Minutes of the Health Commission Meeting August 21, 2001 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The meeting was called to order by President Roma P. Guy, MSW, at 3:10 p.m. Present: President Roma P. Guy, M.S.W. Commissioner Arthur M. Jackson Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sánchez, Jr., Ph.D. Absent: Vice President Edward A. Chow, M.D. Commissioner Lee Ann Monfredini Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF AUGUST 7, 2001 Action Taken: The Commission (Guy, Jackson, Parker, Sánchez) approved the minutes of August 7, 2001. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sanchez chaired, and Commissioner Jackson attended, the Budget Committee. (3.1) PHP-AB 75 CHIP Application - Request for approval to accept and expend retroactively a grant allocation in the amount of up to $4,826,945 from the State Department of Health Services, through its California Healthcare for Indigents Program (CHIP), to provide reimbursement for health services delivered to indigent persons for the term FY 2001-02. (3.2) PHP-AIDS Office - Request for approval of a contract renewal with Haight Ashbury Free Clinics, Inc. (HAFC) in the amount of $339,019 to provide HIV prevention services, for the period of July 1, 2001 through June 30, 2002. (DPH contracted with HAFC for services totaling $8,591,737 during FY 2000-01). Commissioners’ Comments Commissioner Jackson asked where venue based individuals outreach services take place. Cheryl Foston and Tracy Douglas Neil, both from Haight Ashbury Free Clinics, responded that they have done venue-based events with New Leaf, the Women’s Building, and Ark of Refuge, among others. (3.3) CHN-SFGH Nursing Operations - Request for approval of contract renewals with the following firms for a combined total of $1,050,000: HRN Services, Inc., Nurse Providers, Inc. and United Nursing International. A combined total amount of $787,500 to provide supplemental, temporary per diem nursing personnel services and a combined total amount of $262,500 to provide supplemental, temporary traveling nursing personnel services, for the period of September 1, 2001 through August 31, 2002. (3.4) CHN-Office of Managed Care - Request for approval of a new retroactive contract with San Francisco Health Plan, in the amount of $2,346,925, to provide universal health insurance services targeting San Francisco children, for the period of July 1, 2001 through June 30, 2002. Commissioners’ Comments Commissioner Sánchez stated that this is one of the most critical demonstration projects the Health Department is undertaking, and it represents a fantastic opportunity for the Department to work with teachers and school administrators at the school site. Commissioner Sánchez then introduced Jean Fraser, Director of the San Francisco Health Plan. Ms. Fraser stated that all of the entities involved will be able to convey a simple message to families, children and teachers: San Francisco is committed to providing health care to every child. Commissioner Guy said that Universal Health Insurance for Children is a breakthrough program. Commissioner Guy stated that there have been challenges in enrolling eligible children in the Healthy Families Programs, and that these challenges will exist with this effort as well. She asked that as this program progresses, the San Francisco Health Plan communicate with the staff and the Commission what is working and what is not in terms of outreach and enrollment. Action Taken: The Commission (Guy, Jackson, Parker, Sánchez) approved the Consent Calendar of the Budget Committee 4) DIRECTOR’S REPORT (Mitchell H. Katz, M.D., Director of Health) Director’s Visit Diana Bonta, DrPH, Director of the California Department of Health Services, will visit San Francisco later this week and meet with local health officials. I will personally escort Dr. Bonta on a tour of Laguna Honda and San Francisco General. We will take the opportunity to highlight a number of programs and issues for her, including the ISIS Clinic, Emergency Room overcrowding and the LHH Community Transition Program. In addition, she will be meeting with the Hospital Council and Consortium Clinic members to discuss reimbursement rates and integration of physical and behavioral health services. Attached is Dr. Bonta’s complete itinerary for the two-day visit. Possible Reduction to Federal MediCal for SFGH in FY 01-02 Our staff have been actively involved in advocating against a rule being developed by the federal Centers for Medicare and Medicaid Services that would result in lower emergency services supplemental funding for California's public hospitals. The current rule, called the Upper Payment Limit (UPL), provides that public hospitals and health systems may in the aggregate receive Medicaid payments up to 150 percent of what Medicare would otherwise pay for similar services. However, to eliminate abuses of this rule that are occurring in several states other than California, the Administration is proposing to lower this limit to 100 percent. For San Francisco General Hospital, approximately $22 million of