we have been for the last several years working with a number of insurance providers to determine whether we can enter into contracts. part of the challenge with this is that the deal, the kind of fundamental bargain of these insurance contracts is you give a discount in exchange for volume. we happened to have a hospital that is very full right now, and if we were to kind of enter into that standard bargain, we would be, again, providing a windfall to the private insurance without a benefit that supports our

patients or our hospital, and we are also working with our state partners. that includes our state associations, but also our legislative delegation to try to determine whether there are changes to state law that we could pursue and advocate for through the city that would improve the patient situation in the financial world of health care. so that is a lot. our next steps are that we are going to the board of supervisors on thursday to have a similar conversation about some of the kind of categories of approaches that we're taking in response to this challenge, and we hope to get feedback there, as well, and then we will similarly, as we develop full recommendations and share those with you, bring those to the board of supervisors and work with the mayor's office to implement those. so that will happen on thursday this week, and then we will be working actively as we have already started working over the

next roughly i think we're at about 70 days to finalize these recommendations. so that's a lot. i'm happy to answer questions or clarify as helpful. >> secretary: did not receive any public comment requests for this item. commissioners? commissioner bernal? >> yeah, i think that's a great point, because that is fundamentally at the root of a lot of this, where patients who are coming to our hospital are not always able to make a decision about what's in network or out of network. they are coming there to have their life saved and they are often not in a position to make that choice. so i think there are a couple of

things, areas, that we could focus on. number one is to have -- put this system in place where we have, regardless of what your insurance is, we have a fair out of pocket cap, so that you're not being financially exposed by the fact that you were taken to a trauma center and that wasn't a decision that you made. the second thing that i think we do need to look at is at the legislative level, the state and the federal legislative level, other changes we can make to account for the fact we have hospitals like zuckerberg that is a public hospital and it is a trauma center, and we serve a much different population than a lot of hospitals, because we're a safety net hospital that also has this trauma and emergency function to go along with it. so one of the things that we have talked about is, is it

possible that there are legislative solutions that would help allow us to -- allow us to change the way that the payment dynamic works, so we can take the patient out of the conversation between the public hospital and the insurance company and try to advocate for a structure, where we're fairly compensated for our costs as a trauma center and a public hospital, but that burden doesn't fall on the patient. >> president chow: commissioner green? >> commissioner green: i wanted to commend the department and hospital administration for the speed and the detail and the thoughtfulness with which you responded to this. it's incredible that you've come together with this kind of a detailed plan in such a short period of time and the seriousness and thoughtfulness which you've approached it is really quite commendable. >> thank you. >> commissioner green: i was wondering whether you had any detail about, among these p.p.o. plans, which have been the most

difficult for patients to be successful in appeals. in other words, do you know which plans have been the most difficult to get to pay ultimately, and also whether any of these plans in particular are employer driven, because that might be another approach, as well, if united health care, for example, is a popular plan, yet if big employers like the gap find that their employees are going to a trauma center and having to pay out of pocket, that might be another point of leverage. i wonder whether you've gotten anymore details about that group of people who have really ended up with serious out of pocket exposure. >> yeah, i don't have the data with me now, but we can certainly provide that to you. and part of what is challenging in this situation, particularly on the p.p.o. side, you have a large diversity of plans, many of them that are for people who are from out of state and so they are plans that we deal with, a lot of plans that we deal with at a very low volume.

there are a couple of larger plans that's more frequent, and so we can provide that data to you, but that really is one of the challenges, is even if we were to pursue a practice where we're able to do some agreements with certain plans, you do have this large volume of these smaller insurance plans that don't -- we would never reasonably be able to enter into agreements with all of them and then so you'd still have that subset of patients that are affected by this practice. and that's another reason that i think we're kind of trying to approach it from we'll do what we can on the plan side, but we're really focused on the patient and what is the patients' exposure. >> president chow: commissioner chung? >> commissioner chung: thank you, mr. wagner. it sounds to me like there's also some kind of administrative disconnect. the reason why i say that is because i thought most plans

