Programs over to the department along with the new Navigation Centers so think it will be very important for us to receive regular updates are happening and how we continue to serve those that need or services. Could you let me know a little more or let us know a little more about what the governor is actually doing with those funds and exactlyi thought when you were introducing the topic we would get more money, but it sounds like we are getting less money. Ill let the policy director give a update on that. It is repurnsing the dollars. [inaudible] it is taking some of the revenues that come in already for prop 63 and that is tax on people that earn 63 and that is tax on people that earn over a million a year and rerouting so it can secure larger bond funding, 2 billion Dollar Bond Fund that will be available for counties over 4 psycholts for the next 4 years as they apply for Supportive Housing projects for folks that have Mental Illness, homeless or formally homeless. It is a application counties can apply for. Overall can can be the same or more funding for San Francisco in total but earmarked for Supportive Housing purposes. Initially it removals from the prop 63 monies to create this fund for which there are grants for homeless funding . Correct, counties get allocations based on a formula under prop 63 so it takes off the top an amount sufficient to secure the 2 billion in bonds and [inaudible] on a competitive basis. Thank you. Other questions to the director . Commissioner pating. We took a good advantage of the county of the first round of 400 million that came out of prop 63 so i would hopemy question is, other projects in the pipeline you can see taking advantage of this . My other commissionersthe funds from prop 63 are generally commingled with hud fun and private funds and other funds so the projects are very complex to bring together which usually the prop 63 aurfs 1 component mostly the service component. Are there projects in the pipeline you can see are early applications for the i probably am not the best person to talk about the projects in the pipeline. Director garcia and [inaudible] is better to speak to that but one criteria specified in the legislation is project readiness and that is among which the projects will be evaluated. I think they listed 5 criteria projects are evaluated on and project readiness is one of the 5. We know the Homeless Department is given the direction of 8 thousand new housing opportunities for individuals and so there is a pipeline for our regular housing area including most recently one of the propositions , thrfs a housing bond prop in the local election so when we sxh back in august we will get that information to share with you. Our role because all our housing and i call it the bricks and mortar in the department ov2 thousand units of housing will be transferred with staff to the new department and our role is maintained as Clinical Support Service for wrap around serves for those individuals. We will be very involved and connected to that department to insure the individuals in the housing and Navigation Centers and shelters have the kind of Supportive Services they need for success. The other thing i might add is department of Public Health and the staff from the new department of supportive homelessness and housing were involved in discuzs with the state legislature during the development of the legislation and so some of the other criteria are those that San Francisco would also do well on h experience priding Supportive Housing to reduce the Homeless Population and Behavioral Services to the population so they are aurlds areas we do quite well on. Commissioners, any other questions . If not well proceed student the next item. Itedm 4, general Public Comment and have two requests. Yes, first speaker will be ma tt asbone and the speakers note i have a timer of 3 minutes and when the buzzer goes off it means your time is up. Im sorry commissioners there is a photo the public speaker asked me to pass around so it will come your way. Mr. Osborn. Thank you for letting me speak. I had a prepared statement and too nervous to read it so will just speak from the heart. Im a member of the lower haight community and run a business there and in the process becoming a medical marijuana dispensary. Our neighborhood is plagued with crime related to drugs for decades now. As a community dont feel we were given a fair chance to know this happened. The outreach done by the company in question in our pin didnt happenmany people didnt know until recently and have been addressing it since. Sorry, im nervous mptd. There is a Elementary School about 500 feet away from this, 600 feet away from this but due to something in the Planning Department that is unclear to me they are not hearing about the legitimacy of the business. We are [inaudible] as a matter of Community Health as we have a community on the mends from years and decades of pain. We have a community that is not trusting the system currently because of things like the picture im passic around where 3 members from the Planning Department will decide the fate of this made Public Comment about a business they are Still Deciding on which doesnt make us feel confident. I just want to reiterate this is not a argument against medical marijuana, this is not about property values, this is not about, not in my backyard, this is about health and well being of a community that has felt they are under served, some discriminated against. It is about human lives because there are murders related to that i seen and hoping to come up with a way for it community to speak about their health and safety especially students at the scoom and community parks. The community wasnt able to be heard and im hoping for your help. I dont know exactly what im asking for specificically about your help. If you like to speak to me i left my Contact Information and open to communicating in any way. Thank you. Thank you for alerting us and imagine staff will look further fl to this with you. Next question . Next speaker. Brian brooks. Grood afternoon and thank you for the opportunity to talk to the commissioners. We represent the lower haight merchants and residents ontwnt year residents and a lower haight resident and the medical disspencely we are trying to get more insight how the process occurred. Back in 2006, [inaudible] 473 haight street was issued a medical dispensary license because we had multiple dispensarys on the 400 block and it years of violence and murders and assaultsment they closed over the years. We had the vapor room closed which was a dispensary closeed by the federal government because they were 5 feet too close to the parkment we became aware of this the community became aware of this issue may 19 when there was a flier posted about a hearing. We came down with [inaudible] and had two weeks and put together 60 signatures. In that time we have gotten 13 of the 17 businesses on the 400 block to go into opposition. Ma tt shared a picture, this is the latest pr stunt by the organization, spark to reverse that situation. There is a lot of [inaudible] lot of positioning and a lot of procedure that is being done in this certificate transfer process planning. The community had no idea this is happening. We walk the streets and canvas and everyone is like, really, we dont know this is happening. The Company Spark claimed they did outreach in a 5 block radius then on the website they said they did 300 feet door to door, which is different than 500 blocks. We have john mure struggling over the years. We want a dialogue because the neighborhood feels they have not been heard. Wethis is definitely a health issue. We talk about crime, violence and homelessness, the 400 block lower haight is not the right place for this so we would love to work with you the commissioners and spark to open a dialogue so people can be heard. Thank you. Thank you. Again, well have staff work with you. There is one more. There is one more speaker, former commissioner [inaudible] it says Health Services update. So, Public Comment is now, right . Yes. I dont know how to do this. Thank you health commissioners. Nice to see you. So, and represent today taxpayers for public safety, which will be related to the jail health update. I wanted to say before i begin i was asked by supervisor breed and your director to be cochair in the work replacement project so i dont want to say i dont represent that either. So, at any rate i want to say i appreciate the report you will receive because through the leadership of supervisor breed and the board of supervisors, the mayor, the department of Public Health led by the director of Public Health, [inaudible] we have a new opportunity and a new framework to work with around jails that includes jail health because the agenda of inmates is really a very big social issue. As you know, health is a very important part of this. What you will see in the report is there is more detail, the framework is more clear and we have something to work with and really want to thank the leadership for this. There are many more questions and we will come to you hopefully september, october with real recommendations, but right now at least we have some important data to work with, which a year and a half ago we did not. The other thing is the convergency nationally state wide and locally around homelessness and incarceration and relationship to poverty is more clear and punishment is taking at least a little bit of a second place. There has been a cultural shift and that is a good thing and brings about structural change. The 47 beds all that you heard about and will hear more about through had leadership of department of public helt is significant so please i want you to appreciate it and it will cost money and so i just want to say we support that. I think the most compelling statistics you know, is that 65 percent spends less than 7 days in the jail. This is really important if you do a policy change. Also, 86 percent are pretrials, meaning they are there awaiting justice. 86 percent. This is very significant. 2 3 people of color. It doesnt make sense. We have to do something and we can. The leadership is in place and we want to see that it gets done. Time. The new idea i want you to think about is relief center. We need to think it about it the way you think about hospitals. The day you come in, we dont stay in the hospitals anymore and the jails are less than a week for 63 percent. We need to know when you come in there is discharge planning. That is a new concept. Please, listen for it. Thank you. Thank you commissioner. Commission item 5 is the report back from the finance and planning meeting. Commissioner chung. Good afternoon. The finance and Planning Committee met today before the Commission Meeting and we had some really interesting discussions. One of the monthly contract report which is included in the consent calendar for approval, within there there are a couple items we discussed and so one of them is the San FranciscoCommunity Health authority. We were having conversations to see why there is a 15 percent increase in the cost of like running the programs, when there is a reduction of number of services. Of course we do think the infrastructurethe cost goes away. Other items that we had a conversation is like [inaudible] there is a significant increase in the contract with data way so that any difference is 58 percent and that is part ofthat is the ongoing discussion about it Infrastructure Improvement including like the fire walls you can have. I guess like the state department [inaudible] and so these are the costs that will help reduce the in the long run with like reducing the cost of running the department, but right now it is a huge increase as it stands. Lets see, anything else here . And then we also have another new contract that has been added to the consent calendar for approval. It is the survey for patients and workforce experience and they are contracted to do a total of 5 surveys for the Patient Experience for sfgph so one per year and then 3 employee surveys and 3 physician surveys that will be conducted every or year and it is a contract of 5 years. And we also have a presentation by the Business Office of contract compliance to look atthat is a ongoing presentation we have done aroun how to assess Health Impacts and how to measure outcomes [inaudible] and it is a really wonderful conversation to hear how far we have come and looking at ourselves as the Technical Assistance and also provider to help build infrastructure with some the smaller organizations which might have great cultural competency, but lack the business infrastructure to run the organization and help them improve. We also have a presentation on the Third Quarter of revenue and finance report and it is great to hear that we are on track on our surplus. That concludes my report. Questions to commissioner chung . Was there publiccommissioner sanchez it isnt a question. I guess it is in a sense. In reference to the item pertaining to [inaudible] associates, as you read through it they have been involved in the new protocol since 85. They list the regional offices or offices where i guess they have centers or involved in the cohorts. I notice that none are on the west coast are in the midwist midwest and know a multitude of surveys over the years we