Transcripts For SFGTV SFDPH Health Commission 20240712

Shes served with the San Francisco District Attorney since 2005 and bridges a wealth of knowledge and experience to the commission with regards to bee hair youral health and equity. She served on the San Francisco Human Rights Commission for eight years including as president of that commission. Were so happy to have you on board. Ive had the privilege of knowing and working with you for many years so welcome. Would you like to say anything upon your first meeting . I just want to say thank you, dan, for that introduction. Its a privilege and a thrill to be here. Im very much looking forward to being able to join this work on behalf of the city and the people that live in our community. So thank you, its good to be here. Good, good. Thank you to mayor breed foray r appointing you. The approval of the minutes from the last meeting of june 23rd. Upon review of the minutes, commissioners, do you have any edits or if not, we can have a motion to approve and also check to see if we have any Public Comments. Move to adopt the minutes. Second. Im not opposed to adopting the minutes. Im just trying to understand for fourman purposes do we need to write down this was virtual or we dont have to . Thats not necessary but thank you for that question. Thank you. No problem. Thank you. Second. Secretary marwits do we have any comments. Do we have any Public Comments . We have callers but no one has their hands raised at this time. Thank you. Mark, would you please do a roll call vote. [roll call] could you all mute your microphones. Were hearing some background noise. Can i go ahead and call the next item. Yes, please. Great. Give me one second to. Were going to skip item 3 and come back to it because the doctor is having trouble signing. We can move to item 4 which is the covid19 update and we have dr. Seuss an phillip to provide an update on Contact Tracing. And other things too. Hello. Hello. Good afternoon. Thank you. Im happy to be here. Secretary moore you would be able to help me with the slides. Can you give me 30 seconds to load it up. I apologize. And what were doing now, and how were continuing to improve the work. I want to start with just doing a quick overview and contact the tracing and how we think it can help in reducing covid19 transmission. The approach that were taking, what the status is of the work right now and then some of the challenges and the strategies in Counter Measure for thinking about going into our coming weeks and months. Next slide, please. Just to quickly go over key definition and i realize this is old hat for many of you but to level set us all, so when we talk about a case and we talk about Case Investigation, a case is a person who has tested positive for covid19. A contact is someone who is within six feet of an infectious person. Im sorry, this is a little bit outdated. We say its within 10 minutes of someone, within six feet of a case. And then, we have heard the term isolation and quarantine. Isolation is for the case. So that is the person who has tested positive and isolation means having them restrict their activities so that they are staying away from others to prevent on going transmission. Quarantine is what we ask the contacts to do. They themselves have not tested positive but we want them to stay away from others during that period of time in which they may actually end up developing infection so they dont unwhittingly infect other people during that period in which they might be infectious. So thats called quarantine. The infectious period is when that person who are is the case, is considered infectious to others contagious and we believe and we understand the data that that is 48 hours before any symptoms develop up until 10 days after that. Next slide, please. So the whole purpose of the Contact Tracing is to have data, have information that we can act on and to help support members of our community to keep themselves healthy and others healthy as well. This work, whether were doing it here for covid19 or the other core work we do even pre covid, which can be for measles, for tuberculosis, h. I. V. , syphilis and the whole focus is for our trained staff to communicate the people who might have an infectious disease, the cases such as covid19, to ask them about people they may have come into close contact with. We call these people the contacts. To recommend to the cases strategies to reduce further transmission, meaning staying home until they pass the period where they might be infectious to others and improve that Way Community and population helps. So, we are trying to improve and support the health of the not individual case. We are also trying time prove community and Population Health by breaking the cycle of transmission. Next slide, please. And no matter what condition were doing this for, we hold the same principle here as a dph. We believe all of this work has to be very clientcentered. So, we start with asking the case and what is it that you need and stay home safely. And that might range from medical care, it might mean support in food and inhousing in some situation and were recently we have heard about the right to recover programs that supervisor ronen and we have these services as confidential and we dont share peoples information, even with their contacts. We do not release the name of the original case to anyone else. These services are voluntary. People are not compelled to work with us but were hoping that were approaching them in a clientcentered way and well talk more about how we are taking communitybased approaches to doing this. People will understand and will have heard through the media and other ways how Case Investigation and Contact Tracing reduces infections with covid19 and San Francisco and well be willing to its evidence based and these are a proven publichealth interventions to reduce transmission but then trying to make sure that they get such good results in the as they could and and then were working very hard to make sure that we have a culturally and a linguistically and concorded for people and well talk about that as we go on. Next slide, please. So, we are reaching out to people and this slide shows a little bit of a cartoon and you see the case investigator who is speaking to the case, that individual silhouette and who did we come into contact with for six feet and those are the lists of contacts. Theres a Contact Tracer that reaches out to and our teams were together in integrated units and as you can imagine, there are also events that have to happen before the case when the investigate reached including testing and giving them people results and et cetera. In a moment, of prevention and diagnosis ser visions and get tested themselves and their tests may be positive in which case, we then consider them a case and we have the same voluntary interview with them as we did with the original case. And we try and connect people to medical and other Wraparound Support Services to enable these actions and allow them to get medical care if they need it. Allow to safely isolate and quarantine and to allow them to get covid testing, if they are a contact. Next slide, please. What had enabled you us in San Francisco to do this in San Francisco when we announced the first cases in San Francisco in very early on in the epidemic, in march, beginning of march, we have been able to do Case Investigation and Contact Tracing without interruption. Which is not true elsewhere in the state and elsewhere in the bay area. The reason we have been able to do that is because we very early on started using a centralized data case system on this system itself is called com care its by a Software Company which has a lot of International Experience in working and in Data Collection. And, all stages and in terms of understanding and importing test results, importing and putting into our data case our Case Investigations data and Contact Traceing and our isolation and quarantine support. This is been really a key tool that has enabled us to do this work and also go back and measure our outcomes with this work. Theres a different solution the state has started using now for Case Investigation and Contact Tracing that is a stale sports based platform with a company that is helping bring that on board and doing a lot of the training for that. That system is about four to five weeks behind us with our and we continue to look those systems and were constantly value waiting on a regular basis and when it might make sense to move over to the state system. One has been integrated a lot sms messaging and text people that are contact and send them a daily text where they can tell us and if they have need for Additional Services and we can followup. And then we used internetbased phone systems to allow consistency in the phone numbers people call back to speak with us on and allowed us to do a lot of work sharing across our teams and the other thing that it has done is allow us remote and the size and the scale of the team that are doing this work are really unprecedented and this is a very, very largescale effort and it works because we are able to have people working remotely with close communication with the team lead and supervisors. So this kind of Tech Infrastructure is really been needed to do work with our own staff and also to try and move the workout into communities by bringing on cbos to be trained to do with work within communities and neighborhoods that are most impacted with covid19 as well. Next slide, please. So, you know, speaking of working with cbos and also within our own staff, we know that working with community and making sure we are sitting our competencies and our abilities to best meet the needs of community is so important. This is a continuous cycle of improvements that were trying to do. But the Language Skills are critical here you see a pie graph from a middle of april until the end of june and of the langs that were pre verdict in r the interviews for the case thats are positive. 52. 8 were in spanish and 42 english. A very large percent of people who are Spanish Speaking are prefered as the language for their Case Interview. The Case Investigation and Contact Tracing very clearly has to respond to the disproportional Cultural Impact of covid19 and be reflective and appropriate for the neighborhoods and communities that are most effected. So, i think the language concordance is one piece of that and we work as a team to get better at that and also to engage the cbos and the Community Based organizations and agencies that know their neighborhoods and communities best. Next slide. In terms of the actual structure of how our core dpa team and we have 142 total frontline staff. You see the numbers there. 26 in Case Investigations, 85 in Contact Tracing and in Contact Tracing, that is where i think we have, you have seen in the media that there are staff that are other Disaster Service workers that come into our team and been able to learn this work under the supervision of the doctors from ucsf so we have people from the City Attorneys Office and the Assessors Office and many people from the library who have been great at doing that Contact Tracing work. Our Case Investigation staff are dph staff because that Case Investigation stakes some Clinical Skills and knowledge that some of our more experiences dif have and clinicians and retired clinicians have been able to do as well. This client support is so important. These are people that have the social work background and are able to understand and provide linkage and warm hand offs to resource and services that are available to help people including housing, if theyre unable to isolate or quarantine where they currently live, food and even funds and dollars through their right to recover program. So this is our frontline staff and these are often the people that poem want to hear about but theres a backbone. A really important Core Management data support staff, staff that are always trying to look about Quality Improvements and how we do the work. There are additional fts that do that. For these frontline staff its a very involved process. Theres 30 hours of hands on and role playing training that happens even before they start doing their tandem calls or taking calls with a more experienced case investigator or Contact Tracer. The team operates seven days a week. 25 of our current staff are bilingual or multi lingual when you look back to see the distribution of language preferences were trying to do it. The time required is about an hour for Case Investigation and about 20 to 30 minutes for contact casing interviews. And then the interviews can require twice as long. If its done through interpreters and so that is why we really want to make sure that the language concord cannes i ca priority. Next slide, please. And this is what the team has been able to accomplish through the middle of april when all the teams got on to com care through the 21st of june. 1867 were completed and of that 20968 contacts were identified and then 2,285 of those were able to be notified. Next slide, please. So these outcomes and how well do are one of the five key caters for our status as a city in San Francisco and updated regularly on our cater in the covid data base and the data tracker. And these data there were some data issues when i checked today they were not updated this morning but they likely will be later this week. These are slightly outdated data. Just to get an idea and to see where you can find the most recent data, on the left is the percent of case thats have been reached over the prior two weeks and thats 82 . Ideally, our goal is to be above 90 and were 82 at this point in time and then for the percent of named contacts, of the cases who were reached and the named contacts, what percent of those contacts were we able to reach and this was 88 as well. For this again, as well, we would like that to be 90 . It was agreed upon all the bay area counties and i think we are still trying to understand what is the over all percent that must be reached in order to be successful with Case Investigation and Contact Tracing but having that 90 is a good aspirational goal. The terms are working hard to get to the levels, continue to improve those levels. Next slide, please. I think we are doing a lot of Program Improvement and pdsas with the parts of these steps that we control but we talked a little earlier about how this entire process is a continuum and there are parts that have to do with testing and pieces that have to do with people recognizing symptoms so, these are data that were analyzed out of our data base and when you look here, you see day zero. This is a person that has symptoms and again, the infectious period, when we know that they might be infectious to others begins two days earlier. On average, what we found, from the people we talked to, is they have a test three days after their symptoms came on and then got the results two days after that. Once we get the test result back, we are able to, within 24 hours, generally, reach out and do the Case Interview and the contacts are notified usually the same day or within 24 hours. So, you know, that last part there, about from getting the test result on day five, doing their interview on day six, thats strictly speaking the work of the Case Investigation and Contact Tracing team but for us to be successful as a city. We have to look at this entire span of time as a whole and try to see what we can do to shorten the entirety of it so theres work that is happening among all of our teams within the unified command to try and do just that and again we know 40 to 50 of people are not developing a symptom at the time they become positive. They might develop one later or they dont develop symptoms at all. We have to look at our data, published literature and understand who is most at risk for inspection and recommend testing for those people even if they do not have symptoms. Next slide. People will have more contact with other people. We are trying to continue to reinforce the message of covering our distance and washing our hands and they will all reduce the number of contact that could come out of a positive case if we do all those preventative measures. There are significant as we