Minutes of the Health Commission Meeting Wednesday, September 19, 2001 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 Vice President Edward A. Chow, M.D. at 3:05 p.m. Present: Vice President Edward A. Chow, M.D. Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sánchez, Jr., Ph.D. Commissioner John I. Umekubo, M.D. Absent: President Roma P. Guy, M.S.W. Commissioner Arthur M. Jackson Commissioner Lee Ann Monfredini 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF SEPTEMBER 4, 2001 Action Taken: The Commission (Chow, Parker, Sánchez, Umekubo) unanimously approved the minutes of September 4, 2001. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE (Commissioner David J. Sánchez, Jr., Ph.D.) Commissioner Sánchez chaired, and Commissioner Jackson attended, the Budget Committee meeting. (3.1) CENTRAL ADMINISTRATION - Request for approval of a resolution to authorize the Department of Public Health to accept and expend recurring State grants from the State of California for FY 2001-2002. (3.2) CENTRAL ADMINISTRATION- Policy and Planning - Request for approval to accept and expend a new award from the State Department of Human Services in the amount of up to $180,000, to enroll children in health insurance programs, for the period of July 1, 2001 through December 31, 2001. (3.3) PHP-Maternal and Child Health - Request for approval to accept and expend a new three-year grant from the California Family Health Council, in the amount of $525,000 for HIV/AIDS confidential counseling and testing services, for the period of September 1, 2001 to August 31, 2004. (3.4) PHP-Maternal and Child Health - Request for approval to accept and expend contract funds from the University of California San Francisco in the amount of $223,475 to identify barriers to preventive oral health care, for the period of September 30, 2001 through September 29, 2003, and a sole source contract with Polaris in the amount of $156,570 for the same time period. (3.5) PHP-Mental Health/Substance Abuse - Request for approval of a retroactive contract renewal with Morrisania West, Inc. in the amount of $439,434, for the provision of day treatment services, for the period of July 1, 2001 through June 30, 2002. (3.6) PHP-Women’s Prevention Services - Request for approval of a retroactive sole source contract renewal with North East Medical Services in the amount of $218,354 to provide Breast and Cervical Cancer Control Program services for the period of October 1, 2000 through October 20, 2001. (3.7) CHN-Revenue Management - Request for approval of a new contract with Health Advocates, LLP, to enhance Medi-Cal and other third-party reimbursements at San Francisco General Hospital, for the period of certification through December 31, 2005. This item was continued to the meeting of October 2, 2001. (3.8) CENTRAL ADMINISTRATION-MIS - Request for approval of a contract modification to the product and services agreement with Siemens Medical Solutions Health Services Corp., to extend the term of the contract by an additional two years and to increase the compensation by $2,822,658, for a total revised contract amount of $9,990,349, for the term of January 1, 1999 through June 30, 2004. Action Taken: The Commission (Chow, Parker, Sánchez, Umekubo) approved the consent calendar of the Budget Committee, with Item 3.7, approval of a contract with Health Advocates, LLP, continued. Prior to Dr. Katz presenting the Director’s Report, Commissioner Chow asked that everyone take a moment of silence to reflect on the tragedy of September 11, 2001. 4) DIRECTOR’S REPORT (Mitchell H. Katz, M.D., Director of Health) (Report on activities and operations of the Department.) Update from September 11th East Coast Tragedy Dr. Katz informed the Health Commission that, as last week’s tragic events unfolded, the Department quickly went into Incident Command System (ICS) mode. Appropriate staff reported to the Emergency Operations Center at the City’s Command Center on Turk Street, the Departmental Operation Center (DOC) at 101 Grove and the Hospital DOC at SFGH. The Department of Public Health is a front line first responder in the event of an emergency situation. Some confusion ensued over conflicting messages that sent non-essential City employees home and closed all City buildings, but for the most part, the Department responded appropriately as front line emergency responders. Our clinics remained opened, including primary care and mental health services. SFGH activated its Hospital Emergency Incident Command System and staffed the Emergency Operations Center for 24 hours. Many thanks to all our dedicated employees who responded in an outstanding fashion. Last week's series of tragic events presented a new response challenge for all of us. DPH is taking this opportunity to learn from mistakes and to tighten response mechanisms for any future incidents. In the foreseeable future, the number one priority