since i stopped using, our life is night and day. i'm able to withstand cravings, i don't are body acs. >> anyone can do it. >> we are living proof that present. commissioner. green. present. commissioner. christian. present. and. commissioner. salgado. here. and commissioner salgado will read

the land. acknowledgment. for. the san francisco health commission. acknowledges that we are on the unceded ancestral homeland of the ramaytush ohlone, who are the original inhabitants of 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 people. thank you. and today i have the great pleasure of welcoming our newest commissioner, judy guggenheim. any of you who've worked at san francisco general know how

tirelessly, tirelessly she has supported that institution. not only was she has she been the longest serving member of the foundation board, but she's also served as past president as she co-chaired the i heart san francisco capital campaign, which obviously secured funds so vital to the county hospital and beyond her health care commitments. she's also been the chair of the board of the core foundation foundation, as well as the san francisco educational foundation board. so we are so delighted and lucky to have you join us. and i wonder if you might want to say a few words. thank you. no thank you. oh, i turned it on, commissioner. thank you. thank you, commissioner green. i'm thrilled to be on. and i my work at the general was, i think, the work of a lifetime, but my particular interest is in. community.

community organizations that function and function really well. and i believe they're the bedrock of a healthy democracy and a healthy community. and so i'm very pleased to be here. well, thank you so much for joining us. before we begin the agenda, secretary morowitz is going to review our new health commission location and meeting schedule. hi, everyone. i'm mark horowitz, the health commission secretary. we are. we moved to city hall because one on one grove is slowly closing its services, and city hall only had mondays available just for you all to know. in terms of the reason, here are the schedule of our meetings. full commission meetings will be the first and third mondays, starting at 4 p.m, and will be located in four room 408 at city hall. the finance and planning committee will also be on the first monday at 2 p.m. city hall, room 408. the laguna honda joint conference committee will be on the second monday at 4:00, room 408. the community and public

health committee will be on the third monday at 2 p.m, room 408, the zuckerberg san francisco general hospital joint conference committee will be on the fourth monday at 3 p.m. at 101 grove room 300. again, that meeting the jcc will continue to be at 101 grove, likely through the end of the year. while we await a construction on a room at csbg. all of this information is posted on the web on the health commission web pages, by the way. thank you, president green. thank you so much. the next item on the agenda is the approval of the minutes of the health commission meeting on december 17th, 2024. commissioners, you have the minutes before you. are there any additions or corrections to the minutes? i believe i had one adding that verb. you did. and could you could you state it again, commissioner? yes, president. let me see if i can pull that up. it was a very minor correction. on. let's see.

oh. you. it was the word wish. president green, on the first page under call to order the. the sentence should read. president green wished miss chung well in her new role. and i apologize for my error. no. no worries. any other commissioner? corrections. is there any public comment on this? oh, well, we will take a motion. yes. is there a motion to approve? i motion to approve. second. and what about public comment? is there any public comment in the room on the minutes? i see no hands in the room. and how about remotely? there are two of you who have received permission to provide remote public comment. i see no hands. all right, all in favor of approving the minutes, please say aye. i thank you. the minutes are approved. the next item on the agenda is general public comment. and commissioner morowitz, i mean, secretary

morowitz will read a brief statement. oh, i like the commissioner a little bit better. commissioner morowitz. all right. for each item. i'm sorry. at this time, members of the public may address the commission on items of interest to the public that are within the subject matter jurisdiction of the commission, but are not on this meeting agenda. each member of the public may address the commission for up to three minutes. the brown act forbids a commission from taking action or discussing any item not appearing on the posted agenda, including those raised during public comment. please note that each individual is 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. written public comment may be sent to the commission at the following email. address the word health dot. the word commission dot. d.p.h. at sf df.org. if you wish to spell your name for the minutes, you may do so during your verbal comments without taking your allotted time. please note that city policies along with federal, state and local law prohibit discriminatory or harassing conduct against city

employees and others during public meetings and will not be tolerated. thank you. is there anyone in the room that wants to make general public comment? seeing none. and is there anyone remote? yes, there are two. and we'll take them in order. thank you. hi, caller, please let us know that you're there. mr. mayor, you've got three minutes. thank you. this is patrick. monica. code. bebe. this testimony regards something not on today's meeting agenda. please don't cut me off. in february 2023, i submitted next request number 23 to 837, requesting the mock survey documents from when may had conducted the two phases of mock survey number one at laguna honda hospital in august 2022. spdf staff provided two documents, one for each phase of the 2022 mock survey. on

december 14th, 2024, one of my associates requested the mock survey documents, plan of corrections and organizational assessment hsag had completed for the health inspection portion of the mock survey on october 25th and the emergency life, safety and emergency operations portion of the mock survey on october 30th. hsag is now under contract to conduct quarterly monitoring to ensure la sustains compliance with regulatory requirements. but after delaying the records request on december 24th, 2024, sfbf records staff asserted the records requested are protected by california evidence code section 115. i thought la had entered into a new era of transparency. why the sudden secrecy? how could it be that in the throes of decertification in february 2023, sf df provided results of the august 2022 mock survey, but now suddenly the same kind and classification of records are suddenly evidence code protected. what has

changed? what this suggests is that if the mock survey hsag conducted in october 2024 showed good results, lh would release it and lh would speed up admission's refusal to release the mock survey results suggests to observers that lh potentially still has major problems in patient care and safety, and lh is hiding something. our lh h sf df afraid that releasing the mock survey results will generate public criticism or again threaten lh hs, cms and medicare recertification. most importantly, members of the public in san francisco seeking admission to lh h deserve an explanation of whether the october 2024 mock survey findings are causing the slow pace of admissions to the hospital. this commission should answer that question today publicly. thank you. item number ten. consent calendar. chinese hospital professionals. caller

you are unmuted. please let us know that you're there. oh, hi, this is doctor theresa palmer. thank you. i'm hoping to hear in this meeting at some point, even though it's not on the agenda about the getting a waiver for the 120 beds. and if we're not immediately getting a waiver, what the what the barriers to getting a waiver are. this would probably involve being candid about recent regulatory activity. and because the original promise was that once improvement was sustained, a waiver could be applied for. and so why isn't this happening after so many months and so many surveys? the other thing that worries me is the rate of admissions. and again, i have an

ongoing concern with people that are either suffering in the community due to a need for nursing home care or people that are being forced to be sent out of county for nursing home care. one of the things i recently became aware of is a person who wanted to be admitted to laguna honda for rehab, was told that she had to disenroll from her current insurance, but was not advised about working with her current, current insurance to get an exception to their coverage. in order to pay for laguna honda. and even if and so is the admissions department working with people in the community who want to come to laguna honda, who either don't have the right insurance or need emergency disenrollment from their current insurance, or need help in understanding how to

change hmos or get on medi-cal. you've got over 300 beds to fill, and people. really, i'm sure there's a real need in the community, and i would like to reassurance that the health commission and laguna honda admissions and health department in general, is doing everything to demolish barriers to get people in the community who need the beds in. thank you very much. thank you. that's the end of the remote public comment. thank you. the next item on the agenda is the director's report. director colfax. hi. good afternoon, commissioners. grant colfax, director of health. i'm going to try it from this perspective in this new room that works for all of you, i hope. just a few items. i did want to start on a couple of

items that are not actually written. and one, unfortunately, piece of news to share today is that the us reported its first death due to h5n1 avian flu. today. i am relieved that the population health division will be providing you with an h5n1 update today. so the team is here to answer any follow up questions with regard with regard to the situation of h5n1, both locally and nationally. with regard to other items not written on the director's report. i'm really delighted to announce that. director sidhu has been hired, accepted in the role as chief nursing home administrator of laguna honda hospital. as you know, delta has been acting nursing home administrator for a number of

months now. really pleased to welcome him to this to this role. second. second. second item regarding laguna, honda also wanted to give the health commissioners. let you all know that the department has applied for a waiver for the 120 beds we've applied following the process, as instructed by cms, and we are awaiting an answer from cms about whether that the status of that waiver, i don't, unfortunately, have a timeline to give to you because they haven't shared a timeline. but certainly the laguna honda team can provide additional information as we have it, including at the next health commission meeting on january 13th. going to the written items. just really pleased on december. 16th. the dph human resources held the fourth annual

air equity conference centered around the theme it starts with me introspection and tangible actions to advance equity and inclusion at d.p.h. and this was held with 145 d.p.h. human resource professionals gathered at court auditorium at the san francisco main library branch for a day of inspiring talks and activities. group activities helped employees use shared language around preferences, traditions and requirements to enable an environment where hr professionals can advance respectful policies and processes to better serve our workforce. so it was a great fourth annual conference, and i really want to thank the hr team for holding that and organizing it. next, two items are really. just some some important stories that were in the press around the great work that the d.p.h street care teams are doing. one is one was on our shelter health

program and another one was on the care on the street that our street care teams are doing for people who are experiencing homelessness. so i'd encourage you to either read the articles. the links are provided in the report. and i will just say, having been out with our street care teams in at sixth and mission in the tl and in the bayview in the last couple of weeks, they are doing great work as we focus on getting people off the street and into into treatment, including substance use treatment. so just encourage you to look at those articles when you can. and just a last note, as we've complete as we come out of the holiday season, zfg capped off a number of holiday events at zuckerberg san francisco hospital. and i will say, having also gone gone to the zuckerberg over the holiday break, the big event was the

gingerbread decoration contest. and i was told that doctor susan erlich was one of the hardest things in her career to actually choose the winners of the gingerbread competition. so perhaps next year there'll be also looking for more more participation from the commissioners. but i just wanted to add that as well. so that's my director's report. i'm happy to answer any questions that the commissioners may have. thank you. thank you so much. is there any public comment on this item? is there any public comment in the room? all right. none. but i do see a hand remotely. mr. shaw, you have three minutes. okay, give me a second. doctor sidhu was not qualified to be a nursing home director and ceo. his first job as a nursing home administrator was at a facility that could be certified in the facility's owner. paxton chose to close down the facility.

sidhu does not have experience in a nursing facility the size of elacheche. you're making a huge mistake. thank you. all right. thank you. doctor palmer. do you have your hand up for this item? yeah, i do. i just wanted who can we write to call or bother to get the waiver granted? what's what's the best way to do that? so i'd like to know. all right. thank you. thank you. that probably won't be responded to today, but maybe in the future we will have some more information. thank you very much. that's the only public comment, commissioners. what about commissioner questions or comments on this item? commissioner christian. thank you. president green. doctor colfax, i was wondering. great article, as you said, about the street care services and

particularly useful kind of quote at the end by the doctor, who noted that when people see they can get compassionate care for their medical condition, then they start to be more open to working on their substance use. and previously, he'd noted that substance use disorders cause cognitive difficulties. and so i'm wondering whether the department given that and given the number of people that we still have on the street who are not accepting treatment, whether the department has the has any plans or ability to expand the these outreach workers to reach more people, more often in more parts of the city. yeah. so i appreciate the question. so we have dramatically increased our behavioral health system. and doctor collins is here. you'll hear more about that today. but

from from beds to staffing to making sure that people get the care that they need when they need it, wherever they are. so a recent example of that expansion, of course, was the 16 hour buprenorphine program, where now anybody in san francisco can call get a clinician on the phone between 8 a.m. and midnight and get prescribed buprenorphine. so the expansion is happening. it also is continuing. so another example of where we've had great success in our street care teams in in, in in with our night navigators is prescribing buprenorphine on the street as the commission. and i believe doctor collins will be talking about this later today in more detail. i'm getting people what i call bed and bupe, where we get people a bed to stabilize and get buprenorphine. we've had a 90% uptake in prescription prescribing, nearly 90%. so those are programs that essentially started out as pilots, and we're continuing to grow those. i think you'll hear more from doctor collins today. and then i think as we, you know, look at the priorities of the city going forward, along with the budget situation, the

