Minutes of the Health Commission Meeting

Tuesday, March 5, 2002
at 3:00 p.m.
101 Grove Street, Room #300
San Francisco, CA 94102


The Health Commission meeting was called to order by President Edward A. Chow, M.D., at 3:10 p.m.


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


Action Taken: The Commission approved the minutes of the February 19, 2002 Health Commission with a correction on page 11. The action taken for Item 8D)2 was amended to read: “The Commission (Chow, Guy, Jackson, Monfredini, Sanchez, Umekubo) voted not to disclose discussions held in closed session.”


(3.1) PHP-Substance Abuse - Request for approval of a retroactive contract modification to a four-year contract with the Homeless Prenatal Program, in the amount of $83,708, for the period of July 1, 2001 through June 30, 2002, to provide outreach and case management services, for a total contract value of $742,741, for the period of July 1, 2000 through June 30, 2004.

Commissioners’ Comments

  • Commissioner Umekubo asked the Executive Director, Martha Ryan, to address the progress that has been made implementing the Departments’ recommendations. Ms. Ryan said that most have been complete.
  • Commissioner Jackson asked what accounts for the large Asian Pacific Islander population. Ms. Ryan said that that includes all Asians.

(3.2) PHP-Mental Health - Request for approval of retroactive contract renewals with Jewish Family and Children’s Services, Moss Beach, dba Aspira Foster and Family Services and West Coast Children’s Center, as part of the shared San Francisco Mental Health Plan contracts for a total of $3,309,409, to provide mental health services, for the period of July 1, 2001 through June 30, 2004.

Commissioners’ Comments

  • Commissioner Jackson asked if the agency would be able to meet all of the recommendations. Linda Wang said that the agency had some staff problems during last year. They have hired a new director and should be able to meet all the requirements. Ms. Wang said she will report back to the Budget Committee in three months.

(3.3) PHP-Mental Health - Request for approval of a contract modification with Calvin Y. Louie, CPA, in the amount of $301,411, to provide fiscal intermediary services for the Community Mental Health Services supplemental residential care facilities, for the period of July 1, 2001 through June 30, 2002, for a total contract value of $4,560,254.

(3.4) PHP-Mental Health - Request for approval of a retroactive contract modification to a four- year contract with Community Vocational Enterprises, Inc., in the amount of $160,040 for the period of July 1, 2001 through June 30, 2002, to provide vocational support services for mentally ill consumers, for a total contract value of $4,171,676, for the period of July 1, 1998 through June 30, 2002.

Commissioners’ Comments

  • Commissioner Umekubo commended the agency for its excellent contract monitoring report.

(3.5) CHN-SFGH & Health at Home - Request for approval of a contract renewal with Toyon Associates, Inc., in the amount of $355,324, to provide reimbursement and revenue optimization services to San Francisco General Hospital and Health at Home Agency, for the period of April 1, 2002 through March 31, 2003.

(3.6) PHP-STD Prevention & Control - Request for approval of a new contract with Internet Sexuality Information Services, Inc., in the amount of $100,575, to provide syphilis elimination services, for the period of February 1, 2002 through December 31, 2002.

Commissioners’ Comments

  • Commissioner Monfredini said she had heard concerns about a woman overseeing a project that addresses the sexual habits of men. Although she does not agree with these concerns, she asked Deb Levine to respond. Ms. Levine said she has been a health educator for 10 years, teaches a course sex on the net and wrote a book about sex in cyberspace. Because the services will be provided online, physical identity differences are leveled.
  • Commissioner Umekubo is glad to see the Department doing outreach online.

Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report.

Direct Access to Housing - Opening the Star Hotel

Dr. Katz announced that Housing and Urban Health will open the Star Hotel, a Single Room Occupancy (SRO) located at 2176 Mission Street, by the end of April 2002. The Star will represent the 5th Direct Access to Housing building to come on line. The Commission may remember the Star Hotel experienced a devastating fire displacing all tenants Fall of 2000. Subsequently the Health Department worked with the owner and master leased the site and has partnered with Baker Places and John Stewart Company to provide on-site services and property management. The building has undergone a complete renovation and will provide safe and healthy housing to 54 chronically homeless persons.

