Minutes of the Health Commission Meeting Tuesday, January 6, 2004 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 Commissioner Chow at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Harrison Parker, Sr., D.D.S. Commissioner Michael Penn, M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Lee Ann Monfredini Commissioner Michael Penn, M.D., Ph.D. 2) APPROVAL OF THE MINUTES OF THE MEETING OF DECEMBER 16, 2003 Action Taken: The Commission (Chow, Guy, Parker, Sanchez, Umekubo) approved the minutes of the December 16, 2003 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Umekubo chaired, and Commissioner Parker attended, the Budget Committee meeting. Commissioner Monfredini and Commissioner Penn were absent. (3.1) AIDS Office-HIV Research – Request for approval to accept retroactively and expend new subcontract funds from the Public Health Foundation, Inc., in the amount of $890,187, to reduce sexual risk for HIV transmission in substance-using men who have sex with men, for the period of September 30, 2003 to September 29, 2007. (3.2) AIDS Office-HIV Prevention – Request for approval of a contract renewal with Bay Area Young Positives, in the amount of $55,619, to provide outreach and linkage prevention services targeting behavioral risk youth populations, for the period of January 1, 2004 through June 30, 2004. (3.3) AIDS Office-HIV Prevention – Request for approval of a contract renewal with Mission Neighborhood Health Center, in the amount of $142,702, to provide HIV prevention services targeting defined behavioral risk populations, for the period of January 1, 2004 through December 31, 2004. (3.4) AIDS Office-HIV Prevention – Request for approval of a retroactive contract renewal with UCSF-Stonewall Project, in the amount of $100,000, to provide HIV prevention services targeting defined behavioral risk populations, for the period of November 1, 2003 through June 30, 2004. Secretary’s Note – the contract summary page incorrectly states that the source of funds is the Federal CDC. The source of funds is a one-time Board of Supervisors’ add back. Commissioner Sanchez abstained from voting on this item. (3.5) AIDS Office-HIV Prevention – Request for approval of a contract renewal with UCSF-Stonewall Project, in the amount of $105,110, to provide HIV prevention services targeting defined behavioral risk populations, for the period of January 1, 2004 through December 31, 2004. Commissioner Sanchez abstained from voting on this item. (3.6) AIDS Office-HIV Health Services – Request for approval of a retroactive sole source contract renewal with Institute for Community Health Outreach, in the amount of $66,666, to provide case management and peer advocacy services to HIV-positive Native Americans and Alaska Natives, for the period July 1, 2003 through February 29, 2004. Michelle Long Dixon, HIV Heath Services Director, stated that ICHO has completed and submitted its Policies and Procedures Manual, which includes a Quality Assurance Plan. DPH is also providing additional technical assistance to the agency through a capacity building grant. (3.7) AIDS Office-HIV Health Services – Request for approval of a retroactive contract renewal with Shanti Project, in the amount of $405,829, to provide practical support services targeting low income or homeless persons with HIV/AIDS in San Francisco, for the period of July 1, 2003 through June 30, 2004. BHS-Mental Health – Request for approval of a contract modification with Horizons Unlimited of San Francisco, Inc., in the amount of $268,800 per year for a total contract value of $5,775,419, to provide mental health day treatment and outpatient services targeting Latino youth, for the period of July 1, 2003 through June 30, 2007. (3.9) BHS-Mental Health – Request for approval of a retroactive contract renewal with Seneca Center for Children and Families, in the amount of $2,764,030 to: 1) provide mental health residential and day treatment services targeting seriously emotionally disturbed adolescents and 2) conduct assessments and provide therapeutic behavioral services to eligible clients, birth to 21 years of age, and their families, for the period of July 1, 2003 through June 30, 2004. (3.10) BHS-Mental Health – Request for approval of a retroactive contract renewal with Catholic Healthcare West dba St. Mary’s Hospital and Medical Center, for the provision of acute psychiatric inpatient hospital services in the amount of 1) $170,000 in City funds targeting uninsured adolescents and 2) $4,000,000 in Medi-Cal funds for two hospital providers targeting Medi-Cal beneficiaries, for the period of July 1, 2003 through June 30, 2004. Commissioner Umekubo abstained from voting on this item. (3.11) BHS-Mental Health – Request for approval of a retroactive contract renewal with Catholic Healthcare West dba St. Mary’s Hospital and Medical Center, in the amount of $578,761 per year, for a total contract value of $2,315,044, to provide intensive day treatment mental health services, for the period of July 1, 