well hear that within the development agreement report. >> great. >> commissioner chow: if that makes some sense. i think this -- to really understand how many services now, were there before. and any kind of comparison you wanted to make it with. and that this transition, i'm hoping you're able to demonstrate is actually positive for the community. and you've been able to resuscitate the diabetes clinics and under the foundation this really is a valuable service to the community. >> thank you very much for your time. >> commissioner chow: that's my comments. >> another question about the impact. so a lot of folks have been on access to services and the level of services. but i don't know if this is possible. but is there -- have you been able to track the patients that have transferred from the

hospital to the medical foundation, whether on the outcomes of the health of the patients have been impacted in terms of that transfer. because part of the concern was when you move from, you know, a number of concerns, but when you move from sort of a hospital management of the service to the medical foundation, management of the service, does that change the nature of the services in such a way that it impacts the patient's health? >> i don't think i have that data at this point in time. if you're referring to the diabetes, i can say with a lot more certainty that with the breast health center or with the non-invasive cardiology, it's the exact same machine. it's read by the same radiologist or cardiologist. so i would have no doubt that

should not have any significant impact. in terms of tracking diabetes before and after, because many of these are not necessarily sutter pacific medical foundation patients, so we don't necessarily have all of their medical record, access to them easily. and so especially before. and so it's one of these things where it would be a little bit harder for me to -- i think think about if there are ways to do it. but at this point in time, that medical record data, because they're not necessarily seen by our primaries or endo criologists per se. >> it would be helpful if there was sort of a way to observe or to analyze. and if you do, particularly for

those patients who are sort of seen by the same provider, if there's a way. because i think that's an important piece of -- just sort of considering, you know, these kinds of changes, whether it's diabetes or others, that access is one thing. but we're really concerned also about the impact on residents and patient health. >> we may have some data. but we can certainly look into that. commissioner chow. >> commissioner chow: i was just also going to comment, i'm really pleased also that the institute of aging was able to actually complete their work in leasing over at the presidio. and that that seems to be really -- for that portion of that program and transferring it out of cpmc and then to i.o.a. and expanding it, i think has been a positive for us. >> and i hope that we will -- the minutes will reflect what

the relationship so i.o.a. >> other comments, questions? >> also -- i'm sorry. if we're going to -- we think that is a benefit to the city. >> gotcha. >> next item. >> clerk: item 7 is an action item. it's a laguna honda hospital and rehabilitation center medical staff bylaws and rules and regulation. just a reminder, commissioner, they recommended that you -- that the full commission approve this document after review at the may 14th meeting. >> thank you. >> good afternoon, president loyce, members of the health commission and dr. colfax. i'm the c.e.o. at laguna

hospital. on behalf of dr.s hathaway and dr. mcshane. they have worked with the city attorney's office since august of 2018. and also worked to align the medical staff bylaws to align with the medical staff bylaws with the laguna honda bylaws revision. and a they have consulted with dr. chow, as our resident bylaws consultant with the department. i am here to request your approval for the revisions of the laguna honda medical staff bylaws. thank you. >> there's no public comment request for this item. >> because it comes from a committee, we don't need a motion, do we? >> oh, actually you're correct. it usually is -- there usually is a motion here. you are correct.

>> so we can just vote to adopt as a commission. so all those in favor of adopting adopting this report say aye. >> aye. i say aye as well. >> all right. thank you. >> thank you very much. >> thank you. item 8 is the sfdph gender health s.f. update. and please let me know if you need any help over there. >> good afternoon, commissioners, my name is jenna rapues. i'm the program director for

sfdph. i want to thank you all for inviting us to provide an update of our program. just a little bit about myself. so i'm actually joined by my colleagues as well, the medical director and the evaluator for our program. and just f.y.i., the pronoun used is she, her. as an information. all right. i live by myself, i am celebrating my one-year in the program, actually as a program director, it's been a wonderful experience to actually be involved in the program, that has actually centering the experiences and needs of trans folks in san francisco, with regards to access and whatnot. my background basically is i -- before i joined general sfdph, i was doing with a three-year with u.c.f. and i was doing capacity-building on a national

