entrepreneurship cooperation celebrating five owners leaders and senator scott. and also a nice woman tammy who liked our stage. piano fight--is much more. to convert our our 47 type to a 48 type license so we can remove the food. it has come at a great cost. running a restaurant in san francisco is crazy expensive. and while artist and customers are fwining to remember that piano fight still exist, we don't have the level of business to justify opening our kitchen in local theater or upcoming comic. that is because our kitchen does and always has lost money. after the pandemic, we're firmly against doing that. losing money i mean. after three years of doing

that, what we need to do is not lose money. we need to make money by building back a thriving ep o center and you, you guys can help. you can help serve comics, writers, dancers and djs and neighborhood residents and workers and the nice lady who liked our stage curtain by allowing to us to stay open. >> thank you and to all the piano fight team for creating and sustaining such a unique and important venue, especially in the tenderloin. thank you. why don't we go to public comment see if there is anyone who may want to speak on this item. >> clerk: thank you mr. chair. members of the public who would like to make public comment for item number 2, please line up along the wall to the right. for those already on hold

please continue to wait until the system indicates that aoufn unmuted. seeing no in chamber comment, we'll go to the phone. there are zero callers on the queue. >> public comment is closed. colleagues, i understand that supervisor preston is support of this license transfer. so given that i will make a motion to prepare a resolution determining that this license will serve the public necessity and we send the resolution with a positive recommendation as the committee report. madam clerk? >> clerk: aye. stefani. aye. member melgar. >> aye. >> clerk: chair. >> aye. >> clerk: 3 ayes. >> thank you so much, piano fight. madam clerk, please call item number 3. >> clerk: item number 3,

resolution authorizing adoption of the san francisco mental health services act on you'll update fiscal year 2022-23. and then pound and pound again. if you have not already done so, please dial star 3 to line up to speak. the system will indicate that you have raised your hand. please wait until the system indicates that you've been unmuted. >> thank you, madam clerk. and thank you to dp a behavioral health services for all your important work on the mental services acts program and overall mental health, and all the important work that we've been doing here as a city to address the needs in our community. so this hearing today is just the hearing on annual update

for the mental health services act. is this tracy hilton? >> yes, i'm the healthy director of jedi and i'm the acting directer under that title. >> thank you for all that you do. i'll turn it over to you. i know you have a presentation and there is a few other speakers as well. >> sure, i believe claire was going to she was going to remotely activate the slide. >> yeah, there it goes. we can see it. >> yeah, i also want to acknowledge the opportunity to present here today. as i was standing out front waiting to come in. i was thinking how 30 years ago, i was sleeping outside of this building unhoused and now here i am going through periods

of recovery and resilience and elevate myself through the health department and be a example of what the services act is really about. this is our services annual update. next year, we'll be come back with our three-year plan which is our larger plan. next slide. so just to give a little overview of the mental services act. so mhsa is a stage fund. it was enacted into law in 2005 so advocates and people working in the mental health field, family groups got together and decided that there should be a state law that provides a 1% tax on millionaires over 1 million dollars to distributed and administered by the state of california to pay for innovative health services. and really of that, they were going to fill-in the gaps of things that were not available

in the current mental health system. so it was designed to transform the system into addressed unmet needs. and then it has a set of principal which includes collaboration and consumer and family involvement. innovative and wellness and recovery. next slide please. and just to talk a little bit about behavioral health services a whole. so in san francisco, state revenue fund services and activity provided by behavioral health services. so we're inside of behavioral health services, although we're be hold. so bha including a culture diverse network of programs and private psychologist and therapist. mental health and substance health services include outpatient treatment, in patient treatment, services and a larger way of specialized

services. services are available to residents of san francisco who receive medical benefits, san francisco healthcare plan benefits and also residents of san francisco. so one of the caveats that we wanted mention, is mhsa, they do not allow for our funds to be use for substance use disorder. so only if a person has that as their larger mental headlight license are we allowed to use any services for substance use disorder. next slide please. so just to talk a little bit about the annual update. so each year, required by the state to present our annual update to local legislative bodies. the 22-23 annual update is a report that includes community program input and highlights from 21-22 as well as a little snap shop of our plans for 22-23. it's important to note, again that the state determines the

funding categories that administers the funds to all california counties including san francisco. and counties are required to have a plan and we need to submit to the state for approval. next slide please. so just to talk a little bit about the specific five components. and these are the part of the legislative guidelines just to specify that. community services and support. workforce education and training. prevention and inother o vacation and capitol facility. and then in our next slides. our service categories here in the city are recovery oriented, treatment, mental health profession. vocational services. housing for full partnership clients, workforce development and capitol information technology. it may also be a good point to

mention here that as part of the state guidelines, 51% of revenue have to go to what they where smis an outdated terms. so these categories with dlieded based on 50% have to go to the services and those are called full service. so it's wrap around services for people that are considered severely mentally ill and in our system. next slide please. so this just to give a little highlight of san francisco shsmha. which included 46355 undue mrik ated clients. highlights included 15 population focus programs. 12 full service ship program which we had talked about earlier with what is considered

the most severe mental health issues. 7 peer programs. 8, i'm sorry 8 behavioral development programs. the vocational programs. 6 recovery oriented programs. 14 mental health promotion and education programs. four capitol facility and information technology programs. so there is over 4, there is 4 supportive programs which is over 200 units and then there is, 4 innovation programs. next slide please. and then to talk a little bit about our community planning process. so a big part of mhs a all of our services are driven by what the community requests. so this is a huge difference from the way that our service right side delivered. so in 2021, we hosted 20 virtual en cagement meetings.

so our ccp are required for our annual update. over 120 individuals participated in the planning and community member existed programs and the 2022 annual update. and these are our groups of different, different participants in our stakeholder groups, our local veterans and transitional age youth program participants and employees of municipal agencies. the department of equity, black african-american and latinx communities. so we have lgbtq plus community, primary care and medical staff. and also our older adult community. so we hosted current seniors on there. next slide please.

it's hard to do this presentation with a mask on but i am from the health department. so mhsn is slightly different in that we cannot start any kind of work in the particular project until we have an approved plan by the state and they pick these projects on what they consider to be innovative. so you cannot submit an idea and they have to say under their particular guidelines, the project is innovative. so we have the technology base health solutions which is a 24-7 peer chat o our training project with si a program that is working with latinx to address trauma and feeling of inadequacy. and transition project. so that is a project where we're working with having peer

counseling step down people from the full service partnership into our outpatient mental health clinics and that makes room for another person but also it creates a service and a warm hand off to the new service. and also we started online learning system and continuing education credits for an array of topics. next slide please. last year we had an approved plan that we start inside january 22, which is working in the black african community that has four primarily goals.

we're going to engage including those who are under served bit mental health plan. implement and evaluate practices ethicacy and retention. we're looking we're going to be testing particular interventions to see how they work in the african-american communities. and black working in that community to see what kind of services people are more receptive to but also we do an evaluation, next slide please.

folks who have experienced issues themselves. emphasizing the consumer participation in the workforce. at one point, up to 15% of employees were actually peers. with multi area sevensers. another one is in cooperation with, it's the same one with the san francisco state and then also we have mental health certificate program at san francisco city college. so they have 323 peers in fiscal year 2021 working through the behavioral health system. so our peers do everything from taking people to appointments to picking people to making, to taking people to the pharmacy, to see that they get their medication and during covid.

and we're not socially isolated. so that's really a unique part of our mental act services programming. next slide please. and then in terms of our evaluation. mhs a requires evaluation. so that's something that is built into all of our programs. all of our programs, have smart objective that they submit through monitoring through the bocc. so through our emphasis on--so larger bhs system. we improved our tracking efforts to outpatient referrals and outcome. for example, one of the things that we were looking at with our innovation project, how long was it taking for people to link to the peer, what were the barriers? and how can we work to decrease

the barriers to get folks to link into the outpatient treatment program. we increased our evaluation efforts with innovation project. we improved our smart objectivity and rfqs and we also did an valuation with gender sf which is one of the programs that we work with san francisco doing gender affirming care for trans and non con foerping individuals. and also we did work with our prevention, early intervention programs. next slide please. so in our full service partnership, the proportion involves adult clients increase over two folds resulting in 2662 days less spent in setting.

one of you ever stigma production programs reflecting back on our earlier presentation, educating the law enforcement about mental health issues so they work with the cadets and they do educating folks about mental health issues. that peer sevensers are available throughout our entire system. next slide please.

that might be it, thank you. >> thank you so much, ms. healthon for the presentation and all the work from you and the other members of the mept al services attribute team and the community organizations. yeah, colleagues do you have any questions? yeah, i did have a few questions. so, really good to hear about some of the things that you highlighted the new innovation, innovative program based on black and african community mental health needs. and then also the focus on a peer, yeah advocate strategy. can you talk a little bit more about the peer advocate strategy? are they working through dph?

or the peer advocates with community organizations? >> so, so i'm trying to think about the delicate way to say this. because the way that the system is set up. qualifying folks based on the fact that they have a previous history of mental illness has been challenging. some counties like san mateo have set aside classifications. majority of our peer sevensers are contracted out through community agencies. so when we look at our peer contracts, we're having an evaluation process where people end send their end of the year reports. so we really want it make sure that across all of our programs peer advocates are available. and that's actually my nain job function. i built a lot of these programs through, i'm probably the oldest employee i've been working cincinnati 2008.

so really ensuring. when we started, peers were thought to be do the three fs, filing and food and now, everything from, we're not in charge of the so ther team but that's another group that works with peers. that's located, you know about a block in a half from here. and doing navigation in san francisco general hospital helping people get out of pes. the humming bird was an imaging program years ago, that was something that we had helped develop as an innovative program. certification program that was

created with programs and city college. is there a consistent training and inserted guidelines for all the peer advocates? >> yes, so there is two certificate program that is being funded by mhsa. i was meeting with them yesterday. and there was a mental health certificate through san francisco city college. and we're in the process of trying to work with the state of california because they're going to be expanding the billing codes for medical and some of our peers are going to be able to bill through medical. so we're building up our efforts to see how we can expand our revenue base by having peers work and bill those codes and our curriculums match up with that in the future. >> great, thank you. and just, one other basic question. so, what is the amount of funding that we received

through the mhs a program? it's t looks like right now it's funding about 83 programs. what is the total amount of funding? >> this is jessica brown. she is our director of jedi. i believe last year it was 39 million? >> yeah, we received anywhere between 30 to 50 million. we had a bit of a surplus because of covid those that made over 1100% did well. we're going to see a little bit this year. and we set aside money for that.

pe tend to put money in our reserve to prepare for economic down turn if that were to happen. >> thank you, that really significant amount of funding and all of these programs are really important. so thanks again to you for all of your work. actually thanks to the voters for california for passing prop 93 was that what it was. >> yes. >> great. supervisor stefani? >> thank you. i just wanted to inquire as to why refunding is restricted from substance use disorder? >> so actually really speak to that in particular but that has been since inception of mhs a. in the part of the process that i was involved with, there was some concern that some of our clients that experienced severe mental health issues, the funds

were being turned away. so we do serve people with substance abuse issues absolutely. it primarily the aboutsing but in our full service partnership. that's something that we're doing. that's something that we work with. we have folks but in terms of paying for treatment, it's not allowed. >> i don't know your personal story but whatever it took to ask for help, i'm sure took a lot of courage and you provide a lot of hope for people when you share your story so thank you for opening like that. >> thank you. >> actually one last question.

looks like, the approval of bit boefrd of supervisors of a resolution sort of approving the annual mhsa update that's a new requirement from state law. >> and we post it for further comment. >> and then the three-year updated priorities and plan, is that. >> that's what we're working on now. so you'll be hearing that next summer.

