Minutes of the Health Commission Meeting Tuesday, June 17, 2003 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The Commission was called to order by Commissioner Chow at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner Michael L. Penn, Jr., M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE MEETING OF JUNE 3, 2003 Action Taken: The Commission approved the Minutes of the June 3, 2003 meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Monfredini chaired, and Commissioners Penn and Umekubo attended, the Budget Committee meeting. (3.1) PHP-AIDS Office - Request for approval to accept and expend retroactively Year-2 funds for a subcontract from the Regents of the University of California, San Francisco, Office of Research Administration, in the amount of $71,992, for a collaborative study of prevention for HIV-positive persons, for the period of September 30, 2002 to September 29, 2003. Commissioner Sanchez abstained from voting on this item. (3.2) PHP-AIDS Office - Request for approval to retroactively accept and expend subcontract funds from the Public Health Foundation Enterprises, Inc., in the amount of $127,961, to reduce sexual risk for HIV transmission in substance-using men who have sex with men, for the period of September 1, 2002 to August 31, 2003. Commissioner Umekubo abstained from voting on this item. (3.3) PHP-AIDS Office - Request for approval of a renewal contract with Lavender Youth Recreation and Information Center, in the amount of $141,000, to provide HIV prevention services targeting youth, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.4) PHP-AIDS Office - Request for approval of a renewal contract with Stop AIDS Project, in the amount of $875,871, to provide HIV prevention services targeting behavioral risk populations, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.5) PHP-AIDS Office - Request for approval of a renewal contract with Larkin Street Youth Services, in the amount of $190,968, to provide HIV prevention services targeting homeless and runaway adolescents and young adults ages 13-23, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.6) PHP-AIDS Office - Request for approval of a renewal contract with Westside Community Mental Health Inc., in the amount of $135,302, to provide HIV prevention services to female African American injection drug users, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.7) PHP-AIDS Office - Request for approval of a contract renewal with Aguilas Inc., in the amount of $334,418, to provide HIV prevention education services, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.8) PHP-AIDS Office - Request for approval of a renewal contract with Black Coalition on AIDS, in the amount of $144,169, to provide HIV prevention education services targeting the African American high-risk population, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.9) PHP-AIDS Office - Request for approval of a renewal contract with Iris Center, in the amount of $212,137, to provide HIV prevention services, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.10) PHP-AIDS Office - Request for approval of a renewal contract with Harm Reduction Coalition, in the amount of $157,337, to provide harm reduction training services targeting HIV prevention service providers, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.11) PHP-AIDS Office - Request for approval of a renewal contract with Haight Ashbury Free Clinic, Inc., in the amount of $605,727, to provide HIV prevention services targeting behavioral risk populations, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.12) PHP-AIDS Office - Request for approval of a contract renewal with San Francisco AIDS Foundation HIV Prevention Project, in the amount of $591,696, to provide HIV prevention and needle exchange services targeting injection drug users, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.13) PHP-AIDS Office - Request for approval of a renewal contract with San Francisco AIDS Foundation, in the amount of $282,194, to provide HIV prevention services targeting men who have sex with men, for the period of July 1, 2003 through June 30, 2004. (3.14) PHP-AIDS Office - Request for approval of a renewal contract with South of Market Health Center, in the amount of $128,801, to provide HIV prevention services, for the period of July 1, 2003 through June 30, 2004. Postponed for 30 or 60 days. (3.15) PHP-AIDS Office - Request for approval of a renewal contract with Tenderloin AIDS Resource Center, in the amount of $478,226, to provide HIV prevention services targeting behavioral risk populations, for the period of July 1, 2003 through June 30, 2004. (3.16) PHP-AIDS Office - Request for approval of a renewal contract with UCSF AIDS Health Project, in the amount of $513,930, to provide HIV prevention services targeting behavioral risk groups, for the period of July 1, 2003 through June 30, 2004. Commissioner Sanchez abstained from voting on this item. (3.17) CBHS-Substance Abuse - Request for approval of a contract renewal with San Francisco State University, in the amount of $90,000 per