Minutes of the Health Commission Meeting

Tuesday, May 16, 2000
3:00 p.m.

101 Grove Street, Room #300
San Francisco, CA 94102


The regular meeting of the Health Commission was called to order by President Roma Guy, MSW, at 3:08 p.m.


  • Commissioner Edward A. Chow, M.D.
  • Commissioner Roma P. Guy, M.S.W.
  • Commissioner Ron Hill
  • Commissioner Lee Ann Monfredini
  • Commissioner Harrison Parker, Sr., D.D.S.
  • Commissioner David J. Sanchez, Jr., Ph.D.
  • Commissioner John I. Umekubo, M.D.

President Guy requested a minute of silence in memory of Ella Wong, Administrative Secretary at Laguna Honda Hospital, who had an untimely death. On behalf of the Commission, President Guy extended its condolences to family, friends, and colleagues of Ella at Laguna Honda Hospital.

In honor of Emergency Medical Services Week, Dr. John Brown, Director of the EMS Agency; presented the following EMS Week Awards to:

  • Field Provider James Di Modica, King American Ambulance Co.
  • Hospital Provider Ann Stangby, RN, San Francisco General Hospital
  • Community Member Glenn "Raz" Raswyck
  • Special Recognition Acting Captain Dave Franklin, S.F. Fire Department
    (Accepting for Acting Captain Franklin was Battalion Chief Dough Goodin).

Dr. Brown also submitted to the Commission the May 2000 update from the EMS Section that contains the 1999 Emergency Medical Services System Summary.

President Guy announced a special Health Commission meeting on Tuesday, May 30, 2000 at 3:00 p.m., 101 Grove Street, Room 300, for the purpose of considering a proposed $97 million general obligation bond for the November ballot. This bond would improve facilities at SFGH and community clinics.


Action Taken: The Commission unanimously adopted the minutes of the meeting of May 2, 2000.

(Commissioner Ron Hill)

(3.1) Update on the California AIDS Intervention Center’s Contract. Commissioner Hill expressed his appreciation for the follow-up status of this contact.

(3.2) DPH-Central Administration – Request for approval to accept and expend $887,667 in funds from the Robert Wood Johnson Foundation (RWJF), to support an evaluation of the impact of local insurance expansion programs on health insurance status in San Francisco, for the period of July 1, 2000 through June 30, 2004.

(3.3) PHP-CMHS – Request for authorization to accept and expend $837,956 in funds from the California Department of Rehabilitation, San Francisco District, to provide vocational services to mentally ill psychiatric clients, for the period of July 1, 2000 to June 30, 2001.

(3.4) PHP-Community Health Epidemiology – Request for approval to accept and expend a new five year grant from the National Institute on Drug Abuse, in the amount of $1,054,979, for the creation of mathematical models of HIV virulence evolution and antiretroviral-resistance development and spread.

Action Taken: The Commission unanimously approved the Consent Calendar of the Budget Committee.

(Mitchell H. Katz, M.D., Director of Health)


The Governor’s May Revision to the State Budget

Yesterday, the Governor released the May Revision to his 2000-01 proposed State Budget. The May Revision includes revenue and expenditure estimates updated to reflect April’s tax receipts, updated caseload, enrollment and population information for programs, as well as changes to the Governor’s January budget proposals.

California’s revenues are projected to be $5.764 billion above the $5 billion anticipated by the budget proposed by the Governor in January, bringing California’s total surplus to nearly $11 billion for the remainder of FY 1999-00 and for FY 2000-01. Not surprisingly, education remains the Administration’s top priority with the May Revision proposing an increase of nearly $4 billion for K-12 education over the current and next fiscal years. The May Revision also provides $1.9 billion for a one-time prosperity dividend providing each single taxpayer with a $150 rebate and a $300 rebate for married couples filing jointly.

