adjournment. >> madam chair. >> yes. the meeting is adjourned at >> the second will call the roll. >> commissioner singer. commissioner chow. >> present. >> commissioner chung. >> present. >> and commissioner karshmer. >> here. >> and we're expecting commissioner sanchez so we're leaving the see the for him.

the second item on the agenda is apporval of the minutes for 2016. >> so a motion is in order. >> move. >> and a second please. >> second. >> are there any corrections to the minutes? if not then all those in favor of the minutes -- please. >> [inaudible] (off mic). >> of the commission, the minutes -- right? >> (inaudible). >> yeah, it's at the top of the page. are you looking at the second part of the statement? >> do you see them? >> [inaudible] >> here. >> (inaudible). >> you're okay? >> [inaudible] >> okay. any further corrections? if not all in favor of the minutes as written please say aye. >> aye.

>> all those opposed? the minutes have been approved. >> the next item on the agenda is the director's report. >> well, good afternoon commissioners. i wanted to announce we won the bond prop a by 79% of the voters and we're appreciative of the voters believe to create more seismically safe and accessible buildings and as you know it's a $272 million bond where 222 million will go into our hospital and that is for outpatient programming like dialysis, urgent care, bringing some of the clinics integrated into the building and help our partners to make sure they're in safe buildings and $30 million will go into the southeast center and integrating primary care and health services and

$20 million of service centers for seismic and supportive services as well as renovations, so we will bring you a plan for this because we now start on another bond process and as you experienced the way we did the rebuild out of the hospital and we will do that format and give you updates as we move along the process of the bond completion. as you know the department of public health we're sadly shaken by at wake of another mass shooting in our country. we believe that the department of public health violence is a public health crisis. during this time we sent out a letter i had a statement in the director's report and made sure people know the 800 line and the access line and the employee assistance line. we sent this out to not only just the

partner folks but we sent it to physicians in the community and our community-based organizations and we're working with the pride parade this coming sunday and we will have a booth of mental health clinicians that will be able to provide support to any individuals coming out. we are exploring what is coming into the 800 line and i know the staff is developing a report from that. on wednesday mayor lee announced two steps in the city's quest to get to zero. over four years ago i approach the two hiv planning councils. one, these councils were created by the federal government to ensure that people impacted affected by hiv were incorporated into providing direction to local government, and also state government and though their roles are at times

prioritization, identifying new needs and we work closely with those and appointed by the mayor and the supervisors. what i asked them to do now considering the fact with prevention was treatment and treatment was prevention for them to come together. it took a couple of years to get to that conclusion as well and they announced that and the mayor appointed the new members of the committee on wednesday so we're happy with that as well we're starting a new campaign and you will hear about that today and in prevention of hiv and we will be the first city to look at hiv infections trying to get to zero so you will hear more about that in the presentation. theresa sparks who was named to the mayor's initiative and transgender initiative and the first in the city to the advance of rights and creating policy for the transgender community.

we will be meeting very shortly i know she is an incredible applicant and i look forward to working with her. undocumented immigrantses in california moved closer to purchase health insurance and governor brown signed a bill for unauthorized residents to participate in the state's insurance exchange. senate bill ten asked for a waiver for them to purchase plans in california and i will end with this but we had the first step closer to our commitment to dph apex and the electronic record is what we're calling it and we had a meeting on the eighth and apex stands for advanced patient-centered excellence and we had our ucsf partners at the meetings and

dolt presentations from them and yourself and i will stop there and if there are questions on any other item. thank you commissioners. >> commissioners? commissioner singer? oh sorry. >> [inaudible] >> well, thank you and congratulations. if i recall the prop a passed by greater than 80%. >> thanks for all of r of you that voted for it. >> yeah, it was a great deal of work on your part i know and getting the word out to the different organizations. commissioners any other questions at this time for the director's report? >> if i could just acknowledge one person that works for us closely in our capital that did extremely amount of work for prop a and mark primo. i know he's not here tonight. you will see him when we do presentations. he did an outstanding job of organizing

folks from all over and he even sponsored a fundraiser himself and just to note that ucsf sponsored a fundraiser which we really appreciated. >> very good. thank you. we will move on -- was there any public comment? >> no public comment requests for the item and we move to general public comment and i have received no requests and we can move to item 5 and the presentation on the primary care medi-cal waiver. dr. hammer. >> i know i can find it. thank you. hello. i am hali

hammer, the director of primary care. thank you for the opportunity to present to you the primary care and the waves. this is the presentation i gave to the public health committee last month and i was invited to present to you all and i really appreciate the opportunity to do that. i'm going to speak specifically about the work we're doing in primary care to implement the waivers. most of the projects are based in primary care. if you would like to hear more about some of the other projects i will try to answer them. we can also bring those questions to the project leads for the other projects. i also would like to introduce patrick oh who is the lead for the prime project and he will be available to zero questions also so the new state wide waiver is

medi-cal waiver 2020 and when the san francisco leadership were identifying nine key tactics to focus our work over this last year we identified one as that we will leverage the new state wide waiver programs to align care finances and clinical outcomes really to be an accountable care organization. these waiver programs are the public hospital redesign and incentives and medi-cal program also known as prime and gpp global payment program and the public hospital redesign and incentives and today i will talk about the first two and we're deep in the plannings process and implementing. the other two haven't quite gotten to the point of implementation but we can answer questions about those so first prime. prime is built on the success we had with

dsrip. i will talk in detail -- mostly in detail about prime but the vision is to improve the quality and value of care provided by san francisco safety net hospitals and hospital systems so it's really a large quality -- population quality improvement program. the global payment program is completely different. it combines the old safety net care pool and the disproportionate share funding. the target population is the remaining uninsured people and the vision for prime is to incentivize care at the right time, right place, and right care. prime -- first. it's an extension as i think of dsrip and looking over the last five years the work we did for the last waiver, the five year waiver from 2010 to 2015 so we were able to make significant

