The other water flooding out possibly that could be drained back, pumped back up. I dont know what that is going to do. We have ground water and no explanation as to what is going to happen to the existing ground water. There is one final point. I think that we can possibly look at saving the nation. It that a big answer and a lot of people are looking at. When i went to p. U. C. , they use estuary water, not oceanside water which has a lot more brine. Thank you. Any other Public Comment . Seeing none, it is closed. Item 11. Public comment . Seeing none, new business is closed. Item 12 new business setting. Any Public Comment. Seeing none, Public Comment closed. Item 13 communications. Any Public Comment on this item . Seeing none, Public Comment closed. Item 14. Adjournment. So moved. Second. Those in favor. Aye. So moved. Thank you very much. Sfgovtv sfg. The San Francisco Health Commission is called to order. I will call roll. [roll call] clerk the second item on the agenda is the approval of the february 4, 2020 minutes. Commissioners, after review, does anyone have a motion to approve . Motion to approve. Second. All those in favor . Okay. Clerk thank you. There are no Public Comment requests for that item. Item 3 is the directors report. Good afternoon, commissioners. Gra grant colfax, director of health. You have the report in front of you. Just a couple of things. One is we are continuing our covid19 preparations and actions. Ive asked dr. Aragon to provide more details after my report, so he will be doing that in just a minute. We are continuing with our ongoing daily work, and that includes Behavioral Health options for people in the city as part of our Behavioral Health reform as part of health s. F. We are currently establishing a health center, to be established at 180 jones, with a particular focus on methamphetamine users. This will have a 15bed capacity, take care of many more than that over a 24hour period. This is really the beginning of a larger expansion if this initial phase is successful at providing more lowbarrier opportunities for people to have a place that is safe, that provides Harm Reduction approaches and also not only helps them but also mitigates the effects of Behavioral Health issues in the surrounding community. Im proud to announce an expansion of our hummingbird work. This is a pilot model that weve launched in the recent past, and were now looking at 36 valencia with 25 beds. A key issue in the city has been the issue around boarding care, and supporting boarding care. Weve had a number of boarding cares close in the city in the last few years, and we have a number of boarding cares going forward. So just a lot going on in terms of that, creating more beds, and more infrastructure. I also want to say that tonight is black history month, and a key focus across the department has been black African American patients in the community. We have a number of articles that you can read at your leisure. The Lunar New Year parade was particularly relevant this year because of concerns of covid19, and we know that with misunderstandings with regard to how covid19 is transmitted and the people that are at risk, theres an element of stigma and discrimination with this epidemic, and were concerned that were doing everything we can to mitigation that mitigate that, including having a very robust presence at this event. Another event was the hearts in San Francisco event, which is really celebrating the work thats being done at zuckerberg San Francisco general hospital. There was a discussion around Behavioral Health work and strengthening our behavioral work. A number of key faculty were highlighted and honored, including, im proud to say, the social medicine team, and the staff there. As you know, dr. Deb bourne and some of her team launching that across the department. So there are lots of news reports. The d. P. H. Was in the news quite a bit, particularly with regard to covid19 and the expansion of our health work. And i will just ask dr. Aragon to give a brief update on the everchanging dynamic situation with regard to covid19. Good afternoon. Thank you. The first thing i want to point out is the number of confirmed cases globally is over 75,000. Currently, there have been over 2,000 deaths. In the United States, we have a total of 29 cases. I want to explain what i mean by 29 cases. 15 cases the 15 cases i reported last week were people that were infected in wuhan, china. 13 of those, two were spouses. And then, 14 were infected near china. These were the Cruise Ship Passengers that just returned, so the total is 29, but there has not been any documented Community Transmission in the United States at this time. California continues to have six cases plus two of what are on military bases. San francisco continues to have zero cases. I want to point out that the virus has been named sars ii but its been officially named covid19. The virus that causes covid19 is sars cov ii. I also mentioned the repatriation of 14 passengers from the cruise ship in japan. We realize were not able to contact everybody, but were doing the best we can. And the other thing i want to mention is weve been doing site visits to hospitals, making sure theyre prepared there there be any transmission. In San Francisco, were preparing for the time when we would have Community Transmission in place. Were focusing on transmission, containment, and then, community education. If theres ongoing transmission, what would we do in that scenario . Thats what were doing. The last thing i want to mention is because there are no cases in San Francisco and because there has not been documented Community Transmission in the United States, we continue to have the same advice that we had before, so its business at usual. So thats the last thing thats it, unless theres any questions. Before we move on, i just want to take the opportunity to acknowledge you three. Because of your expertise and your preparedness. A lot has been asked of San Francisco by the c. D. C. And others. I know folks have been putting in very long hours, whether its doing outreach or addressing xenophobia in the community. You all deserve acknowledgement for this Additional Task that youve been doing in addition to everything else. So thank you to everyone in the department and for really helping to keep the public and the community informed and feeling safe, so thank you for that. Commissioner girado . I want to echo that. I have one question, and i need some words for you, okay . Sure. If i may. At our Child Development center where we do treat medically fragile kids who are on m. G. S or g. 2s, etc. , weve had a number of families cancel because they do not want to come in to a place where there are a lot of people in that area. And they specifically state flu or coronavirus. Do you have something we can state to families on the phone, in your best way versus mine, to be able to give one versus the other . Yeah. We dont have any confirmed cases, and thats really important. Were about one week away from being able to do diagnostic testing. Itll be another week before the state starts testing, and then, our own lab is going to be doing testing. Testing is really critical because well be able to test folks and to provide reassurance and then also to monitor the situation. So i think having a lot of negative tests as we Start Testing people is going to provide that reassurance that things are okay, so thatll be a real game changer when we have a diagnostic test. So at this point, i should state these two facts that you gave me. Yeah, state the fact. Its important it is important to do that because i know that people do worry, and its natural to worry, so we just keep emphasizing the facts, and tell them to work on sthings th sthi things that they can do, like the vaccine and education. Okay. Thank you. Commissioner chavez . Yes, thank you. I also wanted to add and thank president bernal for his comments, and commissioner b gerardo. As an emergency, and i would say that the press here seems to have been more responsible, also, probably at the fact that you were able to communicate with the press adequately and be able to have a level of credence with them that they were able to give that message out that in our community in chinatown to have the department of Public Health to have dr. Colfax, to have dr. Aragon, to have dr. Faba, be spokespersons. And it looks not only at the medical issues that might arise from this, but also the social issues that were involved, and that the city took a very positive position that was important to have all of us continue. But the other thing was to continue good sanitation at this point in time, and if anything was needed later, i think the credibility of this department is such that theyre going to follow this and listen. But i did want to thank the Department Also for the very swift outreach and meeting the community. I think its very different from where 13, 14 years ago, when we had the sars. We werent as well prepared, and there was a lot more concern and hysteria partly from ignorance. That still extends through much of the world, and particularly, of course, in the areas that are greatly affected, by i noted, but i was very pleased to see how San Francisco is handling the issue. I want to acknowledge victor lim at the department of emergency management. Hes been partnering with rachel kagan and her assistant, veroni veronica vane, and they have been instrumental in bringing us to gordon lau to speak to the students and bringing us to the parents. Can i just i just also want to acknowledge the department of emergency management, interagency, interdepartment response, so i want to acknowledge that. And i also think with regard to many people in the department who have been mobilized for this effort, you know, theres many people who are working literally 24 hours a day, in some cases, on this. And i think acknowledging Susan Phillips who were here just a couple of weeks ago, presenting on Communicable Diseases, as is dr. Julie schulte, who are a Communicable Disease specialist. Theyve been doing outreach at the federal level and also community level, as well. And finally, dr. Pak, who is our director of the Chinatown Health Clinic has just been a really key part of our Community Response as well as our medical response. Thank you, director colfax. Commissioners, other questions . Thank you. I will note for the record that there were no Public Comments. Item 4 is general Public Comment. Just for you all to know in case you dont know how we work here, i toldhold a timer. When the timer buzzes, your time is up. Great. Fix request is from first request is from ron weidel. Good afternoon, commissioners and president. My name is ron weidel. I complained to you on february 4. I stated that that article would render my ability to be ever employed, and if employed, it would reduce my ability to earn what i earned here. While my resume has impressed recruiters and employers, i still have no job offers. As one recruiter explained it to me last week, he was able to show the recruiter and the employer my impressive background and how im an impressive fit for the position. However, the employer had read the article prior to the interview and said it came across me looking at sketchy. I have a career that includes 12 years of military service, 18 years of service with city and county government. Every employer who has hired me has found me to be a valuable and valued memory mer of management. I have no reviews less than exceeds or meets expectations. I have no discipline actions. I also have no negative perceptions with the exception of that examiner article of october 7, 2019. While i have some ideas why the department would orchestrate such an article, i have no proof. But it is keeping me from being employed and putting the welfare of me and my family in jeopardy. When they asked Senior Management why the article was created, they were told it was a mistake. In closing, im asking that you pass a resolution requesting that the examiner have the article unpublished, which would have the effect of getting it offline. Im going to leave a copy of my remarks with mr. Moore, should you desire. Thank you. Thank you, mr. Weidel. And i think someone from the audience looked like he was going to good afternoon, commissioners. My name is barry pearl. Im a San Francisco homeowner, a resident of the ingleside and district 11. Im not sure if this issue has been raised with you, but we received a letter from recology dated january 17 of this year. The subject is adequate service requirements. I called recology in response to this letter which indicates that basically the property was not maintaining the Garbage Service properly, that the cans were overflowing. And when i contacted one of the Customer Service people at recology, i was told that they were completely unaware that this letter was going out, that it was sent to all residents of district 11. Its very accuseatory, without any basis in fact. It should never have gone out to district 11, and id like to know why this district was chosen essentially as this Pilot Project. So i think your relationship with recology needs to be reevaluated, and you need to look into this particular issue. Thank you. Okay. Those are the two Public Comment requests for item 4. Item 5 is a report back from the community and Public Health committee today. The community and Public Health committee met today, just before this meeting. We discussed sb 5 and sb 40, and the local efforts to implement the conservatorship program. We discussed the Eligibility Criteria and also what we might expect based on data from previous years. The goal is to provide conservatorship for somewhere between 50 and 100 individuals in San Francisco based on the criteria with an effort to directing them towards permanent and stable housing as well as addressing some of their Behavioral Health and Substance Abuse issues. After that, we received an update on the Methamphetamine Task force. The recommendations of the task force included the meth Sobering Center, which was addressed by director colfax in his report. The recommendations were grouped into four themes. I believe there were 17 recommendations and those included investing in models to improve health and wellness, to build capacity and training for staff and service providers, and to strengthen coordination among City Services and systems. All right. We can move onto item 6, which is an action item, commissioners. This is a d. P. H. Report, the budget for fiscal year 2021 and 2122. As usual, were having two budget hearings in the month of february. This is the second, however, our format is different than in previous years thanks to a ordinance passed by board of supervisors across all departments on how hearings on the budget should occur. So last year, we did an overview on the instructions and our target, the mayors fiveyear budget forecast, and some goals and themes for the budget submission, and today, were bringing you a package of budget initiatives that