Minutes of the Health Commission Meeting Tuesday, July 16, 2002 At 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The Health Commission meeting was called to order by Commissioner Edward A. Chow, M.D., at 3:05 p.m. Present:  Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Arthur M. Jackson Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sanchez, Ph.D. Absent:  Commissioner Lee Ann Monfredini Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF JULY 2, 2002 Commissioner Edward A. Chow, M.D., asked that the notation after 3.5 saying Items 3.3, 3.4 and 3.6 were discussed together be changed to “Items 3.3, 3.4, and 3.5 were discussed together.” The spelling of vane on page 5 under public comment should be changed to vain. Action Taken: The Commission approved the minutes of July 2, 2002 with the above two corrections. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Jackson chaired and Commissioner Guy attended the Budget Committee meeting. Commissioners Umekubo and Monfredini were absent. (3.1) Central Administration - Request for the approval of a resolution authorizing the Department of Public Health to accept and expend 51 recurring grants from the State of California for FY 2002-03. (3.2) AIDS Office - HIV Health Services - Request for approval of a new retroactive sole source contract with Ramsell Corporation, in the amount of $128,831, to provide Quality Management Program Coordination services for providers of CARE-funded services, for the period of June 1, 2002 through February 28, 2003. Commissioners’ Comments Commissioner Jackson asked if this were a nine-month contract and noted that three of seven members have the same name. Ms. Dixon confirmed both inquiries. Commissioner Guy asked if they had reviewed the instruments of evaluation. Ms. Dixon said yes. Public Comment Patrick Monette-Shaw. He is concerned about the number and dollar amount of sole-source contracts being approved. $28 million so far. LA County is having a problem with this. Urged the Commission to have the AIDS Office and DPH start the contract process earlier. (3.3) CHS-Mental Health - Request for approval or a renewal contract with Lifemark Corporation, in the amount of $475,720, to provide fiscal intermediary services to the Personal Assisted Employment Services (PAES), for the period of July 1, 2002 through June 30, 2003. Commissioners’ Comments Both Commissioner Guy and Commissioner Jackson asked that the information be clarified so that it reflects that the renewal supports the dental piece and does not provide optical services. Po Yee Lindahl stated that the optical portion of the contract has been removed (now being down through Human Services) and there were some holdover invoices that needed to be processed. The holdover is included in the total amount. There is no vision money in the FY01-02 contract. Commissioners Guy and Jackson suggested this item be held over until the August 20, 2002 meeting to clarify and reflect the nature of the contract, given that it a continuance would not impact billing. (3.4) PHP- TB Control - Request for approval of a sole source renewal contract with the Regents of UCSF at San Francisco General Hospital (SFGH), in the amount of $238,764, to provide physician and radiologist services to patients referred to the SFGH Tuberculosis Clinic, for the period of July 1, 2002 through June 30, 2003. Commissioners’ Comments Commissioner Guy noted the increase in the Latino population (24%). Tony Paz said this is the representation that has been consistent. Commissioner Guy asked if there is a trend in increases in any particular population. Tony Paz responded that among the foreign-born, especially Asian, the rates are high. In US-born, African-American population goes up and down but we are currently on the downward side. Commissioner Guy would like a presentation on TB scheduled for a future Health Commission, through the Population Health and Prevention JCC. Action Taken:  New Chief Financial Officer I am pleased to announce that Gregg Sass will be the Department’s new Chief Financial Officer. Gregg has served as the Department’s Chief Financial Officer in the Community Health Network for the past year. Gregg brings 29 years of experience of health care finance, including five years as a partner at KPMG Peat Marwick, and seven years as controller and chief financial officer for three San Francisco hospitals. Gregg replaces Monique Zmuda, Chief Fiscal Officer, who has leaving the Department after 18 years at DPH to become the City’s new Deputy Controller. Angelina Ehrlich, Ms. Zmuda's secretary, will be joining her in the Controller's Office. Ms. Ehrlich has been with the Department for 24 years. We wish both Monique and Angelina the best in their new positions and thank them for many years of excellent service to the Department. City Budget As several unions have rejected the City’s proposal regarding retirement pick-up, the Department was asked to make an additional $1 million in reductions to its budget. The Department was able to meet this $1 million goal through revenue adjustments, largely as a result of anticipated reinstatement of proposed State reductions to the Disproportionate Share Hospital program. The Board had its first hearing on the budget yesterday and will take final action on the budget on July 22nd. Suicide Prevention Workgroup At the request of the Board of the Supervisors in response to the recent tragedy and suicide by a San Francisco high school student, the Mental Health Children, Youth and Family Section has convened a Suicide Prevention Workgroup. The workgroup is charged with reviewing the various factors leading to suicide in young people as well as reviewing the existing protocol for suicide intervention and prevention among City departments, and public and private agencies. The committee will be making recommendations to the Board on ways to address current gaps in services. Treatment on Demand to be the Beneficiary of Marathon Pledge Program The Treatment on Demand (TOD) Planning Council will be a beneficiary of the 2002 San Francisco Chronicle Marathon Pledge Program, scheduled for July 