Transcripts For SFGTV Planning Commission 11917 20170121

First i would in the page 5, after the formal report of the director, then i would have a space in between for after the item on the faces for the future, and as you do, you have a paragraph, but it looks like it belongs to the previous topic and i think i might put in there a topic called the tom waddell incident. Or something . Yes. I see, commissioner. I can add a line, too, so it breaks up the space. If you could do that . Then under the last page, page 8, i think the intent that commissioner singer was reporting on item 11, which was the sf general joint Conference Committee report was that they deferred the medical staff report action items, because it was felt there should be a physician to review the medically oriented rather than myself being specifically mentioned there. Oh, sure, im happy to make that change. The issue there being that there were medicallyoriented issues, but no physicians at that time on the j cc from the commission. So i think that would be clearer. Those are the two corrections i would make. Any other itemss or corrections to the minutes . If not, were prepare for the vote. If there are no objections to the correctionings all in favor of the minutes with the corrections please say aye . Aye. All those opposed . Before we go on to that item, i would like to ask if we had mentioned in the minutes that we were going to have an addendum into the annual report as a followup has that yet been done or sent that off to the board and mayor . } commissioner chung needed to submit an updated bioand didnt do that until thursday of last week and i havent received the final annual report and i will pass along via email when that occurs and cover letter and i will talk to you commissioner chow before i submit under your name. You worked out the wording, that commissioner pating was suggesting. My understanding that commissioner pating was happy to use the wording from the postcard that director garcia had. I hadnt seen the final, but im assuming it would look as commissioner pating requested and let it all see it. So you will do the followup on that for us . Yes, sir, and i will communicate with each of you and let you know its done. Thank you. Go on to the next item, please. Sure, item 3 is the directors report. The directors report, director garcia, please. Good afternoon, commissioners. I wanted to start by announcing that our new director of Behavioral Health services is here with us in the audience. He started with us as many of you know he will be the leader of our whole Behavioral Health service through the city and county of San Francisco and he will be managing the health plan and drug medical organized delivery systems. Mr. Bassari comes from rams, the richmond area multiservices. He was the executive director there for 14 years. And while at rams, he was very successful at directing older adult Behavioral Health and with peerbased wellness and Recovery Services and peer training and ran the Vocational Services we funded through that organization. Prior to rams, gabos served as director of operations in the ucsf department of psychiatry at San Francisco General Hospital where he over saw the intensive Outpatient Service programs. So i think he comes with Incredible Knowledge and experience, and hell be working right back in the same areas that he left ucsf at in terms of working on this side of the road. So i really want to welcome him and if you would like to come up and say a few words to the commissioners . Surely. This time on behalf of the commission, we welcome you, please. Good afternoon. Thanks for the warm welcome. I had a really wonderful welcome earlier today at the community Behavioral Health services and various management and the directors. Im really excited and pleased to be in this position and looking forward to doing really amazing work with everyone else that is really smart and hardworking and with the same focus. Having worked in a Community Setting for years i can bring that perspective and also having worked at the hospital and with the department of Public Health and all of that with serving our consumers with Behavioral Health and substance issues and telling people this is really the beginning of a great start and looking forward to what is ahead and any questions that you have, im very pleased and thank you for the honor to be in this position. We would just like to give you and round of applause of welcome. [applause] [applause] welcome again thank you. Policy director is here and state of california governors proposed budget for 20172018 was rolled out last week. Ill have her come up after my report to give you details. We have a lot of organizing efforts going on and activities going on by our federal representatives in the city. We had an event at zuckerberg last weekend and this last weekend there was activity at city hall. And the department is getting prepared with the rest of the city for potential more of those types of activities on the 20th. So nancy pelosi was in the area and jackie lee and Barbara Spear and also Nancy Pelosis office, i think is planning on doing more of these types of Community Meetings. I wanted to let you know that the Electronic Health record has the request for proposal for new lyndon b. Electronic Health Record was published today and out in the public. We were about two weeks behind in terms of publication and details to work out with the City Attorney and the Mayors Office with rfps. We have been attending and visiting with board of supervisors regarding the ucsf Research Building that comes before the full board in the next couple of weeks and so we have been having oneto one meetings with the board and also there have been two Community Meetings that our staff have attended as well. And just to end this, we just would like to let you know our traumainformed systems training continues to expand and we have done a lot of work and this is going on around the country, cities like philadelphia, the state of maine, are implementing systemwide trauma informed system initiatives like the department. We have a new training coming up on january 26th for staff two things about hr and one of the outcomes we had with lead is our staff taking the lead process to really another level of trying to continue to improve our services in two areas that Human Resources have been working on to create standard work for employee separation and ensuring that they turn in their keys and that were managing their i. T. Systems and also family leave. So using those models of standardized work i think is proving to be very successful to the department. So just wanted to acknowledge Human Resources work on both of those areas. I will end my report there and if colleen could come up and give us highlights of the governors budget, i think than any questions, commissioners may have . Good afternoon, commissioners. Colleen chawla. As the directors report indicates, the governor released its january budget last week. Its 179. 5 billion dollar overall statewide budget. And he is projecting a deficit of 1. 6 billion due to declining revenues. The budget however holds health and Human Services at about the same level. And retains a lot of the progress that has been made in the past, for instance it continues coverage for undocumented children under medical and provides for a bond for under the mental Health Services act, no place like home bond. It also proposes to back fill funding decreases in the Childrens Health Insurance Program and its basically a relatively stable budget for the health and Human Services area. In addition, it includes revenues, borrows from future revenues to establish the adult youth Cannabis Program statewide, which of course the department of Public Health will be involved in locally, establishing those regulations. One thing just to be clear about the governors budget he made clear in his statements it doesnt anticipate any changes to the aca, making any kind of guesstimates isnt so helpful. So it assumes that the law as it is in place now will continue through this budget year, the 1718 year and should there be any proposals that impact the aca and uptake of covered california in the coming year he will amend his budget and the budget process all together the governor introduces his budget in january and legislature debates its budget later in the year, later in the spring and a may revise a may revision to the governors budget is introduced after may 15th. This is just sort of the opening of the discussion for the year. Im happy to answer any questions that you might have . Questions from the commissioners . I had one question, which was there was discussion from the cma that the governors budget was actually then taking or either reducing again medical reimbursement. So i dont see that as listed here as one of the initiatives. Yes. So it doesnt reduce medical reimbursement, but i think there was some desire on part of the medical association that some of the revenues under the two initiatives that allocate revenues to medical would result in an increase in reimbursement, but it did not and i know its been one of the criticisms of the governors budget it doesnt increase medical reimbursement. There was an increase . There were two Ballot Initiatives that dedicated revenues to medical, and the governor used them to avoid reductions in Services Given the declining revenues in the state overall versus to increase reimbursement. Thank you. Commissioner loyce . Thank you for your report, colleen and im very, very interested to hear what the budget looks like as a result of the may revise, and particularly in light of the fact we may know more about the incoming president s decisions around Affordable Care act and i would be interested in what is being said and how it impacts both the state of california and city of San Francisco. Well bring that back to you. Commissioner pating. Related to that, could you just maybe explain how changes in federal medicaid rates, if there are any in the future, would then effect medical reimbursement, and then the state budget . So just in terms of the timetables of federal budget making regarding medicaid medical, the state, and then what rolls through . Okay. So the federal government provides a matching rate for states based on the state income. So right now our california has the lowest matching rate federal to state. So 50 state, 50 federal. But its an entitlement program. So its dependent on the parameters that the state creates to allow medicaid to operate in state. So the