Minutes of the Health Commission Meeting Tuesday, September 2, 2003 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The meeting was called to order by President Chow at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Lee Ann Monfredini Commissioner Michael Penn, M.D., Ph.D. 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF AUGUST 19, 2003 Commissioners’ Comments: Commissioner Chow noted a typographical error in the minutes: on page 19, bullet point six, line four, “confidants” should read “confidant.” Action Taken: The Commission (Chow, Guy, Parker, Sánchez, Umekubo) approved the minutes of the August 19, 2003 Health Commission meeting with Dr. Chow’s correction. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE (3.1) BHS-Mental Health - Request for approval of a contract modification with Bay Area Bookkeeping, in the amount of $291,120 per year or $1,164,000 for four years, for an increased four-year contract total of $3,700,480, to provide check-writing services for payments to state-mandated providers, for the period of July 1, 2003 through June 30, 2007. (3.2) BHS-Mental Health - Request for approval of contract modification with Hyde Street Community Services, in the amount of $516,983 for a total contract amount of $2,269,142, to provide mental health, wellness and recovery services, for the period of July 1, 2003 through June 30, 2004. Public Comment: Ligia Rojas presented a certificate of appreciation the Health Commission, signed by the members of the San Francisco Community Clubhouse, expressing appreciation for ongoing support of the Clubhouse program. (3.3) BHS-Mental Health - Request for approval of a retroactive sole source contract renewal with San Francisco Mental Health Education Funds, in the amount of $251,170 per year for a four-year total of $1,004,680, to provide outreach and police crisis intervention training services, for the period of July 1, 2003 through June 30, 2007. (3.4) BHS-Mental Health - Request for approval of a retroactive sole source contract renewal with San Francisco Study Center, in the amount of $1,316,218 per year for a four-year total of $5,264,487, to provide mental health outreach and client rights advocacy services, for the period of July 1, 2003 through June 30, 2007. Secretary’s Comment: Item 3.4 is erroneously listed as a sole source contract. (3.5) BHS-Mental Health - Request for approval of retroactive contract renewals for the Family Mosaic Program with the following 13 agencies providing services to seriously emotionally disturbed children, for a total of $1,189,855, for the period of July 1, 2003 through June 30, 2004. Contractor Address Service Source of Funds Amount Jamestown Learning Center (JLC) Services 2831 San Bruno Ave. San Francisco, CA 94134 Mentoring Services Medi-Cal Capitation $164,000 RISE Institute 1760 Cesar Chavez Blvd. San Francisco, 94124 Mentoring Services Medi-Cal Capitation $185,000 High Gear Achievers, Inc. 175 Omar Way San Francisco, 94127 Tutorial Services Medi-Cal Capitation $44,000 Occupational Therapy Training Program / Special Services Group (OTTP/SSG) 425 Divisadero Avenue San Francisco, CA 94117 Social Skills Training Medi-Cal Capitation $15,000 Victor Treatment Centers 7 Governor’s Lane Chico, 95926 Sub-Acute Residential Treatment Medi-Cal Capitation, Dept. of Human Services (DHS) work order, Dept. of Juvenile Probation (DJP) Work Order, General Fund $434,350 Families First 2100 5th Street Davis, CA 95616 Sub-Acute Residential Treatment Medi-Cal Capitation; & DHS Work Order $69,888 Big Brothers/ Big Sisters of San Francisco 870 Market Street, Suite #928 San Francisco, 94102 Mentoring & Social Services Medi-Cal Capitation $15,362 New College of California 777 Valencia Street San Francisco, CA 94110 Counseling Services Prop. D Dept. of Children, Youth, & Families (DCYF) Work Order, General Fund $8,000 Milhous Children’s Services 24077 State Highway 49 Nevada City, CA 95959 Residential Treatment Medi-Cal Capitation; & DHS Work Order $32,000 Villa Santa Maria P.O. Box 156 Cedar Crest, NM 87008 Residential Treatment Senate Bill 90 (SB90) $14,697 Lincoln Child Center 4368 Lincoln Avenue Oakland, CA 94602 Residential Treatment Medi-Cal Capitation; & DHS Work Order $68,000 Heritage Schools 5600 N. Heritage School Drive Provo, UT 84604-7701 Residential Treatment SB90 $33,609 National Deaf Academy 19650 US Highway 441 Mount Dora, FL 32757 Residential Treatment SB90 $105,949 Secretary’s Comment: For Item 3.5, the contract with Lincoln Child Center in the amount of $68,000 was withdrawn at the request of the Family Mosaic Project’s Contract Manager. This changes the total for the 12 agencies to $1,121,855 for the period of July 1, 2003 through June 30, 2004. Action Taken: The Commission (Chow, Guy, Parker, Sánchez, Umekubo) approved the Consent Calendar of the Budget Committee. 