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. Cla so today, we have come together for a historic day. Today, we gather to honor 50 years of pride. Yes, 50 years. [applause] this anniversary was hard fought from the days of the Freedom Freedom parade to compton cafeteria riots, to all the work across this country that we continue to do for freedom. And if we look, our theme for this years pride is future of hope. And if we look to the next 50 years, we have a lot to be hopeful for. We look at our past and marriage equality, to the first day at city hall when the first couple was married. We recognize lesbian and lgbtq folks across the city. We remember the work that we have to do across the country as trans kids are being refused access to bathrooms in our schools. We remember the families that standup for them, and we remember the work that we still have to do because this generation is hopeful. This generation will continue to be hopeful, and theres so many reasons why we have this hope. Some of that comes from our elected officials, some of that comes from our own journeys, but we know we cannot do this work without the leadership in our city, and i am so proud to work for a leader in this amazing city whos not only spear headed the work of so many of us and supported so much of lgbt quality here in San Francisco but also is continuing that effort forward, our mayor, mayor london breed. [applause] the hon. London breed first of all, thank you, claire. Thank you to the freedom ban of frisk. Thank you to s. F. Pride and supervisor mandelman and so many elected leaders and Department Heads here in San Francisco to celebrate the beginning of pride in San Francisco, 50 years of what i think has been an amazing accomplishment, so thank you to the Board Members, to the president , caroline. Thank you to our new executive director. Like, so many great things are happening in this city and so many great things are happening with pride. And i know i get really excited, because even though its february and we are not expected to have a number of activities, especially the parade, until june, its going to be so exciting that we have to announce it now. We have to get everybody excited about whats to come because there is nothing that we do better than celebrate in San Francisco. We celebrate our history, we celebrate our diversity, we celebrate what makes San Francisco so unique. And we know that this in this city was the epic center of what has occurred that has led to so much to support our Lgbt Community, and im really proud to be in a position as mayor to help support and carry on some of the many policies that we know are necessary to continue to make sure that there is hope for future generations. In fact, trans home s. F. Has been an amazing accomplishment in this city, and thank you, tony newman, for our leadership. Weve got one of our first buildings, and theres lots more to come, along with Wraparound Services for our trans seniors. [applause] the hon. London breed and in San Francisco, we do celebrate a new record low of new h. I. V. Infections, less than 200 last year. Thank you, dr. Brent colfax, for your leadership in the department of health. We know we will continue to make those investments that well get to zero. We know that we did the count around Homeless Youth. About 50 of the youth that are homeless in this city identify as lgbt, and we want to make sure that we help the next generation of young people growing up in this community so that they have hope. So many great things but also so much more work to do. And i am really confident in the leadership of this city to really help us move forward on so many Different Levels. As we think about just the attacks that we have been under. I mean, we just had a visit from the other number 45 here this weekend, and i cant help but think about not only our city being under attack, but also our Lgbt Community, where we continue to fight for things that we shouldnt have to at this point. You know, when i think about just what were celebrating in the month of february, black history month. Black history is American History. Were celebrating Lunar New Year. Chinese American History is American History. Lgbt history is American History. We are all a part of the fabric of what makes our city and our country so great. So we will not be silenced. We will continue to lift our voices and celebrate what makes us so great, what makes us so unique. And during the month of pride, we will just do it with that much more flair. So thank you all so much for being here. Heres to 50 more incredible years for future generations to come. Thank you. [applause] thank you. Thank you, mayor breed. And one other note im just so proud of, thanks to the mayors leadership, weve invested over 1 million in the next year to seniors. So thank you to the department of aging and adult services, and thank you to all of those in our city who made sure that we were brought to this 50 years and continue to be brought to the right place. So now, a leader that we know will continue to bring us forward in the next 50 years, our new director of pride, fred lopez. [applause] hi. Good morning, everybody. How are you . Excited . S. F. Pride, sfpride50. Before anything else, i just want to convey our sincerest gratitude to the mayor, to supervisor mandelman and all these