then, we will ask in this case, our staff and the director to give us a report back on the resolution. i'm glad that you are already in conversation, and we will look forward to being able to respond, and the director will then give us an update on this. thank you very much. >> thank you, commissioners. item five is a vote to hold a september 6, 2018 joint meeting with the planning commission to discuss the 2017 cpmc annual compliance statement. as you remember, you approved a revised version of your rules and regulations, and it requires that you vote on special meeting dates. >> so commissioners, before you is a need for us to motion that we hold a september 6 joint meeting with the planning commission. a motion is in order. >> so moved.

>> is there a second? >> second. >> are there further discussions to this motion? if not, then i'll move onto the vote. all those in favor of the joint meeting on september 6 with the planning commission to discuss the cpmc annual compliance statement for 2017, please vote aye. [voting] >> all those opposed? the resolution has been passed. thank you. >> clerk: thank you. i'll note there was no public comment for that item. item six is the health care accountability ordinances. commission, this is for your approval today, and if by any chance you need more information, you're able to delay the approve. but if you get what you need today, then you're able to act on it. mr. chang, yes.

>> good afternoon, commissioners. thank you so much for your time. my name is patrick chang, and i am here from the office of policy and planning and i'm here to present to you our recommendations for the revisions to the health care accountability ordinance minimum standards for 2019-2020. as secretary mark mentioned, we're here to ask for your approval, to be effective january 1, 2019 through december 31 of 2020. i'm happy to take any questions and comments that you might hav have. so just a little background, chapter q of the administrative code went into july of 2001,

and this was a pioneering piece of legislation in the u.s. to reduce the number of uninsured in san francisco, and make sure that workers have access to insurance that's comprehensive and affordable. d.p.h. is committed to this law, and it's something -- especially in this environment of uncertainty in the health care environment and especially with things that have happened under this presidential administration, this -- this ordinance is one way for us to really reinforce these values and to make sure that, you know, people have access to affordable coverage. and so the a.c.l. applies to certain contractors and certain tenants much such as those vendors who are over at the airports, the ports, and nonprofit providers. there are exemptions based on employers size and type and other contract parameters, and the law provides two options for employers who are required

to abide by this law to comply. one of them is to offer coverage -- individual coverage to each employee that's at no cost to the worker, and the other option is to pay a fee to d.p.h. to provide services for those who would be uninsured. and this annual fee is adjusted annually based on the increase of the h.m.o. premiums in the states. so ideally, employers would offer coverage to the workers, and employers could save about 45% in cost if they did offer a compliant plan based on current market premiums. so this slide just shows the relationship of the health commission and the work group. these standards are reviewed every two years, and the health commission has full authority to -- to revise the standards. since 2004, d.p.h. has

partnered with a work group that has consisted of a range of broker, employers, nonprofit and for profit, also health plans and labor unions to really share their expertise and their perspectives that these standards with workable, and we try to balance affordability and plan availability for all those involved. and so i'll describe more about the work group shortly in a separate slide. this slide shows the relationship that officer labor standards enforcement and d.p.h. has in enforcing this law. and this also is designed to provide employers and brokers with the support that they need to fall into compliance with the ordinance. so in general, d.p.h. oversees updating the minimum standards every couple years, and also

reviews health plans on -- on an ongoing basis to make sure the plans the employers are providing do comply with the standards. the llc oversees more of the enforcement part around auditing employers, responding to any complaints or violations. they negotiate settlements with employers who are found to be noncompliant, and they also coordinate payment plans. so the work group was convened from april to may of this year, and we had four meetings -- and i also want to thank them. some of them are in this room, and they've been involved in this process -- some of them since the inception of this law, since the original writing of this ordinance, and so i want to thank them for their experience and their wisdoms that they really lend to this process. so there were 13 individuals who submitted bids this year, and they ranged for four profit

employers, labor unions, health plans, brokers, and they've been really invaluable since we started running this work group over the last 14 years. the work group reviewed 170 plans from the small group markets, from second quarter of this year, and we really look at the small group plans to make sure that small businesses in the city have to comply with the law have a reasonable amount of options that they can choose from. so going through all the health plans that we looked at, some of our discussions, we really try to pore overall the parts and facets of the plan, such as out-of-pockets, the coinsurance, deductible to really balance out what does affordability really mean for employees, and how does it balance out with the premiums? and so as you can imagine,