of the Department of Public Health is emergency/disaster/terrorism preparation. It is essential that the Department rapidly improve its ability to protect employees and develop contingencies to deliver high quality health care, should a disaster occur in San Francisco. Dr. Katz thanked the committed staff at DPH for their quick and efficient response last week and asked for cooperation in Departmentwide preparation and response efforts. Hunters Point Facility Task Force As one response to the Health Commission’s February 20, 2001 meeting at Milton Meyers gym in Hunter’s Point, a Department Task Force was appointed in late April to establish a DPH presence on Hunter’s Point Hill. The Task Force, chaired by Anthony Wagner, included representatives of DPH, Recreation and Parks, and the San Francisco Housing Authority. The Task Force surveyed 45 residents of the Hunters Point Hill. After several months of community and City agency input, it was decided to reopen the Ujima Clinic at 195 Kiska Road and also utilize the apartment at one Harbor Road, on site of the San Francisco Housing Authority. The following programs/services will be located at the respective sites: Ujima - 195 Kiska Road Children’s Environmental Health Program - Focus on the Specific health issues of children related to the impact of the environment (at home and in the community). Health and Environment Assessment Program (HEAP) - General education about the Bayview Environment. Health Education Resource Center - Specifically focusing on asthma, breast and prostate cancer. WIC Project One Harbor Road Directions for Positive Change - An alternative program to traditional substance abuse rehabilitation. A Mentorship Program - An Outreach and education mentorship program focused on youthful offenders with law enforcement and ex-offenders partnering as mentors for incarcerated youth and youth-at-risk. The MUNI CalWORKS Program Renaissance Ex-offenders Program Until staff is hired, Karen Pierce, Director of the HEAP Program, has agreed to serve as acting coordinator. She will be relocated to the Ujima site. The Community Programs Division of DPH is now operationalizing the recommendations of the Task Force. A November start-up date is projected for both sites. American Journal of Public Health Publishes Article on Health Benefits of Living Wage Ordinance Dr. Katz reported that the lead article in the American Journal of Public Health’s Labor Day issue was an analysis performed by Rajiv Bhatia, M.D. This paper analyzed the estimated health benefits from a local living wage ordinance. The major conclusion of the paper was that small increases in the wages of working people are associated with substantial health improvements. Dr. Katz was pleased with this paper because it demonstrates to policy makers the close connection between economic conditions and health. Tai Chi in the Parks Program The City has just completed a series of free, weekly Tai Chi classes at 10 neighborhood parks. Medical data supports Tai Chi as a health maintenance activity with beneficial effects on musculoskeletal complaints, stress reduction, promotion of safe ambulation and fall prevention. The neighborhood locations made the classes accessible to patients who are unable to get to hospital based stress reduction classes or physical therapy services. The project has been well received by the community and is looking for further support from the Community Programs Division when the start-up grant funding cycle is complete. The Primary Care Medical Directors group has indicated a strong support for continuation and expansion of the Tai Chi classes. Bureau of Environmental Health The California Environmental Protection Agency recently completed a technical audit of the Hazardous Materials Unified Program Agency. Lead by the Cal EPA representative, the audit team was composed of representatives of four State agencies, including the Department of Toxic Substances Control, Governor’s Office of Emergency Services, State Water Resources Control Board and Office of the State Fire Marshal. The team spent two days evaluating all program aspects, including record keeping, policies and procedures, data management, and enforcement outcomes. Additionally, the auditors evaluated staff during field inspections at regulated businesses. At the conclusion of the audit, the State agency representatives gave high marks to the program and were particularly impressed with the technical knowledge, skills and abilities of the staff. CalEPA considers the San Francisco Program to be a model for others throughout the State and has requested that their policy manual be made available as guidance for other agencies struggling to implement this complicated environmental program. . Successful CLIA Inspection Laguna Hospital’s Respiratory Therapy Department passed its biannual CLIA/DHS inspection September 4th with no deficiencies. Congratulations to