dynamics are going to be how do we continue to expand and strengthen our system of street based care for people and make the decisions about what needs to be prioritized? and we would we will welcome coming back to the commission in the next few months to engage in that conversation. thank you, doctor colfax. look forward to hearing that. thank you. any other commissioner questions or comments? i just have one. you may not have an answer to this in terms of the waiver. do we have concerns that with the changes in administration that would affect the speed with which this request might be considered? in other words, are we do we know if we're dealing with people at such a high level that these shifts will make a difference? or are we dealing with people who know a little bit about us and might might be able to act with greater speed? i can't really speculate on what might happen in this situation. again, we followed the process and procedures. we have

confirmed with cms that they have everything they need to make a decision, and we're we're awaiting a decision. without they did not share a timeline on that. thank you. yeah. thank you. all right. well, hearing no other questions or comments, we will go to a very timely presentation, which is the avian flu update from doctor george hahn, who's the communicable disease section director. oh, we have doctor susan philip here as well. he's our health officer. good afternoon, commissioners. and you will be hearing from from doctor hahn, who is our subject matter expert. but i wanted to open with just a quick framing to say that this is such an important topic. as doctor colfax said, it's very timely. we have been following this issue very closely for months, and you'll be hearing from doctor hahn, representing the great work of his expert communicable disease team that he leads as our director of communicable disease. but we've also had an incident management team that has been going for quite some time, and that has

been stood up by our public health emergency preparedness and response team. we also have our environmental health team because this involves animals as well and food products. our public health laboratory has developed locally based tests that we can use when we might need to. we have had our communications team working with us to prepare messaging. as the time comes, the needs arise and we're working really closely with the network. so representatives from sfgh, laguna honda hospital and ambulatory care are also involved. so i just wanted you to really understand the scope of the work, but i will turn it over now to doctor hahn, who will bring his expertise. and many thanks as well to doctor seema jane, who's our deputy health officer, deputy director for public health services. all of us leaders are following this really closely, and we really thank you for your attention to this topic as well. thank you. good afternoon. thank you, doctor philip, and thank you, commissioners. there are some

slides in front of you for this presentation. so i will be giving an avian influenza h5n1 current situational update as of december 31st, 2024. again, my name is doctor george hahn. i'm the communicable disease section director. so a quick background in general on flu. there are many subtypes of flu viruses. some common human subtypes include h1n1 and h3n2, and there are avian flu subtypes that primarily affect birds but can sometimes affect infect people or other animal species like pigs. some flu viruses are called highly pathogenic avian influenza or hpai because they are lethal to poultry, but possibly oh me to advance the slides. sorry. oh, okay. sorry about that. and yeah so they are

lethal to poultry but but may not affect the wild birds that carry them. they sometimes do and sometimes don't. all flu viruses are constantly mutating and changing. sometimes these mutations spark human pandemics, such as the 2009 h1n1 swine flu pandemic that began in pigs. so the next slide, we'll talk a little bit about the timeline of events. highly pathogenic avian influenza a, h5n1 has circulated globally for decades, spread by migratory wild birds. however, in 2021, a new strain of h5n1 became predominant globally and reached north america. in february 2022. poultry outbreaks from this particular strain began in the united states. and this is the strain that we're talking about today. so back in march of 2024, that's when we started seeing dairy cow outbreaks begin in texas and spread across the country in may of 2024, during routine testing

of a live bird market, h5n1 was detected in healthy chickens here in san francisco, as well as in wastewater. after investigation, however, no human cases were detected to date in san francisco. in october 2024, the first human cases in california were announced in dairy workers in the central valley. so the next slide, we'll talk about the clinical picture in people. signs and symptoms of h5n1 are similar to seasonal flu, but conjunctivitis or redness of the eyes has been a predominant symptom. h5n1 is transmitted, we think, from infected dairy cows and birds to people through close contact. this has mostly occurred in dairy and poultry workers in close contact with infected animals, drinking infected raw milk may also lead to infection. however, pasteurization and so

pasteurized dairy products are safe, and to date, the virus has not been able to spread easily from person to person. influenza antiviral medications are currently effective against h5n1, and vaccines specific to h5n1 do exist but have not been made available yet. and i'll address a couple of questions here that are not on this slide. but one of the issues that have been discussed is, you know, if there's a worker who does get regular seasonal influenza and then is additionally infected by h5n1, there is a theoretical risk that the two viruses inside their body could mix and cause basically a reassortment genetic mutation. and could that be what causes this h5n1 virus to more easily spread from person to person? so the answer is that could be a possibility. we don't

know how likely that is, but that's something that that is a theoretical possibility. another question that's arisen about the dairy workers and poultry workers is what is being done to see if they are actually getting infected by h5n1. and the answer to that is it varies depending on what farm operation they're working on, because a lot of this depends on the california department of food and agriculture and the local public health department. county, with working with the farm owners to monitor the workers. and essentially what is happening in most places is the workers need to self-identify, that they've gotten symptoms, that it's like red eyes or or flu like symptoms. they report it up either to their their farm sort of the operations or to their local public health department. and from there they would get tested. and that's how a lot of the cases have been identified. and we'll talk about how many in just a moment. finally, in terms

of the antiviral medications, they do appear to be working. will they continue to work in the future as the virus continues to change? that's a good question that no one can answer at this point, but that's definitely something that is constantly being looked at every time the virus keeps moving into different populations, there's always an assessment about whether or not the tamiflu or oseltamivir continues to be effective. so the next slide let's talk about animals. so in terms of animal detections in the united states there have been over 10,000 wild birds detected with h5n1 as of the end of last year. this is remember over the last couple of years, since the end of 2021, over 128 million poultry like chickens have been affected, and nationally, 900 over 900 dairy herds have been affected in 16 different states. in california,

at least 650 dairy herds have been affected so far since this past summer. this represents a three quarters of affected cattle herds in the entire country. this also represents over half of all dairy herds in the state of california. and last month, the dairy herds that were affected by h5n1 expanded geographically from the central valley to include southern california. so the next slide is bringing us to our current situation. so in humans, as of the end of december, there have been 66 confirmed human cases in the united states, 37 have been in california, and almost all of them have been in dairy workers, none in san francisco. thus far, almost all us cases have reported mild illness, with the notable exception of the patient we just heard about in louisiana. no person to person

transmission has been shown to date. and so that is a point that is important, and that is a point that all public health every year continues to monitor very closely. because of this, the risk of the general to the general public currently remains low as it has been this whole past year. you may have seen that on december 18th, governor newsom did declare a state of emergency here in california. and this was really done to speed contracting and increasing flexibility for workers and staff, especially those who are responding to the dairy herd outbreaks. you know, the spread from the central valley to southern california was was a factor in this decision. and so this declaration was not due to any increase in the risk to the public, but it was more to help the state respond to especially the dairy cow outbreaks. so the next slide, so we are continuing

and continuously looking for h5n1 here in san francisco. so we've broken this down into three categories. one is health care providers. and so dph has been informing health care providers in the san francisco health network network and citywide about h5n1 and consulting on and testing patients who may have been exposed to h5n1. no patients with h5n1 have been identified yet. next, under disease surveillance, our own public health laboratory is subtyping flu specimens. and so what they're doing is all flu specimens that are not able to be subtyped from san francisco hospitals and clinics are being sent to our public health lab for subtyping in order to determine if it is h5n1 or something else, like the common h3n2 or h1n1. in addition, we are subtyping at our public

health lab. at least 20 influenza a positive specimens per week that are coming from our general hospital, and more than 300 flu specimens have been subtyped by our public health laboratories since the summer. all have not shown to be h5n1. finally, we do look at our wastewater and we do monitor influenza trends in wastewater via wastewater scan. and the next slide shows a little bit of that. we recently or they recently got the ability to look at influenza subtypes h1, h3 and h5. prior to december, they were only able to look at influenza a in general. so this breaks it down into the three most important subtypes. what you'll see. and we have two sewer sheds in san francisco. one is southeast and one is oceanside. so on the left is oceanside and on the right is southeast.

southeast san francisco contains the majority of the population of san francisco that watershed. however, in both of these sewer sheds, we see that the majority of the wastewater detected is h1. and we do see some h3, which is to be expected, and we do see some h5. we don't think that's from humans. however, we think that is from milk that's going into our sewer system, or perhaps waste from wild birds that's going into our sewer system. on the next slide, i'll turn to our incident management team, which doctor phillip alluded to earlier. so using the national incident management system, imts are a way to organize resources to respond to emergencies. this we are using a planning imt structure to quickly organize our departmental subject matter experts, to update and prepare our plans for a variety of scenarios. if we turn this into

a response operation, this imt can quickly team can quickly pivot into a response imt. similar to the organizational structure we used during covid. and so the next slide. outlines in the organizational structure. i'm currently serving as incident commander with a doctor, andy turner from the public health emergency preparedness and response branch. as our strategy lead. we've got, as you heard from doctor phillip, we've been working very closely with the network under our operations section, and we've really appreciated, appreciated pfeffer's expertise in our planning of this imt, as well as our operations. daisy aguayo is leading our logistics section and drew morrell and maggie hahn in our finance. so the next slide talks about the planning for the three possible scenarios. and so these are the

scenarios that that could happen and that we're trying to prepare for. so the first one is the most likely we haven't had it yet. but it's only a matter of time to have an isolated human case of h5n1 in san francisco. this would not pose a public health threat, but the public would be interested in this case and would want, you know, we would need to do coordinated messaging around that. number two is that the virus develops the ability to transmit from person to person, and then that so that increases the threat to the public. and so that would require a lot of different actions at that point. and then finally is more of like a close to a worst case scenario where it essentially sparks another pandemic or leads to high mortality. so the next slide, we're talking about planning steps. and so what we've completed is we have developed anticipated mitigation strategies by these three scenarios. subject matter experts have reviewed and built

out plans for each strategy. and the public has been informed to avoid touching dead birds and to avoid drinking raw milk. currently, our plans are. plans are being reviewed and in the future we hope, perhaps by the end of this month, to have a tabletop exercise to test the plans and address any gaps that are identified. so finally, the next slide. in summary, the h5n1 outbreak is ongoing in california and in the united states, largely in dairy cows. california dairy herds are heavily impacted. this has led to some targeted recalls of some raw milk, and the fda did begin a bulk raw milk testing program in december due to raw milk being identified in california that had h5n1 in it. to date, the virus has not gained the ability to transmit easily from person to person, and the risk to the general public remains

low. however, influenza viruses are known to mutate and thus require ongoing monitoring and planning. so what i like to say in terms of what are the chances of something bigger happening and when would it happen? i mean, it could happen at pretty much any time. it could happen next week. it could happen next month, next year or never. and so that's kind of good to keep in mind that this is a scenario that we're planning for, that we don't know when it might happen and we or if at all. and so but to you know, given all the lessons we've learned from the previous influenza pandemics and from covid, it's better to be prepared than to not. so we are preparing for multiple possible scenarios using a multidisciplinary approach. thank you. and if you have any questions, please. well, thank you for the excellent, very clear presentation. and to the team for, as always, being so proactive in this situation. is there any public comment on this item? is there any public comment in the room? all right.

