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 of improvement for our civil service clinics. but the way to compare it is a little bit challenging because there are many things that are expected from civil service clinics that we don't expect from c.b.o.s, certain responses that we have to do when it comes to crisis, certain things that we have to engage in that we don't expect our c.b.o.s to are involved, and there are certain levels of staffing that are different. so it's sort of hard to compare it that way and to say or judge basically because of this you're doing worse, but definitely, there are areas that we can make improvements, and that's why we're looking at metrics, and this real-time

data could help us. but i think now, it's very good. there's two sides of every story. being on this i had zoo, i can see the challenges and also the demands and requirements that are different. for example, when we had the fire situation, when we had the -- we deploy staff, we deploy staff for a variety of things, and for things that is not necessarily as equal to expect a c.b.o. to respond to, but i would definitely say there are strengths within civil service clinics, but there are areas of improvements, and there are strengths within c.b.o. overall, and improvements, but maybe not exactly the same ones. >> earlier, you thought epic would be of help, so there had been, of course, currently, the mental health programs are on a different platform. is it the intent, then, that epic also be able for the mental health program? >> that would be our goal and

aspiration. >> is it a goal or is it in the -- >> no, it is the phase three and the first phase of hospital. even though it's the first phase of hospital, many are in the psychiatric services or behavioral health that is part of wave one. the outpatient services are on the wave three. >> and if i may, on that epic issue, there is no model for behavioral health systems with the epic. it's something that's in development, and you have to have state approval because the avatar is the state approved system. we can interact and do interruptability, so it is the phase three. we are committed to that. it's not the phase that we've achieved today because we still are exploring that and we still

are needing state agreement with that and also development from our systems, particularly epic and any other system. we've been working on this for over ten years, trying to find a system that would work, and it's just not in the -- 'cause many of them are setup just for hospital, medical systems. but as our director from behavioral health talked about is p.e.s. will be on epic, and the psychiatric service will be on epic, and that would be a big help for us in terms of operablity of our systems today. >> yeah. right. i think it would be useful if we kind of continue to remember that under the epic side, because that's been an -- a long, ongoing question. avatar was a great advancement, although maybe on your side, you didn't think so when it came in. but i think we need to keep an eye on how that is developing.

but you're right, a good number of the clients that have been on the epic do offer the interoperablity that will be an opportunity. but on that one, i think we should continue to use our monitoring to make sure you get what you need there if it's possible. >> and we are also aware that before epic, potentially rolls out for wave three, between those periods there would be a web link that we would be able to access, looking at the data. although we would not be charting there, we could look at the data and identify or clientele that have been in the hospital or been receiving other services in order to coordinate better. >> now i think i've awakened the commissioners who have some questions. i'll just go from right to left, starting with commissioner bernal and we'll just go down the line. >> i had had a similar question

about e pic. it seems when you're looking at the civil service clinics, that mainly what they've identified is the billing. do you believe that it actually is better than it looks, it's just not being do wanted correctly? >> keep in mind that this report was going back for seven years. if we look at what's happening 17-18 and also looking at how the improvement has been, we will see something very different. and also, there are times the services are provided but maybe not documented, or it's not documented in the best way, so that's why all our trainings and doing -- our compliance department going in and doing technical assistance and working with each clinic, training each clinic and the staff has really been helpful. we hire documentation specialists specifically to address these sort of needs.

>> and then, my second question, it appears many times in this audit the need for increased staffing for intensive case management and to utilize data in order to assess what the need is. is there a sense now of how much increase staffing will be needed and what the cost might be? >> yeah. i feel like that's a little bit too early because what my hope is that one, with the first wave of utilization management, we can look at what we currently have and what we currently offer, but the second wave, which was the next fiscal year, when we're looking at all our i.c.m. levels and looking at all our levels, our full service partnerships or sort of wraparound services, once we look at that, okay, then we can identify what's the number of people we need to serve, what's the staffing required, what would be the best caseload, and what would be the best requirement, again, services to be provided in the field.

