Minutes of the Health Commission Meeting Tuesday, August 16, 2005 at 3:00 p.m. 101 GROVE STREET, ROOM 300 San Francisco, CA 94102 1) CALL TO ORDER Commissioner Guy, on behalf of Commissioner Monfredini, called the meeting to order at 3:25 p.m. Present: Commissioner Lee Ann Monfredini, President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Edward A. Chow, M.D. Commissioner James M. Illig Commissioner David J. Sanchez, Jr., Ph.D. – left at 6:00 p.m. Commissioner Donald E. Tarver, II, M.D. Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF JULY 19, 2005 Action Taken: The Commission approved the minutes of the July 19, 2005 Heath Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Illig chaired, and Commissioner Chow and Commissioner Sanchez attended, the Budget Committee meeting. (3.1) Central Administration–Policy and Planning - Request for approval to accept and expend forty-seven recurring grants from the State of California, for Fiscal Year 2005-2006, in the total amount of $29,596,579. Commissioner Chow asked if the increased allocation for TB subvention would preserve Directly Observed Therapy at Chinatown. Ms. Burlew-Lawler will follow up with TB Control and get this information to the Commissioners. Commissioner Sanchez said there is a wide variance in indirect costs. It was his understanding that the counties were going to meet with the State to develop consistent indirect allocation. He asked for an update at a future meeting on the status of these discussions and any progress that has been made. (3.2) PHP–Community Health Promotion and Prevention - Request for approval to accept and expend a grant from the California Office of Traffic Safety, in the amount of $337,725, to improve pedestrian safety in San Francisco, for the period of October 1, 2005 to December 31, 2007, and a contract with O’Rorke PR, Inc., for media services, in the amount of $90,000, for the same time period. (3.3) PHP–Community Health Promotion and Prevention - Request for approval to accept and expend a grant from the California Office of Traffic Safety in the amount of $563,195 to improve child passenger safety in San Francisco, for the period of October 1, 2005 to December 31, 2007, and contracts with the San Francisco Study Center, for fiscal intermediary services, in the amount of $180,000, for the same time period and with O’Rorke PR, Inc., for media services, in the amount of $90,000, for the same time period. (3.4) PHP–Community Health Promotion and Prevention - Request for approval to accept and expend an Environmental Justice Planning Grant from the California Department of Transportation, in the amount of $157,541, to improve pedestrian safety in the Bayview Hunters Point neighborhood of San Francisco, for the period of January 1, 2006 to June 30, 2007, and a contract with the San Francisco Study Center, for fiscal intermediary services, in the amount of $123,200, for the same time period. (3.5) PHP–Community Health Promotion and Prevention - Request for approval to accept and expend a grant from the San Diego State University Research Foundation, in the amount of $55,000, to facilitate development of training resources and a support network for injury prevention professionals in California, for the period of August 15, 2005 to June 30, 2007 and a contract with the San Francisco Study Center, for fiscal intermediary services, in the amount of $4,000, for the same time period. Commissioner Illig, on behalf of Commissioner Tarver, asked that the Commission get copies of the materials that are developed by O’Rorke P.R. Commissioner Tarver is very concerned about pedestrian safety as the 3rd Street Light Rail Corridor gets underway. Mr. Radetsky said the plan is to do a series of meetings where the community will identify safety needs and areas on which to focus. This community planning effort is occurring at the same time the light rail is getting going, so this provides an opportunity to make the 3rd street corridor safer. (3.6) PHP–Occupational and Environmental Health - Request for approval to accept and expend retroactively a one-time award from the California Department of Health Services, in the amount of $175,426.20, for the control of mosquitoes to mitigate the threat of West Nile virus transmission, for the period of July 1, 2005 to June 30, 2006. (3.7) PHP-CHSS-STD Control - Request for approval of a retroactive contract renewal with the Regents of the University of California, in the amount of $115,021, to provide STD prevention services targeting men who have sex with men, for the period of January 1, 2005 through December 31, 2005. (3.8) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Ark of Refuge, Inc., in the amount of $329,687, which includes a 12% contingency, to provide residential substance abuse treatment at Restoration House, for the period of March 1, 2005 through February 28, 2006. (3.9) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Baker Places, Inc., in the amount of $1,755,406, which includes a 12% contingency, to provide residential treatment, supportive services, continuing care services and rental subsidies for persons with HIV/AIDS, substance use and mental health issues, for the period of March 1, 2005 through June 30, 2006. Commissioner Tarver abstained from voting on this item. (3.10) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Baker Places, Inc., in the amount of $663,647, which includes a 12% contingency, to provide supportive services, case management services for the Direct Access to Housing (DAH) tenants at the Star and Camelot Hotels, for the period of March 1, 2005 through June 30, 2006. Commissioner Tarver abstained from voting on this item. (3.11) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Black Coalition on AIDS, in the amount of $393,548, which includes a 12% contingency, to provide transitional housing, case management and groups at the Brandy Moore House, for the period of March 1, 2005 through June 30, 2006. (3.12) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Catholic Charities CYO, in the amount of $627,389, which includes a 12% contingency, to provide supportive housing services at the Derek Silva Community, for the period of March 1, 2005 through June 30, 2006. (3.13) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Catholic Charities CYO, in the amount $584,105, which includes a 12% contingency, to provide partial rent subsidy and housing advocacy services, for the period of March 1, 2005 through February 28, 2006. Commissioner Chow said that many contract monitoring reports reference a problem with the REGGIE system, and asked for an overview of challenges and responses. Mr. Zellers said there have been problems with this system over the past number of years. In the last 16-18 months, the administration of this system has been moved under Health