i see none in the room. and we do have one person remote. mr. shaw, would you like to make public comment on this item? mr. shaw, you had your hand up. are you there? all right, all right, then. there's no public. any commissioner questions or comments? commissioner guggenheim? i just wondered. if this virus gets. please speak into the microphone, commissioner, so we can all everyone can hear you. if this virus gets transmitted to humans. transmissible. what's the relative strength of it? are we looking at another covid or just winter flu or. yeah. so the question is about the severity of the virus, especially if it's transmitted from human to human. the good news so far is the vast

majority of human cases in the us have been mild and people have recovered at home. they haven't required hospitalization. there has been that one hospitalized case, as you heard, that just passed away in louisiana. and that was one case out of 66 in the united states over the last year or two. so we don't know if the virus could change in terms of how severe it is. that's always a possibility. but so far, that's what the data are showing. and of course, we'll learn more and more as time goes on. commissioner chao. yes. thank you. thank you for the excellent presentation and the clarity in which you're really talking about. as i understand from your presentation that the danger to humans is in regards to the milk. so. so what about the dead birds? and what about

bird products and, and eggs, which seem to also have gotten, you know, some discussion in the public press in terms of. yeah, in terms in terms of poultry, what happens in poultry is when this virus gets into poultry flocks, it kills a lot of the birds. so it's very quick to notice that something is wrong. and immediately what happens is the birds are isolated and depopulated. and so none of that meat or egg supply goes into our food supply. that being said, of course, it's always good to cook your eggs and cook your chicken meat as well as drink pasteurized milk. so, so eggs and so forth would not be a transmission issue. i don't i don't know if anyone knows the answer to the question of can you get h5n1 from eating a raw egg? but as i mentioned, you

know, because it affects chickens so quickly that that we don't think would happen. yeah. okay. thank you. what do you then make of the curves that you showed us in regards to the wastewater and what what are we looking for that might be even a more serious sign. yes. i think in wastewater what we're we're still trying to understand how to interpret wastewater data when it comes to h5n1. normally when we look at wastewater, we can say, okay, the influenza in the wastewater is going up. that must mean that there's more flu going around in the in the population with h5n1. we think that some of that h5n1, actually, we think all of the h5n1 that's popping up in our wastewater is actually not coming from people, but from like milk being, you know, going down the drain, or possibly wild

birds who have excreted and then their waste ends up in the sewer system. so i'm not sure we really have a good answer to that question about what we're looking for in the wastewater in terms of h5. but if there is a sudden rise in in either h5 or flu in general, that would be a signal to us. let's look at it more closely. is there something we're missing, or is this to be expected so far? when we've looked at the wastewater, we've been pretty much able to explain what we're seeing in the wastewater. thank you very much. and again, thank you for such a clear presentation. my pleasure. commissioner christian, thank you. thank you for the presentation. as doctor chow said, it's very clear. and so that's very helpful to us. so thank you for that. i think it's slide three where you said that the vaccine specific to h5n1 exists but have not been made available and is that is the reason have to do with cost and

or the fact that the dairy workers or the workers who tend to contract the, the, the flu don't get very ill. is it just. yes. that's a really great question about why the h5n1 vaccine has not been made available. one reason is because there's only a limited number of doses. i think about 5 million in the country. they're trying to make 10 million by this year. i think they are looking at where to deploy the vaccine. one of the places a lot of people have been talking about has been to give the vaccine to dairy workers. that's true. and so we may see some movement this year. we'll see. but but those are all really good possible answers as to why it hasn't been deployed yet. i know that the supply is probably the main issue. and of course, trying to figure out understand more about who's getting this and who's really at high risk in order to deploy the

vaccine to the right population. thank you. is that supply held federally or is this it's a federal supply. and so but we could find ourselves in a covid situation where all those decisions that had to be made about whether to invest, whether to have it be cost free or low cost, have to get made by the federal government. yeah, usually in the initial stages, that's where it's at until it's made like commercially available i think. yeah. i mean, in this case, i think probably an eua would have to be issued and all of that. yeah. great. thank you. i guess i have just a few questions. one is, you know, i recall back at h1n1 days and it was 2008, 2009, and there was quite a delay between the time that vaccines were manufactured and the time that we really had enough to distribute to the general patient population. given the changes in washington, do you have any sense of whether we will confront those same

exact issues if this becomes a more virulent condition, or whether there have been lessons learned? that is a good question. and i know that at the state level, they're they're thinking about ways to adjust to the change in administration. and so we will be certainly in communication with our other local jurisdictions and the state as to what the best strategies might be for us locally. wonderful. another question that you sort of intimated that some of the detection and tracking of these cases is a little bit fragmented, depending on who owns what farms and so forth, how how aggressive and what kind of input and control can the organizations at a state level have to try to bring others up to speed? in other words, to really get more clarity and more data so that if this becomes more rampant or if, heaven

forbid, it goes person to person, we're able to track that. i wonder whether we have the resources and whether there's there barriers to being able to get that information. that's certainly that question is something of great interest to the public health community. and on the calls that we've had with the state, we have bro at up. i'm asking, you know, what can the what can at the state level, the state food and drug brand, excuse me? food and ag, it's the agriculture department who has jurisdiction there. what can they do to mandate? because it's, you know, right now a lot of this is voluntary. and we're all thinking it might be if you're trying to be systematic and be as complete as possible, mandates are what is required. and so i don't know if that's a regulation decision or a decision by the governor or the legislature, but we have certainly brought that up on these calls. great, wonderful. and i guess the last question is, you know, there are some things in the in the press that the public might see that implies that the death rate from

this is like 50%. and i think when you look internationally, i think they had 663 cases and there were quite a few deaths. so can you clarify and kind of dispel that concern? that's a really important question. so at the very beginning, i think i mentioned that there are many strains of h5n1. the one that we're talking about that came to north america in 2021, is the one where there's only been one death that we know of, the 50% figure, mortality figure that's over the last several decades, that encompasses different strains of h5n1 that have occurred globally. and so i think what that speaks to is the level of, yes, we should be proper, like appropriately concerned that h5n1 could at some point be more, you know, lead to more mortality. but for some reason, it looks like so far and the way it's been transmitted here in the united states in the last year or two

has not led to that kind of mortality. well, thank thank you so much for your excellent answers and very clear presentation, and we'll look forward to hearing more as this situation evolves. thank you so much. thank you. thanks. oh yeah. obviously i wanted to thank george and phd for presenting on this at your request. i think to the question of, you know, are there lessons from covid, lessons learned from covid that could be applied here? i think the answer is an unequivocal yes. i think the question is whether they would be applied here, both from the public health community. and, you know, i think policymakers and society at large. the other thing ■ just wanted, you know, in terms of the surveillance of this virus. there's inadequate surveillance, right. so what we're seeing is likely to be, you know, a vast undercount. so we really don't have a denominator on the cases. and there are, you know, probably

many more even human cases that are that are going unreported, especially if they're mild. so i just wanted to be really clear about about that piece because, you know, we don't know how much of the tip of the iceberg this this really is. obviously, if it were an extremely lethal virus that had crossed over into humans and, you know, we would see people in, you know, hospitalization rates go up and testing would commence. but just in terms of the background of cases that are happening, you know, mild cases that are happening. i don't know, george, but i think we have a very probably are undercounting significantly the number of cases. yeah, i think that's true. thank you and i apologize. we're just getting used to this system, looking around and figuring out who who to eye contact and where this comes up. so sorry. i'll try to make sure i am more inclusive on our next agenda item. thank you. which is the resolution to recommend to the board of supervisors to authorize the department of public health to accept and expand a gift of $1,744,131 from

the san francisco public health foundation, and greg wong will present this item. the commissioners, we are presenting a resolution to accept and expand the forthcoming gift from the san francisco public health foundation for your review and approval. the department of public health had performed an annual needs assessment, where the department had identified areas that would require funding to help continue the mission of the department to protect and promote the health of all san franciscans. san franciscans. the foundation that notified the department that the gifts would be distributed, and we ask for your approval in accepting and explaining the gift. thank you very much for your kind consideration. commissioners, you have this resolution before you. is there a motion to approve? so moved to approve. is there a second? i second and is there any public comment on this item? there is. is there anyone in the room who like to make

public comment? can't see everyone. all right. i don't see anyone in the room, but there is a hand up. mr. shaw, would you like to make a comment on this item? no. i got to lower my hand. sorry. all right, no problem. there's no other public comment. commissioners. very good. then this will take this to a vote. everyone in favor of the resolution, please say aye. aye aye. wonderful. thank you. thank you so much. our next agenda item is the behavioral health services update from doctor hilary coons. welcome back. we're very eager for your presentation. hi. good afternoon, commissioners. i too am getting used to, i guess the new. set up. i say next slide. and you are. are you advancing slides? thanks, mark. good

afternoon. really always a pleasure to be here. welcome to our new commissioner, commissioner guggenheim. i'm thanks for your questions. i know this was a little late and due to the holidays. and so i'm going to try to answer as i go through. and of course, if i miss any, please. i am happy to take questions at the end. in this presentation i aim to give. so much has been going on and i wanted to update all of you. i really focused on sort of our key major updates, along with responding to some questions that we had gotten earlier and realized, i have foregone the sort of overall overarching behavioral health services structure particularly relevant to some of the newer folks here. and we're happy to come back, and i'm happy to come back and do that. next slide. so just by way of grounding our vision,

mission and key tactics remain the same. our vision is for all san franciscans to experience mental and emotional well-being and participate meaningfully in community across lifespans and generations. our mission is to provide equitable, effective substance use and mental health care and promote behavioral health and wellness via our key tactics. expanding critical services, improving access to mental health and substance use care, and increasing awareness about where and how to get help. i next want to turn to the first sort of chunk of the presentation, and that is focusing on mental health. sf next slide. so as most of you likely know, mental health sf was legislated in 2019, built upon existing behavioral health services and programs, but very much focused on increasing the

needed support and care for people with behavioral health needs. it prioritizes people experiencing homelessness with serious mental health and or substance use diagnoses. it had legislatively four components the office of coordinated care, street crisis response team, mental health service center, and expansion of new residential care and facilities. note that the msph funded or activities were primarily funded under the voter supported our city, our home, or proposition c. i'm giving you an update at this time because we are in the process of sunsetting our implementation working group. this is three, almost four years started prior to my arrival and

continued and will end this winter. so this is a taken from a presentation that we did for the hearing in last month, convened by called by supervisor hillary ronen, and so wanted to share some of the key accomplishments, what we've been up to and what's still to come. next slide. this slide shares the timeline of the elements that have been implemented under the mental health sf. and i know you've had the slides, so i won't walk through every detail, but things started in 2020. as you know, there was some slowness due to competing worldwide pandemic. things then really began to ratchet up again in 2022, 2023. and you can see and with most of our major

deliverables accomplished this past year with a few things to come, and i'll review those shortly. next slide. our key accomplishments include having added approximately 400 new residential care and treatment beds. i believe commissioner green asked about specifically staffing and challenges with staffing and getting all of those beds to operate. we have certainly had some ups and downs with keeping those beds fully staffed and fully opened. most of them are with contracts with community based providers, and some of those are what we call as needed beds, meaning we don't own the bed only for san franciscans, but we are in a contractual agreement with a provider to use beds, and then we only pay when we get them and

fill them. we also created an office of coordinated care, and i can't say enough about this function that the city now has. we had care coordination in place in behavioral health, not in a centralized fashion, and not nearly to the scale that we have it now. this centralized care coordination functions means we can proactively receive referrals, bridge people into care, coordinate access, and keep hold of the person until they are able to land successfully in some next level of care. this is the way our street care teams work. this is the way our referrals from the hospitals work. this is the way our referrals from jail works. it too sometimes doesn't have

enough staff staffing for the reasons that we've all named that i've named here before. national shortage and behavioral health workers. but we have accomplished a great deal in terms of achieving fairly high levels of staffing or low vacancy rates. the third element of mental health sf is the 24 over seven street crisis response team. this was originally contemplated as a alternative police response, with health workers responding to street crises. this launched in 2020, expanding to provide 24 over seven care. the current construct of the team, and this is held in the fire department with an ems worker and a peer worker, and the behavioral health workers have taken a role becoming our street crisis

