Transcripts For SFGTV Health Commission 91515 20151010

Secretary to change two things that was quoted as saying the car of homelessness it the number one priority is it so one of our highest priorities. What line oh, what section are you on. I dont have the minutes in front of me. Here we go. Ive got it. On page 4 in the middle the page i have noted it councilmember cates noted that homelessness it the most Serious Health issues he wants to put it is one of the most and commissioner karshmer have paid participant i suggest to make to the commissioner said it be considered for example, perhaps looking at model lifechanging like the stop model as showed effectiveness from the population the under the influrence is on we be innovative with the issue. Okay. I see those as corrections from the speaker to the tint of hire his talk and they would be added unless there is opposition okay. So the motion is. Im going to go ahead and commissioner pating on page 7 under the health just want the second paragraph from the bottom id like the intent to be clear what i was trying to point out that we received a presentation with data which was showed some positive things about the quality scores it is t at San Francisco General Hospital were at the j. C. Cbc we see quality scores in certain areas that are concerning relative to our peer group as defined and i just want to point out that there was that discrepancy and im going this entirely captures that and ill explain on the statement to make that clear commissioner. Hey, is the discretion related to different perimeters that were being measured in the quality or i think thats y what dr. Chin pointed out that is reasonable to say in saying that i dont want to lose the thought that and give the public the impression were anywhere near the level we all including the people at general will expect of our quality scores we have a ways to go not prospective how i feel about where we are in the quality scores. Ill make that clearer. Okay okay i think from what youre looking at those minutes we think we would like to get a just what we had said better that will be helpful to articulate that so the secretary can take a verbatim our secretary will work with commissioner fung how that paragraph workouts. Ill accept it from you commissioner pating. Commissioner pating actually have words laughter so it would be that will be helpful we wouldnt have a misunderstanding. Ill draft something and send to commissioner singer and let me know if that works so everybody concurrence well allow it to happen for that paragraph are we prepared for a vote . If. All in favor, say i. I. Opposed . The minutes are approved. Thank you, commissioners item 3 the directors report. Good afternoon, commissioners the california starter legislature adjourned on friday september 11th jorge has until october 11th to act on the bills passed and is high profile set of bills for a regulatory for medical cannabis and the right to die bill and need to reduce the high rate of prescription and allow the state to request the amendments 1115 waiver mike the waiver is not met and the California Children services to medicate managed care and failed to reach on agreement only the organizational tax which is the special section called by the governor weve discussed in the past mayor ed lee opened the Medication Center directed to Homeless Individuals mayor ed lee announced that week this last week, we would be looking another Navigation Center and tried to set up a fund for that that he is looking for a fund to be matched by private sector and the location of the navigation have not been selected were working with the city and theyre looking at other location for that service the department provides the Homeless Outreach team that engages the individual community and help with the housing component and also with the Case Management support to the staff is it are all right. In the Navigation Center i would assume it is the same thing of services than any other Navigation Service on tis the mayor ed lee and supervisor president breed announced to increase the Affordable Housing in San Francisco by 10 thousand units by 2020 the 5 Main Division one thousand depressed unit and affordable units and the housing priorities for neighbors and amendments to the City Inclusionary Housing Program and the establishment of additional incentive for affordable units wanted to just make sure we all knew you have a maternal update there were among 31 San Francisco employers recently recognized for Family Friendly work there is a recent vision zero study featured not San Francisco chronicle in puritan working with the transportation that a Marketing Campaign it stops here and stressing the pedestrians have the rightofway at intersection the increasing by the yielding for pedestrians when paired with enforcement. Also you know we almost forget about our administrative staff that both e do the backbone whether scheduling the processes or helping with the staff or the public that come into 9 office we did will have a gathering ever september 4th to acknowledge a lunch for our staff want to let you know that administrative staff is appreciative and laguna honda created a band that went into effect no longer allow for banning sugary drink beverage see r sugar sweetened beverages from their campus as the whole system in the care depth the wanted to mention cash was thank you for the opportunity 50 are years old there were more Public Health speakers centers and not in primary care but particularly with the Castro Mission that was a clinic that saw in the beginning hiv and aids we want to work with that and the development over the years it is an incredible heartache center for services as well and 80 percent the serious most Heart Disease among the low income africanamericans and latinoamerican healthy San Francisco opportunity i say city mobilizes the health care to give patient the prescription throughout the city their be holding an event on tuesday october 29th and feature the presentations by physicians and fitness provider and our own population heartache leaders i want to acknowledge jackie and others if there are any other questions about the report i object to answer them. Commissioners, i guess we dont have the same copy we have an addendum only a directors report in our packet and that is oh, am i correct. Do you all need full copies. Does everybody have the directors report it is required to listen to it much more carefully laughter . Oh, i see, i see so therefore there might not be questions. I have a question of the addendum the high profile bills which ones did the city support. You can give us that information in the study. Good afternoon with the office of policy and planning actually all of these bills within on the watch list but for the support by the city. Im sorry. All the bills you see here. Those are the notices we saw we supported. Not on the support but the watch list. Oh. Well be present the finalized version. Can i ask in the special section on health that was pit here how does that work the special sections continue and when do they end. When they figure it out the managed care packet like it says it causes a 1 billion hole in the medal if it is not resolved by next may they want to figure out that out so the committees have the option and the leaders can call the session back with before january otherwise in january is is sold and r solid and any bills passed during the special session will be announced. So in terms of the spell Session Committee as written would be able to continue if they were to choose to do so. Yeah. I think if there were impetus to do so if they think a solution can be reached. All right. Thank you. So questions to the director on her report . My apologies i sent the email i should have spoke about the newspaper. My other question weed whacking track the impact thought possible one billion dollars shortfall for the services i dont know if so this a shortfall to the general plan or medicaid the state will be short. It is to the health pa plan to the San Francisco health plan and well have to see how that looks at you know thats as i said to the nonprofits have been holdings tax and theyre trying to give us tax bills in terms of the go tax well find out more and let you know. Thank you. I definitely see the navigation sites and the additional funding you had come back as those are developed and let us knew. Were collaborating with the Mayors Office and involved in the process as they develop the sites well probably not be in charge or that but well be insure they get even though help they need and will there b be some point how the expanded program is working. Yes. A dashboard that is by the Controllers Office we can give you an updated report to those dashboard a great percentage a significant percentage of people gotten directly into permanent how do we do that . And lofsz services theyre receiving and onsite with the mayor and saw the announcement that original Navigation Center is quite impressive. So is it fair to say in a quarter well see that. Well develop a program and invite denver to talk about that with us. Thank you any further questions