hiv disparity by reaching out to african american there was a new campaign in the fight against hiv to end the disparities impacting african american men and the focus is to prevent hiv infection and a new campaign launching will help close this gap by engaging black san franciscans to support in prep messages. gender health recognized an event and i kind of see them of them in the audience. we want to acknowledge them and the mortality rate of black infants is more than twice of white infants and a growing body of evidence shows stress may be among black women caused by racial discrimination and as you saw in today's report some work

is finding better results by focussing on those kinds of issues including working in the community and managing individual stress from the african american community. i do want to make sure we recommend the staff today. >> director, i had one question off the present -- i guess the continuing resolution it then would not have the let it of another shutdown -- i'm trying

so information how that works. i and tis we could have another shut down but this allows us to go forward with the initiatives. >> and on the report our congratulations for all those who have been recognized at the event. >> thank you for the report and the next item. >> public comment and i've not received any requests. >> could i ask karen to come up to acknowledge her? >> surely, please.

>> i know you have experience now and if you can give the commissioners a little bit about your background and the work you've been doing for us. >> i did hiv prevention back in 1999 and have been working there since 2017 and looking for the transgender community. >> we want to acknowledge her for her award at the hearts and heroes. >> congratulations. >> thank you, sir. >> item five is from the commit from today. >> president and members of the public, the community public health committee met this

afternoon. we had two very specific items on our agenda in the child and adolescent health. there's three items discussed in detail. pre-term birth and children's oral health and child abuse. next item was food insecurity in san francisco and talked about hunger in the faith community and over the next few months and later in the year, data will be provided on the ethnicity and perform level and we look forward to hearing from them as a competition. that con cloud my report. >> thank you. i was able to be present at the committee meeting and was struck with the presentation on food security which i understand will be expanded and be available for presentation to the full

commission and understand the importance of food as one of the sociodeterminates of health and what the department is and as a strategic plan working on in order to move forward on that as an important pillar. so we will be agendizing that for a fuller presentation as part of the department's overview. >> thank you, commissioners. >> the clerk: item 6 is the budget and today you'll vote on the issue. if you recall this with us introduced at the last meeting february 6.

>> very briefly and then i'll turn it over to our budget director. as you know we had a hearing in our last commission meeting with a set of initiatives proposed for the budget. this is the second hearing we'll be requesting a vote to forward to the mayor's and comptrollers office. the budget we submitted to you was roughly balanced, however, as we noted during the hearing it was uneven between years where we were over balanced in the first year and under balanced in the second leader and while we hit a target it created an issue because when we're short in the second year it carries forward to the future budget and affects our ability to hit our longer term financial planning goals. so what we've come back with

today for you is a second set of initiatives that introduced the items we were not prepared to bring to the last hearing, but furthermore corrects the balance to we're hitting our target in each of the years and we should be in a good position for our ongoing -- to meet our ongoing general fund target. i'll turn it over to jenny with the initiatives.

[no audio] >> hopefully members of the audience can follow along until we get a larger screen.

so commissioners, as mr. wagner said in the last hearing, we've submitted our base budget overview. we committed a number of proposals that didn't meet target and the concern on the initial proposal is we were very lopside in how we spread out our savings and how we met the target over two years. at this commission hearing we're bringing forward a complete balancing plan. one that actually corrects for the lopsidedness using appropriations and pre-funded appropriations for project in year one. that should hopefully address that issue as well as an additional handful of issues we'd like to bring forward for your consideration. most significantly is the electronic health records initiative we brought forward

and we have paper copies here. let me walk you through this table. the first line is an updated projection of what we feel the project will cost from '17, '18 through 1920 and from mr. kim's presentation last year when he updated on the project basically the bulk of implementation has begun for 1920. the numbers were updated after we finalized the contract with epic and enabled us to figure out what were the services we were getting from epic and other services and we're expecting we'll have $247 million worth of costs related to i mplementatio and this is the updated number from the fall and winter once we

finalized the contract. the second set of numbers you see and so many commissioners may remember over the last several years we've tried many strategies to fund this program given we were progressing $377 million over 10 years when it was something we cannot do overnight. to summarize we did a combination of some base project funding. we did some one-time appropriations and project funds and additional infusion of base project funding and also had a mechanism we started in '15-'17 and we were able to capture the one-time revenues you've seen in the financial statement relate to cost-report issues -- favorable cost-report issues that were able to recognize it's not money we feel comfortable