the hospital's SB1255 and MediCal GME payments would be subject to this new rule and it could result in a loss of more than $10 million for the hospital. Staff are working closely with the City's federal lobbyist, the National Association of Public Hospitals and the California Association of Public Hospitals to prevent this proposed rule from being implemented and to mitigate the impact of any new rule on California. The Department will keep the Commission informed of any final decisions or changes to the projected revenues over the next few months. Capp Street Fire A fire broke out at 4:15 AM August 16th at Capp and 20th Streets, destroying five residential buildings. An eight year old boy smelled the smoke and alerted his parents who woke up the surrounding neighbors. Seventy-five individuals (7 children) lost their homes and possessions in the fire. The EMS section was notified of the fire and the DPH response team was activated. No injuries were reported and it appears there are no serious health issues. Most of the tenants were monolingual Spanish speakers, so both DPH and DHS called on bilingual staff resources for follow-up casework. Red Cross established a service center at 580 Capp Street; and all victims were vouchered into hotels. The challenge now for the City response team is to find alternative housing for the victims. Treatment on Demand Funds CSAS has received $1,105,000 from CSAT to fund three special programs developed in response to Treatment on Demand: OBOAT (Office Based Opiate Addiction Treatment). This is a one-year pilot program, which will provide treatment of opiate dependence by physicians, counselors, and pharmacists working from their regular clinical practices. These treatment providers may be based in hospitals, in medical clinics, or in private practice. Treatment sites participating in the program will include city-run health centers, the City and County of San Francisco jail health services, local methadone clinics, and community pharmacies. This program seeks to supplement the current 2500-methadone maintenance slots in local methadone clinics. One hundred patients will receive treatment through this pilot program. Funds will also support the Pharmacotherapy Project, which builds upon an existing provider education initiative designed to increase the use of pharmacotherapy in substance abuse treatment programs. The project will provide funding for indigent and low-income patients to access medications prescribed as a component of their substance abuse treatment plan. Funds will also support the continuation of the on-going TOD evaluation. Medically Supported Detox We now have three medically supported detoxes in operation within the City and County of San Francisco. Capacity has increased by 200% after the recent openings. Fremont Street Detox, operated by Baker Places, Inc. opened on April 23rd (capacity 16), and Howard Street Detox operated by St. Vincent de Paul in partnership with the CHN opened June 25th (capacity 20.) The Howard Street Detox converted some of its social model detox beds to medically supported status, signifying a strong relationship between the St. Vincent de Paul Society and the CHN in transforming one of the City's long established detox facilities into one that provides medical overlay. The two new facilities compliment the existing Baker Places 4th Avenue Detox, opened in 1995, and with a current static capacity of 10. 2001 National HIV Conference Seven STD Program abstracts were accepted for presentation at the 2001 National HIV Conference in Atlanta, Georgia. The abstracts were as follows: Wanted a Few Good Young People; Sustaining a Youth Peer-Led HIV Prevention Program Sexually Transmitted Disease Screening in an Anonymous HIV Testing Site Higher Levels of Drug Use and Patterns of Anonymous Sex Among MSM Diagnosed with Rectal Gonorrhea in SF, 2000 Higher Levels of STDs and Risk Behavior Among Men Using Viagra, SF 2000-2001 Learning the Ropes: Training Community Based Agencies to Integrate and Conduct STD Screening in HIV Prevention Programs Sex Worker Health, San Francisco Style: A Peer Based Specialty Clinic in San Francisco Are HIV Drug Advertisements Contributing to Increases in Risk Behavior Among Men in San Francisco? Several programs within the STD unit have been featured this past month on websites and national newsletters for their innovative programs. CHN/SFGH CREDENTIAL REPORT (from August 13, 2001 to Aug 21, 2001 08/01___2001 YTD       New Appointments 42     Reinstatements 0 5 Reappointments 43 285   Delinquencies: 0 0   Reappointment Denials: 0 0 Resigned/Retired: 29 126 Disciplinary Actions 0 0 Restriction/Limitation- Privileges 0 0 Changes in Privileges       Additions 2 15   Voluntary Relinquishments 2 14   Proctorship Completed 44 114 Commissioners’ Comments Commissioner Guy congratulated the Department on receiving funds for the Office Based Opiate Treatment (OBOAT) proposal, and the establishment of three medically supported detoxes in the community. Commissioner Guy acknowledged the work of the staff who took the policy direction of the Health Commission and developed programs that have been successful. Commissioner Parker asked how many residential units were involved in the Capp Street fire. Anne Kronenberg responded that there were 13 residential units. 