cover a certain portion of out of network costs. i've never heard of any plans that would flat-out say they deny a certain service categorically, so i'm kind of, like, surprised that this is happening. and, you know, is this something that the office of managed health can mitigate without going legislatively? >> yes, so the vast majority of these situations is not a circumstance where the insurance is denying that the service was medically necessary, but what has happened over time is a lot of insurance plans have -- we will send a bill, and the insurance plans have slowly started to ratchet down the amount that they pay us against that bill, and this has been a dynamic that we've been facing and there are a whole bunch of reasons around it.

so, for example, ten years ago we may have sent out a bill to a private insurance plan, and the plan paid us 98% of the bill, and they disallowed 2%. what's happened increasingly is today insurance plans are paying us in some cases 50, 55, 60% of the bill that we send, and that has -- so they are not denying the claim, but they are paying us less and less, and that's leaving this gap that exposes patients in cases where they have the type of plan where they are exposed. so it's not so much that the insurance plans aren't paying, it's they are only paying a portion of the bill and then our recourse is, essentially, either to legislate or to take legal action against the plan. >> commissioner chung: so they can reduce the amount that they

reimburse us at will, without any -- agreement or anything? it's kind of -- it just bothers me to know it's that kind of unethical practice out there and nobody is doing anything about it. >> yeah, and the framework for it is that under the law there's essentially a provision that says the insurance plan can pay what's called a usual and customary rate, but that is not defined in a formula in the law, it's defined conceptually in the law, and so insurance companies will make their own calculation of what's usual and customary and we might think that's not very usual and customary, but there's no referee that will judge whether or not they have paid adequately. the only way that you can remedy that is through the courts. and we have, in fact, at the department of public health, we have been actually pretty active on that front, where we have

initiated a couple of lawsuits and a couple more potential in the works, where we've actually gone out and said you've ratcheted down your payments to us so much that we now no longer believe you are meeting an acceptable threshold and we've been effective in doing that. we've come to settlements that we've been quite happy with, but that process is time and cost intensive, because it is using the legal system, and so that's not the first choice of how to resolve. >> commissioner chung: thank you, i really appreciate the effort that you all are making into this, and it's almost like those insurance companies warrant some public shaming, so that people could see that kind of practice exist. thank you. >> president chow: commissioner green? >> commissioner green: thank you. thank you, greg, for sharing the draft plan with us, and i also

want to commend you for the swiftness of -- and the comprehensiveness of all of the different aspects, you know, and given that, i want to just kind of caution folks around expectations to come up with the best and right solutions in a 90-day time frame, because what you describe deals with changing sort of revenue-cycle procedures, all the way from dealing with that and the kind of skills and talent and structures and processes that are required to address that to sort of a legislative or legal sort of remedies to try to do that, and so the whole spectrum in between and being prepared to do all of that in a time when the way that health care is being paid for is changing,

right, from fees to values. so i just want to, while i commend you for doing that, i want to make sure that we don't think the first solution that sounds right and looks like is going to be the necessarily the right one, because it will change along with the way that health care delivery's changing, the population in san francisco is changing, and medicare and medicaid policy oversight is going to change. i do want to really endorse the part of the plan that does speak to the cap on out of pocket, because that to me is a very both pragmatic and appropriate step to take, given that these other solutions and these other things, trying to explore insurance agreements with the insurance industry that acts, as you just described to commissioner chung, we have no leverage in terms of the volume that we can provide to sort of do contracts, so that's not

necessarily going to be a great avenue. and so all of the things that we're going to try to do to address this very, very real situation, 1,700 patients a year is still a significant number of folks compared to the 104,000 that we do take financial in many ways a big financial hit already from. so i just want to sort of caution around expectations and to really sort of make sure that we are -- have an opportunity over time to review the data, because everything comes into play just in terms of any one aspect of something that you're going to implement systemwide. >> thank you, commissioners. great point. will take that feedback, because you're exactly right. we will, at 90 days, come back with something, but a lot of what is required here either is going to be an iterative process

