care center that draws down a very small share of its expenditures in revenue, and we will put together a process over the next year to look at whether we can draw down additional revenues at the behavioral health center. we have budgeted it into the second year as us and a commitment for us to work on and whether we can draw more money down at that facility. on the expenditure side, we have a list that includes items that are not on here, but we have categorized the larger value initiatives. i will touch on them briefly. feel free to ask questions. first one, we currently have outpatient rehab services of san francisco general hospital, and in the held at home program. we have an initiative to combine

those programs so they can coordinate and operate more efficiently and work together, so that is what that initiative represents. the second, which are rucker see it touched upon. -- barbara garcia touched upon. supervisor chu: you are not closing down any locations? >> it is a reduction of efficiency, and it could have an impact on the length of time people are waiting to get into rehab. the second one is a larger piece and one of the things we spend a lot of times with -- a lot of

time talking to shareholders about, a reduction to the unmatched general fund contracts. the challenge for us is a we are increasingly in a place where our decisions must be driven by the federal dollars that we are able to draw down our system of care. as we have looked at what we have a available -- what we have available to take on the expenditure side and the budget, it is pretty harsh reality that most of our services are drawing down between 2-1 match dollars up to 20-1 match dollars, and the vast majority are very

highly leveraged with state and federal dollars. the conversations are based on the planning process. it is to target reductions to services that are not drawing down those matching dollars, and that is what this initiative represents. supervisor campos. : thank you. i appreciate the presentation. and i understand your reasoning, and to appoint it makes sense, but there are populations that will never get any kind of federal money to address their needs, but you want to make sure they are protected come in many times

these are some of the most vulnerable populations. you have the undocumented community where there will not be funding available for the community, but that is not to say the kinds of programs that are serving them should be on the chopping block. i am wondering what specifically is we're talking about when we're talking about the approach, and what impact it will have on these types of services. >> it is a very good point, supervisor, and something we've spent a lot of time thinking through. i do not think there is an easy answer to it. the reality is the vast majority of the programs in some ways are torque -- are touching the very bomb rubble populations. like i said, it is not something we are happy about doing, but the choice of cutting a program

is drawing down federal dollars, and one that is not, it seems of both of those are touching the very vulnerable populations. it is not an easy decision to make, but we thought that was the most responsible thing to do. your point is very well taken. supervisor campos: i appreciate that, and i hope there is more discussion on that, because there are some groups that will never get the attention they need from the government. i do not know the extent to which the transgendered community gets much support from the federal government, but the fact that they cannot come it does not mean we should go ahead and cut those services. it means they need of the city to step in and help out. i think it could go the other way. i think we need to be mindful of

that. i appreciate their predicament, but i believe it is not as simple as saying this gets federal funding, that way it is ok. >> thank you. i asupervisor campos: i am also hoping there are some tricks you could bring to avoid cuts. i am still hoping for that. [laughter] >> high pressure. in terms of what is behind the number you see on the page in front of us, again, that is a reduction to unmatched in general fund for programs provided in an outpatient environment then ends up being up 4% reduction to those services to the overall funding for the services, for some programs that are purely

unmatched general fund, and that is their only funding source. caught in some cases it is significantly higher than that. there is one of adjustment that was made at the hall commission in response to the commissioner feedback -- at the health commission in response to the commissioner feedback. the smaller programs, many of which are unique services where there is not fall back provider for those services, we took those reductions off the list before submitting the budget. supervisor chu: this is true for the non-matched general fund? >> that is correct. supervisor chu: it is an effort to keep smaller organizations

that rely heavily on funding in that way? is that something that came from the task force or was it from your commissioners? >> that was a combination of what we heard during the working group progress, and also direct feedback from the public. we had a little bit of good revenue news, so when we made an adjustment, we took that into account and made an adjustment of that initiative. on the hiv housing subsidy program, this is a program that was cut. it is now a general-funded program. it is a little over $3 million program, so this would represent a 5% reduction to subsidies. there are a couple of reasons behind it, but primarily it has

to do with the general fund, and that is the same policy discussion. in addition, there are other housing support programs that do not have abs deep of a level of subsidy. we took this into consideration. this would have to be the negotiated out as implemented, but it would be a combination of hope fully implemented as new individuals come into the system, that there could be some impact on existing clients. i cannot imagine anyone would lose housing as a result of that reduction. the next item is on residential treatment. there are two components. as you know, as part of the realignment state initiative, there is funding initiated with that that is being used in the public safety system for parolees that are being returned