year, for a total contract amount of $403,200, to provide professional substance abuse counselor training and certification services, for the period of July 1, 2003 through June 30, 2007. Commissioner Guy abstained from voting on this item. (3.18) CBHS-Substance Abuse - Request for approval of a contract renewal with Youth Leadership Institute, in the amount of $271,787 per year, for a total contract amount of $1,087,148, to provide substance abuse services targeting teenagers and young adults, for the period of July 1, 2003 through June 30, 2007. (3.19) CBHS-Mental Health/Substance Abuse - Request for approval of a contract renewal with San Francisco Suicide Prevention, in the amount of $413,284 per year, for a total contract amount of $1,653,136, to provide counseling, prevention, case management services, targeting high risk clients, for the four-year period of July 1, 2003 through June 30, 2007. (3.20) CBHS-Mental Health - Request for approval of a contract modification with San Francisco Mental Health and Education Funds, Inc., as fiscal agent for the San Francisco Mental Health Board, in the amount of $72,399 per year, for a total contract value of $719,991, to provide Police Crisis Intervention Training services, for the period of July 1, 2002 through June 30, 2003. (3.21) CBHS-Mental Health - Request for approval of a contract renewal with Continuum HIV Day Services, in the amount of $98,000 per year, for a total contract amount of $392,000, to provide adult mental health services targeting HIV-positive adult residents of San Francisco with severe mental health diagnoses, for the period of July 1, 2003 through June 30, 2007. (3.22) CBHS-Mental Health - Request for approval of a retroactive sole source contract modification with Alameda County Health Care Service Agency, in the amount of $500,838 per year for two years, for a total contract amount of $4,302,636, to provide fiscal management services and access to 24-hour skilled nursing neuro-behavioral care and adolescent sub-acute mental health services targeting individuals with Organic Brain Syndrome impairment, for the period of July 1, 2000 through June 30, 2004. (3.23) CBHS-Mental Health - Request for approval of a contract renewal with California Medivan, dba MV Transportation, in the amount of $79,540 per year, for a total contract value of $356,339, to provide back-up emergency transportation services to Psychiatric Emergency Services, for the period of July 1, 2003 through June 30, 2004. (3.24) CBHS-Mental Health - Request for approval of a contract renewal with Oakes Children’s Center, in the amount of $494,016 per year, for a total contract amount of $2,213,192, to provide psychiatric day care services targeting children ages 4 through 13, for the period of July 1, 2003 through June 30, 2007 (3.25) CBHS-Housing and Urban Health - Request for approval of a contract modification with Mission Housing Development Corporation, in the amount of $50,000, for a contract total of $300,000, to partially cover the cost of remediation of a bedbug infestation at the Altamont Hotel serving 88 formerly homeless clients, for the period of July 1, 2002 through June 30, 2003. (3.26) CHSS-Immunizations - Request for approval of a retroactive sole source contact renewal with North East Medical Services, in the amount of $53,218, to provide immunization project services targeting children 0-4 years old, for the period of July 1, 2002 through June 30, 2003. (3.27) CHSS-STD Prevention & Control - Request for approval of a new contract with Public Health Foundation Enterprises, Inc., in the amount of $220,000, to provide fiscal agency services for the STD Prevention and Control Section-Syphilis Prevention Program, targeting high-risk men who have sex with men, for the period of July 1, 2003 through December 31, 2004. Commissioners’ Comments The Commission requested a 6 months follow-up to the Population Health and Prevention Joint Conference Committee. (3.28) CHN-Primary Care - Request for approval of a contract renewal with Mission Neighborhood Health Center, in the amount of $191,615, to provide primary care services to medically indigent adults residing in the Mission District, for the period of July 1, 2003 through June 30, 2004. (3.29) CHN/SFGH & LHH Facilities - Request for approval of sixteen new contracts with the following fourteen firms: Acker & Guerrero Roof Co., Inc., Agbayani Construction, Inc., Anderson Carpet & Linoleum Sale Co., Inc., Angotti & Reilly Inc., William Decker & Co., Elischer Construction, Inc., Floortrends, Inc., Monticelli Painting & Decorating, Robert Poyas, Inc., Pribuss Engineering, Inc., Sabel Painting Co., Sierra Electric Co., The Shooter Co. and United California Glass Co., in the combined amount of $1,785,000, to provide the Community Health Network intermittent, as-needed facility maintenance services above baseline Civil Service staffing, for the period of July 1, 2003 through June 30, 2005. (3.30) CHN-SFGH Pharmacy - Request for approval of a new contract with Pharmaceutical Care Network, in the amount of $200,000 for third party