there's a lot to look at, and there's been a lot of changes in the health care environment over time. and so we have some really wonderful work group members who really lend a really meaningful perspective for their constituents on these areas. over the -- over the years, the work group's also been very creative with how to make use of reimbursement products out there, whether it's an h.r.a. or an h.s.a. these really have been more prominent in the health care market over the last few years with rising costs across the board and -- so these types of plans and compatible plans have been really helpful in balancing out the economic needs for both employers and employees in a variety of ways. so i'll jump right into the standards themselves, and i'd

like to share with you the work group's recommendations for the standards. there are 16 standards currently, and one of them -- so this isn't a standard, per se. currently, the a.c.l. allows for any type of plan, whether it's an h.m.o., p.p.o., any metal tier level, as long as the plans meet all the standards as they're described by the minimum standards. this year, the work group would like to recommend that all gold and platinum plans for the cost sharing would be deemed automatically compliant. and we looked at this, you know, also because these are designed to provide the most generous benefits. they would really give, really, the strongest benefits for employees while also simplifying compliance for employers.

and so we suspect that this may even encourage some employers just to opt to provide some of these most generous plans. so simplified on their perspective which would be ideal. because bonds plans are historically and actuarily the least variant, they should be all compliant, so this kind of narrowed down our review process, primarily silver plans. you know, so standard one, currently, this prevailing standard is that employers would pay the full premium. this wasn't an easy recommendation for us to all agree on that, that these -- this standard is maintained moving forward to really preserve the intent of the law and to preserve access to affordable care for employees. our second -- the second standard pertains to out-of-pocket max. currently, it's ses at 6,850 --

set at $6,850, and the recommendation from the work group is to align this -- this standard with the california patient centered benefit design for silver plan -- for silver insurance and co-pay plan. historically this has been lower than the a.c.a. plan and national limits. so if we were to anchor it to this standard, it provides protection for employees from the rising costs, and also for employers and brokers to plan for subsequent years. so, for example, for -- for 2018 currently, the state benchmark for this level is $7,000. nationally, the a.c.a. allows for a plan to hit $7,850. next year, the national a.c.a.

limit would be $7,900, and if we peg it to this benchmark, it would cap the a.c.a. allowable limit at $7,550. we don't know what 2020 is, that will be available spring 2019, but we expect this relationship to hold as it usually has. the third standard is -- allows a medical deductible of $2,000, and employers must cover all the actual expenditures that count towards this. especially with the rising cost of health care, this is something that the work group agreed to maintain, so employers will still cover the costs of any expenditures that count towards this, but we -- but the only change would be to clarify some of that language to reduce confusion for employers and brokers, that they would not have to prefund the full amount right off the

bat. and so we do believe that this will continue to remove that financial barrier for people to seek care such as those who would belower wage earners where having a high deductible is actually a barrier to seek care. so to make sure that this is clear, d.p.h. is going to distribute some materials for employers to reinforce this law. regarding description language, currently, the current deductible is set at $250. the recommendation by the work group is to lower this to $200. we arrived at this by looking at all 170 plans, and we saw that silver plans still generally priced the deductibles at or below $200,

and lowering this -- lowering the maximum for the a.c.o. to this amount would not reduce the number of potentially compliant plans for employers to choose from. and also taken in concert -- we understand we're allowing the max to rise with inflation in the market, and so we wanted to lower the -- the hit that employees would be taking in other areas as much as possible. standard five, currently requires that drug coverage be provided and covered by plans, including brand name drugs. the work group agreed to maintain this standard as is moving forward. coinsurance is standard number six. currently, it's at 30%, and that means, you know -- that means that -- about a silver plan, and so the -- the recommendation by the work group is to reduce it to 20%.

