homeless people that's not associated with housing, so this is something we're going to have to look to in the system of care. and then there are other vulnerabilities, what would cause someone to have premature mortality, and they're predisposed to using drugs, etcetera. and now i'm going to turn it over to dr. zevin. >> thank you, doctor, and thank you commissioners and director garcia. just a comment on the slide because i get asked a lot of the time, how many homeless people are there, and why are there so many homeless people? and often there is a great deal of anger and often a great deal of anger at people experiencing homelessness. so this is what practicing health care for the homeless medicine in the san francisco department of public health since 1991 has taught me: this

much homeless people, this much housing. this much homeless people, this was housing. that's why we have this issue. and when we look at what the health consequences of that are, it really is quite a serious problem. so thinking about how users of multiple systems, we have people who are being seen in our medical system, people seen in our mental health system, people seen in our system for treatment of substance abuse disorders. those systems may not be well coordinated, and even when they are well coordinated, a lot of the -- when the -- that coordination falls apart, it falls apart among the most severely affected people who are the most likely to be experiencing homelessness.

those people are primarily using services in the emergency and urgent sector. we've really been able to look at what -- how do our services work and why don't people get what they need if they're using services so frequently? and a lot of that is they're getting services, great services in emergency departments, urgent care departments, psychiatric emergency, places that do urgency, take care of one problem, we're done, that problem's resolved. now you need someplace else to do transitional care and stablization care. we don't do those transitions well. and often, the people who are the highest users, if i go and ask an emergency room doctor, if i ask t.e.s., if i ask the people at joe healey did hetox,

who's your biggest problem? they don't necessarily come up with the people that we know are the highest users because the people who use the systems exclusively in one area, they come to attention. when people are using systems in a lot of areas, they may not ever come up for people to recognize hey, those are the people we need to concentrate on. certainly, these are folks who are suffering with multiple disorders, often several chronic illnesses, and we know or in homeless populations as a whole, but particularly, these populations, high burden of disease, early pathology, and premature deaths. and it's -- actually, it surprised me. if we look at all of the high users, how many of those are actually people experiencing homelessness? and it is well over half, close

to 75% of those are homeless. so these things walk hand in hand. so on a practical level, what i do day-to-day, what are my challenges? information is siloed. we have challenge -- if i'm seeing someone any given day, i'm looking at anywhere from half a dozen to a dozen different kinds of electronic health records and computer systems to try and understand actually what has happened to that person. we're not coordinating well, especially those handoffs from urgent emergent services to transitional and stablization services and from the transitional and stablization services into the wellness and recovery long-term services. we have challenges coordinating. a lot of the time that is because when i see somebody, i

am challenged to figure out what in the world is a plan that's going to help this person? but a fair amount of the time somebody who knows that person has a plan, it's just not a plan that's available to me, and we've got to do better with that. and then finally, i consider myself experienced. i consider myself good at what i do. there's not a day that goes by that i am not humbled by the work that is in front of me. we need to develop systems. we have a lot of gaps in our systems. we have a lot of barriers. but we have a tremendous amount of determination and a tremendous amount of talent in the department of public health to actually do the impossible in some cases, and i see that every day in my work, too.

finally, i think i said that, provider excellence and inknn innovation. this allows us at the end of the day to have made systems changes that are going to make my job easier and make our outcomes better with our high users. so i alluded to our ecosystem of care. i am very attached to this diagram because it's really helped me to understand, why is it that this person goes to the emergency room 25 times and doesn't get what they need? oh, it's an emergency room. they do certain things. they don't do others. we've got to really understand who does what, and really understanding this transition and stablization area, our yellow zone up here, and trying to make the connections from the urgent-emergent to the

recovery and wellness is really, really been helpful to me in conceptualizing how these models should work. the areas that you see underlined are areas that are funded or supported by whole person care. we've done some planning work with whole person care. again, as i said, we've got some is real determination and genius in the department of public health as well as our collaborating departments. get those people in the room and start mapping out, what does it actually look like now? what does it look like if we imagine systems of care that actually will work for people experiencing homelessness who are our highest users, who are our most vulnerable, most at risk? and we identified a system to map that out. we have had a couple of sessions now of really getting people in the room and working

