it's amazing. i felt like i was on top of the world even though i was probably going two miles an hour. it was, like, the scariest thing i'd ever done, and i think it was when i got hooked on surfing after >> commissioner green? >> present. >> commissioner guillermo. >> present. >> clerk: commissioner christian. >> present. >> commissioner chow. >> present. >> and commissioner chung. >> present. >> i'll do the approval of the october 6, 2020 minutes. >> the gang is all here. the commissioners have any edits or if not we can entertain a motion to approve.

>> motion to approve. >> second. >> second. there's no one on the public comment line so far today. >> president bernal: all right. >> clerk: [roll call] thank you. that passes. item three is the director's report. >> commissioners, grant colfax, the health director. a few things in the director's report. we had the pleasure of participating in an announcement with senator scott wiener and mayor breed with reintroducing

the safe injection sites. the senator plans to reintroduce this bill in december. as you know that safe injection sites have been a priority for the department and in alignment with mayor breed's priorities. we need these evidence-based proven interventions more than ever as fentanyl continues its uncrease in san francisco and we have estimated that we've had more than 470 overdose deaths in the first month of 2020. and so this is a much-needed intervention and it remains a priority and able to participate with the senator and the mayor in announcing the fact that -- that the bill will be reintroduced. we continue to encourage everyone in the city to get a flu shot now more than ever. this is certainly not the year to skip on a flu shot. we know that flu shots are safe, they're effective, they prevent flu and they prevent serious cases of the flu. we want to ensure that everyone

stays as healthy as possible during this unprecedented season, especially with covid-19. so we're encouraging people to get their flu shot more than ever this year and working with a number of partners across the city on that as well as it being a priority in covid command. and then another thing that i did this past week, which was very enjoyable, which is to participate with mayor breed and directors of park and rec, and the reopening of playgrounds in san francisco. it's been a long time coming. but we believe that with our covid-19 case rates in san francisco, playgrounds can be opened in a safer way. it's with important guidelines that must be followed in order for playgrounds to open. so we did that this past week. and then just in terms of the amount of work that's going on, i wouldn't say in the background, but, certainly, to highlight with regard to our

work in covid-19 -- in these covid-19 times. the environmental health team is just done an amazing amount of work in terms of ensuring that the food facilities are following guidelines and safe for people to dine in and to receive food from. and just to give you some numbers. during covid-19, the environmental health statues was done and over 2,800 food facility inspections had responded and had over 3,700 phone calls to food facility operators. and have distributed 43,000 informational emails with regard to food safety practices. so e.h.b. is incredibly -- doing incredible work during this time and also incredibly busy. so just to highlight some numbers for the commission there. and then the rest of the director's report is there for you to read. i'm available for any questions and, of course, in the news there's been quite a bit of news

lately and that's in the report. i will follow up with more details on covid-19 in my update as i believe as give to the next agenda item. thank you, commissioners. >> it looks like commissioner chow has a question. >> yes, thank you, dr. colfax. i'm wondering -- that i thought we had closed most restaurants that would have been a lot of activity in regards to how (indiscernible) but there weren't that many inspections. but i'm glad to hear that we have been because we have a lot of pick-up and delivery. is that what is really happening so that after covid we spend a lot of the activity to make sure that our restaurants are safe?

>> that's right, commissioner. so a couple of things -- restaurants were able to remain open for takeout and delivery, right, so i think that is a worker safety component of this is really important. we know from data that food workers are a risk group for acquiring covid-19. so really ensuring that proper protocols are being followed. we had outdoor dining for some time now in the city. so responding to the concerns and issues there. and then more recently we have opened up restaurants to 25% indoor capacity for dining. so there's a lot of work that has gone into this. and as you can see the environmental health branch has been very busy. >> thank you. i think that is a really wonderful report and very good work on the part of our department. and since you did mention staff, it sounds like from all of the different cases that we're seeing that a lot of the safety measures are being taken for staff, and that there has not really been any outbreak amongst

the workers, many of whom we know that have to be fairly cleese to each other? >> so overall the food industry has been very collaborative and cooperative in regard to aligning with the orders and complying with the orders. and it's really been an effort on the part of our health officer dr. tim aragon and the others in the industry, so that people understand what is necessary. and as in other parts of the city we have had instances where there have been staff who have tested positive. that's certainly to be expected, given the activity and the overall presence of covid-19. but we haven't seen an unexpected increase in covid-19 cases given what we know about the risk in this situation, in these settings. >> and now with the outdoor

dining and being able to have perhaps more than the expected types of positives that might come out of that in terms of our tracing over the last, what, nearly a month i guess of having some outdoor activity. >> that's correct. and, you know, again, there have been cases that have been detected among the food industry staff, but we haven't seen an increase beyond expectations of the cases, certainly, in patrons or staff in the food industry beyond, you know, what we know would be expected with the risk factors of covid-19. which is why it's so important that e.h.b., the environmental health branch, works and collaborates and educates the industry about the importance of it now, and social distancing when possible and other safety precautions. and establishments must take it to remain open. >> so i say again

congratulations. and it might that be that kind of information and the public information that having followed a safe activity reasonably -- a reasonably safe activity to be undertaken could be helpful in our economic recovery. >> yes, commissioner. we're using the term "safer" because we have to be -- i think that we know from the data that outdoors is safer than indoors. so i think that people also need to make decisions based on their own risk and the risk of the people they may live with in regards to being older or having chronic conditions in terms of how much engagement they are willing to take. so things -- these steps are actually helping us to be safer moving forward and it's commensurate with the data that i'll show you in a bit about the declines in infections in san francisco. so overall good news. >> thank you very much.

>> commissioners, any other questions? dr. colfax, i did have a question following up on commissioner chow's question. recent national studies were done showing that people who were testing positive for covid were twice as likely to have dined in a restaurant. i understand that even though -- i know that you will talk about this later -- that the state has moved us into the yellow tier or the lowest tier, that we're still holding back a little bit in terms of what we're allowing in indoor dining and other things. is that the case? and is this a factor and a concern? -- the increased risk. >> yes, i think that study was done by the c.d.c. and it certainly is one of our greatest concerns about dining. it also doesn't allow us to distinguish to a degree that we really would like to be able to in terms of, you know, the safer practices, to institute safer

practices, what is the risk, right? and i believe that dr. aragon has joined us and i know that he has reviewed the study and may have comment in terms of how it's affected his thinking in terms of reopening food establishments. dr. aragon. >> hi, good afternoon, commissioners. yeah, that study came out shortly after the state had already come up with its tiered system that included restaurants. so that study was incorporated into their thinking. i think that for us it verified what we knew, with what we expected, in that we expected -- we expected dining to be associated with becoming a case because people do not have face coverings. so that study associated -- it didn't distinguish between indoor and outdoor dining. so whatever was shown in the study it's probably an underestimate of the actual risk. so i think that is why everybody is taking it very, very

seriously. and so though we were assigned the yellow tier, right now we're not going beyond what is permitted in the orange tier for indoor dining. >> thank you, dr. aragon. i see commissioner christian has a question or a comment. >> yes, dr. aragon, did you say that it did or did not distinguish between the indoor and the outdoor dining? >> it did not distinguish between indoor and outdoor dining. so if anything it's the underestimate of a true risk. >> and i didn't read this study and i would hope that the answer to my question would be yes, but was the study specific enough to, you know, to -- to show that it was the dining that was the factor? or could it possibly be that somebody -- people who are more likely to go back to dining are also more likely to be a little

less careful? i mean, from time to time walking around the city to and from restaurants i see people -- like just the other day we were going to dine outdoors and there was a couple that had a couple of young children. the children had masks on, but the couple did not. here they were walking down the street towards a restaurant, towards us within feet and didn't even bother to try to put on a mask. so i think that there are -- i wonder if the study left room for there to be some other correlation or some other cause? >> yeah, so you're asking -- you think like an epidemiologist. yes, it was an observational case control study. so, yeah, the case control observational studies are going to always have problems with residual confounding. they did ask about mask usage. they tried to control it for other factors that would be

associated because presumably somebody who is risky and may go to a restaurant may also be more risky in terms of their mask usage. so the control was for those factors to the extent they could. but you're absolutely right, there could be some unidentified confounding that might explain it. so it's always an issue with observational studies. but it is -- it looked at a lot of different factors. and this was the only one -- there's only two factors associated. one is that you live with somebody who has a case. that one made sense. and then indoor dining. everything else they asked about was not associated. and that indoor dining has the mechanism. so at least it was consistent. and hopefully there will be more of these case control studies. >> thank you. i appreciate that. >> president bernal: commissioners, while you were making your comments, there are

commenters. can we check? >> clerk: so if there's anyone on the public comment line to make a comment on this item, which is the director's report, i believe that it is item 3, please press star, 3, and i can have you raise your hand and i will know that you want to speak. it doesn't look like we have any comments. so commissioner, now you are muted, sir. >> thank you, mr. morowitz. we can move on to the covid-19 update again with dr. colfax. >> thank you, commissioners, grant colfax, director of health. i will provide you with a brief update on covid-19. dr. aragon as you know is here to answer any additional questions that you might have. and let's just go to the next slide. thank you. there were up to nearly 12,000