The Governor has proposed an additional $1.3 billion (in combined State and federal funds) for health and human services, reflecting an increase of approximately 2.3% over his January proposal of $56.6 billion. Approximately $800 million of the increase is in the area of health services. The Governor has indicated that all of California’s $389 million in tobacco settlement funds for 2000-01 have been allocated, along with the other General Fund revenues, for health service expansion. The following table shows the State General Fund portion of the changes proposed in the May Revision:

  General Fund Change for FY 00-01
Medi-Cal +$460.1 million
Public Health +$120 million
Managed Risk Medical Insurance Board +$58.7 million
Mental Health +$65.9 million
Alcohol and Drug Programs +$3.1 million
Prevention and Treatment Initiatives +$90 million
Total +$ million

Because the detail of the Governor’s May Revisions are not yet available reconciliation between the programmatic highlights and the fiscal summaries is difficult. Following summarizes the major additional proposals included for FY 2000-01.

  • Medi-Cal (+$460.1 million General Fund)
    • +$385.3 million for provider rate increases
    • +$25 million reduction to the State administrative fee paid by disproportionate share hospitals for a total FY2000-01 reduction of $55 million
    • +$115 million to eliminate the requirement that families provide quarterly status reports which will result in more families maintaining Medi-Cal coverage
    • Increased spending is offset by savings attributed to fraud prevention and increased drug rebates
  • Public Health (+$120 million General Fund)
    • +$30.2 million for a rate increase for CHDP, CCS, Adolescent Family Life Program and Primary Care Clinics
    • +$2.4 million for HIV/AIDS drug resistance testing
    • +$4.6 million for increased caseload and health care costs for the California Children’s Services (CCS) program, the Children’s Health Disabilities Program (CHDP) and Genetically Handicapped Persons Program (GHPP)
  • Managed Risk Medical Insurance Board (+$58.7 million General Fund)
    • +$59.2 million to provide coverage under Healthy Families for all 639,000 children estimated to be eligible
    • Allows Healthy Families health plans to assist families known to them with the Healthy Families and Medi-Cal for Children application processes
    • +$3.5 million for media outreach
    • Increases are offset by decreases in the Access for Infants and Mothers (AIM) program due to decreased enrollment
  • Mental Health (+$65.9 million General Fund)
    • +$35.6 million for each of the next three years for Integrated Services for Homeless Adults, a comprehensive mental health care model created by AB 34 (Steinberg) in 1999
    • +$15 million for supportive housing grants
    • +$11 million in new Substance Abuse and Mental Health Services Administration (SAMHSA) funds for the Integrated Services for Homeless Adults program, an Older Adult System of Care and the Youth Development and Crime Prevention Program
    • +$8 million for changes in mental health managed care, including an increase in eligible populations and a decrease in the Consumer Price Index
    • +$21.5 million (in federal reimbursements) for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program
  • Alcohol and Drug Programs (+$3.1 million General Fund)
    • +$1.1 million for a rate increase for Drug Medi-Cal service providers
    • +$2.8 million (in federal reimbursements) to expand drug and alcohol treatment to parolees
    • +$4.5 million from a new Substance Abuse Prevention and Treatment block grant for Youth Development and Crime Prevention
    • +$2 million for substance abuse prevention pilot programs serving low-income women on CalWORKs
  • Treatment and Prevention ($90.3 million General Fund)
    • +$60.3 million to backfill CHDP previously supported by Proposition 99 revenues
    • +$20 million for breast cancer treatment
    • +$10 million for prostate cancer treatment
    • +$8.9 million for smoking cessation (supported by Proposition 99 funds)

The May Revision adopts components of several active legislative proposals. If these provisions of the Governor’s proposal are adopted, it is likely that the specific bills that address these changes will stop moving through the legislative process. It is important to note that these proposals do not necessarily comprise the budget that will ultimately be enacted. The Legislature works on budget issues on a parallel track with the Administration. In late May and early June, the Administration and the Legislature will meet to negotiate and finalize the State budget for FY 2000-01. The Department will continue to keep abreast of budget issues that affect San Francisco.

Charity Care Hearing

Last week the Board of Supervisors held a hearing on charity care provided by private non-profit hospitals in San Francisco. At the hearing labor leaders and community groups criticized the City’s private non-profit hospitals for not providing enough care for the poor and indigents. Representatives of the hospitals defended their level of care and provided evidence of their involvement in community benefits.