4) DIRECTOR’S REPORT Anne Kronenberg, Deputy Director of Health, Director of Policy and Planning, presented the Director’s Report. Medical Examiner’s Homeless Death Count At the request of Supervisor Gavin Newsom, the Medical Examiner's office last month released a list of 169 homeless individuals who died in San Francisco between July 1, 2002 and June 30, 2003. Herb Hawley, who complied the list, admitted that the list in no way reflects the depth of previous homeless death counts, but it was an attempt to keep a handle on the number of deaths of this vulnerable population. Tour of Primary Care Community Health Centers As Mitch reported last month, he began his tour of the primary care community centers by working at Southeast Health Center in August. Later this week, he will resume his tour with the urgent care/drop-in at Silver Avenue Health Center the next stop. By working at each of the centers, Mitch will get a better sense of the common challenges faced by each center. LHH Laundry Services Update Progress on the LHH rebuild continued last week when the laundry services for Laguna Honda Hospital were moved to Metro Park-Sodexho in Stockton, CA on August 28th. All affected laundry workers (approximately 39) have been reassigned to similar duties within LHH and SFGH. The new assignments began today. The next phase of laundry services will be in March, 2004 when it moves to the newly acquired/equipped Oyster Point facility. On-Line Ergonomics Training Tools now available on DPHNet DPH employees now have two new on-line tools to help prevent a repetitive strain injury (RSI). The courses, which can be accessed through the OSH Section on DPHNet, are targeted to DPH computer users who may be at risk for injuries associated with computer use. The objective of these courses is to increase employee awareness of ergonomic issues in the workplace, to provide employees with immediate access to information about ergonomics and to empower employees to make changes that can help improve their comfort and reduce their chances of injury. One of the tools, ErgoNet The Personal Assessment, uses a series of specific questions to take the user through an evaluation of their own workstation. The Training Guide for Health Work covers a range of topics important to workstation ergonomics, including information about signs/symptoms of injuries, setting up a workstation, sitting properly, visual issues and even covers safe set-up for a lap-top. DPH has licensed use of the training tools for a one year period for up to 500 users. Commissioners’ Comments: Commissioner Parker asked how DPH estimated that 500 users would use the on-line ergonomic training. Ms. Kronenberg stated that 500 is an estimate, and that the Department can purchase extra licenses if they are needed. Commissioner Guy asked whether the information on Proposition 54 that was presented at the last meeting is now on-line? Ms. Kronenberg noted that staff made the request that it be put on-line and that the Department does have an excellent Webmaster, but that she has not checked to be certain of that. She offered to check the website after the meeting. Commissioner Umekubo asked whether ergonomic modifications are available to Department staff that may need them. Ms. Kronenberg responded in the affirmative, adding that Karen Heckman in OSH does special consultations with staff that request ergonomic changes, and the Department can and does accommodate those requests. Commissioner Chow asked whether the laundry will be ready at Oyster Point by March 2004. Ms. Kronenberg responded in the affirmative. Commissioner Chow asked whether all 39 employees will go to Oyster Point. Ms. Kronenberg responded in the affirmative. 5) HOMELESS AND HOUSING SERVICES ANNUAL REPORT Dr. Joshua Bamberger, Anne Kronenberg, and Marc Trotz presented the Homeless and Housing Services Annual Report. Dr. Bamberger presented on the epidemiology of homelessness in San Francisco. He outlined the causes of homelessness, including deinstitutionalization without increases in community-based care, multiple diagnoses, lack of affordable housing, domestic violence, racism, and family dissolution. Despite difficulties in estimating the number of homeless, Dr. Bamberger noted that the estimates range from 2,000 to 17,000 for single adults and 1,300 for families. Studies show that the homeless population is overwhelmingly male and disproportionately African American. A significant portion is veterans, and most have a history of substance abuse, mental illness, and/or other behavioral health disorders. Homeless individuals have a disproportionate utilization of resources, including E.D. visits and hospital days. Ms. Kronenberg presented on the City’s efforts to solve homelessness. She noted the prominence it’s playing in the upcoming Mayor’s race, and the high profile of Proposition N. The Local Homeless