Proposed Expansion Plan for 1000 Additional Housing Units

Supervisor Ammiano introduced a resolution in February directing the Department of Public Health and the Department of Human Services to submit to the Board a plan to expand the two department’s master lease program. The resolution calls for the expansion of DPH's Direct Access to Housing Program by 500 beds and DHS's SRO Master Lease Program 500 additional units in the by March 31, 2002. Staff is working on this proposal which will include projected costs and timeline for implementation.

Medical Care at All Needle Exchange Sites

The Department now provides medical care at all fourteen Needle Exchange sites in San Francisco. The intention is to use the sites as a means of educating engage injection drug users to treat urgent medical problems including soft tissue infections, teach HIV/HCV and abscess prevention techniques and to refer to ongoing primary care and drug treatment.

Supplemental Appropriation Request

As reported at the last Health Commission meeting, the San Francisco CARE allocation for HIV services was reduced by $2.2 million, beginning March 1, 2002. Supervisors Daly and Ammiano have sponsored a supplemental appropriation request to backfill CARE service reductions that would result from this recent reduction to the CARE funding allocation. The supplemental would allocate new General Funds for the four months remaining in this fiscal year, and allow time for the Mayor and the Board of Supervisors to consider the continuation of funding for HIV services during the budget deliberations. The CARE council met last week to consider the cuts in services that would be necessary to absorb this funding shortfall. The Council voted to make reductions of approximately 6.5% to most of the existing agencies receiving CARE funds. If the supplemental appropriation is approved by the Board of Supervisors and signed by the Mayor, these cuts would be averted for this fiscal year. Dr. Katz will keep the Commission informed on the outcome of this proposal over the coming weeks.

Compliance Officer Acting Assignment

Dr. Katz reported that Kathy Murphy, the deputy city attorney assigned to the Community Health Network, has agreed to accept an acting Compliance Officer assignment while the Department recruits for a new Compliance Officer. Kathy is very knowledgeable about the Health requirements regarding compliance, and has also been working on key committees that are implementing the HIPAA requirements. This acting assignment is expected to last approximately three months.


Health Commission - Director of Health Report (from 02/11/02 MEC and 02/12/02 JCC)


2002 YTD

New Appointments












    Reappointment Denials:






Disciplinary Actions



Restriction/Limitation- Privileges



Applications Withdrawn



Changes in Privileges




    Voluntary Relinquishments



    Proctorship Completed



Current Statistics - as of 02/7/02

Active Staff


Courtesy Staff


Referring Staff


Affiliate Professionals (NP, CNM, CRNA, PA etc)


Total Members


Applications In Process


SFGH Reappointments in Process Through April 2002


Dr. Katz also introduced Dee Epps-Miller, the new director of the Southeast Health Center.

Public Comment

  • Kevyn Lutton, Bayview Hunters Point Community First Coalition, asked for the release of the Emergency Room records from the six months before six months after the Fall 2000 Hunters Point Shipyard fire. The community needs this information to continue the health study of the emissions from the fire. The people who went to the ER need to be reimbursed. The information can be sent to Professor Ray Tompkins via Karen Pierce.

Commissioners’ Comments

  • Commissioner Parker congratulated the Department for providing medical care at the 14 needle exchange sites. This is in keeping with the philosophy that we take services where the patients are.
  • Commissioner Guy asked Dr. Katz if he was aware of the request for reports requested by the public speaker. Dr. Katz said that he received the request yesterday, and it is on his radar screen. The number of visits is publicly available, and he will have Dr. Bhatia work with the requester. However individual medical records are confidential and cannot be released to anyone but the individual.


Commissioner Monfredini, on behalf of Commissioner Jackson, presented the Employee Recognition Awards.



Nominated by:

Health at Home Palliative Care Team
Ileana Burleson 
Maria Calles 
Estrelita Calonsaq 
Norma del Rio 
Barouk Golden 
Ming Gen Hu 
Leonista Kafi 
Gaylen Newquist 
Leslie Payton 
Ellen Quain 
Susan Reynolds 
Daniel Rybold

CHN Health at Home

Mary McCutcheon

Primary Care Interim Leadership
Madeline Daley, RN 
Gay Kaplan, RN, NP 
Sheila Kerr, RN 
Lawrence Marsco, RN 
Marcellina Ogbu, Dr.P.H.

