Minutes of the Health Commission Meeting
Tuesday, March 5, 2002
at 3:00 p.m.
101 Grove Street, Room #300
San Francisco, CA 94102
1) CALL TO ORDER
The Health Commission meeting was called to order by President Edward
A. Chow, M.D., at 3:10 p.m.
- President Edward A. Chow, M.D.
- Vice President Roma P. Guy, M.S.W.
- Commissioner Arthur M. Jackson
- Commissioner Lee Ann Monfredini
- Commissioner Harrison S. Parker, Sr., D.D.S.
- Commissioner David J. Sanchez, Jr., Ph.D.
- Commissioner John I. Umekubo, M.D.
2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF FEBRUARY 19,
Action Taken: The Commission approved the minutes of the February 19,
2002 Health Commission with a correction on page 11. The action taken for
Item 8D)2 was amended to read: “The Commission (Chow, Guy, Jackson,
Monfredini, Sanchez, Umekubo) voted not to disclose discussions held in
3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE
(3.1) PHP-Substance Abuse - Request for approval of a retroactive
contract modification to a four-year contract with the Homeless Prenatal
Program, in the amount of $83,708, for the period of July 1, 2001
through June 30, 2002, to provide outreach and case management services,
for a total contract value of $742,741, for the period of July 1, 2000
through June 30, 2004.
- Commissioner Umekubo asked the Executive Director, Martha Ryan, to
address the progress that has been made implementing the Departments’
recommendations. Ms. Ryan said that most have been complete.
- Commissioner Jackson asked what accounts for the large Asian
Pacific Islander population. Ms. Ryan said that that includes all
(3.2) PHP-Mental Health - Request for approval of retroactive
contract renewals with Jewish Family and Children’s Services, Moss
Beach, dba Aspira Foster and Family Services and West Coast Children’s
Center, as part of the shared San Francisco Mental Health Plan contracts
for a total of $3,309,409, to provide mental health services, for the
period of July 1, 2001 through June 30, 2004.
- Commissioner Jackson asked if the agency would be able to meet all
of the recommendations. Linda Wang said that the agency had some
staff problems during last year. They have hired a new director and
should be able to meet all the requirements. Ms. Wang said she will
report back to the Budget Committee in three months.
(3.3) PHP-Mental Health - Request for approval of a contract
modification with Calvin Y. Louie, CPA, in the amount of $301,411, to
provide fiscal intermediary services for the Community Mental Health
Services supplemental residential care facilities, for the period of
July 1, 2001 through June 30, 2002, for a total contract value of
(3.4) PHP-Mental Health - Request for approval of a retroactive
contract modification to a four- year contract with Community Vocational
Enterprises, Inc., in the amount of $160,040 for the period of July 1,
2001 through June 30, 2002, to provide vocational support services for
mentally ill consumers, for a total contract value of $4,171,676, for
the period of July 1, 1998 through June 30, 2002.
- Commissioner Umekubo commended the agency for its excellent
contract monitoring report.
(3.5) CHN-SFGH & Health at Home - Request for approval of a
contract renewal with Toyon Associates, Inc., in the amount of $355,324,
to provide reimbursement and revenue optimization services to San
Francisco General Hospital and Health at Home Agency, for the period of
April 1, 2002 through March 31, 2003.
(3.6) PHP-STD Prevention & Control - Request for approval of a
new contract with Internet Sexuality Information Services, Inc., in the
amount of $100,575, to provide syphilis elimination services, for the
period of February 1, 2002 through December 31, 2002.
- Commissioner Monfredini said she had heard concerns about a woman
overseeing a project that addresses the sexual habits of men.
Although she does not agree with these concerns, she asked Deb
Levine to respond. Ms. Levine said she has been a health educator
for 10 years, teaches a course sex on the net and wrote a book about
sex in cyberspace. Because the services will be provided online,
physical identity differences are leveled.
