>> aye. >> opposed? the minutes are adopted. >> item 3, directors report. >> director garcia. >> good afternoon commissioners. the directors report is somewhat a small today, but the one item i did want to share with you is that the san francisco board of supervisors enacted a resolution on april 11 charging the department of public health with convening a task force to develop recommendations on operation of safe injection service in san francisco. the department will bring together diverse group of phenyl stakeholders to consider ponel opportunities obstacles with sfr vised consumption uvs and the community need for sunchs and feasibility providing such service. the task force will hald public meeldings to solicit input and require today submit report to . meetings will be poseed on the dph website so that is the only item i'll report on and if you have any questions on any other items in the report i'm happy to answer those. >> thank you. did you have a time yet for the initial task force meeting? >> um, we are just finalizing the membership and but as soon as we do i'll send a note to mark to share not only the membership of the committee but also the dates thof meeting. >> okay. commissioners questions to the director on her report? any questions? seeing no questions, then is there any public comment? >> no public comment requests for that item. >> no public comment on the reports so we will proceed on to the next item >> item 4 is general public comment and not received any requests so qu move to itm 4 which is report back from community and public health meeting from today. >> commissioner pateic. pating. >> want to thank the meebs who joined in the community and public health division report. we heard from dr. cora hoover and susan phillips of the dezize control and prevention subdivision. this is the cdcp is a division which helps us across san francisco by promoting access to the imineization by giving flu shots and see the immunization and travel clinic and serve on dezizes for all position thofz city and overvee and help with disease chrome for example when we have to investigate cases of new and straichck diseases of which they have to track 70 old diseases and when we have new diseases like zika or ebola those are the folks at the department of public health that we call on to help us. um, we heard a-as part the work what they have done with regard to the zika response they produce public health elerts many as clinicians received as part of the helt facts system as well as public education. the department things it has done a very good job and i do as well with records to reporting out the risk of zika in pregnancy, helping to [inaudible] fear squz very happy to report that we had no cases in california of california acquired zika. there have been cases in florida but not in california. we also looked at the issue of how following the cdc instructions our services have been coordinating zika screening for newellly pregnant mothers as part of the prenatal studies. so, again our department is the first line response to the i don't want to call epidemics but health related emergencies and we have seen them do very good work. in fact, we just finished the ebola crisis when the national cdc said that ebola was no longer a epidemic in the west african region, they called off their alerts saying travellers to west africa no longer needed surveillance that was done urltier last year. staff had a two week break and zekey oughtbreak came so got a quick haveication and back to work. we talked about how this strains or stresses the servicess kw staff says we have good people and have what it takes to manage including work wg the airport for example if there is a threat of asian flu going on and i think we have seen them now work across systems, the helt system with zika and pregnancy and ebola system across multiple hospitals so very proud of this division because if there is a question of travel related disease or communeicable diseases i think the evidence is our department is ready in a prevention matter and interventional. any questions othen cdcp division? if not i go to-again, i want to thank dr.s cora hoover and susan phillip for excellent job and leadership of their division. we heard from haly hammer who is director of primary care on true north metrixes. these are the outcomes measures that the department has been developing to make sure that we are making progress across our divisions for commissioner bernal. the areas of improvement oregon score cards include quality measures, safety measures, health equitty measures, measure of the care experience, workforce and people development and then a financial stability and this forms one of the essential basis of our pyramid and commitment to becoming the choice for healthcare and wellbeing throughout the city. so, we heard these metrix through primary care and we specifically drilled down into the developing people metrix, so what i will say is that in future months we will be hearing from primary care hopefully on the whole metrix score card as we look at the score card, but we looked at one metmic in particular on developing people and what i'll say to you is our staff have identified san francisco dph as a good place to work. for example, in the last year i had a opportunity to learn and grow. 74 percent of positions said yes. in 2015, 85 percent of positions said yes in 2016. 3 airth percent the front office staff said they had a opportunity learn and grow and last year 52 percent. someone talked about progress at work, the front office staff and physicians have been receiving regular performance evaluation squz a large percentage of staff felt someone at work was invested in their development. the investment in our people is really an investment in the people who take care of our patients, so it's everything passes from one to the other and we talked about their metrix and how they present to us in a more rolled up fashion at a later time. the last thing i wail is one metrix showed there is a certain amont of effort that goes on in the primary care divisions measured as exhaustion. a fair number of staff say they feel tired but they have good morale and like working and are committed to our work, so i think it is the heart and soul of what it like to work with a population in need and with many needs and just really thank our dr. hailey and all the providers who work under her and medical assistance and front office staff for doing hard work and reflecting the good sentiments of the work that they do. so, we'll get into this more as we look at the metrixes. this was one area and hopefully can present the whole primary care division metrix in a score card to maybe the commission after the committee reviews it. >> any questions on that at all? >> i think this is all part of our ability to now begin to look at our primary care clinics now that the data is starting to really be available. thank you very much. we are wil go to the next item then. >> there are no public comment request frz that item. item 6 is rez ligez in support of vision zireo. the goal of zeeree traffic deaths by 20 twenty-four and 2017-18 action strategy. this resolution was introduced march 21 to you and will be presented again. >> there are no edits as last present snd >> there are no change jz today you vote on the resolution. >> good afternoon commissioners. i'm megan weir the director the program and help with the sustainability andologist cochair the vision zero task force. thank you are fr your consideration of the resolution and happy to respond to any questions you might have. >> commissioners, questions-at our last meeting we did ask to see the action plan and the action plan before you now and is valuable, which is what we are being asked of the resolution to endorse for the years 2017, 2018 is that correct? and that is correct. we presented the strategy and field questions to commission meetings as well. the strategy is really a high level document, we are very proud of this work. the