Minutes of the Health Commission Meeting Tuesday, January 9, 2001 3:00 p.m. at 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The regular meeting of the Health Commission was called to order by President Roma P. Guy, MSW, at 3:05 p.m. Present: Commissioner Roma P. Guy, M.S.W. Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sanchez, Jr., Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Edward A. Chow, M.D. Due to the public disturbance at the December 12th meeting, the Commission continued the presentation of the Department of Public Health Employee Recognition Award. On behalf of the Commission, President Guy presented the award to: David Cassell, Senior Psychiatric Social Worker, Community Mental Health, Quality Management .  Nominated by Bill McConnell, Associate Director of Quality Management 2) APPROVAL OF THE OF MINUTES OF THE REGULAR MEETINGS OF DECEMBER 5 AND 12, 2000 Action Taken: The Commission unanimously adopted the minutes of December 5 and 12, 2000. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE (Commissioner David J. Sanchez, Jr., Ph.D.) (3.1) AIDS Office – Request for approval of a contract renewal with Better World Advertising in the amount of $120,000, for the provision of HIV prevention social marketing and media development services, for the period of January 1, 2001 through December 31, 2001. (DPH contracted with Better World for services totaling $ 99,774 during FY 1999-2000). (3.2) AIDS Office – Request for approval of a contract renewal with Haight Ashbury Free Clinics Inc. (HAFC) in the amount of $105,649, for the provision of HIV prevention outreach services targeting women, for the period of January 1, 2001 through December 31, 2001. (DPH contracted with HAFC for services totaling $9,781,206 during FY 1999-2000). (3.3) AIDS Office – Request for approval of a sole source and a new contract with Survey Methods Group in the amount of $151,200, to provide San Francisco Behavioral Risk Factor Survey services, for the period of January 1, 2001 through June 30, 2001. (3.4) PHP-CMHS – Request for approval of a retroactive contract renewal with San Francisco Psychoanalytic Institute and Society (SFPIS) in the amount of $93,240 per year for a total contract amount of $372,960, for the provision of Quality Child Care Consultation Services targeting center-based and family child care providers, for the period of July 1, 2000 through June 30, 2004. (DPH contracted with SFPIS for services totaling $80,000 during FY 1999-2000). (3.5) PHP-CMHS – Request for approval of a retroactive contract renewal with Homeless Children’s’ Network (HCN) in the amount of $142,889 per year for a total contract amount of $571,556, to provide Quality Child Care service targeting center-based and family child care providers and therapy to homeless children in shelters, for the period of July 1, 2000 through June 30, 2004. (DPH contracted with HCN for services totaling $130,532 during FY 1999-2000). (3.6) PHP-CMHS – Request for approval of a retroactive contract renewal with the Regents of the University of California San Francisco, Clinical Practice Group, in the amount of $2,511,814 to renew the Single Point of Responsibility Program serving severely mentally ill adults, for the period of July 1, 2000 through June 30, 2001. (DPH contracted with Regents UCSF for services totaling $13,999,667 during FY 1999-2000). Commissioner Sanchez abstained due to conflict of interest. (3.7) PHP-CMHS – Request for approval of a retroactive contract renewal with Westside Community Mental Health Center, Inc. (WCMHC), in the amount of $1,627,993, to renew a Single Point of Responsibility program serving severely mentally ill adults, for the period of July 1, 2000 through June 30, 2001. (DPH contracted with WCMHC for services totaling $9,996,940 during FY 1999-2000). The Department reported improvements by the contractor for this program. (3.8) PHP-CMHS – Request for approval of a retroactive contract renewal with Children’s Council of San Francisco (CCSF), in the amount of $171,760 per year for a total contract amount of $687,040, for the provision of Quality Child Care Consultation Services targeting center-based and family child care providers, for the period of July 1, 2000 through June 30, 2004. (DPH contracted with CCSF for services totaling $151,000 during FY 1999-2000). Action Taken: The Commission approved the consent calendar of the Budget Committee, with Commissioner Sanchez abstaining on #3.6. 4) FOR DISCUSSION: DIRECTOR’S REPORT (Mitchell H. Katz, M.D., Director of Health) ADMINISTRATION My Month on the Medical Wards of San Francisco General Hospital As in past years, I very much enjoyed attending on the inpatient ward at San Francisco General Hospital. My annual December stint at the hospital keeps me in touch with the clinical and social needs of our patients, as well as the challenges and successes of our staff. Overall, I think there is no better public hospital in the United States for delivering humane, culturally-competent, and cost-effective care. Compared to prior years, I believe there has been significant improvement in our ability to care for patients in the most appropriate settings. Physician, nursing, and social work staff have greatly improved coordination of discharge options for our patients. Our policy of making the patients of SFGH the first priority for