know, structural barriers to doing the Case Investigation and Contact Tracing work and a prevention of covid over all. We have seen how these infections follow lines of poverty and how racism and xenophobia are associated with peoples concern about testing and inability and not being able to support themselves and their family if they stay home. Theyre important Counter Measures that are being developed and that been put into place in San Francisco which we think are our opportunities and many of our experts also feel that these steps are going to make a big difference in allowing people to work with us collaborative to try to have the isolation and quarantine happen. We need a large and Skilled Workforce to do this type of work. As i said, this is expertise that we hold as a department of publichealth and in Population Health. Weve never done anything on this scale that is this ambitious before and try to involve as many partners as possible so with the cbo work, we are people ready next week most likely. They will start doing some of the Contact Tracing work through the cbos and it will be really a boone to this work and were looking forward to it but its a big list on both the parts of the agency and our teams and staff to make sure that that goes well and those teams have the support that they need to do the work and that were trying to collect data, continue to collect data through this in a very uniformed way to understand the outcomes were achieving by this work. We need to match the language and the cultural needs. This really looking to community, Community Partners and training communities workers to be able to help provide this in the communities they know best. The opportunities that can help meet these challenges, we talked about the cbo partnerships. We need to do strategic staffing within our own teams to make sure again that theres language concordance and as much as possible we are bringing in people who understand communities that are most at risk and can help us with our own internal pdsa work. The right to recover program is really wonderful and beer goingg to see the impact on peoples ability to isolate safely at home for the entire time its recommended. Were working now to coordinate testing and reducing barriers for the people who need it including contacts. And you know, were also going to be working and are working with the unified command joint Information Group in order to really double down and have a message and quarantine and what the resources are to support people in doing that and that is all of us no matter what neighborhoods we should be doing this as second nature. Coming our faces as the primary thing we can each do to reduce the spread of covid19 and then, theres been a lot of interest and could it play a role and could additional tekin ovations platekin ovationsexplore a role. We are exploring that in the City Administrator Office and elsewhere in the city and we think Contact Tracing could be the core of this work and we want to explore what aps apps ad what other technology can do but its likely not going to fully replace reaching out and connect people to testing and provide a wrap around service and navigation and the way our staff are doing. So more to come on that and i think that there will be updates later in the year as we hear more about how some of that technology might develop. I think that the core is going to be the work that were doing personbased work, to try and support people as they test positive or if they come into contact with someone who is tested positive. I believe thats the last slide. Lets see if theres go to the next slide, please. That was it. Trichinella were questions we wanted to address. Should i go through the question now or should i take questions . What would be best. Im sorry, commissioner. You are the president , should you say. Please, go ahead and go through the questions youve received. Thank you, dr. Phillips. Thank you. The first question it appears for each San Francisco case, theyre 1. 75 contacts identified and is there a card number for the contacts notified. We dont have a target number but the goal 190 . Thats the goal were trying to achieve and that we see in that metrics that is updated weekly and are there any conclusions to be drawn based on successful Contact Tracing for other illness thats could inform our current work . Especially regarding the number of contacts per case and the speed of notification. From all of this work we know that faster is better. And so, a lot of our pdsa and trying to do improvement is to reduce that amount of time. The faster we can get someone tested if they have a symptom, the better. The faster that we can notify someone of a positive result the better because they are able to be supported to stay home and reduce further on going infection. So that timeline i think really shortening that, that is the goal of doing this work. So anything to reduce that time is best. Right now, we dont have widely available highly accurate point of care testing for covid19. Those kinds of innovations were going to inaudible . Do we know the percentage of successful contact versus family versus workplace . Well, during the period of time from midapril to mid june when we were looking at 80 of the successful notifications were within households. So the vast majority are within households. We dont know if people are more willing to share the names of people inhouse holds for some reason and then they are in the workplace and i think theres a lot of work that we still need to do understand what we might be learning, what we might not yet understand and how we can make people more comfortable sharing the names. Again, concern about immigration status, concern about employer reactions may have a role to play here. So, we will be working with our own teams, probably working with some of our colleagues at ucsf and cbos to try and understand this better and do what we can to have Counter Measures for those things and to support people. The next large bullet point was to speak to the recent delays and testing appointment and result availability around the u. S. And where we in San Francisco stand in relationship to others. So the first point was do we track the interval from appointment request to test for dph and others. So, we are seeing an increase in the time that it takes to get a test in San Francisco through the sites that we some of the sites we work with. The test city right now is a sevenday wait in order to get an appointment for a test. What i have found out is for people who are ininsured and go to one of the San Francisco Health Networks, testing sites, alternative testing sites, they can walk in and get a test within the same day or shortly afterward. For people who are insured and guesting a test we really dont know but it would be helpful to understand city wide what people were experience what is they tried to get a test. And then last week there was a fourday wait for a person with a pre procedure testing appointment and i think its consistent with what were seeing and we want to ensure the people at highest risk or most likely to test positive are not experiencing the longerend of those delays. Unfortunately, this is a pattern that we are hearing about throughout california and throughout United States and theres more and more understanding and more and more up take of testing which we want. We want people to know that they can have testing. The wait times getting to the testing site and getting the results back unfortunately have been lengthening. Were not doing well enough. We need to continue to do better. We have heard that specimen transport from testing sites is inconsistent and maybe when we have the q a i can hear a little bit more about that and i dont have a specific comment about that. I dont have specific knowledge about that happening. The city test sf site doesnt provide a function to search for the site with the students appointment. For those urgent concerns, this is a great point. One of the challenges is the testing resources are controlled by different entities. Some of them are staterun resources sufficient as a city college site and some are done with our collaborators such such as our San Francisco Health Network sites. It would be a great idea if there was a we way we could have next available on our website but because of these multiple symptoms its difficult to try and triangulate that. Having said that, we want to inform people of where they can go if they need a test urgently and peoples own providers are also a source of testing in some indications they might be faster than our sites so they were supported by city entities was our private providers supplied many fewer of those tests and kaiser tested seven and a half percent of patients and from the best information we have they test beside four and a half percent and so, one of the things that were working on with these systems is to support more pride spread that just dph and the city alone doing this work overtime and where we are fortunate enough to have high insurance rates and were figuring out to provide more low per yar access testing for those people who are covered under those systems. That addresses the last point which was the role of other Health Systems. I see commissioner holding his hand up. Thank you for a wonderful presentation. It was informative. My question with the cbo partnerships and will then that the will it be fed into the we have a full data base its not in a separate system . Thats why its taking time and on board people because were asking them to learn a new system and that is also the beauty of the system that we can have it deployed remotely and have people enter the information. What we may need to do is really understand what are the core elements and we may not be able to gather every piece of data from all of our cbo partners and its ok and we all want to get the core pieces of are we reaching people and how quickly are we doing that and we should be able to get all the cbo partners as well so that is an important point and thank you for emphasizing that. Yes, thank you for such a wonderful the system and im wondering in terms of results, having reached the cases and the contacts as you pointed out, those are the parameters from the key skaters and do we know how many people follow through with the quarantine and also how many contacts in fact had to be quarantined after having been found staying positive. Out of texting. In other words, what are the results here and how is our success rate in following the quarantines . Those are incredibly important questions. Thank you for asking that. I think what we have found is that we continue to areas which we need to improve and one of them we agree weve identified as one of the key things we understand and then, when we speak with contacts we ask them are you going to do the quarantine . What we havent had is the core social work following up at day seven and day 14 to be able to check back in with everyone consistently and i think that is one of our goals to be able to do that also and be able to understand if people are able to stay in quarantine and do qualitative work and interviews to understand what could help them how can we help support them to do that. I agree with you that those are very important measures. I know weve been looking at the data base and you marked down some are contacts and some are Community Based. The ones were looking in the bars you show are contact positive and those are the that have come through the system and become positive and on what dates do we actually take them in as a contact that is positive. Is this the day they did the test . Yes, the day that they test positive . The bars that show us that starting out there are so many that were contacts and that those are people that have gone through this process and have a positive is that what is correct . Its probably a little bit different than this number only in that there might be people who say that they were a contact or someone to the case outside of San Francisco so theyre probably people that are also report being a contact as well as people we know to be a contact from our system so its a combination of those things but i will double check that and send that answer back to secretary morrowwits. Tell us the percentages so in a sense we can tell how well the contacts are doing and it sounds like your challenge was trying to make sure that when someone is isolated or quarantined, that they maintain that and i know in hawaii theres apparently been a tracer system, i guess, and every day those people who are understand either quarantine are isolation or required to call in and if not, then they trace them to try to find out where they are im not sure if its something were able to do since we have a lot more cases. I think that that is one of the challenges is that the number of cases and its going up. Thinking of this as a continuum of everything that we can do up front with reception will increase the likelihood of success of the Case Investigation in Contact Tracing that we are able to do and thats where some other jurisdictions, other states, have said, you know, were no longer able to case investigate and Contact Trace and we are not at that point and so we have to do prevention testing to try and keep us, keep us in the zone where we can with our Community Partners and our own efforts, keep up can Contact Tracing. Thank you, very much. Dr. Green, you are next. And commission green. This work is complicated and thank you for doing such an incredible job. I had a question about the contacts youve identified and it sounds like some of them may not know to quarantine in time just because of the delays of getting results, weve tested those people who were identified, especially with the delays are we moving their tests sooner if they have them in quarantine or are we going after them to make sure we find their contact and outside the circle. You might present that and im sorry if i missed it but im curious to know the thinking of that component of things. That say really important question. When we talked to cases, we do tell them, you know, please make sure those people who are your contacts and we explained to them what that definition is, are staying home and getting a test. So we put the initial message through the case knowing that person may be able to reach their contacts ex theyre going to call them. It doesnt work for everyone because some people name contacts that are not in their household. The household is where that message travels very quickly and then we try and support the people in the household and getting tested. You are absolutely right. Were trying to think through ways to do that more efficiently and effectively for the people that are contacts and what does that look like . How do we fast track their testing. Thats what work working through right now. Well be happy to come back and talk to you about the Counter Measures were doing but we know its one of the areas that we will need to need to work on. Thank you. Commissioner. Thank you. And thank you susan, with my congratulations and thanks along with everybody elses for the information and the comprehensiveness of your report. I had a question about the 80 of notifications that within households and its regarding to the larger question about the socioeconomics conditions that are present with regards to those populations in particular that are the most vulnerable relative to covid. People who are people of color and low income and so on. Are we able to identify anything within the Contact Tracing process around the conditions and the environment that these contacts are living in or working in particularly given that its a very high 80 and i know its not an absolute percentage in terms of definitive, right. But it is a very High Percentage none the less so i dont know if its tracing to capture that data and if it is it would be great for that a little bit more and well see whether we can capture some of that data. I grow with you. The team, again, im representing the thoughts and the work of a lot of people and these are the discussions that the team and the subject Matter Experts in these areas are constantly having and what are the respecters, we saw it very clearly from the ucsf study