budgeting or baseline budget but it is a revenue that we see fairly often but not always in our financial statements. and we believe we have $244 million in appropriations available for expenditures which is a couple millon -- million shy of what we had and the project expenditure and work in the baseline were things done before the budget. and last week we had an issue with our funding with the affiliation agreement where they believed in several years ago they could actually hold their affiliation agreement flat to help support the procurement of the electronic health records but recently this fall with updated projections they didn't feel they could maintain that agreement with us anymore and so

there's a $10.3 million issue we had to contend with to make sure we continue to support the services that you it provides for us. so that $10 million issue basically combined with our shortfall and our deficits over the last three years results in a $12 million shortfall in just looking at the issues. and then as we mentioned before, in addition to this issue we also had the issue of being lopsided in terms of our balancing in our initial budget proposal. so what we are proposing to do here is to shift the funding of the project earlier into fiscal year '18-'19 instead of '19-'20 and allows us to move dollars

and enables us to reduce year two by $10.3 million and reduces an additional $10.7 million of ongoing costs for the h.r. project because we've already pre-funded the e.r.h. project in the future -- i'm sorry, earlier. so what this does is overall all see we will actually have a balance of money for the next two or three years we expect to fully expend by the end of '19-'20 but we do believe we can provide the appropriation of $247 million over the next three years. this is something that we are going have to watch because we didn't reduce our ongoing appropriation and it does make that project a little bit

tighter because we are projected to be at zero at year three but it's something at this point we believe we can manage. i know i threw a lot of numbers at you. do you have specific questions on what i just walked you through? >> in regards to the ucsf changes, has there been a review with ucsf in terms of what the affiliation agreement is expects in the future to have made assumptions or hope for promises and then to come in at the budget time to say that we actually can't fulfill that and there may be very legitimate reasons would seem to be a short-sighted type of process rather than one that should have had a more continuous dialogue

that allows us -- because this is a long-term project, to understand and work together to manage all the sources of funding recognizing there was good will in coming in to say they would participate in the h.r. process. >> yes, thank you for the question. we have been work myself along with a hospital executive team, dr. erlach on her staff and what the directions entail and you'll see the funds removed from the project from the affiliation agreement and in addition we discussed at the prior hearing there's an assumption in the mayor's deficit projection we will fund the non-physician

staff on an on-going basis and between the two sources we believe that there is efficient funding that we will not -- sufficient funding we won't have to come back for an ask. it will be a process we'll have to work through and already started with u.c. so that process is going to be some added layers of oversight and collaborative financial management. so we'll be looking at enhanced process to evaluate whether those need to be refilled. we'll be looking at opportunities both now and through the e.h.r. revenue process and the fees woul offset the need for an affiliation agreement. we are going to be looking at whether there's opportunities to streamline consolidate, identify

efficiency in the affiliation costs and the below the line items in the agreement. there's layers in this but they'll be putting in plis a process we'll put through the next 18 months and beyond to make sure we're including the same level of i guess certainly or oversight in the projections for the affiliation agreement that we are in other items we're bringing before the commission and the mayor's office and five-year financial planning process. so i'm confident it's going to be work but confident everybody's on board between the central office and hospital administration and the dean's office that you see everybody's committed to continuing to work through this to make sure that we can live westbound the

appropriated dollars. >> commissioners, any further questions? we felt it needed some explanation. director gars yeah -- garcia, do you want to make comments on this? >> we know about their commitment and asked for an audit on the costs so we ensure what we are providing will be sufficient. i think it's the same as any other organization as well. i think we'll work through that and as you know we are very dependent on these services and we want to make sure they're qualitative. we will continue to provide the oversight. >> there's actually co-dependents here. i wonder if anybody from either the hospital or ucsf would like to make comments concerning this?