level and also at the time i had left, i was also the interim director for the center for transgender health and transitioned back to the program. so with that history, i'm interning in the department, prior to that working in population health and h.i.v. prevention and research and whatnot. so with that i wanted to highlight -- i really wanted to first establish and show with you all that we're celebrating today a major milestone in the program. we reached 1,000 surgery referrals in our program, which is a huge milestone. so we want to really honor that and really celebrate that and the work that we've done for the past i think seven years now. and we'll get a little bit more in-depth about the data so far. we'll talk about that more in terms of a patient population, but just wanted to share that. that is a huge milestone for the department to be able to move patients through, through

surgeries. so sfdph navigates them surgeries, procedures and resources in order to help members of the transsexual, transgender and gender non-binary people to achieve their hopes and dreams. we are a referral-based program in which patients, who require gender surgery are referred for education and preparation. and navigation and facilitation to getting steps -- we were established in 2013 by the department to provide access, again to gender referral surgeries. for those who are insured and eligible for our program. so currently sfdph provides a wide range of health services to transand non-binary residents, such as primary care, be it for health, preventative care, hormone therapy and numerous other initiatives in the

department, that really serves the population, which includes the population health and other initiatives that are within this department. i also wanted to note that we submitted some supplemental information that you all may have had, which speaks a little bit more about our -- basically -- [indiscernible] that really speaks to our program eligibility, our insurance coverage and navigation services, which is the core and the heart of our program. and also the history that speaks to a more contextual and detailed history of our program in the way in which serves different surgeries have actually become more available, rarely available over the time, so that there's a supplemental document that speaks to that. and also our staffing structure. but speaking to the mission statement, this is something that we've actually developed this year. and our mission statement basically is to increase access

to quality health care for underserved trans and non-binary people in san francisco, regardless of immigration status and their lack of income. and the values that we hold true to our program, includes social justice, community investment, peer-led harm reduction, wellness, advocacy, and compassion whole-person care. just a few milestones that i mentioned earlier, the information that really speaks to more detailed information around programs and milestones. but just a few milestones -- and i think the doctor may talk about this a little bit more later. but i think just i really want to frame the way in which we've had a really extensive collaboration and partnership with the trans community and the program really came out of that partnership, which really started in 2013, where the board of supervisor adapted a resolution that deemed these surgeries as medical necessity.

so it really sparked the interest and the commitments from our department to really develop a program such as ours. and with the health commission actually approving surgery access for development in 2012, right. in 2013, the department managed health care, solutions were removed, which actually increased access and increased interest to get these surgeries for our patient population. so that expanded our program and enhanced also we launched -- at the time it was called transgender health services. i can recall back where transgender, just a small space. i think the doctor can talk about a space, which was in a closet at the c.i.v., which really tells about where we came from and where we're at now as a program.

in 2017, my predecessor julie graham really zillion a lot of work to develop the program and expanding the services and actually expanding the capacity and staffing of our program. where, you know, we've included -- we've hired more staff, included more civil service staff to really increase our capacity to respond to the need and demand. at the same time, too, in 2017 we moved from the closet here at the ivy to a space at cfhg. ward 86 really has proven to be really great success in being able to serve the population through the work that we're doing and really being -- developing programs in the department. and in 2017, we adapted a new program called gender health s.f. in 2018, i came on board to really come in with my experience, with the department, and also really kind of sparking interest and kind of taking on

the next -- the next roles of our program and the next iteration of the program. i'm going to turn it over to seth, who will talk a little bit more about our patient population, demographics and our metrics and outcomes. >> thank you, commissioners, for having us here. my name is seth, and i -- [indiscernible] under the client demographics, i'm the lead for the program evaluation for gender health s.f. and the program evaluation began in 2016. as part of this program evaluation, we have a lot of indicators, many of which i will show you here. for the client demographics, through the end of calendar-year 2018, approximately just over 500 unique patients, three-quarters of this population that we serve, through this program, are trans women, a majority of them are people of color, who are of early, middle age, between the ages of 25 to 44, with low