on, what is it -- what is it going to look like, and i think that planning has already -- to be honest, that's already bearing some fruit for my team in having just quicker ways to identify, what is the barrier for this person having a good outcome? and if the barriers at that adaptation level, what are we going to do? and if the problem is a gap in our services, being able to identify that gap quicker. so thank you very much for your attention, and maria and i are happy to hear input, comments, questions from the commissioners. chow thousand thank yo>> commi you. was there any public comment? >> i've not received any requests for public comment. >> commissioner chow: okay. comments, questions, commissioners? let me ask the first one. you've done a lot of work on

the infrastructures and issues that have risen all the way from the payment. so the first one i was going to ask is you said that you felt that you the qualification for medi-cal was very important from a payment standpoint, certainly, and you felt that most of these members in your cohort are actually medicare eligible. how do we know that? >> well, since the aca, it reduced the need to be disabled to get onto medi-cal to be income, so we can say that most of these people are going to meet that eligibility. >> commissioner chow: it's related to income. >> income, but what would exclude them if they are undocumented, and so there may be 3, 4%, that if we could just look at based upon the fact that they classify themselves as latino, that would be a squint our eyes.

we don't have that knowledge. if they are on medicare, they're not eligible for it. if they're -- have va, if they have any other kinds of health insurance, they're not eligible for it. we estimate that there's a 15% of the homeless people who we know we're already serving could be transferred to medi-cal -- sorry, estimate. >> commissioner chow: sorry. so that last number, you want to redefine that a little bit for me because it sounds to me like you said 57% or so are already on medi-cal. >> right. >> commissioner chow: so do i add 15% to that? is that what i'm supposed to add? >> yes, in a squint your eyes kind of fashion. the real trick is month to month to month, 'cause we bill is month to month to month. so what you see is 57% of the

time sometime in the year had medi-cal, but what we're seeing is they go off, and we're not able to take care of them. >> commissioner chow: sure, and so that becomes a challenge in terms of payments and all. when, as everybody's thinking of their questions, i'll ask some more. as this ends in 2020, and you're putting the program together beginning at 2017, and it's been a year where you've been -- at least you -- you've documented shelter services, when would you expect to have outcomes on your performance metrics, which are, you know, quite extensive? >> well, thankfully, most of the metrics are getting paid for reporting, although it's a huge list to get the data to report it. actually moving the dial's only about five, five of those

20-some metrics. and so is your question, are we going to be able to move the dial by the end of 2020? >> commissioner chow: so are you anticipating sort of in between points in which you would know how you're doing and -- >> oh, yeah. we have to -- we have to measure it every quarter. >> commissioner chow: you're measuring every quarter? >> uh-huh. >> commissioner chow: okay. >> but the baseline is 2016, and then, 2017 would be -- so we haven't -- we haven't -- i guess it's very complicated. >> commissioner chow: okay. so when would they -- there would be the possibility of looking at an interim that says that, you know, you had enough data, and you could give a feeling out of the progress going on? >> i would say a year from now we would be able to see how we are measuring this. we're going to have the measuring, but to show any difference would be a year from now. >> and commissioner, just so --

we're already having conversations about this program and its sustainability post 2020. we've just had this conversation today, but what we're going to be looking forward is system changes, and as we bring epic on, that would be an incredible opportunity for us for someone to be able to look up their client and that will give us a much more opportunity to respond to what their needs are. there are opportunities including working with the homeless department setting up how people are going to get housing, and we're right in that process with them. that will also have a vulnerability index out there that dr. zevin talked about that. as you know, waivers from the federal government don't last forever, so we are anticipating what can be put into the foundation of the work that we can -- that we are doing for future work for this population

particularly because it's an intraagency. i find the whole issue of medi-cal so important, because as you know, that is important for us, for our business, our -- the business that we provide, and we want to ensure that people stay on medi-cal, even in our healthy san francisco, even though we have a single standard of care, they don't get all the benefits of a medi-cal client because they can't pay for everything that medi-cal pays for, so there are some downsides for not being a part of our medi-cal system, as well. i want to honor the work that they've been doing. probably have about 40, 50 years of experience, if you add up both of their experiences in the department and working on this same issue. so it is a really -- really working hard to trying to beat the clock and get as much done. the way the program was done to drawdown the dollars has been a real challenge for them because it's very strict in terms of