administrator services, and $1,200,000 pass-through pharmacy dispensing fees to Rite Aid Corporation and AG Pharmacy targeting CHN indigent clients, for the period of July 1, 2003 through June 30, 2004. (3.31) CHN-SFGH - Request for approval of a Board of Supervisors resolution for a Proposition J contract for the provision of laundry processing services at San Francisco General Hospital, for the period of July 1, 2003 through June 30, 2004. Public Comment John Kosinski of SEIU Local 250 stated that SEIU will oppose this request at the Board of Supervisors for several reasons. When this contract was originally executed in 1994 it was a temporary arrangement and is now ten years old. Secondly, this contractor does not meet the City’s Minimum Compensation Ordinance and pays it’s workers between $6.75 and $7.25 per hour with no benefits. Mr. Kosinski believes that all laundry services should be brought back under civil service when the City’s new plant opens at Oyster Point. (3.32) CHN - Request for approval to enter into a revised contract with the San Francisco Health Plan (SFHP) to continue the Department of Public Health’s participation with SFHP as a Medi-Cal, Healthy Families, Healthy Workers and Healthy Kids provider with reduced administrative obligations commencing July 1, 2003 for a one year term with automatic renewal. Commissioners’ Comments The Commission requested an annual report to the Community Health Network Joint Conference Committee. (3.33) CBHS-Mental Health/Substance Abuse - Request for approval of a contract modification with Westside Community Mental Health Center, in the amount of $1,490,477 for FY 2002-03, for a total contract value of $5,980,917, for the provision of mental health and substance abuse services to CalWORKS clients, for the period of July 1, 1999 through June 30, 2003. Action Taken: The Commission approved the Budget Committee consent calendar. Commissioner Guy abstained from voting on Item 3.17. Commissioner Sanchez abstained from voting on Items 3.1 and 3.16. Commissioner Umekubo abstained from voting on Item 3.2. The following items were withdrawn, and will be heard at a later date: Items 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, and 3.14. The Commission asked for reports to the Joint Conference Committees on Items 3.27 and 3.32. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Bioterrorism Exercise in Progress The Department’s health emergency practice exercise is currently underway across the street at Bill Graham Auditorium. This practice exercise is testing our ability to quickly respond to a large-scale health emergency. The Mayor dropped by this morning to watch the drill in progress and praised staff for their planning and preparation. Over 700 volunteers have joined 200 DPH staff volunteers to participate in the mock inoculation drill. There has been extensive media coverage throughout the day. For those of you who were not able to attend the VIP briefing, DPH is pleased with the success of the exercise and will share its final evaluation and report with the Commission. Pedestrian Safety Project The State Office of Traffic Safety (OTS) has commended DPH’s Pedestrian Safety Project for, "Decreasing total fatal and injury collisions involving pedestrians by seven percentage points." Chris Murphy, Deputy Director of OTS, stated, "Your agency's traffic safety contribution increases the relevance and impact of our California Traffic Safety Program to the overall national program." Information about past and current pedestrian safety efforts is available from Michael Radetsky at 581-2418. Caring Partners Program The Community Behavioral Health Service Pharmacy has come to an agreement with AstraZeneca Pharmaceuticals to participate in their "Caring Partners Program" for qualified indigent clients. At no cost, the pharmacy receives a monthly supply of the antipsychotic drug Seroquel approximately equal to the amount dispensed to indigent clients the preceding month. The first shipment, received in June, represents a cost avoidance of $28,298. African American Health Initiative Updates African American Health Initiative (AAHI) and African American Coalition for Health Improvement and Empowerment co-sponsored a FREE Domestic Violence Seminar entitled "Lifting Our Voices: African Americans Take Action Against Domestic Violence", at Third Baptist Church, June 13th. The Community Empowerment Center (AAHI and the S.F. Sheriff Department) in collaboration with UCSF Family Practice Residency Program held a successful conference in the Bayview on Post Traumatic Stress Disorder. Clifton Hicks, MSW, Community Mental Health clinician was the keynote speaker. STD’s Test Form in Website This week STD Prevention and Control Services will launch a website, <http://www.stdtest.org/> for San Franciscans to print out a test form and take it to a local Unilab/Quest laboratory for a free and confidential syphilis test. Results will be returned online within three to seven days. STD staff will follow up to ensure that all persons and their sex partners who test positive receive treatment. This