>> to the tuesday march 19, 2024 meeting of the san francisco health commission. we have a very full agenda and in recognition of want to go have time to spend on each item, we're going to differ item 5 which is the human resources up take, excuse me, for our meeting on april 2. so secretary will you call the roll. >> yes, there is water in front of you, if you would like. commissioner chung. >> present. >> commissioner christian. >> present. >> commissioner green. >> present. 12346789 and commissioner chow. >> present. >> wonderful, well i was suppose to have the privilege of having of reading the land acknowledgment but stins i just

swallowed some saliva would you be able to read it. >> sure. >> the ramaytush ohlone have never given up their--as guest we recognize that we benefit from living and working on their traditional homeland. we wish to pay our respects by acknowledging the ancestors, elders, and relative of the ramaytush ohlone community. >> thank you so much. the next agenda is the approval of minutes of march 5, 2024, i believe there is one correction. >> yes. >> secretary? >> thank you, president. on page 8, under community and health committee update on

under commissioner comments, commissioner chow add for a statement to be readvised. and i'll read the revisement. >> are there any other additions and corrections to the minutes from the commissioners? all right, do we have a motion to approve. >> so moved. >> second. >> is there any public comment on this item. >> let me first act is there any public comment on the room? we do have one caller, caller, i will unmute you. please let us know that you're there and you've got three minutes. >> speaker: patrick, the way i can tell these march 15th, 2024 are useless when it comes to information on when it might resume because a week later, rolin pickens at 4:31 p.m., on

audio tape during the jcc meetings have made it clear that recertification in the medicare program obviously admitting new patients lhh. quote, clean slate, end quote with plans of correction still occuring regarding anonymous complaints and other incidents reported have all been cleared up. it is unclear how many anonymous complaints. 5067 this commission has a mandatory duty to to members of just how many complaints are backlogged. after all, this commission knows or should know the anonymous complaints are affecting, clean slate, end quote in order to gain full recertification.

i had an mri this morning and i'm not feeling well. i'll submit 150 word testimony for inclusion in today's meeting minutes. thank you. >> that was the only public comment, all those in favor. >> aye. >> aye. >> any opposed? great, the minutes are approved. >> wonderful, the next agenda item is general public comment and i believe there is a statement to read. >> i forgot my statement, i apologize. folks, the public comment period is used for commenting on items that are not on the agenda. no discriminatory language can be used. and every one has three minutes. is there anyone in the room? yes. >> i there is going to be a report, and i urge you to read

that at your convenience. i'm not pointing, but we're trying to figure out why there is finging pointing at one agency to another agency. there are people giving access to systems, via human service agency, via msmt a or any other agency. and there is a difference between illegally and lawful or behavioral surveillance. and what happens is if you're having people do one thing compared to something that is lawful it causes interference. and instead of a healthy intervention, you can have a negative intervention. so if you're trying to get somebody that has covid to get vaccinate asked somebody else

is interfering, it's going to cause somebody to do something that they don't want, like get covid. just like if you have interference and do drugs, it's going to cause the person to do more drugs or drink more. so it's basically noise, from one surveillance to another surveillance system. and in the fbi report before this meeting, i spoke at the board of supervisor sxz before that, the sfmta so they have this fbi report. it's not to point fingers, it's to get the departments working together to working with police commission to figure this all out. we want to have a healthy san francisco, we want the overdoses to go down. we want the incidents to go down. we all want to live in san francisco, we want to be healthy. there are few things that we have talked about with the system and they use that for

investigation purposes. and they use technology too, to question surveys to investigate a person, do they have a drug problem, do they have a substance abuse problem. are they going through an adoption or he'll. again if somebody has access that should have no business, it can cause interference. and it could cause that person to have anxiety to cause a bad intervention. i spoke with sfmta, there is a point of compromise, right outside of city hall. i'm confident that they're working on that, that can cause 25 to 50 percent of all issues by san francisco by balancing a signal to cause an incident or issue in san francisco that impacts public health, human service agency in a negative way. so i would urge you to read that report and we'll go from there. >> time up, thank you. is there anyone else in the room to make general public comment. commissioners i see one hand.

i want to remind folks that remote public comment access needs to be asked for the day before, this meeting and two people have received permission which i will ensure throughout the meeting. all right, let's go. caller you've got three minutes, please let us know you're there. >> caller: -- ~>> you may begin. all right it, seems like there is an issue there. that's all we have for general public comment. >> all right, the next item on the agenda is director's report, director colfax. >> good afternoon, commissioners, director's report for march 19th. i will go over items and then be happy to answer any questions you might have. i'm really delighted that jenny louie is our new chief

operating officer. jenny was appointed as coo and started yesterday in her new position after a great career as our cfo, i'm really delighted to have jenny in this new position. she has a big picture and strategic approach so operational processes improve performance and achieve results. her deep knowledge of the department and the city including our work with other city agencies and partner osings has prepared her to hit the ground running as our new leader in this position. jenny has been with the dph for more than 15 years in addition to being responsible for the budget, she has really been everywhere across and within the department. she is supported the implementation including the transition of laguna honda and

zuckerberg hospital to new facilities. the transitions to affordable act and health record epic mental health san francisco implementing programs including and was a major leader in our covid-19 response just to name a few of her options. so really delight today have jenny at the helm as our second coo. in terms of other leadership development across the development, sgsfg has announced two executive leaders. dr. ortiz who is now chief medical officer and eric wu as the chief financial officer. they're great experienced and great leaders in the hospital and delighted to have them in the new positions and they'll be work withing the leadership team at zuckerberg san francisco hospital. of course dr. earlylike, the

ceo of the hospital. moving on to health, very delight as we move expanding making medication available to people with opioid use disorder that dr. christi soren of substance service for dph hosted a training session titled treatment saves lives and medications for opioid disorder overview for more than 200 community base organizations and dph members, it was really important as the training emphasized that medications reduce the risk of mortality by 50% and expanding these access. and you can read more about the training but we feel like, feel like, we know it's very important for our community providers, members of the community, family members and of course people with substance abuse disorder themselves know that these medications are readily available.

they safe lives and we want to make sure that when people need treatment they can get treatment. next item is supply chain of distinction award as the commission knows by changing is extremely important that our department delivers the services needed. and earlier this month, the global healthcare announced a, which recognizes top performing hospitals and health systems in all of north america. and i'm really proud that san francisco health network under new leadership represented by vcfg was named a recipient of the supply chain award of 2023, it's a big area in north america, there are a lot of hospitals we're proud that the network was recognized for that. and then in another area in our hospitals, we prioritize patient safety and patient

safety, patient national patient safety week was the week of march 11. and safety week is so important and including at vsfg, adrian smith who is quality and patient officer celebrated undertaking five hospitals to achieve safe and equitable care and there are a number of awards presented that represented optimal excellent outcome in the realm of patient safety. and then in terms of our covid-19 update, our seven-day positivity is 1.4 percent. total of 39 of people in our hospitals across the city, with covid-19. up-to-date with vaccinations, i will pause there. did i want to ask dr. philip to

come up and briefly describe some of the changes in the masking policy. and i'm at the, it's at your discretion if would you like to come now or after we ask questions. dr. philip, please? thank you. >> good afternoon commissioners, i'm happy to briefly you let you know the update about the health officer order that requires healthcare workers to match in patient healthcare areas in san francisco. as you recall we have had a policy requiring at least this for the entirety of the covid-19 pandemic. this fall of the bay area counties have aligned to have a health order in place, at least for acute hospitals and skilled nursing facility. and in san francisco we include most ambulatory sites with the exception of behavioral health. those orders are all scheduled

to lift the spring. some of the counties are lifting at the end of march. san francisco has the latest date which is april 30th. and after that time, hospitals and health systems of course can choose policies that still may require masking, but the health order itself will end will sunset after april 30th. so i want today make sure that i let you know that. i know we talked about it before but as the date is coming up, it's a reminder and i have been meeting with stakeholders and leaders across the city to discuss the change and change is always a challenge. but we are trying to work with our stakeholders and partners across the community on this change. thank you. >> thank you very much for that update. we're so delighted and privileged to have such outstanding executive leaders in mr. wu and dr. ortiz and ms.

