[roll call] >> great. i believe that commissioner bernal might have something to say. >> yes, mark. thank you. before we begin, i'd like to address some thing, members of the public who are watching. we are made aware after the last health commission meeting on may 19 that there were issues accessing the public

comment line. we apologize for those issues. we asked a representative from sfgov tv to join us today to moderate the public comment call line to alleviate any issues. and we will have this resolved today and moving forward. mark, would you like to give some specific instructions to members of the public who would like to make comment? >> sure. i want to remind everyone to please [inaudible] and we're hearing someone make a latté or coffee or something. let's maouts our microphones unless we're talking. hi, even. my name is mark morowitz, the health commission secretary. i'm going to flash the side again to explain how to make public comment. the phone number is

888-363-4734. and the access code is 2241350. once you're on that line, you will be able to listen in on the meeting and when you want to make public comment, you press 1 and 0 in order -- yes, 1-0 in order to get on to the line for a specific item. for those of you who are watching on sfgov tv, a reminder that there is a delay on what you're seing from what the live meeting is. so, i encourage you to get on the public comment line one item before you intend to speak so that you're on in time. that way there will be no timing issues. and, again, we apologize profusely for the issues at the last meeting. commissioners, is it ok to go on to the next item, item 2, the minutes? >> thank you, mark.

if commissioners have had the opportunity to review the minutes, without -- does anyone have any revisions or do we have a motion to approve? >> motion to approve. >> second. >> there a second? >> second. >> mark? >> ok. i have call the roll. [roll call] >> actually, let's break here for public comment. i'm sorry. is there anyone on the public comment line? anyone there? >> there is no one here at this time. >> ok. thank you for that. i apologize, commissioners. we heard from commissioner bernal. [roll call] great. thank you very much. the next item on the agenda is

item 3, the director's report. dr. colfax. >> good afternoon, commissioners, and a members of the public. grant colfax, director of health. you have my director's report in front of you. i would like to read something that i sent out to the health department last night. it's alluded to but not directly in the director's report. if you'll just give me a moment. the murder of george floyd has further exposed the ongoing systemic racism that drives injustice in our country. our city is both reflected and acted, demanding change as we confront a pandemic that has disproportionately affected black african americans. these two things, taking action for social justice and reducing

the spread of covid-19, are very much tied together. both address significant and lasting inequities in our society and both affect vulnerable populations and people of color disproportionately. as a san francisco department of public health, it is our mission to address health inequities and serve the most vulnerable people in our community. together, we at d.p.h., have taken every step possible to prepare for continuing demonstrations in the city. we issued guidance to help keep people safe and readied our network for care and testing. it is important to remember that we support the right to protest injustice and remain aware that doing so safely is critically important. especially as we continue to respond to the covid pandemic and do everything we can to stop the virus's spread.

our full dedication to the work is needed now more than ever. commissioners, the remainder of the report goes into incredible detail around our covid-19 response. and i think most of it will be brought forward in the presentations that you are about to see. obviously i'm here to answer any specific questions with regard to things that you read in the report. >> i'd like to call back commissioners. do you have any questions? would you raise your hand, please? or make a comment or any statements? ok. i'm not seeing any. so with your permission, we can move on to the next item. thank you, dr. cold fox. -- colfax. we can move on to item 4, the covid-19 response, testing and recovery updates. and we go back to dr. colfax. >> yes. so, commissioners, as you can see in this presentation, i'm

going to give you an overview of where we stand. dr. phillip will give you a review of our testing operations and then dr. arragon will talk to you about our exciting next phase of re-opening and detail about how we plan to move forward on that. so, to date, our response to covid-19 has produced significant -- and i think -- fairly dramatic effects and just to say that this work is being done not only through the department, but through multiple city departments. and, of course, with the leadership and support of our mayor. the emergency operations center

at the mosconi convention center has been literally filled with hundreds of people every day, not only from the health department but from departments across the city, including human services agency, almost in support of housing and others who are working literally day and night to ensure that we maintain a robust response. this has literally saved lives and flattened the curve consider blifm as we now enter this next phase, we are continuing our response. but also moving into a recovery phase. and we are doing so following the data, science and fact, being cautious as we continue to move forward to ensure that our gradual re-opening can be done in a way that keeps everyone as safe as possible. next slide.

so this is where we stand today. you can see from the slide that we've had 2587 cases of covid-19 diagnosed in san francisco. and i just want to emphasize because i think sometimes there are a couple of things around these diagnoses that need to be clarified. obviously these are only the people who have been tested. so we greatly expanlded our testing capacity and this is not representive of everyone who has been infected with covid-19. the other thing is, for the most part, people have symptoms and are infectious for two weeks in general so just to emphasize that it's only the people in the last two weeks of this who have been diagnosed here who are either infectious or, for the most part, symptomatic. i'm generalizing here. there is some error on both sides ofs that two-week window. but just to emphasize that.

unfortunately we've had 43 deaths in the city. any deaths from covid-19 is one too many. as you will see, we have -- compared to other communities, we have not experienced the same tragic outcomes that others have with regard to a larger number of deaths. next slide. so this slide, unfortunately, probably looks familiar to many of you. this is covid-19 cases by zip code and i'm not necessarily saying it looks familiar to you because of covid-19. you sieve anne a slide -- you've seen a slide at this at the health commission for h.i.v. cases, and for the chronic diseases like diabetes and hypertension. you've seen a slide like this for h.i.v..

covid-19 is, unfortunately, exploiting the socioeconomic factors, the structural factors that permeates our society and allows a situation where infectious diseases spread in communitis that are the most underresourced and are stigmatized and are affected by structural racism and other factors that have not only socioeconomic consequences, but [inaudible]. so you can see here that particularly the bayview [inaudible] areas are heavily affected by covid-19. and we'll talk a little bit more about our efforts to work with communities in those settings with other partners to ensure that there is [inaudible]. and very importantly, that [inaudible] are provided and prevention tools are provided,

prevention education is provided to slow the spread of the virus. next slide. next. yeah. so this is our data from our -- whoops. i think i just lost myself. sorry. my fault. >> you're there. you're there. >> ieb. i'm trying to move my team's bar which is blocking the side. you have to bear with me. it is our testing data with regard to covid-19 and you can see from this slide we've done almost 70,000 tests in the city, which obviously we always want to do more. but we've come a long way from those early days in march where we were watching every swab and being very, very careful and unfortunately not scaling up

our testing as much as we would have liked to. but we made steady progress in that. you can see that our overall test positive rate is now 5% and that overall our numbers -- the last day on the slide in terms of the number of tests reported each day, that last number always lags. but you can see overall that we have done very well and dr. phillip will talk in more detail about this. but we're certainly hitting our lower average mark of 1500 tests per day in the city and are rapidly approaching a mark of between 1800 and 2,000 tests a day. and in terms of cases, this is showing the yellow bars by race/ethnicity, really something that is jammed out here is the latin x population that accounts for really half, half of our cases. again, something that we saw early on at zuckerberg hospital when the majority of covid-19

cases at zuckerberg were latin and you can see other prevalence of prevalence of covid-19 cases by other race ethnicity. african americans have a higher rate of diagnosis. and then we still have a relatively high rate of unknowns. cases in terms of race and ethnicity. but that number appears to be going down over time. next slide. next slide, please. so this is, again, a remarkable curve that i look at when we talk about flattening the curve. this is our hospitalization rate of covid-19 patients across our nine hospital systems. the green bars are the covid-19 patient counts. the purple bars are the people in the hospital with covid-19 and you can see here that we

hit -- this is from april 29 to may 31 and you can see that we've gone from a high of 98 patient steadily decrease in a way that, again, is pretty remarkable to just 51 cases on may 31. again, you can see that those cases have really halved. not only a flat curve, decreasing curve in really two substantial reductions from a [inaudible] in the 90s to the 70s and then the subsequent drop of 70s to the mid 50s. so really important to realize that this has to do with the work of so many across the city and the support of san francisco for these interveptions. this is not the health department, this is not even though the city department, this is really the leadership

of mayor breed and other policymakers ensuring that they have the support of the community moving forward to shementser in place on a way that really slowed this virus spread and saved lives. next slide. so this is an update on the slide that i showed you a couple of weeks ago. it's a little bit complicated. so i will orient you to the slide. this was developed by dr. maya peterson who we have been working with since early march to track the epidemic. she has been an incredible partner. even though this is just one slide, i have to say that it was a tremendous amount of work. this tells an important story, though. this is looking at mobility [inaudible].

just to the end of may. so, the blue line that -- the jagged line that goes up and down until about the end of march is basically the mobility index and this is a rough estimate of how much people are moving. so the r.e., you see an r.e. of 3.3, r.e. of 1 30i8 and r.e. of .84 is the virus's reproductsive rate. and the reproductive rate, again, is how many cases the virus infects per case. for every one person infected, another person becomes infected. a reproductsive rate of two means that for every one person infected, two additional people get infected. a reproductsive rate of 0.5 means that for every two people who are infected, only one person becomes infected. and the whole part of this and

we talk about flattening the curve, our goal in public health has been to reduce the virus reproductsive rate to below 0. it means that fewer than one person is getting infected. and you can see here that because of shelter in place orders, mobility for medics decreased at the end of march. it started decreasing mid march when we started doing our social -- some of our recommendations about reducing crowd size and so forthful and then you see that it really went very far down into -- into just about early may. and the reproductsive rate of the virus. these are estimates, not things that can be updated on a daily basis or weekly basis. this is based on many pieces of data and hundreds of it rations of computer stimulations of these data.

but dr. peterson's best estimate was a reproductive rate of 3.3 early on. that is an incredibly rapid rate for the virus. it then reduced to 1.8 and then we've been down to 0.84. so, again, the data and the hospitalization numbers really reflect these estimates. you can also see here now, starting in midday, we're starting to see activity tick up a little bit. so, we'll be watching that very carefully. of course, the goal here is masking requirements with social distancing and better hygiene. as we increase our activity, we hope that the increase in activity will not be as directly correlated with an increase in the reproductsive rate. right? so it would be nice if a month from now i could come back and show you that this line did

actually increase significantly, but the reproductsive rates stayed below one. we'll be watching this very carefully. next slide. i also think that it is helpful for the commission to see how san francisco has performed in relationship to other jurisdictions across the nation. these are jurisdictions, some would similarly [inaudible] as city of san francisco, we're one of those jurisdictions and you can see the cases by thousand, the deaths by per hundred thousand and our testing numbers. we're at a higher level of testing rate per 1,000 than this shows. at this point. but the death numbers are really, i think, important to point out the death rate. you can see that san francisco is lower in terms of its death

rate than los angeles and significantly lower than every other jurisdiction on here. and even if -- even given our density. so, again, saying that we're saving lives is certainly born out by this data. and then the cases by 1,000, this is obviously varying a libby testing. but most of these jurisdictions have relatively good testing at this point. you can also see that even in places where they had less testing than we did, they had a higher rate of covid-19 diagnosis. you can see, for instance, both philadelphia and new york. and even los angelesful even though they were testing fewer people, that they had a higher testing average than we did. so just important to provide some context here. next slide.