Services so that it is more integrated with programs. Providers have done a marvelous job with inputting data, which had been an issue in the past, and this has markedly improved data. Commissioner Illig is going to continue to encourage joint monitoring of agencies between DPH divisions. This is why he is asking that different contracts with the same agency be presented together. Mr. Zellers said the Department is developing standardized program monitoring. (3.14) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Larkin Street Youth Services, in the amount of $614,901, which includes a 12% contingency, to provide comprehensive housing and attendant care services, for the period of March 1, 2005 through February 28, 2006. (3.15) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Lutheran Social Services, in the amount of $124,970, which includes a 12% contingency, to provide supportive services and case management services to residents of the Hazel Betsey site, for the period of March 1, 2005 through February 28, 2006. (3.16) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Mercy Services Corporation, in the amount of $539,134, to provide property management services in a DAH site, targeting homeless, extremely low-income persons with special needs, including substance abuse, mental health and physical disabilities, for the period of July 1, 2005 through June 30, 2006. (3.17) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with San Francisco AIDS Foundation, in the amount of $2,839,038, which includes a 12% contingency, to provide full and shallow rental subsidies, targeting people with disabling HIV or AIDS, for the period of March 1, 2005 through February 28, 2006. (3.18) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Tenderloin AIDS Resource Center, in the amount of $284,637, which includes a 12% contingency, to provide emergency hotel rooms and client-centered emergency on-site services to medically stable homeless individuals living with HIV/AIDS, for the period of March 1, 2005 through February 28, 2006. (3.19) PHP-Housing & Urban Health - Request for approval of a retroactive renewal contract with Walden House, in the amount of $81,715, which includes a 12% contingency, to provide supportive services in a permanent housing environment at the Planetree Program, targeting very low-income adults who have disabling AIDS/HIV and substance abuse concerns, for the period of March 1, 2005 through February 28, 2006. (3.20) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with Lutheran Social Services of Northern California, in the amount of $504,389, to provide AIDS financial services (money management and representative payee), targeting very low-income persons with disabling HIV/AIDS, for the period of March 1, 2005 through February 28, 2006. Commissioner Illig is concerned that the agency has only four board members. Dr. Elerick, Interim Executive Director, said he is concerned as well. They recently added another board member, hired an outside consultant to provide technical assistance for board development and have four development funds to fund this effort. (3.21) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with AIDS Community Research Consortium, in the amount of $98,635, to provide client advocacy and treatment adherence services, targeting monolingual and bilingual Spanish-speaking HIV-positive Latino/as living in the Eligible Metropolitan Area, for the period of March 1, 2005 through February 28, 2006. (3.22) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with Walden House, Inc., in the amount of $1,073,010, to provide residential substance abuse and comprehensive monitored residential detox services, targeting HIV-positive substance abusing adults and youth, for the period of March 1, 2005 through February 28, 2006. (3.23) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with Catholic Charities CYO (Leland House & Peter Claver Community), in the amount of $154,901, plus a 12% contingency amount of $18,588, for a total amount of $173,489, to provide patient care services (attendant care services) to low-income homeless San Francisco residents with HIV or AIDS between the ages of 18 to 59, for the period of March 1, 2005 through February 28, 2006. (3.24) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with Haight Ashbury Free Clinic, Inc., in the amount of $578,818, plus a 12% contingency of $69,458, for a total amount of $648,276, to provide residential detox and substance abuse services targeting HIV+ substance abusers, for the period of March 1, 2005 through February 28, 2006. Commissioner Illig asked if the AIDS Office has been providing technical assistance HAFC. Joseph Cecere, program manager, said he has been working very closely with Ben Eiland to provide technical assistance. This will be an ongoing resource. (3.25) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with UCSF/Pediatric HIV/AIDS Program, in the amount of $155,979, plus a 12 percent contingency amount of $18,717, for a total amount of $174,696, to provide primary care, case management, psychosocial and nutritional counseling services to HIV+/ HIV indeterminate children and adolescents from low-income uninsured or underinsured families that have no other source of health care, for the period of March 1, 2005 through February 28, 2006. (3.26) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with AIDS Legal Referral Panel, in the amount of $74,800, plus a 12 percent contingency amount of $8,976, for a total amount of $83,776, to provide legal assessment, consultation, or representation to individuals with HIV infection in San Francisco, for the period of July 1, 2005 through February 28, 2006. Action Taken: The Commission approved the Budget Committee Consent Calendar. Commissioner Tarver abstained from voting on Item 3.9 and 3.10. 