Minutes of the Health Commission Meeting Tuesday, June 13, 2006 at 3:00 p.m. 101 GROVE STREET, ROOM 300 San Francisco, CA 94102 1) CALL TO ORDER President Monfredini called the meeting to order at 3:15 p.m. Present: Commissioner Lee Ann Monfredini, President Commissioner James M. Illig, Vice President Commissioner Edward A. Chow, M.D. Commissioner David J. Sanchez, Jr., Ph.D. Commissioner Donald E. Tarver, II, M.D. Absent: Commissioner Roma P. Guy, M.S.W. Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF MAY 16, 2006 Action Taken: The Commission (Chow, Illig, Monfredini, Sanchez, Tarver) approved the minutes of the May 16, 2006 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sanchez chaired and Commissioner Chow and Commissioner Tarver attended the Budget Committee meeting. Items for Approval (3.1) CHN-SFGH – Request for approval of a contract renewal with Saint Francis Memorial Hospital, in the amount of $240,000, to provide outpatient tertiary radiation oncology care services targeting medically indigent adults, In-Home Supportive Services workers and San Francisco County Jail patients, for the period of July 1, 2006 through June 30, 2007. (3.2) AIDS OFFICE-HIV Health Services – Request for approval of a retroactive renewal contract with Catholic Health Care West–St. Mary’s HIV Care Program, in the amount of $152,510, which includes a 12% contingency, to provide primary care and supportive services to individuals affected by HIV/AIDS, for the period of March 1, 2006 through June 30, 2006. Secretary’s Note – Commissioner Illig abstained from voting on this item. (3.3) BHS – Request for approval of a contract renewal with Golden Bear Associates, in the amount of $81,782, which includes a 12% contingency, to provide technical assistance to the Child, Youth and Family System of Care, for the period of July 1, 2006 through June 30, 2007. (3.4) BHS – Request for approval of a renewal contract with RTZ Associates, Inc., in the amount of $226,800, which includes a 12% contingency, with an annual contract amount of $135,000, to provide a discharge planning and a housing system, for the period of July 1, 2006 through December 31, 2007. (3.5) BHS – Request for approval to accept and expend a grant from the Social Security Administration, in the amount of $97,660, in the support of the project entitled “HOPE – Reaching the Hardest to Serve: SSI for Chronically Homeless and Mentally Ill People in San Francisco”, for its third year period of May 1, 2006 through April 30, 2007, which includes a sub-contract with the San Francisco Bar Association’s Homeless Advocacy Project, in the amount of $62,458 for the same time period. (3.6) BHS – Request for approval of a contract renewal with the Fred Finch Youth Center, in the amount of $142,654 per year for a total amount of $718,976, which includes a 12% contingency, to provide Therapeutic Behavioral Services for adolescent, for the period of July 1, 2006 through December 31, 2010. Items for Discussion and Approval (3.7) CHN-SFGH – Request for approval of a contract renewal with the Regents of the University of California, in the amount of $1,700,000, to provide tertiary care services targeting medically indigent adults, In-Home Supportive Service workers and San Francisco County Jail patients, for the period of July 1, 2006 through June 30, 2007. (3.8) SFGH-Health Information Services – Request for approval of a contract renewal with Deliverex, Inc., in the amount of $790,000, to provide medical records storage, retrieval and delivery services for San Francisco General Hospital’s Health Information Services, Medical Staff Services and Radiology Departments, for the period of July 1, 2006 through June 30, 2007. (3.9) BHS – Request for approval of a retroactive renewal contract with Progress Foundation, in the amount of $8,682,902 per year, for a total contract amount of $9,724,850, which includes a 12% contingency, to provide residential mental health services, for the period of July 1, 2006 through June 30, 2007. Commissioners’ Comments Commissioner Tarver asked if the documents were correct in saying that Steve Fields is Board President. Mr. Fields said that he is president of the corporation, which is separate from the Board. He is not a voting member of the Board of Directors. The Board has its own officers. Commissioner Chow commended the agency on meeting its broad spectrum of outcome objectives. (3.10) BHS – Request for approval of a contract renewal with Central City Hospitality House, in the amount of $1,145,088, which includes a 12% contingency, with an annual contract amount of $681,600, to provide mental health socialization and wellness services, for the period of July 1, 2006 through December 31, 2007. Commissioners’ Comments Commissioner Chow asked if the agency has been able to meet all the contract objectives. Jackie Jenks, Executive Director, said that the agency did a good job meeting its objectives from January to March, and continues to do so. They tried to ramp up as quickly as possible. She has no reservations about the goals that are put forward in next year’s contract. Ms. Jenks thanked the Health Department for its support, and she looks forward to a continued partnership. (3.11) BHS – Request for approval of a new contract with Calvin Y. Louie, CPA dba Louie & Pak, LLP, in the amount of $2,493,579 per year, with an annual contract amount of $1,484,273, which includes a 12% contingency, to provide fiscal intermediary services, for the period of July 1, 2006 through December 31, 2007. Commissioners’ Comments Commissioner Chow asked how many checks would be written. Ms. Antonetty said 708 checks a year would be written. Mr. Louie nets approximately $14,000. (3.12) CHN-Jail Health Services – Request for approval of a contract renewal with Haight Ashbury Free Clinics, in the amount of $3,476,478, which includes a 12% contingency, to provide psychiatric and substance abuse treatment services targeting inmates in the San Francisco County Jail system, for the period of July 1, 2006 through June 30, 2007. Mr. Goldenson said he is strongly supportive of the contract and the services that haight ashbury has provided in the jail. However, he is very concerned about hafc financial situation. The financial uncertainty has impacted staff morale and resulted in some staff leaving. Mr. Sass, DPH CFO, said that Haight Ashbury has had a difficult year. They have embarked upon a turnaround plan, and certainly DPH would like to see the agency survive. Mr. Sass meets with the agency regularly to monitor finances. Mr. Sass said the Jail Health contract is the largest contract Haight Ashbury has with DPH. It is in both parties’ interest to see the Jail Health contract continue, with the understanding that should things not work out for Haight Ashbury, DPH has Plan B that would enable jail health services be transitioned. Commissioners’ Comments Commissioner Chow said the Health Commission received a letter in May saying that Haight Ashbury contracts were underfunded, and he asked if the agency feels comfortable that the it can carry out the duties of the Jail Health Services contract. John Eckstrom, Chief Executive Officer of Haight Ashbury Free Clinics, said carrying out the duties of the contract is something they can accomplish. The point of his letter was that contracts have not been adequately structures and therefore their true costs were not being covered. Most of the reasons for this are historical in nature, and the agency has been addressing these issues through the turnaround. He has been working closely with Gregg Sass. They are about one year into a two-year turnaround. Commissioner Sanchez said the alert that was issued in May brought to the forefront some historical issues that DPH has been working with Haight Ashbury on. His concern is that the agency is able to carry out the commitment in the contract. Commissioner Tarver commended the turnaround effort. He hopes the staff sees the Commission’s action today as reassurance to hang in there. (3.13) CHS-PAES Dental – Request for approval of a renewal contract with AmeriChoice, in the amount of $1,284,186, which includes a 12% contingency, to provide fiscal intermediary services to the Personal Assisted Employment Services for dental services, for the period of July 1, 2006 through June 30, 2009. Commissioners’ Comments Commissioner Chow asked what AmeriChoice’s administrative fee is. Maria Martinez said it is 12 percent of the contract. Commissioner Chow noted that this contractor is receiving almost twice as much as the other contract that was approved for check writing. Perhaps the Department should look for other opportunities to find local companies that do this for less money. Commissioner Chow does not want to lock into a three-year contract without looking at alternatives. Commissioner Sanchez asked if the unit cost has changed since the last contract, and also if there is a possibility of getting a local firm to do this. Perhaps we should look at a one-year contract. Mr. Sass said that DPH would collect additional information from AmeriChoice to justify the administrative fee, but AmeriChoice provides much more than check writing services. Commissioner Chow asked staff to come back at the next Health Commission meeting to ensure that the Health Department is getting fair value for this contract when compared to agencies that do similar fiscal intermediary functions. Secretary’s Note – this item was continued to the June 20th Health Commission meeting. Commissioners’ Comments (at Health Commission meeting) Commissioner Illig asked why Haight Ashbury Free Clinics received a COLA while other contracts for next year do not include the COLA. Mr. Sass said that this contract is the only contract administered by Jail Health Services, which had the funding to provide the COLA. CBHS administers many more contracts and communicating with each agency and setting the level of the COLA is much more complicated. Action Taken: The Commission (Chow, Illig, Monfredini, Sanchez, Tarver) approved the Budget Committee Consent Calendar, with the exception of Item 3.13, which was continued to the June 20th Health Commission meeting. Commissioner Illig abstained from voting on Item 3.2. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Health Director, presented the Director’s Report. Civil Grand Jury Report on Emergency/Disaster Medical Preparedness in San Francisco The 2005-06 Civil Grand Jury issued a report on disaster medical preparedness May 26th containing a number of thoughtful findings and recommendations. While some deficiencies are noted, overall the report highlights the City’s progress toward preparedness goals since the 2002-03 Grand Jury Report. Prior to the release of the Grand Jury’s report on May 23rd the Mayor issued Executive Directive 06-03, Emergency Medical Disaster Planning. This directive reinforces DPH’s role in emergency preparedness and outlines the Mayor’s priorities for emergency medical coordination, planning and reporting. As reported to the Commission April 4th the DPH Office of Policy and Planning assumed responsibility for the overall coordination of Homeland Security and Emergency Response planning in 2005. The Office of Emergency Services is responsible for coordinating emergency preparedness and response for the entire City. DPH works closely with OES in coordinating medical disaster planning, grant expenditures, training and exercises. Dr. Katz will continue to keep the Commission apprised of DPH’s activities and progress toward meeting its goals. Assembly Passes San Francisco Long-Term Care Waiver Earlier this year, the Department worked with Assembly Member Mark Leno to introduce AB 2968, which would require the State Department of Health Services to seek a Medi-Cal waiver to increase community-based care options for San Franciscans with chronic or disabling health conditions who would otherwise be homeless, living in shelters or institutionalized. According to a review of residents conducted by the Laguna Honda Office of Social Services in September 2005, approximately one quarter (over 250 residents) could instead be cared for in a community-based setting. However, Medi-Cal reimbursement policies favor care in inpatient institutional settings. As a result, alternatives to institutional care for homeless, low-income Medical beneficiaries with chronic or disabling health conditions are limited, and this population often must remain in costly inpatient settings longer than medically necessary. The waiver initiated by AB 2968 would change Medi-Cal’s reimbursement rate structure to increase support for community-based alternatives to institutional care in San Francisco. I am happy to report that the full Assembly passed the bill by a vote of 76-1 on May 30, 2006. AB 2968 will next move to the Senate Rules Committee for consideration. Ryan White CARE Act Reauthorization After a slow start, the Congressional committees with jurisdiction over the Ryan White CARE Act have intensified their efforts to pass a reauthorization bill, S.2823, this year. Although the basic four-title structure of the CARE Act is preserved, the changes proposed will significantly reduce CARE Act funding for San Francisco over the next five years. According to our Congressional delegation, Republican opposition to the “hold harmless” protection, which limits a jurisdiction’s funding losses each year, was intense. San Francisco benefits significantly from this protection, which the bill would eliminate over three years. We are continuing to advocate for a fourth year of protection. However, it is clear that the “hold harmless,” which represents about one quarter of San Francisco’s Title I award (approximately $7 million), will be eliminated at some point during the five year reauthorization period. Another issue of concern is a proposal to require that 75 percent of the total CARE Act award to a Title I or state grantee be used for specified core medical services that are defined in the bill. Several key HIV services, including non-medical case management, transitional housing, inpatient substance abuse treatment, food and transportation to medical care facilities, are not yet included on this list. These services are critically important to people living with HIV/AIDS in San Francisco. On a more positive note, Congress has agreed to move away from formula funding based on 10-year estimates of living AIDS cases--which undercounts AIDS cases in California by approximately 30%--to an actual living AIDS case count, thereby increasing CARE funding for the State and offsetting some of the City’s “hold harmless” losses. In addition, a proposed shift from CARE formula funding based on AIDS case counts to funding based on combined HIV and AIDS case counts had been a concern for California and other states that have not yet fully implemented names-based HIV reporting (the CDC refuses to accept HIV case counts based on non-names reporting systems). S.2823 includes a proxy for actual HIV cases for these states. The proxy will count 0.9 HIV cases for each diagnosed case of AIDS. The Department will continue to work with our allies in Congress to advocate for positions that benefit San Francisco as this process moves forward. Mayor Newsom Submits FY 2006-07 to the Board of Supervisors The Mayor submitted his budget to the Board of Supervisors June 1st. The Mayor made only minor changes to the budget the Health Commission passed in April. The modifications include the elimination of co-pays for pharmaceuticals and while the Mayor conceptually supports equalization of residential substance abuse rates, he does not support them as a budget measure. The elimination of the Worker’s Compensation Clinic is still in the budget. Capital project funding includes 11.9 million for the rebuild of SFGH. The Board of Supervisors will hold two budget hearings, the first is scheduled for June 22nd, the second a week later on June 29th. New Disclosure Initiative for HIV Prevention The HIV Prevention