the long term care coordinating council is working on and they do, they all really fit together. yeah. >> so, with you, we get to the recommendations we are going to see that as much of what you were just talking about is right in these recommendations. so the first one is really better access to long term care services and supports. and i think that this is one that is especially important to me because this very much highlighted dos's role of moving into the coordinated initiative, dos has for some years now attempted to have a central door for things like ihss and adult protective services and things like that. and we are also the central door for the transitional care program hospital, to home. but, at the same time, that we want a strong central door, we really know that the way people

live in the neighborhoods and they are associated with their neighborhood, organizations. and we want that model to obviously remain in place, but that is how people gain access. and so what we are looking to do is to strengthen that no wrong door model at the same time that we have a central door that people can count on and also when you look at san francisco and all of our diversity and how the community organizations have come together, or not, come together, over the years, but focused on populations of people, and there is a lot of strength in that, and but, over i think that the last and especially, i would say probably the last ten years, there is a lot more of those organizations that come together, so, and i think that this particular recommendation is important to me, because this is really, the community and people in the work group coming together and saying, yes, that should take a leadership role in this area. and it should strengthen its central door and that moves us right into the second recommendation, which is as you

mentioned, to improve access to information, and so again, we took the conversation to the community, and we need to continue to do that and we need to hear from people and what is not working and we need to advertise and we need to let people know, so that they are not i keep forgetting to do that. so that they are not confused about what is going on, because i think, and i don't know, if she mentioned this before, but managed care is going to be one of those situations where if you don't or if you are not pro-active about signing up, you will be signed up. so, the more information that people have, the better people are educated about what their options are the better for them in the end. okay, i will do it. >> the third recommendation is to enhance care coordination and link data systems and i think that this is especially important and sometimes that the people say that well, why did you all put this plan together when it is not going to happen until probably 2016. but, what we know from the

eight pilot county ss that they are just starting now but it was two years ago when it was announced who was going to be in and so those counties have been taking this time to put their plan together so that they could move forward on the implementation date. and so this is an opportunity and it has been an opportunity for us to do the same thing and excuse me, you know as well as i do that our across our departments were not very well linked and so this gives us an opportunity to really look into that. the fourth recommendation is about looking at best practices. and certainly across the country, in the world, but we have some best practices here at home as well and i mentioned two of them earlier and the deversion and community and integration program and as well as the community living fund and you will hear about that later but both of those programs were designed and local, and the programs, funded locally, and designed locally, and they are really begin to help the people who are

institutionalized to come back into the community and the people who are at home stay at home safely. the 5th recommendation, and one that you will see later on, really takes into account some work that the council has done around alzheimer's and dementia and one of the other strategic plans that has come out of the council is the ten-year dementia, san francisco plan. and i think that it was enormously important that the council and this design committee was looking back over the other things that have been recommended and bringing forward the things that still are evident in our community now and so you will see when you read the document that there is a substantial information in there about care givers and supporting the care givers as well as looking at demen that and the difficulty that is or arises from the

people that have that disease, and the next one is training for the care givers and pretty self-explanatory. >> but i think that for those of us who work within the system of it, we know that there are things that we could improve and maybe more flexibility and more options for consume and hers so on and so again, when we are able to, at how we or how ihss becomes better than it is and ihss is one of those four programs that will be rolled into managed care. and the next slide. >> could i ask you a quick question and my apologies. >> could you explain a little bit of what you mean by going back to on the recommendations, number four, diversion and community integration, what

does that mean? community integration? >> so something where, thank you, we are especially proud of. as you know, laguna was actually looking at an old newspaper item the other day and it was from the 50s and at that time, it had 1700 beds and well, i guess up until about ten years ago, it had 1,000 beds, right? and now we are done to 760, whatever it is. part of the work around, you know, down sizing that facility was a recognition that you can't just take someone who has been in an institution and bring them back into the community. we tried that. it worked but had a lot of limitations on it so what through a lot of community work and city work what developed was this community integration program which is when someone we will take laguna honda and so someone is in there and it

is determined that they want to live in the community and determined with the right services of course they can do that and there is a team of people who have decision making capacity so someone is there from the world of housing. someone or a physician is there. social workers. whoever has authority over the goods and services that can help that person be successful in the community is part of a team that helps the transition into the community. and i think that we are the only community that has a program like this. and it is not just starts planning for any of you that ever been in the hospital and just planning in the nursing home is much like it is in a hospital and it is really to move you from here to here and the folks at laguna do a great job of that but this is a much more indepth how do you take someone who is in an institution for 15 years and help them be successful. >> when you talk about integration, does that mean that they stay in the neighborhood and in the area and in the city?

