Transcripts For SFGTV Health Commission 21616 20160222

February 2, 2016 a motion is an order that has been moved. Moved and seconded. Are there any correction to the minutes . Not seen any, were prepared to go. All those in favor please say aye. Opposed. The next item item 3 is the directors report. Good afternoon. I want to give you a quick update. The World Health Organization declared the International Health emergency on monday, february 1. The center for Disease Control has identified additional countries with a virus isnt issue and seeking testing. It also issued guidance to pregnant women regarding sexual transmission to the missed last week, the department has activated and Management Team to respond to Laboratory Testing and share information with medical providers and local communities and last week particularly invited somebody within organizations and certain individuals from Central America particularly to get input and part of that includes representative from the Mayan Community which have several dialects do we want to make sure they are informed. So, we are collaborating with them and work closely with them with the communities in affected areas to make sure they have the information they need. We will also be working with travelers in those areas. As you know, mayor lee announced the creation of a new City Department to address homelessness in early december. We are working very closely with City Employees to help the development of the new department. The new department was created to through the citys budget process which means its a problematic hope will be introduced to the board of supervisors on june 1. Just want to indulge all of our staff. Several hundred staff that worked on super bowl and it went for almost a week. We wrapped up a successful super bowl process ensuring that bay area residents and across the globe have a safe and positive visit to our community. Our Mental Health staff and response abilities ensued in hazardous material, and Communicable Disease also did a lot of work. Sharing information with the surrounding Counties Health departments. So, i want to thank them for all their work. And our public Health Emergency preparedness and Response Branch and Mental Health branch Communicable Disease and control prevention, San Francisco outreach team, inner communications office. I will end my report there. If you have any other questions but if you do what i do want to let you know that one of our employees, richardwhos been working for the department for over 29 years. He started as an industrial hygienist working with toxics including asbestos, radiation, and Hazardous Materials and in the last, in 2007, he was named environMental Health Regulatory Program including food Water Quality health, housing and cannabis dispensary. So we want to make sure that we all give him a good goodbye to his retirement and i know we will be having a celebration for him on march 11 at 6 pm. Theres instructions in and directions in the directors report. I just want to acknowledge him as well. All answer any questions. Thank you, director. Questions for t from the commission . Commissioner pating caucus does anyone have any other questions . Has there are, at this point, been any ceqa reported in the bay area . I think the officer can give you the updated information. Theres been a lot of rumors around. No, there has not yet none in the bay area. Thank you very much. We did no transmission in the bay area. No transmission in the bay area. If we if there are no other questions we thank you and next item item for general Public Comment and would love several request. So, for general Public Comment i will call the list of names and if you could then come up in order. We will have comments limited to 3 min. Each. [calling names] all those making Public Comment of an egg timer and when the buzzer goes off that means your time is up. Thank you. Good afternoon. My name is diana, nurse at San Francisco General Hospital. I want to read you a brief letter from the nurse. Im a resident nurse at San Francisco General Hospital. I would like to make you aware of our continuous problem of missed breaks. We also are never given a 50 min. Rest period and no effort has been made for such. This is not a new problem. It is been ongoing for many years now seems to be worse than ever. The nurses have addressed this issue many times with management with no resolution. It is also a Patient Safety issue. Our unit is frequently understaffed and the nurses are exhausted. It is well known that nurses are tired of no rest breaks, have no meal breaks, make more mistakes. We work hard at the birth center get the birth center is the pride of the hospital just like the Trauma Center. The new hospital is designed in such a way that we require more nurses. We need more permanent nursing positions and not more per diem. The nurses are very concerned the missing your brakes will increase in frequency. We urge you to make the safety of our mothers and babies a priority and to allocate more permanent positions for the birth center. This will not only allow the nurses took meal breaks were consistently, but will allow the nurses to provide optimal care to our families. I want to give you an example of what happens when we dont have enough nurses. I was a nurse of the mother the other day and the baby was not breathing when it was born. I called out for help but because we were short staffed that was nobody around to hear my calls for help. I begin a resuscitation of that newborn. The pediatrician arrived afterwards. They were very upset that they did not get the call in time. There was nobody to make a call. That isnt an unusual situation at the birth center at the hospital. We are understaffed on most days. I also have copies of the 92 emails that went out in the last eight weeks pleading for nurses to come to work. Thank you. I like to turn in letters from the nurses that signed the letter attesting to our shortstop. Thank you. Next, please. Good afternoon. My name is bob eisley. Im a 32 year rn would you like to let your microphone up a little for yourself . My name is bob ivery. Im a 32 year rn working at San Francisco gen. Thomas center. Currently retired. But i do occasionally go back into shifts because this Trauma Center is short staffed. I wish to bring to your attention to numbers. One is 59 . The others 207. 59 is the time last month that the Emergency Department was on the version. I know members of this commission are very concerned with that. We have been over 50 that version for the last three months. The other number i want to give you is 207. 207 are the number of not licensed, budgeted beds that we can operate in the hospital. Obviously, that number is inadequate to keep us off of that version more than half the time. 207 is also the number of the budgeted beds in the new hospital. In other words, there is, according to the report that was given to us in our meet and confer with senior hospital management, no new increase in hospital beds. However, eight surgery beds will be cut and eight icu beds will be open. Eight icu beds requires one to one or oneto staffing. There is, as far as i know, no Budget Proposal to increase the ftes in the new hospital. In addition, although eight new search beds will be cut the bulk of the hospital beds will now be flexbeds and will be able to accommodate higher acuity patients. However, that requires more nurses. There arent any new ftes. You will hear from these verses that they are short staffed as it is, and going to the new hospital is not going to solve that without a Budget Proposal in the budget to hire and train new nurses. I am as concerned about this as i know this commission is. Because ive heard your give and take at the San Francisco general gcc and i know how important that version is. It seems the problem is growing and is not going to be cured. So, i urge you to do whatever it is that the commission can do to urge the mayor to hire permanent nurses and give us the training budget to bring them up to speed. Thank you. After our next speaker, will [calling names]. Hello. Good afternoon my name isim a registered nurse on the medical surgery oncology unit in San Francisco general. Ive been there for eight years. We have been having a perpetual problem with staffing. Generally speaking, we are each nurse is assigned forfive patients. In the last i would say your and a half theres been a push to discharge patients within 20 min. Of an order coming through, but our support staff has been cut. On a daily basis, we work without nursing assistants and we dont have break nurses consistent. Every once in a while we do. So, those 20 min. That you are pushed to deal with that person particularly. In our population the discharge is not an uncomplicated discharge. Many of these people do not have a place to go. They dont have clothes. So, we need to arrange clothing for them to volunteer services, transportation, also, they have problems with medication that need to be discussed with them. So, were put under an awful lot of pressure to discharge patients within this timeframe and we try to do our best. We have patients that as soon as we turn somebody out within a very short time we see another patient. So, the previous 34 patients we have, you are trying to balance the patients that you have that are still need a certain degree of medical attention that does not them to be discharge and your new patients coming in that the level of care is high. So, without the support people, we are really juggling an awful lot and put a lot of pressure. We dont have our full crew of hired nurses in our units. Were using a lot of the as needed nurses, who are currently working fulltime. They worked three shifts per week like a regular fulltime nurse. So, we really wonder why were not given more staffing. Our acuity in the hospital with the new facility is going to go up higher because theres a change in the way the patients are being divided on these particular units. Theres a lot of concern with the nurses for the safety of the patient and also the quality of care the patients will be receiving. We do take pride in our work and we want our patients to leave in a good safe and knowledgeable manner so that when they go home they will be able to maintain their health once theyre discharged from us. Thank you. Thank you. Thank you. My name is. Ive been under set San Francisco general for 10 years and am here to ask that you factor a break leaf nurse into your budget. Will 22 of the california code astonishes the nurse patient ratio. The ratio should be one nurse for every three patient. Common practice is for nurses to break each other, which is problematic as the nurse providing relief has twice the patients. Not only putting her out of compliance with title 22 and the mou, putting her patients and licensure at risk. More than once ive been in a difficult situation of having a patient [inaudible] while relieving another. With patience under my care under unattended. Several of us to to to forgo official patients knowing our patients while inadequate coverage. I myself have not taken a full break in over nine years. The designated budgeted break nurse will alleviate this problem in the breakand the nurse on break can rest knowing her patients will be getting their intended attention. One month ago today nurses at the, general in washington, a similar hospital, one in arbitration the right to a complete break. The buddy system, the same system we use at San Francisco general would be untenable. From page 30 of the arbitration, which you have at least one copy of their, nursing requires knowledge, expense dedication and concentration. Tempered with compassion and patience. To successfully care for patients in need. The related stress both physically and mentally, warrant occasional a moment away from their assigned task at the nurses break should be free from worry and concern and altered the nurses colleague is providing necessary attention to the assigned patient. If that nurse has her own patients doubling the potential workload, even for 15 min. , time away from work is not really a break. So, in conclusion, i can urge you to include a break nurse into your budget plan. Thank you for your time. Thank you. Hello. My name isim a registered nurse at San Francisco general. Im here today to urge you to reexamine the hospitals budget to ensure that there is adequate staffing to meet the requirements under title 22. Title 22 requires that acting ratios be maintained at all times. In currently, the hospital is not doing that. Often nurses have to work out of ratio during lunch break and on transport when they have to take patients to opt in procedures. I currently work on 40 but the situation is not unique to this unit. I examined the 70 day period staffing period on my unit. Nine people at a time provided during the day shift. 11 people at the time provided during the night shift. Although break coverage was provided, it was not enough to meet the hospitals obligation under the law. We had to work out of ratio. What if i told you as a patient, if theres enough people i can save your life. Im not sure what the disconnect is as it relates to 12 through backing regulations but this commission is unique position. You can help our managers to help us provide better care to the citys residents and visitors. By passing a budget to reflect the actual staffing needs of the hospital. As a General Service San Francisco general serves the most vulnerable population. It means you condone the delivery of substandard care. That you see nothing wrong with continuing breaking the law. That you are okay with, missing the house and the safety of the patients and staff at San Francisco General Hospital. I urge you to help San Francisco general leadership to make the hospital a safer place by passing the budget and meet the hospitals needs and obligations under point title 22. I want to leave you with a dispute resolution that is moving forward as we speak. This is on 40 the nurses on 40 our target we can no longer continue to violate the law. We must do something about it. Barbara garcia is it surely speaking shortly because we not receive the adequate response from the leadership at San Francisco General Hospital. I know they want to help us but you have to help them to help us. Thank you. Thank you. So, [calling names]. Thank you, commissioner chow. I can safely acknowledge i face retiring at [inaudible]. To shut me up by eliminating my job classification code and putting me out of a job. The design executive director report and shifting the reporting periods for three out of county discharge summary. I placed the record requests an immediate disclosure request to obtain the out of county discharge data from your 13, 14 and 15 i lost track of that request adjuster member and yes you get 90 days later dph has failed to respond or even acknowledge the next day that november 6 records request. This Commission Still has not provided out of county discharge data which is been repealed the requested over the last several years. So, it is interesting that when you get here most acute care report coming up on the agenda, but also the report of audi county places are increasingly necessary to place longterm care medicare patients including those with tbi, dimension, mental dimension, mental illness, etc. Page 20 of that upcoming report mentions some patients prefer being placed in San Francisco rather than being dumped in the out of county facilities. But nowhere in this report are there any quantitative data. Stratifying the number of out of county discharges that are being made. Commissioner chow and commissioner singer have greatly disappointed me i not inquiring and how the lgbt, transgender, elderly, and disabled San Francisco are being dumped out of the county. This commission has a duty to investigate its report it publicly. Commissioner chow even on this commission way too long. You need some fresh blood. So that we get at out of county docket yet to get off your rear end, sir. Next speaker, please. Im sasha . Hello everybody. I have a petition that nearly 800 people have signed about the renaming of the hospital and i have a poem though that i would like to read to you now. Im a nurseive been a nurse at the hospital for a long time and im not a poet. San francisco general nurses to whom it may concern, please answer several questions id really like to learn. I told you what to call us that you make its mission real. This identity is a very rotten deal. Our hospital in public place, how can i explain the city took its name awake and give it at facebook name. Mark Soderberg Davis money and for that we give thanks but why on earth take the name awake and give it to the banks. Wells fargo foreclose on houses and a profit from displacement. Your patients are discharged from here and left unpaid in. Taxpayers help wells fargo while you learn to be mean. The bank of america. Name has a patriotic flair. The naming unit after it would seem a bit unfair. But some patients get afraid and not