federal government doesnt set rates. It instead says this is for whatever expenditures you may make, well match it with the federal dollar and the state then determines what delivery mechanisms like managed care, that theyll create and what reimbursement rates that theyll create. Its not a federal government rate and actually california has pretty low reimbursement, somewhere like 48 out of 50 states per member reimbursement so pretty low as set by the state. So if the federal government decides to match at a lower rate, would we be on the same cycle, for example . I guess the question is the federal government considering 1718 budgets or are they two years ahead . Because its an entitlement, the way that they have structured it now is they cant reduce funding. They can reduce elbility for or they can reduce the matching rate. So before the aca, our matching rate was 50 50. With the new expanded population, the 138 of poverty single adults, that matching rate is goes down to 90 10, 90 federal government and 10 state and that expansion is under discussion about whether its part of repeals its since its part of the aca and that is of the part of the aca impacting medicaid being discussed as part of the repeal. So either they rescind it and say they are not going to pay any of that 138 for single adults or they could say that they would like us to pick it up at normal matching rate and wouldnt pay 90 , but pay 50 and it would be up to the state to decide if they could cover the 50 . Or more likely how to work with counties to cover that 50 . So its kind of a cascading effect, depending on what the federal government does. This could all take effect 1718, that soon . Because we still have the fiveyear implementation of the original aca phasein; right . With 100 and 100 and drop down to 90 and so forth . Would that have to phaseout . We dont know. I guess i was wondering could there be changes in the federal reimbursement rate as early as middle of next year is the question . I think its theoretical possible to do it that quickly. The other thing they are considering at federallevel is bloc grants and to give state and allocation based on the number of medical eligibles in state and overall funding would be reduced to states for medicaid. Thank you very much. Any other questions either of ms. Chawla or the director. With report to the Race Ethnicity Data Collection parameters, i assume both medical and San Francisco and does it include lgbtq and finally adding to the medical data systems . Its been added with us in particular transgender communities. We have a couple of providers who have been really entrenched and alice chen and susan. I would hope that we can continue to nudge the state to look at the issue statewide. We worked very closely with supervisor wiener on this. We started it and he did . Some legislation and he is now at the state and already let me know that is something that hell take to the state as well. I expect hell do some legislation. Thank you very much. Any other questions . Ill note there is no Public Comment for this item. Okay. Well move on to the next item, please. Item 4 is general Public Comment and i have not received any requests. So we can move on to item 5, report back from the community and Public Health committee. The community and Public Health Committee Heard two reports today, one the update on the mental Health Services act. Every year there is an annual update submitted to the state and every three years, which is this coming up year next there will be a 3year plan revision that will be updated. And the mental Health Services act was enacted in 2005 and maybe our commissioners remember that it taxed 1 of personal income tax of individuals over 1 million, and california has more millionaires than we thought. So this is actually very large fund for mental Health Services in the state. It has five areas, Community Supports and services, innovation, prevention, workforce education and training and capital facilitiess and technology. And for these services San Francisco has been receiving on average over the last five years about 25 30 million plus or minus as the number of tax revenues coming in has varied statewide. I would like to say when we heard their report from the committee, we have been very impressed with the extent of mhsa services in San Francisco. San francisco has always been a statewide leader in Behavioral Health and wanted to comment on three programs in particular for recovery oriented Treatment Service and philosoph physwas full service partnerships, clients that are severely mentally ill that requires whatever it takes services. We have been 1051 clients in this full service program. And the statistics were that it had 85 drop in arrests and clients in this program have a 76 drop in Mental Health and substanceabuse emergencies and 70 reduction in school suspensions. And this is also being implemented alongside assisted outpatient treatment, which we heard last time as well. Two other programs to highlight were the early psychosis program, which is a novel innovation for assisting individuals to prevent and and to provide early treatment for schizophrenia. There has been about 80 clients served with 30 reduction in inpatient episodes. I would just like to say that in general our dollars from mhsa have been used across our system and its almost too hard in a brief thumbnail to oversee the number of programs that we have. But we have been very impressed with the spending on peertopeer services, increasing access, particularly also increasing Behavioral Healthcare in our primary care clinicks and moving towards innovation. The two last items were the prevention and Early Intervention programs and the innovation programs. With regards to prevention programs funded by mhsa, San Francisco had 27,000 individuals that received prevention intervention for Mental Health and really a huge number with many culturally specific programs with lgbtq and again targeting k12 students atrisk with issues around bullying, family trauma, and depression. Two other items that are of importance. The state passed a 2 billion bond last year ab 1618, which the governor signed. This will allow the cities and counties to drawdown special funds for housing. San francisco has already been a leader in state in using state funds for housing. We have one, two, three, four, five, six programs the richardsons, the veterans commons, kelley cullins, renee apartments. The 1100 ocean avenue, which looks really nice and rosa parks 2 senior housing, which we received funding for. And with an additional possible 75 million 80 million that San Francisco might be able to drawdown, the regulations have not been finalized and the prospects for some statefunded projects for Homeless Housing or atrisk for homelessness looks promising. Lastly, just wanted to comment on some of the innovations that San Francisco has undertaken of which the one i think is really important is our transgender pilot. Having become a prominent city for providing Transgender Services, piloting the Mental Health aspects of individuals receiving Transgender Services is a Novel Program that San Francisco can lead the state on. As well as our socially isolated Older Adult Program and First Impressions program. So it looks like were doing well. While the state is expectinging a small downturn, the city has an mhsa reserve fund set aside. So we look like we have enough to continue these programs despite perhaps any fluctuations in the tax base. That was their annual update and i will stop for a minute if there are any questions and i will do the next one, if you would like . Questions . I guess my question in a way, this is a very extensive report, but its the end of a 3year report. No, this is the annual report. Its an annual report. Every year they have to give an update on the annual report, particularly new programs that were added during that time. So sometimes staffing or funding changes and you may add it to the program is given to the annual update. Next year or actually beginning now, the department is doing its communitybased programming to involve Community Partners in the next threeyear strategic cycle. That is actually when were going to see the threeyear plan. This is more of a continuous update of what we have already done. So im not sure its as important to review the annual report other than the changes that were made over the last previous cycle. So your impression, this only relates to the mhsa program . Annual program, the 30 million that we get. Not our total Mental Health program . Not our total Mental Health program which were plan thoughing review with the community and Public Health committee. This is the segment of the report we get from that report because of the act and what the act was doing . I kind of recall at one point that was supposed to bring extra money; right . From this Million Dollar tax i mean millionaires tax. The state fund has 1. 6 billion and we get 30 million, but that 30 million is only 1 10th of our 300 million budget. This is 30 million . Yes. Okay. Highly regulated. But very flexible funds that allow us to do a lot of things that other kinds of funds dont allow us to do. So while it carries and Administrative Burden of a lot of oversight, it actually provides a lot of grease to help us provide the Innovative Care we provide. And you have replaced this years report . We have always done a very good report and this is up there with our best. Commissioner you were interested in the commission has an opportunity to report and the threeyear draft report is going to be is being drafted this year. And will be coming to you all later in the year, after community input. So the commission will have an opportunity to take a look at it at some point in the probably 68 months. Sure. Im trying to find out where all the segments are and how this fits in. Director garcia. Just to say with mark, that well be processing the report, the 3year report within the executive teams of the network and also to the integrated Steering Committee before it goes to the state. So they are going to have to back into that to ensure that we get to see that. The other issue, i think for our new director to hear from Behavioral Health, one of the things i would like to see in the report is a report to us. We had this funding now for over ten years and we should look at it as a transformation grant and how do we look at transform our Mental Health system from what we have learned from all of the funding and innovation that has been in place . So as an example we have