had a number especially a number of midwestern institutions in wisconsin and michigan and california and texas, this will be the first opportunity for this group to have a physical presence in the network here or are they the only group that met the requirements per taining to the solicitation of the request . [inaudible] can respond to that but do know they are in san mateo as well. Good afternoon commissioners. Roland pickens director of health network. This contract is awarded after a rfp was put out. You should rest assureed to know [inaudible] gainee is one of the leading companies that performs this work for acute Care Hospitals arounds the country. They have several hospitals in california, they just happened to be based back east, but they are the predominant player in the area of patient and workforce satisfaction. So, in essence in the review we noted there are i assume some similar hospitals or solutions in california . Absolutely and as director garcia opponented out, san mateo uses them in the eeoceo [inaudible] zuckerburg is familiar with it. I didnt attend the meeting and sure it was answered there. When i read this i wondered here and didnt see a number of things, that is quhie why i thought i would raise it. We are looking forward working with them. One thing they provide is a much more detailed reporting capacity down to the individual units and cost center level which we didnt have before. I concur, this is a critical parameters in databases we will be undertaking as we take a look how we deliver the services and models. Thank you. Thank you. Commissioner shan sanchez, i know this company but it is noted here that they do 50 percent of all the u. S. Hospitals. I did ask as commissioner chung how they would slice and dice and it sounded like they can compare against all sorts of different demo graphics. The safety net hospitals and coupty hospitals and universities and so forth. I think more to the question was whether or notthey were used to being able to survey for Customer Satisfaction within the melthal health field or children or jail health and it was inicated during testimony in the rfp process that actuallynobody had great experience, these people were the people who came up with how they would do it and this was one of the reasons they were awarded the contract. This was justit was clarifyed because we have been through Clinical Trials where we had Foreign Companies come in and promise this and this and something didnt pan out and something did and dont want to go through that trial again. Im glad this is here and you informed me i want to highlight piece that we will have a survey for jail health which means all the folks inside like county jails would be surveyed and they have identified a couple different methods to survey, so i [inaudible] quite impressive with the approach. Questions to commissioner chung . If not, well proceed to the next item. There was Public Comment requested on item 6 which is consent calendar which we just reviewed the two items. Motion came from the committee for the acceptance of the consent calendar. Are there questions extractions . If not we are prepared for the vote on the consent calendar. All in favor of the consent calendar say aye. Opposed . The consent calendar isa proved item 7 is resolution to commitment to trauma care and before dr. [inaudible] step tooz the microphone, i will note that the [inaudible] jcc did recommend approval of this resolution. Good afternoon commissioners. This is a very straightforward commitment. It is one you approved before and comes in the context of a survey we are about to undergo in august from American College of surgeons around trauma services. Happy to answer questions. Question to dr. Urelic . What prompted having the resolution . It is a Standard Approach to the survey coming in august. [inaudible] not at all. I believe every 3 years you all get the same type of resolution you passed and not all have been here maybe for that cycle it is a requirement. I guess the accrediting body was to be assureed the governing body is committed to the trauma service. Exactly so. Any Public Comment . I have not received cards. Resolution is before you for approval. Further discussion . All in favor of the resolution say aye. Opposed . The relution is adopted. Next item, item 8 is jail House Service update. Good afternoon commissioners. Dr. Lisa pratt the new jail health drerter and have been in my role 6 months. It doesnt feel that new to me but compared to dr. [inaudible] who was there 20 years i think i will be new for a while. The first part of every presentation is struggling with it, but not for bill. [inaudible] thank you. So, i want to introduce the Deputy Director frank pat who joins me and tonia marron who is director of Behavioral Health service and reentry of the jail and also acknowledge kate [inaudible] cline who retired after 25 years of commitment and work in the jail throughout that time. So, i will give you a overview of jail Health Services and like you to former commissioner [inaudible] for setting the context for us a little bit. I will tell you some things i think are interesting about what we do at the jail and what makes the San Francisco jail the National Model it is in jail health and talk about some things and opportunity for us to refine and improve or enhance some the programs in the jail. This is where we sit in the San Francisco health network, which really demonstrates the commitment of the network to provide high quality healthcare to all san franciscans in order they live a vibrant and healthy life no matter where they are. When they are in the jail they are afforded the same good quality healthcare as any other ambulatory care or hospital setting. That is a new position for jail health with the advent in the network. This is our organizational structure we are a integrateed multi disciplineitary. Consists of medical care based on the primary care model and Behavior Health that consists of a team of psychiatrist and psychologist, Mental Health. [inaudible] formally called frap, [inaudible] it spans for hiv integrated services and there is reentry piece also. We have dental services, and provide a hybrid of inpatient and outpatient pharmacy at the jail. We have a 31 million budget. Clearly our greatest investment is in the greatest asset which is our people. With about 24 million in salary and another 3 and a half million in indirect and direct care cost as well and 2. 5 million in pharmacy services. We have 163 fte, not all listed here but ill go over the broad categories. 3 nurse managers. We have among the physician staff we have 1. 2 psychiatrist in the jail. 2. 4 primary care physicians mpt 8 Nurse Practitioners. We have [inaudible] psychologist and counselors and 3 pharmacists with farm techs, 1. 4 edintest. Administrative support and support staff that consists of [inaudible] that clean the areas in the jail. We have nursing coverage 24 7 in all jails and primary care presence 6 days a week with 24 7 coverage and Behavioral Health presence in every jail, every day of the week and 24 7 coverage for the jail as well for Behavioral Health as well. Sorry. We serve 15,000 patients in 2015 and this gets to what commissioner [inaudible] was saying about the data. Im not sureim sure and probably have heard dr. [inaudible] talk about the databases and have a bunch of databases we use in jail health and the sheriff has a separate system of data and it is very difficult to triangulate the data and have confidence in the numbers we see today. I probably spent 3 mupths of my first 6 trying to do that so i feel confident in the numbers i present today and can tell you where they come from if it isnt clear from the slides. We saw 15,000 patients last year and im talking calendar year not fiscal year. The average census is about 1250. The difference between prisons and jails for those that dopet live in the world every day is prisons are federal and state entities and people generally serve long sentences there and jails are local authority. They are city or county and mostly these are people awaiting trial or Service Short sentences. Reflecting is our population in San Francisco we are 86 percent the people have not been sentenced or prearraignment or pretrial or precentance and have the remainder who are serving their sentence. Of the entire population you see the percentage, 7 to 14 percent of seriously mentally ill. 65 percent of our people in the jails stay less than 7 days. This speak tooz the churn of the population and then on the other side we got 16 percent there 30 days or more. We have two different sources of sex and gender identity data. The first is from the Sheriffs Department and the sheriff takes that information from the identification from the person arrested or make an assumption. We ask our patients and different rates of response than the sheriff does and we have identified 61 transwomen in the last year and 17 transmen who came into the jail. This just sort of sets a historical context. That is a totally different color. So, im sorry you cant see, but what now looks like gray green bars, there is a number hidden in the bar next to it so it is 21 thousand, 17 thousand, 16, 15. The difference between the two sets of bars starting from fiscal year 2009, we see a persistent and lasting trend of decrease in the jail population and the maroon bars up there, which are gray on my screen represent the people who are arrested who come into the jail. Everybody who makes it to the jail is represented in these numbers at the top. The larger numbers. The lower number are the people who are there after a couple hours and undergo a more extensive intake assessment. Both of those sets of numbers have been declining since 2009 and that is as far back as i have data for. Ethnicity data, thefor those participating in the reenvisioning the jail meetings the sheriff does not collect data around race and ethnicity that includes latinos. This is from the jail Health System and wewhich is called the jail Information Management system. We ask our patientsthese are self identified racial and ethnic profiles and regardless there is clearly a overrepresentation of people of color in the jail which is consistent with jails across the country. Just to take you through how our patients come into the jail and access care, quh they are arrested and sxh to the jail that is treaug. The first thing they do when they walk into the jail is they are presented to a nurse who takes them through questions to figure whether this person is safe to stay in the jail. Safe from a medical standpoint. Sometimes people are injured in the process of arrest or while they are fleeing or prior to arrest or have been on the streets for weeks, months, years and havent accessed hemthcare so the diabetes is out of control or Blood Pressure is high, have a fracture or sellueitis. These people we immediately call it refuse for booking and the arresting agency usually sfpd will take them to the Emergency Department and if it is Mental Illness issue or dpes, so those people dont stay but they come back typically. For those that do stay we parse them out. One track is subacute track so people at high rist for detoxing and people who are appear to or have a history of psychiatric instability. People have a complex medical problems or mobility issues. All these patients go into a specialized housing track, either a medical or Mental Health specialist housing track and remainder the patients go into a chronic care track to access primary care, sicitree and Mental Health, dental and pharmacy as a outpatient model. The way that works in general is by referral. A patient can self refer. The nurses can refer. The deputy sheriffs can refer and Mental Health staff can refer and we can all refer to each other so any door is the right door which is ironic in the jail. Any door is the rith door to access care and typically after the referral the patient either has a nurse assessment or Behavioral Health assessment. In terms of the numbers, last year so the triaunge, the people that first come in are 20,000 and turned away 613 and sent them to the hospital to be seen at zuckerburg general and return. 14,000 went through more robust intake process meanic they were there for a couple hours or more. 31 thousand nursing visits and [inaudible] you see the dentt visits and 200 thousand pharmacy fills. People dont come with their medications and if they do they dont get to keep them. In terms of behavioral Health Services, title 15 mandates that we provide minimum standard for jails in california that we provide basically stabilization, reentry and Crisis Management for Behavioral Health. In San Francisco we do much more than that consistent with and beginning with evaluation, patients are then sort of sent through the path to individual and or group therapy, Medication Management is needed, Substance Use treatment as needed and that is also in partnership with the sheriff who brings in peer base abstinence only. Support groups. We have in preparation for people leaving assessment and referral to community streement, which is through Reentry Services and also crisis intervention. So, 36 percent of the patients who came in last year had contact with jail behavioral Health Services and these are the kinds of parsed out in the stabilization of reentry and crisis intervention. You see the numbers of visits. These are not unique patients, these are encounters. And then we place the 5150, 465 times. 