how they were going to drawdown. one of them was just reporting and taking the report. they can drawdown dollars, and we're talking about $36 million that we can drawdown for the department. >> commissioner chow: really very good. let me just ask one last question because i think it flows from the entire thing. so we're dealing with the individuals and trying to help them, but i think dr. zevin hit the real issue. which is this last slide on the echo system of care, a great demonstration where everything is, and i -- the daunting task seems to be in order to draw all the arrows in between there and lines to make them all coordinate. is that the message that i'm getting? >> the message is that i am convinced that this is going to result in positive systems change for us, and that really does mean -- those arrows need

to connect. and sometimes it means that the -- that there shouldn't actually be an arrow. those things that are needing to be connected should really sometimes just be one thing, and that -- i think that's what this project is going to get us to being able to actually show that that -- you know, that is -- when that's the case. i -- >> commissioner chow: so that takes from where director garcia had mentioned system change is one of the really very big projects that aside from assisting individuals would allow us to do a better job for everybody, right? >> yes, absolutely. >> commissioner chow: okay. thank you. commissioners? commissioner bernal? >> commissioner bernal: yes. first of all, thank you. thanks to both of you for your excellent work in providing this presentation. it's very informative. i was going to ask about sustainability past 2020, but it sounds like we've got those discussions happening. my question was about the count

of homeless individuals served. the first number was 14,377, and it looks like served by dph was about 11,000, which i guess that's the 25% that's only known to the department of homelessness? >> actually, those are two different time periods. so the 11,000 is in fiscal year 16-17, and from our status systems. and then the 14 is from the whole person care, 12 months. so it was a significant increase when we started to add the homeless department's folks that we didn't otherwise know about before. >> commissioner bernal: and neither of those numbers align with the 2017, yeah, period of time, which is not captured. >> because it's one point in time, and so what we've seen because we've been monitoring this vulnerable population for about 12 years, and so what we've seen is about 2,000 new homeless people come in, and

about 2,000 leave, and then, the rest stay. so people -- a lot of people are coming in, and well, going transient. but the 15,000 is an estimate by the -- the homeless department, given the point in time. there's a whole hud method allege for that, and we're actually inching up to about 15,000 at this point. >> commissioner bernal: right. thank you. >> commissioner chow: thank you. commissioner green around the y

have a really hard time relating to yes, we have a department of public health that actually runs a couple of large hospitals in a large set of community health centers and a large health care for the homeless program. that really confuses people because most cities around the country don't. but looking at places that have really been sophisticated about how do they -- really thinking about homelessness as a special population, boston, we're in regular contact with, new york city, we're in regular contact with. baltimore, we're in regular contact with. chicago, we're in regular contact with. los angeles is learning a lot from us here.

i guess your predecessor brought some of that to them. when i talk to people in los angeles which has problems with homelessness that boggle my mind, they are pumping me for any possible information that they can get because they're really starting behind where we are. so yes greenwood i also have an opinion about that, but i'm often humbled about my opinions and how reality based they might be, but it's my observations that almost all the services that you see in the eco system are episodic, meaning you come in, you meet criteria, you get really excellent care, getting your broken arm fixed or whatever it is, and you no longer meet criteria and you're discharged. and that could be two weeks in a detox, or it could be half an hour in a emergency.

so it begins and ends. and for most of our population, that works. for a population who is extremely vulnerable, had many, many years of living on the streets and are complicated and all of the disorders that they are suffering from, the only lifetime service we have in this health department is primary care, and they can't manage appointment driven primary care, many of them. many of those highest needs folks, so what we have to figure out is how do we rethink wrapping around someone in a lifetime and being able to have a team sort of rise to the -- to the acuity of life happens or something happens and be able to still hold them and know that they know this team, and they'll be able to come back to this team when life happens again. that's the primary care idea, but none of this present system is built on that.

