>> we will call this meeting to order. i will call the role. (role call). >> the second item on the agenda are the minutes of january 21st, 2020. >> once the commissioners had an opportunity to review the minutes, is there a motion to approve? >> so moved. >> second. >> all those in favour?

minutes approved. >> thank you. i'll note there is no public comment. item 3 is the director's report. >> good afternoon, commissione commissioners. we will have a separate update on the coronavirus report. dr. arigon will be providing that as soon as he's here. it's the most up to date information we had as of this weekend but the situation changes recalledly with regard to recommendation. i will emphasize a couple of things in advance of the doctor's comment. we have no newly diagnosed cases in san francisco of the coronavirus at this time. there are a total of 11 cases across the country that had been reported. six in california. two patients diagnosed in a

nearby county who were transferred to ucsf. i want to emphasize again, we have no newly diagnosed cases in san francisco. i also think it's very important that we, as a health department, express that this is public health. this is classic public health. we have been through a number of these preparations with sars, with h1n1, with concerns around ebola and so we have expertise in this area to be as prepared as possible. obviously, it's not possible to fully people for every plausible scenario, but we're taking, basically, scientific steps to be as prepared as possible. we're working with other city partners, including the department of emergency management. we've activated a centralized

response so we're ensuring all of the department capacity and other city agencies are ready and alert to respond to any concerns. right now, our recommendations are for the general public to follow procedures for protecting yourself as you would during any flu season. wash your hand, cough into your elbow if you do cough, avoid going to work or school if you are sick and then i think it's worth remembering to remind people, it's still worth getting a flu shot. it does not correct against coronavirus, but it protects against the routine flu, the regular flu, which i think bears reminding that it still kills over 30,000 americans every year and we have a vaccine for that. obviously we have monitoring our focus on prevention and if there is a case of a newly diagnosed

coronavirus in the city, if there's a case not from a high-risk area or immediate contact, we will then be focusing on community mitigation and dr. aragon will go into far more detail on that, but i just wanted to report to the commission that we have activated the department and we're working with other cities to ensure we're as prepared as we can be. and i also have a couple of other items in the report that is wanted to highlight for you. one is that as you know, we activated our -- i'm sorry, we launched our substance abuse website for the public. this was a part of our mental health sf, mental health reform efforts. we have for the first time a

public-facing website that people can go to to see how many sumanysubstance abuse treatments are available. this is not only for providers but for individuals and families, as well. we have been monitoring the vacancy rates in those beds and that has been overall ranging between 20 and 25%. given the state of need in the city, we are taking affirmative steps to better determine what are the potential barriers to filling the beds and how can we work with the providers, people who are seeking treatment to break down those barrier. i wanted to emphasiz emphasize . i'm pleased to announce with equity as a priority across the department, that we've identified 16 behavioral health service's staff who will be racial equity champions and this is something again categorized by our department -- our

division of health equity and having different divisions within the department, identify equity champions who will not only be champion equity, encouraging people to actually demand people work through an equity lens but holding their various divisions accountable for moving equity outcomes forward. so this is an important step this the structure of the department to make sure our culture is equity focused. there's been a lot of news with regard to dph lately, so those are also in your packet, as well, and i stand by for any additional comments from the commissioners with the request specifically around the coronavirus, that, perhaps, they be held after after dr. aragon presents. >> commissioner gerado.

>> i have one question with the behavioral health champions that are identified here and exactly what will they be doing to helps other understand and address racial equity? >> i'm turning to dr. benefit >> there are 87 for the department, the number changes slightly everyday. so they will do 20 to 30 hours of self-education, so we're putting in orientations and other brown bags and things for them to take or area specific things that they might prefer that are related to equity in their area and they'll spend the rest of the 60 release hours on some kind of activity for their area, whether that's an assessment for the area, some

educational program they put on, some way they're supporting the goals that their area put forward in their equity plan for the year. >> will they measure from start to finish the equity growth in understanding in those that they are presenting to in their cohort? how do we know what they're doing is working? >> so we'll do evacuation, both of the champions themselves. , of their education and how they understand it at the end. and the number of hours that they actually end up putting into this, which turned out to be more than they were allotted at this point. and then looking at evaluation of all of their activities and we'll help them design their

activities. that's what the office will do. we're not asking people just to go do something. so many people may want to do the self-assessment work that population health did or csfg did to get how their staff feel about equity and that would create a new benchmark to use in their next year as they look at their equity growth and it fends on the activity they're doing. they all won't be teaching. some will be looking at data and despairty. >> thank you very much. >> dr. bennett, thank you for all of your work and thank you to the 16 champions within the behavioral health division. their names are listed in the report, but i want to make sure they're acknowledged as well. when you say there's time for self-education, does the department provide educational or training modules or a menu for them to choose from? >> there's a menu of educational

activities that are already out. we have activities that are specific to the champions. so, for example, the sfg, they do a relationship-centred communication's training and it has a racial equity focus and that training, the office of health equity paid for them to continue it and allotted slots just for the champions. the same thing in various other things we're bringing in. they have their own individual education. plus, we've giving them an email about all of the things available to them. so it depends what their availability is to do some of those things. if you're a nurse on the floor or somebody, you can't get release. so, perhaps, you're doing a book reading or videos or some other way. >> thank you, dr. bennett. >> no problem. >> commissioners, any other

questions? thank you, director colfax. >> i will no no public comment. >> generaitem 4, it looks like e is going to be one. the budget is going to be a separate item so you would make public comment on that item. general public comment is for items not on the agenda, so if you could hold your comment, that would be great. thank you. so item number 5, which the report back from the finance and planning committee from today. >> good afternoon. the finance and planning met earlier today and we have one item for the consent calendar, which is a new contract for approval. and, also, we had a chance to take a look at the forecast of the annual report which will be presented to the full commission in the next meeting, which is

february 11th. >> 18th. >> oh, february 18th. any questions, commissioners? >> so we can move on to item 6, which is the consent calendar containing one contract that commissioner chung just noted. and we need a vote on this. >> so do we have a motion to approve? all those in favour of approving the consent calendar? all those in favour? motion passes. >> i'll note there's no public comment and item 7 is a resolution honouring dr. irene sung and holly hammer will come up and introduce the item.

>> good afternoon, commissioners, director, secretary. it's a pleasure and an honor to present for your consideration this resolution recognising dr. irene sung for her 22 years of service to the department of public health and the people of san francisco. before i read the resolution, i first want to recognise my debt to dr. sung for being my teacher and adviser and guide as i was learning about the behavioral health services and really delving into tough work that we all agreed we needed to do with behavioral health and irene was an incredible supportive mentoring guide in that work.

i also, before i read the resolution, i want to recognise the behaviour health leaders who are here for their incredible work and support during this time of transition. so the resolution reads, honoring irene sung, whereas irene served the city and county of san francisco as a leader and clinician in the department of public health, behavioral health services for 22 years and whereas irene sung has modeled reflective leadership, encouraging those around her in every position to participate in improving client care, the functioning of behavioral health services and the larger department of public health system of care and whereas dr. sung leaves a legacy of servant leadership, community, collaboration, equity and diversity while honoring the guiding principle of recovering wellness that values client's

wellness and resilience and whereas, dr. sung brought a diverse group of clinicians together while fostering communication across programs in a shared vision for clearing for the most vulnerle in the city. and whereas, irene modeled the collaborative and inclusive leadership style which leveraged the talents of the behavioral health workforce to respond to evolving behavioral health needs of san francisco and whereas, irene sung has a special ability to bring diverse groups of people together and honor each individual's unique contributions while respecting differing viewpoints and whereas, irene sung fostered meaningful relationships with providers, staff and clients through her genuine nature and powerful ability to connect with a larger community.

