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 the

quality audits and the quality of the data, that's something i think we are going to have to figure out where that accountability is coming from. >> if you were in our shoes would you approve this resolution before you knew that? >> i would approve it enthusiastically because the only way to get where we want to go is to have a system in place for these issues in a structured way. >> thanks. >> commissioner sanchez? >> i want to congratulate you for an excellent presentation. california on aging was here in san francisco and they were reviewing a number of programs and changes and at

that point saying we are now just getting under way whether it be the hospital or community model, etc, but we are going to do that. this is an outcome of what has transpired in the year or two. the question is how is this implemented it's varying according to communities. for example, usc has a fantastic research came -- academic science center focusing on palliative care. the california commission on aging which i serve, we also visited these programs last month and they are not only involved with the programs in east los angeles and ventura county but also involved in va

hospitals. they are working in a newly integrated model focusing on needs. they have a number of major grants from the feds and foundations and top programs and post doc working on the status because in that county it's a major significant thrust. you have unique programs here but they haven't been coordinated or integrate in community organizations. this is really a significant major step at this point. so i would encourage you to continue on and i hope that we work this out. it reenforces the acknowledgment that we are making significant head way and we will look at additional resources in integrated programs as we face a critical need in this city with not

only the elderly but people injured at different stages. that's what we need to look at. when you are at age 70 or 80, it doesn't have to do with age. it can be someone who is critically injured and someone who ends up at laguna honda or others. it doesn't have to be a or b. it could be all of the above and with the integrated services and we have the community talking together with the different protocols that we have as part of this on going base. that can be part of the measured outcomes as to how they might look at because they are very interested in taking to look at how we are going to answer these challenges. it's been a tough ride but

you have fantastic input and both with the non-profits and academic institutions, laguna honda, we have a residency program in uc sf doing rotations at laguna honored. before it was a separate entity. take a look at what's going on now. we have clinical social work, now we are getting this integrated model on how to provide dignity and respect for patients at whatever stage using these resources of this great city. you have been able to articulate that in your work. more power to you. i think you have done a great job and look forward to seeing next year's results. >> thank you, any further?

director garcia, you are one of the leaders in this case. your comments concerning this document and the work that was done. >> i think palliative care has been a growing service in the city. if you think back to our hiv and aids epidemic, palliative care was all we had to provide for people. we learned that community and family were the basis of much of that care. as we move into aca, we know we are going to be looking at family and community support to look at people's care. bringing all of these entities especially people who have received these types of services for their families and loved ones, we think it's very important to know how we are

going to support them. whether you are in the va or out of the va and getting payers understand the importance of this. as dr. sanchez says we provide incredible palliative care today at laguna honda, san francisco general and many other places. this is outpatient support also and it's really provided with our aids care and respite services that people need to be able to take care of themselves at home and the reduction of suffering and pain is another area that we need a lot of work in terms of

looking at the medical model. i think this is a great report and we'll continue to look at it from a policy level and implementation level. we are part of a long term coordinating council. when you are ready to have us back as to what our progress is, i appreciate commissioners questions too and what we are going to to do with this report. we do not like to see reports sitting on anybody's desks. we want this to be a living document and ensure this is a recognized service. >> i just want to comment that i think this is really an extraordinary work that reflects upon the dedication of cochairs and the staff and support staff that was there to believe that as i sat through this room in

two or 3-hour sessions in the beginning, just that amount of time and then to have a thoughtful document of this nature i think reflects not only upon staff of course but also as i think was said already the enthusiasm and expertise of the people put together mine being perhaps the exception where we come in where i see as a primary care provider this service is needed in many instances. the ability of aca in managed care environment for so many of our members especially within the states moved towards managed care is this type of service is going to be what bridge is the difference between giving direct service and then trying

to make due on an individual bases where many of us have already had that experience with family. this bridges puts it together. and when you spoke about the last session where we brought in the patients and caregiver, this made it very real. where there was a need with at least information available as people move through the different systems. we are developing through our own sfhn system here that will need the same time of information and integration for our people. so there is some pride having being a part of it and the hours i gave to the commission here or i should say the workgroup is actually vindicated by the fact that so much came

out. another was how can we sustain this, not just coming together. remember the long-term care council appeared before us and this is a perfect place for them to then assist in moving that agenda, i think outside services is a very good example and something that will occur and bringing this to the table with all the of these recommendations this goes to the resolution that working with staff we have before you for your consideration. the four terms because the back end of the pages didn't get printed and some of the versions. i have placed before you the resolution which says that we not only commend our task force but i wanted to go on to the more important aspects in terms of it's fine implementation that we support the advancement of

