>> the meeting of tuesday april 4, 2023. i like to thank secretary morewitz for his work to refine the processings of the meeting as we go back to in-person meetings with opportunity for public comment. with that, secretary morewitz, would you call the roll. >> sure. [roll call] >> and a hearty welcome back to susan christian. we're happy to see you and happy to have you back with your valuable experience and perspective. >> thank you. it's great to be back. >> next, we'll have commissioner

chow offer the ramaytush oholone land acknowledgement. >> it's my privilege to give the land acknowledgement. -- the san francisco health commission acknowledges that we are on the unceded ancestral homeland of the ramaytush ohlone who are the original inhabitants of the san francisco peninsula. as the indigenous stewards of this land, and in accordance with their traditions, the ramaytush ohlone have never ceded, lost, nor forgotten their responsibilities as the caretakers of this place, as well as for all peoples who reside in their traditional territory. as guests, we recognize that we benefit from living and working on their traditional homeland. we wish to pay our respects by acknowledging the ancestors, elders, and relatives of the ramaytush ohlone community and by affirming their sovereign rights as first peoples. thank you. >> thank you, commissioner chow.

our next item is approval of the minutes of the health commission meeting of march 21, 2023. commissioners, you have before you the minutes. if there are no amendments, do we have a motion to approve? >> motion to approve. >> second. >> all right. secretary morewitz, do we have public comment on this item >> yes, forks on the line, if you would like to make comment on item 2, press star three. moderator, please unmute the first caller. i'm sorry, i saw a hand up. i do see a hand. here, i'm going to unmute the person. caller, are you there some >> yeah. it took a while, mark. my code for today is yy. >> please begin. >> i'm grateful, mr. morewitz,

included in these minutes, i my written testimony congratulated commissioner bernal on his reelection as commission president. i testified that commissioner bernal and the full commission should take action on laguna honda's governing body to direct roll and pickens and have a written waiver request to cms slash cdph for an exemption for cms's two (indiscernible) asking with city attorney's office to make sure a written waiver request is submitted quickly to cms and cdph. i have provided you with information on 42 psr

section 483.90 and e and parenthetically roman numeral three, dated march 3, 2023, which provides the survey agencies, meaning cdph (indiscernible) and grant and variation on vacations per room -- when facilities were questioning writing an exemption request with the variation to section 483.90e1 roman numeral one will not affect residents health and safety. during san francisco's career shortage, killed nursing facility beds,

excuse me, i urge you, again, to do quote, everything you can, end quote, to see the written waiver to save laguna honda's 120 beds. please do so rapidly. thank you. >> thank you, caller. that is the only public comment for this item. >> all right. commissioners, any comments or questions? seeing none. secretary morewitz, all those in favor in approving the minutes, say aye. >> aye. [multiple voices] >> opposed? all right. the minutes are approved. our next item is general public comment. secretary morewitz. >> i have a statement to read. sorry. >> for each item, members of the public will have an opportunity to make comments up to three minutes. it's to provide input and feedback from those in the community. the process doesn't allow questions to be answered in the meeting or members of the public to engage in back and

forth conversation with commissioners. the commissioners do consider comments from members of the public when discussing items and making request to the dph. please note each individuals allowed one opportunity to speak per agenda item. individuals may not return more than once to read statements from other individuals unable to attend the meeting and written public comment may be send to the health commission, health dot commissioner dot dph at sfdph dot org. if you wish to spell your name for the minutes, you may do so without taking your allotted time. city policies along with federal, state and local law prohibit harassing conduct against city employees and others during public meeting and not tolerated. we'll take public comment from those attending in person and take remote public comment from individuals who have received an accommodation for a disability. i have given each individuals a code to speak when they begin their comments to prevent others from speaking and then we'll hear public comment from other

individuals. there's a time limit of 20 minutes that can be heard on each item from those who haven't received accommodation for a disability. because of remote comment procedures recommended by the office of city administrator and city attorney's office, please to not raise your hand to make remote public comment on an item until your category is called. all right. so, there are two folks who have put in a request for in person before we go to remote. >> thank you. i forgot how much i love holding these public comment forms so thank you for those who filled it out. first we have, billy gene wall i have a timer. when i say time suppose, finish your statement. >> welcome. >> good afternoon, members of the commissioner. my name is billy jean. i have been a part of the exercise program at dave hey lost for ten years -- davie

hospital for ten years and everyone had to complete an attachment form to the primary care physician and return it to the hospital and wait until an opening and class became available for us to go ahead and start attending the classes. we were very, very lucky because the classes were so very structured. they were taught by incredible instructors who were very skilled and well-learned and who have our best interest at heart and really wanted to improve our quality-of-life. and i just want to say how much i actually miss that program. i've noticed how much i personally have deteriorated since that program has come to a halt. since the program was discontinuing, i'm noticing my mind and bodies are

deteriorating in many different ways. my muscle tone is weaker. my skin quality has changed. my flexibility is rigged. arthritis in my hands and fingers are very painful. i'm starting to have fingers that look like my mother's which is really not something that i want. i have developed trigger finger in both of my hands. my (indiscernible) has changed and i'm falling a lot. i have dislocated my shoulder. i dislocated my hip. i've had four epidurals. i've had many bouts of botox injections and if i continued doing that program, i probably wouldn't have had to have those

procedures done. and in addition, my fibromyalgia flairs are frequent. they are worse and my brain fog is worse. i can't concentrate. everything is more prevalent. if i don't write things down, i forget them and i write down the wrong information sometimes. i just see myself losing all the ground i have grained from that program. it's very disturbing. i have felt more isolated. i'm more depressed. i've been taking more medication, which is not something i like doing. the warm water -- >> your time is up. >> the program was the best medicine i could ever have i and i wish to thank you for your careful consideration in making a prop q hearing for this. thank you very much.

>> thank you for your comment. next, we have collett hughes. >> good afternoon, secretary morewitz, commissioners and fellow san franciscans. my name is collett hughes. i

participated in the cpmc outreach community program for 20 years. about this program, the neuro path i can pain, i have become less mobile and trimmers and spasms increased. like disabled people, i can't tolerate my physical therapy or strength exercises. only in the pool. that's the only place i can do it. to participate in the program, i had to be cleared by my physician and health care information cpmc. i (indiscernible). it doesn't matter if you (indiscernible). i agreed to follow all rules and checking in at the assigned time and respecting the privacy of all and the clinical space and entering the therapy pool unless a therapist was present and forming the therapist of any change in my condition and following exercised therapy instructions during the group sessions and whatever we had to do. we followed those

instructions. individual assessment of pain and function occurred at each session. no medical -- such as free swimming happened as represented by cpmc during this process where all and special medical pool and receiving instruction from cpmc clinical staff. when cmpc did not reopen the pool for a few months in '22, (indiscernible) the local program was not reopened. instead the same type of warm pool, small group exercise classes were offered but only to people needing them on a short-term basis. who had the right interest and could afford the co-payments. they were called therapeutic procedures for which they billed and the small group sessions were therapeutic and medical to the non-pool patients and it was therapy for us as well. it was therapy for us as well. medical slight (indiscernible) is

dangerous. a test to this from my own experience in both sets of classes. the health commission needs to schedule a prop q hearing on the closing of san francisco's only hospital aquatic program that served elders and people with disabilities like me for decades. i think now of the people who were at the pack pool who were thrown out of there because they were told they had to move to davies and they were transferred and they went. and some of them were very comfortable because it was new and they were fragile. many very old at that time. they went to davies and what happened? they were told, goodbye, goodbye, and goodbye without a reason. there's no justification for this. this has to be really carefully vetted. we need a public hearing. please have a prop q hearing without delay. thank you so very much. >> thank you for your comment. secretary morewitz, do we have anyone on the line who is requesting accommodations?

>> we do. so, folks, i gave accommodations to two people and i see many more hands than that, so i'm going to reiterate, if you received, if you haven't received accommodation from me personally by e-mailing or calling, put your hands down. only folks at this point who received accommodation can speak. jeanette, try and unmute those folks and those with accommodation have a two-letter code. as they begin their statement, they will start with that code and that's how we know they have gotten accommodation. this is a procedure passed down to us by the city administrator's office. i know it's arduous. jeanette, please see if the caller has a code. >> dr. palmer, code ww. >> thank you. dr. palmer, begin. you have three minutes. >> as a community true significance and family physician, i'm calling to advocate for proposition q hearing for the davies warm pool

group program. it is -- the sutter told city attorney some kind of crap that led city attorney to conclude that these were not, that the program does not constitute the elimination or clinical services and doesn't prompt proposition q notice requirements. this is not true. these are clinical services and there's one pool. sutter shutdown their other pool in 2017. the low cost group (indiscernible). the same type of medical information that people that are short-term participants who pay with major medical insurance supply. furthermore, cpmc davies provide

the identical service on a short-term group basis when approved and paid for by medical insurance and billed towards as a therapeutic procedure, therefore, cpmc sutter is trying to get out of giving these services because they don't generate the revenue, not because they are not clinical. and this is detrimental to the community. these are low cost services that are needed by the community cmpc is a nonprofit organization. look at the facts and schedule a prop 2 hearing. thank you. >> thank you, caller. jeanette, please unmute the next person. >> yeah. it is wwata patrick. the director's report doesn't mention laguna honda. this

prevents historical information about -- >> sorry for the interruption. if you have a comment on the director's report, that's during public comment. these are for items that do not appear on the agenda. >> this isn't about the director's report, which does not mention laguna honda. so this is testimony. start my three minutes over, mr. morewitz, please. >> how would you like to proceed. >> go ahead. >> (indiscernible) since laguna honda sexual abuse scandal in 2019. they received 138 citations for violation of 78 (indiscernible) related upticks.

plus, an additional 20 (indiscernible) violations for physical plant deficiencies, all across the (indiscernible) three years and four months and the root cause report identified 66 root causes requiring 454 collective (indiscernible). add in 123 substandard care violations uncovered during laguna honda's first (indiscernible) in june 2020. that totals 261 violations of federal regulations, suggesting severe problems with regulatory compliance to provide all health safely to laguna honda vulnerable residents and march 17th, there were 23 more

deficiencies. laguna honda typically was in substantial compliance with cmc (indiscernible) and routinely passed state inspections who would view any regulatory violations. what is known is the recent massive mismanagement of llh. i want to add my voice to the previous callers calling for prop 2 hearing on the closure of the warm pool. my mother, for years, went to aqua therapy in wisconsin and i know how important it is for patients with severe arthritis to receive that therapeutic intervention. you must hold a prop q hearing on this and not fix your

responsibility to make cpmc continue to provide these vital service to san franciscans who solely, no pun intended, need it. thank you. >> next caller. >> all right. so, there are only two folks who had accommodations. anyone else who would like to make remote public comment, you may do so now by pressing star three to raise your hand and we'll move into a 20-minute time limit for the overall of the comments. janet, i'm hoping you have kept track of those who have commented, so we'll go to those who have raised their hand and let's go to the first person. caller, are you there? >> yes. can you hear me? >> yes. please begin. have you three minutes. >> okay. thank you very much. hello commissioners. my name is (indiscernible) and i'm a resident in san francisco. and a member of the great