department of public health in particular informed a lot of actions that address health and equity, community engagement. we are the lead on evaluation and provide a really strong role. [inaudible] my colleagues is here who works on education and excited about a lot hof it work reflected. >> commissioner pating you had a question? >> 2017, are we already implementing the plan or be implement as of june? >> we are well under way with the actions in the plan. >> other commissioners, any questions? >> i had a exciting update about a key state legislative policy action was ab 342, which the commission supported a resolution in support of automated speed enforcement last year and it made it through the privacy committee today so just got the great-it has to pastz through two committees, next week is transportation but this is a significant milestone and reflects the work of dph, our city partner, mta as well as community advocates so really big deal. it will be a pilot in san francisco and san jose. >> commissioner bernal did you understand what the initiative is at this point? >> yes. >> okay. otherwise you get a brief explanation. >> i do, thank you. thank you for your work. >> absolutely. thauchck. >> thank you. commissioners before you is a resolution. you now have the hard copy of the vision action strategy for the two years, which is very well displayed, so a motion for the resolution is in order. >> so moved. >> second. >> there is a motion and second. is there further discussion on the resolution? if not, we are prepare frd the vote and all those in favor of the resolution please say aye. >> aye. >> all those opposed? the resolution is uninanimously adopted. thank you very much. >> thank you so much and thank you to commissioners. i so appreciate your support as well as director garcia and our leadership. >> thank you. >> note there is no public comment for the item. item 7 is the sfdph human resource update. >> good afternoon president chow and commissioners. ron weigelt department of public health human resource. i try give a update, try to do it it yearly of the human resources section and to our accomplishments. the first line that you provided with packet has to do with aso authority. we have the authority to hire 7416 positions budgeted positions. you see that is studally increasing over the years. this year however, the directions were not add new fte's so going in a neutral budget to the extent we can achieve that. so, the first unit i want to talk about is our merit section. this is through [inaudible] on the end. our merit division manager and she is responsible for the work that the merit section does. they conducted 435 recruitments. in order to fill positions we have to do recruitment that involves analyzing the job, posting the job and taking in applications and screening those applications for the manager. as you can see, in 2012/13, we were doing 293 dipped to 256 recruitments and work of the team we have been increasing the number of job announcements and job recruitments which helped fill our vacancies. this is the twnd trend line showing-i went the wrong way. this is the trend line showing the number of applications we receive each year as a rultd of the recrultment. because of the labor market is tightening we added two recruiter tooz the unit and so we are doing more aggressive recruiting, not simply posting and waiting to see what recruitments-candidates we get, we are actively recruiting nation wide and locally and recruiting for specific targeted populations. these are the number of new hires based on the recruitments. you see it steadily increased so as it increasing the vacancy rates drop which sur goal, we want to get people in the door. when i first hired have stories of years it takes people to be hired. we did the process at zuckerberg for the rn classification with the goal to get it down to 9 odays which we accomplished. either 90 days or breter. the next section is operation divisions. i have two operation managers, karen hill and cathy abella. karen does zuckerberg zeneral hospital which is half the department and cathy is responsible for the other half of the department. as you see here for the new hires, they are broken out in this manner. zuckerberg pcs hire and other division pcs hire jz have various other classifications. a pex employees means they are permanent but civil services. pes means they are limited to 6 months or a certain category they can go as long as three years but don't get permanent status with the city. texas prkts b is provisional meanic we hire you waiting for a list to be published. it is a special category under civil service rules. the classifications we most commonly hire into are these classifications. they are slightly different whether they are zuckerberg or other divisions. zuckerberg the registered nurseerize the largest classification we hire into and as you go down you can see those numbers. at the jcc at zuckerberg we report on the vacancy and give update said to getting the vacancy rate down. so, we had of course registered nurses is the biggest classification within the department, the most popular classification with over a thousand rn 's so one thing we did is figure if we can get the temporary rn's which are p 103 to be permanent rn's. our labor relation section work wg the operation section sent letters to the temporary nurses saying are you interested becoming permanent. we have donethality several times over the last several years so the nurses come in temporary from kaiser or other hospitals and we try to recruit them to be permanent. that was fairly successful this last go around. the other thing that operations does is leaves management. ovthe years people talked about how complicated [inaudible] so created unit. help to manage and work with the manager to understand the leaves and work with the employee because they are complicated. you have federal and state leave jz local leaves. it is a very complicated mailtrix so these unit help the managers understand the leaves. these are the types of leaves we are managing. that doesn't count vacation or normal time off for orelt reasons but these are your special leaves. performance appraisem we talked about that in the past. i like to mention in the past i mejzed we would go to a automatted performance appraisal, electron recollect. we did a pilot project with people soft with the county, we did it here and our managers didn't like people soft as a system for delivering electronic performance appraisal. for the sit city as a work group, dph is on the work group we are trying to figure a solution other that people soft. we went from 2900 evaluations in 2014 to nearly 4800 evaluations completed this past year and starting now to prepare evaluations for the coming year to get ahead of it and get the numbers up even higher. i want to show briefly a snapshot what it looks like in termoffs demo graphic. we-they tend to use the 11 available county workforce as the targ lt population. this is the 11 county workforce demo graphic and our demo graphic. what we have been doing is do report with managers that highest level and working down to show people the dem o graphicoffs the unit. we haven't set specific goals or targets but work with manager tooz where we want to see improvements in and will be do more and more of that. we also have in our eeo unit we have-do ada accommodations and that is when i have a medical condition and come to my employer and say i can still do my job but need a special computer screen or can still do my job but need a special accommodation. so, this is the number of accommodations we have going on currently which is 317 managed by two ada staff so that is quite a volume of work for two people, but 150 each and will add additional resource tooz the ada accommodation process. so, this is just a snapshot to give you a example of the kind of things we are looking at. we not only look what is our demo graphic compare today the available workforce we look as compared to patient