330 of those resulted in admission to the sfg 7 l which is inpatient jail ward at the hospital. [inaudible] our next program consists of two different programs. The first is screening and prevention and second is center of excellence which provides primary care to hiv patients. Screening and prevention involved 8900 hiv, help c and [inaudible] and education was provided to our patients as well as overdose education. Condoms are available throughout the jails as many know and have been for a very long time and then [inaudible] narcan is provided to people at risk of overdose. We provide narcan in the jail. The other track is center of excellence providing primary hiv care to our patients. We serve 345 unique patients with hiv last year. Medical Case Management which starts rolling after day 5 of their stay in the jail. 127 patients with 500 encounters. During that time consisting of psychosocial assessment and medication support and discharge planning which includes supply and establishing or reestablishing medical appointments, housing referrals, food voucher jz transportation vouchers, things patients need when they leave as they identify to us as a need. Just a couple of things that aresince im new to the jail coming in in my experience things that are unique here and very powerful for our patients in some regard in the jail are use of methadone and bupomofeen is unusual in a jail. We provide methadone maintenance for people when they come in. We know it works and saves lives and haveprieve prevalence of Substance Users so treat their disorder. Bup mof 15 for detox for opiate user squz a bridge to maintenance when they leave to return to the community. We have prenatal and laboring support for women in the jails who are pregnant through partnership with ucsf. We have a obgyn who comes in. The birth justice projsaeckt unique volunteered service, so when women are laboring they have a [inaudible] with them who also provide prenatal education and post pardm support in particular arount Breast Feeding who want to breast feed after they return to the jail. We have 4 clinical pharmacist clinics, anticoagulation, hi hypertension management, diabetes management and psychopharmacology. We recently entered into a agreement to provide antivieral tooz the hepatitis c patients in the jail and when they leave so they continue their treatment with medications provided when they leave the jail. That is just launching right now. In terms of Behavioral Health, all sorts of interesting things, but one of the most successful programs is around Behavioral Health court with a Collaborative Court and now this is expanded to include the misdemeanor so people wont languish in the jail for long periods of time waiting to have their charge adjudicated if it is a misdemeanor, they can move through had system more quickly and into raprogram that provides appropriate support for them. Meantering and peer support for people who in Collaborative Court is a program that is very special and been very successful in the jail along with trauma screening and treatment for transitional age youth 18 to 25 in the jail. We had the privilege of work wg a consultant, mary sorten and her team and i understand you will hear more about marys report, but what we engaged with around her are some opportunities for areas of improvements to leverage resources in Behavioral Health to cover ever expanding population of people in need of melthal Health Services. Just identified 3 major areas, cauntsnuity of medication which is sometimes difcult to provide in the jail when people come in and somewhen people have case managers and good contact with their outside psychiatrists we ought to be able to continue unless there has been a significant change in their health, their medication and part of our limit is 1. 2 psychiatrist we have for the entire jail so some possibilities to increase the number of prescribers we are looking at are sigh atric Nurse Practitioners and also leveraging the primary care providers as they do at Community Standard in primary care settings to also provide medication for patients with Mental Illness. We also identified we provide a lot of care to a pretty Large Population in the jail around Behavioral Health, and some of that is too much and some is too little so stratifying that care is representing targeting who we want to receive what kind of care is something mary is helping us to do in addition to using a more efficient and equally effective validated suicide Assessment Tool obviously incarceration represents a very high risk time for suicide and we see that in jails throughout the country. And then strengthening and stabilizing our programs in the sigh atric shelter living units thrmpt is a opportunity for individual treatment plans and we do a lot of group therapys as well. And then just the last slide is really some other visioning for jail Health Services. There is a lot of churn, people are not there very long and it is a perfect time for Public Health intervention and we do not screen everybody currently so expanding the surveillance and treatment in the jail is a opportunity we have. Initiating and coordinating, relapse and revention therapy around Substance Use is a another opportunity. We are looking to expand the [inaudible] medical Case Management to insure contty with their community providers. We have somewhat siloed reentry programs hivisand bhs. There is a opportunity to integrate those more effectively. [inaudible] the opportunity for linkage across social service. Our patients in the jail are patients in the community which is what the linkage piece is about. Caring for them during what could be a time of crisis and transitioning them home is our goal at jail House Services. Thank you for your interest in the jail and time on the agenda and happy to take any questions. Commissioners, was there Public Comment first . I have not received any requests for this item. Doctor sanchez. I think that was a excellent update and unique insight and defined the parameters that have been in the past and those we are looking at now and in the future so want to commend you and staff for utizing and maintaining the data based on the realty of those we serve so thank you very much for sharing. Thank you. Commissioner chung. Thank you for the presentation. I have a few questions, the first one is about specialty [inaudible] can you elaborate on what that is . Sorry, specialty . Specially services. We do have a couple of specialist that come into the jail, medical specialist that ob program is one of them and podiatry is another. All our Specialty Care is provided at [inaudible] so other than those specialist. What i mean, it says here intake for specialized housing. That is either medical or Mental Health housing where people need more support. On the medical side if you haveif you use a wheelchair you cant be in a regular part the jail so we have a area that is a Skilled Nursing facility where people can help patients with activities and daily living. If they have appliances like a colostomy that is difficult to manage in a group jail setting or if you are on iv medications for example, that is provided in the specialized housing as is for the Mental Health patientatize is psychiatric observation so patients are under closer scrutiny and provided more support in what is typically a precrisis time. That is what the observation is about. Another question i have is you mentioned here that you referred 613 people to Emergency Department yes that is more than 1 a day. Right. When people are total of the year is about 850 so there is 150 in the jail over the year whos condition detearierates or warrants people get in fights in the jail and that is trauma. Those initial 600 are those rejected from treaunge out of the gate so say this person is too sick or complicated to be here now and need them to go to sfg to get stabilized. They are still under arrest and then they are brought back to the jail when their conditionthe jail isnt the right place to treat a lot of medical problems so until they are in the right place to do that they stay at sfg. Between that number and how many actually went to psych emergency 330. That 330 is a great question. Those are totally over lapping numbers because some of the 5150s happen when people are in jail a while so it isnt just when they come in, but they may get bad news, so they are in crisis and 5150. There is a little vin diagram for those numbers. It is interesting i think there is a lot to [inaudible] for sure. And also there is currentlyi know there is a certain person doing a Hunger Strike. In that situation how does jail health get involved . Um, i can speak generally about that, which is there is a sort of graded policy how to manage it and prior to this job i worked at san quenten 10 years and had a mass Hunger Strike. There isnt a big body of medical literature around Hunger Strikes but we had a lot of experience recently between california and department of corrections in guantanamo. We follow their weight and follow lab data very carefully. We follow the amount of urine may make because if people are drinking they can go 40 days and 40 nights. That is the biblical length of time but much longer. If they stop drinking people get into serious trouble very quickly. We monitor those parameters. Their energy level, their ability to interact and if the patients have capacity at the beginic of the Hunger Strike meaning they understand what can happen and this is decision they are making and [inaudible] around this decision and others, then it is like anything else, they can refuse any treatment and refuse food in the jail. They retain atotomy as patients. Typically when it is difficult is when people get very sick and we are faced with difficult ethical questions about what to do if someone is unresponsive and how we approach that and we havent had to think about that with the current Hunger Striker. That is something we could face. Thank you. Also, it fascinates me to look how we actually [inaudible] self efficacy. At the Sheriff Department or [inaudible] from my perspective is advocating for themselves for safety reasons [inaudible] that is absolutely true. I think the public dont necessarily understand patients retain atotomy whether they are incarcerated or not. As long as it isnt a Public Health issue like acive tb they can refuse or decline treatment as they see fit. My job is protect that atotomy. Commissioner pating. First of all, i want to thank you for the excellent report and for jail House Services having toured, i appreciate how difficult your job is. The most difficult clients in the network and working environment having 250 coordinate service with the Sheriff Department and being at the whim when they are booked and discharged and working around those visits, you have as much complexity as a hospital and integration as the outpatient system so you are key the system. I would like to look at your role in the health network. We have taken a focus on the jail. Just a couple questions. Of the patients more short term, which is 65 percent and clients more long term, which is i guess 15 percent are like over30 days and the rest are between, how does the services break down . Do the short term servicesare they less expensive oregon doing a lot of intakes . Long term clients are they costing a lot . Can you tell us in terms of the budget burden of each of those groups and whether there is a difference. I cannot tell you anything about the cost in that regard and i dont know that we have the sophistication in the data systems to be able to address that in detail right now, but in general people who are there a shorter amont of time unless they have a serious injury or illness and end up at sfg they cost the system less because they are not there long enough to really get engaged t. We restart their medication, that is probably the biggest cost. Those that are there longer, a long period of time, the short period is 7 days is more of a urgent care model and then for those who are there longer term we are into a chronic care primary care model where we look that screening and diabetics for eyes and feet and thinking about corectal Cancer Screening and mamo grams and things where once a patient is stabilized you address in more a prevention aspect, more education about their illness and medication and how to engage around self management for whatever those illnesses are. That doesnt happen in the first 7 daysism s. Can we look at it from those different perspectives . Can i walk through the serviceson one ends your services are vertically integrated and have hospital beds and post opsurgical units for people who receive minor procedures. Subacute and have the regular clinic duties. In that respect, one thing i came away with is you look like a hospital, what are some things you do to make sure the integration goes well . I was interested in the pharmaceuticals because i know that you did not get some of the pricing the hospital got and wonderas much as we offer total care can we get some the cost efficiency of the hospitals . To speak to the first part the question, the vertical integration stops at acute care hospitalization so anybody who has anything