(indiscernible). and i want to urge you to stop (indiscernible) san franciscans (indiscernible) and also [hard to understand caller] thank you very much. >> all right. please unmute the next caller. >> is there any more -- no more callers, great. that was the only other hand, commissioners, for general public comment. >> thank you to the members who called in and came to the meeting. next item is the director's report. for this, we have dr. grant coal next. director of health. director colfax. >> good afternoon, commissioners, grant colfax. i have an extensive director sheet that i'll go through. the first item is non-written item. it's a

laguna honda update. just wanted to again, emphasize that the department of public health remains fully committed to cms recertification and the long-term civility of laguna honda and their families. as shared during the last commission meeting, the cms 90-day survey may talk about the changes happening and we're on the path to recertification. as an example during the first 90 day monitoring survey, we received a total of 124 deficiencys and the second survey saw a decrease in findings with an anticipated total of 23 preliminary deficiencies. in addition, laguna honda staff and leadership submitted all 77 march deliverables for the action plan. this comes after

completing all 126 general milestones in the 133 january milestones successfully. as we celebrate improvement, we recognize there's much work to complete before we are ready to apply for recertification and in that regard, over the coming weeks and months, we'll continue to complete all action plan milestones, prepare the facility for the next monitoring survey and complete the (indiscernible) to apply for recertification. i would like to thank the hard-working staff and partners at the local, state and federal levels. our partnership with the unions as well as laguna honda residents and their families. next item and this is moving on to the written of part of the report. this is an update on san francisco's five-year financial projection and additional budget instructions. on friday, march 31st, the mayor's office controller's office and the office of of the budget and legislative analyst issued an

update to the five-year financial projection. unfortunately, reporting in worse of the two year deficit. the factors around the increased deficit compared to the december 2022 report includes revenue inspections compared to the prior forecast. in addition as the city is in negotiations with the police and firefighters unions, and with the in home support services and provider union and the outcome of the negotiation will impact the projections. the policy decisions with fiscal impact including addressing the structural staffing short arranges in the police department and analyzing the public works street cleaning supplemental and approval and pending by the supervisors and continuing the community ambassadors and (indiscernible) the loss of one time state funds to maintain shelter operations and several other appropriations for new program initiatives

pending at the board. with this news, mayor breed issued an instruction on march 30th, requesting that departments have additional options to reduce general fund support. equivalent to at least five percent by april 7th. for the health department, a five percent reduction represents approximately 50 million of savings in its annual budget. given the request, the mayor's office agreed to allow dph submit its proposal after the april 18th health commission and department staff will work on developing the instructions -- for its review and approval. just an update on a very challenging, even more challenging budget environment that again we'll update you and the public on here in this room on april 18th. next item is

watching the epic welcome at dph. next week, dph will welcome solution. welcome will help our patients prepare if their visits with us. patients will receive text messages reminding them to prepare and check in for their appointments via my chart and patients and their designated family members can receive charts and message their care team. if documentations is required, patients will use ipads to review signed documents as needed. welcome land -- and over the next several months, will launch our hospital -- will launch in our special settings and welcome will be available in six languages. next item is an update with regard to black health wellness and empowerment form. march 29th, the dph office of health equity hosted a community forum to present findings from the office of health, equity and findings as a

part of a process for black community. we sought to see what san francisco's black african american population believes contributes to a vice plant and success way of loss. this is based on strength rather than deficits. the study deferring, which shared aspects of these lifestyles contributed to their joy and contentment and explore how black african americans have been able to maintain their joy dispute race and poverty. after the presentation, attendees had the opportunity to discuss the findings and recommend initiatives and activities to promote black joy to improve health outcomes for black san franciscans. next item is zsgf, impacts of pro (indiscernible) commercial power outage. like much of the bay area last week, actually it wasn't last week. it

was march 21st and 22, the hospital was significantly impacted by extreme weather on those dates. as the city's largest primary care facility and the only one level trauma center serving san francisco in southern san mateo, it's critical that the hospital is providing care during power outages and a series of power outages that began on late afternoon of tuesday, march 21st caused problems throughout the entire campus and more significantly building -- the main hospital where emergency services operating rooms, icu, nicu and family care departments are located began running out of generator power that evening, after the power went out and building five where pediatric and cardiology and outpatient levels are located. the patients were -- until power was restored

which shouldn't occur until the following late afternoon. so, i want to thank all the hard-working staff who helped us respond to this emergency. and of course, the staff worked very hard around the clock until full power was restored. next item is the six annual detailing institute. the capacity building assistant program of gph for learning innovation hosted the annual public health detailing institute on march 29th through 31st. public health is a based (indiscernible) to encourage clinical practice change through brief education on one-on-one provider incident. the institute this year was on the interactions between health epidemic -- this was a multi

state exercise in this work and really proud of the team for leading this effort and by, all reports was it was a great success. next item is volunteers for san francisco's 40th annual carnival and the dph and indigenous (indiscernible), they have volunteers for the historic carnival event on saturday may 27th in the mission district and the contact for volunteers is listed there. also, wanted to shout-out the recognition on the next item, the chief experience officer was recognized by (indiscernible) hospital review, a leading journal for hospital list and hospital executives much congratulations iana johnson, the chief experience officer at gfs for being on the decker's hospital review for the 2023 list of 50 plus hospital

and health system chief experience officers to know. and then last item is with regard to the covid update. as we are basically in a study state with regard to our covid cases, our 7-day rolling average of new cases per day is 48. and 46 people were hospitalized as of march 29th including four in the icu, just a reminder, this is all patients in the hospital who have tested positive for covid. this does not necessarily mean that the people are in the hospital because of covid. 86% of all san francisco residents have been vaccinated. 65% received booster doze and buy violent boosters of those ticked up to 39% of residents who received that. much higher than the state and considerably higher than the national average. that's my director's report. i'm happy to take questions from the commissioners, thank you. >> thank you, director colfax.

commissioner morewitz, any public comment. >> folks online, if any of you have received accommodations, press star three now. jeanette, can you unmute the first caller of those? caller, please let us know you're there. >> this is gloria jensen. i was on hold for the warm pool comment and i was cleared twice. so, may i make a comment on the water pool program? >> there's no technical issue. >> the public comment at this time is for items on the director's report. the appropriate time would have been during public comment. >> right. which i was on hold. >> right. janet, please mute the caller and caller, please feel free to submit a written

comment. i saw the hand and there was no hand up at that time and the person who is moderating confirmed that with me. go to the next caller, jeanette. >> this is yy aka, patrick. can you hear me? >> yes, sir. please begin. >> you have gone on some sort of feint recording. we can barely hear you over-the-phone. i am wondering why pickens last week and now then director colfax is claiming that during the 90-day, the first 90 days monitoring survey, laguna honda had received 124 deficiencies. according to the first root cause analysis repor that was

raised on the 8 surveys, laguna honda received between october 21st and april of 2022, that report, i'm sorry, not that. the first 90-day monitoring report that's dated january 31, 2023, listed a total of 76 citations, according to shag. the question is whether sahg is trying to hide duplicate occurrences of the 76 tags and

try to hide 48 deficiencies from their published report. which is it, dr. colfax? was it 76 as was reported in the first root cause analysis, i mean, in the second root cause analysis report that covered the first 90-day monitoring survey or was it 124? why are you claiming 124 if shag had only publicly noticed that there had been 76? did somebody there at dph or shag have an accounting problem? you do not know how to count? do you not know how to report

this data accurately? this is ridiculous that you have that large of a discrepancy of 48 additional deficiencies. you guys really need to explain this. and let the public know who is presenting what numbers and what numbers are trying to be creatively hidden. i've read all of those reports. the total of 696 pages and i'm flabbergasted at this variance. thank you. >> all right. please go to the next caller. let's see. there's no caller, so folks who do not have accommodation, this is your time to raise your hand. if you haven't gotten accommodation and like to make comment on the

director's report, press star three now. we're on the director's report. no more callers, commissioners. >> all right. thank you, commissioners. comments or questions? vice-president green. >> yes, thank you for the report and i just have a question about how we're going to really track covid because at least where i work, the hospital is only requiring covid test now for people who you highly suspect have the disease and yet we know there's quite a few asymptomatic individuals who may be hospitalized and even for something like a delivery. do we have a sense of how we'll get a reliable set of the prevalence of the disease in the community going forward? the important thing is covid driven hospitalizations, but i'm wondering if we have a sense or if it's worth or manpower to direct this data. >> that's a good question,

commissioner. it's a work in progress and i do not believe we have an adequately system statewide or nationwide to track covid cases and as you point out, as policies change in certain institutions in the city, less covid may be detected because of different testing policies, so today, while i wouldn't say that the numbers that we're getting are exact, they do track fairly well with going up before hospitalizations go up. but going forward, the most likely thing is we still will have a good record of covid cases in hospitalization. that's what we really need doing tracking going forward. there is ongoing work with looking at things like sewage, wastewater that, there's a lot of variation in that and that's in the process of being defined and how sensitive that is and how reliable it is because you get situations, as i understand it, for instance, when you get massive amounts of rain and so

forth, you have delusion events and so, that is an issue with that monitoring as well. i think the bottom line is going forward, we need to be monitoring the hospitalizations and we also need to be watching what i call the state and at the national level for the emergent of variants that may cause more hospitalizations. >> great, thank you very much. >> commissioner guillermo. >> it's a comment much and i want to speak to johnson's recommendation. it's no small feet to be on one of their list, given the permanence of that period journal has in the field and in particular, for a hospital like gfg. we think about the patient population we have there. for her to be

recognized as providing a stellar, excellent patient experience to be recognized as one of the top 50, i think, really deserves another mention and then sort of related to that, the epic welcome that we're going to be launching and it will be a part of the overall patient -- outpatient care experience, so it's good to know that san francisco stands above many others in terms of really trying to make sure that our -- the patients that come to our facilities are treated with respect and dignity and great care. >> thank you. if i can mention with regard to johnson, her leadership and skills have gone beyond sffg. we deployed her at laguna honda to improve that work. >> even better. >> commissioner chow. >> yes. thank you. thank you to director for your report. sad to

hear about our financial projection and at 50 million, i'm reminded in the past when we've had to look at-large sums like this, although we have a huge budget, 5% is still 5% of a general budget, so in the past, i'm just reminded that we did work with our community partners when we were looking at changes, but i'm hoping that since you're going to be bringing this in two weeks, that we'll have an opportunity to have worked with them already through this process, so that we would have an understanding that people are onboard if they are going to be changes on contracts and secondly, we also have to understand, often, the department takes the hit first and i think we should hear then, what that's going to mean in terms of differences in certain

programs we have and so forth so we're all aware of the consequences of this potential and of course, it's possible the mayor doesn't want to put all of that into the budget so you can help us understand -- the mayor has until june 1st. this will be quite a move over those past several years so if you can keep us updated as to how we're going to accommodate all the programs we have been talking about and which ones have to be changed and how well we're working with our community partners, so, the second one was actually less of an issue. i'm happy to hear (indiscernible) has six languages and which languages are they? >> i would have to turn -- we can get you the information on the languages unless somebody

has that. i don't know if mitch, who is our epic lead is on the line, so we'll get that to you. >> sure. because i think one of the questions in the past has been trying to be able to have people make use of this. >> yes. >> and that the language issue has been there for the last several years, so really is a wonderful accomplishment if we're able to have access for all the people who are using a different language as a primarily language and it would be really, i think, a great help. i guess, lastly on the laguna honda, i had a question in terms of where we are standing with the pause on discharges, which is actually again eminent, which the state and the federal government doesn't seem to want to give patients sort of a comfort level, since i believe the data

is still in mid-may or soon after that in terms of what we're supposed to be a resumption, so it's impacting patients. what are we going to do? do we go through this process? and i thought that the second question in that regard and not in that regard, but in regard to our progress, which has been really tremendous coming down from a federal review of 100-sum odd areas down to 23, but those, as i understand, are different than the tags, right, in terms of -- so there could be a difference that these citations actually could wrap into several numbers of tags and therefore the tags may, in fact, be less than the