and so i think we really have to look at how we've designed a system of care around our most vulnerable folks to be different than what we do for most. >> commissioner chow: thank you. commissioner guillermo. >> thank you. this is an impressive design, and i know it takes much more than we can imagine here to make this work. i had a question similar to commissioner green on the back end data. there's just a back end and a front end. on the back enter, the dph part is epic, but all of these different health conditions have different data systems. could you describe that design in terms of the coordination of all of that and what barriers you may have in being able to bring all of that together. and then, if there's time, to also talk about what to the

front apps look like, and do they involve organizations outside of the city and county agencies, for example, grantee nonprofits and such? >> yeah, and a lot of the community based organizations input a latriot of data in tho five systems, so their information goes in. so each one of those agencies have different systems, and they're in different movements. some of them are brand-new, like the one system in the homeless department, and they're just trying to lift it off. and there's another program in the department of ageing and adult services, who for years has been using ca get care, and the whole state does that in their entry and data. so what we're going to do, we're already doing this in ccms in bringing data from folks matching, merging and creating one record. what this, the whole person care platform will be able to

pay for is making that more powerful and adding source databases. so we'll be able to add the database of ageing and adult services. so we will meet with them, and say, what goes in there, and how do you put it in there, and then we will have a bunch of people like barry and myself saying i could seize these three pieces of information. the rest is just a lot of noise. so we'll come up with from this one system, we want 16 pieces of information. and then, our i.t. people will figure out how to get it, bring it back, match it and merge it into the record. so that's how the back end will happen, and that's how we will aproch each one approach each one of these systems. epic will take time to implement in its totality, so we will continue to use ccms-i which does continue to stitch

together these health services, and we will take one, one, one, until we're able to create. the new platform will probably have a warehouse of where this is coming in and matching and merging at midnight and creating this record at the back end. hope that answers your question. now, on the front end is how do you take that data and get it to the people at the right moment, and that is a technology that's new and up and coming in terms of being very agile. it's an innovation. there is no off the shelf app to do what we're talking about, so we're going to have to be working with clinicians and the epidemiology folks, and the management to be able to create a front end. so barry needs to know when he's on the street, and he's under wherever he needs to be able to look up and see oh,

marie martinez, and here's the issues, the most outstanding issues i need to deal with this here. he also needs to have gps and be able to say he's providing service here. how are we going to be able to do that at point service, under the bridge, in the e.d. or wherever? you know, how does care coordination look differently from fixing your arm, physicianing yofixing your depression, how do you deal with that in a whole person way? so we have a lot of ideas, and it's over the course of the next 2.5 years, it's going to be designing, iterating, oh, what were we thinking, and rewinding. so whatever the front end is, it's going to have to be agile enough to modify as we moved. >> question. you asked about gap, and i'll

mention one structural gap that we face, and it's important, and it's important from a policy point of view. the -- as things stand, clinicians on the front end will never be able to see the information from the substance abuse disorder frequency system. that's really protected by cfr-42. it's got extra layers of privacy protection. there's good things about that, but there's big challenges about that. i -- we're not the only people who are noticing that that well intentioned privacy protection is in, in many cases, actually harming people's, like, ability to get the care that they need. so i know in several -- on several fronts, there's people trying to address the fr-42 on a policy front, and that's federal regulation, so it's not

something that any one of us in the room can wave our magic wan wands, but i think it's important for people to be aware that it makes me feel like i've got my hands tied behind my back in the work that i'm doing. >> commissioner? >> thanks. first in the adults and hhs system, are those -- [ inaudible ] -- or is that by service that they're given or is it both? >> which number are you looking at? >> i'm looking at the 11,115. >> that's unduplicated people served in the health department. so the 15,000 is an estimate from the homeless department, presumably, the 11,000 would be part of that 15,000, but because i'm not sure, i mean, we'll find out.