Claudell LeBlanc and his staff on another year of exemplary performance, and thanks to Dr. Valerie Ng and her SFGH team for their support. Physician Selected for Health Care Leadership Program Lisa Pascual, MD, Chief of Rehabilitation Services at LHH, has been selected as one of 25 professionals for the inaugural class of the CHCF Health Care Leadership Program, administered by the Center for the health Professions at UCSF. The intensive, two-year fellowship allows participants to continue in their current leadership roles while further developing their knowledge, skills and networks. MHRF: Appointment of Director of Nursing, Director of Rehabilitation Services and Director of Quality Management Dr. Katz announced the names of the newest members of Mental Health Rehabilitation Facility (MHRF) Executive Staff. Alex Anagnos, MSN, CNS, RN has joined DPH as the Director of Nursing; Maureen Burns, BSN, RN, is the new Director of Quality Management; and Linda Fenn is Director of Psychiatric Rehabilitation Services. MUNI Annual Family Day and Health Fair On September 8, 2001 the African American Health Initiative (AAHI) coordinated and participated in the MUNI Annual Family Day and Health Fair which had over 3,600 attendees at the WOODs Division-Potrero Hill. MUNI staff expressed a desire to integrate health as a permanent component of the Family Day event. The Health Department was well represented. STD Program's Annual STD Update The STD Program's Annual STD Update is scheduled at Carr Auditorium September 20th from 8:00 a.m. to 12:30 p.m., and again on October 3rd from 12:30 p.m. to 5:00 p.m. The Update is for all STD Program Screening Site providers and other health practitioners who provide care to STD clients. The STD Program collaborates with the State of California STD Prevention Training Center to provide CEUs to participants. This year's Update will include a discussion on: 2000 STD prevalence rates in San Francisco, the use of amplified testing for gonorrhea and chlamydia for non genital sites, genital dermatology, an update on the Gonorrhea Iisolate Surveillance Project and an STD clinical update. If anyone would like to register, they should contact Sharon Byrd at 487-5524. Single Point of Responsibility Programs Study Demonstrates Cost Savings During 1997, Community Mental Health Services initiated the implementation of three Single Point of Responsibility (SPR) programs to serve high cost mental health consumers with severe mental illnesses. In 1998, Davis Y. Ja and Associates, Inc. was contracted by CMHS to assess the effectiveness of the SPR programs. The previous evaluation report, based on the first two years of follow-up, confirmed what other studies of such programs had shown--that ACT services break even financially in spite of higher initial service costs - while allowing clients to have less time in locked 24-hour care. The most recent evaluation report has just been completed and these 3-year follow-up findings are beginning to show cost savings, with ACT clients significantly lower in total overall mental health service cost in the latter months of the third year after adjusting for baseline differences between the groups. In addition, days in locked 24-hour care and use of emergency services both continue to show steady reductions. A final report on four-year follow-up data will be completed this fall. Commissioners’ Comments Commissioner Parker said that the events of September 11th were a wake up call for the entire community, and that the Department should take this opportunity to mobilize the city and educate its residents about disaster and emergency preparedness. Commissioner Umekubo commented that the tragedy was a wake up call for the medical community in terms of preparedness. He is concerned that the medical community is not as prepared as it should be, and that each institution will have to examine how to be more prepared. Commissioner Chow stated that the Department, as well as private hospitals, needs to take this opportunity to improve emergency preparedness both on the consumer side and the medical service side. With regard to the two Bayview Hunters Point Initiatives, Commissioner Chow asked why, when the trend has been to co-locate services, services are being established at two different geographical locations. Dr. Katz responded that there was a specific request from Bayview Hunters Point residents to provide services at One Harbor Road, and a separate specific request to reopen the Ujima Clinic. The Department wanted to be responsive to the community’s requests. 