our other DPH facilities, including Laguna Honda, the MHRF, our supportive housing programs, and substance abuse programs has made it markedly easier to move patients across our continuum of care, resulting in better service and lower costs. Our new initiatives, especially the soft-tissue infection clinic, which I visited during my attending month, have also helped to decrease the need for acute hospitalization while improving the quality of our care. One area where I noted greater difficulty than in past years is in hiring sufficient nursing staff. As the Commission is aware, there is a national nursing shortage. Moreover, the high cost of living in San Francisco, has made it less attractive for nurses to move here to take jobs. The result has been that we have not been able to hire as many nurses, or hire them as quickly, as we would like to. It is not a financial issue; it is a human resource issue. Some new initiatives, such as the discharge lounge, may help us to decompress the hospital so that we have more available staffed beds for those patients who need it, but this alone will not be sufficient. Ms. O’Connell is currently researching a variety of short and long term strategies, including having a nurse recruiter at the hospital and identifying sleep rooms for travelling nurses. It is likely that until we have additional intensive care nurses, we will need to use the Recovery Room for patient overflow. I want to again thank the Health Commission for giving me the opportunity to nourish my clinical life, and my terrific staff for filling in for me on days when I did not get back to the office till after dark. Federal Budget On December 21, President Clinton signed an omnibus appropriations bill that included a $108.9 billion Labor-Education-Health and Human Services spending bill. The bill included a Balanced Budget Act relief package, provisions to expand health coverage to children, increased funding for HIV/AIDS services, and specific earmarks for health services in San Francisco. In total, the federal government enacted a record budget of $634 billion for FY2001. The Benefits Improvement and Protection Act of 2000 (BIPA) provides $35 billion over the next five years to increase provider payments for hospitals, nursing homes, home health agencies, managed care plans and other providers that were disproportionately affected by the Balanced Budget Act of 1997. The beneficiary improvements include an additional year extension of Medicaid coverage for people leaving welfare for work and expansion of preventive benefits to Medicare beneficiaries. Further, BIPA permits states to enroll uninsured children into the Medicaid or S-CHIP programs at schools, child support enforcement agencies, homeless shelters, public housing projects, and other sites. To grant providers needed relief from the effects of the Balanced Budget Act of 1997, BIPA freezes the cuts that were scheduled for 2001 and 2002 in the Medicaid Disproportionate Share Hospital (DSH) program, implements a new cost-based prospective payment system for federally qualified health centers (FQHCs), and provides that states will have to cover the difference between managed care reimbursement and costs for FQHCs. Funding for HIV/AIDS services under the Ryan White CARE Act were increased by $213 million over last year's allocation, bringing the total budget for the CARE Act to $1.8 billion for fiscal year 2001. Funding for AIDS-related research at the National Institutes of Health was increased by $261 million. The omnibus spending bill also included two earmarks for health care in San Francisco. The appropriations bill provides $1.105 million for San Francisco's Treatment on Demand Initiative and $1.105 million for HIV/AIDS care for women and people of color at San Francisco General Hospital. Congresswoman Nancy Pelosi was instrumental in ensuring that funding for these critical health care programs were included for San Francisco. Governor Davis’ State of the State Address Last night Governor Gray Davis gave his annual State of the State Address. The State of the State Address provides a framework for how the Governor will approach his proposed budget. The Governor will release his proposed 2001-02 budget on Wednesday, January 10, 2001. The State of the State Address focuses on the following areas: (1) energy, (2) education and (3) accomplishments over the past two years of the Governor’s administration. With respect to health care, the Governor’s comments were limited to the Healthy Families Program. As noted in this Director’s Report, the State has submitted a proposal to expand the Healthy Families Program to parents of enrolled children. The Governor restated his commitment to ensuring expanded coverage for this uninsured population. The Governor anticipates providing health care coverage for 290,000 currently uninsured working parents. The Governor stressed that while California’s economy remains "fundamentally strong," he also indicated that our economy was re-stabilizing and that "fiscal constraint is more important than ever." Those comments may set the stage for how expansive the Governor will be in the area of health services beyond expansion of the Healthy Families Program. Other key components of the Governor’s State of the State Address were: a $1 billion set aside to stabilize the supply and price of