no our appreciation and well move on to the please call the next line item. Yes. Thank you item 4 general Public Comment ive not received any requests. So we move on to item 5 the report back from the Community Health committee i want to thank dr. Chow we heard from dr. Curtis the maternal delinquent health for the efforts to reduce preterm birth the goal to reduce preterm birth with the Health Network and our Health System to reduce the reflex factor we are presented with straevenz that both the Health Network and our Population Health division is trying to take on one to improve the Womens Center of prein all care and the second is to examine determines of health that effect the term of outcomes and the preterm bitter is determined by race and zip codes and paternal prenatal care you family it so many factors it was quite mr. Ginsburg to see the department sort of out a list of priorities theyve begun to implement the first to put together the preconception care passageway package that will include the Family Education and nutritious education and insuring that dlults and other services for women with that are planning to get a package of care particular those at risk for preterm birth and finally those that are looking citywide at to continue to integrate the lower and preterm birth with smoking and employment safeguard for women were looking what were trying to explore in our Community Population division is how to look at issues in this case preterm birth across the network and city seeing there is efforts and a lot of overlap between the general Health Efforts and Population Based efforts were presented with the first year of Strategic Plan that came together in a grant we were both impressed with the competitiveness of that so it is too early for outcomes but both divisions are involved in the forest and well track their process the second effort we heard on oral health in the city with part of the adolescent the framework how are we impacting the mlk with the goal of zero dental care inside and outside the Network Within the network we heard a new benefit for medical patient that was implemented called dental cal full dental services at a minor disbursement that explicit cover everything but services are covered under medal this has a huge burden on our primary Care Planning within the network theyre addressing by increasing the staffing of dental were hiring two new dentists and showing arrival of 27 to 40 percent increasingly if adult visits that koudz out the children and youth Getting Service but when we add the two new dentists that will less than e help with the excess demand that is driven by benefits and in the area of Population Health weve been looking at how the city p will there the underscore itself and commissioner chow saw the lectures to the community i understand well be doing similar presentations to the africanamerican in the bayview and in the mission this is part of an effort to both prompt the practices to integrate those practices in primary care and an evaluation youre seeing the population height and our network working together to help the health in our community again still in the first year we dont have the results but have a coordinated effort for both departments in the hopefully, ill be able to come back more and more as we do as we do and say as we do for the city and within the network for prehealth. Questions of commissioner pating. Okay clarify im not an expert on dental care identification at the chinatown presentation in order to support and is that was an Important Health initiative especially some of the few times chinatown has total red the worts in the city i was courage or courageously that be restored and that we actually put a great deal of effort and actually in the meeting a number of agencies that were within the area of chinatown were actually expressing that they have been trying to seek dental care i think that dr. You and from our department have been working along with the Public Health lives center it bring those together so people from the schools and people from the pediatric units were beginning to converse and find a way to get the kids to get tare Preventive Services that was what i was there for and but only to encourage i think the presentation i heard only the first part that the session today actually helped move our agenda for our coming planning meeting in which we are looking to understand what is happening at Population Health all the things and how does that work with our Delivery System and how does that work with the whole health of the city i think the brief one was one ill courage we look at our next Planning Section in terms of where certain major needs of city are going to be addressed through not just Population Health or not through our Delivery System but some sort of integrated efforts so. If i may commissioners that is an important attribute we have the Public Health division and the delivery gentlemen, i had an laments concerning bringing the agencies and theyre separate agencies in los angeles and it falls under the purview the board of supervisors is trying to bring that altogether the law times editor was asking how we did that in the development if you think about it were under one agency but bringing 4 agencies together to say quite a feat i know that the doctor is ready for that goal i think it is saying a lot for us having the two divisions and the two divisions in the department when we look at the Public Health departments thought the country theyre struggling for survival to fund that preservation component and it will come later were in this to have to activities one looking at Community Health and the other individuals heartache if that is a major goal for my career how to work to tell the truth together to insure we can leverage that. Were going to be hearing today on Emergency Preparedness for the whole city and a presentation on what is emergency precipitating in and out of the framework that will allows you to if we can move the City Services in some ways deal with the those you know great social needs i think that is also a way to show were making progress so youll be seeing this dynamic Population Health level in todays Emergency Preparedness and sxhirsz my questions of commissioner pating and i might point out also as director garcia in terms of the uniqueness in which our Health Services with Mental Health hospitals are under one agency and the strength of that dr. Who is the form heads of cdc and is back in general also have highlighted that nationally saying that the San Francisco model is one, if anywhere we were going to be successful in health it should be in San Francisco. Our please call the next line item. The update on Public Health and Emergency Response dr. Balancing by a. Good afternoon, commissioners it was a great introduction this kind of combination of the Population Health side and the ambulancey care and ill talk about the population height side how we partner closely with the Health Network ill north america vin the director of the Health Preparedness in the department of Public Health. So ill starter first with a rhetoric california question why does preparedness matter the slide is a little bit old but things have happened in the last year which i call the disasters facing california and the nation in the lower left hand is the drought we were at a citywide meeting yesterday were now preparing preparing for el nino switching from drought to rain they have a Health Impact we have to start preparing for the next image is ebola in tradition that is what people think the heartache erroneous the disease we had a big impacts the law a county fires this is the fires occurring has a much bigger impact 60 thousand acres up in flame and 20 thousand people displaced ill talk about 9 Health Impacts and napa county the quarter that happened in august 2014 and the last slide is what happened in april with the battling and in the background the city was the only exultant that got destroyed so what unites those when people think the disasters they think of First Responder referring back to the valley fire the 80 thousand e evicts needs medical care and services that falls under pukt and were responsible for that so when disasters like this happens the entire city comes together were part of the team at the depth of Emergency Management the clinics respond that is important you dont want to be working only on one entity that is putting two or causes problems for another agency in government so we come together as a group to serve the city and puthd is there in disasters yesterday el nino some of the things that came up were you know the pack that there are 6 house to 7 thousand Homeless People on the street and working with the Mayors Office and the hfa to help for the rains that create potential heartache issues our partners need to be activated and the Health Network folks make sure theyre serving the patients and this is San Francisco there are a lot of things happening in the Car Accidents and those types of thing we need to deal with anything including the rains so we know we have to respond have an important place in response but what