beyond a Skilled Nursing need goes out and so thatsthere is a opportunity to bill when they are inpatient so that is out of my budget. That is out of the jail over here. The 340 b or other opportunities pricings for pharmaceuticals is one that im sure joe exploreed a lot and one i exploreed when i first started with the ideawe have our own pharmacy and it wasnt clear if that is something that we should continue to do, should we merge that with sfg and get our meds as a outpatient satellight. We talked a little about that with the pharmacy director and 340 b specifically excludes carceral settings from their pricing. There is no benefit to us. There is a lot of stuff we have to do to become Staff Members at the hospital in order to do this, which would have been great incentive if we got 340 b pricing and once we reviewed the regulations and saw this provision that excludes jails and prisons that stopped that movement. I dopet know why that is historically, but it was pretty [inaudible] and that is where it ended with dr. Woods. Considering Jail Services in the other direction not vertically as the hospital or subacute, with 6 days stay i think you can be at hospital model where you see people doing acute triaunge and cleaning up and linking them. With regards to that, the recommendation of former commissioner guy, the release center for linkage opportunity. I didnt see it in the presentation and wonder what you have discussed to make sure you are a quick triaunge, get hooked up to the continuity of care because this is the only opportunity they get for quite a while or never before. We are in the [inaudible] stages of exploring how to formalize the linkages. There is capacity in the primary care system and dr. Hammer is happy to have us integrate our patients back into the system because they were served by the Health Center or establish care. We havent form alized that yet and that is the last point to figure how to do that in a way that really is a warm hand off and not just we made a appointment tuesday, hope you make it because that historically doesnt work for this population. We are more likely to see them again then they make the primary care appointment most new clients come into you are probably unlinked and not part the system, is that correct . They are linked and out of care. They have seen we got a lot of kaiser patient squz a lot of patients dph patients and [inaudible] patients, we have a lot of ppo patients and they typically just have been out of care for the last time they picked up med in jan or february. There is real opportunity to make that connection if we can getit has to be fast and the idea of Diversion Centers must have that kind of capacity if we dont have the patients in the jail we have to make sure we get that hit when they are in front of us. [inaudible] thank you, we need it. The last two questions is medical. When people go into prisons, they lose their medical. Do people lose med ical in jail . They lose kaiser coverage as well. Do they resume when they get out . If they are in more than 30 days do they lose it . [inaudible] one thing we have done is worked with the sheriffs and social services during the aca process was to really have a process for them to get reinstated on the medical. It goes on pause and isnt shut off which is what happened before. That was a legislative issue. Also we worked hard with the state to insure individuals in the hospital got medical coverage and because that was notwe were covering those costs as well. If you were not on medical or coved california there were [inaudible] to get on those is that what you are saying . They tack that as soon as they come into the jail. Thank you. That is part of the dist charge process and reentry process that is important. Do you have a question on this . I have one more on psychiatrist. 1. 2 for 3 sites . There are 5 and one, two and four which are colocated downtown and 5 is san bruno which is the bigest jail it seems like a lot of territory to cover. It is a lot of territory. Im done. [inaudible] commissioner carson. Thank you for the presentation. I had a couple questions, when i visit ed the jail there was talk about [inaudible] is that no longer something that i think again this is sort of a Early Exploration but one of the opportunities for telehealth that would be a fabulous solution is telepsychiatry. We have as you know the conversion from health right 36, the Behavioral Health positions which include psychiatry neither of the psychiatrist are coming over after the conversion. Psychiatry is the safetynet is a challenge and it is a impacted specialty and one we absolutely cannot do without. We have been in talks with uc around just very early stages the opportunity for telehealth and there is a little technology that has to be put in place to do that as well that has a expense associated with it but it might be a great solution for us for psychiatry and other specialties as well. Telepsychiatry aligns so easily to telemedicine, it seems like that is a waste if we cant figure how to make that work. The other thing, so, since it is the primary care model effectively and i anticipate that you will be part of the network dhr, is that correct . We will. So, some the questions that like cost issues, like how much does it cost to provide the services should be captured by that over time and outcome measures. That would be important for us to see how those Services Impact outcomes with that population. My last is a comment. As you described the population that they come in and leave and transient, it sounds a lot like what we have talked about with Homeless Population. I wonder how connected you are with Lessons Learned out of those populations to usefor them to also get some of your Lessons Learned into their population . Perhaps estimate what the homeless pertage might be in the jail. I was going to say 30 percent and [background speaking] that seems to be a underestimate if you include marginally housed people. I would say the first lesson is these are the same patients, so the opportunity for integration with Homeless Services is huge here and also providing care for those patients in other than, please go to this clinic in this neighborhood on this date, which is really what Homeless Outreach has been doing, just taking care of patients where they are. That opportunity is one that we need to leverage as well and figure how to connect them to the people out there with them with when they are not in with us. Probably the greatest Lessons Learned that we have been able to take away from is just the fundamental philosophy how to approach the patients. It isnt quite operationalized effectively yet but as we grow into a new approach to managing the Homeless Population that is also the jail population, that is also the mentally ill populationwe triangulate around these people and support them in the appropriate way to do that for them where ever they happen to be at the time. Warm hand offs. [inaudible] a couple questions around the integrated services. You mentioned 2015 there were 8900 tests done. Out of the 8900, how many had been positive . That includes hiv, hepatitis c and sti but 7 new hiv positive patients. It is harder to know who had a new hepc diagnosis but greater number than 7 and tons of chlamydia and gone reea and syphilis. Director garcia. I wanted to thank you commissioner guy for coming. She talked about the jail reenvisioning and this is how well try to make recommendations including how to help people get into Supportive Housing and so sthra great deal of activity and lots of great ideas. Very integrated group and want to thank commissioner guy for her leadership along with the sheriff. I just want to note that i believe that part of the issue of why we are the best in Jail Services is when you think about the type of generalfund we put into the system and when you think there is no revenue at all and it sits on general fund of any county, that is one the problems we have in providing a kind of equity in terms of these individuals. Particularly as you know that people of color are the ones getting arrested whether that is a right equity way but medical is something coeen and i have been looking at is can we kbet individuals covered in medical as they continue in jail since they are there for copal days and gets complicated getting back into care. That is apologist question i think we nude advocate for and by the way, children in our Youth Guidance Center have the same issue so thought maybe we should try the kids first and get to adults but that is a problem when we have to use our general fupd and we are a very generous city and county so we are able to provide the type of services. Not all counties have that type of general fund to provide that and that is why you see differences in different counies. We vajail in the hospital called 7 l so when the individuals are acute and have to go to the hospital we have a jail system in the hospital so that is a another area that we focus on. Is that medical and psychiatric . Both. Also, i just want to acknowledge the fact we have dr. Pratt as the dr. In charge. You heard her say 10 years working at san quinton and worked at Community Based organizations including baker place for detox programs so has a deep understanding of the populations we serve and how lucky are we after having joe [inaudible] to have dr. Pratt. I just want to acknowledge robert who helped recruit her. I want to thank her for making the choice to work for us. Andologist her staff who have done incredible work and very committed. Frank and tonia are commit today the population. I thought if we have kate [inaudible] i want to acknowledge her because she is leading us and[applause]as a leader in jail Health Service particularly those with hiv i want to acknowledge her and have the commission acknowledge her today. Thank you. I want to echo the comments of welcoming you and want to just reflect for a few short seconds that our jail house wasnt in this condition when we were [inaudible] back 20 or 30 years ago for nearly a decade and if nothing else that made the city much more away of the need to really take care of this population and dr. Goldensteen assisted in doing this. One of the other things we have been asking for i believe and while the commission has been looking at for example Public Health accreditation as being a positive move to move us into being able to be measured with the rest of the country is that if we believe that our jail system is moving along on a track that jail system and there should be consideration like perhaps we do with hospitals to relook at the Accreditation Process that would then help the commission and understand how we are managing with the rest of theunts country or state. [inaudible] there may be others but encourage we also look for yard sticks that help validate what we are doing and your fine work you are doing. Great. Any comments otherwise . If not, thank you again and thank you so much for the opportunity. [applause] there is no Public Comment and item 9 is, what is collective impact. Dr. Aragon. Welcome back to the united states. Thank you. Good afternoon commissioners. My name is tomas, aragon the Health Officer of city and coupty of San Francisco and director of Population Health division. Today what i will talk about is what is collective impact. It will be a conceptual overview. You received a detailed update but many of these areas so wont go into detail about the specific initiatives but will give a high lechbl overview. I want to start by saying back around 2011, [inaudible] were working on Community Health plan and Health Service master plan and a article came out in stanford social innovation review entitled collective impact and it got people thinking about how we Work Together as different sectors of society to solve complex problems. Collective impact is not new, it is the reframing of how we act collectively with focus and intention to solve complex social problems. The first one i want to show you isthis is actually a slide from australia and the date is 2014. You see from 2011 to really in a few years the concept of collective impact is known globally and inspired a lot of people to figure how to Work Together. What i will try to cover today is what is collective impact, why has it captured imaginations world wide, what does it mean for San Francisco, what does this mean for our organizations, for our staff, what are limitations of collective impact and how dus collective impact comp lment public approaches to improving population helt. Drether garcia and myself are part of leadership training with [inaudible] called emerging leaders in Public Health and as part och that leadership fellowship we decided to transform how we do leadership training in the Health Department. At the top it says pub lb Health Leadership is practice mobilizing people, organizations and communities to tackle Public Health challenges. What you see in the house being built, the 4 component what we call the lead initiative, has the first one the foundation is trauma system squz think you received talks on that. The concept is designing a heal ing organization. Iment provement the idea is designing a learning organization. The two pillars are cultural humillty which is about tranlz forming the workforce and collective impact which is about transformic