progress in terms of building the infrastructure to support a more so misindicated population heavily improvement program than the past and thanks to dsrip we have the nurse advice line. we have significantly improved access to specialty care. we have comprehensive safety program and new approach to overview and a lot of the -- hiv and a lot of things are listed from the reports that we have given on the program. this incentivizes us to improve rather than just to build systems for improvement so we have to show improvement. this slide lists the major differences between dsrip and prime of importance and i want to note there is no new funding relative to districts so we're expecting to continue to achieve and improve any in project in order to receive the same level

of funding, and also really, really important for us because our quality improvement work has always focused on our active patients prime asks us to widen our vision, our population of focus, to include people who have enrolled for care with us but we have not yet seen them so not just active patients. it also incentivizes us to improve over our own baseline and narrow the gap how we're doing right now which is quite well in most of the areas for population health but narrow the gap between that and the medicaid percentile. our planning process to date has included identifying a project lead. we're pleased to have patrick oh as well as it joining us and the executive

ellen chen we named a co-lead and reena gupta and joining the team in july and works with the peoples clinic and expert on care and transformation. we believe putting together for the ten projects which i will show you in a minute, and really defining the roles of each of the teams putting a lot of work into the data definitions for each of these new measures. a lot of them are novel measures, things we haven't measured in the past and can't easily extract from our information systems so a lot of challenges for that and we had the prime kick off and a great success and brings leaders from the network and the san francisco planned

partners with this work so these are the seven required projects, and i won't go into too much detail about each of the projects but we've identified project leads and are putting together our data and analytic teams and project managers for each of the projects. the projects fall into patient delivery system, transformation and projects targeting high risk or high cost populations, so all counties work on these seven projects and then we were asked to choose three additional optional projects, and we choose these, and there's a lot of work, a lot of thought that went into choosing these three projects. the first was public hospital redesign and choose million

hearts and due with health outcomes and dir parities and blood pressure control and other complete speaker cards and documents to be part of the file should be submitted disease -- cardiovascular -- >> that's the -- >> black african-american health initiative. >> that's fine. i wanted them to know. >> so million hearts has to do with the work with that initiative and chronic non-malignant pain. we choose that one because we have a really new exciting initiative based in primary care is the first one, the integrated pain management program that brings in complementary modalities to improve chronic pain outcomes and partnered with the new pain clinic in the department of anesthesiology at san francisco general and we wanted to focus

effort here and measure outcomes to see if we could improve outcomes for people living with non-malignant chronic pain. the next is the chief pharmacy officer david woods and it's in the area of resource utilization targeting high cost pharmaceuticals. i know we're looking at adherence to high cost pharmaceuticals for instance medications for treatment of hepatitis c treatment. these are a few examples of the pie metrics. there are 57 i think rough count and the thing to note about these they look fairly straightforward. yeah, we should know how many babies are breastfeeding. the devil is in the details and pulling the information as well as the metrics to include patients we

haven't yet seen working with the health plan to get data about those enrolled individuals as well. so now switching to the global payment program so the global payment program again is really just focused on our decreasing number of uninsured people in the network. it's a point based system and what it does it incentivizes us to really look at a whole person approach to care. incentivize us to provide non traditional care for people including things like acupuncture, health code chain, nurses, telephone visits by a provider and we in the health network have done a great job with those in the past but not reimbursed with those and with the global payment program

we will be able to -- sorry, i lost my train of thought, be reimbursed for some of the non traditional types of visits. so this is a schematic that just shows sort of and summarizes the progression, the evolution of our approach to quality improvement and population health improvement in the san francisco health network so not that long ago i would say about ten, 12 years ago we prided ourselves on doing a great job for the people that came to us for care so we provided excellent primary care. we had great specialists, great in patient care, but then with healthy san francisco we were really mandated to move to a medical home of population home approach for all active

patients so really to -- we were asked to capture clinical information about all the people we were taking care of, and then to design our quality improvement programs based on this population health approach, so really looking at all the people who are accessing care. with dsrip that really widened our scope of who we were collecting data on, who we were improving health, improving the experience of care to include everybody who presents for care in our health network so including people that come to the hospital, whole medical neighborhood so shared responsibilities for patient care. making sure they could call to get an appointment, to get nurse advice over the phone, so really this much more holistic shared responsibility care approach and with the new

medi-cal programs we are being asked to look at integrating care for our whole enrolled population so really widening about a third or so of our patients of the people who enrolled and see us for primary care. a third we haven't seen yet so this asks us to take responsibility for those people. if they're just using the emergency room or hospitalized or using behavioral health services we want them in primary care because it's the best way to manage their health so this program really intd cent vises again to be accountable for the care of the whole population of people. these are the next steps in terms of implementation of prime and gpp. we're working hard on defining all the data. that takes a huge amount of work and patrick is leading that work putting together the teams

making sure we have the data analytic support we need to do this work, and then the other thing is take a step back and make sure that all of our initiatives especially in primary care are well aligned with where prime is asking us to go and that's been something of a challenge because we have a lot of different initiatives so to bring them together and say they're the true north. they align with with prime and gpp as well as black and african-american health and some other important drivers of improvement in hour network. this is the vision for primary care. prime and the global payment program as well as whole person care and the dental initiative are huge programs that take a lot of work that we're struggling to keep up with you know creating data systems to be able to report and

improve on 57 different metrics but as i mentioned earlier all of us working on this feel this is the right way to go. it's where we know -- they're areas that we have to improve in order to help us achieve the vision of being the first choice, our patient's first choice for health care and well being, and just really in three different areas through reimbursing for non traditional visits so supporting us to build a multi-disciplinary team approach to care. it also supports our whole person approach to care, and also helps us move towards a value based payment approach and away from the old fee for service model so we're excited about the two programs, excited about the direction of health care that these represent, and also i think ready for the challenge. and i would be happy to answer

any questions. >> commissioner singer. >> [inaudible] (off mic). >> please speak into the microphone commissioner. >> is that better? >> sure. >> thanks for that presentation. i have a couple of questions just to make sure i understand so you talked about developing data metrics for each of the 57 trics. are they state mandated metrics that also have definition sorry do we have freedom to define them? >> some of the measures are defined and pretty much everybody knows what you are talking about when you say improved blood pressure control let's say. the thing that is challenging with prime is we're really changing -- usually the denominator so who is the population of focus? for instance we counted active

patients as anyone that had a medical visit in the last two years. with prime and most other health systems we're moving towards defining active over the last year. we have -- you know, changing -- let's see. you could probably talk patrick about the prenatal measures and we haven't been measuring in the way prime asked us to do and the first part of the question whether it's our work. they're state wide discussions where representatives from all of the counties are trying to get clear so what do you mean by improving this and coming up with that? then it's on us to go back to our it folks and our data center and say can we get that information? well, we can get that information if we make this change to the emr so we ask collect the data for the information. does that answer the question? >> [inaudible] >> okay.