where irene sung served as an encouraging support of mentor to the countless staff she has taught is supervised and whereas dr. sung lead behavioral health services with a social justice and equity lense that embodies the core principles of trauma systems through establishing environment of compassion, empowerment and resilience for both clients and employees of behavioral health services. and whereas irene sung leaned in to take the reigns of behavioral health services as acting director in order to steer us on a path forward during a time of enormous change and uheaval. i hea hearby certify the san francisco health commission january 26, adopted the

foregoing resolution and thank you, irene. i'm going to ask the commission to accept this resolution. >> thank you. any comments from our commissioners? >> commissioner chung. >> today is february 4. and i was also wondering if we should add a resolve that we wish dr. sung in all of her future -- success in all future endeavors. >> i had a lot of help from my

colleagues at behavioral health services and i think we could add a clause like that. so thank you, commissioner, chung, we will wish irene, incredible growth, health and happiness in her environment. >> and acknowledging her great leadership, too. dr. sung, thank you for your leadership. it's been a pleasure to have you here giving us updates on the tremendous work of you and your colleagues. you've really helped to set us on a path of addressing the issues that i think are some of the greatest challenges that we're facing as a city and in our collective conscience. so thank you so much for your great work and we'll certainly miss you and your legacy will certainly be carried forward. commissioners? >> i want to add my congratulations and thanks for your service and we wish you all of the best in the future and

also thanks for leaving the legacy that you are in the staff that are remaining here behind you and look forward to continuing to engage with your successor and the rest of the staff as we take on all of the issues going forward in a much bigger way. >> congratulations, as i'm just learning about all of your wonderful work in behavioral health. i, again been congratulate you and wish you well in your next chapter. >> commissioner green. >> i would add to that and say when we oriented to be members of the commission, the behavioral health component was so dizzying and so complicated and the idea that you were able to step in and really keep things going so smoothly at a time that's so pivotal and challenging is really a

compliment. you've brought your knowledge and experience to the table and you've really set the stage for what we know will be an effective future approach to all of the issues we're trying to solve. so thank you. >> thank you so much. put. >> so thank you so much, commissioners. i'm overwhelmed at all of the whereases. there are so many whereases that follow my name. [ laughter ] >> i want to thank hallie. these been a tremendous support. really, it's been such a great working relationship. i couldn't have asked for a better working relationship in this interim period and in all of the work that everybody is doing. really, i appreciate all of the thanks and the tremendous whereases and i could never have done it without the team. i mean, the team came together and supported each other and supported me and so i really want to put the kudos out to the team because they have been in the same whirlwind we've all

been in and they'll hold down the fort and keep walking and hopefully the wind will settle. [ laughter ] >> so thank you so much. i appreciate everything. i appreciate my family who came and i thought -- i actually thought it was on thursday and i called them up last minute. i want to thank everyone. thanks to much. >> if we could have your team and family stand up and be acknowledged, as well. >> stand up, family. there they are. >> you have a resolution honoring dr. irene sung, do we have a motion to approve?

>> could i add to the motion that with the suggested edit. >> yes. >> is there a second? >> second. >> all those in favour? resolution is approved. >> thank you. i wanted to reiterate and add my own whereas. [ laughter ] >> whereas am very grateful for you stepping into the act in the behavioral health director role, whereas we had some very in-depth conversations and i know you did it voluntarily and i really appreciate that you did it in the way that you did. the former director stepped down shortly after i started and given how much has changed with regard to behavioral health and last year, i'm so grateful you were there to support the team

while they were doing the work everyday. , supporting me andother executd respond to some of the concerns that were being raised across the city and i think as a result of your commitment, your perseverance, your wisdom and your willingness to be acting director in the last year, in particular, including with mental health sf, your contributions will live on and make the city a better place and have made marked improvements for the people we serve. that's something i appreciated about you, no matter what meeting we were in and how bureauic it got, you always kept the client's best interests in mind and i'm deeply grateful for

that. >> if dr. sung could come around and shake hands and gather for a group picture.

(applause)

>> commissioners, eel make sure the planner resolution hai'll m. item 8 is the coronavirus preparedness update. >> good afternoon. if my voice is a little rough, it's because i've been speaking for hours today. thank you, everybody, for setting aside some time to talk about the coronavirus epidemic that's happening in china. on december 31st, the world health organization learned of a new outbreak that was occurring in wuhan, china. since december 31st, we now have over 27 -- i'm sorry, 20,000 cases, and we know that

is an underestimate. there's also been over 400 deaths occurring. it has spread to dozens of countries and currently as dr. kolfax mentioned, we've had only 11 cases in the united states and nine of them were infected in wuhan and two of them were spouses to the persons who were infected in wuhan. six of the cases are in california and two in santa clara and two in san bonito and we continue to emphasize that we believe the risk is low. the only infections are people who were infected in wuhan or close contact and we're not talking any recommendations for canceling of events, but we're emphasizes basically concepts around preventing infections.

on january 30th, the world health organization the novel coronavirus a public health emergency of international concern. on january 31st, the united states declared a public health emergency for the u.s. yesterday, the cdc started implementing more rigorous containment -- i would say a prevention strategy. what we're trying to do first and foremost is to prevent infection taking hold in the united states and currently, four nationals other than immediately family of u.s. citizens and permanent residents who have traveled to china in the past 14 days are not being -- are being denied entry into the united states. u.s. citizens that are classified as high-risk and those are people in the past 14 days have been in hubei province

or who have close contact with the confirmed case are being -- are undergoing what's called mandatory quarantine. they're being transported to military bases where they're going to be under quarantine for 14 days. and what's happening is that people who are traveling back from china, they're being rerouted to 11 airports in the u.s. in california, it's the san francisco airport and then the los angelos airport. and the other category, the other important category are people who are returning from china in the past 14 days that's not part of the hubei province. and they'll be tracked into what we're calling voluntary quarantine and active monitoring. so this group that i'm speaking about that are being quarantined are people that come in and that

do not have symptoms. people that do have symptoms receive a different track. they're isolated and they get testing because they're coming from a high-risk area. as i mentioned, all of this started as of yesterday, so this is really a big change. i can't remember in my career that the u.s. has ever done this. i know it was done sometime in the past and so this is actually very big. i do want to emphasize -- i want to read from the california department of public health, because it's important to get this message for the country, california, but also san francisco. the california public health is not recommending the cancellation of public events at this time. there's no evidence of sustained person-to-person tra transmissif the virus in the united states and we have been working very diligently to get

communication's material online in multiple languages. if we do have a confirmed case in san francisco, we will let you know and we will announce it immediately to the public so that everything is transparticipant antransparenta. before i move on, i want to acknowledge, there's a huge team of people working really hard to get us prepared and i just want to acknowledge dr. julie stolte, our disease controller, who is working in the nitty-gritty and dr. susan philip, rachel keagan, our communication's director who has been spending a humungous amount of time on this and also veveronica vein and health centr

number four. i learned they still refer to it by the number and not the health center and he has really stepped up and we've been doing a lot of interviews and communication with the chinese community, media, radio, television and he has just been an incredible partner and i want to acknowledge him. so as i mentioned, the key strategy is preventing introduction. if we have a case that's in the community, that doesn't have a known source, we focus on containment and think of it as ring containment, making sure they're quarantined.

so i'm just going to read to you very carefully how the general approach we take is to identify and transport cases, again, focusing on recent travelers from affected area, isolate, evaluate and test cases either in the hospital or in the appropriate home setting, quarantining persons who have been exposed, and mentioning the high risk and medium risk and then a lot of communication around basic infection control and the reason why this is important is that for the novel coronavirus, there is no vaccine and there is no treatment. and so one common question that

i get is, how does this differ from influenza? and i think that's a good comparison. so with influenza, we know a lot about influenza. we have a vaccine and we have treatment and so, we remind everyone, as dr. kolfax reminded, get vaccinated. with the coronavirus, we know very little. we have no treatment and we have no vaccine. so, in a sense, we're going back to traditional public health measures to prevent transmission. and then the next level that we're focusing on is preparing the public health and medical system for medical and public health surge should it become -- if we were to have ongoing transmission in the community, how would we really handle that? our healthcare systems have to

think about not only taking care of all of these patientses thatt would come, but the healthcare workers could become ill. as i emphasized, in a sense, that's the highest risk of transmission because you think of the healthcare worker with the symptoms and those healthcare workers have the most intense exposures, who may be infected, so the training of the workforce is critical and we're doing fit-testing for our staff and our prepatory work to get everybody prepared and we'll start training field teams so that we're able to, in the future, to go out and do testing in the community if people are not immediately able to come into the healthcare system. and working with the healthcare systems in their isolation rooms and for them to have the type of infrastructure that's required to take care of these patientses that just have intensive

infection control requirements. for more than two hours, i was at a chinese town hall meeting today, where i got dozens and dozens of great questions, so, basically, i'm almost prepared to answer almost anything, including the questions about face masks. i know there's probably a question about face masks. so i want to make sure that -- i don't know if rachel wants to say anything about the community? anything you want to share? i just wanted to give her the opportunity if she did want to share something. >> do you want to answer the questions about face masks in advance? >> i learned to keep things a mystery because it keeps you engaged until the very end. [ laughter ] >> thank you, thomas. i'm the director of communications and just to add on, we've had through priorities. the first is rumor control. we've been putting out public

information, monitoring social media, responding directly to people on social media who may be mistaken in what they are saying. and we also have been prioritizing outreach to the chinese community and we've been doing that through the chinese language media as well as through providers in the chinese community and chinese community organizations and leaders. happy to elaborate on any of that. the third priority is timely, accurate public information. we do want to make sure that people can find the information and can find it from us and know where the verified sources are. we're also referring people to the cdc for the global and national news. we're not trying to become a news service but want to make sure the san francisco news comes from us and that's why we are ensuring that people know that there are no confirm edcases in san francisco among our residents. and if that changes, we will announce it. you don't have to wonder or

worry how you'll find out. i'm happy to answer questions if you want to get into more details about community work. >> so i will just give you the short version of the face mask answer. some people ask, are we going to be handing out face masks and one thing to realize, if there was wide community spread, we would not have the resources to provide everybody with face masks. there are limited medical resources and we always prioritize the resources, whether it's the greatest risk and whether it will be the greatest benefit. so we're reminding people that in the healthcare setting, that we really need to keep the healthcare workforce healthy so they can take care of us if we become ill and the n95 respirators, that's where the focus is. the wearing of masks, the big focus of masks is when somebody is ill. so if i'm ill. if i put a mask on, i've reduced transmission to other folks.