>> so as part of that work, the consumer is consulted on what community they would like to live in and what kind of housing arrangements and west bay housing is the housing provider and they work to find the appropriate housing so that could be any place in our community. >> yes, i know that one question that was asked, you know, are there ever out of county placements that happen? there are out of... when we have a shortage of beds in san francisco in terms of board and care beds, we don't have many of those, so most of our board and care people are going to end up in another county and because that is where those facilities exist. most people that have the small, mom and pop houses sold, because you know the value here is so great. and the people in that are part of this program though, that are going to primarily be here in the city and we might have a few that have gone to small group homes say in south san francisco because if they have

developmental disabilities, but primarily people are here because the service package is going to be here. >> do you keep track of the out of county placements? >> yes. in our office we do, if we are the guardian for that person, yes. we visit them and keep track and all of that. it would depend on what program. now, i mean, that a family could be looking for a nursing home bed, and simply place someone out of county, because they can't find one and we would not know about that. >> i know that i would like to see that information, maybe if we could share that with my office at some point that would be great, thank you. >> supervisor mar? >> i was going to add that we did a study of seniors and people with disabilities and housing needs in the city and i know that that is a huge need as we build more affordable housing but especially for seniors and even in sros and other places who are the most

vulnerable population which seems to be a huge demographic of the senior population that is a critical need of the city and i know that is not your responsibility but i know that as we focus off building the affordable housing that is a key responsibility of the supervisors and the mayor and i wanted to thank them for alerting me on what they have in our neighborhood and another part of our study with the budget analyst was looking at aging in place and the village model from other city and we were trying to do the best with the budget process to support the neighborhood-based programs like next sf in north beach china town and in the neighborhood centers and then non-neighborhood based ones and the different models to support and help the people stay in their homes as long as possible to remain the valuable members of the community as well. >> that is correct. all of those are excellent

programs that really serve our really diverse community, yes. >> if you looked in at the next slide it just gives you an idea of what were the kinds of programs that we believe. and that the council and this design committee and the work groups believe are crucial long term care services and supports and it is a variety of things and it is pretty ininclusive and i would say. and then we go on to the next recommendations, you will see number nine talks about alzheimer's and demen dementia and the resources that they will need regarding that quality assurance and going back to the community living fund and the deversion integration and both of those have quality assurance components to them and we want to be sure that the consumers are well served in the world of managed care and we want to have number eleven talk about

new opportunities for providers to develop, integrated business models and you are going to be hearing more about this from sandy. >> that the work groups and the design committee were far thinking. and we know that if we are not going to have enough money if we don't have enough know to do all that needs to be done in the disabled adult population in our city. and at the same time we need to sees the opportunities i was looking for nine community to do business developments and we were one of those nine

communities and many of the people in this room were part of that initiative and so you know that is really looking at how do we take products that are currently supported by the government dollars but if we want to broaden the population that is served, how do we the health department. what is i am mri menable now and then start doing that over these next couple of years so that we are ready when it comes

to san francisco, and now, we know that there is always this possibility that the managed care will not come here. but we also believe that a lot of the recommendations are or it is good practice for us to do them any way. so, nothing is lost by implementing this, whether it arises or not, eileen anything that else that you want to highlight. and i think that sandy, do you want to take it from there. >> good morning, supervisors and i want to thank you for having this hearing on this plan. and i am sandy mory and i am a member of the long term care coordinating council and i am also the former co-chair of this long term care coordinating council. and as ann and eileen very well explained to you the whole process in the whole plan itself in the recommendations, and you know, in order to implement this, we wanted to