28th. The TOD Planning Council was selected along with five other agencies, which build community, treat the sick, prevent child abuse and ensure the public’s safety in disasters. Conference on Lesbian Health & Wellness The 2nd Annual Conference on Lesbian Health & Wellness, themed “Healthy Choices for Lesbians,” was held Saturday, June 29th. The conference marks the beginning of a 3-year collaborative process between researchers and lesbian communities. María Cora, Coordinator of our Office of Women and Girl’s Health, co-presented one of the keynote speeches on “Multiple Marginalization: Health Disparities of Lesbians of Color.” STD Program’s Continuing Response to Increase Syphilis Cases The STD Program has begun live STD chats on Gay.com. More than 100 subscribers logged onto the first chat. Advertisements have been placed in magazines and websites that target men who have sex with men. Already the ad on one website has had 10,000 click-throughs in the first month, all from the West Coast. The website banner ads focus on the increase in syphilis in the City and allow people to click directly into the STD Program website. Laguna Honda Staff Co-Authors New England Journal of Medicine Article I am pleased to report that John Hollingsworth, Dr.PH, Quality Management Analyst at Laguna Honda, has co-authored an article that was published in the July 11th edition of the New England Journal of Medicine. The article, entitled "A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee," has received a great deal of national attention including airing on NBC Nightly News, a variety of radio stations and appearing in newspapers and magazines. Dr. Hollingsworth has added significant new information to the medical community's body of knowledge about treating osteoarthritis of the knee and has brought well-deserved recognition to the Department of Public Health. I congratulate Dr. Hollingsworth for his fine work. EMS Section Has Moved As of yesterday, the Department’s Emergency Medical Services (EMS) Section has relocated to 68 12th Street, Suite 220. The new EMS Section offices will house the Department’s new Emergency Operations Center where designated personnel will report in the event of an emergency. St. Luke's Temporary Closure In an unusual action, St. Luke's closed their Emergency Room last week as a preemptive move to an announced strike. Dr. Katz discussed the closure with the head of the hospital who said he was under the understanding that they could close because the Emergency Room was closing to everyone, not just to people without insurance. DPH's jurisdiction centers around the Emergency Medical Service agency. The State ordered St. Luke's to reopen by Tuesday, which they did. There may be upcoming court cases and fines against St. Luke's. Commissioners Comments Commissioner Jackson asked what was St. Luke's motive? Dr. Katz said that the motive is hard to prove. The hospital also closed its Labor and Delivery Room. St. Luke's said it was because they could not afford to hire managerial or registry nurses. Commissioner Parker asked if the Suicide Prevention workshop is permanent. Dr. Katz explained that DPH is just organizing it. Sai-Ling Chan-Sew is in charge and if it proves successful, DPH would look for it to be on-going. Staff will prepare a report for the Board of Supervisors and get feedback. The response will be multi-faceted, not just a workshop. Commissioner Parker said the STD website is very impressive and that DPH has raised a high level of awareness. He asked how DPH can measure the positive effect of this website? Dr. Katz said DPH hopes to see the syphilis rates decrease. For the first time in three months, there has been a drop, which may be a combination of several initiatives. Commissioner Guy said it was important to see how the issue of suicide is related to the programs that go on in the Wellness Centers as part of wellness for the school population. Dr. Katz said DPH has the expertise to put together a good plan. Commissioner Sanchez said that when the representatives from Sutter were at the Health Commission, there were some basic assumptions about charity care and services. Is there a review process to assure the quality assurance and to have Sutter account for their actions? Dr. Katz said that once the Attorney General has investigated, there is no mechanism to assure that they hold up their end of the agreement. Commissioner Chow noted that the Health Commission considers this serious business. Special Presentation to Monique Zmuda, Chief Fiscal Officer and Angelina Ehrlich, Executive Secretary. Commissioner Chow presented a plaque to Ms. Zmuda, who has left DPH after 18 years to become Deputy City Controller. She was the first Health Commission Secretary. As a Fiscal Officer she was instrumental in getting many things organized, has stayed within budgets, held to assignments and presented excellent budget reports. It is very difficult to have Ms. Zmuda leave. Angelina Ehrlich also received a plaque in absentia. Ms. Ehrlich worked for the Department for 24 years and has joined Ms. Zmuda in the Controller's Office. 5) REPORT ON THE LONG RANGE SERVICE DELIVERY PROGRAM RECOMMENDATIONS FOR THE SAN FRANCISCO GENERAL HOSPITAL MEDICAL CENTER REBUILD Dr. Mitch Katz, Director of Health, said that the programs that are being planned pose complicated questions, especially in terms of how things will fit together 10 years from now. He compared it to how much health care has changed since 1992, when San Francisco had just hit its peak of AIDS deaths. If you had gone to SFGH then, you would have found about 40 people with end-stage AIDS. Today, you would find only four or five. In 1992, no one would have been able to predict this. All DPH can do is get the best thinkers--analytical thinkers who know the community--and work on it. DPH has worked with the Lewin Group to answer a number of threshold questions that need to be answered. The Lewin Group held many community meetings and DPH has excellent support from individuals who serve on the Long Range Service Delivery Committee. Dr. Katz introduced Keith Hearle who presented the