and similarly, to the deductible, we thought dropping the prescription to 20% wouldn't impact the number of health plans available for employers to choose from. so this in concert with the other recommendations, we wanted to be able to provide some more protection to the employees, since the potentially out-of-pocket costs would be rising over the course of their plan year. standard seven currently allows for a maximum copayment for a primary care visit of $45. the recommendation for the work group is to maintain the standard. we also acknowledge that this was a very, very widely discussed standard, and there's -- there are concerns that $45, it is a high out-of-pocket cost, especially

for, you know -- whether it's a low wage earner or not, $45 is a lot, and it hits even harder for lower wage earners. so this was a concern, but at the same time, based on -- on the marketplace, lowering it below $45 would have drastically eliminated a lot of plans that would be potentially available to employers. and so in concert with all of the other reductions and increases, the work group settled on maintaining the standard moving forward. so -- standards 8 through 16 are more forward. right now, they're all required, and some are required at no cost, specifically preventative care and

preimposed prenatal services. so the work group's recommendations are to maintain these standards, but clarify some of that language that goes along with those standards to -- to point out that the types of services that are required are outlined by the benchmark plan. and we wanted to sync it with the bench mark plan because some states offer -- they have different requirements where some services are not required by the state for small and individual group insurance, such as preventative hearing surgeries, preventative surgery, acupuncture. those things are required, but in california, we wanted to make sure we preserve that level of coverage, especially anything that might happen at the federal level that would erode this coverage. so in conclusion, altogether, this package of recommendations increases the number of plans that would be available to

employers to choose from. it also stream lines the types of plans -- the most generous plans that could be available, and we are optimistic that this is an elegant way to encourage gold and platinum plans to be offered, and also four times more silver plans for employers to choose from. and granted, given inflation over the next two years, that may change, but as a health department, we support these recommendations as a whole, and look forward to your approval of this. and at this time. i'm happy to take any questions that you may have. >> at this time, i want to take any public testimony, and then we'll take questions. so rk ma, we have three minutes each. >> clerk: if that's what you'd

like, yes. >> yes. the speakers are greg brown, debbie lerman, and mark kramer, and then we'll proceed with discussion by the commission. >> clerk: so again, i have an egg timer. when the buzzer buzzes, that means your time is up. >> thank you, commissioners and staff and everybody else. having been on the work group -- and by the way, i must compliment patrick chang. he has to deal with tough circumstances sometimes because there's disagreements, and he's done an excellent job with his staff, and the other people from the city, they're a pleasure to work with, so i commend you on that. as one of the people on the group, i was most concerned -- the purpose of our hcal was to cover more people with insurance and make it affordable. i was one of those people that was against the $45 because having talked to a lot of workers, i find that some of those workers are not taking advantage using their health care premium, which just puts more money back in the health

insurance company's pockets. the reason is the $45 every time they have to go in. that's a lot of money. we have workers under city contract that earn $12 an hour. i represent workers at the airport that earn $15 an hour. when you go in and paying $45 and getting the treatment, it's going to get expensive. and a lot of them were going to san francisco general or free clinics. some of them were not. one of the advantages of this program was it cut some of the money going over to san francisco general and to the free clinics and took away some of that drainage. well now, it's coming back. so we might be insured, but we're not that well insured if you can't go in for treatment. my favorite example is allergies. number of people having allergies as a percentage continues to go up just because of, like, climate change. if you go to the allergy shot sequence, i used to have to do

it. i go in on monday, go in and get four shots in each arm on monday and then friday. and that went on for a while. and then, when they think it's safe, they go to once a week. well, if you go in twice a week, and you're paying $45 a pop, you're going to go broke pretty quick. there's other illnesses like that where, you know, it's going to affect your quality of life and everything else. i will tell you that i'm really oppos opposed to the 45, but i will tell you that one or maybe none of the silver plans have a $45 co-pay. if you see the comparison chart sometime, you see all the plans, and you'll see certain patterns real quick. and it's amazing. nobody offers certain anything

under $45. it's amazing how that works. it defeats the cost of having health insurance. if we're going to have $12 an hour employees in the city of san francisco, and employees making 12, 13, 14 an hour, we've got to do something else. real quick, nonprofits are a big issue for us every single time. i've been on this work group a couple times now. i will tell you that every time, we're always going to the nonprofits, bottom. we're also -- always having to go to the lowest common denominator. once they get reimbursed, they start nickel and diming us and start hacking away at it. >> clerk: your time is up. >> thank you very much. >> so thank you very much. >> next please. >> hello, commissioners. debbie lerman from the san francisco human services network. we're an association of about 80 health and human service nonprofits, most of whom have city contracts, many with the