population. so, this is smaupshot at zuckerberg, and we will continue foowork on this and get better and better comparing the patient demo graphic to the staffic demo graphic and improving those. so, raunda simmons, she supervisors the ada group and is over the workforce development group. this is raunda back here. raunda she's come to us from the mayor's office and has a background in work force development. this is new and didn't have a training sokez so every the last year we started creating a training section work wg the various training sections in popular health and others to pull the resource squz get a sinnergy going to take advantage of the resources. this plains essentially the individual needs, organizational needs and our ability to connect in the middle and pull that together and meet individual needs and oregal organizational needs. i mentioned in the write up career coaching that we start today do that and got good response and gave demo graphics btd about the people doing that. i also mentioned employee engagement survey in the write up. we are-our next employee engagement survey. we scr done one and will do another probably in the fall. we are just finalizing the contract. one of our recent meetings we talked about jcc i believe the importance of customer service oriented attitude. we inserted in the job postings language about the importance of customer services and care, patient care and will continue to include those statements in the postings and do other things that improve our focus and make sure people we are hiring understand how important that is to us. the other area we have is labor relations. as you know, 99 percent unionized. i think you may be the only staff in the department that are not unionized. willie ramirez is labor relations director. i think he was taking care of a legal matter so not here. as you can see, very large union population of union members and keeps them very busy. it used to be i heard this before at other organizations you hear, we want to do something about a problem and we dont get the support but as you can see that is changed a lot and managers do get the support when they ask for it and work with us so this is a snapshot of the sort things the labor relations work on. that is total of 6 people and looking to beef that up especially as we go to electronic health record and need to probably work with the unions on various aspects of that. last but not least is our pay roll unit. pay roll does as you can see 133,000 direct deposits and have 2 82 pay card. we dont do paper checks anymoreism we switch to pay card so you can opt to not have direct deposit but if you don't have direct deposit you have to use a pay card and that is the cycle and that it is a very busy unit and they do a great job. at this point i'll answer any questions you may have. >> so, before i ask for the commissioners i did ask, what is the total number of people who work and do all this work that is within your department? >> plus or minus 100. there is a unit at zuckerberg and one that takes care of downtown and laguna honda and the clinics and labor relations over the whole thing. turnover that is probably about 7 percent. work wg our business intelligence unit to get better numbers oen that. the tricky part because we have the civil service eexempt employees that are time limited at 6 muchckts they have to leave and looks like a separation so we have to pull it out because it isn't turn over. turnover is we ask you to leave or other things listed on the labor relations report or retirements. >> commissioners, questions. commissioner bernal. >> i like to thaj the director for the report. as a new commissioner it a great #3r50i78er for me so thank you. i look at slide 2 the total recruitment and looking that trend line i wonder how much of that could be attributed to increase demand for service and revenue from the affordable care act and medication expansion? >> i think that a large part is due to afford #rb8 able care act because brf 2014 thrfs a surge in hiring and change in network and department since that time so merit is changing the strategy to react to the situation to increase recruitment to meet the needs. >> in the primary care area we did a great expansion to get ready for aca. also with the new hospital and the expanded in termoffs the number of nurses we needed to recruit. i just wanted to acknowledge the fact that this unit has really expanded their world in terms of really trying to meet the demand that we put on them and you can see the demand is clearly there. also, the area of workforce development which we never had before and want to acknowledge we have raunda simmons who is director of the mayor's office of workforce development so brings experience particularly arounds career coaching and that is what i heard from staff is they didn't see the pathway of promotional opportunities in the department. and so now they have somebody they can talk to and how to create that pathway and what things they need to do. as you know, wree have merit and people have to take tests and get on list soze it is a complicated process and mystifying for staff is a important goal. just want to acknowledge ron's leadership. he came to us from the seattle public health department so great new eyes on our area of human resources and we had a great influence on the larger human resource area particularly in classification around it, where that was not a classification in terms of where we are going with it. trying to catch up into the 21 century with the classification it is a important plauss and want to acknowledge all the staff here because they worked really hard during the last couple years as we are growing and opening a new hospital. >> thank you, director garcia. >> commissioners sanchez. >> i thij it is a excellent report. i would too also just say given-i thought when you came here and wow, all these changes and thought we have all this going oen and never meet part of it and take a look what some of the measured outcomes are at this point in time. it is very significant and shows we are looking at the total profile of the new system we have operating and both in reference to recruitment, retention, in-service opportunities and the quality of care for our patients. the one thing i would comment on and wonder your thoughts because it is something we haven't really seen yet that i dont think has come to full fruition but you mentioned the nursing challenges we have, you were-some of your colleagues asked some of the temporaries if they are interested in permanent tracts and i know you were also discussing new pathways. let's say withu sf school of nursing, sf state school of nursing,u c, the community college which could provide new training. samuel merit in east bay is providing and it is providing some really hand on experiences that the general pertaining to training and internship. i wondered if in fact you know, maybe next year or the year after we will see even more significant results in some of the hard areas that are very difficult to recruit for given the new collaborations you have undertaken and with institutions that haven't been on the radar so to speak as much as other institutions. >> i think given the competitiveness of the labor market especially in healthcare and nursing i don't think we have a choice but to look at the partnerships and we have two recruiters, one specifically at zuckerberg and target healthcare and one down here to help with the ambulatory care but think you are right, i think quee have to look at those as options. >> other questions or comments? >> commissioner pating. >> first question is, so how would we unionize? what would you recommend? >> i couldn't address that. >> [inaudible] >> we need something to unionize for though. first of all, i want to give you kudos. we have been struggling, the presentations you have been giving for the last 2 years really about shortening the hiring and 90 days is as good as it gets throughout the industry. 