compared to our innetwork services, which are our chest and breast surgeries. Based on the outcome day taxer data, the program intake, at baseline, our clients are showing pretty good overall, general overall health, being to a National Sample of trans individuals, theyre showing less, serious psychological distress as defined by the kessler six, serious psychological distress scale. Less alcohol and tobacco use, but were seeing more cannabis use. What this suggests from an evaluation standpoint, is that because our referrals to gender health s. F. Are being received through the primary care system, people are already engaged in care by the time they engage with gender health s. F. So theyre receiving primary care, theyre engaged in services, so its not surprising to me, that given the vulnerability of this population, we are seeing Better Overall Health, less serious psychological distress and less alcohol and tobacco use, compared to a general population of trans people. One thing i do want to point out, though, is that when we did our education and programming, we do this while the patients are waiting to have their surgeries, we find that a majority of clients agreed or strongly agreed that the education and programming was valuable and worthwhile. And clients felt that very or completely ready for surgery, as a result of participating in the preparation and Education Services with gender health s. F. s peer Navigation Team. Clients were learning about the possible surgical complications, they were learning how to have realistic postoperative expectations, they were learning about the importance of of having social structures in place leading into the surgeries, so they had good recovery social support, which maximizes the benefits to them in their recovery period. And for managing stress. In addition, where the data allowed, we did see we did some Statistical Analysis and we were able to show as a result of participating in this program and working with the peer navigation staff. Less body discomfort following surgeries, less reported gender dysphoria following surgeries and a significantly increased psychological quality of life, as measured by the w. H. O. Quality of life brief scale. We did show trends, although they werent systematically significant of lower psychological distress measured through the case six. And better social relationship quality, as measured by the w. H. O. Quality of life scale. And the majority of the sample said that they felt that their health was better today than a year ago. Just some brief summary of the quantitative information that came out of the interview for the Program Evaluation. We found that threequarters of the patients that we were able to interview oneonone, for the Program Evaluation, felt that they were treated with respect, they felt safe with their procedures, they felt that the care team was available to them. And the navigators provided an incredible amount of connection and support. And some of the challenges that they reported with care quality were that some of the medical providers they felt lacked a agree of cultural humility, they were being misgenderred a little bit, they werent using the correct propronouns and hearing conflicting information between the surgical staff and then the surgeon themselves. But they did feel that the Navigation Team was able to help them go through the surgical process and get clarity in the information that they need to have a good outcome. The majority of the patients felt that they had positive Care Experiences, that they were treated primarily with respect, that the care team listened and paid attention to them and that they felt more comfortable in their body after surgery, again they attributed most of this to working with the peer navigation staff. Most of them felt that they just they would say over and over again, how relieved they were to have this kind of access and support from the Navigation Team to feel like they were able to access the service, to be authentically themselves, a dream they never thought they would have access to, because of their economic circumstance. And just historically they have not been permitted to access these services. So one thing thats really that i have learned over the past year, that ive been the director as the program, is this [indiscernible] and previously julie graham, which is we are building the shape as we sail. So we are in full operation, but we are relatively Young Program in the department. So we are still in the process of really kind of contemplating and reflecting on the challenges and also kind of our accomplishments and some of the gaps within the systems. So really just wanted to highlight with you all and share with you all are some of the things that we as a program have been reflecting on. In terms of systems, gaps and needs, some of the things that are important to us, that have been some challenges also is the concept of when youre in care, which should actually can be a barrier for some of our Patient Population. So really thinking through what that would look like in terms of different standards that maybe recommended for our Patient Population. And a barrier that really exists for our spark spanishspeaking its Language Access and similarly to patient education materials easily translatable in spanish. So thinking through what that would look like for our Patient Population. Often times we provide trainings in our work, so we have actually we actually