- Commissioner Umekubo is glad to see the Department doing outreach
4) DIRECTOR’S REPORT
Mitchell H. Katz, M.D., Director of Health, presented the Director’s
Direct Access to Housing - Opening the Star Hotel
Dr. Katz announced that Housing and Urban Health will open the Star
Hotel, a Single Room Occupancy (SRO) located at 2176 Mission Street, by
the end of April 2002. The Star will represent the 5th Direct
Access to Housing building to come on line. The Commission may remember
the Star Hotel experienced a devastating fire displacing all tenants Fall
of 2000. Subsequently the Health Department worked with the owner and
master leased the site and has partnered with Baker Places and John
Stewart Company to provide on-site services and property management. The
building has undergone a complete renovation and will provide safe and
healthy housing to 54 chronically homeless persons.
Proposed Expansion Plan for 1000 Additional Housing Units
Supervisor Ammiano introduced a resolution in February directing the
Department of Public Health and the Department of Human Services to submit
to the Board a plan to expand the two department’s master lease program.
The resolution calls for the expansion of DPH's Direct Access to Housing
Program by 500 beds and DHS's SRO Master Lease Program 500 additional
units in the by March 31, 2002. Staff is working on this proposal which
will include projected costs and timeline for implementation.
Medical Care at All Needle Exchange Sites
The Department now provides medical care at all fourteen Needle
Exchange sites in San Francisco. The intention is to use the sites as a
means of educating engage injection drug users to treat urgent medical
problems including soft tissue infections, teach HIV/HCV and abscess
prevention techniques and to refer to ongoing primary care and drug
Supplemental Appropriation Request
As reported at the last Health Commission meeting, the San Francisco
CARE allocation for HIV services was reduced by $2.2 million, beginning
March 1, 2002. Supervisors Daly and Ammiano have sponsored a supplemental
appropriation request to backfill CARE service reductions that would
result from this recent reduction to the CARE funding allocation. The
supplemental would allocate new General Funds for the four months
remaining in this fiscal year, and allow time for the Mayor and the Board
of Supervisors to consider the continuation of funding for HIV services
during the budget deliberations. The CARE council met last week to
consider the cuts in services that would be necessary to absorb this
funding shortfall. The Council voted to make reductions of approximately
6.5% to most of the existing agencies receiving CARE funds. If the
supplemental appropriation is approved by the Board of Supervisors and
signed by the Mayor, these cuts would be averted for this fiscal year. Dr.
Katz will keep the Commission informed on the outcome of this proposal
over the coming weeks.
Compliance Officer Acting Assignment
Dr. Katz reported that Kathy Murphy, the deputy city attorney assigned
to the Community Health Network, has agreed to accept an acting Compliance
Officer assignment while the Department recruits for a new Compliance
Officer. Kathy is very knowledgeable about the Health requirements
regarding compliance, and has also been working on key committees that are
implementing the HIPAA requirements. This acting assignment is expected to
last approximately three months.
Health Commission - Director of Health Report (from 02/11/02 MEC and
Changes in Privileges
Current Statistics - as of 02/7/02
Affiliate Professionals (NP, CNM, CRNA, PA etc)
Applications In Process
SFGH Reappointments in Process Through April 2002
Dr. Katz also introduced Dee Epps-Miller, the new director of the
Southeast Health Center.
- Kevyn Lutton, Bayview Hunters Point Community First Coalition, asked
for the release of the Emergency Room records from the six months
before six months after the Fall 2000 Hunters Point Shipyard fire. The
community needs this information to continue the health study of the
emissions from the fire. The people who went to the ER need to be
reimbursed. The information can be sent to Professor Ray Tompkins via
- Commissioner Parker congratulated the Department for providing
medical care at the 14 needle exchange sites. This is in keeping with
the philosophy that we take services where the patients are.
- Commissioner Guy asked Dr. Katz if he was aware of the request for
reports requested by the public speaker. Dr. Katz said that he
received the request yesterday, and it is on his radar screen. The
number of visits is publicly available, and he will have Dr. Bhatia
work with the requester. However individual medical records are
confidential and cannot be released to anyone but the individual.
5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEE
RECOGNITION AWARDS FOR THE MONTH OF MARCH
Commissioner Monfredini, on behalf of Commissioner Jackson, presented
the Employee Recognition Awards.
Health at Home Palliative Care Team
Norma del Rio
Ming Gen Hu
CHN Health at Home
Primary Care Interim Leadership
Madeline Daley, RN
Gay Kaplan, RN, NP
Sheila Kerr, RN
Lawrence Marsco, RN
Marcellina Ogbu, Dr.P.H.