-- a number of citations and so, i think the public needs to understand that there's really a difference in the types of reporting and the definitions of those. but if you could just respond to the issue on the pause. >> sure. so, if i could just say one thing about the budget because i do think it's important. >> sure. >> just to emphasize, we are -- we presented to the health commission as a five percent reduction in the budget. thanks to the budget team and across dph, you were able to do that without making service cuts or having any layoffs and i can't sugarcoat another five percent, is we were at the bone with the five percent, right. the first five percent, so this is going to be a tough period and quite frankly, it's going to be a period we haven't gone through for a while in terms of figuring out how to squeeze out another

five percent cut. we will do it and as you know, our commission have excellent superb people on the financial side and super people on the operations side and obviously, ensuring that we're working across our system and with partners in the spread. it's going to be a really challenging time and that's why i wanted to emphasize the april 17th date because it's a short time for coming to the table with the proposed cuts. in terms of the pause, we have -- the pause in transfers and the earliest transfers would resume is may 19th. we had not received any further update from cms with regard to that date changing. i will say that you will recall that -- that we were required to submit a closure plan and that plan was submitted to cms and

the state the last, the draft that was requested was submitted in february to cms and the state and we have yet to receive an approval of that closure plan. i believe mr. pickens has made clear, we also wanted to support the laguna honda residents and their families with regard to understanding how traumatic it is to be transferred to another (indiscernible). we saw what happened when we had to go through that before. there's patients, residents at laguna honda who do not need a skilled nursing facility care. for most of the populations without a closure plan being approved, we're not able to transfer anybody from laguna honda at this time. my may update, we don't have a closure plan approved. may 19th is still the date that the earliest that people would be transferred at

this time and again, we've asked for more clarity around when that closure plan will be approved. we're optimistic that plan will be approved some time soon but i don't have a specific date for you. and then one last thing, the 6 languages, i have an update on the 6 languages. let me get that for you, so i don't, so the 6 languages are english, spanish, chinese, russian, that galli and vietnamese for the welcome (indiscernible). >> thank you very much. >> thank you, director colfax. i would like to under score the points made by commissioner chow, not only is the stress of the transfer but the uncertainty that the families experiences leading up to this and the sooner we can let folks know this threat of transfer doesn't exist, the better. we're in support of receiving a response from cms and the state on that one, and also, i would like --

wagner and jenny, thank you for the hard work they are putting into the budget and the adjustments that have been requested by the mayor's office which is an advanced of the mayor submitted her budget to the -- other comments. next item, which is for discussion, ordinance 077-22 healthcare code skilled nursing care transfer -- and we have claire atlman from the senior program planner and office of policy planning. welcome. >> good afternoon. all right.

great. all right. good afternoon, commissioners much my name is claire altman and senior program planner of office of policy and plan and i'm here joined by kelly hiramoto who is a special project planner. we'll present the 22-23 transfer reports as required by local ordinance. so for today's presentation, you have received the 22-23 data report which provides information and data in greater detail. so, and then i would like to say before i begin that i'm joined both in person and remotely by representatives of zfg, kaiser and dignity hospital and chinese hospital. if you have specific questions about the facilities data, they will be able to answer. unfortunately, umpc and cms wasn't able to join us remotely.

i did not invite laguna honda or jewish home to be here for their data because the report really focuses and intent of the ordinance is state about the general acute care hospitals transfers. the last thing i will note, i hope we can save questions for the end of the presentation. next slide, please. all right. so, for today's presentation, i want to briefly note the background and context for this local ordinance. as you're aware, upon the closure of saint luke's hospital, cmpc transferred patients from the saint luke's acute unit to the davies campus and there's 7 subacute patients. and the subacute beds will be closed when the last patient leaves. so, san francisco does not have any admitted subacute facilities in this city and this leads patients and san francisco

residents who require subacute care to be transferred out of county. in may of 2022, the board of supervisors passed an ordinance to have a better understanding of the whole scope of need for subacute care and it was expanded to include subacute care. briefly, i'm going to describe levels of care. skilled nursing care is nursing or therapy care for patients who are medically stable but require health needs performed by skilled professionals daily. and subacute care is a level of care that is needed for patients who require ongoing specialized care like trek only meet care and acute care after hospitalization. it's a level of care that requires medical technology to compensate for loss of bodily function. next slide, please. so the ordinance passed by the board of supervisors, requires acute

hospitals and hospital based nursing facilities in the city to annually report to dph information about skilled nursing transfers. and specifically, per the legislation in the ordinance, it requires facilities to collect data on the number of san francisco residents and non-residents who qualify for skilled nursing care while admitted and they are transferred outside of the county for that care or remain in the city in an acute bed or hospital skilled nursing facility which i'm calling this patients not transferred. and i do want to note that this does not include in-county transfers. so, for each patient category, facilities are required to report demographic information, including age, race, ethnicity, gender, gender identity and sexual identity if it's collected by the information and patient insurance provider and housing status. i want to note at the top of this presentation that that information is not all

accessible for reporting health facilities. and i'll be discussing the challenges collecting that data today during the presentation. and lastly, the ordinance defines skilled nursing care as including general skilled nursing care and subacute care, but given the interest in subacute care specifically, we, dph chose to request that data separately. next slide, please. so, this slide shows the san francisco facilities that are required to report through the ordinance. facility was required to report that our license at acute care are skilled facilities and chinese hospital and cmpc and kaiser, dignity hospital, and zfg are the general acute care hospitals reporting. the hospital, san francisco is a critical care hospital. also known as long-term acute hospital and it's a specialty hospital that

addresses extended hospitalization stays for those with complex medical needs. laguna honda hospital and rehabilitation center jewish home and rehab center are required to report because their license includes general acute care beds. however, because these facilities both primarily serve long-term care and provide skilled nursing care, instead we provide or the department provided special instructions for their reporting, asking instead for patient, their resident ask and census. and dph was responsible for issuing the guidelines regarding the data for the reports and the first reports were due october 1st to the department. the 2022 data is due january 31st of this year and moving forward, data reports will be due to the department every january 31st and then we'll have a report to the health commission annually as well. and i want to take a moment to recognize the work

that each health reporting did. the department did put the data together. they found a meth doll to collect and report this data to our department so i want to appreciate their work. next slide, please. all right. so, the image on the right of the slide shows one of the pages of the data collection tool and the data collection tool is provided in appendix a and b in your report. all reporting health facilities utilized our data workbook to report the data, but they utilize the the variety of tools to collect the data that's required in the ordinance. and so, these methods utilized by each data or each reporting health facility is detailed in the report and some of the common methods are on the slide as well. all reporting health facilities utilized discharge data codes to determine the number of patients who were transferred to a skilled nursing facility because skilled nursing

facilities or skilled nursing discharges is a defined patient discharge status code in the electronic health records which i'll say e hr for now on. subacute is not a standardly defined patient status code built in the d hr. to design subacute transfers, hospitals to rely on manual reviews of medical charts to find those patients. two reporting health facilities, kaiser and dignity hospitals have access to referral management systems and this referral data was used to capture patients that met the subacute or medical -- if they had a referral that offers that level of care. and zfg captures lower-level of care days and the days indicate when a patient's acute medical condition resolves or if they were admitted without an acute medical condition and the patient should be discharged to a different level of care. so in summary, all of these

reporting health facilities had unique tools to report the data. and because of the variety of methodologies that were used, our report for this year was limited and hospitals there couldn't be compared or not aggregated. so for the next few slides, i'm going to present each hospitals present data and their method for collecting that data and i want to note that in accordance with privacy rules, instances where there was patient population or less than ten, they are suppressed in the report and the slides. next slide, please. i'm going to begin with chinese hospital. they utilized discharge disposition data and accepting facility address to determine which patients went to a skilled nursing facility out of county. looking at the skilled nursing transfers between 2021 and 2022, chinese thopt believes the increase has to do with facilities generally being more open to accepting patients due

to changes in covid protocols. and while chinese hospitals is not able to provide an estimate for the number of patients who qualified for skill nursing, but are not transferred to that level of care, they did provide dph with the number of in county transfers and so i'll briefly talk about that even though it's not present on the slide. but in 2021, chinese hospital discharged 121 patients to in county skilled nursing facility and 2022, they transferred 134 patients to in county skilled nursing facilities. by having that detailed information about in county transfers, we're able to see most patients that were discharged to chinese hospital goes in county. to define subacute discharges, chinese hospitals reviewed the charts of those discharged to a skilled nursing facility to find those who didn't meet the criteria for subacute. there were fewer of

ten transfers to subacute facilities. next slide, please. kaiser utilized discharge data to determine the number of transfers to an out of county facility. and to find the population who are qualifying for skilled nursing facility but not transferred, kaiser utilized other referral software systems called care port and care port collected patients who had a referral to skilled nursing or met the qualification for skilled nursing, but ultimately were not discharged to that level of care. kaiser noted that could mean different things. it could mean the patient's health status changed or they required a different level of care, it could mean they discharged home. they may have passed. but what we do know, those patients did not discharge out of county. kaiser e hr and referral system both uniquely have a code for subacute built into this systems

so that's why they used discharge for subacute and stiff populations and there were fewer than ten transfers for subacute in 2021 and 2022. all right. next slide, please. so like kaiser, dignity used a tool to determine the number of patients who qualified for skilled nursing care while admitted at their hospitals and it's called nova health. they matched patients to determine those out of county. in 2021, dignity was unable to match patient epidemic information for all discharges -- patient discharges so have the 2021 populations for

subacute. dignity did change their demographic data for 2021, so all patient were matched in 2022. novi health does not deficiency between subacute and nursing facility acute. for those -- subacute care, dignity referenced the list of certified subacute providers and if a patient was referred and transferred to a facility on that list of certified providers, they would be counted as a subacute transfer or a subacute referral. but many of those facilities on that list provide general skilled nursing and subacute care, so we're conflicting patients who transfrered from skilled nursing care from those who went for subacute care. the table on the slide, it says referrals for skilled nursing, the facility offers subacute care. i want to

mention that there's also duplication between the referrals for skilled nursing and referrals for facilities that offer subacute care in the course of one patient stayed, they may have multiple referrals so they may be referraled to different facilities. one that has subacute care and one that is only sniff care so they could be counted twice in the analysis. looking at the subacute care, it's fewer than ten transfers were made to sub -- to facilities that offer subacute care. next slide, please. so, the cpmc, they utilized discharged data to report the number of patients transferred to skilled nursing facility and their data is in county transfers and out of county transfers. they don't document accepting facility address, so they are unable to determine patients that went out of county verses in county. and for subacute patients, cpmc

coordination team manually tracks information about patients each time someone is transferred to a subacute care facility. and chinese hospital, cmpc says they don't have a mechanism to track patients qualifying for skilled nursing care but not discharged to that level of care. regarding the subacute transfers, fewer than ten patients were transferred for subacute care. next slide, please. all right. so, ucf, discharge data as well for the total number of transfers to skilled nursing facility out of county and they also uniquely have a discharged status code built into their e hr looking for subacute transfers. but cp -- ucff, while they collect discharge information on 100% of their cases, there are gaps in documenting the address of the

facility location that the patient is discharged to. so, ucff found that some patients that had a subacute discharge went to facilities that don't offer subacute care. and instead, offer skilled nursing care or they may offer other services, so the actual number of subacute transfers listed in the report and on this slide is actually, their number is less than what is reported. and ucff wasn't able to confirm all subacute discharges because facility address was not available for all discharges. similar to chinese hospital, ucff can't track patients who may qualify for nursing or subacute care and not transferred but this past year, ucff said they updated their referral documentation procedures so they may have referral information for future

years. next slide, please. they utilized discharge data for the stiff transfers and used lower-level care for patients who qualified by not transferred. as mentioned earlier, it indicates when a patient care was resolved, they were omitted without one and they should be discharged to a different level of care. ucsf says if the patient meets criteria, so it includes patients who are receiving skilled nursing level of care in an acute care setting which is the patient population that we're looking for. and so if a patient meets that lower-level of care criteria during an encounter, they are captured in this data set. zffg noted their