elected officials tod for coming out today to start the celebration right. Every City Department that is present, we want to thank you for your unwavering support for San Franciscos most iconic went. It may cost millions of dollars to produce, but it wouldnt happen without the amazing work of our departments, employees, and volunteers. [applause] as claire said, the theme for San Francisco pride is a generation of hope, and it was originally suggested by pride member larry nelson. That spirit of hope will become visible at the beginning of june when the rainbow flags go up along Market Street, much of Market Street now newly car free. On saturday, june 37, civic center will once again become a site of celebration. All weekend, with crowds in the tens of thousands were expecting. Its going to be a big year, and were excited for it. Then, as clair has mentioned, for many of us, the center piece of pride, the parade, on june 28. 50,000 marchers are expected to be in the parade, all cheered on by more than 100,000 spectators its going to be quite a spectacle this year. [applause] if your organization or group is thinking about marching, we encourage you to register soon because we think the parade might run out of space earlier as it has in the years past, so thats great. For the past two years, our partners at cbs bay area have live streamed the parade so that people around the world can see it live. Wear something cute, and call your mom, because youre going to be on t. V. Thats exciting. Thank you to our friends at kpix. [applause] thats not the only new development for 2020. On april 17, an exhibition entitled labor of love, the birth of San Francisco pride, 19701980 opened at the gobt museum in San Francisco. Itll be up in the museum until january 2021. Further, starting may 7 in the city hall in the north light court, the Historical Society and San Francisco Arts Commission will mount a photography exhibition called 50 years of pride, so make sure to check out the amazing history that we can learn from. Our entire team at San Francisco pride is working hard to ensure that we are ready for this monumental event, and here are some ways in which our communities can help. Applications are now open for our volunteers who provide power during the event. I want to acknowledge that in this room, there are some former Community Grand marshals and honorees, like our board president , carolyn, was once an honoree, and others. If you want to raise your hands, folks who have been honored in the past. Thank you for all of your tireless work. That spirit of tireless volunteerism is at the core of San Francisco pride, and that commitment goes both ways. In 2019, we were pleased to go nate more than 203 donate more than 203,000 to ongoing bay area nonprofits, which adds to our total of more than 3 million since 1997. [applause] finally, 2020 may be the 50th anniversary of pride as a march and a celebration, but San Franciscos pride began way before 1970. The compton cafeteria riots took place in 1966. As we look forward to the next 50 years, lets always remember the valuient struggles of previous valiant struggles of previous generations, and as hectare remilk said, all give them hope. And here at pride, we always will. Thank you so much. [applause] thank you, fred. Were so excited, and we know that pride is in great hands. Thank you. So it is my honor to introduce our new pride chair, carolyn wisenger. Thank you, fred, thank you, mayor breed, thank you to my aunt who has threatened bodily harm if i dont mention them. As fred mentioned, the board is excited about completing our threeyear theme with this years generation of hope. While we are excited about the events leading up to the pride weekend, we are most excited about what that word hope represents. As a community, we are in challenging times, and being in pride, its so different. There is more required now that we are headed into 50. The organizational needs arent the same as they were in 1970, and either are the needs of the community that we represent. Theres more required in the way that we represent community, there is more required in the way that we support our community, and theres more required in the way that we are supported. Now the last leg to 50 is always the hardest leg. Some of you may have been married 50 years, and you know its hard getting to 50. It doesnt get easier as we march in these last months to 50. As someone who grew up in a church thats now 75 years old, i remember in 1995, and how hard that last road to 50 was. I remember the struggles, and i remember the squabbles, and i remember the day it seemed like it would all fall part. We are in a crunch time now, but we as a board continue to believe that it is important to have a celebration that is reflective of the community we serves, and important to be reflective of all of those voices, and to make all those voices be heard. I remember when Bishop Carlton pearson said we have to remind them of the hope, so thats what were going to do, and we ask you to join us for that. [applause] thank you. So 2020 is kind of an incredible year. Also, its not the 50th anniversary, and also, we need to get out there and vote. Every one of you matters, so lets get out there and do that. So now, its my honor to introduce our only out gay supervisor who has been doing some incredible