Minutes of the Health Commission Meeting Tuesday, April 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 3:05 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Lee Ann Monfredini, Vice President Commissioner Roma P. Guy, M.S.W. Commissioner James M. Illig Commissioner Michael Penn, M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE MEETING OF MARCH 23, 2004 Action Taken: The Commission approved the minutes of the March 23, 2004 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sánchez chaired, and Commissioner Guy and Commissioner Penn attended, the Budget Committee meeting. (3.1) AIDS Office-Research - Request for approval of a new contract with Public Health Foundation Enterprises, Inc., in the amount of $63,445, to provide fiscal administrative services for the “HIV/AIDS Surveillance Activities” project, targeting newly diagnosed or reported cases of HIV infection or AIDS in San Francisco, for the period of April 1, 2004 through December 31, 2004. Secretary’s Note: this contract was presented by the HIV/AIDS Statistics and Epidemiology Section, not the AIDS Office of Research, as noted on the Contract Request Summary. (3.2) AIDS Office-Prevention - Request for approval of a new retroactive contract with UCSF AIDS Health Project, in the amount of $100,000, to provide integrated STD/AIDS testing services targeting defined high-risk populations, for the period of January 1, 2004 through June 30, 2004. (3.3) PHP-Community Health Services - Request for approval of a retroactive contract modification with AmeriChoice, in the amount of $100,000, to provide additional fiscal intermediary services to the Personal Assisted Employment Services (PAES) for dental services, for the total contract amount of $328,657, for the period of July 1, 2003 through June 30, 2004. Commissioners’ Comments Commissioner Sanchez asked staff to evaluate the feasibility of having some of the patients served through this program seen at the SFGH Dental Clinic, and report back to the Community Health Network Joint Conference Committee. Commissioner Guy asked Ms. Martinez to explain why the model of having these patients served at Tom Waddell was unsuccessful. Ms. Martinez said the primary factors were facility limitations and the inability to get positions released. Commissioner Penn asked if the average cost per patient for this program is accurate. Po Yee Lindahl said the amount is an average and is for reference only. Some patients use more of the dollars than others. (3.4) BHS-Mental Health - Request for approval of new retroactive contracts totaling $270,000 with the following out-of-county hospitals to provide inpatient mental services for San Francisco child and adolescent clients, for the period of July 1, 2003 through June 30, 2004: Adventist Health-California Specialty Hospital; Alta Bates Hospital, Herrick Campus; Fremont Hospital; John Muir/Mt. Diablo Health System; Mills-Peninsula Hospital; Stanislaus Behavioral Health Center and Sutter Health. Commissioners’ Comments (at full Commission meeting) Commissioner Illig asked why the Department is seeking waivers from the Equal Benefits Ordinance for these contracts. Mr. Sass said that these are sole source contracts for children who need these services. The placement of these children is often out of the Department’s control, and each institution might only have one placement in a year. But the Department needs a mechanism to pay for the services. Commissioner Illig would like all contractors to comply with the Equal Benefits Ordinance and will work with staff on this issue. BHS-Mental Health - Request for approval of a retroactive contract modification with Positive Resource Center, in the amount of $50,798 per year for a total contract value of $250,798, to provide SSI advocacy and training services for disabled, uninsured clients, for the period of April 1, 2003 through June 30, 2004. Commissioner Guy asked how long it has taken to get people approved for SSI. Jane Gelfand from Positive Resources Center replied that they have been able to get 28 patients on SSI in less than one year. This is tremendously exciting, since the perception is that it can take a very long time to become eligible for SSI. Commissioner Sanchez asked staff to clarify whether the modification is for start-up costs or a supplementation to the services. Ms. Martinez said the initial contract was April 2003 through April 2004 in the AIDS Office. Staff wants to renew it in Mental Health, with a contract ending July 2004. So this modification bridges the three months. Also, initially PRC was only going do benefits counseling. Staff immediately saw the need for additional services, and needed the modification to pay for these services. Action Taken: The Commission approved the Budget Committee Consent Calendar. Commissioner Sanchez abstained from voting on Item 3.2. The Community Health Network Joint Conference Committee will receive an update on Item 3.3 within 90 days. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. San Francisco Farm-to-School Report The Occupational and Environmental Health Section would like to announce the release of The San Francisco Farm-to-School Report. In 2002, San Francisco Food Systems in partnership with the San Francisco Unified School District (SFUSD) and the Occupational and Environmental Health Section began assessing the feasibility of incorporating fresher, locally grown fruits and vegetables into the meal programs within SFUSD in order to support students’ health and the surrounding farm economy. The purpose of this project was to understand the local school food environment in relationship to sustaining a farm-to-school project. The final report is available to download from the San Francisco Food Systems website, www.sffoodsystems.org. By advancing our project plan in the years ahead, San Francisco Food Systems hopes to ensure that our local community, including the San Francisco Unified School District, is vested in food systems activities that support sustainable environments and healthy, sustainable communities. Ten Year Homeless Council Mayor Newsom’s Ten Year Homeless Council, chaired by former Supervisor Angela Alioto, began meeting in late March and is expected to deliver a 10-year plan aimed at reducing chronic homelessness by the end of June. The 30-member council is comprised of a diversified group of leaders from various sectors of the community. Dr. Robert Okin, Chair of SFGH Psychiatry and Anne Kronenberg in her capacity as co-chair of the Local Homeless Coordinating Board are members of the council. Marc Trotz, Director of HUH, is providing technical assistance for the council along with Dariush Kayhan from Department of Human Services. The federal government has made the creation of these ten-year plans integral to securing resources for homeless programs. HIV Vaccination Trials Dr. Katz shared the good news with the Commission that in this year's annual evaluation of the 17 HIV Vaccine Trial Units in the United States, Caribbean, South America, Africa and Asia, San Francisco was the #1 performing site. Dr. Katz congratulated the Vaccine Team and the many others in the AIDS Office that support their work. Lesbian Mental Health Conference Community Behavioral Health Services (CBHS) is sponsoring a conference entitled, “SF LGBT Pride Celebration: Current Challenges in Lesbian Mental Health,” on Friday June 25th. This conference will be of particular interest to Primary Care providers as well as other DPH staff working in the field of mental health. For registration and more information, please call 502-5209 or access the information online at: www.lesbianhealthinfo.org. Commissioners’ Comments Commissioner Penn commended the Vaccine Team on their recognition. It is a great accomplishment. 5) ACCEPTANCE OF THE LAGUNA HONDA HOSPITAL FOUNDATION ARTICLES OF INCORPORATION Larry Funk presented the Laguna Honda Hospital Foundation Articles of Incorporation. Mr. Funk introduced Louise Renne, the chair of the Laguna Honda Hospital Foundation. Ms. Renne told the Commission that a number of people have agreed to be on the Foundation Board, and the membership will be announced shortly. The Foundation is dedicated to raising the additional funds needed to make the new Laguna Honda Hospital a resource for centuries to come. The Foundation will provide the Commission with regular reports. Commissioner Chow expressed the Commission’s gratitude to Ms. Renne for all her work in making the new facility a reality. Commissioner Monfredini is pleased that the bylaws are structured so well. Commissioner Sanchez, as former chair of the Laguna Honda Hospital Joint Conference Committee, said he is pleased at the work that was done to build consensus around both the hospital and the Foundation. Commissioner Illig asked why, upon dissolution, the resources do not revert to the institution, but instead to a generic non-profit. Ms. Renne said the bylaws give the flexibility to give money, upon dissolution, to the LHH Volunteers or the hospital or another entity. Under any circumstances, the first purpose is to give money to Laguna Honda. She will get additional information to the Commission. Commissioner Umekubo said the Foundation could not come at a better time, as there are a number of needs for the new facility, including computer hardware. Commissioner Guy commended Ms. Renne and Mr. Paley for committing their time to this cause. Due to their efforts, there is broad consensus in the community that the hospital will be modernized and will have a role in the 21st century. Action Taken: The Commission approved the acceptance of the Articles of Incorporation. 6) PRESENTATION OF A RESOLUTION HONORING PUBLIC HEALTH WEEK Ginger Smyly, Director, Community Health Promotion and Prevention, informed the Health Commission about Public Health Week activities. The theme of this year’s Public Health Week is eliminating health disparities, particularly racial and ethnic health disparities. The celebration includes the resolution, local and federal observances, and sample DPH programs. Ms. Smyly noted a seminal report, San Francisco Burden of Disease and Injury: Mortality Analysis, 1990-1995. Ms. Smyly highlighted sample DPH programs addressing health disparity, including Breast and Cervical Cancer Services, the Immunization Coalition, health services for LGBTQQ youth and the Seven Principles Project. Commissioners’ Comments Commissioner Guy said given these budget times, it is very important to recognize the benefits of projects such as Seven Principles and other public health projects. Commissioner Umekubo noted that the fact that only 21 states recognize Public Health Week underscores the lack of attention to public health. Commissioner Chow said it is so important to highlight the elimination of racial and ethnic health disparities, and the resolution underscores that fact that the Health Department works toward this every day. Action Taken: The Commission approved Resolution #05-04, “Honoring Public Health Week, April 5-11, 2004,” (Attachment A). 