Minutes of the Health Commission Meeting Tuesday, June 1, 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 3:15 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Lee Ann Monfredini, Vice President Commissioner James M. Illig Commissioner John I. Umekubo, M.D. – arrived at 3:25 p.m. Absent: Commissioner Roma P. Guy, M.S.W. Commissioner Michael Penn, M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner Chow announced that the Board of Supervisors is holding its Bielenson Hearing on the proposed Health Department Budget on June 15 at 3:00 p.m. The Health Commission will therefore most likely cancel its June 15th meeting. The public will be notified accordingly. 2) APPROVAL OF THE MINUTES OF THE MEETING OF MAY 18, 2004 Action Taken: The Commission (Chow, Illig, Monfredini, Umekubo) approved the minutes of the May 18, 2004 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Chow chaired Items 3.1 through 3.12 of the Budget Committee meeting and Commissioner Monfredini chaired Items 3.13 through 3.20. Commissioner Illig attended the entire Budget Committee meeting. (3.1) CHN/SFGH – Request for approval of a retroactive sole source contract renewal with the Regents of the University of California, in the amount of $2,550,000, to provide tertiary care services targeting medically indigent adults, In-Home Supportive Service workers and San Francisco County Jail patients, for the period of July 1, 2003 through December 31, 2004. Secretary’s Note – The annualized difference on page 1 of the summary is indicated at “$850,000.” It should be “-0-.” (3.2) CHN/SFGH – Request for approval of a contract renewal with Richmond Area Multi-Services, Inc., in the amount of $4,403,216, to provide culturally competent partial-hospitalization and aftercare treatment services targeting the community’s mentally impaired population, for the period of July 1, 2004 through June 30, 2006. Secretary’s Note – The annualized difference on page 1 of the summary is indicated as “($672,245)”—a decrease. It should be an increase—“$672,245.” The contract FTE annualized difference on page 1 is indicated as “(7.05).” It should be an increase—“1.70.” (3.3) CHN-SPY-YGC – Request for approval of a contract renewal with St. Mary Prescription Pharmacy, in the amount of $415,000, to provide as-needed outpatient pharmacy services for the clients of the Community Health Network, Special Programs for Youth/Youth Guidance Center and associated programs, for the period of June 1, 2004 through June 30, 2007. (3.4) CHN-Primary Care – Request for approval of a contract renewal with Mission Neighborhood Health Center, in the amount of $766,460, to provide Primary Care Services for medically indigent adults residing in the Mission District, for the period of July 1, 2004 through June 30, 2008. (3.5) PHP-BEHM – Request for approval of a contract renewal with San Francisco Foundation Community Initiative Fund, in the amount of $75,000, to provide fiscal agent services for the San Francisco Food Council, for the period of July 1, 2004 through June 30, 2005. (3.6) PHP-CMHS-MIS – Request for approval of a renewal software maintenance agreement with InfoMC, in the amount of $245,160, to provide ongoing system maintenance and application support services for the CCURA3 software application for Community Mental Health Services, for the period of July1, 2004 through June 30, 2005. (3.7) PHP-CMHS-MIS – Request for approval of a renewal software maintenance agreement with The Echo Group, in the amount of $411,597, to provide ongoing system maintenance and application support services for the INSYST software application in use by Community Mental Health Services, for the period of July 1, 2004 through June 30, 2005. (3.8) PHP-Housing – Request for retroactive approval of a new contract with Mercy Services Corporation, in the amount of $763,533, to provide property management services in a Direct Access to Housing site, targeting homeless, extremely low-income persons with special needs, including substance abuse, mental health and physical disabilities, for the period of April 1, 2004 through June 30, 2005. (3.9) PHP-Community Health Epidemiology – Request for approval of a retroactive contract renewal with Mission Neighborhood Health Center, in the amount of $54,000 per year for three years for a total contract value of $162,000, to provide immunization education services targeting Latinos, for the period of July 1, 2003 through June 30, 2006. (3.10) AIDS Office-HIV Health Services – Request for approval of a retroactive sole source contract renewal with Mission Neighborhood Health Center, in the amount of $70,440, to provide HIV treatment outreach and counseling, and testing and referral services targeting HIV positive Latino/as living in and around the Mission District, for the period of September 30, 2003 through September 29, 2004. (3.11) AIDS Office-HIV Prevention – Request for approval of a retroactive contract renewal with St. James Infirmary, in the amount of $102,262, to provide HIV prevention services targeting behavioral risk populations, for the period of