4) DIRECTOR’S REPORT Barbara Garcia, Acting Director of Health, presented the Director’s Report. First Human Case of West Nile Virus As the Commissioners are undoubtedly aware, the State Health Department informed DPH late Monday afternoon that a San Francisco resident was diagnosed with West Nile Virus. The patient is a middle age male who had been hospitalized in San Francisco with a high fever and neurological symptoms. We are pleased to report that he is home and recovering. At this time, we do not know where he may have contracted the disease. There are no reported cases of WNV among birds in the City this year. After confirming that the patient had been informed of his diagnosis, Drs. Rajiv Bhatia and Susan Fernyak hosted a well-attended press briefing. This first case of WNV gives us an opportunity to remind our residents of the importance of prevention through such simple efforts as eliminating standing water around homes, using mosquito repellent, screening windows, avoiding mosquito breeding areas at dawn and dusk, wearing protective clothing and paying special attention to young children, the elderly and those with chronic health conditions. Only about 20% of individuals who are bitten by an infected mosquito will experience symptoms and of those who get ill, only a very small number will require hospitalization. During 2005, California has had 175 cases of human WNV and four deaths. There is no known cure or vaccination for human WNV and we continue to emphasize prevention as a way of staying healthy. We are joined in our awareness and outreach efforts to fight the spread of mosquitoes and their breeding areas by the City’s Departments of the Environment, the PUC, Recreation and Parks and Public Works. Environmental Health The California Department of Health Services, Mosquito Control Fund has awarded the Bureau of Environmental Health a one-time grant of $175,000. DPH will be adding two new staff, two trucks, sprayers and a variety of chemicals to help in the efforts to fight the spread of mosquitoes and West Nile Virus. SFGH is Granted Full Accreditation by JCAHO As previously reported, the Joint Commission completed their survey of SFGH in April. SFGH successfully passed the survey process on condition that SFGH submit the Evidence of Standard Compliance report of the cited Requirement for Improvements (RFI's). These corrective action plans were submitted last week, and on August 3, 2005, SFGH received a letter from the Joint Commission stating that SFGH is granted full accreditation. Ryan White CARE Act Reauthorization The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act represents the largest source of federal funds specifically designated to provide services to people infected with HIV. San Francisco received over $28 million directly from the CARE Act this year for primary care and support services that help people living with HIV/AIDS learn about, access, and adhere to medical care. Additional funds are awarded to the state and directly to community-based organizations. The federal legislation authorizing this important program expires on September 30th. Legislation to reauthorize the program will originate in the Senate Health, Education, Labor, and Pensions Committee and the House Energy and Commerce Committee. No legislation has been introduced. However, it is not unusual for reauthorizations to be enacted after a program’s authorization expires, and passage after the September 30th expiration will not impact operation of CARE Act funded programs. On July 27th, the Bush Administration released a set of principles for the reauthorization that severely threaten CARE Act funding in San Francisco and throughout the state. Specifically, the principles propose elimination of the “hold harmless” protection, a change that would cost San Francisco over $7 million each year, and propose excluding cases from cities when calculating the amount of funding that goes to the state, which would cause California’s award to decrease from $31 million to $11 million. The Administration also proposes a shift from allocation of CARE Act funds based on AIDS reporting to allocation based on HIV reporting beginning in 2007, but refuses to accept HIV reporting data from California and twelve other states (including the District of Columbia) that use non-name based HIV reporting systems. Finally, the Administration proposes a severity of need for core services index that would be used to determine future allocations, and is suggesting criteria for the index that would allocate fewer resources to jurisdictions with strong commitments to HIV/AIDS treatment and care in their state and local budgets. The extent to which the Bush Administration principles will be incorporated into reauthorization legislation that moves through the House and Senate is unclear at this point. The nine California cities that receive CARE Act funding are working on a consensus document that will oppose elimination of the hold harmless and other proposals harmful to California. Housing and Urban Health Grant The Department of Public Health's Housing and Urban Health Section just received a $1 million funding award from HUD. These funds are targeted toward chronically homeless people addicted to alcohol. The Department will use this award to permanently house approximately 60 chronically homeless people who utilize the services of the McMillan Stabilization Project and/or have been high utilizers of ambulance services. SFGH’s Cancer Awareness Resources Education San Francisco General Hospital’s CARE (Cancer Awareness Resources Education) program recently received funds from the Lance Armstrong Foundation to develop and implement a theater program for cancer patients. “Touched by Cancer: Humoring the Tumor,” a bilingual (English and Spanish) theatre event, was written and performed by cancer survivors and their loved ones. Produced by the ARACELI Theatre Project, the patient-centered project was performed at three separate venues during the past two weeks. Through humor and other creative expressions, participants provide an insider’s glance at the emotional landscape of cancer and the various ways people cope with living on the edge of life and death, while also dealing with poverty, isolation and other barriers. YouthPOWER Update The Commissioners received a report last month on the activities of YouthPOWER in Bayview Hunters Point who were redecorating neighborhood corner liquor stores with positive images of the City and their community. Their efforts were well rewarded with an excellent article in the Chronicle. New Program Director - SF Homeless Outreach Team On August 8, 2005, Dr. Rajesh Parekh became the new Program Director for the San Francisco Homeless Outreach Team. "Raj," as he is best known, is a board-certified psychiatrist who has worked with the Department since March 2004. He received his BS in biochemistry-premed from Hofstra University and his medical training at Mt. Sinai School of Medicine in New York. He completed his residency at the UC Irvine Medical Center. His varied experiences include that of an emergency room psychiatrist as well as medical director for an outpatient psychiatry program located in a men's shelter in New York. Dr. Katz welcomes Raj to his new and challenging position. His office phone number is 642-4506. New Director of Administrative Operations at SFGH Dr. Katz welcomes Iman Nazeeri-Simmons, who as of last month joined San Francisco General Hospital's Executive Staff as the Director of Admin Operations. In this role, Iman will help with Hospital issues and questions when Gene O’Connell is not available and will serve as the Public Information Officer for SFGH, so any media/press/community relations’ issues should be directed to her. Iman will also work on projects involving the Health