Section of the AIDS Office is embarking on an important addition to our citywide prevention efforts called the “Disclosure Initiative." An important new direction for prevention in San Francisco, the initiative aims to begin changing community norms around the discussion of HIV status and normalize/destigmatize the sharing of HIV status between people before, during and after they are having sex. With more people disclosing HIV status and thus negotiating sexual or drug use behavior that supports the health and sexual health-related needs of both partners, we believe that we will continue our success at reducing the incidence of new infections. As part of this new initiative, there will be educational and promotional materials, a new marketing campaign, a new website (hivdisclosure.com), trainings for service providers throughout the City, and staff on-call to offer interested community members counseling and referrals to appropriate disclosure assistance services. All programs in Prevention’s network of services are contracted (and being trained) to deliver disclosure assistance services to HIV-, HIV+ and people of unknown HIV status. The "Disclosure Initiative" was kicked off June 8th with a community forum about disclosure and the empowerment of the community around the negotiation of sexual activity based on 'asking and telling' of HIV status with sex and needle sharing partners. This first event is specifically targeting gay men but the initiative as a whole is inclusive of people from all behavioral risk groups. Speakers at the community forum will include counseling staff as well as community members. The forum will be an opportunity for our prevention partners and community members to address issues around personal responsibility and disclosure in hopes of normalizing our discussion of HIV status and the ways we negotiate sex. Issue Concerning HIV Testing Clarified There was some confusion regarding DPH’s HIV counseling and testing protocols reported in the Chronicle two weeks ago. Essentially, the Medical Executive Committee, on Dr. Katz’s recommendation, rewrote their procedure for HIV counseling and testing so that a specific form was not required in order to perform HIV testing in the context of medical treatment. The previously required form, when incorrectly filled out, resulted in the laboratory throwing away the blood specimen and the test not being performed. Consistent with State of California law, physicians must still obtain informed consent from patients prior to HIV testing, must place written documentation in the medical record that informed consent was obtained, and must perform pretest counseling. Some of the newspaper articles suggested that we had eliminated the need for pretest counseling. This was not accurate. It is true that some public health and advocacy groups are calling for the “normalization of HIV testing,” in other words, making HIV testing more similar to testing for other diseases. Without entering this debate, I would say that “normalization of HIV testing” would require a very different process then what we had done in eliminating a bureaucratic form as well as a change in State law. Supervisor Ma introduced legislation recommending that we maintain informed consent and pretest counseling for HIV. This is DPH’s current policy and what is required by State law. Electronic Death Registry System Beginning June 1st, the Office of Vital Records began implementing the new Electronic Death Registry System (EDRS). EDRS is the state’s web-based system, which was designed to allow easy certification by physicians of the causes of death as they appear on a death certificate. Under the new system, physicians will remotely certify the cause of death using either fax or voice attestation. Remote attestation replaces the hand written signature of a physician on the death certificate. The new system is simple, convenient, and will provide us with more accurate and timely cause of death information. The Office of Vital Records held a training session with funeral home directors and staff to acquaint them with the new system. Katrina Health Fair Last month a Hurricane Katrina Survivor Resource Fair was held at the State Building, and drew a dozen different agencies offering services to nearly 50 survivors of Hurricane Katrina. DPH provided free blood pressure screenings and consultations for accessing primary care, mental health and substance abuse treatment. Many thanks to David Nakanishi, James Eskridge, NP; Linda Bosley Thomas, PHN and Bernice Casey for volunteering to help at this important outreach event. Project Homeless Connect Project Homeless Connect XI was held June 9th at Bill Graham Auditorium serving 2, 358 homeless people and drawing over 2,100 volunteers. Homeless individuals began lining up for services the day before to ensure they had the first chance at housing, clothing, food and medical care. New services are added at each PHC, Friday’s addition was the give away of 2,000 pairs of new shoes donated by Deloitte & Touche. A record number of 117 housing and shelter slots were allocated on Friday, 192 replacement identification card from the state Department of Motor Vehicles and 28 repairs to wheelchairs. During the event, staff and volunteers picked up clients from five sites in the Bayview and bused them to