Minutes of the Health Commission Meeting Tuesday, January 7, 2003 At 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 Chow at 3:20 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner Michael Penn, Ph.D. Commissioner John I. Umekubo, M.D. Absent:  Commissioner David J. Sanchez, Ph.D. 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF DECEMBER 17, 2002 Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved the minutes of the December 17, 2002 Health Commission meeting with two technical corrections. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE (3.1) CHS-Maternal and Child Health - Request for approval to accept and expend retroactively a grant from the California Department of Health Services, in the amount of $113,788, to support healthy eating and childhood overweight prevention services, for the period of August 1, 2002 to September 30, 2003. (3.2) CHS-Maternal and Child Health - Request for approval to accept and expend retroactively a grant from the California Family Health Council, Inc., through a subcontract for a performance agreement with UCSF School of Nursing, in the amount of $84,328, for the Child Care Health Linkages Project, for the period of July 1, 2002 to June 30, 2003. (3.3) PHP-Community Health Promotion and Prevention - Request for approval of a retroactive sole source contract renewal with San Francisco Study Center, in the amount of $357,299, to provide technical assistance and support services for the DPH African American Health Initiative, for the period of July 1, 2002 through June 30, 2003. This contract is retroactive due to delays in awarding funding to the contractor and an extended period of document revisions for contract development. The Study Center is currently not receiving contract payment through an Interim Agreement. Commissioner Penn asked how committed the SFSC is to this new role. Geoff Link, Executive Director of the Study Center, said they are fully committed. Commissioner Penn asked if this arrangement is anticipated to be long term. Ms. Selmar said that Booker T. Washington will continue to be part of the coalition but will not be the lead agency, and AACHIE will be assessing what other community based organization can assume the lead role. They will give an update in April at the PHP JCC. Commissioner Penn would like to stay apprised on the long-term integration plan. Commissioner Monfredini asked for an earlier, written report in 60 days. (3.4) BHS-Mental Health/Substance Abuse - Request for approval of a retroactive contract renewal with New Leaf Services for Our Community, in the amount of $1,393,902, to provide mental health and substance abuse outpatient, intensive outpatient and prevention services targeting the lesbian/gay/bisexual/transgender community and men who have sex with men, for the period of July 1, 2002 through June 30, 2003. This contract is retroactive due to the need for the contractor to revise contract documents to incorporate Cost of Living Adjustments and other allocation changes after finalization of the Department’s fiscal year 2002-03 budget. The contractor has continued to provide services and receive payment under a 6-month interim agreement approved by the Health Commission on April 16, 2002. Commissioners’ Comments Commissioner Umekubo asked if staff is happy with way services are improving. Mr. Stillwell replied that the agency is heading in the right direction, but not where we want to be. Commissioner Umekubo asked if EPSDT is this something they plan to expand. Joseph Neisen, the Executive Director, said the EPSDT program is larger than what is indicated by this contract, which is only one funding source. The challenge with this contract is that they tend to have a high no-show rate so have adjusted the contract to reduce the dollar amount to reflect the number of youth they are serving. Commissioner Monfredini asked about board development. Mr. Neisen said the agency has done a lot of board development over the past five years and did a long-term strategic plan for the board, which includes quarterly goals. Commissioner Monfredini would like a report to the CHN JCC in 90 days on the progress of the CSAS Outpatient Program. Commissioner Penn asked if staff turnover was still a problem. Mr. Neisen said they did have a significant turnover, largely due to the economy and the inability to pay higher salaries. However, now it is a slightly different story, and they have been able to increase wages. Have also allowed access to benefit packages for part time workers, which is attractive to the workers. (3.5) PHP-AIDS Office - Request for approval of a retroactive sole source multiyear contract renewal with Institute for Community Health Outreach (ICHO), in the amount of $497,558, to provide case management, client advocacy and health education services to HIV positive individuals living in the Bayview Hunters Point community, for the period of July 1, 2002 through June 30, 2004. This contract is retroactive due to contract negotiations. This contractor has continued to provide services and receive payment under a 4-month interim agreement approved by the Health Commission on April 16, 2002. Commissioners’ Comments Commissioner Monfredini asked if the monitoring report recommendations were implemented. Deborah Oliver Wilson, Nia project director, said they have been implemented. Commissioner Penn asked how connected and in communication all the different agencies are. Ms. Oliver Wilson replied that on a monthly basis there is a providers meeting, which includes BVHPF, Black Coalition on AIDS and many other agencies serving this community. She feels that the agencies do a great job supporting each