Lewin Group’s recommendations. He concluded by saying that the Health Commission has decided to accept the report as one in progress. DPH will continue to seek comment before coming to a final resolution. Keith Hearle thanked a number of his colleagues in the Lewin Group and DPH staff. He also commended the input from the Planning Committee. Mr. Hearle reviewed the reason for the rebuild. California legislation (SB 1953, 1801) mandates that all acute care hospitals meet new seismic safety standards by 2013 or close their services by 2008. This is going on across California. There are still some open questions about the program plan. What are the best ways to meet client needs over the next 10-40 years? The long range planning process tries to look at a variety of issues, such as predicting the range and type of services. Where will these services be delivered? How much will they cost? Two Planning Groups are working on the process: a Community Group of about 45 members and an Internal Group comprised of SFDPH and UCSFMC clinicians. The planning framework started with certain assumptions about San Francisco and San Francisco General Hospital Medical Center (SFGHMC), and with open questions/choices centering on critical issues that require additional analysis or decisions. The planning principles included improving access to care and quality of care; implementing best practices; advancing professional training; conserving debt capacity; operating efficiently; and meeting SFDPH Strategic Goals. Certain assumptions were embraced: SFDPH will continue to operate a full continuum of public health care programs; SFDPH would continue its core mission as a safety net provider and Level I trauma center; social problems will persist; SFDPH will continue its affiliation with UCSF; City resources are limited; SFGHMC will comply with SB 1953; and the rebuilt SFGHMC will incorporate a flexible design and accommodate changes in technology and medicine. There are a number of choices requiring further discussion: Which site options for SFGHMC rebuild should be pursued? The two options are co-location with UCSF at Mission Bay or rebuild at Potrero. How should SFDPH’s ambulatory care programs be configured? Should SFGHMC seek to increase volume for Level I Trauma? Should SFGHMC seek to increase it Emergency Department (ED) capacity? Should SFGHMC develop programs to attract elderly patients? Should the rebuild assume continued provision of inpatient pediatrics and Obstretics or should beds be consolidated with another SF provider? How should behavioral health services be configured? Should SFGHMC rebuild include skilled nursing beds in new space? The choices have benefits as well as implementation issues and challenges. Lewin offered recommendations regarding the choices based on data analysis and projections; interviews with community experts; input from SFDPH planning groups; survey of national best practices and models; and expert judgment. Which site options for SFGHMC rebuild should be pursued? Option 1. Co-location with UCSF at Mission Bay. SFGHMC services/programs would be split between two campuses. Acute services, ED, Trauma and high end specialty services located at Mission Bay (MB) Acute psychiatry at MB is an option Co-located facility vision: "two towers" with one owned and operated by SFDPH, a second by UCSF Joint operation of some ancillaries and support services One ED (at SFGHMC) and Trauma Service Governance would not be shared; approach to shared decision making required Potrero would become a behavioral health and ambulatory care campus Benefits Strengthens existing relationship Enhances quality of care Enhances faculty oversight/supervision MB more accessible for trauma Lower project cost Lower operating cost Coordinated GME and research programs Creates additional financing options Greater public support? Challenges Sufficient capacity must be co-located by UCSF to achieve benefits Land availability Differences in missions and populations served UCSF commitment needed by January 2003 for SFDPH to meet SB1953 Request Letter of Intent (Programs/services to be co-located; resource commitments; decision-making structure; roles and responsibilities for budgeting of shared services, financing project costs and meeting capital needs) Option 2. Rebuild SFGHMC at current Potrero Avenue site. Benefits: CCSF/SFDPH own the land SFDPH would not operate an additional campus SFGHMC services not "split" between two campuses Continue ties to Potrero Avenue neighborhood Challenges Greater impact of rebuild on patient care during construction Neighborhood concerns regarding Helipad and impact of rebuild Benefits of UCSF co-location less likely How should SFDPH’s ambulatory care programs be configured? Shift 30,000-40,000 lower acuity ambulatory care visits from SFGHMC to community. The volume in community clinics is already trending upward and more capacity is needed. Benefits: Provides care closer to home; improved patient satisfaction; SFDPH goal to move care into community; consistent with strategies of other public health care systems; facilitated by technology advancements. Challenges: Current sites capacity constrained; new capital investment in renovation or new sites needed to implement this initiative; requires addressing medical staff/teaching issues in off campus sites; some patients may prefer hospital-based care. Organize Ambulatory Care as a SuperClinic at Potrero Benefits: Integrated "one stop shopping" model is preferred by patients; supports "Center for Vulnerable Populations" concept; supports ACRC planning; moves services from red brick buildings; positive outcomes achieved by other public health systems Challenges: Facilities options need to be developed; higher project cost and funding needs Should SFGHMC seek to increase volume for Level I Trauma? Benefits: Ensure high quality care and access to specialized care; promote public health and safety; positively impact hospital's payer mix. Supporting trauma also enhances SFGHMC reputation as foremost public hospital in the US. Regionalization and development of a Helipad would bring additional