is preparing to the needs. So i put this slide up here this actually theoretically shouldnt happy in San Francisco the golden gate disasters what about overwhelming and how to prepare for something that potentially could wipeout a large part of the population that is displacement kind of chronic medical needs how to prepare when you get a huge sunday morning even with images like this can we prepare one the things theres not a lot of Robust Research because disasters can be unique they tend have their own set of conditions and hard to replicate around them so going to the next slide what happens in 2011 federal government both cdc and ass pa came together and decided to create capabilities along with disastrous preparedness if youre can be cable in those areas that youll be able to respond to my type of hazard so it is divided by funding the fact is Public Health preparedness that is from the cdc has 15 capabilities and the nice things the Hospital Preparedness Program done by the skim secretary they created other capabilities we have two funding streams to people with the Public Health and the individuals side today is presentation is going to focus on 3 targets ill talk about 3 targets with 3 partnerships and ill be happy to answer any questions about the capabilities if they come up so the partnerships are guess the capability were trying to develop in the San Francisco department of Public Health ill focus on the coordination and that basically means how to come together and respond at the department and what is that response entail ill talk about the health care tlvt thats a partnership and other responsibility in the health and finally talk about two outreach things ear doing in the communities at this point so in the department of Public Health the first thing to really be able to respond you need to have people that know how to respond and there are a set of the trainings raider for not only department of Public Health but all City Employees to take and part of the things we need to do is insure that people are taking the training so currently there is no centralized system to track the training into housing the Population Health division has a central database we targeted started with that that is for all trainings not just interpreparedness in the beginning it ends in 2014 most people took the training by the end of the year 20 and 40 percent there and that was putting the training modules into place and reminding people to take the training a couple of times a year weve got good information but tlokd it has its own link 0 and structure and to come in without knowledge is setting people up to not being successful the second reason the it is tied to reimbursement as many of you may know if you follow the news how difficult it is to get the reimbursement for Different Reasons and we want to get the easiest reasons out of the way to people that respond have this training our goals to first of all, centralize and amy care to track their training were move to a Training System that hopefully, will be able to track training and finally for the general fund effort a trainer position approved well be hiring a trainer into our branch we were excited to have a trainer to be able to go out to the branches within depending training is one thing if you train people how they respond and so you can pass that through our response there are two ways we respond one through exercises and the other through actual activation in 20142015 we had two kind of big events few years or first our statewide medical Health Experience that happens in november and this years november last year was special that was a regional effort so it was a much bigger experience and a fullscale experience which means we worked all the way to making an actual activation and last year was ann tell you one of the mandated things we have to be able to provide for a bio terrorism scenario is important it put a lot of i burden on the indicting to provide for the city as you can see the mass can work in a pandemic where youll mix that with the scenarios would be useful we did that in 2014 and had over a hundred people participate as i mentioned a month ago we talked about the response and over a hundred person were assessing that and developed ways to help to help with the Emergency Responders in a disaster one of the things we do with the responses qi is built into Emergency Preparedness throughout the industry not only in the department of Public Health a activation whether an experience or actual response you have to do an action report you talk to the reported and the partners and what went wrong and what are the improvements for next time one the other metrics were trying to do is measure all the things that have been coming and making sure were constantly improving and all that information gets just want updated in the plan ive move to the Second Partnership our Health Care Coalition on preparedness the Hospital Preparedness Program has been typically focused on hospitals and we have a great relationship with our hospitals here we come together monthly to talk about what with disaster krofrnts so similar some of the works what we participated in there was a tabletop that occurred on ucsf we had a major earthquake fundamental experience and a lot of experience at sfgov and ucsf and statewide experience one of the things meerp or they were concerned about the actual shooter portfolios we brought trainers to provide some training to the hospitals and this year theyve identified some key objectives and trial try to identify cyber and help people prepare for an incident the other thing ive tried and the branch tried really since come together is that hospitals actually are a fraction of the health care in most medical care occurs outd outside of the hospital so this is important we part of it in a big incident you get a lot of people that go to hospitals if we can have some of the patent in ambulatory care centers that will help to streamline and get the people that urging need the care and Long Term Care facilities home heartache Residential Health and pharmacies theyre all big partners one the goals this year to really start to get better at being able to engage different entities in the Health Care System and figure out ways we can insure they have preparedness plans in place and finally i wanted to talk about Community Preparedness so the Mayors Office actually received a grant for one of the hundred resilient citys in the u. S. That was the funding has funded a group of people that including or loud a group of people to come together and work within San Francisco and the department of Public Health has been part of the group about the environMental Health and evil Health Emergency branch one the things we come together and talk to the neighborhoods about climatic change it is a good effort because the first thing we talked about was heat and San Francisco has gender a number of heat waves one that was last week and because of the way that San Francisco is structured the temperatures are going from 85 to 90 can be harmful to population getting that information out there and building the Community Partners and what this is really focused on not just providing information but getting neighborhood to start discussing how the neighborhoods are going to come together to provide centers for people or check on the children or elderly in the neighborhood and theres been great response that have come in one the things im going to do is im going to oh, i think okay is that it perfect. Thank you i just wanted to share this website that the Mental Health department created it is extraordinarily on climatic change it talked about the saefltz and extreme heat and air quality and one of the things it has an indicator map we can go allergy neighborhoods and figure out silvers the map this has broeblgd the city by indicators you know it focuses on some of the climatic change for well be helpful for el nino but has great information has great information about vulnerable populations in the city so the percentage of people that are over 5 and the percentage of people underage 5 and people with disabilities how that shakes out in the San Francisco map i found it this transit scores that will be useful for hazards not just climatic change i wanted to share a little bit about this might not help us but a number of maps like this that cuffs indications how San Francisco shakes out with other indicators i wanted to share i feel like this map has helped all the maps have helped with our preparedness effort. Okay and then but the final nifltsd of niflts i want to talk about someone that came up and discussed what was some of the gaps they saw we specifically did with our Emergency Response team and the Residential Home Care Staffing administrator they felt that psychological be able to care for people as if a disaster happens and when anxiety or fear or worry what tools they can help out with people theyre serving so we provided a training or actually multiple trainings to give psychological is a basic training moan can do but helpful in a disaster situation to the training was received by over 2 hundred people