Going to be modified . And how soon will you be establishing those . Are they in the same priority that was mentioned in terms of which ones are going to be focused on first . I would say it is in the same priority. So backing into it, our goal is, by the start of the next fiscal year, july 1st, to have established what those metrics are so we can begin to collect that data right away and report on it. In order for us to do that, getting back to january, we need to have some sense of which ones are looking like they are going to be doable and validated so that we can come back to the table as a network and say, okay , here is the potential universe of data that has been validated. Of this, how much of this support are true north pillars and particularly some of the metrics we have already identified . We feel the metrics we have now are appropriate and has been a 1 1 match within epic in our pre epic sources, we would be continuing along that journey anyway. So it is not as if were looking to change the metrics we have, it is just a matter of can we keep them and reliably get the data for the ones that we have. Thank you. And i understand that there are going to be some that lend themselves to this later, but with regard to quality and Care Experience, i know some of those are going to be based and others are not necessarily. Im just concerned that you were not just developing metric measures that are just about the regulations because, again, given the population that we have in San Francisco and some of the uniqueness around our Delivery System, and the needs and the way things are structured, that we are looking at quality and Care Experience measures that are really getting at what we need with regard to the kind of care we want to provide to our patients and our residents, and then how thats related to the needs with the workforce, some that have been expressed today, but that also are going to really need to be modified in relationship to those other measures. Right. That is a good question. I answered that by thinking about the investments weve made with our workforce over the last few years, particularly in terms of training and trauma informed care, training and racial ability, and the focus we have had the last two years in terms of Behavioral Health and homelessness, i think because of all these efforts, those will help inform the metrics that we choose, so i take your point very clear that we have to go beyond just baseline of whats required, but as i talked about true north being the head and the heart, particularly here in San Francisco, knowing that we have two choose metrics that also tear at our heart and our sense of the populations that we take care of. And really so were not just focused on process, that we are really looking at outcomes across a range of environmental conditions, both in consideration of the workforce, as well as in consideration of patients. I agree. Dr. Colfax . Thank you. I really want to acknowledge roland and his team. It is a huge amount of work and oversight. And we see we are making progress. We are not where we need to be yet. I also just want to acknowledge the commissioners comments about not just process. Some of these metrics are really important because it gets you to the outcomes and also we needed to expand our work in terms of the populationbased approach. So what we are doing the clinics in doing the hospitals is really key, and when we look at health equity, when he to make sure we are bending the curve of the population model. Having the population work within the network side, and we are strengthening other data systems, we can focus on the data science as one of our key areas going forward. We will continue to move in a good direction. Wall where we are compliant with the compliance requirements, but we are also meeting the needs of the community and our metrics are driven by what we need to do in those areas. I appreciate that. Thank you. Dr. Sung . [indiscernible] good afternoon, commissioners my name is irene sung and im the acting director of Behavioral Health for San Francisco health network. Today i will present an overview of our services, a followup on the action items presented by the previous director to the board of supervisors performance audit in 2018, and then finally touched on some significant changes that are coming down from the department of Healthcare Services as they propose changes to the medical Delivery System program and payment. I will be followed by another doctor to talk about changes with Mental Health reform. That will happen after my presentation. San Francisco Health network, Behavioral Health services is the largest provider of Mental Health and Substance Use prevention, Early Intervention, and Treatment Services in the city and county of San Francisco our total budget sits at about 384 million last fiscal year. 800 budgeted civilservice f. T. E. , but that includes not just clinical programs, but also i. T. , building, compliance, quality management, contractor facilities, all the infrastructures that keeps our system running. Over 80 c. B. O. Contractors will also provide a bulk of the Behavioral Health services. I do want to say we did receive your questions, by the way, and i tried to incorporate them into the presentation, so if you dont get them, ask me again. Thank you. We do hope we do hold two concepts. Many of our clients suffer from longterm chronic conditions such as schizophrenia or complex trauma that can span generations these are not