clunties. Those are 4 components. You see how collect chb impact fits into a broader framework that director garcia is promoting. So, what is the idea about tackling complex essential and Health Problems . The way we think about things is problems and solutions can we simple, complicated or complex. The comicated problems are those with technical solution. The complex problems are problems that are very difficult to solve and involve complex social interactions in society. Some people call these wicked problems. There is no off the shelf solution to pull off the shelf and apply. What does it mean as a organization in terms ofhow we work with other organizations arounds some of the complex problem snz one of the most important things about addressing the problems is the idea of humillty. The idea that we dont have theer swz. Collectly hopefully through trial and error and integrating science, scientific evidence, Community Wisdom and community voiz and Community Evidence that we iterate to solution that will work for us. That means we have to be a lot more adaptive, flexible and willing to iterate. It also means we have to have a mindset we continue to learn. We will share solutions. Also means having principles of practice and ill talk about that in a moment. The other important thing about the idea of coming together is there is a huge emphasis on relationships and figuring how to Work Together with diverse populations. You can imagine the way things were in the past or traditional approaches for solving complex problems. Often times you have organizations, non proft organizations that go after funding and they work separately and disconducted and we describe that as isolated impact. The idea is if one organizations figure how to do it, we just scale up that solution. That is the more traditional way of thinking about this. Really the way that we should be thinking about this is all of us working together. Not competing, but working together to have collective impact and that collectively well be audible to solve the problem. That is what this diagram depicts. So, in 2011, john cania and mark craimer came out with a article called collective impact. They articulated or reframed what they considered to be successful conditions for collaborative around the world that were achieving the transformation of complex social problems. They came up with thought they described as 5 conditions. The first is have a common ajendsa and the idea is have an agrud upon shared vision for change. Having a common goal. The second criteria was to have shared measurements. Now, one thing i want to point out is for me it second condition here is really about Continuous Improvement accept that you think about doing Continuous Improvements really at a social scale with diverse agencies coming together. That is Continuous Improvement condition. The next is mutually reinforcing activities that you bring people aroun the table who are already working on these solutions. They are already inspired to work in this area but they have part of the solution. Bringing them around the table so that we can develop a common goal, shared measurements and Learn Together and share our best practices. For me, that third area is about transformation and that is about transforming complex systems and there are two transformations. There is transformation you try to achieve in the community and also and in the collaborative. The fourth area is the idea of consistent and open communication. That condition is really about Building Trust and transforming relationships. The last condition is what they described as backbone support and backbone support being in my opinion one of the most important things that are needed. You need to have both the administrative, data analytic and also the strategic project management support so you can pull off all this coordination and alignment. Some the collective Impact Initiatives are huge. For example, there is some that involve hundreds of organizations. Here in San Francisco we dont have something that big but some can be big. Part of thei would say the last one is soit is very very critical. Foundations have now to xh to realize it is not about funding solutions, because often times the solutions are not easy. You is to discover the solutions with the stakeholders working together. It is also about finding the backbone support so you have the infrastructure for the alignment coordination, learning project management, the data. That is a very important condition. The thing i want you to take away is when i first looked at this, the way i thought about this, this is just Quality Improvements applied at a social scale. At the Health Department we already have a lot of expertise to really contribute in a big way to collective impact and so that is what excites me about collective impact is we have the tools and expertise to make the big contributions. Now, as you might imagine there are some people who wouldare critical of collective impact because they say there are a lot of gaps and limitations and the intention of the slides conditions are not to be comprehensive. It is very concise and resinated with common sense like it resinated with me as a Quality Improvement model. Since 2011, taking into account all the feedback that occurred around collective impact, sfg which is Consulting Firm and think tank in San Francisco, they are really the folks who are behind the idea of collective impact and geped principles of practice. Designing and implementing a initiative with priority based on equity including community members, cocreating with cross sector partners, use data to continuously learn adapt and improve, cultivate lead ers unique system leadership skills, focus on program and system strategies, build a culture that fosters relationships, trust and respect, customize for a local contact. The way to think about collective impact are the 5 conditions and principles of practice coming together. So, because youre bringing together partners to Work Together on comp plex problems, you have to a little patiences. Sometimes there is frustration because you Work Together. On the lest side you see components of success and on the top you see what they describe as 4 phases. I wont go through the chart but want to read one quote from one of the articles. Once the initiative is establish, phase 4 can last a decade or more. Collective impact is a marathon, not a sprint. There is no short cut in the long term progress of social change. Youll see in some of the initiatives that i summarize you see that some of the problems are problems we wont solve over night, it will take years to really make a impact, so we have to have the peristance, but also the patience. So, temrack institute in canada put together the slide towhen i started the traditional model is about competing and coexisting. Collective impact is really on the right hand side focus on coordination, collaboration and integration when appropriate. So, im going to just list herei listed some of the collective impact projects occurring in San Francisco and know there is more but this is aicismal of collective impact projects the San Francisco department of Public Health is involved in. You had several presentations on vision zero. They are getting traffic deaths down to zero by 2024. Getting to zerogetting h eeurfx v death infection and stigma to zero and ill say a couple words about both of those. The San FranciscoHealth Improvement partnerships which you also heard about which is coming together the hospital counsel ucsf, department of pubhook health, ethnic groups and foundation tooz focus on the health of San Francisco, we use that for the health care Service Master plan Public Health accreditation u Community Health imprubment and hospitals use it for Community Benefits requirements. Ill talk about that for a second. The Preterm Birth Initiative is a large grant with ucsf that we have staff here at the Health Department working on. The our children and family city Wide Initiative focus on Family Wellness in San Francisco. The last is black African AmericanHealth Initiative. I want to briefly acknowledge [inaudible] bennett quhoo is right there who will be a key leader in the black African AmericanHealth Initiative and i do also want to acknowledge some of the other leaders working in that beside [inaudible] dr. Ellen chin working on heart health and Blood Pressure control with primary care clinicsism dr. Lisa golden working on breast Cancer Screening across primary care. Judith martin working on alcohol use for mens health and then dr. Yana bennett and susan [inaudible] working on chlamydia screening. I have given you a ovview on collective impact and before i a brief summary of 3 of those areas, i want to just show you operationally how we actually do the work. We take what is the described as a results based approach. Operationally this is how we do it. You see population helths improvements mpt we are trying to improve health in the community. The Population Based health and you hear about this all the time. Hiv infection, syphilis rates. But what we have control over is the specific programs that we can actually control. There is really two levels of thinking about this, there is the assets we control, which are programs, systems, Program Services or systems that we control and there we focus on the Performance Measures you often hear about and we are trying to contribute to a Population Health improvement with Community Health indicator. A individual organization may operate optimally. They may provide the best services for their clients and patients, but they may have a limited impact in the population. If all of these organizations are all working together, the theory is that collectively we will make a difference. That is the idea there. Population Health Improvement is community level, Performance Improvement is the agency level or Program Level. At the ends of the day for clients and people we are service we ask 3 questions, how much did we do . How well did we do it . And is anybody better off . It is always focus ed on improving health and wellbeing of people. I gave you a appendix that goes into more detail how the results based approach aligns with the Management System we are using. I want to show you how it works getting to zero. The goal in getting to zero or common agenda is zero hiv infections, deaths and zero hiv stigma and discrimination. There are 4 strategys being implemented across the city, the first is called rapid to support for persons newly diagnosed with hiv. Retention and reengagement of persons living with hiv and to make sure they are getting high quality care. Preexposure prophylaxis is reduce hiv transmission or acquisition among those that are hiv negative. And ending stigma. If you look that bottom table number 1 that is Population Based indicator. We know for example in 2015 we had 255 new infections and in 2012 we had 453 so since 2012 to today there is 44 percent reduction in new hiv infections and this trend that got everybody excited about the idea of getting to zero. Seeing it go down. We had a historical graph you see it was much higher. The idea is we like we can do this. We are moving in the right direction. We want that to get to zero. That is a a Population Health inicator so imagine the strategies happen at the program and agency level. Now, number 2 and number 3 are examples of really performance indicators. The first is time from diagnosis and first care. The second one is first care to vital suppression, also in days. You see from 2013 where it took 104 days to get the patient vierally surepress from 104 is down to 52. That is 50 percent reduction in getting people vierally surepress. Moving in the right direction. We see endicators in the population level and Program Level are in the right direction. The Program Level is what people comthe lead intcader and contributed to the population indicator. We focus on the program because that is what we can control and expect it to improve at the population level. At the population level it is a combination of all these things, social marketing and people changing behavior. That is what i wanted to cover in detail to give concrete example of those conceptsism i wont go indetail for vision zero. The numbers have not chaimpged dramatly in the past year but this is from the most recent report and can go and get the most recent report for 2015. In 2015, 31 people were killed in traffic collisions. 21 were pedestrians. 