and this is looking at alameda, san mateo and santa clara. our health officer working with his colleagues, leading together with his colleagues across the region, the implement of the shoelter in place order and the alignment in terms of focusing on ensuring that we're looking at the data as we go into this phased re-opening. and just to emphasize here that san francisco actually -- if you look at their rate cases per 100,000 population, you can see that we have one of the higher rates -- has the highest rate on this sly. 292.88 per 100,000. that is different than santa clara which, as you recall, was

one of -- i think [inaudible] county in the state with regard to widespread cases and a case rate of just 144.77 we believe that, indied, santa clara has an overall lower rate. and then you can allegation see the percent of confirmed cases have died compared to some other jurisdictions, our rate has been lower. we think -- again, this is a hypothesis at this point. but we do believe that is likely because of the early infections in these counties. we had some outbreaks in those facilities and a significant number of death but not to the level that unfortunately other counties experience in an early phase, if you will, of an

earlier stage of the epidemic in march. and april. next slide. and this is now looking at cumulative covid-19 cases. this is influenced by testing, of course. but the trend and the curves is important to look at as the county continues to test and monitor their local epidemic, our local epidemics while we have taken a regional approach. there are starting to be some significant differences can which may influence how different counties or even thousand the region adjusts. you can see here that starting in -- and all these are going up. all these lines are going up in counties. but it is really the acceleration of the curve that is the one to watch here. right? so the slope of the curve. the steeper the curve, but more

increasing cases you're getting. the rate is increasing. unfortunately you can see here that alameda has had a market uptick. since may 22, the red curve. how you can see it is coming steeper. you can see, for instance, santa clara, while it hasn't had a lot of cases, its curve is relatively flat. i shouldn't say it's flat. it's not had a pronounced change and that is similar to san francisco in the darker blue line. you can see those two blue lines are very similar in terms of their subs and san mateo, we're watching carefully. it seems to have a little bit of uptick at the end of may again and watching that as well. just some comparisons here. to give you a perspective on how we are doing compared to other jurisdictions in the country, how we're doing specifically locally and some

of our obstacle data and testing and comparing other county, neighboring countis to our work. and this is very important for what you will hear for contact setting for what you will hear from dr. phillips. and dr. arragon. i believe that's my last slide. see, we're going backwards here. i don't know if, commissioners, you'd like to take questions now or wait until the end. >> [inaudible]. >> i'm sorry. go ahead. >> i think we'd like to take questions as we go along. so, first, do commissioners have any questions for -- [inaudible] >> if you have a question or like to make a comment? ok.

i see commissioner green -- yeah. make sure you unmaouts. >> obviously thank you all for this remarkable work. i was wondering whether you had anymore granular information about the demographic of the people who have been tested and maybe you'll discuss this later. everyone talks about the denominator and especially as it relates to hospitalizations and deaths from the disease. i know there have been certain campaigns in certain neighborhoods. i know ucsf has done research with different populations. people who are already members with place like one medical may represent a higher proportion, those who are tested. i was wondering if there is anything to glean or any either demographics or groups that you feel are going to show particular vulnerability or trends or areas beyond what we obviously need to watch, which is the underinsured, uninsured home legislation populations and shelter populations s.

there anything among these that you pull from the testing data, given that it's voluntary and various people are agreing to being tested or snot >> i appreciate that question, commissioner. i think dr. phillips will talk about this more her presentation. we are certainly focusing on the demographic of the people who test positive. right? but the other question is access to testing overall. right? so, for instance, you know, what is the proportion of testing among populations of certain race ethnicity or gender. [phone ringing] compared to other groups. that is something that we are working on, i'm not sure if that is [inaudible] today but we will bring those back to you. at the next commission meeting. it's not just about how many people are tested but about

access to testing and barrier testing and making testing the available to people. we're not going to necessarily go to a health care center or other site. i think we've learned a lot from h.i.v. and we're trying to apply those lessons learned to expand testing in san francisco. >> commissioner, does that answer your question? >> exactly right. it will be very interesting to see that data and how we can try to approach populations that are as a result. -- vulnerable. >> great. thank you. commissioner chow, i believe you had a question. >> wonderful presentation for an overview. i had two questions. both, i think, are related to the question of how we were then reducing our strict sheltering in place, opening up to allowing like construction workers and all and more movement.

do any of the -- do the [inaudible] correspond at all or even the last cumulative and i know that i's still early. but it's like two to four weeks since you began -- well, three weeks since we began allowing construction workers and all. so, is any of that starting to show up here, do you think? do you think part of the r-way is related to that? and are some of the people that are then being found are those which wouldn't have been out? >> yes. thank you, dr. chow. so far -- and dr. arragon can speak to this about why we're choosing the [inaudible] that we recommended. we haven't seen a significant increase in cases that are

commensurate with when we started it as a moderate increase in activity. through, as you're saying the construction work and increase in outdoor activities. of course, this could lag. at least as far as for weeks because of incubation period and the virus and the fact that people are not getting tested and wouldn't show up until later in the hospital and so forth. so we're watching it very carefully and vigilantly and i think it is a little bit too toller tell yet. >> commissioner giraudo? >> thank you so much for the presentation. are we seeing in the relationship of pediatric and inflammatory response that is apparently connected with covided? are we seeing that within our

san francisco pediatric population and hospitalization? >> so, commissioner, i don't have the specific case numbers on that. i can certainly move back to zuckerberg and i think ucsf will have more information on that from their pediatric hospital. we can certainly get you that information for the next meeting or for that [inaudible]. >> dr. colfax, this is dr. phillip. is it ok if i answer that? >> absolutely. [inaudible]. can you turn your camera on, dr. phillips, so we can see you? >> yes. thank you. we have not received any cases. we have put out a provider advisory, advising providers to be on the lookout for this. so, we're thankful but we're watching very closely to see if we receive reports. >> thank you, dr. phillip. >> thank you very much. i have families asking me

continually and with anxiety. so, thank you very much. >> any other questions -- oh, yeah. i see those two. >> thank you. thank you. i was wondering, six counties and the state have been coordinating their service response and logistics to the extent from day one. and i'm wondering now, but it would appear that there may be some movement for the counties to be acting more independently or more individually. is that something that is likely to happen more so in the future, especially given the different curves that we saw on your graph for some of the different activities going on

within counties? and how will that impact it in your opinion? how will that impact us here in san francisco? >> yeah. so i think we're starting to see some variation. i would, for the most local hfp-the counties add jacent to san francisco, i would not characterize it as a major differences. so i think we'll have to see how these things evolve. i also think it's becoming increasingly apparents in a highly dense city such as san francisco, our caution is going to be based on our local data. whereas in santa clara, for instance, where they started off -- didn't start off a, but they were in a situation that was very challenging, earlier than san francisco. their cases have dropped. their hospitalization rate is about half of what ours is when you adjust for the population. so, they may move a little bit.

a little bit faster than we do here. and then alameda, dr. arragon might be able to speculate on his conversations as he's had them recently with alameda. i think there are going to be some differences but these differences may be more in measured by days than maybe a couple of weeks rather than, you know, major changes. of course, that's a fluid situation that could change. but dr. arragon will provide you with the road map that we developed and can comments a little bit on how it varies from other neighboring countieses. >> thank you. that would be helpful if dr. arragon [inaudible] from his perspective. how the health officers are continuing to either coordinate

or work or coordinate less as seems to be [inaudible]. >> commissioner bernal? >> thank you. and thank you, dr. colfax, for this presentation. i had a question of just -- pretty simple questions about a few of the slides. i noticed it appears there is no data for treasure island. and i know we have about 2,000 residents living out there. is that available or why might we not have that data? >> i do think we have data on that so it may not have reproduced well on this slide. and on the mobility slide, an excellent slide with great information. we see that there are changes in mobility from mid may to the end of may but we don't have a calculation for the

replication rate. do we expect those increases in availabilitier or higher replication rate? >> well, we hope not. right? we're starting to deal with the association betweenable mobilities and viral transmission. universal masking health order and obviously we wanted people to comply with us voluntarily and the data are increasingly compelling dr. fauci actually has said that masking is key to recovery. so a smafk what you do when you go out and engendering community support.

just trying to get people to mask when they go out automatically to create a social norm. i think it is a key component can. the other components are developing obviously the social distancing pieces and then also good hygiene. and those factors are particularly important as people gradually go back to work and increase their activity. the other thing i just mentioned is because, as you know, the health department has approaches. you do realize after three months, people -- not everyone can follow the [inaudible] of the social distancing requirements. so, we will be issuing some harm reduction guidelines for people if they do choose to visit.

here's what you can do to ensure that it is safer is. obviously we would not recommend it this time unless it's essential. but we do think it's important for people to have the tools if they are willing to take some more risk, how they can reduce those risks. >> and two quick questions. and perhaps this one is better to wait for dr. arragon or dr. phillip. the department released guidance on how people can don't observe social distancing and participating in demonstration activity. the question do we anticipate having to change course at all in our testing or contract tracing or anything in response to the proximity that people may have had during these demonstrations and tell me if

that's better for later on in the presentation from one of your colleagues or if that's something you could answer a. >> we're encouraging to get tested and we certainly did put out guidelines if people demonstrate how to do it in a way that reduces risk of transmission. in fact, there was lots of work to increase access to masks and so forth. but dr. phillips can still talk about that testing scaling up that could relate to your question. >> and then finally, very impressive data comparing san francisco to other major metropolitan areas. what were the metrics that were used to select those metropolitan areas? because i noticed, for example, that chicago, houston, dallas aren't on here. were there density or other metricks that were used? >> commission kerr, i don't

think that there was a specific methodology used, just where the data were available. they were compiled by dr. jim marx who's one of our quality officers at zuckerberg hospital. we can certainly look into those other places and compare if those data are available there. >> thank you to dr. marx for compiling this. it is very impressive and important information. >> i think commissioner chung has a question. >> thank you for the presentations and yet it is troubling to see the high percentage of cases are representative by latina in the community. i was wondering about an other -- like kind of a point that, you know, there's some stories that were difficult for me to explain to my constituent.

and that is asians consist of about 12% of all the cases, but they account for almost half the deaths. is there a story we're missing there that we need to be able to, like, do some assessment, like is it because of lack of access or language or because they came to seek care later than others? [no audio] >> secretary morewitz, can you hear me? >> yes. >> i wasn't able to hear all of her question. i think it was with regard to the increased death in

asian-americans in san francisco relative to the high proportion of deaths and the question around the testing. so, commissioner, i appreciate the question and area of active investigation by the departments. there are a couple of things. not all of which are conclusive yet. first of all, thae are looking at the asian deaths. there is evidence that the asian population as a whole, on average, is older and we know that compared to other populations in san francisco so that may be part of the reason that there are a higher number of asian deaths corelating with age. there is also component here with outbreaks. there was an outbreak in one of long -- one of the skilled nursing facilities.

that had a particularly high number of asian residents and so they unfortunately had a relatively high fatality rate. that is another component to this. we think. and then there is a component with regards to testing and in the data that we are looking at, it appears that asian-americans are less likely to get tested compared to some other ethnicity groups. so, we are intergaitsing that. we are scaling up testing in asian-american neighborhoods now, including with the help of chinese hospital in order to get those rates up and there is also some data emerging nationally that i think we are unfortunately all aware of.