Bill Graham. PHC is looking to expand its outreach to all neighborhoods in the City. We continue to have many staff that give generously of their time and talents to this worthwhile program. Smoke Free Bus Stops Alyonik Hrushow from the Tobacco Free Project joined Supervisor Fiona Ma and staff other city agencies in late May to welcome a new law aimed at protecting San Francisco bus and transit riders from second-hand smoke. The new “Smoke-Free Bus Stops” ordinance prohibits smoking at all city bus, train and cable car stops and shelters. The ordinance was authored by Supervisor Ma and signed into law by Mayor Newsom on April 20. Many people exposed to second hand smoke suffer immediate symptoms including breathing problems, eye irritation, headaches, nausea and life-threatening asthma attacks. We welcome the protection this new law brings to the public. Best Practices in Cultural Competence A grant from the California Endowment funded the Department of Public Health’s five part training series on Best Practices on Cultural Competence. This final event featured four programs recognized as Best Practices in Cultural Competence and 11 honorable mention programs for their efforts to advance cultural competence in the Department of Public Health. The awardees and presenters were: Newcomers Health Program for Staff Development & Service Intervention (Patricia Erwin, MPH) SFGH Ethnic/Minority Psychiatric Inpatient Programs for Service Intervention (Francis Lu, MD) A Dialogue on Differences-Silenced Voices: A Series of Monologues for Training and Communications (Jenjii Perault, N. Bruce Williams, Victor Damian & Janet King) Community Response Network for Community Collaboration & Linkages (Collaborative: Sal Nunez, PhD, Roban San Miguel, LCSW & John Torres and Staff) Honorable Mention Programs: The IMD Alternatives Program (CBHS) Many Men, Many Voices (3MV), Black Coalition on AIDS (HUH) Chinatown North Beach Mental Health Services (CBHS) Richmond Area Multi-Services (CBHS and HUH) Black History Hair Care Seminar -Collaborative Program Activity Therapy and Nursing Beauticians (LHH) Filipino-American Counseling and Treatment Team (CBHS) Instituto Familiar de la Raza (CBHS & HIV/AIDS) Asian Focus Units Ward C4 & G4 (LLH) Community Behavioral Health Services/ Cultural Competence Plan (CBHS) Pediatric Asthma Clinic (SFGH) Videoconference Medical Interpretation Project (SFGH) Naomi Gray Leadership Award Jimmy Loyce was honored Sunday at the annual Black Coalition on AIDS “Freedom” Brunch as this years recipient of the Naomi Gray Leadership Award. Naomi Gray is a former member of the Health Commission and is a current resident at Laguna Honda Hospital. Ms. Gray herself presented the award, which recognizes leadership in addressing the health related needs of the Black community. The award is presented to an individual who has demonstrated a lifetime commitment to improving health in Blacks through public or community service. Dr. Katz congratulated Jimmy for winning this prestigious award. Shape Up San Francisco Last month, Mayor Newsom hosted the Mayor' Challenge: Shape Up San Francisco Summit urging city employees, elected officials and business leaders to collaborate to address the public health epidemic of obesity caused by physical inactivity. During this conference, he challenged all city staff members to do their part, whether it is walking at lunch, or just taking the stairs instead of the elevator. A group of SF city employees decided to take it seriously by swimming, biking and running the talk: they took on the Escape from Alcatraz Triathlon. The Mayor's Shape-Up Challenge Team included DPH Senior Health Program Planner Christina Carpenter, SFPUC Regulatory Specialist Lori Schectel and SF Department of Human Resources Finance and Information Systems Director Jamie Austin. They placed 20th out of 47 relay teams in the grueling Escape from Alcatraz Triathlon. Christina swam 1.5 miles in cold choppy water from Alcatraz to Marina Green, Lori rode her bike 18-miles through the hills of San Francisco and Jamie ran 8-miles including the 400-step sand ladder at Baker Beach. Their finishing time for the race was 3:04:50. Community Health Network, San Francisco General Hospital Credentials Report, June 2006 06/06 07/05 to 06/06 New Appointments 16 159   Reinstatements 0 0 Reappointments 49 480   Delinquencies 0 0   Reappointment Denials 0 0 Resigned/Retired 20 132 Disciplinary Actions 0 0 Restriction/Limitation-Privileges 0 0 Deceased 0 0 Changes in Privileges       Additions 5 556   Voluntary Relinquishments 3 52   Proctorship Completed 3 135   Proctorship Extension 0 6 Current Statistics – as of 06/1/06   Active Staff 463 Courtesy Staff 572 Affiliate Professionals (non-physicians) 198 TOTAL MEMBERS 1,233 Applications In Process 39   Applications Withdrawn Month of June 2006 0 2 (07/05 to 06/06) SFGH Reappointments in Process July 2006 to Oct. 2006 217   Commissioners’ Comments Commissioner Monfredini congratulated Dr. Katz and the Department on the defeat of Proposition D. She thanked Commissioner Illig and John Kanaley for their tireless work after hours as well. Commissioner Chow said his confusion around HIV testing reported in the newspaper was that pretesting counseling was not required. He appreciates Dr. Katz clarification. He also asked if it has always been true