at different percent and it has reviews people were excited and plan to persian that i wish to out to people that are interested so i know that was kind of a quick big overview but developing a cultivate preparedness is what we do and on the depending we want to do the training and response and insure that you know the critical improvement recommendations that weve created through the ports are incorporated into our ongoing planning and we need to foster and continue to expand our exciting u existing relationship ill leave you with the drop cover hold on i tried to tell everyone in case of a earthquake i want to thank the staff and the work they do ill stop here. Well, thank you. Is there any Public Comment. Ive not where he lived requests. Commissioners comments or questions on the presentation. Yes. Commissioner. Thank you for this you pointed out how this cultivate of preparedness which obviously is important we if you dont continue to use those bills whether the language of Disaster Preparedness it is very difficult remember i guess my question is as you do those coalitions and critical lessons leader you have that can inform the day to day nondisaster how week we take Disaster Preparedness and how we sgrak with one another. I completely agree one the great things about this system it used by all agencies in the Public Health department and not using their own language but what he really think about is just planning we all planning we plan everyday and we all take out insurance around catastrophes what am i going to do when an earthquake hits whenever we talk to staff or anybody it is the Immediate Response am i okay is my family okay do you have an emergency back up plan that is starting with the fundamentals and getting people to think about their families and themselves first because that is going to be the birth barrier and you will have that is part of planning which a lot of people can do on a day to day basis i think being able to get that i guess that story in with people that this is really about keeping you and your family safe and then you know coming in and helping out the city that resonates with people the one thing we can do so not a special but everyday occasion both in personal and also in the way we sgrak with the division to division i think that is the less special the more effective over time. Yeah. I totally agree i think there are times we can use the ic s anyone can be the constant commander and for example, the unit will be coming to the executive team some of us are not the city and executives what are you going to do when you live in oakland and something happens in San Francisco in the middle the night what steps we practice we we need to do in terms of being prepared we can use the ic s for any project and doing that i think we learn from the ebola process one of the things to keep the clinic people if their place and not pull people maybe two to three hundred people in the building didnt have the clinic process we were able to find what what kind of skills and able to staff to be able to provide all the services needed for the ebola process sxhud tracking individuals we didnt center to empty out our clinics but looked at other folks and the ic s structure would be helpful and there are types of large responses that may not be emergency but provides use it would be a center for any type of Service Shell be at the department of Emergency Management and telling me what to do in terms of system it practices leadership and anyone of one of us could be many my seat or her seated. I love the resilience of the neighborhood the grassroots equivalent and your successes it would be interesting to hear an update over time i think that is good and do you include schools like all the Public Schools in our coalition. Theres a picture of the coalitions you have. The schools are part well sfusd is part of the citywide meeting and coalition when we go out into neighborhoods a lot of times people side especially the children do talk about the schools and we can bring in the schools system or sometimes they with go directly to the school system. Thats an important part of the system. Absolutely. We have other School Systems schools the Catholic School system. Commissioner sanchez. I thought that was an excellent update thank you very much for presenting it does he just want to reinforce we have a major responsibility to have 24 7 certified supervision and training in all units that were involved in and i think part of the dilemma as director said given the fact we have many of our people that dont live within the city time is a key variable i know over the years in a number of different protocol going back to the 60s the respond to nonagency and the hospitals to bring it down to a specific block of Time Training and supervision was where the rubber meets the road we need to do those things might be not once or twice or 3 times a year given the world it is more mandated we really you know upgrade and insure that is ongoing priority because it also means we have to work within the agencies of the city there are a lot of limbs and one of the major problems is communication and that folks are only different frequency but all the new things now we can do abc and d but at the same time supervision and training and as i said we need that and i look forward to that well be implementing and working with the departments if, in fact, folks cant get in now that the Police Department has a number of police folks they especially\have before years ago we had helicopters and other aircraft to the airport those things are no longer used so im saying were a Trauma Center and how do we navigate that when in fact, we have the childrens hospitals what im saying all these things a lot of dialogue about you know the time variable the barriers because a new mission bay we need not have command centers and responders there but if it takes place where the giants are playing whatever all those things we have to keep a clear focus we interact with the community and have a responsibility pertaining to buy logical im saying as we move forward ill courage us to make sure we have you know some excellent supervisors people responsible so we have on call twentyfour hours a day and a isnt available i know with b c and d do we have the ability to do Due Diligence otherwise Serious Problems all im saying i know we can do it working not only with our own foekdz folks in the community but the institutions and agencies and thank god were the city and county of San Francisco we dont have to navigate with the santa clara and the other boards whatever were one the same service we have a unique opportunity in the city of San Francisco with the Health Department one other point i notice we have the hazard experiences and training you had a great job i hope youll get shots in october with fleet week in the past particularly a lot of the training consensus that are involved if hazardous experiences and training come up from Camp Pendleton and work with the general and set up fields units and open things with their air vacancy units and i believe one of our nurses who is also a admiral in the navy is going to be involved in one the blts panama canals for the fleet week and great to have people to take into account what is provided to the city because we have limited access to look at the latest updates with a number of areas we you mean will be responsible for this is a very good report and thank you. Thank you supervisor bedrosian. Thanks for the report so the focus on communication is such an important part of those exercises to prepare for what the chips are down i was wondering where you could talk about that and one particular case like ann tell you were not only the only one worried about it federal agencies that are forming around here where are we in our journey of making sure we have as seamless coordination with them. Thats a great question one the things i think is a strength of the bay area we act together and there is the Bay Area Health officers and a preparedness so the preparedness we come together monthly to discuss different issues and willing on the preparedness and specifically the boy logical portion bio watch which is the organization that monitor for those incidents also cvs has quarterly meeting and there has been extensive plans we tested this last november which are the steps and the health call and the decisions how are we acting as a region it is important if San Francisco is doing something in alameda or san mateo we need trust we are committed as a region to come together and talk about the differences and come up with a plan how to move and what are the recommendations are we going to do as region and what did does that mean with depending and the feds and tested in october because of the this fall as you can imagine with the subdivide come on here there will be a lot of folks coming in the city well be practicing those communication protocols. You say that which agrees are involved. So fema, cd c and hums representatives and others it is a huge cgroup. Thank you. I have a question on the Community Preparedness i im trying to understand since 1989 chinatown has a program that is going on underneath prairie particularly for many years they didnt really have enough support to try to maintain and they piece together a number of you know coalitions to support i should say remaining as a coalition to continue to deliver the care youre here talking about building resiliency neighborhoods i recognize that is only the puthd and ems has a major respondent to how are you integrating it so youre able to support the neighborhoods this was with an of the issues that actually was brought i know that mission tried it also i dont believe they were able to sustain it but i think chinatown still has it so what roles do you play to help to support them and theyre the community that has all the sros and a need for coordination of services these people without a Disaster Needs care. Thats a great. 