you know, when you look at the numbers here of two -- just one year, so we don't know yet, to be honest. >> do we know in terms of the population of seniors who are medically compromised and might be a part of the system and/or people of color who might be part of the system, particularly when you look at the over population of blacks and latinos in san francisco and go in and out of jails and will be a part of system, but then will lose their access when they are incarcerated. >> right. we have a lot of data. i'm happy to share that with you of the population that we serve in the health department. so the idea is with whole person care is that every homeless person will have a health record, meaning, they will have been assessed, and every homeless person will have a housing assessment record. so the goal for whole person care is that 100% of the

homeless people are both known to the health department and to the homeless department. but i do have a lot of information about the 11,000 that i'm happy to share with you. >> i look forward to that. >> and a very high percentage of african americans in the long-term homeless. >> thank you very much. this is a very clear and well cart claytoned report that you guys have pyou -- articulated report that you guys have put together today. >> commissioner chow: any further questions? seeing none, thank you for your presentation, and we look forward to a report at the -- i guess this is on a yearly basis that you are doing it. >> we can do it however often you want to hear from us. >> commissioner chow: well, i think you noted that as you were putting this together, it'll take about another year for you to come up with meaningful data, and i think that would be very hope that we'll do a full up in a year. >> okay. great. thank you so much for your time. >> commissioner chow: and thank you for your work. thank you.

>> next item is item eight, and post acute care update. >> good afternoon, commissioners. my name is snehapatil, and today i wanted to present to you some of the information about post acute care and the need for these services in our city. additionally, we have the post acute care collaborative here that was sponsored by the hospital council of northern

and central california that are here to share the -- their final reports and recommended solutions. so a little bit of background. in recent years, the commission has held several hearings on closures of hospital based skilled nursing facilities under proposition q. proposition q requires private hospitals in san francisco to provide public notice before closing an inpatient or outpatient facility or before eliminating services. since 2014, we have seen a reduction in more than 200 licensed hospital based skilled nursing beds, and most recently, the commission heard about the planned closure of cpmc st. luke's skilled nursing unit, and the commission heard this under proposition q in august of 2017. so just as an update, cpmc --

there are currently 17 remaining patients in sub acute patients in cpmc st. luke's, and they are planning to transfer them to the davies campus this summer. so optimally, we know that post acute care is provided in home and community based setting whenever possible. there are several policies that recognize the importance of ageing in place to maximize an individual's independance and to provide care in the least restrictive setting. we also know that the vast majority of patients are discharged home after a hospital stay. however, some patients who cannot be safely discharged home do rely on stillkilled nug facilities for post acute care. you can see on that slide about 9% of all hospital discharges

are to skilled nursing facilities, and less than half a prs of all hospital discharges are for patients who needsub acute care. so i wanted to take just a minute to describe some of the types of facilities that provide care for seniors and adults with disabilities. so starting from the lowest level of care to the highest level of care. so residential care facilities for the elderly, which are also known as assisted living or boarding care primarily provide assistance with activities of daily living, which include bathing, eating, dressing, feeding, etcetera. skilled nursing facilities provide -- can provide short-term rehabilitation such as occupational therapy, physical therapy, speech therapy or skilled services, such as wound care. and skilled nursing facilities can also provide long-term care, which is primarily when someone considers a skilled

nursing facility their residence, their home, and patients primarily need help with activities of daily living. finally, sub acute care is for patients who are medically fragile and require specialized care, such as patients who might tube feed or patients who use a ventilator, and so this care can be provided in a sub acute mursing facility, and in another type of facility called a long-term care hospital. so there are several factors that influence the post acute care landscape. so on the federal and state level, several policy regulations and agencies such as centers for medicare and medicaid services, the california department of public services, and california department of public health have a large role in overseeing facilities. in terms of health plans and health cares, this can really determine if a patient has access to facilities.