>> so for most measurements you get prescribed by the state and others there's a discussion going on among all parties to figure out okay what's the best way to measure this and okay now that we settled on that how do we define? >> right. a good example is chronic pain. there are not heata measures and national measures attached to chronic pain management. we may know what it looks like but in terms of pulling data from the electronic health record and show that we're providing excellent pain care is really, really challenging because really to do that you need to have a lot of information that we don't normally put into the electronic health record, so if i am managing someone with chronic pain i want to make sure i am assessing their quality of

life. i have an agreement with them how they use their controlled substances. i am checking their urine for other substances regularly so a lot of different things that may not be in the clinical information system. >> and now for the gpp, two questions. the first is how many people live in san francisco that will be treated under this? >> so this -- >> [inaudible] >> so this is just our uninsured patients within the health network, so for us let's see -- barbara help me out with this or colleen so it's about 8,000 active patients i think we have right now? >> [inaudible] (off mic). >> but in the health network so it's about 8,000 i think that we have -- 7,000 or 8,000 who

are active patients so those are the people that we will be counting as the denominator -- not really that but our population of focus for these new non traditional accounts that we collect. >> colleen how many people did we find in the uninsured category? >> total but not enrolled in our clinics? >> [inaudible] >> just so i understand the point system -- >> yeah. >> so when you say "non traditional" is that the out patient -- is it a portion -- >> no, it's really the previously what we think of non billable visits so nurse individual visits. nurses are reimbursable under special programs and prenatal and nurse and group visits that are non medical visits and support

groups. navigation, health code chain, acupuncture. >> yeah, you gave us a list but that is outside 3.4 million points. >> no, we get points -- every time we provide one of those services to an uninsured person if we capture it we get a certain amount of points for that particular visit so we're trying to get to 3.4 million. >> okay. but -- >> and we get a lot of poin as you see on the slide for in patient stay or er visit or face-to-face encounter with a physician but during the course of the program we will get more and more points for the out patient services. >> so next year will there be another line on this summary for 15-16 that says this is 14-15 and says non traditional visits or will those be in one of the

existing -- [inaudible] >> i think the types of visits will be the same. the number of points allotted will shift each year. that's my understanding and less for ed visits and in patient stays and more for the out patient visits. >> when you say non traditional is that part of this outcome visit bucket? >> when i say non traditional i mean previously non billable, so when i say non traditional i'm not thinking of a face-to-face physician ent counter or a visit with a health coach or health provider. >> but it has to be in one of the four buckets? >> oh there's a list about 40 sorts of different visits. >> i got it. >> yeah, we just put them in the buckets and actually -- >> [inaudible] (off mic). >> so these four buckets -- these are the buckets that were used to calculate that 3.4

million point total. that did not include most of these listed here. >> i got it. [inaudible] >> so the goal is for us to move away from the traditional reimbursable visits and provide what we think of also high value services that we previously haven't been reimbursed for. i'm sorry. >> and the policy concept here is that if the state reimburses us we're more likely to take advantage of these novel -- not novel but non traditional modalities for the benefit of -- [inaudible] is that the basic logic? okay. >> also commissioners we do a lot of this work but never get credit for it so navigating people to the programming. >> [inaudible] >> yeah, probably but we do a lot that we don't count now. >> a couple of the ones that are great is shift to doing more

-- what i think of total panel management and i as a primary care provider can manage the patients -- i have 80 year old patients that take two buses to get to general to visit me. i can convince my medical director my time is well spent on the phone with the patients and knowing i am trying to keep them healthy and we maybe able to collect revenue. an 80 year old is not a good example and this is medi-cal but we're moving to the place of really looking at, you know, improving the health of the population, improving it is experience and access to care without having seeing them for a one-on-one visit. >> thank you. >> commissioner. >> so thank you for this because i am very excited this is the direction that the world is moving, and that we have now

some way to get back some of the work that's done done, capture some of that and through the applications and not just the uninsured but what we're doing moving forward. i just have a couple of thoughts so we get to define the non traditional kinds of care or they're defined? >> no. they're well defined. our challenge is standardize the way we register in the mdr. we register and document in a standard way and we code in a standard way so for instance right now i call patients everyday and i don't document that at all. i just help my patients by doing that and provides follow up care. now what we're working on is standardizing and making hopefully not too hard a way that providers who can -- whose telephone care we can capture through gpp so they can document clearly when they provide care over the phone so we can

collect, and it's a lot of points. you get a lot of points for each telephone visit. >> does it include home visitation? >> it does. >> the other thing will the county wide, state share the point system across and know what other folks are doing? >> yes. >> publicly reported. >> i believe so and i don't know what the reporting mechanism is but you probably do colleen. >> [inaudible] >> yeah. for dsrip we could see how the other counties are doing. >> so we know how we're doing compared to others. and the last question is about the work force development. you have in your -- the bottom line -- or second -- build a foundation of healthy engaged and primary care work force. what thoughts do you have about that? how will you make that patient of this initiative? >> great. we think one of the best ways to build a healthy

and engaged work force is develop a team based model of care really to train our work force so they're doing work which is aligned with their training with their license or with their certification so that they really share the care especially in the care of our most complex patients that we serve, and what this does i think it places -- especially -- well, we were just talking about gpp so i am thinking about that but it places value on the care provided by nurses and by other members of the team, by health coaches, by navigators and also one thing i am tremendously excited about and we haven't yet decided to what extent we're going to pursue the dental initiative, but really this whole person approach to care, socal cal a couple of years ago -- medi-cal reinstated benefits