patients/ensure viability of Level I Trauma service. The successful expansion is unlikely without medical air transport capability; San Francisco is one of the only large metro cities without medical air transport. Challenges: Volume growth is important to continuing to meet Level I Trauma requirements-SFGHMC trauma volume has declined and just meets the threshold requirement; no other SF hospital has public plans to become a Level I Center; the risk of not expanding could mean that SF no longer can support Level I. Should SFGHMC seek to increase it Emergency Department (ED) capacity? Benefits: Allows SFGHMC to conform to current standard of 2,000 visits /treatment station (now operating at ~3,000); would contribute to improved patient flow; would lower diversion rates. Challenges: Operating and capital cost implications; takes pressure off initiatives to reduce ED utilization. SFDPH should not include SNF capacity in new hospital construction Benefits: Would reduce cost of new construction; would facilitate joint SFDPH long-term care planning; consistent with LHH program plans; consistent with trend by other hospitals to no longer operate hospital-based SNF's particularly in new capacity. Challenges: Proximity to acute surgical/medical beds facilitates patient flow; SNF beds also reduce administrative (disallowed) days; dedicated capacity needed. Few general acute care county hospitals in California maintain SNF units. Should SFDPH pursue a strategy to retain its elder population? Benefits: Meets needs of aging SFDPH clients, including those at LHH; positive financial impacts; poor elderly will have greater needs and reduced resources; serving needs of patients with complex psychosocial needs is SFDPH center of excellence. Challenges: Assuring that needs of SFDPH "core populations" (those without options) are met first; program development needed; implications for facility design and cost; without "champions," success is uncertain. Most Medicare patients in SFGHMC's target market area go elsewhere for care. SFDPH should develop collaborative partnerships in providing inpatient pediatrics and obstetrics services. Consolidate obstetrics with UCSF Benefits: Consolidated program would have higher volume (1300 deliveries at SFGHMC, 1700 at UCSF); research shows that quality improves with higher program volume; births projected to decline further; improved access to UCSF specialists and neonatologists; some high-risk services already transferred to UCSF. Challenges: Requires carefully crafted partnership agreement; ensuring continuation of unique SFGHMC competencies; maintaining midwifery program; potential loss of MediCal reimbursement; community concern about not providing inpatient maternity care. Consolidate inpatient pediatrics with UCSF Benefits: Children and adolescents are better served in a dedicated facility providing specialized care; some complicated cases already are served by UCSF; SFGHMC census of pediatric cases is low (ADC=4); would reduce problems in maintaining specialized staffing. Challenges: Requires carefully crafted partnership agreement to assure continued access for SFDPH patients; ensuring continuation of unique SFGHMC competencies (drug exposed, abused, foster care); impact on pediatric trauma. Behavioral Health Choices Continue exploring options for psychiatric care in the Mission Bay, including: Moving acute psychiatry along with acute medical/surgical beds to Mission Bay Benefits: Continued integration of hospital-based psychiatric care for SFGHMC; psychiatry not “left behind;” coordination of PES & ER. Challenges: Project cost; implications for land need; maintaining services for MHRF clients; integrating psychiatric care into ambulatory services provided at Potrero Avenue site. Maintaining acute psychiatry beds at Potrero campus if SFGHMC moves acute medical/surgical beds to Mission Bay Benefits: Opportunity to have comprehensive continuum of Behavioral Health service at one site; maintains coordination with MHRF; facilitates development of “Center for Vulnerable Studies;” and facilitates integrating behavioral health service with primary care at the Potrero site. Challenges: Assuring medical presence for medically complex behavioral health clients; coordinating care at two sites (PES & ER services. Med/psych patients. Diagnostics); Psychiatry “left behind,” increased stigma for psychiatric patients; risks regarding future resource commitments to the Behavioral Health programs at Potrero Avenue Campus. Maintain current number of acute psychiatry beds. With risks to inpatient programs at other hospitals and forces contributing to higher demand, SFGHMC should maintain the current number of inpatient psychiatric beds. Include a 30-bed comprehensive medical-psychiatric inpatient unit in new hospital construction. (SFGHMC and SFDPH clients have a high level of psychiatric and medical “co-morbidities.”) LEWIN GROUP RECOMMENDATIONS The SFDPH should continue discussions with UCSF to co-locate hospital capacity; definitive agreement must be reached by January 2003; if not, rebuild at Potrero. Adopt programmatic changes: Shift primary care visits from SFGHMC to CHN primary care centers. Expand off-campus ambulatory care capacity. Expand Level I trauma through regionalizing and developing medical air transport. Organize ambulatory care on Potrero campus as a “SuperClinic.” Increase physical capacity of ED, consistent with current standards. Partner with UCSF to consolidate pediatrics and obstetrics. Exclude SNF beds from SFGHMC rebuild. Incorporate design features to improve patient flow, flexibility and attractiveness. Institutional planning process should assess implications for SFGHMC operating at two campuses (MB & Potrero): Operating the Potrero site as a Behavioral Health and ambulatory care campus, including acute psychiatry, MHRF, ambulatory care and administrative capacity. Locating acute psychiatry beds and PES in new space with the acute medical-surgical SFGHMC beds. Operating ambulatory care services at two campuses, with a “SuperClinic” and Urgent Care at Potrero, and sub-specialty capacity on the same site as the acute