January 1, 2004 through December 31, 2004. AIDS Office-HIV Prevention – Request for approval of a retroactive new contract with Harder+ Company Community Research, in the amount of $120,000, to provide technical support services to the HIV Prevention Planning Council, for the period of April 1, 2004 through December 31, 2004. (3.13) BHS – Request for approval of a new contract with ZiaLogic, in the amount of $112,000 per year for a total contract value of $224,000, to provide behavioral health integration consultation services, for the period of July 1, 2004 through June 30, 2006. (3.14) BHS – Request for site approval for relocation of Hyde Street Community Services, Inc., from 251 Hyde Street to 134 Golden Gate Avenue. Public Comment Victor (no last name given), thanked the Commission for its support of this program. (3.15) BHS-Mental Health – Request for approval of a renewal contract with Hyde Street Community Services, Inc., in the amount of $2,548,495, to provide comprehensive mental health outpatient services at the Tenderloin Clinic and wellness and recovery services at the Clubhouse targeting eligible adults in the Tenderloin area, for the period of July 1, 2004 through June 30, 2005. Public Comment Susan Victor, President of the Board of Directors of Hyde Street Clinic, said the program is very healing and there is a lot of opportunity for client involvement. Linda Zaretsky, clinical coordinator for Hyde Street Clinic, said this contract represents community activism at its best. She acknowledged the leadership of Cindy Gyori. (3.16) BHS-Mental Health – Request for approval of a contract renewal with Calvin Y. Louie, CPA, in the amount of $5,444,410, to provide fiscal intermediary services for the Community Mental Health Services supplemental residential care facilities, for the period of July 1, 2004 through June 30, 2005. (3.17) BHS-Mental Health – Request for approval of a renewal contract with Progress Foundation, in the amount of $9,729,503, to provide mental health, residential, outpatient and day treatment services targeting adult residents of San Francisco, with special services for senior, African-American, Asian, Latino and homeless communities, for the period of July 1, 2004 through June 30, 2005. (3.18) BHS-Mental Health – Request for approval of a contract renewal with Boys and Girls Club of San Francisco, in the amount of $112,251, to provide an Early and Periodic Screening, Diagnosis and Treatment mental health services program for youth, for the period of July 1, 2004 through June 30, 2005. (3.19) BHS-Mental Health – Request for approval of a contract renewal with Huckleberry Youth Programs, in the amount of $112,251, to provide an Early and Periodic Screening, Diagnosis and Treatment mental health services program for youth, for the period of July 1, 2004 through June 30, 2005. (3.20) BHS-Mental Health – Request for approval of a new contract with ValueOptions, Inc., in the amount of $100,000, to function as an administrative services organization providing out-of-county mental health placement services to minors, for the period of July 1, 2004 through June 30, 2005. Action Taken: The Commission (Chow, Illig, Monfredini, Umekubo) approved the Budget Committee Consent Calendar. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Mayor’s Budget Calling it “A Time for Change,” Mayor Newsom unveiled his 2004-05 budget today. The budget bridges a $352 million general fund deficit while protecting vital services to the most vulnerable populations in our society – the aged, the young, and the poor – and bringing major reforms to city government. In his budget message, Newsom outlined his vision for a era in city government and his belief that it is more important now than ever that the city carefully target investments in services that San Franciscans rely upon most. As it relates to health and social services, the Mayor’s budget: Prioritizes and expands homeless services, including funds for nearly 1,000 new housing units for homeless individuals, targeted implementation of 24-hour shelter services, and the creation of new street outreach teams to better connect homeless individuals to required services and housing; Protects and expands services for children and youth, including investments to expand the city’s successful health insurance program to youth timing out of existing programs, a $750,000 increase in youth employment programs, and legislation to enable a local earned income tax credit for working families; and Preserves vital investments for seniors with disabilities, including: the rejection of all proposed direct service reductions to naturalization, senior resource center, and housing advocacy programs; a $100,000 investment to allow the transition to a new food bank provider; and funding to backfill parking tax losses to aging programs. The Mayor reached his goal of balancing the budget with the following measures: $114 million in department operating and capital budget reductions; $53 million in employee contributions to retirement costs; $39 million in revenue leveraging, fee