other. (3.6) PHP-AIDS Office - Request for approval of a retroactive sole source contract renewal with Positive Resource Center, in the amount of $105,700, to provide employment development services targeting people with HIV/AIDS who are seeking to enter/re-enter the workforce, for the period of July 1, 2002 through June 30, 2003. This contract is retroactive due to contract negotiations and the late award of some General Fund programs following the budget process. The contractor has continued to provide services and receive payments under an interim agreement as approved by the Health Commission on April 16, 2002. Commissioners’ Comments Commissioner Monfredini asked if people are still fearful of returning back to work. Mr. Lipp, executive director, said that this is still a barrier and part of their program is to provide counseling and services to assist individuals in overcoming these barriers. Commissioner Penn asked how people find out about these services. Mark Misrok, program manager, said there is constant interaction throughout the AIDS services community and the employment services committee. In addition they have significant interaction with the mental health and substance abuse services communities. Most of the referrals come through other agencies. Collaborations have been a very effective way of doing outreach. Commissioner Umekubo asked what their success rate is. Mr. Misrok said that there is a complex definition of success, but last year they achieved just fewer than 500 job placements, 150 of which were considered long-term placement. They hope to develop and track successes moving people into training programs and career counseling. (3.7) PHP-AIDS Office - Request for approval of a retroactive new sole source contract with the Regents of the University of California San Francisco-AIDS Health Project, in the amount of $98,734 for year one and $170,000 for year two, for a two-year total of $268,734, to provide HIV Cognitive Impairment Program and Standards of Care Training for CARE-funded service providers, for the period of September 1, 2002 through February 29, 2004. This contract is retroactive due to the time required to finalize the service specifications and prepare the required documents. Commissioners’ Comments Commissioner Monfredini asked staff to clarify if St. Mary’s AIDS Dementia Unit is closed. Ms. Long Dixon said that the unit is closed but there is a skilled nursing facility, which was the step down for the locked AIDS dementia unit. However DPH does not have a contract for patients at the SNF. The purpose of this contract is to ascertain where these patients previously served by the Dementia Unit are. Commissioner Monfredini asked when outcomes would be available. Ms. Long Dixon said preliminary data would be available at the end of February. Joanna Rinaldi from the UCSF AIDS Health Project said they are looking at patients across the entire system to determine how many individuals have HIV-related cognitive impairments. They are also trying to understand how people with cognitive impairments who are not in LHH or SFGH dedicated residential settings are being managed. Public Comment (at Health Commission) Abdul, volunteer at AACHIE, regarding Item 3.3. The program is really doing well. The staff and volunteers do a lot of outreach and are helpful to the community. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved the Consent Calendar of the Budget Committee. The Commission requested a 60-day written report to Budget Committee for Item 3.3, with a more detailed report to the April PHP JCC. The Commission also requested a report in 90 days to the CHN JCC for Item 3.4. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Star Hotel Housing Program The Department of Public Health welcomed the first residents to the Star Hotel Housing Program on January 6th. The newly rehabilitated Star Hotel, a single room occupancy hotel in the Mission District, is the latest addition to DPH’s Direct Access to Housing Program. The Star Hotel Housing Program is designed to serve homeless single adults with recent histories of being institutionalized, hospitalized, treated in residential programs, or housed in shelters. Homeless individuals with a history of rotating through various systems of care are also eligible. Sixteen units have been allocated for people with HIV/AIDS. The program provides on-site support services through Baker Places, Lutheran Social Services, and Tenderloin AIDS Resource Center. By March of this year, the Star will be home to 54 residents. Jo Ruffin Retires After 36 years of service with Community Mental Health Services, Laura Jo Ruffin retires from the Department this month. Jo’s long career with the Department has demonstrated her unwavering commitment to ensuring and improving mental health care and services for all San Franciscans. The Commission is looking forward to the opportunity to honor Jo at the January 21st Commission meeting. In further tribute to Jo’s dedication to the City, the Independent published a front-page article on Jo’s history with the Department, the Board of Supervisors will declare January 16, 2003 Laura Jo Ruffin Day in the City and County of San Francisco, and a reception will be held in her honor on the evening of January 16th. For more information on the reception, contact Richard Snowdon at 255-3474. Behavioral Health Community Forum On Wednesday, January 30th, the Community Behavioral Health Services Planning Committee will present their work to date on a plan to integrate mental health and substance abuse services. The Community Forum will be an opportunity to learn and give input about the integration process. It will take place at 