Minutes of the Health Commission Meeting Tuesday, September 16, 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 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 Penn, 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 SEPTEMBER 2, 2003 Action Taken: The Commission approved the minutes of the September 16, 2003 Health Commission. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Monfredini chaired, and Commissioner Umekubo and Commissioner Penn attended, the Budget Committee meeting. (3.1) AIDS Office-HIV Prevention - Request for approval of a retroactive sole source contract renewal with Centerforce, Inc., in the amount of $709,863, to provide HIV prevention services targeting incarcerated and post-release inmates of San Quentin State Prison, Central California Women’s Facility and Fresno County Jail, for the period of July 1, 2003 through June 30, 2004. (3.2) AIDS Office-HIV Prevention - Request for approval of a retroactive sole source contract renewal with Continuum HIV Day Services, in the amount of $614,874, to provide HIV support services targeting incarcerated men, women and transgendered individuals and a research project to assess the effectiveness of the program, for the period of July 1, 2003 through June 30, 2004. (3.3) BHS-Mental Health - Request for approval of a retroactive contract renewal with Conard House, in the amount of $5,202,299, to provide residential, outpatient, supportive housing and vocational training mental health services, for the period of July 1, 2003 through June 30, 2004. (3.4) BHS-Mental Health - Request for approval of a retroactive contract renewal with Family Service Agency, in the amount of $6,075,757 to provide mental health case management and medication support services for children and adults, for the period of July 1, 2003 through June 30, 2004. Commissioners’ Comments Commissioner Penn asked when evaluation data would be available. Charles Collins from FSA replied that they expect data in the Fall of 2004, and also will be presenting findings to the State Legislature. (3.5) BHS-Substance Abuse - Request for approval of a retroactive contract renewal with Addiction Research and Treatment (dba BAART), in the amount of $5,519,938, to provide substance abuse services, for the period of July 1, 2003 through June 30, 2007. Jim Stillwell, DPH staff, noted that the contract term is through June 30, 2004, not June 30, 2007 as stated on the agenda. (3.6) CHN-Nursing Operations - Request for approval of contract renewals with the following firms for a combined total of $1,350,000: HRN Services, Inc., Medical Staffing Network, Inc., Medstaff, Inc., Nurse Providers, Inc. and United Nursing International to provide supplemental, temporary per diem and traveling nursing personnel for San Francisco General Hospital (SFGH), Community Health Network, for the period of September 1, 2003 through June 30, 2004. Commissioner Monfredini noted that there is a mistake on the contract summary form (page 3.6). The “Annualized Difference” column has ($64,167) and the correct amount should be ($770,004). (3.7) Central Administration-Policy and Planning - Request for approval of a new contract with P.B. Strategies, in the amount of $323,676, to provide strategic planning and project management services for ongoing primary care capital improvement projects, for the period of October 1, 2003 through June 30, 2005. (3.8) Central Administration - Annual Report of Gifts Received in FY 2002-2003. Commissioners’ Comments (at the full Commission) Commissioner Parker asked staff to clarify demographic information for Item 3.1. Steven Tierney stated that the 14,475 adults represent the total number of prisoners who go through orientation. The health curriculum and the HIV curriculum are part of the orientation. For 3.2 Commissioner Parker asked when the research data would be reported. Mr. Tierney said they would report to the Commission, through the PHP JCC, in December. For Item 3.3, staff clarified the per unit cost. Action Taken: The Commission approved Items 3.4 through 3.8 of the Consent Calendar of the Budget Committee. After separate discussion, the Health Commission approved Items 3.1, 3.2 and 3.3 of the Budget Committee Consent Calendar. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Legislature Adjourns After Passing Major Health Care and Workers’ Compensation Reform The Legislature adjourned for the first year of its 2003-04 session in the early hours of Saturday, September 13th. Among the many measures they passed and on its way to the Governor is a SB 2 (Burton/Speier) the “Pay or Play” employer health insurance mandate. If signed, the bill would require that employers either provide health insurance coverage for their employees or pay into a State pool that would purchase coverage for those employees. The “Pay or Play” mandate would be effective on January 1, 2006 for large employers (200 or more employees), who must offer coverage to employees and their dependents. Medium-sized employers (50 to 199 employees) would be required to comply by January 1, 2007 and would have to offer coverage to employees only. Employers with between 20 and 49 employees would be exempt unless a subsequent tax credit is enacted, and those with fewer than 20 employees are completely exempt. Coverage would have to comply with Knox-Keene HMO standards, plus prescription drugs. Employers would have to cover at least 80% of the premium costs, or pay into the State pool. Health benefits determined through Taft-Hartley or any other collective bargaining agreement would be exempt. If enacted, it is expected that significant litigation will follow, including issues