>> good afternoon, commissioners. we have worked closely with the university to look at the costs and revenue opportunities. we've been doing that ever since i got to the hospital actually two years ago. so i feel very confident that going forward we'll be working together collaboratively on costs and revenue to make sure it's all controlled and maximized as appropriate and i'm happy to answer any questions. >> commissioners? >> thank you very much. >> the clerk: you're welcome. thank you. we'll move on with the presentation. if the commissioners have questions even related back to the h.r., we can take them up

again as we move forward with the remaining changes in the budget. >> the next initiative is also an i.t. project relate to the controller's office of financial systems project also known as f.s.p. the went live july 5 and as the system has a lot of capabilities as you've seen with the different ways to report on the budget there's also been challenges and the implementation of the new system. most significantly for us was an interface between the financial system and our procurement system. we were the only city to implement the procurement module and upon implementation we saw

many links were broken, essentially. so we lost a lot of our automated capabilities so there's the short-term issue of keeping the trains running and making our payments and making orders on time and reconciling systems and it's requiring extra staff and we've been work with the controller's office to understand the i.t. issue but we feel we'll need to create a new interface between the two systems to be able to automate it in the future. obviously we are not interested in doing manual reconciliation moving forward. so it's a one-time increase in the funding we have for a project we expect to use over

the first 12 to 18 months of the next fiscal year and they're continuing to create the modules. there's also other areas in terms of payments where we have manual reconciliation in part due to the conversion issues and we're reviewing the entries and making sure they're all appropriate. and want to make sure we have all the staff for a year-end close which happens in august, september and october of 2018. the budget proposes to create a pool of staffing and allows us to give support for our operations and also proposes for

consulting for us as well as a work order through the controller's office who can help implement better interfaces and modules for the financial system. then the last emerging need is related to the transfer emergency services for our department. as you know, we've been planning the transition for years and it became effective july 1. prior to the transition we did a study on the staffing and program and there were significant issues and there was an additional need for increased analysis and metrics, policies and procedures and proposing a

pool of temp staffing to let us do more discovery on what our operating needs are and then we'll evaluate the costs in the future. next in terms of solutions, we have a one-time revenue related to a 2009 claim for the mental health state plan amendment. this was an adjustment made to our claims and proposed around 2009. after several years it actually we were told to submit our claim and we expect payment. so we'd be pleased to recognize $8 million one time to help offset some of the proposed budget. the rest of the items are budget

neutral and a few years ago we pi pilot piloted a new treatment for hep c to cure patients and the revenues would be -- sore i have, the expenditures of this very expensive treatment which is about $90,000 course is offset by medicare dollars. the pilot has been very successful and laguna hondawood wish to double it from 11 patients for a total of 23 and our request is really just to increase our pharmacy budget offset by revenues. next is our environmental health fees. as you know, we bring our fees forward for your view every

year. this year what we've actually added we've added additional positions for additional inventory and our costs are not for new positions but they are for the work orders for tax collectors to implement a new online permitting system. it will have great impacts on our clients and the people we serve because it will obviously provide greater convenience. people don't have to bring their payments over. they have to come down in person. they can do all of it online. and then also just helps with our internal staff and reconciliation and it minimizes the the paper work on our side and an exciting change on the expenditure side. on the revenue side, we're

projecting minor changes based on inventory and one significant change we did do was that last year's budget we assumed some additional revenue in the food program based on sections relate to cannabis. in the current year the board of supervisors allowed to codify a new cannabis fee we're able to charge. i'm literally shifting the dollars in the program but it's net neutral overall. lastly, our initiative to expand our specialty pharmacy for the san francisco health network would allow our patients to access specialized medications including hepatitis b, oncology drugs at two additional

locations. their expenditures would be the pharmaceutical expenditures would be offset but it increases actions for patients and they've been trained to support our patients or give them a better outcome. so in terms of our overall balancing with last week's initiatives and new initiatives proposed, what you see is we've essentially corrected for the lopsidedness and we are about $700,000 to the good in terms of our budget proposal and fully meeting our revenue and reduction par gets. tash -- targets. there's been a lot of creative thinking on our part but we are pleased to say we're leading the

proposed budget. with your approval today we'll submit our proposed budget to the controller's office and mayor's office. where the mayor will review it and submit his proposed budget on june 1 and then it will go to the full board or budget and finance committee and full board. happy to answer any questions you might have. >> thank you. commissioners, questions at this time? >> my one question which i'll give to director garcia however, was that we had discussed the issue of the tuberculosis control the last budget hearing. >> and i'm still work on it. i was going to be working with our budget folks to try to