these incredible full partnership Case Management programs that could probably be the model that we should transform the rest of our Case Management for high intensity and high intensive need of clients. So i do think we can learn and spread some of those great ideas they have done over the many years and that is the direction we would like to see in the future. Its not just 10 of the system, but also looking at what policy changes, what Program Changes can be made that have worked in that system, or in that Funding Source for many years now . So i think that is the next step were going to have to take. Its an excellent perspective, i think, in terms of how we can look at this as being sort of on the cuttingedge and being able to rate these are new innovations that came about, that would not have come about if not for the act, i guess. I want to underscore what the director is saying. While this is again 10 of the funds, it doesnt make sense to silo it. So these funds are really spread throughout the Health System and wellness and recovery and prevention related to it and how they transfer to our other programs would be something that we would be looking to ask our new director. Thank you for having taken on the burden of getting the update on this particular part of the program. We stay up night reading this one, so you dont have to. [laughter ] so the next report is with our we heard from the applied research, community health, epidemiology, and surveillance, arches. This is part of our backbone team, along with the bridge hiv team and division. Our cphr division. I wouldnt give too much detail, but dr. Aragon had outlined for us with mr. Wayne enanoria a vision of the future related to Population Health. Dr. Aragon is driving the Arches Research unit towards looking at developing patientcentered data surveillance. A certain point when we have our systems, were going to be able to know in San Francisco who is atrisk for hiv and who may not have received treatment for hiv and systems involved in generating lists of clientcentered data about prep utilization and prep needs. So at this point were in planning phases at arches and it looks like they are getting ready for the next leap forward in population management. I wanted to ask dr. Garcia, this seems to me a relatively new resource. Would that be true versus, say five years ago . Did we have such a unit . No, we did not and this is in the reorganization that our Health Officer has made within the unit. As you know we tb and hiv and stds and using the lean methodology for standard work and also to try to merge some of those data sets, this is where now they are in their development. So they have done a very good job and we have hired a new director of that unit, because it merged, all of those areas into one unit. So this is an outcome of both the reorganization and lean process and good leadership in that area. Very nice. I see they have new words, too like deduplication. Right. New language, well have to all learn. Which im thinking means that we dont duplicate. Its a new terminology. We heard about data standardization and segmentation, and a bunch of others it wasnt quite gibberish, but it does point to the future. Im glad you listened to this. I think it might be an area in which our future planning meetings that we have had, it might be something for us to spend a little bit more time on data integration. I think that is great. Really merges well with our emr, ehr. And to see what our new capabilities as were now moving into it. It could be a new area that we would like to all explore and understand how this is going to be that realtime. Im going to have this illness or you are going to have it. I think this is wonderful to begin to have this new development of resources for our Public Health section. Commissioners, any other questions on arches . So far as dr. Pating understood, i have confidence that it really looks like its on the cuttingedge of what we have been asking that our department begin to develop into as a i guess as a new 21st century way of looking at health and health equity, correct . Its merging population studies with different ant analytics and Artificial Intelligence and to predict at the clientlevel the incidents and risks for disease. Is this something just one last question i guess alameda and then san diego have been doing, but they were doing with things like traffic accidents, and social determinants of care or is this different from that . Dr. Aragon is not here and i would have to defer to him. Well get back to you on that. Thank you. Any further questions . If not, we can thank our chair for a wonderful report and well move on to our next item. I will note there was no Public Comment on that item. Item 6 is dph annual gift report for 20152016. This is an approval item, commissioners. Good afternoon. Working with the overhead, people in the back. Im pleased to present the report, the gift report report of gifts received in fiscal year 1516. There was a total of 14. 4 million received in 1516. 8. 9 million was to the zsfgh foundation to support hospital programs, as well as the heart of the city capital campaign. For laguna honda hospital 31,000. 311,000 and Public Health foundation on the second page shows the detail of the donations by the donors. On the following page, oh, there is a correction on page 3. There is a correction on the inkind donation. It says, its from friends of laguna honda. That is actually inkind donations correctly to laguna honda hospital. From the friends . It was pointed out to me and this report with laguna, this is the same report that i believe was given to the probably the jcc earlier in the year, the information on laguna honda and i think they do a separate gift report and this is the same information. I believe the City Attorney has disallowed any discussion of that. It lists the donors. If you have any questions. Commissioners you have had this before you with details. Are there questions on the details . We are otherwise to receive this report, correct . Yes. We approve this report, through the chair . We take commission action. Were asked to approve the report. I would move the commission approve the report pertaining to motion for approval of the report. Is there a second . Ill second. And a second. Through the chair, i just wanted to make a comment that i think its astounding given the world today, and the multitude of variables affecting the Public Health of this nation and our counties and the state, and hospitals, equipment, trying to adhere to all of the new challenges that if you take a look at who has contributed in reference to not only foundations, individuals, families, trusts, the langendorf fund which was the old bakery that closed down years ago that are still active and others still contributing to the city and these foundations. I think its astounding that we are able we as a city, are able to have such a fantastic community that could donate to provide these Critical Services programs, and all of the above, given these reports. It hasnt decreased, at least in our term of duty and it has increased substantially, but its not only increasing in reference to dollar amount. Its increasing in reference to those who contribute, whether they be new people, four and fivegeneration families or old corporations, or young groups. Everybody is involved, and i think we should really be very thankful to our community that they are very cognizant and are willing to step up and make sure that these services are provided to all of our citizens of San Francisco and those who visit our city. So i would just like to state that for the record. Its a job welldone and were very proud and very honored to see these significant dollars for our Health System. Thank you. Thank you. Thank you. I was just going ask also then, because for many years we have been concerned about and were pleased that the avon people were working with us on their Breast Cancer programs and all. Has this become, or perhaps the foundation needs to answer that has this become much more regularized and less of a year by year thing on the part of avon as they work with our center . Or is this still dependent upon each year there be outreach to avon and we have our fundraising with them or what . Im sorry, i dont actually know the detail on the avon gift, but that is something that i could followup with San Francisco general foundation. If you could . Through the chair, i would just add roland our director of network has some information on that. Its a very competitive model. Roland pickens director of the Health Network and i will pinchhit for susan on this, only because i was involved in the original avon grant. Yes. It continues to be an ongoing grant, the amount has decreased about 200,000 since the original one. You remember when the markets first crashed, they made reductions. And they have maintained the contribution to sf g. H. I remember commissioner was very concerned and that we had a way to continue to work with avon on this. Commissioners any further questions . If not, there is a motion before us for acceptance of the report. All those in favor, say aye . Aye. All those opposed . Motion has been approved. Thank you. Well move on to our next item, please. Yes, i will note afterwards that you all that there was no Public Comment to that item. Item 7 is the dph 2016federal and state legislature summary and plans. You all have a resolution before you that youll vote on at the february meeting. So today its just for discussion. Good afternoon commissioners, cyndy comerford. We have prepared a memo for you that gives a summary of our legislative actions and also a draft of the 2017 platform and also as mark just said, we have already introduced a resolution for your support to be voted on the february 7th Health Commission meeting. So this slide gives and overview of what im going to talk about today. First i will give brief background on the legislative platform and after that i will present a summary of our state and federal actions for the last two years. Im also going to talk about some key emerging issues, postelection. Next im going turn it over to niki and she will talk about the policy Platform Development and i will conclude about giving some brief updates about how the legislative cycle kind of intertwines with the state and federal budget cycle. Im not going to go into any piece of legislation in detail, but well leave time at the end to answer any questions that you might have, and any comments or questions you might have on the legislative