care beds. REBUILD TIMELINE July 16, 2002 Recommendations presented to Health Commission for approval July 2002-03 IMP/SFGHMC Rebuild Facility Planning groups meet January 2003 IMP/Facility Plan presented to Health Commission for approval Plan presented to Mayor, Supervisors, City Depts., community November 2003 Election bond measure 2013 Completion of SFGHMC Rebuild REBUILD NEXT STEPS Institutional Master Plan Finance Plan Program Planning Implementation Community Education Anthony Wagner thanked Dr. Katz and the Health Commission for allowing them to go through the process. It is difficult to envision what is best for San Francisco as it relates to the delivery system. We are planning a hospital that would be occupied in 2013 that would have to last us for another 50 years. A number of technological changes will come along that will help us solve many of our concerns. Mr. Wagner also thanked the Planning staff at SFGH and community group members. The next six months are critical. Staff will come back with final recommendations and a report that gives their best thinking. They will also have started a process of blending the programmatic piece with the facility. They have had an initial meeting already with in-house staff and DPW, the Institutional Master Plan is underway and the Finance planning group also meeting. Program planning implementation and continued discussion with UCSF. There are very sophisticated community groups in this City the community education piece needs to get underway. There is still an opportunity for synergy connection with LHH and SFGHMC even though LHH is ahead in its planning process. Public Comment Susan Sniderman, MD, SFGH Pediatrics and Newborn. Thanked the Lewin Group for their work and liked the process. Feels involved. She is Acting Chair of the Department of Pediatrics and in charge of the nursery. In the long run, would be good to have a unified program with UCSF. She attends at both UC and SFGH. UC is not a very drug-hospital-psychotic-friendly place. Problems with translations, sensitivity to cultures, to women with severe psychiatric disabilities and the expertise her colleagues have developed. If you do something sooner, we need to think carefully that these sensitivities are developed. Gladys Sandlin, Mission Neighborhood Health Center. The Center has a long-term relationship with many services at SFGH. They are currently going through their own rebuild. The Center serves people no one else serves-mostly minorities. Very excellent, culturally competent services currently exist at SFGH. Asian and Latinos are population of the future. We need to have community hearings in the evening after work hours. Ms. Sandlin submitted a position paper (on file). Rae Ann Emery, East Mission Improvement Association. Was here about a year ago when the rebuild plan first came up. Currently serving on the Committee. Thanked the Planning staff for keeping them updated on the meetings. Represents the immediate neighbors of SFGH. Everything that’s done at SFGH will affect their property values and sense of well being. Opposed to the helipad. Opposed to taking up existing parking. Would like to be able to support the program but would prefer to support two sites or the larger site at Mission Bay. Would like to be considered in future groups to be interviewed one-on-one. Ed Kinchley, SEIR 790. Mr. Kinchley distributed a letter to the Health Commission (on file). The governance structure, which is now separate, needs to be maintained separate if there are separate structures. As you look through the report, the process has raised more questions than it has answered. Hope we continue the process. Concerned about the impact on the community-the Mission District-and how moving services would impact the community. This does not appear to have been looked at thoroughly. Philip Darney, M.D., Chief Obstetrics and Epidemiology, SFGH. Has been delivering babies for 22 years at SFGH. Concerned about the geography. Important to provide services where people live. We provide a unique service. Should not consider consolidation until we know we have a place on our side of town for our kind of patients. Eleanor Dhey, M.D., Acting Director of Obstetrics. Echoes what Drs. Sniderman and Darney have said. SFGH has a distinct set of services that serves a unique set of clients. She worries the patients will not make it across town. They will be lost on both a literal and surface level. In the long term, how can we preserve the strength of SFGH. She does not think UC can accommodate another 100 deliveries to their already full schedule of deliveries. Phil Hopewell, M.D., UCSF/SFGH. His statements are his personal feelings, not those of the University. He has been at SFGH for 30 years and supports the co-location at Mission Bay. UC has not made a decision at all and does not know their desires. Co-location may be difficult to achieve but would offer three advantages: 1. Increasingly, medicine for trauma is highly complex and our ability to sustain the infrastructure and care is in question. 2. The physicians who provide care are highly specialized and highly compensated. How long could we provide that level of support? 3. Access to research. SFGH is an academic center that focuses on the needs of our patients. If there is a decision to relocate at the Potrero campus, then we also need to accommodate research infrastructure. Thomas Gwynn. Was impressed by report from Lewin. Was president of Board of SFGH volunteers. Increase cooperation and enhancement of this relationship. Hopes the door with UCSF stays open. There has been active community involvement and hopes it continues. Peter Winkelstein, SPUR. Chairs a hospital taskforce to help hospitals deal with the seismic issues and looking at city’s overall needs. Very productive. Would like the Commissioners to consider thinking about ways to combine those clinics at other facilities. Opportunity to look at public-private partnerships. Don’t have to be the only people in the clinic. The neighborhoods have different and special needs and could be tailored to those needs. Going to have to be flexible in