covid-19 cases diagnosed in san francisco, with 133 deaths. next slide. and the population of our characteristics, relatively stable to what you have seen in prior presentations. the inequity among the latino population which, again, is consistent with, unfortunately, what we're seeing across the region and across state and across the nation. latinos account for just nearly half of covid positive cases. and we see gender distribution which, again, is consistent with regional and national data. i do think that it's worth pointing out that we still have a relatively small number of people experiencing homelessness who have been diagnosed with covid-19 at 3%. next slide. i did want to highlight the cases that we've had of covid-19

by race ethnicity. that there had been questions that the commission had around the relatively high -- higher mortality rate among asians diagnosed with covid-19. and just a couple of points. it's not shown on this slide. that asians who are diagnosed with covid-19 are on average eight years older than the average case diagnosed with covid-19. so eight years older. and you can see here that in the situation of looking at covid cases over 65 by race/ethnicity, arbians have a higher percentage of cases diagnosed in this age group. we know that this age group is particularly vulnerable to covid-19. and, indeed, we believe that this is what mainly accounts for the discrepancy with what we're seeing with 38% of deaths due to

covid-19 being among the asian population. this is also supported by data looking at our congregate setting facilities, where half of the asian deaths have occurred in those facilities. so a combination of older age and a residence at a congregate setting, very much explaining that 38% mortality rate in asians in san francisco with regard to covid-19. i would add that the case rate among -- the diagnosis rate among asians overall in san francisco remains relatively low compared to the proportion represented in the population overall. next slide. and then this is looking at san francisco compared to other similar jurisdictions across the country. you are familiar with the slide, but just to emphasize that king

county and peel are cases per 1,000 is lower than other jurisdictions. deaths per 100,000 remains low. and our testing rate is quite high compared to other jurisdictions where those data are available. next slide. and this -- can we go back one slide? oh, okay. i think that maybe -- this is looking at our key health indicators. you will see some good news here. very good news with regard to our hospitalizations, in the green. so covid-19 -18%, and the next two boxes there are also in the green with good capacity. and really the next metric down, the disease situation with regard to the number of new cases per 100,000 population,

down to 3.5%. and the commission will recall that in july and august, that number actually got up as high as 12. and we have seen a significant decrease in our cases. again, despite that high testing rate. and look at the testing number here where it's at, 4,954 average tests. running that seven-day average in san francisco. so nearly 5,000 tests per day. so we're testing even more but our case rate has come down very significantly over the past few weeks. our contact tracing numbers, percentages, are improving. 86% of cases are reached and 81% of the contacts are -- of the case -- sorry, the contacts for cases are providing or are being contacted. and our p.p.e. in the health department remains at 100%, 30-day supply. next slide. here we go. so this is more good news for san francisco and it's

commensurate with us moving to the safety yellow tier today, it was announced today. you can see that we've had a steep decline in hospitalizations across the city due to covid-19 in the two weeks since the commission last got this update. today we're down to 25 hospitalizations with covid-19. patients are in the hospital. so, again, we're back to the plateauing that we saw in late june. and a situation that before that we hadn't had since early april. so really tremendous progress and not only in flattening the second surge but now really crushing that curve the second time. i just want to take a moment to acknowledge the remarkable work that all san franciscans have done with regard to ensuring that we slow the spread of the virus. this is just a remarkable graph and i think that it really reflects the leadership of all

san franciscans in terms of how we have responded to this pandemic. we certainly hope that things continue to stabilize and maintain this way. and as you will see in the following slides we are as a result of these very positive numbers, the hospitalization rate, and the -- the cases per 100,000, we are reopening more. and it's even more important for us to now redouble our efforts with masking and about social distancing. about the protecting of the vulnerable populations. and making informed decisions what we choose to do as individuals and with our families in a way that is safer and, again, slows the spread of the virus. next slide. this is our reproductive rate of the virus. and you can see again -- remember in june and early july that i was -- i became very concerned about the reproductive rate, and going up about .8%,

and the hospitalizations that could result in that as a result of a surge. we have seen a steady increase, particularly now with a steep decrease in september. we are down to a reproductive rate estimate of 0.8% again. so that risk cub, that reproductive rate certainly has followed that hospital curve and it's consistent with the decreases in the cases that we're seeing in that indicator slide that i showed you a couple minutes ago. next slide. so additionally, good news with regard to the high rates of covid-19 that we're seeing diagnosed in the latino population. you can see here that looking at our testing with its percent of tests that were positive, overall in the latino population, the blue line for

march until october, you can see those high rates and those numbers have come down quite dramatically. just to give you metrics in july, the positivity rate among latinos being tested in san francisco was 13%. in september that decreased to 7%. and the first couple weeks of october we're down to 3%. we have seen declines in non-latin x percent positive tests as well. and you can see that that decline hasn't been -- it didn't start as high, so it didn't have as far to decline. and i think that it's worth emphasizing here that, certainly, that the latino population has a higher positivity rate and there continues to be more burden with covid-19 in the latino population. but that percentage coming down. we are making progress there, although we still have much more work to do. next slide. and then taking a step back and

looking at the national picture compared to the picture in san francisco, and looking at this slide, the y axis is somewhat different here, obviously. on the left you see the new cases in the u.s. today and on the right the y axis is the new cases in san francisco in the 10s. and you can see that overall we were following a pattern that was not dissimilar to the nation overall in terms of the number of cases and the surges. so with september you see a great digression there. so new cases in the u.s. over time is shown in that blue curve. and san francisco cases per day is shown in that orange curve and you can see now that we're very divergent as much of the country experiences very serious surges going forward. in san francisco we are seeing that decline. and i want to thank jim marx of the advanced planning team and the data team for putting this

slide together. but i do think that it shows that san francisco is moving in a different direction than rest of the country. obviously, we are connected, we are all connected, so we will see if -- if these gains can be sustained or if over time we start to see increases in cases and, unfortunately, start to see effects like much the rest of the country is experiencing. next slide, please. so as a result of those low numbers, we continue to make progress in reopening. and today we're moved into the yellow tier. we have been very intentful with our reopening and careful with regard to ensuring that we do not move too fast. so, therefore, we have basically moved -- for every tier, color tier that we move into, we have

reopened at a level higher than the state permits. so the way to think about it is that now that we're in the yellow tier, we're essentially taking actions that are permitted in the state in the orange tier. so you can see here that with our transit we are allowing the increased density of the transit riders with signage. and really strong encouragement and requirements to wear masks. we are opening up non-essential offices next week at 25% capacity. and home work is still encouraged, but people can come to work as necessary and required with very strong safety protocols in place. gyms and fitness centers will open up at 25% capacity as well as indoor climbing and indoor climbing. and then higher education will open on the 27th with classes less than 25 people.

next month on november 3 we will do more extensive openings with restaurants, going from 25% to 50% capacity. and movie theatres from 25% capacity to no more than 200 people allowed in any one space. and museums are also permitted to go from 25% to 50%. and then there's a number of activities as you can see here that are still to be announced, and we are, again, monitoring and with regard to some of these other issues. (please stand by)

>> we will issue guidelines with regard to that to travel during the holidays. weather changes. we had a warm fall so if and when the weather becomes more

incomplement people will move in doors. then we continue to be struggling as a nation, i believe, with regard to the lack of national strategy, which affects our ability to sustain our local level. i will stop there and take any questions from the commissioners. thank you. >> before questions. do we have any public comment? >> if you would like to make public comment press star 3. raise your hand and we will recognize you. i am not seeing any hands rais raised. >> commissioner you are on mute. >> i would like to thank dr. colfax for his report. this is the most optimistic

report we have had and i want to congratulate the department, you and your team for everything that you have done. it is no small accomplishment even in a small city like ours, small geographic area to have accomplished what no other city has accomplished to date or no other county has accomplished to date in california. to look at that graph to see us compared to the rest of the united states as you have indicated, it is positive. that reinforcement that i would imagine as long as we keep the issue of the threat alive. thanks to the mayor's leadership in all of this. i have a question and i know you are familiar with the article in

uas today regarding the concern -- u.s.a. concern about the impact of covid on the death rate for asian-americans in san francisco. it is heartening to know the possactivity rate is low, the ultimate concern with the high death rate indicates there are conditions within the asian-american community in san francisco that lead to outcomes that we hope not to continue. i wanted to really just be able to make sure that one of the other things we learned is that our testing is rated that asians are underrepresented in terms of rate of testing relative to

population size in san francisco. i know we don't have sub demographics available to us. i wonder if the high rate of death in asian-americans is likely, as you said, to be old older, those with could more bid did it -- co-high morbidity. very difficult living conditions. i wonder if that under representation in testing has any connection to what we have seen in terms of high death rates or a segment of the population not getting reached because of the conditions with which they live. i am not familiar without reach efforts targeting seniors, low