>>ed thank you. >> madam clerk, why don't we go to public comment. >> clerk: members that would like to make public comment for item number 3. please line up to the right. for those already on hold, please continue to wait until the system indicates that you've been unmuted. seeing no in-person public comment. there are currently zero callers on the line as well. >> public comment is closed. colleagues i would like to move

that we file this hearing, madam clerk, can you please call roll. >> clerk: resolution. >> oh yeah, and i also move that we send the resolution to the full board with positive recommendation. >>. >> clerk: thank you on that motion, vice chair, stefani. >> aye. >> melgar. >> aye. >> clerk: chair mar. >> aye. >> clerk: there are three ayes. >> and i move that we file the hearing. >> clerk: on that motion. stefani. >> chair, through the chair, this is erika, there is no hearing on the agenda for that item, it's just the resolution. >> got it, thank you--we've taken our action. so this will be sent to the full board with a positive recommendation. madam clerk, is there any further business? >> clerk: there is no additional business. >> we are adjourned. >> clerk: thank you. we'll

begin with in person public comment. no one approached the podium so we'll move to virtual public comment. the moderator will notify of callers in the queue at this time. >> we have zero callers on the line and zero callers have entered the queue. use dial in instructions and select star 3 now. if you want to join public comment for this item. we'll wait 5 more seconds and close public comment for this item. board secretary, there are still no callers in the queue at this time. >> thank you moderator. hearing no

further callers public comment is closed. >> thank you we'll move on to item 8. >> item 8 is sfhss financial report as of september 30, 2022. this is discussion item presented by iftikhar hussain. >> good afternoon chief financial officer how are you? you look none for the wear after the audit. you survived. very good. >> it was a team effort and are the results were very clean and we'll hear more about that in the other presentation. the one bragging right i want to say is the controller told us we are the first to finish the audit of all the departments. >> well done. well done. thank you. >> trophy. [laughter] for the first financial result i'm presenting are the first three months of the year. we are

catching up. the fund balance increased by $14.7 million all most entirely due to the settlement payment we will talk about later on the agenda. by the end of the year, this is 14.7 net addition will come down to about 4.7 addition, and that's mainly because of stabilization built into the rates that we are now using, and the other thing i want to point out as far as claims are concerned, the claims are running high across all plans and it really is this unpredictable cycle. we thought after covid the decompression of claims had plateaued but we see another increase in claims. it isn't covid related, it is just people getting normal services and normal

care. we'll watch the claims and update you to see where the trend goes. the good news is (inaudible) would be high because the rates keep going higher so we project about 800 thousand increase but it would be-that is very conservative rfx , it will be more then that. the health sustainability fund we are projecting year end balance of $2.7 million in that fund and in the generalfund we are expecting surplus. those are highlights on the financial. happy to answer questions. >> are there questions from it board regarding the financial statements and this is for the period ending september 30? >> that's correct. >> any questions? if not, we will go to

public comment on this item. [providing instructions for public comment] we'll

begin with in person public comment. no one approached the podium and move to virtual public comment. the moderator will notify of callers thin queue at this time. >> board secretary, we have zero callers on the phone line and zero callers entered the queue at this time. reminder to listners use the dial in instructions and select star 3 now. if you want to join public comment for this item. we'll wait 5 more seconds and close public comment for this agenda item. board secretary, there are still no callers in the public comment queue at this time. >> thank you moderator. hearing no further callers,

public comment is closed. >> thank you. now move to item 9 ck that is action item on the annual audit report. >> item 9 annual audit report. action item andprinted by iftikhar hussain. >> would you please introduce your colleagues chief financial officer hussain? >> my colleagues are independent auditors. [laughter] >> we'll call them colleague s for this round. >> happy to introduce our team from mgo. craig harner and (inaudible) >> i ask that you come to the microphone and articulate their names, so we can hear those. >> it is craig harner is a partner on the engagement and yia yiang is the manager. >> i'll ask you it

repeat that, i could not hear you. >> i'm sorry. i'll let them- >> let them introduce themselves. please sir, come forward and swallow the microphone. >> for the record craig harner general serving professional partner and with me is yia yiang, manager supervisor. >> thank you and delighted to have you today. >> thank you. before we start our presentation i want to thank the management and the staff at sfhss for all the assistance for the audit. we ask

a lot of questions, ask for a lot of supporting documentation so a lot of piles on to their normal work schedules and especially during times when you are going through enrollment and rate setting and fixing the system so it is a big ask, but they always have been able to respond to us timely somewhere as you heard we are the first agency to issue a report for this year. we are here to present the results of our audit for fiscal year ending june 30, 2022. we performed a audit of the financial statements and these financial statements include the benefit trust fund, it doesn't include the general administrative fund. as part of the issue we issue three reports. two of them are independent auditor reports. they go inside the financial statement document. the first one is independent auditor report just on

the financial statements themselves and the very end is another independent auditor report on internal controls and compliance. the very first auditor report we have is concerns the financial statements. it is in the very front of the financial statements again and we are pleased to report we issued unmodified opinion on those financial statements. we issued the report on october 26, 2022. and again for the record, the unmodified opinion is the highest level of assurance a independent auditor can give a organization regarding their financial statements. the second independent auditor report we issue is a report required by government auditing standards so we perform the audit of the employee defendant benefit trust fund and this adds additional responsibility on ourselves again relating to internal controls and

compliance. we don't give any assurance or opinions on the internl control but we have to consider them and if we come across deficiency in the internal role that rise to significant or material weakness we have to report those to the health service bord and we are happy to report there are no such deficiencies or internal control weakness. for compliance we have to take into account laws regulations contracts grant agreements that could in and of themselves have a significant effect on the financial statements and report any non compliance again to the board and we are happy to say no such instances of non compliance. and then moving on, the second report or third report- >> could i interrupt on this for the public record could you go back to slide 2? you indicated third bullet that there were no

compliance deficiencies. i would like to have that somewhere reported in this presentation as well. if you could add that note for the record. >> we'll add that. >> thank you. please proceed. >> just real quick, we'll go over the responsibilities of both management and ourselves if the (inaudible) we are not colleagues we are independent from him, so it clarifies the both management and us at the independent auditors. management is responsible for preparing and fairly presenting the financial statements in accord ance with the u.s. gap or generally accepted accounting principles. responsible for designing implementing internal control over the financial statements and also evaluating whether there is concern or

considerations or anything they are aware that place doubt about the entity to continue for a period beyond a year. which there were no such instances this year. ourselves as your independent auditors are responsible for exercising professional judgment, maintaining professional skepticism throughout the audit and why we ask as many questions as we do as we are probing and inquiry what we are told makes sense given what we are seeing. we also identify assess the risk material statement. the risk of something in the financial statements is materially misstated and we design and perform audit procedures to respond specifically to those risks. as mentioned previously, we obtain understanding of internal control. again relevant to the audit. not for the purpose of opining on internal controls, but just for helping us to understand the entity and design procedures. we also evaluate the

appropriateness of accounting policies used by management and then the reasonableness of significant accounting estimates that are used to prepare the financial statements. and also conclude if there are conditions or events that give doubt to the ability to continue as a going concern for a period beyond a year. we'll move to the last report we issue is a report to the health service board the board of supervisors and honorable mayor. this report is called the required communications and what this contains is our professional audit standard require at the end or conclusion of audit communicate matters to governance in this case the helths service board so i'll go through some of the required communications right now. for significant accounting policy, management is responsible to select appropriate accounting policies and there were no changes and no policies that

guidance. there was nothing out of left field trying to do. significant accounting estimates, there are two. the first one being the fair value of investments. this requires management to estimate fair value of those investments and those are estimated based on the trust position in the city treasurer pool so we have all the money in the treasurer pool, we also audit the pool so look over the pool as a whole, make sure investments are fairly valued and the proportion of share of that is calculated accurately. the second accounting estimate for the health service system is probably the most significant, reserve for claims or ibnr incurred but not reported claims and this is based on calculations claims reported and also assumptions about the claims that are not reported and this is based off membership data and then the

claims lag information that is calculated by aon. we are not experts in the actuarial science, we hire our consultant who is specialist in health care so we give him the same exact data that aon uses to calculate the reserves. he does a independent calculation and analysis and compares the two and then we are happy to report there were no significant discrepancies or differences between the work of aon and our actuarial specialist so we were able to conclude everything was reasonable and in accordance with the appropriate accounting standards. >> thank you. >> and then finally, we are also required to report if there were corrected or uncorrected audit misstatements which there were not. there

were not financial statement disclosures or significant differences. there were not for this year no significant or unusual transactions. the significant financial statements disclosure again is (inaudible) goes over the reserve s for claims information i just talked about. we didn't have difficulties encountered during the audit and didn't have disagreement with management either. as far as we know there were no management consultations with a outside auditor. that would go against something we are saying. and lastly, there is one subsequent event reported in the notes of the financial statement relating to about receiving settlement proceeds from sutter health. that happened towards the end of september , early october and because that happened before we issue the financial statements we have to put a note describing that transaction because of

the significance. >> thank you. >> that concludes the presentation and happy to answer any questions. >> questions from the board at this point regarding the annual audit? i would also point out to the public and those who look at some of the documents that are more detailed then this presentation, the actual report is a part of this item, and in the report there is a great deal of background and history about the governance structure, the things we have done in the past and so forth. it was quite revealing this year. i guess i hadn't looked at for some time but there is a lot about the background, process and governance of this board and the health service system so commend the document or reference for anybody looking for additional information about what we do, how we do it and why we do

it. to chief financial officer and his team, i commend you for your hard work and diligence throughout this process so thank you. are there any other questions from the board? if not, we will have public comment on this item. >> thank you president scott. [providing instructions for public comment]

>> can you pause, i like to call for a motion to approve this item. i did not do that before and didn't want to interrupt read ing. before we get public comment i will not have you reread the guidance. i'll pause and entertain a motion we adopt the

auditor's unqualified unmodified excellent report. >> i move we accept the audit report with gratitude to mr. harner and mr. yiang and cfo hussain with note of no compliance deficiencies on slide 2. >> is there a second? >> second. >> been moved and seconded we accept the report with the other descriptors provided in the motion and having done that and having no comments from the board and having had the guidance read under the open meetings act, we will now entertain public comment. >> we do not see anyone in person for public comment. we be able to move to virtual public comment and the moderator will let us know if there are callers at this time. >> we have zero callers on it phone line and zero callers

entered the queue at this time. reminder to all listners use the dial in instructions and press star 3 now. if you want to join public comment for this specific item. we'll wait 5 more seconds and close public comment for this agenda item. there are still no call rs thin queue at this time. >> thank you moderator. hearing no further callerspublic comment is closed. >> thank you. we'll have roll call vote on the approval or acceptance of the audit report. >> roll call vote. [roll call] >> thank you. we'll move to item 10. >> thank you president scott. item 10 is sutter health settlement

distribution approval. this is action item and introduced by abbie yant and presented by iftikhar hussain chief financial officer. >> thank you. i think our board is very well informed of the long story of the sutter lawsuits that occurred and so i would like to shift our conversation today to talk about the fact that we did receive settlement funds and as you heard they have been deposited and we are expecting a second payment. we have worked with actuarial, city attorney office, the third party attorney to bring the recommendation to you today, and i'm going to let iftikhar do the presentation. i also want to comment that we were a little delayed having the

most robust conversation before this committee and so we did make changes to the memo and the slide that were in your packet and we have given hard copies here now and iftikhar will point out where the changes were made. >> so- >> this is commissioner follansbee, since i'm not in the room, is it possible to transmit copies of this to me electronically so i can review those? >> i can send you the url to connect on the website-are they on the website? >> i can make sure he gets it. >> it is hard to vote on the item if i don't have the information. thank you. >> you'll see it on the screen as well. >> so, we invited emma hu from