2003 through June 30, 2007. Commissioner Umekubo abstained from voting on this item. (3.12) BHS-Mental Health – Request for approval of a retroactive contract renewal with Catholic Healthcare West dba Saint Francis Memorial Hospital, for the provision of 24-hour adult acute psychiatric inpatient hospital services in the amount of 1) $100,000 in City funds targeting uninsured adults and 2) $4,000,000 in Medi-Cal funds for two hospital providers targeting Medi-Cal adult beneficiaries, for the period of July 1, 2003 through June 30, 2004. (3.13) BHS-Substance Abuse – Request for approval of a retroactive renewal contract with Curry Senior Services (previously know as North of Market Senior Services) in the amount of $590,419, to provide mental health and substance abuse outreach and outpatient and drop-in services, for the period of July 1, 2003 through June 30, 2004. Action Taken: The Commission (Chow, Guy, Parker, Sanchez, Umekubo) approved the Budget Committee Consent Calendar. Commissioner Umekubo abstained from voting on Items 3.10 and 3.11. Commissioner Sanchez abstained from voting on Items 3.4 and 3.5. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. State Budget Update Governor Schwarzenegger delivers the State of the State address today at 5 p.m. This speech is expected to be short and general in nature and will not contain specifics about the budget. However, details regarding how he intends to close a $14-billion deficit will be unveiled on Friday, when he is scheduled to release his 2004-2005 budget. It is expected that the heaviest cuts will fall in the area of health care and higher education, two areas that Governor Schwarzenegger targeted in mid-year cuts the Legislature declined to act on last month. According to press reports, Friday’s plan will not include any tax increases but may propose increasing fees for State services. Dr. Katz reported at the last meeting (December 16) that the Mayor’s Office issued initial budget instructions for the remaining six months of FY 2003-2004 and for the development of the FY 2004-2005 budget. There has been no change in these instructions at this time. Dr. Katz will report more detail to the Health Commission regarding the State and City budget at the next meeting on January 20. Newsom Mayoral Term Begins this Week Mayor-elect Gavin Newsom will be sworn in on Thursday morning on the steps of City Hall. In the last week of December, Dr. Katz had the opportunity to meet with the new Mayor and to present him with a transition memo outlining the status of the San Francisco Department of Public Health. This memo focused on several key issues that are most likely to require the Mayor’s attention in the early days of his administration, including the increasing demand and cost for public health services, the San Francisco General Hospital (SFGH) rebuild, the SFGH helipad, the Mental Health Rehabilitation Facility (MHRF), the Laguna Honda Hospital replacement, Housing and Homeless and Substance Abuse programs, and the Healthy Kids proposed expansion to 19 to 24 year olds. The Mayor-elect expressed his admiration of and appreciation for the local public health system and the work the Department does for San Franciscans. The Mental Health Rehabilitation Facility Blue Ribbon Committee The MHRF Blue Ribbon Committee began meeting in September 2003 with the following objectives: To review information about the mission, history, function, financing, successes and challenges of the MHRF; To survey existing models for providing services to persons with chronic mental health problems; and To determine the optimal programmatic design of the MHRF given the available services and unmet needs of persons with mental illness in San Francisco. The MHRF Blue Ribbon Committee holds it last meeting tomorrow (January 7, 2004) and will present its recommendations to the Health Commission at the next meeting on January 20. Commissioners’ Comments Commissioner Chow asked Dr. Katz to give a brief overview of the San Francisco General Hospital Rebuild Steering Committee activities. Dr. Katz said that staff has been working at the Commission’s direction to develop a proposal in the $500 million-$550 million range that, while not meeting all the needs, would address the seismic issues. The Steering Committee is working on a tight timeframe to present a recommendation to the Health Commission at its first meeting in March. 