Non-profit hospitals receive tax exemptions from real estate taxes. In return they are ethically required to provide a non-specified public benefit. The appropriate level of public benefit has never been specified. There has also been quite a lot of debate about what should be considered "community benefits". At one extreme everyone would agree that providing medical care for indigents is charity care. At the other extreme some question whether benefits such as blood pressure screening at shopping malls should be considered community benefits because they also serve to provide useful marketing for hospitals.

The Health Department was asked to provide technical support on the appropriate definitions of charity care and to provide recommendations to the Board of Supervisors on this area. In addition, there is a statewide task force looking at uncompensated charity care. Ken Jensen and Tony Wagner from our CHN sit on this Task Force.

Strategic Planning Update

Since my last update to the Health Commission regarding the Department’s strategic planning initiative several activities have taken place.

The Populations and Programs Subcommittee has developed draft priorities for the programs the Department should provide, based on its previous recommendations for populations the Department should serve. The Subcommittee anticipates presenting its recommendations to the Steering Committee on June 14, 2000. In addition, the Subcommittee has drafted another component of its work plan on how to evaluate the effectiveness of the strategic planning initiative. Both the program priorities and evaluation will be presented to the Steering Committee for approval. Plan implementation guidelines have been developed by the Steering Committee and are being routed to the Subcommittees for review and comment.

The second installments of the monthly community and staff strategic planning informational flyers are being prepared for distribution throughout the City and Department respectively. The Health Commission will receive copies. Over the past month, the Steering Committee co-chairs have presented the Department’s strategic planning initiative to three community advisory boards (Tom Waddell Clinic, Long Term Care Pilot Project, HIV Prevention Planning Council). In addition, strategic planning presentations were given to the Department’s contractors and SFGH medical service chiefs. A town hall meeting for SFGH staff will be held tomorrow, Wednesday, May 17, 2000 at the Carr Auditorium from 1:30 – 3:00 p.m. Additional meetings with community advisory boards are set for the next two weeks and community town halls in four additional supervisorial districts are being planned for June 2000.


Community Health Promotion and Prevention

The Community Health Promotion & Prevention Branch has been awarded a two-year grant of $93,755 from the California Telehealth and Telemedicine Center. This grant will address the digital divide by developing telehealth capacity for African Americans in San Francisco. The project will result in an Internet presence for African American community groups, who will collaborate with DPH in developing and maintaining their own health-related Web pages. Congratulations to Brian Katcher, who wrote the grant and will be overseeing its implementation

HIV Health Services

Laura Thomas, Planner for the HIV Health Services Section will be receiving an AIDS Hero Award for her longtime and courageous service to the HIV/AIDS community at the AIDS Candlelight Memorial on Wednesday, May 17, 2000.

STD Prevention and Control

STD education and urine screening was offered at the CATS nightclub on several weekends during April and early May, starting April 16th. Youth and young adults, one of the highest risk groups for STDs, frequent the nightclub. The event was written up in the SF Examiner/Chronicle, was featured on all major TV stations, is one of this week’s feature stories in Newsweek magazine and is highlighted on WebMD.


Status of Psychiatric Beds at SFGH

As the Commission is aware, the budget that the Department submitted to you in February 2000 included a plan to move patients who were no longer acutely in need of psychiatric hospitalization to more appropriate levels of care. SFGH psychiatric ward had a large number of such patients because of a number of factors including a shortage of viable alternative placements. In the budget we created a set of alternatives including supportive housing, placements in IMDs, board and care placements, and a specialized unit at Laguna Honda Hospital.

Although there has been tremendous enthusiasm for the creation of appropriate alternatives for people who no longer need acute hospitalization, there has also been dismay about the loss of psychiatric beds at SFGH. Last week the Mayor convened representatives from the psychiatric ward at SFGH, Supervisors Ammiano, Becerril, Kaufman, Newsom and Yaki as well as the Controller, Monique Zmuda and myself.

At the meeting the Mayor expressed his conviction that people should be cared for at the most appropriate setting. To prevent the ward from closing, however, he recommended that we hospitalize at SFGH Medi-Cal and Medicare patients who would have once been transferred to one of the private non-profit hospitals because of insufficient space at SFGH. He further agreed to pay the difference between what the other non-profit hospitals charge us and what it would cost us to care for these patients at SFGH.