really look at two priorities that we felt were important going into this next couple of budget years. and so, ann is working very closely with the mayor's budget people to look at these two possibilities of requests for support. one is the community living fund, which is a very important aspect of our plan. we presently have a base bull budget of about 3 million that we are asking for an additional 2 million to this community living fund for the next budget cycle. and this fund is crucial, because this is the fund where people in the community get direct benefit from these funds. and so that a person for example living in their own apartment or living in their own home or living in an sro will be assessed as to what the needs are to keep them in their

living situation. and not have to go to an institution. and so, whether it be grab bars or access to different things to adjust their housing or adjust their apartments so that they can live at home. these are the things that the money will be spent on. and so this very practical kind of thing, and this is not things that are way a pie in the sky and the other aspect and the other priority that we felt was important. >> could i ask, yes. >> how does the community living fund work differ from neighborhood-based aging and place type of programs? >> actually supervisor, it is really, all of those neighborhood serving organizations and the department that the assessment of the individual person whether it be a younger disabled or a senior is assessed by the department of

aging what they call screening the first come into the department. and then those and that staff person then works together with the different neighborhood groups in the communities and in the neighborhoods to see first of all where they live and if this particular organization could help that person stay in their home then that person will get services through that agency. and so this is the whole thing of this is very important to collaborate as part of the integration, and when we talk about the integration, we are talking actually practical integration, you know, we don't, we are really, you know the people talk about integration you know, kind of in a philosophical way and we have to do this and we can't talk about it and so in the council has been working on this for a long time and i mean that we believed in this concept for over the last 15 years and so for those of us

who have started the community we have it from all of the necessary departments which is wonderful because those folks are at the table along with thougher consumers and your advocate and your neighborhood based direct service agencies. and so, that is why we feel that this council, we have been working so long together, and we have known each other for so long that this is something that this is part of our natural thinking and i think that the city to be doing this is a huge step because we have got the bureaucracy to deal with and you have all of the systems and the silos that you go to the break down and it is not easy but we are... >> continue to work on this. >> so my understanding is that

aging and placement programs are more membership based based on the village model and it is more middle income and seniors and people with disabilities and access some level of social support and other types of support but the community living campaign serves people across the different economic backgrounds and especially low income people and i know that i worked with them on technology improvements and this is a specific budget suggestion for expanding more the aging and place type and keeping the people in their homes as long as possible. and i know that there are other technology, projects and other things that they are working on as well, but this seems so important for a low income population to have access to more aging and place types of services that more of the middle income existing neighborhood based ones serve is that a right assumption for me? >> yes, absolutely, supervisor mar, this program includes

diverse economic backgrounds. and it does not, and i think one of the issues of the various models that you talked about there are the various models and i think that san francisco, because we do have so many different models, and then, this particular plan is trying to integrate all of that. and you know, it is going to, and it is going to be difficult, i mean not an easy thing to do and we have to change people's thinking, too. and part of the thing, and you know, this board of supervisors had created the lgbt task force for senior and they are doing their work and we want to work with them and make sure that all of their issues and concerns are integrated into this whole plan and it is very important that everybody talks to each other. and you know, we could not continue to just have the different groupings of people just talking with each other and with itself. you know, we have got to go across the line and talk with each other. and so, the other part that i wanted to mention, in terms of the priority, for asking for

support in terms of the budget, is the you know, the creation of mso. and the management services organization, and this is something that is a new concept. for most community based organizations. and we have to think differently and we have to think more like a business. and so, your average non-profit, is not necessarily think this way and so, we have an opportunity to have some trainings session and get technical assistance to understand what an mso is, how it would apply to the different organizations here in san francisco. and the different cvo and the different non-profit groups and how they can be part of this whole development of an mso. so, if we are able to have about a couple of 100, or 200,000 dollars to hire a consultant to provide that support and so it would be helpful and so we felt that those two priorities are the most important going into this budget cycle.