electricity and an extension of the public school year by 30 days. The Department will continue to keep the Health Commission apprised of any development that occurs as the Governor releases his proposed 2001-2002 Budget and that budget winds its way through the legislative process. Proposition 36 Update On Tuesday, January 2, 2001, the California Department of Alcohol and Drug Programs (DADP) released the figures for the FY2000-01 funding allocation to counties under Proposition 36. Called the Substance Abuse and Crime Prevention Act of 2000, the initiative provides $60 million statewide in the current fiscal year for start-up costs and $120 million annually thereafter for drug treatment services in FY 2001-02 through FY 2005-06. San Francisco will receive $2.3 million for this fiscal year. The allocation formula developed by DADP is based 50% on population, 25% on drug arrests and 25% on current drug treatment caseload. This formula applies specifically to FY 2000-01 and it is unclear whether a different formula will be developed for future fiscal years. In order to receive funds, counties must submit to DADP a Board of Supervisors resolution that: designates a lead agency within the county; specifies the county's agreement to comply with the provisions of the Act; and assures the establishment of a local trust account for Proposition 36 funds. Department staff are working with the District Attorney, Board of Supervisors, the Mayor's office and other affected departments to expedite compliance with these requirements and ensure that any future funding formula is based upon need. Healthy Families Expansion I am pleased to report that on December 20, Governor Davis submitted an 1115 waiver demonstration for the Healthy Families program to the federal Health Care Financing Administration. The waiver proposes to extend Healthy Families coverage to the parents of Healthy Families or Medi-Cal eligible children. The Department fully supports an extension of the Healthy Families program. By expanding health care coverage to parents, the State’s objectives are to increase the number of children in Healthy Families by offering parental coverage, improve the health status of families, and provide coverage to uninsured Californians who do not have an affordable insurance option available to them. Key points of the program proposal include: Covering parents up to 200% of the federal poverty level The State anticipates coverage for almost 300,000 parents in California. Parents will qualify for Healthy Families without regard to family assets; therefore some parents who do not qualify for Medi-Cal due to their assets may qualify for Healthy Families. Benefits mimic the state employees’ benefit package, including dental and vision. Parents will pay monthly premiums of $20 or $25 per adult based on the family’s income, and receive a $3 discount for choosing the Community Provider Plan. Parents with employer-sponsored coverage in the past three months will not be eligible for Healthy Families coverage. If this waiver is approved by the federal government in February 2001, then the State anticipates implementing the program July 2001. The State is holding two forums to receive public input on the waiver proposal. As with the initial planning and implementation of Healthy Families, the Department will comment on this new expansion. The Department will keep the Health Commission informed of this effort as it proceeds. Long-Term Care Innovation Grant On January 2, 2001, as part of the Governor’s Aging with Dignity Initiative, the California Department of Aging selected the San Francisco Department of Aging and Adult Services to receive a $1.7 million Long-Term Care (LTC) Innovation grant award. The proposal funded by this grant (one of over 190 submitted) was developed jointly by the Department of Public Health and the Department of Aging and Adult Services. The proposal is for the development of SF-GetCare: A Web-Based Information System for Integrating Community-Based Long-Term Care Services in San Francisco. SF-GetCare will increase access to community-based LTC services, ensure appropriate service placement, and enhance overall LTC system efficiency and quality of care. The collaborative partner for this project is RTZ Associates, an information technology firm with a background in program-based, policy-oriented research and consulting exclusively for the community-based LTC industry. The Department of Public Health will also be a collaborative partner. Bill Haskell, the LTC pilot project coordinator, will be funded through this grant. He will act as a liaison between: (1) RTZ Associates; (2) the Department of Aging and Adult Services; (3) the Department of Public Health; (4) the LTC Pilot Project Task Force; (5) the California Department of Aging; and (6) the California Department of Health Services, Office of Long-Term Care. The grant runs for 17 months, from February 1, 2001 to June 30, 2002. This award represents a real opportunity to improve San Francisco's LTC service delivery system. POPULATION HEALTH AND PREVENTION McKinney Funding The City and County of San Francisco was awarded $14.9 million in McKinney Homeless Assistance funds. It was a dramatic increase from last years approximately $6 million. All of this money goes to renewing grants to projects funded in previous rounds. Many projects