over time or is going to take much longer than 90 days to implement. so, as you said, if you look at this list, working on state legislation or contracts with insurance companies, that is a much longer term process, so i appreciate that. that makes absolute sense that we should be thoughtful about expectations about how much we can accomplish in the short term and also that this is an iterative process that we are going to have to constantly review and evaluate, so that we don't end up back in a situation where our policies are outdated. thank you. >> president chow: commissioner sanchez? >> commissioner sanchez: i -- excellent report. i just wanted to underline one thing that you mentioned in your report that i think is really a very critical variable in the whole process, and you mentioned communication with the patient.

this is really a key focus. i think we need to look at, primarily because of not only the diversity of patients, the fact we know -- we know, given our public health area, the diversity of the city, the age factor of so many people, seniors, growing numbers, four generations in the city, three, five, two new ones, you name it, occupational workers who drive in from all over and live in the city while they work, coming from india, coming from latin america, they used to, coming from ireland, you name it. they cover the waterfront. and if there's an injury or something happening, the majority will probably end up at the general, okay? now, i could think of numerous cases in the past where an elderly person who might live in a given area was brought in, in the trauma center, and ends up,

you know, at the general, and because there's no wife anymore, there's no son, but there's a grandchild or a great grandchild who maybe lives across the bay and comes in, and sees a grandpa, whatever, they may not know he's a veteran, perhaps, they may not know that he is covered with insurance or not, and then we've had some cases where -- i'm talking about before, where the information pertaining what may be the outcome and who's going to be responsible for this is given right there with maybe extended family that have no idea what this is about, you know, and that brings even more trauma. especially when you talk about -- i know many greek families or maltese families or native american families, again, it's a cultural thing, and it's really part of the equation pertaining to if they would even have access to health care, much less when they are brought in

because of a situation being hit by a bicycle, being hit by whatever, you name it. but what i'm saying is, that is really the critical part, and i think when we look at the communications part of the protocols we could offer them as patients, that we really constitute maybe a core team, whose sole function is to disseminate these programs, whether it be in the peeves clinic, gerontology clinic, you name it, but have specialists trained with multiple languages, so this way you could be called in. so if a family comes in and no one in the family speaks english, but they speak a multitude of languages, et cetera, we have staff that could communicate this in a very positive way. one time you have a social worker, one time you have a nurse, one time you have management, even walking down the hall and a patient may have expired, all of a sudden be

given a bill for -- and nobody -- people say, how are we going to do this, you know? all i'm saying is, you really underline a very important part that's always been a changing focus at the general, and that is the fact our changing populations over the years, but communication, if we could focus on that communication and the multitude of languages, whether it be retirees or young people or occupational workers from all these countries, provide them with the baseline, thank you for having your grandfather or your husband, whatever, be brought here, here are some options you may want to talk about or you may want to give to whoever is whatever, but have people who are caring and understand and could speak the dialogue and make sure that it's communicated. otherwise you're going to have some problems we've had before,

where people don't want to go, because ems is going to hit them for $400, $600, they don't have $400, they can't afford it. all i'm saying is, we've always been aware of the human variables at the general, so as we take a look at the payment plans and protocols, i think we want to upgrade that focus on communication and patient understanding in a cross cultural linguistic model that makes sense to ensure we always maintain and provide the highest quality at whatever cost we could serve in order to provide the service we always have and hopefully will in the future. does that make sense? >> that absolutely makes sense. thank you for the comments. we'll certainly take that to heart and think about how we can maximize the ways that we're able to do that really high-quality linguistically