in healing mood and reminded that they cant afford to pay for rent or food. The banks dont empty euros. Thats far beneath their station. There is no for passing meds. Thats not facebooks location. In the date they used to say beggars cant be choosers. If welfare is all paid to play, plus some end up losers . Your nurses are not economists but these are the facts. Maybe we can keep their name and they can pay their test. Almost at the end of lunch your patients all are secured me ask you one more time ill try to make it quick. Mark zetterberg gave us money and for that we owe him thanks but why on earth take the name awake leave it give it to him and the banks. So, that is my poem. I want the question that i have for you is to make sure that you are fully informed that facebook just a few years ago performed research on more than 600,000 people interventional experimental trial on people, real live people, and had it was in the National Academy of science and journal and is been no apology for that that they did that without600,000 people that they had their emotions manipulated. The title of the study had to do with emotional contagion, so the idea of putting the foxes name on the henhouse for our vulnerable patients is really objectionable to me and i think it creates a lot of fear among patients. I sit on the Institutional Review Board there and im concerned about that. Please, look into that. Thank you very much. That will conclude Public Comment unless there are anymore . Those are all the request i received. Moving on to the next item to get item 5 is the committee and Public Health report. Commissioner pating we heard to reports from division today, which are really preliminary in terms of the way the committee and population like to hear a report. We heard from thems. Rivera from the opposite Health Equity improvement about Performance Improvement efforts. This is really a new presentation. We have not heard the commission yet but it is part of our Accreditation Process that we have a Quality Improvement efforts in Population Health. So, what we heard today that things were doing with regard to the framework for quality implement in Population Health. Theyre doing this at service levels. Theyre looking at Quality Improvement at a communitybased level and this is where were doing a lot of our collective impact work and reporting out committee base results. The department is also doing more microbe level Quality Improvement efforts using the on the Population Health division. One of the examples were using this is the environMental Health unit. For example, looking at it we process to streamline and improve the restaurant certification that we do. We have 8000 restaurants that have to be relicensed every year. We certified every year. The department is looking at ways to improve that. But put a good Customer Base on it so people have a good expense improved outcomes. So, these were given really as examples of our Quality Improvement efforts in Public Health. Ovulation health. We will be hearing more of these examples over the next year, but it was a demonstration of a framework that were beginning to implement and it was one of the reports that we heard here in one of our divisions, the silos of the Population Health division that we saw at our annual retreat several months back. So, any questions on that about quality implement in the Population Health division . Questions . All go on to the second part of the report. We also heard a demonstration of what we would like to hear across the Health Network in terms of operational indicators. Dr. Alice chan presented the metrics in which the city has identified metrics in terms of fiscal accountability, safety, quality, equity, and two other ones. Did i mention safety . I can remember. There is one other one. These metrics will be standard across our division. Our committee, the Committee Operation Health Committee will be assisting and looking at these metrics they apply to the ambulatory care. So, we got a sampling of data that will be presented to us in the next couple of months or ambulatory care on the jails, Behavioral Health as well as maternal child health. So, i just think our oversight is getting sharper to the community Population Health committee and i think this also represents the departments effort to really streamline and produce credible outcomes for us on both sides of the house. That is my report on to north in the Health Network. Any questions about that . The six you are looking for is actually in your eyes in the handout about fourth from the bottom. That was good for just one presentation when do you expect the commission itself would either hear the results were perhaps a general view of what the Quality Program is in the population . Is theredid you get some feeling about that . Also, as our Health Network resolve these net these metrics, im not quite sure what are these little x are well what point will we hope that the commissionable . With regard to publishing help working out the oneyear till result. The delete in implementing for lead cycles as an example in the restaurant races in division. Then i started those yet for couple more months. So, running for cycles ofwithin the year will be able to come back with those numbers. Regarding your second issue, regarding the to true north metrics all turned to director rc. Were hearing these different mediums so part of the true north we heard San Francisco general and i dont know when ambulatory care would be ready but that is a twoday work when we look at the true north metrics of the entire network that believe its during those two days that will be working on the development of that coming forth back to the commission or directly to the commission and probably the director of the Network Major report to you that comes in i believe next month. So, perhaps just to tie that into our Planning Session, which is going to be on the lean methodology there might be some indication or way of understanding, or how these all kind of birds together, and that could be the beginning of trying to understand how then we would see not only the report from the network itself and ambulatory care, but what would be the best way to display how True North Program is working for the department. Clearly would be spending several hours on just the focus of lean processes. So, i think that meeting itself will be a good place for us to get the understanding of how those are being developed and i believe in thein the Network Report should get more time at that as well. Were doing a Planning Session with the commission will spend a lot of time on that. That would be a good place to start putting these into our basket of expectations. Speaking just for the commissioners to understand also, we are trying to become a Lean Organization all the way across the department. Well see activities not only happening at the Network Level but also in the Public Health division and then Central Administration as an example. Weve done a little bit work in our Hr Department to really assist in better hiring processes, along with contacting in our contract office. We are looking towe also want the commissioners to be trained in a process as well. So that youll understand how all those are working together. All the true north may have metrics in several areas, together with the department as a whole. Very good. Any other questions to dr. Pating at this point . If not, thank you and we will go on to our next item, please speak up item 6 resolution authorizing the gate drug and to the board of supervisors to accept and extend retroactively a request from Norma Parenti and accumulated interest in the sum of 26,000 to the gift fund. Good afternoon. Members of the Health Commission and director rc. We are grateful for Norma Parenti passed away on february 14 and at her request has given 25,000 to her last will and testament ms. Parenti also made similar requests that the st. Vincent and st. Peter and paul. Ms. Parenti went 41 years forand was longtime resident of the San Francisco in the marina district. Im here to request the commission to approve the resolution authorizing the apartment to recommend to the board of supervisors to accept the request of ms. Parenti to the gift fund. Thank you. Thank you. Commissioners, the resolution is before us. Imovie resolution theres a motion and a second. Is there any further discussion . Always very nice the people get to the hospital and are so generous. Were prepared for the vote. All those in favor to recommend the acceptance of the sum is bequest it to us to look at a honda lease a aye. Opposed. The resolution is been passed unanimously. Thank you. Thank you, commissioners. Was no Public Comment request for that item. No, i do not have that. Right i just want to note. I guess we could remind the public that he was to make up comment on an item to submit a slip like we do have our next item. We will then call those names for Public Comment. Item 7 bringing San Francisco postacute care challenge. Good afternoon, commissioners. Opposite policy and planning. Im pleased to be here to introduce this project to you and other folks will take on the presentation itself. Just to give you a little history about why we are here today, you all probably remember but to refresh her memory, in 2011 when the details of st. Lukes we build became public, we learned that they were not going to be able to have Sub Acute Services in their new hospital. So things currently has the only subacute unit in San Francisco and was planning to not have that units move into the new hospital. So the commission had her that is part of the Development Agreement cpm see signed with the city. They were required to look into postacute care specifically subacute care and the need for that service in San Francisco. A couple of years later in 2014, and 2015, center came and st. Marys came to to say that each of their hospitals. So all of these things are really related to the same thing to his availability discovered missing facility in San Francisco and as result the Health Commission last year passed a resolution asking that deviate to work with hospitals in the Community Providers and others to research the availability of Skilled Nursing postacute care needs for our population. So, this report is the result of that request of the department of Public Health and its community partners. The project team, ive a summary here of the very some of the went into the project but before i want get into that i want to say, both sutter and dignity came together to contribute staff time and resources to up us a compass this. Through this work we were able to hire unique parish as a consultant. You might remember monique from her the task force. Shes the present part of this report to you today and alsoboth worked hard on this together with the community folks. So, there was a project team and that was represented by dph transition and laguna honda from the deviates up. Cpm see. The department of aging and Adult Services and with descriptive, really designed with the whole project was going to look like. Beginning to end. The data we need, how we were going to get that data, how we convene stakeholders, how design the discussion among those stakeholders and the information we were going to present to them and how to get feedback from them. This is really the design team. We also had project terms. Youll hear a little more about this later. We clarified what we mean by postacute care. It may not range of things but we are specific and tried to stay true to the Health Commissions desire to look at Skilled Nursing facility care. There was quantitative and qualitative data review as part of this work. We look at data and also conducted a breach point in time survey of acute Care Hospitals in the city about their discharge needs. On the qualitative side, monique conducted 24 interviews with stakeholders represented acuteCare Hospitals, Skilled Nursing facilities, City Departments, only to be based Service Providers and researchers and others about their concern about unmet needs, priorities, and barriers. So we got a lot of great qualitative data from their work there. We also convened in Advisory Committee, 35 diverse stakeholders met twice to look at the data that been collected so far and workshop some of that information and the recommendations you see in front of. Finally, the environmental scan performed by another contractor was provided by funding from dignity health. We look at alternative models on a nationwide level that we might take and learn from for this postacute care process. So, at this point ill turn it over towho did a lot of work on my stuff to bring this report to you. Good afternoon. So, for the purposes of this project the project team decided to conduct an exploratory analysis to really assess the needs in postacute Care Services in San Francisco. So, if you could just take a second to define what we mean by postacute care. Generally, following a hospitalization, for injuries such as a head fracture or illness such as heart taylor, many patients will require continued medical care either at home or in a specialized facility, and many of you may be familiar with medicares definition of postacute care. It provides services across four different settings Skilled Nursing facilities, longterm acute Care Hospitals, inpatient rehabilitation facilities, and home health agencies. However, as coney mentioned, since the closure of our hospitals and nursing facilities, and the closure of the subacute at st. Lukes for presented a resource challenge. We decided to focus our efforts look at patients weaving acuteCare Hospitals to lower levels of care and nursing facility. There are a lot of changes going on right now and in terms of postacute care delivery. I want provide a little bit of the big picture and some of the context around trends as well as factors influencing utilization. So, medicare and medicaid lead to primary prepares for Skilled Nursing care. Medicare will cover shortterm stays for up to 100 days. Under cms, the impact act of 2014 we acutecare providers will collect uniform assessment data across those four different settings i mentioned early. The ultimate goal is to improve acutecare as well as reduce variation in cost. Medicaid is the single largest payer for Longterm Services and support for low income seniors and persons with disabilities. That includes coverage on term Care Coverage in a nursing home. However, low reimbursement rates for freestanding facilities are shortterm rehabilitation care. As late as opposed to longterm care. In addition, medicaid is dilating the integration of medical longterm Care Services and support in seven counties in california under the coordinated care and initiative. When we look at trends across acute and postacute care, its fewer beds available, its increasingly important that we ensure Successful Transition of care from one level of care to acutecare hospital to a lower level of care. What efforts around this have shown to reduce hospital readmission rates for many patients. Another area that can affect quality of life has the potential to decrease excessive healthcare utilization. Hospital out of care programs have been expanding over the past year while Community Based out of care is still growing. Finally, on entitybased services are very important part of the continuum. They emphasize providing care in the least restrictive and most appropriate settings for patients. As you all are aware, we earn aging nation. It is estimated that by 2030, 1 million californian seniors will require some assistance with selfcare. And the man for Skilled Nursing care will increase in addition to living alone or lack of family care support is another factor that will influence utilization, as well as the prevalence of chronic illness, illness, and disabilities and dementia. The first challenge that project identified is that San Francisco is at risk for inadequate supply of Skilled Nursing beds in the future. So, one way we can look at our command is by looking at her population projection and the current factors likely to influence utilization. So, this graph shows three trends. San franciscos population is aging. We have more than 113,000 seniors. This is expected to increase. This is expected to increase to 192 x 23. About 40 of our population 65 and older report having disabilities. Some of them have difficulties with independent living as well as walking and cognitive. Finally, we have a significant prevalence of residents who have [inaudible] and this will increase as we age. We know that commissioner singer has expressed concerns that her population projections may not accurately predict future trends emma and so we did take these comments very seriously. Given our current high cost of living and the increasing employment in the tech sector as well as the availability of housing, it is possible that population may shift in coming years as residents decide to move in and out of the city. However, other Demographic Data we did identify throughout this