[inaudible] and there is also data emerging that suggests that mortality rates are virtually higher among asians and we're looking at that and whether that relates to our local data. those are not all answers to your questions. there are more things that we're exploring to intergaits why this is the case. >> commissioner chung? >> yes, dr. colfax. i appreciate that response to commissioner chung. and i think all those factors that you're, you know, putting down there are certainly ones that need to be evaluated. from what you have said so far, though, since you did talk about a nursing home could woe ask if any of these [inaudible] were from the s.r.o.s or housing projects that we have

within the asian community because i think that's part of the concern. and i realize that you have a private program with a chinese hospital and again, i think that was highlighted at the last several weeks in the public and i'm hoping that dr. phillip might be able to illuminate to us where we might be doing more asian testing and how we do that with our partners. i'm wondering, doctor, as you know from the university of california here in san francisco has had his arch study. that was in the chronicle, but for which he continues to be working on a nationwide issue and if you've been working with him to have a better view of the entire asian story. obviously we're talking about

20-some-odd deaths here, certainly disproportioned in the city. but the california state data showed that the asian data was not out of line. but you're quite correct. it is by seven or eight jurisdictions in which the asian mortality rate is much higher than would be expected. i didn't know whether we were also working with dr. nguyen or not. >> i am not directly working with dr. wynne. we can check to see if anybody in the department is doing so. obviously we close relationships with many people at ucsf. we can follow up on that with dr. chow. and i am, as we're speaking, i'm trying to get the latest data on the s.r.o. numbers. i will share that after the next presentation if i'm able to get it. i just wanted to be sure that it's the most up-to-date numbers that we have per your

request. >> sureful . we appreciate very much and looking fortoward dr. phillip's presentation. >> it ok, can you give me a thumbs up if it is to*ek move on to dr. phillip? ok. great. dr. phillip, yes, fantastic. can you say hi to us before i pop your presentation on? >> hello, everyone. >> that's great. >> should i proceed? >> sure. >> ok. so good afternoon. i'm susan phillip. i'm one of deputy health officers. i also direct the preveption and control branch and i've been work on covid for a very long time so i'm happy to come and talk with you about what the entirety d.o.c. has been doing around testing. next slide, please. >> sorry. i was trying to -- >> do you want me to do it? >> no. no. i was trying to put you on as you were talking. i apolicy jiefmz here we go. >> great. so today we'll walk through

very briefly some of our testing principles and priorities, the journey that we have all taken together with testing, a quick snapshot of where we arage then strategy. and i know we'll have a lot to think about in terms of testing. i want to preface this by saying our framework and mindset around testing is that we always need to be doing better. there are some things that we're very proud of and what we accomplished in the time that we have been trying to ramp it up and we need to continue to improve. next slide, please. so, our principles for testing the. we test for a very specific purpose. we want to take action on those test results in order to improve health for people in san francisco. so, we are working to identify when we test, we want to identify and then support people who are positive to isolate and contact the quarantine while they might be

infectious to prevent ongoing spread and we want to do this to protect vulnerable population, especially in congregant setings. we know that those setings provide high density for spread and in certain settings such as skilled nursing facilities, those are considered highest risk for mortality as well. in addition, to this protects hospital capacity. our primary reason for doing this is to reduce spread and ill ness and death in our residents of san francisco and additionally helps preserve the hospital capacity that we know we will need for covid and many other reasons. we want to protect health care workers and other essential workers because they are the ones keeping us going in san francisco and we know from lots of sources, including the ucsf study in the mission that people that have to leave the home are at higher risk. this maintains our hospital capacity. it maintains our food supply. it maintains all the things

that are necessary to support all of us in the city. and it helps prevent further spread, of course. and we also want to do testing to detect the surges, to understand what might be coming. dr. arrago says that testing is like our five sense and i always keep that in mind. this is how we know what we are doing. testing is not everything, but it is a very important baseline and very important way of understanding how we're doing and what we might need to do next. next slide, please. our testing journey, we really came a long way when we were sending specimens to c.d.c., calling c.d.c. on every case for permission to test and when we had our first tests that were done at our public health laboratory right at 101 grove street on march 2. since we've done that, we have expand our testing significantly. we have done more than 69,000 tests and 5% overall positivity

rate which has come down as we expantededed the numbers tested. we have 29 locations collecting samples for covid-19 testing throughout the city. and per dr. arrago's health order in early may, all 21 skilled centers in san francisco are now required to test all residents and staff and our d.o.c. has been very active in helping ensure that that could happen. the average number of deaths that we've been able to complete at tend april is 591, which is significantly higher than when we started and the average number of tests that we did daily in may compared to april is higher. almost three times as high as 1525. so, we really have come a long way and yet again we're not satisfied and want to continue that improvement. next slide, please. and so when we look at how we're doing, director colfax

showed you comparison in multiple ways with other cities around the country and with other counties in the bay area, this is a snapshot from the chronicle looking at the other bay-area counties on the different indicators that have been agreed upon. and i just want to focus on testing there. there is a goal of performing 200 tests per 100,000 people. san francisco, we're close to that. we're not quite there. but we are getting closer every day. so, our goal of getting to 1800 to 2,000 tests will get us to this goal of 200,000. next slide. but it is not just the total quantity of tests that we want to perform as dr. colfax said. it really is understanding what is the distribution of our testing resources, what is the distribution of access and how able and willing people to get tested.

this is remarkable data and math put together by our great advanced planning team at the d.o.c. at mosconi. and what it shows on the left are all the tests, all the people who have had tests geo coded where people are residing who are getting tests. and on the right hand side of this slide, you see the tests that have become positive in the last seven days and this kind of imaging and mapping is really important to understand what is the distribution of. where people are who are able to get tests and where might we need to enhance the distribution of testing sites. the reduced barriers and understand what those barriers are. because we want to be able to make sure that as we're learning and as we understand about the epidemiology of disease. when we confront the map that director colfax showed us, where there are more cases, we want to make sure that we're

matching our testing to meet that. so, we have this overall goal of getting to 1800 to 2,000 tests. but we will not have succeeded if those are distributed equally across the city. we really want to have an equity focus and make sure that we're making the testing accessible and accessible to the people who need it most. next slide, please. >> dr. phillip, i think you meant the 2,000 tests per day. i just want to make sure that's what you actually said. >> yes. thank you. i'm sorry. 1800 to 2,000 tests per day. >> great. thank you. >> ok. so, again, thinking about access as one of our major principles and equity as a major principle for our work at d.p.h. always. we have said that any work that serves san francisco and leaves their home to get work can get tested regardless of symptoms or exposure.

this came out directive -- or this guideline came out at the same time as u.c. f. mission study that really reinforced that 90% of the people had to leave their homes for work so it really was happening in parallel. this understanding that it was parallel was reinforced by the findings of that study. anyone living in san francisco with at least one symptom of covid-19 can get tested and that the symptoms as you can see are quite broad, ranging from runny nose to fatigue. 2340 long rer we limiting testing to people who have symptoms, fever, shortness of breath or cough. and anyone in san francisco who has been a contact to a person who is diagnosed with covid-19 can also get tested. as we said, we're improving and trying to deploy more resources to test all the time. people's primary care provider are also a good source of

testing in most cases. they can call 3-1-1 or visit sfgov to see where all the sites are that might be in their neighborhoods and near where they work and what the hours are and other things, considerations for getting a test there. next slide. and we had 29 sites. those include not only city test s.f. sites but one medical and partners with these health systems that have testing available for their members as well. community testing is available within the san francisco health network, not only for our members but also for people who are run insured. and this has been very important to try to capitalize and utilize these testing sites which are located in communities that we know would need more access to testing. so it is available on campus at cfsg, at southeast health center and at maxine hall.

-- max eaton hall. we have state and community partnerships as well for testing sites in o.m.i., in the tenderloin, in hunter's point and in china town. again, we're constantly, looking at the data and to understand where our next site should be or deploy the assets that we should have. we have great partnerships with ucsf as you all know and they have supported really amazing [inaudible] in the mission. we alluded to the results of. that study that have given us a lot of information for san francisco. and then currently they are doing a second phase of this united and health study partnership in -- with the community groups, the h.r.c. and d.p.h. is a part of that as well to support people who test positive and that has been from may 30 to june 2. as we said, 17 of the 21 upscale nursing facilities as

of june 1 have had their resident and staff tested. that's great. we have to get the other four completed but we're work on that and we feel that it has been a really great accomplishment to have, 17 out of the 21 have testing as of now. next slide. so, again, as important as testing is, it is one piece of our overall strategy. we really want to make sure that we're also emphasizing the importance of doing everything we can to enable people and help them to stay safe by keeping distance and knowing prevent infection in the first place. testing is critically important and as you have heard it's one of the five indicators that the city is monitoring for re-opening. in addition to the number of positive cases, hospital capacity, contact tracing and personal protective equipment. [please stand by]

>> the case summary has a different number for showing. >> i think that's a great question and that 5% is average since the very beginning of our response. in the very early days, it was people that were quite sick and in the hospital and the testing positivity was 34% at the highest point and our current -- if you look at a day-to-day average, it's less than 3% positivity for our testing.

so if we look day-to-day, this is the average overall and i think it's that variation that has lead to that. but i'll check the numbers, as well. >> yes, because if we just look at the presentations with those two numbers, the math seems to reflect the actual picture. and i was wondering because we mentioned about the different sites, you know, to administering tests to neighborhoods. and i was wondering if there are actually fan gaps that we're mig right now, you know, just by neighborhood because not all transient residents in san francisco in shelters. and have they been outreached to and get tested?

>> i think about reevaluating and who are the groups we're missing, that's one of the most challenging things in public health and hard to know who we're not seeing, but the way we get to that is to engage with other groups that know better than us, particularly community themselves, so community organizations, community members that can help us inform what our next cycles will be of

improvement around this and then, also, the fact we are collaborating with other city departments that have very good and deep understanding of how to best serve populations such as hsa and hsh will serve, as well. but i think your point is a very good one of continuing to be very aware of that and not feel that we can't see it, it's not a need and to evaluate that. for the soji data, i think that you're all way ware it's not a state-wide mandate. for people that test positive, we are asking our case investigator to ask about this

data and those data fields are relatively new in our software system, comcare, so we are still working on trying to improve completely of that data but we're happy to come back and share with you what data we have from those sources. >> i have a followup question. thank you for that response. when we look at the current surveillance report, the part that baffles me is that there are 30 terms of gender, of covid 919 cases. in what circumstances will there be a known gender and no? >> i think that is a great question and i don't know all of the categories and i don't know if declined is a separate

category than unknown. i would have to look at that more carefully and we also have also some staff do this work that has not previously worked in hiv, in shi syphilis and somf this may also be -- to make sure people are asking the questions completely every time and i think we have pdsa to do around making sure that a completeness of data goes from the health network and we are talking with a people as a part of case investigations. >> thank you. >> dr. phillips. >> yes. >> could you tell me, you had mentioned that the testing signs and technology is rapidly evolving. could you speak to the ac accury

of the tests we're currently using and whether we have false positives or negatives? >> thank you, commissioner. i believe the tests we are using are molecular-based tests, lab-based. and i think the issues with them are, first of all, there are no perfect tests and no test that 100% of the time picks up every infection and 100% of the time doesn't put infection there and that's just inherent with every test. molecular tests are quite sensitive which is what we want. we don't want to miss a person with covid and there are limitations to that. one is potentially how well the sample is collected and making sure that there is an adequate procedure for collecting these specimens and in that way, some of these sites are getting more and more practise with doing

specimens is good because the quality of a specimen becomes better. the other thing which i think is important, the predictable value of a test is the exposure. there have been studies that put together a lot of separate studies into an overall analysis that look to see, you know, from the time of exposure how likely it is that you truly did have an infection but didn't show up and it's very, very high on day one and it declines a bit over time. but there's still a possibility, 20% or so, that a test might be negative and the person will go on to have infectious covid. so that's why our counseling around negative test results is important. we know what we want to tell people to do in terms of staying home until their symptoms have

resolved or until it's been ten days since infection. the data shows that's when the virus is no longer replicating, where we think it will not infect others. if someone has a negative test, that will depend on the quality of the specimen and when their prior exposures occur and it doesn't tell us anything. it just tells us about that one point in time and if someone has ongoing exposure, they can be positive one day but have an exposure that means they will be negative one day and an exposurt turn negative later. it is challenging. there's not a single easy explainexplains for that. explanation for that. it's about the nature of the ongoing exposure and the counseling around that. that's true for hiv and syphilis and other periods of getting

tests done. this is a challenge and a single negative test is not as useful as understanding the whole context of someone's potential exposure. >> commissioner gilliamo. >> thank you for your presentation and comprehensive answer to our question to far. and my first question was actually answered in terms of the type of tests that we are primarily providing at least from the department labs and the tests that are issued from the department. the second question has to do with the frequency of testing so in the long-term care facility, you said it was 17 of the 21 and how frequent will an ideal sort

of rounding scheduling of testing happen in those long-term care facilities? i understand that was probably the second round of universal testing there and so that is one question. and if somebody has been tested and is tested negative outside of the long-term care facility, what is the protocol or what is the process by which you are able to determine how, when and where a second or third and fourth test? and if somebody has been tested and has tested negative outside of the long-term care facility, what is the protocol or the process by which you are able to

determine how, when and where a second and third, fourth test might be issued? >> thank you, commissioner. those are excellent questions about the frequency of testing. four skilletesting.we're activef looking through the data we have and trying to make our best estimate, because as you can imagine for the facilities, it's quite labor intensive, especially beside the laguna honda and jewish home to be doing testing on a very regular basis. so we don't have a final answer based on our understanding of the incubation period of the virus, it should be no more often than every 14 days, every two weeks. and that is the general schema we have started from but it may be possible to space it out to

conserve the staff resources on the parts of the sniff, but also the testing capacity expect resources. and resources. for people that are not in a skilled nursing facility setting, say, an essential worker, if, again, we don't have the most precise answer but what we've said is they should not get tested any more than every 14 days. they remain asymptomatic, it should be every 14 days. we would need a partnership to do an evaluation or a study of them systematically to take a look in a scientific way to see if there are institutions that were putting out the same advice, but we're a little bit limited now and going by what we know of the natural history of the vira virus which is no moren