60 to 90 days to do background checks and think we should declare victory. i think you are there plus or minus a couple days. and then also you filled all the vacancies at sf fgh and know there are a couple folks that we need, but i think you have done a great job with that and i like to the coaches. what other field can you come in as a orderly, that is me and you end up as going to school and become a physician and then you can become i dont know, a union leader or something like that. a health commissioner, yes. the idea of on the job training is i think a investment in the workforce that i really do-i believe and commend it. so, my questions though is if we take those off the ajepda what might we replace as a helt hr workforce issue? i look at it as your job is get people in the box, keep them in the box and then make sure that we have glorious leavings when we retire from the box. i am interested shifting some of your reports in the future to perhaps in the box looking at how we are doing with sick days, how we do with workers comp, how we do with either used or lost vacations if people are not using vacations and reserve balances and maybe even retirements and retentions. this came up in our primary care discussion at the community population health. we wondered how is the workforce and i know we are tracking sometimes-it is hospitals that track unfilled positions--proxy for sometimes morale so interested looking at some of those in future reports. i know it takes time to get down to that level and you have been really managing your processes in hiring and getting filled but as we get staffed, then i think now the question is how well we are committing to keeping our staff. are we keeping them healthy and well and some the standard hr indicator said you may use to look at that. >> the next report maybe different indicators based on what you said. it gives me time to do resuch. >> that is just my thought because i think it is the next level of hr capacity and how we measure all the leaves and the absen teeism and present teeism across our system. >> certainly. >> um, my other two questions are really just more around just general capacity ish oo issue. do we have internal eap through dph? >> we have city wide eap which we reserve to on a egregular basis. >> that doesn't fall in our division? >> no. >> you work with them? >> absolutely. we tend to refer people. >> is that out of hhs. >> i think health service administration but not sure. >> lastly, do you think maybe this is for commissioner bernal at a federal or state level, workforce shortage we are into year 3 of the aca. you hired up and that is really hard, do you think the workforce shortage is solving or do you think it will always be the gride to find open people is there a measure taken in a more broader way to fill the gaps that we experienced? you can just give a general- >> it tightened up- >> harder? >> a bigger labor shortage with the opening of new hospitals. in response we kicked up our recruitment and hired the two recruiters and do other strategies like getting people to work temporary and hire them-reaching out and doing nation wide recruitment and attending recruiting fairs which we had good success with. and also the local area but as commissioner sanchez said we will have to map that even more. nation wide not sure there is any plan or strategy to actually increase the numbers of any significant way, so it is about us being more competitive and a lot is reaching out and contracting people and talking to people and instilling the virtues and benefit of working in san francisco. >> have we had to drive up salaries to make positions more- >> if i could chim in on my own opinion in terms of looking at this. psychiatrist are somewhat difficult for recruitment and one thing we have done is gotten into the fellowship process withu c-we are lucky and fortunate to have the u c medical school as part of us so the psychiatric area. we also had competition with psychiatrist withcretional where they lifted up the salaries and ours are within the physician area-we found a pathway i believe with particularly in forensic psychiatry that is a difficult one for us but with the new fellowship programs working with u c psychiatric services i think that will really help. we do have the ability to help with the pipeline by work wg our own u c. >> i like that. they say the way to get to the young peoples hearts and get them young. you want to get them to vote you start involving them in the process early and they vote as adults, the same if you get them in the fellowship likely to stay in the public system. anyway, i'll end my questions by giving you the kudos and your right too have a victory banner for reaching the 90 day mark filling san francisco general and creating a learning environment in hr department. thank you very much. >> commissioner burn el. >> just in repauns to the commissioner pateings about the federal budget. propose a 400 million cut which will have a long term impact. it is working its way through congress now but that is a significant cut. >> thank you. i will ask certainly the department has gone a long way and your help in the last several years with first the aca and primary care ramp up particularly and then with filling positions at general but i guess we are still about 8 percent vacancy or so. so there is still work to do but you can declare victory for this year. >> i'll take the victory. i realize we have a lot of work to do [inaudible] >> i know different areas are looking at retention because that's part the satisfaction of a job and what not so that may be that you yourself and your department or division don't have to do that, but to get data from-because you want to know hour successful not only that you fill the slot but that slot worked out and maybe want to look are they still here a year later or still recruiting again because we perhaps or the fit wasn't right or where you can learn. >> great idea. >> when i think aside from that and looking how successful you were in terms of a measure restention, what do you see in the coming year? i know you talked about the tightening labor, yet people are still talking about unemployment in the country, so and i read different things we are really tightening up and there is a difficulty in our area maybe, but there are other areas that are still with sort of open land so to speak to find employment. so, where do do you see in the coming year you have your greatest challenges? >> i think one is continued recruitment in a tight labor market because in the bay area it is a tight labor market which means everybody is competing fl the same worker squz there are not enough of them whether it specialty or healthcare. secondly, the city is trying to update the system and update the people soft system and have a new financial component of that, so that will be a challenge as they update those systems making sure we are on board and do what we need to do to make the most of those. of course the electronic health record. preparing for training and preparing our systems to take on the electronic health record will be a big challenge even ipthe coming year and then the year after that. >> so, in the electronic health record you're working closely with the departments it needs and bringing those on according to their schedule or- >> hr is meeting about once a week for about 2 months now with a consultant and with albert eu and now have laurie wallace who is it project manager for the ehr, so yeah we have been meeting and figuring what we need to do to create a milestone and timeline and dlivables so getting on as early as possible to get ahead oit. >> thank you. any further questions, commissioners? thank you again for this annual comprehensive report. >> thank you for your comments and i'll be back. >> thank you. >> commissioners there is no public comment request for that item. item 8 which is whole person care, california medi-cal 2020 waver. commissioner chow asked for packets to be restapled so included staple on the left so it