7) PRESENTATION OF SAN FRANCISCO GENERAL HOSPITAL REBUILD RECOMMENDATIONS Gene Marie O’Connell, Executive Administrator, SFGHMC, and John Kanaley, Senior Associate Administrator, Support Services, presented a San Francisco General Hospital Rebuild update. The Rebuild Steering Committee was reconvened to focus on the immediate mandate that SFGH be compliant with SB 1953. The focused work did not seek to develop an entire Facility Master Plan, but strictly focused on seismic compliance. The Rebuild Steering Committee began its work under two assumptions: SFGH will be rebuilt by 2013; and there would be a November 2004 General Obligation Bond. The plan was to cost no more that $550 million for a General Obligation Bond. The Steering Committee reviewed many threshold issues, including location of the hospital, location of psychiatric beds, number of acute care beds, status of SNF beds at Potrero, additional sources of funds and location of research facilities. The Steering Committee reached consensus that the replacement hospital should be 267 acute care beds. The Steering Committee also reached consensus regarding psychiatric beds remaining at the Potrero Campus even if the acute care hospital is built at Mission Bay. The process included various public meetings. Mr. Kanaley reviewed the concepts that were developed, reviewed and debated by the Steering Committee: A-1 - Rebuild a new acute care hospital on the north side of the Potrero Campus A-3 - Retrofit the existing Potrero hospital building for continued acute care use, and build a new critical care tower B-2 - Rebuild a new acute care hospital collocated with UCSF at Mission Bay, with ambulatory services at Potrero. Steering Committee Recommendation Many on the Steering Committee felt that more time was needed to fully explore the Mission Bay collocation option. Dean David Kessler of the UCSF School of Medicine re-opened the door to discuss collocation, and many of the SFGH medical staff support the dialogue. The SFGH Steering Committee voted to continue exploration of all options, including collocation with UCSF, before choosing an option. The recommendation does not rule out proceeding with a Potrero rebuild concept in the future. Next Steps Dean Kessler of UCSF has made arrangements for Bruce Vladik, former HCFA administrator, to participate in discussions on collocation. The goal is to reach agreement that collocation is, or is not, a viable option. Staff will provide regular updates to the SFGH JCC and will give a formal presentation to the Health Commission in six months. Dr. Katz said that although the recommendation is for further study, a lot has been achieved already. He was pleased with the process, and that the Steering Committee was able to make a decision on bed size. What remains as the major question is the new openness on the part of UCSF to collocate at Mission Bay. Dean Kessler has a broad vision about what hospital care could look like in a collocated environment. There are still a number of issues that would have to be resolved if Mission Bay is to be a reality. But it is important that all options be fully examined and pursued before a bond is put before the voters. Public Comment Lucy Johns, a member of the Steering Committee since its inception, spoke in support of the proposed resolution. The Steering Committee did the best it could to propose a solution, within financial constraints, that resulted in the best hospital for the public, the medical students and the employees. In the end, they chose to explore fully every opportunity they were presented with before making a final decision. Larry Bevan, Shop Steward, Local 250, spoke against the resolution. His concern is that the November 2004 election is the best opportunity to pass a bond for the hospital. Also, the Commission should look at UC’s history of taking over Mt. Zion. They only keep services that generate dollars. Sue Carlisle, M.D., Associate Dean at SFGH, encouraged the Commission to support the resolution to further study the future site of the hospital. SFGH is the safety net hospital and the city’s trauma center. SFGH is one of the best public hospitals in the world due to the partnership between the hospital and the UCSF physicians. The physicians feel that the two Potrero options would not provide the opportunity to recruit the highest quality doctors. Valerie Ng, M.D., Chief of the Medical Staff, said the Medical Executive Committee fully supports the resolution and pursuing further study about collocation. The best opportunity to provide quality care is at Mission Bay. David Grace said that global warming will have tremendous impacts and there will be a need for more than 267 beds at SFGH. The Mission Bay campus is on landfill, which would be dangerous during an earthquake. Commissioners’ Comments Commissioner Penn is much more comfortable with the present options, and that there are good options even if Mission Bay is not the final site. He asked the timeline for the collocation discussions. Dr. Katz said UC must make a decision on collocation by June or July. Commissioner Penn asked if research would be a topic in the discussions with UCSF. Dr. Katz said that the Dean sent out a letter that said it is UCSF’s responsibility to provide research space. It is the first time that UC recognized that the SFGH medical staff was as much a part of the research staff as those who are on the Parnassus Campus. Commissioner Guy supports the proposed direction, even though it means giving up the November 2004 election. The new