101 Grove, in Room 300 from 3:00 to 5:00 p.m. Vickie Wells Appointed to National OSHA Advisory Committee On December 31st, U.S. Secretary of Labor Elaine L. Chao announced the appointment of Vickie Wells, DPH’s Occupational Safety and Health Director, to the National Advisory Committee on Occupational Safety and Health (NACOSH). The committee, established under the Occupational Safety and Health Act of 1970, advises the Secretaries of Labor and Health and Human Services on occupational safety and health programs. Members of the 12-person advisory committee are chosen on the basis of their knowledge and experience in occupational safety and health. Congratulations to Vickie for her well-deserved recognition as a national occupational health leader. Herminia Palacio, MD, MPH, Appointed Health Director for Harris County Public Health and Environmental Services Dr. Katz announced that Herminia Palacio, MD, was appointed Health Director for Harris County Public Health and Environmental Services. Harris County includes Houston and its surrounding areas. It has a population of three million people and is the third largest county in the United States. Prior to her move, Dr. Palacio, was a primary care resident at SFGH, an attending physician at Ward 86, the Acting Medical Director of Maxine Hall Health Center, and a Special Policy Advisor to the Director of Health. During her tenure at DPH, Herminia was responsible for the initiation of office based opiate addiction treatment (OBOAT) and the creation of a medicinal marijuana identification card. Dr. Palacio sent her best regards to the Commission and Department staff and credits her time at DPH as giving her the experience to take on this challenging job. Commissioners’ Comments Commissioner Umekubo said that many of his colleagues received a letter from Dr. Klausner about the syphilis epidemic that was very informative and well written. He commended Dr. Klausner for this communication. 5) PRESENTATION OF THE EEO/CULTURAL COMPETENCY ANNUAL REPORT Norm Nickens, Deputy Director of EEO Affirmative Action and Cultural Competence, presented the EEO/Cultural Competency Annual Report. Mr. Nickens described the general responsibilities of the EEO Office. The presentation focused on cultural and linguistic competency. Mr. Nickens summarized the CLAS standards, which were developed by the Office of Minority Health and adopted by the Health Commission. Standards 1-3 relate to culturally competent care. Standards 4-7 relate to language access and include legal mandates. Standards 8-14 are about organizational support. 2002 Implementation Activities Distribution of CLAS Standards and Commission Policy to contractors Formation of Cultural Competency Task Force Development of Cultural Competency Web Page Coordination of training activities with Community Mental Health Services, Department of Human Services and Mayor’s Office of Disabilities Training of EEO Office staff Technical assistance to contractors Training for contractors and DPH staff, including Cultural Competency in Working with the Arab and Muslim Communities, Mental Health Needs of the African American Community, Introduction to Cultural Competency and Introduction to Linguistic Competency, among others. 2003 Implementation Activities Various training activities are planned, including Implementation of the CLAS Standards, Working with the Disabled Community and Working with the L/G/B/T Communities, among others. Ongoing meetings with DPH Program Managers By March 2003, development of DPH Cultural Competency monitoring protocol and reporting format Ongoing technical assistance to DPH Program Managers/Analysts Ongoing development of model policies and procedures Ongoing development of a “train the trainer” and technical assistance program for contractors Ongoing review of DPH compliance with ADA and Equal Access to Services Ordinance Coordination with Behavioral Health integration committees. Commissioners’ Comments Commissioner Monfredini appreciates the work in implementing Policy 24. While the policy was straightforward, the implementation of the policy is quite complex. Mr. Nickens said that the Department now has a strong framework to build upon. Commissioner Parker congratulated staff for developing the framework. He was a little apprehensive at the beginning of this process and is now more reassured. He asked if community input is being incorporated into the CLAS standards, or do professionals drive them. Mr. Nickens said that one funnel for community input is the Cultural Competency Task Force. In addition, they try to incorporate providers in all of the trainings. Finally, through the annual reporting process they have identified agencies that have great cultural competency programs and are using these programs as models. Commissioner Parker asked if the seminar for African American Issues in Mental Health seminar is targeted toward community providers. Mr. Nickens said it is targeted toward staff as well. He added that as a rule they try not to charge for the training, unless continuing education credits are given for the training. Commissioner Parker is concerned that cost might be a barrier for some community-based providers. Commissioner Penn commended Mr. Nickens for taking a systematic approach to implementing complex issues. He asked if the reporting structure would apply to DPH programs as well as contractors. Mr. Nickens said the current program applies to contractors, with a future goal of applying it to Department programs. Commissioner Penn asked what happens if there are deficiencies in the reports submitted to EEO. Mr. Nickens said this information is brought back to the program managers. His