unlike other chronic illnesses such as diabetes. Like diabetes, theres often no cure, what treatment can help to manage the onus and prevent complications and negative outcomes. It is important to remember that change is hard. It takes an understanding that theres even a problem in the first place and then times to build enough of trust in a relationship with someone to accept that changes needed or even possible, wherever they are in our continuum of care, whether it be voluntary or involuntary, we work with each individual to support the change that will help them move forward with their lives. Change does not happen in a straight line. You think about any time that someone you know or you, yourself, is determined to change something, maybe start exercising regularly, i have done that. And even when we are committed to make the change, it doesnt always happen quickly. We take two steps forward and one step back. There are relapses, and we work to support each individual or family wherever they are in their stage of change. And with this we know wellness and recovery is possible. We have seen people progress in their lives, build relationships with family, friends and community, and continue to support their wellness. So it is with these key concepts in mind we align our mission and vision. Our mission is to maximize the coverage and wellness and potential for healthy and meaningful lives and our clients communities. Our vision is a Behavioral Health system of care that is welcoming, culturally and linguistically competent, gender responsive, integrative and comprehensive. We value time and access to treatment where any door is the right door. One thing i did want to say is we are rethinking this idea of doors. Much of our Behavioral Health services in ambulatory care are set out by individuals and families. At the same time, we know that there are individuals who we believe would benefit from our services who dont walk through our doors. So while any door is the right door, we are really rethinking this and how to expand our services to treatment and outreach beyond doors. Our overarching goal is still supplying for clients to be thriving in their natural environment. So what does it look like in San Francisco . We have probably seen this before, the upside down triangle , im sure. Our i will go through this quickly because you have seen it in two systems of care, there is the adult and older system of care, the children, youth, and family, Mental Health system of care and the Substance Abuse order of care. There are services that actually bridge these Service Lines like translation, for example, is a good example where children were not able to move into adult hood easel easily and they needed Specialized Services to move them to make sure they can actually retain services. Within each service, within each system of care, there are levels of care from prevention, Early Intervention, to outpatient treatment, to residential, crisis, and you move more into the involuntary services on hospitalization or locked facilities. We really try, most of the people that served at the top are voluntary services and we really try to actually serve more people at the top rather than where it is involuntary. Fuhr for fewer clients and it is much more expensive. The intensive Case Management sits within our Outpatient Service delivery. And entry into our services, most of the entry comes in through Outpatient Services. You have heard of the Behavioral Health active centre which they are trying to expand. They move into outpatient and they are are also people who enter through our crisis programs. They do come in that direction and we hope that we can move more into the voluntary section as possible. This includes Specialized Services, which i talked about, like transitional age youth services. It is growing and becoming its own system of care. We serve nearly 25,000 lives, 25,000 people in our systems of care. I know that the number 30,000 has been brought up in various places. The 25,000 here are really people that we are serving in our specialty Mental Health system of care that we can capture. There are other Behavioral HealthServices Provided in primary care, in jail health, which arent captured in this number because they just dont use the same Electronic Health record system. As you can see, theres a lot of attention to homelessness. I have the homeless numbers up there as well. We provide more services to adults then kids, but it is important to remember the kids are not just the kids of the families, too, that we serve and their numbers are not reflected there. Most of our Substance Use services are provided to adults, and you can see the homeless percentages on the far righthand side, and the 59 are Substance Use clients who are homeless. An important number is the overlap, and that overlap number are the people who are being served by both our Mental Health system and the Substance Use system, almost 2,000, 71 of those clients are homeless. In addition to the Treatment Services, there are other prevention, Early Intervention fronted services, schoolbased services, where we dont actually open up charts on each of them and that is a large number. The last number i saw was about 50,000 people. Our demographics. I dont know if you need me to go through them. Children services, the latin next population is probably the largest served in our system, and then the next is africanamerican, asian, and caucasian, and it is smaller for native american and other