department of public health. i also want to thank patrick chang and the d.p.h. staff, other city workers, our nonprofit representatives that served on this task force from larkin, rams and delores street community services, as well as the labor representatives and the brokers and the wonderful work that they've done. i have also served on this task force since 2004 i think seven or eight times now. as patrick explained, our approach is to find that balance between affordability and availability for both employers and employees. we want our employees to be able to have health care that they can use. we want our workers to be well so they can come to work. at the same time, the balance for employers -- we've always said we want to make sure that a substantial percentage of the health plans on the market are available. we continue simply mandate gold and platinum plans for every

employer because if you do that, you will have nonprofits that cannot afford the plans and that will ultimately have to cut services. that would take the ability of the money to raise salaries, take the money out of the ability to deal with the rising rents that we're struggling with in the city. it is a balance and employers need flexibility. they are not all able to afford high -- these really high level plans, and that is an acknowledgement that we've all had to make. we would all prefer lower co-pays, and the fact that $45 co-pays are the standard doesn't mean that that's what everybody has, and it doesn't mean that every worker is making $15 an hour, which is the minimum wage now in san francisco. so the airport stuff is a whole different -- there's a whole living wage fight going on board around those issues, so that that isn't really relevant here. but really, the thing to understand is that this is an

unfunded mandate to a large degree. we do not get reimbursed for these standards. those workers who are on city contracts, some of those costs get reimbursed, but the city does not fully fund the cost of our contracts, as i'm sure you all well know. you're lucky if 60 or 70% of your contract is funded by the city. but the reality is whatever health care plan you're providing to your contract workers, you're also providing to all of your other employees. you can't give this group a favored health plan and a lower level health plan to everybody else. so if the standard provides -- mandates a really expensive plan, you've got to come up with the money somehow for the rest of your employees. some employees, most of -- others might have ten or 20% of their employees working on the contract, so that is the struggle that we face. that is why we support the proposed recommendations and

hope that you will approve them today. thank you. >> thank you. next speaker, please. >> carl kramer, san francisco living wage coalition. three points i want to bring up with the health commission. point number one, as you heard, there was strong concerns from labor and worker advocacy organizations that the $45 copayment for primary care provider visits deterred low-income workers from seeking checkups and preventative care. the study by the san francisco department of public health office of policy and planning, called san francisco's health care accountability ordinance and health care landscape reported that the california average copayment to visit a primary care doctor is $25. it was strongly felt there should be further efforts to

find ways to reduce the cost to low wage workers. there were questions raised about whether the city was providing funding to nonprofit service contractors for increased costs of health care coverage required by the health care accountability ordinance. there is language in the acao for those increased costs to be considered. in the ordinance, it states when preparing proposed budgets and requests for supplemental appropriations for contract services, city departments that regularly enter into agreements for the provision of services by nonprofit corporations shall transmit with their proposal a written confirmation that the department has considered in its calculation the cost that the nonprofit corporation's calculate, that they will concur in complying with the acao. the san francisco living wage coalition made a public records request for the above-mentioned

written confirmations for the past two fiscal years to the department of public health, which is -- has the most contracts with nonprofits, but so far, no one's been able to find those written confirmations. so without quantitative information, it's not possible to measure whether nonprofits are being adequately funded to pay increased insurance costs. this has had a causal effect on the acao work group of lowering minimum standards to shift the burden of costs to employees in order to lower monthly insurance premiums for nonprofit employers. the third point was that there was a discussion of having a continuing work group on extending health benefits under the hcao to dependants, spouses, and domestic partners of employees and providing funding to nonprofit service contractors to provide family

health care coverage. there is a precedent to having this kind of continuing work group. after the hcao work group on minimum standards finishes its recommendations. after the hcao finished its work groups in the summer of 2004, there was a continuing work group which included the living wage coalition which continued meeting over a year with ann kronenberg with a health benefits program. >> okay. thank you very much. commissioners -- commissioner green? >> yes. i was wondering about dependent coverage, and how that affects your calculus, and how that

affects the coverage of your employees. so what's been the discussion on that and how is that being approached? >> that's a good question. so currently, the hcao only governs individual coverage for the employees, and so dependant coverage, it has come up in our groups. unfortunately it's outside the scope of the minimum standards at this time, so we haven't -- we haven't been able to go really in depth on that, and so any changes to -- to the guidance on what these standards would be, what has to have a separate supervisors process, legislative process to amend the ordinance itself. >> is dependent coverage available through these various silver plans that you're offering? >> that would be up to the discretion of the employers themselves. to my understanding, some employers have worked with their employees to extend that