Commission, strategic planning, local and state policy, and will help Ms. O’Connell support the work of the Executive Staff. Iman can be reached at 206-3455. Credentialing Report 08/05 07/05 to 08/05 New Appointments 20 13     Reinstatements 0 0 Reappointments 39 39     Delinquencies: 0     Reappointment Denials: 0 Resigned/Retired: 7 24 Disciplinary Actions 0 0 Restriction/Limitation-Privileges 0 0 Deceased 0 0 Changes in Privileges     Additions 3 7     Voluntary Relinquishments 1 3     Proctorship Completed 2 4     Proctorship Extension 0 6 Current Statistics - as of 08/1/05 Active Staff 457 Affiliate Professionals (non-physicians) 192 Courtesy Staff 549 TOTAL MEMBERS 1,198 Applications In Process 51 Applications Withdrawn Month of August 2005 2 0 (07/05 to 08/05) SFGH Reappointments in Process Sept. 2005 to Dec. 2005 194 Public Comment Patrick Monette-Shaw said that the hold harmless proposal does in fact cause harm. Other jurisdictions are not receiving adequate funds. San Francisco receives 92 percent of the allocation. The hold harmless provision has existed for 10 years, which is long enough. San Francisco is not being fair to other jurisdictions. The pot should be made larger. Commissioners’ Comments Commissioner Guy commended Ms. O’Connell and her staff on the SFGH JCAHO accreditation. Commissioner Illig would appreciate a regular update on the CARE Act Reauthorization discussions. Commissioner Illig has asked Jimmy Loyce to update the Health Commission as to how they are going to allocate the $4 million in general funds that the Board of Supervisors restored to the budget. Commissioner Tarver commended Dr. Parekh on taking on the new role of Director of the Homeless Outreach Team. Commissioner Chow echoed Commissioner Illig’s concern about CARE Act Reauthorization. It appears that the Bush administration wants to make sure that California, and specifically San Francisco, do not receive adequate funding for HIV/AIDS Services. He and other Commissioners are more than happy to assist in all advocacy efforts. He also commended SFGH, including medical staff and administrative staff, for the JCAHO accreditation. Commissioner Sanchez said that institutions that are providing safety net services in our community, including San Francisco General Hospital, are committed to doing what it takes to maintain these services. 5) PRESENTATION OF THE EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF AUGUST Commissioner Umekubo presented the Employee Recognition Awards for the month of August. Individual Awardee #1 Division Nominated By Wendy Wolf, Deputy Director STD Prevention and Control Services Jeff Klausner, M.D., MPH Individual Awardee #2 Division Nominated By Bi Jian Huang, R.N. Laguna Honda Hospital Cel Herrera Individual Awardee #3 Division Nominated By Jean Balibrera, R.N. Tom Waddell Health Center Doug Pierce-Hanson, Lindy Edward, Linette Martinez, Laura Alpert, Meredith Florian, Mikel Jaye, Michele Dickstein, Alma Garcia, Cordelia Nemeyer, Inna Bleykhman, Mary Manihan, Ninfa Alvarez-Pleites, Ann Dallman, Robin Allen-Contreras, Iris Biblowitz, JoAnne Schmidt, Richard Dolbec 6) 4TH QUARTER FINANCIAL REPORT Gregg Sass, DPH Chief Financial Officer, presented the FY 2004-2005 4th Quarter Revenue and Expenditure Report. The Department is projected to return a surplus of $21,198,000 to the General Fund, which is $11,648,000 more than required as a result of mid-year cuts and carry forward surplus to the FY 2005-06 budget. The increase in projected surplus is primarily due to higher revenues at SFGH as a result of high 4th quarter volume and high collection in the last quarter of the year. The budget includes a revenue-funded supplemental appropriation of $17,800,000 to address structural problems in the current year and fund certain one-time expenditures anticipated for the fiscal year. These financial statements are preliminary and it is expected that changes will occur through the annual audit process that extends into November of 2005. Mr. Sass presented an overview of each division in the Health Department. DEPARTMENT OF PUBLIC HEALTH - FY 2004-05 REVENUES EXPENDITURES TOTAL Revised Current Surplus/ Revised Current Surplus/ Surplus/ Division Budget Projection (Deficit) Budget Projection (Deficit) (Deficit) SFGH $ 563,928,000 $ 565,151,000 $ 1,223,000 $ 563,928,000 $ 546,092,000 $ 17,836,000 $ 19,059,000 SB855 Adjustment (99,650,000) (80,684,000) 18,966,000 (99,650,000) (80,684,000) (18,966,000) - SFGH Adjusted $ 464,278,000 $ 484,467,000 $ 20,189,000 $ 464,278,000 $ 465,408,000 $ (1,130,000) $ 19,059,000 Laguna Honda 155,472,000 154,924,000 (548,000) 155,472,000 156,199,000 (727,000) (1,275,000) Primary Care 42,168,000 44,665,000 2,497,000 42,168,000 42,861,000 (693,000) 1,804,000 Health at Home 7,655,000 7,412,000 (243,000) 7,655,000 7,384,000 271,000 28,000 Jail Health 22,436,000 22,914,000 478,000 22,436,000 22,293,000 143,000 621,000 Public Health 91,410,000 90,718,000 (692,000) 91,410,000 90,509,000 901,000 209,000 Mental Health 172,364,000 172,752,000 388,000 172,364,000 172,360,000 4,000 392,000 Substance Abuse 65,017,000 65,027,000 10,000 65,017,000 64,667,000 350,000 360,000 SUBTOTAL $ 1,020,800,000 $ 1,042,879,000 $ 22,079,000 $ 1,020,800,000 $ 1,021,681,000 $ (881,000) $ 21,198,000 Mid-Year Reduction Target             $ (3,500,000) Carryforward Assumed in FY 2005-06 Budget             (6,050,000) NET DPH           $ 11,648,000 (1) The Revised Budget in the table above includes: Annual Appropriation Ordinance for DPH, carry forwards from prior year, Inter Governmental Transfer (IGT) for SB855, Transfer In and Project Related expenses. Commissioners’ Comments Commissioner Illig asked if the Health Department has ever requested to keep all the additional revenue it generates. Mr. Sass said that if overall expected expenditures were over budget, then the Health Department would request additional funds. But the request has to be based on realistic expenditures. The Department would not be able to creatively develop ways to spend down the surplus. Commissioner Umekubo commended the Department on reducing its accounts receivables. When he first came on the Commission, the situation was deplorable. Commissioner Tarver said it is worthy to consider whether or not the Health Commission can influence on how additional revenues, which are appropriately returned to the general fund, are reallocated. Is there a role for the Commission to influence the decisions, even though it does not have the ultimate authority? Mr. Sass said if the Department was better able to anticipate early in the year that revenue is going to come in over budget, then the Department and Commission could develop new initiatives, but this is difficult. Furthermore, as long as the city continues to face economic constraints, as it has for the past few years, any