sensitive, culturally sensitive communication with patients. >> thank you very much for your report, and i want to echo the comments that commissioner guillermo made, and i also want to suggest that i appreciate the assertiveness in which you take your responsibilities to address this issue. whether or not we get the outcomes that we desire, just know that we're in process and has some periodic updates about where that process is, because it will take a long time. we recognize that. but i like the assertiveness and the position that you have taken in relationship to addressing this issue, and i think the community will appreciate it, as well. >> thank you, commissioner. >> great way to welcome director colfax also. >> speaking of director colfax, any comments you want to make in relationship to the presentation you just heard? >> well, i just want to reiterate the appreciation for greg and his team for being on top of this so quickly and i'm hopeful short-term resolution will come forward, but also want

to reiterate commissioner guillermo's comment, the most immediate solution isn't the best longer term solution, so i think 90 days is a good way to come up with some immediate solution, but i also don't want us to think after 90 days whatever we've done is set in stone. and i know that greg doesn't feel that way, and dr. irlick doesn't feel that way either, but just to reiterate that, thank you. >> i think we can move on. >> thank you. >> secretary: item nine is the homelessness mortality in san francisco: opportunities for prevention. >> hello, everyone. thank you very much. i'm barry zevin, medical director of street medicine at

shelter health, and it is an honor to stand before you again and to present this information. so we're going to talk about our homeless deaths today, and just to preface, what this report tells us is about homeless deaths that we've been able to examine after looking very closely at medical examiner reports. it can tell us who the people are, what kind of demographics are represented in homeless deaths, what kind of services people received in our systems before they died. it can tell us about causes of death, locations of death among people experiencing homelessness in san francisco. what the work we've done doesn't tell us is causes of death that

are directly related to homelessness. it also doesn't tell us about death rates, comparing people who are experiencing homelessness with other poor people or with other citizens in san francisco. and it doesn't tell us about deaths of cases that were not a medical examiner report. we've got opportunities from this information that we haven't had in the past. certainly, it helps us with our clinical practice and the ongoing initiatives in the department of public health related to homelessness. it helps generate systems-level ideas about prevention. for our team, i'm getting information from the medical examiner at least once a week and we're able to then respond, for example, if we know of a location where somebody died, we

can outreach to that location. other people who may have been close to that person may be quite affected by this death, we want to be able to be there to support them, and it may also be an opportunity for that person with that loss or that trauma, who this may be the time where they are ready to make a change in their life. so being able to respond. it helps us monitor trends over time, and you'll see this report as a three-year report. and then we're able to use this, along with all of the other information we have about homelessness and homeless health in trying to determine policies within d.p.h. and across departments on how do we prioritize our scarce resources. so key findings. homeless deaths were steady during the time period 2016 to 2018, and likely unchanged from the 1990s. the last time we used any

methodology like this was in the mid to late 1990s, where we were looking at medical examiner reports, and the numbers we have over the last three years are similar to the numbers we had then. i'll talk more about what those differences might be. i'm not sure whether that's a good thing or a bad thing, but i suppose that it is something that tells us we still have a lot of opportunities for prevention. other key findings, high prevalence of alcohol use and an overlap between our patients with severe alcohol use disorder who are high users of emergency and urgent systems in department of public health, along with this being a common finding in the people who died, should, i think, direct us to this as a continuing problem. high prevalence of

methamphetamine use and the overlap with criminal justice involved population, and again, our high users of medical and psychiatric services, methamphetamine use, clearly, one of the main factors that's affecting the health of people experiencing homelessness and having a profound effect in multiple ways in the health of the city. high prevalence of opioid overdose in this population. but likely less than would be expected considering the national trends, which have seen overdose especially among homeless population rising at very high rates. our rates have stayed steady over a period of time and don't show that same kind of exponential rise, and i think that speaks to the very intensive efforts we've made in overdose prevention.