is easier to flow through inyou want to follow. >> they now read left to right instead of right to left. >> good afternoon. >> it is a stapling issue. >> we are playing with this, i want to give a shout out to the hr department and it department. how amazing they are. yay! >> good afternoon commissioners. my name is maria martinez and i'm here today to introduce you to the whole person care medi-cal waver and i'm going cover three things today. one is just how the waver came about with the intent from the department of helt care services. our particular applicationthality was awarded and started on january of this year and a little about the targeted population. all three are complicated so if you have questions feel free to interrupt and i clar fay for you. the whole person care of the department of helths care service looked at what we are hearing about, there are a small number of people utilizing a lot the healthcare cost and they are defined as people in multiple systems and who are not getting well. actually a lot the work we have done here ichb in san francisco over the past 12 years looking at high use in multiple system influenced the gement of the whole person care waver and initiative. i will go over 6 thichcks they wanted to achieve with it. one is they want counties to start working together. they want them to work across the health system into the social system, into all the agencies, the health plans included, the cbo's to try to begin to work together in a different fashion. they were going to finance for us to do that. and the intent of that is wrap around the most vulnerable population and help them get where they need to go in a much more organized fashion. toort we do that. ultimately they wanted us to reduce the high cost, high risk utilization of sunchs the population was utilizing. they would help us by gibbing giving funds to improve the information we are sharing and using to understand our population. and then they also are providing fund to help us look at pdsa and ways of continuously improving the quality of what we are doing ultimately to improve the healthcare status so this was the purpose of whole person care. it is a 5 year waver ending december of 2020. the california carbed out $1.5 billion of funds for this particular waver and a targeted county. counties could apply for it. only 18 of the 53 counties actually applied for it. a vore complicated waver. most the counties that i talked to who are considering applying for it didn't feel like they were ready and understand this complex population like we do in san francisco. there was $300 million left on the table from the $1.5 billion so dhcs is welcoming 18 counties and all the other counties to fight for those remaining $300 million and we are in the process applying for the fund now. it started in january 2017 and i was asked to direct the initiative by director garcia and i'm so excited to be able to do that. in terms of san francisco's award, we were awarded all most $24 million a year, half is a match from the city and county of san francisco and it was for two thrusts if you will. one was how to improve the way in which we work and wrapping athround vulnerable populations and how do we find it solution tooz help us transform the way that we are doing care coordination. we selected here in san francisco the homeless population. we know a lot about it and i'll share what we know and how we are ranking priority for the population now. we know from the coordinated care system which is a integrated data set department of public health has we touch about 10,000 homeless people somewhere in our health system. may be ed or primary care but we are able to track those folks. about half are an medi-cal managed care, the other are on short med kale and some don't have as far as we know any coverage. we look at this population homeless people somewhere in our health system. may be ed or primary care but we are able to track those folks. about half are an medi-cal managed care, the other are on short med kale and some don't have as far as we know any coverage. we look at this population with two perspectives. one is the use of urgent emergeen care and we look it can be medical, that is traditional inpatient ed utilization, but we also look at our medical respite and urgeen want care and ambulance transports. the two other systems we look at is minuteal health system. we look at urgent care, we look at mobile crisis visit, inpatient day squz substance abuse system because we track all this data and we are able to look at use of sobering center, medical and social detox so that is one perspect ovthe high rist population. the second is how long have they been experiencing homelessness and ccms was able to say the first time we noted them being homeless and the last time we noted being homeless and that may list 10 years. they might have had periodic housing status but basically that is a high risk person when you think in and out or straight away 10 years of homeless synchronize. these are the two perspectives we use. in termoffs the 10 thousand folks we stratified into susleer, high and elevated based on the combination of use of urgent emergent service and their length of time homeless. severe is both, high can be either one, and elevated because we all know homelessness is risky anywhere would be considered all the rest the folks. and so not surprising the high user population uses quite a bit more high cost services than the others. for total of about $150 million a year, homeless folks use urgent emergent service. when you look at the stratification those high user 13 percent of the population or 3 quarters of the cost that we spends for urgent emergent care. we are also able to look at diagnosis and i see 9, i see 10 codes coming from the system jz categorize them into serious medical. serious psycho and drug and alcohol. for the homeless population in general you see that is probably not too surprising about a third of all them are suffering with all three conditions. those are seriously ill folks the 30 percent. when you stratify it here you look the high users those are high user and long term homeless, 3 quarters of them are suffering with all 3 serious health conditions. that is phenomenal so we know that these are very sick people and our stratification is playing out in terms of cost and other risk factors which i'll go over now. in terms of death rate, the high users and long term homeless within the one year of treating them, 7 percent have passed. from the data that i have looking over the course of 5 years, 25 percent of them have passed. very sick folks. in terms of incarceration, the rate of incarceration is similar, a little higher for the long term homealize and high users but in general pretty close. we get this information by looking at our jail records. jail health records. if risk factors erase certainly it plays out with african americans. the general homeless population is 33.5 percent compared to 6 percent the general population in san francisco but when you look at long term homeless, it is all most 50 percent african american. that is just stunning. any questions about the data that you might want to ask now because i will move into how we will address? >> very clear. >> yeah. >> what can you say? in terms of how we serve homeless folks here in san francisco, this is our safety net and so the department of human services have food stamps, medi-cal, general assistance. the san francisco health plan is not only a health plan but also delivering healthcare services in terms of care coordination for comp plexpations. the private hospitals and community based partners are out in a fractureed if not just physical way seeing our patients significantly. ems picks them up and taking to many ed's throughout the cystism. department of aging and adult services does case management and in-home support and all kind of services. department of homeless supportive housing is a relatively new department. they have the shelter jz all the