lui, adrian smith and of course finally the work with the education on substance abuse is incredibly impactful and important. so we're very appreciative to receive a positive director's report. is there any public comment on the item? >> is there any public comment on this item? i don't see any hands remotely, remote public comment. >> any questions or comments from the commissioners? commissioner chow? >> yes, i'm glad dr. philip is here. because my questions were related to the covid reports here and your current report about the lifting of the mandate for masking in health facilities. on the health facility mandate, if i start asking, does that also include long term care facilities? >> yes, it will include long term care facilities as well. >> and that will be true at

laguna then? >> correct. >> and it will be up to laguna what they would like to put? >> yes. >> so each hospital and each nursing facility where we can do this. and we are the last county then, you're telling me in the bay area? >> there are other counties a couple of other counties that are also saying, end on april 30th but that's the latest date. we're in the group of counties that have the latest date. and we have consistently had this requirement in place since early in the pandemic. >> okay, so two other questions. one, our positivity rate that's the test rate that we're getting information on is 11.4 percent, do you believe that that actually is, or maybe, can you compare na to rather to what the state's is and why ours is so low? >> it is very difficult at this point, commissioner, as you

know in this commission has spoken about before. given that people are testing less, testing at home, and the reports that we have are really those people that do laboratory base and clinical base testing which is much fewer of us now. so sing our better indicator is how our hospitals doing in terms of capacity and numbers of patients that are presenting with covid and those numbers reassuringly have been much better. we know there are people who are risk atco vid, we know that covid is still a concern and we're encouraging people to use the tools that we have now, including an updated additional dose for people over 65 that cdc just recommended as well as using the mask that we have and tests as well. >> all right, so in fact, following the covid hospitalization numbers actually, going to be a little

more reliable and this number is similar to what we've seen in the last several weeks. about 39-40, and what about the use of the sewage findings. have those gone up or down? within, you know, give us an indication as to where in here or in the state where ever we're doing the studies that the infection itself is beginning to diminish at least during the spring. >> yes, well we do not fully know that covid is going to be season but winter and the fall time is when multiple viruses can act together which is why the masking was required of healthcare workers by health order during the winter months, not just covid but flu and rsv. you're right that waste water can give us an indication. and to be honest, we have to

get better what they can help us do in terms of action which is what we care about. at this point, there are no actions that we would take or change based on waste water but it's something that we're working with our colleagues at cdph to better understand this, this is a national effort to help us get better at predicting not only communicable diseases but now interest in developing waste water sampling for sur stances, new substances that are coming to the market and other non communicable diseases. >> right so is the trend up or down in the state that you're aware of? >> i don't want to speak, i have to go back and at the draft and the charts to be able to do that but i'm happy to report back to the health commission. >> okay, one reason i'm asking is that i've been following the state's reports at the monthly

video tape, video conferences that they've had and this month our state representatives was absent so she couldn't tell us, you know, the trend that was occurring and that's why i was curious. when has the city then issued the recommendation to the community in regards to the over 65 and all to obtain a additional dose of vaccine? >> i know our communicable team as well as our communication team are working together to determine the best way, the best way to do that to make sure providers are aware and that the community is aware as well. >> i have not seen an advisory from the communicable disease section. so i would encourage that they do so pretty soon, i imagine people are asking their doctors. >> yes, i will follow-up and see where that is in progress. >> okay, thank you.

i appreciate the responses. >> any other questions from commissioners? all right, just want to say that i appreciate dr. chow's question about the waste water surveillance, because it's going to tell us a lot more than what we learned from waste water, it's pretty exciting, strange to say that waste water is exciting, but it's pretty exciting that we are working to and we'll be able to see the different kinds of substances that are high or low in our waste water which will help with public health advising and resources. so looking forward to hearing kind of a regular report about what the waste water is telling us, what we know and what the advances are. >> yes, very much so commissioner. and it's great to have an additional modality to ininform communications. >> including substance that's

are more and more lethal everyday. >> if i may, oh i'm sorry, commissioner you have another comment. >> knoxer i can have any comment at the end. >> i want today add one comment about the hunter's point shipyard since that's been of interest to the commissioners and public. and that's to say that the navy is in the of midst of what we call a five-year review. and it's to go to the end of march but we anticipate that the navy listening to community request may extend that period another 30 days. we will likely find out for sure at the citizens advise' committee meeting that will be on monday the 25th, so i will attend that meet anding others from dph so we're happy to have that. in the meantime, we'll make

sure that the public is aware and ask questions of the navy and regulators. thank you. >> commissioner chung? >> yes, thank you, i think that this, the last two discussions are really important to the commissioners. if i can make a request to have a dedicated agenda item in thed coming future to bring, brings the public in as well to have a better discussion. so i don't think people here in the room were expecting to have this as a discussion item today. so i think yeah, so that's what i would say, you know, and then you know, like of course dr. philips can come back and continue to like educate us on what is going on. >> sure, i'm happy to work with secretary morewits, thank you. >> before you go dr. philip, does the public assuming that it is extended, does the public

comment period have any reference to what the department itself can do other than letting the public know? >> the department itself in working with the other city department that is involved with the shipyard process which is o.c. ii will work together to make comments primarily on the on the five-year review and my understanding is that we will share that. we will share that draft with the commission for your review as well before its submitted. >> looking forward to that, thank you so much. >> yes, thank you for make ing that announcement and we'll be interested in the meeting as well as the five-year review. thank you very much, it's very helpful. so the next item on the agenda we're going to differ item 5, the dph human resources update for the meeting to april 2 and we'll have drew who is our dph

controller and this is a follow-up on baker playses prc which is a dph vendor as well remedial actions that have been taken by the department to assist baker place in response to their cash flow issues, thank you very much for being here. >> thank you. good afternoon, commissioners. i appreciate the time to bring this update. where the agency stands and i want to welcome agencies management team proudly represented here by tang ceo baker places and prc and also hillary cooners, our behavioral health director and max, systems health director for behavioral health. so this is started as an update on where we stand, let's see if i can advance it.

an update on where we stand with agency and in partnership and as dph and the services that they offer what we contract with them for what happened in terms of the financialization in 2022. what we did both as a agency and as a department to stabilize and move past the solve the issue. what kinds of progress we see and why we think this is the right time to bring the repayment agreement. summary of where we got the debt that we have and finally the terms of the repayment and sales agreement. so, advance this slide. our goal throughout. have centered on preserving services and treatment for clients so there is not a disruption for anyone receiving

quair as well as preserving behavioral health services and largely represented treatment beds by baker. in addition, our intention has been to hold baker accountable as stewed arts of public funds we have a responsibility to ensure city dollars are spent responsively and we believe we have gone through a process to get to a better place as we were. so the purpose here today is to provide an update on financial status and update on what we're bringing to the board shortly which is a resolution authorizing a repayment agreement of the accumulated debt.

they will require baker to repay and it will include 333, 7th street. there is a recap baker operates essential health programs for a system of care. essential behavioral health services for some of the most vulnerable residents. outpatient services, i mean furgeson regular. so this together they serve 2 more than 2000 clients and more than 200 treatment beds annually. so beginning in late 2021, october 2021, baker approached

the city and dph specifically signaling critical cash flow crisis. stating it would need to suspend services immediately due to having exhausted its source of cash. we took measures then that will go into later sides. work in partnership with agency to stay true to our goal of preserving services and preserving the system of care in the best way possible. that they would have to shut down all operations, discontinuing programs disposing of facilities they have run out of money. in the background, serious of

audit findings, march of 2022, 1920 audit for baker and finally concluded including a material weakness findings that trial balance had to be provided to the auditor multiple times which means they had to a trouble stating what their cost was. organization had no procedure to ensure, based on this and the cash situation october put, excuse me controllers office and red flag status in december of 2022. so during through the crisis, there are a number of measures taken by the dph by the board of supervisors by the controllers office. in service of our goals with the agency and with our system of care. the board passed an energy grant of 1.2 million dollars to

preserve operations dph did a number of contract changes, convert to go cost reimbursement in lieu of service temporarily increasing the allowable rate allowing baker to invoice, we'll come back that is a key part to the debt accumulation, that it preserve cash flow at the time that it needed. at the time of baker, baker worked with community vision a cbo partner to do a deep dive financial analysis during that time. the interventions were aimed towards continuing these vital services and providing enough time to complete the financial analysis to get a sense of what the costs were and to do a financial planning. so i'm happy today to bring some of the fruits of that work. advance slide. so, since then, there has been

a complete turnover really of leadership team, the management team at baker. that in partnership with community visions work allowed for the financial analysis to complete and really align the costs of services known now by program with the value of the contract. in some cases that lead to dph to adjust the award where they should stay at the provider of the program and other cases, the program needed to transfer to the services to another provider. at the same time, progress was made in showing up fiscal sulvency. audit findings were addressed timing of audits, was accelerated to be in line with dph monitoring goals. specifically, fy20 audit had

been completed in march of 202 2, october of 202 2, the agency completed the fy21 audit, they had dealt with it signifying the did i efficiencies to 3. next year's audit completed in july of 2023, significant deficiencies even further. established a operating reserve, restructured operations by transferring some under utilized programs and shuffling the budget around to match the true cost of services. mitigating previous audit findings to get their

financials, the trial balance or regularly more redictable reviewed by accounts necessary and finally proposing a merger. which is subject by the agency. as fruit of that work, controllers moved baker out of red flag status which is an improvement next level up, but into elevated concern in december and this repayment agreement is a key step along the way to moving them into normal operations. so the summary next slide, summary of debt to be repaid as you can see there is 11.3 million dollars from a 18-16 audit. the vas majority is initial payment that we withheld recovery from in order to

provide continued invoicing of costs during 2022 largely. as of july 2023, the agency began repaying us on the scheduled proposed in the repayment agreement even before the agreement and you'll see the impact of the proposed purchase of 3337 releaving three million dollars of debt. and next slide. the repayment agreement terms, are 23-year term running through january of 2046, including the purchase sale agreement at the assessed value of value of 3 million dollars. to stand behind the debt that baker defaults it includes repayment sted 120, per month inclusive of interest of 1.12 percent. the county pulled rate is the

interest rate over the ten years that we ofrjd that the treasurer maz invested the return on treasury dollars for their county pool. initial payments are not allowed during the duration of the repayment agreement. every year, baker will do annual assessment of available funds after bringing their operating reserve to the level required in the financial plan. they will accelerate repayment towards the debt of any remaining. and finally it includes collateralization of two properties in the case of default. advance the slide. so the purchase agreement, again property transfer of 3337 and so it's a real estate transaction only. preserving existing behavioral health, that treatment services.