-- we requested for 2022, their data doesn't include in-county transfers and the population that received skilled nursing karat zsfg and more level of skilled patients. in 2021, zsfg didn't have a way to collect subacute transfers. but for 2022, zsfg worked at the total population of patients who were disclarjed to a skilled nursing facility and found patients discharged to a facility that offered subacute care and from that population, szfg reviewed each medical chart to see if the patient met the medical criteria for subacute prior to discharge. and as you can see, fewer than ten patients were transferred to a facility that offered subacute care and had subacute orders

prior to discharge. next slide, please. so, kept field san francisco utilized discharge data to estimate the number of patients transferred to an out of county facility for acute care and subacute. they don't have a mechanism to track patients that's -- they are not transferred to that location and cat field believes the reason for the decrease in the number of out of county transfers between 2021 and 2022 had to do with a limited availability of staff sniff beds. i want inform know that kemp field cares for patient population with more complex health needs, which may be the reason that the number of patients transferred for subacute is higher than other facilities and i want to note that for kemp field data, the majority of their discharges for sniff and subacute is not sf

residents so these are out of county and usff data is similar and the majority of them are non-sf residents. both laguna honda and jewish facility, we gave them further instructions and instead of asking for the -- looking at laguna honda, beginning in april of 2022, laguna honda could not satisfy sniff patients and required patients to other skilled nursing facility so the 39 patients transferred were out of county. i i want to note that laguna, the methodology changed

changed from '21 and '22 so the data shouldn't be compared. the total number of residents who received skilled nursing came at jewish homes between 2021 and 2022 should not be compared. jewish home and rehab center did not provide 2021 data and so dph staff used the 2021 hospital utilization data charts that's put out by the state and neither facility provides subacute care. and in 2021 and in 2022 did not make referrals to subacute facilities. next slide, please so, while there's limitations to the analysis of 2021 and 2022 data reports because of the variety of methodologies used to collect the data, we have a greater understanding of the population who required skilled nursing and subacute services

across san francisco and had been transferred out of county. we found that most patients were transferred to an out of county skilled nursing facility were adults over 65. we found the population transferred out of county is racially and ethnically diverse and med i-care is the most common. there's subacute patients covered by are medi-cal compared to skilled nursing. next slide. i think evidenced by the presentation in the report, there's a number of considerations that dph took into account for reporting this data. first, the variety of e hr systems and referral systems that are utilized by hospitals, there wasn't a common methodology used between reporting facilities, which made the data harder to compare

between facilities. second, because subacute is not a defined patient discharged status code that's built into e hr, nearly all facilities had to have unique method for finding those patients. third, patient clinical presentation and treatment needs often change during the course of admission. facilities reported not being able to differentiate between a patient and those referred to a skilled nursing bed and the next day their health improved and they no longer needed the bed. forth, patient data hasn't been duplicated so one individual may had multiple encounters. they may have been transferred to a skilled nursing facility more than once from a reporting health facility in a calendar year and they could potentially be captured more than once in this data set. and then lastly,

facilities were not required to report in-county data so our data set and what we're reporting doesn't show a complete picture of skilled nursing facilities of non-san francisco residents and residents. while these considerations, they did limit our report findings and i want to recognize that this is the first report of this data. and so, there are opportunities for improvement. next slide, please. so without limitations in mind, the department will continue to work with our reporting health facilities to improve the data collection for future reports. and we look forward to sharingal those methodologies with the different reporting facilities. we're also looking into collecting in-county transfer data, which would give us that more cohesive look at skilled nursing facilities. we're looking at collecting administrative data, which may

provide insight into the population of patients who are remaining in acute care bed without an acute care need. it's similar to the lower-level of data zsfg reported. zsfg may report that for future years. i want to acknowledge that any request for additional data that we're looking into would be outside of the requirements of the ordinance and we're focused on the requirements in the ordinance for today's report. so, it may not be possible for all reporting health facilities to report additional data. and recognizing that their data systems that they use are highly individualized and complex, and so, any changes to reporting procedures or request may take years to develop. it may take years and additional staff training for any new procedures and it could lead to significant

financial resources for any of these changes. so, again, i want to share my appreciation though to my colleagues at the health facilities who have been collaborative in to this process and we look forward to continuing to work with them. now, i'm, our next slide, please. so, now, i'm going to invite my colleague kelly hiramoto, dph manager who will speak about the subacute care. >> thank you, claire. good afternoon, commissioners. next slide, please. dph has been working to support the development of new subacute beds in san francisco and addressing limited access to skilled nursing facility that, for hospital discharges and we're continuing discussions with san francisco hospitals for subacute beds. thank you. in 2022, the

san francisco department of public health requested a proposal for subacute skilled nursing and skilled nursing facility beds for hospital overflow. two hospitals were eligible and one is chinese hospital for subacute skilled nursing and skilled nursing overflow and the other was san francisco healthcare and rehab for skilled nursing hospital overflow only. (indiscernible) had to dedicated 22 beds and it's utilized for overflow from sfgh. chinese hospital is working for the acute certification and dph -- (indiscernible) through the controller's office and working closely with them through the process to try and get to successful certification. sfg and usff are confirmed partners to use the snf overflow beds and they provide subacute care. this

will add an additional 30-subacute beds and it will go through licensing and renovation. rehab is 168 beds facility and becoming a contractor for hospital overflow. in 2021, the consultant updated the performa that had cost for maintaining a subacute unit. in 2023, implementation of cal aim brought implementation services under the health plans. this will have financial impact to long-term care reimbursement and begin collaborating so they can we -- become stable. we're happy to answer any questions you

have. >> all right. thank you very much. before we go to commissioner comments or questions, do we have public comment? >> yes. let me make sure, is there anyone in the room who would like to make public comment? okay. so, let's first go to the folks who have received accommodation. if you would like to raise your hand, press star three. again, there are two people. jeanette, please unmute the first person. >> hi, this is richard again. >> please begin. >> thank you. between 2006 and 2019, sfdph public records responses -- [hard to understand speaker]. but only based on very limited data during that 13-year period. tch plans, electronic

health record system is incapable of identifying out of county (indiscernible) but they confirmed to me there is a discharge note module identifying discharge locations by the name facilities discharge including zip code. this -- [hard to understand speaker] >> it shows 148 transfers across all san francisco hospitals excluding kentfield which is owned by marin hospital chain. in the calendar year '22 and 486

discharged booths in 2021. this happened because your commission granted so many prop p closures of private sector hospital-based snf units. we have lost 1,381 snf beds in county and losing 120 beds and laguna honda will push that to 115 beds and there's 2161 remaining snf beds in this city. this commission should aggressively pursue increasingly snf capacity in county. the take away to me from this report is that while it's a

terrible situation, that we have no (indiscernible) facilities who is willing to accept new patients since 2017 six years ago. but the bigger problem is we also are discharging way too many patients to out of county facilities far, far away. and -- >> that's your time. janet, please unmute the next person. >> caller. >> good afternoon, health commissioners. my name is raquel rivera and my sister is one of the six remaining subacute patients at cpmc bay view campus. i want to correct that there are now 6 patients

remaining in the subacute unit that is expected to close when the last patient dies. a beloved patient passed away this morning. i'm here to urge you to prevent the relocation of subacute patients out of san francisco and to take action to ensure that subacute services remain available and accessible within san francisco. the health commission has a duty to promote and protect the health and well-being of san francisco residents. one important way to fulfill this duty is ensuring that necessary healthcare service, such as subacute care, are provided within the community. the relocation of subacute patients out of san francisco has negative consequences for both patients and the community as a whole. patients who are transferred out of their communities often experience higher rates of depression, anxiety, and social isolation. this not only

negatively impacts their health, but takes a toll on their families and caregivers. as leaders within the community, the health commission has a responsibility to consider the broader implications of the relocation of subacute patients out of san francisco by taking steps to ensure that subacute care services is available within the city. i can help promote the health and well-being of patients in their families. again, i urge the san francisco health commission to take action to ensure that subacute care services remain available and accessible within the city. this may include exploring regulatory or legislative options for greater accountable. somen incentivized healthcare providers to keep subacute patients within the san francisco community. health commissioners, what steps are you taking to help ensure this vital care remains available in

san francisco? thank you. >> all right. i believe that was the last caller. jeanette, can you confirm for me. yes. >> that was the last hand up. >> comments or questions, commissioner. >> commissioner giraudo. >> thank you. and i just want to thank you for -- for an excellent report and i'm sure it was very challenging to put together. my question, you may have have the question to, but i'm curious since there was, you know, the out of county transfers are significant for both skilled and subacute. they do have an idea of -- do you have an idea of what counties are the patients are going to? >> sorry. thank you for the

question. so, we did ask if they are able, to provide the list of facilities that patients went to, if they do collect that data or if they are able to share it, some hospitals couldn't share that information with us because it's patient privacy and confidentiality, so you know, i did look through where some of them are. i couldn't find all -- i couldn't find all information, but in the future since we ask the hospital to provide the data, we'll have an idea of what county they are going to. i'm happy to provide that in the future if we're able to. >> it's helpful to know where the patient is going to, are san franciscos going to shasta county or san mateo. i think it would be just on the general basis, i think it would be very

helpful. thank you for your report. >> just, if it's okay, i just want to note also that one thing that we also considered and heard from these facilities, for some of these transfers, for the patient families, they do request they go to a county closer to where family lives as well. it's something we'll have to consider with, if we do look at data or look at the information that's provided where these facilities. in some cases, the family is requesting the patient is discharged to that location. >> thank you. >> thank you. >> commissioner chung. >> actually, following up on what you have mentioned. that's one of the things that i'm curious about. is there a way to capture that to let us know the patients being discharged to subacute care out of county have family in that county?