in the mission, that it is people that worked outside. They had to work outside of the home in essential jobs and the lower wage workers and that is clearly a group that we need to do more to prevent investigation. What weve seen is people that live in large households. Weather theyre not in family units or theyre doing it with the socioeconomic reality of living as a lower wage worker. Those things are also strongly associated with transmissionment and people are not wearing their masks and able to distance within a household and so then what are the countser measures where we can be able to offer house to go prevent on going transmission and these are big challenge and were going to work in community about the best ways we can do this and i do think the wage replacement of right to recover is one step towards people being able to do the things that they would like to do and as the doctor said from ucsf, people want to do the right thing and we have to create the conditions that we can Work Together with people that test positive in order to do that but you are exactly right, they are the people at particularly highrisk and where were seeing multiple people and within one living setting and one household test positive. Thank you, its one thing to identify these issues and a larger challenge in some ways to come up with a solution and what is the role of the department, the Health Department in working in partnership with other parts of the city or with the community in order to address things and these will travel on and the cycle will just keep cycling. If you arent able to ultimately address those environments. Any other questions, commissioners . I just had a few quick questions. I know that theres a target set to the higher tracers for population. Is that what weve met in San Francisco or exceeded . There have been some National Figures of targets per populations that were quite high, 30 per 100,000. When we looked elsewhere in california and the bay area, not many jurisdictions that i know have been able to hit that particular target. So we have looked based on the amount of work and some of the calculations i talked about how long it takes to interview a case and how long it takes to interview contacts. I have worked with with our teams under unified command to sort of recalculate how many ftes we would need and again knowing that they are particular fte we want with language capability and clinical capability, et cetera. So we know that and our cbo work, i think we are in a good position and were continuing for a buildup. Our body of investigators and tracers. So its not necessarily that 30 per 100,000 population target but we do believe that the core group that we are pulling together will be able to handle the current amount of cases we are seeing, even with the slight uptick. Now if there were a very large surge, which were watching for closely now with our caters, some of them turning red for hospitalizations, that if the cases continue to go up, its always possible for the team to be overwhelmed and then we would have to really know which of the people would be prioritized. Who at most risk for serious infection and where would most transmission happen and were not at that point now. Were still able to get to an interview every case and attempt to reach out to the contacts. So, were continuing to always reevaluate that and weve had strong consistent support from you all and the city quite frankly, to do this work. I think it will be a continuous evaluation of how were doing and scaling up if needed. Its the quality and diversity of the team that youve assembled is very strong. Thank you for that and thank you for all of them as well. My other question had to do with San Francisco is, as you said, about four weeks ahead of other parts of the state and for those reasons, we have an integrated into the state wide system that is being supported by sales force. Given that mobility data is showing that people are moving around more and theres a greater likelihood of someones contact being outside of the county, how does that work . Do we [please stand by] alameda and theyre doing the same for us. It is not ideal and there is too much potential for people to fall through the cracks with this approach. We, again, this is why were constantly going to be having regular meetings with state teams to see where they are and engaging them and look to see also within our own team to be able to understand what are the gaps, what are we doing now to address them and what is the statewide solution . We are doing it. Its more of a manual process. Not ideal. It is coming and were going to watch to see when that comes online. That might make the difference. That would be critically important in terms of people who live in a household where there are people more at risk or older people who are in the vulnerable populations and need to isolate outside of their home setting. So well look forward to an update on that. Thank you. Other questions from commissioners . Dr. Colfax, anything you would like to ask . Well, again, id like to thank dr. Philip, her incredible team, including the doctor who has been incredible in leading this work. The work is not just contributing to our San Francisco response, but to our regional and statewide response. Again, also in collaboration with ucsf, so want to acknowledge the work being done. And to reinforce that community its been important from the beginning, but ensuring were investing and equityably paying people in the community to this work is going to be really key because we went from h. I. V. Learned from h. I. V. It takes the Community Leadership and support of that to get this right. Thank you, dr. Colfax and to you, dr. Philip, to you and your team for your excellent presentation and hard work. Thank you, all. Shall we go back to dr. Colfax and welcome belated welcome so you can continue on with your covid update. And after that, we can go back to the directors report. Yes, my apologies, commissioners. One of my devices did not support microsoft as a presenter. So we learn in this age of social distancing. Just before you begin, dr. Colfax, i want to make sure that the public knows that they have not had an opportunity yet to make comment. After you finish, well go to Public Comment and see if anybody has comment before the commissioners ask questions because its all part of one item. Im loading up your presentation right now. Great. I also want to welcome commissioner christian to this meeting. Thank you, commissioner christian, and again, look forward to working with you. So, covid19 update, i have some some can you hear me . No, i cant. So i have some slides to present with the most recent data. I also want to provide the commission with a few updates before we get to the next slide. First of all, this week, the citys covid19 response is making some changes with regard to our structure. We have operated under an Emergency Operation Center Structure under which the department of Emergency Management was really coordinating across various city departments along with the Health Department in terms of our response. Were now moving to a shared command structure. That started yesterday. With d. P. H. , h. S. A. , Human Services agency, and the department of Emergency Management, d. E. M. , sharing the leadership structure. And im pleased that dr. Bennett, our director of the office of Health Equity is one of the incident commanders in this new structure. Our chief operating officer at zuckerberg San Francisco General Hospital is now in charge of operations, overseeing operations for the entire emergency response. Then dr. Jim marks, also of zuckerberg San Francisco hospital is in charge of advanced planning for our response. So, major changes there. But really a structural change that will the benefit our collaborative response Going Forward. A couple of things since we last met. The commissioners, we talked about the variance last time that provided more flexibility in working to reopen beyond what the state was allowing without a variance. The team worked hard to get this variance. We were granted the variance last week, but then as all the commissioners know, we put our intended date of june 29th on opening day of june 29th on pause because we saw an alarming increase in both diagnosed cases and hospitalizations. Since then, weve continued to see a surge of new cases across the region, the state and the nation. And we continue to be cautious in terms of reopening any additional activities. The mayor, mayor breed, announced this morning at a press conference that our intended date of july 13th reopening, if and when that occurs, it would not include Indoor Dining or outdoor bars due to the risk incumbent in those activities. And well make an assessment about the reopening of other businesses, including personal services, zoos, indoor museums, outdoor swimming pools, depending on the data we see in the next few days. Just wanted to provide that context for the data im about to show you. The other piece i want to messages in terms of the hospital mention in terms of the hospitalization. The numbers im going to show you in terms of the surge will not include some of the transfers weve been taking commensurate with the increases across the state, San Francisco, including zuckerberg San Francisco General Hospital, has accepted transfers from our intensive care unit and the san quentin, a number of inmates have been supported in our San Francisco a number of inmates have been supported in our San Francisco hospitals. So why dont we go on to the slides. This is our updated numbers. You can see that as of today we have exceeded 4,000 diagnosed cases of covid in the city, with 50 deaths. I will emphasize that our death rate has been relatively stable for a number of days, which is good and obviously, any death from covid19 is one death too many. Compared to other regions we continue to have a relatively low death rate. Next slide, please. Its up. Demographics, can you see that . There is a delay. Yeah. These are numbers these are youve seen before, commissioners. This is looking at tests collected across time. You can see that overall our testing numbers are bouncing around a little bit, but the Positivity Rate certainly climbing over time. If you step back and look at that green jagged line, you can see overall were now hitting 34 Positivity Rate, while before we were between 12 . Ill talk about the implications of that in a little bit. Weve done a total of 157,000 tests. I mentioned to you during dr. Philips presentation how those are distributed by provider. Again, as dr. Philip mentioned and to reinforce we see a disparate diagnosis rate among communities of color, particularly among the latinx communities, and the general population were also seeing higher rates among black africanamerican residents of the city. And we still have a high rate of unknown Race Ethnicity from our test results of 13 . And that is something we continue to try to decrease in terms of that proportion of cases reporting unknown Race Ethnicity. Next slide. So this is our patient count in terms of hospitalizations. So the dark from april to july, 2020, the blue bars represent the number of patience across the patients across the nine Hospital Systems in San Francisco any given day. The dark blue bars are those in the i. C. U. The light blue in medical surge beds. You can see up until late june, earlier this month, we were having a steady decrease in the curve. So the curve was not only flat, but decreasing significantly. And they were significant from that peak in april of 94 patients. We got pretty far down. Youll start to see increase, though, in the blue bars in july and this is the indication that we were having a surge. The yellow bars that are transfers into our system, again, i refer to those from san quentin and the southern part of the state. There are no counted in our analysis of case surge or Hospital Capacity. Just to be clear on that, theyre not counted in our case surge numbers. Next slide. So, im now going to go through our key health indicators. We talked about these a couple of weeks ago. Were using them. Theyre available on our website. Our change in covidpositive hospitalizations is at the red level. You can see on the curve here, we went up to a very high rate of increase, 69 . That has peaked. We are still in the red zone, however, at 25 , we will continue to watch this. And the reason our numbers got so low in San Francisco that the absolute number of hospitalizations remains relatively low, but remember that the way the virus takes off, the slope of the curve is so important. So by the time you wait for the numbers to show you youre in trouble, the absolute numbers, you often cant catch up, which is why were using the rate. That rate of increase. Its so important to watch it carefully. So you can see that we have been in red for a little bit now while that rate is now decreasing, were still in red and watching that number carefully, particularly as we make determinations as to whether continuing to pause, whether to move forward with another opening date, or even potentially to reverse our openings. Next slide. In terms of available hospital beds, because of the work across our Health Care Systems and our relatively low number of covid19 patients in the hospital, our Hospital Capacity remains good, in the green level. We currently have 35 availability of acute care beds in our system and 30 availablity of i. C. U. Beds or intensive care unit beds. That number has stayed well above green since weve been tracking these data on the tracker. Next slide. So this is another red another indicator in the red. Average new cases per 100,000 residents. We have seen a surge in our numbers testing positive per 100,000 residents in the red zone now for a number of days. We are at level 4, above 6. 0. After getting to red, it dipped into orange briefly and now has gone back up. Were watching this number carefully. But look at that curve as we went from the yellow, the yellow level, to that surge into that area is 6. 5. It happened very quickly which is, again, why we thought it was very important to pause and pause our planned reopening and are taking a look for july 13th. Theyre in the red zone. Were continuing to monitor and determine whether they will go down to orange and hopefully yellow at some point. Next slide. So this is our testing number. This number has dropped a little bit over the last couple of days. This is our average testing number. Were at 1762 tests in the yellow zone. We expect to get back up to green over 1800. Over the weekend, the long weekend, there was decrease in testing, but were hopefully going to get back up to a higher level soon. The other thing i would say is that the delay in reporting of test results as the nation, as the state increases testing, this is impacting our data marker here. Some of the labs are taking longer to result the tests and thats the reason for this delay. Right now, this indicator is in yellow with 1762 test results over a 7day average. Next slide. Contact tracing, i wont spend time on this slide since dr. Philip went through this and described what these numbers mean. Next slide. Then this is looking at our percentage of personal protective equipment across the d. P. H. This is a summary statistic across 12 different p. P. E. Categories. And we are at 89 of at least the 30day supply of p. P. E. Across our systems. Were watching this indicator carefully. One concern we have is as the nation experiences surges in certain regions, whether the p. P. E. Supply chain will remain stable. As you recall in march and april, we were having challenging times due to the lack of any centralized Distribution System for p. P. E. At this point, we are not seeing that there is a problem in securing p. P. E. To protect our Health Care Workers and first responders, but were watching this very carefully. Next slide. So this is analysis done on our reproductive number of the virus in the city over time. This is analysis that has been done by dr. Maya peterson and her associates. The number is the rate at which its reproducing. A number of 1, which is shown on this graph on the dash line, means that for every person infect ded with the virus, that person is passing on that virus to a total of 1 person. A number less than 1, means that for every person infected for every two people infected for every person infected with the virus, less than one person is being infected. So reproductive number of. 5 means that only one new person is infected. Reproductive number greater for one means that for every one person infected, more than one is being infected. Every number of 2 means that every person infected with the virus, two new people are being infected. So our goal to really manage the virus in San Francisco, to slow the spread, is to keep the reproductive rate of the virus as below one as possible. At one if thats not possible. And to try to keep it from getting above one. This Analysis Shows that between april and june 1st, our reproductive number of the virus did remain below one and the commissioners saw that analysis a few weeks ago where we estimated the reproductive number was at. 85. This analysis is consistent with the increase in hospitalizations and the new cases now estimates that the reproductive number of the virus shown on the solid blue line on the graph could be is estimated to be about 1. 