increases and other funding sources; $33 million in debt refinancing and capital asset sales; $25 million in proposed tax increases; and $23 million in current year reductions Among the cost-saving measures contained in the Mayor’s budget is a proposal to have providers competitively bid to provide jail health services. An analysis done by the Mayor’s office reveals that San Francisco spends more on jail health services than most other local jurisdictions. If the Mayor’s plan for jail health services is adopted by the Board of Supervisors as part of the final budget, DPH’s jail health staff will work closely with our labor partners to draft and submit a competitive proposal. Mental Health Clinics Restored I am pleased to advise you that last week, Mayor Newsom announced that he will fully fund Mission Mental Health Services, the Mission Multi-cultural Assertive Community Team (Mission ACT), Southeast-Mission Geriatric Services, and Sunset Mental Health Services at current year levels. As the Health Commission is aware, DPH’s contingency budget originally proposed consolidating these programs into our primary care centers. However, consistent with the contingency budget resolution the Health Commission passed early last month, the Mayor’s office further considered the specific impact of mental health services in the Mission and was able to find the revenues necessary to maintain these services, as well as those at Sunset Mental Health Services. Mission Family Center Open House Mission Family Center, located at 755 South Van Ness, will host an open house on June 9th from 11:00 AM to 2:00 PM to celebrate the completion of an outdoor mural designed by Mr. Rafael Landea. The theme of the mural, which depicts children of diverse backgrounds working in unison toward a common goal of putting a puzzle together, is cooperation and teamwork. . The mural is a reflection of the multicultural population of the Mission District that the Mission Family Center is committed to serving. This project was made possible due to the generosity of Rafael Landea, who donated the mural design and supervised its completion; the initiative of Juan Pauli, LCSW, Mission Family Center Program Director, who contacted Mr. Landea and promoted this project; and the support of Albert Eng, Ph.D., Assistant Director and Sai-Ling Chan-Sew, LCSW, Director of Community Behavioral Health Services’ Child, Youth and Family System of Care. Commissioners’ Comments Commissioner Monfredini said that in these difficult economic times, the proposed budget is extraordinary, particularly the employees’ willingness to pay for their retirement once again. Commissioner Monfredini said the opening of the Avon Comprehensive Breast Center was amazing. Commissioner Illig asked if other Departments were consolidated beyond the Department of Adult and Aging being combined with the Department of Human Services. Dr. Katz said that the Commissions are being maintained and the executive directors are being maintained. But the operations and administrative functions have been combined. The Department of Agriculture is coming to DPH. There is a consolidation of car maintenance facilities. Commissioner Illig asked why San Francisco’s jail health services are more expensive than other Bay Area counties. Dr. Katz said staffing costs are higher, primarily because of the pay equity policy to pay lower salaried workers, such as LVNs, more than the market rate. Further, San Francisco provides a higher level of service, including immunization programs, STD screening, TB screening and others. Commissioner Chow added that many of the staffing requirements at the jail were proscribed by court mandate. The City is no longer under this mandate. Dr. Katz added that all the staff that was required by that agreement has been codified in the MOU. The only way that the Department would be able to be competitive would be if the labor partners agreed to modify these provisions. Commissioner Chow commended Dr. Katz for participating in the Chinese Community Health Summit. 5) LAGUNA HONDA HOSPITAL REPLACEMENT PROJECT UPDATE Michael Lane, Project Manager, LHH Replacement Project, presented an update on the Laguna Honda Hospital Replacement Project. Design and Construction A total of $81.3 million has been received in Tobacco Settlement funds. Approximately $50 million has been expended to date. They are continuing to work with the Mayor’s Office of Public Finance to schedule a general obligation bond sale, anticipated to happen in the summer. The project met the SB 1128 deadline, and will be eligible to recoup some of the capital costs. Completed Access Improvement and Signalization, Hazardous Materials Abatement for Utilities and Hazardous Materials Abatement for Wing G2. In-progress contracts include Utilities Modification, Site Work Package I, Demolition of Valley Structures and Mass Excavation. This work will last through the summer. Staff is working with the contractor to resequence some work. The Temporary Facilities Project is complete. The laundry relocation issue is before the Board of Supervisors