5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEES RECOGNITION AWARDS FOR THE MONTH OF AUGUST Action Taken: The Commission (Guy, Jackson, Parker, Sánchez) continued the presentation of the Employee Recognition Awards for the month of August to the September 4, 2001 Health Commission meeting. 6) RESOLUTION SUPPORTING SAN FRANCISCO’S COMMUNITY HEALTH CLINICS AND DECLARING AUGUST 19-25, 2001 AS “COMMUNITY HEALTH CLINICS WEEK” Barbara Garcia presented the resolution commending San Francisco’s Community Health Centers, and stated that they are essential to providing health care services in San Francisco, and complement the good work of the Department of Public Health’s Health Centers. Dick Hodgson, Director of Policy and Planning for the Community Clinic Consortium thanked the Commission for the resolution. Mr. John Gressman, Executive Director of the Community Clinic Consortium, also thanked the Commission, and said that the partnership between the Consortium and the Department of Public Health has been a success. Commissioners’ Comments Commissioner Sánchez stated that community clinics are a critical part of the safety net, and the partnership with the Community Clinic Consortium is one of the unique elements of San Francisco’s health care delivery system. Commissioner Guy commended Mr. Gressman for his leadership over the past years in bringing the community clinics together and his contribution to strengthening the safety net. Public Comment Elizabeth Frantes stated that she did not receive good care at the community clinic she went to. Action Taken: The Commission (Guy, Jackson, Parker, Sanchez) unanimously approved Resolution #15-01, titled “Supporting San Francisco’s Community Health Centers and Declaring August 19-25, 2001 as “Community Health Centers Week.” 7) YEAR END EXPENDITURE REPORT 2000-01 (Monique Zmuda, DPH, Chief Financial Officer) Monique Zmuda, Chief Financial Officer, presented the Revenue and Expenditure Report for the 4th Quarter of Fiscal Year 2000-2001. The report presents the preliminary estimates on the year-end financial projection of revenues and expenditures for the Department of Public Health for Fiscal Year 2000-2001. Based on this data, the Department of Public Health is projecting a year-end surplus of $19.8 million. This surplus represents 2% of the $956 million adjusted budget of FY 2000-2001. Projected FY 2000-01 Year-End Surplus/Deficit Table Ms. Zmuda stated that the surplus is primarily due to three factors. First, the Disproportionate Share Hospital (DSH) program ended the year with $6.8 million over the budgeted amount. Second, a $4.5 million Federal MediCal match for Laguna Honda Hospital. And third, $4.7 million in additional realignment funds. Ms. Zmuda stated that since the report was completed, she met with the Controller’s staff and discussed a potential $2.5 million grant disallowance in PHP retroactive to fiscal year 1991-92. The Controller has agreed to let the Department set aside $2.5 million of the surplus in the event the Department is unsuccessful in its appeal of the disallowance. Subsequently, the Department projects that the year-end close will result in the return of up to $17 million to the City and County General Fund. Commissioners’ Comments Commissioner Parker asked for a breakdown of the money that has been set aside for past years’ risks and liabilities. Ms. Zmuda provided the following breakdown: In Mental Health, $3 million for a FY 1994-95 disallowance and almost $2 million for the subsequent year that has not yet been audited but will likely be disallowed; $1.2 million assumption of payback for State-funded TB program; and $2.5 million for the fiscal year 1991-92 grant disallowance. If these funds are not used, they are returned to the General Fund. Commissioner Parker then asked if there is any way to predict what will happen to the surplus money that is returned to the General Fund. Ms. Zmuda responded that the Mayor and the Board of Supervisors will make the decision how to appropriate these funds. 8) CONTINUUM OF CARE FOR INJECTION DRUG USERS IN SAN FRANCISCO (Barbara Garcia, PHP Director) Barbara Garcia, Deputy Director for Community Programs, began the presentation by acknowledging Gene O’Connell, Dr. Josh Bamberger, Dr. David Young and Dr. Hobart Harris for their leadership in the development of the ISIS Clinic and the community needle exchange programs. Ms. Garcia also recognized the Treatment on Demand Planning Council and the Heroin Subcommittee, which provided critical input. Ms. Garcia stated that the focus of today’s presentation was on soft tissue infections and the Department’s innovative approach to prevention and treatment. Future Health Commission presentations will address other health effects of injection drug use, including overdose prevention, addiction, and HIV/HCV infection, and the Department’s responses to