follow up team as part of our best neighborhood team, staffed by behavioral health clinician, clinicians and peer workers. and finally, we have increased access to preexisting and some new services that were envisioned to be part of what was called the mental health service center. this includes increasing hours of operation across the work and weekend to by 70 hours, including expanding hours at our behavioral health access center, now operating seven days a week. our pharmacy operating weekends and evenings are what's called office based buprenorphine induction clinic, also operating into the evenings. what is still well, i'll circle back next slide. i think i may have said all of this. let me just mention in this slide for the office of

coordinated care, additionally, is that we have a special focus on performing follow up for people who may have come into the hospital under an involuntary hold, i.e, a 5150, those among the other populations that i just named. other people leaving hospital, leaving incarceration, experiencing homelessness, or with multiple service utilizations are among the prioritized population. on the next slide, on the next busy slide with a lot of numbers, you can see some of our key outcomes in terms of service delivery. overall, i'll just highlight the office has served more than 8500 unique individuals in last fiscal year. that is ending in june. we've hired more than 45 behavioral health staff, and

then i will specifically call your attention to the second line the right box, saying best neighborhoods, which is the team that does exclusively street based care, which have had more than 9000 engagements and more than 1300 direct connections directly connecting people into services. next slide. what is still to come of the commitments in the in the mental health sf legislation and program? i've mentioned already the 70 service hours weekly. i've also i'll also just add that more than 1700 people visited be hac, which stands for behavioral health access center, and our behavioral health services pharmacy. during just the expanded hours. so just during the expanded evening and weekend

hours, we've been able to serve those additional folks together. behavioral health access center and the behavioral health access line. that's the phone number you can call, served nearly 5500 people in fiscal year 23, 24. so what's to come under the commitments in mental health? sf first is our mental health service center. we are in the process of acquiring a site using state grant dollars, and that the arrangement and property acquisition is underway. what is very far along is our what we are calling our stable is now calling our stabilization unit. one of you had a question about this, the stabilization unit you've heard me speak about previously as the crisis stabilization unit. it is coming this year. it is, as you'll recall, immediate care.

it is voluntary care for people in crisis. it will have 16 beds. we expect it to serve approximately 25 people a day. it is being designed and built to include receiving drop off from police and other law enforcement. are ems teams and street team or street care drop off. it is intended also to be medical facility, with nurses able to administer medication, including for psychiatric or substance use reasons. we've modeled this on other crisis stabilization units from around the country and are very excited. we expect this to open in the spring. also to come is additional what we are calling enhanced dual diagnosis treatment. that is for people with both serious mental illness

and serious substance use disorder, expanded residential care facilities and some additional transitional housing for unhoused people with behavioral health needs. i'm just flipping to my a couple of notes. transitional housing. and this bucket really refers to state grant dollars called the bridge housing funding. this is approximately $35 million over about a four year period from the state, specifically to provide transitional housing for people with mental, mental health or substance use needs, prioritizing people coming through the state or local program. the care court program. one of the questions that came to us was, what is the relationship between hsh and us around this transitional housing? and i should share with you that there isn't a single

model for transitional housing. it's not sort of one specific definition. we have had to put all of our projects through state permissions. and so, for example, we are using some of those dollars for tiny cabins in the mission, which you have heard about, most likely in the press. we that is run for example, by h h h h h h with wraparound services from behavioral health clinicians. another example is we have emergency stabilization units for people who might have be experiencing homelessness, need a place to go. and we are using some of this transitional housing dollars for, again, the wraparound clinical supports to help stabilize people and make sure they're getting connected to care. okay. next slide. okay.

switching topics there. it's all the same topic. but i'm going to switch focuses i want to now update the commission on our considerable work responding to overdose. and of course just to since i'm leaving mental health sf. and though it is called mental health sf, we are really intentionally programing wherever we can the ability to take care of people with mental health and substance use needs. there are some regulatory and structural nuances there where we don't always have full latitude, but the principle is you take care of the person in front of you, get them into care. sometimes they may need more of one thing or another. so. so in our overdose response, as you've heard from me before, next slide, we are aiming to strengthen our efforts to lower fatal and non-fatal overdose and reduce racial disparities in those overdose deaths. the work

has really been a department wide effort to coordinate both existing and expand or innovate new approaches to maximize impact. i and you've seen this slide before, so let me move on into some more specific the specific objectives to remind the folks who have seen this. and for the newer commissioners, this may be your first time. our key objective objectives are to expand and strengthen our substance use services continuum, very specifically to improve access and retention in medications for opioid use disorder, that is, methadone and buprenorphine primarily, which are the most effective medications and reduce risk of subsequent overdose by about 50%. we are also seeking to expand availability and participation in contingency management. that is an intervention that provides incentives for healthier behavior, specifically

reductions or cessation of drug use. this is the most effective treatment for stimulant use disorders, that is, methamphetamine or cocaine. we are also aiming to improve our overdose response interventions. we are also at two other goals are to engage community in order to reduce racial disparities and other disparities in overdose. and specifically, we are working with black african american led organizations and community and increasing overdose prevention and connections to treatment in permanent supportive housing, both of which have populations desperately affected by the overdose epidemic. and finally, to launch our media campaigns and increase public awareness. so i want to share some updates. there are more in the additional

slides. the first slide on the next slide shows where we're at. so we are now in january and have data through november of 2024. so we have preliminary overdose death data for the first 11 months of 2024. what we know from those preliminary data is that we are on track to see greater than 20% fewer deaths compared to 2023. so that is very good news and a very big drop. you can see on the graph we compare this year in dark blue to the orange, which is 2023, where we lost more than 800 people to overdose in the city. that is the highest year of loss on record. and it looks like we are may come in,

although too soon to tell. a little bit under where we were in 2022. next slide. so just providing with some key progress updates. and as i said, there are more details in the slides at the end from january to october 2024, we saw more than 1300 new admissions, new people coming into care at dph funded methadone clinics. that is a 35% increase compared to the same period in 2023. we launched a new program and then expanded it to a 16 hour, seven day a week telehealth line with associated navigation services. the program launched in march, and between march and october. the evening program has facilitated nearly

1500 telehealth visits. we are now at more than that, resulting in approximately 40% of clients starting medication treatment for opioid use disorder or opioid addiction. that is a very high number for people that have not chosen to come into care. these are people we are going and finding and offering and connecting. i'll also note that when we are able to connect people with a stabilization bed, that number goes up to nearly 90% of people starting treatment. we also are very happy to share that all hsrr funded permanent supportive housing sites now have naloxone stations and are training both staff and residents. next slide. the next slide focuses on buprenorphine. and here i show this graphically. these are data from the san francisco health network of total number of

clients prescribed buprenorphine. and what we know is that in october, the number of total clients who were being prescribed buprenorphine is 59% higher than the total number of clients prescribed buprenorphine in the year or at the beginning of the prior year. and you can see the curve going steadily up. i believe commissioner green asked us why why this is we think this is happening among our interventions that we think have pulled or drawn more people into treatment include the beam or telehealth navigation program that i just spoke about. we are also really focused, as you just heard, on increasing hours of operation. so for example, at 1380, howard, the office based buprenorphine clinic is open into the evenings and can see more people. we are also focused on a, on a taking advantage of a

very specific provision in the law that allows a non methadone site, methadone, you'll recall highly regulated, only available in special licensed regulated settings. we are taking advantage of a small part of the federal and now state law that allows you to essentially start methadone outside the context. still with a lot of regulations, but outside the context of a methadone program. we've started up and expanded our what's called bridge clinic at csfg, who can start more people on methadone. so we are and will continue to be looking for more ways to make it easier and more accessible to pull people into the treatment. and in future updates, i'll have more specifics on where we're going with contingency management, as well as some of our specific work in the black african american community. okay, third

topic crisis response. next slide. so our crisis system really expands different subunits. and i'll speak briefly about each of these. we have a crisis crisis line that provides 2724 over seven telephone support and consultation. it feeds bidirectionally, our mobile crisis service transfers to 911 and to 998988. and i'll talk a little more about 988 shortly and also makes referrals into our routine services. we have a child specific or child focused system that does a number of activities, including the list that you see in front of you. this is a service that's both run directly by d.p.h staff, as well as contracted

staff, and has a number of different functions. the adult system has both the mobile crisis element mostly responding to people in homes. it also participates in work with the police department, something called our crisis response team and our crisis intervention teams, mostly responding in planned fashions to serious events with police officers. next slide. i have on this next slide a little more about the crisis. behavioral health services for children and youth. and i mentioned, as i mentioned, there's the d.p.h child crisis team. we also partner that with two different crisis services for kids, the 23 hour crisis stabilization unit at edgewood. and just parenthetically, this

is what we are standing up for adults in a way that i just mentioned under mental health sf. we also have a kid, a child and youth specific hospital diversion program for young people age 2012 to 17. we will get back to you on specific numbers served in each of these domains. and we'll do that via. by email. similar adult crisis. i'll just mention in addition to our mobile crisis team, we have other crisis crisis like services, including west side crisis operated by west side, which is a drop in service for people in need of urgent psychiatric care and in particular, medication management, medication refills or urgent care, which has been a longer standing program in the community historically focused on mental health needs. and then

our behavioral health access line, which i mentioned and similar to the to the youth services, will i will get back to you on on numbers. we have some of them, but confirming others. i think we were asked also to speak directly about 988, the 988 suicide and crisis line in san francisco. so, as you may know, the 988 line is a federally mandated and state assigned crisis slash suicide prevention line in san francisco. the felton institute is the assigned 988 provider. the 988 provider provides 24 over seven assessment, counseling, stabilization, safety planning, follow up resources, connections to care and services are available in over 250 languages. from january

to october 2024, the san francisco 988 number took 12,000 calls, of which 41 required emergency dispatch, including 24 people having experiencing suicidal ideation. referrals that the line makes may be to our mobile crisis or ems, or to mental health or substance use services or other service types like shelter. of note, felton is the provider that provides the overnight coverage for our behavioral health access line. so it is really in sort of one universe to going off into the same call taker or being transferred among call takers, local funding or state funding for 908 specifically comes from the state as part of a specific state bill. next slide. and

next. and last topic, i think. you were, i know, interested in our oversight and how we oversee dhs funded treatment providers. this is really a very important part of our work, and we are always looking for ways to improve and strengthen how we do that work. one thing to start is to make you all aware is that all licensed dph contracted, in this case substance use treatment providers. but this is true of mental health as well have has direct oversight by the california department of health care services. additionally, programs that bill medi-cal hav, via a different mechanism, oversight from the state medi-cal program at the local

level. dps d.p.h also have an oversight role. we conduct routine monitoring that is conducted by our programmatic staff and contracting staff. we have required critical incident reporting that comes to our quality management team and gets escalated as appropriate to leadership, and is may be accompanied by further investigation. we also require, when deficits are observed or when practice change or performance change is desired. we have required performance improvement projects. this is part of both our local requirements and state requirements. next slide. i want to just share with you about

sort of a little more detail about some of the information that became that was quite public in the media about some fatal overdoses that took place at at h.r. 360. we are in the process or ongoing part of the process to continue to strengthen practices. one thing i'll say is that after notification of fatal overdoses at the treatment provider, we undertook immediate action, including an investigation of our own and requirement for a number of immediate changes, including increased oversight of client safety and monitoring, improved client screening upon entry and exiting of the treatment facility, and reduction in off site passes.

prioritizing necessary off site visits. you can see some of those actions on the left, and they and we are working currently with the provider on and what is called an agency technical assistance plan. this is a way that we heighten our monitoring, oversight and requests or demands for compliance. you can see some of the actions that the provider has already taken that have resulted in increased level of oversight and safety monitoring. of note, the providers initial practices around checking of patient of clients had already been exceeded state

requirements. and so i think it's important that you all we all are aware of that, that their own practices had already been acts in excess of minimum regulatory requirements. just checking my additional questions. i think, i think you may have others that i didn't quite get to, so i apologize for that. but let me stop here and see what questions we've got. well, thank you as always for the excellent presentation and for really the encouraging progress you've shared with us. is there any public comment on this item? i do not see any hands. all right. how about commissioner questions and comments. commissioner tirado.