process including data by their conversation, department of planning, department of finance, do we indicate that San Franciscos population is aging. We already have an older population compared to the states. We are about 14 and the state is around 12 . The needs of those adults that we have here today will indeed increase. Our senior population has grown by 18 since 2000 and some of the data we used to capture is from the American Community survey fiveyear estimate which unlike the 10 year census is a survey that happens every year and this data has been collected for the previous 60 months to make a statistically reliable estimate. In addition, recent focus group conducted by the department of aging and Adult Services found the senior residents really do enjoy living in an urban environment, where they are close proximity to any the services that they might need whether its commercial, retail or health. Finally, while it may appear some residents are moving into the city, they may only be there for a short amount of time. The 2015 San Francisco city survey found residents under the age of 35 im a as well as parents with children with most likely to say they will be moving out in the next three years. So, even ever aging population does grow at a slower rate due to migration in and out of the city, all indications point to the fact that we will experience a Significant Growth. Another way we decided to look at demand for Skilled Nursing care to look at the number of discharges from acuteCare Hospitals to postacute care settings. So, across all hospitals, we looked at their discharges for adults over the age of 65. The discharge to post acutecare episodes about 41 of those discharges either to a Skilled Nursing facility or home health agency. We know that in one year there are approximately 7000 discharge to Skilled Nursing facilities for San Francisco resident. The data also told us Skilled Nursing closures have resulted in an increase in the number of discharges. As i mentioned earlier, we conducted a reef point in time survey to understand how many patients are waiting in acuteCare Hospitals to be transition to a lower level of care, in particular and what we found the 67 patients the day recall. Were unable to move down and there are many reasons for that some of which will cover in subsequent slides. So, on the flipside, the demand, we can also look at the supply in San Francisco. The table on the licensed by the state hospitalbased beds where freestanding beds located facilities are typically referred to as nursing homes. So, the table on the left shows we have five distinct facilities and in total we have 2542 40 Skilled Nursing in the city and half of these are in our [inaudible] and the other half are in our freestanding facilities. Our current bid rate is about 22 beds per 1000 adults aged 65 and older. If our bid rate supply were to remain constant over the next 15 years and would you age as we project to this would increase our bid rate to about 13 beds per 1000 adults over the age of 65. We are also unique in being to larger facilities that support and provide a larger number of beds within the hospital and jewish home. But when we took a closer look at the freestanding data San Francisco bid rate among our freestanding facilities is 11 beds per 1000 adults 65 and older whereas california is about 22 beds per 1000 adults, about half that of the state potentially suggesting were under resourced in the community. Finally, the graph on the right shows the decline in the number of Skilled Nursing beds in San Francisco over the past decade or so. Through this process we spoke to many providers and many reported barriers to growth including the cost of doing business in the city as well as low reimbursement rates. Subacute care is a level of care that is needed by patient who doesnt require hospital care needs more intensive care and what is provided in a Skilled Nursing facility. Many of these patients are medically fragile. They are ventilator dependent or tracheotomy. So, see pmc has San Franciscos only subacute unit and the majority of these patients have lived in the unit for greater than two years. The current census is around 33 and again the majority are San Francisco resident. When we spoke to other acuteCare Hospitals, it became apparent they also have difficulty placing patients and subacute care. There are a handful of facilities in the greater bay area, but some discharge planners have a problem sitting patients as far as la county due to the lack of beds in just the bay area. The challenge that this project identified is that medical beneficiaries of limited postacute care options in San Francisco. So, in interviews as well is our when in time survey indicated that providers do have a difficult time finding placement for those short and longterm medical patients. The primary reasons that facilities except only limited of medical patients primarily due to low reimbursement rates. Currently, there are no policies around Skilled Nursing facilities accepting medical patients but we know that practices have evolved so that medical patients are disadvantaged. We look at profits for the patient as well as the care in homeland committeebased settings but there are a few challenges in doing so. First, in order for patient to receive care in the home setting must have a stable home environment that can be modified if necessary to allow them to live independently. In San Francisco specifically, as we mentioned with the shortage of Affordable Housing, which obligates this issue even further. Residential care facilities for the elderly, they provide an alternative residential option for some residents, but we do know the number of these facilities has also declined significantly in the past. Especially those willing to accept low income ssi patients. The cost of providing medical and personal Care Services in the home is still excess of good for example, in 2015 the meeting cost for one year of Home Health Aide services was about 45,000. We know that most states have limits on their home and communitybased care options including waders such as waiting list and cost caps but by contrast nursing home facility and taiwan programs meaning that anyone who is eligible willcan you care in a nursing home facility if they have access to them. There are no weightless. So, it is more likely that medical patients needing longterm care will be placed in a facility and receive care in home and communitybased settings. Finally, there are some problematic areas, mainly limited number of hours that are provided. Home health is reimbursed by medicare provides maximum of eight hours a day or 20 hours a week. The average Inhome Supportive Services recipient in San Francisco gets about 21 hours of personal care a week. So, this is a little concerning for some patients who may need 247 such as patients with progressive dementia. Im in a handoff to monique parish to talk about challenges and recommendations. Thank you, commissioner dr. Chow members of the commission and dr. Garcia. So, along with these two challenges that emerge with it was a third one and this will be identified certain communities of adults were vulnerable and difficult to help with postacute care. Before i give you the two large groups, i would like to just mention that the Previous Group medical beneficiaries short and longterm as well as this group, both really theres overlapping. Theyre not just in groups. Silica medical and fisheries to in this group may be homeless and or have some behavioral challenges. So, let me first share with you that patients with behavioral challenges by and large with it repeatedly cited by our qualitative interview have different difficult to place in postacute care. This is specific to largely Skilled Nursing facilities, but also extended into homeland committeebased services. Identified that these individuals often times, because of conditions related to dementia were Mental Health disorder or even a traumatic brain injury might exhibit behaviors that were disruptive, either aggressive or yelling or outburst. Nursing facilities often times are evaluating patients coming in and when patients are disruptive they tend not to be patients that are technically a good fit. Similarly, theres another group. They also indicated incidentally the respect of this, they also need more staff time to manage them and this is not always available in Skilled Nursing facilities or covered by insurance companies. A second group of challenges for a particular group were vulnerable those homeless or substance abusing. In a very recent published survey that was conducted with across the country homeless adults found this a significant number were actually older adults. So, often time people sent to Homeless Individuals think of them as younger than age 40 and roughly half were age 40 and above. In this group they were more sick and often time needing both acute care in postacute care service. So this group also reported having everything from Chronic Health conditions and disabilities to Substance Abuse as well as Mental Health diagnoses. Because of these two groups of challenges San Franciscos hospitals and acutecare providers are finding it very difficult to place individuals not only this group but also the medical beneficiaries, and that is one reason for reaching out side of the community and county of San Francisco to place patients. We know certainly there are similar characteristics in other communities struggle with placement im about because of expense here in the city and some difficulty with growing with her subacute care providers this is been an option get recently identified to our stakeholders that Going Forward, hopefully theres an opportunity to keep more those San Francisco residence here where they live to receive care cheer. There were two other groups i want to briefly mention that emerged that are not necessarily difficult to place in postacute care, but really emerged as to committees that we want to be aware of and integrate thoughtfully and other future postacute care plan. That includes seniors who arent eligible for public assistance get another term for this is the hidden court. These are naval just above the Poverty Level or even maybe a little bit further, but ineligible because of their baby pensions or savings over Social Security to qualify for Public Programs such as medical benefit if they do they have to do a share of cost which can be substantial. So theyre at risk to moving into poverty. Another group is lgbt seniors and in 2013, that was a rather conference of study done in San Francisco looking at the needs of older lgbt residence, and a group ofthat study in particular identified that there was a significant number of older lgbt seniors were both living in marginal housing, that had identified the limited social support system should some catastrophic catastrophic event happen nestle had experienced either directly or fears of discrimination at facilities. Again, this is a group that is similar to the general population. Anybody elses developing alzheimers. Being mindful of the needs of those as well as lgbt seniors Going Forward is going to be essential for a postacute care strategy. So, this is a dedicated process and this was a remarkable contribution by everybody involved from the postacute Care Advisory Committee and the project team. We sort of offered 40 draft recommendations with the help of the project team and Advisory Committee we will whittled it down to seven consensus recommendations. I do if i could just go out and reduce off to you. The first in this group is actually establishing a collaborative. There was general agreement among all the stakeholders to create a partnership that could take the important work of the postacute care project forward. Not only do the conversation but also potentially looking at these consensus recommendations. We would recommend that collaborative, the current Advisory Committee was expanded to include consumers and other groups. The second recommendation is to explore new incentives and Funding Options to bringing in providers that provide facilitybased care. That would include everything from nursing facilities to Residential Care facilities for the elderly as well as subacute care. As you heard, and was underscored, the still need to have that capacity and the supply that can meet our growing needs in the city. So, potentially through this one opportunity to explore some land use through the Health Services, healthCare Services master plan, which is a joint effort between the San Francisco department of health and the Planning Commission it again, looking for potential ideas. The third recordation is to identify the total number of Skilled Nursing facility residents that can transition to the community. This is essential. We did our very best in the somewhat abbreviated timeframe to cover a lot of the quantitative and qualitative data. We know we certainly cannot include a cover everything. So, Going Forward understand who are those individuals that moved to the community and support they need, is going to be important. Related. Is working with the granada to conduct that analysis and south of us in san mateo with a great example the health plan which conducted a similar study. The fourth recordation is to promote flexibility and expansion of committee programs and Affordable Housing. San francisco, again, is really a reflection of many diverse programs, many of which are entirely devoted to addressing the needs of younger served as well as identifying programs for Affordable Housing. But, throughout this project a number of issues surfaced about Affordable Housing, so it was encouraged in this recordation to continue to look at opportunities there. We certainly know that we want people to live in the least restrictive setting consistent with the olmstead decision. One quick recommendation is Inhome Supportive Services providing some hours but its relatively limited. I think theres a maximum amount of 283 a month. So if youre caring for love on the dementia and served moderate stages but it would be a little bit of risk of wondering, that individual cannot remain in place with a provider because of the limited hours. Thats another opportunity there. Our fifth recordation that was identified is exploring Publicprivate Partnerships and is actually different than the collaborative the clapboard of which is the first recordation, is to move forward with a structure that continued this work. The Publicprivate Partnership was identified as a way to show book share both responsibility and funding across public and private entities. The postacute care project is an example of this. You are colleen mention that there was tremendous resource given by those cider in the San Francisco department of public up again example this Going Forward. We also want to make a quick little nod to the environmental scan conducted. In that scan with a look at creative alternative all around the country, again these multiprovider greater Funding Strategies were identified. Our six recommendation is to identify the process or application or technology to provide some realtime information across acute care and postacute care providers. Theres been an example of this in the past and that was the Care Management fleet where acute Care Hospitals used to use this was a way to identify everything from referrals to bed availability. Again, this is something that are being in the center of so Much Technology innovation would be very helpful. Finally, home and communitybased service waivers. This is effectively an alternative to institutional care and this is managed at the state level with the state medical plan. This is a perfect option for forza, as mentioned, we have on bounce a few slots. There cost caps so you only spend up to a certain amount maximum out. And the other aspect about that is it often demonstrate a burden to become eligible and moved into that. This works together in closing really indicated just terrific offered opportunities to develop a coordinated strategy to address postacute care. As we learn the hospitals are dressing, these three challenges of that capacity, and addressing the issue of medical beneficiaries and of course all vulnerable communities, often times having very lengthy weightless or having to place individuals outside of the county. This is really an opportune moment to move forward with this exploratory analysis. In closing, i would like to say that it was just a tremendous amount of enthusiasm and energy among the stakeholders including our postacute Care Advisory Committee to an continued this good working on behalf of the project team like to again thank our postacute Care Advisory Committee members and her team members. Thank you. Thank you. We have several public speakers. I will call them again as we did in the past. [calling names]. Good evening, commissioners. Thank you for the opportunity to be heard today. Im emily webb from cpm c, director of Committee Health programs. We were very happy to work with