groups and there are substantive services that more caucasians are provided in our systems of care then africanamerican. We pay very close attention to demographics and we know the disparities that exist in the system. For example, we know certain groups are overrepresented and others are underrepresented relative to the census. So in december of 2018, we created a new office of equity and social justice and multicultural education to really focus on equity, diversity, and inclusion. We worked with our systems of Care Development equity work plan to address gaps across services and develop an equity improvement work group to look at root causes of identified disparities. Our equity director works very closely with dr. Bennett at the department level. You know our director who is leaving us to another county, unfortunately, but he has built a system that will be able to continue on after he goes. Our gender numbers, we can go through them. 1 transgender patients, and then more males than females in the system. And our budget. These are our total expenditures for your 1819. These two pie charts depict our budget from two different perspectives. On the lefthand side our expenditures by systems of care. This is all levels of care from prevention, Early Intervention, all the way up to facilities. You can see the bulk of the expenditures are within the adult and older adult services. The second pie chart is really reflecting the Funding Resources , and most of these funding trends are subject to regulation for guiding who can be served and what services can be provided. For example, medical does not pay for outreach. It doesnt pay for integrated care. And integrated Behavioral Health homes. And another example is even things like these lockouts. If you are a case manager and have a client to get hospitalized, if you visit that client, that is unfunded. You have to maintain a connection with that client. Our general fund is used to cover these services that are unfounded or Cover Services for clients that are not eligible, for example, immigrants who are not eligible for medical. So the next portion i would like to address the board of supervisors from 2018. Our previous director has presented the Behavioral HealthServices Plan for addressing some of these key issues that were identified in the audit. I will not repeat his presentation, but i will provide updates to where we are with each of the plans. As a reminder, there are four key areas that he addressed. One was around provider performance, second was around access to intensive Case Management, third is on transitions really focusing on psychiatric Emergency Services, and the fourth was around adults who do not stabilize. Those are the focuses and the folks that we are having troubles reaching. [indiscernible] the red is [indiscernible] and the black is [indiscernible] it was presented the last time we came here. So the recommendation is having to do with the performance and one of one thing he implemented was an annual Program Review and random audits that was something that was implemented last year in 2018. We had hoped to put in realtime Performance Analysis using a Business Intelligence system, however, with implementation and a lot of new requirements coming down, we have really had to divert a lot of that attention and resources to meeting those requirements. I really appreciate what you have said about outcomes versus regulation because much of the reporting requirements is really process reporting, timely access , recidivism. [indiscernible] we have 60 process measures that have to track from a monthly or annual basis. It takes a lot of staff time. That is really where the majority of our resources have been devoted. The only outcome data which is required is Substance Use. [indiscernible] even those, we are not required to report the outcome data, which is required to report that we did. So its interesting that this is where all our resources is going just to keep our funding going. We actually did make a choice to do the [indiscernible] we do report that out quarterly on our website. That is it right now for what we do if you look at the outcome data. We are moving this year towards true north metric and to define our work and helped drive the improvement. An example of this is we are trying to move forward on and have some data, but it is not presentable yet. We would look at the percentage of people who are leaving and engaging in outpatient treatment , county people have left. These are new kinds of measures for us in different from what we have been required to do. We have also built in a tracking of people from the civilservice clinics. We have seen improvements improvements since the board of supervisors audit. We have seen a steady increase over the years, an increase of productivity by about 38 . Right now productivity, our current target is 60 of scheduled work time to be in direct, patient billable services. With regard to documentation, to improve documentation, we have seen a lot of challenges. We did create a document online. Our specialist did provide Technical Assistance in clinics and more broadly for the entire system. Unfortunately, there were times in january of this year where we havent been able to continue that. Their position is prioritized to fill it. One thing i did want to say is though we have completed many of these action items, we really do continue to have compliance issues. We are going to get a formal report from the compliance auditor in a few weeks, but