5) JAIL HEALTH REPORT Joe Goldenson, Director, Jail Health Services, presented the Jail Health Report. He began by giving a brief overview of the services provided by Jail Health Services (JHS). JHS provides a comprehensive and integrated system of medical, psychiatric and substance abuse care to the residents of the San Francisco County Jail system. Outpatient services are provided in six facilities. Emergency, acute and specialty services are provided at SFGH. On average, there are more than 2,000 prisoners each day. 75-80 percent have substance abuse problems and 14 percent have significant mental health problems. Programs Jail Medical Services – in FY 02-03, there were 100,000 nursing visits, 17,000 clinician visits and 6,000 dental visits. There were also 130,000 prescriptions filled and 1,800 x-rays performed. Jail Psychiatric Services – in FY 02-03, 20 percent of the jail population on any given day received mental health care. There were 5,000 mental health evaluations, 2,000 psychiatric visits for patients who require psychotropic medications, 500 substance abuse assessments and referrals and 10,000 post-release case management and community placement contacts. Forensic AIDS Project – provided 2,100 HIV tests as of the 3rd quarter of 2003. Provided early intervention services to 600 unduplicated patients per year. Performed 703 hepatitis C tests from January to November 2003, and provided approximate 100 hepatitis B vaccines per month. Infectious Diseases – 10,000 tuberculin tests applied and 7,000 read. There were no new cases of active tuberculosis identified this year. 2,500 tests for chlamydia and gonorrhea were performed. 139 chlamydia cases were identified, and 85% treated. 31 gonorrhea cases were identified, and 94% treated. Challenges – FY 03-04 Budget $4 million reduction 34 positions eliminated (22 nursing positions, 12 miscellaneous positions). This has resulted in a reduction in levels of nursing coverage, over the counter medications not being provided, and patients with acute, self-limited problems such as colds not being seen. Further, patients with diabetes are not eligible for programs at CJ #7 (although this is a temporary problem that will be solved by the opening of a new facility at the San Bruno Jail), and discharge planning services have been reduced. Projected deficit of $2.1 million Structural issues such as overtime, nursing salary savings, fringe benefits and workers compensation. Jo Robinson provided the Commission with an update on the Mentally Ill Offender Crime Reduction Grants. San Francisco received two grants: MIO I – Forensic Support Services; and MIO II – Connections. For MIO I, San Francisco received $5 million to do a high risk model that focused on MIOs at risk for going to State prison. This model provided jail-based psychiatric assessment, treatment and release planning, intensive case management, a specialized probation officer, clinical consultation to the courts and education to community treatment providers. For MIO II, San Francisco received $3.5 million. This program targeted MIOs released from jail as part of the SFSD Supervised Misdemeanor Release Program or the Supervised Pretrial Release Program. Participants were provided temporary housing, case management and community-based treatment, and clients were connected to appropriate community resources. Ms. Robinson showed the Commission a video that was done give a face to the people who are part of the two grant programs. The interviews were unscripted—staff visited the clinic unannounced and people agreed to be interviewed. /p> JHS has preliminary data on the impact of these two programs. The MIO crime reduction grants clearly achieved the statewide objectives to reduce jail time. Locally, for MIO I, the treatment as usual group has a 37% higher arrest rate for new charged than the group receiving services. Arrests for violent offenses were significantly less for people receiving forensic support services than for those people in the treatment as usual comparison group. Ms. Robinson presented the demographics of the inmates who participated in both programs. She said the outcome of these efforts have been improved relationships, the Behavioral Health Court, which began in November 2002 and has 75 clients, and UCSF’s Forensic Case Management. Commissioners’ Comments Commissioner Guy asked how many people have been through the grant programs. Ms. Robinson said in the MIO I program, there were 125 in the FFS portion and 125 in the control portion. For the MIO II grant, there were a little more than 120 participants. Commissioner Chow asked if, since the grants are showing such positive results, is there the intent to institutionalize these programs. Ms. Robinson said that it is included in the base budget next year, and there is a movement within the Sheriff’s Association to have the State continue this program. Dr. Katz said that it should be in the Sheriff’s budget, since the savings are achieved in the Sheriff’s budget. Ms. Robinson added that the Police Department should be involved as well as they are a partner. Commissioner Guy asked how much has been added to the base budget for this program. Ms. Robinson replied that it was slightly less than $800,000. Commissioner Sanchez said that the pilot has demonstrated that this type of program works. In the era of state budget reductions, it is these types of successful, collaborative programs that stand out. Commissioner Umekubo said that the mandate that various agencies communicate and work together has achieved great successes. Commissioner Guy suggested working with the State Legislature and the Board of Supervisors to affirmatively communicate the importance of Jail Health Services and ensure that these services are adequately funded so that we do not have to continue to take money from other important services to cover the structural shortfalls. Commissioner Chow asked how it is determined that an inmate is indigent therefore does not need to pay for certain items in the commissary. Dr. Goldenson said the commissary runs the program, and JHS only had to add the free products to the commissary’s list. Dr. Katz asked Dr. Goldenson how our services compare to other county jail systems. Dr. Goldenson said that, even with the cuts, San Francisco’s level and quality of services are much higher than other counties. 