this wonderful project team on what i think we can all agree was very conference of thoughtful and productive report. Cpm c was happy to engage monique and breaker as an important resource to bear for this project. And offer some Data Analysis resources. So, we are happy to be active partners in this as we have decreased our survive subacute basketweaving visit important citywide issue that will need to Work Together on. Both of the hospital about department of Public Health, and to mebased organizations. We found that theres actually a lot of energy and enthusiasm in looking at how we can build up both the Community Capacity to get us closer to the statewide averages and invest in communitybased services. We think those are really important options to explore and Work Together. So, we are happy to be a part of the collaborative moving forward along with the other hospitals in the city and we thank the project team and the Advisory Council for all their work on this. Thank you. Thank you, commissioners. Nice to see you again. I marry linear. Im the Vice President for Specialty Services at california Pacific Pacific Medical Center and i was one of the cosponsors of this project along with emily and abby. We were glad we got together. I think the report is substantial and shows the amount of work that was intruded by everyone, but obviously is just a start. We need to go farther. We need to get specific recommendations that can be acted on. Clearly, this will require participation, everyone in the city and i think that unique partnership is the thing im here to applaud and be most supportive of. The hospitals and the city agencies and the department of health are going to Work Together and try to figure out some solutions. So, thank you for your support. Thank you. As we are preparing for three more speakers, [calling names]. Good afternoon, commissioner. Abby and vp of Committee Health Initiative Services at st. Francis representing st. Marys as well on this particular matter. Im also a member of the longterm care counsel and so it was a good amount about the make and of many years of service in the city to bring, to me together with the department of Ages Department of Public Health and the private hospitals. We of course were brought into this discussion by the closure of the Skilled Nursing facility operate st. Marys, and in some ways we were drawn to that particular way of doing business in the city because some of our bigger hospitals in the city dont have Skilled Nursing facilities either could we deny the table for a long time just talking about the most postacute care environment into avid opportunity to come together and look at postacute care, we did a whole healthcare master planning process in postacute care is a big piece. So, i think its a been a unique opportunity to bring that together. We also provided the funds for Collaborative Consulting to come in and do the entire mental scan and look across the us and their principal, lori peterson, is providing consultation i think literally today in tennessee in nashville and helping them put these collaboratives to get. I think it something we have a lot of way of putting San Francisco seal on things being done elsewhere. The recommendations, in my mind, we follow the two important categories. One is policy on how we really address postacute care in this community and weve never taken that up. I do believe were going to to generate some Energy Around that. It is something that a lot of people dont think about until late in the game. So, we may have to have a groundswell of political influence to get what we want. We need to protect what we have now is you heard today on its project we had 67 people in San Francisco in the queue for some of the services that are very difficult to find. So, regardless of whether or not you believe in the projections, the problem is here today. So we do have some urgency around that. The second tier is operational. I think this is when we have a quite a bit of opportunity to more effectively and efficiently use the resources that we have with some technology, with some collaborative relationships being built, we can probably move patients a lot more quickly and sooner and be more efficient if we find a way to do that and i think theres an opportunity are really quite close, in front of us, because of the pressures that Health Systems are experiencing around value based purchasing and the Skilled Nursing facilities that hundred day mark is shifting very very rapidly. So, there is capacity. There may very well be capacity in our community that we have to seize the opportunity and be able to use them effectively for the patients we have the hardest time moving out, which other vulnerable, homeless. Thank you. President and honorable members of the commission, dir. Garcia, david sewall, hospital counsel of northern and central california. I also want to add my recognition and thanks to sutter and dignity for their contribution along with the other stakeholders. One of them includes pat lansdale, the Vice President for continuum of care at the California Hospital Association it was a pleasure to work with dir. Garcias staff in these meetings. And to have the hospital counsel is a part of the collaborative effort. So, we look forward to having these discussions with Key Stakeholders that are outlined in the report, and coming up with our own set of recommendations in the future. Thank you. Thank you. Im patrickbut i want you to understand how underwhelmed i am by these reports. Longterm care coordinating meetings and i think about eight years. This moves the ball down the field about 1 inch. On page 23 of the report, table 15 shows the spinner 43. 3 decline of bags bags since 2012. In the 14 years since 21. Of those remaining 1012 45. 1 were eliminated under your watch. [inaudible] build 180 beds. Its a long way towards helping your [inaudible]. Page 21 of the report shows those one of 11 people 111 people on the waitlist for longterm care in jewish home, how many people are we listed at other facilities . Or from their homes for longterm care . Page 14 of the port report San Francisco 65 and older will be 20 of the citys population come 2020. Im sorry. 2030. Thats 192,000 people over the age of 65. Page 15 indicates there is demand for acute care in the city that will exceed supply just four short years from now. Ive been asking about this problem for eight years. Youre finally get around to doing something about it. But you waited too long. Youre facing a sin army of people for unmet needs and you know it. On page 13 many elder san franciscans require acute care now and in the future. On page 14 it says there is a demand for 1000 725 beds sure. Thats 14 years. So table for says just four years from now, in 2020, acute beds appeared to be about 500 beds a short for people 65 years or older and within 14 years, by 2030, it looks like it will be about 1000 beds shorts. Its time to stop this farce. Thank you. [calling names] good afternoon, commissioners. Director darcy. My name is benjamin w a been running the program in San Francisco. Its a longterm Care Investment program. The Health Commission doesnt know anything about us accept under federal and state law we have jurisdiction in Skilled Nursing situations and in Residential Care situations. In addition, and California Law we are the abuse investigator if a person resides in a personal Residential Care facility, as well as we have and that kind of expense or scope. Ive been hearing San Francisco since the end of 1987 and a been specializing in residence care because [inaudible] i have a caseload of Residential Care people many of whom were discharged during the first wave of the institutionalization from the hospital. Some of you might remember the first wave of the institutionalization. Were dependent adults, the rural Health Clients and potential clients who moved always Residential Care homes. Guess what . Their aging in place. Let me give you some numbers i got from licensing printouts. In 1989 there were 140 Residential Care facilities. Theyre about 90 adult residential facilities. Fast forward tothere were 73 Residential Care facilities left out of that appeared in 1989, 40 of the total were the small six bed and under homelike facilities, mostly amatory only above garages. By 1980 i think by 2008, is only 24 small six bed facilities left and huge Residential Care facilities assisted living going up. You can charge anywhere from 4000 9000 per month. Surely, not something thats available to people do any of the reimbursement systems particularly the medicaid system. There is a medicaid waiver for Residential Care started by. This was from the department of healthCare Services for facilities that have a waiver, but none of them are in San Francisco. The list is available. One of my recommendations is that we do a statewide assisted living waiver pulling down as much as we can from medical to widen the scope to make it more appealing. One interesting thing aboutthey have to more specialized ftes. The smaller sixpence do not have have any special ftes. They only have to caregivers who give care giving and good for. Not really professor and some of the issues that have affected the smaller individuals of Behavioral Health facilities as well as the elderly are coronation people come back from hospital. They get worse and i go back to the hospital again. I the handout with more detail. I like to enter into public testament. Thank you. Hello, commission. Ive not had a chance to meet you my name is oscar minorca on the director for postacute care for the Sutter Health bay area. Prior to this role of the marriage of care coronation as cpm see some familiar with many of the challenges. I would like to say im supportive and appreciative of the effort monique did. They did a great job. I also want to echo the concerns they mention in the report. I want to publicly advocate for the need to really address the gaps they mentioned and optimize our postacute care resources in the citys Health Facility and returned to the committee for San Francisco patient. Thats all i have to say. Thank you. Thank you very much. Were there any other speakers . All the other thats all the public request to speak on this item thank you. Commissioners, comments or thoughts on our report that has been so well presented . Or if ms. Cello we should do have some comments . I dont think i have anything else to add. I want to say i think this was a welldesigned project that included input from a lot of different qualitative and quantitative resources, as well as committee folks and i think they get a great job of putting this information together. Commissioners, but to think particularly sutter, cpm see, and dignity for their support on this. Also hospital counsel. I also think its important this is not just a hospital problem. This is really a Healthcare System problem we need to embrace that. I like to thank him for the recommendations and note that the full support of the Health Department and hope you will give that to them today. To really i think we been given lots of great recommendations for us to work with all of our partners. I want to really thank them for this is been something i know dr. Chow you been folks dont focus on for many years and i think we have some really important accommodations today from them. Commissioners chung thank you for the reported either couple questions. The first one that i have is when you are doing the projections how many additional beds we need, did you actually do a cost analysis to see how inflation is going to play out by 2030 . We do not look at a cost analysis for those projections, but it also assumesit looks at other geography benchmarks. It assumesthose projections would be in the event nothing else happens, or in the event one day similar to the statewide average or national average,. There are other ways we could intervene to press reduce the other years the need for nursing beds if we did a better job of enhancing Community Based services were stabilizing people in their homes or other things. So, that is sort of a benchmark based on other standards and not necessarily unmovable. So, i want to play the devils advocate here because we talked about the aging population. We are looking at 15 years because for selfish reasons. Ill be there by 2030. But, i am interested to find out if what are some of the barriers that we have not really mentioned yet. I think we mentioned cost quite a bit. Im talking about the medical reimbursement rate. Actually, i had somebody mention the political will somewhere and i think that is really where this whole can of worms started. Because that rate has not changed and that needs to be reflected. Im kind of optimistic because it we can actually change to make the rates reflect geography and also the rental pricing in that area, to determine the amount of subsidy, i think thats a real room for this to move as well. Its just a matter of political will and how we can actually generate enough effort and manpower to move that in that direction. I am kind of concerns that becausewe been criticized for a lot of things these days including light displacement, displacing residents and hearing about placing them out of county. My first thought is, if they want to come back do we actually support them and return them to San Francisco . So, im not quite sure what happens after you replace out of county. I know we pay for some Services Window placed out of county, but when theyre Getting Better and been discharged from these facilities, where do they go. I think that the hidden costs that we have not mentioned at all yet at this point. So, one more that i want to go down good the oneim really curious about with all the recommendations on that list, which one do you think is best to address our shortterm challenges of not having enough beds now that we have 63 people on the waitlist . Not counting those that might be at home waiting. Commissioner, thank you so much. Just a quick comment. I think you are right on the money in terms of highlighting the complexity of the issue and has abby had said, in response to the cost analysis, looking at policy. As we took what this trend in home and Community Based Services Without changes in some of those reimbursements. Im now thinking and referring to medical even as a waiver benefit i want to knowledge the complexity of that insane has to be someone there. With regard to which one we would promote first, one of the things the Advisory Committee did come up and this was a really monumental efforts and quite impressive. They worked in small groups. So, while the collaborative is that initial structure, we divided them into short and long term but looking at everything on it first, that short list, incentives for funding to bring these providers were examined, and also looking at the specifics within how may people can be moved currently. Not even counting laguna honda but at the freestanding facilities would be important because we need to know what supports do we need in the community to support them. There may be something that would be a next move. Last in a shortterm list for home and communitybased programs in general, again looking at the profile of Services Available in San Francisco quite robust in many ways and of course still needs some further development. We would yield to this collaborative body, which would be the more broadly diverse and inclusive to identify which ones to move forward but an excellent question. Could you clarify the 63 good comedy are longterm versus shortterm need . Without one or the other . We dont haveit really varied. The most common reported were for longterm patients. But there definitely were some shortterm patients especially patients with medical managed care that a discharge plan whom they were unable to place in our facility it did vary across but we dont have the exact breakdown of the number i thought when you did your survey, what you are sayingi think, on a short term care basis the problem is you highlighted in the report about medical reimbursement seems to event have said that these facilities could not take that but that the bulk of these 63 are really for longterm care . Guitar for me to say exactly which its hard for me to say exactly which. We could not get exact Accurate Information about patients length of stay. Thats a good question. One of the challenges we had. Literally a threehour window across i think what degree of 10 hospitals we were interviewing breaking up between the two of us and oftentimes they were not able to identify who would be longterm in that moment. All they could say is we really need to get this person to the next lower level of care and we actually asked the question, can you discern bitter remains a little bit fuzzy in that respect. I understand. In other words, the facility may not know or if they knew, then they wouldve told you but thats why you really dont feel comfortable insane accurately what these are except there was this waiting list. Yes. Okay, thank you. Commissioner