have a trainer who is providing different types of training capacity around surgery access, but also training the Health Clinicians to do presurgery assessments and building to provide gender care, but also really thinking through the Different Things that we have to address within the system to build the capacity of our procedures within the network. Services among providersers is a major barrier as well. Housing is an issue when we think about postoperative care and healing and so often times we are concerned around how do we move a patient through surgery but also thinking about housing and clean, safe places would look like for recovering. Other things that we also think about are just behavioral, health assessments. Often times we know that there are long waitlists and providers are not necessarily competent enough to do presurgical assessments or providing training as well for many of our providers in the network. [indiscernible] surgical dates expect one of the things that were mostly challenged by, most recently sfdph is a trauma center, often times with our patients, who are slated who get surgeries particularly for top surgeries at csfg, trauma cases take over our patient cases, can be distressing who plan their lives to get the surgery and then having a reschedule or delay may actually have major impacts on our patients and what that would look like. In terms of programmatic needs we are in the process of operational practices, simply again because the whole concept of were a relatively Young Program and were still continuing to evolve in network. In terms of Public Health were thinking about smoking, substance use, access to nutritious food, managing diabetes and b. M. I. Which can be barriers to moving forward from a Patient Population, to really thinking through what wellness programming and development is for our Patient Population. We respond to their needs to help them move through the process. So i wanted to add these as Program Accomplishments over the years, which speaks to promoting programwide access. So in that, we are able to provide Health Education in various languages. Were able to provide wraparound care, peer navigation and behavioral Health Services, integrated and disciplinary care coordination, for example, we have a Nurse Practitioner in a program to really help with our Patient Population, either in patient education and patient care. We do presurgical assessments and addendums for our patients needing to move forward through their surgeries. And weekly drops in. But in addition to that, we think of our Program Accomplishments over the past couple of years, we think about staffing. Over the years weve been able to alluded to this earlier, weve been able to build capacity and being able to have more Civil Service positions and more clinical staff, who reflect the Patient Population. So folks who are p. O. C. And some come from the community to be able to be able to hold the positions and work with 9 Patient Population that we work with. Over the past several years, as you see in the history of our program, weve been able to increase different types of surgeries over the years. And more interestingly enough, weve been able to provide or increase surgery access for healthy San Francisco population, for those who are documented, that includes f. F. S. And other surgeries at cfsg. Other surgeries that were actually moving forward with are kind of evolving were able to get releases from our patients, because we really need to have patients who really see themselves and really embrace this whole have had of transvisibility. We made sure that we, you know, got folks from who are actually through our programs, who really see themselves in the materials that were developing. In terms of just testimonials, i know seth conducted some qualitative interviews and has patients who conducted or participated in the survey. Theyre conducted 6 to 12 months postfollowup. And some of the key things that came up around just really how instrumental, how pivotal it is for our navigators to have that kind of relationship with our patients. And im going to read some quotes in terms of patient experiences. Peer navigator made me feel like i have someone on my side before surgery. Its different talking to someone versus reading from a form. Calls from general s. F. Guided me to better understand the process. Gender s. F. Advocated for my identity as a gender queer individual. My gender identity is validated. Having navigator there with me to translate everything meant to me so much. General health s. F. Really played a helpful role in doing a lot of work for me, like helping me with paperwork, searching peer navigation and communications with providers. My experience was difficult, people change and move, but gender s. F. Health care team was there for me throughout the changes. Lastly, i want to end our presentation by recognizing the work of karen aguilar, who is our lead patient navigator. Shes also bilingual. And was once a client of gender health s. F. Karen was a hearts and heroes recipient for always going above and beyond for her patients and communities. Patient access to the best care, to identify when the care isnt adequate and for her work improving the care which transsexual, transgender and gender nonconforming people receive. And here as part of the heart and heroes award, they made a video of karens work. This is a quote from karen. I thought i was going to die without achieving