14 days. >> any other questions, commissioners? >> yes, thank you, dr. philip, and thanks for the wonderful work that you've been able to do on this skilled nursing in such a short period of time and i'm sure the other four facilities and their families will be looking at having you come or having them be able to do it. that does raise a question. in terms of how do we do a count where we do, say, testing on the same patient or the same staff several times? right now, we have a cumulative count versus the number of tests, right? but that's going to get more distorted if we actually will do regular testing. so what sort of is the protocol for that and are we going to get

another number, saying unduplicated? >> yes. i think complicationer, that's a very good point and we will look at that. as we get test results seeing the curve among test results among san francisco residents, those are duplicated and this is a good problem to have, where we're able to test people multiple times and we will need to take a look at that and have some of our dat data and epi-pee to give us options in a clear way. >> my second question is one, perhaps, dr. eragon will do better with which i think was eluded to already, in terms of if we are going to have more frequent testing for oh, say, people who visit their families and all, what that might be. and so, maybe i should best wait for that and get to the testing

question i wanted to ask. would that be quite right, dr. philips and i'll let the doctor try to answer something like. or do you have an answer? >> i'm sure that the doctor would have a great answer to that. i think what i will reiterate that we need to know more about how frequently we should advise people to test. >> so the last question is the one in regards to testing where

you'll be looking for where we should be testing, whether we have not tested enough or whether there is actually an outbreak in that area, but to me, we talked about the homeless and then there are the housing projects and then the housing projects are probably not quite as dense as the sro's. so what are your thoughts in terms of how you were then going to pick which ones and which areas we were going to emphasize? homelessness has been on the table for six to eight weeks already and, you know, and what type of aggregate groups are you thinking of testing for each of these, the homeless, the housing projects and, of course, in the

chinese community that would be the projects which there are three or four and then the sro's, which are communal living, right? >> yes. and i think that the challenges are, we know that we will have to expand in a way that's sustainable and able to hold the values of understanding where the highest risk of transmission and highest risk of mortality is and balancing that with the understanding that while we have very good access to testing now compared to where we did before, it's still not limitless. so i think that those data will help inform us about where we need to go next. and we are also continually gettingetting community input ve community branch of the emergency operation's center via the hrc. so i think that all of those things will help inform us and

as partners like ucsf do additional studies, i think that also helps us to understand better where areas of higher risk may be. as dr. kolfax says with partners such as the chinese hospital and others, if we're able to leverage staffing know-how, community trust they may have, i think we can try to figure out the most effective way to reach communities in areas across the city. really trying to leverage the groups that work with them best and trying to also figure out the best way to stage and to utilize the resources we have, which is another reason why the questions that many of you commissioners are asking are so important about how often should we retest asymptomatic people when we might want to actually prioritize another population, alzheimer's well.

as well. we're looking to expand our capacity and we are directing our resources as we understand a risk of transmission to be a risk of serious illness and to change that based on the data that we have coming in as we do this. so it's a constant feedback loop to do that and commissioner chow, if you have additional createds, i'm interested in hearing those, as well. >> i think it would be really useful to understand and, perhaps, we can do that off-line and maybe mr. morowitz can help in how we've been reaching out to community partners, especially in this area, because they're very well organized and whether or not they also have resources that can work with the city's resources and be a part of a public private type program. that would really help assure that population that there isn't going to be an outbreak there. i mean, it was wonderful that

anybody at laguna tested so well and we did so well. i think ther some of these buils and crowded places may have an outbreak that we haven't had right now and i think everybody would prefer to try to avoid that much sooner than letting some sort of catastrophe occur in that community. we can certainly find out how all of us can help on this. >> thank you, yes. >> any other questions for dr. philip, commissioners? and for those -- >> so i just want to acknowledge dr. philip and her team's incredible work. dr. philip has been incredible during this pandemic.

she and her team have worked nonstop from the early days of the challenges around testing and shortages, making sure the health lab was one of the first in the entire country to test the scaling of working with me key stakeholders and working with policy makers to develop and explain our testing policy. but i just want to celebrate her work and and championship in this time. i wanted to give you data on some of the -- i've had the liberty while dr. philip was going through a few data points relative to this conversation and one with regard to the sro's and we have had 196 people test positive in the sro's so far

there's been a hetergeneity. there's a lot of variation from overall and 6% of the cases of covid-19 that have been diagnosed have been people who experience homelessness and we've had one death specifically in somebody from covid-19 who identified as homeless.

this is the asymptomatic screening for the homeless and control measures were put into place there and then, 1704 staff were tested in this first round and 1699 tested negative with three people positive. so the screening yielded a relatively small number and, again, as dr. phillips said we're looking at testing going forward. there may be different frequency for staff versus residents, as well, given staff -- the data that we see the staff may have significant infection rate. and so just to give you some context in terms of population that you have asked during this.

again, thank you, dr. philip, and thank you to your team. dr. philip was heading up or contact investigation work which is another key foundation of our covid-19 response and i'm sure would be delighted to come back and report to the commission on that other key component of her team work. thank you. >> thank you. >> thank you, dr. kolfax. dr. eragon, can you ho pop on yr camera? know that after the doctor, members of the public cap make e comments. i'll put you on and then i can start the slideshow. >> good afternoon, commissioners. and director grant. and so, i'm the health officer of san francisco and i'm going to give you an update on the san

francisco reopening plan. so we can go to the next slide. the key things to take away, the curve is flat and there's a lag between when we see cases and hospitalizations. the lag is anywhere from two to four weeks after infection occurs and that interval is important to keep in mind as we think about opening up the economy. go to the next slide, please. so here is what i'm going to cover. the key thing to recognise is

that we're doing some smart alignment with the state resilience roadmap, using that as a basic building block. the city has convened an economy recovery task force lead by carmen choo and ben rosenfield with a core group and an expanded group of stakeholders that involves over 100 people. you will see when we go through the different parts that are being opened up, that we're doing it in an incremental way. you'll see that we're going to be using four weeks and we'll explain the rationale why. we took an approach that's risk-based, that takes into account not just a risk of transmission, contact duration, but the ability to mitigate risk and to extent possible, we're coordinated with other counties in the region. we're especially coordinated on principles, but because the epidemiology differs, in each county, you'll see how it rolls

out will be different and the principles were aligned. next slide, please. so this is really important. from kolfax showed you in the mobility slide how our effective reproductive number was below one and you see there on the left-hand side, 0.80%. as we open up in the economy and in this modeling from dr. miah peterson and you can see a number of 1.29%. if the number goes a small amount above 1.0, you can actually have epidemic growth of infections. this focuses on hospitalization census and you can see there that the first arrow pointing to june 1. that's a simulation saying as we begin to lift shelter in place, we have more activity and the

reproductive number goes up and you can see four weeks later, you can see how the hospitalization curve starts to go up. and so, it's really critical to realize how vulnerable we are. so we don't see ourselves -- you cannot see whether you're getting into trouble until at least two four weeks after you've done an intervention or loosening things up. next slide, please. so i gave you back to the rationale of why the interval needs to be four weeks. the state has taken what they're calling the resilience roadmap and call it into four stages. stage one was really about getting ready, and we're currently in stage two is stage two is about opening up lower-risk workplaces and stage three is opening up higher risk workplaces and then stage four is far down the line and that's basically where the ending of the stay-at-home order takes

place and we're thinking that's a day where infection is really under control, treatment is available, vaccine becomes available and people can really go back to a more normal experience. so within each stage, what we're doing is the economic recovery task force took a risk-based approach and then classified workplaces and then that's how we're prioritizing them and sequencing them out. go to the next slide, please. and so, the commission recovery task force did is they took a framework from john's hopkins university that was also tested by l.a. county as a way to restrategize businesses. this is an example of what they did. you can see the contact proximity, contact length, contact volume, difficulty to socially distance, difficulty to disinfect and then they

developed a total risk o score r modification score. on the right-hand side, you see the numeric score they gave. and so it was really fantastic how the task force really got into the data. they were incredibly enthusiastic and they really brought that expertise to really understand -- because they understand these different businesses to come up with this risk strategy. we're proud they did this because even the state did not do this and we are glad we were able to take where the state started off and to take it to the next level. the next slide. so based on that framework, this iframework andthe four-week inte staging out, you can see at the top of the slide what we're calling phase two, what the state calls stage two and you can see early phase two and

later phase two and then you see phase three and you see phase four. and phase two has a very early component which is called 2a and that started on june 1st. and those wit were the orders jt released yesterday. but the bigger one is really going to happen on june 15th. so you'll see the opening of more retail manufacturers and the other thing that will happen is outdoor dining and so you'll see june 15th will be a lot more things will be opening up and then we see here on expanded phase two, the next column is june 13th, where we're hoping to have dine-in restaurants and continuing to expand retail and then -- >> you said june 13th by

accident and that's july 13th. >> july 13th, thank you very much and then phase three, we're talking about mid-august. one thing i want to point out is that the state has designed it in such a way that it allows the variability of counties to move faster. in general, the urban counties, and especially the bay area which is more health protective than the other counties. san francisco particularly is being more health protective because we're the second densest city in the country and we also have a large commuter workforce that comes into the city and we also have a lot of vulnerable populations. so we are uniquely at higher risk than other areas. and so, we're moving one to two weeks behind everybody else to make sure that we have enough time to make sure that we don't get ourselves in trouble and the other reason why you want to do

this is to make sure we have enough time to shift if we need to change course. and then the last reason is by going a little bit slower, it actually allows the infection risk to go down over time. one key concept with infections is this idea that infections in a population really has a feedback loop and so when the effective reproductive number is less than one, you have a negative feedback group and you want it to continue going down. something risky today, two weeks from now may not be risky because the infect ship prevalence goes down. so we really want to lock in the gains we made by getting the reproductive number less than one. the opposite is true when it goes above one. when it goes above one, it's a positive feedback loop and you can get exponential growth rapidly. so we need to shift rapidly if we need to.

and the other thing is that -- i'll give you the url at the end so you can go and actually see the whole list of workplaces that are going to be opened up. and there's always going to be some shifting because sometimes the state will move things around a little bit. when the state allows something, provided everything is looking good, we go ahead and do it in a way ha we feel is safer. but we are moving to where the state is going. next slide. so this i one of the areas where state -- actually, i do want to point out one thing. mark, can you go back to the other slide? so one thing you will notice, so here is one of the things that the state did that confused people in california. and so, the state had -- if you

look at phase 3 and you go down where it says -- you see where it says -- it doesn't say barbershops but you say hair. so what the state did, the state decided to move that into phase 2 and so that caused confusion in the state because they took one area haircuts and barbershops and they moved it into phase two and people in california thought, oh, we're moving into phase three and so that's the way the governor announced its and no, no, we're nonot moving into phase three. we took one area and moved it into phase two. there's a misunderstanding out there and we want to make sure people realize we're not moving into phase three.

we can'in the next slide, whichy last slide, is that i want to really emphasize while we handed over a lot of the responsibility of this thinking to the economic recovery task force, public health was focusing on public health principles on how we can really make sure from a health perspective that we're locking in these concepts and interventions to make sure that we can open up safely. and i think this is really, really critical. on the left-hand side here, four

key things we want people to remember. as we open up the economy that you -- every individual, every business, every organization to really think about making sure that everybody focusing on face coverings, physical distancing, handwashing and to take advantage of the testing that's available to them. and then to design their businesses, design their community practises, to take these into account. and so there's a tremendous amount of work that goes into designing that, but we want every individual to remember these four key points. on our side, in terms of cities and our partners, what we're working on is universal access to testing. we're working on a universal detection systems and coming back to talk about indicators and surveillance systems. dr. philips is leading our case and contact investigation and then, the health officer orders directives and best practise, a

tremendous amount of work goes into that. i've learned by working with other counties, we take what the state provides as guidance and then we codify them into directives and go into detail to make sure it's done in a way to held protective is the economic recovery task force is involving businesses so they have input to make sure that we do it in a smart way, in a way to implement that. and they will be developing toolkits, making sure this will be accessible and doable by the different variety of business practises. and then on the right-hand side is that reminder, for those watching the protests, not everybody was wearing a face covering but for those who were, you could see how important face

coverings are outdoors. the science is beginning to show that it does make a difference. so i'm going to end here and be available for any questions. >> thank you, ministers. we usually take public comment after presentation before the last questions and we haven't done that for the previous two, so to be courteous to the public who may have questions, i would like to see if we have any public comment on these items. >> yes, we do have one person in the cue. >> ok, great. so i'll start the clock. when they come on, you you'll he two minutes once i call you to speak and are you on the line? >> operator: you have one question remaining. >> welcome, please say your name and i'll start the clock. >> hello. i'm kate monaco-kline.

i am a founding member of san francisco taxpayers for the public safety and i am retired from the department of public health befor where i serve as ts project at the jailhouse services. frequently, jailhouse services which i believe is yet to testify, but frequently is a visible public health entity.