baker will transfer the title to the property and dph will credit the amount based on the assessed value against the debt. planning department determines the agreement is consistent with general plan. and as of real estate transaction only, not defined as a project under ceqa. okay, final slide. in conclusion, so that's part of our agreement we're bringing these resolution of the two agreements, the repayment agreement and the property sale agreement to the board seeking approval. the goal remains, we want to preserve services for existing clients in the most stable way possible and preserve be beds in our system of care. and with that, i also have questions that i got in advance so i appreciate it. and i'll go through and make sure that i've addressed them.

commissioner green, i think you had asked given current deficits have any changes been made? and do we have adequate staff to monitor cbs financial difficulties? and i'm bohr aoeg a lot of the work that office reviews and will bring periodic updates. we believe we do have sufficient financial staff wha. happens with pr rc was sudden. there is a lot of technical details as far as we're going into 18 19 noted on going concern. that switched really quickly, we're monitoring them, saw some signs that they're okay, thought they're okay, during covid, i think monitoring was stepped back a little bit. normal practices were suspended. if they hadn't been in the fiscal fear they would have coordinated because of the growing concern.

so the city's monitor did follow the same procedure following the technical assistance and asking the agency for their plan. it accelerated faster than the pace. but at the same time, in the last six weeks, three months, i know that the business office has reinstated a cb of monitoring group and really worked on business office had a lot more to say in the coming few months. okay. and i will invite the agency up to answer some of the questions. i apologize if i skip a question. question about whether baker owns any other properties? they do, they own depending on how you count properties held as an llc six other properties,

all during levels of income brens. as one of the interventions, we changed the payment mythology with the intention of preserving cash flow. i don't have a clear story at the same time, we're doing that conversion, covid was impacting all services. and so if you look at a prior year monthly yearly invoice you see the prior year was higher but what is comingled is a lot of impacts from the pandemic and other sorts of staffing issues. but we know that it preserves, the agency was able to maintain operations.

further, you can see that their annual loss from the consolidated audits, 21 to 22 went down, so that's smaller. we expected to get smaller in fy23. specifically, so what is meant by time studies and segregations of duties. i think insofar as audit findings, this is part of the core issue, it was really difficult for the agency to get a grasp on how much the programs were costing many time studies were not done as needed. they had tributing all of their staff to direct costs with the contract which was lead to under recovered cost just going to say this dollar belongs to the contract. and there are many more details as needed. so, numerous, the question about offering payroll services

and automated association documentation and how that impacts of how that happened in baker. it's not an issue of payroll per se, it's more than the cost in their ledger were associated with the correct program. so that as they incur staff cost overall that they know how much went to the joe heli program versus acceptance place. finally, what is meant by federal indirect rate and invoice without recovery and initial payments. so indirect rate is a term of art for agencies organization that's receive substantial federal money. they have the option to negotiate an indirect rate with their agencies or accept a de fault ten percent. it's just an opportunity to

negotiate for dpc unlts the funding source has different rules, the 15 percent is our max. recovery of initial payment, our normal practice is that subject of funding availability, are eligible up to 45 percent of their annual award in july as we work through the contract. that amount is recovered against future invoices spread over six months. what happened is, the initial payment as you can see were issued and when it came time to recover, the agency was not able to have sufficient cash to avoid layoffs and closure of services. so we stopped recovery initial payment which created the debt situation that we're working out of but in order to preserve cash flow. mr. chow, i think i addressed the 1.1 interest rate.

i think core question that you brought is the formula for contracted services renders including this debt repayment in which case they would be paying for the repayment. i think this is a core question and there is two broad modes of weighing for services. mythology free of service. in both way, specific to cost reimbursement when we construct a budget of eligible to be costs to be reimbursed, that repayment is not eligible. so if it was ever in a invoice it would be xl, deeper service establishing a budget and starts there. but then applies a rate to say okay, they're offering the service and we pay consistent and equitably across all providers providing that service. and we think that largely the

saving necessary to pay this debt amount, will come via that and it will come via cost savings. as we pay the same rate for the same service that we pay for other providers, the agency has forecasted to be able to sustain situation sxz pay back that amount. so every agency providing the service in this case for adult residential service south side getting the same amount, they have to manage their cost or raise external sources such as through client fees and other operating revenue. their monthly repayment amount. does that answer? okay. >> if, mayor president, if we're able to follow-up on that question. >> i think it's time for public comment. >> that's fine, let's do public comment. but i thank you for the

responses. >> and trend is also here to provide answers on the questions that i was not able to. >> all right. >> thank you, drew. thank you, it's my pleasure to be before this commission and i want today start off by appreciating drew monthral, max, dr. kunin, the tph team that has been a tremendous partner organization especially in the past year and a half. this truly is the fruit of dedicated labor. based on weekly meetings that we've, you know, held over zoom and it's been, it's been a pleasure it's my been my privilege to work with such professionals. i want to make sure to answer your questions that reported specifically item number 2, large foundation granters

require extensive annual financial outcomes reporting. our local cbos aggressive in pursuing non governmental grants or extensive scrutiny a deterrent. this is a great question, we are pursuing foundational grants. we do have many foundation partners that support our work and critical to our mission. but the real ability is the caout city and level of reporting on finances and outcomes is much greater with public contracts, i think you'll find all nonprofit saying the same. but for the past three years we've been audited and reviewed and programs within baker at least 48 times and that's just on the program side. so, the requirement to respect to pursuing public grants are much more stringent but we're pursuing foundation grants, we

seek more partners and we have an entire team, my colleague brandi is here leader of our development department and we recognize that this is an area where the organization needs to improve. we need to diversify our fends, we cannot rely entirely on the city, it's just a mile that is not sustainable which we have identified and uncovered through our long term sustainability plan. i can plan on how we plan to diversifying our revenue just as a high level, it starts with developing fee for service contracts with non city partners. so we're pursuing allegation, now that we've corrected many of our dph contracts, we don't have to use our program fees, our client rents to supplement the costs of operations, instead what we can do is invest the resources towards

capitol improvement and invest the resources towards resolving the debt. i also have number 5, flagged for me, acquired baker in 2017, the year of its maximum loss 1.8 million dollars. why did prc take the step knowing this loss? why were processes immediately initialed? i came into this role into the coo role about a year and a half ago. i was not prevee to the losses.

i think they were anticipating a lot of efficiencies and it's true. over the past year and a half, we've been able to realize many of these yet, ideally we would have done it back in 2017. this is also a fiem when we had major staff turnover at including three c.f.o. that returns over. the entire financial staff has turned over. then came the pandemic and we know that story. and we have should have more work to sooner and quicker.

we're very pleased that we're able to do that now with the support of the controller's office and the incredible support of dph. i want to also recognize any team here. my entire leadership team, josh, randy and jessica and many more who are not here but it is only because of their efforts that we are here today. i just, you know, touching on the federal and directory, i know that drew spoke to that but i'm not sure if that responded to the question. if the question was related to the federal indirect rate or foundational rate of what is an indirect rate, if that's the question. i just wanted to make sure to clarify if that's needed. >> answering both would be possible. for us, the indirect rate is the cost of executive management, human resources,

accounting and finance, that all costs a certain amount of dollars right. and by indirect rate, that in proportion of cost of providing direct expenses, what is that rate? it might be 15% for us it's 21%, at one time it's 22.3 percent. so it varies depending on the size and complexity of the organization. and bit federal indirect rate as dpraou explained, when you hold federal contracts you cannot negotiate your rate with the federal government. you can demonstrate your expenses, if you can show that you have 24 percent, while pay you your 21 percent. the default is a cap of 21 percent generally but you have to demonstrate that if you're going to have a higher rate. >> thank you. >> thank you.

we'll now go to public comment. >> is there any public comment in the room? and remote public folks, i don't see any hands, no public comment. >> commissioner comments and questions? commissioner chow. >> thank you. i want to talk about what we're going to do here. yes i saw that there was a pursuit by prc to illegally come together. so i'm not sure from all of the relations or i guess that's what i'm asking, what is the current relationship if they're not one legal entity now?