high prevalence of violence and other trauma, and as a provider, that's something i hear from patients every day, exposure to violence, witnessing violence, being assaulted, seeing the number of violence and trauma deaths brings that home is very important. last key finding, role of shelter. what we know is that a similar methodology in new york city, other cities. no new york city, there's about twice as many homeless deaths using this methodology as san francisco. new york city has ten times the population, certainly ten times the population of people experiencing homelessness, and there are likely many reasons why they are not showing proportionately dramatic number of deaths, but one of them may

be related to them being required to shelter individuals experiencing homelessness, and we don't have currently the capacity to shelter everyone who would need to be sheltered. some responses, continue and enhance our d.p.h. response to the opioid overdose epidemic. the methamphetamine task force you heard about earlier, and their clinical and population health responses to methamphetamine use, we've got to continue and advance our focus on that. we need to do an evaluation and a quality improvement on our very robust system of care for people with severe alcohol use disorder, but a system that may not be put together in such a way to reach the highest risk individuals. incorporate homelessness as a risk related to violence and

injury. again, i've already met with the folks in d.p.h. who are working on decreasing pedestrian deaths, because a goodly number of the pedestrian deaths involve people experiencing homelessness, and supporting any work of how can we shelter unsheltered folks. okay, how did we do this and how does it differ from previous work? we are looking at a wide range of reports from the medical examiner's office. medical examiner does not have a category for homeless. they have a category of people who they consider as no fixed address. that's been a stand-in for homelessness, but by asking them to give us information on a broader range of the deaths that they see, we've been able to

find quite a few of the people who had some sort of address, actually were people experiencing homelessness currently when they died. so that is really an explanation why you may have heard numbers in the past and the numbers now are higher than those. it's not a matter of, oh, my god, the numbers have increased, this is a matter of we've looked much more carefully to identify who's actually homeless in terms of who died in san francisco and was a medical examiner case. we've been able to also look at other data we have in the department of public health, data from our ccms database and from all of our clinical databases to have a much broader understanding of what is this person's health care history, as well as what is their history related to homelessness. there's no indication that we've had increases in the past few

years related to deaths of people experiencing homelessness. how does it work? we get reports from the medical examiner, as i said, once a week or more often. medical examiner has quite a strict definition of what a medical examiner death is. they are what you would be expecting, accidents and injuries, possible homicides and suicides, people who die alone, number of other kinds of deaths, and deaths of people who there is no one to pay for funeral expenses, what they call indigent cases. and not surprisingly, many of those are people experiencing homelessness, so we're able to look at all of those kinds. and then we're able to look in each of those cases at information from our coordinated care management system and information from the clinical records.

2016, 128 deaths, 2017, 128 deaths. i was sure that was a misprint, but turns out two years in a row that was exactly the same number. so far 2018, 134. i say so far, because there are some that trickle in, in the last -- in the next couple of months after the end of the year, particularly those that were indigent deaths, where they are really trying to track down family members and others. the medical examiner reports on manner of death, and they describe accidents, and about 50% of our deaths were accidents. that includes unintentional overdoses, falls, drowning, somebody hit by a car, as well as other kinds of accidents. 11% were homicides. i found that quite higher than i would have expected, and yet i

talk to patients every day about their exposure to violence. 30% were natural. in other words, the progression of underlying disease. that doesn't mean that only 30% of all homeless deaths were natural caused deaths, remembering that somebody who died at the end of a particular illness may not become a medical examiner case if they died in the hospital or died in a nursing facility or a hospice. 4% were suicides. in discussions with medical examiner, they found that surprising, because their general statistics show suicide as a higher cause of death in san francisco than homicide. only 2% were undetermined, and the medical examiner does a very aggressive job at being able to ascribe a manner of death. looking at contributing factors to these deaths, and, again, this included whether it was

listed as the cause of death or a contributing condition or something that was found in the toxicology report. 52% had drugs as a contributing factor. about a third had alcohol as a contributing factor. again, about a third was natural history of chronic disease, and over a quarter violence and traumatic injury. again, those can overlap. somebody can be -- have been drinking heavily and stumbled and fallen and died of a brain injury from falling on their head. we would consider that alcohol related and a traumatic injury. i want to really point out the toxicology. in most cases, the medical examiner does a toxicology report. not every single case, but most of the cases and in the ones that we had access to, almost 50% showed methamphetamine