surplus is going to go toward the citywide deficit. Commissioner Chow asked Mr. Sass to clarify that DPH has been allowed to carry forward $6 million of the surplus to balance next year’s budget, as well as $10 million to $11 million for one-time efficiency investments. Mr. Sass said this is the case. Commissioner Chow also emphasized the efforts that have been made over the last number of years to restore the credibility of the Health Department in they eyes of the Mayor and Board of Supervisors. The quarterly financial reports are stellar, and the Department’s annual budget reviews clearly show that DPH very competently oversees its finances. Commissioner Chow does feel that the Health Commission and Health Department should be consulted about how additional funds should be allocated, which has not always been the case the past. Commissioner Guy emphasized that the Health Department has come a long way in getting its financial reports in order, and this has not happened overnight. She agrees that the Health Commission should have influence about how additional funds are allocated, but said that the Health Department has tremendous credibility with the Mayor, Board of Supervisors and community. The Health Department and Health Commission are well-situated to be respected. 7) LONG TERM CARE REPORT Barbara Garcia, Acting Director of Health, outlined the presentation of additional information on the Laguna Honda Hospital Rebuild Project, which includes three important perspectives: the report by HMA associates, focusing today on the recommendations regarding the Laguna Honda Hospital Rebuild; an update on the Targeted Case Management (TCM) program; and a presentation by the Mayor’s Long Term Care Coordinating Council. Nikki Moulton, Health Management Associates, provided an overview of HMAs finding and recommendations related to the Laguna Honda Hospital Rebuild and patient flow. Laguna Honda Hospital Rebuild Recommendations The Department should not construct any additional beds beyond those already committed to at the LHH site but rather, if the need for additional SNF beds arises in the future, should explore the potential for contracting with existing private SNFs or creating new publicly-funded small SNFs. The Department should manage a 780 bed rebuilt LHH as several (3 or more) subunits in order to mitigate the potential problems associated with operating a facility of this size. Following completion of the rebuild, LHH should be merged under the SFGH license. The LHH rebuild should include a LHH primary care clinic operating under the Department’s Federally Qualified Health Center (FQHC) license. The Department should rethink current proposals to undergo a costly remodeling of existing space at SFGH to accommodate more SNF beds, until all other alternatives are exhausted. The Health Director should initiate a “summit” of the public entities providing SNF services in San Francisco, San Mateo and Alameda counties in order to create cost effective placement opportunities for each other. Patient Flow recommendations Develop or contract with special facilities (including SNFs and/or Residential Care Facilities). Provide specialized training to LHH staff. Prior to completion of the LHH rebuild, consider using the SFGH/BHC where security personnel are readily available. Make the Department’s long term care system (LTC) more fluid. Partner with providers of LTC resources to develop housing, adult day health care, transportation, etc. Complete an inventory of the existing housing infrastructure capacity. Develop a plan to work with State and Federal agencies responsible for funding for low-income housing. Actively pursue a set of Medi-Cal priorities, including securing an Assisted Living Waiver for San Francisco, seeking a change to the “first-come, first-served” method for access to Medi-Cal HCBS waiver services and changing residency requirements specific to Medi-Cal IHSS. Consider local funding of wrap-around services when cost-effective. Ensure all persons with LTC needs residing in the community or in a period of transition have a care coordinator. Liz Gray, DPH Director of Placement, presented an overview of the Targeted Case Management program. Targeted Case Management was implemented March 29, 2004 following the settlement in Federal Court of the Davis v CHHS, Laguna Honda Hospital lawsuit which alleged violations of the Americans with Disabilities Act, the Nursing Home Reform Act and other statutes by failing to provide information, assess for, and provide community alternatives to individuals institutionalized at Laguna Honda Hospital (LHH). The settlement set up a new TCM Program to: Screen all residents of Laguna Honda Hospital (LHH) Screen all residents at San Francisco General Hospital (SFGH) being referred to LHH or at risk for being referred to LHH Assess all residents of LHH and patients at SFGH meeting screening criteria for full assessment. Assist class members seeking home and community based services with assessment and discharge planning. Develop an Individualized Service/Discharge Plan for all assessed residents that will become part of the resident’s medical record and as necessary be provided ongoing case management services by LHH social workers until accepted into active TCM caseload. Accept in TCM caseload LHH residents who are scheduled for discharge within 180 days. Provide ongoing case management if appropriate and if desired, to ensure all needed services are provided, including application for NF waivers, referrals to housing waitlists and coordination of services once housing is secured. Determine the most integrated setting appropriate and whether individuals are eligible for the community supports and services they desire. Consider all the community supports and services for which individuals may be eligible, even if these services are not available yet and use this to identify gaps in services either not available or sufficiently available. The TCM Program’s current role is to assist all LHH residents desiring discharge from LHH by assessing their potential for living in the community. This includes assessment not only for immediate discharge but also for potential discharge in the future, given the support and treatment necessary. TCM is a voluntary program that supports residents’ choices about where they want to live and provides them with assistance to help them achieve their goals. Eventually the role of TCM will hopefully move from a primary focus at LHH to a primary focus at SFGH where the main goal will be to prevent unnecessary and unwanted long-term institutionalization. Current staffing is one program director, one RN case manager, one vacant RN case manager position, six social worker case managers, one health worker and one TCM biller. This staffing allows the TCM program to carry