reduce the integration and we want to work with the city departments. and the other reason why i wanted to highlight this was because in san francisco we are getting older in san francisco, and the percentage of the population of people that are seniors have grown, and will continue to grow. so, it is funny these issues were ahead of the curve some what on this. because this is going to come and is coming fast. and then, the other reason is, i am getting to the age where i have to worry about this stuff too, so this is all personal for me. so today, presenting will be ann hilton from the department of aging and adult services who is the director there, elen from the life works and long term care coordinating council.

and maury, long term coordinating council member, and so to start it off we are going to have tracy famp arona. to kick this off, okay? >> thank you, supervisor, yee for that, great introduction. >> thank you, supervisors for having this hearing today. i am one of the co-chairs of the long term coordinating council and i have a very long name and so no one ever gets it right. >> on behalf of the council i want to thank you for holding this meeting. it is an advisory body to the mayor of 40 minutes and the city departments and community agencies and the community and our goal really is to make recommendations about the long term care, delivery system, in san francisco. and make recommendations for improvement and that is kind of where the long term integration plan came out of. and so we are very pleased to be able to have the opportunity today to present you with the

long term care strategic integration plan and i thank you for that opportunity and i am going to turn it over to ann and eileen. >> and good morning, i just wanted to take a moment before we get into the depths of the plan to talk a little bit about the why. and so just to, i think, think about san francisco, and the community and it is really, i think very gratifying to hear supervisor for you to talk about the process, because i think that is one of the things that makes the council pretty unique. the council's work really is again, as tracy said, we are made up of 40 folks, with about 6 departments being part of the over all council and in san francisco, i think that what we know is that one of of the things that older adults and younger adults really have in

common is this you know really wanting to be at home. and in our world we call that living in the least restrictive environment but what it boils down to as most of us want to cage in our homes and have that, what you know, the flexibility and the control of our environment and that is where we have it most. and so what we have that as an understanding of the population that lives here and really that is the truth for people whether they are in south dakota or knee or wherever they are and we hold that in common, san francisco has really been unique in the sense that it is formed much of its public policy around what its citizens want in this area, and so what we have seen over, i think that probably over the last 20 years is any number of initiatives where, the council and others, have come together to say, how do we move what people want forward. and so, we have things like the community living fund and we

have the deversion and the community integration program. and we have a number of things where we look at people who are in institutions and say, if you can't live in the community, let's help you come back into the community and if you are living at home, let's help you be successful there as possible. so, we have both an understanding and our public policy fits with that. and because of the affordable care act, what the president has put into place, that became this new opportunity for us to move even father into the direction that we have been going as i have said for 20 years any way. so eileen is going to walk you through our process and then i will come back and talk a little bit about the recommendations, and give some time for questions. i think that we will turn it over to you.

>> thank you, my name is eileen and in addition with being with lock ways and i am a council member and also a co-chair for the long term integration, design along with tangerine brinham from the department of health and if i could ask for the slides to be on the screen, i am going to talk about the long term integration and some of the changes that are happening at the federal and state level that are fueling this effort and i think that it certainly has been san francisco's history and as she mentioned really to look at the needs of the community and build very innovative systems in this process of the design group, really gave us an opportunity to look at what we have that have been a strength of our system and what are some opportunities that we needed to prepare for with the transitions that are coming in the future with the changes of the federal and the state level. and what is long term care integration? it is really the integration of primary medical care and acute

care services with long term services and support including both community based home and community based services and institutional services. and the target population is older and older adults and younger adults with disabilities. the glofrn's coordinated care initiative was introduced in january of 2012, but it really was fueled by the affordable care act being passed in 2010, and as we know, the affordable care act included a number of provisions to cover the uninsured but it also included projects that would initiatives that would better coordinate care, and also, achieve the cost savings, for the different public payer's programs. and the purpose of the cci, this is to improve the care delivery and to improve the health out comes for medical and to better coordinate care

by enrolling the individuals in managed care programs and also the goal was to achieve cost savings, the coordinated care initiative has two parts, one part is called cal mediconnect which is targeted for medical beneficiaries who are eligible for medicare, or also an initiative to put the long term services and supports in managed care, which is called managed long term services and supports. what is cal medi connect? as i mentioned cal, medi connect is really a partnership between the federal and the state government to coordinate the care for medicare and medical beneficiaries who are elible for both programs. and the full range of health services and long term services will be included in a single benefit package and managed by the benefit care programs and one of the reasons that it was created in the federal and

state level is because medicare and medical and medicaid at the federal level have a lot of financial misalignments that result in poor quality care for consumers and misalignments that make institutional care, being reimbursed sometimes when the home based services are not reimbursed so not only will it result in poor quality but also higher cost so this program is really designed to better coordinate care for these very many of whom are very frail and eligible and also includes a broad range of individuals, they will be cap taited payments that will provide, two managed care plans to fund these services. cal medi connect is a voluntary program and so the people that are medicare eligible, can choose to keep their medicare benefits the same and not enroll in cal medi connect and it is a three year pilot demonstration, and however, the second part of the coordinated care initiative is what is being called managed long term

services and supports. and for this, all medical beneficiaries in the future will reach their long term services in supports through managed care and we talk about the long term services and supports we are including the ones that we see listed are the ones that at a minimum are going to be delivered through the managed care programs and in-home services and the multiservices program and the community based services program which is the new name for adult and healthcare which is already part of the managed care system and then, skilled nursing, care, funded by medical. so with that program, that is actually will be required for beneficiaries to choose. call medi connect is authorized to begin in eight counties and you can see the counties here listed. the counties can begin for sooner than april of 2014, but each county in the managed care plans that will be options in