that treating physicians can obtain verbal consent from patients, rather than having to get written consent. Dr. Katz said that this has always been the law. Commissioner Chow asked if this is true at the clinics as well. Dr. Katz said it a doctor is a treating physician, oral consent is what is required. If a patient is only going for an HIV test, written consent is required. There is a separate State law with a separate protocol for pregnant women. Commissioner Illig asked if AB 2968 is the same bill that was addressed in the HMA report. Dr. Katz said yes. Commissioner Illig asked what this would pay for that is not included in the current waiver. Dr. Katz said it would do a few things that the current waivers do not. One limitation of the existing waiver is that it is $115 per day and cannot be used for anyone in independent living, cannot be used for rent and excludes IHSS. So the current waiver is not very effective. The new waiver sets a higher amount as the fiscally neutral level, and would fund people in assisted living. Commissioner Illig asked when the AIDS Office would be able to update the Commission on its Call to Action. Mr. Loyce said they are almost ready to present this, and will come to the CHN JCC in the next few months. Commissioner Chow thanked the Department for its work around best practices in cultural competency. He is hoping that one outcome of this training would be more detailed descriptions by program managers of agencies’ cultural competency when each of the contracts is renewed. With regard to the Grand Jury Report, much of the emphasis was on the need for a helipad. Commissioner Chow said the Health Commission has consistently supported a helipad, and asked the status. Dr. Katz said the EIR is in the Planning Department, they are estimating that the Planning Department would be issuing the EIR in the next few months. Commissioner Monfredini said the delay with the helipad has been that the issue is stuck in the Planning Department. 5) JAIL HEALTH UPDATE Joe Goldenson, M.D., Director, Jail Health Services, presented an update on Jail Health Services, with the focus on transitioning Jail Health clients back into the community upon discharge. Jo Robinson, director of Psychiatric Services, discussed mental health services for jail clients. They recognize that continuity of care with community providers is very important to this clientele so when they know that the client has a case manager or provider in the community, they invite that person into the jail when the client is in custody. Jail Psychiatric Services makes several successful mental health places, to places such as acute diversion units, dual diagnosis residential, outpatient placements, assertive case management placements, Behavioral Health Court and many other placements. A few years ago Jail Health Services lost two discharge planners. As a result they have had to change the way they do discharge services. They used to do a lot of hands-on and hand holding work with clients, taking them to appointments, taking them to placements, etc. Now they are able to provide information about the programs and how clients can access these programs. Discharge planners begin to work with sentenced inmates 30 days prior to their release. Patients needing medical follow up are advised if they have a pending appointment at SFGH or are instructed how to see a neighborhood clinic. If needed, they are given a medication prescription. Jail Health provides a two-week supply of psychiatric medication. Kate Monaco Klein presented the Center Of Excellence Discharge Planning, a program of the Forensic AIDS Project (FAP). The goal of Discharge Planning is to successfully transition clients from jail into community, rather than to create a parallel system of care between jail and community. Discharge planning begins with the first encounter in the jails between the FAP case manager and the client. When leaving the jails, a client receives a medical care appointment with a primary care provider, a post-release case management appointment, a GA/SSI appointment, a substance abuse treatment referral, as necessary, ADAP recertification or enrollment and a letter of diagnosis and most recent test results. The primary care provider receives a current list of medications, copies of medical records, lab results and a direct communication from a FAP clinician or an RN. Ms. Monaco Klein said it is the intensity of the relationship between the Center of Excellence team members and the HIV positive clients that solidified the relationship of the clients with the HIV/AIDS community. Dr. Goldenson presented the new initiatives. Through a grant Housing and Urban Health received from the Department of Justice, 15 transitional units will be available for people leaving jail or prison. DPH’s proposed medical respite beds will be available for people with significant medical problems. Jail Health has started a discharge clinic to attempt to address the problem of people who leave jail with medical appointments but do not show up for these appointments. A nurse who works at a primary care clinic will be at the discharge clinic 1-2 mornings a week to establish a personal relationship with the clients. And lastly, improved linkages with the VA hospital. The VA opened a clinic at 5th and Mission and is very interested