that's really what intensive case management is, the majority should be in the field. so i think we can better identify the staffing structure and the caseload after this initial phase. so i felt like it was premature to say we need additional staff because i'm trying to actually look at what we currently have and is this the right level of care for the people that are in it right now, and if we open that up, could that actually address a lot of the need. but then, in the process, we actually need to see how we can keep that going because we really should not have a wait list for i.c.m. our system should not have a wait list, and that's the goal. >> and just a final comment, about having a centralized or coordinated wait list, so you have an idea of how many are on there. >> we will be looking at how many people are coming in because we'll have an authorization process. and if for a larger -- if we're a larger system of care, we

don't have a wait list, however we could work with people if we find out there's a challenge about when somebody needs the service and they're not able to access. how have we met our goals and services within the time frame as required. so it's hard to say we should create a wait list for our services -- we shouldn't have a wait list and we're not having a wait list. but for the i.c.m., we should not have a wait list, but in the process we are right now, we're going to be tracking who's coming in, what are they need, and how long are they waiting? >> thank you. >> commissioner carreon? >> my questions were answered. >> commissioner chung? >> i'm actually very interested in your -- in your -- your, like, introductions to peer based services. that's not billable, am i

correct? >> so when it comes to peer services, there are multiple ways that we approach it. so this grant that we received through mhsa, which was $750,000 for three years specifically to support people who are in intensive case management and hand off to a lower level of care, that is not supported. we have many programs that are peer based services that are funded through mhsa. however we do have programs where peer services can provide rehabilitative services and we actually have that as part of our billable grid, that what peers can provide and whether they are billable or not. it depends which program they're in, and whether -- how is it funded. but many of our peer based programs are funded through the

mental health services act, but some, we have the funding, and we -- we don't have the funding but we still -- we have the funding and we actually have that supported. >> i remember you were introducing that concept. >> correct. >> not that long ago. >> correct. >> the other questions i have with that is do all the patients -- do all the clients have peer services or some do, some don't. >> so peer services are available to all dps clients. we have for example peer center on market street that is available to every b.h.s. client that is part of the

b.h.s. or someone who comes in and says i need services. we have peers who are hired by various programs, and they're providing services. and the goal is really to have peers across our system. we make sure that peer based services are embedded in the foundation and culture of the programs 6789 so i would say the majority of the programs either have peers under staff or in their program or they're accessing it through the services provided within our system. so for example, this i.c.m. flow that we're talking about, they would not be just for one clinic, they would be available to any of the intensive case management programs. and that peer could be available to them. so it's provided throughout, but i would say we started years ago.

i'm thinking about six or seven years ago, a much smaller number. now we have . >> every r.f.p. that comes out, that is sort of embedded into it. >> so -- so i -- another

question i have it, like, were -- are there any indicators that show that peer services are actually beneficial to clients, and if so, like, like, what -- what are you actually measuring? >> so for our mental health services act programs and especially if they are peer-based programs, there are specific objectives that follow it to make sure that the services provided are actually meeting the expectations and the goal. so those are all part of our mhsa contract goals, and those are being monitored. in the other programs, what we can look at is basically the success and improvement of the client and as well as the support they get. we also have peers that help with getting people on medicare, for example, helping people with that navigation. there are multiple ways that we can look at. there's not one lens that i can look at and say well, through

that one, they're successful. there are many lenses. in a partnership in the community, the way we work with them. we -- there's without a doubt that there's peers are enhancing and actually improving our system of care, our engagement, our credibility with our community. and are also resources when certain programs may not be able to provide certain service or may not have the demographics and reflectivity of the community they serve and the peers bring that. so it happens on multiple levels, but certain services have those metrics to show that reflected in the sort of outium. >> thank you. i have no more questions. >> commissioner green? >> i'll leave it for -- >> of course. >> commissioner green? >> this is an incredible report. thank you so much. it's rich, and i want to read more. i'm very curious to understand