(inaudible)-she was involved with this issue 10 years back. if there are questions about the background of this information she is available to answer those questions. >> is she in the room? >> she is remote. >> she is remote. hello emma. >> i can see she is listening. >> okay. thank you. >> just confirming i'm here. >> thank you emma. >> just housekeeping item. i will outline the changes between the posted material and what you see here today. first of all, the amounts that you see here are the corrected amounts. there were two distributions confusion about the first and second disbution total amount about the distribution received is $14.8 million. the second distribution 6 months from now would be another $2 million

estimated. so-and then in the recommended action i think it still says 17, it should be 17.5, because- >> are we rejecting the most current one? >> yes are. this is the most current one, correct. >> the motion at the bottom says 17, it should be 17.5, so not sure what happened there. the reason is the second distribution will be a true-up so could be slightly more then $2 million. the motion says up to an amount, so i thought it is prudent to make it 17.5 in case that amount is higher. so, the thing i want to point out is that the charter does not really address specifically how legal settlements should be handleed so this is something that requires board action. typically what we do

is we estimate rates and in the rate setting process we have a process called stabilization, which has very specific rules about how surplus and deficits are used for the purposes of rate stabilization. this is not rate stabilization, it is just information used in the trust to set future rates in a process similar to rate stabilization. we are calling the process underwriting process. we are not calling it stabilization. >> would you repeat that again? >> we are calling the process--the original write up used the word rate stabilization which has a specific meeting and bound by policy so-the term we are using here is the underwriting rate setting process, which is a broader term then just rate

stabilization. so, the process-so, the $14.7 million along with the second distribution, we would use in the rate setting process beginning with plan year 2024, because 2023 rates have already been set and approved by the board of supervisors. >> iftikhar,b sorry to npt interrupt. in the recommendation slide instead of saying for the rate stabilization you would use the underwriting rate setting procedures? beginning in plan year 2024? >> that is correct, yes. >> (inaudible) >> it should say underwriting rate stabilization process. >> those are you only

changes including the amounts? >> correct. >> okay, thank you. >> happy to answer questions about this. again, this is a lawsuit from 2014. lots of history, and we are happy to have the funds and use that to reduce future rates. >> are there questions from the board regarding receipt of this and the proposed recommended action? >> this was strictly sutter, right? united health care we use sutter doctors through them so when you say only blue shield members would be--rates would be changed. i don't understand that. >> yeah, so we did have a united ppo product, city plan back then, so all those numbers were used so that is now

administered by blue shield. as we set future rates it is through the blue shield product. >> so, when did this end i mean when did this start the lawsuit? >> the lawsuit started in 2014. >> before we had united health care. the retirees in united health care we have sutter doctors too? >> so, we-we have a city plan i think is mostly with the claims. we submitted claims that were eligible under the class action and so we-regardless who was administering them since we went through changes with blue shield and united. >> i think you raise a important question. i think we can creg that and that's why we wanted to be a lilt more open about how we

would distribute the funds, so we are asking today for us to support the fact we deposited the check and it is in the trust, and then with the help of our actuarial and legal advice we might need, we'll carefully consider the distribution, but it isn't my recollection and maybe emma knows i'm not sure, but this lawsuit included the medicare population. that's-it is a good point and we will look into that. >> definitely, because- >> i don't think it should impact [multiple speakers] i hear you. i hear you. we did when we wrote this originally we were being trying to be very how we would distribute it and after we had more robust internal conversation we determined we need ed to think about as we set the rates next

year. there is a lot of time for consideration of questions like that, so if there is others we really appreciate hearing them and we'll be sure to address them before we bring it to you. >> i can't remember exactly what other plans we had back then. besides-i don't know-when did united health care start? >> 16 i believe. >> was it 16? >> something like that. >> commissioner follansbee, correct if i'm wrong but my understanding is the lawsuit really involves sutter health system which is the hospital system. the medical groups, unless the physician became a sutter physician through this more recently enacted mechanism most physicians involve medical groups that are different from the sutter hospital system, and so i don't know this would effect

the physician bills and billing and all that for the various medical groups, i dont think it would. am i wrong? >> emma can you respond to that? >> yeah. it is specifically based on the hospital claims that were submit ted by the carriers between a period starting in 2003 to 2016, so it would not cover medicare advantage, it is just commercial self--funded or flex funded plans. >> thank you for the clarification. are there other questions or observations from the board? hearing none, ready to entertain a motion. >> mr. president i move we approve the sutter health settlement distribution as discussed with future considerations as noted during our conversation. >> second. >> been properly moved

and seconded we accept the recommendation as discussed. are there any further questions or comments from the board? if not, we'll open up for public comment. >> thank you president scott. [providing public comment instructions]

there are no zero callers in the public comment queue at this time and zero callers have entered the public comment queue. reminder to all the callers on the line dial star 3 to be added to the public

comment queue for this item. we'll wait 5 more seconds and close public comment for this item. there is still no callers in the queue at this time. public comment is now closed. f >> thank you. we'll have a roll call vote on this item. >> roll call vote- [roll call] >> motion carries unanimously. we have done very well up to this point and we have a foot slog ahead of us in terms of a presentation so i'll request we now take the next agenda item and then take a brief break before 3 o'clock when our guest presenter will come

aboard. thank you for your cooperation and limiting your comments and observations. at this point we'll take item number 11. >> president scott we are going to wait for our item 11 at 3 o'clock and move item 12 now? >> 12? i have here the strategic plan is what i was calling for. >> yes. agenda item 12 is sfh is rks is rks strategic plan 2023-2025. this is action item and introduced by executive director abbieient and presented by lutischa harris. >> good afternoon commissioners. abbieient executive director. it is my pleasure to present our strategic plan for

the year 2023-2025. we have been through a lot of change over the last number of years and it isn't slowing down. so we went through a rather arduous and lengthy process internally to put this plan together. lutischa lead the effort. it is like herding cats and getting us on the same page and we did choose a style of planning that is different then what we used in the past so that was a big learning curve for all of us. but i have to commend the management team who put in a lot of effort and work directly with their staff to develop the objectives that are already embedded in the plan. with that, i will have presentch >> good afternoon. leticia harris. the

previous draft presented in powerpoint form on the screen now is a picture of the 2023-2025 strategic plan narrative form. at the september board meeting commissioners introduced to tactical approaches refresh activities and overview of environmental scan. to better understand the internal and external factors that shaped our strategy. for today's presentation, i'll begin by reviewing the strategic plan framework including mission vision and values. i'll share approach to leading with equity and are highlight the goal setting methodology that frame implementation moving forward. i'll point out how commissioner input from the last meeting is actualized in the goal s and wrap up with lessens learned. leadership team exercise the core value of inclusivity by inviting managers and supervisors to

take part in the strategic planning process. our staff enrich the process by bringing and contributing diverse divisional perspective in addition to unique lived experiences as a part of the membership. this includes reflection of the past and future station of mission vision and values. our updated mission centers equitable sustainable quality benefit to enhance wellbeing of members and families throughout the life cycle. the updated vision reflects engagement and personal ized care that centers disease prevention and equitable service for optimal health. ourifiable set of values are inclusion compassion operational excellence collaboration alignment and the addition of accountability per the request of staff. our most recent staff engagement activity took place at the all staff meeting and retreat held at the san francisco pier last month. staff were asked to select

value most reflective of them as a person and professional. our staff show up and show out in service of membership. not only as a obligation or civil service, but with sincere willingness. the addition of accountability shows we strive to promote high level of work to promote honesty, encourage dependability and garner trust from the membership we serve. we want to show staff that we hear them, that we see them and we want them to see their feedback manifest in this strategy. per request of the commissioners, we took care to reevaluate the terminology used to describe the goals including the verbs. to make aspirational and brans balance what is within our sphere of influence and impact. as goals and objectives displayeden the screen i'll describe the revisions. goal 1 we drawn a clear

(inaudible) to benefit our external customer service approach. as we await city wide directives around racial equity planning and reporting, we'll use data provided to us by the department of human resources for both analysis and informed discussion. for goal 2, the language has updated from advance primary care to advancing primary care practice. addressing the practice of primary care promotes active member engagement to deliver right care right time in right setting. for goal 3, affordable sustainable. we highlighted the relationship between insuring long range financial stability of the trust and active ongoing commitment of the health service board in stewardship responsibility. this includes the continued provision of diverse educational activities access to subject are matter experts and

areas of fiduciary actuarial legal and administrative matters pertinent to their role. the system that coincide with level of awareness has also been adjusted as reflection of knowledge individual expertise and experience they bring to this role. for the mental health wellbeing goal, a actively engaging vendorers and city partners to identify best practice resources for membership around access utilization to address mental health wellbeing and clinical needs. as announced in september, on the cusp hosting a mental health vendor summit that will impack implementation. goal 5 we observe board recommendation to embed objective jz key result that account for job satisfaction and opportunity for growth within. as

debut the strategic plan we want to make clear leading with equity is the core of our approach. since 2018 inis ception of the plan confronted racial inequities and civil unrest in a nation and (inaudible) these times also shed light on many forms och inequity that stem from structural racism. one form this takes is unequal distribution and access to health care resource. lead with equity to support membership accessing care that they need when they need it regardless of personal characteristics such as gender ethnicity, geographic location and socio economic status. as we advance the strategic plan also aligning with leading health authorities to insure equity is ingrained within the fabric of mission vision values

and goals. the plan will guide activities from adoption trow december 2025. the leadership team will monitor progress toward the stated goals through the development of annual implementation plan based upon the foundational objectives and key results that correspond to each goal area. objectives and key results are effective goal setting methodology and tool for communicating what sfhss wish to accomplish and milestones we need to measure to get there. objectives and key results are used by world leading organizations to set enact strategies. as a foundation for the development of more detailed systemic implementation planning. review implement agz planning quarterly with annual presentation to the heblth service board. the report will include measurable targets for each strategic goal area expressed in the form of objectives and key results. adjustments will be made to

elements of each strategy area as appropriate to changes in the benefit environment. the board will be active in implementation assessment and evaluation of results from the health service system strategic plan for 2023-2025 and beyond. i like to share lessens learned. the strategic plan 2023-2025 process represent a shift from proles vision of benefits to deep er understanding of the helthd of our population. delivery system transformation aimed at better outcomes requires care models that integrate a broad array of services to address physical behavioral and social needs. our department recognizes that race and the social determinants of health conditions people live born work play worship and age play a significant role in wellbeing. having a job and health benefits is

isn't enough. our members need support and are navigating the social clinical barriers that stand in the way of their health and wellbeing. in the medi-cal world social determinant are understood and evidence but because the population has a job and insurance the system makes assumptions about those that are commercially insured. we entered the conversation to dispel those myths and establish our position as a trusted alley for our membership. we hope the strategic plan inspires hope and sets a clear expectation of what lies ahead. to close with acknowledgment we like to express gratitude to health service board to the san francisco health service staff, actuarial consultant aon and members providing invaluable guidance comments and suggestions as our strategy evolved throughout the years. also like to extend a special thank to the graphic designer ryan close. if you are watching thank you for working behind the scenes to breathe life into the form we

advance to the board for approval today. thank you all for your time. >> thank you. are there any comments from the board on the strategic plan? it was sent out with the meeting materials, so-- >> goal number 2 improving primary care, how do you plan to do that? this is desperately needed but don't see it improving, i see it getting worse actually. big picture. >> on primary care- >> can you introduce yourself to the audience? >> hi, this is iftikhar hussain the cfo and part of the leadership team building the strategic plan. the advance-improvement in primary care was a area that i focused on and the key-there are

models of improved primary care (inaudible) in the industry. (inaudible) and recognized by others groups including calpers so the goal is align with other payers like cover california and calpers and to influence change on health plans and the providers to improve access, to improve integrate behavioral health into primary care and so it is i understand it is a aggressive goal and because it is aggressive we need alignment with other payers. >> the access is the problem because there are not enough. >> yeah, so access specifically- >> i don't know how you improve that. >> the way to improve that would be a leverage model where you have not

enough-infrastructure and system and teams supporting the physician is and taking care of patients. given there is a shortage of primary care physicians. >> at one point i saw there they were offering students bonuses if they were going to go in primary care field. i read this somewhere quite a while back but i don't know if that is true anymore. it is so obvious now. >> part is the payment structure for primary care is not very lucrative. to be a specialist you can make a lot more money and pay off medical school debts quicker. this is industry wide delima we are all grappling with and i concur with iftikhar statement it does take alignment working with the other purchasers shifting the payment structure to pay more

for primary care. that will help. and then there is support mechanisms with either front office or back office systems. it systems et cetera that allow the physician to be the physician, and those can be more-make the practice more robust and fulfilling for everyone and many primary care practices are embedding behaviorist to help with mental health issues managed primary care and burn out with primary care. there is a ton of model jz we are not by ourselves. hss can we have a impact on this? no. but together with pbgh, inticated health care association, with many other like-minded folks we are pushing forward. >> seems like it will be a very long-term goal, because there is

such a shortage and takes a long time for student to get through medical school. >> yes and no. we have watched the reemergence of brown and toland the physician group over the last few years so we see where there is some of the supports that are coming from other organizations that primary care can be properly supported. can we do enough quickly in time to keep from continuing to go the wrong direction? it is a outstanding question. >> i would only add to the comment and i understand the concern the commissioner is raising. the fact that we have during the preliminary phase of developing the strategic plan began to focus coming out of the last strategic cycle on primary care

as a issue and we spent what two plus hour s in a room here in the city main library talking about it and so forth, so the point is, it is a longitudinal goal and we need it to kind of craft the structure around it and now we are saying that over time this is where we are going to head and i think that is the real essence of this. we are not in it by ourselves but the fact we are saying that this is an issue for our membership and we need to be directionally aggressive and intentional about how we are going to proceed, so it is not that we said we will solve the issue, we said we are going to focus our attention on trying to get the qualitative services needed over time. so, i think it is a good start and a well articulated goal in our plan and we'll see as we go over the next