is a collaborative effort between the STD Prevention and Control Services, Internet Sexuality Information Services (ISIS, Inc.), Enterprise Business Systems, Enterprise Systems Management, Enterprise Network Management and Quest Diagnostics. This is the Department’s latest effort in response to the increase in syphilis and enhancement of services to the community. SF Pride Parade 2003 Bring your family and friends and march with the DPH contingent at the San Francisco Pride Parade celebration on Sunday, June 29, flyer attached. Share the experience of hearing people cheer and seeing their smiles when the contingent proudly walks down Market Street! Contact 554-8476 for more details. Commissioners’ Comments Commissioner Parker asked whether it is practical that a lab would be interested in developing a home STD testing kit and would it be helpful in infection control? Dr. Katz responded that it would be very helpful, but he’s not optimistic that it will happen. Despite high sensitivity and specificity, home HIV testing kits have not been widely used. He believes that this is because they are blood-based test kits. While urine-based kits could be developed, manufacturers don’t want to face the regulatory hurdles necessary to develop them. Commissioner Penn asked about the “Caring Partners Program” from AstraZeneca. Bob Cabaj, M.D. responded that because the Department has an in-house pharmacy, the Department is able to do this. He added that AstraZeneca is very easy to work with compared with other pharmaceutical companies. Commissioner Umekubo encouraged the Department to sustain and expand this program with other drug companies as it could result in large savings in the cost of healthcare. Commissioner Chow asked about the bioterrorism exercise and whether the Department’s plan for a real emergency consists of one central clinic or a series of clinics across the City. Dr. Katz responded that the plan is for 40 clinics across the City in schools, university buildings, and other public buildings. Each clinic would serve people in English and one other language. This exercise was designed to test the timing of each step in the process to determine staff allocation. There are still other issues to confront, such as how to reach the homebound. Commissioner Guy indicated that she attended, noting that disease outbreak is a different type of emergency than we’re used to preparing for, such as earthquake or the Millennium event. 5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF JUNE Commissioner Lee Ann Monfredini presented the June Employee Recognition Awards. Individual Awardees Division Nominated by Isabel Barajas, Dept. of Public Health, Susan Amdur, PHN, Eligibility Worker Maxine Hall Health Center Maxine Hall Health Center 6) RESOLUTION SUPPORTING THE STRATEGIC PLAN OF THE SAN FRANCISCO ASTHMA TASK FORCE TO PROMOTE EFFECTIVE ASTHMA MANAGEMENT AND PREVENTION STRATEGIES FOR SAN FRANCISCO Rajiv Bhatia, M.D., Director of Environmental Health Services and Deanna Rossi, Chair of the Asthma Task Force presented the Resolution Supporting the Strategic Plan of the San Francisco Asthma Task Force. Commissioners’ Comments Commissioner Guy acknowledged the work and support of the Asthma Task Force. She noted that this is a citywide effort, and the Department wants to do its part. She added that from the information presented, health and medical workers are making an impact. Commissioner Chow asked whether it is the intent of the Task Force to look at data from communities other than Bay View Hunters Point? Dr. Bhatia responded that there is no regular way that measurement is occurring. Environmental Health Services (EHS) has a way to evaluate this, but it does require resources, and EHS is addressing this as a citywide problem. The Task Force has a lot of qualitative data as well, probably more than any other U.S. city. Commissioner Chow responded that he looks forward to the next update. Action Taken: The Commission approved Resolution #13-03, “Supporting the Strategic Plan of the San Francisco Asthma Task Force to Promote Effective Asthma Management and Prevention Strategies for San Francisco”, Attachment A. 7) HEALTHY KIDS, HEALTHY FAMILIES, AND MEDI-CAL FOR CHILDREN UPDATE Jim Soos, Senior Health Planner of the Office of Policy and Planning, introduced the update on Health Coverage Programs for Children and Youth in San Francisco, more commonly known as Medi-Cal, Healthy Families, and Healthy Kids. He shared some quotes from the SFHP member survey of the Healthy Kids Program, noting that Jean Fraser will share more detail of the survey later in the presentation. All three programs provide comprehensive medical, dental, and vision care for members. All children and youth up to age 19 (age 21 for Medi-Cal) in families up to 300% of the federal poverty level (FPL) regardless of immigration status are eligible to enroll. Mr. Soos presented a graphic showing how the patchwork of programs fit together based on age, FPL, and documentation status. Programs are both mutually exclusive (families cannot choose which program to