Coordinating Board developed the five-year Continuum of Care Plan, and DPH and the Department of Human Services are the major City service providers for the homeless working collaboratively with the Mayor’s Office on Homelessness. The CHANGES MIS system, required by HUD for communities receiving McKinney funding, will come on line later this year, and will provide an unduplicated count of homeless individuals seeking services in San Francisco. Ms. Kronenberg noted the number of partners with which DPH works to solve homelessness, including federal and local agencies and advocacy and advisory groups. Ms. Kronenberg outlined the Department’s Guiding Principles noting that DPH views homelessness as a health issue. Specific principles include harm reduction, partnerships with other agencies and organizations, collaboration across the Department, a focus on the chronically homeless, a view of housing as healthcare, and outcomes-based services. She added that the two strategic goals of the Department in working with the homeless population, homeless prevention and appropriate service prevention are consistent with the Department’s Strategic Plan, particularly goals two and three. Providing an overview of Homeless Services in the Department, Ms. Kronenberg highlighted the work of Primary Care (particularly through Tom Waddell Health Center), Health at Home, Community Behavioral Health Services, the Patient Flow Project, AB 2034 - MOST, the McMillan Stabilization Center, the Prevention Section, Laguna Honda Hospital, San Francisco General Hospital, and Housing and Urban Health. She noted that Tom Waddell has 90,000 encounters annually seeing 14,000 patients, provides routine HIV testing, has expanded its HIV outreach and services, and is under renovation. Over the past year, the Community Behavioral Health Section was developed through the integration of substance abuse and mental health. The vision for the new section is “any door the right door,” and is designed to improve access to care by providing wrap-around services and case management. The Patient Flow Project works to find housing and/or residential placement for clients who no longer require acute care. AB 495/MOST has seen a number of successes, including a 40 percent reduction in the average number of days in psychiatric hospitalizations, a 75 percent reduction in annual average days of incarceration, an 84 percent reduction in the annual average number of days homeless on the streets or in shelters, and a 49 percent increase in the annual average number of days employed. The McMillan Stabilization Center opened in July 2003 using 20 beds at the CATS McMillan Drop-In Center. The purpose is to divert inebriants from hospital emergency rooms and to ensure follow-up including medical care, clinical case management, and provide priority status for detox. The Prevention Section’s services are designed to prevent homelessness or its secondary effects. The section includes education, health promotion, testing and screening, adherence support, and primary care. Client directed prevention services are targeted in neighborhoods where residents are “a step away from homelessness.” The goal is to build capacity and skills among the community. In FY 2002-03, 8.7 percent of SFGH’s patients were homeless. Ms. Kronenberg acknowledged that this is significantly less than many studies have shown, and that the hospital is working on better mechanisms to track patients who meet the City’s broad definition of homelessness. She highlighted a number of SFGH programs that serve a primarily homeless population including the ISIS Clinic designed to treat abscesses and provide related services, the IVDU case management program, Ozanam medically assisted detox, the TOPS TB clinic in the Tenderloin, the E.D. Psychiatric Case Management program, and the Inpatient High Users Program. Laguna Honda Hospital is the safety net provider for homeless San Franciscans in need of nursing care. A total of 132 (12.6%) Laguna Honda residents in FY 2002-03 were homeless. In addition, the Substance Abuse Treatment Services (SATS) program monitors 125 residents, 90 percent of whom are homeless. Mr. Trotz presented on the accomplishments of the Housing and Urban Health. He began by raising the question of why the Department invests in housing, which include reduction of the over-utilization of high-end health care resources, increasing the effectiveness of DPH services by providing a safe and healthy environment for clients, and providing housing tailored to the needs of clients and community-based exits from DPH institutions. The Department focuses its housing on the chronically homeless, people with complex medical and behavioral health disorders, people with a history of institutional care, and people who have never or not successfully been housed. The Department spends $15.4 