Report. Good afternoon, commissioners, the director of health. You have the report in front of and you ill highlight a few items and take any questions. On june 13th, california lawmakers approved the 240. 8 billiondollar budget for fiscal year 20192020. And one of the most notable pieces of this budget is that it expands medical budget to 19 to 25, regardless of immigration status. So this is expected to provide full scope coverage to 90,000 undocumented in the first years across the state. So very excited about providing increased coverage to the population in need. And on june 4th the board of supervisors passed legislation to implement sb1045, sponsored at the state level by senator mark wiener and locally by mayor london breed and supervisor mandelman to provide care for San Franciscoians in need who have Severe Mental Health and Substance Abuse disorders. And its part of the mayors efforts to have response for those in need of treatment. And the mayor is including an investment in this years budget on including funding 100 new treatment beds. Last year as well as an additional 100 new beds as part of the budget this year. So a transformative change in terms of investing in Mental Health and treatment beds. Im also really happy i was able to attend this last previous thursday mayor breeds invincible women summit, and it had an outstanding turnout. It was a oneday event that inspires women to activate their personal power and collective strength, provide tangible takeaways and to have coalitions to create solutions to challenges. Among the many businesses and organizations that led sessions i was really pleased that the department of Public Health was there and promoted resources by featuring four exhibits, careers in health care and reproductive help and mindfulness in health and heart health. So really good Educational Opportunity as well and i have to say a recruiting opportunity for the departments. And also on june 7th, we had a challenging climate for three days and you may recall that we activated our emergency heat Response Plan and convene the Incident Management Team in response to the heat advisory that was placed by the National Weather service and it was three days of hotter than predicted extreme temperatures and staff worked 24 hours a day to serve populations under difficult circumstances and the work with our partners and staff implemented the new mrl mutual aid plan to successfully to have an increase for ambulances and to keep our system running and the Public Information was put out in messaging across the city including the populations and the warnings this year to remind people that heat with can remain elevated indoors even after the temperature cools and so forth. So the key thing is that the staff allowed engagement and to have wellness checks for populations that collaborate to work with other agencies and departments. And we did much better this year in terms of our response and we got the information out faster and had a quicker response in terms of ambulance availability on making sure that shelters, hospitals and our primary care clinics were providing cooling for our clients and that cooling centers were made available rapidly and people knew where they were. And that concludes my directors report and if you have any questions with regard to the items that i just went over and other items in the report that i didnt highlight, im available. Thank you. Commissioners . Commissioner chow. Yes. Thank you. And the question really relates to the heat and our own facilities. And the question, as a matter of fact we just happened to not hold a meeting up at laguna and we understand that the temperature up there was like in the high 80s or 9 is. Do we 90s. Do we have a plan internally about the routine services that were providing so that the staff itself could also then, of course, be also be assisting those that need other assistance, but not hold the routine meetings so to speak . Because it m might be that its high enough now that were getting these intense changes in weather and especially heat here what we dont necessarily have, you know, cooling or appropriate in certain of our workspaces that were able to also accommodate our staff along with helping the public. Yeah. So i think that the overall question is what is our plan moving forward for further events like this with regard to for our staff, right. Right. So we have we do have a plan moving forward. I think that we have the immediate plan which is to ensure that we have as many air conditioners and fans as possible to implement quickly and that people know where those are and that we have clear people responsible for buildings and something as mundane as having a clear understanding of who is taking the temperature and where and what time of day so we have a better sense of where things stand. Thats been vastly improved since my understanding from last year when we had serious heat waves. And the next step then is also in thinking and were working with our with our engineers on this and thinking what are the investments that we need to make in our infrastructure with regard to better cooling possibilities, because this heat event was three days and its early june so i think we need to think where wed be five or 10 years from now and when these events would last longer and occur even earlier and what are the cooling systems that we need to put in place to ensure that our patients are safe and our staff can do our work and so we have the Immediate Response which is what can we pull together now and how to ensure that plugin air conditioners isnt overwhelming the power grid in our systems which can occur. And what is our longer term infrastructure, what our longerterm infrastructure needs to build out cooling for what is going to be a profound Climate Change i think in the next