Patricia Pérez-Arce, David Ofman, Phyllis Harding, Maureen O’Neill
6) ANNUAL PRIMARY CARE REPORT
Patricia Pérez-Arce, Ph.D., Primary Care Director, and David Ofman,
M.D., presented the Primary Care Report.
The guiding philosophy of the primary care division is to provide
community oriented health care. In 2000 the Health Commission asked
Primary Care to undertake an internal assessment. The assessment two
vulnerable populations: people with barriers to effective medical care;
and high-risk, complex patients. The recommendation was that Primary Care
attempt to serve both categories of patients and prioritize “high risk,
complex” patients for certain services, and better integrate primary
care and behavioral health services. This integration began with the
reorganization of the Department last year.
Dr. Pérez-Arce acknowledged the Community Clinic Consortium. Their
member clinics are partners with the Department and part of the safety net
of providers. Ten programs fall under the consortium.
Dr. Pérez-Arce discussed Primary Care services in the context of the
Goal 1: Access to health services, emphasizing services to target
52 percent of Primary Care clients are female and 48 percent are male.
58 percent of the client population lives in the DPH targeted
neighborhoods and 10 percent are homeless. The clients represent a variety
of ethnicities and languages. Most clients are publicly insured or
Dr. Ofman said that one of the articulated goals of both Primary Care
and the CHN strategic planning effort is linking primary care users to a
provider or clinic. Of the 73,000 patients who visited a primary care
clinic in FY2000-2001, just under half had a primary care provider linkage
in the LCR (Lifetime Clinical Record). The number of patients assigned to
a provider has increased almost 200 percent since the effort started in
September 1998 to have the information system reflect the linkage of
providers to the patients seen.
Dr. Pérez-Arce discussed public health nurses, who provide at-home
training to mothers and other caretakers, care management of patients with
chronic and debilitating diseases and the first line response to disasters
and disease outbreaks. Staff is currently engaged in discussions about the
changing role of public health nurses.
Total visits to all providers decreased 2 percent between 99-00 and
00-01. Visits to primary care providers, however, increased.
Goal 2: Disease and Injury are Prevented
Dr. Ofman and Dr. Pérez-Arce discussed quality improvement activities
and prevention activities. After a concerted effort to unite the quality
assurance activities of the primary care clinics with the health centers
on the SFGH campus, they have developed primary care-wide quality
improvement activities. The effort to improve women’s cancer screening
was sited as an example.
Goal 3: Cost-Efficient Services and Maximizing Resources
During FY 00-01, Primary Care moved into a prospective payment
schedule, which significantly increased the per-visit reimbursement rate
and increased total revenues by $1.8 million. A number of programs that
enhance cost-effectiveness were highlighted including the Diabetes
Monitoring Program, a joint project between information systems and
Primary Care. Other programs are the Asthma Clinic/Yes We Can Partnership
and Nurse Orientation /Screening Clinics, which are designed to reduce
no-show rates by having the person first have an orientation into the
system with a nurse.
Capital improvements currently under design will allow Primary Care to
utilize existing facilities more efficiently.
Goal 4: Partnerships with communities are created and sustained
Behavioral Health Partnerships
- Pychosocial Medicine at Maxine Hall - UCSF
- California Endowment Grant: Mental Health Services in Primary Care
Settings - CMHS
- Primary Care Substance Use Services - UCSF
- Community Mental Health Consultation Liaison Services - CMHS
- Office Based Opiate Addition Treatment - CSAS and SFGH
- Methadone Van - CSAS
- Youth Services Partnerships
- Hip-Hop to Health Clinic Expansion
- Dimensions Clinic
- Laser Tatoo Removal Program
- SFUSD Wellness Center
- Other Partnerships
- Smoking Cessation
- NICOS Disaster Preparation Committee
- Community Domestic Violence Project
- Partnership with UCSF
- Teaching in Primary Care clinics for interns and residents, medical
students, nurse practitioner students, nursing students, pharmacy
residents and others.
- Resident Training in Primary Care clinics
- Access to Primary Care for unaffiliated clients; increase capacity
to be able to link unaffiliated clients to care.
- Clinic Productivity - right now providers are providing services at
capacity, but this can be improved with facility improvements; the
ability to do case management of patients and disease management
teams, and looking at enhanced systems of access to appointments to
allow for more same-day appointments.