25. So thats the line. And then you see the shading represents the standard deviations of that estimate. So the reproductive rate could be as high at 1. 45 or as low as about. 95. But that estimate is that researchers have is its 1. 25. These are estimates based on thousands of statistical modelling iterations, but this is consistent with the data that were seeing on the ground. And it is concerning we had that repressed with shelter in place going into june and now were seeing consistent evidence there is increase in the reproductive rate of the virus and it is greater than one. So next slide, please. So again, this is a complex slide. This is looking at our longterm hospitalization projections for the i. C. U. Here. And you can see that if the reproductive rate is at 1. 25 over time, we will get into very serious situations with regard to our hospitalization numbers. And i will point you to the blue line, the solid blue line, which estimates that we will have on average nearly 250 people in the i. C. U. And you can see that its plausible that we get into numbers as high as over 2000 people in the i. C. U. Based on the reproductive number where we are now. Next slide. And then with regard to our death projections. Again, weve had a total of 50 deaths in San Francisco. Going into reproductive rate of 1. 25, that takes a while unfortunately, which takes a while to see the effects which is why were so vigilant in those rates, you can see that our death rates increased dramatically here. Where we estimate that there could be, on average, on that solid blue line in the graph, almost a thousand deaths in San Francisco due to covid19 by the end of the year. And, again you see the shaded portions where its plausible we get into a much higher numbers here. And i would just say that our hospitalization rates reflect the increase in the i. C. U. Numbers, obviously, those are even higher than the number that i showed you for the i. C. U. One thing, though that i want to emphasize here. We can change this. If we take the proper precautions, if we if everyone in the city maintains social distancing, wear face shields, facial coverings, uses good hygiene and we each do our part, if we reduce this reproductive rate as we did before, reduce it by 50 , we can make a huge difference and these rates of hospitalization and estimated deaths drop dramatically. But we have a window. And we need to do it as quickly as possible to get that reproductive rate below 1 as quickly as possible. Next slide. So these are, again, the interventions that were working to reduce the reproductive rate. As i mentioned we paused the reopening of june 29. Were delaying the Indoor Dining, the outdoor bars, discouraging gatherings. Protecting the most vulnerable to covid19. Reinforcement of prevention actions which i just spoke to. Expanding our testing and investing in supporting Community Leadership and response. And while we do this last side please with shared commands unit the shared command is working to prepare for an overflow of medical need in our city and community. Our system will be overwhelmed as new york was overwhelmed, but were continuing to build out capacity. This is an example. This would be for overflow of relatively acuity medical care. I visited this facility on thursday and wanted to kudos to the team who is building this out in the event that we get into a place where we have to increase our hospital Care Capacity across the city. This is a relatively small site. This is about 93 beds that we would be able to use, but i just want the commission to know that our planning and vigilance is continuing for a surge. A surge that we hope will not come. If it does come, we hope it is manageable. But again, the best thing is prevention and were reinforcing that message. The mayor reinforced it today. And well reinforce it in the city and region Going Forward as we take the steps needed to get that as close and below 1 as possible. Thank you. Thats my update. Dr. Colfax, could you please turn on your video. And do we have Public Comment . Yes. We have one person right now. And if anyone else wishes to speak, please press star 3. Ill put the first caller in. Hello. My name is roma guy. Former Health Commissioner and health advocate. Congratulations and welcome to susan christian. And i also want to just take this moment to acknowledge and recognize the extraordinary leadership and work that d. P. H. And staff and dr. Philip today taking San Francisco and maintaining our lowest rates. And i just want to also also want the Health Commission to consider looking at the nomenclature of defining who is at risk. Right now we started with aids and Underlying Health conditions, through an equity lens, but i really would like to age and Underlying Health conditions, but i and others would like you to look and add age, Underlying Health conditions, equity meaning race and beyond as dr. Benefit has brought to our attention. So just within two minutes, i want to give not only testing to verify this, but im also giving my own example which is im a person who is in her very late 70s with some significant Underlying Health conditions. But i can practice and prevent use the prevention guidelines of hygiene, social distancing, masking, because of my social status. And so my vulnerabilities of age and medical condition are truly secondary compared to those who have experienced the same virus, but have either gone to work, like in construction, try to keep a mask on when youre doing construction. Not easy. And then also theyre not considered frontline workers. Theyre considered economic essential workers. And so i think we need to look at that. I think dr. Was identifying. Id like you to please consider that. Look at it and well listen for the science around it. Because youre the experts, but i think otherwise [bell ringing] as we try to open, we are going to begin to continue to trade off those workers and those People Living in low economic status. Your time is up. Im going to have to go the next caller. Thank you. Another caller . Okay. That appears to be the end of Public Comment. Thank you, so much. Commissioners, do we have any questions on the directors report . This is actually on the covid19 . On the covid19 report, on dr. Colfaxs portion. Commissioner chung . Commissioner chung thank you, dr. Colfax, for the update. My question is around, you know, like the whole subject of equity and poverty. You know as part of the demographics that were seeing in the new cases. You know, the rising cases. So do we anticipate that the cost of face masks and other sanitizing products become like an issue . Like for some of our constituents . [please stand by] ensuring people have the facial coverings, the hygiene materials and necessary to protect themselves and families and communities as much as possible. We distributes as a key example, over the fourth of july weekend, we distributed hundreds of facial coverings in the Mission Neighborhood to better support prevention efforts there. Thank you. Please unmute yourself. There we go. Thank you, doctor for the explanation of where were going. Im concerned if the covid hospital rate is what you are depicting that, slide did not include a normal up take potential from flu and is there further discussion about trying to hold the line as to where you think you want to have continued excess capacity and just watching and scoring on the card will not get us back beds. Is there a strategy to that right now . Yeah, so, thank you commissioner. Very concerned about the flu season and what the need would be as a serious flu system. Dr. Marks with advanced planning is working with the Hospital Council to determine what our cutoffs would be, for instance, for increasing Hospital Capacity through reducing prohibiting elective surgeries if we start to see the need for more capacity and with our work to the council in march and april we have Search Capacity in are more able to scale that up and given the work that and the spring and so they have both the ability to go to our Hospital Capacity through limiting the elective surgery piece and also to grow our Hospital Capacity both in med surgery units and ico. As you saw in the spring analysis, we can double our icu and increase our medical Search Capacity by a significant amount as well. We dont want to see the anticipation and we can bring that number back down. Thats right. One of the reasons i wanted to show the commission this curve with regard to the reproductive rate being 1. 25 and how serious it gets to 1. 25 doesnt sound like too much but you can see how serious with regard to covid in the fall, the charts i showed you did not did ininclude a burden that could include a significant flu season. Any other questions, commissioners. With your permission, thank you. Can we go to item 3. The directors report. We passed over that. Thank you, mark. So, commissioners, thank you again. I went through the covid update so i will not highlight the aspects of the directors report. I will say that there are a couple of things to highlight here. One is that if we werent in cove and we care for people who can tolerate that and want that and not only in Behavioral Health and you will hear a little bit more about that later today in the presentation and and they want to highlight that work and then there are a number of other components to the directors report that i am happy to answer any additional questions about. No Public Comment. Commissioners, any questions . All right. Thank you. Thank you. Next item, mark. General Public Comments. General Public Comment and im going to pop up the slide real quickly. Give me one second. It will allow that to be on there. Here we go. The number is 408 4189388. 1461 1977731. You press pound twice and if you would like to get in line, raise your hand to speak, you dial star 3. Is there going to be any comment . There is none. Commissioners, with your permission we can move on to item 6, which is the healthcare accountability ordinance viruses to the minimal standards for 2021 and 2022. Give me about 30 seconds to switch over the presentations. Patrick, are you on. Thank you so much for your time this afternoon. My name is Patrick Chang. Im here today to present to you the healthcare county ordinance work groups recommendations for revisions to the minimum standards for 20212022. And we are requesting your approval of the resolution that is included in the memo that was shared to row vice and im happy to take any feedback and any questions that you have. Thank you so much. Next slide, please. The aco is a part of chapter 2 of the San Francisco administrative code that will end in july of 2001. This ordinance is almost 20yearsold and it was a pioneering sub legislation in the u. S. To try to reduce the number of uninsured workers in San Francisco and insure that people who work in city carts despite the uncertainties and healthcare, and the status of the aca, its going to be heard by the Supreme Court and there are all these things that are to be decided. The Department Remains committed to this law and it reinforces the values we have in the city and all people have had access to Affordable Care. And so the acao is one expression of this value and those minimum standards over the years have been one way to avoid under insurance by insuring people can get Affordable Care when they need it. So, this law applies to city contractors and certain tenants leasing city and county space. Those using spaces that Sf International airport at the ports and so its also m. P. Many of our Nonprofit Service providers with dpa and other agencies across the county and there are some based on size and types and also the type of contracts and funds that are in play. So, to compliance and we have three choices to comply. They can offer coverage to their employees that meet all of these standards at no premium contribution from the worker or they can pay anna amount to the worker depending on their work classification and the work location and the d. P. H. To cover the cost of Healthcare Services for the ininsured and this fee is paid to cfsg. Just for some context, im sorry, let me backtrack from there. As of july 1th, that fee is 5. 60 with a weekly maximum of 224 and there were 35 for how many employees we havent yet got get that Data Available and unfortunately, but across the city and county thousands of contracts and many, many more employees the data that we do get based on fee payments and dollars suggest somewhere around 200 to 300 employees are not getting coverage under the law. And, these employees do tend to be temporary workers or Seasonal Workers where offering them a Healthcare Plan for an entire year might not make sense for the employers and so, a lot of the employers who may pay this fee do have staffing and workforce model that tends towards that way. So, next slide, and they try and encourage to offer a plan and its annal decision and and just by offering the plan and first staying the fee and next slide, please. So this diagram shows a very general layout of the relationship between the workgroup. Our office and the commission and so they are reviewing every two years and under statute and and the standards and so since 2004, dph as partnered with this worker and what they would be to standards and propose some recommendations for the conditions recommendation. The recommendations try to balance both employers in terms of premiums and also affordability for employees in terms of their out of pocket costs would be. And also, trying to ballet reasonable so ill share more about the worker process in a little bit. Next slide, please. So this slide shows the relationship between dph and the offer of labor standards enforcement who is the add add straighting agency for this oir defensance anordinance and how s are subject to this law are able to get the support they need to be compliant and make sure that employees do get a really comprehensive health plan that everyone can afford so in general its the Health Departments over and refuse health plans that to make sure it complies to standards and the fee administered the laws and they do audits and they respond to complaints and they handle the process for employers who from april to june this year, our workgroup met four times and one big thank you to them. They have been absolutely wonderful to work with and their values are something that i think we all support and share and the city and a Health Department and theres a list of them in in the memo for the reference. We have 13 members that represented employers across the city and brokers, health plans, and city agencies and many of these stakeholders or their organizations have been involved since the very beginning of the law. They brought such a wealth of experience and such a very firm grasp and of course which really in a 2020 and we look at the small market plans to make sure the small employers are able to afford these plans to negotiate plans as large as employers are able to so we want to make sure a lot of them, the nonprofit and tenants in the city and county spaces are able to support their workers getting coverage and