Community Programs

Patricia Pérez-Arce, David Ofman, Phyllis Harding, Maureen O’Neill


Patricia Pérez-Arce, Ph.D., Primary Care Director, and David Ofman, M.D., presented the Primary Care Report.

The guiding philosophy of the primary care division is to provide community oriented health care. In 2000 the Health Commission asked Primary Care to undertake an internal assessment. The assessment two vulnerable populations: people with barriers to effective medical care; and high-risk, complex patients. The recommendation was that Primary Care attempt to serve both categories of patients and prioritize “high risk, complex” patients for certain services, and better integrate primary care and behavioral health services. This integration began with the reorganization of the Department last year.

Dr. Pérez-Arce acknowledged the Community Clinic Consortium. Their member clinics are partners with the Department and part of the safety net of providers. Ten programs fall under the consortium.

Dr. Pérez-Arce discussed Primary Care services in the context of the strategic plan.

Goal 1: Access to health services, emphasizing services to target populations

52 percent of Primary Care clients are female and 48 percent are male. 58 percent of the client population lives in the DPH targeted neighborhoods and 10 percent are homeless. The clients represent a variety of ethnicities and languages. Most clients are publicly insured or uninsured.

Dr. Ofman said that one of the articulated goals of both Primary Care and the CHN strategic planning effort is linking primary care users to a provider or clinic. Of the 73,000 patients who visited a primary care clinic in FY2000-2001, just under half had a primary care provider linkage in the LCR (Lifetime Clinical Record). The number of patients assigned to a provider has increased almost 200 percent since the effort started in September 1998 to have the information system reflect the linkage of providers to the patients seen.

Dr. Pérez-Arce discussed public health nurses, who provide at-home training to mothers and other caretakers, care management of patients with chronic and debilitating diseases and the first line response to disasters and disease outbreaks. Staff is currently engaged in discussions about the changing role of public health nurses.

Total visits to all providers decreased 2 percent between 99-00 and 00-01. Visits to primary care providers, however, increased.

Goal 2: Disease and Injury are Prevented

Dr. Ofman and Dr. Pérez-Arce discussed quality improvement activities and prevention activities. After a concerted effort to unite the quality assurance activities of the primary care clinics with the health centers on the SFGH campus, they have developed primary care-wide quality improvement activities. The effort to improve women’s cancer screening was sited as an example.

Goal 3: Cost-Efficient Services and Maximizing Resources

During FY 00-01, Primary Care moved into a prospective payment schedule, which significantly increased the per-visit reimbursement rate and increased total revenues by $1.8 million. A number of programs that enhance cost-effectiveness were highlighted including the Diabetes Monitoring Program, a joint project between information systems and Primary Care. Other programs are the Asthma Clinic/Yes We Can Partnership and Nurse Orientation /Screening Clinics, which are designed to reduce no-show rates by having the person first have an orientation into the system with a nurse.

Capital improvements currently under design will allow Primary Care to utilize existing facilities more efficiently.

Goal 4: Partnerships with communities are created and sustained

Behavioral Health Partnerships

  • Pychosocial Medicine at Maxine Hall - UCSF
  • California Endowment Grant: Mental Health Services in Primary Care Settings - CMHS
  • Primary Care Substance Use Services - UCSF
  • Community Mental Health Consultation Liaison Services - CMHS
  • Office Based Opiate Addition Treatment - CSAS and SFGH
  • Methadone Van - CSAS
  • Youth Services Partnerships
  • Hip-Hop to Health Clinic Expansion
  • Dimensions Clinic
  • Laser Tatoo Removal Program
  • SFUSD Wellness Center
  • Other Partnerships
  • Smoking Cessation
  • NICOS Disaster Preparation Committee
  • Community Domestic Violence Project
  • Partnership with UCSF
  • Teaching in Primary Care clinics for interns and residents, medical students, nurse practitioner students, nursing students, pharmacy residents and others.
  • Resident Training in Primary Care clinics


Access Challenges

  • Access to Primary Care for unaffiliated clients; increase capacity to be able to link unaffiliated clients to care.
  • Clinic Productivity - right now providers are providing services at capacity, but this can be improved with facility improvements; the ability to do case management of patients and disease management teams, and looking at enhanced systems of access to appointments to allow for more same-day appointments.
  • Balance the needs of vulnerable patients with the needs of high-risk, complex patients, who require much more intensive, integrated services.