- Balance the needs of vulnerable patients with the needs of
high-risk, complex patients, who require much more intensive,
Quality of Chare Challenges
- Chronic disease management programs, which are enhanced systems of
care for either specific conditions or specific populations. They are
shown to be successful, but also quite costly.
- Information systems are a critical quality of care issue. Efficiency
efforts, quality improvement efforts and integration efforts all
depend on the information system. The Lifetime Clinical Record and the
CHN network have allowed Primary Care to improve care.
Cost Effectiveness Challenges
- Integration of primary care and behavioral health services
- Reducing preventable emergency and institutional care
Dr. Pérez-Arce thanked Dr. Ofman for his dedication to primary care
through the leadership transition. She introduced her team of health
center directors who were at the meeting, including Gay Kaplan, Marian
Pena, Michael Jody, Madeline Ritchie, Marcellina Ogbu, Michael Pyle, Dee
Epps-Miller and Lawrence Marsco.
- Commissioner Guy stated that the reorganization seems to have been
appropriate, and acknowledged Dr. Ofman for his tireless work during
the leadership transition. She wants to the progress to continue but
is worried that the general fund plays such a large role in funding
these services. The change in the reimbursement rate made a big
difference, but the Federal government needs to chip in further.
- Commissioner Parker asked how large a role primary care plays in
prevention and referral of HIV and AIDS patients. Dr. Ofman said that
the primary care clinics see large numbers of HIV infected individuals
and do a combination of medical care and prevention efforts.
Commissioner Parker supports the development of group education
programs. Not only cost-effective, but also people benefit from peers
sharing same circumstances.
- Commissioner Sanchez congratulated staff for a comprehensive report.
He shared some observations from a conference that he attended last
week where there was discussion about the issue of basic research
versus primary care. Many of the issues were the same as those
presented in today’s report.
- Commissioner Umekubo said the importance of primary care as the
foundation to our system cannot be over-emphasized. He asked how often
the Primary Care QI committee meets. Dr. Ofman replied that the
committee meets monthly, and he co-chairs it along with the director
of nursing. Commissioner Umekubo commented that health education is
very difficult, and asked if they use a group education setting. Dr.
Pérez-Arce responded that the group model is not being utilized that
much. Dr. Ofman added that there are a few group formats, but most
health education is done one-on-one. They have received positive
responses from a group prenatal care program, and would like to do
more. The primary barrier to group sessions is that they have not
figured out how to do the billing. Dr. Umekubo asked how continuity of
care is assured when CHN patients get referred to providers outside of
the network. Dr. Ofman replied that private hospitals make a good
effort, but difficult to do sometimes. Dr. Pérez-Arce added that the
consortium clinics will have access to the Lifetime Clinical Record so
will be better to able to track CHN patients.
- Commissioner Chow said that continuity of care is a challenge for
both sides, and emphasized the critical need to continue the
relationship with the consortium clinics. Commissioner Chow would like
the CHN Joint Conference Committee to continue to discuss efforts to
better improve continuity of care. Much has been done since the Health
Commission adopted the resolution in 1989 to provide primary care
services at the clinic. The LCR is a model for many places. One of the
continued challenges is learning how to apply disease management
principles to a public sector program. It would be good to develop a
series of guidelines and protocols that extend across the CHN, and not
just to individuals.
- Commissioner Jackson noted that people can learn a great deal in
7) HEALTH AT HOME UPDATE
Kathy Eng, Director, Health at Home, presented the Health at Home
There are two components of Health at Home: Licensed Home Health
Services, focusing on acute, skilled, intermittent care or clients; and
Continuing Care services for clients who are discharged from the home
health service and need additional care for a time-limited period to
prevent deterioration and admission into a higher level of care. Client
s1ervices are provided 365 days a year.
The mission of Health at Home is to provide high quality, compassionate
home health care to CHN clients, and to maintain people safety in their
home environments, avoiding more costly levels of institutional care and
supporting independence and quality of life. In Fiscal Year 2000-2001,
Health at Home served 715 unduplicated clients, with 17,925 visits. There
are 49 FTE and the average patient census is 200.