income, non-english speaking asian-americans in san francisco. is that something that we have focused on? if not, is it something we are going to be able to focus on? >> thank you, commissioner. just a few more data points with regard to the death rate. we have no indication the death rate is related to the testing rate. we really in looking at the data, asians are diagnosed with covid-19 are eight years older than the average diagnosis in the city. with the deaths, half of the deaths among asians have been in the congregate setting so we do believe it is age and the risk

of the living situation. most of those have occurred in the skilled nursing facilities of half of the deaths. when we look at the distribution of diagnosis by race and age, we see a much higher proportion of asians compared to other races diagnosed with age 65 and over. in san francisco, over 75% of our deaths have been in populations over the age of 60 so we really think it is the factors of the age, older age, and congregate living that accounts for that 38% representation. when we look at diagnosis of covid-19 in the asian population, the rates are -- th inequity in san francisco is in the latino population. we are doing substantial amount

of outreach in education in chinatown with other communities in san francisco working with cpos that work with asian communities to provide multilanguage services. we can provide more details on that, commissioner, later, but we do have a robust outreach and have been working with sros since early on in the pandemic. >> thank you, dr. colfax. i don't want to minimize the effort. i know as much as san francisco is a model overall for how we have addressed covid. it is a model for the competent anti-racist approach, equity approach to not just covid but other things that we are

concerned about here on the commission. i want to point out that there are pockets and there is a belief in the community there is something that is of greater concern than it would otherwise be to be tied with the targeting of asian-americans with regard to the national messages, targeted the population that there is a higher sensitivity and that is important to be aware of it and try to mitigate it. thank you, doctor. >> thank you, commissioner. >> thank you, dr. colfax. commissioner chow. >> yes, thank you, dr. colfax and commissioner for bringing up the topic and to thank dr. colfax for sending us the article in advance because i think it is a little distressing

that after the excellent work san francisco has done beginning, i know, at the time that we began the emergency declaration, a great effort was made to avoid anti-racist approach. part of the concern and the article on the asian community that was in the paper is somewhat dated because it goes back to the original papers that uc students and the doctor put together early in may which has not been subsequently updated. i did reach out to those who were sort of sheparding this along on a national level, but they haven't got back that there was any new data. this morning i did go back to see, and i appreciate the information that the asian population who has been affected by covid are eight years older.

this is the type of information that we were trying to get when we talked about this disparity and death several months ago. i think part of the article could have been avoided if we had more clarity and transparency such as we are getting today, but i find it very interesting and in fact a different approach and doctor aragon probably knows better on how to maneuver the data. i did look at the death rate that we have, and, of course, the death rate is twice that of the white population. they are .08 per thousand. in th the asian community .17. in black community is not much more. latino was higher.

i looked at the hawaii data, by the way everybody keeps data in a different way. as i tried to make a spreadsheet, there were a lot of holes because i couldn't make the translations. i turn that over to our great epidemiologist to do. in hawaii, chinese and japanese they did have numbers i was able to convert. i think iconverted it correctly. in that population they are running .18 and .19. and that was, i thought, very interesting. occasionally perhaps our .08 in the white population may be the aberration that we are trying to compare against in terms of this. i think it wases important to try to understand that when we are at 50% level for asians that i know that dr. colfax indicated

there had been issues with the nursing homes. we couldn't get enough data to help our community understand why this wases so. i think the information you put out today assists us. first of all, the population is older and probably other things that could be helpful would be i know that we have the heat maps. they were placed on asians. it might help the asian community help a scattering. there aren't hot pockets. the sro issue we raised several months ago with an incident in which the chinese press could not get a a satisfactory answer. we follow this protocol

religiously. within the article by u.s.a. today, there was a video in cantonese that talked about, of course, several individuals within the community that said they don't really understand what is going on. they live in an sro, communal dining -- restaurant facilities and they are not sure what they are supposed to do. i do know we have had great out reach on the sros with the chinese community management with those areas and definitely within the community itself there are no real hotspots that we see in the practice, but the fact that there wasn't transparency creates this distrust. then they keep looking at half of the deaths are asian. we are not really testing

everybody. we continue to get and that was an old community back from may. i think what i am asking we have more transparency. this is a large part of the population that may beings it look like we are actually not responding to them. i think the data probably shows we are on okay but doing just as well as we probably can. we have an older population that is getting it in the asian group. we still don't understand the demographics of the sros. that is really something that would be helpful for all of us as we were also looking at the -- and you just talked about the sros. something a little more transparent would help alleviate the concern in the community.

once again, it doesn't take away from the great work that you have all done. it emphasizes that. in other parts of the country, it also does not look like we are any worse. it isn't that asians happen to die more than the white population. that doesn't exist in california's data or the new york data. when they had 700 cases of deaths per 100,000, and meanwhile the white population had 1500. the implication that we are worse is not probably correct, although there isn't uniform data. i wonder if doctor aragon has any comments on that is i want to note that dr. aragon is appointed to the state vaccine

community. i feel much more comfortable that we will have a safe vaccine in california. if you have any view about this data and when i am right or wrong that actually the asian data does not support that for some reason asians are more susceptible and that, in fact, perhaps maybe we should look at our own nonasian population to find out why we are so low. >> yes, i will make a couple of comments. many of the deaths among asians happened early on when the pandemic we were still learning a lot. there are a couple things that the association between ethnicity and dying is

confounded by two major things. one is going to be age. we know that older age by it self-is a causal factor of dying from covid-19. then being in a skilled nursing facility. imagine early on in the skilled nursing facility when we didn't have the systems in place. we didn't have sufficient testing, sufficient ability to do mass testing. infection control was poor. if you were there earlier on you were on the early outbreaks in skilled nursing facilities. the asians that died in san francisco were primarily older and members of skilled nursing facilities. our data is comfounded by that fact asian and being member of skilled nursing facility. when you look at the case rates in san francisco, the asians have lower case rates than the

other ethnic groups which is fantastic. what i don't have in property of me is if there is a disparity in testing. we would have to pull the data to look at that. my overall assessment is that the asians as a group at least in san francisco compared to the other groups are doing -- i think we would have predicted there would have been more disease in asians because of connection with china. i think probably the opposite happened because of the connectn with china the asian was more adherent to pay coverings and taking precautions the rest of the groups in san francisco were not taking because they did not have the connection to china. i suspect that was a protective effect. >> thank you, doctor aragon. i hope that will all be taken

into consideration by people reading our article. thank you. >> thank you, commissioner and dr. aragon. commissioner christian. >> can we get an update on what is going on mental wise? black african-american and the disparities we have been seeing regularly since the data was presented? >> i think we can go back to the slide to show the percentage of diagnosis, is that what you would like to see, commissioner? >> yes. >> we can go back. the slides are coming back up.

if we could go to slide 3, please. this is hard to do. commissioner, you can see that of cases districted 5 -- distributed 5.8% black african-americans. in terms of deaths we have had the data that i have is we had eight deaths among people identified black african-american. again, 80% of the deaths have been correlated with a co-more bid condition. which is consistent with the cities. those are -- with the cities.

those are the key updates with the question that you had. >> if i may, i want to make a comment. that is that the african-american community in san francisco on average has done better than other locations. when you look at other areas especially on the east coast, african community has been devastated by covid. one of the reasons why we were spared is that we have some persons who were really active early on especially working with the faith-based community and really getting the word out early. in fact when you think of when we were restricting mask gatherings we had veronica shepard working with the black african ministers in the community making them sensitive to gatherings and decreasing the

amount of gatherings inside churches. that may have contributed to less of an impact. the other thing that you will notice that is in the data. in bayview hunters point, they have had high concentration of cases. over 70% in the latin x community. it is primarily in the latin x community in those neighborhoods with higher proportions of african-americans. it doesn't mean that could change. that is sensitive. it can change. the neighborhood strategy continues to stay vigilant with all communities of color because absolutely it can change. based on other parts of the country, african-americans are more vulnerable. >> thank you. i would just appreciate if we go forward that you include this

updated information about the black african american community here so people know the department is focused on it. >> thank you, commissioner. will do. >> thank you, commissioner christian. i have a few questions following up. based on the figures you gave me. it looks as though the death rate the african-americans make up 6% of those who had died in san francisco, which i believe is an improvement, i think, just following up with what commissioner christian said. we are seeing data in the future to know the testing rates by race and ethnicity so we know we are penetrating with testing strategies. it creates the fuller picture.

