Minutes of the Health Commission Meeting Tuesday, December 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 Commissioner Chow at 3:20 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 John I. Umekubo, M.D. Absent:  Commissioner Michael Penn, M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner Umekubo left at 6:00 p.m. 2) APPROVAL OF THE MINUTES OF THE MEETING OF NOVEMBER 18, 2003 Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Umekubo) approved the minutes of the November 18, 2003 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Monfredini and Commissioner Umekubo attended the Budget Committee meeting. Commissioner Penn was absent. (3.1) PHP-HUH - Request for approval to accept retroactively and expend a grant from the Substance Abuse and Mental Health Services Administration, in the amount of $1,658,874, for the period of September 30, 2003 to September 29, 2006 and approval of a contract with Baker Places, Inc., totaling $832,466, for the same time period. (3.2) PHP-HUH - Request for approval to accept retroactively and expend a grant from the Health Resources Services Administration through the San Francisco Community Clinic Consortium, in the amount of $808,269, for the period of September 1, 2003 to August 31, 2006. (3.3) PHP-CHPP - Request for approval of a retroactive contract renewal with San Francisco Study Center, in the amount of $218,669, to provide program support services to the DPH African American Health Initiative, for the period of July 1, 2003 through June 30, 2004. Commissioners’ Comments Commissioner Monfredini commended the San Francisco Study Center and the Black Coalition on AIDS. The Black Coalition on AIDS had experience some problems, but is back on track. Perry Lang, Executive Director of Black Coalition on AIDS, and Aimee Zenzele Barnes, Board President, attended the meeting. (3.4) BHS-Mental Health - Request for approval of a retroactive contract renewal with the Regents of the University of California in the amount of $3,948,013 per year, for a total contract value of $7,896,027, to provide citywide case management mental health services targeting Psychiatric Emergency Services clients and county jail inmates with mental illness, for the two-year period of July 1, 2003 through June 30, 3005. Secretary’s Comment The contract summary form inaccurately states that there is a reduction in FTEs. There is no reduction. (3.5) BHS-Mental Health - Request for approval of a retroactive contract renewal with the Regents of the University of California, on behalf of the UCSF Clinical Practice Group, in the amount of $3,645,744 per year, for a total contract value of $7,291,488, to renew the Single Point of Responsibility Program serving severely mentally ill adults, for the period of July 1, 2003 through June 30, 2005. (3.6) BHS-Mental Health - Request for approval of a retroactive contract renewal with Jewish Family and Children’s Services, in the amount of $815,345 per year for a total contract value of $3,261,377, to provide mental health services, for the period of July 1, 2003 through June 30, 2007. (3.7) BHS-Mental Health - Request for approval of a retroactive new contract with Boys and Girls Club of San Francisco, in the amount of $103,040, to provide mental health services for youth ages 7 through 18, for the period of July 1, 2003 through June 30, 2004. Commissioners’ Comments Commissioner Monfredini is excited to welcome the Boys and Girls Club of San Francisco to the DPH family. She asked for a progress report to the Population Health and Prevention Joint Conference Committee as to the status of the pilot project. (3.8) BHS-Mental Health/Substance Abuse - Request for approval of a retroactive contract renewal with the Regents of the University of California, Center on Deafness, in the amount of $475,553, to provide mental health/substance abuse residential/outpatient services, for the period of July 1, 2003 through June 30, 2004. Secretary’s Comment The title inaccurately states that the contract is for residential/outpatient services. The contract does not include residential services. (3.9) BHS-Mental Health/Substance Abuse - Request for approval of a retroactive contract renewal with Walden House, Inc., in the amount of $9,135,851, to provide residential mental health and substance abuse treatment services for the period of July 1, 2003 through June 20, 2004. Barbara Garcia, DPH Deputy Director, provided an update on the agency’s management issues. There are six new board members. Staff anticipates that the Attorney General’s investigation will be closed by June 2004. There has been a fairly extensive program review as part of the Cal Mortgage application process. The agency has continued to bring in more than $1 million in grants. Gregg Sass, DPH Chief Financial Officer, gave a financial update. Because of a variety of fiscal problems, Mr. Sass has closely monitored Walden House’s financial situation. The agency has made a lot of progress. Their cash is forecasted to be positive through year-end. They agency still has the challenge of getting expenses in line with receipts. Mr. Sass will continue to closely