permanent home. we are dedicated to the next many years of supporting the hospital in all of its endeavors but particularly to help advance its primary strategic initiative to be the most excellent public hospital in our nation. that is our goal. so we sincerely appreciate your support. >> president chow: thank you. >> any questions? >> president chow: any questions to our -- >> i wondered if amanda if you could talk a little bit about your renovation. >> absolutely. so we our grown, our staff over the last several years so we don't have adequate enough meeting space. the board of committee and board at large is bidding out -- building out additional meeting space and making sure we have enough cubicle and private office space for our team and have a space to clab r --

collaborate with our colleagues. >> vice president loyce: could you state your full name and title. >> amanda hire, ceo. >> vice president loyce: thank you very much. >> president chow: how many are on the staff that you are going to house at the new facility? >> we currently have 17 staff. t majority of whom are fundraisers, raising funds for the hospital. >> president chow: sure. further questions? thank you very much. i'm sorry, commissioner guillermo. >> commissioner guillermo: may i ask where are the funds coming from, funds from the existing general fund of the foundation or are they being raised specifically for the -- >> they are funds that we have raised and saved over a course of many years. so they are unrestricted dollars that we have set aside for this particular project. we feel like we are at a point where we can execute on the

plan. >> president chow: further questions? if not we are prepared for the vote. all those in favor of the lease? all those opposed? >> [roll call] >> president chow: the lease has been approved. thank you. >> item 9 is the fiscal year 2016 charity care report. >> good afternoon

commissioners. kristen pa tel here at dph and i'll be presenting our charity report. this will be presented to the finance and planning committee on april 3rd and we finalized this report using the commissioner's comment. so thank you for those. for this presentation today i'm going to provide some important background information related to the charity care ordnance and charity care landscape here in san francisco and then i'll go into our annual report in particular focusing on our city wide trends for charity care and then provide a little more information on the hospital specific data section that we have in our report. there are more sections in the report in the long appendix and i'm going to try to focus on those go. -- on those two. so our charity care ordnance in san francis

san francisco was passed by the board of supervisors in 2001 and at the time this law was the first of its kind in the nation and it supported a spirit of of public disclosure to increase transparency, accountability around charity hospital care. the ordnance requires hospitals to report on charity care data to dph annually and notify their patients of free and discounted services. there are eight hospitals that report their data to dph annually, required by ordnance. these are saint mary's, saint francis, children's hospital, cpmc and saint luke's and three hospitals report voluntarily, keizer foundation hospital san francisco, ecss and zuckerberg san francisco general. with these eight hospitals together dph is more accurately able to capture city wide trends and charity care. so before i start on the report i wanted to give you a little bit of a timeline for charity

care because there's some important factors to take into account. this timeline here on your slide provides some significant events that have occurred since the passing of the charity care ordnance and these have had an impact on charity care in san francisco. starting with the creation of healthy san francisco in 2007 this was our health access program here in san francisco that have allowed uninjured residents access to health care services and we are able to capture healthy san francisco patients cost services in our annual report separately from traditional charity care. with the aca becoming law in 2010 and then our preparation period here in san francisco from 2011 to 2013 we have seen an increase in health insurance coverage through medical expansion and covered california efforts. these are highlighted in this fiscal year 2016 report as well. so we are now moving into 2017/2018. it's important to note that

there is uncertainty in the federal level around healthcare and the aca. currently with the repeal of the individual mandate, elimination of cost sharing reduction we think we will be able to capture these or other impacts that might happen in future annual reports for charity care. so moving into the report itself, this charity care annual report helping us compile, analyze and prevent trends and data across our eight hospitals. it captures, again, both healthy san francisco and traditional charity care patients separately. we do want to note about this report that it captures one year of data either on a july to june or january to december timeline based on the hospital's fiscal years. over all this report will give you a high level over view of charity care in the era of health for our city and also showcases how trends are experienced differently by hospitals. so this report we engaged