present in that person's system at the time they died. another 45% showed opioids in that person's system. many of those people didn't necessarily die of an overdose. they might have died of any of the causes we talked about, but using opioids around the time of their death. still a lot of people died with recent cocaine use. about a third recent alcohol use, and still a quarter some sort of sedative. so alcohol and drug use, i think, can be a very major focus of our prevention efforts. i'll stop and say i'm a specialist in addiction medicine, addiction medicine specialist, like to a carpenter, everything looks like a nail to be hammered down, but those are impressive to me. some demographics, 82% of our cases were male, 17% were

female, less than 1% were described as transgender. again, the medical examiner doesn't even have a category of transgender, and for many of these cases, the -- that information might be found in a clinical record if we dig deeply enough. about half were white, about a quarter were african-american. that's actually slightly lower than the overall number of african-americans in our county homelessness populations. for example, the number of african-american people experiencing homelessness is slightly higher than the 26%. 12% latino, and then small numbers in other categories. age was a spread, although in some ways older and probably compared to our work in the late '90s, this also reflects an

aging of the homeless population. again, over half over the age of 50. housing status before someone died, we're able to look at that as best we can using our ccms, which pulls in information from the shelter system, from the department of housing and homelessness, and many people had been homeless quite a long time, of the ones who we knew before. only a small number could we say, oh, they had been homeless only a short period of time. in terms of shelter or navigation center use, most people had no stay, not even a single night in a shelter or navigation center in the past 12 months, and even if we go back to past years, many of those

people had a very scant shelter and navigation center use, and we had very few deaths actually occurring in a shelter or navigation center. so that may suggest that using shelter or navigation centers could be protective, or there's some association there in terms of risk, people who may use the shelter system versus people who are unsheltered. in terms of service utilization, although we talk a lot about high users of multiple systems, most of the people here had very little use in an emergency and urgent systems and even less in our primary care, mental health, and substance use disorder treatment systems. most of these people touched our system in some way over the years, but were not well engaged

with our system, and i think that's an opportunity for us. just a little bit of the geography of this, i think you can see that these deaths occurred all over the city. if people have a long memory and have seen these maps before, there used to be these giant dots in the locations of the various hospitals, especially san francisco general. we actually did a lot of work to get the location of the incident if somebody survived long enough to get to a hospital and then expired at the hospital, we actually were able to get where did the actual incident occur that led them to be in the hospital. so you'll see this spread around town, the particular concentration within a mile of where we sit, and tenderloin, south of market, mission district. i want to thank the people who were involved in this study. this was a collaboration between the department of public health

whole person care office, ucsf evaluation team that's evaluating our whole person care effort, and our street medicine and shelter health team. so thank you very much, caroline, with the evaluation team did a lot of the heavy lifting. i want to thank her for this, and caroline and i are available to answer any questions you have. >> secretary: did not receive any public comment requests for this item. oh, looks like there is one. dr. zevin, could you stand aside while we have the public comment? >> i work for the san francisco community clinic consortium and as you know we are the federal grantee for the health care for the homeless program. one thing that is not directly related to the homeless deaths, but i think this report raises the issue again is the seaming lack of coordination between our housing opportunities, which i know are very limited, and people's health status.

i don't -- it does not appear that the central access i believe it's called takes into account a lot of health issues when declaring who's a poverty -- who's a priority for that system, and i know as our clinics are working closely with the department of public health and whole person care, et cetera, basically people are diagnosed, they get frustrated, no matter how they evaluate the person's care, it doesn't seem to affect their ability to get into some kind of housing situation, whether immediate or long term. so i just wanted to raise that issue about the coordination between the department of housing homelessness and the d.p.h. and everybody who's touching them, so that we could have a better understanding of how we could help patients become housed and hopefully

avoid some of the preventable deaths here. thank you. >> thank you. commissioners? commissioner guillermo. >> commissioner guillermo: just want to congratulate you on a very comprehensive and very, very interesting report. i don't have a memory long enough to know and to compare with previous reports, but it seems to me that there are some very interesting gems in here that will lend themselves to both policy and programmatic development within the department. and sharing that data, as was indicated by the public comment, with other departments would really sort of begin to lend to a much more hopefully i guess