3 years cycle how we are able to marginally or maybe major ways come up with solutions that will make sense for our members. >> also want to add a thought. i think things have changed as well. the time-my provider days, there was a lack of folks in primary care, you don't really make money in primary care. there isn't a lot of attention and it has evolved on the need for primary care and the importance in the continuum of care, so i think we would-i'm optimistic getting alignment from others and taking on this goal. >> are there other questions? >> commissioner follansbee. can i follow up on the issue and bring up another miner point? one is that, i really appreciate the very comprehensive background information we were provided as part of the agenda,

including the evolution of strategic goals slide which looked at area explored and inclusive areas where we had concern and influence so i applaud executive director comments about the alliances with other groups to bring this issue forward, and so i didn't think that from my perspective our leadership is really focusing on this in many ways. one way is possibly we can begin to maybe explore asking for metric in terms of not only what percentage of our members have primary care providers like we question delta dental in response to a complaint, but also what the access time is for some of these primary care functions as well. we begin to develop metric maybe in conjunction with

other partners. again, i think the slide looks at areas explored including where we have influence and where we may need to partner is a important part of the packet. i want to make one other comment and that is, look at strategic goal number 4 and i want to alert-basically reassure our membership that the second objective under enhancing program to support retirey and wellbeing grew out of discussion we felt maybe there were deficiency and what we were able to support holistically. by no means implies we will ignore those people still working. at times the board is criticized for focusing too much on early retirees and retirees but highlighting this grew out of deficiency and doesn't mean we are going to be less

diligent about supporting mental health and wellbeing for all members including the active employees. >> thank you commissioner. i would also like to as a footnote point to page 14 in the document. just as you move the chronology down so that the later years were sort of chronology order, 23, 24, 25, there is one bullet i missed in terms of providing feedback to you on page 14, second bullet, q2, 24 should be at the bottom of the list. that is my error, not yours. >> thank you. >> are there other questions or comments from the board regarding the plan? >> thank you president scott. i want to commend you and the team for this

wonderful product you produced and thank you for indulgeing in all my verbs and other issues. i think it is important that anybody who picks up this plan be able to understand and catch your vision and know where you are going, and i also read through this plan this deep commitment to the members and lives that are touched by the health service system and not to just do a cursory customer service type of service but to dive deeply into the things that matter and the way they receive care and the sustainability of that care, so well done. >> other comments? i would like to read into the record the letter of endorsement of the board, so we have a clear understanding that this is not just sort of like a one and done kind of thing. health service board is dedicated to making

high quality affordable comprehensive health care benefits available to sfhss members and administering the trust in accordsance with the chapter. we are committed to our rule as fiduciary to assure benefits paid for by the trust are available to all sfhss members without special favor or privilege. the mission and vision of the strategic plan will inform and frame our efforts in the near future. this plan as a whole will serve as a policy reference, planning guide, and communication tool as the board interacts with all constitchancy leadership and staff and office of city government. acknowledgment of that understanding, the board at this meeting

approve the design and development of the strategic plan. as the result, the board will be active and diligent in the implementation, assessment and evaluation of results of the strategic plan for the year 2023-2025 and beyond as we seek through responsible stewardship to better serve our members. by adopting this plan today i will call for a motion. we are making that commitment and we again commend the staff through the executive director and project leader mrs. harris and all of those individuals on the administrative team who contributed to bringing us to this point. i'll call for a motion. >> president scott, i move that we approve and adopt the sfhss

strategic plan for the years 2023-2025. >> second. >> been properly moved and seconded that we adopt the strategic plan for 2023-2025, and we'll now have public comment. >> thank you president scott. [providing instructions for public comment] begin

with in person public comment. no one approached the podium, so move to virtual public comment. i'll check our queue to see if there are callers for public comment at this time. we have zero callers on the phone line and zero callers have entered the public comment queue. reminder to all callers on the

line or trying to dial in, please dial number across the screen and press star 3 to join the public comment for the agenda item. we'll 5 minutes--5 seconds and then close pub luck comment for this agenda item. so, no callers joined the public comment queue. public comment is now closed. >> thank you. we'll have roll call vote for on this action item. >> roll call vote- [roll call] >> thank you. the strategic plan as described and edited is adopted. [gavel] now by my lights, it is now 233. roughly.

i would like to have us convene at 255. we'll stand in recess until that time. thank you. [recess]

[meeting reconvened] >> we are ready to reconvene our health service board meeting, and we are prepare today undertake item 11. this is a board education segment and we have a guest presenter and we'll start by having executive director yant. once the item is read to introduce the segment. >> thank you. >> president scott. >> yes. >> can we do roll call vote since we had a long break? >> i'm sure we are all here, but would you have-call the roll again, please? thank you, commissioner. >> roll call vote-

[roll call] >> alright. thank you. we have a quorum. we ready to begin and ready to turn it over to our board secretary to announce this item. >> item 11 is bord education with focus on addiction services including medication assisted treatment. this is discussion item. interdiced by abbie yant exectsk director for sfhss and presented by eric haram consulting llc. >> thank you, abbie yant executive director. pleased to have the presentation before us today . we committed doing a board of education substance use disorder in this calendar year and trying to find the

good speaker, i listen to eric's presentation he did for the purchase business group on health few months ago and what i found most useful is his focus is on commercially insured population. we have many esteemed colleagues at the department of public health who focus is on issues and fentanyl overdose and things like that and i was able to forge new partnership with dph. they can be thought leaders on issues maybe highlighted in the presentation. eric being a third party from maine so why he is attending virtually, but i did find his presentation very comprehensive and how we think about the commercially insured population and are substance use issues all our departments see within their

workforce and we care for through the health service system. thank you very much eric for entering our virtual world. >> while we transition we will have our slides presented. eric, let us know you are see our slides. we'll make sure you are not on mute. >> there we go. i see them, however they are very very very small. not on the main screen, which i see hsb secretary. but rather across the top in the gallery. >> it may mean from your end being able to adjust the view, the layout. there is

quite often underneath a row presenters are names, tool bar you can adjust that. >> my apologies. >> eric, this is our moderator, if you hover over the presentation slide, do you see several docs come up that allow you to pin it to the screen or make it larger? >> i do. it says move to stage. >> yes, perhaps trying that is one option. >> there we go. that helps greatly. >> thank you moderator.

>> again, my apologies for the tech difficulties. i think i can see-if i need to i'll go get glasses. >> welcome and when you are ready to start. >> okay. thanks very much for having me with you this afternoon. i say this afternoon, i believe it's 3 o'clock your time, 6 o'clock mine, and so good afternoon and good evening. we'll take a little time and this evening, i think we have scheduled to 4:30 your time if we have robust discussion and questions following the presentation we may need all that time otherwise i think there is a fair amount of buffer built in. >> this is president

scott, if i may just to be clear about our timeframe, we have another portion of our business meeting to conduct, and we are hopeful that we can conclude before 4:30, because our room here in san francisco is going to be taken over by another commission, so we are hopeful that we can have the type of discussion and your presentation in such a way that we can do all of that. >> duly noted. thank you. launching in we are going to be looking at substance use disorders and what employers should know and look forward for their employees. next slide. our objectives is provide a overview of substance (inaudible) best practice for employers, framework

for evaluating substance use disorder vendors or treatment providers that you may elect for your employees to use and what employers should look from these specific type of vendors. next slide. as exectsk director abbie yant noted, i provided this slate of information to the specific business group early summer and june. they connected a what they call a vendor showcase for a range of employers. i believe san francisco health system was in attendance and we wanted to try to provide good framework on how employers might evaluate the vendors they would like employees struggling with the issues to access and they hired me to help develop

this evaluation criteria which we'll go through in some detail. there is a fairly robust appendix to this slide deck that really unpacks all these areas and so encourage you to review that on your time following. next slide. so, a little about me. next slide. as i was introduced my name is eric haram and live and work in the mid-coast region of maine. lived here since 1997. relocating after a lifelong in another cold place in min neapolis and st. paul. i have been operating haram consultant a strategic planning workforce development and clinical technical

assistance consulting firm since about 2016, and work primarily with states county government, city governments, health systems in transforming their response to public health and safety where substance use and substance use disorders are concerned. next slide. so, for our agenda we'll cover these 4 areas, a brief overview of substance use disorders, look into best practices for employers consideration, provide a framework for evaluating these types of vendors or treatment providers on behalf of your employees and what you may be looking for from them in return. next slide. so, what is substance use disorder? we start with a clinical definition. it is a

chronic relapsing and remitting brain disease that is characterized by compulseive drug seeking and use despite harmful consequences. the additional decision to take substances is typically volen material with continued use the person ability to exert seft control is impaired. that is impairment is the hallmark of substance use disorders. there are screenings measures for substance use disorder and risk and examples include the world health organization screening tool. next slide. how do we see this revealed in substance misuse and dependence? substance misuse refers to the use of substances for the purpose that is not consistent with the legal or medical

guidelines. often involves prescription medication and could mean taking more or less then prescribed. medication not prescribed specifically to you or taking a substance at a time when the obligations are inconsistent with use. and those are examples of misuse. dependence or substance use disorder-the lines between misuse and dependence may become blurred in the presence of clonic use when regular use results in one or more of the following, professional assessment really is in order to help identify the extent of the problem and how best to intervene and when we find health complications as a result the inability to carry out daily responsibilities with consistency, the presence of physical dependence, meaning in the absence of the

substance withdraw syndrome is revealed and that individual is struggling with cravings and preoccupation and things like looking forward to the next episode of use. so, nuance between misuse and substance use disorder and hopefully those lines help clarify that is a little bit and what resources may be needed to help sort of get to the bottom of things. next slide. we talked about tolerance as a hallmark of substance use disorder so let's ubpack and look at that closer. what we mean with this in the absence of use or tolerance, we sort of feel normal. if you look at this fulcrum or teeter todder, that is depicting the fancy word is (inaudible) neuro biological action that underlies

really everyone's ability to feel pleasure. companionship, nurturing kids, self-efficacy, good food, water, intimacy are all examples of neuro bilogic action that interact with pleasure for us, and in the normal state that tone is what we call normal. when we introduce substance the use leads to effect of the drug. repeated use leads to tolerance or a reduced hedonic tone. the opposite of normal or healthy tone is called (inaudible) that is reduced ability to experience pleasure. person uses a substance and experiencesuephoria, perhaps decrease pain sensitivity, sedation or feeling energized

depending on the substance and often lowered inhibition. those are by-products of intoxication. if we look at the next slide, the opposite effect is tolerance. so when a person comes up they come down and the flip side of euphoria is perhaps hang over and consequence. behaving in ways we didn't intend or contrary to our values or obligations. in fact withdraw. the absence of that with this teeter todder back and forth repeatedly what begins to happen is the person experiences reduced pleasure over

time, and the amount of dysphoric or an hedonic consequence is greater and duration longer. eventually a person is using substances not to experience euphoria but just to feel normal. substance use disorder is disrupt decision making and we can see substance use disorder emerge across the 3 domains you see in this-call a stair step table. beginning with binge and intoxication. over time drug use individuals begin to learn the effect. begin to anticipate the effect. absence of that effect

negative affect or withdraw or hangover begin to emerge to where then in the final stage where we see readily or constant preoccupation or anticipation. this is really because there is a neuro biological process happening. there's regulation of a neuro transmatter called dope mean that is big part of our pleasure center and as a result decision making can be diminished, and we find individuals preoccupation is all most too mild a term. what we are referring to is the person becomes all consumed with wanting to escape

this state. this state of the absence of intoxicationer becomes misery. and that is a cyclical thing that feeds the compullson to continue to use. let's look at the national perspective. there are 9.5 million or 3.8 percent of adults over the age of 18 that have both substance use disorders and are mental illness. substance use disorders effect 20million americans 12 and over. most common are related to cannabis and prescription pain relievers. in 2018, 3.7 percent or 9.2 million of all adults age 18 and older in the u.s. had both major mental illness and at least one substance use disorder in the past year.