places that hold homeless folks. they have servicess in those places. that is where the navigation centers and will talk about those services. so that is a new department. the department of public health you all know how big emens and fractureed our helt care servicess are there which leave the person in the middle trying to figure how to get to all those without a bus pass. in termoffs what we are trying to accomplish in whole person, the first 3 physical, mental and addiction is healthcare services. we trackthality pretty well because we bim for it. all the rest of these things here what we call social determinant of health and in our data and service systems we dont collect it, we dont get paid for it, we don't get support for this and all the way down to they have felon things they need to get to get into housing, they have safety issues they can be dv and issues on the street. do they have skills to get and keep a job and support system. so many have blown out their families and creating supports on the streets and most of the recovery folks that we worked with would tell you without a meaningful rule it is really hard for folks to maintain xae kind of abstinence or any kind of recovery. so, part of what we are trying to bring together is the whole story for this person but also wrap around them in such a way that will help them not only reach their-realize the hemth but to keep it. and so in the whole person care it is a multi-agency efforts. the coleads are it department of homelessness and public health. barb raw garcia and jeff are the chairs of the steering committee and all of these departments are at the table and part the steering committee and going to be part thf committees we create for problem solving and idea generation. we will all be signing a charter which is in the harndout that we gave you, the draft of the charter saying we commit to doing better. what we are purchasing in the fund from the state we will create new navigation centers. those are a innovative thing is doing around low bar resource driven shelters lodger term. the care coordination services will braid all these care coordination and doing something different and will talk about that. expanding the medical respite beds. some of the funds we get from the state will help us get our detox centers drug medi-cal certified. we extend the residential days we have in substance abuse program jz department of aging adult services we will focus on how to keep seniors in the housing and keep them safe. in termoffs the other prong, this is it solution. each one of these areas have one or more multiple data systems that they are putting transactions into. they don't talk to each other so the one person who is going in and out of service may repeat, the intake information may not be known they are already in care coordination somewhere else. so, part of watt we will be doing is creating a data sharing platform in 2018 that is going to enable us to share what we know about no matter what door they walk through so if it is the shelter or ed the privacy appropriate information will be available. we will create together a tool that will have let's say 10 things that will help prioritize the person into housing or care and all those will agree on what that will look like see that is the magic and what wakes me up at 2 a.m. so will have shared care plans and communicate with each other through alert so really excited about potential for braiding together all of this and becoming person centric. terms of whault we hope to accomplish, the first one would be is our clients when ever they touch throughout city and county of san francisco, it is the right place to get the right information to get to the next right place. that their health is realized, reduce the amount of urgent emergent service. they get and keep the medi-cal and that they have housing that is sustainable. in terms of the staff, a lot of the issues they have is clearty around who is high priority so this is a way to communicate, yes, this person is high priority and the direction you need to go with this. and that there is a way to prevent people from getting sicker. in terms of the public, having cupassionate solution to the suffering on the street i think will be a big impact, but also reducing from a public perspective reducing the reliance on general fund and medi-cal. and at the end of the day, january 2021, we want to be able to look back and say we really learned thew work together across the city and county of san francisco for a vulnerable population. how do we take watt we learned and apply to other vulnerable populations be low income families, seniors, whatever it is that we want to prioritize that we now have a process and a relationship built to be able to transfer what we learned to other vulnerable population. so, hopefully i haven't over whelmed with a lot of detail, happy to answer any questions you moithd have. >> there is no public comment request for this item. >> thank you. you did have payment sources and all in the >> yes. >> back. where you going to go over thereat? >> i was going to go there if you had questions about it but it fsh over my 15 slide limits. you have quaegz on it? >> i'm trying to understand or the message is you might want to take just glancing at this because for example, under the summary of the homeless, you got all the breakdrown of the ethnicity and all. these are the people that are a part the total thousand- >> 10 thousand. >> 10 thousand you are talking about. >> yes. this is the information in much more detail than what i plented here but this is what we know about the homeless population. did you have any specific questions on the data, dr. chow? >> i get what is sort of a composite of a homeless population person that would be kind of-i know everybodys unique but what would you say what you would characterize someone? >> mostly male. there are some people who i think we should study for the resilience who are over the age of 60 all the way up to 90. generally speaking, the life expectation is between 50 and 60. as i noted, high proportion of african american, disproportionate share of latinos and trying to think. i think part of the people who are served by a large number of them in the clinic consortium which means we have to reach over to the clinic as well. mostly seen at [inaudible] which isn't surprising but also at the hospital in primary care. the highest users tend to have more primary care visits than highest urgent emerge rnt have more primary care and the others very little. even though they are assigned with us they are not engaging in primary care unless they are the really really sick ones. >> so, you are saying that in that profile most are at the consortium clinic for primary care and come for specialty. many of these. is there a disease profile or would they have substense abruce? >> yes, on the- >> sort of missed-- >> that didn't work. don't know how to do that. >> there you go. just trying to get a picture of who-- >> so, here when you see the medical conditions, we use something called the ilex hauser risk for diagnosis. dr. housing looked at 50 thousand inpatient in boston to determine which comoorebidities were a good indicator of premature mortality. we use that on a outpatient ambulatory basis because it is the only one that includes mental health and addiction. all the others are just medical. so, that is why we use it and applying it in the ambultor session and you see on this page here the types of medical conditions that are included so a very high hypertension and liver disease, very high pulmonary disease. i'm not a physician so can't tell you how far that is ovbut can look at the percentages but when you look over to the red, the severe risk, all most 50 percent have hypertension and all most 50 percent live disease, neurological diseases, so in terms of their risk it plays out in the conditions, prevalence in the conditions and anything else in that i'm dangerous in terms of knowing about but know what we are watching