more strategic use of the data and hopefully also strategic outcomes, given that data. so my question then is, so what about the report? is there any -- i know it's relatively early and you have to probably dig a little bit deeper, but what recommendations sort of do you have coming out of the data that might help inform the department and s.f. commissioners for the future? >> sure, i think there are a number of, again, this -- i think it's very fair to ask why do this if we're not going to do any response to it, and it's why we're really focused in this on what can we learn in terms of prevention for future deaths. i think the idea that we've been brought to a methamphetamine

task force perhaps because of the visibility of people experiencing homelessness who are using methamphetamine and having behavioral health symptoms in the streets, but being able to say we're seeing this as a contributing factor in many of our deaths really, i think, makes the need for response much deeper. and so i think this is the year for methamphetamine response, and there is, i'm very interested in that work. again, how do we improve bringing services for the people with the most severe alcohol use disorder and making sure that they are actually being held from the moment they go to the door of our sobering center to the possibility of detox, to the possibility of treatment program, and to the possibility of rehab, to the possibility of housing, and any time that

there's a relapse in that, that they are actually supported and not going to the back of the line and the bottom, that's something we have work to do, and we've already started those discussions. and i think really holding on to our work with opioid use disorder. i'm already having discussions with the directors of our vision zero program saying, hey, how does this affect pedestrians and what we're trying to do for pedestrian safety. so i think that it's just -- it's already, i think, having an effect raising a level of awareness where people are talking to one another who weren't necessarily talking to one another before. so that's pretty cool. >> i have one quick question, and it has to do with, is this report going to both the local homeless coordinating board and to homelessness and supportive housing, will they see this and will there be some sort of

presentation to either of those two bodies? >> we presented this at the whole person care stakeholders meeting. many of the top staff of the department of homelessness and supportive housing came to that presentation. we had a lively discussion at that -- in that particular venue, and i think it is continuing to -- it's definitely on their radar screen, it's at leadership level to make sure that response continues. for example, the public comment, how do we use this in learning better, how do we prioritize the highest risk people for housing? that's extremely important for us in the department of public health, unless we continue to show the necessity of that, it's not automatic, but that's important in other areas.

but i think that the awareness is certainly there now, and what we've heard is a high level of interest in, okay, how do we work together to respond. >> president chow: well, i happen to sit on a local homeless coordinating board, one of my many boards, so i'll bring this report to the local homeless coordinating board and we can deal with it at our level in some way, so thank you very much for your report. commissioner? >> yes, i noticed that when you were talking about the gender, the demographics when discussing gender use, there was no gender identity marker for transgender and given the transgender individuals' experienced disparities in terms of access outcomes, housing instabilities, i realize this is at a federal or state level, but is there a way we can address that and collect that data? >> i think we'll do better.

i think we'll do better as we implement the wide-ranging plan in d.p.h. for collecting data. i think that it is also the least likely place to be able to collect that data is where people who we saw as cases here, where they hit our system. emergency room, psychiatric emergency. that, i think, the same effort that we need to work on, how do we get those folks who are at highest risk actually in front of our -- all of our systems that can bring those people more toward health? those are the same systems that are going to be more aggressively able to implement

the guidelines. so i hope that we're going to be able to see that as those guidelines go into place, that will see, i won't have to see -- really dig into somebody's chart before i can understand that actually this was the death of a trans person. so i'm putting my efforts into that. >> thank you. other comments from commissioners? dr. colfax, do you want to make a comment? >> just want to express appreciation for the report and also acknowledge that you're not only looking at this high-level data, but this morning you were at the health fair treating people, so i think that's remarkable and speaks to the amazing staff that are at d.p.h. and also just to reiterate, the two pieces, one is that homeless -- people experiencing