>> signing as parent company. so they're both a part to this agreement. baker place is the subsidiary, maintains its all separate legal identity from prc. however over the past-six years especially over the past year and a half, we've done so much to create efficiencies between the two organizations. that they're operating as a much more affective and efficient way in a much more affective way than before. but through a lot of work that we've dup through cultural integration, they still maintained separate legal entries but we're operating in

much greater harmony. so what tuz prc do that baker place doesn't do? >> prc provides the support to baker places. so the executive management as i mentioned, human resources, it accounting all of that staff, all of that people power prc provides to baker places. so in this common, saying that they were going to come together, you're intend to go do one organization then.

it sounds like you're an employee of prc. >> i am. >> and you're man aning baker place and while our controller has assured us that the two are going to be obligated under this, it's still kind of strange trying to understand. i understand the beginning. and was going to do that. >> i think it may be helpful to explain the serves versus baker playses. so that you know, we'll probably make more sense to us as commissioners how this come about. >> sure. thank you for that. we start with two organizations serve similar oplations.

sibs then, provide mental health and residential treatment. prc established in oh gosh, 1987, was established to provide social services including legal advocacy to help people access ssiiing benefits and train to go help people with h.i.v. go back to work and also more recently emergency financial assistance in our financial grants to help people stay housed. so if they need rent or first month's deposit they can come to prc and we can issue payment to the vendor or landlord. so the concept was, gosh wouldn't it be incredible if we could come up with a model for service tlifr' where we got the core residential, and then wrapping around that is all the social support including legal

workforce and emergency financial assistance. so prc continues to maintain and provide the social services, as i prescribed the mental treatment. >> that's very helpful. because it's not that prc is simply an administrator but has his own distinct programs and added that component and what is the ultimate legal status that you're trying to achieve? you're going to merge this altogether and bring baker place into the prc or you know, i'm not sure why you decide you don't want to maintain baker place as a subsidiary. >> this is another great question, as drew mentioned, the financial sustainability plan does contemplate the real merger. the reality is legal merge cer complicated. because baker operates over 30

facilities. it's not just a overnight process, this requires our time, all of our time, expertise, skill, resource and so our main focus has been around stabilizing the organization from financial perspective restructuring organization. now that we've done that, we reengineered the financial. we've gotten the two organizations operating in harmony and effectively. now the question, the business question is whether or not it makes us to dedicate the resources in time. >> okay, you know, no i, i think the legal merger is interesting and i'm glad you're still thinking it through, because there are pros and cons to it as you're already saying. and so that was helpful right there.

i started off with a staff attorney helping people with h.i.v. get ssi benefits, i just found my ways. thank you. >> thank you, you've made a great deal of progress. i'm wondering from the dph side, what it is, as you said you're going along and we're monitoring. while the pandemic has some affect, maybe that's one of the lessons that we should learn about going through a pandemic, does it mean that all the gates are open and we don't do anything else. and we know everybody was doing different things. but if we can learn things from the pandemic, that would be helpful to understand, yes,

director colfax. >> thank you, at the chair's discretion, i just wanted to ask, some of the sub text of this conversation pandemic issue put thating aside for a moment, is that it may be confusing. so perhaps you can talk about how who is accountable for holding this agreement given the biforcation.

they're not with prc. prc as a parent organization to baker has signed a parent guarantee under penalty of default and debarment if baker stops spaig, it rolls to prc. prc has to continue paying. penalties apply to both. >> and who owns these properties that you're talking about then? is it baker or prc? >> all the properties contemplated in the agreement, the 3337 which is part of the person in sale, the two collateral properties. >> i see, okay. let me get back to the question to the surprise that occured.

>> so the surprise being the financial condition. >> right, here we're rolling along with recognize back in 21 that there was a problem, the board has and the board has given with some reluctance the papers and all, not the full total that was asked but a partial and that then triggers within our offices, a what does it trigger and why then if it triggered something, that then we were completely priced at this notice that tells us that they're closing in several months. >> so the experience. >> and what we learned from it. i want to know, i would like to know what it is that if we were able to we should have been monitoring something and that's what we're intend to go do in the future or something like that. >> i absolutely think there are

future metric that's are part of our fiscal monitoring. and lessons learned that we're still developing that indicate operating reserves differently. is that enough or and should we look at buy annual system. anytime one of the cbo inskate that they lost cfo, that tends to be a warning sign that we should check in and see what is going on. the depth of baker is unique but we've had other agencies that have had less dramatic but

still needed some hand helping during the course of this. and i say like the updates that were coming from the fiscal monitoring of contracts are coming and there are a number of tools that we're still working on the measures for. so it seems to me that we've gone through this adoration through several different agencies through the course of one or two decades that have required that and the department has appropriately and very well helped them through, this is probably one of the biggest that we've seen. and the commission or commission offers were updating as to what was happening. and recognizing that there was a pandemic and everybody was very much concentrating on that, i'm wondering if we're going to be able to restore

some process in which the commission is updated on those getting corrective plans of this nature. but is it thes very important to they understand and take a role with you or at least make sure if that's our oversight that this is really happening to the best that we can.

and rams almost died 30 some years ago, we brought somebody in from evelyn lee that came and saved the agency, literally and today it's one of our finest. and we're able to support that and work with the community or what it may be. i think it's important to get through the process to work out the process that we can then get a report back on what the process may be.

and after that, we can have accountability we cannot have accountability if we don't know what is going on. but thank you very much. >> thank you, commissioner chow. any other--commissioner chung? >> first of all, i just want to do a disclaimer, it seems i worked everywhere and i've been a patient everywhere and i've been a client for clarity and i'm so glad that prc is work withing baker. because bakers has traditionally has been pursuing mostly government funding. so i see a lot of positive, i

have a attachment to baker. this is like 30 years ago, that i think bakers are doing what some other programs are not doing. that another program has. so you know, like the differences helps but some may be social rehabilitation. so i'm glad that now we're able to move forward. and i do have one other question. so in terms of like your other programs, you know that you

mentioned other properties both are transitional funding program. those are not funded by dph. >> thank you for your comment commissioner chung. to address your question as to the funding for other programs and facilities, baker places is 90% funded by the city. but the vas majority is through the city and dph and the housing community development. we want to make sure that those organizations or community

services that we are funding are a diverse portfolio. every one is going to be in crisis. and i think it's really important for us as part of the the oversight and do the due diligence on the financial committee level. so hopefully we can come back and have more conversations later. >> thank you. >> thank you so much for the presentation and i don't have the association with baker that my shift commissioner does but we do have the experience that m.p. rc has done in the community.

this important organization for our community rise again and hopefully flourish. is it going to cause the city resources necessary to bring it up to any level, to renovate it? is this a good investment in that sense in and of itself? >> great question, commissioner. so our understanding of the property, this is 3337 which currently provides residential or is licensed to provide residential treatment beds.

so with that, we're costs. i'll invite my colleagues max to speak to it but, the critical critical nature of having a location to provide residential treatment services that maintaining those beds, because we can get these this property remodel it and get it ready for the services at a level that is comparable to getting other treatment beds ready. you did it i guess. >> i agree wholeheartedly with

commissioner chung and surely every one else that it's an important resource and we not only out of practical but out of you know, affection and love, we want to keep it going. in and of itself for us. at the fiduciary level. >> 100 percent. and we are still sorting the numbers and we think the benchmark is other beds that we've acquired or the city has acquired and what is a comparable per bed costs. we're still reviewing it but we believe it will be in line even with what is almost exclusively more than 80% of anticipated remodel cost.

so those costs transparently so that every one can see the reality that you have uncovered. >> absolutely. >> between the controller's office and baker places and thank you so much for your extensive and impressive answers. we do have a responsibility to make sure as you said mr. mural that public funds are used responsively. and i think you know to that end and commissioner chow also brought it up, first of all we

will have a commission meeting on may 7th and at that time, the business office will present what kinds of processes we're looking at including both financial oversight as well as outcomes and over the course of this year, we're hoping that we can calendar some presentations by dph leaders that we'll look at their response areas of responsibilities not only looking at the finances but also making sure that our cbos have meaningful and measurable outcomes without you, we cannot take care of our patients and the health of our cbos are certainly vital for us to be able to deliver services to the most vulnerable san franciscans. we're very grateful to presentation and look forward to not only may 7th but future presentations and commissioner chung and chow's how we

can--without causing extra work to dph staff and being more informed. and also the outcome that's people are looking at as we look forward so thank you very much. >> all right, very good. our next item on the agenda. >> and please feel free to leave. there is no need to stay, everybody is very busy you can stay if you like, but take care of your selves. >> thank you and your handout was fabulous by the way. >> good afternoon, commissioners. just want to extend my enormous

thanks to mr. monthral from the finance department who really i think this exemplifies collaboration in trying to support the pres*efshation of services that are hard to grow because of the special technical skills because of the knowledge about local community, about the complexity of care that not only those baker offer but our other community base organizations. so it's loud, next slide. thanks for commissioner for hopefully the slides and presentation was clear. i'm going to try to work answers through for questions

instead of saving them to the end. i'll see if i'm able to hit all of them. i'm going to speak being responsive to the up front question that were shared with me. highlights some of our key specific system elements and then address our data and measuring outcomes work. next slide. this is updated one very slightly our vision is for all san franciscans to experience mental and emotional well being and participate leaningfully and community across their life spans and across communities to accomplish that mission, provide mental healthcare and

wellness among san franciscans. first is to expand and preserve critical services. and increase where a san franciscans can get help. next slide. i want today share again as we have evolved our communication and thinking about our strategy some of our top line, summaries of services. behavioral health services at a glance we are both a medical or insurance plan the manage care provider for what is called specialty services and therefore we must adhere to state and federal regulations.