platform. So to start off with discuss what the legislative platform actually is, what it does . So the platform is a document to serve as a broadbased set of policy priorities, founded on information collected by our department of Public Health leadership and public organizations that align with dphs strategies and goals and also aligns with citys priorities. Essentially it serves as a policy guide that aligns the city and department of Public Health mission to protect and promote health for all San Francisco. What this platform does, it serves as a kind of framework or basis and allows the department of Public Health to recommend positions on content in the platform on state and federal decisions. So this slide shows here how we advance state and federal policies within the department of Public Health. So the first one, the first box is we developed a legislative plan, and niki is going to talk about that box in more detail after a couple of slides. After we develop that plan, we bring it to you, the Health Commission to review and provide feedback. Typically, what we do, we bring it to the Health Commission and then we bring it to the Mayors Office of Governmental Affairs for their approval. But because we had some scheduling conflicts this year, its already gone before the Mayors Office. But they are amenable to adopting any changes or comments you might have and we can resubmit it to them. After we have the platform, if there is any policies, or proposals that come up that may impact the department of Public Health, people from leadership from the department can recommend that we take a position on that policy or platform. So for example, if there was legislation about lactation in the workplace to defer to our maternal and Child Health Section to provide guidance on that legislation. They would take that legislation and work with our office and we would help them advance that policy proposal. So typically that comes in us writing a position letter, but we can also work on legislation by providing expert testimony, or technical support. For highstakes city legislation we also have the opportunity to have state federal lobbyists help us advance that position and our lobbyists serve at the discretion of the Mayors Office. Once we have kind of determined our position, we would bring that position to the Mayors Office of Governmental Affairs, and if its state legislation they have a state Legislation Committee and we would bring it to their agenda. The item would be voted on and if the Mayors Office supports that item to advance the citys position on that policy. The next im going to give a summary of our state and legislative efforts over the last two years. At a statelevel the legislative sessions are convened for two years, and what this means is once a bill is introduced, it has two years to pass through the senate, and assembly, and get signed by the governor. This slide kind of shows the summary of the actions taken over the last two years. So some of the key topic areas that we have supported or put legislation including medical, medical cannabis, tobacco and smoking, hivaids and Speed Enforcement, Affordable Care act and homeless supportive services. In 2016 we tracked over 190 bills and 74 bills were signed into law and 13 of them were vetoed by the governor. The department the city took 11 active support positions on those bills. And those positions are detailed on page 4 of your memo. In 2015 we tracked over we tracked 172 bills and 50 were signed into law and nine vetoed by the governor and we took eight active support positions. Those are detailed on page 3 of your memo. The next one im going to move on to key federal updates. So federal initiatives we took action on were either federal legislation or key decisions by federal agencies. And this slide kind of depicts the types of actions we looked at. So we wrote support letters for the comprehensive addiction and recovery act, which was federal legislation and zika response and preparedness act was also federal legislation reappropriating funding for ebola to go to zika. Medicare gender reassignment surgery was a decision by health and Human Services on a federal level that we comment on and department of justice grant abuse project funded about 103 million to local jurisdictions that was federally legislation and lastly commented on substanceabuse order records and in particular around how some of the confidentiality rules are really prohibiting us to providing whole patient care. And that was on a federal agencylevel. There are also two other notable federal items the 21st century care act and aca. The cures act was signed by president obama in december and allocated 4. 8 billion for ten years for Different Research programs and those are Vice President joe bidens cancer project, Brain Initiative and Precision Medicine initiative to fight the opioid and delivers funds to the fda. The Mental Health reform act of 2016, as well as additional provisions from the housing helping familis and Mental Health mental Health Services act of 2016 and a substantial portion of this bill does relate to Mental Health and Substance Use disorder that really reflects the raising of awareness that has risen over the past couple of years and what has been going on within our cities and counties. Also what is notable about this legislation it was the First Comprehensive Mental Health legislation that was passed federally in over a decade. Next im going move on to the aca and in 2016 the aca saw continued success. As of the end of 2016, 12. 7 million americans were enrolled in the insurance marketplace, and an additional 15. 7 million americans enrolled through the aca, medicaid expanse. The National Insurance un insurance rate dropped and in San Francisco dropped to 8. 5 . San francisco at the end of 2016 had over approximately 37,000 people enrolled in insurance marketplace and about 78,000 who had been enrolled through the medicaid expanse. San francisco has approximately 135,000 residents enrolled in the San Francisco health plan. Those numbers were for the end of 2016. I know there has been on a federallevel nationally approximately 400,000 people that have enrolled in the aca for 2017. So going into emerging and postelection legislative issues, as we were preparing this platform, the election took place, which is potentially shifted some of our priorities that we have and some of the focus of our attention on a citylevel. So going back to the aca, as many of you know three weeks ago, the legislation was introduced to repeal and replace the Affordable Care act. Last week the senate and the house approved that budget resolution, which directs the house and Senate Committees to work with legislation designed to repeal major portions of the aca. This legislation has a deadline to be completed january 27 and would allow republicans to pass future legislation without the threat of a filibuster from democrats. Only provisions that are directly related to the budget may be in draft in this budget resolution, which is kind of significant. Provisions on nonbudget related topics would have to be introduced in separate bills. So while we really dont know what the president elects plans would be, we think the following items would potentially be addressed in a reconciliation bill. A lot of this is mentioned earlier by colleen. This would be rolling back medicaid, or the potential rolling back the matching funds. Ending premium tax credits, and creating a new individual tax credit system. The end of healthcare subsidies and new insurer protections, and also repealinging a lot of aca revenue provisions. So a complete rollback of the aca without a Replacement Program would potentially impact millions of Californians Health care benefits and really disrupt the private market. In california stands to lose potentially 17. 3 billion in federal funding if the medical program was rolled back. This morning, the bipartisan Congressional Budget Office came out with some figures of potential impact of the republicans plan, and what they say is a planned that could cost 8 million americans their insurance by the firstyear and 2 million covered by 2026. Obviously this plan would have Adverse Reactions on the private insurance markets, and insurance premiums would raise 2025 higher than under the current law right now. The other thing that came up as postelbs. Ing issue is sanctuary cities and many of you know that San Francisco is a sanctuary city, protecting undocumented immigrants. In december, San Francisco affirmed this policy and on friday, the Mayors Office launched the equity and immigrant service campaign. This campaign is looking at Funding Legal services for immigrants, and also working in partnership with nonprofits to continue education, outreach, and services for people potentially under threat. Right now across the country there is 364 sanctuary counties and 39 sanctuary cities. There are also four states in the United States that have sanctuary city laws and california is one of them, thus far within the california legislative cycle, defending california against federal encroachment and limiting state involvement in federal immigration laws. And this is all significant, because the president elect has threatened to cut funding to sanctuary cities, and the details of how this might be implement are unknown, but right now the San Francisco department of Public Health receives 68 million in federal funding. I will turn it over to niki to talk about the development of our 2017 legislative plan and i will come back to tie up the presentation and answer questions. So in talking about our 2017 legislative plan, as many of the Priority Areas from 2016 remained highly relevant we used the 2016 legislative plan for the basis of our development of the 2017 plan. We took significant time to meet with directors from different branches across the Health Network, as well as the Population Health division to discuss updates to the Priority Areas and also to learn about my anticipated bills or issues to watch for. The draft plan was presented to the integration Steering Committee for input before being submit to the Mayors Office for approval. And as cyndy mentioned earlier, any feedback after todays presentation we can submit additional amendments to the Mayors Office as well. So this slide is meant to highlight several of the new and coming topics that emerges in many of our discussions. For example, behavioral page health care was repeatedly mention as connected to different topic areas, such issues sharing patient data across