At this point the plan is to fill the 21 beds with paying patients. Although we are still finalizing the numbers, we estimate that $1.8 million in revenue will be generated by the Department of Psychiatry, $400,000 of funding for private hospitals will be transferred from Mental Health to SFGH, and a new general fund allocation of $800,000 will be made to pay for the additional cost to provide inpatient services at SFGH. This assumes that the hospital is able to maintain the improved acuity rate (decreased administrative days and decreased decertified days) they have been doing in recent months. If the ward is not able to maintain the improved acuity rate, and if the number of decertified and administrative days climbs again, $800,000 will not be enough to maintain the ward and we would have to again look toward closing it and once again sending these patients back to private non-profit hospitals.

The Mayor’s Office and the Controller’s Office have informed us that half of the money will be kept on reserve. And the Department of Psychiatry will be required to report on its ability to meet the performance goals. The Psychiatry Department will be asked to go before the Finance Committee to release these dollars.

San Francisco Stunned by Tragedy

The entire City of San Francisco was shocked and saddened by the tragic murder of Ella Wong. Ella had been the LHH Administrative Secretary since March 1999. Ella was well liked and well respected by fellow staff members. LHH held a memorial service for Ella, attended by Health Commissioners Roma Guy and Lee Ann Monfredini. Contributions can be made in Ella's memory to the American Diabetes Association. I am sure you join me in wishing our sincere condolences to Ella’s family on their tragic loss.

Laguna Honda Hospital Pharmacy Services

The Clinical pharmacy services and the geriatric pharmacy teaching program at Laguna Honda Hospital were featured in a recent edition of UCSF Magazine. Subtitled, "What is Aging?" the March 2000 edition of the magazine focuses on research and health related issues of aging. The article on pharmaceutical services at Laguna Honda Hospital spoke to the medical complexity of patients cared for within the CHN, and the commitment of CHN staff to improve our patients' quality of life.

Maxine Hall Health Center's Appreciation Day.

Maxine Hall Health Center recently held its 5th Annual Staff Appreciation Day. The event sponsored by the Centers management team, combines general staff appreciation, with Nurses and Secretaries Week. The management team prepares and serves food to the entire staff. Following the brunch, a staff initiated auction was held to raise funds for the teen clinic. The event, which included a white elephant auction, raffle, donation of personal services (gardening, baked goods, foot massage, quilting, etc.) raised over $1,000. Special thanks to Dody Domish, Dr. Nina Weiss, Sue Thornley and Monique El Amin for a superb job in organizing the fundraising event.

2000 San Francisco Lesbian, Gay, Bisexual, Transgender Pride Parade

Bring your family and friends and march with the DPH contingent at the San Francisco Pride Parade celebration on Sunday, June 25th at 10:30 a.m. Share the experience of hearing people cheer and seeing their smiles when our contingent proudly walks down Market Street! Contact Arla Escontrias, at 206-2332 for more details, pager (650) 997-4264, email arla_escontrias@chnsf.org

SFGH Credentials Report


2000 YTD

New Appointments












Reappointment Denials






Disciplinary Actions



Restriction/Limitations – Privileges



Changes in Privileges



   Voluntary Relinquishment



A special Certificate of Appreciation from George Smith, Mayor’s Office Homeless Coordinator, was presented to Willie Crawford, Facilities Manager for 101 Grove. Mr. Crawford was not only instrumental in assisting the Mayor’s Office to conduct a training session for census takers for the homeless population, but also he had been extremely helpful in setting up the temporary Mission Rock Shelter for the homeless.

Commissioner Chow pointed out that Dr. Katz’s description and explanation on the issue of the 21 SFGH patient psychiatry beds is very accurate in comparison to the newspaper coverage. Commissioner Chow requested, upon completion of the City budget process, an update on the cultural competency capacity in relation to the 21 psychiatry beds.

Commissioner Chow inquired whether a document on charity care was available from the private sector hospitals, (i.e., Hospital Council). He suggested, at the appropriate time, an agenda item on charity case be calendared for a Commission meeting.

Commissioner Umekubo commented that the public and private hospitals need to discuss and collaborate on the issues and definitions around charity care.

Dr. Katz stated the Department will be providing any technical information on charity care, both to the Commission and the Board of Supervisors.

