continuing to evolve and financial incentives don't necessarily align with some form of institutional care. we also know current trend is shifting towards home and community base care however the hospital base nursing care without the investment may result in unmet care needs for the community. for example, we know that hospitals often delay discharges for a patient who can't safely discharge home and often affected by program wait list and for evaluation of services. this will lead patients at risk for at risk events while they are waiting. ultimately highlighting the fact that an investment in community

services and transitional care is critical to compensate for the lack of skilled nursing facility resources in the community. thank you. >> commissioners, any questions to the department's presentation? >> thank you. is there any public comment on this? >> i have not received any public comment request on this item. >> okay. commissioners, we have before us a draft resolution, several draft resolutions and the final one that is proposed has language that speaks to the issue of the short-term beds being defined. we don't have as we

talked about earlier what is actually the number of short-term beds that we should have versus long-term beds as versus to opposed to acute care. in background, if we look back on the commission and that's my role as you are a senior member the sniff issue and sniff closures have been going on since 2007. at which time we have almost identical issues that arise. in 2007, saint frances closed their sniff beds. it's interesting that comments were very close to the comments we are now receiving for st. mary's for the same reason. we had the discussion with the system and again those were the closures of short terms snp

beds. at that time sutter indicated that they were scaling down to the number of snp beds that they needed within their system and there would be capacity outside for aside from their system. we are aware that our own hospital, san francisco general has snp beds for the reason of post acute care and the reason that we discussed before us as to why short-term snp's are needed as part of a transition and continuum of care. we've also heard that chinese was going to put in a number of snp beds but their projection is based on what they need for their system. this is kind what if we know. but there is a

number that we don't know. which is in the change ing environment and the increase of the availability for people to have insurance and be able to place into the correct level of care what level of care should people be and how would they access certain services. is that with the additional services that are available through covered california they actually can have home services and what do we do with the safety net population who may not have a home and maybe in respite or otherwise. so, i think that in these 7 years we have perhaps changed the medical environment but not changed the topic of hospital base snp and we have now the third hospital now closing as snp. that is before you, and i think we have the resolutions before us and i have proposed that we use the last

drafts that we have as the template for discussion and any of the results that were in the earlier ones that could be put back in or we can substitute out of it. but i think we all have that. is that correct, mr. more wits? >> i would submit that we should at least use this as the base of discussion. >> do you need a motion? >> i need a motion. >> motion to the ones that we just had. i don't know how we identify this. >> so it should be in the first resolve that what you have is a red line copy that's first resolve would be changed, the closure of short-term snp beds without ensuring the level of appropriate care in unresolved and unmet short-term care needs of the community. >> i would like to make a

motion that we use this model as our beginning of our discussion and consideration for moving forward. >> that would be moving that draft of the resolution. is there a second? >> right draft again is the one with the red lines that say "in the first resolve that the closure of short-term snp beds without ensuring the appropriate level available maybe resulting in unmet short-term care." just to be clear that will further the second resolve would be that sf dph would work with community base organizationed to research the needs to post acute care in san francisco and submit a report back within 6 months. third resolve is that the

health commission encourages st. mary's medical center to explore post acute care alternatives. that's the one we have. we need a second for it. >> second. >> there is a second and we'll now discuss this resolution and however commissioners would like to take it up. >> before we start discussing it may i offer some language on the first resolve that clarifies it a little? >> you may. would you like to offer that now? >> in the second from the bottom that have paragraph line which says "may result in unmet short-term skilled nursing needs in the facility" can we change to it read "may result in" scratch out "unmet" short-term community not being met?

>> yes. can we accept that as an editorial change? >> sure. >> getting rid of the passive voice. >> i assume that was a consent. because i see that as a potential. >> an amendment. yes. >> you have that language? yes i do. so further discussion is on the resolution 2, back in 2007 we did ask for a study on snp. i think in the 2014 dialogue we said the same thing that we really needed to know more about it. within the resolve rather than

just conversation we did put it into the resolution. i will ask the director if she has any comments? >> that's a fair perspective and we'll take the second to last resolve as our responsibility. that was one of the issues from some of the commissioners to have more data. we are happy to do that and you have given us a 6-month timeline on that and we can meet that. >> commissioner singer? >> first thing i want to do is congratulate both the chair and the director and the staff for sort of thinking hard about our comments last time in trying to incorporate them in a resolution which i find a little bit more palatable from my perspective. i would like to make a strategic policy comment is that we, st. mary's