my dreams. Transgender community. Human beings just like anybody else, you know, should get should treat Transgender Community like any person having diabetes or having a baby or a heart problem. Just health care. Just being able to access Proper Health care. And with that i want to honor karen is actually in the audience. [applause] with that im going to stop there and open it up for questions. And not receive any Public Comment requests for this. Okay. I had a couple of questions. The first one was for dr. Pardo. The evaluation that you shared with us, did that include the out of Network Patients that were having their surgeries elsewhere, outside of sf . Yes. They received their surgeries received because of our the way that were organized. Those surgeries are conducted out of network m. O. U. They have the same relationship with the peer navigator . Yes. Essentially all theres no difference . Correct. Thats correct. So when they evaluate that the staff was caring and such, that theyre talking about wherever they had their yes. Some of the feedback was about the surgical experience, the Care Experience and the surgery team. And some of the most of the testimonials we focused on the impact of the peer navigation staff, on the Service Experience for these patients. Right. Thank you. Yeah. I just thinking it speaks to a good relationship. Indeed. Between the program and both the in and the out of Network Providers and clinical teams. I had another question about the demographics and some of the qualitative information that you shareed. At program intake, you indicated theres Better Overall Health and less serious psychological distress and so on. But the demographics show that these are potentially patients who are more at risk. Thats right. I was just sort of wondering about is it really just a primary care relationship that prepares them for participation in the program . Or is there something about either observable or statistic ally or empirically, theres a different type of patient that we get that comes to our programs . Thats probably one of the single most important questions that i have got about when looking at these data. I dont have a direct answer for that. What i can tell you is that for the people that i did speak with, what i have heard in response to them, in regards to what are some of the things that you feel are making your life a difference in your life, as you interact with this program and what has brought you here. And certainly so many of them say to me, just knowing that they have the opportunity to access these medically Necessary Services motivates them to do better with their health. Because they know they cant access a lot of these services if their b. M. I. Is too high, if theyre smoking, actively abusing substances, they wont be able to access the services, even if theyre available. And this is a primary motivator and a primary driver. And its supported in the empirecal literature, if this is something theyve been waiting for for their whole lives, theyll bet their butts in gear to take care of their health, to access these services. I suspect thats why were seeing such good outcomes as well. Sort of the whole wraparound from the motivation factors to the Program Services themselves. And then post. Correct. There is no aspect of this program any more important than the other. If i were to pick one, its the peer Navigation Team, because of what they do to help connect all of these pieces. But that the program as a whole is making a difference. Thank you. Commissioner chung. Commissioner chung if i can, ill just speak to the experience of talking to patients. I cant tell you how many timeless i have spoken to somebody who says, theyre miserable and says i know i cant get surgery, i know i cant get hormones and being able to say, yes, we can do that. We can do that in the department of Public Health. You can get those things. How transformative that is immediately in peoples lives. And i think thats where weve got to, with our education, theres a lot of people who are hearing, yes, you can get that. Even if they dont even if a provider or social worker doesnt know exactly how that person is going to be able to get it, starting out with, yes, thats possible in our system is a tremendous change. Thank you. Thank you, doctor. Commissioner chung. Commissioner chung yes. Thank you, director for the presentation. Its definitely heart warming to see that, you know, you were able to provide so much services. There are several questions that i have, like, first, maybe this would be a question more for dr. Pardo, about the Health Outcome part. Do you how does that work in terms of the referrals . Do you have referrals from to the gender health s. F. . And like if so, you know, how many and how would their Health Outcome be measured . Is there actually notable changes . Or how to engage services. I dont poke into the medical record to examine those indicators. But if the Health Commission wanted us to, then we would prioritize. I think part of it is like going back to history lessons. , you know, first transgender clinic started in the city is to really like look at to provide, you know, like patientcentered care. You know, give the patient what they need. Give the patient what they want, and so i think thats really the spirit, providing comprehensive, like transitional and affirming services is to be able to like help them also get what they need. And so thats the crucial part for