>> the testing rates are a challenge. the tests are across the city, not just dph sites. the data team has been working extremely hard to ensure the data that we receive is reliable and can be presented. i am optimistic we will be able to share those testing rate data, not just positivity data, the overall testing rate of that population. >> a few questions. i want to echo your sentiment as well as the mayor for thanking the people for how adherent to the public health orders how well our city is doing in controlling the pandemic and also to the fantastic work done with everyone in the department. they are working long and hard at ensuring we are in the position we are in.

i wanted to on behalf of the commission say that again and again. we can't say it enough. two quick questions. you don't need the slides for this. in looking at key health indicators, we are doing very well. our contact tracing and reaching our case investigation is stubbornly in that low 90% range. is there a reason we are not getting to the 90% target? are there more resources required with our partners to get into the 90% range in either contact tracing or case investigation? >> yes, if i could start in and dr. aragon may fill in some additional information. we set a high bar for ourselves with regard to the 8 89 -- 90%.

we are far above other jurisdictions ar. some have stopped altogether because of the high caseload. dr. susan phillip along with drg job. with h.i.v. and other diseases that during the vase investigation requires trusted partnerships. we are expanding training and work with community partners so that community-based organizations and people who have the intimate connections in neighborhoods with community are actually doing this work. today we released a grant opportunity for $5.25 millions to neighborhoods with the highest case rates which includes potential funding to expand contact tracing training

to community-based organizations in order to get those numbers up. i add that our cultural competency within our team. we have multiple languages available with regard to our contact tracing case investigators. with regard to the latino cases wwe are at 90% contact investigation rate. we have met the goal there. we are working. we have 50% case investigators speak spanish. we are working to ensure that we get that percentage up to our contact tasers as well. things are moving in the right direct. to get to the higher level, we need more investment and more training and collaboration with community partners. doctor aragon, do you have additional perspective? >> i was on a state call around

contact tracing. numbers around the state was in the '60s and 70s. i think our numbers are a little higher. i think they will improve as we train more of the community-based contact tasers. >> i think it is important to note that we wouldn't be as high if we didn't have such a robust testing in the city. that helps us stay current and up with our contact tracing. my other question and thanks to jim marks and the entire data team for pulling together the meaningful slides and data to help us understand the disease situation. we diversed from national trends around september 15th. do we know what that could be attributed to? people not going out because of air quality or heat at that time? do we have reason to believe our

disease situation won't sort of start tracking again with national trends as they have in the last two waves? >> i think it is multi factors why we saw things going down. i think, again, people got the message with the july surge. i think there was a big focus on doing more outdoor activities rather than indoor. masks became more social norm that we emphasized. they are so key to decreasing transmission of disease. we saw things moving opposite direction nationally. i think that there are those factors. certainly if we re-open more and dr. aragon said this. we expect to see more virus. while we want to sustain these numbers, the goal is to slow the spread. the idea we are going to stop it altogether is not realistic.

as we go on this -- we are far more cautious than the states allows us to be given our numbers, but we are very thoughtful and the issues we need to pause or as it comes to the need to reverse some of these openings. we are going to follow the data as closely as possible especially the increasing rate of hospitalization and that case rate is key. >> the only thing i can think of. i think san francisco has remained cautious in its approach and the way we use the state tier. it has helped. i think the better explanation for the divergence of curve is what is happening around the country. schools have been opening, colleges have been coming back, there is just a lot of outbreaks and seeding. there was a big motorcycle rally i can't remember the state.

there was hundreds of thousands of people that came together and went be back to the states. they are attributing a lot of outbreaks to the people infected there go back to their states and seed the areas where they are not doing physical distancing or wearing case coverings. these are the areas exploding are those not doing mitigation. that may explain the big guy thg divergence. >> commissioner christian. >> can you give us a sense of what we understand and know what is happening with native-american population in san francisco and to extent that you can the bay area and what those dynamics are and why we have so little information generally? >> commissioner, i can two ride

a few numbers. our numbers are quite small. we have had a total of 36 covid-19 cases diagnosed among people identified as native-american. i don't have information about the regional situation. i think it is worth noting in places, in tribal nations we have seen covid-19 be a huge issue. again, our numbers are relatively small here. dr. aragon may have more details regionally. >> that is a good question. i don't have any more additional information now. i would have to look. for native-americans in san francisco it has been an area we have struggled within terms of data. it has been harder to collect. we don't have the population

estimates to give the type of estimates we give with the other ethnic groups. it is a group area in terms of data. i don't have it at the moment. i would have to look into it more. >> thank you. i understand the work that is amazing the department is doing. it is huge, enormous, widespread. as a citizen in san francisco, i do find it concerning that we as a city are not really -- what is happening to native americans in the community is never really visible. given the expectation, i think, that i would have that their experience with helping with the cities, with this pandemic is

not a great one. that i would like to understand and i think it is invisible to us right now. that is not a good situation. i don't know whether there is any established outreach to the community that we do have in the bay area. i think it would be very important for us to know what is happening to the extent that we can. >> whawhat i can do is look into this. about an i year ago i -- about a year ago i did start meeting with a group around this topic. i will find out what i can. i agree with you. this is absolutely a group area for us. -- gap area for us.

>> equity and systematic problems, it has been th the native-american population has to be visible in that culture. >> thank you. i do not see any comments or questions from commissioners unless i am missing somebody. if we do not then we can move to the next item. general public comment. >> if you would like to comment on item 5, please press star 3 or raise your hands and we will recognize you. >> we do not have anyone. >> from the chair, commissioner. >> thank you. we had presentations on the

following items. we had the maternal child add do less sent child health overview. i will give you highlights p.25,000 clients served. the highlights of the program that were presented. pre-term birthrate. african-americans has decreased. this is a goal of continuing decrease in pre-term births. with the abundant birth access interception programs. they are making progress. also, gave us information and data on the wic numbers and what director armstrong will come back to us with updated outcome data on the pre-term projects so

we can see how -- what if progress towards goal of decreasing the high birthrate of pre-term birthrate. it was very helpful. i was also as well as the other commissioners were grateful for the background information that was not presented but that would give it to us on information such as the child maltreatment. it was a good and comprehensive report. the seconded report was the tobacco enforcement and prevention update, and we do want to note they did a great

job since the staff had all been activated for covid and are just beginning to return now. they were able to give us information on the tobacco enforcement, both the inspections and the decrease in the number of tobacco permits that have been issued, which is positive news. on the prevention front, there was an update of the education and prevention program both at city college, at san francisco international high school, and we have asked if it was possible to gypize that to the high school wellness clinics. they made us aware of the d.o.j. grant proposal for $1.4 million over three years that has been submitted. that is targeting prevention.

the other program that was presented was about the support and that the commit to quit with the media has been very interesting since covid that there have been 45% more inqui inquiries to the sfg support group as well as increase of 68% in calls to the california smokers' help line. we thought that was promising, and there are seven current cbos engaged to deliver smoking cessation programs. then at the conclusion of our

meeting, the three of us, commissioner chung, commissioner christian and myself discussed that we would like all future presentations to our committee to have a racial equity lens so that we have continuity of one of the department's goals of racial equity and that if this would then be included in the theme of all of the reports going forward. we have also asked in our november committee meeting to have an asis presentation looking at the what asis is and the data that can be collected in at all possible, hopefully just a computer search, of the

influence of the asis in trauma on health outcomes for individuals. we also discussed with the challenges that staffing particularly in the clinical areas that has been difficult and compounded by the price of the cost of living within the san francisco bay area, and we will discuss going forward a possible expansion of clinical internship program within dph to not only train future clinicians but it is also a recruitment strategy for those that have been in the multiple

universities in the bay area training in both social work and mft and the doctoral psychology programs. so we will have those on the future agenda. that is my report. >> thank you. do we have any public comment on this item? >> if you would like to make public comment press star 3 on item 6 community and public health committee update. >> no public comment. >> any questions or comments from commissioners? if not we will move on to resolution to recommend to the board of supervisors to authorize the dph to accept and expand a gift of $200,000 to the

laguna honda gift fund from the joan kelley-ryder trust. we have the treasurer. >> it is good to see you again. william frazier gift fund manager. i am currently deployed to eoc and outbreak management group. as you pretty much have read off my whole speech here. we seek a resolution recommending to the board of supervisors the acceptance and expenditure of the bequest from the joan kelly rider trust of $200,000 to the laguna honda gift fund. i will answer any questions you may have. however, anticipating a question, i can tell you that the connection between joan kelly ryder and the hospital she

had a family member who was a resident there and felt like that resident received excellent care. >> thank you. before we go on to comments or questions any public comment on this item? >> we are on item 7. public comment press star 3. i see no hands. no public comment. >> commissioners, any questions or comments or if not a motion to recommend. >> i move to recommend. >> i second. >> roll call vote. [roll call]

>> the item has passed. >> we will move onto our next item for discussion. behavioral health services and mental health reform update from mario simons, acting director of behavioral health services and the director of mental health reform. >> good evening. doctor bland is with me. i am going to run through a set of slides. he does have updates to share. then we will both be available to answer questions. many thanks to the mental health reform team to helping with the

slides. sso we have been asked to provie an update on behavioral health services to discuss and provide updates around mental health sf and reform and talk about our priorities for the coming year in these areas. so you have seen this triangle before. i think it is good to frame all conversations around behavioral health as a reminder about our system. we have a very complicated system and the four bars on the right are the form.