dean at UCSF has reinvigorated the collocation option. But if further study is going to be done, every stakeholder has to be open to all alternatives, including Potrero. She is concerned that the medical staff believes that quality care is not possible at Potrero. Dr. Ng clarified that the medical staff is committed to serving the patients, and they will do so regardless of where the hospital is rebuilt. But there are concerns. Dr. Ng said the medical staff fully recognizes that the decision about where to rebuild is much larger than their views. Dr. Katz added that his priority is that San Francisco has a public hospital-this should be everyone’s number one goal. With that as the context, the Department needs to identify the most viable option for having a public hospital. SFGH closes in 2008 if there is no viable plan. Commissioner Sanchez said there is a new spirit at UCSF. There is a valid concern about whether the SFGH model will continue to work. But we will not know what the new pathway will be until the State budget is approved. UC’s research budget has been cut 20%. Yet the new Dean has still said he is committed to and responsible for research. This is an amazing commitment. In all this turmoil, the Steering Committee has stayed its course. All options need to be explored to see if we can give generations of San Franciscans the services of SFGH. Commissioner Monfredini said she had been opposed to further study of collocation because she did not think it was a realistic option. However, the new Dean has really breathed new life into this option and it is important that the Commission do its due diligence to pursue this option. Commissioner Chow said the Steering Committee has worked very diligently. The goal is to find the very best solution for this county and he believes this can be done and still meet the 2013 timeline. Action Taken: The Commission approved Resolution #06-04, “Accepting the San Francisco General Hospital (SFGH) Rebuild Steering Committee Recommendations With Regard to Bed Count and Maintenance of Psychiatry Wards in Current Building, and Directing the Department to Further Study the Hospital Rebuild Options, Including Collocation with the University of California at San Francisco (UCSF),” (Attachment B), and directed staff to provide a report to the Commission in six months, and update the San Francisco General Hospital Joint Conference Committee on a regular basis. 8) APPROVAL OF DIVERSION PROGRAMS TO IMPLEMENT PROPOSITION M Mitchell H. Katz, M.D., Director of Health, presented the Health Department’s plan to implement requirements proscribed by Proposition M. Proposition M was passed by the voters in November 2003 and bans all aggressive solicitation in public places, replacing the police-based approach to panhandling with a public health-based approach. Specifically, Proposition M requires the Health Department to establish, administer and/or certify: Guidelines for diversion program eligibility, Services to screen and assess violators for substance abuse and/or mental health treatment and services appropriate for treatment of violators, and Guidelines for determining whether the conditions were met Implementation Plan Establish Guidelines - DPH recommends that all individuals convicted for Prop M violations be able to participate in all established DPH treatment programs. Develop Screening, Assessment and Referral - DPH Treatment Access Program (TAP) will provide screening and assessment services to determine the level of behavioral health care needed for each client using the TAP initial screening instrument and/or the Addiction Severity Index Form. Following the assessment, DPH/TAP will arrange placement into an appropriate program. Develop Guidelines for Determining Whether the Conditions of Diversion Have Been Satisfied - TAP will report routinely to the Courts regarding status of client’s compliance and/or completion of treatment. Dr. Katz said that because the DPH Proposition M Diversion Program would only be invoked if the individual does not cease aggressive solicitation after being warned and given a chance to comply with the ordinance, is convicted of a misdemeanor or infraction and agrees to enter the DPH Proposition M Diversion Program, it is assumed that the number of persons who go through all three steps will be relatively small. DPH, in collaboration with the Department of Human Services (DHS), sees Proposition M as one small part of the overall response to homelessness and panhandling. By June 2004, DPH and DHS will be implementing a citywide street outreach program that will focus on several homeless populations, including panhandlers. Public Comment Andre Rucker said that if there are not treatment spaces now, there certainly will not be spaces in the next month. And this proposal will bring two very stressed individuals together-stressed police and hungry people. People will be locked up because there will be no room in diversion programs. Michael Lyon said the plan is predicated on the services existing, and they do not exist now, let alone after $37 million worth of cuts. Worse, it adds the patina of public health to a system that punishes people for being poor. This is below the Health Department’s mission. David Grace, the Health Commission should not enforce unconstitutional rules. Philip McDonald, Coalition on Homelessness, said thousands of dollars will be wasted on going after poor people. L.S. Wilson, Coalition on Homelessness, fears that this is a smokescreen for the police to be able