better. we have to provide teachers with curriculum online, our curriculum is in two different languages and whether it's lesson plans or student fact sheets, teachers can use them and we've had great feedback. we have helped public and private schools in san francisco increase their waste use and students are working hard to sort waste at the end of the lunch and understand the power of reusing, reducing, recycling and composting. >> great job. >> i've been with the department for 15 years and an environmental educator for more than 23 years and i'm grateful for the work that i get to do, especially on behalf of the city and county of san francisco. i try to use my voice as intentionally as possible to

suppo support, i think of my grandmother who had a positive attitude and looked at things positively. try to do that as well in my work and with my words to be an uplifting force for myself and others. think of entering the job force as a treasure hunt. you can only go to your next clue and more will be revealed. follow your instincts, listen to your gut, follow your heart, do what makes you happy and pragmatic and see where it takes you and get to the next place. trust if you want to do good in this world, that

[ roll call. ] >> second item on the agenda is the approval of the minutes of the meeting of march 20, 2018, but i believe commissioner chow has something to say. >> commissioner chow: prior to that, i'd like to welcome our new commissioners. i believe mayor farrell has appointed two new commissioners for us, and i will ask each of them to introduce themselves. first commissioner dr. laurie green. >> commissioner green: hi. i'm laurie green. i've been living in san francisco since 1976 and practicing abat the time rick in san francisco since 1977. i trained at the general, i trained at u.c., and i do a lot of other things. i delivered a baby an hour and a half ago.

[applause]. >> commissioner green: a wonderful little boy, and i'm just delighted to be on the commission, and i hope some of the experiences i've had with ed many, many years ago and i hope some of the other things will add value to this amazing organization, this amazing city. >> commissioner chow: thank you. and commissioner tessie guillermo. >> good afternoon and thank you, dr. chow. i'm a lifelong resident of the bay area, a native san franciscan. the majority of my career has been focused on community health and public health, and i'm very, very gratified to have the opportunity to serve my hometown and the residents here and to be in the company of such august persons, so thank you very much, and hope i can do my best. >> commissioner chow: thank you. we look forward to your contributions and thank you for the sacrifice that you're

providing your time to the city. we'll proceed to the approval of the minutes. the minutes are before you for the march 20th, 2018 meeting. a motion is in order. >> move to adopt. >> commissioner chow: and there was a motion here i saw. are will any corrections? seeing none, we're prepared for the approval. all those in favor, say aye, all opposed? no opposition, and we can move onto the next item. >> next item is the director's report. >> good morning. i try to acknowledge students in the crowd. san francisco nursing students are with us today. i want you to raise your hand and welcome you because you are the future of our system. [applause]. >> also, so let you know, this

is public health week, so i just wanted to let you know we're doing a social media campaign. with that, we'll be highlighting our staff and program that's have made great strides this last year. we we vacuum sinuated 6800 people, and that was due to out breaks we've had in santa cruz. equity project, project pride, street medicine, i see barry -- dr. zevin in the room today. also our environmental health in the department of health and housing, hazmat, and food safety. also, if you don't know, we do weathers and measures, so every time you go to the store and put something on a weight to

ensure the number of pounds, we license those, and our massage programs in which we provide outreach to massage partners to ensure that they are within the law. we also are doing a lot of work around vision zero trying to have zero pedestrian fatalities, and our lead program is our assistance and diversion program for those who experience addiction. staff will be combined with a quote on what they do what they do, and we encourage everyone to follow on the sf dph facebook and dph twitter, so we want to make sure that we all celebrate public health week, april 2nd through the 8th. i also wanted to just acknowledge the fact that we are -- will be sending, as you know, in september of 2017, we had a terrible hurricane in puerto rico, and one of the doctors isn't here today.