Quality of Chare Challenges

  • Chronic disease management programs, which are enhanced systems of care for either specific conditions or specific populations. They are shown to be successful, but also quite costly.
  • Information systems are a critical quality of care issue. Efficiency efforts, quality improvement efforts and integration efforts all depend on the information system. The Lifetime Clinical Record and the CHN network have allowed Primary Care to improve care.

Cost Effectiveness Challenges

  • Integration of primary care and behavioral health services
  • Reducing preventable emergency and institutional care

Dr. Pérez-Arce thanked Dr. Ofman for his dedication to primary care through the leadership transition. She introduced her team of health center directors who were at the meeting, including Gay Kaplan, Marian Pena, Michael Jody, Madeline Ritchie, Marcellina Ogbu, Michael Pyle, Dee Epps-Miller and Lawrence Marsco.

Commissioners’ Comments

  • Commissioner Guy stated that the reorganization seems to have been appropriate, and acknowledged Dr. Ofman for his tireless work during the leadership transition. She wants to the progress to continue but is worried that the general fund plays such a large role in funding these services. The change in the reimbursement rate made a big difference, but the Federal government needs to chip in further.
  • Commissioner Parker asked how large a role primary care plays in prevention and referral of HIV and AIDS patients. Dr. Ofman said that the primary care clinics see large numbers of HIV infected individuals and do a combination of medical care and prevention efforts. Commissioner Parker supports the development of group education programs. Not only cost-effective, but also people benefit from peers sharing same circumstances.
  • Commissioner Sanchez congratulated staff for a comprehensive report. He shared some observations from a conference that he attended last week where there was discussion about the issue of basic research versus primary care. Many of the issues were the same as those presented in today’s report.
  • Commissioner Umekubo said the importance of primary care as the foundation to our system cannot be over-emphasized. He asked how often the Primary Care QI committee meets. Dr. Ofman replied that the committee meets monthly, and he co-chairs it along with the director of nursing. Commissioner Umekubo commented that health education is very difficult, and asked if they use a group education setting. Dr. Pérez-Arce responded that the group model is not being utilized that much. Dr. Ofman added that there are a few group formats, but most health education is done one-on-one. They have received positive responses from a group prenatal care program, and would like to do more. The primary barrier to group sessions is that they have not figured out how to do the billing. Dr. Umekubo asked how continuity of care is assured when CHN patients get referred to providers outside of the network. Dr. Ofman replied that private hospitals make a good effort, but difficult to do sometimes. Dr. Pérez-Arce added that the consortium clinics will have access to the Lifetime Clinical Record so will be better to able to track CHN patients.
  • Commissioner Chow said that continuity of care is a challenge for both sides, and emphasized the critical need to continue the relationship with the consortium clinics. Commissioner Chow would like the CHN Joint Conference Committee to continue to discuss efforts to better improve continuity of care. Much has been done since the Health Commission adopted the resolution in 1989 to provide primary care services at the clinic. The LCR is a model for many places. One of the continued challenges is learning how to apply disease management principles to a public sector program. It would be good to develop a series of guidelines and protocols that extend across the CHN, and not just to individuals.
  • Commissioner Jackson noted that people can learn a great deal in group settings.


Kathy Eng, Director, Health at Home, presented the Health at Home Update.

There are two components of Health at Home: Licensed Home Health Services, focusing on acute, skilled, intermittent care or clients; and Continuing Care services for clients who are discharged from the home health service and need additional care for a time-limited period to prevent deterioration and admission into a higher level of care. Client s1ervices are provided 365 days a year.

The mission of Health at Home is to provide high quality, compassionate home health care to CHN clients, and to maintain people safety in their home environments, avoiding more costly levels of institutional care and supporting independence and quality of life. In Fiscal Year 2000-2001, Health at Home served 715 unduplicated clients, with 17,925 visits. There are 49 FTE and the average patient census is 200.