education, 50%, some college and more -- a quarter unstably housed and a majority are unemployed or on some sort of public assistance. and this flag here shows how our primarily transgender and non-binary sample compares to a 2015 national survey of trans individuals and gender non-binary individuals. this next slide that talks about some of the quantitative evaluation highlights shows the trend of referrals received. the blue line which has systematically gone up since the in 2013, we're also on track, as jenna mentioned, to hit 200 referrals this year in 2019. we're about halfway there. halfway through the year. and the orange line, insurgentries -- surgeries

completed remained relatively flat since 2013. but what this suggests is the demand for the services are increasing, while our capacity to meet those needs are remaining relatively flat. for surgery wait time, if there are questions about this, i do have more information than what it presented on this slide. but generally speaking, we're seeing a longer wait time for services that are heading out of network, which are primarily our genital surgeries, than compared to our in-network services, which are our chest and breast surgeries. based on the outcome day taxer -- data, the program intake, at baseline, our clients are showing pretty good overall, general overall health, being to a national sample of trans individuals, they're showing less, serious psychological distress as defined by the kessler six, serious psychological distress

scale. less alcohol and tobacco use, but we're seeing more cannabis use. what this suggests from an evaluation standpoint, is that because our referrals to gender health s.f. are being received through the primary care system, people are already engaged in care by the time they engage with gender health s.f. so they're receiving primary care, they're engaged in services, so it's not surprising to me, that given the vulnerability of this population, we are seeing better overall health, less serious psychological distress and less alcohol and tobacco use, compared to a general population of trans people. one thing i do want to point out, though, is that when we did our education and programming, we do this while the patients are waiting to have their surgeries, we find that a majority of clients agreed or strongly agreed that the education and programming was valuable and worthwhile. and clients felt that very or

completely ready for surgery, as a result of participating in the preparation and education services with gender health s.f.'s peer navigation team. clients were learning about the possible surgical complications, they were learning how to have realistic post-operative expectations, they were learning about the importance of -- of having social structures in place leading into the surgeries, so they had good recovery social support, which maximizes the benefits to them in their recovery period. and for managing stress. in addition, where the data allowed, we did see -- we did some statistical analysis and we were able to show -- as a result of participating in this program and working with the peer navigation staff. less body discomfort following surgeries, less reported gender

dysphoria following surgeries and a significantly increased psychological quality of life, as measured by the w.h.o. quality of life brief scale. we did show trends, although they weren't systematically significant of lower psychological distress measured through the case six. and better social relationship quality, as measured by the w.h.o. quality of life scale. and the majority of the sample said that they felt that their health was better today than a year ago. just some brief summary of the quantitative information that came out of the interview for the program evaluation. we found that three-quarters of the patients that we were able to interview one-on-one, for the program evaluation, felt that they were treated with respect, they felt safe with their procedures, they felt that the care team was available to them. and the navigators provided an incredible amount of connection

and support. and some of the challenges that they reported with care quality were that some of the medical providers they felt lacked a agree of cultural humility, they were being misgenderred a little bit, they weren't using the correct propronouns and hearing conflicting information between the surgical staff and then the surgeon themselves. but they did feel that the navigation team was able to help them go through the surgical process and get clarity in the information that they need to have a good outcome. the majority of the patients felt that they had positive care experiences, that they were treated primarily with respect, that the care team listened and paid attention to them and that they felt more comfortable in their body after surgery, again they attributed most of this to working with the peer navigation staff. most of them felt that they just -- they would say over and over again, how relieved they were to have this kind of access and support from the navigation team to feel like they were able to access the service, to be authentically themselves, a

dream they never thought they would have access to, because of their economic circumstance. and just historically they have not been permitted to access these services. so one thing that's really -- that i have learned over the past year, that i've been the director as the program, is this -- [indiscernible] and previously julie graham, which is we are building the shape as we sail. so we are in full operation, but we are relatively young program in the department. so we are still in the process of really kind of contemplating and reflecting on the challenges and also kind of our accomplishments and some of the gaps within the systems. so really just wanted to highlight with you all and share with you all are some of the things that we as a program have been reflecting on. in terms of systems, gaps and needs, some of the things that are important to us, that have been some challenges also is the concept of when you're in care,