5) PROFILE OF INJURY REPORT (Ginger Smyly, Deputy Director, Community Health Promotion and Prevention) Ginger Smyly, Deputy Director, Community Health Promotion and Prevention provided an overview of the Profile of Injury Report. This report is the fourth edition to be produced by the Department of Public Health. The goal of the report is get a better understanding of the nature of injuries in San Francisco and examine methods by which the Department can support more injury prevention. The report consists of epidemiological data, cost data, mapping data and demographic data from 1998. Dr. Elizabeth McLoughlin from the San Francisco Injury Center and Trauma Foundation continued the presentation by summarizing the findings and identifying trends. Dr. McLoughlin said that the data for the Profile of Injury Report was obtained from the following sources: deaths; hospital discharge data; trauma registry data from San Francisco General Hospital; emergency care data from San Francisco General Hospital; emergency medical services data from the San Francisco Fire Department; and traffic crash data from the Statewide Integrated Injury Traffic Reporting System. Dr. McLoughlin summarized the major causes of injury deaths in San Francisco: Drugs and poisonings, 40.3 percent; falls, 10.6 percent; firearms, 10.2 percent; motor vehicle traffic crashes, 14 percent; suffocation, 9 percent; fire/burn, 3.2 percent; drowning, 2 percent; cut/pierce, 1.8 percent; and other, 8.8 percent. Dr. McLoughlin then summarized major findings: Numbers of injury deaths are decreasing, but are far too high. Dr. McLoughlin used firearm injury deaths as an example. While there has been a sharp decline in firearm injury deaths in San Francisco, the rate of firearm injury deaths in San Francisco is more than twice the target identified in Health People 2010, the health objectives for the nation that have been developed by the federal government. Elders are at a higher risk of dying of injury and of hospitalization due to injury. This is primarily due to falls. Drugs and falls are major problems. There is a high rate of pedestrian injuries in San Francisco. Prevention is essential. The majority of people who die from injury death die where the injury occurs, never making it to the hospital or other medical facility. Dr. McLoughlin stated that this demonstrates the need to prevent injuries from ever happening. Michael Radetsky continued the presentation by discussing how the data in the Profile of Injury report can be used to reduce injuries. Mr. Radetsky provided a summary of key priorities that were established by the Department’s Injury Prevention Work Group. He also provided the Commission with an overview of current interventions, and focus for new recommendations. Mr. Radetsky stated that the key priority areas developed by the Injury Prevention Work Group are: Pedestrian Injuries Senior Falls Firearm Violence Intimate Partner Violence Poisoning/Drug Overdose Mr. Radetsky summarized the Department’s current unintentional injury prevention programs and the violence prevention programs. The unintentional injury programs are the CHIPPS Senior Injury Prevention Project, the San Francisco Pedestrian Safety Project, a newly funded Traffic Safety Project, the Child Passenger Safety Program, and the Stop Red Light Running Program. The violence prevention programs are Children and Youth Domestic Violence Free, the tattoo removal program, the violent injury reporting system, the Violence Prevention Network, and the Youth Power Program. Mr. Radetsky then provided the framework for how the Department will proceed with developing new recommendations. The Department will develop benchmarks using the objectives identified in Healthy People 2010, evaluate the strength and effectiveness of the current programs, and develop very specific outcome measures for injury prevention. Mr. Radetsky stated that, while specific recommendations will be developed through the budget process, there is one policy recommendation for current consideration: that the Health Commission and the Health Department prioritize the reduction and elimination of injuries by expanding existing primary prevention strategies and developing new primary and secondary prevention strategies and programs based on data, community need, and evidence-based practices. Commissioners’ Comments Commissioner Umekubo asked how San Francisco’s rate of injury from pedestrian accidents compares to other metropolitan areas. Dr. McLoughlin responded that she would provide this information to the commissioners once she has compiled it. Commissioner Umekubo then asked how to make pedestrians aware that even though, in many cases, they have the right of way, they need to be cautious in exercising their right of way. With regard to falls, Commissioner Umekubo stated that physicians now have better tools to prevent fractures such as new osteoporosis drugs and encouraging calcium intake, and he hopes that this will help prevent injuries due to falls. Commissioner Chow asked if the pedestrian injury data has changed with the red light running campaign. Dr. Katz responded that this can be looked at during the next report, since the campaign began after 1998, which is the year from which the Profile of Injury data was collected. Commissioner Chow stated that he looked forward to discussing areas of concerns at the Population Health and Prevention Joint Conference Committee, and developing cost-effective and patient-effective programs. Commissioner Parker emphasized the need to offer prevention programs in the home. He continued that, while private institutions often focus on specific prevention messages for their particular services, (for example heart disease and high blood pressure), public institutions need to be more comprehensive. The Department needs ongoing primary prevention messages and needs to utilize various channels, such as newspapers, television, the community clinics and others. 