enroll children into, but are enrolled into the one for which they are eligible based on age, income, and documentation status), and seamless (all children under 300% FPL are eligible). He shared an example showing that a two-parent household at 200% FPL with three children of mixed documentation status could have children in each of the three programs based on each child’s age and documentation. Through the three programs, San Francisco guarantees universal coverage to children in families under 300% FPL, which helps the Department meet its strategic goal that residents have access to needed health services, while DPH emphasizes services to its target population by expanding health care coverage to the uninsured. Mr. Soos concluded by sharing some background on each program. Medi-Cal is California’s federal Medicaid program with a state/federal funding match of 46%/54%. There are federal mandates regarding populations covered and benefits provided. California goes beyond the federal mandates. Although there are numerous Medi-Cal programs, the focus of this presentation is Medi-Cal for Children. Statewide it is administered through the Department of Health Services, but counties do have administrative responsibility, including enrollment, which is done locally through Department of Human Services. Healthy Families is California’s State Children’s Health Insurance Program (SCHIP). It is also a federal/state partnership with a 65% federal match to the state’s 35%. At the state level, Healthy Families is administered through the Managed Risk Medical Insurance Board (MRMIB). Counties have no administrative responsibility. Healthy Kids is local to San Francisco only, although Santa Clara, San Mateo, and Alameda Counties have similar programs, and Los Angeles, Santa Cruz, Solano, and Riverside Counties are in the planning stages. Funds for Healthy Kids are entirely local and for FY 2003-04 consist of $ 4 million in local General Fund and $430,000 from the local Proposition 10 Commission to cover children ages 0 to 5. It is administered through the San Francisco Health Plan (SFHP). Frances Culp, Health Planner of the Office of Policy and Planning presented on enrollment for the three programs. She noted that families apply for each program in a different manner, with Medi-Cal through the local Medi-Cal Office or by mail through the Medi-Cal form or Joint Medi-Cal/Healthy Families application. For Healthy Families, there is a joint Medi-Cal/Healthy Families application that is usually completed through with the assistance of a Certified Application Assistant (CAA). Families apply for Healthy Kids at the SFHP offices, or through a CAA who uses a paper or on-line application. Locally, outreach is being conducted through Building a Healthier San Francisco (BHSF); Bringing Up Healthy Kids (BUHK); County Outreach, Enrollment and Retention, SFHP, and community and DPH clinics. Ms. Culp did note that state outreach funds have been cut, meaning a $250,000 loss to San Francisco, which has hindered outreach efforts. In San Francisco, 44,186 children and youth are enrolled in one of the three programs (30,927 in Medi-Cal, 10,445 in Healthy Families, and 2,814 in Healthy Kids) out of 127,344 children and youth in the City. Statewide, 3,965,034 children are enrolled, including 3,314,032 in Medi-Cal and 615,002 in Healthy Families. This is out of 10,234,571 children and youth statewide. By race and ethnicity in San Francisco, Asians/Pacific Islanders represent the largest population in both Medi-Cal and Healthy Families, while Latinos represent the largest population in Healthy Kids. By neighborhood, Excelsior/OMI, Mission/Bernal Heights, Visitacion Valley, Bayview, Chinatown/North Beach, Nob Hill, and the Sunset have the most children enrolled, representing more than 50% of all enrollments. By Health Plan, SFHP has 66% of Medi-Cal enrollees, 54% of Healthy Families enrollees, and 100% of Healthy Kids enrollees. This is significant as the statewide average for the local initiatives for Healthy Families and Medi-Cal enrollees is 35%. Jean Fraser, CEO of SFHP presented on enrollment by medical group noting that SFHP has over 2,000 physicians, and six hospital with nine campuses in its network. More people (38%) have chosen the CHN as their medical group than any other medical group. Ms. Fraser next presented on evaluation measures. As to consumer satisfaction, she noted very high consumer satisfaction for both Healthy Families and Healthy Kids. People overwhelmingly expressed satisfaction with their physicians, although expressed lower satisfaction with wait times for appointments and finding a dental provider. On HEDIS scores, an objective measure of quality, SFHP scored higher than the state average for both Medi-Cal and Healthy Families on immunization rates, initial health assessments, and well-baby, child and adolescent visits. HEDIS scores are not yet available for Healthy Kids. Despite these high scores, SFHP’s governing board has made improvement of HEDIS scores a strategic priority. Despite high satisfaction and high quality, retention