around ERISA. The reform package is expected to extend health insurance coverage to approximately one million of the seven million currently uninsured Californians. In addition to health care reform, a seven-bill Workers’ Compensation reform package has also been sent to the Governor and he has already declared he will sign it into law. Proponents claim the measures will reduce costs by over $5 billion, largely as the result of medical reforms, to the $29 billion workers’ compensation system. Supervisor Ammiano’s Homeless and Housing Press Conference Supervisor Ammiano sponsored Resolution 252-03 early last summer requesting a report from DPH on “Strategies for Homeless Individuals with Mental Health Diagnoses, Substance Abuse Diagnoses and Chronic Medical Conditions”. The information requested was similar to that provided in the Homeless and Housing Report September 2nd to the Health Commission. Yesterday, Supervisor Ammiano held a press conference to release the report and called for an expansion of the DAH program, highlighting the lack of permanent housing as a key obstacle to achieving lasting health improvements. Dr. Katz spoke at the conference and concurred that housing is a health issue. Childhood Lead Prevention Program The Department’s Childhood Lead Prevention Program is revising its case management protocol in response to recent and compelling research that indicates adverse health effects from relatively low exposures to lead. Families of children with blood lead levels of 5 - 9 mcg/dL will routinely be sent an information packet containing health education material on lead hazards and lead poisoning. These families may also request an environmental investigation, which may require property owners to remediate identified lead hazards. Families of children with blood lead levels of 10 - 14 mcg/dL will receive an environmental investigation to assess potential environmental lead exposures to children. DPH staff conducting environmental investigations will have enforcement authority to require property owners to correct problems contributing to lead hazards. Prior to this revision, this level of service was provided in accordance with the State Childhood Lead Poisoning Prevention Branch case management protocol, which required an environmental investigation for blood lead levels of 15 mcg/dL and above. AB 2034 Homeless Outreach Program Update The AB 2034 Homeless Outreach Program served 163 clients in FY 2002-03. For these clients, there has been a documented reduction of 40% in annual average number of psychiatric hospitalization days, a 75% reduction in annual average number of days incarcerated, an 84% reduction in annual average number of days homeless on the streets or in shelters, and a 49 % increase in annual average number of days employed. The program has served a total of 205 clients since its inception. APHA Art Contest for SFUSD Students The American Public Health Association (APHA), DPH’s Occupational and Environmental Health Section and the San Francisco Food Systems Council are co-sponsoring an art contest for San Francisco Unified School District students as part of the annual APHA Conference that will be held in San Francisco this November The "Harvesting Health: Food, Health, and the Environment" art contest is requesting submissions by SFUSD students illustrating how growing, sharing and eating good, nutritious food contributes to the health and well being of our communities. This contest is aimed at increasing awareness of and respect for how good food is grown and processed, how it is eaten and recycled. Additional information on this project may be found online at www.sffoodsystems.org, by clicking on "Harvesting Health". Open House at LHH Rehab Services Department In honor of a National Rehabilitation Awareness Week, the Rehabilitation Services Department at Laguna Honda Hospital and Rehabilitation Center (LHH) is hosting an Open House for staff and other Bay Area health care providers on September 25th, from 2 p.m. to 4 p.m. in the Physical Therapy and Occupational Therapy/Speech Pathology Departments. It has been an exciting and rewarding year for LHH’s Rehab Services staff. They continue to develop and refine programming in many areas, including community re-entry, restorative care, restraint reduction, and fall prevention. They have also been distinguished with Best Practice awards and recognitions. The event is an opportunity to learn more about the Community Reintegration Program, Restorative Care Program, and other rehabilitation services at LHH. Intimate Partner Violence Strategic Plan The Intimate Partner Violence project is celebrating the completion of its Strategic Plan on Wednesday, September 24th, from 3 p.m. to 5 p.m. at the GLBT Center. The Plan is the result of a yearlong planning process and focuses on primary prevention of intimate partner violence. It takes a public health perspective and describes the root causes and risk factors associated with intimate partner violence. The plan outlines 15 primary prevention objectives and potential strategies to reach them. Proyecto ContraSIDA Por Vida honors Barbara Garcia, Deputy Director of Health Proyecto ContraSIDA Por Vida (PCPV) celebrated 10 years of serving the Latina/bisexual, lesbian, transgender, and gay communities in resisting/responding to HIV and other diseases. This year, PCPV’s Por Vida Awards honored Deputy Director of Health Barbara Garcia for her dedication to improving the quality of health and health care in the Latino community and for her leadership in the adoption of a harm reduction mandate in San Francisco. Commissioners’ Comments Commissioner Parker