complete that. >> this would assure with all the changes in both the feds and ourselves that we had adequate resources for this important infectious program. thank you. commissioners. the budget is well explained and if there are no questions to ask, then we are prepared for a motion for acceptance and to move it to the mayor's office. >> i'll note there was no public comment requested. >> i'm sorry. is there public comment? oh, there was not. so moved. >> second. >> there's a motion to accept and move it forward to the mayor's office. and there's a second? is there a further discussion of the motion? if not we're prepared to vote. all those in favor please say

aye. all opposed? and the budget has been accepted and will be moved to the mayor's office. thank you very much. >> if i could, commissioners, just to acknowledge their hard work on this and to the staff who tried to maintain the initiatives this year so we can continue to manage our budgets. >> yes. and definitely and we had comment on the clearing of the budget. i think the department and the finance people particularly took next issue of the lopsidedness of the budgets and also refined it so it is now an acceptable budget. thank you. >> commissioners, item 7 is an update from the gender health program and evaluation. >> thank you.

>> if you have any problems let me know and i'll come over. >> i am a math person. >> okay, everyone. we're having technical difficulties today. >> good afternoon, commissioners and director garcia. i'm julie graham the director of gender health sf. this is dr. seth pardo. he's our evaluator and we'll be

sharing this presentation. i'm very grateful to be back in front of you to discuss the incredible work of our program so we'll start with -- maybe we won't. >> so our program began with you all in 2012, the health commission approved the development of a program for people to be able to access surgeries relate to their gender identity. in 2013 my program was established. we called it transgender health services and subsequently

changed the name to gender health sf. in 2013 medical lifted the discriminatory exclusions that had been in place that prevented people from accessing care and we got a location and became a for real program people could walk in and meet with their navigators. so what we do -- so we're the first program in the nation to do this, to provide navigation and access to these surgeries. we're just going to click on this on the side. we're the first program in the nation to do this for public health. we provide access to surgery and navigation and education.

we're under i'm a gender specialist and nationally known expert in gender health. our medical director is also a nationally known expert in gender health and we now have a very part-time nurse practitioner which is very exciting to us. as i said, our evaluator is under quality management. we had a patient care coordinator and two vacant positions we're hoping to fill and the bottom line is our core staff. so behavioral health clinician and karen aguilar our hearts and heroes award winner, tamika

godwin who is a peer patient navigator. how that's important because that's our model. the people who work at our program, by and large, identify as transgender or transgender binary and many of us have had the patients our having and so we're experts in that way and in experts in terms of knowledge. the people doing surgeries for us are at zuckerberg and people we contract with because there's

so few gender surgeons in the united states and we're lucky to have a few in the bay area. our referrals have now -- they've started to get steady and moving back up is what they're seem like but i'll let you talk about that. >> i can demonstrate this and it's a pleasure to present for you. the numbers are increasing annually and though the orange bar which are the surgeries completed are less over time a lot of is because the program takes great care to make sure the patients are prepared for surgery so everybody goes through the education preparation program and through a rigorous assessment of their medical records to make sure

they're stable and ready especially in a vulnerable public health population. what is of note is over the years amongst all patients the number of surgeries completed is essentially hanging steady with this green bar in the middle. these are the number of patients who have discontinued or not been eligible. in the data some of the predominant reasons for eneligibility has been changing of insurance, mainly people get jobs, they get better insurance, they're no longer on the health care and that's a good thing or change providers so they're no longer in that work so it's not bad they're not eligible for this but moved out of the main service category.

for all surgeries completed so far for gender health sf >, most the surgeries completed have been in network another really great thing. most have been for transwomen. you can see the blue and purple side of the pie chart represent both breast surgeries so mem -- feminizing mammoplasties and the vaginalplasties. most surgery covered by the san francisco health plan. 70% of the surgery covered by the san francisco health plan and 10% for healthy sf. out of network surgeries as julie mentioned, we are competing with a worldwide population who are in need of these surgeries and we have a concentration of the most

skilled surgeons here in the bay area. regarding the program flow and evaluation, julie can speak to the flow of the patient through the program if you care to have -- if you're interested in that flow. for this slide i wanted to draw your attention to the items on the left in the purple box. those are where the evaluation are and we do a baseline of where patient in their quality of life and body address and substance abuse and other concerns in the evaluation. we says how the patient satisfaction in the preparation and education program and the support groups that are run by the near navigators and we follow-up after surgery to see how well the patients are doing after surgery and to see how well gender health sf is supporting the patient.