>> thank you for the question. >> yes. >> i would have to refer to the hospitals and ask if that is something that they are collecting in their records or if it's possible to collect. i don't have that information. >> i think this is what we've been hearing. family members feel they are not being transferred to somewhere they can reach them, so you know, if we actually have data to show otherwise, it would be very helpful. >> thank you for the question. >> commissioner chow. >> i want to follow up on commissioner chung's point. it seems to me that when we send patients to skilled nursing facilities, we're required to submit clinical information and on a transfer, we must know

where they are going, so it's really concerning to me that all these different data systems aren't capturing where somebody is actually being referred to. because the clinical data is going with that patient and currently, the staff knows we're sending skill nursing to x, y, and z and also most skilled nursing facilities kind of do a review of the case before accepting this. so, for a data system not to be able to collect this, some data systems apparently, not being able to collect it is really mysterious in honor of where that data goes because it's part of the record. it has to show where people goes and people are transferred with all this medical data, so i'm not sure if the systems -- it

sounds like they are trying to correct systems but either we -- when developing those systems didn't put that data in or it may be a module needed or something like that. it does look like san francisco general is able to understand who is going where. maybe not necessarily which places, but who is being discharged out and just continues to bother me -- we don't know they went somewhere. if i looked up patient a, i could find out where patient a went because it has to be in the discharge records. so, that was (indiscernible) as i read your excellent report and you were really trying to stay within an ordinance that was very fuzzy and i think you correctly also got into the subacute business.

it's a historical issue with me, in terms of this whole subacute problem that we've faced and let me just parenthetically note, the commission noted the loss of nursing skilled beds is detrimental to the county. it's not that we have forgotten that and all prop q can do is say it's detrimental or not. we know the skilled nursing issues of being out of county and multiple reasons here including the high cost of labor did create some of the problems in terms of snf losses so the commission hasn't been ignoring that. with all the different priorities that the department has faced and certainly notwithstanding the three years of almost standstill right there, i think it's amazing you have this report.

let me get back for a moment to the subacute because we remember the subacute crisis came about in part with the rebuild the cpmc and the closure of subacute at saint luke's which was already fairly small. but that really did leave us and we did note that was a significant problem in this city and it asked the department to see what we can do about it. part of the development agreement had cpmc assisting us to get this started but then further assistance was really needed on the part of the department and no longer resource so i'm pleased you have, you in fact, and the last page is really very encouraging, your last pages, the fact that you are coming to some solutions for the city here in terms of us being able to, again, offer subacute beds and i want to

acknowledge that, as you've said, chinese is actually hear in person, i see, with the president, dr. zang and our -- is your title ceo of the hospital, michael? i got that backwards. anyway. it's very nice you're here because i think they are able to offer and the county working together to try to solve both part of the, well, solve the subacute problem and also being active and currently working on behalf of sf general and our problem of trying to get the lower-level of care out, so i'm pleased and thank you, director, for also seeing that these are high priorities at this point from a need that this commission has understood for years. and it really is nice to

see that there is some light at the end of the tunnel, that there's a possibility that we actually will bring subacute beds into the san francisco and be able to respond to our needs, so i wanted to thank you for being able to, you know, answer, after many years, this problem of subacute and i guess in government, we have to take the advances as they come and understand the length of time it takes, but it sounds like we're on the verge of solving a problem that has been here for at least a decade. so, i want to thank you for this report and look forward to the and hope to get an update on how the progress is coming in terms of both subacute and skilled nursing. you had mentioned that

this was a relationship that also then zuckerberg and uc were working with you on, so does that mean that all of the admissions are actually going to be coming from these two institutions or is it going to be open to other institutions that might need subacute and the skilled nursing facilities? >> there's two parts. two different kinds of beds for the skilled nursing overflow beds right now and zsfg and ucff expressed using those beds and -- they are willing to partner. some are thinking about it and some have, at this point, are leaning away from it but we haven't finalized that decision until we know the beds are online and we'll be working more closely with everyone. >> so, at the moment, it is

zuckerberg who is using the snf beds at chinese and that's what we understood in terms of flow problems, but in the future, we're still negotiating beds or it's subject to carriers, insurances or what? >> the access to the beds is really going to be something that the department is negotiating with the different hospitals to figure out who wants to partner to make use of those beds when they are not being used as subacute beds they can be used as snf beds and there's a shared cost to access those beds which is how we're keeping the unit viable and that's the part that got -- it's going to be tricky with cal aim and how we're going to do supplemental payments to keep the unit open but ucff is the only hospital that expressed interest with the extended delayed and admissions at laguna

honda, we are pretty dominantly using it for zsfg is great and they have an understanding. we have negotiated that right now, once things at laguna honda gets more situated, they are access three of the beds of the 23-bed unit and when the three beds come online, we'll talk about increasing that amount. >> so, what would be a good time in which the commission could get a progress report on the subjects since we look like we're moving towards some sort of solution? would it be half a year? >> i would say, right now, the hospital is getting their final survey from cdph which we hope to be scheduled soon in may. i think then we'll have a sense of knowing next steps to get sms certifications so they are

med-- medicaid and we can give you a progress in six months to let you know overall how our negotiations are going with san francisco health program and how the progress is going with chinese hospitals moving forward and the certification. >> so, mr. president, i think it would be helpful to get an update so we can keep track of the progress of this important project. >> very good point, commissioner, chow. our secretary morewitz is taking note of that. commissioner giraudo. >> thank you. i want to thank you for the report, given that this is -- this was a needed collaboration amongst all of the hospitals in this city that needed to be able to provide the data that's necessary. my concern is that given that each of the hospitals have varying

methodologies for collecting the data, i don't and i don't know how long it's going to be, how long it will take to set uniformity, given that most hospitals are a part of systems that would otherwise need sort of the systemic sort of process to collect other than what is required from the ordinance to make -- sort of the information that we need to track the progress and actually to create policy as a result of the data. for instance, the data that would provide us with in-county transfers and comparing that to out of county would give us a better context for being able to understand what the situation is. i mean, right now, we only have, out of county transfer data, non-transferred by

qualified patient data and that gives us some information but it doesn't give us the whole picture, so i think that's something that, if we can get continued cooperation from the hospitals that are making the referrals, you know, that would be important, but i don't think we should get our expectations up too high for that, so we have to look for alternative means to look or alternative data to allow us to really inform the policy and the decisions that need to be made with regard to snf and subacute beds that's desperately needed and i'm interested in seeing where the data can inform policy because this is -- you know, the lack of beds isn't something that is going to improve even with the efforts that -- the allowable

efforts we have seen at chinese hospital and the cup of other places -- a couple of other places we're looking for. it's such -- the environment for widening or expanding the beds that are needed doesn't exist in the present day and time and so, we need to look at alternative policy solutions so what's the data in what's methodology? what's the process that we need that's going to help us to do that? it's something i would hope the department can provide us with some directionality because otherwise, it's going to be status quo and i hate to paint such a pessimistic picture, but it's the reality and i think we need to face up to that reality. >> thank you, commissioner

giraudo. vice-president green. >> i would like to echo the thanks that the other commissioners have voiced. this was a tremendous undertaking for all and incredible amount of data and i think it'-- it's impressive you have drawn the data for the information you had to work with. if i'm understanding correctly, the goal here is to better understand what the capacity need is in san francisco because i think that does information policy but it informs what is needed in terms of financial support to be able to make these beds available and financially feasible, and i was also impressed, as i looked at the data, and maybe i was wrong but it seemed the chinese had a very -- a lot of success within county transfers whereas kaiser did not and so i'm wondering is there any information that will help us understand? as everyone has said, the idea you would be opening beds, subacute beds as

chinese means a great deal to everyone in san francisco. that's quite allotable. with the data limitations, can you say as we look at it, given the asian population and so forth, these are the amount of snf beds and this is what we need in terms of subacute beds in san francisco and parenthetically, i know there's a performa you mentioned for -- for subacute and do you know what the financial feasibility will be to make sure we have the number of beds from both the snf perspective and subacute perspective that we need to meet the need of san franciscans? i don't know if you have any early information about the financial feasibility or whether, in fact, it is accomplishable because there's not the structure from (indiscernible) to accomplish this? >> thank you, i'm sorry, thank

you for the question. a couple of things. in terms of the chinese hospital and kaiser hospital, i do want to note that chinese hospital did offer the in-county transfer information because they didn't have a method of determining patients who are qualifying for skilled nursing care but not transferred out of county and so, they offered their in-county skilled nursing transfers. it did provide a lot of, i think, important information. we saw that a lot of san francisco residents are going to in-county facilities. kaiser, because it was not required, we didn't ask for it. they didn't provide their in-county transfers -- so i don't know the success they have for in-county necessary and they use their referral data systems for that, the population who qualified for snf or subacute level of care but were not transferred and so, you know, really going back to when i was first reviewing chinese

hospitals data, seeing the in-county discharges was really enlightening so i do know moving forward, if we're able to get that information that we'll know a lot more about the population, so, you know, in speaking to commissioner guillermo's comment, i do hope this provides more information for us so we can draw more conclusions. and then regarding the financial feasibility, i'm going to ask kelly, do you want to speak to that at all? the performa? >> so when we did the performa, it was to try and figure out what the supplemental cost to keep a subacute would be. some of the patients would be needing high subacute, some would be medicare, medical. that was

that. the collaborative services, we started to touch on this population of snf only. people who need to go to a general snf. at the time, i think one of the things that makes it hard to project out, what is the projected need for the city to -- or snf or subacute within that is that it puts the focus on the snf is where people ends up going. what it neglects to contemplate, folk can be maintained at home if they had right access to support at home. it's to make home based services accessible to people don't have to leave their home because they will get more services to stay there. we can do a generalized, look to see how many people we project could need an snf bed but the hope would be, as kelly starts to implement and rollout, the need

for snf will go down because people will be staying home. it might be helpful us to do a survey for where snf needs -- maybe a year or two years where we're going. it's a projected need at the time. it's why the post acute care, we start by enhancing the services and supports for lower-levels of care, increased residential care for assisted living in adult so they could stay in community in a lesser -- in a lower-level of care and that sort of -- that's where that mental health sf is help that population and trying to expand that level of care of wes because we move to highest levels of care. >> that's a relevantly important answer. i really appreciate that and i think, as commissioner chow said, when you do report back to us, it would be

fascinating to know what progress can be made with in-home care. it will solve problem was in home care. >> thank you, commissioner green. i have two questions and the commission digs deep on a robust data collection. thank you for that. with regard to the ordinance, this is the first go years of reporting d the ordinance contemplate wrapping up or grace period or penalty when it comes to not providing requested data? >> i don't believe so. >> okay. >> at least it's not included in the ordinance language. >> okay. my second question is, the demographic data that you're collecting, is there anything today you've been able to glean to that? is there groups or demographics that's overrepresented or underrepresented in out of county representation. >> that's a great question.

thank you. the thing about having the out of county data and information is really, you know, making any comparisons. it's quite challenging because i'm missing a population of people who are referred or transferred for skilled nursing or subacute care. and so, that's why the findings at this time really focused on that out of county patient population because i just don't feel comfortable making, you know, comparisons or findings about the general patient population who are qualifying for skilled nursing care or transferred without understanding that, you know, in count-county transfers and another thing is, the presentation did today focus on total. the data was requested by san francisco resident verses nonresidential and i can say that when comparing the san francisco resident population to the nonresidential population, you know, there are -- it's a

much more racially and ethnically diverse population but -- in san francisco, so of san francisco residents so i'm hoping for that in-county population, so i can kind of noodle on other findings to see where there's additional information. >> that would be really important information to have. thank you if you thinking about that in advance and getting new trenches of data. any other questions or comments, commissioners? all right. thank you very much. oh. sorry. director colfax. >> thank you, commissioner, president bernal. i wanted to thank the team for their work on this. as you saw, going through this data was challenging, working with many stakeholders required a lot of persistence. and just with this ordinance, just to remind the commission especially my prior point about our current budget situation,

this ordinance came unfunded through the department, so this was quite candidly added work to the policy team, so i just want to thank them for, again, moving this very important piece of work forward. also, i wanted to acknowledge and thank chinese hospital and chinese hospital leadership for their partnership during this issue. through covid, we did strengthen our partnership in ways that were unprecedented and i just want to empathize from the snf to the subacute, from covid now to laguna honda, that partnership continues to strengthen and look forward to continuing in engagement. thank you. >> thank you, director colfax. we know the importance much community partnerships and this has been an effective one during this time. thank you. >> commissioner, if you recall there was one -- >> thank you. >> there was one hand that went up when we called public comment to be ended so commissioner

