addition for introducing everyone, we have a number of people from the palliative care task force, if you can stand up, any who worked on it or part of it, thank you. nice to have so much support. i will have to tell you that palliative care is not an area of expertise for me. i have had experience with this kind of work but never really under taken to understand what it meant professionally. so i had a lot of learning to do and thank goodness i was surrounded by people with dr. chow and dr. christine ritchie and who really understand this subject because professionally is what they do day in and day out.

part of what the goal for this work was to bring people who have such expertise in this area with people like myself who actually touched the lives of many people in our world and i just say in home support alone we have 22000 people and we have palliative care recipients. i had to figure out as much as i could and how to include the services. before you talk about alzheimer's and dimension strategic plan and the coordinating council, this is a part of that work as well. we learned about an area we needed to learn about and new very little about and it was also an opportunity for people in the medical world

to understand the work that goes on in the community outside of the hospital setting and pull people together so they can partner in the future, not just on implementing the recommendations that are in the report, but partnering together on a daily basis. so, a lot i think was learned from this work. there were obviously some goals we had when we started out and i understood over time that there is a growing need in this area and there are gaps in services because there are gaps in services about any place you look. although i think the jail house folks caught my eye on that with all of their abilities there and what we realized there was no one place where we were gathering information related to palliative care. so if you were a community person or a provider of palliative care, you can go to do this research and know what else was going

on in the community. yes, we don't have enough, but yes we have enough that people need to know about it. the task force was really and this basic i think really important in terms of being able to get the work done and the six sessions we had together. the group was people like us in the program and this is enormously important because the process itself was to do the work in each of these 3-hour meetings. i would wager to say that had it just been executive directors we couldn't have done that, and at the same time it was important tools to manage people there who could move something forward because there were some great ideas. we really met in a very abbreviated period of time because at the very beginning

we were not sure where the report would land in terms of it's recommendations moving forward. there was some thought from the mayor's office that maybe the council could play a role in this but it wasn't clear. the meetings were set and moved forward really fast and there was funding which came and the department of aging services added dollars to cpmc. there were a number involved that helped push it forward. the task force itself, although we have a sense of a few goals we wanted

to work on, we didn't really have it set in stone where we wanted to go. at first the meeting which is only a couple hours long pulling everybody from the room saying what do we want to accomplish in five meetings. what do we want to have at the end of this time. what do we want to be important to our community and have all of us as providers and most importantly help the folks who are recipients of this service. it was determined pretty quickly that if we focused on four areas, systems, quality, community engagement and financing that we could probably cover quite a bit of area in a short period of time. i believe president chow, you were on the financing group, were you not? >> yes. >> i sat in on that one. i got to move around a bit and got a glimpse of information from what was

going on. people self is selected into these groups. there was only one group with three people and came out with tremendous recommendations and did a tremendous amount of work. so you can see there was a lot of diversity there was a lot of different ways that people went about doing the work but nonetheless you are going to see the recommendations from all the work groups. people expected from each of the groups and people had the ability to call on what people might know to share expertise as well. these are open meetings and community people are very much welcomed to attend and participate. people who were not in the task force did participate and attend the different work groups. the three things that in that first meeting or so that we

determined were important for us to focus on was first of all a definition of palliative care and i think we've all been in those kinds of discussions enough to know they can go on for a very long time. this was a topic and something we really did need to spend time and the nuance of it. there was a decision to create an inventory of what was going on in our community that could be shared and updated as we go forward and as i said earlier there were short and long-term goals that were turned over as well. i think i will turn it to christine at this point. i want to call you dr. ritchie but i know you as christine. >> good afternoon, we appreciate your interest in this work. we wanted to

spend some time talking about the definition of palliative care because it means different things to different people. first i wanted to make sure we are on the same page and that our definition of palliative care represents the community. we started with a definition early on in your presentation packet there. it was initiated by the world health organization and focuses on idea of family care and focuses on improving quality of life for those with serious illness and should be provided at any stage or any age of the condition and should be provided concurrent with care so it's not an either or situation. it has to be disciplinary in nature in terms of the services and should be delivered in multiple settings. that's one of our

issues that we have identified in san francisco is that we have palliative care in a lot of inpatient hospital settings but not so much in other settings of care. to amplify that, we have the task force and what we are doing in our community and wanted to emphasize that this care is not pro id by health care providers and it's provided by health care community, by others of the service organization, by members of the family and their community and there needs to be a holistic and comprehensive approach of thinking about the care and the important part of that care is community and collaboration for all of those entities. again, emphasizing that this care is providing concurrently with care and not where people have to make decisions for or against palliative care and

