at the lessons learned and because the next enrollment period that is only like 8 months away and that might be actually and it might be a time line to look at what the gaps are and start preparing for that. >> very good point, thank you. >> i was just going to follow up on dr. sanchez's issue. and well we have a lot of cbos helping with the enrollment and all i thought that part of the message was that we have the two weeks to actually follow up to make sure that was done, and that is, so, is that actually part of the program? that we have asked our cbos is our enenrollment to work with that public that had complete applications. >> it has not been done to date and that news just came out and so it is not something that we have acted on but we can certainly do that. >> we will look at it.

>> thank you. >> and in terms of the, oh,, you have a further comment? >> sure. >> commissioner. >> hello, and director of san francisco, we did send out a notice this morning to all of the san francisco medical homes and it went out to all of the centers, and to let them know that please, that the circumstances have until april 15th, so that went out this morning. >> and that will be the publicity as well and thank you for that update. >> that was dena lawn, whispered to me that the member clinics are also doing the same thing. >> and that is the current response and talk about the current response and the new legislation that you just spoke to, and obviously, it requires some time to do the analysis.

and sometimes, it might also be unintended consequences, and i was going to ask, when we might be reviewing working together because it is partly an answer to the affordable question that we posed. several months or several weeks ago when we in fact agreed that we would extend healthy san francisco that you had indicated for those who were eligible for coverage california. and did not feel that it was affordable. and i was going to ask director garcia this is again, just immediately being introduced today, as to how we will be working with the initiative and with the mayor's office. >> we are already working with the mayor's office and we will also be working with campos's office to insure that we have ample time to look at the consequences of the legislation, as it impacts healthy san francisco particularly, and also, our ability to implement, i think, some important programs in the time period that is being

legislated. so, we are trying to work on that and tomorrow morning we will be spending some time on it and trying to get to the supervisor's office as soon as possible. and again, coordinating with the mayor's office on that as well. >> and if we have received the memo. >> we sent it out through your secretary regarding just a review of the legislation. and some of the time line concerns, and we have not and we are working on the financial piece of it as well as the implementation of the program. the programs because there are three distinct programs that are being impacted. >> okay. any further questions, commissioners? >> all right. question. >> i would just like to thank the chair of the finance committee to bring the matter before the full commission, i think that this is a very important part that the commission is very much interested and i really thank you for bringing it to the discussion today. >> thank you, commissioner, and it was because this is such a

like, brand new, system that we are like trying to help enroll people in, and now that we are open access, and it would be a great opportunity to, you know, like to send the message out to a different media. >> yeah. >> and i think that this shows how dynamic the process is, and not only are we dynamickly enrolling, over these periods of time, but the people who are coming in with the suggestions and how to answer the affordable issue. and that i think not only that we face, but the country faces if we were hoping to have the solutions before the rest of the country. >> yes, commissioner? >> just a word of caution not necessarily for the department of public health, but hopefully working with our elected officials to insure that things don't get done too quickly, so that we live with issues that

may effect us for the long term. and especially when it comes to financial issues. and we cannot afford to pass legislation in a way that it may be too quick, without really thinking how is going to effect us all. >> thank you. any further comments, and it is an important subject and so i am willing to accept the additional comments. >> we can call to the next item. >> item 6 is the consent calendar and i believe that he went through and described what was on there. >> right, it is before us as usual, if anyone wants to pull anything off of the consent calendar, we can have further discussion, otherwise the three items before us, on item 6, and it has been moved by the committee. and comments on the consent calendar, if not we are ready for the vote. all of those in favor. >> aye. >> aye. >> all of those opposed?