coverage and kind of shared the cost of the premiums in a way that makes sense for their own operations and for their finances, but currently, there's nothing in the law that requires them to do so. >> commissioners, further questions? i had a question in regards to that. a potential recommendation that you were looking at extending this to other than employees, how -- how would that work, actually, since our mandate here under the standards is to deal with the employees themselves? >> commissioner -- >> and is there a recommendation that you're offering that -- that includes that, 'cause i don't see that in the proposed resolution. >> the work group didn't arrive at that recommendation, and the

health department currently doesn't have a position on that. it was a -- it was an item that some work group members wanted to raise during our meetings, but it -- we haven't formalized anything or any position on -- on that matter at the time. >> okay. commissioners, i did want to point out that i had asked the question as to how successful, essentially, the hcao has been, and it would appear that there is some success inasmuch as only 27 employees -- employers actually paid 1.4 million, which would sound like while we don't have a count of how many employers would actually be under all of this, it certainly is more than two or 300 employees who seem to be affected by the 27 who were

paying this. and if i recall, in the past, many of these were actually related to part-time employees, right? that often an organization might pay into a plan because it really doesn't cover or isn't actually cover -- >> yeah, some contractors with a city department, that there's so much fluidity in their workforce model that kind of pinning down and offer a plan for an entire year for a seasonal worker or part-time worker that may not be there past the plan year would be some costs for some employers, so they've opted to pay the fee instead. i agree with you, the 200 to 300 employees, fortunately, i mean, it's still a lot of actual human lives, but we've

glad it's not in the thousands of people who are uninsured, so we take that as a win as a result of this law. >> right. i can't remember, were you looking to -- no. okay. are there any further questions at this point? this is a very well written document. thank you. >> thank you. >> once this is up for approval, commissioners, you can vote on this today, and once again, commissioners, if you need more information, it can be deferred. >> so commissioners, what is your pleasure? there's a motion that's been drafted by the department, and it's before you if you wish to consider the motion today. otherwise, please also let me know what other questions you would like answered, and we can take that up later. so your pleasure, please. are you prepared for the vote?

if so, then, a motion definitely needs to be placed on the table. >> i'll move. >> i move that we -- i move that we approve this plan as is. >> which is resolution number 18.2 at this point. >> i'll second the motion. >> and there's a second to the motion. is there now further discussion on the motion? if not, then, we're prepared for the vote. all those in favor, please say aye [voting] >> all those opposed? the motion has been passed. thank you very much. >> thank you, commissioners. >> and patrick, do you mind closing down the preparation? >> thank you. >> thank you. >> clerk: i'd seven is d.p.h. review of board of supervisors audit. and commissioners, as noted on the agenda, the item eight,

nine, and ten will begin around 4:00, so if this goes a little long, i'll probably nudge you all or prod you all to close down around 4:00. >> we can also watch the clock. >> yes, you can do that, too. >> thank you. please. >> good afternoon, commissioners, president and director. i'm here today to specifically talk about the board of supervisors performance audit of behavioral health services, provide some information to you about it, and some of the activities that we're engaged in and some responses. and i have received some questions from you earlier today -- some of you earlier today, which i hope through this presentation, i can cover some or address some. those that don't get addressed, i'm more than happy to come back or provide it in a different forum or in writing

as needed. so we at d.p.h. and behavioral health services, we appreciate audits. we welcome audits, and we find it as a way to understand our system, and make improvements and learn from the items that come out of it to put in practice around various improvement plans. so we welcome it, and we appreciate the information. it's been very helpful for us to have. in that respect, we actually are engaged in multiple audited. we are engaged in annual audits, we have -- by the state that happens. we have triannual audits, and we have annual state department of health care services audit. along with that, the department for the past several years have engaged in self-audits, self-evaluations as well as a self-review of various of our systems that you'll see up