representatives from the hospitals, so all eight and then we present is draft and the report to the hospital annually. this year you'll notice that our report is designed in a more concised streamline format and we still provide all the useful information for charity care in the city. so on the slide are the three major city wide trends that we found this year. this is for hospital charity care. these are mainly related to the acc. these trends have remained relatively consistent from the report presented last year when we first saw the implementation of the aca. so first i'll go through each one and provide data and graphs for them. since fiscal year 2015 and now in fiscal year 2016 charity care in san francisco has declined with the continued implementation of the aca. the first figure, the one on the

left, provides unduplicated patients for the last five years and you'll notice from starting in fiscal year 2014 into 2015 and now again into 2016 we are seeing significant declines in charity care patients for the city. in fiscal year 2015 we had about 60,671 and now in fiscal year 2016 we reported 51,569 or 15% decline. the next rate provides an over view of charity care service utilization by type, so emergency services, out patient and in patient services. you'll notice the inpatient, out patient services have declined from fiscal year 2014, 2015 and now 2016. emergency services from fiscal 2015 to 2016 have remained stable. there's a slight increase in about 3% and i'll get into that later when we talk about

traditional charity care as well. so continuing with the first city wide trend charity care expenditures have also began to decline significantly in fiscal year 2015 and now stabilized around 85 million in fiscal year 2016. there is a slight increase and we don't really think that is significant and it could result from different factors such as patient rate, cost to charge ratio and others. over all there's a shift from charity care to medical shortfall that you can see. med-cal being the difference between med-cal expenditures for services and hospital reimbursements for those services and hospitals typically absorb that cost. with the expansion under the aca this metric has become important and we started to include it in our report to capture all the

uncompensated cost care that's provided in the city. if you look at that top line you will see taken together the med-cal shortfall was a total of $661 million in uncompensated care for san francisco in 2016. so if we dive deeper into types of charity care for healthy san francisco and traditional there's differences to note. healthy san francisco craters to uninsured from the model. healthy san francisco as a population has a greater access to an organized system of care, stronger connections to primary and preventive care and has had support and out reach through the programs to transition onto acc initiated coverage if it was applicable. for these reasons you'll notice that the most significant decline that we see in charity

care, patients on the left in your expenditures on the right are mainly for the healthy san francisco population. this started basically from fiscal year 2014 has continued into fiscal year 2016. you won't see the similar declines in the traditional charity care population. i think that brings us to this third and probably really important trend as well. even when this era of health reform we are seeing that traditional charity care continues to be necessary, especially for these populations that might be harder to reach or may not be able to access health insurance for reasons that may be homelessness, immigration status, for example. in this slide you'll see a proportion of all services by types. so emergency, inpatient, out patient and these are separated on the left by healthy san francisco and on the right by tradition traditional charity care. most absorbed increasing

dependence on emergency care from 2014 to 2015 and then from 2015 into 2016, particularly for the traditional charity care population. in 2016 one in three services that was provided to traditional charity care was emergency care. this trend you won't see in the healthy san francisco population which has been about the same in proportion for each of the services. we think it's important that this population may be harder to reach and only accessing the system when absolutely necessary may not have access to that primary and preventive care that healthy san francisco population might. so continuing with this trend around traditional charity care, these are residents of the traditional charity care patients in san francisco and elsewhere. san francisco residents have and continue to be the majority of

hospital charity care recipie s recipients. we saw a large number of homeless and unknown addresses, around 16%. we also see about 9% bay area residents outside of san francisco, 3% california residents and 1% out of state. these were relatively consistent over the past five years though. as we dive deeper into san francisco residents for traditional charity care, a figure to the right has a break down by supervisor district. consistently we see the largest number of charity care patients are from districts that have lower average household incomes, particularly district 6, district 10, district 9 and district 11. we also provide a complete zip code analysis in the report.