our thinking because no one knows what the services are going to be like 15 years from now. Mary Lou Licwinko, SF Medical Society. Speaking as a long-range planning committee member. She attended every meeting. She urged the Health Commission to accept the Lewin Report. Impressed by process as it included neighborhood, incorporated suggestions, especially many from the community that otherwise would not have been included. Made lots of progress bringing together disparate points of view. This is a working document that should have community input further into the process. Helynna Brooke, Community Mental Health Board. Very fond of SFGH. Chose to have her son there many years ago. She has two concerns but very impressed with the plan: 1) Psychiatric services separate from acute care. Outpatient separation is confusing, especially to the elderly, and 2) Her mother is low income. Primary care providers are at UC and she is not impressed by the care her mother is getting. Sue Bierman. Has been attending both LHH and SFGH community meetings. Interested about both institutions. Her son works in public hospital in NY and was very impressed by the personal care at LHH. Planning process gives her a connection with the City. The community is very faithful about attending the meetings. She will help with whatever our final outcome is. A few years ago her daughter was rushed to SFGH after a bike accident. She was very impressed by the care. She will be following the rebuild process closely. Written Testimony Lucy Johns, M.P.H., submitted written comments supporting co-location with UCSF and asking that the scope of ambulatory care within the CHN system (on file). Commissioners’ Comments Commissioner Parker asked if the bond would provide a changing atmosphere in terms of the Department’s mission and strategic planning. Five areas addressed: response of rebuild relating to SB 1953; endorsement for increase in ED capacity; Level I Trauma Center being supported by a helipad; community centers/clinics services be increased and waiting times reduced; affiliation with UCSF to continue. He is not making specific recommendations about co-location but wants to see his points considered in the final plan. It would be our responsibility to see that the recommendations are followed regardless of where they come from. Commissioner Sanchez observed that it is an excellent, working document. It raises questions in many areas. The speakers today show a high respect for quality care and services. SFGH as a campus now a campus with UCSF faculty. It is not a new pathway; it has been like that for years. The majority of faculty is there because it is where they want to train, practice and provide services. The mission of SFGH is different than that of the UCSF as a whole. These two systems have worked well together at SFGHMC. We have to plan for the future but the timeline is clicking away. Mission Bay was going to be a biomedical center from its inception. Lots of folks at UC think Mission Bay is their area. We have two unique, excellent institutions. There is already a model of collaboration to provide faculty and staff services to this city and we need to ensure that the quality of services continues. There are culturally competent services at SFGHMC that one may not see at UC or Mission Bay. DPH’s timeline is different than UC’s. There should be a summary of the plan in neighborhood newspapers as well as a Saturday Health Career Day to share with the community the model DPH is looking at. This report is very important first step to help us think about the mission of both institutions. Commissioner Jackson observed that DPH has already been partners in many ways with UC. When we know where we are going, we are going to have to have an extraordinary education piece. He thinks it is still a challenge in San Francisco that people still go to the Emergency Room to get services. We must educate staff about how this new system is going to work. How do people get the services they need in the most efficient way? Build this future on information and knowledge. There has been little discussion about internal transportation from site to site. We could develop our own transport system rather than having people rely only on public transportation. Must stay a Level I Trauma Center and part of that is having a helipad site. These are challenging economic times. People are working hard and we will need to say to them that unless they support the bond, they will lose a very valuable resource. Marketing and sales challenge to the whole Department and staff. Commissioner Guy noted that today’s report is a good beginning. She made suggestions about what the next progress report should include. In terms of vision, how does the rebuild of the acute medical center, the heart of our tertiary care, fit into our system? Commissioner Sanchez spoke of our rich relationship and affiliation with UC, which provides research, practice and delivery. Worth it to take a look at it every 30 years. Letting the option of program drive us. DPH should be open to the question of co-location but she would like a progress report on what happens to research if we do not co-locate. Our relationship with UC needs to continue regardless of what campus SFGHMC is located on. DPH’s timeline is different with UC. Ours takes precedence so we do have to make a decision. Our potential co-location partner needs to respect our timeline. She acknowledges questions of finance and cultural differences. Organizational cultural differences are important, as is the community’s diversity. In the planning process we need to accommodate those who cannot come during the day, and anticipate some of the questions such as the downturn in the economy. DPH needs to turn to its congressional delegation for help. The Trauma Center has to be regionalized and this means a helipad. Have to work with the public and neighbors. It is a difficult question and brings up NIMBY-ism but can struggle with it respectfully. She is still not clear on the SNF questions. Just because we have LHH does not mean we put all our SNF beds there. We need more SNF. Various