so for example, medicare will cover a patient's stay in a skilled nursing facility for up to 100 days, and medi-cal will cover the entire stay. hospital discharges take into account several factors when determining what an appropriate placement is for a patient, including what their insurance status is, what level of support that they have, and their medical and nonmedical needs. and so additionally, over the past several decades in general, we know that ageing has moved away from institutional care towards community based living. so one, we know that individuals prefer to live at home whenever possible, and two, there have been several course cases such as olmstead which was a extreme court case, and here locally, chambers versus san francisco, and both of these cases found that

unnecessary institutionalization of individuals with disabilities might be considered discrimination if there are appropriate options for care in a lower level. so giving changing demographics, health care financing trends, and the high cost of doing business, san francisco is facing several challenges. so first, we know we have a growing vulnerable population. our population 65 and older is growing rapidly. it's currently 14%, and this will grow to 21% of our population by 2030. additionally, we have a shrinking supply of skilled nursing beds, and we also have seen a more recent trend of closures of smaller boarding care operators. and finally, we know that there are limited options for individuals who are lower limited income, and especially if they need long-term care or if they have behavioral health

challenges. for example we know that skilled nursing facilities which are predominantly and for profit private businesses may limit the amount of patients that they accept to have medi-cal due to low reimbursement. and so while skilled nursing facilities are a very important health care resource for our community, we do need a multipartner and multipronged approach to address this need that both prioritizes home and community based care, but also supports access to beds in skilled nursing facilities and residential care facilities. and so the department is recommending a few strategies to address this need to better doeth upstream and drown stream, so thinking about it upstream, we really want to prevent the need for institutionalization, and looking at it downstream, thinking about the actual creation of it.

so our first strategy is around prioritizing ageing in place to maximize independance and support care in the least restrictive setting. so this is the idea that we want to ensure that our vulnerable populations can get care at home in had supportive living environments whenever possible. so the first strategy, 1-a is really about supporting the work of the department of ageing and adult services, which is already currently engaged in several programs and initiatives that really support older adults and adults with disabilities, as well as help bridge the gap from acute care settings to community based settings. the second strategy is around improving access to medi-cal's home and community based alternatives waiver. so under this waiver, residents who are currently in skilled nursing facilities or residents who might be as risk of being institutionalized can receive wraparound services in their home as opposed to being institutionalized. so historically this waiver was

administered at the state level, and going forward later this year in 2019, it will be administered by a local agency which will hopefully increase access. and there might be opportunities for us to engage in stayed advocacy around this. the third strategy is a recommendation of the post acute care collaborative, which is to support placement of nonacute patients into the community such as boarding care homes, by either subside gees or wraparound services and supports. the next strategy is around improving discharge planning. so from the acute care setting to lower levels of care. and again, both of these strategies are recommendations of the post acute care collaborative, which you'll hear from in a minute, so i won't go into a lot of detail, but the first is essentially

supporting a citywide assessment tool so we are able to capture standardized data across all of our hospital systems about what type of care patients need. the second is around developing a citywide roving placement team who would have the ability to determine assessments and what appropriate placements are. so our third recommendation is really around preserving the facilities that we have here today. as i mentioned, i know we are losing facilities rapidly, and we want to make sure that if we are able to step in and help, that we are engaged in efforts to do that. so the first, 3(a) is around collaborating with the office of workforce development to look at potential local incentives for facilities that are closing, in particular boarding care homes. so this might include helping with mer mit processing,

potentially business grants, maybe workforce development, so just the beginning of having those conversations. another strategy that we're pursuing with the planning department through a separate initiative called the health care services master plan is looking at our zoning codes to make sure that we are removing bare jerz for these facilities if they do want to open up in the city so it's not as burdensome. the thirt strategy is explor g exploring -- third strategy is exploring a creation of permitting process. as i mentioned since many of these businesses are predominantly private and for profit, we -- there's no systematic way for us to know when they are shutting down in the city, so there might be opportunities to create that legislatively. the fourth strategy is incorporating residential care facilities into the city's

housing trends. so we would like to work with city agencies and think about housing strategies and goals and in a way that accommodates people who are ageing in place. finally, supervisor yee has been very interested in residential care facilities, and he recently announced a work group that both the department of ageing and adult services and the department of public health will participate in. so again look at tools and promote sustainability of businesses. and so our final strategy is real ae looking at unused health care facility space in the city that might provide opportunities to create new beds. so the first strategy that we have here is collaborating with st. mary's medical center to talk about the possibility of developing a skilled nursing and sub acute unit. we know there are no longer any sub acute units in san