i remind people when they go so the doctor's office and they walk into the waiting room, there's a thing there that has masks and says if you have a respiratory infection, please clean your hands with hand sanitizer and put the mask on. so there is a role for masks. i think part of the reason we communicate this is because we don't want to make people feel like they're doing something wrong if they choose a mask but begin to educate people that if you do use it, there's a better time to think about when to use it so that we don't stigmatize people for wearing a mask. so it's important to have that type of communication. so what i'm going to do is just leave it open. if you have any questions for me, i can expand. >> dr. kolfax. >> first, thank you, commissioner. i want to acknowledge dr. aragon's work in this. he's been going 24/7, along with

so much of the rest of the team and applying traditional public health principles is, you know, something that this department has done many times before. i want to mention that we are also collaborating with other city agencies in this preparedness and response and we obviously take this very seriously, so we're both balancing what we know now in san francisco, meeting with spinescience is preparing for scenarios that include potentially more cases being diagnosed in sanfrancisco and how we need to respond to that. part of that, as of last week, we activated the department's operation center and a key part in that has been the department of emergency management under mary ellen carol who is the head of the department. again, we've done these things before, but i want you to have the broader picture that we have

quite an infrastructure now that is requiring lots of people working at all levels, including clinical logistics, operations, communications and so forth. and so i'll turn it back over to aragon, but i wanted to have you have that perspective, as well. >> thank you. >> thank you, director. i would like to commend the department for the public communication. it has been very strong. i know the press conference, i believe held a week ago yesterday, received a lot of coverage, particularly in the chinese press and aa press and attending public meetings as you did today and thank you for that. commissioners, any questions? commissioner giliarmo? >> i have a different but related question. my understanding because of the travel restrictions in the

transportation, logistic restrictions, there's been a worry that there might be a lack of supplies, medical supplies and things like that that often are actually imported from china in hospitals and i in clinics ad i'm wondering if we're monitoring that, as well, or if it's affecting us? >> yes, we are. what health systems are doing, they are ordering supplies. the problem is that everybody across the world is ordering supplies and so, what happens that case is that they rotate.

we're ok at the moment. >> dr. ara diversiogon, are we g any help? >> we took the cdc guidelines. our staff are tightening that up and they'll give it to the department of human resourcings to circulate to everybody because everybody is asking about travelers, what school -- we have a school guideline. we have a draft from the state as of yesterday and they're going to come out with a final and we're going to be fine-tuning the communications, because there's a lot of questions about healthcare workers, schools, work. and so everything that we have put together will be put in multiple languages so that it's available to the community. >> the second question was, if

the public was to find information on their own, are we still directing people to the cdc website or do we have a portal at the sfpd website? >> yes, or sf72.org is the other site. that's a good point. we're directing people to the reputable websites and there's really just a who, cdc, state and local but that's where i would go. i would not go anyplace else because there are rumors that circulate that are just not true. >> commissioners, other questions? thank you, doctor. >> thank you very much. >> i'll note there was no public comment requested on that. item 9 is the first hearing on fiscal year 20-'21 and '21-'22

budget. >> good afternoon, commissioners. greg weidner, chief financial officer and i'll make a couple of introductory comments and turn it over to jenny louie. so this is our first of two and probably more than two hearings on proposed budget for the coming two years. we're doing things slightly differently this year than we have in the past and big part of the reason for that is that the board of supervisors passed an ordinance during last year's budget process with a goal of kind of standardizing and improving the process for public hearings and public input on the

budget and so that ordinance that was adopted by the board and signed by the mayor requires a few things. it requires each department to have public hearings and it sets some standards for which should be included in those hearings and we're following the goals set out in that ordinance. so for today, we'll be having an initial hearing where we talk about doing some overview of what our current budget looks like, some of the larger issues that we're aiming to address in our budget submission that will go forward at the end of the month in february and then, at the second hearing, two weeks from now, we'll bring a set of budget initiatives for you for your approval. so what we are hoping to do today, again, is to go through at a high level, our approach to the budget process, some of the major issues, gather thoughts and feedback from the commission on that and then we'll move to

the actual budget documents in the second hearing. so i'll pass it over with that to jenny louie to walk through the presentation. >> and commissioners, if i can clarify, the items at the next meeting will be an action item. so today is just hearing facts. >> if you. >> good afternoon, i'm the dph budget director. so as mr. wagner said, we are going to be providing a budget overview as part of our presentation today and i will just dive right in. so dph's budget is currently projected to be $2.4 billion. this is all in operating capital, special projects, grants. we are the city's largest budget and i won't read you the numbers, but as you can see, san francisco general is the largest division, followed by behavioral health and l laguna honda hospital. in terms of expenditures by

type, personnel is our greatest resource, representing more of half of our expenditures, followed by non-personnel expenditures and these are contracted services, but a majority of the contracted services are really related to the cbo partners that we have behavioral health services, as well as the ucsf affiliation agreement which provides clinical and other services at zuckerburg san francisco general. so a bulk of our expenditures are really getting services out the door, materials and supplies which also seems fairly significant, really do represent, like, medical materials and supplies, not only the regular bandages and it also represents pharmaceuticals for us, which is something that we definitely try to keep pace with in this current environment. and in terms of workforce, budgeted fts by division, again, san francisco general is the

most significant and you'll see sort of a switch between laguna honda hospital and general health. this is significant where a large majority of the services by behavioral health are contracted out. we do have some civil service providers, but we work t so closely with the partners, you won't see as many positions in behavioral health but there are still positions to support that and laguna hospital which has no affiliation, it has run almost entirely by civil service. i'm pretty proud of this slide. this represents -- this slide represents the general fund support and the revenues that the department generates to offset the need for general city fund. if you look at the blue bar on the bottom, it represents the revenues that the department leverages by each division and then, the orange represents a portion of the general fund needed where our revenues don't quite cover, where we're

required to have a match, where we have patients who might not be eligible for entitlements and can't draw down initial revenues on their service. and so, we offset 65% of our costs with revenue and we're requiring only a 35% general fund subsidy, which is, i think, a pretty respectable percentage. but it is important to note that 861 millions of of the department's budget, you know, 35% is general fund and again, not an insignificant number, you know, when you're looking at the larger budget, as a whole. this is obviously something that we will continue to look and monitor as part of the mayor's budget instructions. and in terms of our projected salary spending, we are expecting to come in pretty much at budget for selling infringe costs for the operating budget. this projection is consistent.

we've had, in prior years, and our most recent closing fiscal year, we ended the year with 4.5 million balance. again, that does seem like a fairly significant amount of money, but when you compare it to the billion-dollar operating salary that we have, it represents less than half a percent of where we are. so, again, it's large, but it can be a little challenging. so anyway, we will continue to work aggressively to hire permanent staff and place per diem and make it part of our annual budget process. so moving to the five-year financial budget and the mayor's budget, which is sort of the context for our proposal, what you see here are the last four updated years of the five-year projection. every other year, the controller

proposes, works to develop a joint report on the five-year projection and the following year, they just do an update to the remaining four years, which is why you only see four years in front of you. but this represents the projected deficit that was issued by the control and the mayor in december. and what you'll see there is that sources are growing at the top. it grows by 89 million in the first year and by year four, to 423 million, which is great. and so revenues are expected to grow for the city. however, if you look at the uses, if you calculate all of the expected costs the city will incur in that same four handcuff yea-yearperiod, you see the grer growth is greatly outpacing the growths of revenue and so, of course, what you have there is a projected deficit or shortfall in each of the fiscal years and

protected to grow by $630 million by year four. touit's important to note, the courses as i mentioned, are projected to grow every year. and so that means the economy is expanding and not receding. so the assumption in this four-year budget cycle is that in these numbers is that there will be no recession. as i mentioned, in our memo, we are now in year ten of the longest period of economic expansion in the u.s. history, think, since 1949. and so it's something that we are going to have toma mon to md we'll have to see if that holds true. but just know that is what the basis of these numbers. assuming that holds true, the two-year deficit, what we're trying to solve in the four-year

budget proposal, is 195 million in year you one or 220 over the years. how does the 420 rate, relative to prior-year deficits? in '6-'17, it was 4 million over the two-year period and spiked up in '18-'19 and then drops back down again, but for the last six years, the projections have been lower than what we're seeing now and so this is probably a part of the larger ongoing trend and again with the revenues flowing and it's more

of a cautionary note as we think about how to move forward with our budgets. so the introductions from the mayor's office is to propose efficiency reductions, to reduce general fund support by 3% in the first year growing to 7% by the second year and seek solutions that prioritize care functions, minimize service impacts and minimize lay-offs. and we're looking to find solutions that explore revenue options, consolidate contracts and streamline programs and pilot solutions. so with that said, the goals and areas of focus for dph, i want to give a high level. most significant for us will be mental health sf. so as you know, i understand you've received several director's reports on this

legislation as we've worked on it over the summer i and this pt fall. i wanted to provide you the context in a little more detail behind, like, what this legislation outlines. it's an ambitious framework for transforming the mental health system and increasing access to our services. the target is unsured adults with behavioral issue. this is a joint legislative effort by the mayor and board of supervisors and there's five service areas under which the legislation really prescribes growth. so the first one is the mental health service's center and this is a 24/7 central access point for patients needing care, so it's triage, referrals, consultations and pharmacy hours to be expanded and available at least seven days a week with transportation services, urgent care and a drug service center.