he really made the point of what are we going to do this in response? it's taken us a while one, not to be a burden to puerto rico, but two, to provide some support. we are conducting a puerto rico relief mission. we'll conduct a medical relief effort in puerto rico to assist with the efforts in the wake of hurricane maria. a 15 person team made up of doctors, nurses, and workers will depart april 6th on a trip to the northwest island commonwealth. this is going to be led by the director of primary care for the san francisco health net work. we will assist a federally qualified health center serving communities where the storm damage and health impacts are still very present. in hurtado, water and power have not yet been restored. the frisk team will split into

two groups with one based at a clinic treating parents, and another going door to door in the community providing assessments, delivery and care to those who may not be able to reach clinics. as an example because many do not have electricity, as an example for diabetic patients, they actually deliver the insulin on a daily basis because of the fact that the infrastructure of those areas are still not impact. the storm as you know can exasperate and has exasperated chronic illnesses such as respiratory conditions, asthma, diabetes and high blood pressures. residents may be affected due to increased dust and mold in the environment. the macrorefrigeration for medications and difficulty accessing care are some of the reasons that we are going, and we also want to ensure that we are supporting federally qualified health centers and also primary health centers in puerto rico. so i would like to -- our deployment team, our relief team to standup and so we can

give you a round of applause. [applause]. >> and if i could, ask dr. hammer, come on up and give us a little bit of your perspective on this, and i really want to thank you, and we have a logistics team. why don't you raise your hands, because they really have been doing all the -- as you know -- [applause]. >> -- we go into our incident command system, which logistics is a really important part of it. but dr. hammond, thank you so much for taking lead on this. >> well, thank you so much dr. garcia. it's been so much a pleasure and an honor myself and i think for all of us to be called to action to use our clinical skills and our -- and other skills to support the medical personnel. we're really looking forward to the trip. i really do want to appreciate and thank you for recognizing

fiza delgado and tony liss who have been our primary logistics team. i anticipate about 50 people from throughout the department of health who have offered us their support to get us ready for this trip. so we leave friday night. we'll be traveling to hautillo and going out to the community every day starting monday, and we look forward to umm canning back and reporting on the work that we do there, as well as really trying to cement some relationships so that the health care providers there in the community health center that we'll be working with really know that they have a friend and support in san francisco and the department of public health. so thank you so much for this opportunity. we'll be sending information back to you all while we're there, and i think we have a lot to learn, and a lot to

bring back, so thank you. >> thank you, dr. hammond. let's give them another round of plauz. [applause]. >> i do want to acknowledge that we have behavioral health clinicians who are going, and as you know, behavioral health, mental health is one of our -- one of the issues that happens and people need throughout this process considering the fact that you don't have electricity or running water off and on for over a year. it does cause a lot of concern, so i just want to acknowledge both of our behavioral health clinicians, if you could standup, and we just want to acknowledge your work. both of these individuals work every day on your crisis response team. that's the end of my report. if there are any questions on any items of the recoport, i'l be happy to answer any questions you may have. >> commissioner chow: thank you, and thank you, dr. hammer for leading this group.

and we wish you god speed, and we look forward to your report when you are returning after the mission. the health commission is very proud. >> and just for one other comment. i did -- our health officer did put a quick report together on some of the health issues and impacts on puerto rico just for you to have some background. >> commissioner chow: okay. thank you. thank you very much, and we appreciate the work that you're going to be doing. thank you. commissioners, questions to the director on any of the subjects on her report or any other questions that we wish to ask her at this point in regards to our department? seeing none, we then will proceed to our next item, please. >> sure. i will note there were no public comment requests for that item. we can move onto item four, which is general public comment, and i've not received any general public comment requests, so we can move onto item five, which is a report back from the finance and

planning committee. commissioner bernal chaired, and if you could give a brief summary. >> commissioner chow: all right. commissioner bernal. >> commissioner bernal: yeah. so the finance and planning committee met today immediately before this meeting. we considered the monthly contracts report, as well as requests for approval of the new contract with kpmg for health information management consulting as part of the electronic health record project. both of those were approved by the committee and are on the consent calendar fore the full commission to consider today. we also received a presentation on the draft charity care report for fy 2016. as many of you know, the san francisco charity care ordinance was passed in 2001 and requires hospitals to notify patients about free and discounted services and to report out on the charity care that they provided over the course of that year. so we reviewed that presentation, offered some

feedback, and i believe that report will be coming back to the full commission in a future meeting. >> commissioner chow: thank you. commissioners, any questions to commissioner bernal on any of the items? otherwise, we will then proceed to the consent calendar. on the consent calendar and to explain to our new commissioners, items that the finance and planning committee have already recommended are on the consent calendar items. any of the items can be pulled out, including the contract report. contract report usually includes information on already existing contracts or modifications. the new contract before you has a summary of new contract requests, and that's why it's in a more expanded format. any of these items can be pulled from the consent