we operate two managed care plans. one is mental health the other is s.u.d. managed care. we have similar rules and regulations and requirements similar to those of the san francisco health which is complex. we also deliver services. as managed care plan we purchase two-thirds of the services from community-based organizations and deliver aid third through civil service. the green bar at the top of the triangle. the role of those early intervention is to be sure we have behavioral health resources embedded in as many places as we can in the community. we have staff ready to identify the earliest signs of issues,

behavioral health concerns and engage people in care. we see that by embedding services in early child care settings, senior centers, care clinics. we are working with the faith-based community right now. if you go along the more traditional mental health and substance abuse treatment path without patient residential programs, crisis programs and of course the highest level of care in the hospital. clients enter our system through many different portals of entry and frequently need to move through the system. we know that one of our challenges is about the access and flow. we have a lot of great things that are working. there is opportunities for us to do better to let people know the services are there and help them to successfully engage and the flow is helping them move

between systems and different level of care. we will go into more about the system. we wanted to provide that. stop me if you have questions along the way. there are a lot of things happening for the behavioral health across the health department including prop c, mental health sf. we have quality improvement work that we are pushing in behavioral health. we are expanding access across the department. we started to think about how are we organizing the work that we are doing over the next few years? we are organized the beginning of our three year plan around true north of none of this can be separated from mental health sf and prop c. i want to talk about the

framing. on the care experience we want to be sure we have enough of the right services which is what that network adequacy meads. timely access we are getting clients into care quickly so we know for outpatient we want people to get into outpatient appointments at the point they requested within 10 days. we need to establish metrics to track them for access to residential in terms of case management. when people get to care we want to be sure they are engaged. there are a number of people touching the system not staying engaged, and we need to understand that. of course, we want the care we provide to be cultural relevant for the very diverse communities we serve. the work force which is our most valuable asset that we have, we want them engaged and supported. that involves everything from clinical training to professional development, supporting them to grow in their

careers in advance through classifications in the health department and also taking care of their wellness and really acknowledging the incredible work that they do. on the equity front you will notice that equity goes both across, up and down and side to said. that is to acknowledge that every one of these as w we start to get to the specific metrics which is where we are right now. we hav have to look at everyonef these from the lens of ethnicity, gender, language spoken and other things to be sure we are identifying and addressing disparities. we want our work force more reflective of communities we are serving and within the equity framework we continue to push on better gender identity data collection. we are a treatment system.

when people come to us, we want to be sure we are achieving the goals for their treatment. the safety topic we are looking at reducing the time that our clients are in crisis, in jail or living on the streets. very, very much we focus right now on reducing harm from substance abuse. there are new numbers showing 450 that happened in the first months of this year. we are doing active work. on the financial stewardship we have a lot of opportunities we have uncovered with research recently to generate additional revenue. you will be hearing more about this, but i wanted to share the frame and we believe that if you look at things happening on the federal level, state level, local level, even funding from

the police department, all of the goals and initiatives and funding can easily be addressed. not easily. they can all fit in with this framework, and we will be able to have everybody across dph understand and work more collaboratively to get to these goals. i wanted to share a little bit about covid and the impact on our system. for everybody across the city it has been a very profound and difficult time, profound impact and difficult time. dhs for the last 8 months is focused on different goals related to the covid response. really wanting to maintain essential services while also

keeping clients and staff safe. we have been integrating behavioral health services across the covid response system, providing support to city staff and first responders and promoting wellness in our communities. i can answer questions about more details. i wanted to frame the work we have been doing. so we are seeing a definite impact from covid, all to our crisis lines calls increased. link caninlinkage and outpatiens increased. we know the impact of covid has been significant especially for our vulnerable families. there is escalating violence and

family conflict and increased calls to crisis and psychiatric hospitalizations for children. covid has impacted our system across the board. we have had to limit some of our face-to-face outpatient care. we are still doing intakes and urgent appointments. it is really the numbers have gone down. clients are serving our -- are receiving telehealth care. we have been successful in expanding telehealth. we have had reduced capacity because of social distancing in residential treatment programs, and psychemergency has been expanded. we are going to continue to see impact on revenue streams because we are not billing as many units of service because of

covid. so there were a set of questions that mark shared, and this slide is intended to address those questions. a couple other issues that we know have been priorities in the past that we wanted to touch on. the timely access i talked a little bit about. we definitely are seeing because of covid impact on the time in which clients who need a patient and residential are getting delays and access to care which we are trying to figure out how to address. a lot of that is related to existing vacancies. i will talk in a moment about hiring work we have been doing. we also have a number of our staff employed to the covid response. the vacancies with the

deployment have impacted the capacity of our clinics to keep up with intakes and to continue working with clients, many of whom have that increasing acui acuity. on the intensive case management front we have better able to track data around how many people are waiting, how long it is taking to get them to care, we implemented in january a new icm wait list system that before we had individual programs maintaining wait lists. now we have all of that information centralized. we did assessment recently looking at wait times how many people were approved for icm. we looked at that by ethnicity. there are not any disparities we are able to find in that one piece of access data. obviously, there are many other things we need to look at.

the wait list is 10 to 150 days to three months easily on average. thankfully with children with our case management programs there is no wait time for that program. i mentioned hires is -- residential treatment. we aren't able to tell a clear picture about the access -- wait times to residential programs. again, a lot of our c.e.o.s maintain individual wait lists. we implement something new soon as part of mental health sf something called call intake. a module within a vatar

system-wide for residential and outpatient to create a record when a client calls or walks into any programs that use it. we will track that contact into an episode getting opened into how that person gets engaged into what the outcome is. it will be a game changer in what kind of data story we tell about access in our system. we are very excited to get working on that. dhs is working to take that management on. we are ready to post the vacancy data for mental health residential treatment. we just have to get that turned

on. this call intake is really important. on the hiring front, we are weeks away from round one interviews for the new director. there is a memo that provides more detail about the hiring outlook. >> we have 97 vacancies. >> they will help on the hiring. >> supervisor mandelman: ger side to make sure they get everything -- we are working on a hiring 40 f.t.e. which is

behavioral health clinicians. some from primary care. but the goal of that hiring which we are doing similar to the nurses for general is going to allow us to fill most of our vacancies across the board and start to plug in to some clinical deployment so the staff can come back to the clinic to take care of clients. historically it takes a year to hire behavioral health staff. we want to tell the story in a more clear and data-driven way that they are partnering on the dashboard. we have had some examples how that is done in the past so it shouldn't take too long to get that up and running. we are looking at how much is in the hiring plan. in each different stage so we can identify somewhere some of

the bottlenecks are. so that is something we will be able to share very soon. we are doing a lot of work in work force development. we are finalizing. we had an equity work plan from dhs last year. we are finalizing the report out from that work and getting ready.

chair coordination and are really necessary to better serve people and again, really upping our game around harm reduction from policy to practice. next slide.

mental health sf, just is a reminder of the frame is it really asking for dph and behavioral health to build a system that is more client-centered and that the target population for mental health sf is again, those that are experiencing homelessness. it also talks about everyone who is enrolled in medi-cal and calls out a specific need to better serve people coming out of the criminal justice and.

>> now that we have the names we're moving for planning and hope to have that first meeting in december and january. so we have organized ourselves on the n.d.p. h to get this massive amount of work done and we're using a similar structure to what was done with the epic implementation and so you are see in the chart it's really a simplified version and looking at the five main areas of work first is the office of coordinated care and the street

crisis response teams that we're developing and the mental health service center and new beds and facilities and then the implementation working group which i just mentioned. and we are currently getting so much support from bch leadership which really is horrific to get as much project management support as we can and leadership investment is really, really clear and then our data and i.t. systems, hr, all of our enabling organizations and are stepping up to be the backbone of this work and we're highering the new director and the mental health reform team is invested in and actively engage in in all of this work. next slide. so in order for us to be successful we know that we have some things we need to pay close attention to that project management support is key.