office is in the process of ranking the reports on a scale of one to four. The ultimate goal is to have more information reported as part of the contract renewal process. Commissioner Penn said that this is a very important component of contract evaluation. Commissioner Penn emphasized the importance of bilingual services, and agreed with Mr. Nickens that just because a person speaks another language does not mean they are competent to provide medical interpretation services. Commissioner Umekubo commended staff for evolving this issue over the past four years. How is DPH doing in this area compared with other California counties? Mr. Nickens attended a national conference and was struck by how much more complex these issues are in San Francisco than other areas. For example other areas deliberate over English/Spanish bilingual signage, yet in San Francisco DPH has signage in so many other languages. Also, the main theme of the training in other counties was how to convince the governing body of the need for culturally competent services, which is definitely not an issue here. Commissioner Guy appreciates the progress that has been made. The goals for 2003 are appropriate and reflect where DPH wants to go. While the information that is presented with the Budget Committee reports will still not be at the level the Health Commission ultimately wants, this will eventually happen. She thanked the contractors who, with their exemplary reports, provide models of culturally competent services. Mr. Nickens said that they are beginning the effort to incorporate lesbian/gay/bisexual/transgendered standards of care. Commissioner Guy wants to begin the process of applying these protocols to internal programs next year. Commissioner Chow said that the groundwork would carry DPH into the future. Now, this needs to be put into a usable format and tested. The hope is to have more than two lines about cultural competency in the contract reports. Mr. Nickens said that the first iteration, to begin in July 2003, would probably be a one to two page checklist for each agency. Commissioner Chow clarified that the intent is to use the new monitoring protocols without negative consequences for the first year. Mr. Nickens said that this is correct. Commissioner Chow recommended that both of the topics of the new contract monitoring protocols and how DPH begins to extend these efforts to internal programs be referred to all of the Joint Conference Committees. He also wants reports on the progress of improving language competency within the Department. 6) PRESENTATION OF THE STATE LEGISLATIVE ANNUAL REPORT Colleen Johnson, Assistant Director, Office of Policy and Planning, presented the State Legislative Report. Ms. Johnson gave an overview of the legislative year, which was marked by tremendous fiscal uncertainties. In May 2002 the Governor anticipated a deficit of $23.6 billion, which was $11 billion greater than he had anticipated in January 2002. Although significant cuts in health services were made, many of the Department’s highest legislative priorities were successful. Another highlight of the legislative year was in hospital outpatient care. AB 915 (Frommer) established a program to allow public hospitals to match their local general fund contribution for outpatient services with federal Medicaid dollars. For San Francisco General Hospital (SFGH), this could mean an additional $5 million in Medicaid revenue in 2002-03. Trauma Services received a second year of one-time funding of $25 million to be allocated to trauma centers like SFGH’s. The Governor reduced this allocation to $20 million but this funding is still seen as a victory. In the area of HIV/AIDS, the Governor signed AB 2197 (Koretz), which provided Medi-Cal benefits to Californians with HIV who meet the financial requirements but who are not considered disabled. Ms. Johnson described the City’s legislative process. Individual Departments do not take positions on State legislation. DPH makes recommendations to the Mayor’s Office of Legislative Affairs and the Mayor’s State Legislative Committee for City positions on health-related legislation. At the beginning of each legislative session the Mayor’s Office approves DPH’s State Legislative Plan that outlines the Department’s recommendations on issues likely to arise. In addition, positions are taken on a bill-by-bill basis for those issues that are not addressed in the plan. Ms. Johnson summarized the 2002 legislative highlights (Attachment A). Ms. Johnson said the 2003 State Legislative Plan is comprehensive and addresses anticipated health-related issues to be debated in the Legislature. Significant issues are anticipated to be bioterrorism, Medi-Cal/Healthy Families, Realignment and the State Budget. (The Governor will release his proposed budget on January 10.) Commissioners’ Comments Commissioner Chow noted that DPH was opposed AB 1833, an emergency medical services bill that passed, and asked if we are still opposed. Ms. Johnson said the Department is still opposed to the mandated change in billing structure for Maddy EMS Funds. Although the bill passed, regulations still have to be developed and the Department will be commenting on these regulations. Commissioner Chow requested a federal legislative update in the fall. Commissioner Penn asked how the Department voices opposition to cuts to programs such as Medi-Cal. Ms. Johnson said that San Francisco has a very strong delegation in Sacramento, led by Senator Burton, so it is relatively easy to get our voices heard. Commissioner Guy would like continued updates on the State budget through the Director’s Report, since this is such a difficult legislative and budget year. The Commission can add to the advocacy efforts. She asked if there could be a future report on the implementation of AB 1421, Court-ordered assisted outpatient mental health treatment program. Dr. Katz said that the Department has done a very preliminary analysis and it is unlikely that the Department would recommend implementing the program. 