show specifically how we intend to propose to the commission that we meet those goals and targets. So you have a set of initiatives in front of you that were seeking your approval for today to submit to the Controllers Office at the end of this week and then to the Mayors Office following technical amendments or technical analysis. So this week, we are seeking that approval. The budget process, of course, doesnt end today. Once we submit our proposed budget from the departments to the Controllers Office and Mayors Office, the Mayors Office has really a space of about three months to deliberate what weve submitted, to have discussions with us and other policy makers in the city about what the mayor and the Mayors Office would like their budget submission to look like, and then, the mayor submits a budget to the board in june, and then the departments submit their budgets. Weve got a lot to do until june, and in previous years, we were going to use that time in collaboration with the Mayors Office and other interested stakeholders. The biggest piece, as we discussed last week, was the Mental Health s. F. Program, which, as you know, was legislated in 2019 with the active involvement of the defendan department. It was an ordinance passed by mayor breed and the board of supervisors, and it was a robust ambition that we could tackle budgets in San Francisco. Were not proposing exactly what that would look like. What were proposing to do is use that remaining three to four months to work with the Mayors Office and other stakeholders to come back then with a proposal for what that first twoyear budget cycle of Mental Health s. F. Would look like. The scope of the the real vision for that program is going to take time to really roll out, and its going to take money to roll out, and those are both things that are still under discussion is whats the sequencing of how we approach this, and what are the Funding Sources there . The funding measures could include budget measures or other sources of revenue. We want to build the infrastructure and start to launch on this as soon as possible. So in the Budget Proposal before you, we are meeting the instructions from the Mayors Office, so that means were covering the revenue projected in the fiveyear plan, we are meeting our target for reducing the rate of our general fund growth that was given to us in the mayors budget instructions. And in addition to that, were attempting to leave some balance over and above our target that would be a starting point for kind of a down payment to begin building out some details of how that Mental Health s. F. Program will look like over the next several months. So that theme, a little bit of a different approach, we have used in some past budget budget cycles before the commission, but i think its an acknowledgement of theres still work to do and thinking and decision make to do about Mental Health s. F. As we go through the rest of the budget cycle. So ill turn it over to jennie, and were happy to take questions. afternoon, directors. Im jennie tam. The first two items were around revenues at zuckerberg San Francisco general. The first item is our baseline revenues, which youve seen in years past, and so im pleased to say that we project to continue continue to project Revenue Growth at the hospital, and one thing youll note is that in the second year, our projection does drop by 15 million. This is due to the current the expiration of the current medical waiver thats due to expire at the end of this calendar year, december 2020, and the state and federal government are in the process of negotiating a new waiver. However, the devils in the details on that, but our team is definitely monitoring all the changes that are happening at the state given the close contact. But given the fact that they dont expect the actual specific details until the end of this year, it makes it hard for us to predict which programs will continue, in what format theyll continue, in what forms theyll be implemented, how do the other counties actually factor in, because its not just San Francisco that are interested in these waivers. So with that uncertainty, were projecting a lower amount of revenue, but this is something well definitely revisit in the following year. The second is around s. F. G. Revenues. Basically, were projecting 69. 5 million of onetime settlements, and this is related to the waiver, as well. As part of the negotiation, the federal government says if california is interested in any kind of new waiver, it must close out all the old reports from prior waivers before the end of this year. Currently, for San Francisco, we have eight years open, starting from 0708 to 1415. Assuming there are no significant changes in our cost reporting, we do expect we will be able to release the reserve against those reports, recognizing that revenue to help us balance. The third item is laguna honda baseline revenues, and this is our annual baseline projections for laguna honda, and this does report a release date. Item 4, im excited about this. Commissioners who have been here for several years, youll note that for several years, 1617, weve been loggislogg away for Electronic Health records. Its an integrated system thats both clinical and billing. There were multiple systems, multiple incident faces that will all be replaced, and im pleased to say that for wave one, were expecting 11 million worth of savings for that. This is partially catching up on the cost of doing business, so were requesting a 5 adjustment on our base contracts just for i. T. , but that still leaves 9 million and 8. 6 million ongoing to reach our general Fund Reduction target for the department. 85, the next item, is related to back funding, population for federal Funding Health grants. Population health is pretty specific about receiving grants from the federal and state governments, but there were some grants that expired, and pilots that were expected, and then, there were some grants that supported our core functions. So theyve requested to backfill 1. 5 million related to grants that are expiring and not expected to be renewed. The last Revenue Initiative is actually one thats revenue neutral, and its around the San Francisco health net work creating its own Specialty Pharmacy. This is a new program that would actually allow for the network to create a Specialty Pharmacy for patients with complex needs. This isnt just penicillin, but h. I. V. , oncology, antipsychotic drugs. Its a real hightouch population, and its a need that we see in the community. Based on our projections, we believe that we could cover recover and still provide the services for the community. It will take about two years to fully implement. The next cost is 3 million, analyzing the 8 million, but recognize many of these costs are having to do with contracts with smaller pharmacies to fill these requirements. We are centralizing our Quality Management program at the two hospitals, at laguna honda hospital and San Francisco general. This is being driven by three reasons. The first, as you know, drrp deficiencies found at laguna honda hospital with the discovery of patient abuse and diversion of nonpharmaceutical drugs. Secondly, with the implementation of epic, we found that the work flow has changed significantly, and to ensure that we are sort of maintaining best practices, we need to augment staff. And then third, in the last several years, the center for medicare and medicaid studies have been increasing its regulatory reporting requirements. These three events have caused us to think and rethink our Quality Management, and so we are centralizing, and so it is all under the health net work as opposed to having the central the hospitals having their own individual programs, and both the programs would report to a single q. M. Director, and this allows for a standard report and also allows for assigned separation of the g. M. Versus q. M. Versus the operations at the hospitals. In addition, to support our own requirements on compliance and privacy affairs, were going to be adding two positions to that program, just to make sure that we are maintaining and keeping up with all the regulatory requirements there. Next, we have three new Maternal Child Health equity initiatives. These initiatives are really focused around around birth and young families and pregnant young women, particularly from communities of color. Whats interesting about these programs is they really touch on three narratives. The first one is perinatal, and it provides basically Community Support and engagement for for expecting and new mothers. The second is a Doula Program that, again, supports women that have been identified by a Maternal Child Health program that would be interested in additional care and support during their pregnancy and shortly thereafter. And last is the abundant birth program. Its a financial Payment Program for women who are expecting. And so and women of lowincome that are expecting, and it actually is an income supplement program. And so when youre looking for these three initiatives, were looking at creating a community with the Financial Support and with the care, and that is sort of this multipronged approach that were looking at in terms of Health Equity. Because if we can intervene early on, thats where were going to get the most bang for our buck. These are interesting pilots and well be interested to see the impacts of them in the future. Next, we have operation and the census at San Francisco general. As you know, since weve opened up the new San Francisco several years ago, our census has been about budget, and so weve been running at a high census. And we recognized this in 1718. We created what was called the census project, which was sort of a pot of funds which would allow for the s. F. G. To tap into should it be going over census. But what it didnt provide was actually permanent positions, and so we now fast forward three years into the new zuckerberg San Francisco general, what were seeing is that our census projection isnt really dropping. What we hear is we want to operationalize the census that we have, add permanent positions, and were supporting the operations in three ways. The first is were going to be opening up a new med surge unit. Theyll be funding to flex up to 15 beds annually on average for im sorry, up to 15 beds per hospital policy, but it has permanent nursing positions to staff that adequately. We need to support our ancillary services, so we need to support Food Services and environmental services, including porters just to sort of maintain the hospital operations. And lastly, well be budgeting permanent licensed psychiatric technicians to support the e. D. To make sure that were meeting the hospital requirements around observation of clients with some acute Behavioral Health issues and be able to intervene as needed. Lastly, were our goal is really around workforce and supporting the work that we do, we have a lot of existing operations, and our goal with these with proposing 20 positions, supporting all aspects of h. R. Is really to better support our h. R. Operations. This is really just about getting supporting the operations, but what it does is it enables us to take on new initiatives, including Mental Health s. F. As well as meet the regulatory requirements at zuckerberg general and laguna honda. So when we take everything into consideration, and when we look at some of the Revenue Growth that was already assumed as part of the deficit, we see what is proposed as a surplus of 7 million. What we would like to do with this surplus is to put it as a down payment for Mental Health San Francisco. Again, we dont have the specific details of how we would implement that. Were working on an implementation plan, working with the Mayors Office for her budget submission. But with your approval, this is what we would like to do. All right. So as mentioned before, well be requesting your approval, and well be requesting programming, which can include all of these items, Mental Health services, drug sobering, street outreach and infrastructure included in the legislation. A few commissioners have asked me about wage equity in our department, and its a reporting requirement as part of the minimum compensation ordinance, and im pleased to say that the department has been involved with the Planning Efforts around the minimum compensation ordinance. For the commissioners that arent aware, its an ordinance that increases the minimum wage for employees on city contracts. So what this does for the current year, it increases the minimum wage from 15. 50 to 16. 50. The city participated in a process with the controller and nonprofits to sort of plan for the impacts of the minimum compensation ordinance. That is a citywide process that was represented also by the Human Services agency and the Controllers Office. As a result of that, that committee made recommendations on how to address both of direct and the indirect impacts. So when we say direct impacts, its literally that change in the base wage, from 15. 50 to 16. 50 an hour, if youre making 15. 50, and reporting to somebody who made 17, theres sort of a compression issue. The controllers went through a rigorous application process where we notified the pool all of the funds were available. Nonprofits actually submitted applications to the Controllers Office, and through their evaluation, they allocated the department 1. 2 million that will be ongoing in our budgets to address the facts of n. C. O. We are expecting a 2. 5 increase for the cost of doing business also for our city contracts. Weve been receiving 2. 5 to 3 for the last several years. C. P. O. S are free to allocate this as they feel is appropriate, so they could use it towards wages or rent or whatever they believe is most appropriate for the organizations. All right. So the next step is we submit on friday, but we are not done. Well work with the Mayors Office over the next several months. On june 1, the mayor will submit her balanced budget, and we will go through the board approvals in june and july. Thats all i have for you at this time, but im happy to answer any questions you may have. All right. Before we go into questions have commissioners, we do have four requests for Public Comment. The first, taken in order, is mary kate buckelew, and after that is anthony carrasco, wesley reagan, a. Hi. My name is mary kate buckelew. Im here to support hespas budget asks and our Behavioral Health bucket. There are three asks that were making this year. One is for an Overdose Prevention site. They basically let people use under clinical supervision and access counseling and referrals and cares. The second is Transition Youth Services for transitionaged youth or t. A. Y. The request is for a t. A. Y. Residential center. We dont have ongoing funding. So the Overdose Prevention site would be about 2 million, and the special treatment ongoing operational funding would be about 1. 