which should actually can be a barrier for some of our patient population. so really thinking through what that would look like in terms of different standards that maybe recommended for our patient population. and a barrier that really exists for our spark -- spanish-speaking -- it's language access and similarly to patient education materials easily translatable in spanish. so thinking through what that would look like for our patient population. often times we provide trainings in our work, so we have actually -- we actually have a trainer who is providing different types of training capacity around surgery access, but also training the health clinicians to do pre-surgery assessments and building -- to provide gender care, but also really thinking through the different things that we have to address within the system to build the

capacity of our procedures within the network. services among providersers is a major barrier as well. housing is an issue when we think about post-operative care and healing and so often times we are concerned around how do we move a patient through surgery but also thinking about housing and clean, safe places would look like for recovering. other things that we also think about are just behavioral, health assessments. often times we know that there are long wait-lists and providers are not necessarily competent enough to do presurgical assessments or providing training as well for many of our providers in the network. [indiscernible] surgical dates expect one of the things that we're mostly challenged by, most

recently sfdph is a trauma center, often times with our patients, who are slated -- who get surgeries particularly for top surgeries at csfg, trauma cases take over our patient cases, can be distressing who plan their lives to get the surgery and then having a reschedule or delay may actually have major impacts on our patients and what that would look like. in terms of programmatic needs we are in the process of -- operational practices, simply again because the whole concept of we're a relatively young program and we're still continuing to evolve in network. in terms of public health -- we're thinking about smoking, substance use, access to nutritious food, managing

diabetes and b.m.i. which can be barriers to moving forward from a patient population, to really thinking through what wellness programming and development is for our patient population. we respond to their needs to help them move through the process. so i wanted to add these as program accomplishments over the years, which speaks to promoting program-wide access. so in that, we are able to provide health education in various languages. we're able to provide wraparound care, peer navigation and behavioral health services, integrated and disciplinary care coordination, for example, we have a nurse practitioner in a program to really help with our patient population, either in patient education and patient care. we do presurgical assessments

and addendums for our patients needing to move forward through their surgeries. and weekly drop-s in. but in addition to that, we think of our program accomplishments over the past couple of years, we think about staffing. over the years we've been able to -- alluded to this earlier, we've been able to build capacity and being able to have more civil service positions and more clinical staff, who reflect the patient population. so folks who are p.o.c. and some come from the community to be able to be able to hold the positions and work with 9 patient population that we work with. over the past several years, as you see in the history of our program, we've been able to increase different types of surgeries over the years. and more interestingly enough, we've been able to provide or increase surgery access for healthy san francisco population, for those who are documented, that includes f.f.s.

and other surgeries at cfsg. other surgeries that we're actually moving forward with are kind of evolving >> we're able to get releases from our patients, because we really need to have patients who really see themselves and really embrace this whole have had of transvisibility. we made sure that we, you know,

got folks from -- who are actually through our programs, who really see themselves in the materials that we're developing. in terms of just testimonials, i know seth conducted some qualitative interviews and has patients who conducted or participated in the survey. they're conducted 6 to 12 months post-follow-up. and some of the key things that came up around just really how instrumental, how pivotal it is for our navigators to have that kind of relationship with our patients. and i'm going to read some quotes in terms of patient experiences. peer navigator made me feel like i have someone on my side before surgery. it's different talking to someone versus reading from a form. calls from general s.f. guided me to better understand the process. gender s.f. advocated for my identity as a gender queer

individual. my gender identity is validated. having navigator there with me to translate everything meant to me so much. general health s.f. really played a helpful role in doing a lot of work for me, like helping me with paperwork, searching peer navigation and communications with providers. my experience was difficult, people change and move, but gender s.f. health care team was there for me throughout the changes. lastly, i want to end our presentation by recognizing the work of karen aguilar, who is our lead patient navigator. she's also bilingual. and was once a client of gender health s.f.