important to the Department and the clients we serve received renewal funding including transitional housing for homeless families with mental health issues, safe haven housing for multiply diagnosed women, residential services for youth, housing for victims of domestic violence, employment services for homeless people, housing for veterans. There were several projects that did not receive renewals. One that is of particular concern to the Department is the Dolores Hotel, a transitional housing project for persons with Mental Illness. We will be exploring alternative funding sources to ensure that this project remains viable. Balboa High School Shooting On Wednesday 1/3/01, DPH was notified by a psychiatrist at the Children's System of Care unit that there has been a shoot-out at Balboa High School and that the entire school was locked down. The Police Department asked for activation of the DPH counseling response plan. LaDonnis Elston and Sai-Ling Chan-Sew and the Child Crisis staff went to the school immediately, attended a de-briefing meeting with parents and youth who witnessed the incident. With the mobilization of almost the entire staff from Child Crisis (10 staff), CMHSprovided extensive grief counseling and de-briefing services. Staff from the School Health Office and the Balboa Teen clinic were also involved. Word from the SFPD (Sgt. Jerry Salvador in Special Ops) was that the DPH response was invaluable. January is Chlamydia Screening Month In collaboration with the San Francisco Health Plan, which has declared January to be Chlamydia Screening Month, the STD Program prepared STD packets which are to be distributed to 100 Health Plan providers. The packets contain information about City Clinic, STD fact sheets, CDC Treatment Guidelines and a letter asking providers to participate in Chlamydia Screening Month by screening their eligible clients for chlamydia. CSAS - Bridging the Gap Conference On January 11th and 12th the San Francisco Department of Public Health will present Bridging the Gap in San Francisco: Harm Reduction Research, Policy and Practice. The Conference will feature speakers from around the country and will examine a wide range of issues related to harm reduction. I want to thank Alice Gleghorn and her staff for all of their work on the conference. COMMUNITY HEALTH NETWORK January 3, 2001 San Francisco General Hospital Plant Services Incident Report During the scheduled commercial power failure drill conducted at 0630 on Wednesday Jabuary 3, 2000, an internal emergency power distribution buss failed. This resulted in partial power failure in critical areas of the Hospital for a duration of ten hours. This was not a complete failure of the power system.. The areas that experienced a partial power loss are: the Emergency Department; Trauma Rooms 1 & 2; Stat Lab; Clinical Laboratory; ICUs 5E (3 rooms) & 4E 4 rooms); 6C, Nuclear Medicine; 1st Floor Pharmacy; Operating rooms 5, 6, 7, and 8; Cysto Room 1 and 2; paging server, and the Cat Scan in Radiology. 0730 - 0830 auxiliary power was supplied to critical areas through extension cords. The cause of the failure were fatigued lug nuts securing the three-phase buss into the emergency power switchgear, F4-4. Due to expansion over time and cyclic fatigue the bolts became loose and the subsequent heat generated caused extensive arcing. This caused the buss to fail. Replacement may take as long as 6 weeks to complete due to the availability of the parts. Temporary repairs have been complete and power was restored by 1630 with an all clear to the building occupants by 1730. Preventative maintenance measures failed to identify this buss as a possible problem. A review of these measures is underway. Plans to survey and inspect the entire Hospital distribution system is also underway. Expanded Services for Employee Needlestick Hotline The Occupational Health Service [OHS] at SFGH in collaboration with the Worker's Compensation Division of the City & County of San Francisco is offering a new service to all CCSF employees. The Needlestick Hotline which was previously only available to DPH employees will now be open to employees of all City Departments on a 24 hour basis. [Hotline number is 415-469-4411]. OHS clinicians with experience in occupational infectious diseases will provide coverage for this new program. For more information please call Maggie Rykowski, RN, MS, OHS Director, at 206-4294. SFGH Bed Utilization Committee Report The Bed Utilization Committee was convened in 8/00 in anticipation of a high winter census and charged with developing strategies for improving patient flow, decreasing patient wait times in the Emergency Department, and maximizing efficient bed utilization. The Committee included representatives from nursing, Medical Staff, Quality management, Utilization Review, Social Services, Pharmacy, and Environmental Services. Highlights of the Committee’s work include: The Patient Discharge Lounge was opened on 12/11/00. A comfortable environment is provided for patients waiting for discharge medications, transportation, and placement reservations. 