million on an array of housing services, including long-term permanent (61%), transitional (19%), emergency/stabilization (8%), direct medical services (2%), and other (9%). The Direct Access to Housing (DAH) program provides permanent housing using a low-threshold model, moving people directly from the streets and institutions. Sites provide a variety of on-site support services, including case management, medical care, behavioral health, property management, and third party rent payments. Access points into DAH housing include street outreach teams, emergency shelters, community-based organizations, high-utilizer case management teams, primary care clinics, and institutional settings. Mr. Trotz gave an overview of each of the six current DAH sites including the Pacific Bay Inn, Windsor, Le Nain, Broderick Street Residential Care Facility, and the Star and Camelot, the last two which were newly opened in 2003. In total, DAH offers 393 units. In terms of outcomes, two-thirds (67%) of DAH residents remain housed for at least two years. Other outcomes include moving to market-rate housing (11%), moving to a higher level of care (5%), death (4%), and eviction (13%). Mr. Trotz pointed out that evictions happen under only the most difficult of circumstances, not for minor or first time offenses. DAH healthcare outcomes include a 58% reduction in emergency department use, a 57% reduction in hospital inpatient bed use, and a reduction in the length of psychiatric hospitalizations. Mr. Trotz then gave an overview of Department-wide planned projects for 2003-04. They include: Integrate and expand respite services Develop senior-specific housing Develop a federally funded DAH site Expand health services at DHS hotels Continue the renovation of the Tom Waddell Health Center Continue to develop the McMillan Stabilization Center He concluded the presentation by noting the Departmental recommendation for which staff is seeking Commission recommendations: Expand housing options Continue to assist in moving people from institutional to community settings Increase health services in DHS facilities Expand primary care for homeless people Increase mainstream funding sources Continue to integrate services and connect sections within DPH Maintain and expand connections to state and federal advocacy organizations Commissioners’ Comments: Commissioner Guy asked what would be the net increase of units from the federal grant and the Board of Supervisors’ addbacks. Mr. Trotz responded that HUH is planning 90 units from federal grant. They are, however, hoping to partner with other agencies to open approximately 290 units of respite, senior, and permanent housing. Commissioner Guy added the importance to recognize that the Department is attacking the problem systematically to address the housing and service needs for a particular subset of the homeless. She recognized Mr. Trotz and his staff for their efforts and leadership in developing a vision for the Department. She also recognized Ms. Kronenberg for her work with the Local Homeless Coordinating Board. Commissioner Guy asked how Laguna Honda Hospital is incorporating the homeless population. With the construction of the independent living units, is this a population that can be housed in these units? Mr. Trotz responded that the goal is to make these units state-of-the art for disabled, at-risk population who would otherwise be homeless. Commissioner Guy noted the need to keep this in mind while developing next Strategic Plan. Commissioner Umekubo asked how many homeless refuse housing and services. Mr. Trotz responded that he does not have scientific data but believes it is a small number. When services get developed they’re overwhelmingly utilized. He did note that shelters may be perceived as unsafe or as not meeting needs, but has not seen that with other services. Commissioner Umekubo noted the difficulty in getting data on the homeless population, and believes that developing a database makes sense. It will make it easier to get information on the particular problems of homeless population and develop services that are tailored to those needs. He asked whether overutilizers of health services are the target population for housing. Mr. Trotz responded in the affirmative, adding that because we’re the Health Department we need to be targeting our resources to solve health problems. Commissioner Umekubo asked whether homeless is a national problem. In his view from traveling to other cities, homelessness doesn’t seem to be as big of a problem in other communities. Why is that? Is San Francisco a magnet for homeless and, if so, how can this be solved with limited resources? Mr. Trotz responded that homelessness is on the rise nationally. San Francisco may have a somewhat different problem in that homeless is not as visible in other communities. San Francisco has