different systems and ensuring pay rates and for the jail population and integration of general care and the opioid abuse prevention and treatment into the platform. Another important topic was affordable housing. Affordable housing was identified as a key underlying area of need that must be systematically addressed in order to get at root causes of many of the Health Issues that people are seeing across the department. So the memo in your packet contains the complete state and federal plans for 2017. This slide just highlights the key issues, and you can see that our resulting 2017 plan is divided into sections that encompass the many key issues and areas that we heard about from across the department. I will note that there are already several current state legislative items that were beginning work on that we wanted to highlight in particular from this list. The first is that were working to reintroduce legislation which would allow for automated Speed Enforcement in San Francisco. This is something that didnt move forward in the past legislative session. Second and importantly were monitoring any new legislative changes to cannabis regulations, both for medical and adult use. There have already been bills proposes on this topic and lastly as you heard about several times earlier, were tracking closely the no place at home initiative, proposition 63 funds for permanent Supportive Housing for homelessness measures. So with that i will turn it back over to cyndy. So this last slide here just shows our timeline for the legislative process. At the statelevel we just started a new twoyear session. So bills are being introduced right now. By the end of january, beginning of february, most bills have been introduced and well begin to track them. The state budget by the governor was introduced last week, and this will go through revisions and revised budget will be proposed in may. On a federallevel, we have talked a little bit about some potential legislative action items. Its a little more unpredictable on the federallevel. Rake right now so far as a budget were operating under continuing resolutions and that resolution ends april 28th. So we could potentially see a new federal budget for the next federal fythat starts october 2017 by the end of april. So were happy to answer any questions you might have on the platform or any of the issues that you discussed and if you have any feedback were happy to incorporate that and revise the platform and the resolution. There are no Public Comment requests for this item. Commissioner loyce . You stated 8. 6 drop and 8. 5 in the uninsured, drop from what . I dont know what the previous uninsured rates were, but i do know this is the lowest rates in history that we have had. Im happy to look that up. It was cut in half by 50 . Thank you very much. Thank you. Commissioner pating . Sorry my comments are a little bit disorganized here. I just wanted to highlight some things that i think are really great. I went through all of these at the state and federal and i think you have hit every major topic area. And the level of detail in your policy positions is really great. Medicaid funding for inmate Health Services to get that passed would be great. On page 1216, really happy to see that. Happy to see the lgbt Health Promoting the use of Data Collection which collects gender and identity and sexual orientation. On Behavioral Health, 12 of 16, i like the removal of the imd exclusion and support for the federal regulations to remove 42 cfr. So i guess those are all federal. Were a little less effective at the federallevel than the statelevel and inasmuch as those are also state issues to also look at that. One issue i didnt see in this was telecare. Any issues of either because we are a Specialty Center for transgender care, i guess we could telecare out and provide services or telecare in . I think there needs to be some clarification in telecare roles, including across state lines with telecare might be an area to look at the federal or statelevel . I dont know that state telecare reimbursement rates have been worked out its not on the radar. On the federallevel, nih funding has been cut, i dont know 2050 over the last several years. Unless we have adequate nih funding were not going to be and innovationrich nation, nor city. So would really recommend that anything can help restore nih funding at all levels would be really great. Thank you for your comments. Those would be two items, telecare and nih would be my recommendations, but other than that, this is a really excellent document. Thank you for your comments. Well add them in. Commissioner. I think it was an excellent overview and review of really the dance of legislation. Where it starts here and last two years and projecting over another two years. Both the bills that we were tracking and those that were approved and those not approved and those we concurred with. Its an excellent report and very inform ative and thank you very much. Welldone. Welldone. Thank you. I just had several comments, because these reports are just wonderful. These so succinct and allow you to think about some of the issues that they raised. So ill just bring an issue i raised only because i dont have the answer, but its on page 13 of 16. We continue to talk about the increasing supply of primary care providers, but and i dont know the science of it right now, or i should say the evidence. This has been a call for many, many, many, many years, and somehow we continue to believe that were undersupplied in primary care providers. But there are other literature coming out indicating that were maybe not quite as undersupplied and that its a misallocation, a misdistribution, and or, in fact, with new technology misapplication of how we use our providers, versus just simply the simply statement that we need to just increase supply of primary care. So i only point that out to suggest in future we might want to look into that as being a point that we want to continue to support . Because its kind of like almost apple pie, but maybe the pie has a new mix . And im kind of persuaded to look at that if there is truly an undersupply or as i said, misallocated, misappropriated, misused as far as primary care providers . Because were constantly talking about that. That is just sort of to look to the future. Two areas i thought of funding that i think we could be more proactive in at the statelevel and im not taking the state associations position. But one that just is of commonsense, if were at 48 out of 50 states in reimbursement to our physicians, and other providers, and that includes us as a department, then this really hurts access, or the acceptable, even as we continue and that has been the call. We have increased medicaid by a third, but we havent necessarily been able to increase the providers that are available. So kind of speaking against my primary care provider earlier, but this may be an area in which there are people that isnt accepting these patients because we actually are underfunded for them. A good part of the state of californias medicaid population is taken care of outside of the county, in small, private, usually ethnicallyoriented offices and these are the people that arent really getting those dollars down there to make it, perhaps, available for that population . So even as were dealing with access on the Affordable Care act side, but we have all of these people who are here this year, i think that the state legislation should not only look at nocost, but continue to advocate for added reimbursement in the appropriate specialities that we may be short in . I dont know which one those are, but im pretty sure that is probably a real problem. So i think that becomes an important emphasis in this. Being proactive to try then to improve the reimbursement, which just as the system we know is underfunded. But as an overall state need, i believe, continues to be underfunded, not overfunded, but underfunded. I just wanted to commend you and the city for continuing to support screen 23. It was drafted into state law and thank you and it did start here at the city again. So i think we should once again take note that San Francisco does try to lead in many areas. I was looking at the detail that you have concerning the people who are insured. How many people do we have left in healthy San Francisco now . Just sort of the number that im missing . I think there is approximately 135 residents that are insured through San Franciscos health plan . How many . Healthy San Francisco . [ inaudible ] 14,000. I apologize. I initially of course and mistakenly mixed it up with the number of San Francisco health plan and realized the number we were missing in your nice summary was, in fact, how many were in healthy San Francisco . And i would recommend that be put back into your summary, because that does tell us what core is still there, that is uninsured and undocumented and perhaps even potentially then falling through the cracks for many reasons; right . That allows us to know what that number is. Otherwise, i just have to compliment staff, again, for each year coming in with an even clearer report of how well we did, how our format allows us to look very clearly and what our priorities are for the year. It seems to me that the commissioners have expressed certain areas would have a im not sure what our process is now . Because its kind of backwards here, because this would have been incorporated and sent over to the Mayors Office. We are now in a position where the Mayors Office has received this. Were saying that we would like to add some nuances, in order to add these nuances that were pointed out by commissioner pating and myself, it would seem that we would then need to add that into the resolution for the next meeting; right . So that you could formally move that forward . Because its actually not our own individual thought, but that of the commission that really goes to the department. So i would ask that we incorporate those suggestions from dr. Pating and myself in terms of what we would like to add into the report to the Mayors Office. With regard to my suggestions of telehealth and nih funding i would refer to the director and our policy staff whether or not it adds additional value . That would be two areas there has been lots of conversation that i didnt see something on, but if you feel there is a reason to leave those two out i would defer to your expertise . Commissioner, we would support those two items, particular in nih. We have watched significant downturn on the amount of money