for adults with medi-cal and this really -- that initiative asks us to look outside the four walls and see how we can really improve thor alhealth of our whole population. i am excited about that. i think that is part of work force development. >> as you unfold this and as you present to the commission and what is going on and your successes i look forward to what kinds of activities that focus on work force whether it's developing health coaches, training health coaches -- >> let me give you one example you will like to hear about and one of the areas for the black and african-american health initiative and improving blood pressure control and improving disparities in this area. in primary care one of the really great initiatives we have done is to go teach every medical assistant how to take blood

pressure correctly, how to talk to their patients about blood pressure, how to help the patients relax so if the first reading is high they can reposition them, move them to a different room, retake it and talk to the patient. you would be amazed. a number of our clinics how empowered the medical assistants are and improve th blood pressure and not what i am supposed to do and find the right medicine but talk to them how they take the medicine, how they adjust the diet and lifestyle to improve their blood pressure. we had a couple weeks ago -- i hope you heard about it at southeast center and community outreach days ifed on healthy hearts, improving cardiovascular outcomes and teaching the community about blood pressure and control and that is an

example of work force development and we're teaching them how to take the blood pressure correctly and talk to the people we work with how important it is to their health. >> thank you. >> we're training nurses to have one-on-one visits with patients and do medication teaching and adjustments to control blood pressure control. >> thank you. >> commissioner sanchez. >> yes. i think this is an excellent baseline to look at what is going on in some of the initiatives working for and some of the new challenges forward. >> yes. >> but as i read through it and the part that excited me the most and you mention standardized coding for [inaudible] non provider visits and in essence add to the scores over time -- >> right. because they weren't counted at all. >> and at the same time we're seeing a number of innovations

pertaining to large programs where nurse visits are even more critical today as you mentioned and ambassadors and in reference to the growing number of elderly in certain areas in certain cities they're finding it's more cost effective and quality care and physicians are spending time visiting "the quality of care, the quality of life where the patients actually life". >> right. >> and goes back to the community medicine model the quality of care and the home environment are critical variables. if you send that patient home and has asthma and on this or that and go back in one particular room old victorian that bring on and the recent fire in the mission and these homes and some have

seven, children and seniors and two generations and the thing that excites me the most we're coding some of the new data whether the visitors whether a nurse, ambassador, primary care doctor or resident that makes a visit there could enter one fact they have observed. i am saying this because we've had too many of these fires particularly in the mission sector among these old victorians. i don't want to get involved in a number but we had and there's a number of variables that affect this. at the same time we have a number of inspectors based on regulations from different agencies, you know, even our health department is now involved in inspecting apartment units and inspecting rooms, passage ways where the owners have to pay fees to the department and then they get inspected for if there's bed bugs, if there's rats, if

there's access, a broken panel, if there's a number of variables that our inspectors write down in code. that same building could have inspected by a fire inspector who is written multitude of things and puts it down and his book. then the building codes come out and they come out and inspect so you have about four, five city agencies and zero in on some of the places where our patients live, but somehow there's no integration or sharing of that data. i mean it would have been interesting had there been some common data we have a chance to integrate in some coding model and get money from them or others and this affects the quality of life for our children and elderly in these areas if we had integrated data and showed there was a multitude of violations from the fire department, from the health department, whatever and

nothing has been done but everybody has their own individual file we might have saved lives and improved the quality -- this not only applies to ik torians but think of sunnydale and potrero hill and we have the mass units where people can't get their water or plumbing fixed, rats -- you know and yet our doctors and students know these things exist and the patients go back stot environmental areas that are not changing. all i am saying as i read through this wow this gives us a unique opportunity to not only recode and integrate some of these -- i mean data is fine but unless you can actually share it among the different agencies and services and put it in the coding and show

these are variables we're looking at and really make a difference in the quality of service and patients and follow up and how we address the public health and the health primary care of our city. i know i am sort of long winded but it seems like a great opportunity we play and facilitator. you're going to the prime movers over the years. what a great chance to restart it again. >> yeah, i am a big believer in home based care. i didn't talk about the home kairs initiative and separate but it's amazing to do an inventory and where are all the places we're providing in home care and if we succeed, which will help us to do and standardize the way we collect information about what we're seeing , what we're providing, and then you know the next level would be to see what's most value added in terms of improving the health of our

patients keeping them out of the hospital and keeping them healthy, and the next level you're talking about which is collaborating with other non dph and other city departments is exciting. >> just a note on that and two issues dr. sanchez that's one of the recommendations that our environmental health department through that policy and around that but as you recall we have this in the tenderloin and we have fire after fire after fire that the department responded to and we did a whole sro work with tenants because part of it was some the ways they have their electrical currents and et cetera and of course the building owners so i totally agree with you and a recommendation we're trying to push forward but we do have to do something around the sros and had a successful model in the tenderloin and didn't have the

fires anymore and involve the tenants in the safety precautions on that and we will follow up with you and the commission on that. >> thank you. >> commissioner chung. >> so this is really from the finance and planning perspective because i am excited to also hear about the non traditional type of services that now we would have a chance to like look at doing them and gets me to think the first thing within our housing and facilities program how much of the services that we have been providing all these time that are deemed unbillables such as health workers like doing wellness check can be billed and i am interested in if there is a way for us to get a follow up presentations on the cost saving aspects of it, and when we think that we can actually have some of the numbers coming back? i think

that is a really important piece. you know we have been doing master lease programs for over a decade. we have health workers. that is part of the team and providing like peer driven support, but you know like almost it sounds like this is the one chance that we have to really look at how to incorporate all that into our primary care models and i am really excited about that. >> yeah. i am excited too. i think -- >> somebody else is paying for that paycheck, yeah. so can we schedule something. >> i wonder if you could respond to how we can get some of that -- >> probably need to have a time frame because that was one of my questions with all this work and you know you're out the front door all right, right, and

you're galloping along and i was going to ask how are we able to capture the data for this year? are we really close to it? you know what's the percentage because this gets to the whole question of what finances are. >> right. in answer to the question about this year for a global payment program the number i saw that we're estimated about 94% of the way to our target number for this year. we will know in a couple of months whether we hit o targets. that is for the primary care and doesn't include the mental health visits and they're still collecting that. i will let staff answer the question but commissioner chung i think what you're getting at this is a five year waiver and we think this is the last of these waivers so this is really our push to say who are the