4 million. And i also just want to put in im very grateful to the department for the budgeting around the m. C. O. And codb, as a member of the Human Services network, were always pushing to see the deficits that were seeing across the nonprofit organizations are properly funded. It would be great to see the investments in the codb as well as the increase of 4. 3 . Thank you very much. Thank you. Hi there. My name is anthony carrasco. I work with mary kate over at p compass, and for the city of berkeley, i serve on the city Homeless Panel of experts. Maybe something that you might not be aware of, if you engage in conversation with someone about the topic of family, studies have shown that theyre dramatically more likely to have a strong sense of connection with you, and its a very, very interesting phenomenon. I have a hard time talking about family. I dont come from a very good family. My family experienced homelessness for about ten years, and Substance Abuse took one of my brothers away from me. But got to go to u. C. Berkeley, and i get to have a nice job now, but i do want to advocate again for some of these Substance Abuse issues. Youre all here because you care. Youre all here because some of this impacted you, and i just hope that other folks can be able to engage in conversation about family like anybody else. So the last thing im going to say is the ask that hespa are putting forward are completely in line with the Mental Health s. F. Initiative, and i hope that youll consider supporting it. Thank you. Thank you. Thank you, commissioners. My name is wesley saber, and i am the project manager with glide, and im speaking in support, to, of the hespa budget requests. Significant gaps persist. These result in long waits for shelter and housing, unmet Mental Health needs among homeless people, and a lack of exit from the Emergency Shelter system. Young people, too, need safe places to sleep and places to meet their needs. We desperate we i want to focus in on the Homeless Youth population. Current estimates suggest there are 1,145 transition age youths on the streets and in transition shelters. Among the Homeless Youth population in San Francisco, 76 of unaccompanied youth under 18 and 8 3 of transitionaged youth need shelter. Homeless Youth Experience major psychiatric disorders at rates up to 4 times higher than their peers, and 31 identified areas of Substance Abuse as a homeless need. Addressing homelessness is widely viewed as a preventive strategy up to 50 of chronically homeless adults are estimate today have been homeless as youth. Homelessness now translated to homelessness later. We have fantastic youth providers in San Francisco such as the Homeless Youth alliance, and larkin youth street services. Thank you. Good afternoon. My name is marny reagan. Im the director of larkin youth street services. Im here to support the hespa budget ask. It would use a model that sbienz substan sbienz combines Substance Use treatment and counseling, capturing youth through early intervention, screening and referral and decrease or eliminating substance misuse while increasing wellness through clinical intervention. Currently there are no programs to serve the needs of transitional age youth. There is tremendous need for both residential need for transitional age Homeless Individuals suffering from severe Behavioral Health needs. The two are linked as one is not successful without the other. As individuals churn through the systems, through the hospital and back on the streets, this is a key intervention to halt that cycle. Thank you. Thank you. Commissioners, questions . Commissioner chaplin . Yes, thank you. Thank you for the very comprehensive explanation of the budget initiatives. Im struck by the fact that we are looking at a total budget of almost 2. 5 billion, and therefore, our target, there, as you have pointed out is somewhat less, of course. Its a 3. 5 , right, per year. Correct. Which is therefore and that will equal 141 million over the years. And so i think what we would what i would like to look at is the thought that has gone into the initiatives. Im assuming that we have carefully been evaluating the different programs that we already have, and i guess the first thing, though, if youd answer, when you brought up the wage equity initiatives, this is in addition to this or its already been incorporated into the total cost, and likewise, the cost of doing business. Are those additional amounts that we dont have to count for or that have come from the controller or is it in our budget . Thats correct. The 1. 2 million and the 6. 6 million were expecting for the cost of doing business are in addition to the proposal you see before you. As you know, theres a number of costs that the city looks at overall in addition to the cost of doing business, m. C. O. It is our staff wages, Health Benefits, fringe benefits, and what you havent seen it the impact is the impact to that because thats sort of centrally managed by the Mayors Office and Controllers Office i do think thats an advancement in our budget here because perhaps in the distant past, those had to be absorbed by our budget. So i thank the Mayors Office for such instructions, really. Okay. So if we can go and im sorry i wasnt here at your first presentation. Im sure it was excellent, so ill only look at the budget initiatives and ask several questions maybe you had already answered them in the previous meeting. And in particular, the first one is i the estimate of about 38. 5 million additional in general revenue seems very large; so could you put that into a perspective . What percentage is that increase . I know its in here, ive read it before, but i cant quite remember. I mean, thats a big piece here of our budget balance. Well, i dont have the exact figures with me, which i should have. But so of our 2. 4 2. 3 to 2. 4 billion budget, about threequarters of that is revenue based. So actually, in the grand scheme of things, if you take our revenues together, and were at 1. 6 billion or so, this 38 million is significant. Its big. Its a lot of money, but its not often that we see in terms of how its increasing or how it comes through the various state and federal programs. So a couple of things that you are seeing in these rates is that we have or in the revenues that are in front of you are we have continued for the last several years, and you see it in our financial statements, to outperformed our Service Budgets in our fifa revenues and our budget revenues. Those are kind of the core waiver programs. Were conservative in those estimates. A portion of this revenue increase is us shoring up our revenues to what were seeing in terms of our actuals in the prior years financial statements, in the second quarter, the previous years financial statements. Well have those to the commission shortly. As generally described jennie described, we are budgeting a back down, so its not a yearoveryear, but its less aggressive, and that is us trying to be conservative for the reason that jennie described. We have a lot of moving pieces in terms of the current medicaid waiver, which is about 150 million in revenue for us. We dont know exactly what thats going to look like. In prior waivers, weve done better or worse, depending on the waiver and depending on the subbucket of money within the waiver, so we are anticipating that well have pieces of our waiver funding continue, albeit in a different form, but were trying to leave ourselves both a little bit of room, both to be conservative if something goes wrong, and frankly, so that next year, when were back here, if things go right, well have a little bit of room to work with. Okay. So if i may ask several more of them and i agree. I did find also that youre putting in 13 million of new revenue from the graduate program, is that right . Yes. Well, your first year. Thats correct. And then, the second year, youve dropped back. Yeah. Thats a new funding source. Compared to the 1. 6 billion thank you this is a smaller amount of money. It looks big it is big. It is. But i think at one time, when we started on this commission, we were under 1 billion as a total, and these numbers are just sort of shocking to me sometimes. And so when youre speaking oh, let me go onto actually the expenditures. On the expenditures, we show a considerable number of f. T. E. S that are being added to the budget, and i know that each one seems to have a logic. Im wondering, we currently have two Quality Management programs already, one in each of the hospitals. By combining them, what is the logic for them adding ten more f. T. E. S . The basic logic is the event the at laguna honda exposed some deficiencies in our q. M. Systems, and so as weve reacted to that, and the team is still learning and going to learn as we implement this about what our program is going to look like. Theres several things that have come up. First, its the fact that there were issues that we didnt identify and remediate. Weve got work plans that have come out of the regulatory reviews in addition to that. And in particular, weve identified some issues when issues are identified, they are delivered to the management in nursing to investigate, and thats not a best practice. The best practice would be that you have a team that is outside and doing that investigation both so that youre not pulling away from patient care time, but also so that youre having clear delineation between those that are investigating and those who are responsible for providing the care. And so thats a piece of it. I think that the q. M. Team is being pretty direct, that there is going to be learning to do as we get this up and running. Well have parallel structures at each of the opportunities, and i think this is one of the things that came from the laguna honda patient care issues. When that happened, the zuckerberg general q. M. Team flexed over. Its more productive to look at ourselves as a system, where we can support each hospital. If theres a problem at one hospital, the team can flex to support that hospital and vice versa. I think therell be some learning, and over time, as we ve develop this model, therell be opportunities where we can share learning, but thisll be a learning Program Building out programs at the two hospitals. Also included in the network are some pharmacy positions that are driven by the work flows in epic where the medication the pharmacy protocols associated with epic are more rigorous and labor intensive than they were under our previous system, and so were correcting for that belatedly. So if i may go on with the issue of the f. T. E. S and understanding, under b3, theres f. T. E. S and i assume you really are meaning medical surge as versus medical surgical. Theres two words. Theres a medsurg unit, and we have a medical surgical policy, which is related to census. So when we open that unit based on criteria of census. Right, and thats what youre referring to, med surgery wimed surge, with an e, as opposed to a medical surgical unit. Okay. Shes giving me a thumbs up. With regards to this, weve heard of staffing in the emergency room and all. I notice that youre talking about bringing in also technicians to work in the psych units, right . Yes. At psych emergency. Are both going to help resolve part of the problems that we have heard in public testimony with regards to the issue at general . Sk yeah. And maybe ill ask if susan would be willing to come up and give a little color commentary. [inaudible] so ill comment about both initiatives. The first one, the staffing medical surgical beds for when we have surge at the hospital, like now, h 58 is one of our medical surgical units. We have been using it almost continuously for the last several years, and as greg mentioned, weve been doing that using temporary or p103 staff. There have been several times over the last few years that weve been able to close it, during the summertime, but most of the time, it needs to be open to accommodate four to 15 patients. Today, for example, its open with 12, and its only open to 12 because we dont have the staff to initiate it to 15. What this would allow us is to have that staff of 15 so we can staff it more reliablely, particularly in the winter, when we need it. So thats h58. The l. P. T. S, when our joint Commission Survey which was exactly almost eight years ago, we have four Emergency Rooms in pod a. Those require constant monitoring, and we do that with two assistants who can do that with cameras and staffing in the rooms. Recently, weve been using l. P. T. S one l. P. T. , precisely, that weve been able to find through the registry to ha staff that function in part. And its been extremely valuable because they come with training that even nurses in the medical department dont have. So weve been trying to use them to help us manage those patients who come in with Behavioral Health issues, some of which we treat and release, and some of whom who get medically cleared and go to psych emergency. So is the answer partially yes towards what we have been hearing in terms of the stress in the units, especially in the emergency room . There are stresses in the Emergency Department, for sure, and weve acknowledged that, and we have multiple plans in place to address both the staffing issues, the just basic keeping the keeping our units staffed, but also the issues that come with the Behavioral Health issues we have. These l. P. T. S are just one of the many things that were doing in the Emergency Department to address some of the things that you heard about. I have questions, but not on that. Thank you. Im great satisfied with the explanation on b3, and im hopeful that it will improve our overall quality of care. Strengthening the h. R. Says youre adding more personnel again, and i know that several years ago, we had very few personnel, and that created a number of issues. How do we know that this is the right number, because youve been adding all this time . Number two is that part of the problem is not our own department, but the citys own system in the delays in hiring. So how does and what creates an anticipation that this will actually then help answer our problem of more swift swiftly being able to add personnel to our staff . Yeah. Good question that weve been talking about ourselves, and it is part science. Its try as we might, the staffing in the division doesnt lend itself to a clean model like you might see in other areas where you have similar class or type of worker thats performing a similar type of service repetitive. T the so far starters, the department has added a lot of f. T. E. S over the last few years or so, but so those have been f. T. E. S associated with the opening of the new zuckerberg hospital, expansion with our new initiatives, etc. Second issue, within these f. T. E. S, there are a number of these that we have added as Temp Staffing to try to close the gap and keep up, but weve never budgeted them permanently. If we dont budget them permanently, well actually go backwards on those positions, and thats a quarter how many of those positions are cad18s . Thats a piece of this that were trying to lose ground. The other piece of