in working with Jail Health around inmates who are veterans. Commissioners’ Comments Commissioner Monfredini asked if the population served has changed much from last year. Dr. Goldenson said overall it has been much the same, although there was a slight increase in the number of women served. Commissioner Monfredini asked about increased efforts to improve medication compliance upon release. Ms. Robinson said the jail is required to give two-weeks worth of medication, but people must be willing to take the medication. Commissioner Monfredini asked if the 15 transitional units that will be available through HUH are beds. Ms. Robinson said they are rooms, not beds. Commissioner Tarver said the average entry into outpatient psychiatric services is often two months. How is the gap bridged when people only have two-weeks worth of medication? Are there any policies around prescription refills? Ms. Robinson said clients receive the actual medications, not a prescription. With regard to appointments, Ms. Robinson said they are using CBHS’s open access of care, and they have not had any problems getting the initial appointment for clients. It is true that it takes a long time to get a second appointment. Commissioner Tarver said that capacity limitations result in an inefficient system. It would be an improvement to set a policy to have behavioral health appointments booked before release. Ms. Robinson said they have found that open access works better for this population, at least for the first appointment, until they establish a relationship with a provider. She will follow up with Commissioner Tarver. Commissioner Illig noted that there is no data in the report about the age of the jail population. Dr. Goldenson said most of the patients are younger than 40 years old. It is not necessarily a healthy population, given the level of substance abuse, but the long-term impacts of lifestyle choices have not fully developed. Commissioner Illig asked how to improve clients’ connections with Primary Care. Dr. Goldenson said that a few years ago, they had a program with Primary Care where discharged clients had priority appointments. This program ended as a result of the large number of people who failed to keep their appointments. He is hoping to rectify this problem through the discharge clinic. Commissioner Illig asked if the database of DPH beds that will be developed by RTZ would be accessible by Jail Health Services. Ms. Gray said the database will include every bed in the Department of Public Health, and Jail Health will have access to the beds that are controlled by the database. Commissioner Chow asked if it is still true that people do not keep appointments at Primary Care Clinics. Dr. Goldenson said they make appointments for mental health patients and AIDS patients but, until the discharge clinic is up and running, do not make appointments for primary care visits. Commissioner Chow is concerned with people who have chronic diseases and an ongoing need for medication. Dr. Goldenson agrees that appointments are the way to go, but case managers are crucial to making the transition—to meet the person upon release and take them to the clinic. If the budget continues to look good over the next few years, they would like to get some case managers back to work with people with serious medical problems. Dr. Katz said that it is fortunate that within this population the incidence of disease besides HIV or mental illness is fairly small. The Urgent Care Clinic is one resource. Dr. Goldenson added that almost all of their clients on insulin have a regular primary care provider. Commissioner Chow is concerned that we give very good care in the jail, yet only provide information about how to receive care in the community post-discharge. The process needs to provide a level of confidence that continuity of care will exist. Dr. Katz said they will pursue this issue further, and he feels that the Urgent Care Clinic is a good resource. Commissioner Sanchez thanked that staff for the report. He was especially interested in the discharge clinic and the fact that the VA is coming off of the hill and into the community, and being part of this new model. Different schools of public health are looking at violence and the forensic population, and could be a source of interns. 6) MOSS ADAMS REPORT ON PRIMARY CARE Gregg Sass, Chief Financial Officer, presented the findings from the Moss Adams Report on Primary Care Clinic revenue maximization. This review was conducted, at the request of the Board of Supervisors, by Moss Adams LLP under contract to the Controller’s Office as part of the City Services Auditor Charter mandate. The study analyzed potential improvements in the health clinics’ billing procedures with the intent to identify revenue maximization opportunities that do not add extreme cost to the City General Fund. The study focused on the following six clinics: Castro Mission Health Center, Maxine Hall Health Center, Balboa Health Center, Curry Health Center, 1M General Medicine Clinic, and 5M Women’s Services Clinic, though some of the findings relate to the entire system. Joann Sutton, Moss Adams LLP, reviewed the revenue opportunities identified in the report: Increase physician productivity - $1,600,000 Revise billing codes and improve billing practices - $206,000 Schedule