an active caseload of 90 residents. A total of 1370 cases have been screened and 1091 assessed at LHH and SFGH. As of June 30, 2005, 140 residents have been accepted into the TCM program. The total number of TCM cases that have been closed is 48. Reasons for TCM case closure includes patient being discharged (16), patient changing his or her mind about being in the TCM program (16), family conservator refused TCM (2), public conservator refused TCM (3), serious decline in medical condition (7), resident left LHH AWOL or AMA (1) or the resident died (3). Ms. Gray said that perhaps the most critical issue regarding the TCM program is the lack of services that are necessary to enable people to be successfully discharged from LHH, including lack of adequate housing, inadequate support at time of discharge, $35,000 limit to the Nursing Facility Waiver, inconsistent quality and types of case management available in the community and others. Commissioner Guy asked if commissioners had any clarifying questions of Ms. Moulton or Ms. Gray, which would be answered prior the next presentation. Clarifying Questions Commissioner Umekubo asked how other counties that do not have public SNFs care for individuals who need SNF care. Ms. Moulton said they rely on private SNFs. They generally have a small number of SNF beds at the acute care hospitals for initial rehabilitation, but patients are discharged to private providers. Commissioner Illig asked Ms. Gray to address the statements that are being made that 84 percent of LHH patients could be served in the community. Ms. Gray said the number comes from the assessment instrument. When people really want to live in the community, and the City is able to provide these resources, there can be successful placements in the community. Commissioner Illig asked if the Davis settlement requires that TCM only serve people for 180 days from time of placement. Ms. Gray said the program can carry people for longer than 180 days, but after that time reimbursement is not available. Commissioner Chow asked for further explanation on the Nursing Facility (NF) Waiver that has a cap of $35,000. Ms. Gray replied that this money provides for the purchase of services in the community but cannot be used for housing. There are people who need many more services than $35,000 could pay for in order to successfully live in the community. Commissioner Umekubo’s perception is that there is inadequate non-ambulatory housing for people of all ages, not just those under 65. Ms. Gray said this is true, but the case is even more dire for the under 65 population. Commissioner Guy asked what the annual budget for the TCM program is. Mr. Sass said that it is approximately $1.5 million program. When these services are provided to individuals who are Medi-Cal eligible and within 180 days of discharge, approximately 50 percent is reimbursable. Long Term Care Coordinating Council Presentation Sandy Mori, Long Term Care Coordinating Council (LTCCC), said Mayor created the LTCCC in November 2004 to advise, implement and monitor community-based long-term care planning and to improve the coordination of home, community based and institutional-based long-term care services. The LTCCC has recommendations regarding Laguna Honda Hospital, which five members of the LTCCC will present to the Health Commission. Ms. Mori summarized the policy recommendations regarding the replacement of LHH, and said the debate needs to be shifted from beds to people and San Francisco needs to think creatively about how to provide appropriate housing with services for people who need health care and supportive services. Norma Satten said skilled nursing services can be provided in the home, in community settings or in institutions. The focus needs to be on the people who need services. The LTCCC’s emphasis has been on expanding home and community-based care for people. The LTCCC recommends that LHH be rebuilt with an appropriate lower number of beds. LHH is a resource for many years to come, so we need to analyze demographic projections and trends, evaluate best practices and consider the recommendations of the professionals. Donna Calame talked about transitional support. She highlighted that there is a thorough report that addresses and identifies transitional needs. There are a few model programs in the community that should be expanded. There needs to be safe and reliable discharge planning. Nancy Brundy said there needs to be a range of housing to serve disparate community needs. San Francisco needs to broaden the definition of homelessness to include people who live in institutional housing who want to return to the community. We need to increase affordable housing for people of all ages who have disabilities. This includes transitional housing that is geared to give people the support they need to succeed over the long term. San Francisco should pursue leasing or purchasing housing stock. She described the Day Health Housing Model, which is a combination of an adult day health center, affordable housing and in-home supportive services. Herb Levine presented funding recommendations that are identified in the Community Placement Plan that could be used to support home and community-based long-term care services, including reallocating the operational savings that would be realized from operating smaller LHH to support community alternatives to institutionalization. This money would be placed in a community living fund, which would fund a variety of consumer needs. They are proposing a set of priorities for the disbursement of the fund, which is outlined in the plan. Mr. Levine reviewed other recommendations, including expanding the IHSS Share-of-Cost Program, utilizing to a further extent programs such as PACE that do not draw down on general fund, expanding the TCM program and funding a San Francisco-based Medicaid waiver, among others. Sandy Mori encouraged the Health Commission to do evidence-based decision making. The LTCCC is pleased with the progressive recommendations in the HMA report, as they are consistent with the LTCCC priorities as well as the Living With Dignity Strategic Plan. Even though LTCCC has not taken a position on the number of beds at LHH, it is consistent with their policy recommendations that if San Francisco is going to build 780 beds, the rest of the funding be used to expand community-based services. Public Comment Elizabeth Grigsby, Mayor’s Disability Council, said instead of building another big institutional setting, we need to build smaller units. We need Laguna Honda, but it does not need to be big. A lot of people that reside at Laguna Honda do not need to be there. We need to spend more money out in the community buying more affordable housing for people with disabilities. For people that need long term care, let’s build