you did answer just about all of my questions that i usually always submit to. you. just one was on the time for child crisis in their mobile teams. and between child crisis team and the seneca team as well. is there any kind of a time log? just because i've experienced long delays? let me get that back to you. i knew there was something i was forgetting. we will. i appreciate very much appreciated the question and we will get back to you. i think super important question. and when you do, if you wouldn't mind, i'd really like to know what is seneca's criteria for responding? because i've been

told to. no, no, we're not going to do it. no thank you. and that's not within what we do. so i think it would be really helpful. yes. appreciate that. thank you. commissioner chow. i had to get used to this. thank. thank you for this very comprehensive discussion of the work that you're doing. i commend you, of course, on the 20% fewer deaths and the national press also indicates that in the nation there has been a decrease. and i know you probably have had the same question. how does our decrease sort of look different if it does? or is it that we're all on the same page working nationally

to really create an awareness of fentanyl and, and, and that these. efforts that we are making and others are making are really making a difference, or do we have anything also in addition to that, to add, have we added to the national dialog? yeah. so i think that's a great that's a great question. thank you commissioner chow. overall our numbers are by and large exceeding the drops that other jurisdictions are are seeing. so if you look nationally using cdc numbers, for example, we seem to be doing a bit better in the drop in that we're seeing. i think there's lots of hypotheses why we are seeing, thank goodness, a drop nationally, including from a public health

point of view, a lot of work innovating, access to treatment, taking very seriously the need to increase access, increase access to the most effective forms of treatment, taking innovative approaches like putting people doing street based care, doing care following an overdose to get to people with offers of treatment in real time. i think there's other elements that likely play into the change nationally. one thing that is frequently mentioned is the upswing during covid and post covid in overdose deaths, perhaps driven by increases in drug use or substance use, increases in using drugs in isolation during times of social distancing, using drugs in riskier fashion because of

increased other stressors. others have spoken about changes in the drug supply, which are very hard for us. it's hard to measure. and i'll leave it like that. i think i'll leave it there. so, so well, i mean, it's of course all good news. and that's interesting about the fact that we're now measuring against what was happening during the covid era where people were perhaps more inclined, as you say, to, to actually overdose and all, especially if you're isolated. but so thank you. i in in the mental health questions, we've looked at the fact that and you

have indicated we've now added 400 residential care beds. are there is there a new assessment? i think i saw somewhere that there was. and how does this new assessment then give us new targets. and in face of the new city administration, is this something that the city also is looking at, or are you finding resistance, or are you finding encouragement? well, let me answer the first part. we and i think i came to speak with you all about it, but now i'm uncertain. we completed an updated assessment of what the city needs in terms of residential care and treatment earlier this i guess earlier last year. so we have targets for what we think will get to,

as we defined it, wait times of near, you know, near zero days for levels of care where we have found that we have the largest gaps in care is in the level of care locked subacute treatment, very high level of care where we estimate we need between 55 and around 100 locked beds. we also know that we need more what we call burden care. sometimes residential care for the elderly, residential care facilities for people with very specific and highly complex needs like traumatic brain injury, like having forensic involvement, having high level of physical health needs. so need help with activities of daily living. and we know that we need we think around 40 or so of those beds. there's some

other things in our bed analysis we have applied for prop one state bond funding. that application went in in mid-december. we as a city should hear about the results of the that grant application for six different projects that would meet the majority. these needs that i just mentioned, plus some of the others. we will hear about that grant application in may that will provide funding for capital costs, not for operating costs. we have some of the operating costs identified and we'll need to work towards others. the other thing i'll just mention is we have have built capacity and we'll continue to update that analysis on a yearly basis. and so we will be able to assess in

much more real time how the expanded beds are affecting wait times and placements, and ideally able to adjust as we go. and this is new capacity. the first bed analysis, i think was done 2019 or 2020. we repeated it in 20 late 23 and into 2024, and so we will do the next one late 25 into early 26. so it will be much more close in time and be able to see the impact. so with these estimates and if in fact you're able to carry them out, will that reduce the number of the homeless. so we know that in the case of involuntary care and moving people, for example, a minority,

these are a minority of people, just to be clear, who do not who lack capacity, who are gravely disabled, moving them into appropriate levels of care, which may be board and care which may be locked, subacute care. we know this is a vital part of the solution, though in in effects, probably some of the most serious, apparently seriously ill people that are visible to us on the streets here. and we know this is this can go to helping. increase our flow into those needed high levels of care. great. i just have one last question, which is in regards to the state's new or federal new 988. we previously did have a sort of volunteer suicide line that we were sponsoring. where is that? that is still there. so that is the

suicide prevention line run by felton, largely by volunteers. nine eight, eight was sort of built on that service. so that's that was the one you were alluding to then was. yes. and has been with additional state money has been expended, you know, strengthened clinically and expanded capacity. great. and so then the numbers that you gave actually combine the work that both of them are doing or, or is that just simply i'm let me let me check on that. okay. well, thank you very much. and thank you again for this very fine update. commissioner christian. thank you, president green. hello, doctor. it's good to see you. this is such a sprawling area of work that is morphing, you know, moment by moment. so i don't know how you remain sane and but just want to

acknowledge what what a difficult task this is to even get the hold on what the problem is. and you've done a great job doing that and identifying the problems. and so thank you for all that you do moment to moment. you and your teams do moment to moment. but couple of questions. one, following up a little bit on doctor chow's question about the san francisco's place in the decrease in numbers of people who are being found on the street or using, is that. a are we measuring apples to apples or apples to oranges, like when they say that when you say that we're doing really well compared to other people nationally are decreases, are are higher? is that are we measuring the

decrease in our own numbers or a decrease in numbers that you know, from, you know, compared to new york or pennsylvania? are we are our numbers on our streets down more than. i think you understand what i'm trying to articulate. yeah. let me, let me, let me try to let me try i'll try to respond to the specifically i was talking about decrease declines in overdose deaths. okay. so that is pretty apples to apples, meaning there is a standard sort of a death adjudication through a vital statistics determining cause and what's called cause and manner of death. and so when i say we're our decline in overdose deaths is higher than the declines observed in other jurisdictions. that's that's what i'm saying. and i think it's pretty apples to apples. it

is not specific to whether the death is on the street or in a home. or. and i sounded like you were getting at that as well. okay. what i was trying to articulate and didn't do a good job of. so are we having fewer people overdose on our streets than pennsylvania? or is just our percentage the percentage that we've decreased that number for us is larger than the percentage that they have decreased for their numbers. we what i am intending to convey is that our the 20% fewer people died of overdose, regardless of where that is a higher number than other places. most overdose deaths still take place inside in san francisco. doesn't mean the person wasn't experiencing homelessness, but the location of death is still in san francisco, most frequently

indoors. and that is true nationally. and that makes sense, is because people might not be found. there is less opportunity to be rescued with naloxone or ems. we've not looked and happy to and happy to take that back to the team, because it sounds like thinking about the proportion of deaths, proportion of people we lose who are experiencing homelessness. and does that differ? what we do know here in san francisco is that people experiencing homelessness are at disproportionate risk compared to people who are housed. there's very high rates of overdose deaths among people experiencing homelessness. that makes sense, and that is true nationally. whether it's i don't know that we know that, you know, exactly. we i don't know that we have an apples to apples comparison on that, but we certainly could look at that,

see if we can figure that out. thank you. and circling back to a question that i asked doctor colfax when he was giving his director's report about. the great article, noting the success when people are contacted about, you know, kind of engaged with taking care of their health overall or giving them something that they want or need more immediately from their perspective than maybe the city's perspective and how creating that relationship is really the path to getting people engaged. so i haven't been in the tenderloin lately, but our sixth street around there. but people who have, you know, just said it's from their perspective, worse than ever do. does the department have the funds, the funds? and is the

department increasing the number of outreach vans and people in that area as we speak. so both just let let me also speak just i think as doctor colfax did over the last two or so years, the number of staff members or and team members have tripled. so we have gone from. i'll talk about first behavioral health and then thinking about the department as well. we've gone from a division that was, by and large, a brick and mortar division, meaning most of the work was in a clinical building of some sort. and we have built out, with the help of prop c and msph, a real street presence, street medicine in my colleague division in ambulatory care has

a long history of street medicine and has has had still relatively small footprint, but together the presence of street care teams staffing wise has tripled in the last two years. so it is very much a change in orientation and in recognition of how important it is for us to be out in the street and find opportunities to engage people and get them into treatment. and so that means that we have capacity to pivot as well and to focus on different areas of the city that might be more affected at different times. and so we have been very much focused on the tenderloin with, i think, some very good effects and are working on increasing presence on sixth street and ready to do

it where, wherever else. it's not infinite, certainly, but it is a kind of capacity that the department was not nearly so built out in the department three years ago or so. it's also a very specific approach, which is engaging a person and making rapport. making a relationship is and building trust is vital. and setting goal goals for what is next, whether that is both trying to be person centered, meaning what is the person want, as well as with the clear mission to encourage people to come into treatment to achieve help them get healthier from their substance use, reduce risk of overdose. and so we are very

focused on important health goals. and acknowledging this is really in in the field of behavioral health that these are new functions. these are not the way historically county behavioral health really was thought of itself or thought about how it did its business. this was true when i was in new york. this is sort of true in california. and i think what the state and is seeing and what and it is with more street outreach teams, with more, you know, using multiple disciplines, having more people in neighborhoods, it it really is very clear this is a vital part of the continuum of what we need to do in behavioral health. it's not enough. it's not the only thing, but is sort of part of the picture. yeah, sorry. i'll hold on. okay. just to also add

to that from the department wide part, i mean, we thanks to doctor cohen's work and her team and others in the department, there's been a lot of innovation, a lot of piloting, scaling up. and the. the night navigators are on six and mission. i've been out there with them. there's high demand for treatment there. then you know, when i'm out there, they're literally they're lining people up with the doctor who's on the phone getting people treatment and prescription. we also innovated. and with this whole blueprint of bed, right. those beds are filled. we it was a pilot. we only have we have 19 beds now. we started with ten. those are filled around the clock. so we are there. we're innovating, scaling up. but to answer your question, do we have enough? no. you know, there are days of the week where we don't have capacity to be out there. so, you know, there are

resources and needs. i think we have a really strong foundation to move forward, and we now know where there is demand for certain treatments, which cut the risk of death by 50%. we have not come. we haven't reached the point of where that demand has been saturated. sure. i think it's clear that a strong foundation has been built in the last couple of years, something that, you know, you're growing already, you're growing on every day and is a good structure, a great structure for what, you know, expanding it more. what's to come. the state dollars that are have come become more available. are those dollars available to expand on this platform? do you mean specifically street based care? sure. yeah. not thus far. so

each of there have been a total of six rounds of what is being called behavioral health infrastructure dollars. they have been, by and large, with some nuances available for infrastructure as, as the title says. so building new things, we have been able to use some of the dollars, as i mentioned, with expanding behavioral health supports in transitional housing, for example. so we think it's sort of maybe related, but not specifically about street care. there are time limits to the state dollars just to be aware. so one challenge is how do we make sure that we can sustain the programs following expiration of the dollars. so sometimes that's through medi-cal billing.