15-18 patients have utilized the Lounge every week since opening. The Pharmacy developed an internal "alert" system to prioritize discharge prescriptions processing and worked with the Messenger Service to expedite the delivery of medications to the Patient Discharge Lounge. A "Condition Yellow" algorithm was developed to address immediate patient flow issues when 10 or more patients are waiting in the Emergency Department for bed placement. The hospital has only needed to implement "Condition Yellow" twice. A "Condition Red" algorithm has been drafted to address immediate patient flow issues when all the following conditions occur: 10 or more patients are waiting for bed placement, the post anesthesia recovery area is at capacity and only one critical care bed is available with no pending transfers. When the above conditions exist indicating that the hospital has marginal capacity to accept incoming patients, a "Condition Red" and internal Level 1 Disaster will be initiated by the Administrator on Duty to focus and further identify resources needed to address the critical patient flow issues. The "Condition Red" draft will be reviewed by the Medical Executive and Hospital Executive Committees in January. As a result of the Bed Utilization Committee’s work, Alan Gelb, MD, Chief of Staff reported that no patients have waited over 24 hours in the Emergency Department and total diversion has steadily decreased over the last 3 months. In addition, since September 2000, none of the Operating Room cancellations are due to PACU bed unavailibility. The Bed Utilization Committee will continue to monitor events in January and February to determine if the strategies implemented are sufficient. SFGHMC Annual Skilled Nursing Facility Survey On Wednesday, January 3rd, the California Department of Health Services began their Annual unannounced Licensing and recertification survey of San Francisco General Hospital Medical Center's Skilled Nursing areas that includes Unit (4A) and the Mental Health Rehabilitation Facility. This is a five day survey which will conclude on Tuesday, January 9th. I will continue to update the Health Commission as more information becomes available at the conclusion of the survey. Commissioner Parker requested clarification of the Proposition 36 allocation to San Francisco. He also commented that the shortage of nurses has always been a problem and should have been addressed years ago. Commissioner Umekubo inquired about the short term and long term solution for the nursing shortage and other labor areas (i.e., pharmacists). He also asked about improvements in the enrollment to the Healthy Families Program in San Francisco. Commissioner Sanchez pointed out the need for dialogue with the State and nursing schools on recruitment programs for nursing and pharmacy. President Guy commented on the need for academic and citywide pressure on the nursing shortage. She also questioned whether the expansion of coverage of parents on the Healthy Families Program would result in increases in enrollment. 5) PRESENTATION OF JAIL HEALTH SERVICES Dr. Melissa Welch, CHN Chief Medical Officer, introduced Dr. Joe Goldenson, Medical Director of Jail Health Services; and Jo Robinson, Assistant Director of Jail Health Services and Director of Jail Psychiatric Services. They presented a summary of health care services provided through Jail Health Services of the CHN, background information on Correctional Health Care, and a summary of FY 2001-02 Budget request. A copy of the full report is available in the Commission Office. Subject areas covered were: Disease Rates on the Incarcerated Mentally Ill in the S.F. County Jail Suicide in Jails Substance Abuse Issues in Correctional Health Care Public Health Opportunities Challenges Mission and Vision Statements Commissioners inquired about the TB rates, HIV testing, general health assessments, linkages between jail health services and the CHN staffing, medication compliance by the mentally ill prisoners, and assignment criteria for housing of prisoners. President Guy expressed deep appreciation and acknowledgment of the hard work for Jail health Services by Dr. Goldenson and Ms. Robinson. 6) TIME SPECIFIC: 4:15 PM - PRESENTATION OF A PROPOSAL AND CONSIDERATION OF A RESOLUTION FOR THE SAN FRANCISCO GENERAL HOSPITAL REPLACEMENT FACILITY Dr. Katz introduced City Attorney Louise Renne, who will Co-Chair with him the Planning Committee to rebuild a new conforming San Francisco General Hospital by year 2013, consistent with SB 1801 (Speier). City Attorney Renne expressed her willingness to do anything Dr. Katz requests. She believes SFGH is an important part of health care in San Francisco. She also thinks this would be a difficult bond, which would need a broad-based coalition and an open planning process. Commissioner Monfredini expressed her support to assist City Attorney Renne. President Guy advocated for an open public process. She expressed appreciation of City Attorney Renne’s leadership. President Guy encouraged discussions to take place at the JCC-SFGH. Gene O’Connell, SFGH Executive Administrator, presented the planning model, membership of committees, and a timetable for the SFGH rebuild. Action Taken: The Commission unanimously adopted Resolution #1-01, entitled: "Supporting the Rebuilding of San Francisco General Hospital." Commissioner Sanchez stated the willingness of the diverse populations in the City to participate in this rebuild project. 7) OTHER BUSINESS/PUBLIC COMMENTS None. The meeting was adjourned at 4:50 p.m. Sandy Ouye Mori, Executive Secretary to the Health Commission