so that concludes the city wide trends. i do want to focus a little bit on the hospital specific data section that provides charity care patients, service utilization, expenditures and med-cal shortfall as they experienced by hospitals. the trend that we focus on, i think this section provides you a little more descriptive information about each hospital itself. it was important to note that there are reasons, various factors that can influence charity care across hospitals, patient preference, others. to give you examples from the report from this section, the first one on the slide is charity care across hospitals for the past five years. over all the san francisco trend is that charity care patients are declining. we do see it may not be the case

for all hospitals and they may not be declining at the same rate. so with that gives you another hospital for hospital specific data related to charity care expenditures. we are preventing a lot more descriptive information with the section so you'll see that the trend that we saw in san francisco may not again be experienced in the same way per hospital. some hospitals even saw slight increases in their expenditures such as ucsf. on the left you will see the break down, the percent of total charity care expenditures to provide a general summary of care across the hospitals. so just to condition collude -- to conclude, we have been allowed to collect 10 plus years of data around charity care. we have consistent data and it

would be able to track the aca if they are applicable to charity care and have influenced our policy planning efforts for the future. currently of course as i was mentioning there are efforts made to dismantle the aca and although we don't know what those impacts might be yet, they could impact charity care moving forward and we'll hope that this report will be able to see some of those if there are any. now i want to acknowledge our hospital representatives here that worked with us on the work group and thank them for their continued support and partnership. i would like to thank the commissioners for the opportunity to present today and i'll be happy to take feedback or k questions. >> there's one public comment. >> president chow: we will take the public comment from david seawall from the hospital counsel. >> good afternoon,

commissioners. how are you, president chow, honorable members of the commission, director garcia. the regional vice president for the hospital council of northern and central california. i wanted to first start by thinking the incredible work she did in assembling this report. so thank you very much for working with our member hospitals. we as a council, as a hospital community understand the intent, to be transparent and provide information to the department and to the commission to make informed policy decisions. but as miss patel noted, work goes into it in coordinating and providing the data. so it's a big expenditure of time by hospital staff to comply with the ordnance and i want that acknowledge -- that should be acknowledged. they are here today and i thank them for the work they did in

getting this report together. the report continues to be refined. if you look at where it first started and where it is today i think that you are getting information whether it be the medical shortfall, the zip code, everything. it's become a report that i think is incredibly useful to the department and to the commission in the decisions that you make. so thank you for the report. to the commission, for the work and the friendliness. >> president chow: thank you. any -- certainly thank to all our hospitals for participating. it's become quite clear in these years aside from the beginning of it back in 2001 that as the landscape on healthcare changes we are able to actually track and understand far better the market forces and the cost and

the work that each of our hospitals are doing. so we would like to thank the hospital console and its member hospitals for its participation. commissioners questions? commissioner guillermo. >> commissioner guillermo: thank you so much for the presentation and it's always a useful tool. i'm also interested in what's the implementations of this data in terms of its policy, both in terms of the facilities and the services that the health department is responsible for and then the partnership with the hospitals throughout the -- in the system throughout the city. i had a question specifically on this one chart on page 10. that shows the -- i guess the difference between the

population utilization of services relative to -- or the difference between healthy san francisco and traditional charity care. do you have insights as to why those -- the title says that it continues to be essential. it doesn't really speak to why there is a difference in the utilization. and what that might mean for policy. >> i think one is that we also noted that for traditional charity care there has been more dependence on emergency services as i was mentioning. some of the hospitals did bring that up during our work group meeting. i think that these populations are going to be harder to reach for healthy san francisco. we've tried to move people into aca initiated coverage so they're not going to -- hopefully not going to be utilizing the emergency services as much because they have those connections to primary care preventive care as well.