next slide. so, when we look at drug use among age groups, there are emerging trends. younger people are more likely to use drugs that are the rates of drug use among 50 and older is increasing faster then among younger age groups. genx are getting older and the habits acquired in the 80 have fallowed them. drug related death rates for users over 50 increased 3 percent annually, 75 percent of deaths from drug use disorders among users age 50 and older were caused by opioid. 6 percent deaths 50 plus age users were from cocaine and -i

have to say the vast majority of our patients are in the late 40's, 50's and early 60's. that's both unique to the geography, maine is the oldest state in the nation and york village is an amazing place to vacation. none the less, i see this in our client base. as of 2022, close to 1 in 10 full time working americans met criteria for alcohol use disorder. 1 in 10. the rates of alcohol use have increased substantially, including among the employed population. reports show increased alcohol use during the work day. additionally, use of alcohol and drugs

among adolescent and young adults remain high. next slide. so, i put this in because we will talk about what has happened national trends of substance use, particularly these last two years during covid. i use this slide because community norms really are a big deal. we have our own thoughts, feelings and values about the use of substances. there are also community norms. these were examples during early covid, the first 6 months of advertisements i thought spoke to those norms and so a an icdotal post er from veterinarian society, day drinking and stoned clients thin covid era. how do we

deal with that? cathy lee, martha and snoop. there was a about 4 minute video on saturday night live early covid musical number called let kids drink and then we have ida our (inaudible) with the gigantic cosmo. early studies show that social isolation and other covid-19 related stressers were big contributing factors that increase substance use. in fact, 13 percent of americans reported increase substance use in 2020. also in 2020the u.s. saw the highest rates of drug overdose ever recorded. approximately 30 percent increase.

that trend continues. fentanyl has been a significant factor in those overdoses. stagling statistics and many employees may have families and their families and kids may be among covered members. among adolescent fatal overdoses increased 94 percent from 2019 to 2020. i will pause for a minute because that is a very sobering statistic. let's look at best practices for employers to consider now that we are armed with the lay of the land. substance use disorder working populations further. next slide. so, let's look at productivity. studies show substantial correlation between alcohol use disorder

and absenteeism. despite only making up 9.3 percent of the population, individuals with alcohol use disorder accounted for 14 percent of all absences so if we look at the table from the national data and looking at the level of alcohol use severity, correlated with days of missed work annually, no alcohol use disorder the average employee miss 13 days with a mild alcohol use disorder increases to 18, moderate, 24 and severe alcohol use disorder just over a month missed work per year. i have not included in the slide deck, but a an icdotal survey done one year post covid state of emergency declaration

polled 3 or 4 thousand employees from fortune 100 companies and asked them about their drinking behavior and the question simply was, have you been consuming enough alcohol during your work day you're concerned about returning to the office or to the workplace? in other words, returning from a virtual situation. the positive response to that was, 40 percent , which is remarkably high in terms of thinking about culture and what happened and what kinds of things were occurring when we went home for two years. alcohol use disorder are more common among full time workers who are men, younger individuals, white or hispanic.

alcohol sales increased from 2019 to 2020 by about 20 percent. additionally over the course of the pandemic alcohol use patterns were altered substantially. the death rates from alcohol related complications have skyrocketed. so, if we think about diverse populations and patients with substance use disorder up to 50 percent of substance use disorder patients are fully or partially employed and that fall into the two columns on the right. moderate stable housing, level of employ access to transportation and perhaps under-insured versus the stable column where individuals are stablely housed employeeed, have a personal vehicle and private insurance. look at the next slide. so, we need to take time and talk

about health disparities, which is in my field of behavioral health and substance use disorder is talking about institutional stigma and bias and i think sometimes pull the punches by using language like disparities, stigma when really what we are talking about is discrimination and racism occurred at a institutional and cyst systematic level. lack of cultural understanding by health care providers contribute to under diagnosis or misdiagnosis of mental illness in people from racial and ethnically diverse. black patients are 77 percent less likely to receive medication

assisted treatments or opiate disorder or (inaudible) lead to greater criminalation resulting in greater reluctance of individuals to seek help. there are entire factors of the national substance use or drug court treatment systems that have significant problems with blocking access to diverse populations as bonifyed diversion programs. next slide. there are populations we know to be more at risk. people with existing mental health or substance use conditions may experience and did during the pandemic experience increased distress and trauma symptoms. the treatment may have been disruptive and care providers put

under additional strain where we saw many people the past few years fall through ever widening cracks and our safety net. older adults and those with cognitive decline or problems with self-care, people at risk for sexual or jnder base violence and adolescence with (inaudible) so, again when we talk about this on slide 4, we identified substance use disorders as a chronic illness, chronic disease i want to underscore that with this context substance use disorders are perceived and treated differently then other chronic conditions, yet the relapse and remit rates are on par. in other words, the potential for relapse with substance use disorders as you can see is very much

aligned with type 1 diabetes, hypertension and asthma. we onin primary care however don't take people off the treatment panel for a1c not moving or not taking their hypertensive medications or doing the other sorts of maintenance that all people with chronic conditions be29 begin to take ownership over as they move into sustained remission. next slide. how can employers support employees with substance use disorder? one, reduce stigma and bias against substance use disorders and empower to seek help for themselves or family member. the main thing there is nobody wakes up one day and says i think i like to acquire a substance use disorder and need professional treatment. it isn't a

goal people have. it is something that happens to them and it happens sudally. it is a sudictive process and before people know it they are in up to their neck. then telling someone that and asking for help is very very difficult. our response to that are providing pathways for that are hugely important at being able to help our employees make a u-turn and engage in recovery and move forward becoming valuable productive talented employees for you. promote availability of timely accessible relevant and engaging treatment options. that sounds fancy but it is not. when a person needs help and needs to be there. it needs to be

easier to get then to avoid. and once they show up stuff they are provided needs to work. it needs to be relevant and needs to be delivered by people who engaging. understanding the power of language. modifying to align with non-stigmatizing messages. your words really do matter. examine the culture that relate to substance use of norms of business or life, stress relief, modify. to infuse normst thaimpuv health wellness and accom aidate the expanding workforce in remission. if you have a population of employees concerned about you feel are at high risk, getting folks together outside a happy hour would be a worthwhile endeavor. next slide. so, there are resources that i want to make

folks aware of. these are in fact employer tool kits. these are three such that are really i think salient. you will not get a lot of fluff from these. you will get right to the facts and some real great examples of the types of things employers can do to reduce stigma and in fact show employees if you need help we can help you obtain that. next slide. so, if we put this all together we are talking about substance use disorder as a cycle. of the three pair of glasses i have here, none are the right ones. we are starting to see the cycle of addiction in the middle-swooping arrow at the bottom is active use. then we

have person emerging remorseful. they may have a recommitment and begin to engage in abstinence or use reduction and recovery oriented activities. then some trigger may occur for an individual and for some it may simply be boredom and wristless (inaudible) dangerous things for folks early recovery to sit with because it sets off this chain of events again and so next slide. so, when we think about substance use disorder in the course of recovery, i-what is most important here for

folks to grapple is is that there sadly isn't a magic wand. for those that saw some of the movies promoting treatment and recovery in the late 80 early 90, the programs that meg ryan went to and rekindled with andy garcia are fewer and farther between. the film clean and sober with michael keaton, similarly. there is again this car nisty to substance use disorder that involves phases of relapse and remission and what we see is that individuals who struggle with substance use disorders do so for a good long time before they move into full

sustained remission, and most individuals with substance use disorders, particularly working adults, are able to be highly functional and sustain a very high level of professionalism and career mobility in spite of perhaps a pretty significant substance use disorder and what we see is people self-initiate cessation taemps for 4 or 5 years secretly on their own before beginning to seek professional help. when i see somebody for treatment and it is their first time coming to a professional for treatment, what a lot of people dont know, that person often has been really really working hard to regain

control often times for 4 or 5 years before walking through the door the first time and saying i have a problem and need help. and i think that is the biggest thing i want people to be aware of is by the time someone comes to you and says i think i need some help, there is a lot that has been going on that nobody really knows about in terms how hard this person has been trying up to that point. and i say that because i hope if you find yourselves or any of your business leads, directors, managers et cetera find themselves in these conversations with people, if you contextualize it that way first it is easier to find empathy and what folks need in that moment is some empathy. certainly some (inaudible) expectations and boundaries and understanding of

what's tolerated and not, but most importantly is this may be a difficult conversation but i want you to know you did a good thing bringing it up. let's start there. next slide. so, i am not a expert on california law, but it is a big enough deal that i wanted to include this here and this relates to sb221. the initial law that of course required initial appointments and no greater then 10 days after the initial request and as of july of this year further requires that follow up appointment offered no more then 10 days from the initial appointment as well. systematically what that means for the state and service system and people who run these type of programs and businesses, quite complex for employers and employees and

individuals needing this help, it is a really really big deal. i'll say from the engineering side of the work that i do, what i know to be true is individuals who ask for help for mental health or substance use, if they can acquire it within 48 hours, two days of that initial request, 85 percent of the people will show up to that appointment. any amount of time longer then 48 hours or two days there is highly correlated reduction in the show rate to that first appointment. the same is true of the second. this is a pretty big deal to try to do this in 10 days and legislate it, it is 8 days longer then the data tells us to be predictable of capturing and engaging up to 85 percent of those people requesting that first appointment. so, 10

days is great progress, but if we want to get everybody in who says i want to go, you got to try to get that in faster. next slide. so, access. front end process in the patient impact. these are just universal truths and things for you to be aware of. the behavior. the access characteristics of the programs that you want your employees to be interacting with. also steps we take from the first contact through the end of the first clinical appointment make or break a prospective patient resolve to attend and return. no one aspires to have to go to substance use disorder evaluation or treatment program. the many steps thin road to recovery are not palatable in the first contact or appointment. there is very little use in

asking someone to take a sip of water from a fire hose. they won't come back. rules and lists at the initial point of contact are distracting from the intent of that first contact. i am at my end of my rope, feel horrible about myself, keeping this secret and calling and asking for help. what again the person needs to hear in that moment is, well, when it seems like all these things have been going wrong, you did really good thing today. you did call the right place, we know what to do and can help. let's get started. because if we all think about our experiences in the service industry, particularly health care, we rarely remember what we are asked in the pre-appointment paperwork. we always remember how long we wait and we do remember if people were nice or not. on

the front end of this, basic customer service is what you are looking for. are people nice? do employees have to wait? next slide. so, we are moving way ahead of pace and i think any concerns about timing of this evening's event are well in hand. as we look at the third itedm now i want to talk about a framework for evaluating substance use disorder vendors. these treatment programs and providers that maybe want to contract with your particular entity or health care provider or third party payer, these are kind of the things that i think you want to know. another way of talking about this is kicking the tires of the programs that you like your people to get help from. so, the desired characteristics for the best impact are when you interact with