>> are there any questions for dr. etc etch eragon. >> is it ok we go to the next item? >> again, this is grant kolfax and i wanted to acknowledge his incredible leadership, the health orders and directives, the guidance.

>> item 5 is general public comment and do we have any general public comment today? >> there are no callers in the cue at this time. >> thank you for that. item 6 is a resolution honoring stephanie cushing and if i can call you back to introduce the resolution and say a word or two about miss cushing. >> thank you for giving me this opportunity to talk about stephanie cushing.

she's been with the health department over 33 years and she is a powerhouse. i can't say enough about stephanie. when she came to the health department, she has worked in every single part of the health department, whether it's hazardous waste, food, and so her depth of knowledge and leadership is phenomenal. and for me, she's been amazing. she's always available 24/7. when she became the leader of environmental health brand, she became the first woman leader of the branch and she's and avid swimmer and she as a tremendous sense of humor. i don't know if you've had the opportunity to see how she works with the staff, but they have a singing group and they really lift the spirits of everybody in the health department up and they contributed to our vision, making san francisco the

healthiest place on earth. and that vision came from environmental health under stephanie's leadership and she teaches me a tremendous amount and under stephanie's leadership, environmental health branch became an early adopter of the lean management system and they've taken it to the next level and they've won state-wide awards on their accomplishments in improving environmental health and i want to say i'm incredibly proud of stephanie and we're going miss her, but we'll definitely stay in close contact with her. so i'll turn it back db -- i tk the commissioner will read the resolution and tell stephanie thank you, thank you, thank you. and we're so grateful for your public service. >> commissioners, i am going to read the resolution and then one of the environmental health employees asked me to read a statement into the public comments because he's not able to be here.

stephanie cushing has served as a leader in the public health branch for 33 years and she has modeled practical and innovative leadership throughout her tenure and whereas director of environmental health, miss cushing oversaw programs from food safety to ecigarette policies and massage and tattoo business monitoring. and majority of the programs enforce 40 of the 42 health codes with local and policy bodies. whereas she is the first director to begin her dph tenure as an inspector before promoted as a senior inspector and manager. this provided her with the knowledge to lead successfully. whereas miss cushing is the first woman to hole th hold then

of environmental health director. this improves the efficiency of the branches of services and whereas the california conference of the director's environmental health recognise miss cushing is just by awarding her the excellence in environmental health award and now therefore, be it resolved that the san francisco health commission honors her for many years of outstanding service, contributing to the health and well-being of all in san francisco and wishes her well in all future endeavors. here is a brief statement. here are remarks from joseph afye. she's always very supportive of staff and daily work. she is super and there have been many times to help us deal with community appeals and she's never failed and the group is satisfied. she's leaving us with tons of

knowledge and we can use all of this program to bring this forward and provide the city as a whole. >> i invite my colleagues to speak. we want to thank her for the critical functions of the commission and i think after be take wetake a vote, we would lio ask her to say a few words and

maybe we can do a screen shot since we normally do photos with resolutions honoring assisting with career and team members. i guess finally, i wasn't aware of this singing group and, perhaps, we can invite them back to sing for us at a future meeting. so it would certainly bring some brightness to what we're all working so hard on. so i would defer to my commissioners if they would like to say anything. >> thank you. it seems like we have a vote. and then we can add her to speak if she would like to and i will call the role call. (role call).

>> i want to say something quickly just to thank stephanie for her service and to say that while we didn't work together for much of her tenure directly, i always felt doing any of the many things that her team were making sure that public health was preserved. she's one of those people when you meet, you look forward to the meetings because she tells you something not only what you need to hear and tells you something interesting, has a great sense of humor and came with some insight, some knowledge and wisdom to share and i always learn so much for her. so i will miss you very much. i wish you well in your

retirement and your retired employees have a way to find their way back and i'm hopeful that we will see you again with the health department in some capacity going forward. whether you plan on that right now or not, but my gratitude to you and for everything that you have done for the department and for san francisco. >> miss cushing. >> thank you, mark. i would like to thank the commissioners, dr. aragon and dr. kolfax for all of your kind word. it has been an interesting journey for me. i was reflecting on it. recently, when i first started here b, i was also newly married and because i had applied as stephanie jung, the only way they could solve the problem was to hyphenate my last name and it

was stephanie jung-cushing and i did not fit on my paycheck and the milestones occurred while working here in the health department coincides with the birth of my sons, graduations, graduations from high school, college and i know a clinical psychologist and an attorney. so the good works from public health and certainly learning a lot and using enforcement techniques, i raised two sons who i like as adults. and with regards to yes, the singing group, i find that the best way to get a point across is to use humor. and so we have songs, people who participated in videos and i do want to say, too, that i have

creative group and people become environmental hel health inspecs and it's shown as a state and national level. so it's kind of gone viral and hopes to get a million facebook likes but we haven't managed that. i would like to thank you all and i would like to thank mark for having time to let me snip leaves off of his plant and to try to root them and listening to me at a time right after my mother passed away. so again, thank you. i've had a wonderful time here. environmental health is so broad and different and i'm staving off alzheimer's and thank you again. >> thank you.

>> and thank you, miss cushing. you have at least six more likes on facebook what you told us and we'll get you closer to your goal of a million. and also, just thank you so much for your leadership in so many of the progressive areas where san francisco has been a leader in the country. we hope you'll be staying in touch. >> i will, thank you. >> thank you, everyone. we can move on to the next item. but before we do that, i would like to flash the public comment phone line. leave it there for ten seconds. the next item will be item 7 and the dph budget update. and i will flash that and mr. wagner, are you on? >> yes, i am. >> i will on and put you on.

>> i'm make this brief. just a quick update in tens o if where we are. we talked with you at your previous meeting after just receiving the strucks from the m the mayor's office and we're working those internally and the deadline for the submission of the budget was june 12th. we have spoken with the mayor's office, the fact that you have your next commission meeting on the 16th and we asked to have an extension of that deadline so that we can discuss the budget with you at the meeting on the 16th and they have agreed to that. and so, that gives us a little built more time to work on the

product and it was important to us that we would be able to bring that proposal to you before going to the mayor's office. so that allows us to do that at the next hearing instead of having a kind of rushed in and half done plan for you here today. and so, a couple of things that are going on to give you an update. we are working on a multi-proppinged approach and thimultiprongedapproach and thit turn-around to get something ready. it's about a third or a little bit less than a third of the time that we normally have to work through a budget proposal. and so the few things we are working on is that we have been working centrally in the finance division on doing everything that we can to work toward that target and we have each of our divisions working on options and

savings ideas and revenue ideas that we're vetting through with them and the second piece of this puzzle is, of course, the ongoing piece of the covid response. and as you heard in a lot of detail earlier today, that will be an ongoing effort and we'll have pieces of that response that will be in place semipermanently or permanently within the department and so, as we're working through meeting that target and working with the mayor's office to balance, we need to figure out how wire going twe'regoing to align thath staffing and resourcing all of the activities that are a part of the covid response. so we've. working with the team's

operation center for those initiatives is working with the sections in the doc two times over the last week and this week to try to firm up what that proposal looks like. and then we are looking at how we can realign our resources within the department to meet those goals and the covid response and attempt to retain as much of our operating structure as we can at the same time. those are two sides of the same coin that will fit together in our budget proposal that we're working on. so this is very more complex than our normal budget process will be. we have coming up on monday, we're going to have a town hall meeting, the second town hall meeting with our cbo partners to talk about the budget situation

and our covid response. that will be dr. kolfax and myself participating in that and that will be an opportunity for ideas, thoughts, from our cbo partners to work together with those partners on both our budget challenges and the resourcing of the covid response.

>> commissioners, before we get to questions, is it ok for commissioner ber nelnell to seef we have public comment. >> no public comment. >> thank you, and thank you greg, for the update on the budget process and one that has

to be made by less than ideal information to make those decisions and draft the budget. i have a question about revenues, projected revenues outside of general funds. can you give us a little bit of an idea of how you would expect our revenue sources to change and revenue or any potential significant revenue changes that may be happening with the cuts that need to be made? >> thanks. big question. so a few categories of things. the first are the medical waivers. as you know, we had been in the process with the state, our counties and the federal government of negotiating a successor program to the

medicale waiver set to expire in six months from now and we received a large portion of our funding from that and that's our global payment program, full-person care and other programs and the department has been working primarily through the california association of public hospitals and health systems with the state to attempt to propose an extension of the existing waiver to buy everybody time to reevaluate and that will be extremely important because the prospect of implementing a new waiver for which the last two have really meant very significant changes to the way that we're funded and the way we need to operate to draw down federal funding. this is going to be very important to have that extension

to to give us time to be able to plan for that, which we can't do while we're grappling with the covid-19 response. so that's one of the big pieces, fending on those discussions go, that could have a positive or negative effect. there are pots of money in the waiver that were scheduled to expire or be assume or subassumed into new funding programs in the successor waiver and payment programs. if we can get that extension, that will give us stability and potentially offset some of what were the anticipated reductions in federal revenue we would have seen at the end of that waiver and that's one revenue piece that's important. a second bucket is the federal funding that is associated with the covid response and this has enormous implications for us.