francisco, so this is a priority for the city. so -- and currently as saint mary's medical center, kentfield owns and operates a long-term acute care hospital, so there might be an interest for expanding care for those patients. additionally, chinese hospital has a 23 bed unit that's unlicensed, but we are currently working with them to help get it licensed. that process can take quite sometime, so we are working with the mayor's office and looking at options to help expedite that process. the third objective, which is more longer term is to look at the potential expansion of our existing residential care facility at our behavioral health center located at san francisco general hospital, and the final strategy is to explore the development of additional post acute care and senior living housing services

at the jewish home campus. so all of those things that i've just discussed, you know, will take at least a couple of year yea years before they can be fully implemented. so the things that i just mention does, and we want to continue to have conversationed with the hospitals i mentioned to help bring services on-line as quickly as possible, and we will be participating in supervisor yee's work group which will hopefully get off the ground in the next couple of months. so with that, i'm done, and i would like to introduce daniel ruth who is the chairman of the jewish nursing home, and who would like to come and talk to you about the collaborative.

>> commissioner chow: thank you. >> sorry. i'm a mac guy, so using a pc is a bit of a problem. president chow, members of the health commission, director garcia, and to the public, my name's daniel ruth, and i'm the president and ceo of the san francisco campus for jewish living, formerly the jewish home of san francisco. i would like to thank you for permitting us to share with you today the report and solutions of the post acute care collaborative, otherwise known as the p.a.c.c. i had the honor to serve as a cochair for the p.a.c.c., along with kelly hiromodo, your extraordinary director of san francisco health net work transitions. the p.a.c.c. included some of the finest health and care coordination experts in the

city of san francisco, both from the public and private sectors, representing a true partnership and collaboration. some of them are here this afternoon, and i would like to recognize them. nivic hirosz who is the director of laguna honda hospital center, elizabeth pollock, who ais the director f patients and transition management at ucsf, and molly shane assistant director of management at ucsf, margaret williams, continuity of care service director at kaiser permanente greater san francisco, and ruth simon who is the post acute manager for the san francisco bay area for

dignity health. we were greatly supported on the p.a.c.c. project team, which consisted of our consultant, monique parrish, sneha patil at dph, we also brought in adjunct members to assist and support us with discreet issues as they occurred throughout the process. commissioners, it is my understanding that you should have a copy of the report. i want to take this opportunity to highlight just some of the important elements of our delivery process that led to the recommended conclusions that my fellow cochair kelly will cuss discuss in a few mom. as you may know in february of 2016, the commission adopted a

report as part of the san francisco post acute care project, and one of the recommendations was the recommendation of the post acute care collaborative. at that time, the san francisco section of the hospital council that comprises ceo's of the 11 public and private hospitals in the city agreed to sponsor the p.a.c.c. effort. our mission was to implement financially sustainable solutions to the post acute care challenge for high risk individuals in san francisco, and our corresponding vision was to empower individuals and families through strengthened social supports, collaboration and partnership.

the p.a.c.c. affirmed that placing post acute care patients in the right setting at the right time would positively affect patient outcomes, and needless to say, it is the right best thing to do in the best interests of those patients. as a result, we began work in march of 2017. it was a facilitated, deliberative and data driven process, and there are just two points that i would like to make note of. there are key informational interviews between april and june of 2017. project team members conducted extensive key informed interviews and site visits. interviews were conducted with a broad range of post acute care stakeholders. site visits were conducted at leading post acute care programs. and finally, there were --

there was a point in time survey in april of 2017, the p.a.c.c. completed a point in time survey across the hospitals to add critical data about the numbers, needs, and the characteristics of patients waiting for post acute care placement. the interviews, the survey, and the p.a.c.c. deliberation informed our next steps. so at this point, it's my pleasure to have kelly come up and -- to do the presentation. >> thank you, daniel. thank you, commissioners. the -- this was actually really a perfect group to work with. everybody was really committed to trying to tackle the issue at hand, and we worked very good together, so thank you to