there around the s.f.g. services, psychiatric health, looking at acute psychiatric system around patient flow, looking at patient management and how we can improve one-on-one as well as looking at our ongoing documentation review and claims review. and there was a recent audit or report that happened on our crisis intervention services, c.i.t., which is specifically working with the police department and working with the fire department, which i'll highlight at the end. one thing that's very important to notice is along with the fact that we appreciate audits, we have had multiple accomplishments, and we have a very, very robust system of care that should be recognized for it. we have outstanding reviews, 95% compliance ratings of our mental health plan by the state at their triannual audit. we have had ongoingly

consistent high satisfaction rating by our consumers that we serve. we've received local awards on our data gathering and various service delivery as well as national awards. so it's important to recognize that along the fact that we're working to improve, we've been recognized for a lot of the work that we done, including our trauma inform system of care, our gender health services, and we even looked at how -- what's the success of our clients to discharged, when they're discharged at the time, how they are doing around their treatment plans completion, partial completion, and we've had 60% of the people who come -- leave our system at the time of discharge, they've actually had successful transitions or partial success under a treatment plan and showed stability. on the board of performance -- board of supervisors performance audit, i just wanted to highlight few things. this audit was conducted starting august 2017 to 2018,

but it went back to -- all the way to 2010, 2011, all the way to 2016-17, looking at multiyears. there were 50 recommendations that came out of that. we agree with the recommendations and on many levels, we agree with the concept, we agree with what was identified, and we've actually been engaged in a lot of the work and activities before the audit identified those, but we also have some disagreements around the arching, overbroad monitorings. so there was some over arching, broad conclusions that we thought it was not necessarily best stated. and the fact that again, we've been off tinvolved in many of activities before this audit that specifically relates to many of the recommendations.

so out of the recommendations, there were multiple recommendations, but i wanted to highlight the top five that i thought was very pertinent and very important because it addresses around our service delivery as well as the system of care and the flow. so i wanted to highlight five of those recommendations that came out of the board of supervisors audit. one was around c.b.o. performance, community-based organization contractor performance. one was around civil service, our own d.p.h. operated clinics. one was around client case management, intensive case management and how they're transitioned to lower level of care as well as intensive care management wait list and finally, there was a recommendation around p.e.f. discharge, people who are being released back into the

community. so the recommendation one which focused on provider performance, the one area was on c.b.o. performance which specifically wanted to look at monitoring and what we're doing looking around productive and service delivery and supply-demand. i wanted to highlight that we've actually been engaged in a lot of specifically specifically focused -- activity specifically focused on that. one, we do annual program review on all of our c.b.o.'s on various metrics that that happens on an annual basis, and redo -- we do random audits, as well. we believe that good documentation results in good quality of care as well as communication of our good quality of care as well as physical monitoring, so we've done a lot of training around documentation improvement, as well as providing tools and assistance around it. and specifically, we're looking

at this year on looking at the quality assurance plans that the c.b.o.s have and looking specifically at what they're doing around chart monitoring and documentation monitoring and making sure that all of those elements are in place that meet the standards, and giving feedback. another area that we've invested is our business management software, which we can look real-time what -- how the organizations are doing, around service delivery or around their performance objective, and on real-time, be able to figure out what's good on, is there improvements we could make, what are the gaps and what are the needs. so that is one thing that i wanted to share specifically around real-time measurements. around civil service performance which still falls under the provider performance, number two recommendation that i want to highlight, is around documentation training, performance monitoring, and corrective action plan.

so in relation to that, again, many things have been going on. what's been very, very helpful is that recently in the past few years, we are looking at civil service clinics on the same standards as the c.b.o.s, and we're looking and monitoring them on a similar set of standards so there's not a disparrate set of standards that we are being monitored as well as we have our data real-time review. in addition, we're doing a lot of work around documentation, training, hand holding, training, mentoring, supervision, even our supervision initiative and clinical supervision addresses that aspect. and what i wanted to highlight is that we made major improvements from the triannual audit that happened in 2014 and what happened later, the last week, in 2017, when we made a dramatic improvement in

reduction of our error rates as well as our disallowances. and one thing that we've also implemented i am is to looking at the q.a. plans and c.b.o.s, we're doing rondom audited of the clinics, our civil service clinics, plus every staff, we're doing random audits, and those survey results are going to be looking at documentation as well as improving system of care and training needs that we'll be addressing. the recommendation three focus is on intensive case management, and focuses are specifically the flow from intensive case management to lower level of care as well as monitoring a wait list. we don't have wait list for emergency services, we don't have a wait list for p.e.s. and emergency services. we don't have a wait list for patient services, but in the intensive case management, we