a little bit more about your process versus your out come metrics. i notice, like, on page 20, some of these civil service clinics have been underperforming since 2013. but i wonder, number one, whether your out come metrics with going to be uniform across the system or whether they're mandated to you or whether you're going to develop your own. and also, i anticipate if you improve documentation that in fact there'll be more money coming from medi-cal which would allow you to hire more staff and answer some of the questions about availability of services. correct. >> so two issues. so one is on performance measures, out come versus process. so were you not -- one is the performance measures we have across the system, and that's become pertinent to sort of the our delivery of our services. we have -- as a result of this,

we have actually always have had out comes, and we have multiple metrics such as our cans or ansa, tools -- for example, we are a cans county, for children's services, the assessment and out come we use to see how our children are doing, or the family and the household is doing, and this is so successful, the state adopted the cans and is requiring it across all the county, and we already were doing cans, and we are already a cans county, so we already do have measures and many out comes that we're monitoring, so that is something that we wanted to put in place. secondly, we recognize we need to have many recovery memory out come measures. so this year, we look at all the measures what are in compliance, what are out comes, and out of that, we are adding new objectives based on having

it be out come measures, but some are process that links to out come directly. so for example, let's say having services delivered post hospitalization. so that's a process. you know, we want you to provide a certain number of services, but then, the goal would be that out of that, we have another objective to make sure this person doesn't go into the hospital. so some are process, but they're embedded together, and pulling them apart and saying this process doesn't relate to out come is not the best way to align them. so that's something we're doing this year, and this year, that's the focus of performance objectives. and then, during this year or next year, we're really trying to add more compliance -- out come and plug it into the compliance, so that's theest that's happening now. -- so that's the -- what's

happening now. i certainly believe -- sorry, the evidence shows, the more we do document our services -- obviously, results, more revenue, but the more we document properly and document it in a way that we can minimize the error rates, that would really also help. and ultimately, that results in being able to generate more revenue and medi-cal, which ultimately again will help the system of our. and our utilization could look at that more and more. so we're looking at the error rate which is just basically compliance and then there's a quality of care. we want to make sure that we meet all the standards when it comes to the quality of care. a significant is missing, something needs to be there, but then, we need to look at quality of care. so the documentation is sort of connected to quality of care, fiscal improvement, and that's looking at a lot of it before this audit happened, and we're

going to continue doing that. >> director garcia. >> just i really appreciate all the questions from the commission. i did want to acknowledge drochlt bocere and his -- director bocere and his work. it's kprikted performance and all of the multiple audits that he had. under the grand jury because that was the newest one that came to us most recently, about a month ago, i want to acknowledge that the director has worked with me on a question that mayor lee asked us, which is how could we predict issues of safety for the police when they've identified them as 5150 many times, so we've worked with the police and b.a.r.t. police. just want to acknowledge

everyone who is working closely with him in trying to provide the best care to an individual that could be at risk directly involved with the police, so that has worked, and it's something we should probably share with the grand jury, as well. i also -- unless there's any other questions, i see a lot of our behavioral health staff in the room, so we they could standup and we could acknowledge them. [applause] >> and we don't get to see them at the commission much, so i want to acknowledge them personally as well. i think our director has the system well understood, and i do want to acknowledge his leadership. >> i think i skipped commissioner sanchez, i'm sorry. >> yeah. no, that's okay. i've -- i think all of our colleagues have asked, you know, the substantial questions, and whatever i -- i'm glad that our director garcia just stated, 'cause that's exactly what i was going

to focus both on her and the whole team that has been involved. i have never seen a response that was submitted from our thing from 123 on, the director garcia sent to the director campbell, utilizing all of the data pertaining to all the issues raised, etcetera. i mean, each one was answered significantly, with up-to-date data in progress. we degree, we partially agree, we disagree, we've implemented. each one of these added was unbelievable in reference to methodology and out come and how in fact a response should be, given the nature of this department of public health and how we're trying to and are establishing a comprehensive baseline which ensures that we have a radar system that will take a look at all the

variables that not only have come before but have come past that. i just want to acknowledge everybody for a job well done and really an exceptional report. >> thank you, commissioner sanchez. i'll also note that the last recommendation that the department was agreeing with was to bring a report to the board of supervisors as part of the budget presentation, and i will assume that that report will come here first as part of the proposals for the budget. so commissioners, any further questions? if not, then thank you, and we thank the department for the comprehensive review of the performance audit. thank you. >> and i want to thank director garcia for all her support and all the directors and managers here who just make it happen. >> we thank all the directors who came and the work that they're doing for the city.