in the next decade or so. Yeah, im just wondering if maybe in about 60 six months we could get a followup and we often have very warm days in october. Yep. So these extreme days are apparently going to be more routine as the former Governor Brown even noted that its a new world. And i think that its important then that we take these measures that you are doing and then it would be good to have the followup. Im happy to bring that and to also bring the community and to inform people in the community and people on the street in terms of how to take care of themselves. And the heat levels will certainly include that. And i have asked the team, given the last this last week with what happened to come up with a plan with with a projection of what resources are necessary so that we can certainly bring that to the commission. Good. Thank you. Commissioners, any other questions . Seeing none. Clerk item 4 is general Public Comment. And for those of you who are making comment i will have a time theyre when it buzzes please know that is your cue to finish your sentence and let the next person come forward. Im going to call out a series of names and line up. And gloria simpson, and Raquel Rivera, and bruce palmer and mark argon. Please come up. Hello, commissioners. Were back with the same arguments, pleading to have a hospital base in San Francisco. These patients that have been diagnosed have been at st. Lukes for many as 10, 20, 30 years and then in less than 12 months theyre dead. Tell me honestly have you ever heard such a thing . Losing a patient almost every month, there was 17 and now theres 11. We mentioned last year that they did not have experience of acute staff. They hired r. N. S and trained them for a few weeks. When st. Lukes staff had over 50 Years Experience combined. If San Francisco had a permanent hospital base, then they would have been forced to keep proper staff and care for these patients but now theyre doing the bear minimum. How are six patients dead in less than 12 months . When is it going to matter when youre sick and when you cant breathe, i have photos here of my sister which we mentioned several times to have her in a walker and they did not. I told them that my sister was sick and they didnt believe me until i had to call the doctor. And she had pneumonia and was in i. C. U. And her foot, she fell because she didnt have a walker. And this is the type of care of minimum staff that we have at cpmc. If you could please have the Permanent Base of subacute before its too late for the other patients. Thank you. That was gloria systemson sie sister is a subacute patient. And my name is Teresa Palmer and im a retired geritrician and i used to work with the subacute families. And there were 23 you know, them wanting to close down subacute so anyone who needed this complex pharmacare would have to go out of county because the community and the families organized cpmc did offer to care for the 23 remaining out of the 40, and now theres 11 left. And during that time we were having talks with director garcia who did indicate that it was possible that deaths could be realized at st. Lukes. For a permanent subacute, a private Public Partnership of some kind. And this is critical. Its egregious that people this sick have to leave their families and their communities in order to survive. If you had copd and you ended up on a ventilator and your quality at life at home was good and you knew you could get off that ventilator but you needed some months to do it, to have to go to fresno or san jose is crazy. Its demoralizing. Theres a higher death rate. You need to be where your support system is, your psychological and support system is. And the other thing that is making the subacute families very frightened is that as the subacute patients die off that the staffing is less and less. The subacute patients have to be distinct from other patients so that the dedicated staff has up and left. Okay, thank you. Good afternoon, commissione commissioners. My name is Raquel Rivera and my sister, sandra, is one of the 17 patients that transferred to cpmcs davies campus late last year. Sorry, im trying to catch my breath. Last year we told the committee that these were the same that these very same 17 subacute patients rivered transfer trauma and as a result possible death based on the historical medical datas. In less than 12 months, six of the acute patients have died. Im here today because my sister almost died too from the neglect of cpmc. My sister had sustained injuries from a fall which caused severe bruising on her foot and ankle. Within one week from the fall after insisting that something was very wrong with my sisters health, she was admitted into i. C. U. For breathing complications. It turned out that she had pneumonia. My sister almost died. And if it werent for my familys regular checkups, cpmc would have let her die. Those six patients probably could have lived today if cpmc had kept permanent experienced staff. Instead, they hired nurses who have no specialized subacute experience. At st. Lukes, cpmc gave severance packages to those experienced subacute staff instead of transferring them with the patients. My sister would have died if this unit wasnt hospital based. Because she was suffocating and only had minutes for emergency treatment. Im scared for my sisters life and to wonder what will happen to the level of care when there are only a few subacute patients left. Im sorry, its time. I dont want my sister to die. We need to maintain hospital subacute care. We need experienced permanent staff. Commissioners, we need to reopen the discussion of subacute care in San Francisco. For the care of my sister and the rest of the patients, thank you. Thank you. Commissioners, i am mark ericsson, a professor of law at the university, and i work with our