access and servic services. The next two slides cover the elements of the other things that are theres a lot of wrestling and considerations of how to balance the the burdens that different employers and their workers making facing. Theres a lot of talk about so in the context of rising healthcare costs for everybody, for all parties in the system, our group has been very fortunate to have very thoughtful and creative members who have proposed a lot of ways that we can leverage reimbursement products such as hras and hsas and in ways that can workers and protected this was a characteristic of this years meetings. Next slide, please. So, over the course of the meetings, some of the major themes that came out consistently in all of our meetings was theres a very strong value amongst all of our worker members about protecting the access to healthcare for staff is something that everybody felt very, very strong with and the everyone should have access to services and healthcare. And so, with that, theres also recognition that there are a lot of challenges that amplified in this current times with covid19. Its a lot of financial challenges that i think have been amplified by the finance situation that the city theres also a sentiment that its increasingly difficult to revise the standards every two years because of the way there was a lot of emphasis on what can we do as a city to think differently about this law and so, some of the challenge thats employers wanted to put fourth were that they do need some more assistance regarding how to think about finding the healthcare and costs, especially for some of the smaller non profits that may face a budget cut just as city agencies are over the next few fiscal years and non profits, many of them are unable to raise their prices during contract periods to generate revenues that other contractors at the air like hertz or budget rent a car or some food vendors so there are additional restraints that they want us to make sure that we conveyed. Employees also state additional challenges of some rising out of pocket costs as we all know, and in this pandemic, it would be considered vulnerable and i really under scored for everyone to have access to Affordable Care and so all these things really push a lot of the carefulness. Next slide, and this light so, the recommendation is just to clarify these are under plans for in california and employers really let this allowance because it simplifies compliance for us to say i can provide a gold plan for employees and im good. And the plans are the most generous for employees and so, everyone was very, very pleased with how things unfolded around this allowance and standard one the recommendation is to maintain the standard to make sure that the workers can still have a comprehensive plan and they keeps them lying around that and they would be required to pay the full premium. Standard 2, its pertaining to the out pocket maximum and starting in 2019, this limit was sinked to the state benchmark for silver co play man and the rational was to do this because this is predictable and it allows us to be more objective about how were moving forward in terms of out of pocket limits and historically it is also lower the federal and it pro voids protection for workers and rising costs and for brow he can and for employees and example, the states benchmark and oust pocket and versus 8,000 and next years increases will be 8200 for this benchmark and for the aca so, maintaining this standard is beneficial to both parties for our workers and the employers. Next slight, please. So standard three, pertains and since 2017 they havent required to reimburse all expenses and the recommendations to maintain that requirements and to increase the maximum allowable delectable and this way workers continue to be protected from that this rising cost sharing element but it opens up more silver plans for employers to chose from and that was important given that in this current environment, with these standards only golden platinum plans are compliant by far and next slide. The arso the next two standardsn regards to prescription coverage. The deductible is 100 and the Healthcare Market shows that the plants are both trending up to 300 and so the consensus was to allow the increase to 300 and the prescription deductible was very hotly debated for a period of time and so this increase is recommended in concert with some other adjustment to the other costs which ill touch on. Number five, Prescription Drug coverage is this was something the workgroup agreed that we should maintain to make sure that employees have coverage for all tiers of drugs with the report. Next slide. So standards six and seven, these were considered standard four that pro description deductible and these given the way that values are designed for these plans, it was the thee of these were very relate and we have to work with them all together so when we looked at various configurations, of adjustments, maintaining coat insurance at 20 making most sense since the cost of the service or treatments is arrangely unknown to a healthcare consumers until well after the visits and so, in order to protect a patient from a potentially very high out of pocket cost for service they maintain the 20 co insurance. So, with that, they allowed they agreed to allow the co payment to rise to 50 and so, this combination will open up a greater number of silver plans available for employers to chose from while hopefully managing the costs for patients as much as possible. Next slide. So standards eight through 16 are related to the essential Heath Benefits and the workgroup recommended no changes to these standards and there was a discussion about how to handle testing and services in care that would be related to covid19 and currently, staying federal roles as you know, requires that these things be covered at no cost sharing for patients and there is evidence moving forward when these waivers sunset about how the insurance will handle this and when presumably, a lot of these things might be folded into standards of care or the annual vaccines. So there was too much as you know known at group wasnt comfortable calling out specifically and there was a concern that if it was calling out if it diverged from the Health Industry or a lot of plans non compliant. So the notion was that the workgroup would not make any specific call out for covid19 services or care and dph will keep an eye out how its handled and covered and well proceed from them, depending on how things shake out. Next slide, please. Over all, they increase the plans from 40 of only golden plan increasing at the 52 and it opens up in some silver plans and they contain a price where employers opportunities to offer golden plans and while also accessing the silver plans and that would be a lot of people were very happy with. While also providing protection for employee needs from increasing rising costs. So these recommendations will ease increasing afford pass times for some times for all involved and it will comp fie compliance for employers and brokers and so, it will encourage employers to offer coverage to employees and we support these recommendations put fourth by the workgroup so we ask for your consideration and approval of these changes and were happy to take any questions or comments that you may have. Thank you, commissioners. Thank you. Commissioners, do we have any questions . Actually, commissioner, lets check for Public Comment, first. Do we have any Public Comment . Yes. We have someone. Hello, commissioners, this i . Yes. Thank you. Hi, this is debbie from the San Francisco Human Services network and i have served on the working group every two years since 2004 with the left contractors and im asking the commissioners today to approve the proposed standards and it also like to convey some of the challenges that our working groups face as we seek consent every two years. This is challenging for non prove its whose contracts have not funded 100 by the city and were now facing a pandemic and a budget deficit and we do not expect to get business increase this is our contacts although premiums projected are to rise six and a half percent. At the same time, all working Group Members share the concern that employees out of pocket costs have to remain affordable so workers dont forgo immediate care. These days, there are no other pay and were struggling with the declining number of plans that offer 20 co insurance rate. And were also concerned about the em pac impact large out oft with a severe medical condition. We cant face that full burden on employers either. So to maintain affordable premiums we need to include some level plans under the standards and this year we were able to reach agreements based on the availability of the mere 10 compliance at a level plan. In order to make sure that the standards will work for another year. Time is up. Im sorry, i didnt mean to cut that off. Ive moved on to the next caller. Hi, this is carl kramer, im campaign co director for the San Francisco Living Wage Coalition and you know, needless to say, in the midst of the health crisis, there was a lot of pressure on us given the great deal of uncertainty thats happening right now. But theres reason to believe that the monthly premiums will not be going up any time soon since the Insurance Companies have lost work because of the employment. Theyll keep down the cost of their product to remain market share. We were not happy about the Prescription Drug deductible going up 100 to 300 in the co payment for the visits increasing 5 to 50 and the policy and planning did a study that noted the growth and out of pocket cost comes at a time when wages have been largely stagnant. The Mayors Office has put a pause on the july 1st cost of living for workers at cityfunded nonprofit agencies who were paid 16. 50 an hour and were waiting to see if they receive a raise in the budget starting october 1st. We felt we could live with these increased cost this is it meant avoiding an increase in the co insurance from 20 to 30 , which we felt would be a real killer. You want to thank Patrick Chang and see era nesbitt for their work in broking this compromise and we urge a yes vote by the commission. Thank you. Any other callers . Thats it. Thank you, very much. Any questions . Commissioner chow. Yes, thank you. I wanted to note that over these years, i believe that the ordinance helped fulfill a great before the with the a ca the ordinance now actually more mirrors the ability of the plan that are more uniform than when we were back in 2002 and starting to review these. And that certainly recognizing the covid challenge really creates for the industry, providers and obviously for the recipients a great uncertainty. I want to point out that i think theyve done a marvelous job in actually being able to expand the possibilities of the types of plans available because in a world rights now where we are seeing asia rinking opportunities from the healthcare costs i guess effect the marketplace and make insurance harder for the employees and for employers to purchase, we can actually relook at that as needed and one can actually go back and be able to look at circumstances if they change drastically and effect the availability of insurance for those that we want to be sure can obtain coverage. I would support the resolution. I have one question on minimum standard 8. Page 7 where its noted that the Coverage Mental Health and Substance Use Disorders Services including Behavioral Health. My question is, did you especially with the silver plans, what is the minimum coverage . Some of the plans i know i have had to work with have a maximum coverage of six visits, six Behavioral Health visits and its i guess thats one of my concerns within this minimum standard for Behavioral Health. If you determined thank you for that question. Commissioner. I unfortunately dont have that on hand but i will find it and get it to you as soon as possible. I would appreciate it since its especially post covid, its extremely important that is included in the minimum standards and thank you for pointing that out. Commissioner green. You had so many difficult issues to decide and a very challenging environment. So this is just an incredible detailed report, excellent work and i congratulate you. These are really assault decisions. I did have one question. I suspect that you thought about this. We look at these organizations, is there any potential for them to come together and give them more cloud as they negotiate with heath plans and in other words, if these are independent employers on occasion you have employers in a certain sector that are able to come together. Is anyone thinking about that or anyway you can umbrella these non profits together so that they might have more options it has come up. The states in response to California State Association health plans that would take on that structure and the response to a round of time that is from the federal administration was loosening the types of plans that would be allowed under the aca or whether they made short term plans and associated health plans allowed the state legislation within state boundaries. Those would not be an option at this time. The other question is last yaws there was public testimony about the copays in particular so i wonder, do you have any data or is it possible to get data reflecting whether your concern you articulated this afternoon about people not seeking care. Because of these barriers with the copays . Do we have anyway of track tag or understanding that that could be a tall order. I think it might have a huge impact on we can talk to leadership to see how we can start to wrap around our arms around that here. At least within the Health Network. Thank you. Thank you for this really incredible work. To everyone who made such a great effort here. Thank you so much, commissioner. Any questions . Thank you for all of this great night over your hard work this year and your intern and we all know how important interns are to getting our work done so thank you because this might look different to them the last time they select aid plan for themselves and their employees. Thats a really a great point you raised commissioner and up a lot in our work as well about how do we kind of get ahead of the insurance is it can be they didnt say com Police Station and theres a lot of things that people who are not in industry are not, you know, heavy users or even active in their own advocacy with insurance can it is confusing for many people and so theres been a lot of conversations of how can we support employers with get ago head of it and when they offer coverage, what kind of education and what materials would be useful. What kind of supportive structures or resources to be provided by dph or some other mechanism to make sure this information goes hand and hand. Here is the health plan, here is what we think and here is how you use this and its not sure and here is who you can get help from. And so, theres been a lot of competition with that and i think what that would look like on the ground is still pbd given that the complexity and the variety of the employers that do contract with the city and also the role of insurance carriers and and how we can ensure everyone gets the support we need. To use insurance. Ill make a note, its been noted. Ill make sure to followup with all of our stakeholders and the workgroup. Thank you. Any other questions, commissioners . Commissioners, this is an action item. If not, we can move to a motion to approve. Do we have a motion . So moved. I so move. Ill second. Can you please take roll. [roll call] fantastic. Thank you so much. Thank you commissioners for your time. So commissioners, we can move on to the next item. Give me one second to populate my slide show. Item 7 is contingency report annual dph report for board of supervisors resolution 563. 