you'll see that that actually isn't the case. but for the population that now is not -- was not moved into medcal or aca initiated cover cal california or healthy san francisco, these are the hardest to reach in our population. these are people that may not be able to access insurance, because of the government and other factors and these may be reasons that they are utilizing emergency services as the last resort. >> commissioner guillermo: i can say that the whole person care report that we saw, we are working closely with hsa and the homeless supportive housing department. what we are finding is that people will get on med-cal and then they have to renew their med-cal and at times there is some gap between that period of time when they get renewed and one of the things we found is that individuals have to present an income tax form in order to

show the ability to renew their medical as an example. so one we try to keep people out of the emergency rooms by having everybody have medical homes but there may be a gap there in terms of charity verses being able to -- and how far we can go back to medical if this person is not -- has lost their med-cal access because of the renewal process. so we are working closely with hsh to include -- i mean, with hsa, which is the med-cal renewer for us to see if we can eliminate this requirement of an income tax form for some individuals as a way to maintain them on med-cal for five years because we can't do that. we are working on that part. that's a little bit of insight that we've learned from really digging into why cannot particularly homeless individuals keep their med-cal

for a period of time. >> commissioner guillermo: i was also wondering and maybe this is for future data collection is the health status of some of the folks, so if we are seeing an increase in the emergency room, what is the profile. >> yes. >> commissioner guillermo: of that patient population coming in. >> that we can give you at another time to look at our coordinated case management system. if -- in fact, we just did a lovely view of 3400 patients who are homeless. we tried mental health, substance abuse and medical medications. we have over 66,000 individuals in the system with 15 different sets of data that include everything from ems, shelter systems, including all of our

programs that we have in our community. so we'll try to calendar that in the future for you to really see, get a sense of that. we are hoping that we will be able to use that data set that we've been using for over 10 years and collecting data around particularly homeless individuals who are high utilizers in our systems as a way to target them for service and also to look at some of their health status so we can bring that forward on the calendar for your review. >> thank you. >> uh-huh. >> president chow: commissioner sanchez. >> commissioner sanchez: i would just make a comment. i think it's an exceptional report. we thank you very much for it. i just wanted to ask, perhaps as we move forward, the whole concept of hospitals in in -- many ways is being shifted. a lot of pcs are moving out of the hospital. you have affiliations pc units

in different parts of -- all of the city and as an example market street i noticed today, valencia, golden gate healthcare an affiliation of ucsf, commission bay, all over the water front. there's other hospitals in the area that have done the same thing. you name it. the shift is -- the question i have, are we going to be able to chart this? is this going to be part of our affiliated quote, whatever that means, units? are they going to be part of our over all due diligence pertape -- pertaining to quality of care to make sure that we are providing, you know, due diligence and oversight to ensure that we are tracking how services are being provided? just a question.

related to the charity care report in the ordnance, we only collect from hospitals in particular so we wouldn't be able to do that unless we can change or ask for different reporting metrics. we haven't done that in the past and that's something that we could consider. that's something we want. >> i had one or two questions and i was looking for the slides and i actually can't find them. oh, there it is. it's on page 25. in regards -- actually, i want to commend all the organizations that have been able to put this together because one of the questions and it is a national question too is the value of a non-profit in the exception for taxes and therefore what the benefits are to the community.

this helps quantify it somewhat in a place to see that so many of our facilities and systems are certainly within the state average if not above the state average. and that we are continuing to, at the moment, show saint luke's separately which i think up to the point as they open the new saint luke's so it will be interesting what will happen. historically that's been a very major safety net provider for san francisco. how that will be in the future in terms of its reporting, what will be interesting an i realize that suter and cpmc is trying to combine this all but i thank them for having separate recordkeeping because it does show that the saint luke's

enterprise fair is contributing twice as much as the state average, for example. that's work that i think deserves some recognition on the part of saint luke's. like wise, some of the other hospitals, saint mary's has been, again, measured against the state average i think is very important. it would continue to be there for part of my interest to say that all the hospitals continue to move forward in the work that they are doing. so i just wanted to comment on that. historically that's been one of the areas that we all like to be able to continue to try and be able to share that or non-profit

hospitals are doing their part working with the county and developing care. i think we've all said that it's the collaboration that will then be able to actually help serve this public and that our public system cannot be the only system that serves. this then helps quantify what our non-profit hospitals are actually doing on our behalf. we recognize that keizer cannot be within this so we don't want to ignore keizer. it's in the footnotes here. the work they have done is highlighted in their report. all that is just to say that this type of information as we enter the uncertainty of what is happening nationally and statewide will welcome even more valuable. where we go with the -- our own healthy san francisco program -- i do want to sort of end with