we serve through medical and reflecting on the prior presentation. part of the diversity of revenue in fact is derived from medical billing which is federal and state dollars. and that is supplemented by a local match and also general fund contributions to services that are none medical available. so taken together we offer about 100 connections. we serve approximately 20,000 people in what we call specialty behavioral health that's our specialized programs. the top three was primary

diagnoses which is i like to share. substance disorder, schizophrenia and other psychotic disorder ptsd and other disorders. prevention services and you can see the types of crisis services i put there below the circle. access and navigation services and these really are an area that we have grown tremendously since i've been here. outpatient treatment is next and fine pally which is often

the subject of most conversations humanly and public is residential care treatment and support which is really quantitative a minority of services that we provide. next slide. people can get into our care through a variety of pathways. you can see some of them most of them represented on the slide in front of you. we sort of in accord with the state standard which is under medicaid or medical reform or cal aim, no wrong door. so the standard is, somebody ought to be to present in one door even if that's not the right door that we help them get to the right door. and so that is, increasingly a standard and there is a standardize assessment tool which is being required which

has been adopted to help clinician and help folks through the right door. this is likely not ebbsings haas tiff so it's more comprehensive next slide. so i want to in the next couple of slides, map out where our services are in the city. and i'm stafrting first, i think i went out of order, i'm going to start with my colleague services and primary care. so you can see on that map, the primary care site that offer

integrated health. most of this is not considered on the mental health side serious mental healthness. but maybe mild to moderate depression, mild to moderate anxiety disorder and also folks who might need more intensive care but maybe unwilling to go. the primary care sites also do a lot of care around substance use and particularly around describing medication for opioid use disorder among counseling and other services. so you can see the sites on this slide anywhere family with these map, from our ambulatory care section. next slide. the heart and soul is our specialty care behavioral health program. so the map which you can see

includeses 55 sites. serving approximately 15,000 people in fiscal year 21-22 those are outpatient programs. these include both dph run programs or civil service programs as well oz our many contracted programs such as baker prc. next slide. on this slide, we depicket our residential care and treatment that is taking care across our city. the majority are contracted out and they do not depicket the large number of sites that we contract for that are out of county. so that part of the sector is both in county and out of county reflecting the difficulty at times to identify

in county providers. next slide. as you all know, we have been aggressively aiming to increase the number of residential care sites to meet the goals of mental health san francisco and to meet a bed utilization study that was done in 2019. we update this dashboard monthly and have opened about 350 of the 400 intended spots. many of these are in county and as well out of county. next slide. so one thing that has been central is really improving access or entry into care and

once, sort of identifying a any coordinate that entry and coordinate transitions and care. for example from hospital into care, from jail into care, or across levels of care somebody gets develops more symptoms becomes more ill needs to step toup a higher level of care. that has been enabled by two major efforts. one is in the top box are behavioral access line and behavioral access center. these have been preexisting services but have been increased capacity over the last couple of years. and you heard me speak about this, behavioral access center is now opened 7 days a week. and in that center, people can walk in and get assessed, referred chatted with, find out what they need.

triaging somebody's needs and best street or neighborhoods team, the best care management can work with somebody to get them situated into care. best neighborhoods are teams that out in the streets working with folks referred from our fire department and street crisis response, refer from community members, these are folks that we find and look for in neighborhoods and continue to work with. next slide.

those are folks that we did not enroll in ethics or in our health records but who were dropping in that wanted information, they might want referral but maybe not, they did not necessarily want to have a full engagement. i will share with you, in the future the sort of combined people who registered and people who dropped in but these are anonymous encounters. so we're serving a lot of people who are just walking in. one of you asked about october 2023 where we saw a lot of high numbers of drop ins. we think this data may have been an anomaly because we were getting our data system up and runing. we see a steadily flow in the 300s so we'll be tracking that and because of this data is early, we're going to be

watching early, we don't think it's going to be represent a drop off. next slide. similarly, this is, these data represent behavioral call-ins. these are again not people who reend up enrolling in services but people reaching out help, asking for advise, general health advise maybe our supported on the phone. and maybe willing to call back or go in a different data or access center. so we're very excited to start having these regular utilizations data in order to monitor sort of how much how much we're doing. i know that a number of you asked and i heard from the previous conversation about what impact our services are having. one of the way to see do that is just real estate' quantify our reach and this is sort of a book about how we are doing

that. next slide. switching gears, i wanted to highlight what we are calling our intensive outpatient ens program this is also known intensity case management. this is treatment that is integrated with wrap around supports whether it's case management, whether it's housing navigation, whether it's physical health needs. this is a really important part of our system of care. it's a higher level of intensity than straight out in patient and lower level than residential treatment. we want to be able to step people up or down to this level of care as appropriate. how do you get in here? the access point mostly through these level of care comes from

somewhere via dph either from outpatient program who is having difficulty retaining the person or as i just described in the prior slides, through our office of care management through one of our best teams, work withing somebody thinking gheez they're not going to really be supported enough in a straight up outpatient program. we want to step them into a case management program. and stipulate i canly these are referred of people that we know already, we talked, we're working with them in the hospital or on the street or somewhere else and we're able to get them into this level of care. this is an area where we have made investments under mental health sf and it is an area that we're interested in continuing to expand capacity. what does it mean to have this

level of care be successful? the goals of this level of care, is recovery oriented to support people to do well in their life in their community be connected to other people to family to friends to jobs. and so success is measured really depending on the person to achieve a greater level of stability and independence. these programs are not necessarily designed to be graduated or completed, they can be for many months or years serving acknowledging that some people have a more chronic course to their challenges and some people are likely to get better and be able to step down. so it's unlike, you know, thinking about some of our health conditions like we do diabetes or high blood pressure that you graduate from diabetes

care, it just may change depending on how you're doing. you're managing your illness and how you're doing in your life around managing illness. next slide. another really important aspect that is not exactly our own system of care but really reflects the extent in work our coordinating care has really stepped up in the last year to 18 months. a big part of what we do is aiming to coordinate our response with other agencies aiming to increase the stability of people, connection to see care. we're very careful to protect health information and confidential of course, and we also know that we need all of the partners who might have information, that we don't for example, who who may have

resources who don't have and you may have resources that others don't have. we have coordination with our colleagues, in the other city agencies particularly around street engagement and both engaging and retaining people in behavioral healthcare. next slide. and i want to sort of end with using some of the ways where we're using, data to inform what we are doing where ever we can. and still bl data systemsed to solve, so fill-in gaps where we have strong data. so the first data is our own dose response data and how we are looking at and using a variety of data sources to do that, next slide.

so this is data that are familiar to you. and as i've discussed with all of you, we are have seen an increase in overdose deaths in 2023 compared to 2022. we we are using this data and i think it's later in the presentation, i got my report out of order but we'll return. next slide. i want to speak overdose response tactickly for a moment. where we can strengthen the full continuium. this slide is really slide from

the health psychology stage of change literature. so the bottom is named the stages of change for somebody who may have an addiction or any behavior in fact that they may want to or need for health reasons to change. so a person may be precontemplated thinking about making a change preparing to make a change, taking steps to make a change and then maintaining that change. we really are thinking about very broadly how to get to people and how to deliver the right care that is scientifically based for people along the stages. and to help deliver care that moves people along those added their change. so for example, and this is been a lot in the media for example.

perhaps they're still in treatment and they need to live somewhere while they continue to get their regain their ability to connect with community and connect with a job or family or faith community. this is for people coming out of residential treatment and then having a place to live for up to 24 months receiving support and engaging in outpatient treatment. we know, that we have also built up services around medication treatment aiming to make it more accessible for example in addition to the behavioral health access center.

we've added evening hours at ad howard. meaning we know medication works for people who are making changes. we need to make it easier for people to get into and stay into. and then, an area that has fought a lot of attention also locally and nationally is what do we do for folks not able to willing at that make a change at present time. that set of interventions can be called harm reduction but it's likely due in primarily care, figuring out what the person wants. helping them make changes towards health and then moving them along healthier state. and so things like both thresholds counseling, like our

humming bird psychiatric are examples of pulling people into care who might otherwise not be receptive and then engaging them in that care and moving them along. next slide. we are also engaging fatal and non fatal overdoses. we're currently within the department, really a evaluating all of the work that is happening in the department aiming to align it, reduce any redundancies, expand things to scale that could be expanded and are proofing affective.

as you all know, methadone is highly affective in supporting people in recovery as well as reducing risk of overdose. however, under federal and state regulations it's not always accessible. we're aiming to increase access in our jail in our county jail where at present we can administrator continue somebody on methadone but they cannot start new patients on methadone. that's a regular tory issue. we're interested in expanding our methadone site where we can continue to people in methadone

but don't have the capacity to start patients there. we hope that these are two examples of being able to pull more people into care. we're also increasing the number of programs offering contingency management. as you know, we talked about it here where somebody may get an incentive or or reward for example for negative urine toxicology. and work with african-american to address overdose in communities that they work with. and we also know that there are disproportionate overdose under people who are unstable and unhoused and we're working to

increase the lockzone access in phs which stands for permanent supportive housing. and lastly to meet our goal is supporting people to know where and how to get help, will be launching several media campaigns aimed at increasing awareness of services. we've developed a palm card which we're distributing widely in our own services, summarizing where and how to get help for substance abuse. >> can we get a copy of that? at some point? >> absolutely. so on the next slide, sorry i always think, it takes me longer than i always expect, a couple of last slides. we are again, aiming to increase up take of people receiving services for substance disorders.