7) PRESENTATION OF THE COMPLIANCE UPDATE Dennis Scott, Chief Compliance Officer, presented at Compliance status report. CY 2002 Compliance Focus HIPAA Administrative Simplification and Privacy Compliance Briefing and Training Compliance Intervention Announcements and Updates Compliance Council Meeting Schedule To insure that meetings are conducted every three months, Compliance Council meetings will have a specific date, which is the second Wednesday of every month HIPAA Budget Process Objective is to identify FY 2003 and FY 2004 implementation costs, and include in DPH budget priority discussions. Costs are significant. UCSF Data Security Agreement Transmitting clinical data outside of the DPH secured network to unsecured UCSF sites creates exposure for DPH Gene O’Connell and Dr. Phil Hopewell have begun preliminary discussions on conditions of transmission and possible UCSF indemnification of DPH Dennis Scott, Chief Compliance Officer, and Dave Counter, Chief Information Officer, will assume responsibility Compliance Division Mission Division has expanded dramatically in the last year, and needed a focus for how to conduct business The mission is to encourage an atmosphere of integrity in DPH clinical and business operations, and promote understanding and compliance with federal, State and local privacy and other health care regulations. FY 2003 Objectives Effectively manage HIPAA implementation to insure that regulations are implemented and deadlines are met Analyze OIG’s 2003 Compliance Work Program and work with DPH operating departments to minimize exposure Promote cooperative working relationships with DPH operating departments Mr. Scott gave a project status summary for HIPAA implementation and status on coordination with other City Departments. Mr. Scott discussed significant developments, status of implementation efforts and compliance risk factors for both HIPAA privacy implementation and HIPAA business associates requirements. Mr. Scott updated the Commission on the Department’s Compliance Activities. The focuses of the OIG FY 2003 Compliance Plan are: consecutive inpatient stays, medical necessity of Inpatient Psychiatric stays; uncollected beneficiary deductibles/coinsurance; procedure coding of Outpatient Physician Services; hospital specific Disproportionate Share payment limits; Medicaid diagnosis-related group payment window; Nursing Home Quality Assessment and Assurance Committees; nursing home survey and certification; Medicaid payments to SNF for Medicare-covered services; immunization and Ryan White Grants. Mr. Scott also discussed other significant activities including MD profiles, UPIN numbers and coding and documentation training for providers. Commissioners’ Comments Commissioner Monfredini commented that one of the areas she believes DPH is still vulnerable on confidentiality is providers and staff talking about clients inappropriately. Mr. Scott said that this is addressed through training. This is a big area of exposure because the Office of Civil Rights is going to respond to complaints, rather than perform audits. Commissioner Chow asked if the Department is going to have a single privacy notice to be distributed to patients, and will this be bilingual. Mr. Scott said there is a model policy that applies across DPH but developed to allow modification for more appropriate versions for different programs. The notices will be in the target languages. Commissioner Chow asked for a six-month update to the Commission, and also recommended that the SFGH JCC and LHH JCC stay apprised as compliance deadlines approach. Commissioner Umekubo said one vulnerability is that the education is very hit or miss. Different clinicians get different levels of information. He asked if the implementation is proving to be as costly as anticipated. Mr. Scott said it depends on what decisions are made. In DPH budget priorities, patient care is clearly the highest priority. DPH is seeking reasonable accommodation given its budget priorities, and will not be developing a Cadillac HIPAA program. DPH has to focus on areas that might generate complaints. Commissioner Penn asked what the estimated implementation costs will be. Dr. Katz said that personnel costs are the major expense and there are five staff people in Mr. Scott’s office. There is not an added cost for computer systems because the equipment is HIPAA compliant. Commissioner Penn asked how big of a problem transfer of data between UCSF will present. Mr. Scott said it is not a huge problem but there is a lot of research that goes back and forth between the two institutions and need to ensure that there are appropriate protections in place. He feels confident that this will happen. Commissioner Parker said that HIPAA is an additional cost of doing business, and also requires an annual cost to maintain the program. He asked if DPH is liable if DPH contractors and other agencies the Department does business with do not comply. Mr. Scott said that there is contractual language that requires entities DPH does business with to be HIPAA compliant. Due diligence will be required in following up on complaints, but DPH is not required to audit these agencies. 8) PUBLIC COMMENTS None. 9) ADJOURNMENT The meeting was adjourned at 6:10 p.m. Michele M. Olson, Executive Secretary to the Health Commission