>> debbie: sure it's as streamlined as possible and there are critical and very basic especially looking at the equity and disparities across our system and there are a lot of groups and initial focus across the city and that is a very and there's so much alignment that they want us to achieve and real estate is a big issue. being sure that we have enough space for all of this programming and working on contracts with cbos is another area of our business operations where we need to work on streamlining. next slide. in order to get this work done,

we havwe are making some changeo the dhs organizational structure and i'll talk about those but first i just wanted to mention that where we are vhs fits within the dph structure is changing so there's a solid blue box and that's where i sit currently reporting under ambulatory care and behavioral health will be moving out of ambulatory care and up the organizational structure closer to rolland and grand next slide. so this is the behavioral health services kind of future state organizational chart and there's a lot of things going on in this

chart but i just wanted to call out a couple key things. one is the director of behavioral health at mental health sf is here we haven't really built the structure we need to do that as well and successfully so the managed care side of the house is going to manage things like our regulatory affairs and quality improvement assurance and roadway bust member service and work around communication and the specific mental health and that's where you will see a lot of the focus and flow and getting points to the front door and the system and is part of

that as well as awe new and ensure clients are get what is they deserve. system is care is where we're asking and greenish boxes and that is where we are imbedding the crisis street response system and we also have within the system of care and the wark wore doing in the shelter and hotels and our -- it will be the engine that drives a lot of this work and the legislation

mentions a lot of how that access and flow, a particular challenge, on this slide you will see on the right side and there are similar graphics on the slides that are coming up. this shows where we are kind of developmentally in our planning phase and you will see a lot more details in these slides as when we come back next time. but these slides are similar but focused a lot of phase 1 is hiring staff and building that basic infrastructure so the office of coordinated care has responsibility to coordinate all behavioral health services across the city and across dph and private hospital and work better with the community clinic consortium so there's and

consultation is linkage peace will be key. provides one door with a big blinking life and anyone who has concerns with clients can come to this door and we'll help the client get tclient get there. we have to sends someone out to do an assessment and warm hand off and other times we need a really intensive wrap around kind of a friendly stock to go get someone engage and we help connect them to care and we don't stop until they've connected and we step back.

case management, at the intensive care management level, down to our out patient programs and it's something that we have resources to expand with mental health sf and prop c and then improving our data collection and evaluation services across the board. we are building out street crisis and there are about 21,000 phone calls that come into the 9-1-1 that relate tie mental health related issue and our goal is that we have our crisis response teams will be the response to those calls that no longer will the police be responding to mental health emergencies. these teams are going to be deployed rapidly. they are made up of a ems6 which is a fire department paramedics

and behave aerial healing clinicians and trained peer providers and those teams are going to be able to provide again the rapid response, do a lot of deescalation and those teams will work very closely with the consultation of linkage teams of the office of coordinated care you will see the timeline. we're hoping to have our first team live by the end of november and then bit end of the fiscal year we'll have up to 16 live and then we will build the teams over time. we are aiming to have 12-hour coverage seven days a week. we're going to be really data-driven about where those teams are going to be placed and what hours they're going to be placed. we have a lot of terrific data

from the department of emergency management and to help us make these decisions. we're also want be to be very conscious that the 9-1-1 calls coming out of the southeast spector of the city are relatively low and we expect that we want to be sure we are understanding the need and not just the data if that's not a full picture where the need is. next slide, so the mental health service center a key part of the legislation calls for there to be a threshold drop in center with 24/7 access to mental health and substance use assessment diagnosis, pharmacy

and psychiatry and transportation and we don't yet have a service model for this and so we're excited to be working with the implementation working group because we really need to be clear where people are coming from and what are we going to do with them when we have them and where will they go after. we node a clear service model before we start building out the space. so there will be more on that soon and i have two more slides and the next slide -- is thanks to the great work of the team, we have a data-driven understanding now of where the bottlenecks in our bed systems are and we have kind of a ingredients now for and the

crisis diversion facilities because we have these crisis teams on the street and where is it they can bring people and sometimes the current capacity is not enough so we want to have more capacity to divert people away from the hospital. the last slide is looking ahead and big focus on a structure and hiring in the next six months and working with all of those city initiatives that are invested in behavioral help and the prop c we also believe that the work about redistricting funds from the police department are very relevant in these conversations and the alternative housing behavioral health program is a lot of the behavioral health happening and we want to fold into this work and then i just want to close

with the reiterating and really recommitting this came out of mental health but it's still so relevant is that people facing homeless niece needs to have low barrier and healing care that matches their needs and we really need grounded in evidence-based and increases recovery and is we are going to see changes in our system and look forward to talking to you again another time soon. i'm going to share a couple of things. >> thank you. hello dr. bland.

>> hello commissioners, hi, i'm here today to update you about the release of an update from the mental health reform team. this update was released in i believe included in your packet and the background for today and and the public available on the dpa and this document and it was initiated by mayor breed to start the transformational change for mental health services in san francisco. there are a couple of key takeaways that you will find within the document and one of qi is we want to characterize this work and really and projects and increases transparency and all of our city programs and we focus on the

homelessness. and we notice this document reports around equity best achieve equity for our system services and then lastly that it's fully aligned with san francisco and advance services and initiatives that provide the foundation from mental health san francisco's planning and implementation. there are a couple of key themes within the they will expand and

crisis response system and we are actively engage in the response teams and that director is involved and you may recall that our teams supported the development of the drug sobering system and prior two coronavirus response and lastly you will see a new model of care for crisis

introduce telehealth medium and so i will stop with that and i'm happy to join director simmons for any questions and again, the link for that report will be posted and it's available on the website. >> thank you. i also want to acknowledge that in addition to all of the work that you've been doing, and you are entire team to set up this whole new system to layer on top of that, everything that's required to respond to the covid pandemic as well and adapting work to that, we're very grateful for all of the additional effort that is taken on top of everything you've done because i wanted to make sure to

acknowledge that as well. do we have any questions or for director simmons and i see to the extent of the work and i would hope and i would like, especially in the areas of mental health reform with the crisis team and the coordinated

care all of the different area that you profiled today and if we could have just highlighted data and i know for me to understand what -- how you are working going forward and i don't want it to be a laborious you are going forward with w but in march to give plenty of time when you will have the third phase of the street crisis team that you will just have some

information in data and to bring back to us within all of the areas within the mental health reform and you are going forward. so it's just an idea, a request to update our -- both the committee, my committee on the public-health committee as well as the full commission and also, in whatever we can also do so however we can support your work within the community and i would personally appreciate any help that you might need to please reach out in going forward.

so it's more comments than it is a question. >> i want to say thank you for that opportunity and particularly in crisis response team. we have planned a robust evaluation and actually that will begin in the process of the planning for that this week and so i expect that as you indicated by march, we should be able to report out our initial findings and at least the first half of that period of time around our outcomes so i'm looking forward that that. thank you. >> thank you, and a apologize to mr. moore owe wits, i forget to ask if we have any public and prayer commissioner comments. >> if you would like to make public comment on the item, press star 3. there's only one caller at this point. looks like there's no public comment. at least we've done our due

diligence. >> commissioner chow. >> yes, i'd like to thank both for the wonderful presentations and very complex presentations and just i guess is merited because of the complexity of the situation. and i echo commissioner gerardo suggestion that we try to have a framework even with benchmarks and or time lines and some progress that allows us a fairly simply to be able to understand the work that or how we follow a building progress and how we're following actually the bond issues and where we then and a

fairly simple outline hoping not to overburden for details but then that would allow for context as to where the goals are which benchmarks we have or have not received and you've got your phases already so that's very good. and then ultimately, and i know on primary care it took a while to get to the score cards, but i would imagine a score card that would then tell us how well we were meeting our progress but, i would certainly second commissioner gerardo's process of a suggestion. thank you for that. commissioner christian. >> first of all, i want to echo what everyone else and said and what everyone else is thinking.

thank you so much for this incredible work. the doctors and i also want to thank you for the clarity with which you have presented a very wide ranging and complex endeavor, several endeavors leading into one over all effort and it i visually, it's laid out in a way that is really enhancing the ability to follow and understand so, i want you to realize that you hit the ball out of the park on that level and thank you again for this and echo commissioner gerd arrow is now that you have a incredibly clear and youthful and what is

is, it's like 150 million a year and at least 50% that have will go to housing and at least 25% of it is going to mental health and substance use services for people experiencing homelessness and so like there's that implementation working group for mental health sf, there's also a oversight body for the prop c and so that group just has started to convene so it made up of a mix of cvos and community

advocates and real champions who help to get that passed and so we're working with that committee and i did a presentation for them today and to share about all the worrying we're doing so we'll work very closely with them and supervisors pushed on mental health sf and the mayor's office and there's a lot of people involved. so that is help around the prop c? is that what you wanted. >> that's a great reminder of what prop c is and what it did and it would be wonderful to have links for the names of the

people who have we can share that information for sure. director coalfax. >> thank you, i wanted to express my gratitude to behavioral health division and the behave yearal health reform team so the work is and doing this during second and it's challenging and in any given year, without covid-19, this work and the implementation on mental health sf as we restructure our behavioral health system would be working preportion and epic in the true sense of what we did with epic and i think the transformation that we are all committed to having happen is unfortunately going to have to also go more slowly given the competing needs

of covid-19 but we will get there and i appreciate the commissioner's comments and we are responding to covid and addressing the behavioral health consequences with covid, this opportunity to reform our behavioral health system is incredible and it's going to take more time and thinking this presentation that we will get there. >> thank you director coalfax. commissioner green. >> well, they have a structure you've created and i was referring and 11 months ago and the supervisor in 2018 instead

of these four marries and audit and that's when i implications concepts but they had been in no way and developing and or involved having the. >> carolyn: edible and structure and will allow some of these areas of concern and to fall into under buckets and ways we can participate better and one of the questions i did have those is one is how we'll ought i had or see the results from our cbo partners and case management and i know you mentioned that the timing is longer and i know in november they said that we gone from, we've gone from 14% of individuals in intensive and 30 days so 36% so this is incredible and progress and over the course of the year and why