it has been passed next item. >> 7 is an update on transgender health project. dr. barry zevin. thank you for giving me an update on the transgender project oh, boy i get to control, oh, great. and so, just a little bit of history and then i will talk about where we are now, and where we hope to go and in the near future. and prior to 1993, the department of public health was involved in transgender healthcare, and i would say that at that time, there was a

conventional model that was focused on mental healthcare, and assessing patients in terms of stability. and many of the transgender people in our community did not get healthcare at that time. and many of them saw untrained doctors or were buying hormones on the street. and in 1993 was the origin of tom model transgender tuesday and soon after that, the origin of dimensions clinic for youth as well as the continuing of the services, on a small scale especially service and behavior health, and all of the services that were delivered at that time were informed by sfdph policies, and things like any doors is the right door and our

policy on harm reduction, and what we are able to implement, and was, an approach with integrated care, and that really looked like the primary care medical home model. and we have goals through that time, where providing access of healthcare to under served populations and very strong focus on hiv prevention and facilitating treatment for hiv and other conditions when they were occurring in transgender people. advantages to this approach were that we were able to provide culturally competent healthcare to the community and our patients had a high acceptance of this and we had much less use of black market hormones and much less unmonitored hormone use and at least from our statistics less

psychiatric decompensation of these patients once they have access to the medically necessary hormones and the high patient satisfaction with the gender related issues from the challenges, for us, prior to 2010, we continued to get reports of discrimination in our healthcare system, several reports of widespread discrimination. we continued to hear about access and quality of care issues. and in the limited number of specialty settings. and access to transgender surgery was very limited. and our response to those challenges a commitment to comprehensive and ininclusive training, and mandatory transgender 101 training for everyone in the department of public health who has any contact with patients. and recent advancing that requirement for training, to all of our contractors as well. and a very strong uptick in

that training. and in 2010, and we were able to establish the transgender program and the goals of that program is to improve the healthcare across the department to improve access to the transgender surgery and we were able to do this, without any additional budget funding by redeploying the staff and the use of mental health services act funding. >> and in terms of expanding access to transgender surgery and just through the 1990s and the early part of 2000 very few poor people had access to any type of srs and during that period of time, at least for the past eight or nine years, medical has considered sex

reassignment surgery medically necessary, but since the private surgeons would not accept the low fees offered by medical we did not have access for those patients. some changes that increased accessibility in 2010, medical changed to a predominantly manage care model and the cost saving measure and an unanticipated part of that is was the entities for providing the services including transgender healthcare including hormone therapy and surgery. and in 2011, members of the community approached sfdph about providing sex reassignment surgery for uninsured indegent individuals and advocates reached out to the politicians and influential people in the community, and the city and county agreed to fund an srs program for uninsured people and the health

commission was highly supportive of this and also in 2012, two surgeons moved into the bay area, offering srs in the practices which was a great expansion of services locally. last year, a medical managed care clarified their position. and on the coverage for transgender services and offered a letter to all of the plans in the state saying that medically necessary services needed to be covered and would be as defined in the international guidelines put forward by them in the standards of care. >> and 2013, we are all established our transgender health program, and looked at an established guidelines for the department of public health, in terms of policy and procedures across the department, and initiated an ininclusive planning process within the dph and in the

community, as far as how would we effectively expand transgender surgery? >> some challenges to that, doing a needs assessment has been difficult and we don't have good numbers in terms of the number of transgender people in the community and the number of those people who might want srs. and we were able to make some estimates. and we also had challenges in terms of these are scarce and all of our healthcare is scarce resources and the political process determined how these funds would be spent within the public health. the question of and challenge of whether or not the people would come to san francisco specifically for this service, and had a manage that. became a challenge. and some key decisions and i won't make anyone read through the small print but i will point to it and a few of our

ski decisions and we have established a community advisory board for our transgender health project, and we have created a transgender health portal within the san francisco dph, website, and which is kept updated with the current information for the potential clients for the people who are patients in the system and for providers through the system and that is kept updated with the resources and with the current policies. we decided that the criteria for uninsured patients for surgery would be the same as the criteria by the san francisco healthcare plan and we work closely with the san francisco health plan on making those criteria as evidence based and sensible as they could be. we have developed guidelines and trainings that we have been