the fact that i think one thing you've highlighted differently for us this year is that other -- i wish -- we should just go back to the chart you had. that i think is to me really new knowledge that there is really a pattern within what is now a more stable traditional charity care, assuming that if we are able to offer insurance a number of people get on to the programs and they go into a system similar to healthy san francisco and the fact that the emergency room services are so high within this population and that if, again, this looks loo -- like a target population that we should continue to work with, part of the homeless, those who don't have the support services and it would be nice to see if then

somehow -- i know that hospital costs takes on different project. whether that is one that's coming out of this data that is something. i know the saint francis programs that has been working in the tenderloin, whether that subset can really show a change within zip codes that show lesser use of emergency services as they partner with saint anthony's and others but if this becomes the stable population that we have what more can it do because it shows that we are not moving the needle on this. this is part of the value of looking at this and looking at prioritization and then as we see changes in our own ensured system as we move forward in the next several years we might even note some changes -- further

changes here. >> absolutely. >> so i think this is new information the way that you've been able to demonstrate in these three years with the stability of our charity level that this in contract to a manage situation, be it healthy san francisco and i would imagine this is very similar in the insured population so such as significant difference in the use of the emergency services for example as -- you know, one of the areas that we have been trying to highlight. does that make any sense? >> yeah. >> i'm just trying the find some of the new lessons coming out of this. i agree that the report continues to be more readable and we can pick out things like this now in terms of areas that we might want to be able to highlight and concentrate on for the future. >> absolutely. this data is from 2016 and some

of the hospitals from 2015 to 2016. so we may see changes in, you know, the 2017 data and whatnot with the work that's being done and we'll hopefully be able to showcase that here too and continue to track it. >> president chow: we really do appreciate it and we do use this and we are going to want to continue this. i think several years ago there was a question whether the federal or state reporting could replace this and i don't see it. this is a very important and different slice for our city and i'm pleased that we actually have been able to continue this work. again, thank the collaboration of all the hospitals that are involved. thank you. >> thank you. >> president chow: any further comments? if not then once again we thank the hospitals and we thank our own staff for having created a very fine report for 2016. thank you.

>> and commissioner, if i may could the people here for the charity care report that participated stand up so we can give you some acknowledgment? >> president chow: we would like to acknowledge you. thank you. >> [applause] >> president chow: we have also a former health commissioner, commissioner ella, thank you for coming. >> thank you, commissioners. item 10 is other business. you have the calendar before you. i'll remind you that august 7th is the community meeting in the richmonds and then we are still trying to find dates for the planning session. thank you to all of you who responded to my request about dates. >> president chow: thank you. i'd also like to announce some appointments that we have made also further for some of our committees. commissioner green will join us from san francisco general on the joint conference committee, commissioner guillermo will join us at laguna honda onto joint

conference committee. commissioner chung will be our representative at the san francisco health. so we will make further appointments as our new commissioners continue their orientation. thank you. >> item 1 -- any other questions commissioners? item 11 is a report back from the may 8th laguna honda jjc meeting. commissioner sanchez. >> president chow: commissioner sanchez. >> commissioner sanchez: i believe i chaired that item. >> i apologize, commissioner chow did chair that. >> president chow: oh. okay. >> it was a very good public committee. in our open session we did discuss the administrators report, the employee health and safety heard about energy repairedness. we looked at summary revisions

of the hospital policies and procedures an approved all of those and in closed session approved the credentials reportfrepor reportfrepor reportful -- report. you'll receive a full report from the mayor. any questions, please? >> commissioner loyce was there too. did you want to add any comments? >> no, you did a wunonderful j. >> thank you. >> next item please. >> consideration for adjournment. >> president chow: a motion is in order. >> if i may? i just want to ask if the commission if we would adjourn in memory of a physician who passed away dr. richard joblec who served here. he was from the east coast and came here and was a distinguished officer and served as a medical officer in vietnam.

he spent many, many years here in various categories and more importantly i think that he was involved in the tom ladel center for many years and the mission neighborhood health center. he really was an exceptional physician. i would hope that we adjourn in his memory. >> president chow: i would accept that. a second? >> second. >> president chow: so all those in favor of the motion for adjournment and in recognition please say aye. >> [roll call] >> president chow: we are now adjourned. thank you.