is the tridisorder when they have all 3 that there are very different outcomes. and in terms of is it-we don't know if living on the streets causes one to buffer and drink and smoke or be depressed, who wouldn't be. or if those are a confluence of those factors cause one to be homeless, that isn't something we know. >> some of the interest of the commissioner think about goat toog zero and 20 of percent of the high usererize hiv or aids. thasat population we have to focus on getting to zero. that is the population we will think this will also help with many collected impact initiatives. >> commissioner burnole. >> thank you for the presentation. the data is great and looks like it get stronger so thank you for that. two clarification when you talk about coordination was that among crossing county lines because so many folks- >> right? it is just within the county in terms of accountability for the dollars. in terms of we all know it needs to be a regional thing. we will meet the whole person care will meet together next week and talk about that. i they think that's-i think we all know we got to deal with this together. >> just my second question is you said the second roun of proposals was accepted march 1. has san francisco submitted proa proposal and is there a specific focus? >> we are still in negotiation and haven't had the application accepted yet so a month and a half of negotiation. if it is accepted then there will be a significant focus of whole person care is in the homeless department. >> thank you. >> definitely coordinating across agencies a what this is all about and-- >> so, i found also on slide 18 that we didn't get to, that those performance measures you are looking for in the coming year? >> yes. >> or is this the 5 year? it is actually three years, 2020. >> some of them are due in june and some of them are due in 2020 at the end of it. i will get to that. for the audio sake. these are my sneak in. >> yes. that is what i was looking for. >> yes. um, so some of them will be reported annually and some of them looking at them quickly-some are one time things like the assessment tool. if we just create the tool, we get money for that. the first year of the whole person care we got money just for applyic which i thought that fts cool. the rest of them we either have to make a difference in the impact and health outcomes or do stuff like create a care coordination tool, a assessment tool. create that platform that i told you about and then there will be did we make a difference getting keeping people in permanent housing. so we have a baseline which is 2017 and if incremental improvement in the out comes. >> and so i guess we will be following that. commissioner sanchez. jrsh this is a excellent-as you shared it really gives us a unique baseline right now. as we move forward as you shared, we are now working with a cohort of our agencies looking at a specific population thatd we were not able to do before. >> right. >> and this way it is like on our radar. we have them on our radar and we have our subsets within that same scope, where we can really utilize the data that will be generated even though all systems may not be operational yet but they are coming up per taining to the tracking and data but that will happen because there is communication and trust going on at this point in time. as a example i can think of a couple who would be veterans who dont want to participate with va services but utilize our service public health and other services including the dialysis unit, and they will be tracked in 2 or 3 of the systems and it will take time to really focus on and take a look at you know, how to provide as you said, comprehensive integrated system where we've cut out all the variables that had been limiting our ability to take a look at the whole person. so, it is really a awesome undertaking and i'm really glad you are excited-and we move forward on this and really look for as you said, some really informational outcomes which perhaps many will not be aware if it were not thought about as a possible hypothesize but yet because we have this limited "cohort" we are working with i think it can be excited per taining to watt we can learn from the joint effort so thank you vaer much. >> you're welcome. my pleasure. >> commissioner pating. >> first i want to say to mrs. martinez, congratulations on your promotion or this new phase. you did a great job in compliance and know you'll do a greater job in the new role as well. also, just from a previous life i was a chair of california whole health coalition, this was behavioral substance abuse and primary care that [inaudible] the aca full benefits and glad you doing this and when you talk about right care time and place you are speakic my lan wj and glad you figured how to get past the hipaa issues. that is why you are thinl compliance person with regard to the cross system information shareic. that alone i think wins you whatever brownie star we give out for that. my questions to you are to maybe ask us-help us as a commission to play a role in some of the whole healthcare. as i see it, ewoo have opportunity to weigh in onditions that may come up, one is i vurks drug injection site. one is 4 a.m. alcohol bar policy that is going before the state. we have african american initiatives in the bayview which is hypertension and well synchronize control and tom wudel is under our system and but there is a call for maybe new services in the tenderloin. these are things as a commission we might weigh in on but wondering if you can do a little more analysis on the template. for example, i am wondering where the african american clients are or why african american clients, what is driving that and whether there are a cluster of servicess we should gear toward the african american community and where are they, in the tendser tenderloin or bayview so we can get spinge supporting policy that help you. another is issue of what drugs. those that are using alcohol consider having a different subculture than those using heroin and/or meth and african meerns using heroin and meth or alcohol. i think we can do another level and this is where dr. aragon is my guide trying to do cluster analysis. nowio have siteewide demo graphics but i believe they probably localized even more micro populations by street. we know the drug use on cap street and sishth is different than on polk so if we capture the dynamics maybe we can torg td servicess because as the number gets smaller and smaller it isn't citywide impact, it has to be a finding the pockets, the community of 5 or 12 yee users and figure how to target those and know you are doing it but i'm interested more because i think some the policy iges as will effect us if you look at injection sites. part may say not in my neighborhood but if my neighborhood is where this that is going to help us with some the policy decisions. if you could-doing the different level of cluster analysis recognizing everyone is unique, but there is probably 5 or 6 clusters older folks drinking, younger folks that are traveling through little transient and finding the heroin culture on polk. just making this up, but if you could help us to find those then i think it will be helpful from a policy end to speak to a couple of some of the issues that are going on. so, that is my main request. the second one is more a question. so, of the issues that are not helths related for example education, even housing and some of the basic care initiatives that don't include health services, are those coming out of the 1115-90 is that part the flexibility or 1115-90 is mostly for us on the health side and other services have equal fund so who is paying for the whole range? part is health and part is not health. >> it is a complicated funding structure. so, in terms of pulling down money for doing things, i'm not really sure at the back end where the money goes once we pum that in but basically the servicess are already in place. they are fractureed though. so the social service