asked what impact the workers compensation reform would have on the Department. Dr. Katz said it is not yet known. San Francisco is self-insured, which is different from how other employers operate. Commissioner Chow asked how DPH identifies children with high lead levels. Dr. Katz said there is mandatory reporting of lead levels from other laboratories to DPH. Commissioner Guy said that the State legislature should be applauded for AB 2034 Homeless Outreach Program. DPH can demonstrate the positive impact of this program on so many levels. The Department can continue to learn about what really solves homelessness from this project. Commissioner Penn asked why SB 2 would not be effective until 2007. Dr. Katz said the delay is partly political and partly to provide businesses time to prepare for implementation. Commissioner Penn asked how many children would be impacted by the revised protocol for lead exposure. Dr. Katz said that it is not a large number of children, but the research demonstrated that the lower levels did result in detriments to intelligence where previously it was not thought so. Dr. Katz will provide the Commission with the New England Journal of Medicine article. Commissioner Umekubo is pleased that the legislature is paying attention to the plight of the uninsured. With regard to workers compensation, he asked if there would be more changes to workers compensation. Dr. Katz replied that he does not know, and this is a balancing act between businesses and patient advocates. Commissioner Parker asked if the SFUSD Art Contest would include a focus on youth obesity. Dr. Katz said the emphasis would be on healthy food, rather than a negative message about obesity. Commissioner Sanchez added that a key part of children’s health is physical activity, not just healthy eating. There has been a tremendous decrease in play areas over the years. 5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF SEPTEMBER Commissioner Monfredini presented the Department of Public Health Employee Recognition Awards for September. Team #1 Awardees Division Nominated by Judith Klain CHN - Planning Susan Fernyak, M.D., Director, Community Health Epidemiology and Disease Control Amy Pine, Immunization Programs Manager PHP - Community Health Epidemiology and Disease Control Ann Stangby, EMS Specialist SFGH - Disaster Planning Team #2 Awardees Division Nominated by Frances Culp, Health Program Planner DPH - Policy and Planning Anne Kronenberg, Deputy Director, DPH Jim Soos, Sr. Health Program Planner 6) PRESENTATION OF A REPORT ON THE McMILLAN STABILIZATION CENTER Barbara A. Garcia, Deputy Director of Health, Community Health Services, presented an update on the McMillan Stabilization Center. The Board of Supervisors appointed the Hospital Diversion Task Force to address hospital diversion and the medical burden of chronic public inebriates. One of the recommendations was to develop a pilot sobering unit project that includes medically safe triage protocols for inebriate transport to a sobering center and on-site case management and linkage. Project funders included DPH, the Hospital Council and other private sources. It was a truly collaborative effort with many DPH programs, the Fire and Emergency Communications Departments, the Hospital Council, CATS and Baker Places. Dr. Barry Zevin continued the presentation with a description of the McMillan Stabilization Project: McMillan Drop-in Center (MDIC) - located at 39 Fell Street, provides drop in support for unsheltered homeless people. MDIC is operated by CATS. Sobering Unit - 20 stabilization beds at MDIC and staff assigned to ensure that intoxicated clients will safely sober up. McMillan Stabilization Pilot Project - Sobering Unit and associated primary care and behavioral health providers collaborating to facilitate long term stability for clients. When fully staffed, the project will operate 24/7, 365 days per year. Paramedics will triage inebriates on the street. MDIC nursing staff will be guided by protocol with specific inclusion and exclusion criteria. The project has a robust case management model. And throughout the entire department, services will be prioritized for project clients. McMillan Stabilization Project Goals To provide better care for chronic public inebriates and improve their health outcomes. This goal will be measured through discharge status and utilization of the treatment system. To decrease the number of inappropriate ambulance trips that are transporting chronic public inebriates to the Emergency Department. This goal will be measured by seeing if there has been appropriate triage and transportation of destination for the client on the street and if there has been a decrease in the total number of hours of ED diversion. To decrease the number of inappropriate chronic public inebriates seen in the emergency room. This goal will be measured by determining if there has been a decrease in inappropriate ED use and the number of pick ups by the MAP VAN after clearance at participating hospitals. It is anticipated that the program will serve 500 unduplicated clients per years and will have 5,000 to 10,000 encounters per year with these clients. The project had an ambitious timeline and Dr. Zevin said they planning committees (Project Oversight Committee and Medical Advisory Committee) have met the timeline goals. Dr. Katz said one expected outcome is an improvement in the payor mix at the SFGH emergency department, which is important because these savings have already been allocated to fund the program. Public Comments Scott Campbell, M.D., Chairman of the San Francisco Ambulance Diversion Task Force and emergency