>> i want to welcome you here to the civic center hotel. my name is gale dill man, the c.e.o. of community housing partnership. in 2015, this was the second navigation center to open its doors and welcome over 92 individuals living inen ca encampments in the street. this announcement will ensure that before individuals have the opportunity to enter shelter and navigation centers, they can receive vital services and treatments that they so much need and deserve. and on an on going basis. on behalf of all of community

housing partnerships, and the 91 navigation center individuals here at this site, we are so excited and honored to introduce our mayor mark farrell. [applause] >> thank you, gale. good morning, everyone. i want to thank you all for joining us here today. as we all know, san francisco and the rest of our country, and cities around our country, are dealing with an opioid crisis hitting our streets. it's unfolding in our neighborhoods and in our sidewalks in front of our very eyes. fighting this fight means that we not only have to use existing programs but if we're really going to solve the issue and make a dent, we have to be creative. we have to come forward with new policies and new programs that will make a difference on our streets. and that is why we're here today. to announce a significant investment in a new, addiction

treatment program with our street medicine team. the street medicine team has long been a part of how san francisco seeks to deal with the health of individuals on our sidewalks and in the streets of san francisco. the street medicine team is on the front lines every single day here in san francisco. bringing service and treatment to those who need it here in san francisco. the small but vital team works every single day to care for those were in a traditional clinic or hospital, it's simply not the answer and it's not working. their work is rooted in compassion and acceptance and meeting people where they are. including streets, our shelters and our navigation centers here in san francisco. with this new investment of over $3 million a year, we are adding 10 new staff and increasing

resources to focus on the drug addiction on our streets of san francisco. and to address the opioid epidemic, right here on the streets of san francisco, the team will be expanding the work that they started with the pilot that started last year and expanding this program across the entire city. i am proud that san francisco is going to be the first city in the nation to take this approach. san francisco is a leader in so many areas and once again, we are stepping up with professionals that know how to get job run right. leaders willing to take bold approaches to address the issues confronting san francisco residents and those that need our help on our streets. by providing this medicine out of a traditional clinic setting, we're expanding our outreach

capacity and taking every opportunity to help those individuals that are on our streets suffering from drug addiction. the program, which sometimes i have trouble saying, is an important part of our larger strategy here in san francisco and with our department of public-health, to address those struckelling with addiction. which includes detox to residential treatment services. this investment, let me be very clear about this. this investment will ultimately help save lives. and it will improve the conditions on the streets of san francisco. i want to thank a number of people who have brought this program to light today. first of all, director barbara garcia from our department of public-health. [applause] >> dr. sven for his leadership and ingenuity.

we knew he would get the loudest applause and he deserves it. our department of homelessness and their partnership in leadership as well. and all the other providers and healthcare leaders that are behind me here today that are working so hard every single day in san francisco. to get those that are on our streets with the help that they need. whether it's homelessness or drug addiction or the other issues plaguing those on our streets, our goal in san francisco is to be compassionate and get people off the streets, on to their own two feet and on to better lives. thank you for being here today and with that i love to turn it over to director garcia for remarks. [applause] >> good morning. thank you mayor for your commitment to the effort of treatment access for those suffering from opioid addiction.

i'm barbra garcia. i want to acknowledge all of the d.p.h. staff here that work every day to heal and support san franciscans who are in need of healthcare. i'd like to give them another round of applause. [applause] we know science has proven, for a long time, with many personal stories and the medication assisted treatment works. addiction is a challenge of a lifetime treatment and recovery happen and people do get better. mayor lee, a year and a half ago, asked me is there something else that we can do? we need to reach people on the streets who are clearly suffering and in the grips of addiction. what else can we do? we know that some of our traditional approaches of addiction treatment, that is, waiting for people to be ready to come to us to seek help. it doesn't always work for those suffering from addiction and especially if they are homeless.