homelessness generally age about 20 years faster than people that are not homeless, so the kr chronological age is not respective, and again, i think we really see the disparities, particularly in the african-american, black population, while that number is not higher than proportionally with the homeless overall, it's much higher than it should be in terms of an equity perspective, in terms of the portion of african-americans in the city, so bringing that equity lens to the presentation, as well. but thank you. >> thank you very much. i will say next steps, in addition to what i already spoke about, is looking at in another methodology deaths that will -- see how that will broaden our perspective on what that will do for prevention and we do need to

look, and that we need to look at the deaths of formerly homeless people who are now housed in supportive housing or other s.r.o. housing, because we know from the medical examiner there are a large number of deaths in those settings and there may need to be responses that go beyond just people on the street. so thank you very much. >> president chow: thank you. >> secretary: commissioners -- [ applause ] item ten is other business, and you have the calendar before you, if you have any questions. >> president chow: commissioners? >> secretary: hearing -- oh, yes, thanks. item 11 is report back from the february 12 laguna honda j.c.c. meeting, and i believe commissioner sanchez will make that. >> commissioner sanchez: yes, the j.c.c. laguna honda met on

february 12. it was a closed session pertaining to review of the quality and credential reports. no actions taken, and that's -- that closes our meeting for laguna honda. >> secretary: any questions on that? all right, then we can move on to item 12, which is a consideration of a closed session. >> president chow: can we have a motion to go >> yeah. >> president chow: all in favor, yeah. >> secretary: all right, then let's wait for them to let us know. great, then please consider -- >> president chow: motion to not disclose the subject matter of the closed session. >> so moved. >> president chow: all those in favor say aye. we will not disclose the subject matter in closed session. >> secretary: now you have consideration for adjournment.

>> move to adjourn. >> president chow: is there a second? >> second. >> president chow: all those in favor signify by saying aye.

>> i personally love the mega jobs. i think they're a lot of fun. i like being part of a build that is bigger than myself and outlast me and make a mark on a landscape or industry. ♪ we do a lot of the big sexy jobs, the stacked towers, transit center, a lot of the note worthy projects. i'm second generation construction.

my dad was in it and for me it just felt right. i was about 16 when i first started drafting home plans for people and working my way through college. in college i became a project engineer on the job, replacing others who were there previously and took over for them. the transit center project is about a million square feet. the entire floor is for commuter buses to come in and drop off, there will be five and a half acre city park accessible to everyone. it has an amputheater and water marsh that will filter it through to use it for landscaping. bay area council is big here in the area, and they have a gender equity group. i love going to the workshops. it's where i met jessica.

>> we hit it off, we were both in the same field and the only two women in the same. >> through that friendship did we discover that our projects are interrelated. >> the projects provide the power from san jose to san francisco and end in the trans bay terminal where amanda was in charge of construction. >> without her project basically i have a fancy bus stop. she has headed up the women's network and i do, too. we have exchanged a lot of ideas on how to get groups to work together. it's been a good partnership for us. >> women can play leadership role in this field. >> i tell him that the schedule

is behind, his work is crappy. he starts dropping f-bombs and i say if you're going to talk to me like that, the meeting is over. so these are the challenges that we face over and over again. the reality, okay, but it is getting better i think. >> it has been great to bond with other women in the field. we lack diversity and so we have to support each other and change the culture a bit so more women see it as a great field that they can succeed in. >> what drew me in, i could use more of my mind than my body to get the work done. >> it's important for women to network with each other, especially in construction. the percentage of women and men in construction is so different. it's hard to feel a part of something and you feel alone. >> it's fun to play a leadership

role in an important project, this is important for the transportation of the entire peninsula. >> to have that person -- of women coming into construction, returning to construction from family leave and creating the network of women that can rely on each other. >> women are the main source of income in your household. show of hands. >> people are very charmed with the idea of the reverse role, that there's a dad at home instead of a mom. you won't have gender equity in the office until it's at home. >> whatever you do, be the best you can be. don't say i can't do it, you can excel and do whatever you want. just put your mind into it.