data that we have that is imperfect is a couple of years back, the budget and legislative analysts did a comparison of city departments to try to look at kind of very high level squint and take a look at your ratio of h. R. Staffing to f. T. E. S, and it wasnt perfect, and they acknowledged that it wasnt perfect, but we had fewer h. R. To f. T. E. Compared to some bigger departments, including the p. U. C. , airport, h. S. A. So this is moving us toward that direction and catching up. What this would get us to is if you would add all our positions, including the ones that arent filled, wed be a little over a 50 1 ratio, so that is one person doing all of those functions that i managed per 50 staff, which its a big number of h. R. , but its relatively lean in terms of what you see regarding benchmarks. So i wont make the i. D. That we have identified the perfect number, but we have a new Human Resource director who you know this has been with the department in the past, has had a citywide civil perch, and this is his recommendation kind of coming in and doing a review of some blatant gaps that need to be closed, 1and well continue to evaluate that as he gets a little bit more time and his team gets a little more time to get a confident level. But i think we all agree if we dont make a change, were going to continue to lose ground. Well, i think my next question well well, it is a question. Im glad were taking the position, and we should take the position that we cannot do this without resources. You have indicated that the twoyear total shows 7 million. However, only the first year shows a positive, and by the second year, we show a negative. Im not sure if we use this balance well, first of all, its a very small amount compared to what must be a big program. Im in favor of being able to maintain the balance or even a positive that allows us to have health programs. But seriously, how much do you really consider that Mental Health is going to cost all of us . Well, so your first point about it being lop sided between the two years, thats a concerning one. Its a little beyond our view how all the city pieces will fit together, but weve already kind of contemplated for the vision for Mental Health s. F. , but there are pieces that are going to need to be definitive ongoing programs, and there are other pieces that are building infrastructure. So for example, if were going to launch a new program, one of the first things that we might need to do, and in some cases, weve already identified, is renovate a space to increase capacity, and thats the perfect use for a onetime or year one pool of dollars. On your second question, in terms of the total scale, theres still a lot of decisions to be made, but as we ballparked what this looks like, i think theres consensus that full implementation of this vision would be 100 million or more, and that would of course happen over time, and that is dependent on a lot of decisions, including how you scale up each time of programs. Thats why were going to look at the building blocks, but to get that full vision is going to require a Revenue Source thats either comes from their discussion about potentially a ballot measure, about whether therell be state or federal funds that we could draw that would support this. It is building the infrastructure so that were prepared to scale up when the city identifies the funds to do so. Thank you very much. Commissioner guillermo. Thank you, and thank you for addressing the questions last time that i had about the waiver my cowaiver impact, but i had another medical question. As c. M. S. Has had a couple of new proposals about how the states are going to fund their portion of medical, and the oversight that theyre going to impose, has that been built into projections . Are you referring to the mfar proposal . Yeah. So we are not proposing a budget that assumes that that regulation goes forward. Its such a big change that its hard to comprehend. I am confident to say that that would really very significantly disrupt the medical and safety net delivery system, and the biggest piece of that would be, as you point out, restrictions on the way that states or local governments can fund that nonfederal share. In San Francisco, we are predominantly funding our nonfederal share with city and county general fund revenues, and so that, at least on the very surface of it, is an issue for San Francisco counties. There are other counties in that systems that are funding that with kind of patch work revenues that theyre able to put together. But regardless of which county, we know that our entire statewide financing system is built collectively around those tools for financing the nonfederal share. And the counties are tied together. Were in it together, because we have the statewide allocations of resources that are distributed across the counties. We have a collective effort for thats being built over many years for the counties and other entities fund that federal share, so if that goes through, its going to cause a significant rethinking of the safety net that goes on in california. I think were very actively worrying and watching that and working through our organizations to advocate on that, and i know we have support from our policy and elected officials in california. But we havent budgeted around that because it doesnt exist its not finalized, and if it does become finalized, theres going to be a lot of steps for the state to determine how we react to that. So that is a big risk and fear thats out there. Yeah, and itll affect across the board pretty much everything that we provide through medical, and so im just im glad that youre watching it and worrying about it and working with other constituents, medical constituency provides around that. But i think providers around that. But i think if thats not the proposal that goes through, theres going to be Something Like that just because thats the way its going with this particular administration at c. M. S. And so i think the beneficiaries of our Medicaid Services are going to have to be informed because it affected its going to affect it affects us on a budget basis, but affects them in terms of their lives and their wellbeing. Absolutely. So i think thats something we should get involved with. The other question i had was around laguna honda. There is almost a double or a 100 increase in projected revenues that is shown. I think jennie, you mentioned it was rate increases. I was wondering if those rate increases are related to the new regulations that c. M. S. Has put into place with regard to the i dont know what to call, the not paying for therapists or therapy and other kind of things. Are those two things related at all . No. So the revenues that you see, you look at the numbers on a4 i totally see why it looks like 100 . That first 6 million incremental, thats over and above what we budgeted today. I think jennie knows what that percentage is it looks like shes looking. Off of a 200 and 300 million base, so its a few percent. And then, in the second year, that incremental portion doubles, but its all told, its a single digit increase to the rates. And whats represented here is simply taking our updated estimated medical per diem, multiplying it by our bed days, and then calculating our medical revenue. So its a this is a fairly straightforward, and there are there are a number of potential changes that could significantly affect revenue at Laguna Laguna revenue, including how nursing funding is financed entirely. But what were proposing here is just that very simple baseline revenue based on the medical daily rate. So again, just something that would, i guess, bear watching and informing both us at full commission and the j. C. C. In terms of those impacts. Absolutely. Thank you for that suggestion. Thank you. Is there other questions . All right, we can move onto a motion to approve the sfdph budget 2021 and 2122 budget. So moved. Second. All right. All those in favor . Commissioners, if i could, i just want to say a special thanks to jennie lui. I could standup here, but she really is here until 9 00 at night, pulling this stuff together, as well as the budget team for the department. We have a really Incredible Team who does a huge amount of work of pulling it together and then keeping it together for the rest of the year, so i just want to acknowledge all of that work by jennie and all the budget team. Thank you. Thank you, jennie and all of you, as well. All right, commissioners. Lets move onto item 7, which is Drug Overdoses and drug use, a presentation. And let me know if yall need me to help you. [inaudible] good afternoon, everyone. Good afternoon, commissioners. Thank you so much for providing us the opportunity to come speak this afternoon. Dr. Kaufman and i are going to speak to Drug Overdoses in the community and some of the ways to address those. So todays presentation todays presentation, were going to go through some data thats going to show overdose reversals and some of the work thats happening in the community. Were also going to discuss Treatment Options and some of the services that we have to address drug use in the community and overdoses, and then finally, well end with some of our immediate and longer term strategies to address the situation. Okay. So i want to start with the data, how we get the data initially. So when a Drug Overdose happens, the death is reported to the medical examiners office, and then, the toxicolo toxicologist collects all the data, and that data is important because a Drug Overdose is different from other deaths in that its a rule out death in most circumstances. For example, somebody passed away, and you have no idea why. You have to collect all this data. Maybe they have a high level of methadone in their system, but theyre a patient in a methadone clinic. It takes a while to collect all of that and come to a cause of death. The cause of death determination is what takes the most time and limits our ability to get realtime data. That data then goes to department of vital records, and they confirm, Fact Checking and make sure that everything is collect. California has the reporting system, which is a fantastic system, that reports on all deaths that occur, and that is the data that we get back that we use for our analyses. Overall, because of the time it takes to close a case, its about five to six months before we have complete data. For example, if i were today to pull the data for january, i would capture about 3 to 4 of the Overdose Deaths that happened, which means that i cant pull data until about six months have passed in terms of getting complete data for any period of time. We are not alone in that. Most all the cities that i know of that report mortality dat data, they generally have a sixmonth lag between the time it takes to report cases. The other question i have is the frequency of reporting. The data ill present today is were going the presenting every six months. We have anywhere from 7 to 31 deaths in a month, so if you look at it by monthly reporting, one month, it looks like were doing great, and the other month, it looks like were doing terrible. The numbers are small, and theyre unstable until we get to at least sixmonth time periods. In terms of the number of Overdose Deaths, this chart gives you the numbers per sixmonth period because we only have the First Six Months of 2019 as complete data. As you can see in the first as you can see, we really maintained a flat number of Overdose Deaths relatively until through the first half of 2018, which is pretty impressive. We had the prescription opioid crisis, we had the heroin crisis, we had an estimated tripling of the number of people who inject drugs in San Francisco, and the mortality level remained flat during that time. With the second half of 2018 and progressing into at least the first half of 2019, we are seeing escalating deaths, and well run through those numbers more, but theyre generally driven by fentanyl. I havent seen a community that didnt suffer an increase in the vast number of Overdose Deaths, including places like vancouver, British Columbia that doesnt have the restrictions on federal programming that we face. A little more detail on this data in terms of opioids. What you can see here in gray is the number of fentanyl deaths. Below that is heroin deaths, and below that is prescription deaths. Back in 2010, we were pretty much all prescription deaths. As prescribing reduced, the deaths kind of transitioned to heroin, and then fentanyl started to emerge. We saw the first whiffs in 2015, and then, in 2019, fentanyl deaths increased substantially, and all of our data from 2019 are partial. They may represent anywhere from 30 to 70 of what the total will be. So Harm Reduction is the philosophy of the Health Department, and thats recognizing that people make change in different ways. So while we have the syringe access and disposable program, we also have absent space programs, and theres all these entry points in between, and thats acknowledgitaking the s acknowledge that everyone is different, and everyones behavior to change is different. Harm reduction treats people with respect and dignity so that when theyre ready to make that change, were there as the Health Department to offer that array of services. Harm reduction principles often come directly from the community, and i say this because philip mentioned the increase in fentanyl use in the city, and were definitely seeing that. And amongst the community of people who use drugs, many people are seeking out fentanyl, and many of them have developed a mechanism to reduce their harm, and we sue thee th a Harm Reduction strategy, for example, smoking fentanyl opposed to injecting it. Many safe consumption sites are offering tinfoil now. Other reduction strategies include methadone, and buprenorphine, which also allows that flexibility and that low barrier to engage people into services. So this slide demonstrates the work of our funded provide, the dope project, drug Overdose Prevention education project. The blue bars show the number of refills, people are returning to, whether its our syringe sites or any of the Distribution Sites to get a refill on their naloxone, and that may mean that theyve reduced an overdose, or it may mean that their naloxone was taken, but you can see that number has significantly increased overtime, and that just demonstrates the great work in the community and the importance of the messaging of having narcan available, and being trained to be able to administer it. Other efforts that are happening in the community to address the overdose are in the jail, where if someone has a history of opiate use or mentions that they are an opiate user, then narcan or naloxone will be put in their property upon release, and thats key because we know that a lot of people leave the system or leave jail and go immediately to use, and so its another strategy. And then, the newest is project friend, and thats working with First Responders and their families to distribute naloxone. And