karen was a hearts and heroes recipient for always going above and beyond for her patients and communities. patient access to the best care, to identify when the care isn't adequate and for her work improving the care which transsexual, transgender and gender non-conforming people receive. and here as part of the heart and heroes award, they made a video of karen's work. this is a quote from karen. i thought i was going to die without achieving my dreams. transgender community. human beings just like anybody else, you know, should get -- should treat transgender community like any person having diabetes or having a baby or a heart problem. just health care. just being able to access proper health care. and with that i want to honor -- karen is actually in the audience. [applause] with that i'm going to stop there and open it up for questions. >> and not receive any public

comment requests for this. >> okay. >> i had a couple of questions. the first one was for dr. pardo. the evaluation that you shared with us, did that include the out of network patients that were having their surgeries elsewhere, outside of sf? >> yes. they received their surgeries received because of our -- the way that we're organized. those surgeries are conducted out of network m.o.u. >> they have the same relationship with the peer navigator? >> yes. >> essentially all -- there's no difference? >> correct. that's correct. >> so when they evaluate that the staff was caring and such, that they're talking about wherever they had their -- >> yes. some of the feedback was about the surgical experience, the care experience and the surgery team. and some of the -- most of the testimonials we focused on the

impact of the peer navigation staff, on the service experience for these patients. >> right. thank you. >> yeah. >> i just thinking -- it speaks to a good relationship. >> indeed. >> between the program and both the in and the out of network providers and clinical teams. i had another question about the demographics and some of the qualitative information that you shareed. at program intake, you indicated there's better overall health and less serious psychological distress and so on. but the demographics show that these are potentially patients who are more at risk. >> that's right. >> i was just sort of wondering about is it really just a primary care relationship that prepares them for participation in the program? or is there something about either observable or statistic ally or empirically, there's a different type of patient that we get that comes

to our programs? >> that's probably one of the single most important questions that i have got about when looking at these data. i don't have a direct answer for that. what i can tell you is that for the people that i did speak with, what i have heard in response to them, in regards to -- what are some of the things that you feel are making your life -- a difference in your life, as you interact with this program and what has brought you here. and certainly so many of them say to me, just knowing that they have the opportunity to access these medically necessary services motivates them to do better with their health. because they know they can't access a lot of these services if their b.m.i. is too high, if they're smoking, actively abusing substances, they won't be able to access the services, even if they're available. and this is a primary motivator and a primary driver. and it's supported in the empirecal literature, if this is something they've been waiting for for their whole lives, they'll bet their butts in gear

to take care of their health, to access these services. >> i suspect that's why we're seeing such good outcomes as well. sort of the whole wraparound from the motivation factors to the program services themselves. and then post. >> correct. there is no aspect of this program any more important than the other. if i were to pick one, it's the peer navigation team, because of what they do to help connect all of these pieces. but that the program as a whole is making a difference. >> thank you. >> commissioner chung. >> commissioner chung: if i can, i'll just speak to the experience of talking to patients. i can't tell you how many timeless i have spoken to somebody who says, they're miserable and says i know i can't get surgery, i know i can't get hormones and being able to say, yes, we can do that. we can do that in the department of public health. you can get those things. how transformative that is

immediately in people's lives. and i think that's where we've got to, with our education, there's a lot of people who are hearing, yes, you can get that. even if they don't -- even if a provider or social worker doesn't know exactly how that person is going to be able to get it, starting out with, yes, that's possible in our system is a tremendous change. >> thank you. >> thank you, doctor. commissioner chung. >> commissioner chung: >> yes. thank you, director for the presentation. it's definitely heart warming to see that, you know, you were able to provide so much services. there are several questions that i have, like, first, maybe this would be a question more for dr. pardo, about the health outcome part. do you -- how does that work in terms of the referrals? do you have referrals from -- to

the gender health s.f.? and like if so, you know, how many and how would their health outcome be measured? is there actually notable changes? or how to engage services. >> i don't poke into the medical record to examine those indicators. but if the health commission wanted us to, then we would prioritize. >> i think part of it is like going back to history lessons. , you know, first transgender clinic started in the city is to really like look at -- to provide, you know, like patient-centered care. you know, give the patient what they need. give the patient what they want, and so i think that's really the spirit, providing comprehensive, like transitional and affirming services is to be able to like help them also get what they need. and so that's the crucial part