community, the Economic Development clinic and San Franciscoioans for housing and jobs and justice. And we ask to be distributed to you before the presentation today a position paper. Its the latest revision of our position paper that has additional Background Information and on the last page it lists proposals. Were here today to urge you and we have met previously with director colfax and met with Deputy Director patel on this issue and they have been receptive. But given the the number of priorities that are around we are here today to urge you to make subacute care a very number one priority. Now our paper addresses in detail background and some of our concerns. I want to highlight today just one very important point that has to do with cpmc and it is relevant to the 2017 charity care report that you just had submitted to you at a previous meeting. I apologize for us not being there at that time. One of the striking facts that comes out in that report is that since the Affordable Care act has been administered, not surprisingly, the number of people on traditional charity care is down with the amounts of money spent by hospitals on traditional charity care is up. This is mainly because of people getting private insurance through the exchanges and the expansion in medical eligibility. Whats gone along with that for every hospital in San Francisco except the cpmc hospitals, is that the medical shortfall, the difference between what they say they charge for their services and what they get reimbursed, has gone dramatically up, sometimes two or three times at other places and at cpmc, time has gone down. This is very suggestive that cpmc is not doing its fair share of meeting the poor, the health care need. Time. Thank you so much. I have extra copies of this report if needed. Thank you. I have three more names here. Ken kom, and paul cartier and latia montana. Latia montana. Many of us know that from our experience with our elders, a real impact and risk when you move people away from their supports and their loved ones and family, that is actually detrimental to their health and actually puts them at risk of passing away. And so i think you know from our own experience, this is a real fact in our lives. This is the impact of whats happening. And so i saw call on cpmc especially as the largest, as the most profitable, private hospital chain in San Francisco. I think a unique responsibility that we need, both from all of our health plan throughout the city, but especially with cpmc. Especially with them to provide the care that our Community Needs and deserves. Thank you. Good afternoon. My name is paul cartier. And im a citizen of San Francisco. I have been for 40 years. I made my home here. I have a we bought a house here, my wife is here, my daughters right here at the moment are here. And im very concerned about the moving of any kind of subacute sniff services out of the county. This would create a if i was in that position, and i can easily imagine a situation as a cyclist, as a driver in the city, where i might be put into a situation where i would have to be taken care of in that kind of facility, to be moved to somewhere tollly out of the region, not just out of county, would be an extreme hardship on my family. And would be a hardship on anyones family frankly. And it would be hard on me as well, because has been cited the survival rate is not good for people who are outofcounty, who do not have, you know, regular access from their families. I believe that cpmcs decision is basically unethical, its immoral and inhumane. And it kind of defies modern reality is youre in the city. Thank you. Thank you. Hi. Im with senior and disability action. And also the coalition. And i every time we come here here at city hall, i i feel really bad about the city where we live in, its a city that doesnt really value human life and allows well, maybe the whole country actually, it allows really forprofits, hospitals to run as nonprofits. And allows them to do the bare minimum and get more profit. So i dont know what kind of power the commissioner and the director have. But i i beg you to really see how you can make this hospital accountable. Its not its not easy to hear that in 11, 12 months this vision that weve been fighting along with has died. And these families have to face this loss. And the hospital is not accountable. And what is going to happen to the rest of the people that need this kind of support. So, please, if you have any power over them, use it. And make them accountable. Thank you. The last speaker i have up here is michael lion. Yeah. Im michael lion. I lived in heights for 40 years. We fought like hell to keep st. Lukes open. Cpmc and sutter did everything they could to try to close it. It only stayed open because somebody on the inside revealed that, in spite of cpmcs promises that nothing would let them close st. Lukes, they actually intended to do it all along. And at that point all hell broke loose and they had to keep the st. Lukes hospital open. However, the level of services that have happened since then have gone way down. Were going to be talking about that later this afternoon. But its so perfectly obvious that the deaths that have occurred on the subacute unit, the death that happened all over the city back of the lack of continuum care for old people, comes only from the profit and the profit mode. And it comes from the fact that the hospital cpmc dont get reimbursed as much for subacute or sniff care. But their obligation their obligation to provide that care remains. This is such a demonstration that capitalism kills. Thank you. Thats the list for Public Comment on this item. Yes. And if i may, commissioners, just a note to the public that the standard for city commissions, with receiving Public Comment, is that they dont comment on the