bernal stated that it would be okay to go to that and let that one person speak. so, jeanette, please unmute that person. great. caller, please let us know you're there. >> oh, hi. this is teresa palmer. >> great. >> thanks a lot. i just wanted -- one of the things i found about the report confusing out of county is it's illegal to have a bed that's both a subacute bed and skilled nursing bed. and subacute beds are best in the hospital and in a hospital base because if a subacute patient gets sick, it's complicated and they have go to the intensive care unit. it's not a good place to have subacute beds and i didn't -- i wasn't sure of the total number of beds that's available because i heard 23 and then someone else said 30 more. and it sounds like we need at least 40 beds in san

francisco. it looks like there's a minimum of 40 subacute beds a year. looking at what the health department said before and looking at what this tally says. the other thing is, i'm really sorry that cpmc is not doing its share. they have the same medical records as everyone else. they have ethic. they can do their bit. not only did they shutdown lots of subacute and nursing home beds, now they are not cooperating with the tally and i find that very and this demonstrating the huge cost of not having enough wes in town and if laguna honda cuts beds, it will be worse. this is additional ways to get a waiver from the federal government to not cut 120 beds. it's a risk to

human life to send someone far away and usually to lower quality nursing home so their families can't monitor them. thank you very much. >> great. that's all done. >> secretary morewitz, do we need to skip this item because the chair of our jcc had to step out for a moment? >> i'm sorry. the revised agenda in front of you is the presentation for the health services and permanent supportive housing is next. >> i apologize i sent you -- i included the wrong listed order in your packet but i gave you the new copy. >> okay. i don't have the revised one, so if you can guide us along. the next item. >> health services and supportive permanent housing presentation. >> thank you. >> please bring up the

presentation. >> good evening, my name is dara papo. integrated care. can you hear me okay? >> yes. get really close because the mic is bad, not you. >> thank you. it's an honor to be here tonight. i'm going to talk with you about health services in permanent supportive housing. if we can go to the next slide, please. we're going to talk about four different programs and ways in which dph partners with the department of homelessness and supportive housing hhh, provide health and wellness services and provide housing retention for individuals living in permanent supportive housing. we're going to talk about the facts program, facts of the ph, the permanent housing advanced clinical services, our site based nursing in phc, supportive houses services provided but behavior health or funding for and

additional programs. if you can go to the next slide, please. the facts program, again, permanent housing advanced clinical services was really launched out of conversations between dph, hhh, and permanent supportive housing providers about ways to support ph tenants who didn't have health services available in their buildings. as we talk further about the limits of health services, there's about 150 buildings providing permanent housing in san francisco. about 10,000 tenants and really only about 9 of those buildings right now currently have nurse services included in their buildings. so, there really was a large need that has been identified and out of this conversations, there was a proposal we developed a mobile team to provide both health and behavior health services and

permanent supportive housing. this was brought to our city, our home committee and the program has been funded by prop c. it is run, not just as -- it wasn't just a collaboration in planning. the program is run in coordination between whole person integrated care and behavior health services in conjunction with hhh. services have been in place for a year. we started with a pilot of ten buildings scaled to 23 and currently providing services in 69 buildings, which is about half of the phs portfolios and looking to scale to serve all psh buildings. the goals of the program are three fold. we talk about facts actually, sort of being a triangle. the base of

it, the bulk of services are really consultation and coaching for the on site supportive housing services staff, which has been a population that is really primarily to working with individuals, which doesn't have a lot of access to information in somebody's health record system. there's sort of, in the middle of our facts triangle, short-term onsite support services to help people stabilize and connect their resources in the community and the tip of the triangle are individuals that receive ongoing in-home services, either through our medical providers or through behavior health team. and, again, the goal to direct people to community resources, but sometimes people need a period of receiving services before they can make that connection. if we can go to the next slide, please. i find that sort of the

stories are often times the best way to get a flavor of a program. and so, we have two stories of individuals that have been served by the facts team. the first one a man who is in his 30s, who, in his 30s, had uncontrolled diabetes. this caused him to lose his vision in one eye. started to impact his vision in his other eye. he also has already had one of his foot amputated and pretty severe nerve damage in both his feet, so his functioning was definitely impaired and his diabetes put him at high-risk of losing vision in his remaining eye and additional amputation and heart disease. he hadn't seen a primary care provider or eye doctor for over a year, so he was really had risk for pretty severe health issues. when the housing providers learned about the facts program,

they identified him as one of their first referrals. in addition to his severe medical issues, he also experienced mental health and substance use issues. his room was failing the habitability inspections that occurred monthly, which was putting him at risk for eviction. everyone could agree this was not somebody that we wanted to see return to homelessness. so, he had a caregiver he had fired and having a lot of conflicts and challenges obtaining another caregiver. so, the facts team initially worked to help him connect with a culturally con grewing caregiver, somebody that he felt more comfortable working with. reconnected him to primarily care. helped him, both, with transportation and an escort, either making sure his caregiver could take him or

sometimes the facts team went with him as well, as well as working with his primary care provider to change his medication from something that he had to take daily, which was always a challenge and hard for him structurally do to a monthly injection he received on a weekly basis. because we had medical staff, we were administering the injection to him up to the point to where his caregiver was trained and able to give him the injections himself. that was one way we helped bridge care. they worked with the housing staff and caregiver to understand the requirements for the habitability inspections so he was able to get the work done for him to pass the inspections. as an outcome, this tenant's diabetes is under control. his room is passing inspections. with a couple of blips, he has been able to maintain his

relationship with his caregiver and closed out his case. available if things get rocky again, this is somebody we can connect to community resources. the other end of the spectrum, if we can go to the next slide, we're going to talk about a woman in her late 70s. she has chronic lung disease and memory issues and high blood pressure and high cholesterol and arthritis and history of bladder cancer and losing a lot of weight. she referred to fax because of memory issues and the fact she was really frail and she was at risk for eviction because she owed thousands of dollars of rent and had not paid rent for over three years. camacho due to the covid eviction moratorium, eviction wasn't pursued but there was a

lot of concern that this woman could end up in her late 70s returning to homelessness. the facts team connected her with resources, and coordinated an escort to help her get to appointments and also to address the follow up. they coordinated screening for her bladder cancer. she had missed her past screening. thankfully, she was still in remission, which was a huge release. she was anxious to get the screenings which was the reason she wasn't following through. they worked with her around a number of her basic needs. the laundry, getting a new mattress, and one of the most important things for her was they connected her to a community day program, which provided transportation support for her and she's been going two days a week, so she had structure to her life which helped with some of her

cognitive challenges. they connected her to a payee so she didn't have to manage her money and pay her rent directly. she's on a payment plan, so that her back rent will be paid and they also connected her to meals on wheels. her weight loss was because she didn't have access to food. and wasn't able to sort of navigate getting groceries, both the finances and the practicalness of this. so, her payment plan is supporting her housing retention. her caregiver is making sure her room passes habitability and she has food and she has social activities and facts team is staying connected to her and to her team as we continue to monitor to make sure these connections stick. and while a lot of her work is with individual clients, if we go to the next slide, the bulk is working with severe providers.

what we know and what we have heard and what i, myself, have experienced before i came to dph and i worked in permanent supportive housing for a number of years, is since the coordinated entry in 2019, 2018, individuals coming into permanent supportive housing have had more acute medical behavior health substance abuse issues. this is the goal of those individuals who need the most support to function onsite support services are the people going into permanent supportive housing and people who just need short-term support or -- to get subsidy. also, it's a workforce that doesn't have access to

dph's electronic data, so they are reliant about their health conditions. do they have a doctor, do they know they have a doctor? and often times feeling like it's hard for them to know how to navigate the health system. sometimes even where to begin, and so, a lot of the work for facts is really to help identify when their connection to care provide support, consultation and coaching to the on site services team as well as when they feel like they hit a wall connecting people to our system of care, the facts can help them either think through sort of problem solving or sometimes if one referral doesn't pan out, really work with them to identify what might be another ongoing resource. so, the consultation for the housing providers is another resource that is ongoing. and if you want

to turn to the next slide, please. we have a service provider or consultation story. that was a referral made because a tenant came to the service provider and this was a direct quote, said, i'm out of important medication. but i don't remember what it's called. i don't know if i have a doctor. this is a common scenario when people are really sort of unconnected to care and the service provider had recently learned about the fact team and said, this feels like a great referral. and so, the facts team was able to identify the individual did have a primary care provider so that was the first success. and was really able to sit down with the housing care manager to provide coaching about both how to schedule an appointment, what might be the type of questions they would want to ask with the client when they took them to

the appointment and how to support the tenant around medication management. housing providers don't administer meds but there's a lot of work they can do with reminders, with coaching for people to be able to help manage their own medication and independent living, and stayed in contact. we received a lovely unsolicited e-mail from the housing case manager that said facts helped me to connect my tenant to services. they helped my identify questions to ask about the appointment they wouldn't have thought of. it's like a huge burden has been lifted off my shoulders because i had no idea who to call to help my tenants obtain medical care. and this housing provider has made it one of our goals to now also talk to everyone that she works with her building to see if they

have conditions to housing and care and she's a champion training her colleagues on how to connect them to care. she wasn't sure how to start, now that she feels like she's able to her her colleagues do likewise. so, if we can go to the next slide. they are are three primary reasons why clients are referred to phacs. about 38 percent is for medical needs and 30% for behavior health needs. about 20% of the time is a mix of all of them. in calendar year 2023, so about 3 months, phacs received 106 referrals and a third were successfully resolved through consultation and coaching to cvs staff. and about 2/3 were

assigned either for assessment, which could result in consultation of team but more of, here's a name or number or direct services being provided. and a lot of what the work that phacs does is looking up in the different health records systems, is somebody connected to care, screening? is this tenant eligible for cal aim and health care management and helping them get enrolled if they are not already and make eligible. working with the onsite staff to understand more about the individual and also to have that health -- and how to make that introduction to our health team and not a random person knocking on the door, i heard you have health issues and how can i help. they meet with a tenant to help identify their goals and come up with a care plan and work through the coordination and direct services and when the goals are met, mown

tore it before closing the -- monitored before closing the case. people can be monitored for the same or different issues. we're on the next slide on the process. being a new program of planning our metrics and outcomes. for phacs and connections to routine care and behavior health services when warranted, non-medical services such as in-home health services and medicine assisted care or addiction related care. our goal is 90% of individuals eligible for health insurance are connected as well as who are connected to enhanced care management services if they are eligible. we're working on some goals and metrics for monitoring chronic health issues such as

buy buy bees and -- such as diabetes and hiv we're doing management about chronic health conditions. we're here to talk about a big mobile health team serving a big population and php nurses have been around for 20 or so years. that provides onsite direct nursing care and care coordination for individuals living in permanent support housing. there's a lot of work that happens between dph and hsh to make sure those are housed within this building because this is a level of health care support that exceeds what phacs can provide as a mobile team. these are individuals sort of point

towards fte, to point forward a full time working in the buildings. and we have nursing facilities in the building and three new ones added in year. three ran by -- 8 run by dph and 3 run by ucsf. there's a lot of work done with -- providing long acting injectables and triage and care coordination. and the health services, both nart per with phacs when there's reason for referral as well and works really closely with onsite support services. on the next slide we have an example of an individual and this is a man who is in his late 50s. he's been a resident for, in his building for two years. he was a