i believe its federally funded, but its available through San Francisco general and also u. C. , and these are just strategies to address the current trends. So i mentioned the needs to be flexibility with people who use drugs, and with that comes the need of many different strategies. Often low barrier strategies to engage people into services, and these include going out with health fairs, going out to homeless homeless encampments, and really engaging people. Also, the Harm Reduction therapy van has been able to set up in communities where people are hangout and just engage people into services. In the earlier presentation, it was mentioned about the crisis outreach teams that will be part of Mental Health s. F. Again, thats another example of really just responding to the needs in the community and recognizing that one strategy does not work for everyone and the need to constantly be flexible and reinvent the services that we have so that we can engage people. And the low barrier medical services at the syringe sites is such a good example of that. I had the opportunity to be at one of those sites one night, and it was amazing to see five people waiting in a queue to talk to a medical provider because they heard that they could get started on buprenorphine to curb their opiate cravings. And i think that thats very telling because its a safe place where people are already accepted. There are multiple different strategies that we use at the Health Department when there is a spike in overdoses. Were really fortunate that we work so closely with our funded provider, the drug Overdose Prevention education program, or d. O. P. E. So when there is an indication of overdose is, they work very closely with their providers to get the message out to the community to people who use drugs. Additionally, the Health Department sends out a medical advisory, and we send out messaging to the navigation centers, to homeless shelters, to schools. We have a very exhaustive list to share that sort of messaging. Additionally, with the syringe access and disposal program, we have a monthly meeting thats called the syringe access collaborative, and thats an opportunity for us to discuss the trends that were seeing in the community and have an opportunity to say, well, how should we address that . Additionally, there is a project thats called acdc, and thats a project of the d. O. P. E. Project, and thats where theyre actually able to get a sample of a drug supply that may have been associated with an overdose and test it, and then get that messaging back to communities. I should also add that our syringe access and disposal programs all carry Fentanyl Test strips, and thats an opportunity to test your drugs to see if it is tainted with fentanyl, and if it is, to use a Harm Reduction mechanism to engage in your activity. So basically what this slide shows is what ive been saying, theres just there needs to be a comprehensive plan when addressing Substance Use disorder. And so we have multiple or the Behavioral Health system has multiple entry points to address Substance Use, and that ranging from low barrier, that may be at a syringe access site or maybe as telebupe being offered as an option all along that continuum. And i think thats really important to note, and i often sound like a broken report saying that because no ones path getting into the system is different or some people may want to manage their use, and low barrier is what works for them. Other people may need more comprehensive services, and we have that capability with our system of Behavioral Health care. So just a little more on the Behavioral Health side. Generally, theyre providing buprenorphine and methadone, and this is in the context of Substance Use Disorder Treatment programs, which dont account for all the Substance Use disorder that goes on, has that treatment has definitely expanded within primary care settings, and jail health, as well, provides this therapy. There are 491 residential beds that are going to do Residential Management and treatment that goes up to 90 days as well as the residential step down programs. The Residential Program which eileen has referred to include the medical Street Program that dr. Zephen runs, and thats been impressive. I think one of the most innovative things that San Francisco has done is by going out to where people who are experiencing homeless live and providing buprenorphine in those settings, i think thats some of the really impressive work. The Behavioral Health pharmacy has expanded services. Theyre able to provide buprenorphine and continue patients on buprenorphine in that setting. And the buprenorphine prescriptions having increased in San Francisco. We also have two programs that provide contingency management for methamphetamine use disorder, and thats really the most evidencebased intervention that we have at the time. And then, we have pharmacotherapy research, which is the work that i run, and that dr. Colfax initiated in his prior incarnation at this department. And weve had some success in particular with medication mirtazapine, a Research Pathway that we continue to explore. In terms of use Disorder Treatment, these are the numbers for 2014 through 2018. There has been some reduction in treatment numbers, particularly, you can note in hal and a little bit of a reduction, about 150 fewer people treated for heroin use disorder in 2018 compared to 2014. I actually think a major driver of the decline in some of these numbers is the transition to primary care for treatment of many of these use disorders. For example, expanded use of medications for alcohol use disorder and have really seen an up tick in recent years. As you can see in the graph on the right, buprenorphine treatments have increased substantially. So weve actually probably seen an increase in the number of people receiving treatment for use disorders, although a slight decrease in those accessing traditional Treatment Programs. So we gave some background on some of the stuff that were working on, and i just want today highlight some of the immediate actions. One of the biggest things is findtreatment. Org, and that was the site that was mentioned earlier at the Committee Meeting where it shows the availability of treat beds, and thats huge because its updated every day, and it will allow us at d. P. H. The opportunity to also have realtime feedback of, well, why are x beds at x Agency Always empty as compared to other beds that are full . So itll give us realtime feedback and data, and itll also provide the opportunity for Different Levels of staff to be able to just check in realtime what are the Treatment Options available as i work with my client. Also, the expansion of the Hummingbird Community model, which we know that the model at San Francisco general has been very successful, and now, the Health Department is looking at expanding that to a Community Location where programs such as the Syringe Programs will be able to refer people directly to anybody needing that sort of respite. Additionally, we are working on expanding the or opening the first meth Sobering Center, which is also something that we heard directly from the meth task force. It was a recommendation by the group, and were able to move forward on that. So theres a lot of Different Things that are very exciting, and to address the issues on the streets. And a little further on that note is the efforts on Overdose Prevention. So about a third of the Overdose Deaths in San Francisco occur in singleroom occupancy hotel units, and thats always been a particular challenge because people are oftentimes isolated, and so simply providing naloxone in the community may not be able to prevent some of these deaths. So we have some support from california partner of Public Health to initiate this as a Pilot Project working with some of these facilities to try to develop really tenant run Overdose Prevention projects. Project friend was already mentioned by eileen, and that is a situation where paramedics are able to give innaloxone takehome kits to Community Members. And then finally, just lowering barriers to treatment, and that includes expanding the hours at our cbhs clinic, and also expanding the opportunities for telebupe, and thinking how can that expand, how can we expand other areas for people to access treatment . So for future initiatives, back in december, the mayor and the board of supervisors unanimously passed Mental Health s. F. , and were really excited about that because in that, we will be able to think through other initiatives that well be able to address issues on the streets, and that includes the expansion of crisis outreach teams that will be out in the streets that will be able to work and address concerns and be able to engage people directly into services. That also means expansion 247 of the Behavioral Health pharmacy, Mental Health reform, and also thinking through, well, how does Substance Use and alcohol use fall into that, and just thinking of the opportunities for expansion within that . And just thinking of the Overdose Prevention sites and other dropin sites that are an opportunity to engage with people who are on the streets and need a safe place to be inside. And then finally, we are available for questions, but we also have our colleagues here from Behavioral Health who would be able to answer any of the questions on Behavioral Health services and Substance Use treatment. Thank you. Thank you for your presentation. Commissioners, questions . Commissioner chung . Hi. Thank you for the presentation. So this is the questions that i asked in our previous meeting, and hopefully, youll be able to help me out here. I see that theres actually an increase in meth overdose related deaths, and how do we well, since theres no real treatment, how do you prevent death . Like, what strategies are we using to prevent methrelated Overdose Deaths . Thats a great question, and a very difficult one to answer. The cause of death from acute methamphetamine poisoning is a difficult one. Its not like an opioid death that can be reversed with naloxone. Its generally thought to be a cardiac event or sesh certi cerebrovascular event, or a brain bleed. This is to encourage people to get into a Treatment Program or to modulate use, things like that, and those are those are also sometimes full of challenges, so i dont have a great answer for you. I wish i did because id love to see love to be able to directly address that the way we can directly address opioid overdose. Thank you. I dont have any other questions, and i appreciate that in addition to that because personally, i think that sometimes there might be a different cause of death and and sometimes like, you know, exceptional death, like falling out of buildings or something, but it might be caused by psychosis of stimulant use. How do we actually tell that story, you know, in these, like, death reports . So in those death reports, the data that i provide are deaths that were determined to be due to acute prisoning from the given drugs, when you look more broadly, you could, for example, look at all deaths that involved a positive toxicology report, and thats going to include a Motor Vehicle accident, a Motor Vehicle collision, or, you know, any cause of death. And so in order to look at more something more directly that we know can reasonably be attributed to the drug, we restrict it to acute prisoning. The other one acute poisoning. The other ones are going to be tricky. If somebody falls out of a window due to a drug, that may be, but its a tougher question to answer. Thank you. Director colfax, you had a comment . I just wanted to thank the team for their presentation, and i think the other key point, as dr. Kaufman has made, just the important of good data here, and ensuring that were using data to drive our decisions. I think one thing that bears mentioning is the s. T. D. Reports that you see that dr. Ph phil dr. Philip presented. And then, the work that eileen did with, the work for community partners, theyre not here as much today, but that were always reaching out and engaging in. To the commissioners discussion about methamphetamine use, and i think we have to be and the meth task reports emphasizes and says that an array of options need to be available. We dont have the buprenorphine that we need to see. We have a National Institute of Health Research program that is specifically looking at these pieces so you have a full spectrum of work being done across the departments, including the Harm Reduction approaches that were taking today. And then dr. Kaufmans team has done a number of randomized controlled studies. But i think there are tihings that we can do for methamphetamine users going forward. I also think from the Harm Reduction perspective, the morbidity piece, while the overdose death is the final common pathway, and the most tangible one, we know that drug use is affecting people. We need to know that the department is commit today that, and we dont lose sight of the use or primary use. Really make sure we take that Harm Reduction approach, not just focused on that drug at the moment but across the continuum of care. Thanks. I just had a quick question. With regard to first of all, the data is excellent. Thank you very much. Looking at the dramatic increase in deaths by fentanyl overdose, does your data differentiate whether the fentanyl is in a different substance or fentanyl on its own . No, in general, it doesnt do that. In general, we know the narratives from case reports of people who had died as well as the access of the d. O. P. E. Project and the syringe project and research of people who use drugs in San Francisco, most people who are using fentanyl choose to use fentanyl. Its a drug that can produce a more reliable effect than, for example, black tar heroin. It is less expensive, its easier to transport, so it has largely replaced the other opioids on the street because it is favorable it has those favorable elements to it. Unfortunately, its also much more likely to result in death. There are cases where there may have been contamination, and there are definitely cases where people who were using intended to use cocaine or methamphetamine but it happened to be fentanyl. I think in general, opioids in San Francisco historically were black tar heroin, easily distinguished from a white powder stimulant, and now were seeing white powder opioids that arent so easily distinguished, and theres been some tragic errors in consumption, as well. Commissioner green . Yes, thank you for this wonderful work. I had some questions about your point of entry because it seems, you know, that a lot of these require clients to come to a place or show up to a place, and im wondering if youre gathering data about a few things. One would be what time of day to people come . What point of entries are prominent . Are you giving out, you know, both Fentanyl Test strips and naloxone . And then, how are you going to kind of quantify that so we can understand where to focus the resources . We have