another pillar of the mental health legislation is the office of coordinated year tasked with expanding case management to ensure all patients who are engaged has a treatment plan and case managed. it creates an inventory of all city-funded mental health programs and requires coordination with psychiatric emergency services at san francisco general, as well, as jail health. there's a crisis response team and this team would be engaging persons on the street to ensure they're connected to services and this team will coordinate with existing health services and existing outreach services within the and within the city. there's a service's expansion and we can't be expanding our case management and increasing access to resources without the

actual treatment services. and so, some of the areas that we'll be looking at are residential treatment, secure and patient hospitalization and transitional treatment beds. lastly, there's also the creation of a new office of private insurance accountability and it will assist residents who have private insurance to ensure they're obtaining mental health care through their own healthcare network providers. we are still work wi working wie mayor's office on which agency will implement and be responsible for this program. beyond the five pillars that was specifically named in the legislation, the legislation talks about other areas of focus and most importantly, it's looking at developing a behavioral health workforce to sustain all of this work. (please stand by). and lastly,

note, medi-cal healthier tly, california for all, it's also previously known as cal-aim. this is the new state waiver that is being developed in partnership with counties. right now, the waiver that we

have is worth $150 million of revenue for d.p.h., and the state is negotiating a framework right now. what's nice is that it builds upon a lot of the previous works that we've had in waivers, such as whole person care, the primary hospital redesign, and so its goals are to reduce member risk, increasing flexibility in medicare and medi-cal and increasing flexibility in our driver system. so this will take probably well over a year in developing some of the details, and some of the details are not expected to be finalized for years to come, but because it is such a significant impact to our budget and revenues, it is something that we are going to be tracking and monitoring very closely over the next two

years. so in terms of our strategy, our goal for the mayor's instructions that we are looking at revenue of -- to get -- to use revenue to meet our reduction target. it increases to $53 million in year two. our goal, again, is to not have any services -- no service reduction and maintain services and if not increase our behavioral health services significantly in our proposed budget. so for the next meeting, we will bring detailed proposals to you. we will complete our balancing plan, and we will request your approval of the health commission for the health commission for submission to the mayor, and we will include some initiatives around health sf, but we likely will not be

able to complete all of them until the mayor's june budget. that is all i have for you. i'm happy to take questions, and then, i'm available for public comment. >> thank you. we have one public comment, and that comes before question. >> all right. we'd like to call up paul kramer of the san francisco health coalition. >> mr. kramer, i have a timer that will go off when your time is up. >> commissioners, yeah, i just wanted to read to you a section of the health compensation ordinance. when preparing for budget appropriations or contract services, cities regularly enter into the agreement of services by nonprofit corporations shall transmit with their proposal a written confirmation that the department has are considered in its calculations the cost of

nonprofit corporations calculate that they will concur with in complying with the compensation ordinance. further, it shall be the policy of the city to ensure sufficient funding to prevent a reduction in services to the community provided by nonprofit corporations and public entities. so the intention on this language is that there would actually be a written letter that's delivered with the budget when the budget's submitted to the commissioners, and the commissioners send it to the mayor's budget office. that's saying that you'd looked at what are the -- or in fact that you had a bdialogue with the nonprofit agencies that you're contracting with and asking them what do they expect to be the effects of the wage increase that takes place under the minimum compensation

ordinance. the minimum compensation ordinance for nonprofits will go to $16.05 per hour on july 1. that's a 55-cent increase. last year, you know there was a process that was set up that the mayor's office and then board of supervisors suiput mo in a pot, and then, the controller's office had a web portal and process for nonprofits applying for that additional funding to fund the wage increases. that process is not happening this year. it's expected that this should take place at the department level. thank you. >> thank you very much, commissioners. any questions? commissioner guillermo? >> thank you. thank you, jennie, for your presentation. i had a question.

i know we're going to get more of the details in subsequent meetings, but one of the points that is listed here on this -- this fund reduction target strategy, the goal is to meet general fund reduction targets with revenues with no reductions in services, and i was just wondering if you could share with you at this time what the revenue generating side entails? >> yes, absolutely. so revenue will be the bulk of our solution to meet target. so there are multiple components of that. we have our fefr service revenues, which are generated for hospitals and primary clinics. you've seen it and you'll see it again in financial reports when we bring you the six-month report for the current year, but we are continuing to

strengthen our fefr revenues due to a couple of factors. it's the proportion of our patients that are medi-cal expansion patients that we receive a higher payer for. but a significant portion of our revenue growth that we'll be budgeting is through a number of the supplemental payment programs that we receive related to medi-cal that are negotiated between the state and federal governments, so there are two components of that. there are the programs that we are able to drawdown supplemental federal funds. those are the enhanced payment program quality improvement program, etc. those are programs where we meet certain criteria that allow us to drawdown federal funds. in addition to that, as jennie mentioned in her presentation, as the state is nearing the end

of its section 1115 waiver in january of 2020 -- or i guess december 31, 2020, so at the end of this calendar year, there is a requirement that the state close out all of the old years of the waiver, and this goes back quite a long time. so for many years as we've been going through old waivers, we have the books still open on those as the state's been very slow to close those. and each year, we reserve a little bit of money in case we have a payback on those audits when they settle, and now, we've got eight or 12 years of those. and so now as the state closes the books on those old years, we expect we'll have a substantial amount of those reserves that we'll be able to close out and move it to income and balance the budget, so that'll be one of our big

initiatives that you see, but from a programatic perspective, a couple of the big things that we'll be working on and that we're going to include in our budget submission is we are continuing to have a significant portion of our payments in federal and state programs that are tied to outcomes, so that includes what is currently the prime program and the quality improvement program. those are dollars tied to metrics, and we need to be good about meeting those metrics so we can drawdown our dollars. that is a good part of our financial strategy is exercising improvements to meet those metrics and those are quality metrics and other related metrics. another thing is use of epic.

it provides us an opportunity to improve our -- well, essentially, our revenue capture, our charge capture where we're documenting the services that we provide and going through the revenue cycle in a way that allows us to get paid more for the services that we're already providing under medicare, medi-cal, etc., so we have a big effort underway, and with epic, we have immensely improved visibility into the data in our revenue cycle, and that gives us a window into areas that we can target for improvement and getting those bills into the system and collecting at a higher rate, so that's a big focus of our revenue strategy, as well. that was a lot, but we are going to depend on our revenue for a significant portion of the target. >> thank you. i did have a follow up on that.

with the new waiver application, and in knowing that at the federal level, there's some changes that are being proposed in terms of block granting and all of that, assuming california's not going to voluntarily accept a block grant in the waiver, but still, do we anticipate at all that waiver process is going to result in a different financing structure for medicaid in california relative to some of the value based moves that are happening in sort of the largest delivery system particularly when it comes to medicare, but also affect commercial plans? and i'm also sort of wondering even though we have a very small percentage of commercial coverage, if we're planning to grow that, then we're going to have to pay attention to that. and then also what may happen

with regards to the processes of focus-based care. >> we're spending a lot of time on that in regards to what you raised. i would anticipate the way we get paid in a couple of years will be substantially different than the way we get today. a couple of things are happening. at the expiration of the waiver -- we will have some dollars that continue in the form of a waiver, but the federal government is moving away from waivers in the form that we have historically received them. and what that means is that the direction is that the state is moving -- and this is i think driven by both state and federal policy -- is to -- moving more of those dollars through the health plans and -- i can never -- cal-aim and now it's healthier medi-cal for all -- i forget what the new name is. that's really the structure

that has been proposed, is that a lot of the funds that we're receiving under our current waiver, so whole person care, some of the things that we're billing under that, and some of the dollars that are going through our other supplemental payment programs will now get built into the rates for medi-cal managed care and go to the plans as a per member, per month payment with new services included in the benefits for our medi-cal managed karcare enrolees. so that means the dollars will be folded into our medicare managed care benefits, but it also is a challenge because it's a new structure that requires us to coordinate much more deeply with the health plans so that san francisco health plan and anthem blue cross. we have already set up a structure -- a government structure with the san

francisco health plan, which is the vast majority of our managed care, and we are working jointly on watching the process and responding to it as we're working through it. so that'll be a challenge and an opportunity to have medi-cal fund a lot of the services that we're providing that are enhanced care management, some of the nonstandard benefits that are -- we're doing through whole person care and general fund in the city that could be paid for with medi-cal, things like care coordination, sobering, other services that are not traditionally funded. on the commercial side, as you say, there's a number of things moving on that front that create some uncertainty in a little bit less active with everything that's going on federally, but there has been discussion with regard to changing in pharmacy pricing.