has an extremely legitimate issue from what we have seen in that they are also wrestling like everyone in our city with the change in landscape and health care in trying to be very rational about where they provide care. on the other hand we as a city have pretty rational concerns that look until we get that capacity available the consequences of not having those snp beds at st. mary's, you place it in a balloon and it comes out of someplace else like the taxpayers of san francisco or patients are not getting the care they need and that is unacceptable. the challenge is we are in a system that is so inter connected and awe fully organized, not our fault, but the fault of history. that

any change that someone makes one place is going to have consequences someplace else that is going to upset someone. if we don't have the courage to kind of move forward and make changes and tolerate some of the consequences with changes, then we are not going to move our city forward and people are not going to get the care they deliver. so, we live in a very tricky time right now because we are forced to changing, but all the forces of inertia in the system are aligning up against us changing. and so i think we have to keep that in mind as we push forward on this stuff because we got to be courageous to get the system where we need it to be. that means us as a city stepping up and taking some risks and our community partners, the hospitals and their organizations stepping up as

well. >> i think that's fair comments and we should be engaged with many of the systems in the community who are wanting to take the peak to the right level of care and as they move out of the hospital. we need them to invest in the projects that we have in the community as well. not investing means they sit on top of the existing system. so i think we can be more proactive with our partners to ensure that they are looking at those other needs of their clients so as an example of the department doesn't take on the responsibility for on going care for them or another system has to do that without the support that the client needs. we'll work hard on that and i think it's upon the dignity to come forward and work with ctmc on this to think with us strategically in the future because it's very hard

to change the dynamic of the direction with not enough time to do that and we can certainly that's one of the reasons we have in the further revolve to look at your community investments that you showed us that we really start to think about how to invest in those next levels of care in partnership because that will help you to help us and particularly your client. and so, we definitely can work with our providers more closely and more proceed pro actively. >> i agree with that and we'll start to see from our partners in the profitable sector and working with the city and community in which they do business so they will serve as examples for everyone to have a little bit more courage to change. >> thank you, commissioner chung?

>> yes i have a question here because the second resolve about research for the need short terms for snp's and short acute services is definitely a reasonable thing to do, but in order to push us forward i want to ask questions. are there any alternatives to models out there that we can do a comparison because ultimately this is really about like improving health outcome and reducing rehospitalizations for these acute care patients and for my experience, a lot of people prefer to go home than to go somewhere else also. if we have the complete picture what was the plethora of care that's possible that's not necessarily

rely on the snp's because from what i'm hearing also is the census doesn't match the number of beds right now anyway. if we don't do something different we will have arguing around and around. that's my sense of it. >> commissioner patting? >> to summarize, i think this is a good problem to have. with the expansion specifically brought in new dollars into the system and chasing the same resources. this is the idea that more people are getting care, the more people are getting the right care and the right place. the problem now we need to look for new partnerships and use this as an opportunity to build and develop public and private partnerships. this is the way we need to go. there is not really a public and private system. it one health care system but we have been looking

at it -- for a long time. if we build the system t whole palate iv care network. dollars will flow and it's a good problem that was anticipated. we are glad to be here. >> i just gave you a report about the medical respite that the department is going to be opening. we are leaving an opportunity for some of the partners to look into those beds to partner with us. we'll be talking to all of them about that where we will also have that conversation with kaiser and looking to private providers to look into this care particularly the homeless population who don't have a place to go

home to heal other than the shelter system. that's an opportunity already that the department will be offering and we'll be working with our providers in the community to look at who would like to share with us in that process. >> in terms of the resolve, it occurs to me that what is not just report on what are the needs but recommendations for what to do about them. if we can expand that to include some ideas. >> an actual plan associated. >> it also goes with dr. chung. the other part is i don't know the law particularly well for this proposition q. has it been the case that we request and this is to the present to the chair and the director that when any facility, it's not just about a resolution, request something that would offset it to the other

thing. it will do this but will do this to sort of scratch the surface of what we are trying to get at now that this is a systems issue that if you do change something it's going to change anything else. is that part of the part q? >> it hasn't been. it's really around patient dumping in making sure that entities do not push patients out of services. that's one of the reasons that president chow asked us to look at that prop q to strengthen it in the time of today, the 21st century and is it still relative. it gives you according to the city attorney a lot of the ability to add that and we haven't had that. we've only had the determination, the ones that i have seen and we need to get further into the solution to the closure of the

program. sometimes the program closure may not have a big impact on other levels of care, but this would have one. that's the call of the commission i think he's done some good negotiations amongst us to figure out how to best solve the problem versus just making a statement. >> it occurs me moving forward that we start encouraging that part of the work. the one change but this is a good idea for the other side. >> yes, you are correct t proposition came about in part because of concern due to economic reasons there were changes in services and wasn't always being clear or transparent what was happening first all of. things happening without any notification and this notification to the public. if you are going to build an addition to your