available for our researchers. So i think we can look at those and add those. Okay. Okay. Would i would ask that we dialogue about those if issues that we have raised that we perhaps misunderstood or, in fact, you are able to support, we add them into the resolution and have that before us for the next meeting. Thank you for your comments. Yes, i think all of the suggestions made can be easily incorporated into the platform and the resolution. Also just wanted to provide some additional context on your question about medical funding and reimbursement. That is something we can definitely add in to augment that through state legislation with a plethora of bills to support additional funding. Im sure you are not opposed to it, but to put it in a proactive way in our document. Thank you. Thank you. Commissioners, any further comments . If not, the resolution will try to reflect our comments, and well have that for action at our next meeting. Thank you. Thank you for your time. Item 8 is the california end of life option act. Were not voting on this today, is that correct . No. So this was actually just a discussion item and i believe commissioner chow asked for a resolution. So you have a resolution before you that is not on the agenda. So you all can talk around it, but you really cant talk about the resolution specifically, because its not agendized. You can make suggestions about what you would like to have for the next meeting on the agenda i mean the next resolution. The topic was presented and realized this was an important issue that the city should be aware that our department is going to be offering the end of life option and thought this would be a worthy resolution to present and for our consideration at the next meeting. Please, proceed. Good afternoon, commissioners. My name is sneha patil and im senior Health Program planning in the office of policy and planning and today wanted to provide you with an update regarding the california end of life option act and the work we have been doing in the department to support this. The office of policy and planning took the lead role in coordinating the process of convening representatives from across the department to discuss implementation of the law. And so today i will be talking a little bit about the background of the law and i will describe what the process is, and i will review the key components of our policy. And i also want to note that our medical leadership on this policy, dr. Alice chen, the chief medical officer for the San Francisco Health Network and dr. From San Francisco general are both here today to answer any questions that you have. The end of life option act was signed into law in october of 2015. And it took effect on june 9th, 2016. And essentially the law allows a terminally ill patient to request medication from their physician that will hasten their death and this process is known as aid in dying. So aid in dying drug is the medication that a physician would prescribe for this purpose. So the act requires a very specific process for patients, and physicians, and it also requires very specific procedures and forms. Prescribing aid in dying drug is completely voluntarily for any physician and also participation in any activities under the end of life option act is completely voluntarily for any health care provider. So who is eligible . So in order to qualify, patients must be 18 years or older, and must be a resident of california with a terminal illness that has a prognosis of six months or less. They must have the capacity to make medical decisions, and the ability to selfadminister an aid in dying medication. So as i will note the request must be made directly by the patient to the attending physician and cannot be made on behalf of the patient through an advanced care directive for through any other surrogate decisionmaker. So what do we know from other states . California is the fifth state to legalize aid in dying, following oregon, washington, vermont, and montana, and recently colorado passed a ballot measure, similar ballot measure in november. So based on data from oregon and washington, we know that patients who tend to request this option tend to be white. They tend to have higher levels of education and overwhelming majority tend to be Cancer Patients and less religiously affiliated. We think its important to know that many more patients will actually think about it or talk about it then will actually end up administering the medication. So based again on data from oregon and washington, we know that about 6070 of patients who get the prescription will ingest it and about 3040 will not. And in 2015, you can see that a very small number of individuals requested an ingested aid of dying drug in oregon and washington and if we take that percentage of the Patient Population and apply it to californias population we might estimate that roughly 2,000 patients would request this. In a given year. So i will talk through the process so a patient must make two oral requests directly to their attending physician at least 15 days apart. And then and the patient completes a witness form witness by two witnesses and the physician will determine eligibility and provide education and counseling and attending physician is also legally required to provide information on alternative options for end of life, such as hospice and Palliative Care. The attending physician will refer the patient to a consulting physician to provide a second evaluation of the patient and at either time either the attending physician or consulting physician feel that the patient has a mental disorder that might be interfering with their ability to make medical decisions for themselves, they can refer the patient to a Mental Health specialty. Specialist. So after that process is completed, the attending physician will write a prescription and differ deliver that to the pharmacy and deliver the aid in dying drug to a patient or person designated in write big the patient and then the patient will have the medication or ingest the medication whenever they choose to do so, if they choose to do so. So a little bit about our policy development we decided to take a systemwide approach, and we convened an Advisory Committee with representatives from across the network that are listed there on the slide. And also in order to better understand how many or if there was willingness among our physicians to participate, we conducted a survey at San Francisco general, laguna honda and primary care and reviewed policies of other Health Systems to understand how they are approaching this. The next two slides are really just key components of our policy so we respect Patient Choice, and Patient Choice to make the Patient Choice to make medical decisions for themselves at the end of their life. Our policy is intended to balance patient rights and protections and we permit our providers to participate and clearly do not mandate any participation. In terms of education, our Advisory Committee felt that we should require some training for our physicians who are willing to serve as an attending or a consulting physician and so were planning to develop a training that will be made Available Online for all physicians. And in terms of regulatory and compliance, San Francisco general Regulatory Affairs and laguna honda hospital will take a key role in managing documentation. There are four forms that need to be submitted to the state, and so theyll be overseeing that process. And then our medical staff office will be collecting data on physicians in the network and their willingness to participate as an attending or consulting physician on an ongoing basis. So in terms of questions and concerns, the main point here our Ethics Committee is available for physicians if there is concern the Ethics Committee will help facilitate those conversations. In terms of ingestion and the law specifically states that the patient cannot ingest an ends of life dying drug in a public space and we know from oregon and washington 90 of the patients have ingested the drug in a home setting and enrolled in hospice and we hope that is true for our patients as well. We do know if patients do not have an appropriate residence, or transitions to the division will facilitate placement for them. And then lastly, secknal will be made available at San Francisco general and laguna honda hospital pharmacies and medical is covering the cost of the drug for all medical patients and lastly Drug Disposal and provider guide encourage ours about appropriate dug disposal in event that the medication is not used. I want too note since this is a new policy statewide, not only for the state, but for the network, we intend to revisit this over time as a few patients have gone through the process and to determine if there are areas where we might want to modify or adjust the policy, if needed . Thank you and were here to answer any questions that you might have. Thank you. If you wouldnt mind, commissioners, i wanted to have the physicians just make some statements. Considering they are the areas of expertise and our chief medical officer. Absolutely, that would be fine. Ill be brief and also invite dr. Kinderman up. I just wanted to first commend the office of policy and planning and they really led the process, and the process of engagement. We are by far a more diverse state and larger state than any of the other ones that have previously gone before us. So i think that is a reason we wanted to take a very proactive approach. In talking to many of our sister Hospital Systems there has been a watchandsee approach and we decided to reach out and be proactive and set guidelines and properly educate people about this. Our main i dont want to belabor the point but our main concern is really walking the fine line between providing access to an Important Patient right, and protecting vulnerable patients from many potential abuses or perceptions of abuses. I think i would only add with the information to reinforce a lot of these policies were developed after looking at the experience that has been had at similar institutions in oregon and washington, safety net hospitals and other institutes. Institutions and were trying to learn from their experience over many years now. I think this is a really key thing that were being proactive, because providers have a lot of gaps in their knowledge around these policies. So to develop a knowledgebased to support our providers i think is really important. Thank you. Let me see if there is any Public Comment . There are no Public Comment