5 riding motorcycles, 4 bikes and within person driving. There is a lot more stats in the updated reports. I wont go through that. The last one i want to mention is San FranciscoHealth Improvement partnership. At the very bottom you see we have a common agenda. At the bottom we have draft shared measurements under Behavioral Health access to care and eating and physical activity. Now we are in the process of finalizing theenedicator said we will focus on and deciding how to address those. Those are 3 examples that were intimately involved in. The last thing i want to do is just describe how does this fit in with the other Public Health tool s we use to improve population helt. We have 3 core ways doing this. At the top is idea of Health Impact assessment. All these approaches you see they are system approaches because we work with communities. At the top is Health Impact assessment. We ask the question, what is non Health Impact of programs what is the Health Impact of non Health Programs policies or proposals. If someone proposes to build a freeway in a certain neighborhood, what is the Health Impact or the Health Impact putting bike lanes for example. The idea there is that if you go from left to right you see there is multiple impacts. Collective impact is the reverse of that. We are saying, lets bring people together, the mutually reinforcing activities to focus on a specific Health Impact and goal so just the opposite. The last one i want to mention is called Community BasedParticipatory Research and San Francisco is very active in this area. That is where you engage the community to come up with the quigz and solution and work with them to address the problem. A lot of our Tobacco Control initiatives work wg youth groups is done through this approach where they identify the problems and do the research and learn how to take a idea through policy makes and getting something passed with legislation and board of supervisors. Those are the 3 praimary ways we work with communities to transform health. What i covered today is collective impact. Collective impact is not anything new, but it is really a reframing how we Work Together with focus and intention to transform complex problems and, it is a Important Pillar in our lead Training Initiative that director garcia is leading with the Health Department. That is my overview and im available for any questions. Thank you. Commissioners, questions to dr. Aragon . There is not Public Comment requests. Thank you. Dr. Aragon, the first questioni mean the idea of collective impact is something that we have been using for a number of years in the city and bringing together a number of different organizations for different topics, right . Particularlyand this sounds like you have interwoven it to a lean process, which the department has used now as its key metedology for developing programs in your scenario here, is that right . Yes, they really comp lment each other. Lean has a focus on methodology to improve processes and deliver on results. When you engage the community, you dont start with focusing on process, what you focus on is what you are trying to accomplish which are results. You focus on results and then you say, how do we get there and yes, improvement methodology will help but you dont start. Where you work with staff and focus on improving process, the lean approach is really provides the tools to improve the processes so they compliment each or. It is just where you start. That is reason quhie ione thing that excites me about Continuous Improvement is as we engage with communities we wim have better tool tooz help thel. We will be able to provide that value as we engage with different agencies around these complex problems. If we can go back to your first one that you have. It showed all the 3 areas. 4 areas. There we go. This is one of your tools to create thisthe house here. Right. Continuous improvement we focus on that at a organizational level but tools we can use that with communities to help improve their processes. Again, Continuous Improvement and [inaudible] internal to transformation but we engage with our patients in communities. Collective impact is about outside workingthe Health Department work wg other agencies on complex problems so vision zero about traffic injuries we work with Police Department and mta and department of Public Healths and Walking Group jz, all the organizations come together and focus on a common issue. Department of homelessnessit is one of the collective impacts . Sleuthly. Absolutely. The the complex cuply in many different areas. The clinical analogue of this is coordinateed Case Management. You have a complex patient and you need a you have different providers who are coordinating care around a complex patient. Take the idea of coordinating Case Management and scale it up to a social scale. That is what collective impact is. When you look at it carefully people are familiar with it but the things we bring to it now with more rigor especially with Continuous Improvement and Relationship Building and trust component. You have to acknowledge these are complex issue squz have to get to a solution and build trust and transform reslaigzships. Any other questions at this time . I think the answer is what is collective impact and the answer is the most important thing we can do at this point for Population Health. With that, i just want to thank you for all that you are doing. When i inquired about the collective impact project particularly in the budget im impressed how much Financial Leverage we get out of these in terms of the not how little because i know we invested a lot but a relative benefit we get for the dollar we put in we get a lot of Financial Leverage. My question may be to udr. Aragon or director garcia, are we funding directive impact out of sur plus funds, the mayor comes windup a good idea or department comes up with a good idea so get backbone funds to fund this or is there a line item to fund the collective impablth because it should be a ongeeing structure . I think both areas. One thing we want today look at is we could look at lean and look at it separately, cultural humillty. We tried to bring the training components together because we felt each had a important contribution particularly as we are a Delivery System and we are responsible for all the Health Status of all individuals in San Francisco. Using both the lean process, collective impact, trauma and [inaudible] because that is who we serve, individuals who are traumatized by a variety of different social determinants and cultural humillty as well is one of the ways of looking at Workforce Transformation particularly reflecting whom we are serving in the workforce. So,all this is funded as of today, the 3. Collective impact is a example getting to zero 3. 2 million from the Mayors Office and that will have some of our backbone in. We have to to fund each separately but there is a background growth we want to continue to support and have done that through Public Health accreditation to insure they have Quality Improvement staff and we have been bringing in at least 2 million of new infrastructure for Public Health so they have backbone for the staff necessary. When we looked at Public Health division, what we found is epidemiologists were funded by hiv. I think you had one epidemiologists or 1 and a half when you think of all the other Public Health demesnes. We are looking how we grow the backbone of Public Health division and had 1 and a half when you think of all the other Public Health demesnes. We are looking how we grow the backbone of Public Health division and had to dollar. How do we provide backbone to any Public Health. We have the zika issue and had to deal with ebola issue. We have to contend with different areas. Part of the commitment i made to Public Health division as we go into the thirds year oof 5 years is to try to build the backbone of our Public Health division to participate in many activities you usually dont see Public Health departments do. We get efficiency as we do more. We have collective impact Case Management division that run the projects. Interest is make sure you dont get hammered by funding when you feel they are essential to do them. That is the intent. Absolutely. I asked for a 5 year funding plan for this. You caen just start lean and think tomorrow it is done. This is going to be for a decadethis has to be interwoven into our work so we have a working process of 5 year commitment. At least to plan out and tine continue to look at that. I donts worry how to make investment especially in the days having more revenue, with competing things like Electronic Health records but we have been able to fund this. When new organizations as a example, there is a new several new researchers out of ucsf that feel they can get to cancer issues and get to provide for that. That is one thing we talked about that it is important for them to have a backbone and have funding to bring people together and work with all the other groups in the community versing starting new with the same group of people and that is what we found with Health Improvement process which we had hospital counsels in the plan separately coming to this commission. We had the Community Groups coming with their plan and Public Health and multiple health assessments, so i think [inaudible] policy planning area have been able to bring that under one umbrella and structure and philosophy and i think that is important. Community partners is one of the most important things because we cannot do this on our own. We have to Bring Community in and be driven by community responding to their needs. Is there a process by which new ideassay the cancer projects and how long does that take to roll forward before we assign the designation or commitment to provide the structure . I assume you get good ideas. You started one which was hepatitis c. In one meeting you said cant we get to zero and here we are. Part is that we didnt have a backbone so that is a a think we had to look at how to do this. You can establish them but you always have to have extra for the issue you are working on. I would say it is through our planning process so the Community Health improvement plan. It has to fit into the priorities because you have to prioritize and cant focus on everything. We are never going to go back to isolatediment pact. It is a waste of resources so complex issues you have to bring people together. I think for us the real challenge is for to develop deep expertise how to do that for all these different problems so it is us becoming experts on convening people and fus sating through a process where we cocreate solutions. Thank you for this. Thank you for putting to together because we had presentations about common form systems and lean process to have it all together in this helps me see how it all works. In fact, as you develop and have developed this expertise in collective impact, one thing that would be help fm from my perspective is as we have presentations we continue to use this language. This is where we are going with a backbone toward collective impact so that is a good way to see how they are linked. And priorities, this is where we are going now. Thank you for that and look forward to continued use of this language. It is very helpful for me. I think [inaudible] it was great to understand the pillars you are building to develop a stronger Population Health program for us and we appreciate your presentation. Your welcome. Thaunchg. Thank you. Item 10 is the sfdph it update, eElectronic Health records readiness update. Mr. Kim. Good evening commissioners. Director garcia. Before i start, i would like to welcome dr. U who is our chief Health Information officer who has been extremely crucial putting this effort together. There he is. Great. So, dr. Eu will be available for questions as well but i will lead the discussion or presentation. So, commissioners, first of all i like to point out that this is not a update on all of the it, but specifically around the things we are doing in regards to the Electronic Health record. So, the first few slides i will go over fairly quickly. They are what i call the background slides or more importantly, frame of reference slides. I like to make sure everyone is on the same frame of reference. First of all, i like to go over business challenges and solutions, electronic record procurement status. [inaudible] i will take any questions at the ends. This deck also has a appendix of all the high level timeline of work that is being done today. So, first of all, the challenging solution. This is a many people used to see this as a it solution, this really is a business challenge and business solution. So, the challenge that was posed is that we need to have a integrated Delivery Network to improve operation efficiency, effectiveness and improve patient care and long term vinelt in shifting health care delivering in the financing world. The solution is very sound, the problem is you do need the right tools for people to be able to become what they can be. We mustto have a unified electronic Health System, not record but system which is technology, people and process, we need to be able to leverage our information with the organization. So, that means we must have a right tip for youth Electronic Health record, maintain effective it. We can take and get [inaudible] use it effectively. We must also establish and maintain effective people process and governance. All 3 of these areas must be in place to achieve towards the goal. You have all seen this. This is us today. Extremely disjointed. You can say this is services broken into little pieces and how our information sits. Realty is it is very des prit. We try to force it to fit. What we want to get to is this. If you look at the top, the sitting part, that is the integrated information workflofement there is a blue thing that breaks apart. If you imagine the previous slide coming together as a circle. In order for that circle to be effective we need to have an effective it. We also need electronic right fit [inaudible] and also need people process and governance. What have we done . So, i would like to talkpresent to you and give