rates have been disappointing. Currently, Medi-Cal retention statewide is 64%, Healthy Families statewide is between 60% and 76%, and Healthy Kids locally is between 66% and 76%. Some reasons that children lose coverage include aging out of the program, failure to pay premiums, failure to return annual enrollment materials, moving out of county, and securing other coverage. Ms. Fraser emphasized that the underlying issues include the mobility of the population that makes it difficult to stay in touch with them, and a fragmented system with poor program coordination. As to recent program changes, Ms. Fraser noted that statewide Healthy Families parental expansion has been delayed for at least two years and “Express Lane Eligibility” through the School Lunch Program will begin in pilot counties only (not San Francisco). The Medi-Cal/Healthy Families Bridge program providing continuous coverage for children moving between the two programs now works in both directions, and technological changes including on-line applications (Health-e-App and One-e-App) and the CHDP Gateway are just getting underway. Finally through state legislation (AB 495), San Francisco should begin drawing down federal funds for its Healthy Kids program later this year. Next steps for the program include expanding access, minimizing the impacts of program cuts, and improving HEDIS scores. Commissioners’ Comments Commissioner Chow noted that the patchwork of programs depends on where the lines are, but AIM seems to overlay. Mr. Soos responded that AIM does overlay both Healthy Families and Healthy Kids, but it depends on the mother enrolling prior to the birth of the child. If a mother enrolls in AIM prior to the birth, then the infant is covered through AIM after birth. If not, then the child is eligible for Healthy Families or Healthy Kids. Commissioner Chow followed up by asking whether AIM is separate from Medi-Cal or Healthy Families. Mr. Soos responded in the affirmative. AIM is a separate program administered through the State Department of Health Services. Commissioner Parker noted that this does follow the Department’s Strategic Plan goal of providing universal health insurance. He asked that since this is a patchwork, how are children of Healthy Workers represented? Ms. Fraser responded that Healthy Workers is an employment-based, not an income-based program and does not include dependent coverage. To the extent that children of Healthy Workers members are income-qualified, they would be enrolled in Medi-Cal, Healthy Families, and Healthy Kids, and included in the data presented today. Commissioner Umekubo asked about the number of uninsured children in San Francisco. Mr. Soos responded that there is no solid estimate of the numbers of uninsured children or adults in San Francisco. He noted that the Department estimated 9,000 uninsured children in San Francisco in 2000 when program planning for Healthy Kids began. Based on the rate of enrollment in Healthy Kids, it appears that it was an accurate estimate. Commissioner Umekubo asked about HEDIS and incentives for providers. Currently there is no provision for quality, so the incentive to reward for quality is powerful. Ms. Fraser responded that currently SFHP is providing incentives for immunization. She added that providing incentives for salaried providers is difficult, although SFHP is looking at some options, including models developed by Blue Shield, which changed reimbursement to providers and costs to members based on quality measures. Commissioner Sanchez asked whether in trends among young children (child care, school-based programs, etc.), which are going through enrollment challenges plus parents who are moving out of the City and keeping kids enrolled here, are there any safety net programs for these people, who may be working in San Francisco, but now residing in a different county? Ms. Fraser responded that with many Bay Area counties developing Healthy Kids-like programs, there may be some opportunities to make it seamless, although for many reasons this will be difficult to do. Commissioner Guy noted that it is now possible to see the interaction between the three programs. She asked, in the longer term, what changes should we be looking to make to these programs? Ms. Fraser responded that access (receiving services in a timely manner) is one issue SFHP will be addressing. Secondly, she believes we should be attempting to do the parental expansion in San Francisco. Currently SFHP is working with Blue Shield to develop models, and State legislation has been introduced to give local initiatives access to federal SCHIP funds for parent coverage. Commissioner Guy follow-up by asking about the cost of parental expansion. Ms. Fraser responded that she would estimate that full-scope coverage without dental or vision coverage would be approximately $200 pmpm. Commissioner Penn asked how we mitigate the loss of outreach funds. Ms. Culp responded that the CAA infrastructure is being dismantled. Healthy Families has really relied on CAAs to enroll, and Medi-Cal and Healthy Kids have