patient orientation visits together with physician visits - $72,000 Patient registration improvements - $244,000 Charge for free family planning services at Balboa Clinic - $13,000 Bill for introductory Medicare services - $35,000 Mr. Sass presented DPH’s response to the recommendations, as well as an overview of other revenue enhancement efforts DPH has undertaken. In general, DPH is in agreement with the findings. DPH agrees that increasing productivity offers the greatest potential for revenue maximizations. DPH also agrees with the recommendation to update the Charge Master Description. He noted that the Moss Adams report does not include any recommendations related to the DPH patient registration and billing practices. Mr. Sass commended the work of Diana Guevara and Patient Billing Services, which has resulted in improved collections and reduced accounts receivable. Community clinics do not represent the major source of collections in the DPH system. That said, collection in the Health Centers have grown 52 percent over the past six years. Mr. Sass said the most important component of the Moss Adams report is increasing clinician productivity. DPH does not believe it is possible to achieve a benchmark of 4 visits per clinician hour worked. Interviews with public clinic directors in other counties in California and in other states found that most public health primary care sites have visits per clinician hour in the 1.6-2.5 range. Several DPH Health Centers have clinician productivity rates greater than 2—the average is 2.08. Efforts underway at neighborhood health centers to increase clinician productivity include: Monitoring and feedback on clinician productivity at the neighborhood clinics Consultations to redesign the patient intake and treatment processes Renovation of DPH clinics to increase the number of treatment rooms Implementation of Open Access at selected clinics to increase volume Upgrades to computer network to improve connectivity Formation of a revenue enhancement task force Ms. Sass said that DPH agrees with Moss Adams’ findings about the Charge Master Update. It is clear that a complete evaluation is needed, not just at the clinics but also at the hospital. He is working with the Controller’s Office to see if this review could be funded by Proposition C monies. Commissioners’ Comments Commissioner Illig asked why medical directors have higher levels of productivity than other MDs. Ms. Ogbu said that they have fewer clinics that other doctors, and also tend to run urgent care clinics, which see more patients more quickly. Commissioner Tarver asked if there are differentials between clinics in terms of time spent on administrative duties. Ms. Ogbu said they are trying to set a department-wide standard of 75 percent clinical duties and 25 percent administrative duties. Commissioner Monfredini asked Moss Adams what could be done to increase clinician productivity. Ms. Sutton said the non-clinical duties physicians have had to pick up have increased dramatically over the past five years. New regulatory requirements have added to administrative duties. Keeping a clinic open longer than eight hours increases productivity, but is very taxing on staff. Medical residency and training programs offer an opportunity to increase clinic productivity. The strongest barrier to increased productivity is the shortage of administrative and support staff. Open access also allows for an increased number of patients to be seen on a daily basis, which increases productivity. Commissioner Monfredini asked if the recommendation about nursing orientation visits has been implemented. Mr. Sass said this recommendation relates only to the 1M clinic, and he believes changes have been made. Commissioner Sanchez said this report was very enlightening. He noticed that there were differences between the teaching clinics and the non-academic clinics. There are many things that could be done to move forward with the clinics. We have a mission to serve the most vulnerable, and we do so through neighborhood clinics. Commissioner Chow said the report provides guidance to policy makers and staff. It is clear that DPH needs an adequate charge master. His concern is that there are different charge masters at each clinic. While primary care clinics have a lot of autonomy, this should not result in silos. There needs to be some uniformity of administration, in terms of charge masters, how encounters are classified, etc. Commissioner Chow said that DPH was criticized for cutting staff while at the same time not going after revenue aggressively. This report shows that this is not the case. Commissioner Tarver said this report will incentivise the Department to do some creative thinking, and he urged that the providers be included. Commissioner Tarver said that many clinic patients are medically complex, and their visits are not straightforward. This impacts productivity. He also encouraged using the sites that have the highest levels of productivity to develop best practices that could be applied to other clinics. 7) PUBLIC COMMENT/OTHER BUSINESS None. 8) ADJOURNMENT The meeting was adjourned at 6:00 p.m. Michele M. Seaton, Executive Secretary to the Health Commission 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 noted 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.