to county jurisdiction, but there is also funding in the program for treatment of the individuals. that population is in many respects the population that is in contact with our services when they are not in the criminal justice system. part of this initiative is we have been working with the adult probation department and agency is overseeing that funding, and they are going to purchase some of the capacity of the residential treatment to redirect to the realignment population. that will be using the state funding, other than general funds for those. another piece of this is we would be converting 50 beds that are residential beds into support of housing. when you look at the costs associated with those

approaches of the policy direction of the city, on of -- on the cost of the residential unit to the city, at the cost is about $2,500 per month. the support of housing in is 900-1600 a month. it is half or less of the cost. a lot of the evidence shows you can have similar outcomes with housing. it is more permanent and stable. the initiative would be to transition residential treatment beds into housing superviso. supervisor chu: in terms of outcome, they tend to be similar? >> i defer to barbara f. to go into details. -- barbara to go ointinto detai.

>> there is usually about six months day. then they leave. then they get back to the streets? what we found is a lot of people upcoming for the residential programs over and over again. we find housing is a stable in rent -- environment. in the baking get into outpatient services that are more affordable. walden has a large program and los angeles. there are facing problems -- problems for funding. it next week we meet with office of drug policy, because there is a concern that within the health care reform there is no obligation for departments like us, like i just discussed, the

obligation to run the things we have for medical access. there is nothing like that for medical programming. there could be a scenario and the future that we could lose our match for residential programs. that future is unknown. we're looking at changing some of their services and treasure island. we are working with them on that. i wanted to address the issue of the undocumented for a moment, because it is a challenging issue, but to note most of the program serve the undocumented. so if we were not to take the non-matched general fund, we will be here with and $8 million cut. most of the dollars are not

attached for the undocumented. we could give you a scenario what that might look like for that amount of money, but if we brought in any of the other cuts, it would probably be doubled the amount of people we impacted with it. supervisor kim: i just have more questions. by the way, i completely support this. we had discussions before that. oftentimes we had clients or patients but stayed longer at the very expensive hospital beds because they do not have anywhere to go come and we do not feel comfortable throwing out folks on to the street, especially because they still have needs. so in this partnership, are these in new units? >> they have units at treasure island that right now they are using for substance abuse services. they will transition the client

from the programs once they complete the program, because we did not kick people out in the middle of the treatment cycle. we're still working on this, because we have months to plan this out. then what we will do is at the staff necessary for the supportive services. also, they also have a primary care component to them. they will be able to provide medical services on site to support of housing as well. we will incorporate some of the cost to that as well. >> the units are currently used by clients better in the substance abuse program. i understand he would not kick out anyone in the program right now, but i assume they have a waiting list. >> we have waiting lists throughout the system at any given time. to say this would not impact the community, i think there will be some capacity issues.

when you look at the number of the people recycling through the programs over and over again because of the lack of housing, we think we can stop that by moving people more into supportive housing. there will be an impact in the number of people that can impact residential care beds. supervisor kim: i just want to be careful if what i am understanding is we are eventually replacing patients that are in substance abuse programs currently listed these other high-need patients verses expanding it the resources. >> we are not in an expansive mode in this area right now. we're looking at areas of how we can stabilize the community overall. we totally believe in residential care programs, but we're trying to find initiatives that could solve a couple of problems at once.

we also have an initiative to bring the substance abuse programs into the general mental-health program. we tried to create it -- be creative in the way we were doing it. sup>> just to continue on, and we are near the end of the presentation. direct access to housing clients. this has been an initiative that has come up in the past, but essentially what the proposal is that there are two facilities that are leased by the department with the expiring leases coming up in the next fiscal year. those are two hotels, which are

the camelot hotels. they have leases expiring, and as part of the normal pipeline of supportive housing, over the coming year we anticipate having 200 + units of supportive housing coming on line. i am looking for the figure, but it did not have it at my bigger tips. the idea would be as the leases expire, that we could take the clients in the leased facilities and move them into the new units coming on line and would save on the lease cost and move the clients into facilities that are newer and higher-quality that would require people to move, which is potentially the negative aspect of this, but overall a still -- overall still

a net increase to the number of units available in getting people into our own facilities. lastly on the list is a convergence of the program at san francisco general, which is currently a community treatment facility to a level 14 group home. what this essentially means is it is changing the legal standing of the program so that it has a lower staffing threshold and other changes, but currently the program we would change is very unique. very few cities, only us and l.a. have the facilities that are operating at this height of a level of care that would be moving down to create staffing flexibility it would not be a