monitor actual expenses. Receivables are lower than they were a year ago. A continued concern is the fact that the agency does not have an auditor on board, so the FY 2003 audit is not done. Mr. Sass continues to ask for a number of monthly reports, which are due on the 15th of each month: financial statement, cash forecasts, update on status of Attorney General investigation, status of Cal Mortgage application, status of the audit and updates on personnel and governance issues. Commissioners’ Comments Commissioner Monfredini expressed disappointment with Deloitte and Touche for walking away from Walden House. They overlooked inappropriate expenditures in the past, and to walk away when the agency is trying to get its house in order is reprehensible. She offered to meet with the firm if it would help. Commissioner Monfredini thanked Ms. Garcia and Mr. Sass for taking on the task of working with this agency. She congratulated Board President Chris Cunnie and Executive Director Chuck Deutschman for starting the process of turning the agency around. Chris Cunnie thanked DPH staff for working so closely with Walden House staff and board members. The job is not done, and the Board is committed to continuing the work. Mr. Deutschman said Walden House has so many wonderful staff, appreciates support from DPH staff and the Commission. Commissioner Umekubo asked about the prospects for retaining an auditor. Mr. Deutschman said the four firms Walden House met with are not willing to go forward until Deloitte and Touche provides completed information from the previous audit. Commissioner Monfredini asked Walden to commit to continuing to provide DPH staff with monthly information. She asked the status of the Cal Mortgage application. Mr. Cunnie said they still pursuing this, but until the Attorney General’s investigation ends, this will not move forward. The board and staff are working closely with the Attorney Genera’s Office and Bank of America. Commissioner Monfredini commended Mr. Cunnie for continuing as board president during these very difficult times. (3.10) BHS-Substance Abuse - Request for approval of a retroactive contract renewal with Center for Juvenile and Criminal Justice, Inc. (CJCJ), in the amount of $249,250, to provide substance abuse recovery services targeting San Francisco male parolees over 18 years old, for the period of July 1, 2003 through June 30, 2004. Commissioners’ Comments Commissioner Monfredini expressed concern about the lateness of FY 01-02 audit, which was due in December 2002. Dan Macallair, CJCJ Executive Director, said that it took the agency some time to catch up on its audits. The FY 02 audit is almost complete. From this point forward, the agency will meet all fiscal and administrative requirements on time. Commissioner Monfredini asked for a report to the Community Health Network Joint Conference Committee when the audit is complete. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Umekubo) approved the Budget Committee Consent Calendar. Walden House (Item 3.9) will continue to provide monthly reports to DPH staff. Item 3.7 was referred to the Population Health and Prevention Joint Conference Committee for a follow up report. Item 3.10 was referred to the Community Health Network Joint Conference Committee for a report once the audit is complete. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. McMillan Sobering Center The McMillan Sobering Center has generated a great deal of attention since its opening earlier this year. The staff has been very generous with their time, allowing reporters occasional access and sharing what has been learned about opening the Center with professionals from across the country. Tonight at 11 p.m. and repeating Wednesday night at 5 p.m., Mike Sugarman from KPIX TV, Channel 5, will be showcasing the Center during those news hours. While the specifics are not certain or what the final story will have to say about the efforts being made through the McMillan Sobering Center, DPH is confident that the program and services will reflect a positive image. DPH’s Charity Care Report in the Media Several local media outlets covered the Department’s charity care report and the hearing on the subject at the last meeting. The San Francisco Business Times wrote the most extensive article. A small article also appeared in the San Francisco Chronicle, which was picked up by California Healthline, the daily health update sponsored by the California Healthcare Foundation, and DPH was contacted by The Examiner for a future article. Additionally, KTSF, Channel 26, taped part of the hearing for their Chinese-language programming. The Board of Supervisor’s has expressed an interest in holding a follow up hearing early next year. Dr. Katz will keep the Commission informed as more information becomes available. Maxine Hall Grand Re-Opening The Commissioners will be receiving an invitation to a grand re-opening of the newly renovated Maxine Hall Heath Center and Westside Methadone Maintenance and Detox Center scheduled for December 10th from 1pm to 4pm. Thanks go to Marcellina Ogbu, Center Director, her staff and Mark