house you have to post something and this became the posting and there would be changes because of a more strict interpretation of the proposition then the commission has been using only the strict words we need to find a determination. city attorney has looked more broadly at this and this is taking a new step towards trying to take the opportunity as commissioner singer has said to really use what might be happening i think it's well-spoken that there should be alternatives because as in the proposition to read it that the commission should be seeking alternatives. people have come to us before and last year they did telling us where they were going to put these patients. we want to go further than that. the question being within the continuity of care and under our new health care reform can we do

better and therefore turn the proposition turn prop q into a positive hearing rather than just simply saying do we find something bad or it's neutral at best. and so, i think this allows us that opportunity and the reason we've crafted it this way was to take advantage of that and be able to answer these questions and move the topic so that not only do we have the transparency and the public has been aware of this and if it's a real burning issue it can come before us as it has in the past but if not also understanding how it fits into our new continuum of care. that's exactly where i'm pleased the commission is to go so we can take advantage of that and find the best we can do for what is happening. are there further comments at this point? are we prepared for the

vote? i'm sorry. was there public comment? >> thank you. i'm patrick shaw. this commission had a hearing regarding cpm that it would have a detrimental impact on the community and now you are facing this same issue today. it's not about st. mary's closing snp beds since it's closing the license. closing 42% between 2002-2013 and by 2015 there was another decline to 2007 beds

citywide. at least another 56 beds will vanish by 2020. the beds will have declined between 2002-2020 by a whopping 42%. ms. pattel notes a long wait in san francisco because there has not been a 31-42% increase community base post acute care alternatives. i urge you to vote that st. mary's snp closures like cpmc will be detrimental to the community. the hospital base snp beds is very significant in a 1 year period. you need to get consistent with

your proposition ruling and that closing will be detrimental. commissioner chung might know that snp's out of county discharge data can help inform community base post acute planning. this commission has an obligation to report transparently to san francisco just how wide discharges are to the community. we have a right to know this data. supervisors campos, peppers director garcia about discharge location data on march 20, 2014, to learn whether patients were being dumped out of county or integrated into san francisco communities. dph has refused to provide historical data on discharges or admission diversions out of county since 2003. it's

unknown why dph struggles so widely for this release. from the delta campus on march 20th. "there is a crisis. we don't have enough nursing beds. they are gone. they now specialize in short-term rehab" you should notify garcia for out of time discharge data so it will help you inform your discussions about community based post acute care. commissioner chung, demand that data. >> commissioner # garcia, that

data that you show 8% go to long-term snp's. 76% either go home or unfortunately pass. i want to make sure we calibrated on the size of the issue that we have. >> that's the data we have collected. >> are there further comments. >> the resolution doesn't have on the first sentence "will or will not" to be clear for the record, you are proposing -- >> we'll correct the title of the resolution. it is not "will or

will not". it's actually, we have to revise the title of the resolution because we are not finding "will or will not" we are instead resolving that skilled nursing bed closed. we'll need to have post acute care or found not to be helpful to the health of the city. it's a different finding. >> so, commissioners as you often do with resolutions there can be tweaking of language if you approve the body of the language and send out the revised title. >> we'll retitle. the body of the resolution is the important issue. >> thank you for catching that. >> once again i will reem phasize that the district attorney as indicated

discretion. >> all in favor say, "aye". >> aye. >> any opposed? >> the resolution is passed. >> item 8. >> this might be to our benefit, a future meeting to have an agenda item to look at the history of prop q as well as you know the changes in the snp beds in san francisco and some protection. >> a request from president chow at the last meeting. >> right, we'll wrap it into the report that may come in 6 months or else do it separately in terms of another item in terms of background for prop q. thank you. >> can we go on to the next.

>> i will reannounce. >> thank you for the people who have come. >> i will announce it again. responding to the increasing std's in san francisco. >> i'm the director of disease and control branch with the health department. i'm here to represent the work of many colleagues and many individuals throughout the city in responding to std's in san francisco. so our vision for san francisco is very broad. it's broader than just std's. we are focusing on an audacious goal for sexual health for every individual. the world health organization described social health and physical and

social well being. it's not merely the absence of disease. so having said that, std's and hiv are still important focus of our work in order to improve optimal health. but it's a piece of overall sexual health. secretary moore width has a great suggestion of putting this in context of optimizing health and supporting people throughout san francisco and within disease prevention and control we are responsible for operation of city clinic which is the sole municipal clinic and capitol -- clinical and biomedical in std's and hiv. it's led by