1 of the things you you know exultant is a big word the way that we go into the community what youre goal is it is because of the people on a day to day basis struggling during a disaster it is going to be very hard and theyre the people we need to support the most the other part going out into the community and having communities identify where we can help i dont want to come in and make assumptions we need this we and cant do it but other departments we can start you know making the connects weve been out to chinatowns ill say chinatown suffers from one the most organized communities that ive come across we really have a wonderful plan in place as you may know they have their ic s systems and ham radio operators that is incredible so in any way we can support them were glad to do it this neighborhoods thats been set up but the office of administrator is has been working on neighborhoods weve only covered three or four neighborhoods but chinatown to cover all the neighborhoods another some point during the hundred city resiliency period does that answer your question. Well, not exactly it was sort of a do it yourself project it sounds like it continues to be i was hoping for more support on a citywide structural basis that takes the exultance that are already organized and try to add to their support and im going quite sure i heard that you were actually doing that if they have a need come and talk to you. Actually, im going back what happened a big citywide thing call do spur System Community come together to communicate up to the he oc level unfortunately, that never actually got action and chinatown really did it in a good way youre right this system was never materialized were going out into the community and finding out their gaps and start to help figuring outing ways not only Public Health but other issues as a City Government agency so, so not that centralized plan to come together and but more of a Grassroots Campaign were going to each neighborhood and talking about their needs and seeing what is at the top the communities list and if there is no list figuring out what they want at the top of list but no centralized system. No centralized incentive for what your requesting as well through this project funded to the city to try to develop you know something so for us to keep our thoughts about during the budget process but other neighborhoods that dont have any structure as youve discussed about chinatown and there are far, far away if you think about the bayview and how many freeze can, disturbing our abilities took the staff to the community to figure out the barriers getting to the areas if we have a freeway collapse is a big issue we have to coordinate that with the city this is a mighty little team we have but they have 8 thousand employees they can pull upon and have the support this is the kind of work theyve done. I certainly dont want to north america gait it is more of a central question in terms of how and what kind of support theyll be able to give their neighborhoods even as you go out to the bayview and help bring that about theres got to be a some sort of resources for infrastructure behind f it seems to me the city has not had the ability to get counsel into the grassroots as you are now talking about trying to reach and unless were able to provide more facilities in the department in emergency systems i think saying youre only outstanding your own for 72 hours doesnt work for Homeless Population and director is exactly right the problem is at a central level youre still working on. Having may we approach having a personal experience in the loma prieta earthquake we didnt have a contract with the city it took me two years he to get grurjd it was a thought how to insure that the cbo handles the agreement and any cbo has a addendum their broadwaysansome apartments be Disaster Service workers with different responsibility one we can pull to provide the service but also theyre part of the Disaster Response if they have expenses we can respond to them youre exactly right we need to do more of the work not a funded process at this point but something we need to continue to do. Right. Commissioner pating. Ive had the pleasure of meeting with the heartache committee how do we know they were able to see the details in terms of the the Public Health Emergency Preparedness check list a detailed accept preparedness you do and the depth and what impressed me we have to go farther than the airlines a Single Source how we respond or the responded response to the ebola. Some of the questions i know were in continued preparedness one area if he were to have the large earthquake multiple systems taking out the whole city what areas are depressed and what would the Commission Look for to make sure that at least from the Health Department we have what we need to get to what we really have one time big disasters the question where do you think the greatest needs for future development and focusing on where would you like us to support us as we continue those preparedness efforts. The preparedness shouldnt be a special words but i will really exactly and try to make more possible within the department i think you you know the big disaster were planning for is earthquake where all Communication Systems go down the cell phone towers and texting everything we rely on and how to communicate had in that situation how do you get that information and respond when youre not sure what is happening we have a number of systems we have radios and ham radios and we have hear Network System some people dont use because theyre out date and foutd the niece of the city this is the most thing that really bad somewhere everything fails and it can happen weve seen it in the globe the systems fail and people without interested and pour the best way be able to communicate having a plan like barbara is talking about so people dont have to rely on communication they know they have to report to some place so well start rolling and figuring out the impacts the other kind of big thank as you may know the Health Care System is it complicated on a day to day the disaster mode is something that that is really hard to think about when patients are over flowing from every single hospital and ambulatory care is overflowing we have to set up disaster areas looishg like katrina youre getting to a place nobody wants to go but if you stabilize that way youll go there those are places i see as a model you know huge issues that we have to work through as a department as all departments do in the city and you know as we covet start to develop more of the plans and team effort on i shouldnt say plans but train more people on those scenarios that will get us there. I found that reinsuring it makes sense youll do a lot of a triage and get people to fourth where they are thank you very much. Uhhuh. Commissioner mcghee. Thank you. I want to get more clarity about the training you know how for the trainings are. I want to see from the training sets are transferable you have our basic disaster like ann tluks or ebola how do you determine who needs what kinds of training and how many people for specific training. So the trainings i mentioned theyre general trainings only to understand the link 0 and structure so when you got into situations youll understand what the Planning Section and understand what a form is so it is really basic training overview our constant command structure i didnt bring a slide i object to send goes into tit n depth and i think surveillance has a pathetic plan so those people will be preidentified and have been theyre ongoing being identified they have at skills on a day to day basis our environmental heartache has responders that are you know theyve been training to deal with hazmat and surveillance and other programs you know their cable of dealing and with Infectious Diseases but the thing with these the command structure if so valuable you can use it in any somewhere the department has a lot of Technical Expertise and getting the people to go into the structure and be able to respond in any situation and being able to plug into that. When we look at the network for example, those are directly responsible for patients care are they trained as well. Theyre being trained and leslie hopefully, will giving up give you an update arrest San Francisco