people whose health were responsible for in the health network? and what services are we providing that are actually leading to better outcomes? and are we measuring that? are we keeping track of how -- you know the investments we're making which you referred to, are they really leading to better health? are they keeping people out of the hospital and lead more vibrant and healthy lives? that's the question we're going to be asking over the five years because we're not going to continue to get encountered based payments even for the non traditional visits. we have to show we're actually improving peoples' health and experience with health. >> i would love to know how it is progressing along and what we can do to have follow up conversations. >> yeah, absolutely. >> so just a couple of things. is this is a teafl two or more

cities. at the beginning hali mentioned there is no additional funding for these initiatives so we're excited that they're allowing us to capture and receive reimbursements for these services that we've not able to bill for before, but it's coming from the same pot of money so it's not we're getting new additional revenue. it's just redistributing what we're getting and allowing us to at least to the greatest extent possible have a source to offset what had been traditionally general fund supported. in terms of particularly the accounting for those non traditional visits valerie inouye, the cfo is the lead on gpp. she presented to the group several months ago. really all the work that has been done over

the last nine months and working with all of the units that have anything at all to do with some of these non traditional visits like maternal child health where they do the home visits. working with them as hali said how do we capture within the electronic system because that's the one source of truth that we're actually validated against when the state comes to do the retrospective audits when we report the numbers to validate they're real and exist, so there's tremendous amount of work done within every sector of the -- not only the network but other parts of the department to capture the non traditional visits and keep all of these groups and the commission updated in terms of where we are with the numbers and commissioner karshmer, yes, we will be able to see what the other counties are doing. it's all transparent reporting and i think everyone is struggling to

optimize to the greatest extent what they can do within their existing ehrs. >> i will ask a broader question while you're there the presentation speaks to and dr. hammer you already said this is really related to what you're doing in primary care and there are other areas and even within that you haven't spokenning about the [inaudible] program or the dental transformation and as mentioned there is the still the same thought and in fact it's more difficult to get to the entire pot in regards how it's redistributed and we're counting other things but there are many other things such as some of the in patient measures they have dropped and therefore we're -- if we can make the case and this might be the end of the five year waiver coming up to five

years but nevertheless if these things really do work they will probably put them into ply -- play as part of the primary care or accountable care and put it into a payment mechanism and this is a good experience to see as we [inaudible] (low audio) and what are the outcomes and how well people do. what i am asking here is now that we're getting into the medi-cal 2020 and seen one segment and i know you had a presentation of these are the pots. what is the our opportunity and how we would best then illuminate the other segments of this initiative and what timelines do we have for those that are comparable to where we are in primary care? >> sure. i am scheduled to give the full commission an update on the network on

august 2 with emphasis on the whole person care program which is one of the components so you will receive a more in-depth review of where we are with the whole person care initiative. as hali stated we're still in the process of drafting what our proposal is to the state and the state then has to send it on to cms but at least we will come to you in august to show where we are now and in terms of our thinking with that program and do the same thing with the dental initiative and the drug medi-cal waiver. >> okay. because then what we're going to have to do is figure out how we continue to work with you and track this and whether it be in segments or is it best as a full commission or what? this is certainly the beginning of understanding this new world, right, of reimbursement under the new waiver program, so commissioners

any other requests? >> i would suggest that we keep it under the san francisco health network report and remember these are services for the uninsured, not the medi-cal population so in terms of that piece -- the global. >> true -- [inaudible] >> i will ask the network staff to do is really kind of -- >> okay. >> -- model for your report back as part of their overall reporting and track this. >> perhaps what we need to see -- okay. this is the entire medi-cal waiver and this is the portion we're talking about and this another portion and make sure we're able to piece these all together and understand what the entire apple looks like. >> we could do that. >> okay. a few mixed metaphors there. sorry. commissioners any other questions at this point? this has been very helpful to begin to see how the work is rolling out and how we're taking a portion of it and then as we understand the other portions i

think it will help all of us understand what medi-cal 2020 is all about and what we're expecting to have to do. all right. >> commissioners anything else? if not we will proceed to the next item and thank you for the presentation. >> commissioners i will note there were no public comment requests for that item. item 6 is expanding prep access and implementation in san francisco. >> good afternoon and thanks for the opportunity to give you an update on where we are with expanding access to prep and with prep implementation in

san francisco. my name is stephanie cohen, the medical director at san francisco city clinic and we're in the disease prevention and control branch and with them we're collaborating with others in the health division including the community equity and approaches branch and cri and bridge to support implementation and working with the san francisco health network and the primary carry clinics. as a reminder our accreditation domain is assurance of healthy places and healthy people. dpc includes std prevention and control and communicable disease and prevention and public health

laboratory and control and this branch is under the direction of dr. seuss an philip. we are part of a citywide effort to support prep implementation. as you know prep implementation is one of the four major initiatives of the getting to zero consortium and "getting to zero" is really a multisector collaboration across all of the group listed on the slide. there are a number of community partners with prep access and implementation. this is not a complete list but certainly san francisco aids foundation, api wellness, health alliance project, project inform, shanty, center for aids prevention studies, aids education and hiv and std prevention are playing critical roles. in addition there are providers and health systems increasing prep access for patients with large numbers of

patients on prep at san francisco kaiser, one medical group, ucsf and many private providers in san francisco now offering prep to the patients. within the san francisco health network ward 86 has a prep program under the leadership of dr. hymen scott and him and myself and other colleagues have been providing technical assistance to the san francisco health network clinics to integrate prep into primary care and then within the population health division there's a large number of initiatives going on. we have funded four community based prep navigators who are embedded at health alliance project and api and san francisco health foundation. city clinic has a large prep program and initiated 800 individuals on prep since we

offered it through a funded demonstration project. bridge hiv has been awarded a grant from the california hiv research project to do a transgender prep demonstration project and ph.d. has been awarded a large grant from the cdc and project pride and number of components of project pride to increase awareness to prep and access to prep and include a special marketing campaign which i will speak about in a few minutes, a popular leader intervention, access to prep navigation, using what we call data to prep really using the std and hiv survivance data to identify providers that need additional technical assistance and training around prep and