we are now and and then there was a whole issue of transition to lower levels of care and what we're doing with the adult who's don't table eyes and of course, what you are talking about with the street teams and clearly going to go a long way in that less element and i'm wondering a little bit about the whole question about and the slide you shared about the various ways of people entering the system is can you speak a little bit about how you are going to follow-up with the rcbo partners and also, what we're going to do with that whole issue of intensive care management because, without it, we can't really expect great outcomes and wonder how it relate to staffing and that regard where there's -- they are

waiting for services and where we have the better tracking system and so our data is better now and that is within of the very first things we're going to start doing and that will be moving quicker because we're going to be able to contract with our existing icm providers to expand their caseloads so we won't need to do a new -- a lot of new contract and and the management team. we talked a lot last year about improving the management so knowing when someone is able to

move down and make plans to really look at our case, 1,200 current slots and figure out who was ready to graduate and step down and we started that work but then we started to really understand that stepping someone from an icm program down an out patient program, sometimes it's a challenge because the person is ready to leave the icm but they don't have the case management capacity that they need to really hold the clients during the transition and so our case management expansion under mental health add best will be both at like critical linkage, attempted case management and at the out patient program and so we can start getting the flow and then we'll also be building out the utilization management structure we don't have so we will start to identify when people are ready to move or sometimes they need to move up and so it's a step up and step

down. all of those pieces are going to really, really help us. we need more capacity for sure. i hope this answered your questions. >> thank you so much and i think what you are doing is excellent and now we have a structure that is actionable it would be great to see the data and it would be positive as we go forward. >> thank you for that. commissioner chung. >> hi, thank you dr. simmons and thank you for this presentation. so, i guess for me it's kind of has a context to what i want to say like in the last 30 years, i get to witness someone who needs to be clustered like (inaudible) like clustered in order to get

into a certain level of services and then when i was working for substance abuse programs, i breadread writing out a referrar the committee. this whole process, in terms of the change in technologies and also this integrated systems, i am really excited, you know, to learn what is going to continue to develop because this will save a lot of lives and this is going to help people find the stabilization they need so they can continue to experience good quality of life and this is not easy work and i've been there with certain people up and down and the level of care and so, my

you can do it with the push of a button. how is mazing is that. i want to be sure they get the credit they're due as well.

we are a lot of discussions in the time took to fill positions many times and as long as 12 months and i wanted to ask you particularly when you look at things you were saying that covid is taking a greater toll on our children youth and families and their care management positions that are not filled in those areas and it just brings into sharper focus

covid is hard on everybody and home schooling and the work they do in public mental health wasn't easy before covid and now it's taking a toll so again, we're upping our game around staff wellness and support and look to go better understand those barriers to access and we have a lot of work to do and i wish i had something more and balancing with demands and not enough staff is hard. i wish i had more to report and i welcome anyone else from the leadership teamworking so hard to we're starting to track data

in a way we haven't before so we can tell that story. >> it's important you let us know is happening and you appreciate that and the commission is going to work with dr. coalfax to ensure we're doing everything we can to hopefully accelerate those processes and i know it we can't express to the dhs and everyone for your hard work and acknowledge the additional (inaudible). >> the left of support we're getting to address these issues and is really, really terrific so, they get the priority and they're supporting us and we're hiring new ht staff for behavioral health and this is been identified as a top priority for everyone involved so i expect to see movement very soon and that data dashboard and

we'll see that clearly. i see hands up and i'm not sure if they're leftover or other commissioners have comments or questions. for everybody's information to support what director simmons and the child they have at cpmc not just for behavioral health but for all of our services that conclude ot and social work and bee hair yearal health we have a wasting list of 415 families and so i just want to support them

and knowing they're doing their best but there's so much need out there and we have staffing issues and with our medical centers and there is a lot of need in dps but is not alone and i wanted to thank staff for everyone's understanding that we're all trying to meet the needs but it's big. >> thank you. >> >> thank you for the commission support. i just wanted to take a moment to acknowledge simmons work and leadership and she stepped into the director role without us anticipating -- well none of us anticipating quite a year it would be. and her intrepid leadership has been tremendous and managing to balance as much as we can all

these competing needs that were there before covid-19 and covid-19 only highlighted them further and created more demands on our system and i think as we've thought through in the presentation, how to restructure our system and the new investments coming in we'll get there and i just want to really thank her for stepping in and stepping up and it's just been a remarkable role for her to take on during this unprecedented time. >> thank you, director coalfax. commissioners, any other questions or comments in if not, thank you again dr. bland and director simmons for your very informative position and thank you to you and your team for all of your hard and excellent work. >> thank you so much, everybody.

>> ok. we will move on to our next item which is the opioid and stimulant overdose mortality in san francisco 2020 update. dr. coffin, dr. phi dr. philip . so i'm going to talk briefly about the current status in terms of opioid overdose death and substance use in san francisco. the data is different from what you saw from the medical examiner last week. the medal examiner data includes both post closed and open cases and the data that i'll present is only closed cases. so, it only goes through 2019 and as you probably saw, the

data for 2020 suggests that we're on track for the deaths in san francisco. so, this chart shows you the number of drug overdose deaths by mutually exclusive category so in the bottom in flew, is opioids without stimulants on board and as you can see, it is fairly flat and it increases a little bit in recent years but otherwise it's not too, not interesting too much and the orange bar and the gray bar and the cream bar which of the second third and fourth bars from the bottom, those three bars those that are actually increasing the most in last couple of years and this is opioids and and looking at just

ownership deaths this gives you an idea of the number of opioid deaths by type of opioids and so in plumas is pro description opioids and things like morphine, oxycodoan and things like that and excluding heroine or fentanyl. in orange is heroine deaths and we see heroine deaths are really quite low and the era when prescription opioids were the driver of ownership overdose mortality in san francisco and they increased a little bit as we reduces prescribing opioids and they increased a little bit and they're still not too, too high. what really happens was fentanyl and the gray bar which we saw first start to pop up the tental deaths is where you start to see a little increase and that is the manufactured fentanyl and

you see that start to really pick up the second half of 2018 and that was it's older than most other locale tees and with most stuff happening among people in their 40s or 50s and and in terms of rate per population africapoppopulation,s bear a higher rate of opioid overdose death than other racial and ethnic groups.

there were 162 deaths among non white non hispanic individuals and 79 deaths among non black individuals. we have a number of people who inject drugs in san francisco and they suggest that 40% are white and 40% of black african american. so, it's the issues may be different from just a higher overdose mortality rate and and in terms of fentanyl, the substance that most concerning on the streets today, this chart gives you a sense of the deaths

of fentanyl in combination with other drugs. the blue bar being fentanyl alone, and the other three bars at top which are fentanyl and so it's fentanyl along and it's not heroine and the reason for this is likely this is in unstable dose for us what we're seeing is it's sold as festiva as black td you know you are accessing fentanyl and you are intending

to access fentanyl in so, again, looking at the orange this is methamphetamine deaths so we've seen not increase in methamphetamine deaths through 2018 and it was an increase in

part in methamphetamine deaths and starting in 2018, really, the increases that we saw were fentanyl related. is he, the fentanyl deaths look like ownershi opioid deaths in f demographics and they tend to be more driven by opioids and to appear more like opioid deaths and than they do festiva fentanl deaths. the game goes for cocaine. with the gray line representing cocaine with fentanyl and blue bars are cocaine without opioids. so i wanted to spend a little more time on the fentanyl.

we're seeing deaths for young people for fentanyl than with other opioids. now, this is a little bit of a confusing chart but if you look at green, that's the age distribution of the fentanyl overdose deaths among african american black individuals and san francisco. as you can see that really is among the older of people around

60. the individuals in the blue and pink is a little bit concerning to me because if suggests -- they can respond to an overdose and we don't see as much death among younger people from overdose events. it's among older people who might be more socially isolated or have co morbidity so seeing that spike to the left among white and latin x individuals is concerning to me.