pating. One question into comments. First of all, in regard to the longterm, shortterm needs inside it sounds like you didnt know but what about availability and terms of bed shortage shortterm versus longterm . Is there more need to acquire longterm or shortterm beds . Do you know . I know the last breakdown of short and longterm beds in San Francisco. Among our distinct facilities the two larger facilities jewish home and the good honda primarily provide longterm care and its about 77 of the beds orientated towards longterm care. When we look at our facilities we dont know with complete accuracy, but an annual survey reports for every patient at the time of the census and in the last census, in 2014, about 59 of the patients recovered by feeforservice medicare which indicates there likely to be longterm patients. So, that amounts to about 640 beds out of the 1223 licensed Skilled Nursing beds in our freestanding facilities. So, thats the best approximation we can make. May be overa little over half or so of the beds going to be needed want to but is that what youre saying . Yes, in the freestanding authorities, yes. We tried to clarify that or understand, youre postulating that because 59 were under feeforservice medicare will that that was longterm . Yes. There likely Patients Enrolled in longterm versus a shortterm basis that might be [inaudible] were trying to distinguish. Youre also trying to distinguish there are needs that are shortterm versus longterm correct. I two comments. I want to again offer thanks and congratulations. I mean you guys build atop a very short time. Maybe october, when did you start . End of August September and the three hospitals thank you for contributing to hospital counsel. I think a really good wellfounded start. Its only questions just 34 months ago and i think you we saw open questions, but you frame this quite a lot and you moved the ball. I think more than an inch. I think a couple of inches forward. With that, my second comment is that Going Forward, i can see the complexity of this and i can see theres also going to be some value as we move forward. I would like to speak i hope you might considerbecause a minor recommend we endorse this budget Going Forward because theres questions that still need to be answered. One is is not clear to me for going to need 500 or thousand or whatever the number that would have enough room in the city to build these number beds. We are looking for homeless pets as well. So, i hope we will consider out of city maybe even multicounty options. Were not the only country that has this concern. Maybe working with across the bay area it gives you a broader perspective to be able to solve some of these problems. The second is that, while hospital counsel has offered its time and effort, this is not just a hospital problem. I think we need to get inhome Health Support agencies and the vendors and everybody will both have part of the solution and part of the pain, and hopefully adequate financing that goes around with this. My third would be that were going to need be creative on this. Just like we were with the Health Security ordinance which i think is a password for billions and the policy folks who patch together all the funding for that. I hope this would be a little bit a few pennies here and a few dollars there and will create something as affected. Then, lastly my hope would be we will learn from other places with his might have been solved for efficiencies and opportunities to make our system better. I do not see any report that doesnt mean that they are there or not there, and im really optimistic at the next round that again, we dont consider any options impossible at this point. We start date and work backwards because i think we have a gap here looking to be solved and i think the hospital has shown their commitment to working with this and try to get the rest of the players involved as well. Its a community solution. Thank you very much for your work so far on this. Thank you. Next, commissioner sanchez just a few comments. When we had our last hearing, over the years, some of us felt we were losing the ability to really highlight the importance of dismantling of healthcare in a given pattern were given cluster. When cpm c came and we goaded voted, either feeling we , pardon the resolve and what could take place might not take place. I think reading this document again since its been revised again and again is astounding. I mean, consider putting your head in the sand going back to individual silos, everybody came together and talked about, number one, we have some major problems. We dont have common data. We dont havewe have incremental reporting. We dont have anything which could generate a uniform policy that would address the challenges that each one of our institutional units are major hospitals, are nonprofits, are small facilities, and again, are there other things that are being done statewide which could be at least highlighted here briefly, which was done. I just want to say i think this is an exceptional reports. Everybody who put the time and energy and creativity in it should really be commended because it speaks to what San Francisco is about. People together and we say, okay, heres the challenge and were going to rise, everybody, and provide the highest quality of care and services we can. Thats what this document addresses. It also says, in particular, we need to continue this continuum of dialogue and there were some other comments made about over leader could be generated in philosophy and implementation at the same time measured outcomes pertaining to how, in fact, we measure not only in the city and county but in the region and state. I particularly, i guess was sort of in the footnotes, but i was reading this specific recommendations because we had hearings at the California Commission on aging pertaining to what is going on in the different counties. Regarding how to care in the state and theres no uniform reporting of what is california doing. We have more information in this document pertaining to different counties that are doing Different Things not only that but listing the programs, whether it be a nonprofit, whether an institution, whether it be a school, just an excellent documentation to continue on as we move towards finalizing and presenting an overall philosophy of how San Francisco will address this issue and towns. All i want to say, so, well done and we really have made fantastic headway and we are so proud and honored to listen to these recommendations and to read these really exceptional insights pertaining to how we arehow we have adjusted, how we will address it and the challenge we face, not just the strings. So, i thought was an exceptional document and i want to thank everybody for your participation and contribution. Commissioner karshmer im particularly pleased him to please were talking about beds and care. I think its pretty important. I think as we move forward, whether because of the space in the city were cost of the city, but i think we have to be very shrewd about postacute care or subacute care. I also think we cant overestimate how important the connection with housing and Affordable Housing is. I think that of all of these things, the housing issue , if we are going to move beyond think about putting people into bed weve got to talk about also subaltern of housing wherever they are. I just have a question. In your shortterm plan, you have these champions. Have they agreed to be the champion needs for this . Yes. Weve reviewed these regulations were budgeting. Mostly identified in the recommendations were members of the project team and they have reviewed and agreed to be leads and partners in each of these. So the last question is whats the next step . One et seq. Or to happen . What is our timeframe and when we can get a report back in our going to be with to get this moving forward . The last thing we want to do is stop this. Adequate general agreement among all of us to continue going for. The hospital timeframe has agreed to review this and upcoming meeting in april. Interview this more closely and have at that time i think well have a better sense about the next upstart and the department of Public Health and aging will be partners drop that effort. Commissioners, i just want to take advantage of an opportunity i talked about in my direct report. We are developing a department of homelessness. Its charging 8000 individuals to be house. One of the issues that are very supportive of is our direct access to housing is a Supportive Housing model. It has Critical Services surrounding it. As we identified homeless populations , mental populations, are going to be real important accommodations from this could go to that department about how we are developing and enhancing the new housing that will come on board because i believe that a score to be a critical component to keeping people housed and healthy. Thats a population that we have most trouble with in terms of trying to find after discharge where they go. Medical respite is an example of something we developed. It also did some work on the shelters were many of the nurses come back and say, that could be reallyif we had a Skilled Nursing facility in a shelter would meet the needs of the community but you know that means. From a licensing point of view. Those kinds of enhancements to keep people out of the hospital would be helpful towards the trend as people age. But you have an opportunity right now within the apartment to influence the housing correction, and i know the leadership there is already think about how to work with the most chronic homeless, which is the next population were going to need be servicing. Just as an example of what you can influence in the next coming months. Mr. Taylormcghee thank you very much for the report. One of this wouldve challenges and received a port thats so offensive is that raises a lot of questions as you probably know. One of the things i do not see in your recommendation was how do you build into a strong advocacy component . As someone who has expense healthcare crisis and trying to look at post acute care, i mean those issues are important. In this you can advocate for yourself and i fortunately could, theres a lot of holes in the system. So, sort of what commissioner karshmer said, hardeeville from talk about beds to care . Quality care and Skilled Nursing facilities is an oxymoron. So, i would like to know how to build in a component . I did not see it in your regulation. It may be some are hitting and there. For semithing you identified something thats really important and what we didnt share with you actually looking at a consumer perspective. Again, going back to commissioner karshmers focus on care and not beds. So, bringing that experience and efficacy is so important. You should try to engage consumers and patients, and it turned out to be a little more obligated than we thought it but not withstand. While we were doing these in time surveys we were trying to get out into two hospitals we actually tried to do exactly what youre saying. So, you are right in that it was not a developed component because its absolutely the key ingredient Going Forward. One to build the advocacy but understand people in experience what this is like, and it sounds from your experience you have great sensitivity and insight about that. So i would recommend as we move forward, hopefully with a collaborative, making sure consumers are very vitally engaged that we understand their stories. So i hope that is answering part of unfortunately for not successful but excellent point here is the unfortunate reality. People do get lost in the system. Do you have any idea of how many people are sort of stock right now just overall, any numbers . I know there are people waiting for postacute care and people waiting for Skilled Nursing facility beds. I know theres a host of things but you have any idea in San Francisco right now what the number is . What we talked about in terms of numbers . Do you know . What we have is that one point in time day really consider 67. You can imagine on any given day you would have that i think youre also speaking when we think we talked about the hidden poor but theres a lot of committees i think dir. Garcia mentioned, we are not capturing in this. So, i think in this complexity there still rays of hope Going Forward we can try to really get at some of that need and move forward with a little conference of this. One thing i want to point out that i have a chance to mention, we were very fortunate to work with two renowned researchers from ucsf dr. Robert newcomer dr. Charlene harrington we interviewed and russell participants on the Advisory Committee. These are absolutely dedicated individuals so understanding the 101 who in perspective, individual perspective and also global Population Health perspective. Again, taking advantage of all that as we move forward would be important thank you very much and one final comments. Again, thank you for your report. I like to put a plug in for really taking into account the special needs of women and making sure that, as you look at those advocacy components, that you take that into account. In particularly for low income women of color. I mean, there is a real area of need. Just as the Lgbt Community can experience discrimination, women of color can do the same thing. Please, i just want to plug that. Thank you. Thank you. Commissioner chung one question i forgot to ask is i heard there are times when we have to do out of county placement as far down to Los Angeles County it is that correct . How do we connect them with a primary care in the area . So im super curious about that. Unfortunately, with the scope of this we were unable to really explore that but i think you raise an earlier comment similarly, what happens when the place that of county today come back and we were unable to answer that. But i did want to mention, some of the cost you indicated earlier on often carried by two hospitals whether waiting they might need for out of county a period them. Commissioner chow also reference a bit that got more to be uncovered but we are taking notes and will do our best to make sure we address this in the future. Im curious about what actually is the true cost for those who could not be placed and what are the rates of remission or, also, because San Francisco, like we are a commerce center. A lot of these also have to do with whatever commerce they present so they might not have anything connected. How do we ensure that that they have the resources to heal and not get readmitted over and over again . Good questions and youre right onto something. This is a Risk Commission chow, whatever cheats it would be nice if we could have an inservice on the cost of care could i be interested for example in a sample scenario interviewer go to a Skilled Nursing facility what is the cost and the quality of care versus inhome health versus the different kinds of options just to begin understanding how the system works. I can imagine there might be a point where if youre staying at home your quality falls off or cost goes up being in a residential setting, these different balance points and how they balance out. Just i think it would help me to understand to see the different parts of the system as we go through. Presentations thank you, commissioner. Youve hit on what might be our next Planning Session following the lien Planning Session in april. Since we been trying to do these about every half year, were looking at doing one that will look at finances and the issue of selfsustaining and i would imagine that we cani definitely would imagine we can obviously need to look at the cost of care. And what that may be. So, thank you for adding that. We were going to present that as the potential next topic after we get to our next Planning Commission. I was reading your mind. Thank you. I do want to also on behalf of the commission thank all those who participated. I think when the commission asked there be a study of this entire topic, i dont think we couldve imagined within the short period of time is commissioner pating pointed out you actually could come up with a landscape as it is today. It is clearly a changing from 20 or even 30 years ago when we started, and at this time, we are much clearer that there are at least three different subgroups of Services Within this, which is just only part of the postacute care. Its a great title. How to care, we heard so several months ago and were please the work youre doing with that and the longterm care council. We would hope that something of a similar nature, looking at the specific areas. I recognize that while subacute care for at least a segment of our population doesnt go away until 20182019, i understand. You must wish they could complete the hospital. We would not be able to terminate this intuitive solution to it, but i think i reckon eyes any report and presumably in the collaborative, this will continue to be an important topic. One that you point out is