all of our services are voluntary and we have to develop care relations to engage people into care and it does take time. but i really want to thank dr. barrie sven who took this challenge for mayor lee and myself and add this service to his existing street medicine team. medication assisted treatment. to the streets where he goes daily providing care to the homeless people in need. that is how this program was born. in the fall of 2016. we have served over 95 people since then bringing medications to fight opioid addictions directly to them on the streets. by expanding the program today, we are first taking a big step towards our ability to combat the opioid addiction in this city. the new funding will allow us to directly serve 250 new individuals but we also know that we can serve more once we

get those engagements and those relationships because in all of our clinics, we can access the service and medication. so this program is a big step forward to saving lives, lost to heroine, fentanyl and methamphetamine addictions and overdoses. homeless people who use drugs are especially vulnerable and our health system is adapting going directly to them with compassionate outreach and expertise. we're able to help a group that gets missed in the traditional structure of visits and appointments. our low barrier medication program is just one piece of a city-wide effort to increase treatment. we are also providing emergency rooms at sucker burg general hospital and implementing a new addiction consultant service within our hospital to ensure all physicians at the hospital have access to treatment experts for their patients. the doctors from this service are also here today. so again, i want to thank mayor

farrell for supporting all of our efforts to address those with substance abuse disorders and continuing our efforts to save lives. with that i'd like to introduce dr. barrie sven. [applause] >> well, thank you very much, mayor farrell and director garcia and the city of san francisco for the opportunity to do this. i have been working with people experiencing homelessness in san francisco since 1991. my philosophy in this work is do what works, do what is needed. i didn't come into this work with a preconceived notion of what it is that is going to work. when we see what the problems are, then we develop what are the possible solutions? it doesn't feel like it's a

great innovation to say if people are not able to come into a clinic let's go out and see them where they are. i think what feels like an ininnovation about that is many people have the pre conception or the stereo type that a person experiencing homelessness doesn't care about their health. a person with a substance use disorder isn't very concerned about their health. what we see, day after day, one person after another, is that people are deeply concerned about their health. they may have more compelling concerns. where are they going to eat? where are they going to lay their head down and if they pend on drugs, where will they get drugs to prevent themselves from having severe and awful withdrawals. if we're out there with our team and this is absolutely about a team, not about me as a single physician, doing something, if we're out there as a team we're able to meet people where they

are. we see and talk to people about the harms related to their substance use. we also see what the damage to the community related to that substance use is. and we're talking to people about treatment. you've heard the term bupinorfine. that is our medication that we are primarily using. we're also often recommending and referring and assisting people when it's appropriate, to get to methadone treatments and we're using another medication to treat opioid use disorder. having these medications have changed my attitude towards seeing heroine users. earlier in my career, not that i didn't like heroine users, but i never felt like i had something

to offer. now they're my favorite patient. i have something that can immediately change your recollection with the drugs you use and change what your circumstances are. many people who we see have heard about it and they haven't had the opportunity to talk to medical providers who have expertise and get prescriptions. the basic idea is bring it to people where they are, get people stabilized, and then they're able to move into those next steps because when you are strung out on heroine, when you need to use or else have awful withdrawals, every four to six hours, it's really hard to do anything. what we need to do is provide something that is at least as

compelling to people as what is happening to them on the streets. medication is absolutely necessary. human contact, treatment and caring for people is the other thing necessary. with those things in place, and this program expansion, is allowing us to do that, we have the opportunity not only to reach the 250 additional new patients but that really has an amplifying effect. when one person is on the street felfeeling hopeless and sees thr buddy getting help, that is a tremendous boost to that person being able to take maybe that one more step to say, maybe things aren't absolutely hopeless, maybe there's something i can do. maybe that other person doesn't even have an opioid use disorder. maybe they don't use heroine. maybe they have a problem with alcohol?