we have started receiving valors under the care's act and the stimuli, i guess, is the word that had been passed to date and that's been helping offset some of the costs with covid and then very significantly, there's the ferfema reimbursement and this l be costs with the covid emergency, but there is uncertainty and potentially the state would also reimburse some of the costs but significant uncertainty around that including at what level we will be reimbursed, which types of expenses will be reimbursed and the duration of the fema program and how long we'll be able to claim expenses against those fema dollars. that has to be one of the most significant revenue factors in our budget and the city-wide budget given the size of the

covid operation and some of the initiatives that are happening like testing, like ing and hotel programs and so that's a big revenue factor there. the other piece that we are really looking at and our divisions are looking at internally are baseline medicale and medicare and other operating dollars and there are a few opportunities there. there is the fact that we have gotten our feet under us with epic and we have a lot of work going on to try to increase the level of revenue capture that we're seeing in epic. the behavioral health division is looking into a lot of opportunities to increase our billing for services that we currently provide and that takes

infrastructure, but that would be net new revenue and in addition to those, the other big piece is that as the economy is changing, we're going to see even under the existing waiver structure, a change in our revenues as you have state budget changes, but also you have most likely significantly increased enrollment in medicale, which is not something we want to see because it's due to people losing jobs and incomes as a result of the economy, but the silver lining that is that it will mean additional enrollment and revenue that we can use to support the patients in our services. and so there are a lot of moving parts and we also are looking at

a lot of the kind of financial safety net protections that we have built into our finances over the last several years and that we have talked about with commission, including building our reserves and kind of creating some buffer for exactly this event. and so we'll have some of that to offset the impact, which is an improvement compared to where we were at the prior recession, but it won't be enough to cover this whole target. >> thank you very much. >> thank you. and any other questions, commissioners? >> commissioner chow? >> i was just wondering, once a budget gets through, how the city was going to be trying to

monitor it? this is an unusual budget year, then. are there thoughts that they would, you know, be withholding funds for the latter part of the year and have some withholds that we would have to show revenue targets? are they going to monitor and make sure there are the funds coming in and our expenditures are coming down. >> yeah, that's literally the hundred million dollar question and so two pieces to it. so we do have our normal financialmafinancial monitorings that we'll have to beef up and we have flexed these up and down, depending on where we are

in our financial condition. so i expect that within the department and with the controller's office, we'll be putting additional layers of approvals and reporting into place as we have done in the past and so that would be additional controls over hiring, over materials and supplies, expenditures and all those types of good financial hygiene tools that we have. so we'll be rationing those up. and the second big piece, which i think you're getting to in your question is around the covid 19 situation and we have uncertainty due to the fact that we're learning about this as we go, but also that we don't know what the future is going to be in terms of the actual course of the epidemic and we have a lot of scenario planning happening

that you have discussed on one of your prior items. but i think one of the choices that the city is going to face and that we're going to face is how aggressive or conservative we make our budget assumptions. so are we planning the things to continue along the course that they are? are we planning with an assumption we will have a surge in cases during the winter? or are we planning to be much more conservative than that and plan for a higher course over the entire year each one has large implications for the budget. i don't think we collectively as a city have figure ou figured oe

we'll land. regardless of what we do, we'll have additional layers of management and reporting in place with the controller's office on all of this covid-19 expenditures. so all of those expenditures we have segregated into a special project fund that enables us to monitor the spending and we have a structure in place -- well, it's not quite yet in place but we're building it into place in the department operation's centrcenter to monitor expendits that are coming. i think there will be a piece of this regardless of where we make an assumption of what this looks like and we have to react quickly operationally and financially as soon as we see the data looking different than

we anticipated. and is that will be a city-wide conversation, i think, is probably going to occur well into the next month or six weeks as we're leading up to the mayor's budget submission. >> thank you. i know with you there, we'll be a part of the conversation and i have confidence that you'll be able to carry the message that is needed by the department. we're working very closely that our city-wide partners have been right there with us on this. and so we're grateful for it. >> any other questions, commissioners? thank you, mr. wagner. >> thank you.

>> item 8 is the multi-contract's report and as miss ruggles is on the line.

this is a contract that the department of the city's department operated called county adult assistance programs which provides funding to the individuals, but there's a work requirement and so this contract is the behavioral health side where there's assessments done for employment readiness and then to the degree that there's an unmet need identified or linkages needed, there's behavioral health and mental health services provided at varying levels with the goal to have someone's unmet needs

addressed that may be keeping them from moment. employment. i wanted to add, because this has come up and the health commission raised it, the board of supervisors and the mayor's office. we're asking you to approve a contract today and the reason is we're following our current policy is you would approve contracts that are more than 500,000 annually on an ongoing basis. if we don't come to you today, then this contract will expire and so this approval is our existing policy to continue the contract. just as we don't have any allowance to skip the approvalpy the boarapprovalby the board ofo review our contract and what does that mean for approving a multiyear contract when, perhaps, the contractor will be

cut? and it is kind of a disconnect, but at this stage, you're not actually -- well, we have a big cut that greg just talked about and it hasn't -- we haven't trickled down yet to the contract level and we don't know yet which contracts will be impacted. we do know that no contractors will have a 2.5% cost of doing business going forward and that won't be added. but at this point, we don't know and it's important to continue

this through the boiler plate language. are there any questions on this contract? >> actually, this is the only contract on the report, isn't it? >> i'm sorry, what? >> there's own one contract on the report. >> only one contract, yeah. >> there any public comment? >> no public comment at this time. >> thank you. commissioner chow, a question. >> yes, it's a fairly simple question. we normally would get what the

total ram's contracts are that we have, just as a proportion or dimension as to what we are adding to or continuing. >> let's see, you know what, you're 100% right and i didn't think about that. i won't have something updated now for 2020. >> when they have multiple contracts for this. >> sorry about that, you're correct. >> thank you.

any other questions before we take a vote? would anyone like to make a motion regarding this item? >> i would move it. >> second. >> great, and i will do a role call. (role call). >> we can move on to the next item and i'll put the public comment line back on the screen. item 9 is an ethic update and i will put that presentation on

the screen in one second and i wanted to make sure anyone with public comment has information in front of them. i'll put you on the scream and >> good evening, commissioners. thireflecting on all of the prir presentations this afternoon, i am pretty humbled by coming in to tell you about what we're doing with the electronic health record, but it also dawned on me part of our emergency response is a continuity of operations, being able to maintain aspects of our regular work and even in the face of something as daunting as covid-19. so it's my pleasure to get you up to speed with an update that actually was postponed with shelter in place. i would like to recognise our chief health officer and the director of our epic program. we agreed it would be easier to

have one presenter this afternoon. i'll read this to you quickly for those who may not have a screen in front of them, where we're thinking about getting better with epic and this vignette is the voice of the patient. when i started receiving care at the general, it was frustrating. the patient experience was rather poor and continued to improve and has gotten much better since the switch to epic. test results and appointments can be scheduled online. instead of having to wait on the phone, the service through epic secure messaging is much easier and these capabilities that this patient shared with us were not available prior to august 3r august 3rd of 2019. so it's exciting to see adoptions of this new recordkeeping system in very

robust platforms, not just by the folks who work here in gph, but also by our patients and clients. we are prepared to take part in our surface domains. next slide, please. first, epic is definitely becoming the tool we cannot live without. most notably, in our response to covid-19, you know, a day hasn't gone by where somebody hasn't said, we can do that in epic and how can it help?

and it's been just wonderful to be able to wield this new tool and make it bend and shape itself into something that can assist us, not just with our day-to-day but when things are extreme. we are also rapidly resolving the stabilization issues, as i mentioned, and heading towards optimization in our future ways. and we also are on track to decommissioning our legacy electronic systems that the large part of them will be commissioned in about a month. and we'll have a financial update where our project is in line with our budget. next slide, please. pouso as a short vignette, thiss from the voice of the provider. i love the epic mobile app

checking labs and notes and put in orders without having to rush to the computer. it makes it easier for me to supervise trainees and students during rounds so i can view the data for myself while still focusing on the presentation. and pretty powerful. this, foo was wan too, was a cae did not before us. next slide, please. ok, stabilization versus optimization. the last time we spoke, we were talking about stabilization being about things that we might have gotten wrong when we first deployed the epic software and we were fixing a lot of things. we're also taking on small works, less than 40 hours of time, using our improvement charter methodology to problem solve and i'm happy to report we're getting ready to move into the optimization phase, which i think of as the fun part of

software. we get to explore requirements from all customers on the new things they would like epic to do, new workloads, features, functionality and being able to translate the standard work that goes on day-to-day by our staff and the standard work we can build into the software hoping to automate as much work as possible because that leaves more time for our providers, especially to spend time with our client. and next slide, please. ok, so we're here. and i think there was some questions that this has been worked down where we can respond to an incident and resolve it within that day and, also, take

on optimization items, as well as be ready to move into our new implementation ways. i think there was a question specifically about the areas that where we're not quite stabilized and i'll talk about that in a moment. next slide, please. so here is a quick breakdown, quick summary of the stabilization staff. 5% o 58% is fully resolved and s inactive, which means they were overcome by other changes to the software and will resolve that way or they are items that have been moved on to the optimization work ahead. and we are left with 20% of our items. (please stand by).

>> one hundred patients have had records exchanged, either their records have been augmented or other healthcare organizations who would have cared have actually requested those records from ourecords. so it's exciting that we're already at that level. next slide, please. so i think there were questions about the impact of covid-19 on our work in epic. we can see a percent related to the covid-19 issues with the epic platforms peaked at around 30% are now around 20%, which is

very significant and, again, if we look back to talking about stabilization and being able to have a bac backlog of service requests a nominal level to deal with them quickly, this was a little bit of a burden for us, just because as we were watching the numbers decrease, numbers started to increase in early march. and so, i hope that this is providing a little bit of context for another aspect of how covid-19 is impacting dph. next slide, please. so i'm excited to talk about implementation wave two, because from a continuity of operation's standpoint, we have started epic wave two. and we are living up to the promises for what would be contained in epic wave two and most notably, jail help is the

largest project in epic wave two, but we have a whole number and we're working on preventing any additional spending and so, looking specifically at the replacement of the existing outpatient pharmacy systems, as well as the occupational health systems will allow us to absorb services into epic and decommission additional contracts over the course of the next year or so. we're also inciden integrating whole-person care into epic and i watched this work recently and we're adding what is called the coordinated care management module into epic allowing us to start bringing in the social determinants of health and juxtaposing them with the medical information that we have in our electronic health record. and so this is a very exciting

development for us. and then, of course, we are accommodating emerging demands. we were on the precipice of moving into mental health sf, looking forward to seeing that come back to life in whatever shape it is and, of course, i mentioned that we have been very involved with the covid-19 response and these are the things that -- and a summary making up wave two at this time. next slide, please. this is our very busy chart, but it is the wave that w way we'veg the plan with you and i'm trying to maintain consistency. the column on the left side of the chart that covers most of the first half into the third quarter at 2019 was wave one of

epic and that was our go-line and all of the fine print where the model you'lls that we implemented on august 3rd. following that, we moved into the stabilization which moved so the end of the calendar year and we embarked upon something that amazingly, we were able to do amidst covid-19 with very little impact to customers, but epic releases software on a quarterly basis and we were three quarters behind because of our go-live cycle and we did three updates at once in april. and had really no appreciable impact to operations. we are excited about that. i think there were some questions about how the epic schedule is moving around and especially as a result of how we're working within covid-19 and our continued and enduring response. what i would say is that most

wave two work has been initially pushed between 30 and 90 days out on the calendar. a lot of that is just us trying to be prudent about the uncertainty of what we're facing over the summer and into the beginning of fall. but if you look at the bottom of the chart, you will see that videos and interpreter services that had originally been further to the right are further to the left because with shelter in place and the need to reach out is interact with our patients and clients, it was essential that we get a video solution this lace and so we have an interim solution in place now and we are now embarking on the journey for the more permanent solution that allows us to integrate video visits and interpreter services into the epic experience and it's a seamless solution. i'm happy when we can go back to

the slide if you have questions about any of the other activities. next slide, please. so this short vignette on getting better with a video lense. today i congratulated one of my patients who was struggling to make one appointment and now is making all of them and he can save all appointments to his calendar on his phone. with a big smile, he would log ob to show me how easy it is manage his own care. it's all good now, he said. exciting that this capability that has been available to many of us h fo for a long time is nn the hands of our patients.

i think there were questions about, well, why didn't we spend as much as we had planned in the first two years. and i think even though i wasn't here, having being a part of large projects, budgeting can be difficult based on the sequences of when they have to implement new contracts, as well as when you bring in new staff. , as well as third-party consultants to help with the work.

it's from all of our providers to everyone in worked in the reporting and all of the people on my time that support ep epici think we go and march into wave 2 and then wave 3 in the future. next slide, please. so we're going to talk about benefit's realization.

our commitment has been to decommission legacy software applications replaced by epic and our plan is by july 1st, multiple systems will be decommissioned. i'm pleased we're at a point to get to literally turn off physical hardware and don't need it any more and we have moved all of the necessary information off of those systems.

a handful in epic wave 3 will include behavioral health, which is the largest item, alzheimer's welas well asworking with some t centered tools as welcomed kiosks and getting information, >> from we go tis there any pub?