those counties have to meet the readiliness standards, for example, the mateo county which has been working on integration for a long time will begin in april, and then, the other counties will begin when they are ready and so for example, santa clara is not slated to start until january of 2015. so, in terms of the intent, and certainly it is an intent by the state to expand these coordinating care initiatives state wide. and at this point, the legislation only authorizes eight counties in addition legislation is needed to expand to additional counties and i think that there is no question that the legislature wants to see that the program was working for beneficiaries before expanding it and i think that there is a desire to expand it and so we are anticipating that it could be expanded to san francisco as early as 2016 possibly and then certainly the goal is to expand

it state wide. the health plans that are the target for the cal medi connect options across the state is really focusing on the health plans that have traditionally cared for the beneficiaries and so the options for san francisco would include the san francisco health plan, which is a public health option and anthem blue cross, which is the commercial plan, these two have enrolled medical beneficiaries first with children and families that are eligible and more recently for senior and people with disabilities who are only eligible for medical and historically only covered medical services and with the coordinated care initiative, they will be covering long term services and supports. in addition, the statute allows for all care for the elderly to be an option and the pace is different because it is not a

mandatory option and it is only a voluntary option, because it targets the people that are eligible for nursing home care and so it is a different model. those are the programs that we will anticipate with the options in san francisco. you can see on this start that it is 45,000 individuals but i want to under score that this is a diverse population that includes people with disabilities and disabilities and people who happen to be low income and we are talking about a diverse population that requires centered care. and i am going to turn it back over to ann to talk about the recommendations of the long term care integration. >> before you do that, sure.

>> with the group of 65 and up, i don't know if you will have it in your head or not. >> i don't have that information off of the top of my head, but we certainly could get that information, because what we do know is that the numbers of people that are 85 and above is certainly growing, as a proportion to the older population, which also kind of, you know, really emphasizes the need for developing these services. >> yeah, i think, that is i guess, that... >> i could follow up and get you that information. >> right. because i assume that once you most of the 65, to 70 may not need as much a...

>> exactly. >> thank you. >> thank you. >> so the next slide in that you have in your packets, really talks about the design group and who was on it. and so just to or for me to think back, the coordinating council, this is actually i think the fourth strategic planning document that they have put together. and then, very much involved in. and so the way that the work has always been done was done in this case is, an oversight on this case and the design committee was formed in depth thinking and who are the players that you need at the table if you are going to have this kind of conversation about managed care in san francisco. and regardless of what day it is coming to our community.

the departments that were involved and the broad strokes and we will have all three of the health plans and ihs because it is one of the four programs slated into the managed care and we had consumer advocates and a member of and there were actually probably several members of the council on the oversight committee, it was a relatively small group but from that group, six work groups were formed and so we had a data group and service and coordination work group and finance committee and so those, as those folks met and did their work, and they brought it back to daoet sign group for really that group to understand and to move forward to get to the final recommendations so the work was done and that is how the coordinating council

has operated since it became into existence. >> may i ask a quick question? >> could you talk about the involvement of the community, the folks who are directly impacted by these policies? >> right. so, i think one of the difficult things for the council is something that they grapl, with a lot is that a lot of the things that we work on together, are topics that you know you really have to take what the people say a dive deep into it and immerse yourself in it and so the council is fortunate that it has advocates on it and it was harder in the design group to have that kind of involvement. although there was certainly a lot of out reach done.

what was this work all about and why were the people working on this and it really was to have the people who did some of that work to hear from the people about what was working for them now and what was not working for them and so if we are going to move forward and we are going to create something better than what exists now, then tell us, what are the things that you would want to secluded. and we had very interesting things and the people talked about pedietry and dental and vision and a lot of the things living in our community don't have access to and so all of that was incorporated into the larger that you see in front of you. >> was there involvement by relative and family members, and the people that are that you served. >> in the focus groups that we did in the neighborhood, yes, there were a lot of families who attended those, i did four of them and there were a lot of folks who were involved in that. >> which was great. >> thank you very much. >> great way to get the word out to or across the general.

>> i think that this is part for how the systems work and how in san francisco we are taking advantage of different federal and state programs and coordinating a really, really strong community-based organizations that serve our senior and people with disabilities. i think that it is an incredible model and i think that sandy is here and many others, and my office has been working on aging friendly city policy and we are working with the checklist and i am working with the health services and the community parts and i think that they and it looks like we are doing a lot of what... >> yes. >> the world health organization is recommending and other cities like new york are as well and i was going to ask a couple of the bullets and adequate health and services offerd for promoting and

maintaining and restoring health and it looks like we are tying everything together from the community to the government. there is another one that the health and social services are located and accessible to all means of transport and i think that with the community based programs there is a lot of examples of that and clear and accessible information is provided for the health and services for the older people and the digital makes it difficult for the people without computers but i know that we have people without systems and the delivery is coordinated and simple and i think that simplifying and then the last one, economic barriers and impending access to the services is minimized and it looks like we are doing a lot of those couple of bun elpoints from the suggestions but i am really glad about this system development and strategies and it is wonderful to see it all laid out so well. >> it is nice to see the various initiative and how they pull together, that work is another key component of what 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 e