thank you. we'll move onto our kmex item, please. >> clerk: yes, commissioners. item 8 is a commissioner q hearing. the new location of program is to be determined. >> commissioners, as you know, cpmc has presented several items from prop q and we have divided them into topics so that each of the topics could be discussed separately and item 8, 9, and 10, then will be presented by the department. >> good afternoon, commissioners. my name is neha bhatia, and i'm with the department of policy and planning with the

department of public health. so today as doctor chou mentioned will be the prop q hearing related to the first of several items that have been raised by cpmc in answer to expects changes that they're expected to make. the second date for this hearing will be august 21. so in april of 2018, california pacific medical center notified the health department of upcoming changes that are anticipated to occur this year. you received a memo that has more detailed information about each of these issues, so today, i will just be providing a brief summary. and so i'm going to begin with an overview of prop q, and then, the first item on the agenda which is the change in licensure. additionally, we have representatives from the

institute on ageing, the c.e.o. as well as a representative from sutter pacific medical foundation. so proposition q requires that any time a private hospital in san francisco makes any changes such as a closure of an hospital, inpatient or outpatient facility, eliminates or reduces a level of services provided or prior to leasing, selling or transferring management, that they notify the san francisco health commission. in recent years, the health commission has reviewed four proposition q closures. three of these closures have been cpmc skills nursing center, st. lukes, and st. mary's medical center. at these hearings, the health

commission typically makes a determination about whether these changes will or will not have a detrimental impact on health care services in the community. so in april of 2018, cpmc notified the health commission of three changes. the first is the change in licenin >> so i'm going to begin with the first item that we have on the agenda, which is item number one. so the swindell's alzheimer's program service apz estimated 70 residents who have mild to moderate dementia and approximately 30 patients on any given day. this program is located at

cpmc's california campus. it is currently jointly licensed by the cpmc and the institute on age, you about the the program will be independently licensed by the institute on ageing in 2018 and 2019, and cpmc has related this was related to the closure of its campus in march of 2019. so just a little bit about adult day programs. generally, these programs provide a range of nonmedical support services, including psychological and physiological support that promote the quality of life for older adults. programs are typically designed to provide care and companionship for older adults who might be assistance or supervision during the day. generally these services are provided less than 24 hours. participants attend a certain number of days, and generally participants also payout of pocket as this level of care is not reimbursed by health

insurance. these levels of care also offer recess piet for families and their caregivers, and they're licensed by the california department of health and social services. the program on the rite indicates adult day programs in san francisco. there are ten programs in total. three who serve adults with did he shen shall or alzheimers, and one that serves adults who are vehemently disabled. in addition the department of ageing and adult services provide some assistance for adults with dementia or alzheimer's. so while cpmc has been working together with the institute on ageing on this planned change, currently, the institute on ageing has not identified a new location for the day program, and so the impact of this change is uncertain? we know there are a limited number of adult day programs in san francisco that serve adults with dementia or alzheimers,

and they are an important resource for keeping the adults in the community and out of institutional, long-term care. if this program were to close then it would result in a loss of services and would have a detrimental impact for residents in san francisco. and with that, that concludes my comments on this item? i'm happy to answer any questions. >> okay. and so what we will be doing is taking testimony on each of the items as we proceed. i -- and several people have asked to speak to each of the items, and some people have spoken to only asking for one. so -- but the public is encouraged, if they wish, to testify on each of the items as we go through each one. and trying to focus, then, on the subject of that item, which we believe will be the clearest.