ambulatory care questions need to be discussed further at the joint conference committees, including Southeast’s long waiting times, the physical capacity of ambulatory care capacity, and Potrero Hill as the site for the SuperClinic. On behavioral health, need to deal with the stigma question. One way to handle it is to configure a Center of Excellence. It is true what research and community says-medical needs and psychiatric needs must go together. Some complexity to it if we go to co-location. We should be looking at Best Practices data from others who have tried to see what works and what does not. Commissioner Chow said that the process has been one that has included many hearings and we are not here arguing the information but what to do with the information. The process has been more than many of us anticipated. One thing that has come out today is that the cultural competency is not just words that reflect language or demographics. It is what distinguishes the care at SFGH. Implicit in all of this is cultural competence. Whatever we do, it has to fit the population we target. There are a number of issues that require continued discussion, the first being co-location and where to rebuild the hospital. If we stay on Potrero, how do we assure we have continued research excellence? Need to get this responded to. If we are going to go with co-location, we need to find examples that it works and that culturally competent care continues in that venue. Who is the dominant partner? If we continue with co-location, how is it that people will receive competent services? The second issue is Trauma, which is not in question, regardless of where we are. In order to keep Trauma, there needs to be air transport. We have a waiver at the moment that we are going to do that. Commissioners have expressed a need for emergency capability for terrorism and our own natural [earthquake] vulnerability. SNF issues require a continued look and whether SNF should be part of the rebuild at SFGH or just LHH. We have heard more about OB and pediatrics. Without pediatrics, can we have Trauma? Ambulatory care is another topic that needs to be discussed separate from what and where we build. It is not just a facility issue. What are the different capacities? For example, in Chinatown, we can use the second floor with the elevator. If we have more staff at Southeast, we could take care of more people. The issue of public-private partnership is important. We already have a relationship with the Consortium. Where does this stand and what does this mean for providing community care? On the question of ambulatory care and the SuperClinic, we have to hear a lot more about where and how we deliver care. There are facility implications but first there needs to be a policy issue around ambulatory care. In terms of SFGH rebuild, the Joint Conference Committees have to hear these issues. Combine this with how we carry out the Trauma. If it’s a good idea to have better behavioral health services more integrated-whether we have or don’t have a Mission Bay, this needs further development. Pediatric services should be further discussed at SFGH. Elder care is a market issue. If it changes the configuration of how the hospital is built, then it has implications for how and where the structure gets built. Finally, the need for community input and education needs to be at times that are convenient for both. We need to get more public input from immediate community and survey our own patient population and what they feel are the needs. We have an ambitious agenda over the next few months. Anthony Wagner assured the Commission that staff would continue to engage the two teams. Lewin will continue to report back to us and work with us. Dr. Katz thanked the Commission for their comments, which will help staff in doing the next stage. In thinking about his own job for the next year, he wants to prepare a terrific bond measure. It is complicated, there are lots of questions, and more study that needs to be done. But he is convinced that we will do it and it will be a great program, whether it is at Potrero or co-located. It will be the best and it is the best public hospital in the US and will remain so. Staff has nine months to complete the program plan, which must be done by April 2003. All the questions do not need to be answered prior to the bond going on the ballot. LHH continues to change in response to request of residents, staff, architects and the project team. It is not possible to answer every question about it in the next nine months. We do have to get the answers to the questions raised today and put together the very best program plan and seek community input. Ultimately, it is the voters who will decide. There is a lot of hard work ahead of us and we look forward to it. Commissioner Guy asked if January is a good deadline. Dr. Katz said that it pushes staff to the limit but if they are not further along in the co-location discussion in two months, then that is the end. January is the drop-dead time for an MOU. Based on LHH, the bond measure does not have to specify the location, but has to specify the program. The public may accept some openness. By October staff will know whether DPH is going on its own or going on with UC. 6) CONSIDERATION OF A RESOLUTION ADOPTING THE ENVIRONMENTAL IMPACT REPORT FOR THE LAGUNA HONDA HOSPITAL REBUILD PROJECT Larry Funk, Executive Administrator for Laguna Honda Hospital, introduced Michael Lane, project manager for the Laguna Honda Hospital Rebuild Project. Mr. Lane described the new design. There are three resident buildings and a link building. This is the design concept they have been working on since 2001. The design has evolved out of the valley-clinically better to get into more daylight and avail themselves of the open space. In order to contain construction operation, they will be using the valley area as a staging area and not spill into the community. They will be retaining existing buildings and will be future location of assisted living and be directly accessible to support services. Looking at the valley floor, there will be therapy