Public Comment. And theres not interaction between the body and you all. So just i wanted to make sure that everyone understood that. Item 5 is the committee and Public Health committee. Report back. Good afternoon, commissioners. The community and Public Health committee met earlier this afternoon. And the chair commissioner bernal was not able to attend and so i chaired the meeting in his place. And he had two pretty interesting presentations. The first one is from the food safety. So its food safety program. And, you know, to really hear how much they have to do in, you know, in addition to like inspecting, making like over 8,000 inspections a year. And, you know, its definitely, you know, a very educational. The second presentation was for h. I. V. , h. V. C. , s. T. D. Road map. I think right now and director Tracy Pickard did some presentations and really, you know, highlights how, you know, they are like looking at im looking for. Like more integrations on how services are provided across d. P. H. And also to really get the kind of care that we san franciscans deserve. And also we will be looking at a very similar to center for excellence model, except this time, you know, it was really also in the other components that often get missed, for instance, you know like to really able support drug users and other atrisk populations. And there will be r. S. P. Coming out shortly. And that concludes the presentation. Commissioners. I was wondering, as i perused the presentation on the restaurant inspections, what they were envisioning as coming in 2019 in their final power point. Is this a new public way of expressing something concerning a restaurant . Or they now have codes, you know, numerical codes that are suppose to be displayed prominently in a restaurant. So does this replace this . I believe so, from the presentations, they are going to adopt this process, which is called plaque. And apparently we are going the last county around the bay area that is like implementing that right now. It really you know, we really look at focusing on, you know, the highrisk you know, highrisk category and there are five of them. Instead of like trying to like take on every single little detail, you know, so like it gives like business owner, you know [indiscernible] recommendations as fast as possible. And so were doing away with the knew mirecal system and moving on to a pass system. Yes. The green, the yellow and 9 red. And are the other counties doing that, too . They have already implemented that. Is this sort of a state of california . No. The bay area counties. Bay area. We so we look at the counties around us, currently were the only one who hasnt adopted this. Okay. So now were going to look for green for the restaurant. Its not going to be a numerical score. Yellow means that theyre still open . Im just very interested. Because were going to be a consumer, right. Well, believe me. After we saw the pictures, thats what we think about as well. Yeah. And i think that what i understood was that, you know, this new system would provide more realtime, you know, like changes to, you know, like when they address the issues. You know, they can resolve that almost like as soon as immediate, to change their color. Like so to speak, you know. If theyre yellow, if they can improve, you know, like in a very timely manner. Instead of like having like a point system, which you know like 10point drop might not be like highrisk factor, it might be, you know, very low factor. But it would impact, you know, like the revenues of the restaurants. And so, you know, this is really looking at that they can work better together. So a yellow says these things have to be done, but you can still go there. [laughter] im just trying to understand why theres a yellow. But lets have dr. Colfax help us. Yes. I was just confirming with the secretary that we would come we would bring this to the full commission for a followup report. I believe that the intent to do that is before this is adopted. No. No. Thats fine. Its certainly something its going from a quantitative measure to a qualitative measure. And there are lots of interesting pieces that the team can the teams worked really hard on this for a number of years. Im sure they would be very excited about sharing the thinking behind this in great detail to the commission. All right. All right. Ill certainly defer questions tonight. I do think something of this magnitude, coming to the commission, is appropriate. Other commissioners . Next item, please. Okay. Thank you. Ill note no Public Comment for item 5. Item 6 is an update from the december 4th 2018 proposition qhearings. And the change of management of Outpatient Departments from cpmc to the Sutter Pacific medical foundation. Good afternoon, commissioners. We have the policy and planning. The department of Public Health. Today im going to be providing you with a brief update on some of the changes that were presented to the commission in 2018, regarding several changes that cpmc announced. Before i begin to do that, i just want to, just as ra he mind reminder, proposition q requires private hospitals in San Francisco to provide Public Notice before closing a hospital inpatient, or outpatient facility, reducing the level of Services Provided or prior to selling or transferring management of services. So in 2018, cpmc notified the Health Commission of three changes that they were making. The first is a change in licensure of the swindell alzheimers day program. The second is the closure of swin january dells alzheimers Residential Care facility for the elderly. And the third is the transfer in management of five Outpatient Services from cpmc to Sutter Pacific medical foundation. So just as a reminder, the Health Commission held three hearings regarding these changes. On july 17th was the