palliative care practices that serve individuals in the least restrictive setting possible. that the resolution request that sf dph consider palliative care when appropriate when considering palliative services which the director said she was going to be able to be doing. so placing that resolution before you and hoping that we can get passage. i need a second. >> second. >> this has helped me out a lot. i think the ca with some concept of a system we have not flushed

out besides health care but rehabilitative care. in my experience, hospitals have figured out palliative care when you do discharge planning but oftentimes it's limited to fill out the end of life form and from outpatient car to their hospital to the board and care to in home health services. it's where san francisco has something to contribute to the conversation given our long history. i think i'm getting it and thanks everyone for the conversation because i think this is more of a conversation figuring out what's this benefit and what can we learn from san francisco's

previous expertise. i hope this training for positions on this as well is part of this because i think a lot of us need to be part of this larger system, not just hospitals and some of our higher level acuity services. i support it on that basis. >> comment? >> yes, commissioner singer. >> i'm also support is -- supportive but i want to elaborate. if you talk about where the patient showed up, the link between your recommendations and the work you want to do and affecting those patients lives who you heard is an insane focus on measuring what you are going to do and holding people accountable. and we've had over the time that i have been here several resolutions where it's wonderfully thoughtful policy work, but

my guess it's going to end up like in the past where you have this wonderful policy and you wake up 5-10 years later and you think this was a waste. as a department we have to get the religion of pushing ourselves like we can't do great policy work unless we agree how we are going to measure it and how we are involved. you are not going to achieve what you are passionate about. it's got to be culturally ingrained in us. the resource fight is going to get greater for public health care systems and ours included. you think it's rough today, it's going to get rough in the future. we'll see a presentation from greg wagner who shows what happens in a

recession. it gets complicated. i implore you to really focus on this because it's the thing that's going to make us deliver for our most needy patients what we need which isn't reports, it's care. >> are there joint commissions or cms measures that address this? i assume they are because i have seen them in s quality form. >> the question was are there measures already out there? >> yes. the medical palliative association has worked on this on the measures of what matters campaigns have measures for appropriate settings for care. these have been endorsed and we had a meeting last week

for medicare services and other entities across the country to make sure it's important for the actual thing to make sure we are measuring this. i hope we can come back to you in a year in a report to talk about that. >> if there are no further comments. >> all in favor say "aye". >> aye. >> any opposed? thank you, the resolution is unanimously passed. thank you very much. [ applause ] >> we will ask to calendar a progress report, a follow up report at an appropriate time, no less than 1 year. >> yes, i will make a note of that commissioner. >> thank you very much. >> the next item on the agenda is item 8. a resolution authorizing department

of public health laguna hospital to enter into a cal department of transportation standard agreement to acquire one large transit shuttle vehicle as part of the federal transportation administration section program. >> good afternoon. last month i came before you to ask for a resolution for two shuttle vans and we got word that we were approved for another vehicle. i would ask for another resolution to enter into an agreement for laguna honda. >> so moved. >> okay. the resolution is before us. was there any public comment? >> there is no public comment. >> it's been moved and seconded. questions? >> what color is the van? >> i don't know, i will have

to check it out. we will have to work with our city department and we'll let you know. >> we'll report that out of our jc. >> are these replacement? >> they are to replace the 12-year-old shuttle vans and when the grant was written it was to support and compliment our community outings for individuals living at laguna honda. >> so it will add to our capacity to do this? >> yes. and one of the plans we hope to explore is we go from forest hill to three places in laguna honored -- honda, we hope to explore to hope park farther than the 3-mile

radius. >> any further questions. >> i appreciate this. >> we are prepared to vote. all in favor say, "aye". >> aye. >> any opposed? the resolution is passed and congratulations. >> thank you. >> item 9 the budget update. mr. wagner. >> good evening, commissioners, greg wagner, financial officer. i'm here to officially kickoff budget

season for the 15-16-17 budgets. this is the first step in the formal budget process although we have already been doing quite a bit of thinking internally within the department, but this is the point in time each year when the mayor's office releases the forecast for the upcoming budget cycle and this year the forecast for the 5 years ahead of us for city finances and department's instructions on how we should prepare our budget. so the global news in the mayor's 5-year financial forecast is very positive. as we all know the economy has been doing well and with that the acceleration of the economy