regional. I think we need to be sure to be able to distinguish longterm versus shortterm in Skilled Nursing. Because there are Different Solutions to those. I was very pleased also you were looking at not just what we been trying to do at laguna terms of understanding who can be in different settings of care safely and even appropriately within the remainder of our system that we have not done because, odyssey, we were doing it within our own system. So, i think those are all very important areas that you have arty touched upon. The recommendation presenters are fairly broad at this point and obviously, is commissioner sanchez said, some of them more specifics are really intriguing. Id also like to emphasize, is commissioner pating has, while its important to understand the out of area and please understand we need to understand more about. Questions came up, what happens. How long is the Financial Stability versus the care part of it that i mean, all these people out there and how do we actually understand whos going to care and who doesnt. We know within the Mental Health segment with great responsibility, but we believe, i believewe continue to track those. What happens, then, for these people who then go outside . Not just within our system because Mental Health is all the goodie here we have the people in the private sector. Along with consumers, and other interested stakeholders including perhaps companies that are interested in putting up more housing or more beds or what not, i think we also need to have the provider delivery community. That would include some of the people within our own private sector trying to find where their patients are going to. I think commissioner taylormcghee has alluded to that. A real problem within just a few isolated and then you told your going to be moving in you and your doctor are really stuck. The insurer says your time is up. Meanwhile, theres no place to go. So, i do think thats another stakeholder perspective that needs to be there along with obviously, the consumers. I would like to ask dr. Garcia how we would proceed at this point . I think our commissioners have notice of themselves this is a good first step. It lays out the landscape and that we would like to move this further. I think your approval of the plan today and supporting the recommendations and allowing the group to continue to do their work. Ill give an example today of how this work should influence the department of homelessness is an example. Im sure that some of those particularly those shortterm recommendations and we should follow the Collaborative Group and see how they would like us to proceed with some of the recommendations being brought for. Maybe some easy things to look at in terms of Collaborative Group of putting together but there are some complex processes. I was just reading our recommendations. Some of those issues i could see us working on it immediately. One of them as an example those out of county have no other case manager dan our own individuals from this county. Even though in answer to question, when you move to the county medical needs to be transferred to the county to receive care. So there are some things i think we can work on but i like to just support the direction of the committee and let them lead us to and bring us back on some of these issues may be state issues. Some could be local. So, i think we should let them come back and once they get into these recommendations how they would like to proceed. As it pertains to the department some of these issues or lobbying efforts or policy efforts as well. So, i know commissioner taylormcghee i just had a brief comment. I like the way the report was done. I like the way you use the qualitative and quantitative data its an easier good as why want to appreciate that. Commissioner chung has suggested we then put on the agenda for action and ask the staff to drop a resolution of the reflecting our consensus and asking for moving forward to the collaborative. Then, maybe we could have a little more detail on how that could happen. Some of the timelines as commissioner karcher was speaking to, and so if we can put that on the agenda and look at the reports from a official approval, potential approval standpoint. You have some parameters around how we would expect the work to go. Yes, thank you. Thank you very much within the short period of time creating this very conference of reports that allows us then to say that there are steps we can take that we hope will benefit our public. Thank you very much. Thank you, commission. Once an excited voice to the dph budget for fiscal year sick steam18. Mr. Wagner. Mr. Wagner could do you need assistance with the computer . Now i can probably. Could you use a pdf instead of the powerpoint . Good evening, commission. Greg wagner chief financial officer. So, we are here to present on the second hearing of our opposed proposed budget for fiscal years 1618. So that is our update to our rolling Committee Budget for fiscal year 16something the additional proposed responses for 1718. As you know, the last hearing we discussed the initiatives required to meet our general fund revenue targets for the will do this on the flythe feast hearing at this hearing. We will talk about some additional initiatives were proposing to fund within our budget. Were also meeting a requirement under the budget instructions. I want to look at some of these tables up here, but i want to just set in context a little bit what we are looking at today. As you know, we do have a rolling twoyear budget. So, in last years budget cycle we adopted a twoyear budget to couple your fiscal years 1516, the current year, and 1617 the coming year. All the initiatives adopted in that budget remained in the base budget, and they dont show up on the presentation thats here before you today because a party been adopted by the board of supervisors. We are making some small modifications and amendments to that but they dont show up here for that reason. I think important reason to emphasize this is because i think one of the ways were seeing this budget is in the context of the process we been going through over the last four years, five years, probably, which started when the Affordable Care act was passed. Then we began going to our various Strategic Planning processes to prepare for that. That led for the Health Reform Readiness Assessment beginning about three years ago that was concluded and that included a set of recommendations and strategies that were going to employ as we moved into the Affordable Care act and beyond. So, i lot of that, as you know, in last years budget to a significant initiatives adopted to implement those recommendations. Those are still in place. So, examples of those include major investment in access initiatives for primary care, to improve Patient Satisfaction and retention, did they include the budget for the new San Francisco General Hospital, which had expansion of 118 ftes and 32 million in new funds for the operation of that hospital. All of that is still underneath the budget that youre seeing today. What you are seeing today is simply the adjustments over and above could also, in the context of that strategic plan, as we had planned last year we did put those initiatives in the budget could those are still in the track we are on. So, we are continuing to implement those. The next phase, as we had planned, after we did our primary care expansion a lot of our Health Reform Readiness Assessment activities, the next phase in what you are seeing in this budget is continued stewardship of those initiatives and moving on to the big next priority which the implementation of the unified Electronic Health records system and those are complement three to one another. So, some of the changes that you see in this budget relatively modest, but they are building on a lot of the work weve done over past several years. Again, just to advertise the chart you have on slide six, and i skipped over a few because they were in your packet last week. They are there for reference if you want to look at them again. The chart on page 6 shows the growth in our base budget for 1617 thats already been adopted. This is also building on the 1516. You can see just the annualized portion of the positions of the new San Francisco general, you can see the analyze portion of the positions and 1617 for primary care expansion, and the positions for the it infrastructure and operations improvements required to lay the foundation for the unified eh r. So, in terms of what is new in the submission before you today, and i know you have much more detail in your commission packet, so all go through these multiply quickly and we have the staff here to answer detailed questions as you have them. I will take these a little bit out of order and then ask Roland Pickens and thomas to come up and talk about little of whats coming happening in their areas. We have several initiatives on the Behavioral Health side. Those involves a commendation of revenues and expenditures. These are probably the biggest change to our budgets that you have not yet seen and passed budget. This is significant investment of resources in our hero Health Systems proposed in the budget before you today. The first line item that you see is the drug medical organized the livery system. This is a medicaid 1115 waiver. A different waiver than the one we discussed last week about which was the bridge to medical 2020. Sorry. Im confusing my waivers. This is the drug medical organize delivery system. This is a programmer new funding is available to pay for Substance Abuse Disorder Services that historically really been fallen into the countys responsibility to fund with general fund. The waiver is a pilot to determine whether increased Substance Use services can reduce the total cost of medical care to the populations involved. So, there is significant new revenue that comes with this program. As you will see in your pockets on the budget initiatives, your are about 6. 2 million of drugim sorry, 6. 5 and the total revenues in the first year growing to over 10 million in the second you. What that revenue comes significant additional expense because, under this waiver, will be required to operate in ways weve not in the past. That means upgrading our staffing patterns. It means upgrading our ability to report, to do compliance activities associated with the waiver. There will be a significant new standard that we hold to justify an drawdown the money under the program. But, it is a very big and important change for our Substance Use programs that fits very well with all the work weve been doing as a network. So, this a very positive thing for us. The other item you will see included in this and youll see is a theme running through a couple of the other initiatives in your packet is proposed to do some conversions of contracted positions to Civil Service positions. In the drug medical waiver initiative we have roughlyi can add that fast ontheflyabout 15 or so annualized positions. What we have done over the past probably 18 months is taken a look at a lot of services that weve added over time. Some of those were pilot programs. There were added in budgets and we want to see if they work so we appointed him to contact. Other things have been in the longterm funded through contracts. We have been working on an assessment of a lot of those services to determine what makes sense to remain as a contracted service and what makes sense to bring into Civil Service positions. There are a number of reasons it does make sense to bring them inhouse, even though in many cases an additional cost associated with them. I think one of the biggest ones a lot of these services are operating sidebyside with our Civil Service programs staff on the ground and bringing them inhouse allows us to integrate them, have a unified Management Structure and have a more integrated with our other services. The Second Initiative on this list is another the Rural Health Program and initiative. This is our realignment dollars. The 2011 the dollars that go to pay for Mental Health services. We have proposed in his budget growth of 3. 9 million growing to form a dollars per year in revenues, and we budgeted some expenditures against those revenues, although the next is the revenues are greater than the expenditures, which is why you see a general fund savings. In the expenditureim sorry could you point out which one, and also clarified the heading of the brackets or costs . Yes. As a point of clarification, which we discussed earlier, the way to read this table is the negative numbers here are a reduction in our need for general fund support. So a negative number in brackets helps us to balance. A positive number is a new cost that we need to offset in order to be balanced. So, when you see on drug medical organize delivery for example, there is a negative number. That means the revenues are greater than the expenses. So that is helping us to actually produce our general fund. So the bucket is savings . Yes. Okay, great. Thats good. The labels all over the place. My apologize. Thats the overriding way to look at it. Something that is in brackets is a reduction to our general fund, so that is helping us balance. Apologies for that. So, again, under realignment we do have some new positions and contract dollars budgeted for various services. Theres funding for special Mental Health services for youth. There are some positions and contract dollars for quality management. This could positions to actually manage those programs, and to add to administrations. Again, the conversion of Civil Service on chuck positions to Civil Service. I will skip environMental Health and moved to Mental Health services act. As you know, we get significant funding under an hsa is a tax on income of over 1 million approved by voters several years back. It goes to supplement Mental Health services. This Program Shows up as budget neutral. The revenues equaled the expenditures, and that is done by definition. The program can be used to supplant general funds. Theres a spending plan thats approved by the board and submitted to the state for how we plan to spend these dollars. There are some new cost proposed in the program again supported by revenues that are in the budget before you. We have some funding for our transgender Health Services program. There is one position budgeted here and for conversions of again fiscal intermediary positions, and then a set of other investments, staffing for hummingbird place pure respite, fiscal intermediary conversions and a Civil Service conversion in various system capacity in psychiatry and childrens Mental Health, and then as one of the categories under an hsa theres funding for it systems. So that will help us to support our avatar and Behavioral Health it system and integrate them with programs. Again, theres a long list of programs here. If you have questions on those, we have our experts in the room to answer them. Lastly, before i turn it over, another fiscal intermediary Conversion Initiative which the jail health initiative. We have stats are Mental Health services in jail health through contracts historically. In the current years budget we begin the process of the converting those positions to Civil Service for the reasons that expand earlier. This budget we are completing that transition. So, there is a cost to that. It will allow us to more efficiently and manage those programs and integrate them with their existing staff. So, i will turn it over for environMental Health and Population Health Program Investments to dr. Aragon. As you know, one of our initiatives that we began last year as rebuilding of the Network Capacity in the network as an institution, we also committed to a path of building up the Population Health division integrating its improving coronation with the network and so theres been a commitment and last years budget and this years budget to commit some general funds to build the gaps where they are unable to do it they need to do effectively because of constraints of their largely grant funded programs. So, i will turn it over to to discuss those. Good afternoon. First of all, i want to thank the commissioners for your commitment to investing in the Population Health division. Really, the major area our Core Infrastructure and also infrastructure for Performance Improvements. There are five different areas that are to be helping out. I will summarize them briefly. The first area is environMental Health. One thing i want to point out in by Mental Health with the economic boom in all the building and all the food establishments in all the construction, all of the places a big demand on environMental Health. For example, we have over 8000 food facilities that need to be inspected. That number is increasing. If you follow the newspapers, recently, you will read about some of the shortages weve had similar restaurants weve not been able to inspect. So, we are in the process of hiring three new food inspectors that will go a long way to helping reduce that shortage of inspections. The other area thats going to be important, we mentioned last week about investing in vector control. Its something we start planning earlier and ugly onset of those ecovirus and climate change, we know this an issue wouldnt have to be stronger at and its can include a position for vector control. The other important area environment to health in the area of Performance Improvement. Environment to hold is very unique in that it collects over 20 million annually in revenues. While the revenues have to be spent on dermatol services, that should provide the opportunity for us to build in continued improvement to environment out to be more efficient in how we deliver services, to clients across the city, for us to not only save money but also increase our ability to collect all the revenues that we should have coming to us. It turns out, because of some inefficiencies, were unable to collect all the revenue that we actually need to collect. This is than helpless with that. Its also that help us with a streamlining of the permitting process. By building Continuous Improvement into environment of, it really improvesits take the resources that come in and give us the opportunity to develop indepth knowledge and proficiency in in barn itself that we can share with the rest of the division. So, thats going to be incredibly important. The other area that were going to be is were going to be hiring 1. 