mostly come out of human service agency and the health services in our backyard along with aging and adult service and the shelter and housing and the health service in housing are in the homeless department. so, we are going to be purchasing some additional services. i don't see them as being the social services that we are purchasing it is like the medical res pite expansion. we are trying to get what we do now more cohesive. >> there is real flexibility in the funding and sounds like we some may come to us and some to- >> existing dollars that we committed from general fund as a example to the homeless housing department. they have a pipeline that is already working and at least developing it. so, trying to leverage that and the wrap around subess for those individuals is where the 1115 wave can come. trying to maximize every dollar we get from different sources but specifically for these programs they are more health related than anything else. >> then i guess as a fullo up, do you director garcia arounds the issue affa little more specificity to help us understand. i thipg there will be future issues we will play a roll in, do you see that as reasonable? >> what you just talked about with cluster analysis i think that is a excellent suggestion for us particularly as we try to target areas. a example is a lead program, we targ eted specific neighborhoods where we work with police at bart areas and we really looked at from a citation piece. but having this data of cluster analysis you can see where the clusters are but to have the numbers suggests we could exactly what you just said. so, this is what i continue to tell maria is that this is a 1115 waver but the bigger job is that when that goes away, we have to have a replaced system of care that we put together because of the status and relakezship how we work together and get a natural working relationship that we always will leverage with each other to insure people get a wrapped around serve squs do whole person care throughout the system not just internally in the department because we need that as well. as a example with our emergency department and looking at their flow, we should be looking at the [inaudible] population going through the emergency room and ask should we prioritize the individuals into lower levels of care as a way to reduce the number of ed visit quickly verses spreading out to a number of people when yoi know you have a concentrated cluster. >> [inaudible] >> exactly. >> [inaudible] >> i think your suggestion is a natural outcome of that, but it is sfozeed to have a lasting effect not just a sillo of fund{that is our hope. >> thank you. >> thank you. so, this is tremendous data that i keep reading and i reading it now because you put it into the context of what i can now understand as i look at the numbers. i'm wondering director garcia, when would be it appropriate to get a follow up on how the project is coming? >> i think twice a year and if we find a place where we come every quarter, i like to give them a little time to get their feet under them and her feet under her. she is in the process hiring people so i would not suggest us to do bng until probably the end of this year calendar year and if we find significant change or outcome we with come in earlier. >> i think we put a follow up report on this by the end of the year because this is a very important initiative. >> if the injection site comes before us and weigh in we may get data. >> sure, we can again maria needs to get that data needs structure and one person right now, but certain we can look and see how we match. >> i'm thinking that we will be looking forward to how this is all beginning to be cohesive and just amazing amount of data that you have been able- >> let me say something about that because over12 years ago maria work would me on the homeless outreach team and we want today figure out a way for them not to dupe wait their work because avenue time they saw somebody they duplicated everything everybody else did for that individual so mariacreted a system of pulling data from 15 plus systems that we thought was significant that homeless individuals will be at. and then she has ovthe years a significant amount of cross-we know the data 10 years ago and started focusing on individuals and so one meeting we had it was like i have seen enough data, let's do something with the data which is get to the top 10 and the next top 10 and started doing that and saw significant drops of their costs and knowing they are at the urgent emergent level of cairb getting primary care homes or stabilizing them in hoizing housing fs reduction in cost so this is a extension of the continued work maria folked on even when doing compliance she worked on privacy and health so just want to acknowledge that we are so much farther ahead because we have this data structure that we have worked on refining and refining and it will be a important part our electronic heth record to allow the physicians to know where the person has been and their story of need and care. >> i just think as director garcia said this is a tremendous extension for the work that you have been doing irn in the homeless project and all those terms on the high utileizers so why i believe we do have a desire to see how this is all going to come out because this is sort of taking the work you have done and now creating even a greater basket for you to actually have a impact on these peoples lives. >> it is a very small team, small but mighty team that has been working on ccms for the laest threne years. carol chatman and can can [inaudible] when i came back hopefully i can share all the people working on whole person care. >> we look forward to your progress. thank you very much for the presentation. >> item 9, commissioners. other business and commissioner chow i believe you want today review the committee assignment. >> yes, commissioner bernal on board we will officially announce the appointment of his term on to the finance and planning committee or placement to the committee and also then dr. pating will be a full yeggural of the zuckerberg general conference committees of today so these are the new assignments for the coming period of time until we need to make new ones. i just wanted to have that announced and thank commissioner bernal for agreeing to serve on the finance and planning committee and also dr. pating for taking on the regular role at zuckerberg. thank you. >> thank you. >> shall i move on? >> yes, please. >> item 10 is joint conference committee reports and commissioner sanchez has a rorlt back from the april 11, 2017 laguna handa hospital jcc. >> commissioner sanchez. >> yes, the jcc was listed as a closeed session meeting so therefore we did vote for closed session and did review everything within our jurisdiction under that including medical and everything from recruitment to also quality assurance so there was annal open discussion and no public speakers and we opened up again at the end and voted to keep matters confidential and there was-it was a good constructive in >> student siteful meeting so thank our colleagues for participating. >> thank you. we can't have questions about a closed session. y item 11 is committee agenda soteing. on july 18 we have committee meetings set and that seems to go with everyones schedules or most commissioners schedules so that's at the moment what is planned. >> okay. good note there and you have the revised master calendar from the 13th of april before you all so use that for your information. and thank you for your cooperation letting our secretary know when in the coming year you will at this time foresee you may be away from a commission meeting. appreciate that. next iletm, please. >> consideration for adjournment. >> the next item is we are prepared for a motion for adjournment. >> so moved. >> and a second. >> second. >> all those in favor please say aye. all those opposed? the meeting is now adjourned, thank you. 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