calendar, otherwise, we will vote on the entire calendar. is there any extractions? >> i'll also note that there's no public comment requests for this item. >> commissioner chow: thank you. there not being any extractions, we're prepared for the vote. all those in favor of the consent calendar please say aye. all those opposed? the consent calendar has been adopted. >> thank you, commissioners and congratulations, new commissioners, on your first vote. the next item up on the calendar is the whole person care update. >> hello. good afternoon, commissioners. my name is maria martinez, and

i'm the director of whole person care, and i have a side kick somewhere behind me. [ inaudible ] >> dr. barry zevin. i've been asked to come back and update the commission on the project called whole person care, and i know that some of you are new to this, so i'm going to try to give as much background as i can. i'm happy to answer any questions. so in 2016, the state of california department of health care services issued a waiver to medi-cal called whole perp care wi -- person care with the idea that there are a small number of people who are costing a lot of money using urgent or emergent care in california and not getting better. so they carved out i think it was $1.5 million for counties to apply what they deemed whole person care, and only 18 of the counties applied for it -- the funds, and each county had the

opportunity to target the special population. san francisco chose to target single homeless adults, and we started in january 2017. i came in, i think it was march in 2017 to update you, and i'm now coming back to say how far we've come along. so i'm going to talk a little bit about some of our -- our approach to whole person care and here in san francisco and secondly about our challenge of getting and keeping homeless people on medi-cal. this is a medi-cal waiver; therefore, we can only drawdown funds for people who are on san francisco medi-cal. i'm going to talk a little bit about the i.t. solution and a little bit more about our target population. dr. zevin will be talking about that, and then how we are looking at our whole system of care here in san francisco. so san francisco, at the end of

the day, has about $36 million of funds for this effort. half of it is matched through general fund. we have a two pronged approach. one is how do we improve the services and -- how do we stitch together a very complex system of care in a way that's human centered, and how do we use i.t. to help implement that idea? and again, we are targeting homeless single adultes. so we are looking at homeless single person care in three domains. we are looking at health services, obviously. the array of services that we have here in the health department are vast, but also, these folks need to have housing and they also need to have benefits in order to succeed. we are coleading with the department of homelessness and supportive housing, c garcia and jeff kosinski of the

department lead this effort. and then we have a number of departments, ageing and adult services, ems, both 9 health plans and community based organizations in this endeavor, human services as being the benefits. in terms of what we're trying to accomplish, this ends in december of 2020. it's not a lot of time to do the administrative lift of getting programs off the ground, getting them ready and actually implemented and evaluated. what i'm showing here are the met rick th metrics that the counties are committed to achieving. these are the health outcomes. they should be pretty straightforward. many of them follow the hedus measures, and this is the homeless population that we would get for this measure. about half of the income that we get are going to services

being delivered in the department of homelessness department of supportive housing. and then, we also have some items that we need to deliver on, and i'm going to talk a little bit more about those in a moment. those are the performance goals that we have for whole person care. in terms of the people that we have served in 2017, it goes by calendar year, not fiscal year. in the 12 months that we've been doing whole person care, we have served over 14,000 people who are homeless. about half of those people are only known to the health department, so they're not asking for services yet in the homeless department, going to the shelters, going into navigation centers, etcetera. so the health department is a really important partner in addressing homelessness because that's where people come in to get services. and then about a quarter of the

homeless folks, we actually share, meaning they're in both programs, and a quarter are only known by the department of homelessness. that same number of people, only about 57% of them have san francisco medi-cal. so one of our biggest challenges is trying to convert folks who are obviously can meet the criteria for income, to get them through the arduous process of getting medi-cal and staying on medi-cal. so this is just one picture of one of the services that we are billing for. this is called outreach and engagement services. it's a night in the navigation center or sober sheltering center. so this shows month by month the number of people that are housed in one of those three centers. and you see that the bar, the

line, rather, is the goal that we have for drawing down revenue from the state. so we're almost there in terms of people who have san francisco medi-cal who are in those. but if you were to add the people who actually utilize those services, who are not on san francisco medi-cal, we far exceed the numbers. however, we can't bill for that green block there, and that equals about 851,000 of under produced, unbillable services from the state. so we know that we have a bill challenge here, and we've been working very closely with the human services agency to try to improve the way that we get and keep people on medi-cal. and so one of the things we've been working with, on a design for fjord, we've been working on two projects with them, and they doev into seeing what is the process of someone who is trying to get on medi-cal for