10 submitted to the board of supervisors by july of each year. Michemichelle is on the phone ws to discuss this item. Good afternoon, commissioners. Sorry i do not have a camera on my computer at work. So today, as mark said, im presenting to you the Department Annual 1920 contingency report and it is actually for informational purposes to you and to requirement torus to submit to the board of supervisors. Just a quickly by way of background, especially if you havent been seeing this report before, when you, the Health Commission approved contracts, what you are approving is the total not to exceed amount and this is the amount that includes all the funding estimated for each year the contract plus a 12 contingency value so that means that your approving a Contract Value that is 12 more than what we anticipate that the contract will need to spend and that 12 value is called the contract contingency and its not funded but if we receive additional funding which we do and the cost of doing business and what we can did is add that amount to the annual value and the equal amount so theres no over all change in the contract and that not to exceed amount and why we do this is because it allows us to increase the budget without having to amend the contract. When we amend the contract we return to the heath commission, so by having a contingency value included in our contract, it gives us 12 worth of flexibility which has been a streamlining tool we have used since woul 2004. When we first started using this, and it started to a peer on reports before the board of supervisors, it was confusing to come members. It generated a lot of questions and then how does that confusion request to submit an annual report which is formalized in 2010 and in 2012, the legislative annalist conducted an audit and got more information and the Health Condition and the format reflects all the agreed upon reporting. Its interesting. Im not sure how useful it is in the grand scheme of things but what you have before you is a list of all the contracts that are current board of supervisors approval. If they have approved it once and its still within that same word its on this list. So the list has 29 contracts and all but nine of them had usage in we access the con stinziano again see in fiscal year 1920. That means that allowed us for all of the usages to avoid an amendment and not in every case but to return to the board so, what you can see by looking at the detail which we added to it, you could see why were accessing the contingency and sometimes its for the cost of doing business and or last year we had the minimum compensation ordinance. The other big items when theres board of supervisors for new initiatives that come or a new grant that needs a quick start. Anyway, that is what it is. Its straight forward but im happy to answer any questions. Can we check to see if theres any Public Comments. Theres no Public Comments. Thank you. Any questions . I do have one question. Thank you for this report. Knowing how many times we have contract modifications coming to the commission and sort of above the line, below the line is at 12 , how does this contingency use compare to the ones that would end up exceeding 12 and need to come back for approval. Is it a larger number and this is a smaller number that fit within the contingency . I think usually the contingency covers what our increases are in an annual basis. Sometimes if a need for adding additional money comes at beginning of a Contract Term then we still have some of the out year value that we can tap into. I think i dont know if i totally understood. I think sometimes when we come back to for amendments its often times because weve hit the end of terms and that would be one reason we come back to extend the term. Generally, until you are in the last year of the contract, probably the contingency will cover. My question is more having to ask on a different how often does any increases needed exceed that amount so that we do have to see and act on it again. I havent counted that. Its all in mind. Thank you. Commissioner chow. Thank you. I have another twist on the question i think that the commissioner was asking. If we understand the cost of living and so fourth in which you are able to put them in because they are certainly well within the 12 but the center off, how was it determined that the hsa work order was going there to the hsa and if instead number two, so, how is it if theres a new Service Coming out that isnt clearly an extension of something that someone already does that you do or that you find the money that you would then use an extension rather than having it go through a contract process which presumably should be a way of making sure that everybody got an opportunity to get that new service. Im kind of mindful as to the current environment in which there arens concerns how the funds are moved and so and it funded 30 more beds so that was clear but what if its a new service that saying the board suddenly said, its a great idea that we do xyz for 200,000. Would you then just go and be able to find someone and add 200,000 that did that and put it in there without it going through a commission process and in terms of suitability for the contract. If we get new initiatives or new money, i mean, in theory i guess if it fits within the 12 but often times the money that were getting so you are hearing about your part of the budget process. We also look at we cant add money. Remember, with our soul source report, we have to list out anything thats a sole source. We also get sometimes random add having and they have a strong interest to get implemented early so well do that pending the col istation and we have that ability through the sole source the 2142 from the admin code to start something up but generally if its something that is a big ticket item it will come before the Health Commission, like humming bird place or valencia. If we add the money to a new contract, of course its going to come here and i think this work order, what im going to guess with that work order, because i cant remember exactly using that example is that the School District hsa were and dph were working on a Service Model that is an extension model of something that seneca was already doing. We tried to if we can, if the service has if the vendor is already doing something, then well add it using that solicitation authority. And if its im rambling. We have to get approval. We cant just add money and its either has to be approved by a sole source or approved by our chapter 2142 and if its large enough it comes back to the commission. It depends a little bit on the timing of when it is. Thank you. Thank you for stating your question much more clearly than i had stated mine. Any other questions . Sounds like we can go to the next item. Give me one second to flip this. We have a resolution approving the appointment of Marla Simmons as interim director of the San Francisco Mental Health plan. I think we have dr. Hammer on or dr. Horton . Dr. Horton is on and if dr. Hammer is also on, shes closer to the issue and im happy to have her introduce it and if not i will introduce it. Are you on . I will introduce it. Good afternoon, evening, commissioners. This is a resolution approving the appointment of Marlo Simmons and the interim director of the San Francisco Mental Health plan. I believe you have the resolution before you. Why think we have it on the screen, do we, mark . No. I will go ahead and read it just so people know the basic pieces of it. So, it will be me introducing it. So, as the California Department of Healthcare Services needs to implement and administer and manage Mental Healthcare to agreement with Mental Health plans and they are required to provide oer arrange for the appreciate of specialty Mental Health services to in their county to meet medical necessity criteria and because the department of publichealth community Behavioral Health services operates the Mental Health plans for city and county of San Francisco and the director of Behavioral Health Services Overseas and directs all Client Services for the San Francisco Mental Health plan and Marlo Simmons, has held and activities and she has been for example the director of the Mental Heath Services act whereas, the hcs requires approval of the appointment. Local Mental Health plan director and the Health Commission services of governing body of the dph it would be resolved that the health would authorization the appointment as the interim director of the Mental Health plans for the city and country of San Francisco. Are there any questions about marlo or the resolution itself . Before we get to questions. Is there any Public Comment . Theres no Public Comment. Thank you. Commissioners. If not can i make a comment that i just want to express my appreciation to marlo for her work, especially during covid19 and presentation and i just want to expression and respect during this particular low challenging time we know that Behavioral Health has a multitude of challenges and opportunities and before it and marlo has stepped up in addition to the challenges faced before covid19 and to address the over wrapping challenges of our respons respoo covid19 which has Health Implication this is addition to our behavioral needs across the city. So just to thank marlo for her efforts and thank you dr. Horton for introducing the resolution. I want to echo the thanks to marlo with such a critical area and shes really stepped into a really Important Role and period and address these issues. We said goodbye and now we have you back already. Its great. [laughter] thats right. Great. Mark. So, commissioners, this is an action item. And so we need to have a motion and then we can move forward. Move to adopt the resolution. Second. And i will do a roll call vote. [roll call] thank you so much, everyone. Congratulations. Thank you. Do we have marlo on the line. Do we . Im here. Wonderful. Congratulations. Would you like to say anything . No, thank you very much for this support. Look forward to giving you an update in just a minute. Yes. Im slashing the Public Comment phone line information and ill go on the number before we go to the next item. Its 408 4189388 and access code is 1461977731 and you press pound twice to get onto the line. We can move onto the next item which is item 9. Its Behavioral Health services update. We have Marlo Simmons and also dr. Anton nigussebland who is on the phone with us. Not visually but he will speak to a few slides and answer your questions. Welcome marlo. Thank you. Good evening, everybody. Commissioners, secretary and i appreciate your nice comments and thank you for the help with that resolution. My name is Marlo Simmons and ive been acting director for dhs since february 17th. Prior to that i was the dhs Deputy Director for four years and prior to that i was the director of Mental Health services act for four years. And im pleased to be able to provide this update few and again im joined by dr. Anton nigussebland. So, i wish that i could tell you all of the great work thats happening at dhs but im going to focus on these four areas. One ill provide a real believe system overview as a refresher and commissioner asked for some updates on our children youth and familieses system of care so i will provide some of those updates and let you know a little bit about what weve been doing during covid19 and as well as our clients and look forward and talk about our budget outlook and the challenges that were facing as well as our priorities moving into fiscal year 2021. The update that is not included in the slide because its very, very new updates is dhp has recently posted a new position and i will leave it to dr. Coalfax to fill in details but its basic low a new position for the director of the Behavioral Health services as well as the Mental Health sf implementation so its a very exciting position to have a higher level leadership position and the department. And then when i am done i will hand it over to dr. Bland and he will provide an overview of the bed optimization plan. And im happy to take questions as we go. Our system Behavioral Health services is a very large and complex system. Primarily we provide specialty behavioural Health Services for the publichealth safety net in San Francisco and we provide a lot of Mental Health promotion and Early Intervention services. Our work in many of these areas is done through Inter Department at initiatives and we work with the courts, lots of different city organizations and systems. Our Treatment Systems reach 25,000 people a year and our prevention and Early Intervention programs reach almost 40,000 people and our system is supported by a budge of of 450 million and we have 650 Civil Service staff and our partnerships with Community Based organizations twothirds are delivered through contracts with 80 different Community Based organization and they manage 200 programs for us. Next slide. So you will see on this upside down triangle that our Services Fall on a broad continuum of care and our prevention and decide and intervenes as early as possible when Behavioral Health issues emerge and we do this by embedding Behavioral Health resources in childcare settings, schools, homeless, and senior dropin centers and primary care clinics and we have out patient and intensive Case Management programs and our itm programs are anything it takes level of Case Management and Treatment Services and we have residential and crisis programs and on to placement and hospitals and locked facilities for our most acute clients. And there are many Access Points in our system and clients do enter through lots of different portals of entry. One area of focus through our Quality Improvement efforts across the department are focused on access and flow with so many different different types of service and programs it can be very difficult for clients to connect and we face challenges in moving between these different systems of care and so one of the components of the Mental Health sf, which ill talk about later is an office of coordinated care and that work will help us build the infrastructure we need to improve both access and flow through our system. Next slide. So this is a very high level budget overview of the pie chart on the left that shows expenditures by systems of care. We have Substance Use disorder in blue and our childrens system in green and our light green is our largest system which serves adult and older adult and for simplicity this includes our forensics and transitional age use which are newer and it could be divided into three different areas. One is federal revenue, state revenue and local revenue and we have a higher percentage of revenue coming from local sources, next slide. This slide shows the ethnic breakdown of clients that we served in our treatment programs in fiscal year 1819. Broken out by the adult system childrens system and Substance Abuse system of care and what you will see in this data is that we have lower than expected penetration rates for the Asian Pacific island communities and higher representation of African Americans relative to the population in San Francisco and weve been doing a lot of work across our system and early achievements of that team, the osme team was the development of a bhs equity work plan and this plan has measurable goals for every single system of care and section across dhs. Our team is also working with a group of internal Racial Equity champions and they are involved in the departments equity fellowship work [please stand by] some of our training efforts around because of covid and we hope to start those again soon. So for our children, youth and families and they oversee and manage about 20 of our resources and services, that system of care is a plan rooted in trauma informed principles and focuses on workforce developments, engaging clients and building specialty practices and most recently theyre developing a website to increase access to those developed and we struggle with leadership vacancies and the director of dys has been vacant of october of there were safety concerns that were allegations of abuse towards youth and so in august of 2019, the city stopped placement and our team has worked with many city stakeholders to implement corrective actions and develop plans for on going monitoring and the city reassumed placement to edge wood and its another area of work and we have a primary care and Behavioral Health clinic that we manage. The city respects legislation that districts and the city closed juve nil hall and we have staff that represent dph on two of the hall closure work groups, specifically