room physician at Kaiser San Francisco, said that this pilot project is a new model of public/private partnership for alternative transportation for a very complex group of patients. This has not been done before in California. The data shows that the number of ambulance transports a city generates directly correlates with how busy emergency departments are, so anything that can be done to decrease the number of transports will be beneficial. Abbie Yant, St. Francis Memorial Hospital and member of the Ambulance Diversion Task Force, said a number of decisions, including the Police Department decision to not transport inebriates to jails, culminated in the crisis of emergency room overcrowding. This project addresses a disenfranchised population in a way that meets their needs. They do not need to be in an emergency room, but instead in an environment like the stabilization center. Ron Smith, Hospital Council, said this was a wonderful public/private partnership that can be used as a model. The program has already had successful results. Glenn Ortiz-Schuldt, Emergency Communications Department, said ECD is excited about this new partnership. Currently ECD fields 6-8 calls per day from emergency rooms that are referred to the MAP van for patients to be transported to the stabilization center. On October 1, paramedics will for the first time transport from the scene directly to the sobering center. ECD will be tracking this data and can provide various reports to DPH upon request. Commissioners’ Comments Commissioner Monfredini asked about the staffing pattern. Dr. Zevin said the center has LVNs, medical assistants, nurse practitioners, caseworkers, social workers and sometimes physicians. Commissioner Monfredini asked if IVs could be used at the center. Dr. Zevin replied that if a patient requires an IV, he would be transported to a hospital. Commissioner Monfredini asked if the MAP van has the capacity to accommodate increased numbers. Barbara Garcia replied that the MAP van staffing has been reworked to now provide more than just transportation. There will be gaps, and the pilot project evaluation will identify these gaps. Dr. Campbell added that Seattle and Portland have been using MAP vans very safely and effectively. Commissioner Chow asked how the Department assures that the right mix of staff will be at the center. Dr. Zevin said that he visited both Seattle and Portland, talking to medical directors and reviewing their protocols. This information, was discussed through the Medical Advisory Committee, which developed the specific protocols for McMillan. Quality assurance will be performed throughout. The protocols are available on the DPH Intranet site. Commissioner Penn asked if the MAP van staff is trained on the same protocols. Dr. Zevin said MAP staff is not trained medical personnel, but trained on working with this population. They use their own protocol to determine where the person should be transported. Once a person is taken to McMillan, McMillan staff will reevaluate the patient and may determine that the person does need to go to a hospital. This is the same evaluation as that done by trained paramedics on the street. This will be fully analyzed as part of the pilot project evaluation. Commissioner Penn asked if the pilot project evaluation would allow the Department to see if it is impacting the 20% of the patients who use 80% of the ambulances services. Barbara Garcia said they already have a cohort of 140 and can immediately look at their utilization. Furthermore, the new computer systems will allow the Department to look at service usage throughout the Department. Dr. Campbell added that many physicians are awaiting the data that will come out of McMillan and will provide another level of review. Commissioner Umekubo commended everyone for developing the public/private solution for this complex problem. With regard to funding, will the Hospital Council continue to fund a portion of the project, and how will funding be sustained. Ms. Garcia said the hope is that the private partners will continue to fund the project, there is funding from San Francisco General Hospital and funding will continue to be a high priority for DPH. Mr. Smith stated that the Hospital Council will evaluate the data and if the program is successful would look favorably at providing additional funding. Commissioner Chow asked when staff would be ready to report evaluation findings. Ms. Garcia said they could provide updates every six months. She noted, however, that there is no money attached to the evaluation piece but a number of people are interested in undertaking the evaluation. Commissioner Chow asked for an update on the October 1st implementation in November, in terms of volume of people being served. Project evaluation updates should go through the Community Health Network Joint Conference Committee. Commissioner Monfredini asked for the San Francisco General Hospital Joint Conference Committee to be kept apprised as well, specifically regarding the impact on SFGH ED diversion. Commissioner Guy asked how DPH would use the evaluation to identify both successes and areas that need modification. Funding for the evaluation is critical and needs to be identified. Ms. Garcia said that evaluation is a priority and there is a commitment from staff to undertake the evaluation. Commissioner Sanchez said there might be some evaluation funding available through state sources. Commissioner Parker is excited about the McMillan center, which has been badly needed for a long time. Crisis often leads to creativity, and this is one example. The money DPH will save in the emergency department will outweigh what is spent on this program, so DPH should continue to fight to maintain this service. This program will have a positive impact across the board, from diversion rates to homeless deaths, to quality of life. Commissioner Chow commented that the real message is that this program focuses the problems of public inebriates. This emphasis got lost in discussions about revenue losses at private hospitals and SFGH. This program emphasizes addressing the needs of this complex population. 