5 ftes in massage and special. This worker years because of changes in the state law the number of massage establishments we have two permits and also inspect has increased dramatically. With the issue of prostitution and Human Trafficking and making sure were working withwe are supporting the legal establishment and helping with other agencies to reduce Human Trafficking, its really important area for us to be strong and. Thats can help with that. Whether the hiring industrial hygienist and also inspector in the area of Hazardous Waste and also hazardous material. Again, with all the building thats going on and that means more Hazardous Materials are stored across the city. We have to be sure those are all stored safely. The other thing that we have is called a ordinance. Every time they break soil for new Building Construction we actually approve the plans on how the dust is good be controlled whatever soil will be moved. So, we are actually one of the bottlenecks in terms of allowing construction to happen in a timely manner. Even though would be investigating investing a small ft, a total of two ftes here, with the city will recover will easily recover that just by loan the construction project to move forward in a timely. The city as a whole is going to come out ahead. Under the Public Health administration, but in the investing again in a continuous we need to have some court Continuous Improvement act for peace in that in the division. Bring being quality apartment is new for us so were going to have some court equities that conserve across the debated initially, the focus on operation and also focus on disaster preparedness. The third area is in Disease Control. There we had to takewe are fixing some of the positions that were misaligned previously. We have an epidemiologist with doing Disease Control because of the need for epidemiology expertise. Weve moved deposition to epidemiology and we are hiring a supervisor for Disease Control. In past budget cuts, tuberculosis and std clinic lost half a nurse manager. We are making a whole again so that std clinic as a nurse manager entity clinic has a nurse managed. Right now the splitting under center across both clinics thats not sufficient for the ability for us to deliver those important service. Thats making us whole for my cut that happened previously. In our committee Health Equity in Promotion Branch we are hiring it to fte to provide rapid spots syringe clear. Again these are things you probably have been reading in the news recently about the syringes that are left especially in the civic center area. While it is important for us to have syringe access for preventing hiv transmission is also important for us to respond to the real public concern about the needles and syringes that dont make it back into the disposal. That we send teams out there to clean it up. Then the other one is were going to have a position on the black africanamerican help sf rfq bids for me investing over 1. 5 million in the Bayview District 10 area and one of the things we want to do is make sure we have a position to make sure all the activity there is aligned, coordinated, and working and making progress on Health Equity issues. So, those are the key areas i want to highlight and i want to just express our gratitude for investing in the Population Health division and thank you so much. The afternoon, commissioners. I want to share briefly with you some of the detailed app items the third from the bottom initiative on sf reinvestment into the delivery system. As greg wagner mentioned, we continue to increment the recommendations of the Health Readiness we form assessment done by hma over three years ago. One of the big components that is the first item you see there, which is an investment in centralized call center for the network. Similar to many of the large systems, rather than calling each individual clinic our patients can now call one centralized number with are able to their appointment, there was one available throughout our system. The people answering the phone there were also providing nursing advice line and consultation. That was one of the main things that also came out of our managedcare assessment is that able to be successful as we venture more into managedcare we need to provide better Patient Experience by having centralized call center. You talked earlier about making sure we are consistent when it comes to lean in our true north across the network in the department. One of the components of true north that you will find among all components of the network is that of fiscal financial stewardship. So, everything you see in this category represents a repurpose them of vacant sessions we had within to not request fund dollars to make sure we have enough, as much resource as possible going to fund the dhr. So, in terms of a position for the call center, additional nursing and physician ftes to expand medical respite, to give us more availability to have flow across the continuum of care, all these things were funded by vacant positions. Theyre not new dollars. At the same time, we also to recognize you have emerging needs. One of those is the transitional food program that you see listed here. It actually will be a joint venture with project open hand, i partnership, where we will partner with them . 50we will match their donation to provide meal service for patients leaving zetterberg San Francisco general with congestive heart feather diagnoses. In looking at the literature one in five of our chs patients return to the hospital to be remitted within 30 days of discharge and looking at the detail we found 30 day readmission strange enough, was not due to medication noncompliance, but was directly wishing should a trivial to their nutritional diet and supplements not meeting the nutritional needs to keep them functional not back in the hospital. So, that program will provide the first 90 days post discharge for our patients, three meals a day, and for the next 90 days, two meals a day delivered to them at home. So will monitor that in terms of outcomes if we see a decrease in 30 day readmissions and other outcomes for those patients. We also are adding Additional Resources to the Emergency Department of the zetterberg cm San Francisco gem. Dr. Chow and others will will remember we need to change how we need to do medical screening exams in our Emergency Department. Grievously, those have been done by nurses and we were informed by the california state Health Department that we were out of Community Standards and needed to have physicians providing those screenings. So, we are providing Additional Resources to do that initiative also. Thats a general overview of how we are trying to the diligence in our true north measure in financial stewardship, of looking ahead before asking the general fund for new dollars. Commissioners, the last item on the list is our Human Resources division. I know we discussed this quite a bit at the commission. We have, over the last couple of years, weve been trying to correct for historical deficiencies within Human Resources. We have added significant staffing capacity. What you have before you today is an initiative that includes accommodation of new positions and conversions of existing positions being funded on a temporary basis into dominant positions. Categories include eto, leads management, exams, which have been a significant area investment for us, and whistleblowing and compliance. So, we have a total, over the twoyear budget of about 14 new permanent positions that would be added to try to continue to maintain the momentum that we have with Human Resources staffing and operation. Ive got a summary, and this is a little bit dense, but ill give you kind of the bottom line. A summary of position changes in the proposed budget. The first two columns, which are under total position change, there is a total budgeted fte growth. So, proposed budget includes 25 ftes in the first year. Growing 275 in the second year. In the next two sections we broken that out by two categories. The first is the Civil Service position conversion from contracted functions. Again those are bringing inhouse contacted functions. That accounts for the bulk of that growth. So, 50 and 70 positions in the two years respectively, and then the last of the net changes due to the other initiatives before you. So, again, a lot of the position changes that youre seen in this budget are due to the fiscal intermediary conversions. Underneath, again, in the base, there are still Significant Growth and our positions. Theres a trend of growth. We are at higher than her therecession total in terms of fte and we do have room in the budget to continue to implement programs aggressively and according to the strategies that we been laying out over the last several months. So, the big picture, and again, weve got a parentheses issue but a negative is something that helps us balance. So, we are using in order to tip our targethit our targets, 23hit our targets, 23. 8 million of revenue and 7. 5 million of savings. Those are used to hit our targets for general fund production jet hit our Revenue Growth and pay for other initiatives on the proposal before you today. At the bottom line, the line that says that balancing, that is our change in our general fund supports. So, we look at this over a twoyear period because its a twoyear budget,. In the first year you can see weve exceeded our target and pay for all of our initiatives. Weve exceeded our target by 12. 99. However come in the second year we are short of our target by 11. 1 million. That thing those two over the budget we have a modest surplus. That will be used to offset it costs and likely be used to help with some of the things that come up over the last months of the process. The next thing that we want to update you on, although its not directly tied to the balancing of the budget before you, is our Electronic Health records initiative. You are all very familiar with it. We are asking for your approval in this budget submission for the expenditure authority, the new expenditure authority, that we need to go forward with the dhr program is envisioned. As you know, this is been one of our Top Priorities for multiple years is getting our it in order. We are, as you voted to support the directors course of action at a meeting, Commission Meeting two hearings ago, we are moving forward on the under the assumption we will enter into negotiations with ucsf Medical Center for shared use of the Electronic Health record system. Were making that assumption. However, it does require approval for the board of supervisors to enter into negotiation and require us to successfully negotiate a contract, and require us to bring that contract back to the board of supervisors for final approval before we actually begin implementation. So, there are steps in the way, but we do want to request your approval for a budget that would give us the Spending Authority to move forward pending all of those approval hurdles the next. The estimated cost and this will be finalized during contract negotiations for the system, is 100 for the system, is 183. 79 over five years. Its a big cost. The big hurdle and its been something we have been focused on and planning around for two years now. The target completion date would be 2019. The process from here, again, were asking for your approval for the Spending Authority that we would need to go forward on this plan, but there is going to be some more work that has to be done over the next three months before we get to the mayors budget submission to determine exactly what this is going to be budgeted as in the appropriation ordinance and will bring that back to for updates as we go. The total new Spending Authority that we would need in this budget is 7 million in the first year and 17. 4 million in the second year. That would allow us to move forward on the schedule we have forecasted. So, i have got a highlevel summary of what the proposed cost and funding strategy is for the hr program. At the top you can see, again, a fiveyear total of 183. 7 million. The bulk of the cost occurs in those first three years which is the intensive period of implementation, and then it levels out as we go to stabilization and operation of the system. In the section below, existing and planned appropriation, you can see there are some numbers in regular font and some in italics. The numbers in regular font items for which we have existing appropriation authority and we have budget initiatives in place that can be used to fund those appropriations. So, we had 9 million of ongoing funds that we budgeted and last years budget, thats already on the base. The second line is that weve been working with, ucsf at San Francisco general, and thinking about how the adoption of the unified Electronic Health record system and in this case in particular, the shared use of the uc system which they know their physicians know and are familiar with would affect their cost. We believe we can avoid additional cost with the affiliation agreement for five years if we are able to implement that system. So, what you see there isthis is projected growth in the affiliation and the cost in the cities fiveyear financial plan. We are saying were able to do this we would not need to see the cost to grow and we can redirect that projected spending back into the project. We project 9. 8 million of unspent balance in the project that will Carry Forward at the end of this year. Thats mostly due to simply the timing of the contracting process, but the funds are there and available. In the next section, you will see some italicized numbers. A couple things going on here. There are two sections where we would actually need additional procreation authority, which is not already in the budget and thats what we are requesting from you in this budget submission. We will need to be appropriate some dollars from existing projects. Weve been going through our existing appropriation to look for balance is that we can close out and reappropriate to offset the cost of this project. Weve got 11 million the funding in mind for that category. The prior to revenues and transfers in is the policy that was adopted in the last budget, where the Mayors Office and the board of supervisors agreed to a budget provision that allows us to attain up to 25 million of certain revenues that are above budget and transfer them directly into the project. We have in our current years Financial Statements which you will see at committeeat the next hearing. 