Primeau, Project Manager, for seeing the project through to completion. Healthy Kids The San Francisco Health Plan's 2nd Annual Healthy Kids Appreciation Night was held on Tuesday, October 28th. A number of CHN Primary Care staff and programs were given special awards for their role in creating access to care for our patients: 2003 Healthy Kids Crystal Heart Award: Hospital Eligibility Workers (2908s) Lola Escobar, SFGH Sharon Kong, Noreen Lum and Maria Quevedo of Community Primary Care 2003 Healthy Kids Clinic Certificate of Excellence: Chinatown Public Health Center San Francisco General Hospital Silver Avenue Family Health Center 2003 Healthy Kids Health Hero Award Patricia Pérez-Arce, Ph.D., past Primary Care Administrator, Director of CMHC Sharon Thyne, M.D., Medical Director of Children's Health Center, SFGH Assembly Bill (AB) 846 - New Smoking Law On January 1¸2004, a new law affecting public buildings goes into effect. The new law prohibits smoking within 20 feet of main entrances, exits, and operable windows of any building owned, leased, and occupied by the s tate, county, or city, and buildings of the University of California, California State University, and California community colleges. The previous law prohibits smoking within five feet of the doorways of these buildings. Commissioners’ Comments Commissioner Parker is pleased that the Board of Supervisors is interested in holding a hearing on the Charity Care report. This report should be used to demonstrate that the Department needs more resources. Commissioner Chow expressed appreciation that the San Francisco Health Plan held an appreciation night. 5) FIRST QUARTER FINANCE REPORT Gregg Sass, DPH Chief Finance Officer, presented the first quarter financial report (Attachment A). The report projects revenues and expenditures for fiscal year 2004, based on revenue collected and billed, and expenses incurred for the first three months of the fiscal year. Unless the Department institutes a decrease in spending rate, it will end the year with a deficit of $5.11 million. Projections include revenue surplus of $3.432 million in over expenditures of $8.533 million. Mr. Sass presented financial information by division, and presented a deficit reduction plan to enable the Department to balance its budget by year-end. The plan consists of: $2.3 million in projected additional cost report settlements anticipated at SFGH and Primary Care $2.325 in other expenditure savings including anticipated contractual savings due to underutilization of services and deferral of certain new initiatives. Close unexpended balances in two capital projects: $261,000 for the Laguna Honda Roof Replacement and $215,000 for the SFGH lobby restroom. Commissioners’ Comments Commissioner Chow asked why workers’ compensation expenses are such a large part of the projected deficit, and why are the expenses largely in Primary Care. Dr. Katz said that the City’s Human Resources Department, not DPH, does the projections. They are actuarial estimates that can be skewed by buyouts of certain claims. DPH has made a number of suggestions to the City Attorney about how to control costs. Dr. Katz pointed out that the $5 million projected deficit is a relatively small variance for this early in the year. His concern is what is going to happen in January and February. 6) AIDS OFFICE UPDATE Jimmy Loyce, Deputy Director of Health, AIDS Programs, presented the 2003 AIDS Office Report. The AIDS Office has four sections: Prevention; Health Services, Research; and Statistics and Epidemiology. The focus of this year’s report is epidemiology and research, to provide a context for the myriad HIV/AIDS prevention programs and direct services. HIV Prevention Challenges New funding guidance from CDC and the State of California will require new RPF for all prevention contracts in 2004. New data suggested more targeted prevention efforts and provides a challenge for long time community agency-partners, the AIDS Office will provide training and technical assistance to help these partner agencies remain relevant and competitive. Increased HIV infection among African American MSM is significantly among those not identified as gay. Men who do not identify are hard to reach. CDC and federal guidelines that limit the scope language used in health promotion and risk reduction messages will require San Francisco to maintain our commitment to culturally and linguistically appropriate education and information. HIV Health Services 2003 Accomplishments The Title I Award Standards of Care were developed for the major service categories The HIV Planning Council has allocated funds to support a community planning process aimed at enhancing primary care services for African Americans in the San Francisco Hunter’s Point Bay View district Prevention for Positives Funding for Office of Minority Health Title III capacity building grant from HRSA Dr. Sandy Schwarcz presented the 2003HIV/AIDS Epidemiology Report. Dr. Schwarcz presented data on cumulative AIDS cases in San Francisco, annual AIDS incidence rates since 1993, for both males and females, survival curves and HAART use by