the emphasis should be on the patients dignity and peace and supporting family and their larger community and supporting the illness and throughout the process and at the time of death. this was about the population and we divided the population into short-term and long-term perspectives. long-term everybody should understand what palliative care and should be educated and we need to make sure that everybody has their preferences about their treatment well understood to make sure we are respecting their wishes and preferences. short-term are those individuals who had a high illness burdens, from the

treatment of conditions and illness. that focus is to gather data around gaps and needs for that population. then our second deliverable, well, our second deliverable you heard about around the inventory of palliative care resources within our community. this is really an amazing experience to be a part of where all the community agencies and resources are part of this task force along with what they knew were able to communicate with palliative services they were providing and finally coming up with an extra set of recommendations around those quality areas around community engagement. i'm going through this quickly because i want to respect your time. with respect to quality, we wanted to emphasize to measure quality of care, palliative care in different

settings. particularly for hospitals which most hospitals in the san francisco community have access to palliative care in the hospital and also to encourage all of our payers for optimizing the quality of care and in addition to that promoting palliative care training forefront line workers so they can also make sure that all individuals within our community are having access to palliative care. under finance, a lot of folks we discovered actually didn't recognize this sort of powerful opportunity of palliative care which can provide both approving quality of care but also reducing expenditures around care that they are receiving by default. so really trying to understand and support a better understanding of the business case and the value proposition for palliative care from a

finance perspective and promoting that across the board. interesting from our finance group that the recommendation was made to have an advisory board so we can implement these recommendations over the long hall that sat within the long-term coordinating council so we can make sure that these recommendations sat on a shelf and they are moving forward. around systems, we talked a lot about supporting across collaborating systems with the difference between disparities as many individuals who have different situations do not have palliative care and we want to across all areas of care to do a better job in providing that access and developing standards for care planning so everybody has the opportunity to communicate to health care

providers as to what they want. around community engagement we saw what san francisco has a community with conversations around their treatment when they are ill and we can be leading the way in the state of california around wellness campaigns for treatment preferences and advanced care planning. then finally sort of recognizing that these deliverables have to be managed and thought about carefully and implemented systematically, the recommendation came for again the san francisco long-term coordinating council would be a natural place for this work to continue and happily last month we met with the coordinating council and welcomed the idea and voted

to have palliative care task force activities continue there and our first meeting will be this friday. so we are very happy about that. so this really is an exciting time to be a part of this work. we want to again thank commissioner chow and the department of public health the adult services for facilitating this conversation. in our community we feel the time is right to make a difference for people with serious illness. lots of things are happening in our state with sb california and ensuring that many have health services and ensuring that providing are helping individuals for opportunities for palliative care if they have a serious or terminal illness. we feel like again san francisco can be a real beacon for this kind of work and we

really appreciate again the support of the commission and the support of our community to move this to this place. thank you. [ applause ] >> there was one thing i meant to add in my earlier presentation about the process and how we conducted part of the work that we did. that was that we determined early on that because we were all coming from different places, different walks of life with different information at hand that we would have a portion of each of our times together as a learning session. so we had people who were experts in different areas come to the task force and speak for a short period of time on various topics which really helped us to come together as a group. i especially wanted to mention the last time we were together because it was decided that we would bring

in, search is for and invite a panel of people who were both recipients themselves of palliative care or had family members who had died in one of our facilities in the city or at home and had palliative care support throughout their time. i would mention that one of the young women that spoke her mother was as laguna honda. it was very moving. all the speakers were but it was moving and special to hear her speak when we were all part of the city family together. though four presentations, it's always important that we just don't bring together the people that have knowledge but we listen to the voice of those who have experienced whatever it might

be and that certainly was the case with this. i think we are at the point of the resolution and i don't know who is going to read it. >> the commission will. thank you. >> okay. >> thank you, director and dr. ritchie. do we have any public testimony? >> no public comment request for this item. >> so commissioners we'll entertain discussion. questions at this point? commissioner, please? >> thank you for this work and bringing this important area to our attention and for the on going work. i'm curious where is the repository for the services that you were able to catalog and how do people get access to that? >> we can provide the

website link for you. it's available on the website. >> do you have a plan in mind for how to get the message to all the folks that are not necessarily part of the system already? >> so one of the recommendations really does include dissemination, larger communications within the city around these efforts and i think we'll have a lot of work around that effort especially momentum towards sort of this inventory. i'm hoping the eventually will serve as a starting point for more communication more coordination and also peer pressure to make sure we are all doing a great job. >> great. are there ways for people to contribute to that? >> yes, there is and we can work through the department of

public health so we can communicate additions. >> commissioner pating? >> thank you very much for a wonderful presentation and improving services for our adults. it's important. reading the slides from the back, i would like to ask a very similar is -- simple question to give me some context. i don't know why the workgroup or task group was launched now and what was the problem attempted to be solved that brought this to our attention. was it the california "let's get healthy" initiative or why was this a priority? >> it came to my attention because dr. bj miller who was in hospice