us. Depending on the procedure, the rate of h. I. V. Positive patients were seeing differs. But for vaginal plasty, its somewhere around 15 to 20 of all of our vaginal plasty referrals and procedures h. I. V. Positive. And as far as i weve looked at, were not seeing any difference in the outcomes for those patients. Sometimes does take a good bit more planning and good bit more coordination with the surgeons to make sure that surgically the outcomes are taken into account somebody may have consequences of a chronic longstanding immuno suppression. As i said, the big change in health often comes at that moment where someone says, yes, you could have access to this. And sometimes we get referrals and when i respond to the referrals, we need to say its really important that this person has good control of virallology and immunologically if theyre having h. I. V. Disease. And then were seeing that people are working with their providers on that. And those numbers are available. But i can say that its it is really good seeing how stable people stay. Okay. Good to know. And certainly, you know, its really important to really ask these patients their quality of life. And, you know, because thats different Health Outcome. You could have good Health Outcome and miserable life or vice versa, right. The other questions i have is when you mentioned about the ability and for some that needs, you know, housing how do you normally address that . A patient coming in with no stable housing. One of the things weve been clear about is that we cant be an intensive Case Management program. So were really working with primary care providers, Behavioral Health providers on that on the housing stability issues. Again its casebycase because sometimes somebody might be living in their car, for a procedure thats relatively minor, if we can admit them to medical respite, they can have a good recovery. And yet we didnt theyre going to have a lot of challenges in their quality of life, because theyre living in their car. But weve been able to take care of one aspect in terms of gender dysphoria, that really was something that was holding that person back. So were working with other programs. As you know, i dont have to talk about the problem of homelessness and just how hard it is to get anybody going forward. But working with our shelters, working with our specialized programs, weve had some ill say for me some surprisingly good outcomes in people who were homeless, when they presented to us, and maybe are still homeless going through a good part of this process. But really getting them held through so that they can i mean, it ranges from everything from respite, shelter placement, period of time at laguna honda, a bunch of things that weve been able to figure out, so people can get through the process, even if were not able to get them a good living situation during it. Thats a lot of collaboration. Thank you. And congratulations to miss aguilar for getting the award. And really showing a prime example of like getting patientexperted care. What happens when somebody gets patientcentered care and, yeah, and thank you so much for all of your work. Dr. Chow. Commissioner chow yes, thank you. And thank you for the presentation. This started back in 2012. And how or what we were going to have. Now you really have a whole program. So im looking at the quantitative evaluation and trying to understand the numbers a little bit. And as we move forward in the program, it would be sort of nice to know, youve got client demographics. What would we need in order to actually look at client outcomes in terms of, you know, making these changes in some of the numbers like, you know, theyre no longer unstable, theyve been able to be in housing and what not. And it might be that im looking at how many of these sort of come into our program the way that you have your demographics and then how have they done in this process, aside from the qualitative surveys that you have done. And so if im reading the numbers correctly, is this that each year these numbers of the referrals are individuals, so theres these are all different individuals and theyre kind of in yearly sort of like going through school, all right. Theyre not the same people, right . They are different . Theyre distinct . The client demographics place, this is one cohort for the entire program of the over 500 patients served by the unique program. The client demographics are about 500. So youve answered my question, that these are aldi stint, different people on the next page, that shows how many came in during what period of time. Some of the referrals are we average about one to two referrals per person. So some may come in for two procedures. All right. Okay. I see. So a referral is not a distinct person . A referral is not a distinct surgical completion, its not a distinct indicator. But the number of patients represented in the demographics are unique patients represented in the tong. Thats just over 500 people. And thats over the course of the seven years . Yes. Six years. Okay. So over the course of the six years, these are sort of their profile. Since we have begun doing surgeries and all, is there a way of understanding what has been, you know, the results for these individuals lets say the 500 individuals about, say 100 of them came in six years ago, just so make this a little easier. Where are those 100 now and how successful are they been in terms of, of course, youve demonstrateed that