non-engaged with so site services, would not talk to them. the property management staff noticed he was having behavior changes and he was wandering the hallways and stairwells at night and entering into tenant's rooms and urinating in shared spaces and he had a number of lease violations and wouldn't meet with property management about them and he was considered at risk for eviction. the nurse onsite engaged the tenant through talking to the tenant doing an assessment and doing a chart review. the nurse identified that the client was not connected to care and had a history of hepatitis c and actually had in stage liver disease. the nurse assessed this behavior and this confusion, where was his room, where was the bathroom, how did he get there? it was possibly something that was a symptom of his liver disease and really

talked to the property manager to say, please hold off on the eviction. we think this behavior might be due to an underlining medical issue. let's see if we can get him some help. the property manager said "okay." and they linked the tenant to primary care and specialty clinics. he was prescribed medication to mitigate the confusion he was experiencing from his liver disease and the nurse worked with him closely. a lot of reminders from incentives, of knocking on the door with coffee, with medication to really continue taking his medication. his hepatitis c was treated. he was stabilized and managed his liver related symptoms. and his housing was considered safe. and due to his chronic and stage liver failure, he transitioned

into hospice care and was able, with support to die at home, which was his request. so because we had this medical staff onsite, they were really able to identify some things that allowed him dignity to not just improve his symptoms and quality-of-life, but to be able to die at home. see, we also have similar goals on the next slide for phs nursing which is -- psh, which is connections to care and primarily care, special cares and services like in-home service care and reducing unnecessary hospital and visits and management of chronic health conditions and like the last individual that we have talked about, supporting end of life care. if you go to the next slide, we have two funding streams that are over seen by behavior health services that support permanent supportive

housing. the first one funds onsite case management and crisis intervention services and psh buildings and second one is funding through state funding through the mental health services act that provides onsite support services in psh buildings and focusing on adult was serious mental illnesses. there's two more programs and there's the citywide team that provides services in about 28 psh sites for individuals who are considered at risk for individuals and facts team coordinates closely with them to make sure we're not duplicating services and we also have a lot of work that is being led through the office of care coordination and population behavior health around the overdose prevention work, also supported by whole person integrated care to make sure

that individuals in permanent supportive housing have training, resources around overdose prevention and follow up as well as connections to medication for addiction treatment, including in-home delivery of epinephrine. the collaboration between psh and sfdph is a work in progress. we're improving our services but it's wonderful to see the way this collaboration has both improved the lives of some of the tenants in permanent supportive housing and supported the on site health staff onsite housing case managers who were really sort of the life blood of the buildings. so thank you. please let me know if you have questions. >> thank you. thank you for the excellent presentation. secretary morewitz, is there public? >> folks, if you would like to

make public comment, press star three. i don't see any hands right now. let me make sure, and check with jeanette. yes. no hands. >> i would like to start to say, the illustrations of the personal stories are so important for us to hear. it really helps us know what goes into the work, the challenges that exist. the needs that people you serve have. working in a constituent service area myself, one of the biggest challenges is just helping somebody isolate the problem, people with multiple needs might not know what is happening with them? how a path to resolving some of the challenges they have, so the individual stories are just really helpful and particularly the story about the cbo partner as well was really great. thank you for that. that's my comment and i'll recognize vice-president green. >> yes. thank you. this was an

inspirational presentation you gave and it's -- i hope you're publishing this information and i echo commissioner bernal that the stories are incredible. as i read them, the beginning and i thought what can they go to accomplish this and to see what you have done is remarkable. it also speaks to the idea that you're bringing to the table everyone with a whole variety of different skill sets especially the cultural -- the cultural competency. do you have enough manpower and enough funding to continue this remarkable program because these examples are phenomenal? >> thank you. that's a great question. you know, we've been really lucky to have the funding from proposition c and currently, we've staffed up with primarily the physical health services, health workers,

nurses, nurse practitioners. a par-time physician. what we're currently expanding is the behavior health services. we had originally intended those to be provided by dph staff and the psh providers were like, what about our workforce and how can we support our own agencies so a request for proposal is going to go to really probably, you know, add on the behavior health services and that i think, we're anticipating we'll get going in the next year. that will really improve the coordination with the cbo partners and booster ore health capacity. looking forward to coming back in a year and reporting on that. >> thank you. >> commissioner guillermo. >> you answered my question with the amount of staff and thank you. that was my concerns when

expanding to 69 buildings. but i my other question is on the city (indiscernible) and my question is, how many have been serve so far in this or will provide the 28 psh sites, if you know how many have been served or with -- and how often will the woven team be at the 28 sites? you may not have the data but we're interested in seeing how many people are served with this. i thank you as well with this data. it's wonderful. >> thank you. i'll make sure we follow up with the information about citywide. >> thank you.

>> commissioner christian. >> thank you. i echo the comments from my colleagues. thank you for the presentation and the work. it was very clear. this is an example, an excellent example of success by meeting people literately where they are, right. and then, once you do that, meeting their basic needs, keeping them housed and getting them the treatment that they need, behavior health treatment as well. this is an example of a different version of the work that -- some of the other work that dph has done in the last year and months about meeting people where they are on the street to get them off the street and get them, as well as they can be, so this is obviously the path forward and a change that -- a lot of the change we want to see in our communities and i want to thank

you so much for it and it's incredible and i'm looking forward to further reports about any funding issues you have and the funding you're getting and how we can bring more resources to the work. so thank you very much. >> thank you. this program is a testament, i think, to the vision that has been set by dph and psh leadership that says we're going to work together both across sections of dph and not work in silos and we'll work together across departments so it's the vision that the health commission and the department leaderships have been setting that really allowed the work as these initiatives move forward. >> it's very good innovation. >> commissioner chow. >> thank you so much for your presentation and the stories and again, you know, i like jumping

into the chorus and want to say praises to the work you have been doing. i know this work has been going on forever. this was one of my first jobs when i got hired over 20 years ago. yes. and to know that it continues to grow, it's just -- it makes my heart warm because, yes, you know, we definitely see a lot of clients who just need that little bit of, like, outreach and, you know, and connection and they thrive. and, so one question i have though is, are they all in the same buildings? -- when we talk about permanent housing, you know? >> got it. we work with half of the supportive housing buildings that people submit referrals. it's common that people will have one or two clients at a number of buildings. >> okay. all right. so, that's

even better. before they all had -- they all are staying in the same building. >> right. >> -- where i worked, thank you. >> thank you. >> commissioner guillermo. >> department and also that funding is being put to the use that was intended and again -- the public needs to hear that, you know, or the voters need to hear some things they have passed has led to this -- to the stories that's being told, so if there's a way that we can somehow disseminate this, i think it would be great and maybe lead to finding some of that staff that -- at the either

at the cbo or the department who might want to be a part of a program like this. i had one quick question. you used the term culturally congruent. i haven't heard that before. is that a new term or am i out of it? is that culturally competent? >> in that scenario, the individual was assigned in-home services staff. didn't speak english as their primary language and this individual spoke english and for him, this was a disconnect so the staff identified somebody that both spoke the same language and the same ethnicity. the person felt that, because when you have an in-home caregiver, that person is in your home. they are doing your laundry. they are bathing you and for some people to have someone they can't relate to or

a different gender, it could be uncomfortable so that was the situation for this client. >> i get it. i guess it's a new term of describing something that has been around for a while in terms of a need, but thank you. >> commissioner chung. >> yes, thank you. i got in on the last half of it, but i mean, it's an excellent report, also, as my colleagues have noted and i think for the future, it would be really nice to understand the staffing dollars that you're talking about and the numbers of people that are in certain staff positions, whether you have social workers or what the mix is. my question was, and i might have missed this, how do people get referred to you? is it by the managers of these

units? you're talking about the supportive housing program and so forth, so what is the mechanism that someone gets in and taken care of by this wonderful team? >> that's a great question. the onsite supportive team makes referral. we have a poll for people to submit a referral. and we've done a lot of work, of the phacs team to let people know this program is there and knowing about resources is challenges for case managers so we have done a lot of work and we have housing meetings and talking to individual agencies and individual agency staff meetings about this. >> is there self-referral? >> we don't have a mechanism for self referral at this point? >> not at this point. >> maybe somebody is afraid to talking to the upper side or the manager of the apartment or

whatever it is, but feels they have a need, so -- >> yeah. that's a great question. at this point, the way and again, we're still in the early initial iterations is that the relationship with the onsite support services is really critical. there's an eyes of the ears of the building and really the ones that are going to be helping follow up on recommendations and so, i think at this point, we've really -- we want to work on that capacity building for the housing providers as well as their support for follow up, but definitely something i'll bring back and make sure that we're continuing to talk about. >> okay. thank you. >> thank you. >> director colfax. >> thank you. i just wanted to acknowledge again some of the comments that had been made with regard to the enter agency collaboration and also one of the things that i think, i hope the commission heard from the

presentation is also making sure there's a seamless integration of behavior healthcare with physical healthcare. that's something our department and the healthcare system struggles with and that's so important especially given the conditions that we're dealing with now with the pandemic of overdose deaths and that as we continue to work to make sure that people have the physical healthcare they need, the behavior health services are there and available as well and of course, the other thing that is so key here is that this is allowing our other healthcare systems or acute care systems or emergency rooms to also work better because if you get care where you live, it's freeing up resources for the people who do need to actually go to the emergency room and get the care, so i wanted to highlight that and thank the team. a lot of this was, i envisioned before covid and now it's being realized and also, i

think a lot of lessons learned from covid, including the shelter-in-place, that work contributed to the scales you see here, so thank you. >> thank you, director colfax. thank you again for an excellent presentation. we look forward to seeing you again with more great examples. >> thank you so much for your time and support. >> okay. our next item is the consent calendar for this. i'm handing this over to you, commissioner chow. >> no. i believe, it is commissioner chung. >> chung for the -- >> first the report. >> two parts to the consent calendar. so, i will -- the finance and planning committee met before the commission meeting today and we reviewed ten items on the contract report and also two new contracts and

we're recommending the commission to approve them on the consent calendar and another thing we actually was discussing is because some of the sizes of these contracts, you know, it brought back ongoing discussions that we have, you know, like what is considered too big as an organization because with all the merges that happened so the contracts ended up snowballing and getting bigger and bigger so we're going to set some time to have that conversation again. >> great. thank you, commissioner chung. and then there's another item on the con calendar have to do the recommend -- having to do with the zsfg and the jcc. let us know what the remaining calendar items are. >> these are rules and regulations and standardized procedures that's to meet

guidelines and bring them up to date and in compliance with what the remainder of what the staff is doing so these are updates and the joint conference committee is recommending that they be approved. >> okay. so, aligned with the recommendations of the finance and planning committee and the zsfg committee, do we have a motion to approve the consent calendar. >> i second. >> any public comment? >> folks on the line, if you would like to make public comment on this item, press star three. i don't see hands right now. just confirming. >> all right. comments or questions from the commissioner. >> seeing none, all those in favor say aye. >> aye. [multiple voices] >> opposed? all right. approved thank you. next item is joint conference committee and other committee reports. we'll go to commissioner chow for an update on the zsfg and jcc meeting. >> jcc met right here on

march 28th as our first hybrid meeting of the committee and key staff were present here and similar to today's meeting. the committee review the standard reports, our regulatory affairs report, still waiting for a hospital joint commission survey. the report harboring and vacancies and the challenges that continue and some of the successes in filling some positions and the medical staff report. the committee was pleased to see a reduction in the diversion rate below their target, close to about 40% instead of the escalating numbers that are going up to 60. and there's work to be done by the hospital and the staff to continue to bring that down, but they were pleased with that and they were -- there was a reduction in the people who left