for us. >> depending on the procedure, the rate of h.i.v.-positive patients we're seeing differs. but for vaginal plasty, it's somewhere around 15% to 20% of all of our vaginal plasty referrals and procedures h.i.v.-positive. and as far as i -- we've looked at, we're not seeing any difference in the outcomes for those patients. sometimes does take a good bit more planning and good bit more coordination with the surgeons to make sure that surgically the outcomes are taken into account somebody may have consequences of a chronic long-standing immuno suppression. as i said, the big change in health often comes at that

moment where someone says, yes, you could have access to this. and sometimes we get referrals and when i respond to the referrals, we need to say it's really important that this person has good control of virallology and immunologically if they're having h.i.v. disease. and then we're seeing that people are working with their providers on that. and those numbers are available. but i can say that it's -- it is really good seeing how stable people stay. >> okay. good to know. and certainly, you know, it's really important to really ask these patients their quality of life. and, you know, because that's

different health outcome. you could have good health outcome and miserable life or vice versa, right. the other questions i have is when you mentioned about the ability and for some that needs, you know, housing -- how do you normally address that? a patient coming in with no stable housing. >> one of the things we've been clear about is that we can't be an intensive case management program. so we're really working with primary care providers, behavioral health providers on that -- on the housing stability issues. again it's case-by-case because sometimes somebody might be living in their car, for a procedure that's relatively minor, if we can admit them to

medical respite, they can have a good recovery. and yet we didn't -- they're going to have a lot of challenges in their quality of life, because they're living in their car. but we've been able to take care of one aspect in terms of gender dysphoria, that really was something that was holding that person back. so we're working with other programs. as you know, i don't have to talk about the problem of homelessness and just how hard it is to get anybody going forward. but working with our shelters, working with our specialized programs, we've had some -- i'll say for me some surprisingly good outcomes in people who were homeless, when they presented to us, and maybe are still homeless going through a good part of this process. but really getting them held

through so that they can -- i mean, it ranges from everything from respite, shelter placement, period of time at laguna honda, a bunch of things that we've been able to figure out, so people can get through the process, even if we're not able to get them a good living situation during it. that's a lot of collaboration. >> thank you. and congratulations to miss aguilar for getting the award. and really showing a prime example of like getting patient-experted care. what happens when somebody gets patient-centered care and, yeah, and thank you so much for all of your work. >> dr. chow. >> commissioner chow: yes, thank you. and thank you for the presentation. this started back in 2012. and how or what we were going to have. now you really have a whole

program. so i'm looking at the quantitative evaluation and trying to understand the numbers a little bit. and as we move forward in the program, it would be sort of nice to know, you've got client demographics. what would we need in order to actually look at client outcomes in terms of, you know, making these changes in some of the numbers like, you know, they're no longer unstable, they've been able to be in housing and what not. and it might be that i'm looking at how many of these sort of come into our program the way that you have your demographics and then how have they done in this process, aside from the qualitative surveys that you have done. and so if i'm reading the numbers correctly, is this that each year these numbers of the

referrals are individuals, so there's -- these are all different individuals and they're kind of in yearly -- sort of like going through school, all right. they're not the same people, right? they are different? they're distinct? >> the client demographics place, this is one cohort for the entire program of the over 500 patients served by the unique program. >> the client demographics are about 500. so you've answered my question, that these are aldi stint, different people on the next page, that shows how many came in during what period of time. >> some of the referrals are -- we average about one to two referrals per person. so some may come in for two procedures. >> all right. okay. i see. so a referral is not a distinct person? >> a referral is not a distinct surgical completion, it's not a distinct indicator. but the number of patients represented in the demographics

are unique patients represented in the tong. >> that's just over 500 people. >> and that's over the course of the seven years? >> yes. six years. >> okay. so over the course of the six years, these are sort of their profile. since we have begun doing surgeries and all, is there a way of understanding what has been, you know, the results for these individuals let's say the 500 individuals about, say 100 of them came in six years ago, just so make this a little easier. where are those 100 now and how successful are they been in terms of, of course, you've demonstrateed that they are feeling better and they're doing better. are we also able to assist them in their housing and employment and all, which then gives them a