also things that we had discussed in this commission in the past year about surprise billing and what the relationship is between insurance plans and providers that we'll have to watch closely and that would be a policy change that could affect us, as well. so a lot of uncertainty that goes along with that. >> thank you. >> commissioners? commissioner green? >> yeah. thank you. this is a really wonderful presentation. i wonder if you could give us some detail about potential revenue sources about the whole area of behavioral health because it sounds like on a national level, there may be some funding coming forth. it is one of those things that was widely agreed upon regardless of the party, and then we have our own ordinances and potential funding that could come from the state. i guess i'm a little confused about the timing of these things. and also, i know that health

san francisco focused on the mental health of adults, so i'm wondering what you might see as projections where these come in. again, we have a broader workforce, and we're deploying some 668 people that are now in the system differently or whether we're going to have to bring in some people into the system triggering increased needs for salaries and benefits? >> yeah. i think it'll be both, to answer your question. there'll be areas where we need more and there'll be areas where we do need to deploy differently. a couple of the big changes that are out there, and we aren't yet at the point where we have enough clarity to really take these proposals and say we can turn them into a dollar value projection just because they're not fully formed, but there are some discussions that are happening at the state and federal level, and we're active in those

structures that i described before. we're actively involved in those. but there is talk about changing the way that behavioral health billing works. so in california, we have relatively unique system under our short behavioral health medicare system than the way a lot of states pay behavioral health. but there is talk moving away from our cost reimbursed system to something more like what we have on the physical health side where we would be essentially using the intergovernmental transfer model, and we have the opportunity to earn more based on incentives. and so that would, depending on -- the devil's always in the

details, but that's potentially a good thing in that it may allow us to -- essentially right now, the most that we can earn for a given service is break even with our cost. this may allow us the opportunity, if we can really show that we're moving the needle and make a difference, to get paid for that. it also incentivizes us and other counties to change the way we meet those incentives and actually improve quality, so that's one change that's happening. another change that's contemplated in the documents that have come from the state is -- and this is still in the early stages of thinking, but is to try to do a pilot of some sort where the behavioral health and the physical health, for lack of a better word, are essentially a single capitated

benefit. so a lot of things to still kind of feel out to see what that looks like, but those are two potential changes that could affect the way that behavioral health services are paid. we also will, as we develop the current health sf under the existing structure, we will be looking at some of these supplemental medi-cal programs, what are a way to provide services that are billable and we will drawdown revenue to support and expand those. >> any other questions? >> yeah. i want to thank greg and jennie for their work in this process. we obviously have a large budget. it's incredibly complex, and you can see that we have

experts at the ready to help us move forward. i also just want to go back to the behavioral health questions that were raised. and obviously, there's a lot of uncertainty with regard to where fed, states, and to some degree mental health sf, what the final results will look like. but i think together, they're catalytic to help modernize our behavioral health system, and i think it will help us better measure our results. what gets measured is better managed, and what's better managed is more efficient, and allows us to drawdown more dollars. we're also looking at the efficiency of the systems and taking a new look at things. as we think about where are there inefficiencies in the

system now that we can correct, that may require some more dollars, but it also just improves from baseline where we are now, and we're not making assumptions any longer -- not that we were making assumptions before, but we're being more inquiztive about are the current services that we have serving people in the best ways possible? so improving both what has been baseline and employing and innovating and learning and deploying a behavioral health system that learns, adjusts, and most importantly --

[inaudible] [please stand by]. >> we do expect to have a -- an initiative to bring to you that would be on our -- our h.r. and our workforce process, and our strategic process.

we have identified hiring process as one of our key processes in the coming years, and there is one area, in particular behavioral health, which we have identified target priorities for hiring for existing positions, but also as we are going to be ramping up in specific areas related to mental health sf, we're going to need additional capacity there to be able to deliver on some of the ambitious goals that are set forth in that ordinance. the other one is -- well, there are multiple areas, but one of the real areas of focus is on nursing, and that has been a long-standing goal of ours, to improve the efficiency and speed that we're able to hire at, and michael brown, our new

director, has been focusing on that and removing some barriers so we can focus on that, and i'll ask dr. colfax if he wants to expand on that. >> yeah. we're working on moving forward both on the department as a whole and including in time in the departments of behavioral health. i think one of the key things is that we need to be recruiting new leadership. obviously, we're grateful for dr. sung's leadership as interim mental health director, but it's important as we look at the structure of mental health sf, we don't currently have additional resources to execute on some of these things, so while we're hopeful and enthusiastic about what can be done there, we also are awaiting the resources that will be needed to execute on

some of this. but getting back directly to the workforce issue with the new leadership in h.r., michael brown is looking at unsticking things that are apparently in some cases are steps that are extra steps that i think were developed with the best intentions but have actually had counter effects in terms of our ability to hire the right people at the right place at the right time, so we're working on breaking down some of those inefficiencies while we still have optimized our system systems to hire a diverse and talented workforce. and we are clearly needing to expand h.r.s capacity to meet the workforce. the other part of that is

workforce hiring and recruitment, if you will. and the other bucket is workforce development and pathways. that is something that needs to be developed more in h.r. we're starting to do that, and perhaps especially with our community providers, what are our incentives with regards to workforce retention. and there are a whole number of ideas and concepts in legislation with regard to that, and conversations that we've had about programs and so forth. i'm very excited about that, and the department is very supporti supportive of that. we have to figure out where that can be done, where does that live within the department or even the city or even externally in terms of how those models would look going forward, but we're certainly looking at all of these right now, and they're in various levels of execution. i think the focus at h.r. right now is breaking down the barriers that we -- we've sort of self-inflicted, increasing

those efficiencies, and then figuring out our capacity to move forward in these other areas skbl thank you. commission -- >> thank you. commissioner guillermo? >> thank you. i just wanted to comment there are structures that we're improving our own processes, and i'm glad that's a major focus, but also wanted to mention the structural issues that make it difficult in order to process some things through. as an example, the lack of r.n.s that are available to us to hire in. i mean, i just read an article today that there are more advanced practice nurses that are not necessarily going to be available to us. and you think about how difficult it is to live in san francisco and the bay area, and so some of those things, even if we improve processes, are not going to necessarily bring

us the solutions that we are hoping for. same thing around behavioral health, the need for social workers, certification programs, residency programs, and training are all kinds of things that we also have to pay attention to that are making it difficult for us to really be able to implement these needed and ambitious programs, not to mention that we're looking at diverse workforce on top of all of that, and so i just want us to be as realistic as possible even while we push ourselves. and also just sort of laud that we are not going to shrink away from it, that we are going to meet these issues, but understand these issues, we're going to have an even more difficult time achieving this. they're things that we all have to just be very, very attuned

to. >> commissioner cheung? >> thank you for the presentations. i was wondering, since these are issues we've been talking about as far back as i can remember, improving out, like -- like, billing capacities, to make sure that we don't have as many unbilled services. and also, the other piece is about, you know, really looking at -- well, actually, that's an area that we actually haven't talked about a lot, how much we spent on overtime versus, you know, on per diem staff, versus, you know, like, having, you know, a real staff. you know, i think some of these might be better conversations to have on the finance and planning committee, but i think that in order for us to really

help and support, you know, your goals, you know, to earn more and spend less, i think these are the things that we should have some discussions about and not just limit it to, like, the hiring and overtime but also, you know, exploring, you know, like -- 'cause i believe, you know, that there are some -- some teaching hospitals out there that utilize, you know, like, research grants, you know, you know, like, to amend the budget. you know, is that something we're considering, as well, especially in the growth of behavioral health? i think, you know, there's a lot of dollars dedicated to research instead of, you know, just, like, you know, surface providing. and the last part that i am interested in to find out also is we heard a lot about, you know, about nonprofit, you know, our relationship contractors. exactly how much of our budget

actually goes to contractors, especially, like, local vendors and contractors for services? >> i can -- thank you. that's a -- we -- so a few answers to that. i think it would be good -- i don't have the data on overtime right here today. but we can certainly provide that and have a discussion at one of our committees. all things considered, we are not at the point where we wish we were with permanent staff, and from -- it's one of those areas where there's some places where finance is pushing back on overtime. this is not one. we're really in support of aggressively hiring because we would rather have those shifts staffed with a full-time employee rather than have high levels of overtime or per diem or that otherwise.

but we can go over some of that data with you. in terms of total spending on contrac contracted services, we have the very high level dollars here, which are our total nonlevel personnel budget. some of those are payments to drawdown federal funds, but we have $500 million easily in contracts with our service providers, so that is a big part of our service provider infrastructure. and we can definitely -- i'm not sure what the schedule is, but you had mentioned what is kind of the nature characteristics in terms of local businesses that we're contracting with. i know we had periodically put together a report on that at the committee, and we'd be happy to refresh that. >> yeah. and part of the reason why i asked that is, like, what i observe is that we often, like,

go into with these, like, contractors, five years' contract, which would be a long contract, and how does that actually impact, you know, oour, you know, budget planning, when we're looking at, you know, ahead two years, you know, with all these cuts and deficits in mind, so i'm happy, you know, to have more conversations around that. >> happy to do that. thank you. >> thank you. >> questions, commissioners? all right. thank you. >> thank you. >> thank you, jennie. >> sure. >> item ten is the health care services master plan 2019 plan update. claire, would you like me to help with the -- >> i think i can figure it out.