in brief, the primary outcomes for the evaluation are surgery readiness, timely access, patient satisfaction and quality of life indicators and we hope to see annual relative improvement in surgery readiness where patients feel they're ready for surgery following the preparation and education program add gender health sf and able to access them in a timely fashion and hope with advocacy they can continue to access the surgeries sooner and sooner so they're not waiting as many as a year to two to access some of the surgeries for such a vulnerable population as has been waiting decades. for patient satisfaction we hope to see a minimum of 80% of our patients satisfied. that's a standard threshold. we aim higher than that and finally for quality of life we hope to see relative improvement

to baseline for quality of life indicators, psycho, social, wellness and decreases in body disphoria and for the outcomes we're mostly on target. 80% of the patients served by gender health sf felt very or completely ready. we asked how ready do you think you were before the surgery which is a testament to the preparation the staff are doing for the patients. over time, the wait times have increased for out of net-work surgeries and medical is now funding them and we're now compete a global market and 69% were satisfied with their surgery experience. some of the room for improvement is through the patient and education program to accommodate the unrealistic expectations.

people have an idealized outcome for the surgeries and there say high complication rate upwards of 50%, 75% and when i'm waiting my whole life to access something that i've needed or wanted to have an amazing quality of life, it's easy from a psychological place to think this won't happen to me but it does. and we're working on making sure our patients are prepared for that and with the surgery experience there are active engagements with staff across gender health sf to increase sensitivity training to make sure the patient experience increases over time and we have seen outcomes for psychological and social wellness and

connectedness and decreases in body discomfort and gender disphoria as we expected. >> one of the other issues about people being satisfied with the outcomes is there's so much misinformation out there it's part of why we do what we do. there's so much misinformation many people are disappointed they don't have body parts that are exactly the same as people who were born with penises or vaginas or vulvas and that's a piece of the dissatisfaction is the surgery can't replicate that yet. >> for those who would like to see pictures like me, this a data visualization and so the needle doesn't move a lot down

people are experiencing they're ready for surgery after the fact and this is a graph that shows timely access and you see the genital surgery and the wait times are four times higher than for in-network surgery. >> i just want to talk about a couple key accomplishments in the last year. so up 2016 we started to be able to do evaluations. so that hasn't been very long it's been a serious effort to evaluate ourselves and what's happening. all of our program navigation staff are peers. they're people from the community who have accessed these surgeries or have accessed medical intervention.

we have accessed information. we can do more pre-surgery information and preparation for patients. we have peer-led support groups. smoking is a huge issue and interferes with good surgical outcomes so we're able to address that with people prior to surgery. we have people talking about nutrition and gender disphoria and managing it while waiting for surgery. we're able to talk about hiv and prep with our patients. we have post-surgery support groups and we talk about sexuality post surgery and we have done a number of in-service training including the lgbtq sensitive trainings for the staff. and as i said, we secured a program location and that was huge.

most do an intake and if you do intake with us you'll learn something. we'll do information on the procedures so you know what you're getting into. we do surgery, education and preparation and we've been bringing the surgeons who do these in to do this for us. everybody is able to have a peer navigator go to appointments with them and walk them through the process. we have a nurse practitioner to assist with those worried and are having complications and they're not comfortable talking to their surgeon and we have a nurse practitioner with them and so someone who has a significant mental health issue or medical issue that's interfering with

access to care we can keep them moving forward. we do monthly patient education and preparation groups both in english and spanish. about 26% -- i think 26% of our population are spanish speaking. so it's critical that we have spanish education. we do it's a real goal for us to develop our peer staff. and we were able to money from nhsa hire patient navigators who are peers and using the program through the department of h.r., that was huge. we now have staff who are civil service employees which i fundamentally believe is critical. these are folks who are going to be here for the long term for

our patients. we have increased coordination with surgeons and primary care providers because the surgeons don't necessarily talk to the primary care providers. everything is still very siloed. part of our role is to decrease that siloed experience for folks. we have developed a protocol for under age 18 to begin accessing surgical intervention and developed a relationship with speech pathology at zuckerberg and ucsf which is thrilling because these are things very important to people. let me see if i can make this go up. challenges. so many of the challenges that we face are the same as the last time i was here. one of the big ones is at the bottom, misinformation in the patient and provider community.