the team. jumping to the key findings of the survey, we did a point in time survey because an he can dotally jucan -- anecdotally, just talking to the hospitals, they were behind, so try to get some data to really identify who was actually found to be long staying at the hospital, so we can two point in time surveys. those surveys found 117 patients were waiting for post acute care placement across the different eight acute hospitals that we surveyed. most had medi-cal, and half required post acute custodial care or 24 hour supervision. that's not a skilled nursing care, but activities with daily living, and not an actual skilled clinical need. many of them presented with behavioral challenges, some due

to behavioral health challenges, some with ongoing dementias. some had substance abuse issues, and some had mental health issues. so with that and furthering our discussion, we were able to identify populations that are high risk post acute care patients that are really the ones seeming to need the assistance and attention to try and move along to get into right level of care. so the primary populations that were identified for the -- from the group to really focus our work on were two similar but a little bit different populations. the first are people who predominantly cognitively impaired. these were people who were post acute care patients that impaired 24-7 supervision and were unable to manage their activities of daily living and

otherwise manage their care. the second group of people were more the presenting feature were people who were very behaviorally challenged, and these post acute care patients were people who either were experiencing a traumatic brain injury deficit. a cognizant impairment from dementia, substance abuse disorder or hypoxia, either a psychosis or mood personality, and/or substance use disorder that was manifesting in behavioral health -- acting out behaviors. so an analysis of their needs in recognizing they primarily comprised of people with low income and limited social support. it was clear that support settings were more appropriate than a skilled nurtsing facility were what needed to be identified. so we continued to work and develop some solutions to address gap in care for both of the populations, those that are

cognitively impaired and those that are behaviorally challenged. we came up with three solutions. the first was to adopt a standardized post acute care assessment tool. we identified the locus, which is the level of care utilization care systems. it's one of the tools for mental care placement. the second was to establish a citywide roving team, and the third was to find placement alternatives. the locate us, currently hospital use -- [ inaudible ] >> -- by using locate us, hospitals would share a level of care assessment tool that would facilitate treatment planning and would allow the hospitals to talk a common language around when they're identifying a right level of care. so it will also allow us the

opportunity to collect aggregate data that would allow us to collect the data in the level of care postulation. citywide roving placement team. [ inaudible ] >> hospitals have to have access to expertise and access assessing behaviorally challenging patients waiting for post acute care placement and a roving team would allow us to provide an assessment that would identify strengths, limitations, and appropriate level of care for placement. it would also give us the opportunity to do consultation, so we could provide behavioral and medication management recommendations. there are a group of people that if we intervened sooner and early on when an admission into hospital happened in an acute care stay, we would be

able to preserve the housing where the person came from or allow them to return back home to their families, and some of that is just knowing right resources and how to being assess them quickly and also managing care for a person in an acute care setting that could be duplicated when someone steps down into the community care setting. so an example would not be prescribing a medication regimen that doesn't work when you're in a hospital but works when you're discharged out to the community. there are also some interventions that are used in hospitals that can't be duplicated in the community setting that we could work with teams early on. the last, we would promote patient flow in hospitals and nonskilled facilities -- [ inaudible ] >> -- in order to help do that, it would be helpful to fund

subsidies and residential care -- [ inaudible ] >> -- for those who could live supported in the community. and then, the last would be expanding the residential care facilities in the mayor's housing initiative. there are quite a few boarding homes that are closing their doors, particularly small homes that are operated by small operators. so those are the three recommendations that we've landed at in a nutshell, and so thank you for your time and now the vice president of the hospital council, so... >> good afternoon, commissioners. david surano-sul, the director of hospital council of northern and central california. good afternoon. you have the report in front of you in your packet. we didn't include it in the slide presentation, but page four is an infographic, and that just really outlines

everything that daniel and kelly just spoke of, and that is sort of the process that p.a.c.c. went through through most of 2017. daniel in his comments introduced the p.a.c.c. members that are here this afternoon. again, they met every month, lots of time and effort that was put into it, commissioners, and could not have done it without their incredible support. i don't know if they raised their hands, but hello. they're here. thank you, and so appreciate everything that they did. when we started this process, we couldn't have done it without two committed cochairs: kelly hiramoto and daniel arusz. they elevated the discussion at every step of the way. and when we provided updated to you, president chow and director garcia, you helped in that process, as well, so thank you very much. the first meeting of the san francisco section for