7 million of that is in place in the current year. So, that is in regular font and thats projected to happen. We have another 25 million for procreation authority in the budget for the following year. The last section is a little bit of a catchall and theres a lot of things that need to be defined over multiple budget cycles in terms of what that appropriation actually looks like. But, this is for essentially a placeholder for future budget initiatives that we will use to fund the mr project for philanthropic support that we may receive in support of the project. As you know, we been working with the San Francisco General Hospital foundation. They are very interested in the project. They believe there are opportunities for philanthropic support, and so that is a great prospect for us to be able to close the gap on that last line over the next five years of expenditure. Again, that is the outline of what we are planning to do. This be a multiyear discussion. Youll be hearing from us for the first foreseeable future. What we are asking from you today is for an appropriation authority responding to the two lines project fund reappropriation and department the appropriation savings and for philanthropy, give us Spending Authority to move four. Work with the Mayors Office and Controllers Office to come back with the final running package as we go through the board of supervisors and the mayors budget could you state that reduce growth records sure. That is essentially a for able to go down the path we want the shared use of the uc hr system, they there are significant benefits to our providers at San Francisco General Hospital under the uc affiliation agreement. So its not the Medical Center. This is our uc providers at San Francisco General Hospital. They believe that if we are able to have that system in place through a combination of productivity, their own revenue capture further that they bill under the services they provide at San Francisco general, savings and training costs that are associated with lost time and effort to staff the hospital, that would be required to learn a different hr and required to double train on hr systems, all of those things added up ucsf believes it can commit to no growth in its cost for the five year is a mostly positive discount. Is like a discount. Its cost growth we were forecasting we would have to pay in the fiveyear financial forecast that looks like if we go down this route we will not have to pay. So, yes, it can avoided growth in costs that we would not otherwise be able to achieve commissioners, you can see this uc sf General Hospital, their investment into the emr. Its their investment. If i may, did you finishgreg . The laughing of zero through the calendar. I think you know it. We have june 1 where we submit formally our budget pending your approval to the mayors and Controllers Office this month and then we work the Mayors Office over the next submitted on june 1 to the board and the month of hearings at the board and final approval scheduled for mid july. So if i may, commissioners, one, i want to thank both greg and jenny. This is again one of the budgets that are likely working hard in the last couple months particularly to jenny whos had to change the budget several times because of the definitions have issue quickly. I want to thank her for the patients in that. I also want to thank dr. Aragon magically roland, network director. We have many initiatives people want to create revenue that we sometimes wonder if we created it. So, i just want to knowledge but that they have done a really important and Due Diligence to this budget. They look at their savings in the previous years because we did invest a lot and that had to readjust to figure out what the future path for them once. Without having to add new dollars into the budget. Thats exactly the kind of leadership that we need for the future so i want to thank him for their important work in a budget process. I think that is bringing everybody together trying to figure out when you have new vacancies, and really today is a different day to go forward whether its a call center or any of their other initiatives. This is one way for them to manage well and also the investment and everybody understands the importance of this Electronic Health records. So, i just want to think that leadership that is but his budget forward. Its one of the best budgets ive seen and in terms of balancing out future needs and really trying to balance out and be really, i believe, conservative in terms of the way the looking at the future state of the network. So, again i want to thank them very much for their leadership. Thank you. Commissioners, comments or questions at this point . Commissioner taylormcghee i have two or three small question. Its not affect your bottom line. Dr. Aragon mentioned in the Public Health committee today, that there were 8000 facilities they need to be investigated, not investigated but monitored. But you only had two ftes, i think im sorry. That number struck me as being not enough. No no no. We have Something Like 10 ft. We are increasing at, bringing enough toi think were at seven were bringing it up to 10. The small cadre but we need more. The fees are all covered. It revenue neutral. It doesnt come out of general fun because we collect the fees and you set these to higher the staff. I think you also mention because you do not have enough people some of those fees were not being collected, correct . Well this is just a general we have a think 18 programs. A lot of them are permitting programs. We collect fees on a lot of Different Things and unfortunately, sometimes people dont for a variety of reasons sometimes the business made changes and were not able to deliver correctly. Theres just inefficiencies like that but if we get the owners correct address we can send them the right bill and collect the money. This money that supposed to be coming to us that we missed because of some of these collection inefficiencies. So we want to fix those so we collect the money that were supposed to be collecting give a number in terms of how much money that is . Or is it Something Big . I dont know the exact number. When i sort of poke around and ask to get an idea, ill get a variety of answers, but i been told we probably i can remember this is the whole circuit we probably lose maybe around 300,000. We collect 29 was not a big percentage of the 20 million, but nonetheless, its the percentage if we can collect its going to be will to strengthen the work we do. Thank you. The other question i have for roland was, how do you choosei know you done the pilot for the mills. How do you choose one, who gets the milk, and two, what vendor you use to supply it . In terms of how we choose who gets it, its targeted just for patients with congestive Heart Failure coming out of the hospital. Thats the target population to in terms of the vendor, its project open hand is a local notforprofit. They are providing that service. Okay. I want to make sure we were getting the best. Commissioner pating first of all, i like all these positions. The return on investment for all the positions they clear sense. I like enhancement of the population between positions that increase revenue and services. I also like even though weve expanded our total impairment membership growth and Health Network, were doing well with the same number of bodies. Thats me were having efficiencies in the Health Network site. To me, this is overall very very positive. Thank you all for working so hard operationally to keep our costs down. My question is directed towards director darcy. I guess with regard to Electronic Health records, this is not a budget item, but whether you could maybe in your directors reports in future meetings, give us a little status of where we are with the negotiations. It sounds like were moving quickly and we may have to have some approval action at some point on it. So, just to know where you are. Depending on how much we can be open in terms of those negotiations, absolutely i can tell you where we are. We havent really organizedive kind of organized in our side how we we go about that. One committee that can be a Technical Committee that. With a technocommittee from uc were still in negotiations with this because we have to go to the board of supervisors for their approval. Then, go be a higher level negotiation with uc Leadership Department leadership, in looking at those items that the Technical Group brings in. How do we create the contract . And any details as we go through that process and the contracting possibility for payment and also, another concert will be about Data Governance and how we manage to put that into a contractual arrangement. So, we will let you know the big area the big step as we go through that then, second thing tomorrow i want to make sure we have speakers this mind speaking to an hr issue with San Francisco general. I dont see that as a budget issue. They were raising budget matters. Living that our Human Resources director response that issue. Good afternoon, commissioners. We have regular meetings and San Francisco junket in joint management. They were talking about rights and not having breaks. That something we talk about every meeting we have. Weve got to the point where there really wasnt a problem with people getting their breaks did they were asking for position. All address that in a moment. I understand theres never any proms with a break. Well look into the specific complaints, but in general its been a very collegial environment and seemed like we were close problems out and continue to do that. For the other staffing items, give a dispute over title 22, title ii of the code. Where they are seen were violating the code and we are saying we are not. We are saying we are not because every now and then if you periodically go out of alignment are thinking as you can possibly staff for every possible contingency it every moment of the day. Sometimes people are to be a little bit out. To have an ongoing dispute were trying to resolve with the union, specifically addressing their concerns. We also added a lot of positions, over 100 positions for the new hospital, but i know that its never enough. Hr, of course, were asking for some additional positions, but weve added positions wake up to 100 because we need to get that things up and running we know we cant sustain that were actually cutting back. So nobody gets all the stuff anyone but i understand their frustration. Why dont you share with the commissioners that were going to be going to labor negotiations. That was the other thing. Last time we went into negotiations to union into Health Commission meetings and the jcc had about staffing and wrapping up the negotiations. So were going into the negotiations in march and i expect you seen union, not only here but at the jcc talk about staffing and put pressure on us to add staffing. Your input is always valuable and we listen and work with them in the negotiations. But probably this is not the forum for adding staff. I think roland and others as we go through this will be able to address more specifically the staffing situation. Commissioner chung my question is actually pretty a director. I think this is like an exercise we go through every time when theres a budget cycle that requires us to be really creative around meeting the needs of the nurses. Meeting the directors. How much authority do we actually have two say, can you look more like the nursing needs versus thats not something that we actually can do anything about that to go to higher than us . First of all, let me say we have and we are continuing to work with the union any disputes or concerns they have. This last year i went to lease 34 of those meetings to really work with the union to ensure they understand the direction of aca and the needs. Just let a major new hospital being built. So, we all have an working together to try to figure out how that staffing is. Today, very soon, we are going to be in a Union Negotiation of a contract for nurse. We need to let that play out and that is also managed by the citywide to go shooting team. So, at this point i think we need to let that work out because that will be determining how we move on that budget process. I thinki do think its important for the commissioners to hear the needs of what the nurses have brought up. I certainly take those needs seriously. Then, we get into her room and figure out the best way to work out that ago shenzhen. Any of the daytoday issues number as one says, will get that management table and will try to deal with those operations because thats important and we want to have a Good Relationship with a union so that we can move forward on the work we need to do i would just add, absolutely respect the union and the role in this and our spector union members. I think these nurses they came forward today the lookout for the interest of the patient and try to provide the best possible care. Theres going to be some tension between management and labor because management has the job of operating the hospital and managing the budget and the nursing staff has a job of doing the best they possibly can. So theres a little bit of a difference in terms of roles that are sponsored abilities, but i absolutely respect them for that role. Commissioner karshmer just in the spirit of those cuts of comments, anything that can demonstrate transparency around what it is that the additional places, anything additional, that shows this is not status quo. This is not the same number of nurses. Across all the types of employees . I think the more information people have to clarify that the better we have actually as we go through that negotiation but ill also say were going to be doing a staffing study no also have some clarity to the. As we go through the different units and do the staffing study to figure out what is the best staffing model and is particularly important as we change the way we do business, we need to make some adjustments so how we move the stuff. I agree transparency is important. Account dashboard Going Forward on how the staffing models have a change in packaging. Good point. Commissioner pating state my interest and make sure we do have a budget itemit sounds like this is not part of a Budget Discussion it sounds like this is hr and uncomfortable with you handling that. With regards to some of the hiring, do we have a gap of about 100. Have we caught up . Commissioner, i think were down to about 6272 but thats in need of 330 and the struggle throughout. Theres various classification. Some aestheticians like porters we held off on hiring is you dont need you porters of you dont open the hospital could win a good position to our registry use which is essentially temporary medical staffing is gone from 15 at one time, 21. I think were using one. That indicates staffing his way up. So the pipeline is working effectively. Always in our pockets where youre going to critical shortages. Her example and radiology. Might be hard to get a radiological type because maybe that something thats in demand in the area not be paying higher salaries but overall were doing well for the stuff and i dont see a problem there for staffing affecting the opening. I do think we tend to contact the budget and it is roland has indicated were using a similar budget as in the past. Were going to be able to meet our commitments on the budget issue that we are discussing whether or not you have felt there needed to be more ftes were not. I do appreciate that you are able to really describe that the ftes at this point are down to just minimal use of per diems. Thats hugely, as we all know, for working hospitals a good indicator of whether or not we have adequate staff that is on our stock. So, i am assuming thats all within the same budget that the Health Network has projected and that you are all working diligently in for some of the issues that brought up. I know, as you said, the network would be looking at to be sure where looking at watching for the safety of patients. I do recall a number of years ago we were following all the suppose of title 22 requirements and most every department was at zeros or ones in terms of our interpretation of what title 22 is. So, i just want to throw that out. I do think the staff and the Department Needs to become limited for taking a very complex budget and actually simplifying it down to a few34 pages. Most of which had an excellent, i believe, an excellent expiration including all the details. What i would like, though, you added a slide in regards to the fte the variation and i think theyll be good of the commission were to be literacy that is part of the slide. I have that right there. Okay, good. I think because everyone always talks about ftes. It would be good for our knowledge to be accurate in terms of what is happening on this. The department has asked that we have an approval of the budget as presented, as i think mr. Wagner and you want to sum up once more what you want us to do quick tax yes. That is a request of the commission to approve the initiatives from this hearing and this hearing on february 2 commissioner karshmer moved and seconded. Is there any further discussion . If not, all those in favor of the approval of the budget to be submitted to the Mayors Office, please say aye. Opposed . The budget will be afforded to the Mayors Office. Thank you very much. Thank you. Item 9 as other business. Any discussion for other business, commissioners . There are no othercommissioners, any other items you want to discuss under other business . If not, item 10 item 10, a report back from the gcc and a brief update we met on february night for primary close session in which all reports were reviewed. Thank you. Be difficult to ask questions for a close session. Item 11 is Committee Agenda setting a lighter note theres a Public Comment request. Yes we want Public Comment request. You have 3 min. This wont take long. I think you heard today our concerns as nurses of the hospital overstaffing. I heard from you yet some questions that are not answered. I would like for there