>> all right. good afternoon, commissioners. my name is claire lindsey. i'm a senior health planner with the department of public health in the department of policy and planning. today i'm joined with my colleague, sheela, and she's a planner with the san francisco planning department. today we're here for an informational presentation on the 2019 health care services plan draft. so you all received the actual draft of the document, and then, in addition to that, you received a memo that had some background information and a revised consistency determination guidelines, which is a part of the plan. and i want to just note that the full draft that you all received is actually out for public comment right now, and so we'll talk about that in a

little bit, as well. but today's presentation is actually one of the required hearings, so the goal of this meeting is to talk to you a little bit about the plan but just receive feedback and answer any of your questions that you might have about the plan and how it's implemented, and it's also about preparing the commission for the march 12 joint hearing with the planning commission. which that joint hearing will be for adoption, so today's a discussion item, and then, at the joint hearing, we'll be adopting it. and i also want to mention that we were here in november with the finance and planning committee to do an introduction of the plan, as well. so for today's presentation agenda, i'm going to begin by just doing a brief overview of the master plan ordinance and the requirements that really describe what the master plan is. then i'm going to be describing how the master plan is used through our process, and i'm going to be providing a brief

look at what is in the 2019 master plan. my colleague will be presenting some of the key findings around land use specifically relating to health care services and then we'll also be presenting our recommendations that are included in the 2019 draft, and our consistency guidelines determination. we'll also be proposing some of our legislation changes that are accompanying the plan. and then, the last thing i'll be closing awith, just the nex steps in the adopt process. t

. >> the requirement components of the part of the ordinance, and those are the assessments, the recommendations, and then any updates to the guidelines, and so i'm going to be speaking about those a little bit later in the presentation. but the ordinance does require a process for the update, and so there's an update for the

process, and that includes two hearings. a joint hearing to adopt the plan, and the hearing was with the planning commission and the health commission, which is currently scheduled for march 12, and then finally an adoption at the board of supervisors. so now i'm going to be covering what the plan or how it's used. so to better kind of understand how the plan is used, it's helpful for me to put -- because i -- kind of some policy context into where the master plan really sits. state and federal agencies are the primary responsible parties for making sure that facilities are licensed and they're adhering to standards of medical care, and so the health care services master plan is really structured less as a regulatory tool, and it's more of a mechanism that we can use to identify what facilities are needed and incentivize facilities to meet the needs of

san franciscans. so while it's called the health care services master plan, the plan itself really focuses on land use policies such as zoning, which the city has authority to influen where health facilities and influences are able to go in the city. so kind of taking all that into context, the consistency determination process is really the representation of how the plan is implemented. so what is consistency determination? it's a set of about roughly 50 guidelines, and those guidelines are used to create a framework that the department of public health and the planning department use to evaluate whether or not a proposed medical use service is going to be meeting the goals of health care facilities in the city of san francisco, and i'm going to use the term medical use, so just medical use is what we mean by it could be a hospital, a doctor's

office, or primary care clinic. so any proposed medical use projects applies, and they apply by selecting guidelines that they meet and they have to provide data and evidence to provide how they're meeting certain guidelines. important to note, projects do not have to meet all of the guidelines. rather, they select a guideline or two that they meet that's relevant to their project. so after review of the application by d.p.h. and planning, projects are determined to be consistent with the health care services master plan or inconsistent, and if they're inconsistent, there might be some required hearings, so the idea is that projects must be consistent with the goals of the health care master plan in order to move forward in the process of

developments in the city. so it might nbe easier to understand if i provide an example. for example, if we have a project sponsor who's interested in getting all the permits and becoming a provider. so in their application, they have selected one or more guidelines that they feel that they meet, and they have provided data and evidence to support that. one of the guidelines is participating in healthy san francisco, so if they are a provider, and they plan on supporting that, then they would provide that in their application. so once the planning department looks at their application, sees that everything's there, they send it over to the department of public health, where we have planners that evaluate it, and we assess whether or not they are meeting the guidelines. so d.p.h. planning staff reviews the application, and

we're the first ones to say whether or not we believe it's consistent or inconsistent. and consistent applications go right back to the planning department where planning confirms it, and they put it out for public comment, but inconsistent applications actually go for a hearing at the health commission. and so at that hearing, d.p.h. provides our recommendation on why it's inconsistent, and then, the health commission provides recommendation to the project sponsor on how they could -- or how they could improve their application and how they could make their project consistent with the health care services master plan. and then, there is also some incentives to this, so certain projects that are meeting certain guidelines -- like, we have some priority guidelines, they receive priority processing at the planning department if they're consistent. so since the establishment of the consistency determination process in 2013, there have been five projects that have applied, and all of which were

determined to be consistent for a variety of different guidelines. and so as part of the 2019 plan, we assessed how consistency determination was working, and we have some proposed revisions to the legislation around consistency determination, and we also have some proposed provisions to the guidelines themselves, and i'll talk about that a little later. so for the next few slides, i'm going to be focusing on the elements and the process and the findings of the 2019 plan draft. so as mentioned earlier, there's three main components to the plan. there's the assessments, which is the bulk of the plan. if you all saw the large document, it's about 90% of the document. then, there's also the consistency determination guideline, and any supporting documents and policy regulations. so within the assessment portions, there's four main assessments. first is the community health

assessment, and that one is actually directly drawn upon the community health needs assessment that's done by d.p.h. and sfhip. so this assessment looks at -- excuse me. getting over a cold. it looks at health trends and morbidity and mortality. the second assessment that's included is a land use assessment, and that one analyzes the current supply of medical uses, it looks at the demand and need for new medical uses, and then, it also looks at the potential impacts that any new medical developments may have on the neighborhoods or other the community. the third estimate is the capacity and gaps assessment and that is a unique assessment that looks at utilization and resource availability when it comes to health care services. it also looks at cultural and

linguistically appropriate access. and then, the fourth assessment is the health system trend assessment, and that one, we're looking at health policies and state policies that are impacting service delivery. and so the plan that i had mentioned earlier, the plan included updates to the consistency guidelines and a set of revisions to the planning code since this document does sit in the planning code. so the 2019 development to the master plan was updated with the following objectsiive of t things that we wanted to develop in the graph. it's to highlight healthen

equities in emerging health issues. third, it's to conduct an assessment of trends in medical facility developments. next, it was to assess the 2013 consistency determination guidelines for potential revision, and then lastly, it was to develop recommendations that will end up support or advancing the goals of improving equitable access to care. the examples of what those will be, free clinics, residential care facilities, planned parenthood, those types of organizations that we feel are priorities. we don't want to limit those -- we don't want to limit them by putting them through more bureaucracy than necessary. so once we've created that definition, we'll make them exempt -- we're proposing to make them exempt from our notification requirement. that's called section 311 of the planning requirement, so anybody that wants to move in,

they have to go through a six to eight-week notification process. so we have to do sort of a few tweaks to the code where senior housing can go in, and we will to remove conditional use process throughout the entire city. we're proposing that we make health services principally permitted on the second floor and above, and i'm happy to answer questions about what that would look like in our code if you have them. >> actually just to close, just want to recap that this was meant as an informational hearing and on march 12, when we have the joint hearing, we'll have a lot more time with you so we'll go into the findings, go into the implications of what some of these legislative changes may have, but of course right now, we want to answer any questions or receive any feedback that you have on the plan draft. and also, i just want to know

that the public comment period was started on january 10, and we have not received any comments, and i want to invite sheela back up unless we have any public comment. >> i have not received any public comment on this item. >> commissioners, questions? commissioner giraudo? >> thank you very much for your presentation. i have a couple of questions on the recommendations, particularly number one and two. number one was to increase access to appropriate care for san francisco's vulnerable populations. my question is how are you going to do that? and, i mean, what's the plan in order to increase this access other than have this -- you know, just, it's a great goal. >> yes, of course. so i just want to go back to the recommendations that were mentioned, they're very broad. and then, within the recommendations, we have a set