>> there's to public comment at this time. >> thank you. so no public comment. commissioners? >> ok, commissioners chow. >> thank you very much for your presentation and congratulations on achieving what we have achieved in the midst of some very challenging conditions and times and wish you well in wave 2 and other future efforts. i had a question about issues around cybersecurity and in order to save a time for the

rest of the questions that you could probably answer this and you don't have to answer now but later because there's a lot of information that needs to be gathered, to be shared. but you have not mentioned much about whether the issues of cybersecurity have risen, how much they've risen and how much we need to pay attention to them relative to the implementation of epic if we could get information how that is

affecting us, that would be helpful. >> we would be happy to do that. >> thank you. >> commissioner tung, you're up. >> thank you for the presentation. it's exciting to see this whole vision that, you know, the whole team has come up with and only took shape but it's taking off. and you mentioned about some of the positive feedback from patients and epic. is there an estimate that the percentage of patients actually are neutralizing epic to help manage their own health. >> that is a super question, commissioner chung. i looked at a figure earlier and it's embarrassing to say that

the chief information officer's computer crashed, but it did. i can tell you that 7% of our active patients are signed up for my chart, which is the epic mobile app that allows folks to manage their own care. and i'm happy to get back this touch with you when i have the data pulled up on my screen or i can send it to you, as well, and the rest of the commission to share with you, where we are with the implementation of my chart, which puts a patient's health information in their own hands. >> yes, thank you. i think that's really part of what is exciting about epic, is that patients get to be a part of a team, to plan their own healthcare. and you know, i look forward to learning more from the data that you can share with us.

>> this might be good to be able to reference that with your implementation scheme for the wave 2 and that also tells us where we are in wave 3. my real question is how well you think we're going to survive the need for, first of all, the implementation with the budget issues and what we might need to do without disrupting the patient care side and yet realizing that a good part of

the system actually is revenue generating. so i don't know what kind of conversations you're having. do you feel confident that we can get through the phase two and not as confident as phase 3 or not each confident about phase 2. >> i would say i'm confident about both, but pinning down the start date for 3 is definitely a challenge until we know, for instance, what percentage of our workforce will be telecommuting versus working in an office. it sounds straightforward but making sure folks who might be using components of the tool in a remote setting will be important for us to know. in wave 2 we'r 2, for instance,e jail health, to make it work this a jail, there's physical it

work that needs to happen. i'm confident and it's how long it will take us to move ahead and we are starting the coordination with all of the components of wave 2 so that we can figure out when we will be at a place specifically with regard to our covid-19 response that there will be enough bandwidth to take it on. it's important to have enough leaders and folks who will be leaders to be able to have the time to do the work to build and use the solutions.

there's not a lot of software development work that gets done, a lot of person-to-person work and some of the work will likely be delayed longer. but i will keep all of you apprized. >> so this is a followup more towards mr. wagner that as we hear the budget presented, that we understand what will happen to our epic project because we all know that it's taking a long time and different funding to get there and i think it would be important not to lose the advantages of epic and yet, we need to meet with some fiscal responsibilities. thank you, commissioner chow. i see mr. wagner, his

microphone is muted and i'm not sure if he was at the meeting, but i will pass that along to him. >> it's something we would like to hears hears a hears hears t presentation. any other questions? >> commissioner green. >> congratulations on your continued success with epic. mr. wagner spoke of how important optimizing revenue with epic as a tool would be as we face our future deficits and you mentioned that there was, maybe, some issues in

stabilizing the optimization and so i'm wondering if maybe you can either elaborate a little or tell us in your future update, you know, how that is being approached in the context, also, the anticipated increase in the medicale enrollment and in-patient versus outpatient billing, you'll approach that, because it sounds like a great source of revenue for the department and it pivots on all of the aspects on what you're doing in so many ways. >> to bring together a shared perspective because a lot of the work that's going on already has been about, you know, the tools that we had prior to epic were a lot older and they didn't have a lot of the features that we have

today that actually help both providers, as well as the staff that are supporting those providers, making the best choices when it comes to something like clinical coding. as well as making sure all of the i's are dotted and t's are crossed before a set of charges can be released and move into the claims, the revenue cycle engine where the claims get generated and i think it would probably be -- we included this our nest quarterly update, if that's soon enough. >> yeah, absolutely. >> we really appreciate it. >> great. any other questions, commissioners? it looks like we can move on to the next item. >> i just want to thank remind the commissioners that eric has been an incredible member of the

goc. i'm not sure how he managed this overview, managing many data requests, building systems and you saw the jo geomapping and hs been a champion of data and information in the pandemic response and he's doing the work offing of epic overall and ensuring that our information around covid-19 is going as well as possible to the department and public. so thank you. >> thank you, grant. >> thank you, dr. kolfax. item 10 is a service's update. we have dr. pratt. do we have you on audio or visual? >> i think you have me on both. can you hear me? >> i can hear you but i can't see you yet. can you make sure your camera is turned on.

>> it says it's turned on. >> it's all possible. [ laughter ] >> i will sort through this while we're -- sorry, my last call i was visible and i'm not sure what's happened. >> well, i set up the slide so that your slides are there, maybe while you're doing the slides if you want toking tole h the camera. >> thank you to everyone. it's a pleasure to be here. and so i know that there are a

lot of particular questions that people have or at leas i will gy through the background to orient everyone to jail health and we can talk about some of the things on your minds about what's currently happening. next slide, please, mark. just an overview of jail health services and the way that the particular disciplines work with each other and jailhouse medical, which includes nursing and the providers, behavioral health and re-entry lead by tonya mira who many of you know. our hiv services and the prevention team who are in charge of our std testing and education, all of our point of care education and testing. our dental team and pharmacies. next slide, please. just a quick overview of our

budget for '19-'20. the majority of that is nursing and salaries, we have contracted positions with ucsf for high-risk ob and psychiatry, as well as our radiologics which is plain film in the jail and that's almost $37 million budget. next slide. so this is the jail population in the last two years and we'll talk a little bit more about this year, which is much more complicated, but it's typically been around, you know, 18,000 incarcerations and that represents 12 and 11.5000 unique patients. the distribution between male

and female and percent male is green and that's been pretty stable. although, nationally the percentage of women in jail has increased relative to many and we don't really see that or haven't seen that here yet. next slide, please. and then, just to look at, we're not quite done with this fiscal year, but i wanted to present what we had because this is very consistent with our usual race and ethnicity breakdown. so, again, 39% of the people coming in are black african american didn't we know this is a huge disproportionate representation in the jail relative to the community. though, it does represent,

really, the entire bay area because people in the jail, about -- i'm not sure what it is right now, but typically, it's around 25% are from out of county. next slide, please. and then, this is the best value of who is actually in the jail and you know notice that the big jump in the percentage of black african-americans who are in the jail on any given day and that means functionally, that black african-americans are less likely relative to other races or ethnicities to leave jail. and we see it's pretty consistent year over year and this is what we call a snapshot data and when i pulled this year weird to this year is really not a significant change in that. next slide, please. this is a proportion of the

people who are black african-american in the jail versus the community and, you know, i think that data often paints the picture well for peach who don't believe that there is any systemic racism in law enforcement, there is a huge gap between the representation of black african-americans in our community and the representation in the jail. that has started go down a little bit and we see that line, but it's been pretty consistent over decades relative to the population in san francisco. next slide, leases. please. and this is probably the biggest change, right, so beginning probably after the election. , we've been going down.

the population is going down slowly, slowly, slowly with this goal of having somewhere around 1,040 people and so that we could close county jail four and that's the goal number, the orange line going across. and we have achieved that more quickly because of covid. there has been an accelerated decarsation in our jail because of covid-19 and a threat living in congregate settings and settings that are densely participate. densely pop pugpopulateed.

next slide, please. i know this is a very complicated slide and it's not for you're to absorb in any real way except to stay this these are all the points of intervention that can occur to get somebody out of jail. and these are the things that with our partners in criminal justice, we have been able to effect to get people out of jail more quickly. in particular, the partnership

with the sheriff's department and district attorney bodine, who has been, of course, incredibly progressive around issue as they always around, very eager to help people get out more quickly. it has resulted in a decrease in jail population at a time when people said that this would be very hard to do because our incarceration rate in san francisco is incredibly low.

6% had been evaluated for coordinated entry and 7.6 were on high priority status and there may be questions about this and that hs priority status is not something that is a designation that we provide in the jails. i just want to say that this reflects what the city has decided i.

the first part was to decrease the population density and as i mentioned working with the criminal justice partners, the reduction of the jail population has allowed us to have more space in the jail, so people are not -- people are single-celled when possible and we have peoplm settings because that is, obviously, a place of great risk for transmission. and in that vein, we want to identify people immediately when they come in through booking. to understand their covid risk and

infection. and when we have those results and a wonderful thing that's happened for us in the jail is that we've been prioritized for rapid testing. instead of having people move into the jail and potentially expose people who have been there for a longer period of time, we have the test results and we can then isolate them immediately or move them into a quarantine location, and wait for 14 days, awaiting the second test. we also have the space to cohort our medically vulnerable and though there are many, many, many medical vulnerable people in the jail, we have some people who are very high risk di dialys patients, people undergoing chemotherapy and we want to be completely separated from anybody coming and going from

the jail, at least incarcerated people to prohibi protect them m community exposure, as well as having stable and consistent staffing so that they are not exposed to other staff who may be bringing covid unknowingly into the jail. next slide, please. >> and in great collaboration with the sheriff's department, we have really blanketed the place with patient education and staff education, handwashing and hand sanitizer, masking all staff, my staff, the sheriff's staff and the incarcerated people are all provided with masks and are asked to use them at all times. distancing when available, we are cohorting incarcerated people in smaller groups. for showers, for eating, four groups for substance use

treatment and things like that, and asking everyone to report symptoms to us as well as temperature checks daily. and allowing people to understand that there will not be a punishment for people who are found to be sick or to have covid infection. and by punishment, i think an incarcerated setting, many people fear that they will go into some sort of solitary confinement, where their privileges are taken away didn'd that does not happen in our jail. the sheriff closed the jail to all personnel and only his staff are there and screen checks for everyone entering the jail and both people who are arrested and all staff and masking requirements, as i mentioned and increased cadence for cleaning and sanitizing the facilities and allowing incarcerated people

to also have those supplies available to them, which is unusual in the incarcerated world and something that other entities do not do and it's been a wonderful way for people to participate in controlling their environment in the jail. next slide, please. this is complicated and only here as an example of how we house people to make sure that we are keeping playing keeping s separate. so if somebody come in and they test negative, they go into quarantine for 14 days and they do not move out of county jail during that time and typically, an additional seven days. if someone tests positive, we have had ten positive cases in the jail, all asymptomatic, all identified at in-take, they stay

isolated by themselves, housed alone until they tested negative again and anybody who has symptoms also is isolated and if they continue to have symptoms, even if the presence of a negative test, we continue that isolation and we try to put people in single cells if they decline testing. and i've looked at the data, it's a little bit. difficult. on april 13th, the day after easter, we started offering testing to everyone comes in and shockingly, we've had a 69% acceptance rate for testing. i say shockingly, because generally people do not want to undergo any kind of testing at

intake. and this includes people who test on days two, three, and four because we reoffer it to toeveryone who hasn't been tested. that's a great improvement in our usual acceptance of services like this for people coming in. they were shocked to here there were people who didn't want to be tested and the same is true in los angelos, people are availing themselves to testing at a greater rate than san francisco.