sometimes that is through has been through general fund dollars or and sometimes and we are we are sort of always planning as we are taking these dollars in. yeah that's a huge problem ongoing i guess. does cal aim support any of this, particularly the piece of maybe particularly, i don't know, the piece that focuses on people who are part of the jail population leaving reentry, things like that. so cal aim, which is also, as you know, a very large multi-dimensional medical medi-cal medicaid reform project. very important part of this is you are asking about is an ability to build medi-cal for people who are, during the time of incarceration, to do to

conduct both discharge planning and connection to care, so that billing potential will enable us as a department to offer more care coordination, discharge planning, planning care, connection services. that is, as you know, happening now, much, much planning the beginning of the implementation and will progress over the next year or year and a half. there are other elements of cal aim. i'll just give you another example. there is a category called community support services. this has been intended under medicaid reform nationally and locally. now to be able to bill for services that are not clinical in nature but serve to improve health outcomes. we were able to get, for example, soma rise or drug sobering center designated as a

community support, and it can bill medi-cal. and that revenue helps offset some general fund dollars. so that's an example of probably many more. and i know you've heard from the cal aim team. and so we are always looking to take advantage of where we can draw down medi-cal dollars. thank you for that. looking at the msph programs to come, the bed expansion, the 15 or 16 beds that you were talking about, are those the beds that will be at general or some? these will be at 822 geary in a building that the city purchased three ish years ago. and so that will be in community. and we have a very nice rendering, which i will we will send to

you. great. and the other, a couple of weeks ago, maybe i came across on came across something called california behavioral health community based organizing networks of equitable care and treatment b h connect. yes, that is that something that. so good. yes. those are funds that we are going for. so b h connect is yet another medicaid large medicaid reform package happening in the state of california. that's going to bring new services as potentially billable. and some of those are really wonderful opportunities to offer evidence based services to folks in san francisco building new. and so,

yes, we are figuring out what and which ones we will sign up to do. it does require implementation of new practices, signing up for additional oversight as we implement and potential, and then having the possibility of pulling down incentive dollars. one thing to just be aware of is when we open new services, we need to put in more local funding in order to derive the state, the federal match. and so one budget challenge is we will need to be put up local dollars, local fund dollars, general fund dollars in order to take advantage of that. and that is kind of something to weigh is in a time of constrained general fund dollars, what will we be able to afford and what of the programs,

all of which valuable in b h connect really gets at some of our major objectives? is that always a problem? oh, yes. this dangling money over here. but then say and so you need to put up like 50% of what we're going to give you or something like that. yes. not very helpful. somewhat helpful. i think. i think i'll just end on a question regarding your helpful presentation about improving safety practices and community providers. i mean, it must be incredibly frustrating to not control, have the control to go in and just say, okay, we're going to change this, this and this, and you're working with a provider in the community that has a contract with with the city. you know, you noted that the provider at issue most

recently had practices in excess of what was being called for. but if i'm not mistaken, part of the issue was whether they were following those practices. yeah. and so and then there was also in the article a quote and it's usually there that this is so expensive, we don't have the money to hire the people that we need. and in the article about the young person who's who passed away and someone found him later. there was discussion about what the atmosphere, what the what the place is like, and it didn't. and there was a quote from someone who had been there and said, it's not a place where anybody feels like they can get well. and it's not, it's not that's not supported. what can

what can we say to the city and to, you know, those families about how and what can be done to make sure that these, those types of things are changed and are not just left to be. and, you know, what happens, happens. so first, i just so thank you for the question, i, i think to the heart of this is how do we deliver consistently excellent care that keeps people in care and gives them every possible advantage towards recovery. and it's a serious illness, often accompanied by relapse. and in the in the setting of fentanyl, a mistake can be deadly. and we

want to keep people alive in care and in settings that are as healthy and rewarding as possible. and i think that is exactly what we are aiming for, not with this and other providers. and by way of background, just worth to mention in the field, there had been and has been a long history of discharging people. if there's a relapse, you have not followed the rules. we are going to exit you from the program. you are not sort of the sort of traditional language. you are not ready for treatment, and you are then more able to keep a setting or site that is much more free of relapses, because you've discharged the people who may have relapsed. and that is a

challenge in the field of addiction. and we've got to get it right, and we've got to work harder to get it right, as we are with this and all of our providers to create healthy, recovery oriented places for people who are anxious to not be around substances. and we've got to find a way to support people who may have had a relapse and keep them close and in care and do both those things at the same time. extremely difficult. final question around this page, which is really helpful. you say that d.p.h has instituted weekly leadership huddles between behavioral health services and facilities. what is that, generally speaking, look like without, you know, getting too specific, right? i mean, i think we are, have been and continue

to set up clear metrics, clear oversight structure, clear reporting structure and also problem solving structure. so for example, some of the issues around budget or finance, we want to create space. like you say this is a problem. let's talk through potential solutions. so we want this to be both set up accountability and structures as well as an avenue for fast problem solving. that's a great example. that's really helpful. thank you for giving that. and i said at the last question, but this one will be my last question. the shortage of providers, clinicians nationally, it's a real thing national. and then we are in a jurisdiction where the cost of living is so high that it must be exacerbated by that. are there things that that are being

spoken about in the city to do to ameliorate, ameliorate that a little bit? housing subsidies, places for people to live, things that cut off the some of the expenses that make this so disproportionate to other places where we can maybe boost our numbers more than we've been able to so far. are there things like that going on? so we have been working quite diligently on recruitment pathways that really have yielded fruit. we have also been working with we don't set wages for community based providers, but we have looked to strategies that there are budget lines can be more flexible and more flexibility around wages. and in the case of this provider, that has also helped with their vacancy rate, we are aware of some state dollars

being applied to the behavioral health workforce with the prop one reform and hsa replacing mhsa, and we expect to see some state investments, though i don't know specifically around cost of living. i think you i'll mention one other thing. we are aiming to make our some of our sites health shortage area sites that allows for people coming in to be eligible for loan repayment as a cost reduction strategy. i think you raised some other good questions that i will absolutely take back, but a lot of empty buildings in the city right now. thank you so much for your work. it's herculean and you're doing it. and so we're so fortunate to have you and your team. thank you. thanks. and i just really want to acknowledge the volume

of change that has been coming at my and our teams is herculean. and for behavioral health workers who signed up to see patients or see clients and take care of folks, the amount of change and changing environment is can be exhilarating, but also quite daunting. and so that is what the teams are carrying for sure. it's a big load, but they're doing a great job for what they're doing. thank you. yes, we all associate ourselves with commissioner kristen's comments. i think sprawling was quite a good definition, and your answers have been so encouraging in a way. they're so excellent. they're so informative. and clearly you've thought of every detail and every opportunity, as well as work through all of the challenges. i know director colfax has a word to say as well, which is. again, just to thank doctor collins and her team and the people across the department who are doing this work. this is, you know, so much

of this has fallen on behavioral health. but we also, as we move to strengthen our system of care, to meet people where they are on the street, but to also make sure that when they're on the street that we're doing everything we can get to get them into treatment, that that is the responsibility across the department. so on the operations side, air hiring, getting contracts out to population health side, helping us drive with data at the network side, ensuring that the hospitals and the clinics are aligned with this work. so, you know, just as a key example, the hospital, zuckerberg hospital, has an amazing addiction medicine program that served over 2000 people last year that they have shown reduces the risk of death. if you see that addiction medicine program while you're in the hospital, that's not a capacity yet, because a third of the admissions to the hospital have a substance use disorder. so just an example of, you know, this is a department. this is a department wide responsibility. and across the department of leadership, across the

department, whether people are in the field or administrating the programs, this is this is the context in which we're working toward. i also just wanted to emphasize the need for flexibility and to pivot. and what we would really ask the commissioners for your support in championing. and, you know, i talked to doctor a lot of doctor cohen's time and a lot of her staff time are spent doing a lot of paperwork that, you know, that are requirements for the state and federal level. and there at some point is calling the question, is this what we really need to be doing in order to save lives? i think we've shown in other fields that quality oversight and outcomes make a nice, tight package. if you really focus on all three of those things, that monitoring shouldn't be monitoring the right things. the quality should be about ensuring that the care is delivered effectively and then outcomes are showing our results. that is not the state of the field yet. certainly with the bureaucracy under which

doctor collins and others, you know, work under, so that when you're telling us, even with resources, you know, the commissioner christian, when you made the point, like, oh, you get this money, but you have to put 50% and you have to do all these different things. so i think that as a for us to succeed at the, at the, at the local level more effectively and faster, shaping system, change at the state and federal level is, is also really, really important. so i just wanted to emphasize that if you don't mind, i'd just like to say yes and reply a little bit. and the number of new mandated programs that the state is, you know, providing great ideas but no resources. and it all, even if they don't say county mental health often, they don't say anything about anything. you're going to do this, you're going to provide this treatment. they don't even point to county behavior, county dollars. but

when they do, they haven't given the county any money for this. % asking, i'd love to know what you think. i think we'd all love to know what, from your perspectives, we could do in this out in that outside area, where to focus on and what to say and what pressure points. because it is it's just piling more necessary work on to the county and the city without providing any resources to do it. and it's just a recipe for disaster. thank you. thank you, thank you so much. thank you. thanks so much. have a good evening. our next agenda item is administrative. the administrative code section 21 .8.2. parentheses f five year report on the use of a group purchasing organization. and nader hammond, who is the executive administrator vice president for support services

for the health network, is going to present. welcome. good evening commissioners. good evening everyone. okay. so we're talking about the gpo authority. i'm not hammoud. i'm the administrative executive for san francisco health network for support services and supply chain reports. up to me. we'll be talking about the gpo authority. we'll cover from the beginning to the end and how we're going through and why we would like this program to continue. as mentioned, the administrative code section 21 a to f dictates that after five years of using the gpo authority, we are expected to come into this commission and present our assessment and evaluation. and this is what we're doing here today. so a quick definition of group purchasing organization or gpo. it's an entity that leverages the collective. sorry. next slide mark. next one. yeah. it's

an entity that leverages collective purchasing power of its members to negotiate and secure discounted and special prices, goods and services. if we think of costco, it's kind of something similar. and the standard, the industry standard in healthcare is for organizations, for healthcare organizations to be members of gpos for the benefits it offers. for example, in our area, all of sutter, kaiser, adventist health, alameda health, north bay health, all of the ucs, ucsf, uc davis, uc irvine, uc berkeley, every all the uc system across the state are also part of a member of the gpo and within gpo. the one that we're using, stanford are the member john muir health. so it's not just public entities as well as it's the best practice and the standard for private entities as well. so the gpo, the gpos are

critical for us as hospitals and healthcare organizations to help us in reducing expenses and achieve efficiencies. and as we go through this presentation, you will see how we are taking advantage of that. what's critical for us is availability of the products. when we want to purchase a product or a service, the availability of that product is of critical, essential, of critical importance for us, as well as the timeliness of having such products, because in healthcare we're not like any other organization or other services. when we need something, we need it immediately to support our patients and our residents. so consequently, san francisco public health joined one gpo, which is vizient, and the contract currently expires in december 31st, 2028. so why did we choose vizient? the admin code gives us the option to

choose 1 or 2 gpos without even any solicitation or any effort. but the san francisco health network did conduct an informal solicitation in 2019 to look at the available gpos in the market. there are currently there are two. one of them is vizient, which is the more specified and specialized in healthcare. the other one wasn't as qualified and the reasons are mentioned here. it's offered higher rebates from. we'll talk about rebates as well what that means. but vizient offers higher rebates. it is a member owned entity, provides pharmacy program which is extremely important. we'll see in numbers as well. and they did not charge us for its impact standardization, which is a service that will give us some cash back as we standardize our services across the organization. next slide. so

we'll talk about about the services we use through vizient. these are the ten services currently we utilize today. but what vizient offer in general or the gpos specifically vizient is all across the board. whether you're trying to purchase a product or you're trying to purchase a service, or you want to look at your performance and have someone external with expertise to assess your program, is it efficient? is it helpful? can you do something better so they have all these options from capital equipment to distribution to supply, to lab, to hr to products, ophthalmology, pharmacy, cardiology, surgical. so whatever you look for, if it's in their system, then you can use it. we rarely have things or services that we purchase outside the vizient or outside of the gpo, because we would like to take advantage of that.