work not only in his district but for the Lgbt Community at large and in San Francisco at large. Please welcome supervisor raphael mandelman. Supervisor mandelman good morning, everybody. It does you know, february does feel like a slightly odd time to be celebrating time, but i will say theres never a bad time for the Queer Community to take the mayors balcony, so we are happy to be here. And madam mayor, i think it is just worth noting the extraordinary collection of queer Department Heads you have, from clair farley at the o. T. I. , and grant colfax at the department of Public Health, and jeffrey tumlin, and sherreen mcspadden. You have a very queer administration, and we are quite appreciative of that. [applause] supervisor mandelman the trustees never get acknowledge them, so im going to acknowledge them now. We have our past president , Alex Randolph of the college board, and our current president , tom temprano of the college board, doing great and important work. You know, as i and then, i also do want to congratulate fred lopez. Thank you, fred, thank you, carolyn. Thank you to the whole board. Pride has never been easy, but it is important, so i this year is particularly important and seems to be particularly challenging, and i know you will get through it, and i am grateful for what you are doing to get us through what will be an amazing 50year celebration, so thank you. [applause] supervisor mandelman i was trying to think about that 1970 gayin, the people who participa participated in that. The next 50 years, what did they imagine it would be like . Did they imagine that in a few years, a gay man would get elected supervisor in San Francisco . And after that, rainbow wave after rainbow wave would come crashing down until the last election when we got a Record Number of gay, lesbian, and bisexual people elected, even in virginia. They would not have imagined the extraordinary Community Response that would come to it. Tom and i were just over at the airport where the quilt is getting brought from atlanta. It is finally coming home, and theres going to be a fantastic rollout of panels of the last ten years on april 3, 4, and 5, and everybody should come. But the resilience of the gay community, responding to that crisis and building an aids movement, they had no idea. And would they have imagined same sex marriage . No matter how you feel about pete buttigieg, would they have imagine that a gay man would be one of the leading candidates for president s this year . And gay c. E. O. S, and so much of what they imagined would have come to pass. I dont think they would have imagined that the mayor of San Francisco would have been an African American woman who grew up in the projects, and i do think they would be particularly amazed and delighted at that prospect, because harvey milk talked about the uses and those who had been left out of the power structure in the 70s, and those who had just begun to imagine that there might be a universe where they can take power. So its amazing with our Department Heads and our mayor i dont remember, San Francisco and our mayor, San Francisco is living up to the hope. I feel like i have generationally benefited so much. And in a lot of ways, the work is about building, acknowledging the institution like the lesbian gay freedom ban. That was a great moment for the city, but some of those other great moments, a second building, and now having purchased a third site and affirming lgbt senior housing. Thank you, mayor, for that. Theres just around the corner from that, the gay mens chorus. They are becoming the national lgbtq center for the arts, and we got some help for them into the budget last year. Again, thank you, madam mayor, and thank you to my colleagues on the board. We have inherited so much, and so i think going forward, obviously, the obligations to move forward on that, and to fulfill the unfulfilled promises. In 1970, we knew that people had been left behind, and in 2020, we know that people have been left behind. We need to eradicate the epidemic. We need to reach folks who have not been reached, and so the work of justice which they know we needed to do in 1970 and 80 and 90, and they know the work that we need to do. It was the work of 50 years, so it was exciting, and now, fred lopez is going to come back. [applause] thats a great way to sort of summarize all the Amazing Things that are happening in San Francisco. We are so incredibly fortunate to live in this amazing place and be supported by all of these amazing people and institutions that surround us. I do want to say quickly that i make sure i acknowledge the Board Members of San Francisco pride who are here. Give us a wave. [applause] and San Francisco pride wouldnt happen without a really talented teams of contractors or staff. If youre a contractor or staff, give us a wave. [applause] great work. Finally, as raphael said, it is i went through a lot of struggles in my life, and i am blessed to be part of this. I am familiar with what people are going through to relate and empathy and compassion to their struggle so they can see i came out of the struggle, it gives them hope to come up and do something positive. I am a community ambassador. We work a lot with homeless, visitors, a lot of people in the area. What i like doing is posting up at hotspots to let people see