requests for this item. Well provide with discussion. Commissioner pating. Okay. My first question is this is implemented in june. So have we had any cases since june . So there has been i would say four or five cases that im aware of in which inquiries were made beyond solitary conversation with a provider. There is one patient im aware of who has gone through the entire process and has received the aid in dying medication. To our knowledge, this person has not yet ingested the medication, but has the medication. There have been other patients as happens in many of these situations some people decide they want to pursue aid in dying very late in their disease course and my understanding from working with hospice providers in the city, many people die in that gap period of 15 days that is required between the first request and the second request. So i know there has about cases that patients have passed way before going through the process. Sounds like we found means to provide the adequate pathways in the interim. I think its because this policy that our procedures have been in development. We were able to support the providers who were involved in that case, kinds of with the best guidance based on our policy draft that we have. So seeing what you have written, and the slides, it seems to employee that you it seems to me that you are will be developing specialists to provide or that would sign up and be willing to provide end of Life Counseling and the services, is that correct . And this would be a small team as opposed to the whole department being competent to provide this service . Yeah, i think just to put this in perspective, in speaking with colleagues who practice at Harborview Seattle who had the law in place for years now they have 17 cases in total in the system. So the number is going to be very, very small is our expectation. And so what we have the process that we have taken is to allow people providers who want to participate to voice that through requesting additional kind of trainings specific to the act. And then can get credentialed through processes. Related, would there be a team on the outpatient and team at general and team at laguna honda or a network of providers capable of doing this . The way the law is written, the attending physician is providinging longitudinal care. Were very fortunate to have service in our network to provide expertise and guidance as needed, but its actually the intent of the primary care provider, if they are willing . The reason were doing this survey of all providers, if case that particular patients pcp isnt willing a group of providers who have volunteered to serve as attending physician and any event that is needed is supported by both Palliative Care and Ethics Committee. I have seen it done as a consulting system and i think it has worked well, but soundses like that is not your intent at this point. You will be a little not diffuse, but a little more distributive. In number of locations and providers . Exactly. Would that be the same for the Mental Health providers to do the cognitive exams or backup . When the law provides for Mental Health consultation, if there is concern for competency and engaged our Behavioral Health teams, they wont be serving as attending or consulting i physicians as defined in the act. So lastly with regard to staff and staff either personal feelings about the procedure its an optin as opposed to optout . Exactly. Great. Commissioner loyce. Thank you for your very thorough and indepth presentation. Two things, one its an optin that you are not requiring folks to physicians to do this, but you are saying if you are interested, well provide the training and support for you to opt into the service and most important part for me is the fact that you are protecting the patient as best you can, given the set of circumstances that would make them even consider an end of life. I really appreciate that and thank you very much. Thank you. If i can ask one or two questions . One is the hospital considered a public space or not . Good question. We discussed atlength, given our very vulnerable Patient Population to selfadminister and ingest the medication and whether or not we would admit them to one of our two hospitals . We decided as a system, the Transitions Team would help us find a placement for those patients. So we actually at this point are not anticipating ingestion in either of our hospitals i apologize certainly not at zsfgh. Laguna honda is grappling with the issue that they have residents and if there is a terminal resident, that is their place of residence. That is considered because its a residence rather than versus at general you are saying that then it would not be you will be finding a different space . That is our plan. I was thinking, not only the homeless, but there are people who prefer that they might not want that happening in their own home. For cultural reasons. For cultural reasons. But would like to have it in a space. So it sounds like you are looking for an alternative there. Yes. Thank you. That was my one question. The protocol is very wellwritten for the system and commissioners what i have asked is that there be a resolution to note that this is a service that will be available for our Patient Population as an Important Patient right through the San Francisco Health Network. If you are not in the San Francisco Health Network, then what happens . If somebody were then to say within a this is my other question say a private sector that then decided this was really important and they had a physician who was not interested, i mean, something that the physician felt couldnt do, but physician felt maybe they could refer . Because now our county does offer this . Would there be some way that you make a connection as then a new primary or does the law require a certain number of months in service to be the primary or what . The law is silent in terms of the longevity of our relationship with attending physician. The spirit of our policy, it should be a true relationship. We are not interested in serving as a Referral Center for private physicians who are not partaking in that. So this is really a service for our network patients. So were kind of silent on that. I would also say that there are resources in the community of physicians who are Offering Services for a fee for patients whose primary care providers do not participate in the end of life option act and so we have been referring people the services can be quite costly. So its difficult for our patients who are in our network, but were providing access in our network. Okay. Thank you. Director garcia, did you have a comment . I was just going ask are any of our hospice units working with us on that . So we have in the conversation with laguna honda around providing access to residents we had conversations with the Palliative Care unit at laguna honda about whether that is an option . There are a lot of layers to the issues around staffs comfort in participating and so i think there is more work to be done in kind of investigating in laguna honda developing their own policies and procedures. I was asking about the freestanding hospice . To my knowledge, there are some of them that are participating. Thank you. Mr. Chair, i just had a question about the Advisory Committee as cited here and then we have the Ethics Committee. My question, does the Ethics Committee, does it include both medical and our health from either social workers, from both laguna honda and the general and the Health Network or is it what . I mean, i just wondered if, in fact, is it a standing committee, like for three years you do rotation and then whatever . Because the Ethics Committee could be a very, very good Due Diligence pertaining to how are we responding to each particular request . As you said, there are requests and there is time, and its all welldocumented and exceptional. But i was just wondering about the Ethics Committee because i didnt really much into it other than the fact there an Advisory Committee and i can see representation from everywhere, which is good. Yes. So i can speak most directly to the Ethics Committee at the general. Laguna honda has their own separate Ethics Committee, but i would say that most Ethics Committee by nature want to draw a variety of perspectives. So we have Community Members who are not hospital staff or part of our committees. We have people from a wide array of backgrounds, from legal backgrounds, social services, chaplain, physicians, nurses, et cetera. So the Ethics Committee we had representation from the Advisory Committee from our Ethics Committees and the Ethics Committee separately looks at the policy and made suggestions about language and other consideration, which we took into account in drafting the policy. And we did talk about whether we needed a mandatory ethics consult for every case that came up . I think the discussion the members of the Advisory Committee and Ethics Committee thought that would only be necessary on an asneeded basis if providers felt there was questions regarding corersion and overseeing the process of paperwork and things. I think were all on the same page. Yes. Very good. Thank you. Thank you very much. Thank you. Any further comments . If not, i have asked that we have the resolution available for our next meeting to discuss the support of the implementation of the program at San Francisco Health Network thank you very much for your hard work. Thank you, commissioners next item, 9, commissioners, which is other business. So the next item is no. What . No. 10. Well, item 9 is other business and i didnt hear anything, so well move to item 10. Right. Reportback from commissioner sanchez about the january 10th Laguna Honda Jcc meeting. I would like to make a correction. We had a member who was excused, but is reported here at the meeting, but she wasnt there. So maybe we could do that correction, please. Sure, okay. Okay. Unless i misread it wrong . Okay. Anyway, the committee the jcc met laguna honsad honda with a very nflative security update, reviewing the activitis, training and protocols that have been undertaken. And questions were asked and it was welldocumented update in protocol. Second was the laguna honda health at home annual report, which was really done indepth. I think the committee was very impressed by the quality of not on the work, but the presentations by a different cohort of our staff, who really presented some astounding data for us as a joint Conference Committee pertaining to our service area, and how, in fact, our