of guidelines. so for example, i'm going to read you -- the guidelines are what -- a new medical facility that's coming in, if they're a hospital, in the permits, they have to tell us if they're meeting it. and the example is they're not receiving the guidelines, they get the permit -- they should not get the permit. >> so your recommendation is for new facilities, correct? >> correct. so i'll just provide of an example. what we've proposed as guideline .1 is to improve the accessibility of care in low-income areas, so we have those defined guidelines in

each recommendation. and the guidelines are in the memo that you received. >> no, i wasn't completely understanding that it was for all new facilities because in your draft, for example, on increasing access to -- or current behavioral health services, when i noted what the for behavioral health in who some of the provider are on page -- i did get particular on page 106, i was concerned when we're looking at who some of those providers are, that some of them do not accept medi-cal patients, so that it was just a concern of mine that when we're looking at what we're looking at for access, behavioral health, what has been defined in hospital-based behavioral health services, they don't accept medi-cal for some of

them. >> yeah. >> thank you. >> director colfax? >> i think the other piece that dove tails in some regard to this is with regard to the budget presentation, mental health sf, the budget accountability, that is where services embody some -- as mr. wagner commented, it's not determined where that office will live in the city, but that will have some specificity surrounding where people that are covered get the coverage that they already have in other city systems outside of d.p.h. >> okay. thank you. >> thank you. >> commissioner guillermo? >> thank you, and thank you for your presentation. i just had two questions, one on the planning code update and

the next on -- one on number four in the utilizing health care information systems. i saw in the memo that one of the examples is to support technology based solutions such as telehealth. what i would recommend is to expand that, particularly around care coordination. the movement towards using digital and mobile solutions and technology is something that i think is really important, and much more realistic, given that most of the patients are not going to have in their homes, broad band wifi and other things that allow them to participate in telehealth services, but most of them have mobile devices, and a lot of that technology is developing, so i would recommend that we just sort of update a little bit in terms of

keeping updated where the technology is. >> thank you. >> thank you. >> the other thing is around the planning code amendment around the definitions for priority health services. i just had a question around -- because you chad mentioned the growth of urgent care and the medical health facilities, are those going to be included in the definitions in the medical code. >> so they will not be included in that definition in the new priority health service definition, so they would still be subject to the 311 notification. so the way it's structured, we have a large category of health services, and that includes pediatricians, optometrists.

we really feel from the planning perspectives if we put limits on those kinds of organizations that we also put limits on these other kinds of providers, and that given our insurance rates, it's important to have that kind of care in the community. >> i wasn't addressing that as a negative thing, i was saying if they're subject to these kinds of requirements that you could, if they're expanding, bring them into the full per se in terms of really sort of complying with the master plan around access sfl o. >> oh, making them subject to the consistent guidelines determination. >> or something similar because there is growth obviously in those types of facilities. but if our focus is on growth and access to care, that they're somehow, you know, somehow included in the equation, and i don't know the appropriate way to do that, then you are also taxing those

entities with the ability to incorporate the population -- >> yeah. so the urgent cares that are included in the hospitalization, like the dignity health, those are subject to the master plan, but the one medicals are a little bit different, so i think we still need to -- it's an interesting point, and we've talked about it and can think more about how to approach that one in particular. >> commissioner chung? >> thank you for the presentation. i think that, you know, the master plans has come a long way since we first got involved. i remember, you know, that was one of my responsibility when i got onto the commission, that i got appointed to the master plan task force. and actually, it was during that time, you know, that i had some questions that seem to be unanswered. it's not so much what --

towards the master plan task force, but it always seems like we have an unfinished story between the story or collaborations between san francisco health plan, community improvement plan, and the san francisco health master plan. and i feel that when we hear presentations, like, from each individual report back, we miss the picture by a little bit, you know? but then, you know, when you add it up, you know, like, that turns into big disparities. you know, the case in point that i want to make, like, for instance, the two data point that you actually used as example, one is the the behavioral health question -- questionnaire and knowing that, you know, like, one out of three san franciscans are not

getting their behavioral health needs met. and also, you know, knowing that we've always been recommending, like, increased capacity and access to long-term care, but yet, you know, like, we still see such a big decline between 2013 to 2017. are there any, like, discussions at all about how can we actually turn some of these into mandates and just set up just suggestions? and i think that this falls on anybody because anybody is running a business, and the business models, they don't want to keep something that keeps losing money. but if we don't have those conversations and make those hard decisions, some of these recommendations will never be fulfilled. so that's my concern, you know?

as a san franciscan, as a health commissioner, you know, as somebody who's been, like, watching this process unfold. >> i echo what you just said. and i want to respond. one of the great efficiencies of the master plan is it does draw on all of those other reports so we have this unified message that i can be speaking on what the needs of the community are, and then somebody else can come up and reinforce those needs. that's why we're able to have the discussions around removing conditional use, removing neighborhood incentivization so we can make it easier for some

of our providers who are caring for the mental health population. so i just wanted to say that is one of the benefits of continuing the conversation with the master plan. >> yeah. that's a great, like, glass half full, like, kind of viewpoint. and from my point of view is that i think that's also the irony. because a lot of these health care institutions have been involved with the master plan, have been involved with the health improvement plan, but yet, they're the ones that came in and told how many long-term beds that they're closing or moving patients away to, you know, out of city. and i don't think that -- >> so the process of the 2019 master plan included a series of assessments. outreach, as mentioned earlier is a requirement in the

ordinance, including two public informational hearings, a joint adoption hearing, and then a hearing at the board of supervisors. but outreach for the 2019 plan did go above and beyond those requirements. it includes canforma interviews, meetings with different advocaty organizations and other city agencies. it also included a policy brainstorm, so those are kind of some of the different forms of outreach that we did. and the master plan that was adopted in 2013 had a very extensive public process. it included a 41-member task force to actually complete the plan, and so for the 2019 update, we looked at the members of the 2013 task force, and we started by reaching out to those individuals and organizations. and a list of all the organizations that have been involved was included in the

plan draft. >> good evening. these two maps compare our health facilities in 2013 and our health facilities in 2019. there's a few of the smaller dots are missing in the '13, but you can see the red dots and the yellow dots on them. those are our large hospital facilities, and then, the blue dots in the 2013 match up with our clinics on the other side. so this -- i apologize. they don't match exactly. they were developed at different times, different people. but the message is we are not seeing substantial big changes in where our medical facilities are located, that things are staying fairly static, and we can still see that there are persistent trends. there continues to be lack of

access in the bayview neighborhoods. and one thing is proximity to health care does not necessarily mean access. it means so much more than that. it's having linguistically appropriate health care, it's knowing that these services exist. so in health trends from 2013, we've added 200,000 square feet of hospitals and 200 beds, and that's in mission bay. since 2010, in the past decade, we've added 12,000 jobs in the health care sector. we are seeing this emergence of these urgent care facilities. that's a new thing that's happened since we had the 2013 plan. we count -- there's currently 14 urgent care facilities, and we are making a distinction between the urgent care and the

one health medical. in addition, we've got another 775,000 square feet in the pipeline, and that's predominantly in mission bay still, plus the kaiser facility and the planned parenthood facility. and all of the details of exactly what growth has happened and all of what is coming is all in our land use chapter of the plan. >> all right. so for the next two slides, i'm going to be reporting out what the 2019 health care services master plan are. and so i just want to note that although -- since 2013, although there have been, you know, particular health topics or priorities that have emerged more recently, but many of the original findings from the 2013 plan remained the same or they still hold true today. and so given that, d.p.h. and planning, we really focused our efforts on refining the

recommendations and providing edits and consolidating the guidelines themselves. so as a reminder, the recommendations that are listed on the slide, they are broad. and then, within each of these recommendations, there are a set of guidelines and that they be are used for consistency determination. so then, the first recommendation is to increase the access to appropriate care for san francisco's vulnerable patients and to increase access to incapacity of long-term options for san francisco's senior population and folks with disabilities so they can live and grow in the community. and i do want to just point out that the two data points that

are on the slide, those are just examples of two of our key findings and they are in the plan itself and in the executive summary. so then, the last three recommendations that we formed for the 2019 master plan is increase in technology information systems. next, it's to ensure that all san franciscans have arranged alternative transportation options so that they are able to reach any of their health care destinations safely and affordably and in a very timely manner. and then, the last recommendation is to ensure that health care facilities are contributing positively to the neighborhood and that includes promoting health and safety features. and so like i said, the six recommendations that i just mentioned are our broad recommendations that then all

of the guidelines have been based off of. and i believe all of the guidelines are listed in the memo that you were provided. so then for kind of the final piece of the presentation, we're going to be summarizing our proposed legislation, and we're hoping that all of this proposed legislation will really help advance the goals of the master plan. so they fall into three buckets. the first proposed legislation is around improving the process of the master plan. -- which i'm going to say, i.m.p. from now on, just in case, and then, the third one is we've found a few areas in the planning code that we can really be removing barriers to incentivize health care facilities to come into san francisco. all right. so the first proposal is to make changes to the master plan process itself, and so as of