Ms. Eng discussed how the work of Health at Home aligns to the DPH
Goal 1 - Access to Services
Patients served by Health at Home live throughout San Francisco and
mirror the population seen as SFGH. 70% of clients reside in the
Tenderloin, Excelsior/OMI/Visitacion Valley, Potrero Hill/Bayview Hunters
Point and the Mission. Nearly 50% of the clients are ethnic minorities.
The average age of Health and Home clients is 58, which is younger than
the regional and national norm for other home care agencies, whose average
age is 73. Over 50% of Health at Home staff speak languages other than
Goal 2 - Disease and Injury are Prevented
Ninety percent of the unduplicated clients served by Health at Home
fall within ten top primary clinical diagnoses. The majority of referrals
come from SFGH and the community clinics. The Health at Home team
structure includes a Resource Group Leader and a multi-disciplinary team
that focuses its case conferences and problem solving on targeted groups
of clients. Health at Home has CARE-funded home care contracts for in-home
respite, clients with HIV disease living in SROs and home infusion
therapy. There are five Health at Home Service Delivery teams: Ortho-Neuro;
Med-Surg; Palliative Care; HIV/AIDS; and Continuing Care.
Ms. Eng also discussed the quality management activities undertaken by
Health at Home, including a patient satisfaction survey, and provider
satisfaction survey and quality management benchmark reports. Ms. Eng
highlighted the Palliative Care team, pediatric services planning and
HIV/AIDS services. With regard to pediatric services, there has been a
slight bit of a delay in terms of working on resources to move forward.
The Palliative Care Program serves clients who either may not qualify for
hospice or choose not to go to hospice, but rather die at home. In
2000-2001, there were 2844 visits to 300 clients. In HIV/AIDS services, 25
percent of all Health at Home clients has HIV disease. Last fiscal year
there were 3,100 visits. Most of the clients also have mental health or
substance abuse problems that prevent the individuals from managing their
disease. Health at Home staff work to stabilize the person.
Goal 3 - Services are Cost-Efficient and Resources are Maximized
Health at Home recently moved into a prospective payment system. This
necessitated a reorganized delivery system and increased clinical
oversight and review as a result of increased regulations and
documentation. Ms. Eng said that a lot of emphasis is placed on staff
safety, and they have an escort service, educational sessions,
communication about particular clients, support groups and case
Goal 4 - Partnerships with Communities
Health at Home has a number of partnerships:
- CHN Linkages
- Clinical rounds at SFGH
- Positive Health Program
- Medical High Utilizers Program
- Laguna Honda Hospital - Case conferences to transition clients
from institution to community
- Collaboration with Community Providers
- SF Adult Day Health Network
- AIDS Health Project
- Tenderloin AIDS Resource Center
- Tenderloin Care
- UCSF Home Care Program
Challenges and Opportunities
- Bridge the gap in care for DPH clients in the home setting
- Link case management and other long term care resources, such as
public health nurses.
- Identify MD oversight for home care patients needing primary
- Lab Services for homebound patients. Most of the time,
reimbursement is not provided for lab services, and need to
examine if SFGH lab services can be applied to health at home.
- Space - A necessary resource for expansion
Dr. Katz added his support for the agency.
- Commissioner Jackson asked what percentage of clients lives alone,
and how long is the average visit. Diane Jones, Coordinator of Home
Care Services, stated that the CARE contract funds direct patient
care, rather than respite care, which is an indication of people
living alone. She will get the actual percentage to the Commission.
The standard visit is two hours, but this includes travel time and
paperwork. An admission takes approximately four hours.
- Commissioner Chow asked if the OASIS data could be further divided
to reflect the different patient profile in San Francisco as compared
to state and national averages. Commissioner Chow is trying to
understand what impact San Francisco’s different client population
has on our quality outcomes. The outcomes would seem to indicate that
we are not doing well in some areas. Our population is so different
from the national average; the average age is younger and there is a
higher portion of AIDS clients. Pam Bohman said that CMS is going to
develop risk-adjusted reports to take into account high-risk
population and things such as substance abuse and living alone.