Ms. Eng discussed how the work of Health at Home aligns to the DPH Strategic Plan.

Goal 1 - Access to Services

Patients served by Health at Home live throughout San Francisco and mirror the population seen as SFGH. 70% of clients reside in the Tenderloin, Excelsior/OMI/Visitacion Valley, Potrero Hill/Bayview Hunters Point and the Mission. Nearly 50% of the clients are ethnic minorities. The average age of Health and Home clients is 58, which is younger than the regional and national norm for other home care agencies, whose average age is 73. Over 50% of Health at Home staff speak languages other than English.

Goal 2 - Disease and Injury are Prevented

Ninety percent of the unduplicated clients served by Health at Home fall within ten top primary clinical diagnoses. The majority of referrals come from SFGH and the community clinics. The Health at Home team structure includes a Resource Group Leader and a multi-disciplinary team that focuses its case conferences and problem solving on targeted groups of clients. Health at Home has CARE-funded home care contracts for in-home respite, clients with HIV disease living in SROs and home infusion therapy. There are five Health at Home Service Delivery teams: Ortho-Neuro; Med-Surg; Palliative Care; HIV/AIDS; and Continuing Care.

Ms. Eng also discussed the quality management activities undertaken by Health at Home, including a patient satisfaction survey, and provider satisfaction survey and quality management benchmark reports. Ms. Eng highlighted the Palliative Care team, pediatric services planning and HIV/AIDS services. With regard to pediatric services, there has been a slight bit of a delay in terms of working on resources to move forward. The Palliative Care Program serves clients who either may not qualify for hospice or choose not to go to hospice, but rather die at home. In 2000-2001, there were 2844 visits to 300 clients. In HIV/AIDS services, 25 percent of all Health at Home clients has HIV disease. Last fiscal year there were 3,100 visits. Most of the clients also have mental health or substance abuse problems that prevent the individuals from managing their disease. Health at Home staff work to stabilize the person.

Goal 3 - Services are Cost-Efficient and Resources are Maximized

Health at Home recently moved into a prospective payment system. This necessitated a reorganized delivery system and increased clinical oversight and review as a result of increased regulations and documentation. Ms. Eng said that a lot of emphasis is placed on staff safety, and they have an escort service, educational sessions, communication about particular clients, support groups and case conferences.

Goal 4 - Partnerships with Communities

Health at Home has a number of partnerships:

  • CHN Linkages
    • Clinical rounds at SFGH
    • Positive Health Program
    • Medical High Utilizers Program
    • Laguna Honda Hospital - Case conferences to transition clients from institution to community
  • Collaboration with Community Providers
    • SF Adult Day Health Network
    • AIDS Health Project
    • Tenderloin AIDS Resource Center
    • Tenderloin Care
    • Continuum
    • UCSF Home Care Program

Challenges and Opportunities

  • Bridge the gap in care for DPH clients in the home setting
    • Link case management and other long term care resources, such as public health nurses.
    • Identify MD oversight for home care patients needing primary care
    • Lab Services for homebound patients. Most of the time, reimbursement is not provided for lab services, and need to examine if SFGH lab services can be applied to health at home.
  • Space - A necessary resource for expansion

Dr. Katz added his support for the agency.