smaller hospital units and get rid of institutional settings. Howard Chabner, who has an elderly relative who lives at Laguna Honda, urged the Commission to rebuild Laguna Honda at the level that was approved by the voters. There is enough money for a full rebuild and an expansion of community-based services. He urged the Commission to reject HMA’s recommendations. Mr. Chabner submitted a written copy of his testimony, which is on file in the Health Commission office. Sandy O’Neill, a member of the Long Term Care Coordinating Council, said when the voters approved Proposition A, they did not anticipate the Olmstead Act and did not understand that peoples’ civil rights are often violated in an institutional setting. People who want to leave Laguna Honda Hospital must be given the resources to do so. As a resident of San Francisco she has the right to expect more from the Health Commission when it is being told by the DOJ that peoples’ civil rights are being violated every day. She expects more action, more passion. Derek Kerr, M.D., a doctor at Laguna Honda, said there are many good ideas in the HMA report, including the recommendation for a Chief Operating Officer and Director of Long Term Care. Good management can make things happen. Elissa Gershon, Protection and Advocacy, commended the TCM program for the outstanding work they are doing. She confirmed that Protection and Advocacy is working with DPH to negotiate with the State around the Nursing Facility waiver. They believe it is patently illegal for Medi-Cal to fund LHH at $270 per day and community services at only $100 per day, which is what the change in the Nursing Facility waiver means. Thirdly, phase one of the lawsuit has been settled. Phase 2 of the lawsuit involves whether people are actually provided with the community services they are assessed to need and prefer. They sincerely hope to avoid having to file phase two of this litigation and whether they can avoid this will require collaboration with the city and other community advocates. Jennifer Walsh supports the Laguna Honda Hospital replacement program that gives the power of choice to residents. People should be allowed to choose their surroundings. Why should she be afraid that if the support system that allows her to live in the community fails her only option is skilled nursing care at Laguna Honda? If LHH is built only as a skilled nursing facility it will be promoting stigmatizing people with disabilities. The majority of society would rather live in their own homes. Diane Rovai, Independent Living Resource Center, said that San Francisco is a progressive place and the plan for the new Laguna Honda feels like stepping back 100 years to a time when people were isolated in institutions. Elizabeth Zirker, Protection and Advocacy, has been working with LHH residents for many years who want to live in the community. She described two of her clients that would leave today if resources were available. People need support, including support for their civil rights to live and succeed in our community. The message to San Francisco voters should be that San Francisco is committed to providing care to its senior and disabled residents. Michael Lyon, San Francisco Gray Panthers, said their position is that San Francisco’s senior population is going to rapidly increase but affordable housing and facilities are decreasing. Seniors deserve long-term care where they want it, and the City must provide these resources. However, we are going to need more not less SNF beds, so Laguna Honda must be rebuilt at 1200 beds and be designated for frail and disabled people who do not have behavioral problems. Patrick Monette Shaw said that decisions are based on flawed data and none of the reports have included any information about demographics. Dr. Katz has not presented his white paper, which he committed to presenting within 60 days of the March 15th Health Commission meeting. The elderly and chronically ill are not just another segment of the disabled community, and their voices are not heard in this discussion. We need all 1200 beds. Ivana Kirola is in favor of expanding community resources such as assisted living and she is in favor of building a smaller Laguna Honda. She is not a stranger to the Laguna Honda issue because she used to go there on behalf of a community organization—CIAPA—that lost funding and therefore folded. She worked with residents to invite them to CIAPA meetings that concerned issues that affected persons with disabilities and seniors in the community. She sees this process delays the expansion of community-based resources. Ed Warshauer, SEUI Local 790, said we should all support the lowest level of care required for people who need care, including people who live at Laguna Honda. The union realizes that there needs to be expansion of care in the community. But they feel very strongly that 1200 beds need to be built at Laguna Honda. The San Francisco BHC should be re-evaluated for the potential to expand long-term SNF beds. It would be self-defeating to reduce the level of beds at Laguna Honda in mid-stream. Antonio Morgan, (see attached statement of 150 words or less). Commissioners’ Comments Commissioner Guy said the Commission’s orientation for this meeting is to listen to presentations and public testimony and ask for any additional information necessary to make a decision in the future. Commissioner Illig asked if the Long Term Care Coordinating Council has taken a position on the Controller’s Report Option 1 or Option 2. Herb Levine said the LTCCC has taken the position that that Laguna Honda should be rebuilt with fewer than 1,200 beds, but has not taken a position on the specific number of beds. This number needs to be evidence-based. Commissioner Chow asked Ms. Moulton if HMA could estimate how many people might need Laguna Honda-level services. Ms. Moulton said it is very difficult to project need, and projections of need for long-term care are unreliable. However, they do know that the population is aging and the need for long-term care will increase over the next 40 years. However, all states are facing an aging population, yet they are turning to community-based options and employing other options such as deliberately downsizing the number of nursing homes. So despite the aging population, there continues to be the public policy desire more community-based services. There is no evidence-based information that says that 1200 beds are more appropriate than 780 beds or any other number. Further, HMA still maintains that if additional nursing home beds are needed, this should be done either by contracting with private providers or building smaller facilities in various locations in the community. Commissioner Monfredini and Commissioner Chow asked Ms. Gray to estimate how many of the 84 percent of