Mental Health work groups and reinvestment in policy work groups. The expansion of the Response Team and this was expanded in response to things that were seeing during shelter in place. We very concerned about the shelter in place and weve seen increases in child abuse, Substance Abuse, domestic violence, family conflict and weve had increases in calls to our crisis line and an increase and they have only been aware in justify nile justice involved youth and now because of the expansion, its available to all youth under the age of 18 and the team works 24 7 and has multiple languages theyre able to serve young people with. They do work on tele health and safety planning, Linkage Services and its been a very exciting expansion. The last update was work that our Leadership Team is doing with the strengthening family and Community Task morse which is a city Wide Coalition photographic uses on transforming the Child Welfare system and really specifically looking at bias with a number of black and brown children being involved in the Child Welfare and juvenile Justice System and in particular this group has been focuses on this 60 of mandated reports that relate to poverty related neglect and trying to have those reports result in support rather than separation we have our acting director and she deserves special acknowledgment for her incredible leadership. Moving onto the next slide. Im going to talk about our Covid Response activities. We have been in full response mode since the beginning of the publichealth emergency and weve done that through providing clear and timely communication to our staff and cbo partners and it was a lot of work given how rapidly thanks change, especially early on. We adjusted our physical environments for physical distancing, facilitated p. P. E. Across and all of our Civil Service and programs and maximize the Clinical Care that were providing via tele health. During the emergency we have maintained our out patient programs and continued to do new intakes and many other most of our other services have continued. We also focused on integrating Behavioral Health services into the covid19 response efforts and we have had as many as 25 of our Civil Service staff be deployed to the Covid Response. Our working in the shelter in place and the isolation and Quarantine Hotels and supporting street based outreach and work on Contact Tracing and soon will be part of the alternate care sites that are opening and as we begin to plan for phase 2, and believe we will have more facetoface visits and weve had to pull back some of our staff from deployment but we still have 18 deployed. Our third goal has been to provide support for city staff and first responders. And weve done this in a variety of ways and multiple wellness webinars and weve developed selfcarrie source and provided access to oneonone Mental Health support and we staff the role of the wellness officer at the Department Operations center and we developed staff and on wellness webinar and other wellness resources. Our most recent webinar focused on the latin ex community. We had over 700 participants and so were very proud of that and i also wanted to just briefly highlight the work that our peers and populations specific programs which are mhsa funded have done and a lot of Community Engagement and outreach from well choke phone calls and drumming and singing groups and support groups done and the groups make up our covid Response Team. Two people i forgot. I apologize to those people. Irene and moving on, to the next slide. Covid has i am pacted us. Weve seen increases to our warm lines and crisis lines and increased reports about acuity. Ive talked about the shelter in place is having on our children and their families and weve also had impacts across our system around access and flow. So weve seen fewer people facetoface and we are still doing intakes and weve increased our tele health work and weve also scenery duced capacity and residential treatment and people were spending test result and weve had residential programs that closed because of exposures or positive test appliance and staff. One thing thats been interesting is we have not seen the spike at the higher level of acuity that we expected. Within the inpatient units at the hospital or psychologist for example, they have to hold to their 18bed capacity and new safety protocols before admissions and weve also seen a reduction in the units of service in avatar. And the last point oil make about the impact is we have many more clients that are unsheltered and living on the streets. Its really because the shelters have gone down and theres really the conditions on the streets are a terrible as ever. Moving onto the next slide. So this slide talks a little bit about our pivot to tele health. So we move very quickly over a very hectic few weeks. Right before the emergency was declared. We started on this move and we, over that period of time, shifted the number of telephone appointments we were doing or the percentage of our inencounters. Initially were about 12 this orange line shows and we increased over 60 of our encounters with clients being done over tele health. And we did this by equipping staff to remote work, remotely, we had about 360 staff that we provided a lot of clear and timely guidance, especially around changes that came quickly around hipa and guidance around tele care and we provided training and skill building and how to use technology and especially the clinical aspects of providing care in a new method and then we worked with supervisors to be sure we were helping staff, supporting staff, to be accountable for their time. This blueline shows the number of encounters and so, one of the things were proud about is that we have been able to maintain contact with over 85 of our registered clients and during the crisis, you will see a dip in the numbers to the farright. And that they are related 20 delays from our cbo partners so those declines are not as dramatic as they see. Next slide. The shelter in place hotels, definitely one of the Silver Linings of covid has been the citys ability to house 2,000 people which of course is very exciting. We have been working and were taking a variety of approaches. One is to train and coach on site hotel staff and what we found is if you provide housing staff, with training and deescalation and motivational interviewing that they are less likely to need Crisis Intervention Services or rely on extreme measures like eviction. We also are giving those staff a consultation line that theyre able to call when they have concerns, which is also something thats very helpful and we are doing peer support teams providing individual and Group Engagement booth inperson and using westbound based platforms. We have a mobile low threshold engagement teams that are providing individual support and for clients of mild to moderate needs and then for those with more intentative needs we have an this is in line with the Mental Health legislation so were getting a jump start in the implementation of that. Im going to if we can just skip through this. Its repetitive from stuff i said. The budget outlook so after months of Crisis Management, its been really exciting, excuse me for after months of Crisis Management its been exciting to have strategic conversations again about the future of dhs and the discussion around the budget is central to that . As people know the budget outlook is not good. Right now, we have multiple federal and state Revenue Sources that are projected to decline local level projections are also discouraging and however, i am thrilled to report that dph was able to meet the mayors budget and route removing any and the other thing is dhs. We worked on optimization initiatives that we project will result in additional five to 10 million of additional revenue a year. And i just have two more slides and ill hand it over to anton. This slide really highlights some of the challenges that we have in our system. So funding is obviously important but it really is critical that our workforce is healthy it was inspiring for us when they supported this notion by identifying the work and priorities and i and i just couple hours got updates to this and working really hard to address our vacancy rate and so theyre and the Staff Engagement across dhs and we have had consistent Engagement Survey results over the last two Engagement Surveys and at the third and the percent its lower than most other nation wide and for example, 32 of our staff report and these priorities listed here include some of the goals of that plan. And the last slide im going to talk about is our budget priorities, again, we are very hopeful that there are conversations on going with the mayor and the board to identify resources so we can make foundational investments in the Mental Health sf and other budget priorities. So of course we will continue to support our Covid Response work and we hope to expand a street Crisis Response and engagement teams, implement Mental Health sf, especially the office of or coordinated care and we hope to Optimize Flow by making additional behavioral. So im going to pause, hand it over to or take questions and mark im going to ask that you just skip through the next two slides. If i could recommend that we move forward and take questions at the end and the comments before the im going to get to your slides and were here . Thank you. Thank you. Theres a delay in what i see on the screen. Let me know when i can start when the first slide is uploaded. The first slide is Behavioral Health beds on the screen for us. Great, ok. Thank you. And im delighted to be able to update you about our the purpose of the bed optimization process is a tool to guide the department in calibrating its bed capacity to increase access to acute Behavioral Healthcare beds. Dph contracts about 2,000 beds and various local facilities but access to these facilities with the department does not maintain fixed capacity are heavily influenced by market factors of supply and demand. Including the operators to the client accept our patients. Based on the quantitive results of the bed on it minimum in certain parts of the Healthcare System in order to begin to improve patients through those levels of care and im sure if we dont have to remind you, were very familiar with the consequences in the Health Perspective and of having patients who were boarding inappropriate levels of care and we need to make the best possible use of the resources that we already have and make strategic data informed investments to get the system we have running smoothly. Lets go to the next slide. That simulation model, the risk fro data driven weight to inform the department and calibrating its bed capacity to increase access. This level of quantitive data now they hope its a first for the department of publichealth. And in early 2020 through the Financial Support of Tipping Point community the department of Mental Health team engage in experiencing vendors to develop together we have a simulation model to evaluate for decrease the boarding of patients who need on going Treatment Services and however, this is not an assessment of the demand for in San Francisco they have about 2,000 beds across the spectrum of care and in fiscal year 20182019 and this analysis in ways to remove them. We built the simulation model using data from the department of publichealth coordinated Care Management systems and they were held Electronic Medical records and information shared as system wide stakeholders meetings and personal communications with environmental stakeholders. After verifying the model structure we have base time simulated patients level and this includes more than 7,000 behavioral and 25,000 missions within our inaudible . The report illuminates that about 68 of these patients included in this analysis are experiencing homelessness and they are dis resented along and the time period. Lets go to the next slide. As the validation process, the model results related to patient carrying were also compared with informat data systems and take hold end put with additional input, we have rules of patient flows so they better reflected at full patterns of utilization and you see a representation of annual occupancy prepared categories of the health bed continuum. Its not targets account for their demand for services is 58 . This makes inaudible that are over subscribed. The accessibility to be patients for need of those services. Ill point out that i was talking uncover a discrepancy in the occupancy for 12 month Mental Health and Mental Health programs. It was 90 . This is reflected in the full report which received the background information. Lets go to the next slide. And now analysis is four categories of care with the services exceed the staub standards for maintaining optimal flow based on the wait times. Blocks of acute treatment and Residential Care facilities for the elderly and Residential Care facilities in general which are known as board and care for non elderly individuals. The team identified issues with the capacity of our 12 month treatment programs and in each scenario, question added a bed to the treatment unit that is the bottleneck unit and until a boarding threshold of one day or less was reached. We have the outcome of the analysis including the bed categories with the highest utilization with the capacity increases. And they need to reduce the boarding time to enter this bed category. We provided estimates for the annual cost for operating these additional beds based on the most recent assessment of the cost per bed. Over all, the recommended 117bed expansion represents a 12 increase in our bed capacity. S i conclude i would like to highlight the fullness of recommendations in report for the benefit of the republic including making the investment in these beds here and you have longer wait times and not limit today monolingual non english speakers, people with criminal justice involvement and patients who are not ambulatory. For it, creative robust wait time that Data Tracking sick tom to better understand the impact of operational barriers on the patient wait time. Number five, investors facilities with six beds dedicated for use by dph clients rather than shared by other Health Systems and they do not have set aside at a number of facilities and creates challenges for the plan in and the healthcare treatment four the most vulnerable san franciscans when they need it. Thank you, ill take it. Lets just take this Public Comment. Yes, we have Public Comment. Ill put in the first caller. Just to make clear all the folks making Public Comment i have a twominute timer and when your time is up, please wind down your last sentence and then we will go to the next caller. Yes. We can hear you. I wanted to comment on the previous presenter just made on the state of our streets and San Francisco the mandate the board of supervisors has laid upon the department of health and sf Health Officer and theres been no movement to exercise that power to house said unhoused neighbors into these hotel rooms where we now have vacancy and the power to house them. Thank you. I yield my time. Hello. Hello. My name is nell and im calling to raise also the issue of the unhoused people in San Francisco because we know that being unhoused puts people at increased risk of the virus and it is great to house people who are frail or who are symptomatic but you know, being unhoused is its a risk factors because you are unable to the handwashing covid is the new normal and its 12 to 18 months at least were dealing with this and what is being being. Hello. Hello. Yes, im starting the timer. For me. Yes. Sorry, theres a delay. Hi, my name is molly brown and im in district 1 and im calling about the board and care homes because i think they tie in with this conversation. And i want to make sure that beyond what has been done by the supervisors in terms of the increasing daily rate and putting a hold on the even if the city has to go into the real estate business and purchase them. I think in terms of the hotel rooms, we should be looking at securing those and purchasing as well and my last comment has to do with the families and edgewood im thrilled to hear that youth are now being referred but im more concerned