and laguna honda i dont include them in the training they have a regulate training and when it is requested their up to date on their standard and ambulatory is collecting on their training and im sure thats important. At what point can we say for example everything o everybody has been trained. A percentage or. You know its a great question id love to get hundred percent but with a turnoff no i think over 80 percent of department is trained thats a really good target to hit. Thank you. Uhhuh. Thank you any further questions thank you for a very comprehensive presentation. Thank you. We move on to item 7 which is an update on ambulatory care and preparedness and response. Good morning, everyone commissioners director Barbara Garcia im leslie im the chief integration officer for ambulatory care my goal to rectify the current status of disaster plan and also the activities we employ to insure youre readyness and the maintenance of the continuity of care for the patient in into events whether local list or citywide emergencies before we get into the details of ambulatory response i thought that would be helpful to see and review just how ambulatory care is situated within the San Francisco network youll see the relationship of ambulatory care to the other divisions within the network like San Francisco general and laguna honda this is our ambulatory care structure ambulatory care is come permitted of four Behavorial Health and jailhouse services and primary care the real question i hope to answer today hundred dollars and will ambulatory care maintain services for the care of our patients during a disaster in San Francisco. Currently our ambulatory care leadership are Behavorial Health and operational sections all thankfully in a 1380 power our depending disaster Operations Section is currently located app at 13 howard. Dr. Babe by a talked about coordinating the citywide events and depending responses during citywide disasters 1380 howard serves as a command center for localized incidents that may require ambulatory services some of the functions that the operation section at 1380 howard are intakes and communication of information and triaging of coordinates and deployment of services andes salvation to the depending ambulatory care has a wealth of resources at its deposital for the citywide events for example, our Behavorial Health deploys crisis Response Team that respond to a wide variety of instances from street violence to other incidents they provide family and Community Outreach they also deploy Behavorial Health collisions to determine whether or not those patients have needs to be met in the event that individuals are identity our San Francisco Health Network patients are connected to tare medical home or after hours their referred to San Francisco general urgent care our out of Network Patients that need Additional Health have San Francisco general the Emergency Department or make referrals to their proper medical home within their network in terms of primary care one the main responsibility and goals to maintain the continuity of care for the patients through proactive outreach and ive listed 3 different types of population weve focused on each Primary Care Clinic has the ability to identify quickly its most highest security and utilityers of service that we can proactively outreach to make sure theyre receiving the proper care they need cola whether or not is in the medications certainly our diagnoses parnlts are top tier patient were concerned about most receive their dialyses so we can quickly identify those but each Community Clinic has the ability to identify those patients as well another group of patients would be our methadone patient and o b y treatment those patients typically have a limited supply of medications that theyll need to refill quickly in addition every Primary Care Clinic has their own Disaster Response ban planning that is Site Specific and have their own cash of disaster supplies we have standardized procedures throughout ambulatory care in terms of communication with our nurse center 1380 howard. All the Primary Care Clinics have the ability for triage and if necessary transportation to a higher level of care. In addition our other seconds like maternal child and adolescent health the nurses can be leverage for supplies and assessment of vulnerable populations we have leverage them in the past for clinical diseases they monitor the shelter population and Childcare Childcare and Housing Population and our sros there is also additional ancillary personnel one the maternity those are occupational therapist in terms of jailhouse services their actual Response Plan falls under the San Francisco Sheriffs Department but nurses and medical personnel can be leveraged in the past to respond to a citywide event the Ebola Outbreak of 2014 certainly is a great case study in the need for integrated ambulatory care preparedness once ebola came here the United States was unprepared to deal with the Health Consequences of an outbreak in San Francisco we took a systematic and he strategy approach to deal with that our depending d oc w activated quibble we brought to the table all the interested stakeholders that need to develop an integrate and systematic plan for dealing with this outbreak we had partners from the centers for Disease Control and prevention control and Health Members and Infectious Disease with San Francisco General Hospital and laguna honda out of that collaboration came the ambulatory care responses that resulted in a screening process that cast a wit net in the approach we also leveraged our colleagues at oppositional a health and training to make sure that the training that all the clinics received were systematic and standardized to one clinic was not doing one thing and another clinic Something Else we parishioner listed it by having drills site drills one at for example, at potrero hill the patient was identified and isolated and the treatment started and transported to San Francisco general where the triage patient was met and preceded through the process some of the Lessons Learned was it certainly we recognize how for the needs for this very integrated approach to Disaster Preparedness noble in terms of ebola but other potentially highly Infectious Diseases that ambulatory needs to be prepared that relatives in practices the way we serve and interact with the patients some of the challenges i see the commissioners mentioned how to maintain those competence when you have a high incident like an infectious out breaker we are reinforcing the trainings and trying to develop the marks of success that some of you have spoken about to insure our staff are properly trained and prepared all the time so how integrated are we our response is driven through the ambulatory Disaster Committee on that competent we have representatives if separate including dr. Babe by a and internal health and child childs care and streamlined ours processes and disaster activation is a twentyfour hour operation activity open howard and actually have a server not here in the city by sacramento it is landscape from services here in the city in case there was a citywide event that knocked out for instance, telephones and pager systems we have standardized as possible all the operations not only the clinics but our support and Emergency Office of emergency procedures we currently environmentally the staff who needs training and working with colleagues in our Human Resources department to try to mobilize our e he learning systems to deliver those trainings but track them over time again to tell the supervisor who has and not have those trainings those are ongoing discussions and work today in terms of looking forward to give you a status we have been focusing for the last 9 months an primary care in the first stage how do we prepare primary care the first one that all Primary Care Clinics get a series of model train by rosemary one of the kworntsd and dr. John brown our medical director of cms those are broken down into 3 models the fierce the phases of Disaster Response and the Disaster Service workers and the roll specifically of primary care and in a disaster as noted it delves into the basic structure of i c s one the gaps weve noticed the gap in terms of psychological triage and assessment and moved that to the forefront not an afterthought but Psychological Assessment is being delivered in the acute phase of a responded the second model has nothing to do with with the clinic stabilization of the things that clinics should be prepared and model 3 looks at the allocation of resources weve excused ethical considerations and common needs and reacts is to survivors as well as Disaster Recovery currently, we measure there are 6 hundred of ambulatory staff that have had all trainings but 14 clinics have had all 14 trainings moving i dont understand the training we thought it it very important in this last half of the calendar year to focus on hands on moving from the didact to hands on training two methods this first are tabletop experiences for each clinic management and command staff at each clinic what we do if in these tabletop we have a