6) STD UPDATE Jeffrey Klausner, M.D., Director, STD Prevention and Control Services, presented the STD Program’s response to the increases in syphilis in San Francisco. Factors associated with increased syphilis in San Francisco include: men who have sex with men; HIV infection/HAART; changing attitudes of HIV positivity; increased number of sex partners; increased proportion with multiple partners; methamphetamine use; Viagra use; and Internet use. The public health response has been to reduce infectiousness and risk. Enhanced surveillance – quarterly blinded syphilis testing at anonymous HIV testing sites; monthly review of syphilis tests at clinics, hospitals, emergency rooms, jails; weekly case review; neurosyphilis case review Expanded clinical and lab services – City Clinic prioritizes cases and persons exposed to syphilis; community prevention center (MAGNET); private hospital screening; online testing service at www.stdtest.org; UCSF PHP-West 18th and Folsom site; sex club screening Health provider education – grand rounds, noon conferences; mailings, education packets, website; provision of benzathine penicillin G; strong encouragement of prophylactic treatment; provider visits Community health promotion – coalition development; venue notification and outreach; social marketing; Internet Patient-delivered Epidemiologic treatment – Azithromycin, distributed by syphilis patients to partners and friends. This utilizes natural sexual-social network. Address select risk factors/p> Reduce methamphetamine use Educate Viagra users Use Internet for health promotion Public health evaluation Dr. Klausner gave various statistics about syphilis tests by site, proportion tested for syphilis by HIV status, proportion tested for syphilis by number of sex partners and syphilis cases by quarter, January 1999 through December 2003. He also acknowledged the various partners in this effort. Commissioners’ Comments Commissioner Chow is pleased that the trend is moving in the positive direction. He asked how many tests are being done through the on-line testing service. Dr. Klausner said that approximately 500 people visit the site each week, with up to 10 people taking the form to get tested. Commissioner Guy asked what factors might be leading to the decline in cases. Dr. Klausner said the widespread adoption of syphilis screening and other STD screening among the at-risk population is one factor. At the beginning of the epidemic, this was not the case. Now, there is screening, testing and treatment. Commissioner Chow asked if there is any concern about allergic reactions to zithromycin. Dr. Klausner said the antibiotic is very safe. The concern has been that there would be syphilis strains that are resistant to Azithromycin. This has happened, although there has been no sign of strains resistant to penicillin. Commissioner Umekubo asked what the state of the art is around syphilis detection. Dr. Klausner said the City Clinic is a state-designated training center for syphilis detection. They can make an on-site diagnosis of syphilis. Commissioner Umekubo asked if there has been a noticeable increase in hits to the website. Dr. Klausner replied that there has been a significant increase in visits to the new site. They are currently trying to ascertain the impact of the website in getting people to visit the clinic. Commissioner Parker said the STD program is doing a great job increasing accessibility to and availability of treatment. He asked how long it will take to evaluate whether the campaign to educate people who use chat rooms about syphilis is working. Dr. Klausner said that they continue to work with various sites that are frequented by MSMs but it is a challenge, as most Internet companies are not interested in having syphilis information on their sight. Commissioner Guy congratulated the STD program for working with a community coalition. Dr. Klausner and Wendy Wolf have provided the PHP JCC with continued updates on the epidemic. Commissioner Chow thanked Dr. Klausner for persevering with this effort during years of much controversy. This program is a fine example of public health. 7) PUBLIC COMMENTS None. 8) ADJOURNMENT The meeting was adjourned at 5:10 p.m. Michele M. Olson, Executive Secretary to the Health Commission