without being seen in the emergency room. those were all good news. the committee then approved the policies, what you just voted on today and heard a presentation on. the true north score cards, of course, is only, less than a quarter at the moment. working together on achieving these goals. in closed session, we'll approve the credentials report and the (indiscernible) report. >> thank you, commissioner chow. any public comment on this item? >> no hands up. >> commissioners, comments or questions? all right. our next item is other business. is that right? i just wanted to acknowledge this past friday, international transgender visibility day, we're grateful for the written support of environment we have in the bay area and i want to acknowledge really the politically dangerous and threatening environment that

we're in today for the trans community particularly with rights being commander assault by state governments particularly in the south, so i wanted to acknowledge that as well. commissioners, is there other business? >> i was going to mention that the chronicle was able to have an open forum article on hepatitis b screening, commending the hep b program which the city participated in and the community. let's hoping one day we'll get an update on how we're meeting the requirements and hep b is the reason for the article. they indicated that the -- the preventive committee of explanation, and i forget the null name, they are recommending that in fact, hep b screening is

done on all patients at least once. just seeing to see if we were keeping updated with our health programs? >> thank you, commissioner chung. i know, secretary morewitz will note that for a future meeting. commissioner chow. >> thank you for bringing up the tran transgender -- it's hard to see what's going on in our country and out in africa, that they are passing lgbtq laws that would require those who identify as lgbtq to possibly facing, like, death sentence or life sentence in prison and for us, you know, yes, we should celebrate that. we live in the bay area, but i'm not sure if everyone knows that we actually have been a clinic and also, you

know, like a provider, we had received death threats and threatening phone calls ongoing to harass them here in san francisco and it's one of the community clinics that serve the community. so, i think that's something that we also have to look into since we also provide services to the community and to make sure that the staff are safe. >> thank you, commissioner chung. commissioners, anything else some other business? oh. commissioner christian. >> thank you. just building on what commissioner chung said. obviously, these attacks are physical attacks, but they are psychological attacks and it's -- the ways in which it undermines and degrades people's health, mental health, which leads to other problems and so,

i'm thrilled to be back. i'm not sure what the department and the department has been doing -- i'm not sure what the department and the county has been doing on highlighting this issue and working to protect as much as possible the public health at the mental health level, but i think it's something i would like to think about, how we can engage publicly and to support and bolster people's resilience and their health. >> thank you, commissioner christian. it's wonderful to have you back. commissioners, any other business? if not, we'll move to our last item, which is a consideration of a motion to adjourn. >> so moved. >> is there a second? >> second. >> second >> okay. all those in favor. >> aye. >> [multiple voices] >> opposed? all right. we are adjourned. [gavel]

>> (clapping.) >> in san francisco the medical examiner performs the function of investigating medical and legal that occurs with the city and county of san francisco from a variety of circumstances in san francisco there is approximately 5 thousand deaths annually i'm christopher director for the chief mr.

chairman the chief my best testimony a at the hall of justice on 870 drooint street that is dramatically updated and not sufficient for the medical chairman facility i've charles program manager public works should a earthquake of a major are proportion occurs we'll not continue to perform the services or otherwise inhabit the building before the earthquake. >> we're in a facility that was designs for a department that functions and in the mid 60s and friends scientific has significantly changed we've had significant problems with storage capacity for evidence items of property and also personal protective if you're doing a job on a daily basis current little storage for

prirjs are frirnlsz we're in an aging facility the total project cost forever ever commercial is $65 million the funding was brought by a vote of go bond approved by the voters and the locations is in the neighborhood the awarded contract in 2013 and the i'm the executive director we broke ground in november 2015 and that started with the demolition of existing facility we moved into the foundation and january so pile foundation and then with second construction of the new facility. >> one of the ways that we keep our project on time on budget and we're having quality to have regular meeting and the variety of meetings with

construction process meeting as well as cost of control meeting and i'm a project manager for public works the office of chief commercial we want walk the project site when we sign up and also with a contractor insinuates for a change over we need to verify what or what was instead of. >> the building is 42 feet tall so it is two stories and 46 thousand square feet roughly we're that's a great question to be on time and budget have the roof complete a the exterior moving with the site work. >> and as you can see we've got a lot of the interior finishes installed. >> in an effort of an differentiate the facility that designed to work for 72 hours. >> not taking into account there was a lot of structural updates made into this building

not seen in other construction throughout san francisco or other barriers we have friday morning examiners from 8 to one public comment monday to friday because of air circulation we literally have to shut the doors and so the autopsy is done without staffing being able to come and go or exit the space and literally lock down the autopsy in the new facility we have bio build one door opens and closed behind you you can gown up and go through a second seizures of doors that has its own independent air supply and now in the exterior opt space having that middle space have greater flexibility of staff as they move in and out of the

area. >> in the current facility investigative unit has small tiny, tiny place in the area of the new facility is almost doubled in all divisions from the current facility and the new facility. >> the planning we have here gives them the opportunity to have the pool needs to complete theirs jobs in a much more streamlined fashion. >> we're looking forward to have secured parking to minimize the egress of you know visiting and the members of the public but really to minimize the investigators remaining remains from our advancing and so the facility. >> we have a new visitors area we're building that is a little bit more friendly to families. >> one thing you may notice in the room no windows there is no

natural light not good for most autopsy but in the new facility at new hall we made that an objective they want to insure we were able to look up in the middle of exam and see the sky and see natural lights. >> that's one of the things the architect did to draw in as much light as possible. >> we have staff here onsite we insure the design of the new design enables the investigators and other investigators skiefksz to consider to house on site this meant we needed to design and plan for locker room facilities and shower rooms the ability to sleep. >> third of the construction going into the building has been

by contributions of small businesses. >> part of the project is also inclusive to the sidewalk have all new sidewalks and new curve cuts and landscaping around the building we'll have a syrup in front of the building and rain guardian. >> the medical examiner's office has been a several if in their contributions of the understanding the exception and needs. >> it's a building that the chief medical examiner has been looking forward to quite a few of the. >> it is extremely valuable contribution to the, neighborhood address san francisco as a whole. >> the building will allow is to have greater very much and serve the city and county of san francisco and the neighboring

my name is doctor ellen moffett, i am an assistant medical examiner for the city and county of san francisco. i perform autopsy, review medical records and write reports. also integrate other sorts of

testing data to determine cause and manner of death. i have been here at this facility since i moved here in november, and previous to that at the old facility. i was worried when we moved here that because this building is so much larger that i wouldn't see people every day. i would miss my personal interactions with the other employees, but that hasn't been the case. this building is very nice. we have lovely autopsy tables and i do get to go upstairs and down stairs several times a day to see everyone else i work with. we have a bond like any other group of employees that work for a specific agency in san francisco. we work closely on each case to determine the best cause of death, and we also interact with family members of the diseased. that brings us closer together

also. >> i am an investigator two at the office of the chief until examiner in san francisco. as an investigator here i investigate all manners of death that come through our jurisdiction. i go to the field interview police officers, detectives, family members, physicians, anyone who might be involved with the death. additionally i take any property with the deceased individual and take care and custody of that. i maintain the chain and custody for court purposes if that becomes an issue later and notify next of kin and make any additional follow up phone callsness with that particular death. i am dealing with people at the worst possible time in their lives delivering the worst news they could get. i work with the family to help them through the grieving process. >> i am ricky moore, a clerk at

the san francisco medical examiner's office. i assist the pathology and toxicology and investigative team around work close with the families, loved ones and funeral establishment. >> i started at the old facility. the building was old, vintage. we had issues with plumbing and things like that. i had a tiny desk. i feet very happy to be here in the new digs where i actually have room to do my work. >> i am sue pairing, the toxicologist supervisor. we test for alcohol, drugs and poisons and biological substances. i oversee all of the lab operations. the forensic operation here we perform the toxicology testing for the human performance and the case in the city of san

francisco. we collect evidence at the scene. a woman was killed after a robbery homicide, and the dna collected from the zip ties she was bound with ended up being a cold hit to the suspect. that was the only investigative link collecting the scene to the suspect. it is nice to get the feedback. we do a lot of work and you don't hear the result. once in a while you heard it had an impact on somebody. you can bring justice to what happened. we are able to take what we due to the next level. many of our counterparts in other states, cities or countries don't have the resources and don't have the beautiful building and the equipmentness to really advance what we are doing. >> sometimes we go to court. whoever is on call may be called out of the office to go to

various portions of the city to investigate suspicious deaths. we do whatever we can to get our job done. >> when we think that a case has a natural cause of death and it turns out to be another natural cause of death. unexpected findings are fun. >> i have a prior background in law enforcement. i was a police officer for 8 years. i handled homicides and suicides. i had been around death investigation type scenes. as a police officer we only handled minimal components then it was turned over to the coroner or the detective division. i am intrigued with those types of calls. i wondered why someone died. i have an extremely supportive family.

older children say, mom, how was your day. i can give minor details and i have an amazing spouse always willing to listen to any and all details of my day. without that it would be really hard to deal with the negative components of this job. >> being i am a native of san francisco and grew up in the community. i come across that a lot where i may know a loved one coming from the back way or a loved one seeking answers for their deceased. there are a lot of cases where i may feel affected by it. if from is a child involved or things like that. i try to not bring it home and not let it affect me. when i tell people i work at the medical examiners office. what do you do? the autopsy? i deal with the enough and --

with the administrative and the families. >> most of the time work here is very enjoyable. >> after i started working with dead people, i had just gotten married and one night i woke up in a cold sweat. i thought there was somebody dead? my bed. i rolled over and poked the body. sure enough, it was my husband who grumbled and went back to sleep. this job does have lingering effects. in terms of why did you want to go into this? i loved science growing up but i didn't want to be a doctor and didn't want to be a pharmacist. the more i learned about forensics how interested i was of the perfect combination between applied science and criminal justice. if you are interested in finding out the facts and truth seeking

to find out what happened, anybody interested in that has a place in this field. >> being a woman we just need to go for it and don't let anyone fail you, you can't be. >> with regard to this position in comparison to crime dramas out there, i would say there might be some minor correlations. let's face it, we aren't hollywood, we are real world. yes we collect evidence. we want to preserve that. we are not scanning fingerprints in the field like a hollywood television show. >> families say thank you for what you do, for me that is extremely fulfilling. somebody has to do my job. if i can make a situation that is really negative for someone more positive, then i feel like i am doing the right thing for the city of san francisco.

the tenderloin is home to families, immigrants, seniors, merchants, workers and the housed and unhoused who all deserve a thriving neighborhood to call home. the tenderloin initiative was launched to improve safety, reduce crime, connect people to services and increase investments in the neighborhood. as city and community-based partners, we work daily to make these changes a reality. we invite you to the tenderloin history, inclusivity make this neighborhood special. >> we're all citizens of san francisco and we deserve food, water, shelter, all of those things that any system would. >> what i find the most fulfilling about being in the tenderloin is that it's really basically a big family here and i love working and living here.

>> [speaking foreign language] >> my hopes and dreams for the tenderloin are what any other community organizer would want for their community, safe, clean streets for everyone and good operating conditions for small businesses. >> everything in the tenderloin is very good. the food is very good. if you go to any restaurant in san francisco, you will feel like oh, wow, the food is great. the people are nice. >> it is a place where it embraces all walks of life and different cultures. so this is the soul of the tenderloin. it's really welcoming.

the. >> the tenderloin is so full of color and so full of people. so with all of us being together and making it feel very safe is challenging, but we are working on it and we are getting there.celebration). >> nowruz hi, everyone thank you so much for joining the 18 year have come at san francisco city