identify individuals in communities who are highest risk for hiv and may benefit from prep. the center for learning and innovation is developing some communities of practice to bring together key staff who are involved in prep work. for instance prep navigators as well as providers to provide ongoing trainings and dissemination of best practices across those groups and lastly we're launching a public health detailing effort. this is modeled on the concept of pharmaceutical detailing where we have trained staff who will go out and working with providers one-on-one and providing brief educational sessions on prep. here we summarize the "getting to zero" 2016 prep goals and priorities which were to create a sustainable model of delivery by building capacity, enhancing

funding and a network of prep navigators. secondly to improve access to prep for populations that are currently underserved specifically to youth, trans women and men, men who have men of color, people that use drugs and those with history of incarceration. helping to coordinate social marketing campaigns because there's a lot of folks involved in prep and we're working to have consistent messaging across campaigns and make sure they reach all of the diverse populations, and that we're reaching into neighborhoods and working with community organizations to reach populations at risk and monitor our progress and use data to inform strategies and decisions by integrating data from diverse sources. some of the highlights of the "getting to zero" prep efforts for 2017-16 include launching a prep ambassador

program, funding -- not specifically funding but having over ten pref pref navigators from a variety of sources from clinics and cbos and prep delivery is now expanded to over 30 clinics in san francisco and that number increases everyday. over 100 clinical providers and 50 hiv counselors have been trained on prep delivery and counseling and referrals and navigation and we have established a city-wide prep navigator group meeting on a regular basis. i think some additional highlights here are the please prep me website. this was spearheaded by shannon weber who is the program director at hive. it's a great resource where people can go on the web and find a prep provider near them. you see images of the ambassadors doing

outreach at the folsom street fair and the effort was really an effort that was launched by the prep users sub-committee of the prep committee of "getting to zero" entirely volunteer effort. i wanted to show highlights from the social marketing campaign that we in ph.d. -- really it went live yesterday. this is funded through project pride and the campaign if you haven't been in civic center bart it's all over the bart station. there is muni lines wrapped with these images and the campaign will be out in the community with a lot of high visibility during pride and will be up through the end of july. this campaign really celebrates the fact that prep is revolutionary hiv prevention tool and aiming to reach young men of color and trans women.

there is a website associated with the campaign as well and has additional information on prep. it has phone line to the city-wide prep navigator and email address for clinicians who want clinical consult aitionz or education around prep. all of these efforts are having an effect. this slide shows the percent of patient at city clinic who report they heard of prep in blue and they were on prep in red and you can see from 2011 to 2016 there were an exponential increase in the percent of patients who heard of prep with over 90% of the hiv negative men sex with men who have heard of prep. across the same period you see a steep rise in those that report being on prep with the latest figures now being about a third of our patients reporting they're on prep with the

highest rates of prep use and those that report the highest levels of risk. however, can you see there's a pretty large gap between acknowledge and use and prep awareness is not the same across demographics so we see the disparities in prep knowledge by age, race, etnissity and gender. you can see here that those in the youngest group under 18 are less likely to have heard of prep and african-americans were also less likely to have heard of prep compare with whites and asians and latinos. only a third of the female patients at city clinic heard of prep but 7% of new hiv infections in san francisco are among women and prep really may not be a relevant strategy for the female clients but certainly finding those women who are at risk for

hiv and making sure they have heard of prep is a challenge and we're continuing to work on. the demographics of prep users should rereally reflect the population diagnosed with hiv in san francisco. that would give us confidence we're reaching the right population with prep. this figure here shows in blue the far left bar in the sections is the percent of those diagnosed with hiv that fall into the category and 93% of new infections among males and 11% blacks and 27% latinos, et cetera and you can compare this to the demographics of prep users at three of the major prep programs in san francisco, kaiser in the sfdph clinics in green and city clinic in purple so you can see at kaiser

-- 69% of the prep users are white compared with 45% of the newly diagnosed city-wide. i think you will see that city clinic and the san francisco health network clinics the demographics of the prep users in the program better match those newly diagnosed but we certainly have work to do and ensuring prep uptake for african-american men who have sex with men. so the population health division is working to refine and measure a prep cascade for san francisco much like we have a robust care cascade. this slide is really a draft of the cascade. there's a lot here that we still need more data to fill in and answer but you can see the cascade starts with all hiv negative men who have sex with men in san francisco. again not all of these men will be appropriate for prep and they're not all

elevated risk for hiv but it's a starting point for the cascade. again we know from city clinic, stop aids and other data sources that about 85% of those are aware of prep. in our prep demonstration project we conducted we found about half of those who are offered prep wanted it so there's a big drop off between awareness and uptake and there's questions about affordability, and then uptake and adherence. so this cascade i think will help us really figure out where we need to target our efforts in improving access to prep among those that need it most. now all of these efforts with prep scale up in addition to other hiv/aids preventions and increasing linkage and retention and care and decreasing viral suppression have caused the decline --

fantastic and impressive decline in new hiv diagnosis since 2002 and further declines between 2014 and feign but at the same time and i know you have seen the data here before rates of sex yeal transmitted diseases in san francisco are increasing and you see the divergence of the rates started the mid to late 2000s. we know from some data collected at city clinic as well as through other population surveys that the numbers of nsm men using having condomless sex have been happening for years and this article shows they're happening nationwide and show rates of condomless anal sex from 2005 to 2015 and you can

see the rates are increasing particularly in the youngest age group. the std section and disease prevention and control and chap have been working together to think how do we counsel about std prevention in this biomedical era. we conducted focus groups in 2014 and followed up by town halls and i want to summarize the quotes. i am not suggesting this is how everyone in san francisco feel but the themes were echoed in several -- in many folks that participated in the process. when it comes down it it happens -- here being an std. it's a part of sex. it's a concern but it will happen.in how to treat it and you move on from there. and another participant "go get tested every two months or so. if you have something it's treated and it's gone. you know what i mean

there is no change whatsoever so why worry about it" so again i'm not suggesting everyone feels this way but this is a sentiment out there and we feel there's a lot of opportunities to engage clients in an conversation about the sexual health goals and some of the points we convey the clients at city clinic and counseling emphasize prep doesn't prevent other stds and recommend and provide access to quarterly screenings and address other drivers of risk including substance use and mental health issues so in conclusion city-wide efforts to coordinate prep delivery are feasible and maximize prep and conducting metrics and share best practices and facilitates coordination and implementations. robust