those programs, people are spoken to in real time, a human being answers that first phone call for help, and the place accepts walk-ins. we characterize substance use disorder as a chronic illness and something we call window of opportunity illness, which means there are times when a person is open to this idea and when that window of opportunity is just a little open and they-i think i want help-the folks need to pull them in and that's what you get with this real time human being interaction and the ability to accept walk-ins. multi-cultural competency. availability of multi-lingual professionals. clinical triage versus financial. what's going on with you versus what is your insurance? we will get to what your

insurance is, but it doesn't have to be the first question. provider for what is tolerableo back to the drinking from the fire hose analogy. the physician that is the medical director in my program is also a family medicine provider and primary care and when she first diagnosed a patient with diabetes she talks with them about what we will be doing in the next 30 days. she doesn't talk about what happens over a life span in that first appointment because you will scare the heck out of them and may not come back. so, again, availability to troubleshoot barriers. do you have problems with transportation, child care, medication assistance. during covid do you is a smart phone and are you able to attend appointments on zoom or webex, and do you

have the right technology and bandwidth and all that? employers should look for these access characteristics in programs that they purchase directly or indirectly. another thing i'll say, a sud program in 2022 that doesn't include medications for addiction treatment is not practicing in this time. these medications received fda approval and overwhelming evidence of their efficacy to improve outcomes and reduce mortality in 2004, 2005 . if we haven't gotten there now, you are not providing a relevant service. next slide. so, the current evidence base around treatment. let's look at alcohol use disorder opiate disorder and

stimulants and of course, many of our employers and individuals that are struggling with substance use disorders may be struggling with multiple uses of substance, and so for alcohol use disordser want you to be aware of assessment and treatment of withdraw. always be careful to assess a person withdraw from alcohol. fda approved medications for treatment of alcohol use disorder cognitive behavioral treatments that include motivational interviewing, prevention strategies that reduce stigma so those are the components you like to see. for opiate cognitive behavioral trement, overdose prevention, relapse prevention and fda approved medications. for stimulant,

motivational interviewing. contingency management. this is simply put as really incentivized based care, and community reinforcement approaches. meaning there are multiple professional actors involved and wrapped around a individual's journey with treatment and recovery. next slide. treatment comes in lots of different flavors and packages now, and the good news is there are national medically accepted standardized patient placement criteria to describe these things, and to match the level of acuity or how ill a person is with the type or intensity of treatment that may be best aligned to need. and so we do have digital options. these are things like

treatment programs that live on our phone. there are a number of them that are very very high quality. they often most frequently provide what we call american society of addiction medicine. outpatient to intensive outpatient levels of care so may be individual therapy once a week, it may be group therapy for hour and a half once or twice a week. the minimum and maximum might be intensive outpatient program which would be typically 3 hours of duration 3 times per week for 9 hours of treatment each week total. that's what we see in the digital platform which are able to monitor breathalize, urine drug screen, technology through smart device blue tooth and commitment they may send to people in treatment is a part of the cost of

care can all effectively be delivered in this modality. digital treatment that is difficult is it is really hard to tangibly put through the paces. how do knroe know this is a quality product because it lives out here in the internet and ether? the best way i can say to do that is think of coordination of care. thou our treatment may be app based i might have a primary care physician, a eap program, a number of professionals involved in my life that are invested in this treatment experience that we are all paying for, and the way a digital solution or treatment provider coordinates is really important. they have to be able to do that relibly and credbly.

there are brick and mortar programs that deliver outpatient individual counseling family counseling groups, in person virtual hybrid models the same with intensive outpatient programs discussed. short and long-term residential programs that range from say 1 to 4 weeks up to 18 months depending upon the intensity of need and duration of need. there are clinically managed inpatient and hospital based inpatient floors. this is where we would find mostly the need for inpatient withdraw management. the new term for years referred to as detox. next slide. again, thinking about this continuum of care and

the types or flavors of treatment i want to see the full continuum moves left to right beginning with early intervention, outpatient service, intensive outpatient services, day treatment programs that may be 6 to 8 hours a day, 5 days a week and are then into the varying intensities of residential and inpatient hospital based programs. criteria which employee assistance program professionals and the programs and professionals they contract with would be very aware of and if they wrnt polk that would be somewhat problematic and something i think you would want to look into. next slide. all of this is what we are getting at with this american society of addiction medicine criteria is, aligning the person's functioning with their

intensity of need and we do that by looking at 6 domains or life areas. we are interested in the persons level of intoxication and withdraw potential. any bio medical conditions that underlie that complicate or make things more dangerous. emotional behavioral cognitive conditions that add to complexity like mental health conditions, learning disabilities, individuals mental status and then look at readiness to change. relapse or continued use potential risks, and then their environment. what is it like where they reside and living. we simply raise those across severity of low, medium or high and then that array if we look at the one previous slide-there

we go-let us know which flavor or bubble on it continuum is most appropriate for that given person. let's go two slides forward. there we go. so, the rational for medications for addiction treatments we heard about (inaudible) exectsk director abbie mention thatd at the beginning of the introduction and would be remiss if we didn't take a moment to underscore. the rational for medication for addiction treatment and when we say map, what we refer to is medications for addiction treatment. the formulary. mat is the integration of fda approved medications that assist in stabilizing treating maintaining sustained remission from substance use disorders. medication for opiate use include methadone, bup morefen

or suboxon (inaudible) come in tablet form medications individuals take orally or there is extended release injection that individuals can elect as well. alcohol use disorder, naltrexone (inaudible) for (inaudible) all the medications greatly improve mortality rates, treatment outcomes and sustained remission. next slide. what is recovery and what is the goal of recovery from a substance use disorder? that is the process of change through which individuals improve

health wellness and livl a self-directed life and strive to reach full potential. that is definition of recovery from substance use disordser and with our last 2 or 3 slides, let's underscore again what employers should be looking for from treatment providers that you may develop relationship with on behalf or pathways for employees. next slide. one more. so, if we pack all this in and just salient slide here, high quality substance use disorder solutions or treatment programs include these 5 characteristics. one, use evidence based behavioral modification, change approaches. include medication assisted therapy or medications for addiction treatment. and they have high quality

engagement strategies. if you ask what percentage of patients attend their first scheduled appointment, they ought to be able to know that statistic and talk about it proudly. they should have a welcoming first contact and intake process designed to maximize engagement. that is what we call low demand characteristic versus high demand characteristic. we are talking a window of opportunity and so proving that you really are ready, prove you deserve the treatment and trully motivated to come in. those are examples of (inaudible) high demand characteristics versus low. we want to provide timely access within 24 hours to the first clinical appointment and multiple referral channels. no wrong door is what we mean by multiple referral channels and direct

cooccurring mental health conditions. 80 percent of individuals with a substance use disorder have are a trauma history or a mental health cooccurring condition such as anxiety, depression, ptsd. we want to understand and strengthen clients environment and support system. that means family, their ecology, employment. their social world. lastly, we want welcoming intake process and robust assessment with validated tools. next slide. thinking about these key features substance treated. are they treated alcohol, (inaudible) offer a continuum of care that match a range of acuities? is there high quality referrals and coordination if they don't provide

intensity of service a person needs. are they using evidence based behavioral modification approaches? integrateed medications into their clinical landscape? provide for co occurring mental health conditions? access access access. knowing pathways to getting in treatment and being able to articulate their performance in those areas is really important. care coordination and integration with existing providers. do they coordinate for the person's primary care provider? other existing health care mental health care providers that may be involved and again (inaudible) in the mix. is it equitable? is access and cultural care. are

there peer services integrated and opportunities for families and community support? i think that might be our last slide. let's look at one more. key outcomes for selection. again, if we look at these in chunks, thinking about access for your people. thinking about engagement and satisfaction of their customer base. improvements and outcomes. able to demonstrate that it's measured and articulated and continually improved. and then behavioral health improvement. what types of metric standard tools are used to determine pref-post outcomes for individuals. the last two items in blue are accreditations. do you have a level of accreditation from a national body like the

joint commission for example. i think-next slide. so again this is a quick list of the 12 areas that we did develop in that showcase for employers to that different treatment programs they wanted to direct contract with so that is included here and think if we look at one more slide we are done. so, with that, i will turn this over to our moderator. maybe i should stop my-- >> thank you very much for the presentation. it was very comprehensive. i have one leading question. we have been going through a crisis in california with providers and i notice a number of these things employers should be doing and looking at as they consider the access is

that you are talking in terms of not only a state requirement of 10 day s but further recommending we get people assessed within 24 hours after the first contact and i don't know how that is going to happen in our current staffing environment with most of our health plans. i know they are working on these things diligently and trying to negotiate with existing staff and recruiting and training new staff, so there is a real tension in my view of trying to use some of this guidance in the current environment. you have any reaction? >> i see why. i don't have a simple solution. what i can say is i think the

legislation is strong and certainly points towards investment in individuals accessing these services much more rapidly. that meeting 10 days is a gigantic lift. currently it is something i empathize with as a employer and individual who runs a substance use treatment program as a part of the community fabric here in southern maine. what we are getting at i think or what i'm wanting to convey as a non california resident or legislator is we find the performance and outcomes for individuals with these conditions greatly improve when the rate of access gets better. if you are used to be

4 weeks and have a new reach goal of 10, that is significant amount of progress. that still does point to sort of our data that demonstrates that the faster you can get someone in the more likely they are to show up. people begin change by showing up and so the first rule of thumb is you can't get treatment if you are not in it. we just start there. people will fall through the gaps the shorter the wait time is. start where you are and go from there. i think- >> can i ask a subsequent question? commissioner follansbee. can you maybe briefly outline what the future is of

virtual encounters and for access? is this a area of active investigation? are there data that would support it or not support it at this point opposed to in person access? >> that data is of course emerging. what we learned the last 2 and a half years we were underutilizing that technology. what we see from the data is that not only have outcomes remained consistent as good as they were pre-covid or pre-virtual care, more people are able to access the service. anecdotally i have patients that say we work very hard where i

work to live these values and outcomes and assure people can get in as swiftly as possible and our patients are often in disbelief when the happens that way and again it backs up to that really basic thing that a individual cant engage in treatment if they are not in it. this technology is very very functional and the data is showing us that the outcomes have at least been the same then before we used this technology. compelling enough that federal and dea wavers granted during covid are going to be sustained at the end of the public health declaration. you will be able to see patients with substance use disorders on zoom for health care, you will be able to prescribe controlled medications and wont have to

necessarily establish with a face to face encounter before doing so. those rules from those bodies don't change easily and that we moved into that i think are really strong bellweathers about utility of virtual treatment. >> are there other questions from board members? none. well, i thank you for the presentation and we can certainly use this as a reference as we continue to focus on this strategically and operationally going forward and my hope is that as we do this and we know there is a increased need, how we get the resource and the person together at a appropriate time early on as you are

suggesting is going to be the continuing challenge in all of this. so, i thank you very much for your time today and sharing this information with us. >> thank you very much mr. president and i appreciate you all thinking of me and feel free to reach out as you move through this complicated work. >> alright. anything else director yant? >> no, i don't think so at this time. >> okay. >> thanks eric. >> thank you. >> thank you. trying to see if there is public comment on this. there is public comment on this presentation. please. >> thank you president scott. in person public comment is first and then virtual. anyone in person welcome to approach the podium now. each speaker is allowed to comment for 3 minutes each. all

public comment concerning the item presented. caller may ask questions of the body but no obligation to answer. for those on the line when i welcome on the call state your name clearly but you may remain anonymous. give you a warning with 30 seconds remaining and when ended thank you for the call and placed on mute. remote viewing is available on sfgovtv and online using webex. [providing instructions for public comment] we'll

begin with in person comment. no one approached the podium. we'll begin virtual public comment and the moderator will notify of caller in the queue. >> we have zero callers on the phone line, zero callers entered the public comment queue at this time. reminder to all, please use the dial in instructions and dial star 3 now if you want to join public comment for this specific item. we will wait 5 more seconds and then close public comment for this agenda item. there are still no callers in the public comment queue. >> thank you, hearing no further callers, public comment is closed. >> thank you. we'll move to a committee portion and i will take a rest and turn