Commissioner Chow would like a follow up report at the CHN Joint
Conference Committee on the quality indicators, and further discussion
about why San Francisco’s adverse events are higher than the
- Commissioner Umekubo asked how long it takes to do one OASIS
assessment. Staff responded that it takes 3-4 hours. The assessment
has to be done at the start of care, and a reassessment has to be done
every 60 days. Commissioner Umekubo asked the difference between
palliative care and hospice care. Dr. Rybold said the essential
difference is the regulations that govern the provision of hospice
care. Dr. Katz added that hospice is a specific Medicare and Medicaid
benefit, so there is some additional reimbursement, but many
regulations. Also, hospice does not work well for some of our patient
population. The same end results are achieved. Commissioner Umekubo
asked who signs the care plan. Dr. Rybold responded that sometimes the
attending physician signs, but there are times when the attending does
not feel comfortable signing off on a plan if the patient does not
have a primary care clinic. Most patients are followed by a primary
- Commissioner Parker is impressed by the number of volunteers they
have in the program.
- Commissioner Guy said that this presentation was presented at the
CHN Joint Conference Committee, and everyone is ecstatic that this
program exists. There are some questions that the Health Commission
needs to understand better, and there needs to be discourse at the
joint conference committee level, particularly about public health
nurses, quality assurance and space issues.
8) MEDICAL STAFF BYLAWS
Renee Navarro, M.D., Chief of Medical Staff, SFGH, presented the
proposed amendments to the Medical Staff Bylaws, Rules and Regulations,
Corrective Action and Hearing Manual, Credentialing Procedure Manual and
Committee Manual. Dr. Navarro said that the Medical Staff Bylaws Committee
met regularly over the past year to review and update the bylaws. Dr.
Navarro said that the bylaws committee obtained a copy of the evaluation
tool used by the California Medical Association and used this to make the
needed changes to the bylaws. The JCAHO mock surveyors reviewed the
document and did not find any serious problems or oversights. Dr. Navarro
said that that recommended changes reflect new areas of focus or verbiage
by the CMA and suggestions from the mock surveyors. The most significant
policy changes for the medical staff has been the change from Quality and
Utilization Management to Performance Improvement and Patient Safety.
- Commissioner Monfredini, chair of the San Francisco General Hospital
Joint Conference Committee, asked if the reporting structure to the
governing body has been addressed. Dr. Navarro said yes; the Chief of
Staff is responsible for reporting the activities of the Joint
Conference Committee to the medical staff and the Director of Health
is responsible for reporting to the Governing Body.
- Commissioner Umekubo said that he reviewed and asked questions of
these amendments at the San Francisco General Hospital Joint
Conference Committee and recommends approval of the amendments.
Action Taken: The Commission approved the Medical Staff Bylaws,
including the Rules and Regulations, Corrective Action and Hearing Manual,
Credentialing Procedure Manual and Committee Manual
9) PUBLIC COMMENTS
10) CLOSED SESSION
A) Public comments on all matters pertaining to the closed session
B) Vote on whether to hold a closed session (San Francisco
Administrative Code Section 67.11)
Action Taken: The Commission voted to hold a closed session.
The Commission went into closed session at 6:05 p.m. Present in
closed session were the Health Commissioners, except for Commissioner
Sanchez who was excused due to a conflict of interest, Deputy City
Attorney Joe Sandoval, Alison Moed, Gene O’Connell, Mitch Katz and
Michele Olson. Commissioner Monfredini left at 6:10 p.m.
C) Closed session pursuant to Government Code Section 54956.9 and San
Francisco Administrative Code Section 67.10(d)
Conference with Legal Counsel - Existing Litigation
Proposed settlement of a litigated claim for $500,000, Rosa Corrales
v. Regents of the University of California et al, San Francisco Superior
Court Case No. 315-584
D) Reconvene in Open Session
The Committee reconvened in open session at 6:20 p.m.
Possible report on action taken in closed session (Government Code
Section 54957.1(a)2 and San Francisco Administrative Code Section
Action Taken: The Commission (Chow, Guy, Jackson, Parker, Umekubo)
approved the settlement.
2. Vote to elect whether to disclose any or all discussions held in
closed session (San Francisco Administrative Code Section 67.12(a).).
Action Taken: The Commission (Chow, Guy, Jackson, Parker, Umekubo)
voted not to disclose discussions held in closed session.
The meeting was adjourned at 6:20 p.m.
Michele M. Olson
Executive Secretary to the Health Commission