>> thank you. >> any other questions? >> are you... >> so, with that supervisors, i think that we have the members of the public who are also members of the council who may want to stay a few words thank you. >> i have one card here from benson madel? >> good morning, supervisors. i am the program director three minutes. i am the program director of the san francisco long term budget program and i think that we have to do some crisis and emergency planning and support the whole plan as well as community living fund. community living fund, allows individuals at 133 percent of federal poverty, income level, to participate in community living fund dollars. the medicaid expansion and part

of aca, which allowed for the expansion of medicaid, up to 138 percent, stopped at the age of 64, when individuals are no longer eligible for medical or medicaid, so the community living fund is an important stop to allow the individuals to live not only in their homes but participate in neighborhood and community services as well. and i gave a hand out based on why i think that there is a crisis. but we don't have enough nursing home beds, they are gone. most of the nursing home beds are now specialized in short term rehabilitation including the jewish home and honda and the push is to get the people out, even the individuals who have been there for more than 4 or 5 years. and plus it may allow for the certain placements but not everyone, that everyone are the people who are in your respectful districts or neighborhoods who cannot participate in the department

of public health system centered around laguna honda, there are the nursing homes there and they get discharged from the rehab and they cannot participate in the dph model that centers around getting people out of laguna honda and that is why the community living fund is essential and so i as a member of the council, urge that we support this only alternative, because, it is not just giving people the option of not going to nursing homes, there aren't any. in addition to that, there are not any low income or affordable care homes in the city as well, and so the squeeze is on, and we have no choice, thank you. >> i was going to ask him, could you mention what you do as the ombuds person? >> we are authorized by both the state and federal law with the rather skimp y budget to identify the problems or the complaints made by and behalf of residents and long term care facilities complaints about

health, safety, welfare or rights and we have jurisdiction in the nursing homes and all of them in the city and all of the residential care homes and under the state of california, whereas the abuse of investigator and if there is someone abused in a long term care facility and recently, i would say for the last ten years, most of our case work has to do with discharge planning and the people being pushed out and returned to the community with inadequate service and inadequate discharge planning. we have cases like this every day of our workweek. it is astounding. >> and i just google the fund which is different from the campaign, and i am looking at it and it really reaching low income up to 300 percent of the federal. and it is just... and yeah, larger but don't forget that the people under the age of 65 do not get the medicate expansion benefit from aca or obama care and this is

essential that we get capped and allow for the services to be provided for people at 33 percent thanks for that correction and it is absolutely essential for the family members and individuals, seniors living alone, and the individual seniors being pushed out of these rehab centers with, you know, reasonable, hope for failure, and rehospitalization, and it is a really big deal, going on here in the city, and i think that we need to support, at least this important augmentation to the safety net, thank you. >> thank you for your comments, are there any other public comments at this point? >> good morning, supervisors, i am patrick, and i am here on my own time, and one of the city's few remaining skilled nursing advocates. i notice from the presentation, that das, and it was talking about a full range of

institutional services. and i found it really interesting that supervisor campos asked what the program is. and i was working at laguna honda when that program was implemented and it is gratifying to her her say that she is especially proud of that program, but then, when campos drilled down and asked, how many of the discharges are out of county placements? i was shocked and the sentence says that her organization and the long term care coordinating council would have no way of knowing how many invitations are being sent out of county, that is absolutely false, the program, is or relies on the software program developed by rdt, or rtz, associates that has always tracked discharges

from laguna honda, not only by the type of facility, that they are discharged to, but the location to report how much discharges there are, and the health commission, finally admitted in late, 2013, it would start reporting out of county discharges and in fact, 12 percent of the second quarter it is not to report these to have a historical context in which to compare it to. i strongly urge this committee. to require dph and miss hinton

to have the data there and it is analyzed and they can create the cross quirries, and i can access the access quirry and summarize the number of discharges per they can do it as well. and before you make any policy decisions, you owe it to the old fund, or elderly and over 65. to find out, what has happened in the passed seven years and just how many people have been dumped out of county and because as he says, there are no skilled nursing facilities, between eureka bakersfield because there is a lot of elderly people that cannot live in the community and should not

be dumped out of county i am the director of the services and we are the contract mode, of the ihs program here in san francisco, and we basically served the most challenging consumers and we all want the programs, and that was talked about that, and we will be rolled under the managed care essentially. and this is a very exciting time, and in terms of the healthcare field and it is a challenging time and you know, all of us, i think on the and not to change the program and not to be proactive and to do that, it is going back into the 200,000 that we need in terms of managed service or