the gavel over to the governance chair for this board, commissioner follansbee. >> thank you very much. we have agenda item 13. >> thank you. item 13 is health service board annual self-evaluation and employee performance of sfhss exectsk director evaluation and timeline frz the plan year 2022. this is action item and presented by the governance committee chair follansbee. >> thank you very much. outlined in our packet the committee met with a full participation of our three members on november 2, 2022. this item deals with the health service board self-evaluation timeline and draft as well as performance evaluation for exectsk director for 2022 and

the draft. there is one correction. i dont know if our board secretary has hard copies of that, but the self--health service board self-evaluation itself item in the packet item 3, which dealt with the assessment of the orientation was inadvertently dropped and added back for consideration with a new category which is not applicable. in other words, if health serveerse board commissioners don't feel they can address the-this is the old-this is the incorrect form. the correct one is not available. three was inadvertently taking out and added a few category and this category which isn't

applicable. helths service board member did not participate in orientation in the last calendar year, they would indicate not applicable. in addition, item number 16 moved to item 15 on the incorrect form so don't know if we have the correct form in front of us. 16 we eliminated the word single word, routinely from the statement the board routinely adheres to the policy. number 16 should read, the board aderhoos to its own policies. with that, the timelines and the rest of the form is as we reviewed and i will--this- >> commissioner follansbee- >> this is the incorrect draft 15

here should be 16 and because when we add 3 back which is the board orientation then everything moves down one number. hope that is clear to everybody. sorry we dont have a correct form here for you to review. with that, i'll entertain discussion or questions. >> if i can- >> board secretary. >> for commissioner follansbee, thank you for noting the edits. what is currently posted online you're right is incorrect. now that you noted them they will be updated with approval today. >> alright. i move that we adopt the self-evaluation forms and timelines as distributed and edited. >> second. >> if i have a motion in addition to adopt performance ealivation outlined in the timeline to have a

vote on all 4 items >> that is-apparently i didn't say that correctly. i move we adopt the self-evaluation timelines and forms as distributed. >> second the amended motion. >> any further discussion? if not, open up for public comment. >> thank you. [providing instructions for public comment]

we'll begin with in person public comment. no one approached the podium and move to virtual public comment. the moderator will notify of callers in the queue at this time. >> board secretary, we have zero callers on the phone line and

zero callers have entered the queue. reminder to all callers on the line, you must dial star 3 now if you want to join public comment for this specific agenda item. we will wait 5 more seconds and close public comment for this agenda item. board secretary, there are still no callers in the public comment queue at this time. >> thank you. public comment is now closed. >> thank you. >> thank you very much. i will now ask for roll call vote on approval of the four items under this agenda item as proposed and seconded. >> thank you. roll call vote- [roll call] >> passes unanimously. thank you very much and again i apologize for not having hard copy of the correct

self-evaluation form for you. now move to item 14. >> item 14 is health service board annual education planning process. action item and presented by governance committee chair follansbee. >> thank you very much. again, we were waiting approval of the three year health service system strategic plan which occurred today. before we go ahead and develop a more detailed education plan, which we will do at subsequent meeting of the governance committee. with that, i will open up for-all we are asked to today is to approve the process as simply outlined. i think it isn't projected, at least to me but think you have it in your packet. any discussion?

>> thank you chair follansbee. i move we approve the health service bord annual education planning process as presented. >> second. >> moved and seconded. further discussion? if not, open up for public comment. >> thank you. [providing instructions and public comment] begin

with in person pub lic comment and no one approached the podium. the moderator will notify of caller er in the queue at this time. >> board secretary, we have zero callers on the line and zero callers entered the queue at this time. please use the dial in instructions and select star 3 now if you want to join public comment for this specific agenda item. we'll wait 5

more seconds and then close public comment for this agenda item. board secretary, there are still no callers in the public comment queue at this time. >> thank you moderator. hearing no further callers, public comment is now closed. >> thank you very much. moved and seconded that we approve health service board annual education planning process calendar as outlined and now call for roll call vote. >> roll call vote- [roll call] >> passes unanimously. thank you very much. we now move to item 15. >> item 15 governance policy in terms of reference 2022 review process and timeline. this is action item and will be presented by governance committee chair follansbee. >> i refer you back to the agenda packet,

which again states that the governance committee met on november 2 and approved timeline to review health service board policies and terms of reference. remind all of us that this is an off year for the comprehensive review, the last comprehensive review was performed and approved by the board on february 10, 2022 under the excellent leadership of then chair scott and prior to that february 19, 2019 also under the expert governance chair leadership of that opponent chair scott. so, we have three items that we identified for review. the first is a policy 210 regarding reassurance stop loss and how that is handled by the board. we review this annually as everyone recalls and we recently had a nice

presentation from (inaudible) about this. the second item is review audit and compliance language to make sure that it is up to date and adheres to what the policy has been and the third area was brought up as we reviewed the self-evaluation, and took out a word from the question number 16 for our self-evaluation as health service board regarding our compliance with our terms of reference and policies. and we realized we need to review them to see if we outlined a policy to on the very rare occasion make exception which we have done really incredibly rarely in the past to handle some more urgent matter so we want today review that. the committee will meet early 2023. our

policy and procedures mandate that these changes be circulated 10 days prior to a board meeting for a lot of the time for the public and board members to review completely rather then the 5 days that is mandated for the regular agenda. in order to accomplish that, we will meet beginning 2023, finalize the changes and circulate 10 days before the march 2023 regular health service board meeting. with that , i ask for any questions or comments and then a motion to approve the timeline and process for the health service board governance for reference review for 2022. >> mr. chairman, in light of a recent action by this bord today and letter contained in terms of

the settlement received there were no terms of reference or charter policy, charter guidance regarding the receipt of monetary it says legal settlement, but think we need to add-i move we amend the topics to include topic 4. receipt of legal/monetary settlements. we need to have a more defined process. this was kind of as i understand it, we got the money, it was reviewed internal administrative consultation, consultation with legal our legal counsel and so forth and then the recommendation was brought forward, and so we have-it has been without precedent i guess more recently, but there could be this type of issue that confronts us

again and might make a different decision so i think we need to at least include it. we may not be able to decide all the aspects of this by the time of the rest of the terms of reference review, the other three we talked about, but i would like to highlight that that gap needs to at least be addressed so i would at it -add it to the list and may have to come back at another time. my motion is that we add a fourth topic, receipt of legal/monetary settlements. >> i'll second that motion. >> so, can i interpret your motion to say that you move we approve the statement as outlined with the addition? >> yes. >> of a fourth area for evaluation discussion and possible presentation back to the board at the regular march circulation of march meeting 2023. the

motion includes reviewing the three areas already outlined, correct? >> that's correct and adding a fourth one. >> thank you. commissioner canning i think your second includes those 3 items as well. >> correct. >> in addition to the fourth, correct? >> that is correct, mr. chair. >> thank you very much. okay. any further discussion from board members? >> commissioner follansbee i want to clarify, the board packet indicates january 2023 meeting, so but you have been saying march, so is it march or january? >> i think-good question. let me-i don't see the outline. >> if i can commissioner, we talked about this timeline and we would try to get it done originally by december, and then we realized we were biting off more then we could chew so we

said january, but we have a complete authority if we can't get it done by january to move it further. but we said we would move it out of december and into january as a target. based on the completion of the work. >> you're absolutely right. i stand corrected. we added-haven't established a date yet, but we approved the committee approved addition of additional meeting early december to deal with the three issues that the committee talked about and now the fourth issue with the idea that a final policy change would be circulated by monday january 2 for review at the thursday january 12, 2023 health service board meeting so stand corrected, you are absolutely right commissioner. thank you very much. >> you're welcome. >> so, we have a

tentative december 1 governance committee meeting scheduled. tentative at this point. any further questions or comments? >> i move- >> open up for public comment. >> thank you. [providing instructions for public comment] we'll

begin with in person public comment. no one approached the podium. we'll move to the virtual public comment. the moderator will notify of callers in the queue at this time. >> we have zero callers on the phone line and zero callers entered the public comment queue at this time. please use the dial in instructions and select star 3 now if you want to join public comment for

this item. we'll wait 5 more seconds and close public comment for this agend a item. board secretary there are still no callers in the public comment queue at this time. >> thank you moderator. hearing no further callers, public comment is closed. >> thank you very much. it is moved and seconded that we approve the process and timeline for the review of the 2022 governance policy in terms of references with the three areas outlined in the agenda and the addition of a fourth area to review regarding the possible mechanisms for handling receipt of financial settlements as a result of legal or other actions. with that, i like to call for roll call vote. >> roll call vote- [roll call]

>> passing unanimously and that concludes the business of the governance committee and turn the agenda back over to president scott. >> thank you commissioner follansbee for your timely conclusion of that committee meeting and the results. with that, i have understand we have no presentations from any health plan representatives, and they have sat here dutifully throughout this meeting today and we want to thank them for coming and sharing their time with us and listening to what was a rather routine we think meeting. i want to wish they and their families very happy thanksgiving so thank you for coming. with that, we stand

adjourned. [meeting adjourned] >> my name is holly doudiet.

h2 firefighter with the san franciscowired. what inspired me to be a firefighter was in 2008 i graduated college . the recession had happened so there weren't any jobs. i was having troublefinding a job. and i was kind of looking around . my dad was a firefighter and i thought what a great career he had. so i asked my dad, never thinking about it at first before. i said dad, what you think about me being afirefighter and he goes yeah, thatwould be a good idea . i took some classes, i ended up loving it . i grew up and actually and i think it was a good fit for me because it's a physical job and it's enjoyable. you never know whatyou're going to get and it's a team effort . i first realized i was part of the lgbt+ community in sixth

grade. i looked on the other side of the classroom and i sawthis girl i thought was really attractive and i thought i want to be her boyfriend . though my experiences in the city growing up in the city and countyof san francisco were always verypositive . i came out in high school . i actually ended up being prom king my senior year in high school and a lot of peoplewere very supportive . myparents were very supportive . they just let me do my thing and my dad knew of a lot of lesbian women in the fire departmentthe time because he was a san francisco firefighter . for me it's very important to be part of a community and organization and an agency that supports my lgbtq status because if you're not yourself, how can you perform to the best of your abilities? you're always holding back in some way whether it's your personality or your abilities

or your overall skills and with agency that supports me being a lesbian i can truly be myself. i can be happy. i can be social with other people. it makes me want to work as a team and we all work better together when we are happier and we can be ourselves. >>. [music] >> >> i'm connie chan district one supervisor and welcome to the richmond.