until terms of what you're seeing, representing people receiving a service during the year not specifically new people. we do have slides and i will accepted to you our link on sf.gov with new and on going patients. we do measure another outcome and we report this to the state. folks who are retained in methadone and that's important metric for substance disorder.

i think that's you commissioner green asking about standards across the fields and they're often sort of service specific, so you heard about one, there is no wrong door standard that is rolled out in california examine locally, another standard in behavioral healthcare is on the substance use side is retention and care. we know that people retain, meaning they keep coming back, tend to have better outcomes. so what we can measure is how well we have retained people. now as we go find more people, the to pull them into care, you can imagine that if we get more and more folks that are ambivalent or not ready, our retention rates paradoxicalley can go down. so it can be a metric to interpret.

so with that as a caution. next slide. you can see our top number there is 20,000 analox indoses that has gone year over year over the last three years. let me then end next slide. with the last three data slides. these next slaoe slides are posted on the website. we are, this is version 1.0 we will have subsequent as we have more data available. we are aiming to have a place

track of fatal and non fatal overdoses are also posted so we can see what is going on city wide. this is examiner data. this is the number of people treated by methadone by year. we are hoping to put up also both new and on going clients. so what you can see here, is a drop off we're aiming to reverse that. interestingly, on this slide, which is about morefine

clients, city wide not just bph, we saw an increase in 2021, we don't know why, we hypothesized it may be actually because of lots of folks in shelter in place hotels, with shelter staff engaging with them, we were able to increase the number of clients by our colleagues in integrative care. we did see a decrease in 2022, perhaps as those shelter and place hotels were no longer available. the 2023 number is still early, it does not represent the totality of the year. so we don't know yet where we will land. these data are state data so we have to wait until they share them with us. and then last slide. so, i think was it you commissioner?

how do we evaluate health outcome so if mentioned a couple. one is retention and care. another is really being adhere ant to state standard for example the no wrong door. what you see in the slide in front of you are some very specific sections, system of care assessment tools something called the cans for children and adolescent, the ansa for adults and strength assessment. this is basically state required structured questionnaire that's we're required to complete with clients overtime assessing multiple as commissioner chung you mentioned, not just their biomedical functioning but their social functioning.

that is routinely done and by program and with programs, we also have a number of internal quality reviews where we routinely review complex cases with programs. we assess quality. lastly let me just mention that which is not on this slide there is a new medicare or medical requirement that is happening both nationally and locally which is implementation of heathist measures hospital health performance but new heathish measures and alcohol use which mostly focus on two key areas. if somebody presents to an emergency department are they then referred to or do they then get on going care? and the second is around receipt of medication, if they have an opioid use disorder. so we're very focused on those

gathering so we can report on them, but you can see, i would say unlike many aspects of physical healthcare, don't always have across the board metrics that we're reporting on. but there are standards in medical that we do consistently report on to the state in addition to the ones that we see there. we report to timeliness to care and time prevention and as i mentioned retention. is suspect or wonder whether some of the questions that i got on this also had to do with some of the contract and performance pretricks of contract that you heard, i heard about may 7th where we're looking forward to coming back and speaking more about that. i think that's it. i'm sorry if i went on too long. >> thank you so much. is there any public comment?

>> i don't see any in the room, remote folks raise yaer hand, i see two of you. no hands. >> all right, how about commissioner questions and comments? >> i just want to thank dr. cunan for such a thorough presentation for to us get learn about the behavioral health system, not just you know, like services. so thank you so much. it comes a long way. from back when i was working in the substance abuse. >> your documents increasingly they have always been for me, it's helpful to have this

detail bun overly detailed information that we can use and refer to from time to time. thank you for taking the time and the effort to make it so clear. you were talking about retention and other metrics that might go up or down depending on if you're more successful in getting people into care. i wonder if there is, if you think that there is any use or something that can come from separating these metrics when people enter through the criminal justice system through jail versus people who enter through the community and you know, the number of people who come in and the number of people who are retained and what those pads look like.

because people who enter from jail are obviously, from my perspective doing it as a result of some kind of something that is course sif but they're in a situation that they can help themselves legally and otherwise if they do something that they have not wanted to do. and finding ways to increase retention and success overall for people who enter that way is obviously a goal for every one for so many reasons. and any thoughts you have about that, yeah, thanks for any question. i'm going to answer with more complexity which is different kinds of care also are known to

have different levels of retention. so for example, we know that methadone treatment and people and particularly methadone treatment has pretty high retention mates so why is that? it's very affective, it's a medicine that, a person does have a continues to have a physical dependence on the opioid so if they don't take it, they will experience withdrawals. we know that retention rates in methadone are higher this is from national not local data, people trop out of residential treatment. and so, we would have to think about it, by not only by referral source by what the intervention is. and it's a really great point because we want to make treatment appealing, we want to people to come into care and we

want people to stay in care. so we want to meet the needs and make it personal friendly and person centers and trying to meet people's needs so they stay with us. we know that the longer they stay with us, the better they will do. i will bring that back to the team and let us give it some thought and then it's a great important question. >> and thanks, for the answer and i appreciate the complexity. in your thinking where the department the necessity of having interventions and treatments and housing and facilities that are focused on people who are coming out of criminal system forensics place that's are geared towards the particular needs of people coming through that path and

having those issues associated with their whatever challenges and disorders that they have. what are resources of add qua see that we have right now. >> so i think in your packet, we have in the end and i didn't get to this question, a resent analysis that we are using similar methods as we're done in 2019, we have more experience as a team and so we are like the revisions. let me say two things to your question. one is, we identified early in my tenure a need for residential care for people can forensic involvement or criminal involvement and a feeling among my colleagues and

in jail house that we didn't have service for that. we partnered with probation to create the project which we don't have a formal evaluation for but it's high level of clients on this action, high rates of people being developed into the program and that's a partnership between us probation with west side as believed agency delivering the supportive care, transitional work with another cbo or ucsf city wide doing what is, what is the wrap around. >> case management. >> we don't call it that exactly but it is like that. and that is really not out of, we designed it locally with a lot of work and a lot of collaboration and it's been a really great example of the

taylored service that is finding acceptance my senses pretty widely. we have some gaps that we identified through our bed analysis specifically i'll just highlight two complex levels of care. one is something called mental health rehabilitation center also known as lock sub acute, so this is involuntary tare' facility for people who don't have the same level needed in somebody psychiatric patient unit. those have been difficult to buy purchase enough of. it is there aren't enough sellers of that service. so this is an area we need for expansion. another area where we have difficulty is placing folks

with certain complex needs in again, board and care level of care. also called residential and also for older folks residential care for the elderly when folks have a set of needs that includes a memory issues not like serious dimension did you mild to moderate cognitive involvement, placements are very difficult. and those are some of the people that we have challenges in finding the right place. again it's because these are hard to purchase and this is something that we think is a gap we think it's a solvable gap but it's something that we're going to be working on. >> thank you. commissioner chow. >> i just wanted thank you for this wonderful overview. and i know, you mentioned that there were state reports that

you have to send forward and i think in future reports on this topic, it would be nice to actually be able to see some of that and i think you mentioned that earlier. >> happy to do that. >> right. and i just want to thank you for this clients scenario. so, i'm wondering like on the methadone, is there sort of a de nominater.

which is the number of people with opioid use disorder in the city and how many of those folks do we have on medication treatment. we are in the process of contract with our colleagues with ucsf to calculate that and we expect that will help us set exactly that goal. it's, you know, there is a lot of lessons here for example h.i.v. which in which myself worked for many years without that denominator to know how we're moving across, it ought to be similar for substance abuse. but we have some catch up, i know i always say this but that's where we need to be thinking.

>> thank you and i look forward to the on may 7th some of the outcomes and the last report that we have for the community. the community was really extraordinary showing that many of our services are measured very well and yet we're not able to in our case merge it with the contract themselves. so thank you. >> i had a question to follow it up, it was under staffed. so i'm wondering how things are now with staffing, with that particular program and also do you have any sub setting of how many of the individuals that are maintain on methadone are using are actually within that intensive case management sub set in the same way that have come through the justice system.