also become dependent upon the CAA system. She is somewhat optimistic that the loss of the $50 per successful Healthy Families enrollment will not be a significant loss to organizations, as they have not relied on those funds in the past. The $250,000 loss to BUHK is significant, and the organization is looking for other sources to replace those funds, including foundations and the United Way. She noted the importance of assuring that DPH clinics are enrolling. Commissioner Penn asked about the under enrollment of African Americans in the Healthy Families and Healthy Kids programs. Ms. Fraser responded that to date Healthy Kids has been primarily enrolling the undocumented population and has not penetrated the 250% to 300% FPL market. She added that the lower income status of African Americans in San Francisco makes them disproportionately eligible for Medi-Cal. Commissioner Penn asked about the status of the One-e-App and Health-e-App. Ms. Fraser responded that they help some, but currently generate paper on the back end, which gets mailed to the single point of entry. One-e-App has good possibilities, particularly for counties like San Francisco with a local program, but is not there yet. Commissioner Penn asked how long it takes to become enrolled in each program. Ms. Fraser responded that it varies by program. For Medi-Cal, enrollees are eligible to services on the day the application is received, and providers may be reimbursed retroactively for services rendered while the application is pending. For Healthy Kids, members may enroll up to the 25th of the month for services the following month, so the wait time ranges from six to 30 days. For Healthy Families, members are eligible on the day the application is approved, which can vary. Commissioner Chow noted that Healthy Kids was part of the original Commission looking at uninsurance in San Francisco, and this is what the Commission envisioned. He did express some concerns about the potential of partnerships with others in that we may lose some of the special San Francisco characteristics of the program, but that linkages may make sense to ensure that eligibility transports across county lines. The success of Healthy Kids in reaching the Latino population really shows in these data. Commissioner Chow acknowledged the access problems adding that another area of concern is access to specialty services. If Medi-Cal requires specialty participation across all lines of business, it may be a problem, and providers may drop out. He noted that access is a broader issue than just with SFHP and may require work at the state-level to maintain community-based access. He noted that the report, by putting together the three programs really shows the full picture. He congratulated SFHP and Dr. Katz as the Chairman, noting that Commissioners Umekubo and Sanchez also deserve credit as they too have served on the Board. Commissioner Parker noted the ongoing question of the lack of African American representation above Medi-Cal. He acknowledged the gap, but asked that if African Americans are remaining in San Francisco, and their health needs are not being addressed, in the long-term they will become a liability to the system. He questioned whether the system is trying to prevent increased health problems in the future, or are we just making it their problem? Ms. Fraser responded that the gap is not as large as it might appear. The percent of African Americans with public health insurance is higher than other populations. However, SFHP has not done the best job of finding kids between 250% and 300% of FPL or overcome the belief by working parents that Healthy Kids is too good of a deal to be true. This is not limited to the African-American population. Commissioner Chow asked whether it is possible to look at the census data to get a better picture of those eligible. Mr. Soos responded that to the extent possible, this has been done. Currently, census data only show residents below 100% of FPL, not for example those between 100% and 300% FPL. The data so far show that overwhelmingly, African-American children are eligible for and enrolled in Medi-Cal. Dr. Katz recommended combining tables 7, 8, and 9 into one table, and preparing a written response for the next Commission meeting. Commissioner Penn asked whether other surrounding counties see the same thing? Ms. Fraser answered in the affirmative. Commissioner Chow stated that it would be interesting to see enrollment data for the surrounding counties. Dr. Katz responded that staff will include that data as well. Commissioner Chow concluded by noting that the report mentions an obesity program, which if tied to school-based programs, would be useful as a universal approach. He requested to look at the data again without waiting a full year. He noted the importance of retention, and perhaps a full report on retention including some recommendations or solutions. Commissioner Umekubo departed at 5:10 p.m. 8) BEHAVIORAL HEALTH REPORT Bob Cabaj, Director of Behavioral Health Services and Jorge Partida, Deputy Director of Behavioral Health