they are feeling better and theyre doing better. Are we also able to assist them in their housing and employment and all, which then gives them a life . I know youre implying it says they do. Id like to know if we have actual data that begins to show, im working on 500 people here, the first 100 over the six years, while theyre only threequarters of the way through their transition or whatever it is, this is also whats happened to their demographics. Is there a way of doing that or just too complex to understand what kind of outcomes were getting . Its certainly something that we could do, by going into the Behavioral Health record and or the primary care record. But within the scope of what the program does, it would be a little bit beyond the scope of the program itself. The program serves as a surgery access and navigation for accessing these medically Necessary Services, as opposed to a larger as dr. Zevin said, it doesnt function as the hub of intensive Case Management. So could we say how many people completed through what you would consider a completed course of this and then what have those people done. Is that something that we have . The Program Evaluation follows patients over the course of approximately 12 months. So we captured them at ip take and then we follow them up approximately six to 12 months after a surgery. Again its a voluntary process, people dont have to participate in the Program Evaluation. Weve captured data represented here, is just over 60 people. We have now approximately 75 data points for followup surveys, although we have over 150 interviews in an entirety. Certainly this is not this is 1 5, 20 of all of the patients served uniquely by this program. But in terms of getting a profile of following a day in the life of some of these folks, might be able to do Something Like that. Ticket talk with my team back in quality management. I guess im just more interested in knowing at what point were able to say that we have actually been able to help people and in order for a number of people to understand why we have these programs, i think its necessary to show that we are helping people. Were helping through the course of treatment. In terms of what these surgeries are shown in the literature to change, in the life of a patient served by this program, we do have the indicators for for that. In the peer navigation Wraparound Service and accessing the medically Necessary Services, using the same psychological and social Outcome Measures used in Natural Services such as the United States Transgender Survey and some surveys that look at the general u. S. Population, regardless of gender identity, for psychological well being, as measured by the w. H. O. , quality of life scale, and then useing some of the psychological distress measures as measured by the kessler six, we are definitely showing significant improvement as a result of accessing services in this program, for psychological well being, sense of hopelessness, better reduced body discomfort, reductions in gender dysphoria, reduction in substance use. Those are some of the primary indicators that we show are primary have Health Disparities in this population in general. So could you say that 60 people have exhibited that . Yeah. Im looking at the numbers in front of me, about 60 people have participated in the program. Okay. We think that this survey has shown at least these 60 and whatever stage theyre in, have shown improvement in these elements. Yes, sir. Well, i think that as we move into maturing the program, it would be good to try to really continue to hone in on that. And get some uppitification to the qualities that we believe is happening. And it would also be good to show how were able to change some lives as we go along. Its obviously taking a long time to get that. And even to have 60, i think is a good number to even talk about in these six years. To say weve helped these people. And it would be good then that we continue to look at this program and in this manner, in which we try to understand them, quantify how many people we are helping. Thank you. Thank you. Commissioner chung. Commissioner chung actually more questions. I think that, you know, its great that we have this service. And, yes, i understand that gender health s. F. Is not intensive Case Management. But i think its a great tool for other d. P. H. Departments, especially primary care and mental Health Services. So it would be it would be great to like have some feedback from, you know, like from primary care, for instance, or from mental Health Services, you know, like that. What kind of improvement, you know, that providers actually clinicians actually observe, for instance. I think more adherence to medications, are they like following up with appointments and i think that that would help us understand how to tell that story effectively. Thats great feedback. Thank you. So commissioners, president loyce had to leave and ask i that continue to chair the meeting. Im take that prerogative and make one comment. This might be where can be quite useful, because i recognize the program itself doesnt do all of those things. And even to be able to tell me you feel 60 people really involved in having been able to come to a positive position in life is really important. But to do as commission chung was talking about, we should be able to then through our coordinated efforts in the future, to really understand whats happening in the other spheres of our