current Laguna Honda Hospital residents that could live in the community if resources were available would choose to do so. Ms. Gray said based on the data she presented today, 60 percent of these people would choose not to leave Laguna Honda. However, this is a fluid number. Commissioner Illig said that Mitch Katz’s 1999 Laguna Honda Hospital white paper, upon which the 1200 beds was based, could not anticipate the Olmstead Act and other civil rights rulings. In addition, the Department of Justice is breathing down our necks. San Francisco is extremely committed to providing long-term care, and is unique in its level of services. He urged the Health Commission to use the resources and the expertise of the Long Term Care Coordinating Council for research and data collection. He would like to bring a number of the HMA recommendations to the next meeting of the Laguna Honda Hospital Joint Conference Committee, for example starting training for the new building now. We need a lot more money to train the workforce, regardless of how many beds there are. He is also interested in hearing from the medical staff the implications of merging Laguna Honda with San Francisco General Hospital. He believes that the number of people who would choose to leave Laguna Honda would increase if people were presented with options. Commissioner Umekubo shares the concern about the workforce. There is a shortage of individuals who want to be caretakers and this has implications for community care. San Francisco needs to make decisions about how it is going to care for its elderly. Housing is a major barrier. Another challenge to community-based care is transportation. Currently, many of the transportation companies will only drop patients off at the doorstep, and do not help them upstairs. Ms. Calame, executive director of the IHSS Authority, said that over the last number of years, the Authority has worked to increase wages and provide a benefits package to their employers. As a result, there has been a dramatic increase in the number of people who what to be in-home support workers. Commissioner Tarver said while he supported Proposition A in 1999, he is not sure he would do so today. It is true that we need institutional skilled nursing care. But the amount we need is dependent on community resources. With more community-based alternatives, less institutional long-term care is required. The Broderick House is a 33-bed facility that serves patients that might otherwise have gone to Laguna Honda. Six of the beds are for non-ambulatory patients. Funding has to be dedicated for the required resources—housing, transportation, nursing care, etc. He looks forward to further discussion of the HMA report. Commissioner Monfredini is concerned that 60 percent of current Laguna Honda residents have indicated that they do not want to leave, and she does not know how to address this. She is anxious to hear from the Long Term Care Coordinating Council and others ideas to help people through transition. Ms. Gray said this 60 percent comes from initial intake data. The more people are successfully discharged, the more likely this percentage will decrease. TCM staff in the process of re-screening, which might result in lower numbers. Ms. Moulton said much can be achieved through choice counseling, and she described an experience she had in Florida providing choice counseling to people living in an ICF/MR facility. Commissioner Chow said he will agendize for discussion at the August 22, 2005 Laguna Honda Hospital Joint Conference Committee meeting the HCA recommendations related to the management of Laguna Honda and seeking FQHC status for the planned LHH clinic. In addition, if there is time, the Joint Conference Committee will discuss labor and workforce issues. He commended the Long Term Care Coordinating Council report. Commissioner Guy said the Laguna Honda Hospital Joint Conference Committee is going to have to help the Health Commission look at the assumptions upon which the decision about the rebuild will be based, and help draft the resolution or resolutions that the Commission will consider. This discussion is about more than the number of beds at Laguna Honda. It is about a transformation in our community. There are going to be assumptions and questions that the Health Commission cannot answer. One of her concerns is that Health at Home, which DPH has made a huge investment in, has not been incorporated into this discussion and no report recognizes this resource. Commissioner Chow said the Joint Conference Committee would work with the members to develop the best process to thoroughly discuss all the issues that would lead to a decision by the end of the year. They are going to begin the discussion on Monday, looking at concrete issues assuming 780 beds. Commissioner Illig asked how DPH is responding to the HMA recommendation that the planned SNF at SFGH not be built. Ms. O’Connell said no work has been done on this project. Dr. Katz is developing the steering committee that is recommended in the HMA report. The steering committee will evaluate all the recommendations. Ms. Garcia said that the steering committee would meet with the HMA consultants on September 9th. Commissioner Tarver asked what the role of the Health Commission is in terms of the steering committee, and what is the link between the two. Ms. Garcia said the steering committee would make recommendations to the Health Commission. 8) PUBLIC COMMENT/OTHER BUSINESS Patrick Monette Shaw said there must be correct data when making decisions about Laguna Honda. He disagrees with the establishment of a community care fund. The RAI-HC assessment is not a valid tool. Michael Lyon understands the frustration in trying to nail down the number of people over 65 who will need SNF care. However, there must be other experiments across the country that have resulted in a reasonable number. 9) ADJOURNMENT The meeting was adjourned at 7:45 p.m. Michele M. Seaton, Executive Secretary to the Health Commission Presentations (Acrobat files): The Laguna Honda Rebuild and Related Issues: Findings and Recommendations, San Francisco Health Commission Meeting August 16, 2005 Targeted Case Management Program Health Commission Update, August 16, 2005 Health Commission meeting minutes are approved by the Commission at the next regularly scheduled Health Commission meeting. Any changes or corrections to these minutes will be reflected in the minutes of the next meeting. Any written summaries of 150 words or less that are provided by persons who spoke at public comment are attached. The written summaries are prepared by members of the public, the opinions and representations are those of the author, and the City does not represent or warrant the correctness of any factual representations and is not responsible for the content.