a system and youre going to obviously expand it, and all the ideas that i think are forth coming are really excellent. I guess the other one is how much is this happening at night because thats one of the worries in terms of points of entry. So what date are you planning to gaer to gather on that component. I think i would call one of my colleagues from Behavioral Health as far as points of entry on the systems of care. I can say for the syringe access and disposal programs, we have Services Available seven days a week at different sites and hours vary to meet the need. Two of the sites specifically that offer low barrier medical care are in the evenings, and weve had to think creatively on how to, if someone needs a prescription for buprenorphine, how can that get filled in the evening hours so that we can stay engaged with people. But i think that people are staying engaged, people are coming back to the syringe site do sites, and for whatever reason, they werent seeing that same type of respect at a fourwall clinic. Were, again, recognizing that need because we had a meeting about a year ago with front line workers, with Behavioral Health, and we talked about a lot of the barriers that were seeing directly in the field, and that was one of them. Like, if someones ready at 9 00 at night, saying well come back at 8 00 a. M. Doesnt exactly work. Good evening, commissioners. Im the project manager. So we have about 65 programs that we are funding from outpatient methamphetamine services, residential. And what eileen was mentioning, we were expanding the service hours. We are working with healthright 360 to have an intake person that can go into homes in the evenings and provide the medication. Because in healthright 360, we have two intake sites that will be open from 5 00 p. M. To 9 00 p. M. , and also we are working to expand the pharmacy 247. Those are the improvements that we are making into the point of entry that youre requesting. So do you think youd be able at some point to give us some data about points of entry, which are more successful, whether expanding hours makes a difference, you know, in terms of zip codes and things like that . Also, the other thing i think wed be interested in is working compliance, whats working and has the least chance of recidivism. I think 95 of our high risk homeless and mental patients are alcohol, not necessarily drugs or maybe a combination, and also im wondering how that works in the system. Yeah, we can provide that because we work very close with healthright 360, and they have the Drug Management services. With their Drug Management is mostly alcohol, but then, we are expanding services in the pharmacy to provide medication, and also, the telebupe that we are providing. And also, healthright 360 is a close partner that we can collect some data. Also, this is a pilot that we are studying . Maybe in six months we can come back and give you some preliminary data that we have. I think also i know philip mentioned earlier dr. Barry zephen who manages the street Response Teams and prescribing the buprenorphine, and i think they would be able to share that story, really, about how people are showing up and how people are being really successful, and situations where people have graduated from having a regular prescription to some people transitioning to getting a monthlong injection because they have been consistent, so i think that would be an opportunity to share. Additionally, we have our Sobering Center, and what sort of what the different hours are and people that are there. Thats something we could go back to our colleagues and our partners to find out that information. Yes, thats true. We are opening that Sobering Center at 180 jones in the tenderloin. We are partnering with healthright 360 and their staff. They can come in and mostly rest, and its going to be mostly alcohol. I think dr. Colfax mentioned at the beginning, its going to be 15 beds, and its like, you know, every eight hours, we can turnaround, so we can provide some preliminary date data probably in the next six months. So we open april 20. We have varying staff working with d. P. W. And the various departments in all these settings to be ready to start april 20. So just thank you for that. I just want to clarify. We are looking to open the Sobering Center as quickly as possible. Hopefully in the spring. We dont have a specific date yet. If i may, just for your edification, commissioners, you will have two items at your next full Commission Meeting on a pop up to approve the hummingbird as well as the drug Sobering Center, so youll hear more at your next meeting on both of those. Dr. Tare . Yes. That was a great presentation. Other places have used this data to indicate that San Francisco and its programs are failures. As always, you can take those numbers and make them say whatever you want to say. With that, you can say the increasing Overdose Deaths, obviously, our program has failed. I think we also need to hear, as weve been talking about here, what are our points that we consider a success, how do we measure how well the population that were working with is doing . Who have been able and some of that is anecdotal, and some of it will be referred to but i do think its important to demonstrate as we continue to go along, why the Harm Reduction model, and why these programs are really effective because some of these are under attack, and i do think we need to show that people are being helped with this with transition people into various things, weve been able to you know, whatever data we can say. Its always hard to show how well preventative measures have worked because its a preventative measure. But there must be some sort of measure that we can point to as advocates of this to show that this is the right way to go, so thats i think moving along that same line of requests, whether it be at the next presentations. But i think when we do get these presentations, it would be also good to look at what we have been doing on the positive side. Thank you. Thank you so much for that. I just wanted to make one comment on that. Whats happening with the overdoses is happening nationally, and were really fortunate in San Francisco in that we have always had such a proactive approach, and that our Syringe Programs and the d. O. P. E. Project are working directly with people who use drugs and getting narcan into the hands of people who are using together. And so fortunately, were not at that place where our deaths are at that number. But i feel like because we already have a lot of mechanisms in place, its why were allowed to be ahead. Just recently, the community Health Equity and Promotion Branch was funded to be mentors for other jurisdictions in the u. S. To develop an overdose response. And San Francisco has been assigned jefferson county, which is in colorado, king county, which is in illinois, and perry county, which is in rural missouri. And just having phone conversations with these three jurisdictions, and just really reflecting on, like, how can we how can we share knowledge with them so they can, like, at least get ahead to the point where they have narcan available in the community when theyre not even talking to . So theres always work to be done, but also, i feel like were doing a lot of work, and i feel like we could do a better job of highlighting the efforts that we do, so thank you for that. Thank you. Other questions, commissioners . Commissioner chen . I have one more because we and thank you, director colfax, for reminding me of this question. We talked about death and also prevention and also, you know, presenting a psychiatric emergency. But how how about, you know, medical hospitalizations . Like, home you know, do you have any data at all . Sure. So we we published a report in december that included multiple data points for each drug, emergency room visits, hospitalizations, Substance Use Disorder Treatment admissions and death. Those are the four main data points that ive tracked over the years, and those numbers tend to go up. Theyre not we cant narrow down to the type of opioid, for example, so its opioids in general, but methamphetamine numbers have definitely gone up in terms of Emergency Department visits and hospitalizations. The i apologize. Im doing this from memory, but i think opioids went up a little bit. You know, i also wanted to go back to your methamphetamine question. And you know, a lot of those deaths increasing methamphetamine deaths in the last couple of years have been attributed to fentanyl. Reviewing it, if i had to blame it on one, id blame it on fentanyl because those deaths tend to look a lot more like fentanyl deaths that the person has in terms of morbidities. You know, methamphetamine is a major issue to address in San Francisco francisco. In terms of addressing the mortality, i think our focus is more on fentanyl, and our resources, including things, like, buprenorphine which functions not just as a medication to treat as opioid use disorder, but also, it blocks the reseceptors, so if u have buprenorphine in your system, its hard to overdose on fentanyl. There are things that that were not able to do here, but that might help us push through a crisis like this one. No other questions . Thank you very much for your presentation. Thank you. Thank you. All right. Commissioners, we can move onto item 8, and lets thank mr. Garra, the presenter, for his late presentation. Its the 20082009 d. P. H. Annual report. Good evening, commissioners. My name is max garra, and i work in the office of policy and planning. Im here to present to you the final draft of the report for the fiscal year 20182019. I want to appreciate you for the feedback that i presented to the committee, and for the feedback afterwards. Your recommendations have been incorporated into this draft, and i would like to request your approval for this report. As youre aware, the report is required by the city administrative code. It provides a summary of the departments highlights and accomplishments over the past fiscal year. This years annual report maintains the overall format and Design Elements from the previous years. So the onannual report opens wh a message from our director, grant colfax. It features three stories. The 2019 Community Needs assessment, mean tall healntal reform, and Mental Health is a right issue. It touches on leadership issues the department has experienced over the past fiscal year. It acknowledges the successes of former director barbara garcia, and welcomes dr. Colfax as our new director of health. It notes our preparation for epic and efforts on Behavioral Health. Lastly, it acknowledges the services of former commissioner david sanchez. Both messages provide our leaderships organizations to the department. So the next set of sections provide an overview of the functions and services across the department. The sections start by introducing the departments two divisions and their roles in protecting and promoting the health and wellbeing of all san franciscans. The next section reviews the departme departments true north and its six true pillars, which is then followed by the departments organizational chart. The last introductory section provides an overview of the commission. So at the commission kaerz commissions request, it includes commissioner guillermo, and notes that she joined in the previous year. It includes the numerous accomplishments of the department over the last fiscal year. The first describes the Community Needs Health Assessment and the adoption by the commission. The summary describes the stakeholders that supports this process, the findings that were identified by the assessment, and how the cfha improves the department and processes. The feature discusses the appointment of the director of Mental Health reform, and it introduces the reform framework thats being used to drive this work. The feature also touches on some early milestones and provides a preview of what this work will look like moving forward. The last feetu [inaudible] and the departments efforts to address this issue. So the following section provides the different features and the 22 or i should say the 22 different highlights that span the different d. P. H. Services and programs. The highlights are sorted into three main categories. Building infrastructure, protecting and promoting health and administration, and i want to thank all the d. P. H. Staff that provided their support in drafting and collecting these highlights. And commissioner chung, i want to note that your comments have been incorporated into the soji update. So the next major section focuses on data, starting with the d. P. H. S budget. It provides information on expenditures, revenue, and major investments. The next section highlights the San Francisco health net work data on visits, patient demographics, and care type across the major systems of care. This is followed by the Population Health data section, which focuses on the various Program Impact metrics, and as recommended by the commissioners last year, Additional Data has been included to demonstrate the impact on the division. So for example, new data points are included on Food Safety Program inspections, Healthy Housing Program inspections, and the number of major events or major emergencies and events responded to by the department. And lastly, each of the 15 Health Commission resolutions are also included in the report. So the report ends with an overview of the Departments Service sites and contractors. The maps for Service Sites this year have been updated with a more stream lined look, and lastly, the report includes additional d. P. H. Resources, such as where an individual might obtain Health Coverage and several key foundations and organizations that support the work of the department. So at this time, i want to thank you for your time, and im here to take any questions or comments. Thank you, max. Any questions or comments from the commission . Commissioner chung. Just a comment, and thank you for incorporating the suggestions into the soji data highlight. And i also want to thank for putting into the footnotes for patients by gender to really help understand where the gap is and provide insight of, like, what had it just sort of sitting there or you had it just sort of sitting there rather autonomousily. Thank you for the feedback. And thank you for the report. I just happened to see that the other night. Commissioner guillermo. Thank you for your presentation and for an impressive report. I just had a question about the distribution of the report because it really is an opportunity to see you know, let the public know and other constituencies how important this department is, and who is responsible to who, so whats the mechanism, and how far and wide does it go . So once the report is approved, well incorporate the final edits and postit on the department of Public Health website and distribute it to other departments with a message. Were also going to do a printing of about 15 to 25 copies, as well, for distribution to