next slide please. so to the evaluation, to the evaluation of the gpo that we've been using for the last five years, the admin code doesn't specify how to evaluate it. so we took on ourselves to evaluate it based on does it streamline our acquisition process, what rebates it offers us, and does it introduce cost savings. and we'll go through each one of these in the next few slides. next slide streamline acquisition process. so being part of the gpo, the admin code gave us the authority that we do not need to do any solicitation or rfp when we need to buy from a supplier who's part of the gpo that makes our life much easier. and we can achieve streamlined process obtaining goods and services. they have a very wide variety of products and services at pre-negotiated prices. so

what the gpo does, they go out. they have 4300 member organizations, health care organizations across the united states. they go out to the suppliers, they negotiate with them. they tell them, my members might be able to buy, instead of buying 800 pumps will be buying $10 million worth of pumps. give me your best price. so the vendor will give vizient their best price, and then we as a member will take advantage of that. if we don't like that specific pump. vizient also negotiated with the second member in the market for the pumps for also a discounted price, so we can opt to that as well. so that variety, that availability is crucial for us and we like it. it's standardized process for services, equipment and supplies. they have an incentive that if we use consistent standard products, which actually aligns with our vision and our goal to have standard type of equipment and services across d.p.h, we are we are

given a benefit by receiving an extra cash back because we're standardizing with that product, and they have a dedicated inventory and team for d.p.h. so if we're signing up with one of the vendors, we have a guaranteed supply with that vendor because vizient gpo guarantees us that option through their contracting with the supplier. next slide. moving to the rebates. so vizient they charge their member their suppliers to join them and be part of them, and they have some administrative fees that they collect from the suppliers. they give part of that administrative fees back to their hospital organization members such as department of public health. the first table you see is how they assess what's the percentage that you'll get back in rebates. as you can see, we the above

$70,070 million a year equate to 68% of rebates. and the department public health has been consistently during the last three years, ending in 2023. because we don't have the 2024 data yet, we've been hitting that 68%. so we've been receiving the highest tier of rebates. and if you look at the lower table, you'll see that the rebates received in 2023, for example, it's a bit more than $2 million. this is received as cash back. and checks we receive for the health or for our hospitals and services to utilize. and the second service i mentioned earlier, the impact standardization, which is like a benefit you achieve by standardizing services, that's an additional $281,000 we received in 2023. so in total,

we received back from vizient just in 2023. as an example, $2.3 million. that's the rebate. just to note that, how do we use those rebates when we receive them? those are being used by the different hospitals. for example, for xfg, 12% of that goes to nursing services, 68% goes to materials management, 20% goes to pharmacy. as to abate the expenses. next slide. cost savings. so as i mentioned earlier, that that negotiation that the vizient gpo does with all the suppliers automatically results in savings. these savings are achieved by just being part of that gpo. and we can usually on the top of that, what we do is we consistently and continuously keep

negotiating and looking for better options for us, for higher quality and less cost, because the gpo is always consistently adding members and suppliers. so we always explore those options. and we have a value analysis committee at both hospitals that does that monthly meet and explore. what are the options that are available for us. just an example that even though with medline we were receiving the discounted rate, that's cheaper than not being part of the gpo. we did extra negotiation with medline, and in 2024 we were able to achieve an additional $100,000 savings by just meeting with them and saying, okay, even though you're giving us the best price, but we will commit that extra like 10% of our expenses with you. what can you give us? and we were able to achieve that additional savings. so there is always opportunities. and this is kind of our always everyday exploration. next slide. so being a member doesn't come for

free. they require us to pay membership. so the membership dues are paid annually. and it's associated with the services we ask for. so if you remember the slide that what are the services we had. we had ten lines. so each line of these services we pay a specific fee. so the total fees we've been paying, for example in 2023 was 486,536. this is how much we pay them fees to be a member. but the cash back we receive from them rebates, it's $2.3 million, so we don't actually pay them. what they do is they deduct those fees from our rebate and then practically we don't issue them any payment. and we haven't issued them any payment ever since we signed this agreement. as you can see in the table. next slide. so. as a conclusion, taking into account that we have

such a supplier access with included including a wide variety of options, the membership costs and the rebates that we're achieving and the efficiency and standardization we're taking advantage of. sftf assessment is that the participation in the gpo has an overall positive benefit, and would like to continue with that. going forward, we will be monitoring our rebate tier to make sure that we are always at the highest tier, and if we are at the highest tier, we're receiving the maximum benefit. we will continue monitoring as we are always monitoring our tier with the suppliers because they have tiers with the suppliers as well, that if we're spending like medline, if we're spending this much, spend just 10% more and you will be at the higher tier, so you'll get even more discounts and the rebates that we're receiving back from from vizient to d.p.h. thank

you. any questions? thank thank you so much for the presentation for clarifying this. it's really helpful. is there any public comment on this item? i don't see any hands. i'm going to give the person an extra second. mr. shaw, if you want to make a comment, please raise your hand. i see no hand. any commissioner questions or comments? i guess i have one, actually, i'm not seeing other hands. so we've had several shortages, most recently the iv fluid shortage. i found out this morning that the controlled syringes, that those are also on backorder, at least at my hospital. so i'm wondering what the organization does to try to anticipate as well as have some kind of influence on just the supplies and the effort suppliers make. i know the iv shortage was really a revelation, because it was due to so few plants in the country that actually make iv fluids, but it was really i mean, cases

were canceled, and there have been other situations where care and hospitals in particular has been delayed because of shortages. is there something that you're doing as a group? is it a matter that maybe the discounts are too much? what would you say about, you know, what kind of clout this this group has in terms of some of these challenges, because they seem to keep coming. i mean, we've had we've had propane shortages and all kinds of things. yeah. and that's that's great actually, because that kind of gives him an opportunity to boost up and show the good work that we've done. we were lucky we didn't have to delay or cancel any of our procedures and any of our organizations in the department of public health, because one of the advantages of being part of the gpo and working with a standardized supplier that feeds us, we have a guaranteed supply, as i mentioned. so that guaranteed supply, we start reducing our expenditure of or use of the iv fluids. for example, when we had that shortage in coordination

with all the clinical teams at the sfgh and laguna honda. while we're consuming that guaranteed supply in a way to keep everything operational without like keeping keep vein open type of someone is not in the mood to drink water, just give him iv. we changed that to make sure that the iv is being used where it's actually necessary, and utilizing our supply that's been allocated for us, and it's guaranteed in a very. aware like thinking of it with every 1000ml milliliter bag with every 500 milliliter bag. is this where it needs to go. so we've we were monitoring that multiple times per day. communicating with the leadership at gsfc and laguna honda to make sure we're keeping track of what's happening. and we had some further discussions with our supplier that they were able to guarantee us also an

additional supply because of our commitment and our business with them that they said, you know, we can make sure we give you one week extra of supplies that helped help release any need to cancel any surgeries. and the reason this is critical and important because alameda health is part of the gpo as well. but alameda health, they found themselves obligated to cancel surgeries because they weren't able to manage the performance and the usage of what they have in a proper manner. but the leadership of supply chain did an amazing job in coordination with the clinical teams, and we're proud to say that we didn't have to cancel or delay any surgery. well, thank you for making that point, because i think it's really unusual for that kind of coordination to happen between the boots on the ground clinical services and organizations that are suppliers, your central supply at most hospitals, like this big black box somewhere down in the basement that you you have no idea what they're really doing.

or often there's a disconnect. so it's really good to hear the degree of coordination that you've been able to accomplish. and thank you so much. all right. seeing no other oh, go ahead, commissioner guggenheim say congratulations on having such a successful program and such a clear way of explaining it to us. thank you. thank you so much. thank you. thanks so much. okay. wonderful. our next agenda item is the finance and planning committee update from commissioner chow. thank you. we had six renewal renewal contracts. one was an administrative contract for immigrant services with helena. helena health. three others were mental health contracts and substance abuse contracts of

services, which you heard today. a final contract was with ucsf for the food program, which is part of the pips program for the san francisco health network and the commission. the committee is recommending that the commission approve those. we had three new contracts. one was an mma contract for the evaluation of our billings for fcaatsi. and even though they are cost based, to be sure that we are evaluating this correctly to maximize the income that we can get with our 15 plus fqhc clinics, which are under the actually the license of the clinic consortium. and there was also a contract with chinese hospital for about half a year in order to make use of their

sniff beds. and these are that is as a as needed contract staf. and in vicki, well i'm trying to. oh. impress imprivata which actually is a whole complicated contract that allows that workers in our two hospitals are able, with over 15,000 different licenses and management things, to be able to access any of the computers and information that they need. and they have some fancy things that they're coming up with a new phone systems, which i see as the updated pagers and. and anyway, something needed for our thousands of employees. and that is a new contract on bid, all three of which we recommend. there was a question as to my status with chinese hospital,

which i'd like to explain that in the last two years i've been disassociated with any fiduciary or actually administrative commitments with chinese and, and now what? they have banned me to the affiliate category, which has absolutely no privileges but allows for solicitations and also am a consumer. so i did not feel that i needed to recuse myself from that particular contract. the committee does recommend approval of the contracts report and the three new contracts. very good. well, so sorry to hear about your demotion. and is there any public comment on this item? there is. and if i may add, i respectfully add commissioner, there also was a quarterly fiscal report. oh, yes. quarter. there was our

first quarter report. and gee, i shouldn't have forgotten that because it actually, in spite of all of our issues and needs, we are showing a $13.3 million surplus. remember this is first quarter. many of the deficits were related to the new packages for the employees that as we know, last year they had a mega negotiation. and so those were part of the deficits. but we were able to close the quarter at a 13.3 million. so that was perhaps the most important report. i'm sorry. thank you very much for reminding me. and there is a public comment that's. i hope you heard commissioner chow's comments. would you like to make a comment? i did, i didn't find it. i didn't find it convincing. i'm sorry. so do you have a comment? i do. okay, so you've

got three minutes. this contract appears to be exercising a second option to extend the initial contract from december 1st, 2022 to november 30th, 2023 into a third year until june 2025. why just six months? why isn't it being extended a full 12 month period? what aren't we being told? nonetheless, it will push the $18.85 million contract approved to date to a new, revised total contract value of $24.3 million. this is nonsense. today, six months, $5.4 million contract extension with the chinese hospital association to expand skilled nursing bed capacity, ostensibly at laguna honda hospital, should be totally unnecessary. the attached request to the health commission form summarizing this department operational support contract states in its purpose of contract section, the 23 regular skilled nursing beds at chinese hospitals had been used during the covid surge, and

during the time l.a. was unable to admit new patients. end quote. until l.a. is able to fully admit new patients, end quote hogwash, the justification proffered in the purpose of the contract that, quote, as l.a. capacity to increase the level of admissions, there will no longer be a need for this contract, end quote is simply bonkers and completely unbelievable. both of those events, covid and ability to admit new patients are long over. so this so-called surge contract shouldn't be needed. as it is, l.a. gained medicare recertification on june 20th, 2024, but dragged its feet before resuming new admissions on july 31st. l.a. has been able to admit new patients for the past six months, making this contract unneeded. if l.a. would just speed up admissions, this $5.4 million contract extension wouldn't be needed. this contract points to the probability that l.a. still has major problems in patient care

and safety. that appears to still be slowing down. new admissions just speed up the laggardly admissions processes. thank you. that is the only comment for this item. any commissioner questions or comments on the report. all right. seeing none, we can go to the consent calendar. and in addition to the items presented by commissioner chow, the jcc of sfgh also recommended that we approve the policies, procedures, and reports that you see listed on the consent calendar. so is there a motion to approve the items on the consent calendar? so moved, and is there a second? and is there public comment on the consent calendar? i see a hand. okay. mr. mitchell, do you have a comment on the consent calendar? calendar? yes, i still am not accepting doctor chow's. decision not to recuse within

within the last couple of years, he has recused on chinese hospital contracts. so his explanation doesn't seem to hold water. thank you. all right. thank you. all right. that's the only public comment for this item. okay, all in favor of approving the consent calendar, please say aye. aye. great. thank you all. and the next item is other business. is there any other business from the commissioners. all right. seeing none i guess we go to adjournment. is there a motion to adjourn? i motion second. all in favor? aye. thank you. thank you all so much. and welcome, commissioner. guggenheim. appreciate it. give me one second. the 13th. yes, yes. yes,

yes. not not on the 20th. not on the 20th.