>> to the second question, i don't have the answer and i will, i'll look into that. i don't know that we know that. i will say that this is, on going challenge for our substance use and sides of the health because of confidentiality laws. it requires a specific as you know, a specific release of information and so those two systems don't always see what is going on, well it's really outside of substance does not always see what is going on within substance use and that is consequence of our federal law. part one. part two, is stapping, i don't have a quantitative estimate of staffing, i will say that we have not achieved our full funded capacity within

intensive case management because of recruitment difficulties in the behavioral health sector. i don't have the estimate about to what extent capacity is expected by staffing but it is, we know it is. it does changeover time, so it's not always like one program versus another. so staffing does ebb and flow with the different programs and it affects our full ability to realize the funded capacity. >> i really appreciate it and it could be interesting to get more data on the intensive case management. it seems logical that those individuals would be on a path to returning to a more stable life and housing and so forth. and if we can proof that, that would be really helpful not only for san francisco but other jurisdictions as well. >> and we know just for context that there is evidence base

model called act which is assertive community treatment. that is a reimbursable model shown in good well done studies to reduce hospitalizations, reduce incarcerations, increase employment, increase stability and community. so it is an approach that is well accepted, well studied and making sure we are staffing that to adequately and executing the specifics of it well. you know, to me is very important and achieving the outcomes we're looking for. >> thank you so much, i wish there was a way to socialize it to the public because so many

people complain about what is going on in the streets. and yet when you look at this and realize the work that it goes, and the intricacies, i don't know if we have the means to get this out there but most of the time you talk to people and the public have no idea. it would be great to find a way. any other commissioner christian >> just building on what you just said, perhaps there would be with the departments or the cities communications people, pushing an article like a long article or a series by mental health reporters and major newspapers. that could document that and show what is going on in san francisco, you know, something

like you know, the times or the, the "l.a. times" or new york sometimes or something like that with a story. heather knight, "new york times". >> thank you commissioners and i want to acknowledge and appreciate dr. cunnings and her team to her team for this work. which all want to go faster but i really appreciate everything that they do to persevere and to persist. i do want, just touching i do want to highlight and made this to later presentations. but one of the things that that affected the response is the

ant indicated, antiquated. it's easier for me to describe fentanyl for pain than methadone. thank you imagine if you had an infectious disease and, it would be like h.i.v. you could only get if hesing, if you had an h.i.v. clinic. i just want to highlight we're working at the policy level to try to drive this. every four and a half minutes somebody dies of an opioid related overdose death and we cannot get methadone out as

quickly as we need. and if you go out on the streets when you're asking the streets who are actively using what it would take, i hear the ask for methadone repeatedly and it's so bureaucratic. we're not meeting people where they are because of the federals, i just wanted put that on the record, thanks. >> i put in the historical context of this. so once upon a time we tried the treatment on demand but the resources went dry. i think that was the bigger challenge, you know if we continue to have this type of persistence of sigma, we're going to run into walls. so we need to have more conversations. and also i want to say that i really appreciate how you put this stages of change on your treatment, different treatment

phases for somebody who was trained on this 30 years ago, this is the actually the first time i've ever seen somebody who had actually clearly stated that and demonstrated that in the program development process, so thank you. >> wonderful, thank you so much. i think we've directly colfax just pointed out even a better article for the "new york times". thank you. >> i appreciate it. >> all right, the next item on the agenda is laguna honda hospital and rehabilitation center. cms recertification update from director pickens. >> and we thank mr. pickens for his patience. >> could not spent the time with a better group of people. good evening, commissioners director of san francisco health network and in response to laguna health

recertification. next slide. so as we shared previously in december of 2023, laguna honda completed the reasonable period for the statutory required second medicare recertification survey. that survey showed results showed improvement from prior cms monitoring surveys with overall less findings and less findings of lower scope and severity. the laguna honda team developed robust plans of with quality expert required by cms. and in response a plan of correction was submitted on january 13th. next slide.

so it's important to recognize with commission of those plans correction laguna honda is still not recertified in the medicare program. the next step in the process is for cms and the california department of public health to approve those plans of correction. cms and cdh will then come back out for laguna honda to validate the completion of plans of correction. subsequently cms will ask determination to be recertified in the medical program. and the long term sustainability of all corrective actions that have been implemented over the last two years. next slide.

i would like to provide you with an update on the status that who no longer require nursing care. you recall in march of last year, the federal department of human and services are directed laguna honda to move forward with discharging residents who no longer met the level of care. have been discharged under that directively. currently remaining 44 residents who no longer.

this director referenced. this is good news, there is the san francisco government award and this year, an inter disciplinary team from dph are set ant of good government a pardon for the work on honda recertification. so honorees include jennifer weighed, nursing home administrator in laguna. chief of medical staff, director of quality at laguna and troy williams of the

director of quality for network commander. and in addition our colleagues from city attorney office hairy and medina who were instrumental in all of the success. so there is a group will be recognized at the 43rd annual good government award city hall and again want to celebrate their achievement on behalf of all of those at laguna who work to get the organization to this point. next slide. i would like to operate you on a few more activities. as you know, we've been

recruiting more than a year for direct of emergency management for laguna honda. you recall in the early days of certification, there were serious gaps when it came to emergency preparedness and management at laguna. so we're pleased to announce that after a nationwide search and several rounds of trying to identify candidates we were pleased to announce the new director of emergency and her name is angela lazarus. has over 17 years of experience including as director of operations at the san francisco campus for jewish liberty. angela joined the team yesterday at laguna and is working alongside tiffany rivera who is the deputy director for emergency preparedness for dph and who

has been deployed at laguna for the last year to assist. so tiffany will be handing off for the great work to angela and angela will take the helm from there. as you know, tiffany helped develop and implement a very robust response program which contributed to the zero response--tiffany really has set up laguna for success. and we know based on angela she will continue that hard work in that area. i would also like to update you on the admissions process for laguna honda. as you know, laguna has worked to remine its admissions plans and policies over the last several months. many of those policies have come to the jcc and forwarded here to the health commission and you have approved them. all of those processes, and policies were based upon our

available information. those policies included a relook at the laguna honda admissions process and criteria for admission and all of those have come to you in previous smitions. submissions. as mentioned we're waiting for that. once that plan of correction is accepted and approved and validated, and laguna receives a recertification to the medicare program we'll look at the plan of correction to see if there are any implications for making additional changes in the admissions criteria for laguna and if so, we'll make those changes submit them to the jcc and then have them come here to the health commission. it's important to note that the laguna team has been working for the last six months on a

readmissions plan. but we cannot finalize until we get final in terms of this last plan of correction. once that final sign off is approved we'll come back to the commission to present to you the admission plan for laguna and note that that admission plans will outline out reach that has already been done to those residents that transferred to other xas ilts. and as a reminder those are in what we call priority, they will be considered for and admitted to laguna before any other new external referrals are received and adjudicated

for admission. we would like to update you with new regarding regulatory visits to laguna. as you know laguna honda often has surveys onsite and they are typically onsite and response to two activities, one are what you've heard referred to as fries or facilitied. the other are a non news complaints this is where any individual can call california department of public health and make reference to something that happened at laguna or any other skill nursing facilities. these are typically part of the routine of any operation. as you know, laguna takes a

both the fries, facility incident report asked complaints very seriously and we have an established protocol when those complaints are received and, how we deal with them. i want today bring to your attention that on march 11th, two statements were received regarding two resent survey visits. where residents had fallen. laguna honda has very robust process for investigating all of that includes a medical quality review by quality

physician, dr., oh go, dr. christina. no, kwan. >> dr. kim. >> dr. kim, sorry. long day. and then, once that review is done, it's submitted to our jcc, because these two cases came in on march 11, our jcc was on march 12. so the detail will be given at the next jcc and it will make its way up to the health commission. the plans of correction are due back on this thursday the 21st, plans of correction are almost ready and so those will be submit today and then go through the normal process. they may have back and forth.

asking us to make changes to our proposed plans of correction regarding the findings that they made in their onsite visit. we anticipate that once those plans of correction are submitted, and hopefully to the satisfaction of cdph that then cms will move forward in still outstanding planned of correction from the department visit. and so those are some of the updates and i'm happy to answer any questions or comments from the commission. thank you for the update and it's wonderful with the government a wa,ds thank you for letting us know about that. is there any public comment on the item.