been more tolerant of the homeless on the streets, while other cities have taken more of a “crack down” approach. Dr. Bamberger cited a study that shows that 90 percent of the homeless have been in the City for 20 or more years, dispelling the myth that homeless people migrate to San Francisco. Commissioner Parker asked whether there are problem-solving mechanisms to deal with problems within facilities. Mr. Trotz responded in the affirmative, noting that there are one-on-one services, case management, property management, building meetings and councils, and other services structures in place to help individuals relearn how to live in an apartment. Commissioner Parker asked how disputes are handled between renters and owners? Mr. Trotz responded that mediation between renters and owners does not happen because buildings are master leased, and the owner is not in the picture. As the master leaser, in effect DPH is the ten-year owner. Commissioner Chow asked how staff selects which services go to which buildings? Mr. Trotz responded that it is partly related to which funding was available when building was established, and is also related to resources available within the department. Commissioner Chow referenced Appendix D in the written report, which includes unit allocation to agencies. He asked if Laguna Honda has seven slots and those slots are occupied for two or more years, does Laguna Honda get any additional slots? Mr. Trotz responded in the affirmative, adding that HUH does not maintain waiting lists. Effectively each agency owns its allotment of rooms and when they are vacated that agency is notified of the vacancy and can use that room as it sees fit. He added that the Department could look at a different model, such as case review based on the current priorities of the Department, especially if priorities change over time. Commissioner Chow asked about the vacancy rate in the DAH hotels. Mr. Trotz responded that it is effectively zero. Commissioner Sánchez noted the challenges that face DPH, adding that data generates more questions. He noted the need to establish modalities to address the diversity of the homeless population (vets, young people, seniors), and the need to ensure that DPH looks at evidence-based outcomes as it develops services. Commissioner Guy noted the need for a Community Health Network Joint Conference Committee discussion. Given the progress that the Department has made, it needs to look at population shifts and how data are being collected, particularly from sections within the Department (SFGH, LHH, HaH, MHRF, CBHS). Not only is the population complex and varied, but also the way services are provided within the Department is complex and deserves examination. Commissioner Guy noted that if San Francisco is a magnet for the homeless, DPH needs to examine how San Francisco is a magnet. She drew a parallel to the early years in AIDS epidemic when people came here because San Francisco was the only place that was able to handle the crisis. Commissioner Chow noted that recommendations two through four are ripe for further discussion at the Community Health Network Joint Conference Committee. He added that it’s becoming clear how the Department is approaching the problem, and that targeting housing to high users is a clear strategy. He believes that the report laid out the Department’s philosophy and clearly gave the Department a strategy. Dr. Katz responded the he is proud of what the Department has done. It has required close work among staff and the Commission to make policy changes. The big decisions have included adopting a housing unit within the Department, which doesn’t negate what other sections are doing; developing master lease housing, which provides faster access to units than building from ground up; and deciding in each budget cycle to fund housing ahead of the savings that the Department believes would accrue from developing that housing. It has been a marriage of policy and implementation. He concluded by noting that along with SFGH, Laguna Honda, and the MHRF, the DAH program represents another 24-hour service of the Department. Commissioner Chow concluded by noting that there can be a solution targeting what San Francisco is facing as a community. This report shows that there are solutions to what seems an intractable problem. 6) PUBLIC COMMENTS Joseph McInerney spoke out against involuntary servitude in residential treatment programs in the form of requiring clients to do chores as part of their treatment plans. He has filed a class action lawsuit and criminal charges against the Department and the Commission. He added that a resident in the MHRF is being held against her will because she has evidence and could testify to this. 7) ADJOURNMENT The meeting was adjourned at 5:27 p.m. Jim Soos, Acting Executive Secretary to the Health Commission