medical record for that patient, in order to really demonstration the positiveness of the program. So do we have any other comments, commissioners . If not, then we thank the presenters for their fine work. And we look forward to future reports. And we can go on to our next item, please. Thank you, all. Commissioners, the president has recommended that you defer the next item, due to time. And go to closed session. So we want to thank miss scarborough for being here and we will schedule her for hopefully the next meeting to present. Because its not about the intent or the interest of the topic, but its about the timing in the closed session. So, commissioners, without objection, we will take that recommendation. And we are now open for motion in regards to the closed session. Was there any Public Comment on the closed session . Actually if i can quickly go through two other items before we get to closed session, just other business, i can name then. Any other business . Hearing none, we can move on. The joint Conference Committee update, the meeting at the laguna honda j. C. C. Was yesterday. It was a closed session. I can speak for commissioner guillermo. And then now you can canner a vote on the closed session. Okay. There are no comments on closed session before us. A motion for closed session is in order. Motion to move into closed session. Is there a second . Second. All those in favor of a closed session, please say aye. Aye. All those opposed . We shall then now go into closed session. Thank all of the public for being present and those who are not present for the closed session so commissioners we have a vote to go back into open session. A motion whether to disclose or not discloses. Motion not to disclose. Second. There is a motion and second not to disclose. All those in favor of not disclosing please say aye. Aye. All those opposed . We shall not disclose. There being no other business, the motion for adjournment in order. Move to adjourn. Second. All in favor please say aye. Aye. This meeting is now adjourned. Thank you. Hi, im lawrence. We doing a special series about staying safe. Lets look at issues of water and sewer. We are here at the San Francisco urban center on Mission Street in San Francisco and im joined today by marrielen from puc and talk about water and sewer issues. What are things we should be concerned about water. You want to be prepared for that scenario and the recommendation is to have stored 1 gallon per person per day that you are out of water. We recommend that you have at least 35 days for each person and also keep in consideration storage needs for your pets and think about the size of your pets and how much water they consume. The storage which is using tap water which you are going to encourage. Right. Of course at the puc we recommend that you store our wonderful delicious tap water. Its free. It comes out of the tap and you can store it in any plastic container, a clean plastic container for up to 6 months. So find a container, fill it with water and label it and rotate it out. I use it to water my garden. Of course everyone has plastic bottles which we are not really promoting but it is a common way to store it. Yes. Its an easy way to pick up bottles to store it. Just make sure you check the label. This one says june 2013. So convenient you have an end date on it. And there are other places where people have water stored in their houses. Sure. If you have a water heater or access to the water heater to your house, you can drink that water and you can also drink the water that the in the tank of your toilet. ; not the bowl but in your tank. In any case if you are not totally sure about the age of your water or if you are not sure about it being totally clean, you can treat your water at home. There is two ways that you can treat your water at home and one is to use basic household bleach. The recommendation is 8 drops of bleach for ever gallon of water. You add 8 drops of bleach into the water and it needs to sit for 30 minutes. The other option is to boil water. You need to boil water for 510 minutes. After an earthquake that may not be an option as gas maybe turned off and we may not have power. The other thing is that puc will provide information as quickly as possible about recommendations about whether the water is okay to drink or need to treat it. We have a number of twice get information from the puc through twitter and facebook and our website sf water. Org. People should not drink water from pools or spas. But they could use it to flush their toilets if their source are not broken. Lets look at those issues. Sanitation is another issue and something people dont usually or like to think about it but its the reality. Very likely that without water you cant flush and the sewer system can be impeded or affected during an earthquake. You need to think about sanitation. The options are simple. We recommend a set up if you are able to stay in your building or house to make sure that you have heavy duty trash bags available. You can set this up within your existing toilet bowl and once its used. You take a little bit of our bleach. We talked about it earlier from the water. You seal the bag completely. You make sure you mark the bag as human waste and set it aside and wait for instruction about how to dispose of it. Be very aware of cleanliness and make sure you have wipes so folks are able to wash up when dealing with the sanitation issue. Thank you so much,