you, as well, but were open to feedback and other suggestions. Does it go to the board of supervisors. Yes, and the Mayors Office. And the Mayors Office. And the library, as a record. I would suggest if it goes i dont know if hard copy or online, but to the other hospitals that do and do not partner with the department. I think its really important that private sector providers also understand the scope of the departments reach that oftentimes intersects with what they do and should intersect more. Great. Thank you for that feedback. Commissioners, other questions or comments . All right. So this is actually a discussion item. Traditionally, you all say thank you, and thank you, and is. Thank you. Thank you. Thank you. Great. Commissioners there was no Public Comments on that item. Item 9 is other business. Youve got the calendar before you. You can always email me with questions. Item 10 is the joint committee reports. February 11, 2020, j. C. C. Meeting was mostly closed session regarding Quality Affairs and thats it. Okay. Item 11, motion for adjournment. Do i have a motion . So moved. Second. Were adjourned. Thank you, everyone. [music] San Francisco city clinic provides a broad range of sexual Health Services from Stephanie Tran medical director at San Francisco city clinic. We are here to provide easy access to conference of lowcost culturally sensitive sexual Health Services and to everyone who walks through our door. So we providestd checkups, diagnosis and treatment. We also provide hiv screening we provide hiv treatment for People Living with hiv and are uninsured and then we hope them Health Benefits and rage into conference of primary care. We also provide both prend post exposure prophylactics for hiv prevention we also provide a range of womens reproductive Health Services including contraception, emergency contraception. Sometimes known as plan b. Pap smears and [inaudible]. We are was entirely [inaudible]people will come as soon as were open even a little before opening. Weight buries a lip it could be the first person here at your in and out within a few minutes. There are some days we do have a pretty considerable weight. In general, people can just walk right in and register with her front desk seen that day. My name is yvonne piper on the Nurse Practitioner here at sf city clinic. He was the first time i came to city clinic was a little intimidated. The first time i got treated for [inaudible]. I walked up to the redline and was greeted with a warm welcome im chad redden and anna client of city clinic even has had an std clinic since all the way back to 1911. At that time, the clinic was founded to provide std diagnosis treatment for sex workers. Theres been a big increase in std rates after the earthquake and the fire a lot of people were homeless and there were more sex work and were homeless sex workers. There were some Public Health experts who are pretty progressive for their time thought that by providing std diagnosis and treatmentsex workers that we might be able to get a handle on std rates in San Francisco. When youre at the clinic youre going to wait with whoever else is able to register at the front desk first. After you register your seat in the waiting room and wait to be seen. After you are called you come to the back and meet with a Healthcare Provider can we determine what kind of testing to do, what samples to collect what medication somebody might need. Plus prophylactics is an hiv prevention method highly effective it involves folks taking a daily pill to prevent hiv. Recommended both by the cdc, center for Disease Control and prevention, as well as fight sf dph, two individuals clients were elevated risk for hiv. I actually was in the project here when i first started here it was in trials. Im currently on prep. I do prep through city clinic. You know i get my tests read here regularly and i highly recommend prep a lot of patients inclined to think that theres no way they could afford to pay for prep. We really encourage people to come in and talk to one of our prep navigators. We find that we can help almost everyone find a way to access prep so its affordable for them. If you times we do have opponents would be on thursday morning. We have two different clinics going on at that time. When is womens Health Services. People can make an appointment either by calling them a dropping in or emailing us for that. We also have an hiv care clinic that happens on that morning as well also by appointment only. He was city clinic has been like home to me. I been coming here since 2011. My name iskim troy, client of city clinic. When i first learned i was hiv positive i do not know what it was. I felt my life would be just ending there but all the support they gave me and all the information i need to know was very helpful. So i [inaudible] hiv care with their health about a quarter of our patients are women. The rest, 75 are men and about half of the men who come here are gay men or other men who have sex with men. A small percent about 1 of our clients, identify as transgender. We ask at the front for 25 fee for services but we dont turn anyone away for funds. We also work with outside its going out so any amount people can pay we will be happy to accept. I get casted for a pap smear and i also informed the contraceptive method. Accessibility to the clinic was very easy. You can just walk in and talk to a registration staff. I feel im taken care of and im been supportive. All the information were collecting here is kept confidential. So this means we cant release your information without your explicit permission get a lot of folks are concerned especially come to a sexual Health Clinic unless you have signed a document that told us exactly who can receive your information, we can give it to anybody outside of our clinic. Trance men and women face really significant levels of discrimination and stigma in their daily lives. And in healthcare. Hiv and std rates in San Francisco are particularly and strikingly high were trans women. So we really try to make city clinic a place that strandsfriendly trance competent and transwelcoming everyone from the front desk to behind our amazement there are completely knowledgeable. They are friendly good for me being a sex worker, ive gone through a lot of difficult different different medical practice and sometimes they werent competent and were not friendly good they kind of made me feel like they slapped me on the hands but living the sex life that i do. I have been coming here for seven years. When i come here i know they my services are going to be met. To be confidential but i dont have to worry about anyone looking at me or making me feel less a visit with a clinician come take anywhere from 10 minutes if you have a straightforward concern, to over an hour if something goes on that needs a little bit more help. We have some testing with you on site. So all of our samples we collect here. Including blood draws. We sent to the lab from here so people will need to go elsewhere to get their specimens collect. Then we have a few test we do run on site. So those would be pregnancy test, hiv rapid test, and hepatitis b rapid test. People get those results the same day of their visit. I think its important for transgender, gender neutral people to understand this is the most confidence, the most comfortable and the most knowledgeable place that you can come to. Onsite we have condoms as well as depoprovera which is also known as [inaudible] shot. We can prescribe other forms of contraception. Pills, a patch and rain. We provide pap smears to women who are uninsured in San Francisco residents or, to women who are enrolled in a statefunded program called family pack. Pap smears are the recommendationrecommended Screening Test for monitoring for early signs of cervical cancer. We do have a fair amount of our own stuff the day of his we can try to get answers for folks while they are here. Whenever we have that as an option we like to do that obviously to get some diagnosed and treated on the same day as we can. In terms of how many people were able to see in a day, we say roughly 100 people. If people are very brief and straightforward visits, we can sternly see 100, maybe a little more. We might be understaffed that they would have a little complicated visits we might not see as many folks. So if we reach our target number of 100 patients early in the day we may close our doors early for droppings. To my best advice to be senior is get here early. We do have a website but its sf city clinic. Working theres a wealth of information on the website but our hours and our location. As well as a kind of kind of information about stds, hiv,theres a lot of information for providers on our list as well. Patients are always welcome to call the clinic for theres a lot of information for providers on our list as well. Patients are always welcome to call the clinic for 15, 40 75500. The phones answered during hours for clients to questions. Growing up in San Francisco has been way safer than growing up other places we we have that bubble, and its still that bubble that its okay to be whatever you want to. You can let your free flag fry he fly here. As an adult with autism, im here to challenge peoples idea of what autism is. My journey is not everyones journey because every autistic child is different, but theres hope. My background has heavy roots in the bay area. I was born in san diego and adopted out to San Francisco when i was about 17 years old. I bounced around a little bit here in high school, but ive always been here in the bay. We are an inclusive preschool, which means that we cater to emp. We dont turn anyone away. We take every child regardless of race, creed, religious or ability. The most common thing i hear in my adult life is oh, you dont seem like you have autism. You seem so normal. Yeah. Thats 26 years of really, really, really hard work and i think thises that i still do. I was one of the first open adoptions for an lgbt couple. They split up when i was about four. One of them is partnered, and one of them is not, and then my biological mother, who is also a lesbian. Very queer family. Growing up in the 90s with a queer family was odd, i had the bubble to protect me, and here, i felt safe. I was bullied relatively infrequently. But i never really felt isolated or alone. I have known for virtually my entire life i was not suspended, but kindly asked to not ever bring it up again in first grade, my desire to have a sex change. The school that i went to really had no idea how to handle one. One of my parents is a little bit gender nonconforming, so they know what its about, but my parents wanted my life to be safe. When i have all the neurological issues to manage, that was just one more to add to it. I was a weird kid. I had my core group of, like, very tight, like, three friends. When we look at autism, we characterize it by, like, lack of eye contact, what i do now is when im looking away from the camera, its for my own comfort. Faces are confusing. Its a lack of mirror neurons in your brain working properly to allow you to experience empathy, to realize where somebody is coming from, or to realize that body language means that. At its core, autism is a social disorder, its a neurological disorder that people are born with, and its a big, big spectrum. It wasnt until i was a teenager that i heard autism in relation to myself, and i rejected it. I was very loud, i took up a lot of space, and it was because mostly taking up space let everybody else know where i existed in the world. I didnt like to talk to people really, and then, when i did, i overshared. I was very difficult to be around. But the friends that i have are very close. I click with our atypical kiddos than other people do. In experience, i remember when i was five years old and not wanting people to touch me because it hurt. I remember throwing chairs because i could not regulate my own emotions, and it did not mean that i was a bad kid, it meant that i couldnt cope. I grew up in a family of behavioral psychologists, and i got development cal developmental psychology from all sides. I recognize that my experience is just a very small picture of that, and not everybodys in a position to have a family thats as supportive, but theres also a community thats incredible helpful and wonderful and open and there for you in your moments of need. It was like two or three years of conversations before i was like you know what . Im just going to do this, and i went out and got my prescription for hormones and started transitioning medically, even though i had already been living as a male. I have a twoyearold. The person who im now married to is my husband for about two years, and then started gaining weight and wasnt sure, so i we went and talked with the doctor at my clinic, and he said well, testosterone is basically birth control, so theres no way you can be pregnant. I found out i was pregnant at 6. 5 months. My whole mission is to kind of normalize adults like me. I think ive finally found my calling in early intervention, which is here, kind of what we do. I think the access to irrelevant care for parents is intentionally confusing. When i did the procespective search for autism for my own child, it was confusing. We have a place where children can be children, but its very confusing. I always out myself as an adult with autism. I think its helpful when you know where can your child go. How im choosing to help is to give children that would normally not be allowed to have children in the same respect, kids that have three times as much work to do as their peers or kids who do odd things, like, beach therapy. How do speech therapy. How do you explain that to the rest of their class . I want that to be a normal experience. I was working on a certificate and kind of getting think Early Childhood credits brefore i started working here, and we did a section on transgender inclusion, inclusion, which is a big issue here in San Francisco because we attract lots of queer families, and the teacher approached me and said i dont really feel comfortable or qualified to talk about this from, like, a cisgendered straight persons perspective, would you mind talking a little bit with your own experience, and im like absolutely. So im now one of the guest speakers in that particular class at city college. I love growing up here. I love what San Francisco represents. The idea of leaving has never occurred to me. But its a place that i need to fight for to bring it back to what it used to be, to allow all of those little kids that come from really unsafe environments to move somewhere safe. What ive done with my life is work to make all of those situations better, to bring a little bit of light to all those kind of issues that were still having, hoping to expand into a little bit more of a Resource Center, and this Resource Center would be more those new parents who have gotten that diagnosis, and we want to be this one centralized place that allows parents to breathe for a second. I would love to empower from the bottom up, from the kid level, and from the top down, from the teacher level. So many things that i would love to do that are all about changing peoples minds about certain chunts, like the Transgender Community or the autistic community. I would like my daughter to know theres no wrong way to go through life. Everybody experiences pain and grief and sadness, and that all welcome, everyone. And thank you so much for coming and i am Claire Farley and the director and a Senior Advisor for mayor breed and tony newman, and today we are gathered on this historic day to open up San Franciscos first trans home for transand nonconforming adults in San Francisco. [applause] and its such an honor to work for a city that continues to celebrate but also to do the work to make sure that our Community Gets housed. Without housing, without housing we will not be able to help our communities thrive. Every one of us need to come together to be a part of this solution and st. James and larkin street are doing that today. Thank you. [applause] so first we have honored guests with us today and ill turn it over to her. And mayor breed has led the effort and she made 2. 