an update on the [inaudible] procurement efforts. Now we are in Due Diligence and negotiation. We formed joint Program Management team that meets weekly. It is attended by dr. Eu of ucsf and several key personnel from ucsf and dph. Ucsf and dph joint structure is established and had a positive kickoff as well as [inaudible] kickoff and im happy to say we have a consensus on high level scope, proposition, risk priorities and Lessons Learned. We also formed workgroups establishes and Due Diligence is underway. The goal is have a decision which is the question of can we do this . Dph, ucsf by end of september 2016. It dozen mean we will have a contract in place but will have a level of confident we can proceed. To give a idea the complexity of the group, the governance groups, i like to show the next slide. I will go through the slide in detail but this shows all the players and key areas that are in play today. They are meeting and have met and will continue to meet until we get to the september goal. The next one is a very similar slide but shows how decisions are made and work efforts being done. You can see in red the deliverables by individual groups. How it goes escualated up the chain and decision are made and goes to ucsf and dph leadership and stakeholder. The next slide you have seen before in a different iteration but this is a slide of the timeline. As you can see, the red mark, the red bar is we are here and you can see where go live one and 2 are and you notice that the yellow bar, which is previously reported activity. You see on the contract and Due Diligence we started later part is because we couldnt engage ucsf without boardf supervisor approval. We are tacking to the original timeline and expect to meet the timeline unless our Due Diligence shows otherwise. The next one is i will say a timeline of the contract Due Diligence and negotiation component. All these actually can go into serious level of detail and you can see all the work happening, the deliverables that are due and who is working on them. I would like it go at leisure. This can be hard to get a clear picture so what we did is actually put a check list of things and where they are. You can see the checks saying yep, we are done with that and the person working is we are in process. You can see what the overall status is as well. Hopefully this will give those who are graphically inclined a better idea where we. The workgroups have formed and governance is still in process and the governance is formed where we socialize the different methodologies and approached and the legal team is starting to form as well and have many meetings, but that is still not 100 percent formed so doesnt have a check mark. Okay, that is the chart part so well get to in september go, no go, can we do this with ucsf . Going back to the stool diagram we can put it in the [inaudible] if we dont have a it organization that cant support this. As you know for the last 2 and a half years we have worked very hard getting our infrastructure and it ready. What i have is a simplified version of the areas we have worked on. The status will show two things, it will show current and what is trending. You see wide area networkthe organizational readiness is also very important. Before i go into the slide i would like to make a note that the first bullet dph, ucsf isnt shred, but shared. Shared Program Governance need to be in place and are working on that. That is how to install and maintain and optimize what we will share. How to sustain Technology Innovation . We do not want tothis goes back to dr. Aragons slide, how to get on the same goal. We also focus quite a bit on investment in people and as you can see we have a lot of leadership development, talent management, [inaudible] kernly demarcation of ucsf and dp h roles. We work on standardize process. Execution and optimation and increased accountability. So, ill take anydr. Eu and i can take any questions you have but if you allow i would like to show a page from an appendix that is a sample of the work group and work effort they have in front of them. Going back to questions and answers, any questions . No, there is no Public Comment for this item. Im glad you clarifyed the shred. A very nice presentation on where you are going and commissioners, questions . And this is withcould you explain go live 1 and 2 sort of quickly . Why do we have 2 go lives . Actually ill sum it in one sentence. Resources to support our clinical team. When we go live, you have to have certain number of trainers and certain number of support. To go live for a organization of this size we need a army of people. We will build both phase 1 and 2 and start build at the same time but staggering our go live to focus more resources to when we gee live because that is the critical component. Okay, so i couldnt understand. Gain experience from the first go live. If we talk resources the question may be whether or not it would be better to have everybody on at one time. I dont know the plan because and may take units and so forth, but i just want curious as to the two go lives. Sure, commissioner. Dr. Eu. The go live two faces is also about the applications we are currently using. Whee have a very very time sensitive deadline on all programs and systems using in [inaudible] but where we bill Inpatient Services [inaudible] that group of program said must go live first phase. Even there it may not be one big gang go live, it may be multiple mini gangs. The second go live is programs like avatar and Behavioral Health side, jail programming. That is a phase two go live for those other programs. Clearly, we can do that at one time if the resource allow. We dont want to do that from having Prior Experience of avatar and acw, that would not be a wise strategy technically. No. If it were important and going to be better than perhaps the question is getting the resources but i think previous experience also says that you probably do better going unit by unit as you described the priorities. In future maybe as you develop that you can tell which are go live 1 and go live 2. That is exactly what we are working on now is the phases and approach. We do have a pretty good plan but we are revalidating before we commit our sevl said; because i think this is modeled on where we had before in terms of the whole rebuild process for general that you maintain what was the baseline so we can see if you are at a advantage or disadvantage versus baseline. Right. It shows 3 bars so the next iteration you will see the yellow go back too match theif you look that third bar the contracting, Due Diligence negotiation, the yellow will change to mirror the one and a quarter year but the gay stays because that is the original baseline. Okay i think you are looking prox mmly at the go, no go decision. How will the decision of go or no go be made from our perspective and what do you see is the Biggest Barriers or risk that may result in a no go decision . As you get to the date. I think one of the biggest drivers for no go is if ucsf can come back with a proposal that is within the budget the board of supervisor jz director garcia approved as well as a timeline that meets our deadline which is when [inaudible] and vision is no longer supported by the vendor. A lot is driven by the cost and schedule of what ucsf comes back for contract for implementation. To inform that we have to define the scope, what is within the scope the contract is part the discovery work and probably the biggest risk whether they meet the budget and timeline of what we need. Second, ucsf doesnt have a lot of business lines we currently. Jail, Behavioral Health, Long Term Care are examples. How much can they commit to building those modules for us as well as supporting on a ongoing basis is another sort of big determinant driver. We actually want a solution that can cut across the enterprise to insure patient flow throughout each piece the department seemlessly. We have confidence they can do this, they have confidence they can do this it is just a matter if it can be done within t cost structure. Do we have to always work through them as a vener or subcontract with their subvendors if it isnt a area where they have a primary clinical interest or focus . That is a select question, commissioner pating. They are partners so we are not contracting directly with [inaudible] so everything we get in terms of installation, maintenance and support and subsequent enhancement and upgrades will be pretty much provided by ucsf because they are the direct customer to epic the vendser, however, in modules ucsf hasnt implemented in epic qu it is available, if it looks likewe willfrom a cost model and go live schedule, they could very well say lets bring in the epic vendor and come in and build that module as if they are working with us directly through the uc contract with epic so those are options we will be exploring to make sure to meet it within the time schedule we have set assuming price model. To meet the september timeline is contingent them doing the analysis and getting back to us. Do you think that we will meet the timeline. September is coming up quick, we have about 3 months. The goal is for ucsf to come back with a contract proposal within which we can begin to negotiate and get agreement on the terms, the schedule and cost model, but the aim is for them to come back us to by midto late september with at least the initial proposal for implementation to bring us live by sort of late, 2018 or mid2019 and have another 3 months to go back and forth through the negotiating committee that director garcia is chairing to finalize the contract by early 2017 or late 2016 because we really do need to begin the planning Implementation Phase by early next year if we are going to meet the deadlining have first site go live the end of 2018. Commissioner pating, in our process board we added time. All i have to do is go back and make sure we can extend the time if we have. We are trying to keep to a tight timeline because everything will continue to be later down the timeline where we need to particularly insure we are able to meet the fact that some of our it systems will be not be supported anymore. So, in september if we find it looks really good, we are pretty close and need another 30 days that is something we can do in the contract. If we find that seems to be not working out, not going to be in budget then we have to have another process which we already started thinking about in terms of what our next process would be. We are still looking at plan b. I cant remember the vendors. It is written within the structure of our sole source. I think this is a very good update as to the progress made and thank you very much for bringing this presentation and i guess our next point would be after you come to the point where you would have a decision. Thank you, commissions. You can see on our calendar we have made a calendar of every Commission Meeting we will come to so hopefully by september well knhoe. Well get a progress report. Thank you this is a very Important Initiative on our part so appreciate the update and the charting that will give us progress. We move on to item 11 is other business. So, does anyone have new business to bring up for our consideration for the future . If not well go to the next item. Item 12 is joint Conference Committee report back for june 28, zsfgjcc meeting. At the zuckerburg general the committee reviewed the quality and report resource report and hospital administrateers report. More importantly, not that those wont important but dr. [inaudible] gave a ovview of the plans priorities in a powperpoints i believe the commissioners have already received. She also did reported the transitions in the New Buildings continue to go well and showed there were some small operational issues or not unspected and she feels confident that they will be continuing to address those and also work to improve the patient flow throughout the hospital. The hospital staff is under stress because the changes occurring but they are coping and expects morale willgood about the new building and not so good about the new flows but are working this out and it is spect expected in such a major change. In the Patient Care Service report, the committee continued to discuss the diversion rates to note they decreased in the last month and this is prior to opening the new hospital. Under the medical staff report, the Committee Approved the neuro surgery Clinical Service rules regulations policies, procedures and the new emt and pediatrics list that had mine revisions and in closeed session approved the credential reports in the [inaudible] so, if there were no questions about that you will see a more complete report in the minutes and we can go on to it the next item item 13 is Committee Agenda setting. You want to remind the dates . September 6 is meeting in the tender line at [inaudible] church and october 4 is your next Planning Session which is focus on the 5 year budget. Thank you. So, is there any other discussion on the Committee Agenda setting . If not at this point well go to the next item would you like to consider vote for closed session . I think we should consider a vote for closed session which should be reasonably short for the commissioners. So moved. Second. There is a motion and second. All in favor of