first of these hearings. On august 21st in 2018, the commission made a determination about the ciaos of the Residential Care facility, indicating that the closure of the 24bed facility would have a detrimental impact on the community. And at the meeting in august, the commission felt that they did not have enough information about the other two changes. And requested to have a hearing at a later date. So at the last hearing with had was on december 4th, at which the commission passed resolution 183 and 185, which determine the impact of the licensure change, as well as the transfer of management of services. And so at the december meeting, i know the Health Commission encouraged the department and cpmc to continue to update you about the progress of these changes. And so thats what ill be sharing briefly here today. So just as a reminder, the swindell alzheimers day program serves around 70 adults with mild to moderate dementia. It is currently located at the cpmc california campus. And its currently licensed by both the institute on aging, as well as cpmc. And the proposed change was that the program would only be licensed by institute on aging alone. So in december, the resolution that the Health Commission passed noted that this change would be detrimental if the institute on aging was unable to secure a new location for the program. And to continue to provide similar or expanded services to seniors without interruption. So today our update, as of june, which we are pleased to share, is that i. O. A. Has signed a lease for a property in the perseido and anticipate to move in july of 2018. I believe they estimate the program can serve up to 88 people today. We have a representative here who can elaborate on this, should you have questions. The next change is the management the change in management from cpmc to Sutter Pacific medical foundation for five Outpatient Departments. So these departments were the breast and mammography center, the noninvasive cardiology at st. Luke 80s, the Diabetes Center at st. Lukes and california campus, as well as the outpatient psychiatry clinic at the pacific campus. So the meeting in december, the resolution that was passed by the Health Commission, said that the change would be detrimental on the cpmc and Sutter Pacific medical foundation took specific actions to see no disruption in services, to ensure that culturally and linguistically appropriate services were provided for individuals impacted by these service lines. And that there would be continuing education for patients, who have nongestational diabetes at the st. Lukes campus. So we have a few updates on this change today. So in december of 2018, cpmc reported that, due to a staffing issue, they were unable to see nongestational diabetes patients for several months. And in the interim, patients who had been seeing a diabetes educator at st. Lukes, would be sent to the california campus. And so as of june, cpmc has indicated that the medical foundation hired a diabetes educator on january 7th. And so, therefore, the diabetes patients do not no longer need to travel to the california campus to receive that care. And i have two bilingual diabetes educator and an onsite medical assistant. With regard to contract negotiations in december of 2018, cpmc reported that the medical foundation was contracted with brown and tollen medical group. And was still in the process of negotiating with San Francisco health plan hill physicians. So as of june 2019, the foundation does not anticipate that they will be able to secure a contract with hill physicians. Hill physicians believe that its Current Network of providers is adequate to provide the care for patients that are referred today. And with regard to the letters of agreement, Sutter Pacific indicated that in december that it is their policy to develop letters of agreement, with all patients who have noncontracted health plans, so there is no loss of coverage. As of today, there have been about 240 letters of agreement that have been submitted and approved. So that concludes my brief presentation. I know that we have dr. Calvin lamb, who is the chief medical officer for Sutter Pacific bay area here, to help answer any additional questions about the change in management transfer, as well as tom, who is the chief executive officer who can also speak to the swindell day program. Commissioners, several Public Comment requests for this item. I have two. Yes. Thats what i have received. Okay. Im going to call the names for the Public Comment. Once the Public Comment has been completed, this will be in the hands of the commission for us to discuss. And ask any questions we may have. The first name i have is dr. Theresa palmer and the second one is liga montano. Yeah. My main concern is with the swindell center. It sounds like it successfully transferring to the precedeo without an interruption of care. So thats good news. I am concerned about the Diabetes Center. Whats gone on is the transfer to the medical foundation was part of the picture of ongoing, progressive defunding and moneysaving measures on the part of cpmc. Although we were assured december 4th that the medical foundation and the hospital is quote unquote under the same financial umbrella, this these financial people have done everything to limit payroll and save money. And not reach out to the population in the mission, around st. Lukes, who are very much at risk of diabetes. We know the extremely high rate in latin and filipino populations have diabetes, of underserved people. There is no r. N. Diabetes counseling. Its no longer in the montego lobby, its hidden some place at montego. What weve heard from st. Lukes primary care physicians is people arent bothering to refer there any more, because aint nothing happening. You cant get your patients insulin type rated. And so