pools, physical therapy and a gymnasium. There is a desire to expand rehabilitation services out into the valley area if needed. Dr. Chow asked how many rehabilitation beds there would be. Mr. Lane replied 60. The floor above the rehabilitation center would come into the Town Center with the library, gift shop, art for elders and activity rooms. Mr. Lane continued to explain the floor plate. The typical floor plate has 15 households with dining and living rooms on either end. Comes together for a core space that has four dining rooms, activity therapy space, nurse’s station and galley. A triple room opens to a common area. Other floor plan is a double. They are making an effort to restore the valley and provide garden access. Landscaping will develop gardens between households. The landscape architect is working with residents on how to plan for them. Budget update. They are going into construction document design and were looking at a $30 million design development over-run. Overall floor plate increased 1200 sf. As they went through design process, the geo-technical information showed the foundation had to go down further. Took another look at escalation and reduced it. Refined design more in handling soil and foundation. Deferred renovation of administrative wings A, B, and C but kept renovation in buildings that had to connect. Planning Process. EIR (Environmental Impact Report) was issued on 12/1/01. Public hearing was held on 1/10/02 and public comment closed on 1/16/02. Received Rec & Park Commission approval, a Comments and Responses Document was issued; Civic Design review and Committee Approval from Planning Commission. Four households filed an appeal with the Board of Supervisors this week on the EIR. The appellants said the EIR failed to address the impact on the surrounding community. The design should have triggered an amendment with the Master Plan. Planning Commission said neither of these points have merit and they will respond. The crux of the issues with the households is that they said they did not know where the buildings were going to go. The timing of this appeal is frustrating because they were sending documents to the printer to be ready for the July 22nd hearing. Staff held a number of neighborhood and community meetings where this did not come up. The Board will hear the appeal of the EIR either August 5th or 12th. Could prove very significant if the Board upholds the appeal. Would set us back six months and millions of dollars. Would have to cut more from the project to keep this on schedule. Unfair to have gone through the process and would have to go through it again with no guarantee that someone else would come up with something again. Have received many letters from community groups already and have worked to resolve them. On the overall schedule, have Central Plant out for bid. Would let us locate it out of the valley. Coming out in August with a roadway plan. Waiting to hear about the laundry location. In 2003, we will have completed design and will begin demolition of first stage. If all moves forward, would have the final move in of the new facility in 2009. Commissioners’ Comments Commissioner Jackson noted that there has been good outreach to the community. A couple people are harsh in their criticism. In the overall picture, the staff has done their job and this last minute appeal is unfortunate, especially because we do not have a Planning Commission at the moment. Every time there is an appeal, it costs money and we have to cut space or reduce something. He does not know if the public understands this. We don’t want to lose space. It is the staff-from medical to clerical-at LHH that makes LHH what it is. Commissioner Sanchez said that it was fantastic to see the staff open up and listen to the cohort of health providers within the context of what LHH is about. There has been an on-going dialogue and they have continually taken the message back to the community. It is an exceptional process and a dedicated group at LHH who provide high quality care. Commissioner Guy observed that it has been an amazing process. She appreciates Mr. Lane’s leadership and management. The unanimous vote of the Planning Commission is what we want to hold onto and the Forest Hill Association is important strategically. She has confidence that the process the groups have taken will rule the day. NIMBY-ism is real and part of the democratic process. We are fortunate that Mr. Lane is leading and managing the project. Many good people brought us to this moment, including Dr. Katz, Tony Wagner and Larry Funk. Commissioner Parker thanked Mr. Lane for his leadership and acknowledged his frustration with the appeal. What are the alternative plans? Are they primarily prompted by the historic issue or the neighborhood views? The choice to renovate Clarendon Hall or move independent living to the back. In terms of reading this, is there a reason that prompted the alternatives? Michael Lane replied that the plan is fixed with the wings. Original concept talked about assisted living in Clarendon Hall. Clinical needs said to move the assisted living. Commissioner Chow said that the work is well-planned. Many neighborhood associations support the project and the Board of Supervisors will understand that. This is an important process for a large project. It already has been two years and has run relatively smoothly. You have been able to maneuver between the challenges while keeping the amenities that people want. These are important accomplishments. Commissioner Chow announced that this item would be continued to the call of the Chair. 7) PUBLIC COMMENTS Patrick Monette-Shaw. Testified in May the PositiveResource Center had a subcontract with LaFrance. Several problems. Two months late in concluding the final report. Report still in draft stage. LaFrance now four months late. Appears LaFrance is not submitting contracts. Performed poorly. Ask the Health Commission to investigate this contractor’s non-compliance. Report should go to CARE Council. 8) ADJOURNMENT The meeting was adjourned at 7:00 p.m. Eileen Shields, Public Information Officer