Services presented. The update included planning for integration, the integration plan (including challenges and recommendations), and next steps. Dr. Cabaj discussed the reasons for integration, including data that show that many individuals with mental health or substance abuse disorders have both. The goal of integration is to integrate the administrative, clinical, and fiscal functions of CMHS and CSAS into a comprehensive behavioral health delivery system by July 1, 2005 to improve clinical outcomes, maximize resources, and increase client, provider, and employee satisfaction. He noted that this is consistent with the DPH Strategic Plan, most notably in the area of prevention. The focus of the integration is clear, consistent standard in both substance abuse and mental health, and integration addresses the structural differences between CSAS and CMHS. Dr. Cabaj discussed the key elements of integration and the planning committees involved, and Dr. Partida discussed the community input process, noting that it focused on community concepts of health, wellness, and being. Dr. Cabaj discussed the timeline, noting that many of the milestones have been completed, with integration achieved in June 2005. Drs. Cabaj and Partida discussed the challenges and recommendations for integration, including those related to client relations, clinical services, cultural competency, provider relations, quality management, placement, evaluation, research, and grant development. Next steps for the process include complete integration of CSAS and CMHS into CBHS by June 2005, and planning for integration of CBHS and Primary Care. Future milestones include agreeing on a clinical model, setting evaluation criteria, training staff, and determining services to be brokered. Commissioners’ Comments Commissioner Parker noted that two closely linked services are being integrated and the importance of integration to improve services. He acknowledged the challenges and opposition that will be faced, and the end result will require a change of mindsets. He added that STD and HIV prevention are also important to integrate into behavioral health also, given the risky sexual practices people engage in while using substances. He noted the need to integrate other Department services also. Dr. Cabaj indicated that they’re not waiting until 2005 to integrate other services, but that is the timeline for financial and administrative integration. Community Behavioral Health Services is already working with STD prevention, particularly related to issues of methamphetamine use and risky sexual practices among gay men. Commissioner Parker concluded by saying that behavioral health is also linked to environmental health in that behavior often changes as the result of environmental changes. This does not occur in a vacuum. Commissioner Sanchez praised this as an inclusive model, encompassing the totality of the DPH mission. He noted that there will be challenges, but that integration is also happening in other settings such as colleges and universities with integrated faculties. Commissioner Guy noted that other stakeholders within the continuum need to grow also, such as Health at Home and Laguna Honda Hospital, in order to provide necessary services for clients. She added that there will be a lag time of acculturation. She noted the importance of training in accomplishing this successfully adding that this will take financial resources to provide training, and we will need to develop partnerships. She asked whether there are any best practices. Dr. Partida responded that there are 16 model programs in the country that have developed best practices, and staff will be looking at them to see how they might be applied in San Francisco. He noted that there needs to be a paradigm shift that includes not only “any door the right door,” but that “once inside, the room has changed.” Commissioner Chow requested a six-month follow-up at the Community Health Network Joint Conference Committee, and that integration with primary care be explored before 2005. Dr. Partida responded that this is consistent with the data that many people come into mental health and substance abuse services through primary care, because they are not comfortable entering the system through mental health or substance abuse. Commissioner Penn noted that the cultural change is huge. There needs to be emphasis that this change is a partnership between the Department and providers, and to work through the process together. He asked who are the trainers and are contractors being given sufficient time to prepare for these changes. Dr. Cabaj responded that many providers are already working from a behavioral health perspective and it’s the Department that catching up to them by taking down this false division between the two services. He concluded by saying that there are many good trainers in the Bay Area and the section is exploring them. 9) PUBLIC COMMENTS There were no public comments. 10) ADJOURNMENT The meeting was adjourned at 5:55 p.m. Jim Soos, Acting Executive Secretary to the Health Commission