3 Million Investment into transhome which includes this opening today which is going to be 13 folks housed and 55 folks to receive subsidies for folks who are low income and she spearheaded with the community and the office and tony and were so honored to have a mayor that continues to commit and really work to make sure that everyone in this city can thrive. So please welcome mayor breed. Mayor london breed thank you for joining us on this historic day. When i first became mayor in San Francisco and met with the folks in my office, many of the department heads, i made it clear that equity would be at the top of our agenda in everything that we do. We need to change the culture of San Francisco and not just talk about the problems that exist, but actually to make the kinds of investments that will deliver real results. And it comes from my own experience of growing up in San Francisco in the African American community, living in poverty, and waiting for something to be done. We know what the data says, but we dont always make the right investments that ensure the results that are going to change the lives of the people that we want to serve. And so when i met with the transadvisory committee and we talked about the challenges that continue to persist around the opportunities for grants and the Arts Community and opportunities for housing and opportunities for programs and other services, the discriminatory practices that exist with Job Opportunities that they seek, the challenges with our Homeless Population and learning that people who are part of our transcommunity are 18 times more likely to experience homelessness than anyone else in this city, i knew that it was important to not only listen and hear what they had to say, but to invest ar resources in tryino make sure that we can change what those challenges are for the better. And so im so grateful to be standing here with Claire Farley who is the director of the office of transgender initiatives for San Francisco, because she has brought so many people together and to come up with incredible solutions. And is the reason why we have invested in this past years budget, thanks to the supervisor of this district and others, supervisor peskin, 2. 3 million for this initiative of transhome s. F. And this is one of the first, most incredible projects that we are cutting the ribbon on today that will provide safe Affordable Housing for people who are experiencing homelessness. And so it is so great to be here today. And i really want to thank tony newman because tony newman [applause] and shes a force and is committed to this work and she has hit the ball rolling with staffing up and working with folks in the community and making it clear what was needed, which makes it easier to provide the funding right to the places where we know that its needed the most rental subsidies and wraparound support and services and making sure that we have the right people in place to get the job done so that we can get people off the streets and to get them into housing. So thank you so much to tony and the work that you do, to the Mayors Office on housing and community development, and to the coalition, to larkin street and Youth Services and especially to the San Francisco transadvisory committee who i have mentioned before the work that they continue to do to make sure that we call attention to all of the inequities and the various city departments as it relates to funding and how it needs to change to make an impact on the lives of people who are a part of this Amazing Community and a true important part of San Francisco. So i want to thank. Our young people, as well as reaching the thousand new shelter beds which is such an accomplishment and thank you so much for your leadership to make that goal happen. Also i want to recognize our commissioners who are in the house today as well as our department heads, dr. Colfax from the d. P. H. And others, leadership at mohcd for their support and really making sure that these programs get funded and that theres equity continuing throughout the work. And as well i want to welcome the District Supervisor aaron peskin. Thank you so much. [applause] thank you. I think that everything has been said but not everybody has said it. In addition to our d. P. H. Director grant colfax i want to acknowledge and to thank the director of our department of building inspection, tom hooey. Thank you to larkin street and thank you to st. Jerusalems and to the office of transinitiative incentives and the Mayors Office of housing and community development. I am here to give a district 3 welcome. And let me just say that we are delighted, we were delighted to appropriate the funds, and i could not be more proud that this is the first facility and it is located here in district 3. Which has a very proud, long lgbtq history from the black cat down the street to polk street on the other side, this is where it all began in San Francisco. And we are profoundly aware that homelessness is acutely an lgbtq issue. And today we are taking a large step in addressing it and in solving it. Welcome to district 3, to the 13 individuals, i will register you to vote the second you move in. [laughter]. [applause] thank you, so much, supervisor, and thank supervisor mandelman and supervisor haney, they were not able to join us but their teams are here and so thank you so much for your efforts. Before i introduce tony i wanted to recognize the anonymous Building Owner of this property who is renting this space to us and he and his partner are committed to making sure that transhome is a success and that we continue to work to make sure that our communities are housed in the city. And without having such a strong and supportive and inclusive manager of this building, we would not be here today. So lets please give he him a hd and thank them for their support. [applause] so now its my honor to introduce tony newman, shes the director of st. James infirmary and i would like to say that i helped to kind of create the idea, and now shes the mother of the project. So please welcome the mother of transhome, toni newman. [applause] welcome, everybody. Im just so excited to be here today and i want to thank all of the partners here, hugo from the Mayors Office of housing. And we have open house and we have larkin who have been very supportive. And larkin is so supportive to me and st. James and the navigating team of matthew payden and jesse and camden, that have been working day and night to make this available for you. Were excited that st. James can be a leader with larkin. And larkin has been leading the youth for many years. And they have taught us how to do this. And i want to thank my board of directors for coming and i have four board of directors and two will be speaking and now i introduce Akira Jackson did shes here. Shes a sponsor and shes been fighting for housing but i dont think that shes here, so jesse santos is going to come up and to introduce our first resident moving into the house this week. Jesse, and jane, please come up right now. Good morning, everyone. Thank you for being here and this is a dream for us, for the Transgender Community. I will introduce jane, the resident in our house and shes a beautiful woman. [applause] hi, i am jane cordova and i was born in central mexico and i came here when i was 16 years old and i grew up in l. A. And eventually made my way to San Francisco, which is i live here for 10 years. And i went to new york and we stayed there for another 10 years and im very happy to be back in this city where our community has the most resources and im very happy to be here and to have a place finally to call home. Thank you. [applause] id like to call up joquaim and jane, come on up. [applause] hi, thank you for coming, im joaquin ramora and im here where i proudly serve as a board member and as an advocate for Harm Reduction and transsupport in the greater bay area. Thanks to mayor breed and our transhome and everyone else who helped to make this project come together. Today we can celebrate that our transhome is a step in the right direction for the city of San Francisco. This ensures that transgender people have an opportunity to become successful in our society. Stable housing is fundamental to creating access to resources for survival. Our transhome will provide this foundation to create a support system for those living on the margins within our city. Excuse me. Members of our community are constantly faced with unjust incarceration and poverty and constitutional and emotional violence. Some encounter even more severe consequences and our transgender sisters of color are experiencing hate crimes and murders on a daily basis and this goes unnoticed. The society must understand discrimination based on race and gender presentation. We must continue with this momentum and inspire more programs for the needs of our community. Its our Due Diligence as transpeople to ensure that the issues are confronted and change. We need companies and foundation and government to commit to advocating for transgender causes. Our transhome will provide the opportunity to not only recover and survive but to thrive and survive the Power Members to become leaders and role models. And protecting our Community Members and we are shifting the narrative away from being defined by our margins and barriers towards being defined by successes and positive impacts on the world. The housing crisis in the bay area has become recognized as an ongoing issue and despite this were continuing to demonstrate that theres ways to empower and to support our communities with pride. I feel proud to know that San Francisco is a place of historical resistance and refuge for people of all walks of life and that we continue that resistance by uplifting our marginalized communities. Thank you. [applause] id like to take a second to acknowledge Akira Jackson who is unable to be here today. Id like to thank her leadership, without her we wouldnt be here today. And st. James is honored to be part of this project connecting folks. Thank you connecting folks with the services and homes that our Community Needs. We look forward to continue to fight for the rights of our community. Thank you. [applause] well, thank you all so much. And now were going to move the podium and cut the ribbon. One, two, three,. [applause] thank you all so much. [ ] i really believe that art should be available to people for free, and it should be part of our world, you shouldnt just be something in museums, and i love that the people can just go there and it is there for everyone. [ ] i would say i am a multidimensional artist. I came out of painting, but have also really enjoyed tactile properties of artwork and tile work. I always have an interest in public art. I really believe that art should be available to people for free, and it should be part of our world. You shouldnt just be something in museums. I love that people can just go there, and it is there for everyone. Public art is art with a job to do. It is a place where the architecture meets the public. Where the artist takes the meaning of the site, and gives a voice to its. We commission culture, murals, mosaics, black pieces, cut to mental, different types of material. It is not just downtown, or the big sculptures you see, we are in the neighborhood. Those are some of the most beloved kinds of projects that really give our libraries and Recreation Centers a sense of uniqueness, and being specific to that neighborhood. Colette test on a number of those projects for its. One of my favorites is the oceanview library, as well as several parks, and the steps. Mosaics are created with tile that is either broken or cut in some way, and rearranged to make a pattern. You need to use a tool, nippers, as they are called, to actually shape the tiles of it so you can get them to fit incorrectly. I glued them to mash, and then they are taken, now usually installed by someone who is not to me, and they put cement on the wall, and they pick up the mash with the tiles attached to it, and they stick it to the wall, and then they groped it afterwards. [ ] we had never really seen artwork done on a stairway of the kinds that we were thinking of because our idea was very just barely pictorial, and to have a picture broken up like that, we were not sure if it would visually work. So we just took paper that size and drew what our idea was, and cut it into strips, and took it down there and taped it to the steps, and stepped back and looked around, and walked up and down and figured out how it would really work visually. [ ] my theme was chinese heights because i find them very beautiful. And also because mosaic is such a heavy, dens, static medium, and i always like to try and incorporate movement into its, and i work with the theme of water a lot, with wind, with clouds, just because i like movements and lightness, so i liked the contrast of making kites out of very heavy, hard material. So one side is a dragon kite, and then there are several different kites in the sky with the clouds, and a little girl below flying it. [ ] there are pieces that are particularly meaningful to me. During the time that we were working on it, my son was a disaffected, unhappy high school student. There was a day where i was on the way to take them to school, and he was looking glum, as usual, and so halfway to school, i turned around and said, how about if i tell the school you are sick and you come make tiles with us, so there is a tile that he made to. It is a little bird. The relationship with a work of art is something that develops over time, and if you have memories connected with a place from when you are a child, and you come back and you see it again with the eyes of an adult, it is a different thing, and is just part of what makes the city an exciting place. [ ] [roll call] clerk we have