visibility. They ask you questions, ask you directions, they might have a question about what services are available. Checking in, you guys. Wellness check. We walk by to see any individual, you know may be sitting on the sidewalk, we make sure they are okay, alive. You never know. Somebody might walk by and they are laying there for hours. You never know if they are alive. We let them know we are in the area and we are here to promote safety, and if they have somebody that is, you know, hanging around that they dont want to call the police on, they dont have to call the police. They can call us. We can direct them to the services they might need. We do the three one one to keep the city neighborhoods clean. There are people dumping, waste on the ground and needles on the ground. It is unsafe for children and adults to commute through the streets. When we see them we take a picture dispatch to 311. They give us a tracking number and they come later on to pick it up. We take pride. When we come back later in the day and we see the loose trash or debris is picked up it makes you feel good about what you are doing. It makes you feel did about escorting kids and having them feel safe walking to the play area and back. The stuff we do as ambassadors makes us feel proud to help keep the city clean, helping the residents. You can see the community ambassadors. I used to be on the streets. I didnt think i could become a community ambassador. It was too far out there for me to grab, you know. Doing this job makes me feel good. Because i came from where a lot of them are, homeless and on the street, i feel like i can give them hope because i was once there. I am not afraid to tell them i used to be here. I used to be like this, you know. I have compassion for people that are on the streets like the homeless and people that are caught up with their addiction because now, i feel like i can give them hope. It reminds you every day of where i used to be and where i am at now. Shop and dine in the 49 promotes local businesses and challenges residents to do their business in the 49 square files of San Francisco. We help San Francisco remain unique, successful and right vi. So where will you shop and dine in the 49 . Im one of three owners here in San Francisco and we provide mostly live Music Entertainment and we have food, the type of food that we have a mexican food and its not a big menu, but we did it with love. Like ribeye tacos and quesadillas and fries. For latinos, it brings Families Together and if we can bring that family to your business, youre gold. Tonight we have russelling for e community. We have a tenperson limb elimination match. We have a fullsize ring with barside food and drink. We ended up getting wrestling here with puoillo del mar. Were hope og get families to join us. Weve done a drag queen bingo and were trying to be a diverse kind of club, trying Different Things. This is a great part of town and theres a bunch of shops, a variety of stores and ethnic restaurants. Theres a popular little shop that all of the kids like to hanhang out at. We have a great breakfast spot call brick fast at tiffanies. Some of the older businesses are refurbished and newer businesses are coming in and its exciting. We even have our own brewery for fdr, ferment, drink repeat. Its in the San Francisco Garden District and four beautiful muellermixer ura alsomurals. Its important to shop local because its kind of like a circle of life, if you will. We hire local people. Local people spend their money at our businesses and those local mean that wor people willr money as well. I hope people shop locally. [ ] working for the city and county of San Francisco will immerse you in a vibrant and dynamic city thats on the forefront of economic growth, the arts, and social change. Our city has always been on the edge of progress and innovation. After all, were at the meeting of land and sea. Our city is famous for its iconic scenery, historic designs, and world class style. Its the birthplace of blue jeans, and where the rock holds court over the largest natural harbor on the west coast. The citys Information Technology professionals work on revolutionary projects, like providing free wifi to residents and visitors, developing new programs to keep sfo humming, and ensuring Patient Safety at San Francisco general. Our it professionals make government accessible through awardwinning mobile apps, and support vital Infrastructure Projects like the hetch hetchy Regional Water system. Our employees enjoy competitive salaries, as well as generous benefits programs. But most importantly, working for the city and county of San Francisco gives employees an opportunity to contribute their ideas, energy, and commitment to shape the citys future. Thank you for considering a career with the city and county of San Francisco. George Washington High School marching band. [applause] please welcome kayla smith. [applause] good morning, everyone. Hows everybody doing today . Thank you. Thank you for joining us today for this historical occasion. My name is kayla smith, and i will be your mistress of ceremonies for the evening. Growing up in San Francisco d5, hayes valley, to be exact, since the age of four, i have been privileged to receive mentorship from my community. I went from running departments at project level to now earning