>> is see two hands, i will start caller let us know that you're there. >> it's dr. calmer can you hear me? >> yes, you've got three minutes dr. palmer. please begin. >> speaker: hello. >> yes, dr. palmer, you can begin. >> i'm sweating mails and i also worry about the deficiencies and i would like more transparency and why this

is taking so long. and i i wish there was more transparency about, how we're going to, it's laguna honda get through this, how are you going to prevent it from happening again.

is would like the medicare recertification that is going to be occur and if not we need to look at receivership. does the department of public health and the city and county have the wherewith all. thank you sd we've fwot one more caller. >> caller you're unmuted. >> okay. >> you've got three minutes. >> speaker: this recertification report is worrisome.

it sounds like smiggage, the swedish word for bologna hot air and complete utter, nonsense, that's because for the past two months of health commission and jcc meetings the public has submitted plans of corruption and january 17th respective low. but mr. pick ens examine others have hidden details. revealed op closer that they took thrilling down into that meeting drawing out pickens that they had asked for revisions for the january 13th and january 17th plans of correction submitted. then hcc apparently submitted corrections to cdph and forwarded to edits along with

cms. end quote, that's cms had revised changes for just one month. but the truth is, lah and pick ens had not disclosed the last two months in the plans of correction and that the edits had been submitted. you kept the public in the dark for two months. you cannot have accountability if you don't know what is going on. no shit, sherlock. more like sniggadi, you collective low through commissioners through a long long time. why didn't you tell members of the public previously to help

us understand the delay in obtaining recertification. still burning, body, end, quote, thank you. >> that's the last public comment. >> okay, commissioner questions or comments? commissioner chow? >> yes, is think call that we heard, what was the number 2057? >> oh 2567 and those are not unusual in terms of the that

findings are returned to us, whether they are a severity, the 2567 does it carry a severity code or is it that, you know, we need to write a plan of correction for something or other. >> yes, so we do need to write a a plan of correction and the 2567 do carry, if the findingses with the federal tag it does have a level of severity, attached to it. >> yeah. okay, and meanwhile we'll file that in a timely fashion and then that is going to be as timely in terms of the response? >> exactly that is true. you know, we in every case for the last two years, laguna has met every required timeline for submission. unfortunately that's not the case in the other end for my regulators, they have time

lines and unfortunately we don't control them. the other regulators and they have leeway in terms of when they respond to us. much as much as we would like it sooner, we have no control over their response. >> okay and so, in regards to i think we looked last like, the falls at laguna were in fact left for thousands days or whatever is measured, then the norm in california. >> that's correct. >> that's correct. >> and so it's not unusual that there be a fall but of course we need to always be working and all falls reportable. >> absolutely. >> and so this just, comes along in the fairway, unfortunately that normal process although we've been diligently working to reduce all the falls.

you know one fall is one fall too many but hospital infections you can have a best infection control process in the world but the reality is due to the micro organisms that are present, you're going to have facility acquired infections and falls are similar for skilled nursing sector, as much as we try including care planning and physical obstacles and supports they unfortunately do happen. but there is a very robust program for falls that we've even had the cms improvement expert come back in and reassess lagunas plan for these two 67 related to falls and they have slacked off in their plan knowing that they address

all the areas that need to be addresses. >> good and, do we have any feebling as to where we are with the federal response to us now that we understand cdph forwarded it? >> yes, so again, we don't control cms but our best our best feeling of where we are is, after submission of these two 25-67 plans of correction and that cdph has done their due diligence to approve those plans and validate the corrective actions. our at that point, cms will take up the plans of correction we submitted in december to allow us to finally go through the final process for recertification.

>> okay, thank you. >> any other commissioner questions or comments? well thank you very much. i just have one question. if between our meetings we do get some good news from cms or approved plan of corrections how will members of the public are obviously concerned. how will we communicate this? sometimes we have two or three weeks between meetings? >> so typically when we have occurrences, i notify the chair of laguna honda jcc so i would differ to whatever processes are allowable to the health commission for communication. >> great, thank you very much. all right, very good, thank you and thanks for staying so late. we really appreciate it. so the next item on the agenda is the drink conference committee from february 27th, 2024. and that's a clerical error, this is the update but it's

from the march 12, 2024 and my apologies commissioner chow is ready to give that update. >> wonderful. >> well it can be fairly short because director peckins has given substance of the report. to the consequence of 2567, but we want to have that shared with everybody so they understand part of the tlai here in cms action is whenever there is an outstanding issue, prior to them making a determination, that will holdup the process of the certification. so, also at this meeting however, we did review the consent calendar and we found

as as a result of new policies which are to meet state guidelines, we found that laguna honda is not a license facilities to provide transfusions. it's got a policy where you do not admit go you have to be qualified for the acute ward. so we, so it was brought to our attention that there would be concern that more standard routine, transfusions for chronic illnesses would require transport to a appropriate facility and the team assured us that they were reviewing that to see whether it would be appropriate to apply for a license and they would come back after recertification as to the findings and what we might need to do in regards to more elective transfusions.

so, in close session we did approve the predeshls. credentials. >> thank you. >> thank you, any public comment on this side. >> yes, there is give me one second. caller you've got three minutes. >> caller: i'm so tired of these so-called clerical mistakes, i didn't have a chance to prepare comment. end quote on the agenda, you should have taken off the agenda. can't this commission follow the dam rules? >> all right, thank you. the last public comment on this. >> any commissioner comments or questions? all right. thank you for the report.

and in reading this next, the next item is consent calendar. so you have the laguna policies and procedures, the committee did recommend that the full commission approve these particular policies as listed, is there a motion for approval. >> so moved. >> is there a second. >> second. >> and what about public comment. >> is theres a hand up. call you have you've got three minutes. >> never mind, you guys are pathetic. [whispering] >> thank you, so did i miss two motion ?z >> we motioned and seconded consent calendar. ?fm all those in favor? >> yes. >> consent calendar is approved. >> next is community public health committee meet thating commissioner will give.

>> commissioner chung and i heart presentations hepatitis-c, they reviewed the registry programs. total of 3009 case nz san francisco with men being the languagerest cohort for new cases and men comprise two-thirds of the cases. total of 3109 cases in san francisco, i said that. highest prevalence are in the tenderloin and eliminating help sites c includes integrated testing using pure out reach, increase linkage for same day diagnosis and treatment increase overdose presensing, outbreak protection and responses.

anything interesting here? commissioner chung did note something that is significant and that san francisco should remember and be proud of that san francisco was the first to provide hep-c treatment. she would know better. and we did learn that the, we're not able to understand who among the individuals tested are transgender, they just do it by sex at birth so it's male or female, it's--the labs, the resource for the data on sex and this is the way that

they're currently collecting and reporting this. and prafps we can get a dictate that requires more nuance in the reporting. let's see. great presentation, and the news is is good, i would say, i would note that the the race and ethnicity of all the cases reported of hepatitis-c in 2022, showed that black african people make up 12.5 percent of newly reported cases but black african-american people comprise only 4.9 percent of the san francisco population and while this is, you know,

alarming and problematic and upsetting, we were--it was noted that in 2009 it was one-third of black african people rather than 22.5 percent today. so while it's still ex extraordinary una acceptably high, it at least is going in the right direction. the second presentation, was a presentation on primary care and we had the immense pleasure of having dr. gregory the director of primary care present to us. she gave us a wonderful presentation on the primary care system. there are currently 19 dph outpatient clinics including four at ccsg, 39,000 patients

are enrolled but have not been seen in the last 18 months. she keep tabs on the data about how long it's been since people have been seen. currently there are 617 total ftes and 139 vacant positions. dph is primary include anti racism anti racism and equity and building a culture of integrated behavioral health services and dr. gregory talked to us about those that there are certain sites in the city that provide both medical and behavioral health services, not all do. but we have a large number that do. data is an important tool on how these clinics to understand their strength and areas of

improvement. that is weekly sent the weekly manager so every one can build upon the culture of working together. we talked about how hopefully in the future that data will reach the providers themselves so will not only will the supervisors be able to look at the data but providers themselves hopefully when, it is worked out structurally, will be able to look at their own data and consider how they are doing with respect to how they want to be doing. and she included successes including 7% improvement in all overall breast cancer screenings and 10% improvement for the black population. 7% in hypertension scores for overall population and 5 percent for the black african population.

and at commissioner chung's urging, dr. gregory shared a vin yet about a patient that she treated tom la del where she staffs and this is an undocumented immigrant from china who came to the clinic and she examined him and you know, provided him with medical care and during the examination, it came out that there was a great deal of trauma that this person had been experiencing throughout their life and which lead them to leave china and come to san francisco. this was a man who was gay and forced into apparently, this is not uncommon scenario was

forced into heterosexual marriage and very depressed and kind of harmed by this. and when he did let his family know that he was gay his father committed suicide which left him with trauma. so he came here to a place where he thought could live more freely. and what dr. gregory was highlighting was the collaboration across disciplines looking at all the needs of the people who come to the clinic. and addressing all of the needs that they have and so, there was an engagement with both him around the issues and others that he had and obviously this is a terribly traumatic experience for him but it was still having huge impact on his health. and at the end, he said that this was, that he volunteered

that he was felt very seen in a way that was probably for the first time and the response from one of dr. gregory's colleague one of the four who dealt with the man that day was that he winked at him and said you're family that that is the kind of thing that these primary care clinics provide to people in the community and give them a sense of well being and so we encouraged her to continue to share these things with us when these reports are gifp. --given. so commissioner chung, i don't know if you have other things you want to highlight. >> you are very thorough commissioner christen. >> thank you. >> thank you for that story, very poignant story, the need

to heal beyond just the body and spirit. that's the way that they have dealt with patients, so thank you for sharing that story. is there any public comment on this item? >> yes, i see a hand. you've got three minutes. okay, i guess we don't have any public comment. >> no public comment. is there any commissioner questions or comments on this item. seeing none, thank you. our next item is other business. is there any other business? >> not today. >> all right. >> i don't see a hand. >> wonderful. so next item is a motion to adjourn. >> so moved. >> second. >> all in fair. >> aye. >> aye. >> aye. >> thank you, every one. >> thank you for staying so late.

>> thanks sfgovtv.

county of san francisco government audit and oversight committee meeting this morning at 10:00 am., thursday, march 21, 2024. >> board of supervisors i'm supervisor preston and joined by commissioner chan and supervisor peskin thank you, sfgovtv for staffing that meeting