6) BAYVIEW HUNTERS POINT COMMUNITY SURVEY (Dr. Rajiv Bhatia, Director, Environmental Health) Dr. Rajiv Bhatia began the presentation by acknowledging the many people who participated in creating the Bayview Hunters Point Community Survey. He then introduced Raymond Tompkins, who presented the community origins and motivations for the Bayview Hunters Point Community Survey. Mr. Tompkins said the community became engaged in combating environmental injustice when a new power plant was proposed for Hunters Point. Concurrently, a number of women in the community had become concerned about the prevalence of breast cancer in Bayview Hunters Point. The community discussed their concerns with the Department of Public Health and created the Bayview Hunters Point Health & Environmental Assessment Task Force. There was limited neighborhood health and disease data, and the task force decided to undertake their own community-based survey. The task force believed that if there were community participation in the survey, there would be more community buy-in in terms of what actions are needed to create a healthier community. Jennifer Mann continued the presentation by discussing the objectives, survey methods, and notable findings of the Bayview Hunters Point Community Survey. Ms. Mann said that the first objective was to involve the residents in the entire survey process, from developing the questions to doing the interviews to writing the report. The second objective was to obtain neighborhood-level health data. The third objective was to understand and prioritize neighborhood concerns. The fourth objective was to evaluate barriers to health services access. This objective came from the fact that Bayview Hunters Point has one of the highest rates of hospitalization for what are considered preventable diseases. Another objective was to understand the residents’ environmental concerns. The last objective was to obtain information that would be useful for new city services and other programs in Bayview Hunters Point. Ms. Mann then described the methods used to conduct the survey, which was a random, representative sample. The survey had two parts: a household questionnaire and an individual questionnaire. 249 randomly selected households participated in the household questionnaire, representing 71 percent of households contacted. A randomly selected adult was chosen from each participating household for the individual questionnaire, and 68 percent of those individuals (171 total) participated in the survey. The household questionnaire was administered by an interviewer and the individual questionnaire was completed by the individual. Notable Findings Local asthma prevalence data - Approximately 10 percent of people in Bayview Hunters Point have asthma. Approximately 15.5 percent of children have asthma. While there was difficulty with comparing these with national asthma rates, it is still clear that asthma is a problem that needs to be addressed. Smoking prevalence - 48 percent of households in Bayview Hunters Point had at least one smoker. The rates were the same for households with children and households without children. Concern with crime, violence and drugs - More than 40 percent of people rated crime and violence and drugs and alcohol as their two top concerns. Only 15 percent of residents thought that environmental concerns was one of the top two, but almost all residents thought that it was either somewhat important or very important. Views of public services - Almost half of the respondents rated environmental clean up in Bayview Hunters Point as poor. In addition, drug and alcohol treatment programs were rated poorly by almost 40 percent of respondents. City Health Clinics were the least likely to be rated as poor. Percent insured - Approximately 20 percent of non-elderly adults in Bayview Hunters Point were uninsured, compared to 26 percent statewide. Ms. Mann stated that this indicates that something other than lack of insurance is contributing to preventable hospitalizations. Reliance on diverse health providers - Only 14 percent of respondents had a regular source of health care in Bayview Hunters Point. In addition, people in Bayview Hunters Point are receiving