neighborhood. The survival rate for African Americas with AIDS is worse than for other groups. Dr. Schwarcz said HAART use predicts better survival and African Americans initiate HAART later in the course of the disease. HAART use is lower among residents of low-income neighborhoods, and African Americans tend to reside in low-income neighborhoods. Dr. Schwarcz discussed the history of HIV transmission in San Francisco and the HIV incidence among MSM seeking HIV testing. Conclusions and Challenges New AIDS cases and deaths declining Number of persons living with HIV/AIDS increasing Increased demands for prevention, health and social services Need to address disparities in HAART use to improve survival for all HIV risk behaviors and incidence may be stabilizing but need to expand efforts to monitor the leading edge of the epidemic Dr. Susan Buchbinder, AIDS Research Section, discussed what staff is learning about HIV risks and strategies to reducing HIV infection rates. Research moved from observation studies in the early 1980s to mid-1990s to testing interventions. The main target population is MSM but also testing interventions that may work across populations and in sister sites in Zimbabwe and Puerto Rico. The research focuses on interventions with the greatest likelihood of reducing HIV infection rates. Dr. Buchbinder presented the HIV prevention approaches: behaviors, focused on sexual practices and reducing substance abuse; vaccines; STDs; microbicides; and antiretrovirals. Research Challenges Finding ways to help people make and sustain behavior change Involving at-risk communities in research studies Speed in testing new strategies; speed in implementing old strategies Possibility that political concerns will limit research. Mr. Loyce concluded by summarizing AIDS Office challenges. Public Comment Hank Wilson said that poppers were promoted at the Folsom Street Fair, and asked the Department to inquire of the organization that sponsors the fair about this practice. He also asked the Department to inquire of the Federal Trade Commission about allowing the widespread advertising of poppers. He also asked that the annual report include a statistic about the number of homeless individuals who have AIDS. Commissioners’ Comments Commissioner Guy applauded the approach of providing the epidemiology and research context. However, there is clearly the challenge of diminishing resources and even though this was not an emphasis of the report, it should not be forgotten. Commissioner Chow said there has been much discussion about infection rates in and services to the youth population, but did not see it in this report. Dr. Schwarcz said that AIDS cases occur a long time after HIV infections, so they expect AIDS cases to be in older individuals. They see new HIV acquisition in gay men in their mid 20s to mid 30s. The Annual Epidemiology Report does document homeless individuals with HIV/AIDS. Commissioner Umekubo asked the amount of the funding decrease over the last year. Mr. Loyce said that grant funding fluctuates from year to year. The CDC is beginning to cuts its research dollars. Commissioner Umekubo asked how the CDC approaches primary prevention. Mr. Loyce said that the CDC is becoming less inclined to fund primary prevention and moving toward funding more medicalized prevention. Mr. Loyce said there has never been a longitudinal study on the effectiveness of primary prevention approaches. Commissioner Umekubo asked if AIDS dementia has decreased. Dr. Schwarcz said cases still occur. Dr. Katz said that antiretrovirals have greatly decreased the number of individuals with AIDS dementia. Ms. Long said that the Health Service Section is examining the issue of clients who have dementia, but not AIDS-related dementia. Commissioner Parker said the report is encouraging in that San Francisco’s rates are declining and people are living longer compared to the rest of the country. He asked if there is any data that indicates that infected individuals are coming from other cities. Mr. Loyce said that there is anecdotal data that the African Americans go to San Francisco, Oakland, San Mateo and other cities to socialize. So there needs to be a regional approach. Commissioner Parker asked how inmates receive education, information and services about AIDS. Mr. Loyce said the AIDS Office works with Centerforce to provide all new inmates with AIDS information. 7) FEDERAL AND STATE LEGISLATIVE UPDATE This report was continued to the December 16, 2003 Health Commission meeting. 