President Guy reinforced the Commission’s support for the appropriate level of care for patients coming into SFGH and the CHN system.


On behalf of the Commission, President Guy presented the May Department of Public Health Employee Awards to the following:

Individual Nominee Division Nominated by
Susan Langdon San Francisco City Clinic, STD Prevention and Control, Population Health and Prevention Wendy Wolf, Deputy Director, STD Prevention and Control
Nora Macias " " " " " "
Team Nominees Division Nominated by
Paul Carlisle, MPT, GCS Rehabilitation Center, Laguna Honda Hospital Patrick Monette-Shaw, Secretary II, Rehabilitation Center, Laguna Honda Hospital
Marilyn Brandt, MS, OTR " " " "
Pamela Horenstein, MS, CCC, SLP " " " "
Lisa U. Pascual, MD " " " "

Commissioner Hill left at 3:45 p.m.


Jimmy Loyce, Deputy Director of Health, and Dr. Melissa Welch, Chief Medical Officer of the CHN, presented the work of the Bridge Committee, which formed as a result of a recommendation from the Reducing Reliance on Institutions meeting in January 1999. The Bridge Committee, chaired by Dr. Welch, brought together staff within the CHN working with the most medically and psychiatrically complex patients. A copy of the full report is available in the Commission Office.

The Bridge Committee’s first year report included the following:

  1. Background
  2. Principles, Change and Membership
  3. Scope of Work
  1. Resource Sub-Committee
  2. Placement Sub-Committee
  3. Other Focused Work
  1. Laguna Honda Screening Process and Special Units
  2. Mental Health Rehabilitation Facility
  3. Conservatorship task Force
  4. Site Visits
  1. Medical Hills
  2. Napa State Hospital
  1. New Models of Care
  1. Policy Issues and Recommendations

Policy Issues

  1. What is the availability of GAP dollars (Patch) and expansion of those dollars for next fiscal year 2000/01?
  2. How do we address the interfacility issue with private hospital)(s) stabilizing then referring or refusing to accept patients who are unsponsored or who are sponsored and are likely to be difficult to place? Are there EMTALA issues here"
  3. How do we determine residency status of patients who are previously San Francisco residents but have been in long term care in another County?


  1. The final disposition of a Bridge patient should continue to rest at the Placement Committee (or Bridge) level, per the Director’s Policy Statement in May 1999.
  2. DPH should charge a work groups to do a financial analysis to determine whether it is more cost effective to continue to patch patients or to create a model of care to address the needs of patients who need a locked unit/facility. This group should also explore any opportunities for waiver initiatives that would allow leveraging of funds.
  3. DPH, as an interim strategy, should allocate funds to continue to patch the most difficult to place patients, especially those who need locked or Napa level of care.
  4. DPH should further explore use of MHRF to meet the needs of a subset of difficult to place patients, recognizing that issues of relocation of CHMH patients currently at the MHRF would need to be addressed.

Attachments to the report included:

  • Bridge Committee Work Plan
  • Inventory of residential settings operated and/or funded by DPH
  • Resource/patient information form
  • Summary prior to DPH work with difficult to place patients
  • Patient placement Sub-Committee
  • Group identified as difficult to place
  • Criteria for referrals to Bridge Committee
  • Persons designated to make referrals to Bridge Committee
  • Referral Form
  • Referrals
  • Clinical, demographic and behavioral characteristics of Bridge patients
  • Admission referral process and personnel for LHH
  • MHRF information
  • Bridge models and issues

Dr. Welch and Mr. Loyce would like the Bridge Committee to continue resolving the ongoing and critical issues of the most difficult to manage patients. The Committee will look at issues of non-bed resources, intra-agency collaborations, cost benefit analysis of new models of care and ongoing special housing needs.

Commissioners’ Comments:

  • Take objective look at cohort of providers and existing support services; see if new pathways are needed
  • Great report; supports work and recommendations of the Bridge Committee
  • Very difficult job in placing complex patients; things will improve with the Bridge Committee work
  • Include the inventory of services from the Homeless Task Force
  • MHRF needs to the re-examined, looking at its original criteria; presentation to the Commission could be a future agenda item

Dr. Welch pointed out the high utilizers of SFGH inpatient services and the Bridge Committee patients are two different populations.