now, the master plan is scheduled for an update every three years, but since we realized that the plan really does focus on land use related to health care services, we are recommending that the plan be put on a timeline that is reflective of development timelines as something sheela pointed out in the last six -- or since 2013 till now, health care has not changed dramatically in terms of facility locations. and then, additionally, as one of the efficiencies of the plan, the master plan utilizes data and findings from reports that are done on a more frequent basis. like i had mentioned, the community health needs assessment is a continuing chapter in the master plan, and that is updated every three years. and then, the updates are done on an emerging needs basis, so anything that's coming out on health care reform, we've also

looked at other reports and that will continue to be the source of truth for that data, and those city recommendations, and the master plan continues to reference that. and so instead, we are proposing that the full health care services master plan be updated on a ten-year timeline, and then, we will also include a monitoring report at the five-mark. and so the monitoring report will include all of the unique items have the master plan, and that will include hospital closures that are subject to prop q, a summary of any of the planning code amendments that may have been made that affect health care, any planning pipeline updates, so as sheela had mentioned, there's over 750,000 square feet in the pipeline, and the last would be a summary of any federal, state and local trends in health

care. and the second piece or bucket that we are proposing is a retooling of the consistency determination process, and so as we mentioned earlier, since 2013, since the process was actually introduced, there have only been five applicants for consistency determination, and all applicants were determined to be consistent because they met multiple guidelines. and so some of feedback that we received from applicants and the staff that had evaluated those applications was the consistency determination or consistency determination guidelines actually ended up giving more process to facilities and health care providers that we actually need in our community on a more urgent basis, so it ended up lengthening their timelines when they all would have been consistent. so instead, we're going to be proposing to apply consistency

determination to san francisco's institutions that have larger footprints in the city, and then, we'll do that through the i.n.p. process. so just a little bit of background on the i.m.p. institutional master plans are required in all institutions in the city, but it also includes any of their additional outpatient clinics that are owned by the hospital, any medical clinics that are owned by the hospital, so anything included in the hospital campus is supposed to be included in the institutional master plan. they describe the existing and proposed institutional development, so that includes where they're located, what services they provide, what populations they're serving, and then, it also includes pretty detailed plans into where they feel they will be developing in the future.

and so institutional master plans are written every ten years, and they're with the health department, but then, every two years, institutions provide an update to the planning department. and i just want to note that the health department is engaged in the master plan institutional process and there is feedback on any of their changes. this will stream line one of the reporting processes for them, but it's also anticipated that highlighting the degree of, you know, match between the consistency determination and the institutional master plan, that institutional projects will end up meeting more of the goals or having -- they will end up focusing on what the city's needs are, so that's what we're hoping. and this legislative change would then remove consistency determination for any of the

health care facilities that are not part of the hospital. so if we rhenthemember that si threshold, those would no longer apply if they're part of a hospital. and at the bottom of the slide, i just wanted to note the other reporting requirements where a hospital is engaged with the hearing process, so these are the local reporting requirements. >> i'm going to talk about a few of the planning code changes that we're proposing, and planning code can get really jargony. one of the changes that we propose is take out some zoning in certain areas regarding residential care facilities. a few little tweaks in places so residential care facilities won't be limited in where they can established. we're going to add some requirements for definitions of

state license types. >> and i have real questions around that, but that our need is pretty glaring right there. just an observation. >> i just wanted to piggyback on commissioner chung's observation. probably not a question, but your data lays out clearly an elegant but access gap. if you compare those who need access to services to those who have access, it looks like 2 out of 3 people, and in california at large, it's 5 out of 6 people. that really underscores the need for comparison and need for services in san francisco. commissioner green? >> yes, this report is amazing, and what's so laudable about it is the extensive data, and i

think you've beautifully outlined the problem with excellent statistics, and we know where the problems lie. i think where i'm having a hard time connecting the dots is how we transmit this into implementation. because some things are conflicting, we have a transportation problem, and yet how do we encourage, even with these changes in the land use, individuals to go in that are underserved that you've outlined these areas very clearly. how do we encourage medical facilities to go that way? we've had meetings where some of the large facilities have dialed back some of the services, especially in the mission area. and you know, we've listened to their changes, and what do we do to then replace those services? we talked about the behavioral health issues. there's a shortage of primary care providers, and they don't

take medi-cal. only 3.4% of san franciscans are uninsured, so that's why i am of am -- why i'm trying to figure out since we've got this population to serve our under served population, and it does start with telehealth availability or actual physical availability of services within the community in addition to all the cultural competencies that are required for both, you know, patients to come to these facilities and compliance once facilities are developed. i don't know if that's part of your purview, because i think the goals are laudable, and even attached to metrics, but how do we get there, especially in light of what commissioner guillermo has mentioned, there

are no nurse practitioners in the press oncology that you see, because they live in east bay, so they're not going to come to mission bay anymore, which is one b.a.r.t. ride away. so i don't know whose purview it is, but it's troubling because you've given us a lot of great information, some of which may be identifiying problems. >> thank you. i also want to add that that was a similar sentiment that was brought up at the planning commission, so i look forward to the discussion that happens during the planning commission and health commission joint hearing. i think some of those things are a great usefulness at that meeting in particular when it comes to the master plan.

>> thank you both for your presentation. we look forward to seeing you at the joint meeting coming up on march 12, 10:00 a.m., city hall. thank you. >> that leads me to item 11, which is other business, and you have all your calendars in front of you. that was the one thing i was going to announce. we can move to item 12, which is a joint conference committee report backs, and i believe there's several. >> and before we do that, i want to thank commissioner green for chairing both of those meetings, so thank you very much for assuming that role and bringing this report to us today. >> thank you. so we had two excellent meetings at laguna honda as well as san francisco general. on january 14, 2020, the joint conference committee at laguna honda had a director's report

that continued to elaborate on the monitoring and plans of correction and they're doing an excellent job, the quality group at l.h.h. is really doing a wonderful job. we did a facilities assessment report for 2018-2019, which really gave us a wonderful profile of all the residents in facility as well as their top diagnoses which i think will help how to improve resources, and then, we got the green transformation update. we approved a series of hospital wise policies and procedures, and then we reviewed the credentials report. then on january 28, we had a regulatory affairs report, and several others which are standard. and then very interesting was the four strategic a-3 topics from the host strategic plan

update, and these were great, and i think of all of our various divisions, they are doing an excellent job really leading the way as we develop some of these jobs linking the entire system. it is really wonderfully done. and then, we had a real wonderful update. there's a patient care quality improvement fund that was a donation from mark zuckerberg and dr. priscilla chan. and they have six goals that they've outlined for the use of these funds, and they've really developed our thinking, and i think they're -- the

zuckerberg-chans will be very proud of the way the staff are utilizing their funding to improve the quality of care equity and making this a great place to work. and then we reviewed the tips minutes. >> thank you, commissioner green. >> any comments? great. now we are at consideration for adjournment, commissioners. >> do we have a motion to adjourn? second? all those in favor? we're adjourned. thank you .

>> i went through a lot of struggles in my life, and i am blessed to be part of this. i am familiar with what people are going through to relate and empathy and compassion to their struggle so they can see i came out of the struggle, it gives them hope to come up and do something positive. ♪ ♪ i am a community ambassador.

we work a lot with homeless, visitors, a lot of people in the area. >> what i like doing is posting up at hotspots to let people see visibility. they ask you questions, ask you directions, they might have a question about what services are available. checking in, you guys. >> wellness check. we walk by to see any individual, you know may be sitting on the sidewalk, we make sure they are okay, alive.

you never know. somebody might walk by and they are laying there for hours. you never know if they are alive. we let them know we are in the area and we are here to promote safety, and if they have somebody that is, you know, hanging around that they don't want to call the police on, they don't have to call the police. they can call us. we can direct them to the services they might need. >> we do the three one one to keep the city neighborhoods clean. there are people dumping, waste on the ground and needles on the ground. it is unsafe for children and adults to commute through the streets. when we see them we take a picture dispatch to 311. they give us a tracking number and they come later on to pick it up. we take pride. when we come back later in the day and we see the loose trash

or debris is picked up it makes you feel good about what you are doing. >> it makes you feel did about escorting kids and having them feel safe walking to the play area and back. the stuff we do as ambassadors makes us feel proud to help keep the city clean, helping the residents. >> you can see the community ambassadors. i used to be on the streets. i didn't think i could become a community ambassador. it was too far out there for me to grab, you know. doing this job makes me feel good. because i came from where a lot of them are, homeless and on the street, i feel like i can give them hope because i was once there. i am not afraid to tell them i used to be here.

i used to be like this, you know. i have compassion for people that are on the streets like the homeless and people that are caught up with their addiction because now, i feel like i can give them hope. it reminds you every day of where i used to be and where i am at now.