we have seen city revenues and we have seen more in the general fund than we have in many many years. the projected general fund deficit for the 5-year financial plan, you can see in that first year, we are facing a $15.9 million deficit. still $15.9 million but compared to where we've been over the last many years, we were consistently in deficits approaching half a billion dollars. so we've come a long way. a couple things to point out in terms of what the financial picture looks like and this is what we have seen consistent over time. you see the smaller deficits in the near year are driven by this revenue growth do -- due to the economic

year. it's a huge amount. generally the rule of thumb $100 million is very solid general fund economic growth and we are at double that. you can also see that in out years we are leveled off. there is consistent growth on the cost side and leveling out of revenue. that suggest that this boom in revenues not in boom to keep up with the cost. it a caution for us to think about the future years, 2, 3, 5 years out what the general fund picture might look like and what that means for how we do financial planning and think about as we are making expenditure plans how we need to be prepare for

potentially increasing a pressure on the general fund. nonetheless in the immediate term it's very good news that we are very happy to hear. just another kind of caution that the mayor's office presented when they put this plan out. the 5-year plan does not represent recession. it's fairly hard to predict in terms of when it will happen and what it will look like, but it's fairly predictable that there will be a down turn somewhere in the not too distant future. this is a history for the national economy but a history of time between recessions, so quarters of negative growth since 1900 and it varies over time and the average of that hundred year period is

146 months an they tend to be longer in recent years. nonetheless we are at our 64th month of economic expansion and that is not out of line of when you should start thinking on average when the average cycle compared to that data on the economic cycles that we should be expecting that it is a significant possibility that in a coming 2, 3, 4, years we see another economic down turn. if we get through these 5 years without an economic down turn, it would be the longest period since the history in the chart that we have seen recessions. it is a possibility there will be another down turn around correspondingly from the mayor's office is to think about as

we are planning our initiative and planning our long-term operational plans for the department. just a little bit more kind of detail on that and what it would look like if we did get into a recessionary scenario. this is a forecast of a scenario, it's not part of the forecast, but if we took a look at what our prior down turns look like in terms of the city budget and based on what the timing might look like if we had a typical recession that came in the 17-18-fiscal year and used the average impact on the general fund that we experienced when we see a down turn, this is what the forecast would look like which means over those last three years of the3 years of the 5-year financial forecast,

things will get a billion dollars worse in the program. we are part of that department and a billion shares would be for us to solve. that's the important thing we are trying to think about as we go into this budget cycle and into our financial planning is let's not assume that happy days are going to be here. let's plan out in case we need to make a general fund reduction in the coming years, how are we going to do it and be careful about putting programs in place that we may not be able to sustain over the 5-year horizon so we are taking that very seriously. the instructions are despite the cautions about the economic picture and what maybe the instructions are very positive compared to what we have seen in the past years. first of all you

will remember in late summer after the budget passed, the mayor's office asked for contingency reductions that went into the election in november under proposition b at the november election that did pass but the city had some better than anticipated news in last year's year-end final financial statement and that was used to offset that ballot measure and they will not need the reductions. that's good news. the next good news is the first year of the budget cycle there is no general fund reduction target asked of the department. this is the first year since i have been with or near the city that we have not actually had reduction target that we

had to come up with to help solve the general fund deficit. so that does give us some significant freedom to work with and it means we are not starting out with a gap that we need to fill in that year. it also means that we need to absorb our cost and we need to be judicious about how we plan on any increases or new programs that we would like to fund. in the second year, the mayor's office asked for a 1 percent contingency reduction which is about $2 million for dph. we will need to plan for that in the second year. in addition to the kind of general cautions about not getting overall exuberant. we have a couple of things which you all know about that are on the horizon for us which could impact the financial picture. we have the upcoming dish cut that are

part of the affordable care act that are not assumed in the mayor's financial forecast. we have the continuing changes as part of the aca to take back of realignment and dual eligibles to managed care and the waiver can all have significant impacts on our revenue picture and we are watching those closely. in addition a big thing for us in this coming to your budget cycle is to focus on our information technology needs and that is getting our basic infrastructure up to date, planning for electronic medical records and other things such as idc 10 and others we'll have continuing focus on some of the issues that we've been looking at for the last several budgets which is getting our population health division where it needs to be, planning to open the new