life? i know you're implying it says they do. i'd like to know if we have actual data that begins to show, i'm working on 500 people here, the first 100 over the six years, while they're only three-quarters of the way through their transition or whatever it is, this is also what's happened to their demographics. is there a way of doing that or just too complex to understand what kind of outcomes we're getting? >> it's certainly something that we could do, by going into the behavioral health record and/or the primary care record. but within the scope of what the program does, it would be a little bit beyond the scope of the program itself. the program serves as a surgery access and navigation for accessing these medically necessary services, as opposed to a larger as dr. zevin said, it doesn't function as the hub of intensive case management. >> so could we say how many people completed through what you would consider a completed

course of this and then what have those people done. is that something that we have? >> the program evaluation follows patients over the course of approximately 12 months. so we captured them at ip take and then we follow them up approximately six to 12 months after a surgery. again it's a voluntary process, people don't have to participate in the program evaluation. we've captured data represented here, is just over 60 people. we have now approximately 75 data points for follow-up surveys, although we have over 150 interviews in an entirety. certainly this is not -- this is 1/5, 20% of all of the patients served uniquely by this program. but in terms of getting a profile of following a day in the life of some of these folks, might be able to do something like that. ticket talk with my team back in quality management. >> i guess i'm just more interested in knowing at what point we're able to say that we

have actually been able to help people -- and in order for a number of people to understand why we have these programs, i think it's necessary to show that we are helping people. we're helping through the course of treatment. >> in terms of what these surgeries are shown in the literature to change, in the life of a patient served by this program, we do have the indicators for for that. in the peer navigation wraparound service and accessing the medically necessary services, using the same psychological and social outcome measures used in natural services such as the united states transgender survey and some surveys that look at the general u.s. population, regardless of gender identity, for psychological well being, as measured by the w.h.o., quality of life scale, and then useing some of the psychological

distress measures as measured by the kessler six, we are definitely showing significant improvement as a result of accessing services in this program, for psychological well being, sense of hopelessness, better -- reduced body discomfort, reductions in gender dysphoria, reduction in substance use. those are some of the primary indicators that we show are primary -- have health disparities in this population in general. >> so could you say that 60 people have exhibited that? >> yeah. >> i'm looking at the numbers in front of me, about 60 people have participated in the program. >> okay. we think that this survey has shown at least these 60 and whatever stage they're in, have shown improvement in these elements. >> yes, sir. >> well, i think that as we move into maturing the program, it would be good to try to really continue to hone in on that.

and get some uppitification to the qualities that we believe is happening. and it would also be good to show how we're able to change some lives as we go along. it's obviously taking a long time to get that. and even to have 60, i think is a good number to even talk about in these six years. to say we've helped these people. and it would be good then that we continue to look at this program and in this manner, in which we try to understand them, quantify how many people we are helping. thank you. >> thank you. >> commissioner chung. >> commissioner chung: actually more questions. i think that, you know, it's great that we have this service. and, yes, i understand that gender health s.f. is not intensive case management. but i think it's a great tool for other d.p.h. departments, especially primary care and

mental health services. so it would be -- it would be great to like have -- some feedback from, you know, like from primary care, for instance, or from mental health services, you know, like that. what kind of improvement, you know, that providers actually -- clinicians actually observe, for instance. i think more adherence to medications, are they like following up with appointments and i think that that would help us understand how to tell that story effectively. >> that's great feedback. thank you. >> so commissioners, president loyce had to leave and ask i that continue to chair the meeting. i'm take that prerogative and make one comment. this might be where -- can be quite useful, because i recognize the program itself

doesn't do all of those things. and even to be able to tell me you feel 60 people really involved in having been able to come to a positive position in life is really important. but to do as commission chung was talking about, we should be able to then -- through our coordinated efforts in the future, to really understand what's happening in the other spheres of our medical record for that patient, in order to really demonstration the positiveness of the program. so do we have any other comments, commissioners? if not, then we thank the presenters for their fine work. and we look forward to future reports. and we can go on to our next item, please. >> thank you, all. commissioners, the president has recommended that you defer the next item, due to time. and go to closed session. so we want to thank miss