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[indiscernible] it is never too late to >> you are watching san francisco rising. a special guest today. >> i am chris and you are watching san francisco rising. focused on rebuilding and reimagining our city. our guest is the director of financial justice in the san francisco office of treasure to talk about how the city has taken a national lead in this effort and how the program is comlishing the goals. welcome to the show. >> thanks so much for having me. >> thank you for being here. can we start by talking about the financial justice project in a broad sense. when did the initiative start and what is the intent? >> sure. it launched in 2016.

since then we take a hard look at fines, fees, tickets, financial penalties hitting people with low incomes and especially people of color really hard. it is our job to assess and reform these fines and fees. >> do you have any comments for people financially stressed? >> yes. the financial justice project was started in response pop community outcry about the heavy toll of fines and fees. when people struggling face an unexpected penalty beyond ability to pay they face a bigger punishment than originally intended. a spiral of consequences set in. a small problem grows bigger. for example the traffic ticket this is california are hundreds of dollars, most expensive in

the nation. a few years back we heard tens of thousands in san francisco had driver's licenses suspended not for dangerous driving but because they couldn't afford to pay traffic tickets or miss traffic court date. if they lose the license they have a hard time keeping their job and lose it. that is confirmed by research. we make it much harder for people to pay or meet financial obligations. it is way too extreme of penalty for the crime of not being able to pay. we were also hearing about thousands of people who were getting cars towed. they couldn't pay $500 to get them back and were losing their cars. at the time we hand people a bill when they got out of jail to pay thousands in fees we charged up to $35 per day to rent electronic ankle monitor, $1,800 upfront to pay for three

years of monthly $50 probation fees. people getting out of jail can't pay these. they need to get back on their feet. we weren't collecting much on them. it wasn't clear what we were accomplishing other than a world of pain on people. we were charging mothers and grandmothers hundreds of dollars in phone call fee to accept calls from the san francisco jail. we heard from black and brown women struggling to make terrible choices do. i pay rent or accept this call from my incarcerated son. the list goes on and on. so much of this looked like lose-lose for government and people. these penalties were high pain, hitting people hard, low gain. not bringing in much revenue. there had to be a better way. >> it is important not to punish

people financially there. are issues to address. >> sure. there are three core principles that drive our work. first, we believe we should be able to hold people accountable without putting them in financial distress. second you should not pay a bigger penalty because your wallet is thinner. $300 hits doctors and daycare workers differently. they can get in a tailspin, they lose the license. we dig them in a hole they can't get out of. these need to be proportioned to people's incomes. third. we should not balance the budget on the backs of the poorest people in the city. >> financial justice project was launched in 2016.

can you talk about the accomplishments? >> sure sometimes it is to base a fine on the ability to pay. consequences proportional to the offense and the person. other times if the fee's job is to recoupe costs primarily on low-income people. we recommend elimination. other times we recommend a different accountability that does not require a money payment. here are a few examples. we have implemented many sliding scale discounts for low-income people who get towed or have parking tickets they cannot afford. you pay a penalty according to income. people with low incomes pay less. we also became the first city in the nation to stop suspending people's licenses when they could not pay traffic tickets. we focused on ways to make it easier for people to pay through

payment plans, sliding discounts and eliminating add on fees to jack up prices of tickets. this reform is the law of the land in california. it has spread to 23 other states. we also stopped handing people a bill when they get out of jail and eliminated fees charged to people in criminal justice system. they have been punished in a lot of ways. gone to jail, under supervision, the collection rate on the fees was so low we weren't bringing in much revenue. the probation fee collection rate was 9%. this reform has become law from california and is spreading to other states. we made all calls from jail free. the more incarcerated people are in touch with families the better they do when they get out. it was penny wise and pound

foolish. now phone calls are free. incarcerated people spend 80% more time in touch where families. that means they will do better when they get out. we eliminated fines for overdue library books. research shows were locking low income and people of color out of libraries. there are better ways to get people to return books, e-mail reminders or automatically renew if there is no one in line for it. this has spread to other cities that eliminated overdue library fines. these hold people accountable but not in financial distress can work better for government. local government can spend more to collect the fees than they bring in. when you proportion the fine with income they pay more readily. this impact can go down and revenues can go up.

>> i know there is an initial group that joined the project. they had a boot camp to introduce the program to large audience. is this gaining traction across the country? >> yes 10 cities were selected to launch the fines for fee justice. they adopted various reforms like we did in san francisco. as you mentioned we just hosted a boot camp in phoenix, arizona. teams of judges and mayors came from 50 cities to learn how to implement reforms like we have in san francisco. there is a growing realization the penalties are blunt instruments with all kinds of unintended consequences. it is the job of every public servant to find a better way. governance should equalize opportunity not drive

inequality. >> quite right. thank you so much. i really appreciate you coming on the show. thank you for your time today. >> thank you, chris. >> that is it for this episode. we will be back shortly. you are watching san francisco rising. thanks for watching. [music] san francisco emergency home program is a safety net for sustableable commuters if you bike, walk, take public transit or shares mobility you are eligible for a free and safe roadway home the city will reimburse you up to $150 dlrs in an event of an emergency.

to learn more how to submit a reimbursement visit sferh. when i shoot chinatown, i shoot the architecture that people not just events, i shoot what's going on in daily life and everything changes. murals, graffiti, store opening. store closing. the bakery. i shoot anything and everything in chinatown. i shoot daily life. i'm a crazy animal. i'm shooting for fun.

that's what i love. >> i'm frank jane. i'm a community photographer for the last i think about 20 years. i joined the chinese historical society. it was a way i could practice my society and i can give the community memories. i've been practicing and get to know everybody and everybody knew me pretty much documenting the history i don't just shoot events. i'm telling a story in whatever photos that i post on facebook, it's just like being there from front to end, i do a good job and i take hundreds and hundreds of photos.

and i was specializing in chinese american history. i want to cover what's happening in chinatown. what's happening in my community. i shoot a lot of government officials. i probably have thousands of photos of mayor lee and all the dignitaries. but they treat me like one of the family members because they see me all the time. they appreciate me. even the local cops, the firemen, you know, i feel at home. i was born in chinese hospital 1954. we grew up dirt poor. our family was lucky to grew up. when i was in junior high, i had a degree in hotel management restaurant. i was working in the restaurant business for probably about 15 years. i started when i was 12 years

old. when i got married, my wife had an import business. i figured, the restaurant business, i got tired of it. i said come work for the family business. i said, okay. it's going to be interesting and so interesting i lasted for 30 years. i'm married i have one daughter. she's a registered nurse. she lives in los angeles now. and two grandsons. we have fun. i got into photography when i was in junior high and high school. shooting cameras. the black and white days, i was able to process my own film. i wasn't really that good because you know color film and processing was expensive and i kind of left it alone for about 30 years.

i was doing product photography for advertising. and kind of got back into it. everybody said, oh, digital photography, the year 2000. it was a ghost town in chinatown. i figured it's time to shoot chinatown store front nobody. everybody on grand avenue. there was not a soul out walking around chinatown. a new asia restaurant, it used to be the biggest restaurant in chinatown. it can hold about a 1,000 people and i had been shooting events there for many years. it turned into a supermarket. and i got in.

i shot the supermarket. you know, and its transformation. even the owner of the restaurant the restaurant, it's 50 years old. i said, yeah. it looks awful. history. because i'm shooting history. and it's impressive because it's history because you can't repeat. it's gone it's gone. >> you stick with her, she'll teach you everything. >> cellphone photography, that's going to be the generation. i think cellphones in the next two, three years, the big cameras are obsolete already. mirrorless camera is going to take over market and the cellphone is going to be better. but nobody's going to archive

it. nobody's going to keep good history. everybody's going to take snapshots, but nobody's going to catalog. they don't care. >> i want to see you. >> it's not a keepsake. there's no memories behind it. everybody's sticking in the cloud. they lose it, who cares. but, you know, i care. >> last september of 2020, i had a minor stroke, and my daughter caught it on zoom. i was having a zoom call for my grand kids. and my daughter and my these little kids said, hey, you sound strange. yeah. i said i'm not able to speak properly.

they said what happened. my wife was taking a nap and my daughter, she called home and said he's having a stroke. get him to the hospital. five minutes later, you know, the ambulance came and took me away and i was at i.c.u. for four days. i have hundreds of messages wishing me get well soon. everybody wished that i'm okay and back to normal. you know, i was up and kicking two weeks after my hospital stay. it was a wake-up call. i needed to get my life in order and try to organize things especially organize my photos. >> probably took two million photos in the last 20 years.

i want to donate to an organization that's going to use it. i'm just doing it from the heart. i enjoy doing it to give back to the community. that's the most important. give back to the community. >> it's a lot for the community. >> i was a born hustler. i'm too busy to slow down. i love what i'm doing. i love to be busy. i go nuts when i'm not doing anything. i'm 67 this year. i figured 70 i'm ready to retire. i'm wishing to train a couple for photographers to take over my place. the younger generation, they have a passion, to document the history because it's going to be forgotten in ten years, 20 years, maybe i will be

forgotten when i'm gone in a couple years but i want to be remembered for my work and, you know, photographs will be a remembrance. i'm frank jane. i'm a community photographer. this is my story. >> when you're not looking, frank's there. he'll snap that and then he'll send me an e-mail or two and they're always the best. >> these are

chinatown. >> (music). >> welcome to san francisco historic chinatown a place with a past, present, and future merge with the street culture and cuisine join us as was take you on a journey. san francisco chinatown is a feeling testament

of china's immigrants and arrived in 1950 during the gold rush but hardship built a 35 community that served for generations. today san francisco chinatown is a burtonsville neighborhood brimming with history and culture. one of the highlights of this vibrant is worldwide can i intervene aim first and the oldest. we are known for handmade our claim to fame is our unique food and few places in the world. >> (speaking foreign language.) >> chinatown is a food louvers paradise with a rich engrave and cuisine. >> back requires and moon

contacts and every fine dining. >> welcome to (unintelligible). >> sandy spring /*. >> (speaking foreign language.) whether you're an ad veteran urban forester chinatown has something for everyone. >> chinatown is not just again food also a hub of creativity and take a stroll down the street with murals as culture exhibitions to celebrate the heritage of this city. >> what the sun sets schoun

truly come alive. >> it's night life is old and new a myriad of bars and you can distance the night away with friends. the museums and culture nonprofits play an important role in chinatown to teacher us about the past, present, and future and providing a platform for artist to engage in conversations and welcome to the china's holistic the mission so collect and preserve common council in america any person of my background can see themselves in chinatown for all people. and our founders help to create the studies. and usa with a was an amazing collector. chinatown

center was founded no 1965 an art center for infer served for people for education and the center is an exciting place for dialogue and engage with the actor right now have a exhibition present tense playground that looks the development of chinatown and also with the vast asian with taiwan and honk con. >> welcome to the square a new culture hub celebrating chinatown a gateway tell stories of chinatown the people here the culture and the history and past, present, and future all through arts and culture. that is a 35 community there is

so many to see shopping and buy food and suv inferiors and we welcome, everyone to come in and see what is going on here. >> so whether or not you're a history buff foodie an art person or simply looking for a night of excitement san francisco chinatown has something for you come and explore and experience the heart good morning.l of the private good morning. and let me say that again. >> good morning.