8) APPROVAL OF SAN FRANCISCO GENERAL HOSPITAL ADMINISTRATIVE POLICIES AND PROCEDURES, (HOSPITAL PLAN FOR THE PROVISION OF PATIENT CARE, IN-PATIENT UTILIZATION REVIEW PROGRAM, PERFORMANCE IMPROVEMENT AND PATIENT SAFETY), AND PRESENTATION OF EMPLOYEE PERFORMANCE AND COMPETENCY REPORT AND ENVIRONMENT OF CARE SAFETY ANNUAL REPORT Gene O’Connell, Executive Administrator, SFGHMC, provided the introduction to the various reports. John Luce, M.D., summarized the changes to the Administrative Policies and Procedures. The major changes to the Hospitals Plan for the Provision of Care is that the information in the plan was reorganized per 2004 JCAHO standards, updated statistics on the communities served by the hospital is included and there are added sections on education of patients and family, medication management, management of environment of care and information systems, competency assessment for non-medical staff and infection control surveillance. The major changes to the Performance Improvement and Patient Safety Program is that a reference to HIPAA has been added and it now includes PIPS, Executive Committee and Medical Director of Quality Management roles in review and oversight of the Tertiary Care Contract and managed care programs. These two changes were also made to the Inpatient Utilization Review Program. In addition, the additional responsibilities to the Supervising Nurse Manager were added, as well as a Bridge to Wellness to the Psychiatry Utilization Review Plan. Rod Auyang presented the Employee Competency Report. As of October 31, 2003, 97 percent of performance appraisals for CCSF SFGH employees had been completed. Employees exceeded or met standards at least 98.2% of the time in all areas. The performance evaluations with “unmet expectations” ratings showed three primary reasons for the need for improvement: time management, communication and quality of work. Human Resources works with managers to ensure that developmental plans and monitoring are in place, particularly for direct patient care staff. Mr. Auyang also discussed recruitment and retention measures. Future challenges include State-mandated nurse-patient staffing ratios in inpatient settings effective January 1, 2004 and analysis of the correlation between vacancies/attrition and clinical and service indicators, which is now required by JCAHO. Linda Henson presented the Environment of Care Report. FY 02-03 focused on security management. Accomplishments include: Implemented main lobby security system - 94 percent of staff found wearing badges during EOC safety rounds. Developed one-day badge system Secured access to the main hospital and outer buildings via tunnels Secured access to hazardous waste shed Implementing card key system Other issues include: Continue to address and review smoking policy violations Citywide master contract prepared for disposal of medical waste Need to replenish shortage of N95 respirators Need funds for nurse call system repair and elevator upgrades Approved loan for power plant upgrades The transfer of DPH Institutional Police to Sheriff’s Department is completed Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Umekubo) approved amendments to the SFGH Administrative Policies and Procedures, specifically the Hospital Plan for the Provision of Patient Care, Inpatient Utilization Review Program and Performance Improvement and Patient Safety Program, and accepted the Employee Performance and Competency Report and the Environment of Care Safety Annual Report. 9) APPROVAL OF A SUPPLEMENTAL APPROPRIATION FOR THE LAGUNA HONDA HOSPITAL REPLACEMENT PROJECT Gregg Sass, DPH Chief Financial Officer, presented a request for approval of a $211.5 million supplemental appropriation for Laguna Honda Replacement Program construction expenditures. The source of funds for this supplemental appropriation is General Obligation Bonds. No General Funds are requested. The requested supplemental appropriation will allow the encumbering of capital expenditures for the Replacement Program through December 2005. The LHRP project team has projected that the project will have to encumber $295 million through December 2005. The Health Commission and the Board of Supervisors previously approved an $82.7 million appropriation. The Mayor’s Office of Public Finance anticipates introducing a bond sale resolution to the Board of Supervisors on December 9th. Action Taken: The Commission (Chow, Guy, Monfredini, Parker) approved the supplemental appropriation for the Laguna Honda Hospital Replacement Project. Public Comment Patrick Monette Shaw (given verbally then submitted electronically) - A $14 million discrepancy exists between the $211 million in General Obligation Bonds Mr. Saas’ memo states the LHH Project Team estimates needs to be issued and the $225 million the Department of Public Finance and Business Affairs will propose to the Board of Supervisors seeking another Supplemental Appropriation Ordinance. Commissioner Monfredini’s excuse the $14 million is required to prevent “cash flow” problems is ludicrous; when bond instruments are signed, money becomes available instantly, so claiming “cash flow” is unbelievable. Surely you know the proposed settlement of Louise Renee’s lawsuit regarding $25 million raided from the tobacco settlement fund to balance Mayor Brown’s budget involves a $5 million gap; the tentative settlement allocates $20 million to the furniture, fixture and equipment project. Where is the missing $5 million, and why the $14 million discrepancy? Taxpayers hadn’t voted to pass Prop A, as I did, permitting misspending this combined $19 million. 10) PUBLIC COMMENTS None. 11) ADJOURNMENT The meeting was adjourned at 6:10 p.m. Michele M. Olson, Executive Secretary to the Health Commission