house is a nightmare in san francisco as we all know. after care, surgery, housing for people is very critical. coordination among providers i feel is improving and part of our patient navigator and care coordinator. it's hard to take care of people in other counties. people have trouble having follow-up care if they have to go across the bridge to san rafael. the network capacity is -- we don't have what we need and so it does mean people are wait very long time to access surgeries. the fact that we have an overweight population and population that smoke are issues we're actively trying to address in our program. substance abuse continues to be an issue and we work with people

abusing substance to move them forward. there's not a lot of facts in this so we're trying to develop an evidence-base that doesn't exist anywhere. we were trying to get people to open hand for nutrition. people are struggling with minority stress in their life and the impact of that on surgery. many of the vast majority of our patient trauma survivors so there are behavioral health issues and people report they lack a place to be and congregate and we can't offer that. we're too small. neurodiversity there's a number of transgender and transgender binary system in the autism spectrum and that brings up its own challenges in providing

care. one of the other challenges that isn't here is our need for elec trick -- hair removal. i've resigned so we have to replace me. we have to stabilize our staff. so get a new director and fill the clinical director position and get the trainer. we've been missing those key roles and we need to get those filled. we're going to -- once we have that we'll do more training for mental health primary care and the community people think surgery is like what they see on television and it's nothing like that in terms of recovery. many of the primary care doctors have one patient who is

transgender so they don't know what the aftercare's supposed to be. we're working to create a smoke cessation program at the gender center at ucsf and at castro mission. we're working to try and create a gynecology specific care for transgender people. both trans men -- we have a problem with trans men going to the women's clinic at zuckerberg. that's a disaster. we have men that won't go because it's called the women's clinic and we have folks who really need to have a gynecologist to follow them through the process. we want to work on developing that. we're going to formalize a consultation practice for the department of public health so whenever doctors have questions, they really know to call us whenever mental health providers have questions they know to call us. and we can walk them through how to think about the clients

they're caring for. last, this is for the staff of gender health. we have an incredible just hard-working excellent staff they want to thank for all their incredible work. i also want to thank role and -- rolland. he sat through weeks of meetings and we wouldn't be here without him. so that's our presentation and i'm happy to answer any questions. >> thank you very much. commissioners, questions? >> i couple questions. one, is a patient who's identified as having a substance abuse issue preclude from having the surgery if they're deemed an

appropriate candidate though they abuse substance. >> the answer is no. if somebody is actively using a substance that will interfere with their surgical outcome, an example, methamphetamine, it brings you up, sedation in surgery brings you down. those folks are likely to have peri-operative awareness and that's a bad outcome. we work to get people at least sober for a period of time if they're using those chemicals. there's not great research on this and i feel this is something we'll able to contribute to the field because we're paying attention but it doesn't preclude folks. if people use marijuana. you can't smoke cigarettes and you can't smoke marijuana. we work with them to switch to edibles and tinctures. we're trying to figure out to give people what they want

because they're self-medicating often for gender disphoria. [please stand by] .

. >> so maybe that's the worry. not so much what we're doing here, but that there aren't enough providers to respond to the -- we've got a bottle neck, and that has really been a concern from the beginning. >> thank you. >> yes, commissioners. >> i have a question. well, actually, it pertains to actually the education in preparation within the various disciplines. 'cause you mentioned that we have a very highly trained, talented group of surgeons, and the fact that we have an increase in surgeries, and the

increase is decided by our colleague here, i guess the thought that sort of flashed to me is that the different specialties that are certified by san francisco general, we have, iklike urology, which haa number of specialties in it that participate in numerous, i assume, surgeries here, and they have the residency program where they have a major cohort, and their subspecialties, where they have outstanding training programs, and the list to rotate through the general has grown substantially. but my -- not concern