came to see me about what was going on in the city and explain to me the work he was doing and to express his concerns around two of those three areas, the gap and trying to put together some kind of city plan that was helpful. he met with a number of city departments, myself, mayor's office, and it was out of that conversation and thinking about other kinds of strategic plans that we put together and implemented and the more i understood about what this effort would entail that we begin to see that there was actual lau -- a way and turns out there was amazing people who worked in this area who once invited they were very interested and began to work on this. so

somewhat interest in a topic who met with other people who also had a growing interest. >> and also commissioners, we had several groups from hospice come talk to us really at the same time. partly because i think of the aca direction and really how did hospice sit within those systems. so i thought it was a very beneficial process as well to really look at this service which i think is important for our community and how does it fit in with the care. >> i saw this integration throughout the report and i really support that. could you explain your vision of what you think the destination pros card will look like. we've done the report with some cycle of quality

improvements. where would you like us to be in a certain amount of time? >> i can tell you from having been part of the alzheimer's strategic plan which is a plan, i don't think the council would be looking for something that long in its effort. but what we have learned i think over time is that you put your recommendations together and you begin to move on those and there will be an oversight body off the council who will be not just working on the recommendations but making sure that things are moving forward and report back to the council. what we have learned in the past is every so often you have to look around and see what's changed. are there new opportunities and this changed that makes it no longer relevant that we have to work here. i would expect over time that some of the these recommendations will be finished and others will be added and

some things may actually fall off because something else has happened in our world. >> hi. i'm monique parish, the project manager. i would like to add the work fwor this effort. nationally there is the data about not only affordable care act but major health care institution that health care provide this opportunity to meet patient's needs and also with lower cost and improved quality. the state of california already had taken tremendous effort into palliative care. san francisco with extraordinary and exquisite quality of care and

community service it was a tremendous point in time and the intersection of those two systems could come together. so i just wanted to provide a little bit of that national context and then as far as where this will go, i think as people have the conversation about those end of life care but also what's important to them as we look at patient centered family care that we look as the direct goal and work on behalf of the resident. >> thank you. commissioners singer? >> dr. ritchie, i had some questions and my instinct is you are the best to address. my question on many of these topics that have multiple constituencies and seem overwhelming. where do we really need to focus our

efforts. it's not to say that any of the recommendations struck me but anything other than sensible and thought fully proposed but what do we really need to get at to make progress here. that's my first question. >> there is lots of ways to answer that question. there are two extremes in terms of power that are both very important. first is actually at the grass roots level which is actually making it okay for people to actually talk about what they want with respect to their treatment preferences and understanding what the true options are that they can have informed conversations. that's at the grass roots level. the other is in the area of payers. it's assuring access to services and the overall

spectrum of services they provide and quality of those services. i think both of those things are critically important and they also have the tools to understand what the value of proposition is. i would say both very much at the grass roots level and the payer level and there is a lot of energy right now in our community. there is the opportunity to actually improve communication across settings of care around services. right now oftentimes i may say exactly what's important to me in reference to treatment care but it's not communicated to next, so it's a full and powerful curriculum because what's being discussed is being honored. >> as you know on that last point there is incredible amount of

energy within dph about getting the it systems up to date so that continuity of care can really be recorded and accessed by people. my second question is and if you can be specific that would be helpful when you think about quality of care in here, what exactly do we measure? >> this is the world in which i live. i'm happy to answer that question. there are both processes and outcomes that we measure. the services that are provided and the outcome measures are the patients experience, are they actually experiencing less suffering and are they having their needs addressed in a holistic way. this is a measurement and family experience

same thing where we have to ask the family, was your loved one treated with respect, did they have their needs attended to. the process measure are we actually assessing for the right things and asking people about their treatment preferences. are we actually looking at whether or not people are not only having their pain or their other symptoms addressed but it's being followed over time to ensure optimal quality of care. i think the quality of care piece has multiple dimensions to it. historically we focused on structure and processes about the fact did you ask about pain and recognizing that's in sufficient and we have to ask what the nature of services they received. >> when you come back in 2

years to tell us how we are doing or however long, who is the person responsible for the integrity of data collection and making sure it's at the breath we need? >> that's something that has to the determined. it's a great question and important question where we need to actually think very carefully about where we have recommendations in our quality section around assuring that actually we are measuring quality of care and that we are actually addressing quality of care. right now part of the challenge is that a lot of the naturally endorsed measures around palliative care are in the adolescent phase in terms of actually the care of the measures, but there is still sufficient for us to get good information in terms of