rolling out across the healthcare centers both the dph and the health centers and the jail health service and to help and providers understand what our criteria are and how do we access those services. and we are currently developing a and we will start this week, our first series of education and preparation sessions for the patients who are planning on under going transgender surgery within our system and specifically four, three-hour sessions that we have developed in collaboration with the center to make sure that the special challenges that are faced by our public health patients, who are resource poor, that they are getting the same education and preparation in fact, we would like to think that i... and more effective and education and preparation, than patients who might have

the means to pay for these surgeries on their own. and so we are very excited about that program starting. and i want to establish a contract with dr. curtis crane to provide surgeries for our uninsured patients. and that contract has been finalized for the first year of this and it will be finalized for the second physical year of this in the near future. and finally, establishing a goal that we would be able to previed all of these surgeries in our network at san francisco general hospital, and a task force has been formed to solve the problems that and present a plan that would allow us to be providing these surgeries all in network, soon after the opening of the new hospital,

allows us more or time, and capacity to actually provide these. and so that is a big project but we are on track with being able to do that. >> just some details as far as the expansion of surgery, and as the health commission knows, funding was established for this physical year and 300,000, and the next fiscal year, 500,000 for paying for paying the surgeon on a contract basis to provide the surgeries and there was also funding to provide, particular surgeries in network at san francisco general. and to pay for the salary of the specialized plastic surgeon in the department of plastic surgery to do that. and thus, far, as of i have got the numbers of january here, and but i believe that we have got slightly elevated numbers in a hand out and we have had, and thus far about 85 patients

referred to our program, through our centralized referral. and about 15 of those patients have completed surgeries as of this point. and those are both medical and uninsured. and both in-network and out of network and we have broken that down in a table for you a little bit more. and we are keeping those numbers updated as they are changing every month. >> some changes this year, to pay attention to? aca, if you have not heard enough about that yet this morning afternoon and a lot more people have medical and are working with san francisco health plan, and with anthem is even more critical and we have had very good working relationships both with the medical director at san francisco health plan and the staff there who are working on this. and more challenging working relationship with anthem, but developing the relationships

there as well. so that our patients do have access to the services that are medically necessary. >> i should mention that this all exists in a parallel process, with services for privately insured patients. and they, the state insurance commission and managed care, commissions, have set out regulations that prevent exclusion of these services from any of the healthcare plans in the state of california. and this means that all of the healthcare providers in california facing the same challenges of how do we effectively provide the transgender surgery services when we have not been doing that before? and it is given us in the dph an opportunity to work closely with the providers at kaiser and providers at other sites, on kind of facing the same challenges together.

and being able to develop a city wide kind of a wisdom on this. and so that has been exciting. model of care, very briefly, we are seeing surgery, as a means to improve our patients' over all health. our referrals originate with the primary care providers and it is a little different than the conventional model in which the referrals or in ated with the mental health professionals and we think that since the system is primary care centered that that makes sense and we have needed to train our primary care providers, as well as our behavior health providers in how do we, and what do we do this? a requirements are very much insync with the international guidelines put forward and there are a few very exceptions now to align this with the san francisco health plan policy and considerations and at this

point, those exceptions are, i would say, very minor and we have been able to really align this with the international guidelines. and we focused on training the additional health staff and to meet the need and we have done a number of trainings and have done a number of training of consultations available and as i said we have focused on the patient education and preparation to assure the best out comes and we have developed the curriculum for education and preparation that i think is going to be actually a valuable for our patients in san francisco, but this is a model that we are going to able to desiminate locally and nationally and so i am proud of that. critical steps in this, i am not going to go through everything in the small type, but, we have needed to graple with what is the scope of services? some of these surgeries, are quite expensive and how do we provide them to the patients

who need them? and how do we make this work for all of us? we have, struggled with services that i have thus far been excluded and that, clinickly, might be important for some of our patients. and again, much of this is stuff that needs to be decided at a state level and we worked with our advocate colleagues who are working on trying to make some of these happen, things happen so that it makes sense, both for our patients, clinickly and for our community and it is not something that we end up myered in controversy or we have something that is going to bust the budget. and so, that is where i would like to end except to say that