we have had a large focus on prescribing and we've increased every year the number of people who have a decrease in the prescriptions issued in 2019 compared to 2018 but an increase in the number of people that prescribed it and it would suggest that more people were prescribed it but fewer people were retained that year. the numbers have again down since 2015 and we have increased

the opioid disorder not decreased as this graph suggests. likewise, alcohol primary care team and the methamphetamine treatment admissions they did go

up in 2018 and 2019. by rate of the population and and if there's a on black african american individuals compared to white or latinx. in terms of naloxone programs, project recorded over 7,000 refills in 2019 and well over a thousand new additional people dispensed naloxone and over 2,500 reversals reported to the program and this only represents part of the in the event that

they interact with someone with a disorder and or who surf suffn overdose so this is only a portion of the naloxone dispensed in san francisco at this point. we also -- the city started funding the addiction care teams and in and at the dcfg and that program which efficientlily supported i believe to one half of one attending and that program has picked up it's pace and continues to grow with a fantastic addiction medicine fellows team at the hospital and

has expanded with patient navigation services and really trying to kind of close the loop on care in san francisco. they managed in fentanyl without suffering an increase in over mortality generally about a for fold increase which we are probably on the path towards. even cities like vancouver, which are not hamstrange by federal policy restrictions they do save consumption facilities

and even facilities like those have not managed to avert the increase and have really struggled with getting it under control or trying to reduce the number of overdose deaths related to fentanyl. massachusetts put a investment to stabilize the number of deaths and it looks like they were coming down until 2020 they have it's related to covid in san francisco the real covid, the only increase that i can really clearly attribute to covid is a spike that we saw in the month of may that we believe was related to social isolation and it was actively addressed through the dope project and our

other partners and that spike could resolve and and there are other interventions that we've heard about of course the sobering center for drugs that was supposed to get off the ground last spring and got that

is the category we expect to see increase what's we see increases and so that ask not too surprise to go me and more concerning to me is the younger spike that we see among white and latinx individuals. and we're seeing increases, even though we have fewer opioid prescription and more naloxone, it's all explained by the speed with which fentanyl kills despite the interventions so as i said, no locale tee has really achieved, found the way to

control the fentanyl crisis. it's a real challenge and it relies a lot, i believe, on people becoming comfortable with the drug and markets stabilizing and it's also challenged by the fact that festival is not just one drug but multiple times of comment which are less than twice as powerful as heroine and 50 times more powerful than heroine so we do see both of these in the community. people might be accessing fentanyl one day and a very difficult fentanyl the next day and people tend to believe that by smoking fentanyl, they reduce their overdose risk and because they can tie trait the drug more

readily. i don't know if that's true. i think it's a great subject for future study. next question was what are we going to successful treatment programs and again, but no one has been able to avoid the increase all together. i'm happy to take any questions. there's no one on the line so there's no public comment. commissioner. >> thank you dr. kaufmann for an excellent data report and i was

wondering there are no (inaudible) information on the report and so i just wonder to the extent the (inaudible) are you able to break down. a again dea gender or sexual orn from age and ethnicity. >> we have a slide limit. it's pretty consistent overtime and in terms of substance use and.

>> that's an excellent question and one that comes up often with this topic, since so many of the deaths involved fentanyl and the stimulant. so, this comes more anecdotally and it's more from talking with people on the streets as well as the naloxone distribution collects samples of drugs that caused overdoses and has those tested at the clin lab and those

samples tend to show either fentanyl or stimulant so they're not mixed together and there's some slight contamination sometimes and we don't really what we think we're seeing, we haven't done the kind of work which would really be called forensic interviews where you would actually take a large cohort of people and looking descendants and try to get details and test the substances and so those kinds of work is generally not done in these cases and it would be more of a research project, which i would love to do. and i believe that most of these deaths are either intentional use of fentanyl, people property

with the fentanyl lasts a long time and lasts longer than heroine in contrast to the short acting sometimes they're not getting things done and getting everything taken care of so they'll use a stimulant to be able to take care of things. so there is a lot of intentional co use of stimulants with fentanyl and there are cases and i don't know the preportion, my total guess is it's somewhere around 10% or 15% of cases or accidenaccidental use of fentanl because they took the same. people are used to opioids being brown and tarry in san francisco and stimulants are white or powder' and rocky and they show

up as we use a line of cocaine and they just use it and drop immediately and then the people with them don't know what to do so we try to encourage naloxone for anyone who accesses street drugs whatsoever. >> thank you. it was really informative and very much appreciated. >> thank you, commissioner green. commissioner chow. >> yes, thank you for this informative if not depressing report. and i'm just really mystified that throughout the country there doesn't seem to be a feeling that -- amongst the people taking it and you are saying so many are actually even

amongst the young it sounds like a lot of it is quite deliberate and and you are saying nation wide we haven't found a way to try to, i guess, the word education is probably not right but, almost necessarily really

you you said there's no real solution. i guess i'd like to ask what are data, what do we think we are doing about this and just also incidentally i don't know if there's any data of any healthcare population and so we're categorized under other again. >> the numbers are too low to separately list. >> is there a reason it's so low within them or is it just because they're used to it low and something there that and we

have the number of people who inject drugs and among those estimates it's a small preportion who are it and of asian or pacific islander heritage. so, i wish i had a great answer. what we do is we take every evidence-based tool that we have and we try to deploy it as aggressively as possible and recognizing that we're not going to stop this but we can probably lessen the blow and speed the resolution of it. the reason festival takes over is it is so much easier to make, easier to distribute, cheaper, more potent, bang for your buck essentially is just overwhelms any of the other opioid

products. it overwhelms heroine for sure and it also with pre description opioids on the decline they're extremely expensive these days. >> so, i guess, you know, we've had a very successful run on trying to reduce smoking and trying to reduce you know, and seen just self-center. >> a lot of that is taxes and it's hard to tax illegal drugs. unfortunately the punitive approaches have not born fruit

around the country either so, the educational approaches, again, a lot of the prevention programs were dis proven like for example dare was proven hazardous and some take more of a harm reduction or age-sensitive approach to how they address substance use in among youth that might have better evidence. i'm not sure. this is a. >> thank you for your honesty and it's really depressing and i'm hoping there's got to be some solution to it that i know

it sounds like you are trying and i'm really very disheartened that it's so readily available and yet. >> number one is sounds like from what you are saying most of the folks who we're seeing who are overdosing are actually seeking out fentanyl. so it's not as though fentanyl test would be effective, is that correct? effective measure for distribution to folks? >> yeah. we'd like to see fentanyl test strips is a great idea and for someone not using an opioid it makes you have to dilute and they're we have to dilute in

half a cup of water and test it which sounds simple but it's too complicated for a lot of people to achieve. so they don't end up being as useful as we have hoped and i don't know if there's anyone trying produce a test strip for a cure drug that won't cross with methamphetamine. >> and then in the directors report, dr. coalfax mentioned in his first item the legislation reintroduced by senator scott wiener at the state level. what you are your thoughts how helpful it can be to reduce the tragic levels of overdose and deaths we're seeing? >> it's really essential. and this kind of spike draws -- it's yet another reason that we need the type of facilities in san francisco and there's a limit to what it can do because of the limit of the number of

people it can serve and it's not going to fix anything and it can help additional, i would like to see additional drop-in sites. a lot of these services though, conflict with our covid aims so, we have a little bit of time now and whether it's just to exist. >> thank you. >> commissioner chung.

>> thank you. for the presentation and it's like all the customers says it's disheartening to hear like the kind of numbers that we are seeing now. in terms of the harm reductions approach, we believe the overdose messaging that existed in san francisco allowed the city to avert the first two waves of the opioid crisis in terms of overdose deaths. we didn't, we saw a huge increase in the number of people who injected in san francisco but we didn't see any increasing in mortality and we think that was achieved through this messaging and culture of

overdose prevention that grew in the city and fentanyl is different. fentanyl can cause deaths very quickly and so if in general, it takes at least 30 minutes to die from a heroine overdose. and the needle in the arm doesn't happen and in general it takes about 30 minutes to die. your respiration rate declines and if someone responds and 30 minutes you are almost certain to survive. fentanyl is very different. it comes on very fast. it crosses the blood brain barrier extremely quickly and is very potent. so, people, you know, if you -- if two people are using together and one of them overdoses on fentanyl, the other one formally, if it was heroine when the other one woke up from roused themselves from after injecting, they would have time

to save their friend, however, with fentanyl, you don't. by the time they wake up 10 or 15 minutes later, that person is in cardiac arrest.

>> hi. i'm chris manners, and you're

watching coping with covid-19. here are some suggestions about how to deal with poor air quality from wildfires. they're pretty similar hohto h we're dealing with covid-19: staying inside and wearing a mask. [♪] >> the best thing to do when the air quality is poor is to stay inside and have your windows and doors closed. some modern heater units can clear the air indoors if they have a fan setting. another alterna anotherti another alternative is to consider purchasing a fan set up. if you need to go outside, wear a mask and keep your outdoor activities as short as possible. if you're driving, avoid the outside smoke by running recirculated air in your car and keeping your windows up. unfortunately, cloth and surgical masks don't protect

you from wildfire smoke, and n95 masks, while effective, are still prioritized for essential workers. there are other options, though. some cloth masks have a pocket that fits a p.m. 2.5 air filter. worn properly, they can help protect you from fine particulate matter. while they're not exactly the same, they provide effective protection from the virus and wildfire smoke. limit your exposure and avoid demanding outdoor activities. check the filters in your heating unit, and also your car's passenger compartment air filter. replace them if they're clogged or overly dirty. another thing to check is your vacuum cleaner. it could degrade your indoor

air if the bag is fullerton o clogged with dust. checking local a.q.i. values is a good way to know when it's safe to go outside. there are websites and apps you can check for data, and you can also sign up for the air quality alerts. less official sources, such as purple air, and the visual app also provide reliable data. and air s.f. will send you air quality alert if you text your phone number to 888777. finally, try to not create indoor pollution by not smoking inside and lighting candles or

incense. you can cut down on driving and other outside driving and other activities that produce dust and emissions like barbecuing or using outdoor fireplaces. here's a quick recap. and that's it for this episode. you've been watching coping with covivivivivivivivivivivivi >> hi. i am alia, and i am