strategies are needed to bolster std efforts in this biomedical era and an area of a lot of ongoing work and lastly additional outreach is needed to ensure prep is reaching all populations at risk for hiv. thanks for your time and i am happy to take any questions. >> commissioners? commissioner chung. >> thank you for the presentations and it definitely very educational and enlightening. one question that pops into my head right away when we're talking about the difference -- you know like groups that seems to most impacted by you know like hiv. somehow i think -- you know one of the groups i would think about but not mentioned is sex workers, so are we seeing

they're not actually at risk or -- you know like what was the rationale with naming every group except the sex workers? >> yeah, it's a great point and they're a population of concern and probably should have been mentioned. with that said i think sex workers in san francisco have been accessing sexual health services and we don't see a lot of new infections in sex workers but again they're a very important population to ensure they have access and knowledge about prep and good to include them in the list certainly. >> the reason i asked that you mentioned the teach studies and from that we also know that transgender women are more likely to have unprotected sex with a primary partner and not so much the secondary partner outside the primary relationship, so with the message to them using prep

kind of different? >> well, tell me more what you mean? >> so i think like -- you know like for men who have sex with men it's really just about taking prep because you know like they think that -- you know, having increased sexual activities translate to like -- you know, higher risk for stds but shouldn't prevent them from taking prep and be -- you know, like be -- you know, taking these preventive measures because they are exploring other sexual relationships, but for transgender women and i think in some ways it's kind of like that whole sex workers' mentality i was think going this they're less safeguards with the primary partners, you know, because

that's where the unprotected setion actually happens. that's what the teach study told us. >> i hear what you're saying. i think what you're getting at is important and the perception piece of prep uptake and some are not aware of the risk and the strategies they're using are protecting them and may not be accurate and i agree with you there and also for men who are in -- who perhaps always use condoms with casual partners and not the primary partners and the primary partner has outside partners and the risk perception piece is a challenge and there are tools for people to assess their own risk and i certainly agree and for trans women or sex workers in that situation we need to explore their own risk perception and provide them the appropriate counseling. >> one more question here is it comes up quite a bit now.

like in the positive communities when -- especially you know like hiv positive men or hiv positive women and heterosexual relationship or who is considering starting a family that the whole conversation of prep you know comes into the picture, but what kind of messaging are we actually providing those who are in that kind of situation? are we trying to say like having suppressed viral load is not enough and the partner should take prep at the same time and how do we encourage the conversations? >> yeah, that's a good question so if i am hearing you correctly in the context of this and heterosexual couple that wants to conceive and for instance the male partner is positive and undetectable and how are we counseling the female about prep. >> or vice versa.

>> certainly. the hyde -- hide program and the bay area program has a program that works with couples either the male or the female being positive partner and counsel them through the decisions and it's such an individual decision. i think a lot of times people do choose to use prep even when the primary partner is undetectable and for a long time because they want to have that absolute layer of confidence about the protection and some people having that partner who is undetectable is enough. i think we try to help people make their own decisions about it and give them all the options. >> thank you. i think that's the part that really interests me because people are looking to ask for answers sometimes, you know, like because we have so many different -- you know hiv

prevention mechanisms and including prep and that's not what we talked about here so i think you know in order to really look at the idea of having everybody having access to prep we really need it to know what is the different reasons that drive different populations, yeah, and i am glad that you know like -- you know, gay brothers are able to access it the way they do, but you know what do we need to do to translate that same kind of like ease of access for the other populations and that's something i am really interested to like hear more when you have more data to present. thank you. >> thank you. >> commissioner singer. >> thank you. so let me try

and frame my question so we have been struck for the last several years about the desperate directions of hiv infections and other stds, and i was also struck by your comment of kind of taking a play out of the pharmaceuticals reps play book and positions so my question is for the physicians and other health workers who are involved in prep and educating them is there also an effort to educate people who prescribe the meds for the other stds about all the stuff we just talked about? terms of safe sex, et cetera, et cetera? >> yeah,. >> (inaudible). >> no, absolutely. i think what we envision is detailing the -- prep detailing is the first component in a broader detailing effort that will have a lot of different content

topics that we can deliver to providers and one reason it's housed in disease prevention and control and use the strategy to talk about immunization recommendations and latent treatment and std treatment and screening and those topics. with that said the std is a critical piece of the prep detailing effort as well so we're finalizing our prep materials but they will have a big piece about the importance of std screening and how to do it and make it easy and routinized. >> that wasn't -- maybe i definitely wasn't clear so what i am interested? you have a group of people contracted stds because of the behavior you talk about and the head scratcher for a lot of people on one hand and understandable on the other how people get there and it's

already a self identified group almost. they need more education about -- not just related to prep but to other practices and this really comes from a long-term concern that it's a rare drug regimen that didn't lead to resistance organisms that given this behavior we could very well end up almost with certainty over time, right, that you will have strains of hiv. the population of hiv is enriched for strains resistant to prep and then have the graphs and not just syphilis and gonorrhea but hiv again reassert itself and since you have the population that is

much more susceptible to that event. >> thank you for the clarification. i think to the second point in terms of resistance there's a lot of data around the possible emergence of resistance to the medications and tru vatta and use of prep and i have to say that the data are quite reassuring in terms of that possibility, and i can talk for a while about that, but i want to address your first point. however, i think resistance to gonorrhea is in the future. it's coming so at first i thought that was what you were talking about with resistance and yes that's a huge area of concern and the resistance of certain medications because of prep use is not going to happen. all of the modeling suggests that scaling up prep we will actually decrease resistance by the prevention of hiv but we need to figure out ways to decrease stds because the

emergence of resistance to these infections is real and imminent threat and i hear what you're saying and that is part of the dat and the prep concept and taking this surveillance and have provider lists and target for the efforts and it's a good idea. one of the tricky things about our stds reported to us we don't know if the patient is already on prep so there's still a role for the detailing around a more comprehensive sexual health prevention tool box but a lot of patients are probably already on prep so we're working out the details of trying to use that in an efficient -- use the list in an efficient way. >> i mean the realities that the farma companies have which we should figure how to draw on