to crack down on people for being poor. In order to make the legislation look good, the Health Department is going to have to displace people who have been waiting for services for months. John Melone, Homeless Senior Task Force, the task force worked diligently to get money for 100 units of housing, which was deposited in the Health Department’s budget. They are requesting an additional $2 million to provide housing and services to help solve the homeless problem. Diana Valentine, Coalition on Homelessness, said the Health Commission could prevent this program from being implemented by not approving this plan. Services do not exist, so the Health Commission has the responsibility and the ability to say no to this program. Karl Start, Citation Defense Program, asked how the police are supposed to know which panhandlers have been contacted by an outreach worker and offered real treatment, and who is going to pay for this? Larry Bevan is concerned that the engagement and outreach process is very time consuming. There are so few services available, and resources are becoming even more limited. The Health Commission needs to really look at how services are going to be allocated. Commissioners’ Comments Commissioner Illig asked if DPH is guaranteeing that anyone who gets cited and gets diverted through this program will be placed in a treatment slot. Dr. Katz, yes, they would be provided with treatment. Commissioner Guy said there are only so many treatment slots available. Will these individuals displace others, because this is now a priority? Where is the capacity, and who is being displaced? Dr. Katz replied that there is no question that under this plan, the Health Department would be prioritizing people who were found guilty under Proposition M, so it is possible people could be displaced. Proposition M did not come with any additional funding. Commissioner Monfredini clarified to the public that Dr. Katz developed this plan because he was mandated to. Commissioner Monfredini is not very concerned that people under Proposition M will displace current clients, because so few will get referred to the Health Department through this program. Commissioner Penn asked for clarification that there will be no directive to our outreach workers to refocus what they do to prioritize panhandlers over any other person they are outreaching to. Commissioner Guy said even if five people are diverted through this program, the questions are appropriate because there are not enough services. The Health Commission needs to carefully monitor this plan to see if it is successful. How will this plan be evaluated? Dr. Katz said the evaluation parameters are fairly clear-how many people, where were they placed, what was the outcome. He will provide a report through the Community Health Network Joint Conference Committee. Commissioner Illig is reassured that people will get treatment as part of this plan, not just assessed and given a referral. Commissioner Penn said DPH has no control over what the police do under Proposition M, so while we can hope for the best, we do not know that there will be a low number of participants. He is not sure that as a Health Department the first priority for services should be for this program. The resolution should reflect that there could be a reshifting of resources. What happens if through monitoring we find that this is deleterious? Dr. Katz said we would have to make hard choices to provide additional residential mental health and substance abuse treatment. Commissioner Penn does not want to put the Department in the position it is in with Jail Health in that the Commission has communicated that it is okay with a plan, does not communicate its concern, and will be stuck with it. Commissioner Chow said the monitoring process would allow the Commission to assess the impact and possibly suggest other priorities. Commissioner Guy said there is nothing in the resolution that assures the public that diversion means treatment. And she wants the resolution to address the capacity issue. Action Taken: The Commission approved amending the resolution to add: “Further resolved that the Health Commission will review on a quarterly basis the number of individuals assessed, treated and diverted under Prop M and the impact of more diversion on system resource capacity. Action Taken: The Commission approved amending the resolution to add “eligible” before the word “panhandler” in the third whereas. Action Taken: The Commission unanimously approved Resolution #07-04, “Approving the Guidelines and Identifying the Diversion Programs Mandated by ‘Proposition M - Aggressive Solicitation Ban’ Passed by Voters in November 2003,” as amended (Attachment C). 9) PUBLIC COMMENT Andre Rucker, the Health Commission just voted on something when the public is screaming that it will cause harm. When the program is reviewed, the information should be in writing. David Grace said the homeless population is expected to increase to 20 million people worldwide by 2010. This is an ugly scenario, and the Health Commission should be preparing for it. Karl Start, Citation Defense Program, the Police Department has already begun to issue citations under Prop M. 10) ADJOURNMENT The meeting was adjourned at 6:25 p.m. Michele M. Olson, Executive Secretary to the Health Commission Note: These Minutes will be adopted at the next Health Commission meeting. Any amendments to these Minutes made by the Health Commission will be recorded in the Minutes for the next Health Commission meeting.