their healthcare from a variety of different sources. Mixed sense of personal control - When asked if they agreed with the statement “If I take care of myself, I can avoid illness,” more than 80 percent said yes. When asked if they agreed with the statement “Health and illness are entirely beyond my control,” approximately 50 percent agreed with this statement, which is not necessarily in line with the first statement. Ms. Mann stated that the department made an obligation to all participants to share the report with the community. They presented the report at the Landscape of Our Dreams Conference, which was held in Bayview Hunters Point, out of which came the HEAP’s Good Neighborhood Project. In addition, the report was hand delivered to every single household that participated. Since the report was published two months ago, 1,000 copies have been distributed. Dr. Bhatia concluded the presentation by describing the community building efforts that will, or in some cases already have, come out of the survey process. These efforts include the following: The Health & Environmental Resource Center. The creation of a number of asthma collaborations, including the Yes We Can Campaign. The Food Security Initiative, where youth leaders are identifying barriers to healthy nutrition in their communities and developing action plans to remove those barriers, such as bringing new supermarkets into the community. The Youth Power Initiative, which uses participatory approaches to deal with the issues around violence. The African-American Health Initiative, which is a collaboration of many organizations to deal with issues of chronic disease. Dr. Bhatia also discussed two new programs in Bayview Hunters Point at 195 Kiska Road and One Harbor Road. Dr. Bhatia said that that valuable lessons for health promotion came out of this survey, including respecting the everyday wisdom of citizens, accessing and demystify information, lending the resources of institutions and building on community capacities, assets, and skills. Commissioners’ Comments Commissioner Sánchez asked if most of the individuals who did not respond to the survey were non-English speaking. Ms. Mann responded that this was the case, even though the surveys were translated into Spanish and Chinese and there were bilingual interviewers. Commissioner Sánchez commended the Department for involving the community in the research, and added that now we need to generate funding to support programs to address the problems identified in the survey. Commissioner Parker congratulated everyone who worked on the report for the community survey. He is concerned, however, that we are continuing to gather information to validate what has been known for decades: that there are health disparities in Bayview Hunters Point. He emphasized that what the community needs are results, and for this we are going to have to do things differently. Dr. Bhatia agreed, and said that they department is going beyond traditional health services to make change in the community, including partnerships with the Redevelopment Agency. Commissioner Umekubo appreciates the community perspective. He noted the high prevalence of smoking and said that clearly one part of the solution to asthma is to reduce the number of people who smoke. With regard to the prostate cancer screening rates, Commissioner Umekubo said that physicians, understanding the high prevalence of prostate cancer in African-Americans, try to start screening around the age of 40, and the Department should encourage and support this. With regard to access to care, Commissioner Umekubo said that he did not understand why respondents were not receiving health care in the community when the Department has two clinics in the area. Ms. Mann responded that one factor is that approximately 30 percent of the community are Kaiser members, and there are no Kaiser services in the community. Commissioner Chow said the Department should work with Kaiser to provide services in Bayview Hunters Point. In response to Commissioner Parker’s concerns, Commissioner Chow said that the goal of the African American Health Initiative is to address the entire gamut of needs in the community, not only the health needs. Commissioner Chow expressed concern about health beliefs, particularly the fact that so many people feel that illness is entirely beyond their control. Dr. Katz responded that he not very concerned about people’s perception of control over their health, which might result from religious beliefs. He is concerned about how healthy people think they are. The respondents rated themselves significantly lower than the nationwide response, which indicates that their health is lower, and that they are feeling more precarious about their health. 7) OTHER BUSINESS/PUBLIC COMMENTS None. 8) ADJOURNMENT The meeting was adjourned at 5:00 p.m. Michele M. Olson, Executive Secretary to the Health Commission