scenario and walk us through and everybody has disaster their job action sheets we walk through those so including the communication and reports. Following that within a month we actually had a full site disaster hands on during this trial with the triage patients they have a scenario and know what the scenario is and go through the motions of a. M. An actual activation something new were trying out were trying to have tools as measures of success scoring the basic competence who knows what and how did he do in areas of improvement at those full side drills well be trying to look at the capabilities in terms of the surge capability to do the delivery delivery that each clinic has weve developed an evaluation guide and something new were trying instead of having the clinic evaluate themselves were bringing in outdoors that will give us realtime feedback in terms of the outcomes the last phase of our moving forward in terms of our future state beginning in january well be having a targeted focus on the Behavorial Health section our cbo and internal child health the reason for that excuse me. Behavorial health and cbos are dispersed throughout the city and assess we needed to get our arms around we are at the cbo sites were mapping out but also in terms of trainings theyve had and some of the gaps in training theyll need in order to catch up again well be developing metrics specific sections focusing really on Behavorial Health and so with that, ill take any questions the commissioners may have. Thank you questions commissioners . I would just i think this is an excellent report it really covers all the phases with our Organization Chapter to what the focus is and the methodologies and development and training and hands on and measured outcomes also the development of may new tools that are being used in other areas but some should be changed because of the new requirements for the feds to respond to this too so as with both reports their excellence and you really it is well done well done thank you. It seems to be a lot of work in the training and preparedness of that and when did you start on this type of program for the ambulatory fair clinics i guess or did they have something before or how does it integrate into what weve heard earlier. So in terms of the actual models of the entertaining were talking about o those are ongoing for the last two years and taken that long to get all the clinics to actually absorb all 3 off the trainings over the last 9 months taking a rigorous and targeted focus with ambulatory care to get them all up to date in terms of those modules as a foundation and looking forward our goal to have each clinic have their own Disaster Preparedness into their clinic operation not again once a year thing or you know every november we have to get ready but quarterly id like to see each clinic have its on tabletop or disaster exercise their exercising those skills theyve learned. So while you have that goal is that goal that the Health Network has adopted for their clinic training that is easier for you to get the quarterly programs. The goal is more of a mandate because of the recognition that the Disaster Preparedness is integral to our clinic functions not only for the Network Patients but United States dual role as city you know First Responders as well. So it is up to you for you to make any comments from this prospective. Please step forward so we can hear you on the microphone and announce for the folks. Dr. You those are the goals of planning care and clinics. Good. Good arrest. Commissioner karshmer it sounds integrated our sort of the proactively work to identify those folks that are going to be most at risk we saw a disaster about a person being left in the fire and none knew that that is a great segue to keep the ongoing work of the ambulatory care clinic to have those in mind of high at risk so it sounds like youre fully building that into the fabric of the clinic i applaud you for that. Thank you. A comment we heard in the committee it was expressive with the ability to twrak our pablts or patient and make sure they get the continuity of care that was what was with the katrina they had no where to go and redundancy i was reassured maybe you can describe what are your plan if one clinic shut down to you to o how to deter care to another clinic were still taking care of people another the whole network not just 14 landscape sclinz can you expands that will demonstrate the fluidity and the resources. Sure what weve done create a new facility status report not only take account of the physical states but whether or not operations can be maintained with that physical states part of that vornt is personnel what personnel and skills whether language or medical Clinical Skills so on and so forth if those operations need to be crossed down that information is transported it is evaluated and reduction are given where to send staff as well as make plans for diverting patient from that clinic to what one that is closer or can absorb the capacity. Thank you this for getting your clinics prepared and well hope it that you never have to use it, it is there and it sounds like a tremendous amount of work put in place so well have a functioning system in the instance of a disaster. Thank you. Thank you. Thank you. On that note commissioners no Public Comment item 8 other business. Commissioners any other business at this point f you want to bring up. Item 9 is the report back from the laguna honda j. C. Cc on september 8th sky commissioner karshmer. Yes. We had a j. C. Crook crook under open session they heard a presentation think lodged rate presentation on the laguna honda Rehab Program and as well the administrators report also at the open session talked about open wide policies in closed session they talked about the criminal report thats all. Thank you. I guess you have no comment on the survey. Other than it is going on right now and im sure it is going well. Thank you. So move on to item 10 we have Committee Agenda setting id like to to note commissioners as commissioner chow mentioned earlier the october 6th planning meeting is coming up ill send you the details and also note that october 22nd is the joint meeting with the Planning Commission to discuss is cdc agreement i know that all of you are able to make it to remind you for those how didnt say they could attend. Hfa have we sent reminders on that letter out recently. I have not but i object to do so and that is good. There will be a staff report well be receiving beforehand. Yes. Theres were ref is now we want to give it to you in advance for our review and any addition you need and theres a last piece of the Financial Report were finishing up. And the ability to be able available if we could continue that practice that would be useful. Any other comments on Committee Agenda south setting well precede arrest we have a consideration of a closed session. Is there any Public Comment on the closed session. Ive not received any. Were prepared to vote on whether or not to have a closed session a motion is in all in favor, say i. I. Opposed . The commission will go into closed session. Is there a motion in order whether or not to disclose or not disclose. Destruction in closed session. Most to no disclose. All in favor of not disclose or not disclose. All in favor, say i. Opposed well not disclose a motion for adjournment is in order. So moved. All in favor, say i. Of adjournment. Opposed . That meeting is adjournedit. Good morning, everyone. Welcome to the 311 calling center i know that our director nancy welcomes me usually we get to announce another great tool if not a modification of our 311 center the public and residents like to see you know when we first created the 311 center we were here for that start we wanted a tool that lifts the burden off all the vacuums of calls going to 911911 is for real emergencies life or death and whatever it happening on the street currently that will be of the emergency nature needs to be called through to 911 well get an immediate fire and police and department of Emergency Response on that on to day to day basis we have a lot of other calls we have tried to direct those now thousands everyday that come to 311 and were glad because their calls for information, for refers for how to do this and that of the various departments of the city. As you may know weve been active in helping our people on the streets particularly our Homeless Population to get the services they need a challenge because we not had all the hours housing we want were building that as soon as possible and rehabilitating affordable units as much as possible but things happen on the streets our residents say should i call 911 or Small Business i see somebody they dont look healthy weve had a few instances on the street if we had an earlier call appropriate there can have been a health check, if you will, or check on someone that may have not looked at not an be able they doesnt see something happen that is an emergency often myself ive made calls to 311 someone is not necessarily in a door front but passed out and needs help those are things that happen on the street were very