net loss of capacity in the system, but it would be differently regulated so we can say funding by making that change. we would work on implementation of that over the course of the first year. so that is all we have. after that, we just have the remaining ryan white slides. i am happy to answer any questions you have or take comments. supervisor chu: thank you very much, mr. wagner. just a question for you. i know there are a number of stakeholder meetings that will be occurring. the budget office is having a number of meetings as well. today's purpose of the meeting committed addition to the ryan white funds -- in addition to the ryan white funds come it is the board would have an

opportunity to provide feedback. what is the best way to do that? what are your thoughts on providing feedback as to go forward? >> i have already had several meetings with some of you, and we will continue to do that. we will set goes up again. i am sure after the presentations you may have questions we could answer. >supervisor campos: thank you. a question on the ryan white funding, we note the amount of a cut that the federal government has made, but one of the things i am wondering, do we have a sense of what the fiscal impact would be if the funding is not restored? in other words, what would be the impact if for some reason

this funding was not restored and these services were not being provided to these patients, what is the impact on the system? i imagine if you will have an increase cost anyway. >> we know testing is an important part of the prevention area. we know that needle exchange is an important part of our prevention. clearly we could have an increase of hepatitis c. -- impact on hepatitis c. we know if people are not regularly taking medications. in the department we would have a pretty difficult time with our primary care system that right now provides a lot of the care to clients.

this is a chronic disease that is managed well. i think the mission neighborhood medical director has said it best in terms of the multi disciplined approach we have to have. it is an important process, but i want to let you know we see the writing on the wall in terms of how health care reform will be the future for ryan white services, and i am working closely with providers to see what that means. that is why they are giving us the other dollars in getting ready for the advancement of 30,000 people throughout the city to will have more medical. that is something we're trying to prepare for in the expansion of the primary care center. just as we are stepping up, we have a step backwards. and we do know there will be an impact. community providers would be greatly impacted, because some

are dependent on them for this fund. >supervisor campos: i appreciate that. there are costs involved for not acting also. i think it is important to keep that in mind, and that long-term the inaction could be a lot more expensive, and maybe even short-term the impact can be pretty significant as well. >> we have a great deal of experience and was services in hiv. one of the initiatives we will take on its substance abuse and mental health. we are going to go back to those services to make sure, as this happens, because we will see a reduction in the future, it that we have a more integrated approach to our clients, so you also get hiv prevention activities as well. we're looking at that within the

general fund application we have today. supervisor chu: given that, why don't we open up public comment. i would like to now open it up. i would like to thank everyone who came and sat patiently through the presentations. i am going to call the names fromm cards. if you a dirty spoken, please ignore that. every individual will have two minutes. sara avilas, alex asmara, lee jewel, charles suro, felicia houston. come on up.

>> thank you. good afternoon, supervisors. i of the medical peer advocate at the black hills foundation. thank you, supervisor wiener. i ever resident of district 8. -- i am a resident of district 8. we work with hiv-positive african americans with disabling hiv to our entire risk of transmitting hiv to others. our work is to provide mental health and substance abuse counseling and a wide variety of support systems to ensure they say engaged. the new policy is what we do. being and medical care reduces the hiv-positive tittity of a vl

load. a 20% cut to the black hills center of excellence would have a significant negative impact on the capacity of clients. we will lose between 25-35 hours of staff time per week and need to stop or reduce services to approximately 20 or more of our clients. 20 may not sound like a large number, but let me describe one client who represents many others just like him. this is a case study. jerome is a 32-year-old hiv -- a black man who just tested positive for hiv. he rarely uses condoms. he distrusts doctors and has avoided contact with the health- care system. he talked to me months ago and agreed to a test. he tested positive. i connected him with medical

care as infants as the general hospital, and now i help him get to his medical appointments. we combine motivational interview techniques and counseling and substance-abuse counseling to help him in disclosing to his wife his status and to get the partners tested. supervisor chu: thank you. mix speaker, please. -- next speaker, please. >> my name is michael scott jarvis. i live at care facility for people with aids. budget cuts will see -- will impact the level of services needed. i know about my treatment because they used to be a volunteer their. medical staff and support has made things easier for me to recover more quickly than the

doctors and dissipated after my recent surgery. my knowledge of one care in physical distressing live beyond normal nursing care. if i were not there, i would only have option of going through an sro. as a person with aids, i ask you to please put the money in the budget to support this during the time of ryan white funding cuts. supervisor chu: thank you. >> hi. my name is michael smith. i am the executive director of passionate care. we are a 24 hour residential care facility.