these health effects. Dr. Josh Bamberger, the Medical Director of Housing and Urban Health, continued the presentation by providing background on soft tissue infections in San Francisco. Soft tissue infections accounted for approximately 3,000 Emergency Department visits, 2,400 admissions and 1,000 Operating Room cases annually. Dr. Bamberger said that the Department started two soft tissue infection initiatives: expansion of medical care at needle exchange sites and opening the ISIS clinic. Medical Care at Needle Exchange Sites Soft tissue infection treatment is provided at 13 of the 15 needle exchange sites. On average, 70 unduplicated clients are cared for each week. In addition, a full range of urgent care services is provided at the sites. Services are provided as a collaboration between the Department of Public Health, Haight Ashbury Free Clinics, and UCSF. Dr. Bamberger stated that the next steps for the community needle exchange program include expanding to provide medical services at all needle exchange sites, integrating Hepatitis C prevention services and drug addiction referrals to services provided, and providing urgent care services at Mission Resource Center. ISIS Dr. David Young presented the Integrated Soft Tissue Infection Services (ISIS) Clinic. Dr. Young stated that the basic goal of the program is to provide compassionate, efficient and cost-effective care to patients with soft tissue infections in a user-friendly, non-judgmental environment. ISIS is staffed by attending surgeons, nurses, substance abuse counselors, social workers, pain management specialists, rehabilitation therapists and other ancillary services. Dr. Young stated that majority of patients are heroin users. At the time that these patients were seen at the clinic with their infection, 23 percent were on methadone. Dr. Young continued that the remainder of the patients was not on methadone, but when asked if they would like to be 74 percent said yes. Only 3% refused methadone treatment. Dr. Young stated that the majority of the patients come from the Emergency Department, and the second largest number are walk-ins, which indicates to staff that the clinic is a success. Dr. Young presented graphs that showed the impact of the ISIS Clinic on hospital admissions, operating room volume and Emergency Department visits. Dr. Young stated that prior to the inception of ISIS, soft tissue infections accounted for 500-600 bed-days per months. After the opening of the clinic, this has dropped to half that amount. In addition, after the opening of the ISIS Clinic, there are less than 20 cases a month in the operating room, which has decompressed the operating room. Dr. Young continued that, with regard to the impact on the Emergency Department, there has been a decrease in visits of several thousand visits a year, which directly correlates with the number of procedures done in the ISIS clinic. Dr. Young then discussed the substance abuse counseling component of the ISIS program. Over 1,000 patients were referred to methadone detox programs, and 310 enrolled in the San Francisco General Hospital program. The ISIS Clinic budget includes 30 Methadone maintenance slots, and 33 patients have been enrolled. Dr. Young presented the following conclusions: ISIS is successful and exceeds twice the estimated patient volume. To maintain this effort, ISIS needs: More space More nursing staff Additional funding Commissioners’ Comments Commissioner Guy stated that this program is the result of the Department of Public Health being willing to take risks. She asked if the ISIS Clinic experiences peak hours. Dr. Hobart Harris responded that there is no way to predict when the busy times will be. Commissioner Guy then recommended that there should be further discussions about these programs, and their future needs, at the Community Health Network Joint Conference Committee. Commissioner Sánchez congratulated the team. He then asked how, if the program expands, the Department could disseminate the important health information to communities who are at greater risk. Commissioner Sánchez suggested that the information be given to teachers, counselors, and school children. Commissioner Jackson asked if San Francisco’s Health Department is unique in its patient-focused approach to health care. Dr. Katz responded that, while San Francisco is not unique, the Commission has supported access to services and cultural competency that lead to the best models. Public Comment Colin Eaton, Chairperson for of the Treatment on Demand Planning Council’s Heroin Committee, said that the Heroin Committee met once a month for six months and developed recommendations related to health consequences of heroin use, including: overdose prevention, Hepatitis C, and soft tissue wound treatment. Mr. Eaton conveyed the Heroin Committees’ thanks to the Department of Public Health for its dedication to responding to the committee’s recommendation. 9) OTHER BUSINESS/PUBLIC COMMENTS None. 10) ADJOURNMENT The meeting was adjourned at 4:30 p.m. Michele M. Olson, Executive Secretary to the Health Commission