congested city we want to make sure that if it is not a 911 call but perhaps there could be a health check or care check on someone maybe 356 can do something about that over the past weeks 36 through the leadership of flabs our city administrator that oversees it w the putting and Police Department and Public Works Department and hot team through dpevenz combevenz hope program to you work tot to respond to what neighbors are telling you there should be an act perhaps something a little bit more modern use people dont have to the time to make the call but can actually with their footprints r fingertips simultaneously complun with 911 and not try to figure out whos responsibility but 311 will figured out for the residents for someone that seize something on the sidewalks we should be able to respond to in this app were excited in the past fewq weeks to see whether or not to develop an app to low people to scroll through a push bum efforts something on this street or particular intersection you need to see and someone should check on this individual ear r we care about the people on the streets and make sure it is not an emergency but ought to being sure to follow up on someone that is in need of help a care arrest health check followed up we created the 3 11 a. M. And i know that nancy will pop up it on the details i want to lead this effort by saying a big thank you to her team working with all the other departments they want to also be able to get to where someone suggests to us there might be something that is happening with someone we care about i believe that this is an infection of combpgs of the city having a deeper compassion to people on the tree we want to provide it to the right agency to follow up with this is why all the departments here are working together 0 so they can be part of it in the meantime we do what we do everyday the dpw and the hot teams visiting encampments of people on the street we assist them more and more and getting them into places like the Navigation Center or referring the services to the shelters we have or inviting them to the latest project Homeless Connect Program we have all the services housed on a quarterly basis in different parts of city and while we work on short term and long term answers to getting temporary and more long term housing were focused on ending chronic homelessness for the veterans by the end of this year weve been focus on the transitional aids youth and more and more getting the data together to respond to more of our families and youth being homeless through the School District and food for thought creative ways to tackle this challenge a housing crisis in the city were trying to build and stabilize neighborhood as were doing these so a lot of people from the development and the business segment to the nonprofits theyre all collaboratively with our city agencies to do better and Barbara Garcia and i are working diligently with interpreting moreno has has as we introduce trying to figure out the Mental Health and challenges happen on the streets in the meantime we ought to make sure that the things happening on the streets can be respond to weve done with the 311 app to invite the people the people that walk our streets an ability to communicate request City Services that do care and will respond to situations on the street and particularly to people who might be on the street in need of something may not be a 911 situation i want to distinguish between 911 and 311 911 will continue to be the number everybody calls if there are a true emergency if something something is happening whether a Public Safety issue or health issue but 911 is where it may not but in your mind someone ought to follow up with something and persons on the streets we dont know all the time whether in immediate need or not but if it appears to someone that someone is in need that they dont look like they are comfortable at all perhaps this is where the 311 health check ought to be had with that, id like to introduce over the course our director of 311 nan ofarrell to go over the details thank you, mr. Mayor for your asking to implement those changes all of us can make a differences by reporting streets events at 311 were looking at improving ways for the public to connect with government over 50 percent of the questioning requests for broken street lights we see the demand is high for people wanting to assess Government Services and expanding the 311 app of nonemergency to include homeless concerns a convenient way for the public to be proactive in reporting issues as they see them at this time id like to to a thanks my team as well as the departments here the office of hope and department of emergency and the Police Department and public works the Public Health department and the City Administrators Office took all those departments to build a partnership today with this ill introduce the police chief greg suhr thank you. The nonemergency number it cant be stressed enough that the way to report on emergency is still call 911 if you want or need someone in a hurry you have an emergency something that process or someone in danger youve got to call 911 with that said, nancy and the team she mentions to come up with that 311 app is a fantastic way in a city that, you know, how the Innovation Center of the word now to come in the term an app we met this smurp is mo magic and the Mayors Office and the hope sf and one of the things we have is apps to reporter things we have an entire generations that has touch phones it would be great for a whole tech safer i didnt city like San Francisco to call on a. M. We could be headed for a especially pick winter and make sure that everyone is taken care of this 311 app will go a long ways not only is it about time it is timely this year ahead of a wet and cold winter to take care of the less unfortunate none can imagined how much they need you applaud the team behind me certainly the mayor that know how and nancy alfaro shes modest but nothing short of a he or sheic effort before the winter is upon us to check on the wellbeing the less unfortunate fortunate i appreciable are appreciate it now to introduce the next member of the team from fellowship this would not have happened larry sprinkler. Morning public works is out on the streets two r 27 we understand were facing challenges this app hemming heels a lot thanks to the leadership the mayor and nan alfaro for alexander this to the app we have 3 pro activities crews through the city many times a week we may adjust and be responsive as well as with the predefined im looking forward to getting the data to evaluate the route, however, with this information allowing the public to report it will gridlock help us to go our job. Ill now introduce my other partner Barbara Garcia. Good morning were excited about this new app preservation our Homeless Team has doubled the members on the team weve responded to 311 but multiply calls someone calls 311 and determine what status it is with this new app well have that directly and that will help us in ronalds to the call i want to note the deducting 23 23w47 programs people are i will are picked up were able to provide that care as an e in San Francisco General Hospital we have teams that are out there we have teams that go out to homeless issues and violate issues on to twentyfour hours those are Homeless Teams in every district and compared to the 311 call theyre excited and trained and ready to continue as i walk down the street i see everyone with a cell phone the public will be responding as they help those no need and make sure the public we respond to the Homeless Needs to the community thank you very much. Now i will introduce Erica Sandburg shes an example of a Community Member began calling and helping us lead this program. Hi so, yeah im a resident of San Francisco i am a lover of San Francisco as soon as i set eyes on the city i fell in love he have a daughter a Second Generation san franciscan it is unconsciousable it is so depressing and so upsetting to walk by people every day on particular every block and say i cant help them i so ordering my neighborhood and beyond we have to something has to be done is it not right who can we call not just helping people on the street but combrrn the neighborhood this is okay. We cant continue to walk by so someone had a great idea there should be an app everyone has a smart phone and next thing i know theres an app great idea and great minds think alike i vibrate an what is happening he want it on everybodys phone and i want it on visitors smart phone in ms. Shorts windows they download this app lowerincome and moderate income a major victory of that because it is so necessary we need to find a way to get those peoples anybody this is getting them off the streets im a huge optimistic this is a great way to go i couldnt be more excited i want to get the word out i love innovations it is San Francisco and so thrilled absolutely atheist and happy to be i dont know who there you go. Prior to concluding i want to show the types of concerns record to the app and this demo. inaudible at the top inaudible that concludes this event thank you very much for