Commissioners’ Comments

  • Commissioner Jackson asked what percentage of clients lives alone, and how long is the average visit. Diane Jones, Coordinator of Home Care Services, stated that the CARE contract funds direct patient care, rather than respite care, which is an indication of people living alone. She will get the actual percentage to the Commission. The standard visit is two hours, but this includes travel time and paperwork. An admission takes approximately four hours.
  • Commissioner Chow asked if the OASIS data could be further divided to reflect the different patient profile in San Francisco as compared to state and national averages. Commissioner Chow is trying to understand what impact San Francisco’s different client population has on our quality outcomes. The outcomes would seem to indicate that we are not doing well in some areas. Our population is so different from the national average; the average age is younger and there is a higher portion of AIDS clients. Pam Bohman said that CMS is going to develop risk-adjusted reports to take into account high-risk population and things such as substance abuse and living alone. Commissioner Chow would like a follow up report at the CHN Joint Conference Committee on the quality indicators, and further discussion about why San Francisco’s adverse events are higher than the national average.
  • Commissioner Umekubo asked how long it takes to do one OASIS assessment. Staff responded that it takes 3-4 hours. The assessment has to be done at the start of care, and a reassessment has to be done every 60 days. Commissioner Umekubo asked the difference between palliative care and hospice care. Dr. Rybold said the essential difference is the regulations that govern the provision of hospice care. Dr. Katz added that hospice is a specific Medicare and Medicaid benefit, so there is some additional reimbursement, but many regulations. Also, hospice does not work well for some of our patient population. The same end results are achieved. Commissioner Umekubo asked who signs the care plan. Dr. Rybold responded that sometimes the attending physician signs, but there are times when the attending does not feel comfortable signing off on a plan if the patient does not have a primary care clinic. Most patients are followed by a primary care provider.
  • Commissioner Parker is impressed by the number of volunteers they have in the program.
  • Commissioner Guy said that this presentation was presented at the CHN Joint Conference Committee, and everyone is ecstatic that this program exists. There are some questions that the Health Commission needs to understand better, and there needs to be discourse at the joint conference committee level, particularly about public health nurses, quality assurance and space issues.


Renee Navarro, M.D., Chief of Medical Staff, SFGH, presented the proposed amendments to the Medical Staff Bylaws, Rules and Regulations, Corrective Action and Hearing Manual, Credentialing Procedure Manual and Committee Manual. Dr. Navarro said that the Medical Staff Bylaws Committee met regularly over the past year to review and update the bylaws. Dr. Navarro said that the bylaws committee obtained a copy of the evaluation tool used by the California Medical Association and used this to make the needed changes to the bylaws. The JCAHO mock surveyors reviewed the document and did not find any serious problems or oversights. Dr. Navarro said that that recommended changes reflect new areas of focus or verbiage by the CMA and suggestions from the mock surveyors. The most significant policy changes for the medical staff has been the change from Quality and Utilization Management to Performance Improvement and Patient Safety.

Commissioners’ Comments

  • Commissioner Monfredini, chair of the San Francisco General Hospital Joint Conference Committee, asked if the reporting structure to the governing body has been addressed. Dr. Navarro said yes; the Chief of Staff is responsible for reporting the activities of the Joint Conference Committee to the medical staff and the Director of Health is responsible for reporting to the Governing Body.
  • Commissioner Umekubo said that he reviewed and asked questions of these amendments at the San Francisco General Hospital Joint Conference Committee and recommends approval of the amendments.

Action Taken: The Commission approved the Medical Staff Bylaws, including the Rules and Regulations, Corrective Action and Hearing Manual, Credentialing Procedure Manual and Committee Manual




A) Public comments on all matters pertaining to the closed session


B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11)

Action Taken: The Commission voted to hold a closed session.

The Commission went into closed session at 6:05 p.m. Present in closed session were the Health Commissioners, except for Commissioner Sanchez who was excused due to a conflict of interest, Deputy City Attorney Joe Sandoval, Alison Moed, Gene O’Connell, Mitch Katz and Michele Olson. Commissioner Monfredini left at 6:10 p.m.

C) Closed session pursuant to Government Code Section 54956.9 and San Francisco Administrative Code Section 67.10(d)

Conference with Legal Counsel - Existing Litigation

Proposed settlement of a litigated claim for $500,000, Rosa Corrales v. Regents of the University of California et al, San Francisco Superior Court Case No. 315-584

D) Reconvene in Open Session

The Committee reconvened in open session at 6:20 p.m.

Possible report on action taken in closed session (Government Code Section 54957.1(a)2 and San Francisco Administrative Code Section 67.12(b)(2).)

Action Taken: The Commission (Chow, Guy, Jackson, Parker, Umekubo) approved the settlement.

2. Vote to elect whether to disclose any or all discussions held in closed session (San Francisco Administrative Code Section 67.12(a).). (Action Item)

Action Taken: The Commission (Chow, Guy, Jackson, Parker, Umekubo) voted not to disclose discussions held in closed session.


The meeting was adjourned at 6:20 p.m.

Michele M. Olson

Executive Secretary to the Health Commission