an incredible amount of experience and data what is effective and how effective you can be in the details. >> yeah. >> and independent of what you think about whether they have used it for whatever purposes the large pharmaceuticals companies it's definitely a place we could if not learn three or four levels deeper how to make sure we don't deliver too many messages, what kind of messages resonate, et cetera, et cetera, because there is no use in reinventing the wheel that we sadly spent -- these companies spent tens of hundreds of billions of dollars getting extremely sophisticated about. >> thank you, yeah. >> well, thank you also for the presentation and i am interested that we're integrating the message also that we talked about with the

rising other stds and i note that the posters carry that too and one concern when looking at the contract, right, as to how they were intending to do it so it's interesting. these however -- you have the civic center because i was just at bart. >> okay. i haven't been in there. i know there's a few out but i know the station domination hasn't happened yet but i think -- has anyone seen them at bart? and i heard there are some up and have to go when i go home. >> maybe they're up now but i came back three hours ago. >> okay. >> and it wasn't quite there or downtown and i'm not sure they put it on montgomery street and right now it's a [inaudible] they have there, but the point si am actually quite encouraged. i do think it's important that

the whole idea how much messaging you give and what you leave is really critical, and that's with detailing, and also with this type of message, so i see the message and that's good because right away with the fact that this is safe and effective. it then says oh by the way this is important. this doesn't help with the other -- so that word is out there but of course they need to realize that std is a real issue and that's where -- i was going to ask you in your trajectory of understanding people that understand that prep is there had you also surveyed how many people really understood aside from the quotes that you have how important or serious this is? because the quotes indicate this is nor more than the common cold so this is part of the problem with the

education; right? because if that is all it is i will wait out the five days or take my medication and that's it, and what would you expect as you're watching these curves of education versus acceptance of prep that you would like to see as a goal for acceptance? is it about a third where you think it is because of people who are already positive or people not? what are we aiming for as being a successful campaign? >> right. so i think dr. bob grant lead some modeling work to try to answer this question and how many people do we need on prep in san francisco to really bend the curve in and if i recall i think the estimate or goal was to get to 15,000 prep users in san francisco. we don't know exactly how many prep users we have currently.

i think the best estimate and a big range between 6,000 and 12,000 prep users, so certainly 6,000 is the minimum. that's based on really talking to the largest prep providers and how many people do you have on prep and adding it up and there is a lot of prep delivered in primary care and smaller numbers here and there and harder to enumerate that. the 12,000 and the top end comes from the aids survey and stop clinic survey and a third report being on prep so we're getting you know pretty close potentially. i mean there's still a ways to go and i think the biggest issue highlighted is the disparities so we've got a lot of while msn on prep and need to get more people of color and women and trans on prep. >> that's my first reaction

and i have to be honest and share when we talked about prep and it's not a cure for other stds the first thing that comes to my mind taking prep is also not a cure for poverty and discriminatory and depression so i think there's still a lot that we really need to learn from the community itself. like -- you know, like gay brothers, gay and bisexual brothers so excited about it and others are still very reserved and ambivalent about making that decision. >> yeah, i think that's right and have major competing life priorities and preventing hiv can't be at the forefront because you're worried where you will get your next meal or other things so i totally agree with that, and the navigators i think -- that's one of the pieces of components them and there's a

sum degree of case management that happens with that. they're not case managers but they have to understand they have to assess people's psycho-social issues and basic information to provide referrals and address the other drivers and otherwise if you address prep you can't stay on prep. >> that's the thing i noticed and talked about social determinants of health and of hiv but nobody brought up social determinants of prep when it's one of the most expensive medications. >> yeah. >> well said commissioner. >> thank you so much. >> thank you. >> thank you for the presentation and the information. it was very helpful. >> thanks. >> commissioners there were no public comment requests for the item. move on to item 7 which is other business.

>> commissioners any other business that you wish to bring as topics for us? otherwise you do have the calendar before you and i point out that we do have two dates set for first a meeting in the tenderloin. >> yes, that is on october -- i'm sorry, september 6. >> yes, september 6 , right. >> [inaudible] >> and at that point a planning session on the five year budget is tentatively on october 4. >> yes. actually i don't think that's tentative unless you would also like to consider that. that's the one date you're actually all together. >> okay. well let's note it's october 4 so people note that in the calendars. >> great. >> because those would be two important sessions for our ability to plan. >> so we move on. >> any other comments? >> move on to the next item.

>> yes report back from commissioner karshmer on the laguna honda. >> yes, we met in closed session and reviewed the quality report as well as approved the credentials report. >> okay. any other comments on that? if not -- i only ask -- i would mention jcc has taken note of the number of suspensions and they're working on this under the director's report in terms of credentialing. >> item 9 is committee agenda setting. i think you all covered that under item 7 unless you have other suggestions for the calendar. >> just note from our last session we're in the process of completing our evaluation of

our secretary and ask that you submit your comments to me within coming two weeks. thank you. >> now we have consideration of adjournment and commissioners if i may i request that you consider adjourning in those that lost their lives in orlando, florida. >> in term of the motions -- >> yes. >> so we can have a motion for adjournment for that please. >> i move to adjourn in the honor of the victims in orlando who our thoughts are with them and families. >> okay. is there a second to that? >> second. >> okay. all those in favor of adjournment in honor of the tragedy in orlando please say aye. >> aye. >> all those opposed? it was unanimous and we're now adjourned. thank you very much. [gavel]

>> good morning, everyone. welcome to the department of emergency management on church street i'd like to take the opportunity again remember those individuals those families that were victims of that hoeveng tragedy in orlando and also to know that we're coming together as a city not only to mourn but

to celebrate our diversity take a moment of memory well, thank you for coming this morning we're here at department of emergency management not only the public safety but our pride organizers and supervisor wiener's office that has been proprietors working with the private bars and gathering with all of the different parts of the castro area and also the rest of the city whether the nonprofits, state and federal television stations and the difference departments and communities organizations we're going to have a very big pride celebration this coming weekend and it is composed of a number of events