the first time, and what happens? why are people falling off? about a quarter of the people fall off of medi-cal within two years, and why is that happening? first of all, identity is critical. i.d. is critical. homeless people don't get things in the mail. it goes to general delivery. the post office, it has like a three or four hour opening where everybody, all of rest of us can go eight hours on aymond through saturday, but homeless people only have this much time, and we know that they are worried about bigger things than getting to the post office for their general delivery mail. there's also no incentive for people -- very little incentive to go through the process of getting and staying on medi-cal. it's the single standard of care. it's the way san francisco rolls. if you meet standard, you get the service, so there's no, i

have to meet standard in order to get the services. there's a lot of confusion. what we are doing is implementing a benefit navigators pilot, and they'll be in the shelters, trying to help people in the shelters. talk more about that in a second. another finding that fjord found on us with us is you have the option of oughty renewing on medi-cal for up to five years. it has to be a box that the person actually checks off, and we can operationalize that. we can get people to do that. but then we found out at 12 months, the federal hub will spit out that application if they haven't done a tax return, and so how many homeless people do we know do tax returns? so it's an automatic, another, you know, rock to push up the mountain there. so that in working with the human services agency to advocate for legislative changes there.

another thing we have -- much of our medi-cal comes through emergency medi-cal in the hospital and behavioral health doing medi-cal conversions, so both of those are disassociated with the medi-cal office. so we are trying to work with the hospital base and the behavioral health base to improve that process of getting and keeping people on medi-cal, and then, there are just many myths and confusions, and we need to figure out how do we write about this process in a simple way, not only to homeless people but the people who serve them. benefits navigator pilot, which we are starting is not only getting people on medi-cal, but also getting them on food stamps and general assistance. we're training our hot workers to go into the shelters and to get people to find the right people, get them onto medi-cal and its pilot.

>> commissioner chow: maria, i'm sorry. could you explain what hot is to the new commissioners in. >> sure. hot is the homeless outreach team, and it's a program that we started here under dr. garcia 12, 13 years ago and now it's moved over to the homeless department. and so any way, we're targeting the people to help them get and stay on medi-cal, and it -- we are working together very closely with the assume service agency and the housing department and the health department to try to address this issue. in terms of the i.t. solution, we are looking at merging data from five different systems. in the dph right now, we're moving toward he piepic. we have many systems that don't talk to each other. we are pulling together the health data, but we also need

the homeless department's data, the department of ageing and adult services, and the department of human services for the benefits data to come in under one platform, integrated to create one record. so that's what we are working toward with gartner. it's a consulting group to help us design the future solutions. what we need at the end of the day is the ability when people are serving someone to have integration that comes from all these systems. tcs is our interim solution, but it can be faster and it can be better. table management, population health and invoice is, so this is the highlights. it's a very quick summary of a complex process that we're going to go through. happy to answer questions. at the end of the day, we need a data share that is human centric that's at the right time, at the right level, isn't a lot of noise, is action

oriented. we also are going to dpsh-we've agreed, all five of us, to create a universal assessment tool that in 15 questions can answer, should this person be fast tracked into housing, should they be fast tracked into intensive health care? we're going to share our care plans in a way that no matter what door they walk-through, the next right question or the next right action is known. it could be the shelter, it could be into the emergency room, it could be into intensive case management. so that's how we're going to share it on this platform. wither ae going to share this with each other and give each other alerts, and we also know from working with each other in the last 12, 13 years in an interagency fashion, data doesn't really change anything, we have to learn how we use the data and hold each other accountable, so the system of care is going to have to adapt

and adopt across these agencies. in terms of the targeted population, we know a lot about the homeless population through ccms. about 11,000 that we served in the last year that are known to me, the homeless department believes there's about 15,000 people. we've served about 11,000 people. whole person care between the two of them is almost so 15,000 people. we stratify our knowledge about these folks in two or three different ways. one way is are they using emergent or emergency health services? are they a high user of the emergency room, inpatient, medical detox, so we know in

the homeless population about 12% of the homeless population are in those high user categories, but they constitute about 75% of the dollars, so there's a small number of people who constitute a high cost, high use population. and then, we also look to see how long they've been experiencing homelessness. if they have over ten years of continuous or periodic homelessness, they're going to have a lot more complex tridisorder issues going on with them. one of the things that we're -- also have seen is there's an extremely high percentage of the long-term homeless who are avenue can america african american, so we know there's a pipeline of the 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