holding closed session please say aye. Opposed . We will be holding a closed session for the stated purpose and ask that all those that will not be participated please vacate [committee in closed session] vote not to disclose. Right, and then adjournment. Are you ready . A motion whether to disclose or not disclose the discussion, please we are prepare frd the motion. Move not to disclose this is motion not to disclose the discussion. All in favor say aye. Opposed . We shall not disclose discussion. Any further business before the commission . Seeing none, any motion to adjournment is in order and second . All in favor, please say aye. This meeting is now adjourned. Thank you. [meeting adjourned] singing clapping. piano. singing. i want to be ready with jesus comes ive been in chains but the lord has lifted me up clapping. i have seen the glory of the glory of the lord of the coming of the lord his truth is marching on glory, glory had will yllelujah glory, glory hallelujah i cant his truth is marching on his truth is marchingi ant his truth is marching on his truth is marchingnt his truth is marching on his truth is marchit his truth is marching on his truth is marchingt his truth is marching on his truth is marching his truth is marching on his truth is marching on clapping. singing great is the water, great is the water children. Great is the water clapping. the community of choir senior Choir Community of voices please round of applause thank you. clapping. thank you thank you choir microphone feedback. how is that. I think were fine mr. Charles okay. He think were fine everyone can you please see if we have enough chairs for people to seat wed like for you to take your places yeah. Okay lets start i am so delighted so honored to be standing housekeeper today my name is linda im a board of the Bayview Hunters Point Center for the chair of the groundbreaking and Ribbon Cutting summer want to give honor to god let me repeat i want to give honor to god. clapping. for the opportunity to be standing here on the podium with the mayor and all the dignitaries and with the community of looking out i see that judge davis family and i see about everyone this is a great day for the bayview Hunters Point this is a great day for the community clapping. what this is vision people dont perish a man that is responsible was responsible for bringing all of us here today his vision was to insure that our seniors have a place they could live and die gracefully he reached out to a lot of people in the city it has taken decades for us to get here but look at where we are today in his absent the vision and legacy folks are realized today, i want to essentially thank the mayor ed lee for his presence by the way, if you look at across the city that kind of setting back is taken care of all over the city this man has a passion to help seniors and youth and do it all over it is left for us to make sure we have to publicize the kind of things and trying to him him get his record straight without further ado, were expecting former mayor willie brown horrified you oh, my god oh, my god you see we have held everything until he got here mayor willie brown as always a fine gentleman and leader of the city thank you so much, sir fewer presence and helping us and made your time for the Little People to come out every time to make an event like this happen we thank you and may god continue to bless you, your the next person on the agenda youll help us to get this program you know going you thank you, sir. clapping. thank you, very much. Linda it was a pleasure to have as a part of group of people over the years have been given the proper approval to every single one of the steps that have been taken to make that particular place what it is today for those of you who dont know not having an opportunity to see it youre on the inside you will not want to leave the nature of each one of the Living Spaces the kinds of things that have been done plane overhead. . laughter i cant believe it caltrain would do that to me. laughter the nature of the space and the way in which it is incredibly plagued and excused ive got to tell you i came out on more than one occasion as the process was unfolding ive been so much a part of original effort that george had made to address the needs of seniors in the bay area and in particular, the bay area part of Bayview George worked for me and one of his obligations to Pay Attention and do something and move the city to be r07b8g9 responsible to the needs of People Community particularly seniors the vision always was a choosing campus a senior campus with something of everything welcome george youve got to know this is exactly what happened clapping. i have to tell you mr. Mayor i would come out here and you do women doing the painting and all the sculpting i dont know any women paternity in the union and were black and having a good time and the music waltz played and serving coffee it was amazing the nature of how this board you think folded and believe me ill wonder who was here nor there and ran into kathy and the architects were great every time they thought was a perfect design kathy was stuck r recurrent them and a kitchen you have to die for that kitchen could feed everybody on one setting back that god feeds 3 a times a day it is just that incredibly expressive the Senior Center is the same way and a quiet room mr. Mayor a space for you and i the george davis room a chair the spirit of everyone or everything is absolutely right here on this across it is a real celebration thank you to the city of San Francisco. clapping. and and im delighted to be part of ceremony before we go too much further we need prayer prairie need some prayer i dont know about the rest of you but after last night i need prayer so come on over here our georges pastor and you must bring it in. Thank you thank you mayor willie brown let every are heart player father god we thank you for giving us dr. George davis the vision to build it Senior Citizen collection some 25 years ago when the center was broke probation officer, and on top of you called him home now 8 years ago when the dream was just in its yes, maam brisk stage some of us became discouraged but he left his widow here kathy davis who was endowed with the same vision as she was in able to inspire others to get a glimmers of that vision and come together in unity and brick it to fruition. And thats why were 0 grateful that we are able to stand here right now this moment with scissors in our hands to cut the ribbon that will allow us to go in and really show our combruld for what you have enabled us to accomplish but shirley there is much more work to be done here and the southeast sector of this great city San Francisco so were praying that you give us all of the vision just as you did with dr. Davis and also with your great saint st. Francis of the ostracize give you that faith we can pray the way he prayed grant dosido god i may have been able to work in our vineyard there where there is injury let me sow seeds of potters where there is hatred love, where is a darkness, light. For it is in giving that we receive so lord grant that i may not sow but seek to be loved as to love to be understood as to understand to be comfortable as to comfort it is in giving we receive, and it is in dying that we are born into each others life in jesus name we pray amen. Amen. Mr. Mayor that was january of 1996 and we were altogether in front of the Martin Luther king fountain a dreary day not one as magnificent as this when reverend walker got up to say prayers the sun is shining its been shining since then reverend walker how aau code compliant to the houshld willie brown we all respect and love to the distinguished mayor of the city and county of San Francisco mayor ed lee to our distinguished guests that are being with us along with today id like to at this time call all of the members of the board of directors to stand with me come and stand with me. clapping. now ill introduce them one by one in a couple of minutes and to all of my fellow citizens of the city of st. Francis by the way of the golden gate and the bay bridge and you cant San Francisco as we know a worldclass city you cant have a worldclass city expect you have a worldclass leadership you cant have a worldclass city without a worldclass bayview Hunters Point and the Seniors Service center itself well, there goes the train again ladies and gentlemen, id like to introduce the Board Members ms. Arrest lay nixon. clapping. treasurer of dr. Czar cellist well. Our main fundraiser mr. Melvin hall. clapping. and the person that helped and pulled this program together and structured and organized it linda richardson. clapping. and overlook one gentleman that is on the board the president and this is mr. Walker. laughter clapping. also like for the very fiscal and person that gets things done kathy davis to come and stand. clapping. piano. she is the effective mover executive director of this particular program that the reason why were here could i i want everybody to hear and understand and you dont have to talk about it you can look at at the reflection all around us this board stepped up and take advantage and make sure this would happen on today as kathy out leading giving us direction i want everybody if you be so kind if youre incapacitated dont have to stand but id like everyone to stand and give this board and kathy a great round of applause. clapping. i believe you can do better than it you can do better than that. clapping. thank you very much you may be seated id like to leave this point on one occasion the daughter of her one of the major freeways going to do business for the family and all of a sudden a terrible horrific storm arose and the wind and rain and lightning was so bad until cars began do pull over and stop and the daughter said dad should i pull over and stop he said keep on driving after awhile the big wheel and trucks began did pull offer and stop she mind dad the big wheelers are pulling over why not stop he said keep on driving and after awhile they droech out of the storm beyond the storm the subpoena as silencing hike today and the dad said daughter pull over just pull over they pulled over he said lets get out of car and walked back to the back of the car he said daughter look at the storm is still happening back there but you kept on driving we drove out of storm my point we have storms we have storms to get where we are today but the walker pastor walker dr. Walker said keep on driving and we are here today thank you clapping. a medicaid waiver sermon but nevertheless, a sermon laughter it is now my great pleasure to have a man who literally picked up what other mayors have started couldnt complete because they didnt keep on driving he kept on driving and we are now in the sunshine and were celebrating because mayor ed lee kept us heeding in the right direction mayor ed lee. clapping. hello bayview yeah. Well, i just want to say a couple of things obviously my friend former mayor willie brown in 1996 been 10 years since the dream and discussion when i wanted people to know is something that ive often said in the bayview were not doing anything new even though this is new housing in a new centering were here to fulfill old promises in the city is that right. clapping. and he know in 1996 or somewhere going close to that mayor willie brown tapped me youll be on the team we have to get stuff done and thats kind of a few years later i tapped me for the hardest work the department of public works an appointment all in two minutes and my head was swirling since that time but all in the spirit of saying if you help us get the promises done dont make any new promises but the ones done and for the bayview in particular for you community here the promises that we have been making around equity and equal jobs and december sensitive housing for our seniors not new promises old promises and be it takes time to get here and, yes 10 years is a heck of a long time to fulfill a promise but were glad were here and were glad were fulfilling other promises at the same time look around bayview is not what it was 10 years ago and ive got a goal of thirty thousand Housing Units in the city guaranteed half of them affordable to low income were on the way what is happening in the shipyards under construction and happening in Alice Griffith under construction what is happening in Hunters PointHunters Point and west brook and shipyards and candle stick all under construction we are fulfilling all promises in getting things done we will always wanted your help were not doing in alone im here to say kathy davis keep an bugging my office and keep on coming in and telling me willie used to call on people which of any bureaucracies aint working and ive learned that lesson well, because as a student of mayor willie brown you tell me what is not doing the job well recreate it as we recreate ours Housing Authority never to be isolated and poverty housing in partnership with hud thank you Housing Authority and hud and leader pelosi for your wonderful leadership i want to be i want to be with leader pelosi and the on the floor of congress because we need to End Gun Violence in this country we need to do that and also want to say thank you to senator leno because were working at the state level with his help were able to get the governor to