maybe they have a problem with mental health disorder. seeing that hope where someone is hopeful. the most positive, most effective thing i've seen in this program is one person telling another, hey, i got this medicine from the street medicine team. i saw dr. evan, i saw one of their nurses. that person saying well, i can't believe it. you were the least likely to succeed guy. you were the worst-off person. you are the person with the worst addiction i know and now you are telling me you are not using? that's tremendous in building hope and that's what we need to do as we address the problems that we see. so i'm going to introduce chris, one of our initial low barrier buprenorp hine patients. someone who will tell you about his experience. so thank you. [applause]

>> good morning. my name is christopher rafino and to piggy back on what dr. svens said, one rainy morning, as i got out of jail, and i contacted dr. sven, via the mail and telephone and to other people, i did not want to use anymore. i had tried many, many attempts unsuccessfully of shaking my addiction to heroine of 28 years. nothing worked. i tried everything. residential programs, everything. well, dr. sven met me out in the rain with my bicycle in hand and the clothes on my back and spoke to me for 25, maybe 30 minutes. he said look, i'm going to do this for you. dodo not let me down.

i don't believe i have. three and a half years ago, that occurred right over here. three blocks away from here. my life has changed dramatically. i am a substance abuse councilor myself. i work in a facility across the bay. my life has changed. i have everything back i lost. i owe my love to dr. sven and buprenorphine. out that i was loosing hope you but i got it. i'd like to introduce someone from the homeless outreach program or the homeless program, jeff >> thank you, chris. [applause] >> my name is jeff with the department of homelessness and supportive housing. i want to thank you all for being here today. i want to thank the department of public-health. homelessness is a complex problem and it requires the partnership amongst many city

departments and individuals and people experiencing homelessness to resolve this issue and this is just one of many steps that we need to take. we're very excited about expanding this pilot that we started with d.p.h. many, many months ago. i believe it was in late 2016. i want to thank mayor farrell for his leadership in expanding this important program. so thank you again for being here today and we'll take questions over at the side. thank you. [applause] francisco. >> my name is fwlend hope i would say on at large-scale what all passionate about is peace in the world.

>> it never outdoor 0 me that note everyone will think that is a good i know to be a paefrt. >> one man said i'll upsetting the order of universe i want to do since a good idea not the order of universe but his offered of the universe but the ministry sgan in the room chairing sha harry and grew to be 5 we wanted to preach and teach and act god's love 40 years later i retired having been in the tenderloin most of that 7, 8, 9 some have god drew

us into the someplace we became the network ministries for homeless women escaping prostitution if the months period before i performed memorial services store produced women that were murdered on the streets of san francisco so i went back to the board and said we say to do something the number one be a safe place for them to live while he worked on changing 4 months later we were given the building in january of 1998 we opened it as a safe house for women escaping prostitution i've seen those counselors women find their strength and their beauty and their wisdom and come to be able to affirmative as the daughters of god and they accepted me and

made me, be a part of the their lives. >> special things to the women that offered me a chance safe house will forever be a part of the who i've become and you made that possible life didn't get any better than that. >> who've would know this look of this girl grown up in atlanta will be working with produced women in san francisco part of the system that has abused and expedited and obtain identified and degraded women for century around the world and still do at the embody the spirits of women that just know they deserve respect and intend to get it. >> i don't want to just so

women younger women become a part of the the current system we need to change the system we don't need to go up the ladder we need to change the corporations we need more women like that and they're out there. >> we get have to get to help them. >> sustainability mission, even though the bikes are very minimal energy use. it still matters where the energy comes from and also part of the mission in sustainability is how we run everything, run our business. so having the lights come on with clean energy is important

to us as well. we heard about cleanpowersf and learned they had commercial rates and signed up for that. it was super easy to sign up. our bookkeeper signed up online, it was like 15 minutes. nothing has changed, except now we have cleaner energy. it's an easy way to align your environmental proclivities and goals around climate change and it's so easy that it's hard to not want to do it, and it doesn't really add anything to the bill. >> good morning.