Dr. Katz commended the Bridge Committee for its work and emphasized this is another step towards integration and intra-department problem-solving, with the goal of doing better for the patients.

President Guy thanked the staff for an excellent presentation. She pointed out the work of the Bridge Committee reflects the Commission’s direction for the Department to act as one Department, and to be patient-driven. She expressed her sincere appreciation for all of the contributions by the members of the Bridge Committee. She is deeply encouraged by their work.


Gene O’Connell, Executive Administrator for SFGH, introduced Dr. Talmadge King, Chief of Service, and Dr. Alicia Fernandez, Director of Inpatient Medical Services, who conducted research on high utilizers of SFGH Medical Inpatient Services. Their findings reinforce the previous policy direction set by the Commission to focus on supportive housing and community alternatives to hospitalization.

A copy of the slide presentation is available in the Commission Office.

Dr. Fernandez highlighted the following areas:


  • High Utilizers (HU) comprise 13% of patients yet account for 35% of admissions and bed-days
  • High utilizers utilize CHN resources about five times more than Non-High Utilizers (NHU), and Emergency Department (ED) and Primary Care Clinics (PCC) three times as much
  • HUs are diverse, and disproportionately African-American, young, male
  • Drug addiction is the most prevalent diagnosis


  • Interaction of clinical and social issues determines high use
  • HU have access to care, yet have unmet needs
  • HU demonstrate the limitations of a biomedical model of care, as opposed to a biopsychosocial model of care

Specific Objectives

  • Define magnitude of "high use" of SFGH medical inpatient services
  • Examine HU use of CHN, ED and PCC
  • Describe demographics of HUs: housing status, gender, age, race
  • Describe clinical problems of HUs
  • Understand role of co-morbidities of high utilization
  • Understand role of homelessness in high utilization
  • Determine stability of HU population from year-to-year

Future Directions

  • Develop HU prediction rule
  • Natural history study of HU: what happens in year two?
  • Intervention trial of medical, social or case management services
  • Patient survey of HUs
  • Working conference to improve care

Dr. Fernandez invited Commissioners to attend the following a one-day conference:

Title: Creating a Coordinated System of Care for High Utilizers of the SFGH In-Patient Medical Service

Date: Monday, June 26th, 8:30 a.m. to 4:30 p.m., Laurel Heights Conference Room


  • Department of Medicine
  • Department of Psychiatry
  • Department of Family Medicine


  • CHN/SFGH Acute Services
  • CHN Primary Care Service
  • UCSF Dean’s Office
  • S.F. Department of Public Health

Participants: Staff from acute clinical services, outpatient’s services, psychiatric services, social services, housing, etc.

  • The Conference goals are to:
  • Discuss unmet clinical needs
  • Discuss unmet social needs
  • Improve coordination between services
  • Expand discussion of clinical pathways for specific disease entities
  • Expand discussion of pathways for specific social/medical problems

Note: Commissioner Monfredini left at 5:15 p.m.

Commissioners’ Comments and Questions:

  • What are the costs for high utilizers?
  • This research helps to dispel myths about these patients
  • Need to address the whole patient-physical and psychosocial needs
  • Need to have integrated programs
  • Urged the inclusion of community clinic staff into these discussions
  • Appears to be a disconnect when a patient has a physician and an address
  • Compliance is an important part of medical care

Dr. Fernandez pointed out that the data show primary care alone is not enough; there are psychosocial needs that also have to be addressed:

  • Mental health and substance abuse issues complicate the needs of patients
  • Encouraged use of field clinics where the patients are
  • Presentation shows excellence in research and cultural competency and being inclusive
  • To reduce high utilization, need to reduce alcoholism, substance abuse, and aging (i.e., the social ills of society) and bring them into control
  • Lack of ongoing support for high utilizers
  • Look at co-location of mental health and primary care (i.e., example at Maxine Hall Health Center)

President Guy thanked Dr. Fernandez and Dr. King for the informative presentation and encouraged them to move forward with their research.



The meeting was adjourned at 6:05 p.m.

Sandy Ouye Mori, Executive Secretary to the Health Commission