scarborough for being here and we will schedule her for -- hopefully the next meeting to present. because it's not about the intent or the interest of the topic, but it's about the timing in the closed session. >> so, commissioners, without objection, we will take that recommendation. and we are now open for motion in regards to the closed session. was there any public comment on the closed session? >> actually if i can quickly go through two other items before we get to closed session, just other business, i can name then. any other business? hearing none, we can move on. the joint conference committee update, the meeting at the laguna honda j.c.c. was yesterday. it was a closed session. i can speak for commissioner guillermo. and then now you can canner a vote on the closed session. >> okay. there are no comments on closed session before us. a motion for closed session is in order. >> motion to move into closed session. >> is there a second?

>> second. >> all those in favor of a closed session, please say aye. >> aye. >> all those opposed? we shall then now go into closed session. thank all of the public for being present and those who are not present for the closed session >> so commissioners we have a vote to go back into open session. a motion whether to disclose or not discloses. >> motion not to disclose. >> second. >> there is a motion and second not to disclose. all those in favor of not disclosing please say aye. >> aye. >> all those opposed? we shall not disclose. there being no other business, the motion for adjournment in order. >> move to adjourn. >> second. >> all in favor please say aye. >> aye. >> this meeting is now adjourned. thank you. hi, i'm lawrence. we

doing a special series about staying safe. let's look at issues of water and sewer. we are here at the san francisco

urban center on mission street in san francisco and i'm joined today by marrielen from puc and talk about water and sewer issues. what are things we should be concerned about water. >> you want to be prepared for that scenario and the recommendation is to have stored 1 gallon per person per day that you are out of water. we recommend that you have at least 3-5 days for each person and also keep in consideration storage needs for your pets and think about the size of your pets and how much water they consume. >> the storage which is using tap water which you are going to encourage. >> right. of course at the puc we recommend that you store our wonderful delicious tap water. it's free. it comes out of the tap and you can store it in any

plastic container, a clean plastic container for up to 6 months. so find a container, fill it with water and label it and rotate it out. i use it to water my garden. >> of course everyone has plastic bottles which we are not really promoting but it is a common way to store it. >> yes. it's an easy way to pick up bottles to store it. just make sure you check the label. this one says june 2013. so convenient you have an end date on it. >> and there are other places where people have water stored in their houses. >> sure. if you have a water heater or access to the water heater to your house, you can drink that water and you can also drink the water that the in the tank of your toilet. ; not the bowl but in your tank. in any case if you are not

totally sure about the age of your water or if you are not sure about it being totally clean, you can treat your water at home. there is two ways that you can treat your water at home and one is to use basic household bleach. the recommendation is 8 drops of bleach for ever gallon of water. you add 8 drops of bleach into the water and it needs to sit for 30 minutes. the other option is to boil water. you need to boil water for 5-10 minutes. after an earthquake that may not be an option as gas maybe turned off and we may not have power. the other thing is that puc will provide information as quickly as possible about recommendations about whether the water is okay to drink or need to treat it. we have a

number of twice get information from the puc through twitter and facebook and our website sf water.org. >> people should not drink water from pools or spas. but they could use it to flush their toilets if their source are not broken. let's look at those issues. >> sanitation is another issue and something people don't usually or like to think about it but it's the reality. very likely that without water you can't flush and the sewer system can be impeded or affected during an earthquake. you need to think about sanitation. the options are simple. we recommend a set up if you are able to stay in your building or house to make sure that you have heavy duty trash bags available. you can set this up within your existing

toilet bowl and once it's used. you take a little bit of our bleach. we talked about it earlier from the water. you seal the bag completely. you make sure you mark the bag as human waste and set it aside and wait for instruction about how to dispose of it. be very aware of cleanliness and make sure you have wipes so folks are able to wash up when dealing with the sanitation issue. >> thank you so much,