the and furthermore, the cpmc sponsored clinics in the neighborhood have only m. A. s. And so the only person to type rate the insulin is the doctor on the big 15minute visits that they get with the very complex patients. They essentially have no help, they have dietitians, but not nurses. And so theres disinvestment in the community, ha has been progressive. Time. Thank you. Thank you, doctor. Im liga montano. As a person with a family and a background heavy on diabetes, i just feel that feel that its not the most responsible way of dealing with services. If they are really thinking about the community, they need to understand the community. What count of issues, the Health Issues the community has and what kind of needs comes with that. So i think that they are not providing the services they were actually providing before. Just saying they really dont care. And they are transferring the accountability to somewhere else i heard that they were trying to contract, you know, older places to do some classes on diabetes. But i think its beyond that. Its not just education, but also the service that is provided. So like i said, you know, my family we have high incidence of diabetes and i know its common in the latinos, like myself. And the filipinos and some blacks also. And we tend to be on the low income side. So its not profitable for them. And i think it goes back to how come they run as a nonprofit, when theyre not providing, you know, for lowincome. Thank you. Thank you. Any other Public Comment . It is now in the hands of commissioners to raise any questions for clarification with regard to the cpmc update, as provided for us. So, commissioners. Commissioner green. I wonder if any information how does volume relate to, number one, unique patients, what the actual conserve is, you can look at the average number of patients from closure. But whats happened august compared to may . In other words are there any data of attrition of patients . Then the other thing that i was very confused why is how many of these patients i dont have contexts what the l. O. A. S mean in terms of actual patient volume. I guess the last question i would raise, whether any consideration given to those contracts that couldnt be accomplished for cpmc to keep those the contracts and subcontract with sfdph. I wonder if any more detail on the items that someone might have. Ill ask dr. Lang from the medical foundation to come and speak to this. Good afternoon, commissioners. Im dr. Calvin ram. Im the c. E. O. Of the medical foundation in San Francisco. So regard to commissioner greens questions, ill start off with the last one, because i can remember that one. Subcontracting requires both parties. So its not like hill can contract with lets say cpmc or another party. And that party can then subcontract out with someone else, because often these contracts restrict that you cannot subdelegate. So thats not something that will still require the other party to agree to subcontracting. Because otherwise then that gets around a network issue. Then your network is wide open. And that may or may not be the intent of any particular i. P. A. Or physician network. In terms of our population and the payer mix, the data that i have so far, we can certainly look into more, but the data that i have is certainly showing that before and after the transfer of these programs, the patient volume has remained pretty similar. It hasnt really changed much at all, as well as the peer mix has also remained fairly similar, before and after these programs. So any other questions that you had . Well, i was just curious if you keep the diabetes program, whether the actual, you know, unique patient volume has changed. And also what the before the spacing of time, when you didnt have the services available. Because clearly in a disease like diabetes, if theres several months without services, theres clearly going to be some patient attrition. I was just confused about when you say 85 patients per month, is that the same patient coming back twice a month or is that actually a volume of patients that hasnt trailed off since the services have waned . I believe those are unique patient counts, not patient visit numbers. But we can certainly look further into that as well. Any other questions that i can answer . Thank you. I had a question about the cardiology. There wasnt really a mention of what the i guess the impact on these services are, particularly is this data point similar to commissioner greens questions about the around the average of 60 patients a month, compared to 85 patients seen prior to the change. And if you could comment on that. And on the impact in particular. I think overall thats still within a volume where i think up and down its hard to say whether why the referrals might have gone up and down a little bit and varies a little bit. But i think statistically speaking its certainly within a similar number, before and after, for this particular program as well as the Breast Health and diabetes programs. So when we look at it, we didnt really notice a significant volume change from before and after. But in both cases, the volume has gone down. So in that sense, there is sort of from a bigpicture standpoint, right. Even though maybe there isnt statistical significance to that, theres still a trend in terms of lower volume . We have every time a patient has come and they have had existing services or theyre requesting services, weve made every attempt to get, if theyre not in our networking to get letters of agreement with their insurance to allow them to be seen in our office. And for the most part, weve been able to make 200 plus separate letters of agreement. But there are those with particular h. M. O. Networks, where they prefer to steer their patients into their own network of providers and believe