about edgewood sustainability and how we can make sure that that resource is available to our youth Going Forward. I understand theres conversations about changing the contracting and that concerns me because fee for service as opposed to cost basis is not going to work i in and its notions, thank you so much for your time. Thank you. That concludes the list. Yes, before we move on, just with regard to the the situation on the streets just a reminder to our fellow commissioners and others that while the department of publichealth sets the standards and the guidelines through which people. Ive got it. Thank you. Well, thank you for the presentation. So this is this is my question is for the doctor. And then the reason ethness tee as you know stated and do you have any plan on improving who are trans and gender non conforming identified. Thank you for the question. This is dr. Anton responding. With respect to the observation around people who have accessing care and there are a subset of our population who grabs barriers and certainly ambulatory status that can be a factor and and criminal justice involvement and their mobility and you just faded out. Can you repeat the last sentence because your mic just faded in and out . Hi, so commissioner, thank you very much for the question. I just want to point out there are clients in a subset of our system of care who do have a challenge engaging and services and sometimes those issues can be because of their physical Health Status and being non ambulatory can be a little itsing factor fofactor. They were significant justice involvement and people are registered sex offender who may find it difficult to be placed in a Residential Treatment Program because San Francisco is set to a dense see packed city that made it difficult to be within an appropriate paid yus and and and you know with the work thats been done to collect that information and our Data Collection was high and the vast majority and the race and ethnicity. Its a similar situation in the sense that we were and the systems. I appreciate your response and i hopefully you know this will be resolved and and a really high number and and looking at those numbers. Thank you, commissioner. Thank you, ive got a couple of questions first to thank marlo for the update on my children youth and families. I appreciate the information and also that i did have an interaction with the mobile Response Team, the expanded mobile Response Team and i want to just let you know and they are appropriate and i appreciated that. My other questions and i guess s concern and when i look at the budget children youth and families expenditure is really that same as Substance Abuse and it is onethird of adult and elderly Mental Health Going Forward it. I just want to state a concern and in the future particular since i know for kids and adolescents access for Behavioral Health services is a real issue and it is something to be considered so that mental healing substance Youth Service as well. So its just one of my own going concerns since very to my questions and in your presentation, i know it is to go forward in the future, but i always would like to see what your consideration of application is and how what you presented would translate number one what was your timeline if in fact you have the 10 million and for the bed expansion and if so, have you identified and where the potential beds might be . Those are my two questions s questions. It is dr. Anton. And the department is in the midst of planning for the acquiring these additional bed resources and its been included in the component subject. And they must recently the Mayors Office initiativated a pond measure for the November Ballot to also help us in procuring appropriately to regular out to go about pre suring these bed resources its not unknown right now what is your timeline to and then utilize what you presented today . So i would have to do it thats an operational question and i dont have oversight over the Clinical Operations for the department i have to defer to dr. Hammer and Marlo Simmons about their process for procuring more beds and im happy to advise them in the process but its really beyond my scope. Do you have any sponsor comments to the commissioner. We feed to get back to you. Were talking about a variet a f beds and some are readily available that we have providers already that we can purchase additional beds from and others that we would have to be kind of starting from scratch so to speak. And so we would definitely need to get back to you and would be happy to do that and were really hoping that well need to develop that plan soon. Thank you. I appreciate it. Just to followup to the i will be the person to followup, marla, would there be and the folder. Well find out if what the budget reality looks like. And then we would need to develop a plan for moving forward so i would hope in the next couple of months, they would not projected work plan to get the beds online. I need a calender. Thank you. The fouryear presentation and for ms. Simmons, thank you for your acknowledgment and the presentation of your work team its name our former commissioner dr. David kateing to the department of work so thank you so that i notice its been a while since we work at regular capacity or regular order of business but im always very concerned when i see the vacancy numbers like the ones ha are included in your presentation here and while you had noted some progress, im always concerned to know the impact that these vacancies have not only on the services and the people that the department serves but also on the very hardworking staff and professionals within the department who are stretched very thin in terms of their workload. Could you just share what the impact is of having this level of vacancy, within your area. The Hr Department has been working and higher as possible and i was excited to hear today that because of a 1 recent clinician and again that clinician vacancy rate and with everything you said is certainly true that having fewer staff means other people are having to work harder to especially true now that we have so many staff for covid. We are also probably not going as much as we could be serving as many clients as we could and i mean really the significant concern is the impact on staff moral and so im really encouraged by how hard hr has been supporting us and dph leadership has been pushing on hr to provide us with the support we need to hire. Im very optimistic and again, the psychiatry number dropping from 23 vacancy to 5 is significant and hr deserves center as well as the decision of the department to change the Compensation Structure to be more competitive and that has been significant enough being able to recruit some really talented doctors to our team. Im encouraged by our optimism and add thanks to the Hr Department and others and understanding how overworked some of the folks who are there and impact the moral. Pleplease extend the commissionr their hard and dedicated work. I appreciate that. Thank you and thank you both to ms. Simmons for your presentations. I know that its got to be as difficult as you have ever imagined to operate under these conditions budge tarily. I had a question, my comment on that as it relates to one of your priorities around workforce and were going to be able to expect some movement versus what we might not expectations that we would like to meet and so i just want to support and support hr in that effort but we all know how difficult it is with the supply of qualified workforce and so, just want to acknowledge that i know that you are trying and i am happy that that priority exists and i want to turn to the budget for a second and you had mentioned you are starting on Revenue Optimization initiative. If you could just detail what the initiatives look like and what they might yield. You mention aid 10 milliondollar figure and a broad amount in just can you categorize it a little bit . Yeah, and i could talk about Revenue Optimization for hours. Im not sure how i can be succinct. Obviously medical say significant Revenue Source for us. There are, in addition to district billing, which is what our clinicians enter information into avatar, there are different pots we can drawdown. One is Mental Health mob, medical administrative activities that have a lot to do with helping clients get to services and we are currently not accessing Mental Health ma revenue and theres a lot of complicated revenues why and now is the time to explore that revenue stream and theyre also are revenue that we have not been accessing related to our activities for utilization review and Quality Assurance that we need to do some work to capture that work. Its already happening. We need to capture it, document it ask submit it to the state. And then in the District Service billing area, we also have a lot of opportunities for improvement and better supporting our clinicians to maximize, theyre working really hard and theres no doubt of that and so sometimes the work theyre doing isnt getting as effectively documented in our Electronic Health record avatar as it could, and it results in lower claims. Just this past month, we started working around our leanbased a3 to maximize our District Service billing and theyre also our opportunities and the Revenue Cycle beyond the clinician and we are studying now and around how we register and track peoples eligibility for medical. A lot of people fall off medical for reasons and we have opportunities to improve the structures we use to monitor who son medical and get them back on as soon as possible and were working on hsa so we can intervene sooner and rather than helping someone get back on, were going to work to keep them on and the last opportunity we have is because of limited capacity to manage complicated federal grants, we have not drawn down as much the grant revenue as we could and so that is another opportunity we want to explore. I wish you luck. Thank you. Commissioner green. Commissioner grown, you are e muted. Is that all right. Thank you for this exhaustive analysis and also to the Tipping Point community thats been so supportive of our needs and our work. I might have missed this in your presentation, can we get a sense of proportionality where you have the 10 milliondollar cost analysis. I would be curious to know more, not right now but perhaps after the preportion of beds this increase represents but im curious to know the magnitude of need or double the number, triple the number and that would help understand the problem. I also wonder if you could give us a little more information about the portion that is our lower level and facility which we know have been closing and it involves staffing as well and some of which is more because i know at the county and other courts of the dph and billing and tracking and i wonder if theres any possibility in we have issues with intensive Case Management and number of individuals that we have available with Language Skills as well as the credentials to be able to do that and so im wondering all might fit together and and in terms of the barriers that are alluded to and women might hear more how we work through those and our workforce might dig into what is really in all of this. Thank you very much to be foes comments and questions and im happy to afford to you answer those points and i know the hours are getting late and i do have a hard stop at 6 45p. M. I do have a response to those questions and i will forward them to you to mark to be able to share with the entire commission. I wanted to clarify in response to the of our wait list in departments in the terms of beds to go to a more efficient system that would significantly reduce wait times and given our current demand so i just want to make in terms of the we need to drug and its across the population versus what the demands and and people entering the system and the needs based on that not on the demand and not and im you are not accessing the system and asking for a bed and they would not, that would not necessarily be reflect inside this estimate. Can you clarify that . Were looking at people in our system for care so theres a population that is not engage in services and we would be difficult to estimate what the true need is for that population without further analysis. This particular investment would be the first in a series of investments towards moving our systems to becoming more efficient and smoothing the flow and thats why i emphasize repeating the inaudible on an annual basis so that as a part of the planning, we recalibrate and recess based on whether theres an increase in demand from the community and people come into care or we are able to meet the needs of the individuals and so, this is 12 increase at that point at these levels of care and i think its the first initial step but this process would need to be repeated on an annual basis to continue to move the system towards the optimal number of beds. Thank you. Dr. Chow. Yes, thank you. I want to thank for the report and the recommendation and i actually think that they actually inform try to lower level and reduce the accused site demand which you showed very well in scenario two and i am concerned that the public, however, needs to really understand that better we do not have adequate acute psyche beds and theres a part of the population that feels that is what we should be doing. I want to know your thoughts on that or perhaps in your report, rather than just being simply scenario two, it should really comment on the rational on somewhat more in terms of why go towards the lower level of beds. I know that you meant the argument but it takes reading through the entire report and getting to scenario two to answer that question which is definitely before the public in terms of why are we not having more acute beds and for the last several years, weve been trying to fight that trend. [please stand by] that being said, its important to acknowledge that weve also looked closely at understanding who is occupying those beds now. And most of those individuals are people who should be receiving services at lower levels of care. The model accounts for as you move people through psychiatry. Were then able to provide services to that level of service to people who have a medical need to be in those settings. It can be difficult to visualize in a way, but essentially, a significant percentage of our acute inpatient psychiatry beds are occupied by people who dont need that level of care. As we move people into these community settings, that are consistent with the medical need, that creates more opportunity for people who have a need for acute inpatient psychiatry. So analysis accounting for the increased number of beds at these lower levels of care. Were able to adequately meet the demand for the services in our modelling. I really do appreciate that. And the fact that is a good explanation. Those of us who follow. Were all well aware of that. Its close to 8090 of those could be moved into other appropriate settings. I think the investment youre calling for is actually a reasonable amount for all the difficulties that the city is having and im hoping that wed be able to try this out and we can review this as we go along to see if this is not the appropriate hypothesis so follow. Thank you vex. Thank you very much. Any other questions . Id like to note that dr. Hammer who several times weve called out to noted in the chat she is listening to the call, but shes away from the office for a while. Im not sure if shes on vacation or leave, but extends her apologies for not being able to respond, but is listening. We wish her well with what is going on. We can move on to the next item. Other business. Im going to put myself into any comments or questions, commissioners . If there is no other business, we can entertain a motion for adjournment. So moved. Second. All right. I will do roll call. Commissioner bernal . Yes. Commissioner chow . Yes. Commissioner christian . Yes. Commissioner green . Yes. Commissioner chung . Yes. Commissioner guillermo . Yes. And i would like to congratulate commissioner christian for getting through her first meeting [laughter]. Thank you, all. Be safe, take care. Thank you, commissioners. Have a good evening, everyone