there is psychiatric housing, but this is the purview of the sheriff's department and because of covid, we're involved to make sure people are isolated, cohorted and staying safe. next slide, please. this is how we define who goes where, under what classification and when they can be released and this is more to show you the standard work that we've created for isolation and what staff needs to do, what the patient needs to do and whether they can go for showers and go to court or be out in the mill-u. didn't the same for the

quarantine category. so the quarantine people are those who have not had no known contact prior to arrest or contact to someone who tested positive during their incarcerated period. and we have not tried, we have kept county jail four and five separate and nobody moved from county jail two, which is essentially the new arrivals to one of the other locates for a total of 21 days of monitoring. they have to have gone through 21 days of monitoring, no symptoms, no fever, negative tests before they will be moved into what we call a clean jail to protect people who have a

much longer stay in our jails. next slide. i'm almost done. so moving on to the county jail for closure, as everyone knows, the board of supervisors voted to close this in november and what the plan is from the sheriff's department is to increase the county jail, so right now county jail sits around 220 patients today and all of the county jail 4 patients will be moved except the 20 kitchen workers and this is to happen beginning on july 11th. the final closure date has not been determined by the sheriff. and then, county jail 5, which is working on a capacity or a census right now of about 420

will have this capacity at 676, as you see here and county jail 2 requires renovation before jail 4 can be closed and that will remove some capacity in that location, as well, and some of the cells will be turned into one or two-person cells instead of dorms and that reduces the capacity. next slide, please. this is what we currently have today over in county jail 4. this is our staff, the dph staff working there. and we have 24/7 nursing and half to retain that. we have a nurse practitioner, a behavioral health clinician and then part of the dentist's time, dental assistant time. and next slide, please.

looking forward to what the post co-vid world looks like in jail, after the closure of county jail 4, we will necessarily need to focus more staff on re-entry planning, especially for the people experiencing homelessness. and we currently are able to get most people into an isolation and quarantine hotel when needed. for behavioral health services, we cannot have large groups as we did previously for symptom management and maintenance and sobriety and things like that and so, we will need increased programming because of that. and b we do have the opportunity to redeploy some of the nurses leaving county jail 4 when it

closes and we have noinfection control staff and no nurse educator. so those two roles are critical in the post covid world and pre- covid world, but we didn't have the bandwidth and there will be ongoing testing in county jail 1 at intake, which has been -- because of the movement issue, it is somewhat labor intensive. the testing itself is not, but then the constant monitoring of movement, isolation and test results is and that's become more challenging because the san francisco general that's supplied our rapid tests is now out of rapid tests for the jail and working on getting us four-hour turn-around time and we still await that. that's the end of my

presentation. i am so grateful to do this work with you and i am very proud to be a mem of the san francisco department of public health where people who are incarcerated are treated like everyone else in our city, who is deserving of good healthcare didn't i'm happy to take any questions. >> thank you, dr. pratt, for your excellent presentation. i'm grateful for all of your work. i had a few quick questions before going to my fellow commissioners. and i think they're all on three consecutive slides or thereabout. but i don't know that you need to refer back. looking at the jail population trend, dropping significantly in february of this year. >> yes. >> keeping in mind and looking at the changes in bail reform on the 20th of february in that we have the emergency deck clar eighdeclaration on the 25th of february exthe first covid case

on march 5th, do you think that this trend would have downward to this extent, even without the pandemic, given the changes in the bail reform? or where do you think that might have been absent pandemic? >> yes, great question. a little bit hard to know. but i know that we have made significant progressive strides in decarceration because of the election of jason boudine. and he has approached the pretrial experience for people in san francisco differently than even mr. getco who was progressive. the d.a.'s office is a very different place now and bail reform was underway and then,

you know, the state judicial council jumped in state-wide because not many other counties do weigh wer what we do in san o to get people out without paying a lot of money and so, i think those two things were coming together, mr. boudine's ethos with the bail or bail reform to decarsate. we have martialed resources in the city to provide a place where the court has always said, oh, we're not comfortable releasing this person without a place, without a plan, without services.

that's our challenge. >> very quickly one or two more questions. when you look at the behavioral health population and the percentage that we're on, psychiatric medications, were they already receiving the medication or was it first prescribed and administered while after being incarcerated or sort of a combination? >> that's a great question and typically, we do not have people who are medication naive. they may not be on their medication when they come in new they typically have a long history in avatar or care in our city and even in our jails and occasionally, we do get someone who has had their first pyschotic break and are very ill, you know, it tends to be

young people, 18 to 24, very vulnerable. >> finally, you mentioned rapid testing and supply. will you please keep us posted how that's going and if there's any aadditional assistance any additional assistance? >> yes, appreciate that. >> commissioner, any questions? caany public comment for this item? >> let me check. i can no longer see officially because the site crashed because i'll check site one. >> operator: you have one question remaining. >> hi, caller. can you say your name and i'll start the timer.

>> i'm from the taxpayers for public safety and thank you, commissioners and president and director kolfax for today. the jails in san francisco are a congregate sitting. we have not perceived them that way but that's the fact. in do covid, challenges have ben exposed and we owe a great appreciation to the staff leadership, dr. lisa pratt and their supporting team. we deeply appreciate their accomplishments and the equity lense they are implementing as dr. kolfax implemented.

thithe dph programs will need to link more collaboratively than ever with the version on the custody services, authorized by the court. (please stand by).

and have been collaborative and ensuring that everyone in san francisco gets the health care they deserve as a right. so just want to thank her for her work and her incredible work, especially these past few months and going forward. >> before we move to adjournment, i would like to acknowledge the pain, hurt and frustration that our community

is experiencing because of the violence we continue to see as it relates to black and african-american individuals and police across the country. we certainly appreciate all of the courage. at the same time we need to ask for the support of our community in san francisco. as you know, we're under a curfew from the hours of 8:00 p.m. to 5:00 p.m. to ensure the community is safe with some exemptions. nonetheless, we do recognize that covid-19 continues to threaten the city and we have a stay-at-home order that remains in effect. for those who choose to go out and engage in peaceful and legal and safe protests activities, the department has outlined steps that people can take to ensure the health and safety of

themselves and those -- of course include wearing a mask at all times when out of your home, away from people other than folks you live with. and maintaining social distancing of six feet. and to consider with those you live. and to seek alternate ways to engage in peaceful expression and protest, whether that's online, contacting politicians and other things. i would like to acknowledge the work for dr. bennett, the director of health equity who is serving as the commander for the

department of public health emergency center for san francisco, for her work to guide the department and issues of institutional racism in our community. just wanted to share those reminders and the difficulty many are facing right now. and to thank everybody for the department of health and your extraordinary work. >> thank you, sir. let us know if we have public comment on the item. >> let me man the queue and we'll see. >> you have zero questions remaining. >> great. so commissioners, you're at item 12 which is adjournment. i believe dr. colfax has something to offer. dr. colfax still on? >> yes, commissioners.

i just wanted to comment in memory of margo eddie. she was an amazing force of nature, a real treasure, for the city who was very focused on social justice, especially as it related to homelessness. and providing care and shelter. really put the focus on help. she was a long-term health department employee for many years. i had the pleasure of working with her in my earlier tenure at the department. she worked with many, many people in our department as well as our city. and, unfortunately, died last week. mark, i know you had a few comments, but i wanted to

acknowledge her leadership, her incredible boldness in terms of the work that she not only did her herself, but asked us do every day. she was one of those people who lit up a room and inspired us all to do better. i will miss her and i know so many people across the city will miss her. including and especially the people that she interacted with and helped every day in the shelters, the navigation centers and on the street. >> thank you, dr. colfax. you said it well. she was a lovely person and very proud she was part of d.p.h. >> commissioner chung: actually, i have known margo for 25 years and it's really a loss for the city with all her contributions

from one of the multi-diagnosis programs to shifting to the department of public health to one of the -- like integrated case management programs in the city. and michael has contributed so much to the city -- margo has contributed so much to the city. and i am certainly grieving right now for the city and also loss of my friend. >> commissioner, i believe you had a suggestion regarding adjournment? >> yes. i also knew margo and she was a true public servant and whenever she was in the room, she was -- all of those who -- people whose

voices were not often heard. and director colfax was right, she would light up a room. her enthusiasm was infectious. in her memory, i would propose that the commission adjourn this meeting in her honor. so motion to adjourn in honor of margo. >> so moved. >> seconded. >> yes? aye. >> aye. chung yes. yes. thank you, everybody. >> thank you. have a good evening.

be safe. >> be safe. thank you, all. thank you, commissioners. thank you to those watching. >> hi, i'm chris manus is sfgov tv and you're watching "coping with covid-19." today i'm going to the gas station. [music playing] now, these are just my stories. i'm not a medical professional of any kind. i'm a video guy. and the reason i'm getting gas so we can go to the doctors. if you want to get the most

up-to-date and definitive information about the coronavirus pandemic, i highly recommend the f.a.q. that is available at sfgov. there's great info there. today i'm taking two plastic bags and a hair tie and following the new bay area guidelines and i'm wearing a mask. i'm taking the smallest number of items with me. just my car key, credit card, i.d., the bags and the hair tie. i don't want too many items to wipe down later. as aleave, i put on the outside shoes i've left on the porch. can i track the virus inside with my shoes? i honestly don't know. but my floors are cleaner now. when i get to the gas station, i get out of the car, remove the gas cap and put the big plastic bag on my right hand and secure it with a hair tie. there are three main share surfaces here i'm concerned about touching. the p.i.n. pad, the pump handle and the button to select my gas. after i use my card, i put it

into the smaller bag and stash it. most gas stations have a paper towel dispenser or maybe there is a piece of paper already in your car that you can use. once i fill my tank and replace the pump, i walk to the trash can, roll the hair tie up my arm and let the plastic bag fall into the can. on my drive home, i'm careful not to touch my face. i leave my outside shoes on the porch and as soon as i get through the door, i wash my hands for at least 20 seconds. next i wipe down my credit card, i.d. and my car key and, as an extra precaution, i wipe down the front door nob and clean the sink taps. finally, wash my hands again. that's it for this episode, i hope you found it helpful. thank you for watching. - >> tenderloin is unique neighborhood where geographically place in downtown san francisco and on every

street corner have liquor store in the corner it stores pretty much every single block has a liquor store but there are impoverishes grocery stores i'm the co-coordinated of the healthy corner store collaboration close to 35 hundred residents 4 thousand are children the medium is about $23,000 a year so a low income neighborhood many new immigrants and many people on fixed incomes residents have it travel outside of their neighborhood to assess fruits and vegetables it can be come senator for seniors and hard to travel get on a bus to get an apple or a pear or like

tomatoes to fit into their meals my my name is ryan the co-coordinate for the tenderloin healthy store he coalition we work in the neighborhood trying to support small businesses and improving access to healthy produce in the tenderloin that is one of the most neighborhoods that didn't have access to a full service grocery store and we california together out of the meeting held in 2012 through the major development center the survey with the corners stores many stores do have access and some are bad quality and an overwhelming support from community members wanting to utilities the service spas we decided to work with the small

businesses as their role within the community and bringing more fresh produce produce cerebrothe neighborhood their compassionate about creating a healthy environment when we get into the work they rise up to leadership. >> the different stores and assessment and trying to get them to understand the value of having healthy foods at a reasonable price you can offer people fruits and vegetables and healthy produce they can't afford it not going to be able to allow it so that's why i want to get involved and we just make sure that there are alternatives to people can come into a store and not just see cookies and candies and potting chips and that kind

of thing hi, i'm cindy the director of the a preif you believe program it is so important about healthy retail in the low income community is how it brings that health and hope to the communities i worked in the tenderloin for 20 years the difference you walk out the door and there is a bright new list of fresh fruits and vegetables some place you know is safe and welcoming it makes. >> huge difference to the whole environment of the community what so important about retail environments in those neighborhoods it that sense of dignity and community safe way. >> this is why it is important for the neighborhood we have

families that needs healthy have a lot of families that live up here most of them fruits and vegetables so that's good as far been doing good. >> now that i had this this is really great for me, i, go and get fresh fruits and vegetables it is healthy being a diabetic you're not supposed to get carbons but getting extra food a all carbons not eating a lot of vegetables was bringing up my whether or not pressure once i got on the program everybody o everything i lost weight and my blood pressure came down helped in so

many different ways the most important piece to me when we start seeing the business owners engagement and their participation in the program but how proud to speak that is the most moving piece of this program yes economic and social benefits and so forth but the personal pride business owners talk about in the program is interesting and regarding starting to understand how they're part of the larger fabric of the community and this is just not the corner store they have influence over their community. >> it is an owner of this in the department of interior i see the great impact usually that is

like people having especially with a small family think liquor store sells alcohol traditional alcohol but when they see this their vision is changed it is a small grocery store for them so they more options not just beer and wine but healthy options good for the business and good for the community i wish to have more