7) PRESENTATION OF A REPORT ON THE SAN FRANCISCO FOOD SYSTEMS COUNCIL Rajiv Bhatia, MD, MPH, Director of Environmental and Occupational Safety, said the focus on food consumption and sustainability came out of the environmental justice movement in Bayview Hunters Point. DPH initiated the San Francisco Food Systems Council as a partnership with the San Francisco Foundation Community Opportunities Fund in 2002. The Council’s mission is to build bridges between urban food consumers and regional sustainable agriculture in order to support accessible and affordable nutritious food for all San Franciscans. Fernando F. Ona, PhD., MPH, Occupational and Environmental Health, continued the presentation. A youth led survey of food needs along the third street corridor resulted in four priorities: a grocery store, farmers markets, better food choices at corner markets and better fast food choices. One of the initiatives is the Farm-to-School project. Staff did a school food environment survey at SFUSD schools, and has started a pilot project with SFUSD School Nutrition Services. Another big issue is to have local farmers’ markets accept food stamps/electronic benefit transfers. This is a complex, controversial and somewhat political issue. But if Subway can accept EBTs, then farmers’ markets should be able to. Coalition, Partnership and Collaboration Building Food Alliance Technical Advisory Board and Strategic Planning Working with SFUSD, CBOs and other entities Community Food Assessments and Community Action Research The San Francisco Food Systems Guidebook Childcare provider Food Assessment - they received a grant from the USDA to provide healthy food to providers in Visitation Valley West Point Hunters’ View Food Assessment Visitation Valley Food Ethnography Alemany Mini-Community Food Assessment Food Assistance at Farmers’ Markets Technical Support and Assistance Integrating Food Systems Activities Supporting CBOs in food work Connecting state, regional and local food systems’ work Building capacity of communities Bridging academic, government and community Mr. Ona stated the six strategic plan goals: To increase awareness of food as a systems issue within San Francisco and the importance of a sustainable and equitable food system for San Franciscans. To support local and regional sustainable food production. To maximize opportunities for the sale and distribution of local and regional sustainable agriculture in San Francisco’s urban markets. To ensure access by all people at all times to enough nutritious, affordable, safe and culturally diverse food for an active, healthy life. To encourage recycling of all organic residuals, reinforce the elimination of chemical use in agriculture and landscaping and promote the use of sustainable practices that enhance natural regional biological systems upon which the City and County of San Francisco depends. To establish and coordinate mechanisms for community participation in the development of relevant policies to achieve a sustainable and equitable food system. Next Steps Implementation of the Strategic Plan Continued development of the website (www.sffoodsystems.org <http://www.sffoodsystems.org>) Building the Food Alliance Strengthening food systems’ work Supporting community capacity building Publication and dissemination of work Evaluation Commissioners’ Comments Commissioner Monfredini is frustrated that the farmers markets do not accept food stamps. This needs to be rectified. Commissioner Monfredini also noted that many urban neighborhood markets carry fresh fruit and produce, and this should be replicated at all of San Francisco’s markets. Commissioner Umekubo said that food is such a fundamental issue but is also very complex. How can the Health Commission support the initiative? Dr. Bhatia said that they have been able to leverage funds for this effort, so funding is not the primary issue. The Food Alliance will be developing policy solutions and the Health Commission can advance these policies through resolutions and other actions. The Health Commission can also help break down the silos in the City by working with other Commissions, through panels, meetings, etc. Commissioner Umekubo asked if the Farm to School program was at private schools. Mr. Ona said not at this time, but hope to expand to all schools in the future. Commissioner Chow asked why a simple issue of creating a salad bar at a school is so difficult. Mr. Ona said there are many impediments, including lack of food preparation facilities at schools, the labor required to prepare food, and the lack of will by SFUSD to engage in Farm to School. They are working to overcome these obstacles. Commissioner Guy thanked the Commission and the Department for being open to looking at health and nutrition from a broader perspective. It took a long time for the problem of unhealthy food choices and food systems to develop, and the solutions will not happen over night. The Commission will continue to support the good work of this initiative. 8) PUBLIC COMMENTS None. 9) ADJOURNMENT The meeting was adjourned at 6:10 p.m. Michele M. Olson, Executive Secretary to the Health Commission