direct people to our transgender health services website. and it is on the front page of the sfdph website. and sometimes when i don't have the patience for that, we are the first hit, if you gaog the sfdph transgender health services that is a quick way to get to the website and the contact information is available and i particularly like to thank my colleagues in the san francisco department of public health transgender health program, conrad wensel our coordinator and julie gram or mental health coordinator and candy pat ter son and the go to person for just about everything and we have added the new staff today. and montica that i am pleased will be joining us and also thanks to the community advisory board, special thanks for commissioner chung who has been a great advocate for this project even before joining the

health commission and especially to our community partners advocates and to our patient whose we learn from every day, so thank you. >> if i may before president chow, to thank dr. barry zevin he is a great advocate and one of the founders of transgender tuesday and he has done an incredible and the stake holders and i want to thank him as well. >> and i want to join garcia to give dr. zevin the accolades because we recently celebrated. and i think that that is something that as a city and we as a health department with be proud of because we are leading the way for good and really

appropriate transgender healthcare and with that i actually have a question. and it is really about the role map that that you have mentioned at the end. and the providers of the surgeries and i believe that there are some conversations happening before, and at ucsf which is teaching institute. and so, creating a center of excellence through this partnership. >> i think that is a great question and i think that the workers working on this, and includes carlisle and the chiefs at san francisco general in plastic surgery, and urology and obgyn as well as the?

>> the first words is that this should be a center of excellence for transgender care in our system. and i think that it is way essential that we are working with the high degree of medical expertise at ucsf. and i don't need to be the first one to say that a large academic medical institution like ucsf has its own processes in politics. and i don't feel like i am... or that the one who is going to be able to navigate all of those processes but i do feel like i know who needs to be in the room to be able to navigate those processes. and i think that we have got a very good start. to be able to say that let's not setting up competing

systems let's set up a system certainly, it is of the interest of administratively at san francisco general hospital. to not only be a center for or within our own network and to look at this at the opportunity to be a center of excellence because all of the counties in california are facing the same issue of patients who require these medically necessary procedures and not a whole lot of resources in those counties to be able to provide those surgeries and okay. and we have got the surgical at san francisco general hospital to be able to train up our surgeons to be able to do this and possibly do this in a way that is helpful to our other counties and frankly helpful in a way to as a business model.

>> so... that is i think it answers that. >> and also, because we when we adopt a resolutions we have brought up this is, you know, like we support this entire process because we believe that this would be help to improve. and it will help in the department of public health and i believe that you have a plan on how we can track that as well. >> we absolutely have a plan for this, and as many of you know i can be ambition in my ideas about how are we going to evaluate how this has improved people's healthcare in the biggest sense. and but, that is the very ambition kind of evaluation is something that we continue to

discuss through the divisions in dph about how are we going to look at transgender healthcare and the out comes. but we do step forward with a very practical kind of evaluation plan for each sfep of this. and how well is the referral process gone. and asking our primary care partners is not working for you and how well is the preparation program going to work. we have an evaluation and then follow up the plans with the patients and did this problem and met your expectations and then looking at over all, and how has the health of those people continued? and so, that evaluation plan is in process. and i am more ambition i would say, as far as how much evaluation i would like to do, but i think that it requires resources and times so we are

working on that. >> thank you. >> commissioner melara? >> yeah, i want to go back to this concept of of a center for excellence and the possibility that not that i want to give more work to the department, but considering that this is something that we have initiated that we might want to be the lead in developing in the center for excellence if we are going to level off the cost of these surgeries in the future. it is going to come from us growing new surgeons in the community. and it is not going to come from god and additional general fund sources and we need to reduce the cost for the more people have access to it and the only way that we are going to do it is to insure that we have more people and there is more providers. because the less providers