that their network is currently adequate to steer patients into their preferred network. Commissioner guillermo okay. Anything else . Commissioner chow. Commissioner chow yes. Thank you, doctor, for coming. I want to make a little different perspective, because i actually reading from director payos report and encouraged at what the foundation seems to be doing, in terms of the transfers and working on the letters of agreement. And certainly on a competitive basis, some Groups Holding their own contracts may feel that this may be an opportunity to transfer patients back into their own network, if youre not part of their network, of course. Im looking from a patient standpoint, in order to access these services now, as versus when they were under cpmc hospital itself, is it a more difficult for the patient, that is is there a seamless approach in registering and getting into and having the service rendered . Or do they now have to actually go to a spot three blocks down . Or is this just as convenient . And all that happened was there was a change in registration and who actually was the payer for the service. So for the most part, these services are still within the same location or the same building. Commissioner chow okay. I like to believe on the foundation side that often its easier to register on the as an outpatient, on the ambulatory side, as sort of a foundation outpatient than registering on the hospital side. So, if anything, it might be a little bit easier. Commissioner chow thats your feeling. So youre saying most of the services are actually or are all of these Services Still in the same location, except for the ones you said you were moving . Right. Commissioner chow okay. So if i just switch over then to the question of the Diabetes Center. And i do see in the update, and i think we should reemphasize this, this is one of the big contentions that the question of the culturally educateor of diabetes, you have, in fact, then had the ability to hire the diabetic educator, is that right . Thats correct. A bilingual diabetic educator has been hired. These are difficult employees to come by. But we were fortunate enough to hire one relatively timely in january. And on board and get things going. Commissioner chow and that you then it says there are two bilingual diabetes educators. So did that add to one already . Or is there more that you added . And onsite medical assistant, who is a certified translator. So do you feel that youre able to actually then treat the bilingual, culturally or mono lingual, spanishspeaking people and that the Diabetes Center has been doing outreach to indicate that this is what you have over at the center . We certainly are now able to treat the spanishspeaking and we have other Translation Services for other whether its chinesespeaking or some other languagespeaking patients as well. Because in San Francisco its not you know, we have multilingual patients and we try our very best to serve the whole community. Chow yes. So if, in fact, at the Diabetes Center it appears that previous to this there were 95 patients per month, its the way im reading, since youre saying these are patients and not visits. And now we have 85. Not a huge difference but still. Do you feel that the mix is the same or different . And what what has the center done in terms of outreach to indicate that youve actually been able to bring back the bilingual services and are encouraging and would like to encourage people using the center as a community service. Sure. We sent out letters to former patients, who were utilizing these services at the same site. So weve certainly reached out to those existing patients. And, if anything, our payer mix our proportion of medical patients have slightly have gone up slightly and not done. So were serving a little bit more of the underinsured patients. But again whether its whether it is statistically significant or not, that is a little bit more difficult to say. But if anything its gone up a little bit. Commissioner chow sure. I know this was a question that probably will rise again at the Development Agreement level. Because there was great concern as to how this center was going to help serve and hoping to enhance, for our community, the diabetes services. So im wondering at that particular time, rather than asking to bring back data now, because this is june and more than likely the d. A. Visit will be probably what september, october. If at that time, some of us might ask and we would like to know then some quantitative data, perhaps, of the loads of services that youre able now to perform, what was performed say now as versus prior to the takeover. And the problems that occurred when there seemed to have been some loss of the ability to have culturally confident services. So you can actually help demonstrate and the type of outreach to show the types of services youre now rendering, the quantities and the mix of the patients. I think that would help answer some of the questions that the commissioners have. And rather than asking you to come back here, i think we could well hear that within the Development Agreement report. Great. Commissioner chow if that makes some sense. I think this to really understand how Many Services now, were there before. And any kind of comparison you wanted to make it with. And that this transition, im hoping youre able to demonstrate is actually positive for the community. And youve been able to resuscitate the diabetes clinics and under the foundation this really is a valuable service to the community. Thank you very much for your time. Commissioner chow thats my comments. Another question about the impact. So a lot of folks have been on access to services and the level of services. But i dont know if this is possible. But is there have you been able to track the patients that have