>> i'm an immigrant and came to san francisco china town when i was 13 years old with my mom and brother. my first job is at the community organizer for public safety with san francisco state. and land in the city hall and became a legislative aid to sophie maxwell. went through city departments when kamala harris was our district attorney i'm proud to represent the richmondad district supervisor. [music] we have great neighborhood commercial corridors that need to be

protected. the reason why we launched the neighborhood business for supporting the [inaudible] for 15 years special more. we have the legacy business program the business around for 30 years or more and thought, you know, we gotta make sure the next generation contains for generations to come. am i'm ruth the owner of hamburger haven we came back on july 11. we were opened in 1968 at that time i believe one of the owners of mestart today went through a guy named andy in the early 70s and my father took it mid 70s. >> originally was just a burger joint. open late nights. then it changed over the years and became the breakfast staple. we specialize in breakfast, brunch come lunch now. i love this neighborhood.

i grew up here. and it feels like home. i walk down the block and recognize people of people say hello. you say hello you talk and joke. has that familiar environment that is enjoyable and i have not experienced anywhere else. there are many things i would like to see improve ams the things we might see are making sure that our tenants stay housed our small business in tact and those are the solutions that will contain to push to make sure that you know our communities can take root, stay and thrive. >> i'm proud of you know, welcoming folks to the richmond. everyone loch its we got farmer's market every sunday there. the you see really business at

the noaa. ice cream at toy folks and going to chop for book like green apple. and that's when you like the deal is pizza place haall families love. you will see a lot of great chinese shops that is readily available for everyone. >> and that is just thein are richmond there is more to do in the richmond. what is love is the theatre. >> i mean adam and with my wife jamie, own little company called cinema sf we operate the balboa theatre. the vocabularying theatre on sacramento and soon the 4 star on clement. >> balboa theatre opened in 1926 and servicing this outer richmond neighborhood since then. and close on the heels the 4 star opens since 1913. >> when you come in to a movie

theatre, the rest of the world has to be left behind. but you get e mersed in the world that is film makers made for you. that is a special experience to very much we can all think of the movies that we saw in the big screen of with everybody screaming or laughing or crying. it is a shared human experience that you get when you go in to places that are gatherings and artist presented to you. >> a shared experience is the most precious. and the popcorn. [laughter]. at the balboa especially, we stroif to have movies for people of every generation from the pop corn palace movies on the weekend mornings, for families and kids. this is for everybody of all ages. >> what is great about the

richmond is it is a neighborhood of the immigrants. belongs to immigrants not ap i immigrants you will see that there are also a huge population of rush wrans and ukrainian immigrants they stay united you am see that the support they lend to each other as a community. and cinderella bakery is another legacy business. if you go on the website it is known as a russian bakery. the first thing you see their pledge to support the ukrainian community. you will see the unity in the richmond i'm so proud of our immigrant community in the rich monthed. >> my dad immigrate friday iran the reason he stayed was because of the restaurant. has more centamential value it is the reasonable we are in this country.

when he had an opportunity to take over the instruct he stayed that is why we are here part of our legacy and san francisco history and like to keep it going for years to come. >> another moment i'm proud to be supporting the richmond and the only asian american woman elect in the office and as an immigrant that is not happen nothing 3 decades. you see it is my ability to represent especially the asian-american community. in my case the chinese speaking elders in our community that really can allow me to communicate with them directly. i'm program director of adult day centers. i have been here for 7 years i love to help the communities and help and the people with disability. i foal a connection with them.

i am anim grant i love helping our community and new immigrants and improvements. >> if you want nature, richmond is the neighborhood to go we are between ocean beach heights and golden gate park. >> i love the outer richmond. for me this is the single best neighborhood in san francisco. everybody knows each other. people have been living here forever. it is young and old. the ocean is really near by. and so there is that out doors ocean vibe to it. there are places to seat golden gate bridge it is amazing. businesses are all small mom and pop businesses. houses get passed down generation to generation.

it has a small town feel but you know you are in a big city at the same time. it's got a unique flavor i don't see in other neighborhoods j. it is about being inclusive we are inclusive and welcome the communities, anybody should feel welcome and belong here and shop local, eat local. we believe that with that support and that network it come in full circle. it is passing on kinds knows. that's when richmond is about that we are together at once. welcome to the richmond. [music] . >> shop and dine the 49

challenges residents to do they're shopping with the 49ers of san francisco by supporting the services within the feigned we help san francisco remain unique and successful and rib rant where will you shop the shop and dine the 49 i'm e jonl i provide sweets square feet potpie and peach cobbler and i started my business this is my baby i started out of high home and he would back for friends and coworkers they'll tell you hoa you need to open up a shop at the time he move forward book to the bayview and i thinks the t line was up i need have a shop on third street i live in bayview and i wanted to have my

shop here in bayview a quality dessert shot shop in my neighborhood in any business is different everybody is in small banishes there are homemade recess pesz and ingredients from scratch we shop local because we have someone that is here in your city or your neighborhood that is provide you with is service with quality ingredients and quality products and need to be know that person the person behind the products it is not like okay. who

is r. my name is debra alvarez rodriguez. i'm the deputy director in san francisco. my background is one in which i have spent the entirety of my life committed to finding solution to poverty and addressing the issues of inequity so people and communities can have accesses to resources and financial freedom. one thing true anode dear to my heart was the power of business ownership in creating pathways to financial freedom. we have still in infancy. we had over 100 entrepreneurs come and start their businesses. some are food trucks. some are restaurants. some are in farmer's markets and so farther. that's an incredible legacy and record to build upon. this was the perfect opportunity for me to come back home, you know, come back

to the neighborhood and take my skills and networks and resources and put it backseat in service of the community. given everything with racial reckoning and pandemic it was time for me and everyone else that had the opportunity to leave and get educated to come back home. we have a opportunity to grow our impact in terms of the number of people we serve and how we serve them. we grow our impact in taking the money we make with our entrepreneurs and circulate those resources back interview the community for community development. the third thing is we have a opportunity to have an impact on public policy in terms of the policies and practices the district has been notorious about interms of inequities. all of those are just the beginning of what is possible in terms of growth and

impact. ♪ [ music ] ♪♪ >> san francisco parks, golden gate park transforms into one of the greatest music festivals of all time, let's journey, inside, outside land. ♪♪ >> to this, our 6th year doing the outside lands and our relationship with san francisco, rec and park. and we work very closely with them in the planning and working very closely with the

neighborhood organizations and with the city supervisors and with the city organizations and with the local police department, and i think that the outside lands is one of the unique festivals in the world and we have san francisco and we have golden gate park and we have the greatest oasis, in the world. and it has the people hiking up hills and down hills and a lot of people between stages. >> i love that it is all outside, the fresh air is great. >> they have the providers out here that are 72 local restaurants out here. >> celebrating, and that is really hot. >> 36 local winerries in

northern california and 16 brewers out here. >> and you have seen a lot of people out here having a good time and we have no idea, how much work and planning has gone into this to make it the most sustainable festival in the united states. >> and literally, in the force, and yeah, unlike any other concept. and come and follow, and the field make-up the blueprint of the outside land here in golden gate park and in the future events and please visit sffresh parks.org. >>

for us, we wish we had our queue and we created spaces that are active. >> food and drinks. there is a lot for a lot of folks and community. for us, it started back in 1966 and it was a diner and where our ancestors gathered to connect. i think coffee and food is the very fabric of our community as well as we take care of each other. to have a pop-up in the tenderloin gives it so much meaning. >> we are always creating impactful meaning of the lives of the people, and once we create a space and focus on the most marginalized, you really

include a space for everyone. coffee is so cultural for many communities and we have coffee of maria inspired by my grandmother from mexico. i have many many memories of sharing coffee with her late at night. so we carry that into everything we do. currently we are on a journey that is going to open up the first brick and mortar in san francisco specifically in the tenderloin. we want to stay true to our ancestors in the tenderloin. so we are getting ready for that and getting ready for celebrating our anniversary. >> it has been well supported

and well talked about in our community. that's why we are pushing it so much because that's how we started. very active community members. they give back to the community. support trends and give back and give a safe space for all. >> we also want to let folks know that if they want to be in a safe space, we have a pay it forward program that allows 20% to get some funds for someone in need can come and get a cup of coffee, pastry and feel welcomed in our community. to be among our community, you are always welcome here. you don't have to buy anything or get anything, just be here and express yourself and be your authentic self and we will always take care of you.

>> driver, bye. >> hi. i'm will b. mixture weltake a walk with me. >> i just love taking strolls in san francisco. they are so many cool and exciting things to see. like -- what is that there? what is that for? hi. buddy. how are you. >> what is that for. >> i'm firefighter with the san francisco fire department havings a great day, thank you for asking. this is a dry sand pipe. dry sand pipes are multilevel building in san francisco and the world. they are a piping system to

facilitate the fire engineaire ability to pump water in a buildings that is on fire. >> a fire truck shows up and does what? >> the fire engine will pull up to the upon front of the building do, spotting the building. you get an engine in the area that is safe. firefighters then take the hose lyoning line it a hydrant and that give us an endsless supply of water. >> wow, cool. i don't see water, where does it come from and where does it go? >> the firefighters take a hose from the fire engine to the dry sand pipe and plug it in this inlet. they are able to adjust the pressure of water going in the inlet. to facilitate the pressure needed for any one of the floors on this building. firefighters take the hose bunked and he will take that

homes upon bundle to the floor the fire is on. plug it into similar to this an outlet and they have water to put the fire out. it is a cool system that we see in a lot of buildings. i personal low use federal on multiple fires in san francisco to safely put a fire out. >> i thought that was a great question that is cool of you to ask. have a great day and nice meeting you. >> thank you for letting us know what that is for. thanks, everybody for watching! bye! [music]

you're watching san francisco rising with chris manors. today's special guest is jeff tumlin. >> hi, i'm chris manors and you're watching san francisco rising. the show on starting, rebuilding, and reimagining our city. our guest is jeff tumlin and he's with us to talk about our transportation recovery plan and some exciting projects across the city. mr. tumlin welcome to the show. >> thank you for having me. >> i know the pandemic was particularly challenging for the m.t.a. having to balance between keeping central transportation routes open, but things have improved. how are we doing with our transportation recovery plan? >> so we just got good news this week. we're getting an extra $115 million from the american rescue plan and this is basically the exact amount of

money we finally needed in order to close the gap between now and november of 2024 when we'll have to find some additional revenue sources in order to sustain the agency. in the meantime, i finally have the confidence to be able to rapidly hire, to restore services and to make sure muni is there for san francisco's larger economic recovery because downtown san francisco doesn't work without muni. >> quite right. i guess the other impact of the pandemic was that some projects like the valencia bike improvements had to be put on hold. are we starting to gear up on those again? >> yes, so it's an interesting case study. of right before covid hit, we were about ready to invest in quick build bike lanes. arguably the most important bike order in san francisco.

that got stopped with lockdown and then as you'll recall, during covid, we invented all kinds of other new programs like shared spaces in order to support our small businesses as well as sunday street light events for neighborhood commercial streets where streets were closed off to cars and turned over to commercial activity. those successes now that they've been made permanent actually interrupt the draft design we had put together. so we've gone back to the drawing board and we are looking forward to having some additional community conversations about other design ideas for valencia. we're committed to completing a quick build project on this calendar year. >> that's such good news. valencia is a really great street for biking. so there are two huge and exciting projects that are about to be or have just been completed. let's talk about the bus rapid transit project on van ness avenue. how extensive have the

improvements been? >> what's called the van ness transit rapid project is in fact more about complete reconstruction of the street and most importantly, the 100-year-old utilities underneath the street. so all of the water, sewer, telecommunications, gas lines under the street were basically rebuilt from market street all the way to lumbard. the part on the surface which provides dedicated bus lanes for golden gate transit and muni, that was relatively straight forward and we're so excited we're going to start revenue service for muni on april 1st. >> that's fantastic. i understand there were some sidewalk improvements too. >> there were sidewalk improvements. we planted 374 trees. there is new storm water treatment including infiltration in the sidewalk, there's a bunch of art.

there's all kinds of things. we put in new street lights for the entire corridor. >> finally, the other big news is about the central subway. can you briefly describe the project and give us an update. >> yes, so the central t-line project, another stop at union square that connects directly into powell station and a final stop in the heart of chinatown at stockton and washington. that project has also run into challenges. it's 120' under muni, under bart, 120' down and out under chinatown in some unexpectedly challenging soils. but that project is nearly complete. it's at about 98% completion right now which means we're

testing trains, we're testing the elevators and escalators and the final electronics and we're still on track to open that in october presuming all of the testing continues to go well. so fingers crossed on in a one. we're really looking forward to allowing people to have a subway ride from the heart of chinatown all the way to the convention center to the caltrans station and all the way down to bayview and visitation valley. >> it's great to see all these projects coming to completion. we're all grateful for your team's hard work and i really appreciate you coming on the show, mr. tumlin. thank you for the time you've given us today. >> my pleasure. thanks for having me. >> and that's it for this episode. for sfgov tv i'm chris manors. thanks for watching.

>> goovend, everybody. >> how is everyone doing today? >> awe some. great weather we were dreading it would rain today and look at the sky behind me. gorgeous. this was meant to be. my name is natasha i'm the executive vice president the development at bridge. for northern california. i will also be our mc today. on behalf of bridge and ken lombard could not be here today. i want to welcome all of you and