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 organizations and what the hope is that it will help the

non-profit community to be able to be competitive in the market place. they will be purchased by the managed care organizations and the hospital and the group and now everyone is pdsing that the only way that they can have an effective cost healthcare system, is to integrate

>> there needs to be much more funding for the ages and the workers and i know that a lot of care givers live in our district, especially in the richmond and a lot of the patients or the people that they serve are in our districts too, but what more supports do you need from the city? >> well, what is going to happen, i think, is you know, say, that the ihs program and we don't know what is going to happen, but the expectation is that, in many changes are happening. and if you look at the... and if you look at the federal, and new regulars in terms of over time for our ihs workers, and what the government proposals are, and not to pay over time.

the >> we are fortunate in the san francisco, that the dos has funded a very large, training, yet, program for our ihs workers, we are trying to stay ahead of the curve and we do know and we believe that ihf and ann was talking about how it has to change how it operate and we want to be the people who is to come up with those ideas. >> and i also just wanted to ask you, i know that some labor and community groups here had supported, a federal effort called caring across generations, to increase the

number of care givers especially from low income communities and i am wondering does that compete with or is it complimentary to what the ihs system does here. and i don't know that that program specifically, but, i would imagine that it is complimentary. i mean, the need to expand the direct care workforce is a huge challenge. and nationwide. and in california, and in the san francisco. we do not have the cohort, that we used to have, and in the nation. and then in the number of you know females between the age of 24 and 45, has decreased in the nation, and that has been the group that has gone into the home care, workforce, looking now, at we have helped that

population to become more nraout in english and it is a challenge and we don't have the funds and at this point, san francisco to work with that in terms of, vocational, and esl programs and but these are going to be the critical pieces in the long term is to have that workforce available, and so it is a big issue nationwide. >> and i just wanted to thank you for constantly advocating for the strongest possible program here for the ihs system and it is such a economic benefit when people can stay in their homes longer and not be institutionalized and i strongly agree with you that the workers deserve a living wage and to be treated as professionals. and we are hoping that the mayor's minimum wage proposal will go through and we hope that it will be applied, and

that the ihs workers and that they won't carve out that workforce. it is a bunch of money and we understand that. but, i mean that these workers are so under paid and their jobs are so tough. so, i mean we are really, optimistic, at this point. and it is to get the additional funds in. so thank you very much, supervisors. >> good morning, supervisors my name is donna and i am the executive director of the ihs public authority and i wanted to pick up on the themes that i have heard and emphasize that the changes that we are talking about are not just systems, and it is really a mentality and an approach, and i think one of the concerns of consumers is ihss is very much a social services program. and even though there are

healthcare die mentions, not only can they not make a meal or do the laundry or so on and which does not involve a medical issue but it is an important program that can delay, or prevent hospitalization or institutionalization to get care, and managed care organizations themselves, recognize that they don't fully understand the provision of social services. and so i think that that is part of the reason that the group here in san francisco has been so important is because it is broad based and trying to convey how it could change the notions of what medical care is, and that the low level services really do keep the people out of institutional

care and settings and then picking up on ihss and that a lot of people in california have not understood how it is in the united states. and the issues around the wages, and no one would argue, with these workers being paid what they deserve for the hard work. there is a cut in services and i would poind out that, that 60, or about 60 percent of the program here, in san francisco, is family members state wide they say that it is 70/72 and i am mentioning that to say that there are unique aspects that are not like other employment areas. and if we don't for sure, press for funding, of the wages

increases that are being entertained, it is a cut on services and also a cut on the worker's wages but it is a complex issue and a complex dynamic and if our society does not step forward to fund the decent kind of home care, and assistance to help the people move into the community and go to school and work and not just be taken care of in their homes, we will literally be falling behind on what our society i think should be provided in this area. >> thank you. >> considering the data and do you have any comments on that?

>> if i misspoke, sorry, it is the provider of it and we get a lot of information since we are following them after the discharge, we have that and what we speak about earlier is that our department does not necessarily know for the vast majority of people who are living in our community, how many of those people say need care or need nursing home because we would not track them and we would track them if it is a public guardian client and we would know it in the program, but, it would have to be within the purview of the data that we are collecting and so yes, we do have that and i think that supervisors you asked for some information that i think that the specific to the guardians office of how many of those people get placed and we can provide you with that. >> that is great. >> and the key, living fund is there to support the people living in our community and not to live in other communiies

>> if they have to go out of county and is there a strategy where you start to think about creating something here so that the people stay locally? >> i think that the biggest issue is that like, and no different than that, the housing issue of people being kind of priced out of the market as i was saying, a lot of the board and care of the facilities were houses, where maybe, five or six residents lived there. and well, the people sold those homes, because the market here is what it is. and they moved to the other places and so to find a board care, that in this, in our community, any more, is benson would say, is pretty, unlikely, and so the people that are going to freemont and in places beyond that. and in terms of smith, or skilled nursing facilities,