staff are going to areas that many of our people in San Francisco thought we would never be that much involved. Its always been a different isolated area and what im trying to say, they give an excellent part with data, showing as an example, one of the most highvisited area was the excelsior and tenderloin and mission, bureau of alcohol, bayviewhunters point, places where we have training and followup. It was all presented with the breakdown of data pertaining to patients need and measures outcomes. It was so impressive that both of us, i know had suggested this would be an excellent report for the commission to hear in full, because this the numbers are going to be growing and the training and supervision that we have in this model i think is second to none. So it was an exceptional presentation as i said with our people and led by the whole hospital and by an exceptional leader, our nurse who was both here at general and at laguna honda and at the United States navy in charge of nursing services. So it was a great presentation to present before all of us. Last was the strategic goals and update on technology, and the hospital is upgrading its smartphone system. It will be used throughout the program, and we also reviewed in closed session an approved the credentials report for the medical staff. Unless there is any further discussion, that was the joint Conference Committee at laguna honda. Thank you, commissioner sanchez. Any further comments . If not well go on to the next item, please. Yes, item 11 is committee agendasetting and as a reminder again, commissioners that february 9th is the joint meeting with the Planning Commission to discuss the cpmc annual report. February 9th. 10noon. If there are no further items well go on to any Public Comment on the closed session . I have not received any requests. Okay. Motion is in order to vote on whether to hold a closed session. So moved. Second. All those in favor, say aye . Aye. All those opposed . The commission will now go thank you were now back in open section and a motion is in order to vote on whether to disclose any of our discussions during closed session. Motion to not disclose. A motion not to disclose and second proposed. All those in favor, say aye . Aye. All those opposed . We shall not be disclosing the discussions at the closed session. Is there any other business before the commission . If not seeing any, a motion for adjournment is in order. So moved. And second . Sec. Second. All those in favor, say aye . Aye. This meeting is now adjourned. [ gavel ] thank you Womens Network for sustainable future. San francisco streets and puffs make up 25 percent of cities e citys land area more than all the parks combined theyre far two wide and have large flight area the pavement to parks is to test the variants by ininexpensive changing did new open spaces the city made up of streets in you think about the potential of having this space for a purpose it is demands for the best for bikes and families to gather. Through a collaborative effort with the department we the public works and the Municipal Transportation Agency pavement to parks is bringing Initiative Ideas to our streets. So the face of the street is the core of our program we have in the public rightofway meaning streets that can have areas perpetrated for something else. Im here with john francis pavement to parks manager and this parklet on van ness street first of all, what is a parklet and part of pavement to Parks Program basically an expense of the walk in a public realm for people to hang anti nor a urban acceptable space for people to use. Parklets sponsors have to apply to be considered for the program but they come to us you know saying we want to do this and create a new space on our street it is a Community Driven program. The program goes beyond just parklets vacant lots and other spaces are converted were here at playland on 43 this is place is cool with loots things to do and plenty of space to play so we came up with that idea to revitalizations this underutilized yard by going to the community and what they said want to see here we saw that everybody wants to see everything to we want this to be a space for everyone. Yeah. We partnered with the pavement to Parks Program and so we had the contract for building 236 blot Community Garden it start with a lot of jacuzzi hammers and bulldozer and now the point were planting trees and flowers we have basketball courts there is so much to do here. Theres a very full program that they simply joy that and meet the community and friends and about be about the lighter side of city people are more engaged not just the customers. With the help of Community Pavement to parks is reimagining the potential of our student streets if you want more information visit them as the pavement to parks or contact pavement to parks at sfgovtv. Or. clapping. in 2013 San Francisco legislators newsom agreed to allow the reciprocate of our soft story buildings those building house one and 20 thousand resident a program of that collect requires extensive outreach and this continuation of that process who is here and bill graham the perfect venue so in 2014 we have the first earthquake retrofit a huge success were repeating this model what weve done it put together venues that are time professionals and contractor are financing institutions a other services that help people comply with the retrofit and as you can see the thousands of members of the public their assessing over one hundred vendors to comply with the ordinance or make improvements on their property i came to get specification information and puck h picking up information if you dont know what twaur doing i take it overwhelming. Were pleased a Critical Mass of people are keying into knowing their relents and understanding what had are the next steps to take and theyre figuring out who to talk to not only the contractor by the mustards and the architect and the Structural Engineers and getting the full picture of what options are necessary and being proacti proactive. So im very pleased to see the soft story buildings 99. 9 percent complies the highest of the program of this scale of the history a citywide effort high Blood Pressure in every stretch of San Francisco to understand real risks associated with earthquake and those are universally agreed on. At some point you need to gather information ill be talking to another engineer to come out and take a look at it and basically get a Second Opinion im for second and third opinions it is inspiring to see all the Property Owners that want to do the right thing and for proactively figuring out what the solutions to get them that. What is amazing to me here we are over two years of first retrofit fair and at the time we are rh2 out to contractors to help us and reaching it out to Design Professionals that soft story buildings is in any and people understanding how to comply now it is different an industry that springs up as a result of the their professed and gotten the costs down with lower Financing Options and these are defined and now the gene progression and have the buildings are buildings and the compliance we understand the 2020 one and 20 thousand San Franciscos 15 messenger of our population will live in a retrofit building those people buildings or lives in buildings with 5 or more residential building is soft story and wood frame and built before 1978 that house that one and 20 thousand san franciscans. San francisco is being the leader in getting in done and as you may know los angeles passed their retrofit law two months ago at the sort of taken San Franciscos lead on the one and tenth anniversary as the residents San Francisco this is a road map to the city and going to give us us plan are these to keep folks here on a disaster and steps to build a resident waterfront by 2020. This involves more than one and 80 individuals and over 60 nonprofits and other companies this is a huge plan and what are the challenges we realize that people are concerned about climatic change, Sea Level Rise and not only the affiliated hazards but things hike youre our amp infrastructure and consumed by social and other things we see this in society everyday and how we try to mitigate those are ultimately a direct result how resident we are after earthquake other issue out of the strategy of the concept after a major earthquake of keeping 95 percent of population here in San Francisco thats the single best thing to help a equitable recovery to keep people here keep people back to work and kids in school and a residents of normal after a disaster. Alliance energy in our partner undertook comprehensive bid process we interviewed a halfdozen of folks who wanted to have a part of our soft story buildings are ordinance so Alliance Energy project programming is a clean assess energy a special financing that is done using the taxed authority of local multiples and one of the interesting features the loan is tied to the property not the vital if an individual didnt have good credit but it is another option for people not able to comply to find another avenue the assessment is actually places on the property and the builds for in that come literally a line item on the tax bill thats how you pay off the segment and tax. 20 or thirty years is all paid up front there are advantages your property tax well it is important to give people on option and many private banks that provide loans over a are shorter term we wanted to create a longer pay back term. I think the next step for Property Owners after at the create themselves to take the plunge and quit the working downey done and have works of work done right of the right rest of the Property Owners can understand this process across the city. We need to do it. It is safety you know thats the bottom line safety. Earthquake safety a everybodys responsibility that is providing the resources that people need to get done if you want to know more of the resources as a san franciscan sfgtv meeting of the Historic Preservation commission occurring on january 18, 2017 will begin shortly. Wednesday january 18, 2017. Our first meeting back from the break, so happy new year. The commission does not tolerate disruption our outbursts. Please silence the mobile device squz when speaking before the commission if you do state your name for the record. Like to take roll. Wolfram, herement hi lnt, here. Hasz, here. Matsuda, here. Pearlman, here. We do expect commissioner johnck to arrive shortly and commissioner johns to be absent today. First is general Public Comment. At this