do have wait lists, and i'm going to address it in the next slide. but in that respect, we ourselves identified with the state a performance improvement plan specifically looking at people who are in intensive case management and the flow into the lower level of care. we're looking at what is happening at the intensive level of care and when the person is transitioning, what the issues are, what the needs are, and what's the the best way we can do to make the connection on the lowest level. as well as we recently received an nhsa award specifically awarded to peer or peer support, sort of hand off from case management to a patient level of care, and we felt that was an improvement, a way we can improve our system. we're looking at through a consultant at transforming a

intensive case management services, really looking at what is the definitions, what is happening in the intensive case management and how we can improve what's happening there but also to the flow to a lower level of care. and with that, the utilizization, so one thing, in addition to looking at this intensive level of care and case management, and how we can transform it, we want to look at all the current cases we have, the 1400 slats, and look at certain measures of finding out whether is this the best level of care at this time for this individual? and through that process, be able to open up about 200 or more slots right away in this fiscal year while we're looking at the bigger system of care transformation around what is i.c.m. that newe believe needso be in place, what happens when they were there, what happened in treatment and when they are

being discharged, what do they need during this process, and also makes sure the services are being provided in the community and in the field because that is what the clientele need at the intensive level of intensive case management. in our case system of care and our r.f.q. that we're going to have, we are going to open up 40 new slots of intensive case management, and we are going to be doing a utilization of care within our intensive case management as a way to address this wait list issue so this year and in the up coming fiscal year to try to eliminate that sort of barrier. and the other item, recommendation number five that i wanted to highlight is about p.e.s. discharge, people who are leaving from p.e.s. into the community. this is not -- an -- actually an area that we have

disagreements with the audit report. we do have a notification system in place when someone is on p.e.s. and they're released back into the community. in their data, it appeared that there are many people who are being self-discharged, they are being discharged to no one, which is not the case. we worked with chief of ski at cfsg, and p.e.s., and we pulled records of people that it appeared they were being self-discharged, and the way it's coded and identified is not what's actually happening. we found out those people were already connected and they were just provided -- referred back to their current provider. if they're already connected, we're working on making sure that they're going to get back on notifications in place, and if they're not connected,

specific things will be done to make sure the linkage happens, or the referral happens and we can work on the linkage on the back end. we have staff that can support the p.e.s. care, and we have humming bird that is on the campus that can do warm hand off from p.e.s. directly into humming bird to address the need when someone from p.e.s. so the notification's in place. however we do want to improve on our documentation of these discharge categories and making sure that these are reflective of exactly what's happening, and i believe with epic, when we roll epic out in our system, we can really track this much better, much more effective in a unified way. the last report that just recently was completed and shared is around the crisis intervention services which is

the bridging of support services -- support with the police and department of public health and addressing people who are in dire crisis. in their report, there were four recommendations specifically focused to d.p.h., and i want to highlight that one was around completing the hiring of the crisis intervention specialists. we have hired four, and they're already in position. one position's still being filled -- i mean, it is a vacant that we're filling, and we believe that the position will be hired by september. there is a psychologist's position that we are recruiting and we would have that position filled. to review and update the m.o.u. between us and san francisco police department, we will review and update that m.o.u. that's -- and then, the other one was they wanted more -- the report indicated more support and leadership representation from d.p.h. on the c.i.t. work group, and we will have the representation from d.p.h. on the work group.

and finally, there was a recommendation to hire five additional crisis intervention specialists. this will be something that we can assess as part of that new budget -- and budget cycle and the new budget initiative as well as assess the need. with that in mind, if you have any questions, this concludes this part of the presentation. >> clerk: and i've not received any public comment requests for this item. >> thank you. questions? >> well, it is an extensive report, and you have a lot of areas in which you have been working onto try to respond -- not just respond, but this is just a part of what you had specifically identified and spoken to in terms of the flow. and i know that in the past, commissioner royce isn't here

right now, or commissioner keating, but they had identified a large number of people were staying in higher levels for a longer period of time. which the report did emphasize, again. so in those areas, you've been with the department now for about a year. is that right? >> a little over 1.5 years. >> okay. my memory is -- >> no. >> it's not pretty good. so it's now fair to ask you, what has been done at this point because i believe you've also identified many of these same issues when you first came. >> so what we have done is to really dive into the data and figure out where people are at and at what level, and is that the appropriate level of care. so obviously, the biggest one that we're thinking about is the intensive case management. because at the hospital level, we're doing very active

utilization management through p.e.s. we have more people coming in to p.e.s. with less diversion and less stay than ever before. really, the focus is on intensive case management, and that's the area that we've been looking at very closely to identify, are these people at the right level of care if they've been with us for five years or more and they've not been hospitalized, and they're receiving mostly office based services. then we're looking at people who are receiving mostly office based services, and they're not receiving hospitalization and they're not receiving a lot of services. and people are receiving 15 hours or less and mostly office based services, so we're you kn know -- unifying that.

so that's the area that we've been looking at, and we've been looking at a lot of other factors around completion and how people are completing within our system of care and adding additional -- you know, looking at adding additional outcome measures to our performance measures. so those are the things that we've been engaged in. >> so as you're doing that, and you're, you know, first of all, being able to get ahand handle the areas in the area where it was demonstrated there were a high number of long-term clients, what will you be us doing in the coming year to make sure that you've correctly identified to move the continuum further down for a

number of people to open those slots? how will you know, and what type of report would we be able to get to understand that that is happening? and this is a question i know because commissioner loyce isn't here, he and i had talked about where he would like to see outcomes, also. >> correct. correct. so a couple of things. we are adding performance measures around hospitalization -- repeat hospitalization recidivism, as well as when people leave hospital, what service are they getting upon leaving. so that's one thing we can easily give data on because we're going to start getting that. as we start finalizing the grings of the i.c.n., starting in september, we're going to be doing utilization --

[inaudible] >> -- coming up with a transition plan. one agency, as we complete one, go to the next one. so starting september, we'll see that flow, and then, you would basically be able to see how we are opening up slots, and we'll be able to sort of be able to provide those slots to people who need it. and this is the work that directly we're doing with our consultant and system of care and our providers. and the other thing i wanted to mention, even though this is identified in the triannual audit, we have actually done very well when it comes to access and our access to services where we've done very well. skm many, we're not -- and many, we're not only doing better than the state average, but doing better than other counties. so the issue of access is something we're doing well, but in the area of intensive case management, this is an area of work and we've embarked on the

area and hired a consultant to kind of transform this process for us. so you will have reports back as these management activities happen, as the service slots open up, and as we have the new grant that i mentioned we received to see the ability to be able to hand hold the supportive arm, hand off from intensive case management to outpatient or lower level of care. and the performance improvement plan with the state -- [inaudible] >> -- which is a quality review, they actually will measure us on the performance of our performance audit, which we also can provide and it's actually public, and it's posted on the d.c.s.'s website, so there would be very clear metrics to follow and say, did this happen, actually. >> do you have a comment on the comment in here that the city

clinics have a lower level of rating than the c.b.o.s did with an average of approximately two, with the c.b.o.s at approximately a three to four level? >> so as far as their performance? so i think -- talking about the performance outcomes -- >> where they -- >> so -- >> they have so much data in here. >> well, again, one of the advantages of this audit, which we welcome, is the ability to look at things over a longer period of time and pull that data and compare it. now bh it comes to the monitoring, we're actually looking at very specific period of times, and so consistently, that's not the outcome and that's not how performances happen for all of our civil service clinics, but there are services that we need to make improvements, and we will have the monitoring that identifies those and plan of corrections are put in place. but yes, there are programs that have issues that we need to work on, and there are

programs that do very well. and c.b.o.s similar ly, so i do think it's hard to say that this is one compared to the other. and again, it was looking at a very specific year that they highlighted all of the outcome measures. so -- but this is an area that we're looking at. we monitor -- again, this is more recent that we're monitoring our civil service clinics and looking at it on the same standard that we have across our system. >> so taking advantage of the fact that you, of course, came from one of the more successfully, you know, rated c.b.o.s, this -- do you believe that it is a fair assessment that most of the civil service areas can certainly have a greater level of improvement, and you're expecting that? >> i definitely believe that there are areas