for a decision. Beginning a prototype of a working bathroom, to get critical feedback from staff prior to construction. The project has been registered with the U.S. Green Building Council. The Replacement Program proposes to work with San Francisco community-based organizations to implement a local hiring plan. Artwork The Laguna Honda Hospital Replacement Project will generate $3.9 million in art enrichment funds for a comprehensive art program that will contribute to the quality of life at the hospital by aesthetically enhancing the environment. The artwork programs are: Resident Floor (neighborhood) Identity; Link Building elevator lobbies; Link Building town center and connectors; Aqua Therapy Center tile design; Laguna Honda History; Courtyard sculptures; conservation of historic artworks by David Edstrom & Glen Wessel; miscellaneous artworks currently in the Hospital’s collection. Assisted Living The design team, in collaboration with the Hospital staff, has identified an approach to sequencing the construction and the resident relocations that would allow renovation of the wings earlier than originally scheduled. This plan to start the renovation earlier would need to be approved by OSHPD and the Mayor’s Office of Housing. Schedule From the last quarter, the program has slipped slightly such that the end date for the last building, Clarendon West, has moved from late 2009 to the beginning of 2010, and completion of the Child Care Center in the Assisted Living Facility has moved from the end of 2011 to the beginning of 2012. They have experienced delays during construction on this phase related to underground soil conditions and regulatory issues. They are bringing in the next phase contractor on schedule in July. There is a 54-day delay in the overall schedule. The schedule will be updated after they receive bids in August. Budget Prior to beginning the bidding process for the new building, the team became aware of unprecedented spikes in material prices, particularly steel, and asked for update cost estimates. A preliminary update shows an overrun of approximately $30 million. Mr. Lane described the instability in the steel market. The project includes 6,000 tons of structural steel. Mr. Lane said there have also been increases due to additional design scope and insurance premium, for a net increase of $52 million. Existing contingencies of $22 million bring the net overrun to $30 million. They are currently proposing $5 million in additional value engineering. Recommendations for How to Proceed Compare the updated cost estimates to validate the reasons for the cost overruns. This will be completed in May. Identify and proceed with value-engineering proposals. The team has been directed to focus on items that can be changed without resulting in a delay. A realistic target for savings from value engineering in this pre-bid stage of the project is a maximum of $5 million. Proceed with the first set of bids to validate what the estimators are projecting. The original contingency plan in the case of an overrun was to reduce the size of the last new building, West Clarendon, from a 7-floor building to a 5-floor building. This plan did not anticipate anything of this magnitude and further savings would be needed. So as they proceed with the bids for the first three bidders, they will direct the bidders to submit pricing showing one less floor on the East Building and the South Building. This information will allow them to make an informed decision. Because of the particular uncertainty in the structural steel market, keep the structural steel package on hold and evaluate the market on a month-to-month basis. Work with the general contractor to maximize competition on all bid packages. Delay bidding the West Clarendon Building. Proceed with a competitive selection process to procure project insurance. Update the Turner estimates for the renovation and the future site work.   Commissioners’ Comments Commissioner Umekebo asked if the decision were made to eliminate one floor in a building, is there a possibility of adding the floor back on at a later time. Mr. Lane said that for Clarendon, yes. If the bids indicate that the problem is a big as they think it is, they could not bridge the deficit with the savings from Clarendon. With regard to the other buildings, once the decision is made to reduce scope by a floor, it would be very difficult and expensive to reverse this decision. Dr. Katz added that there could be a decision to build a shell at either of the two buildings, which would result in less savings. If a floor is shelled, cost savings are approximately $3 million. If a floor is eliminated, the cost savings is $8 million. Commissioner Chow asked if the three buildings are going to be built at the same time. Mr. Lane said that three of the four buildings would be built at the same time, so a decision must be made for all three buildings. Commissioner Chow asked if the bids allow for a cost savings if the price of steel stabilized or came down. Mr. Lane said it currently does not. Staff had analyzed the possibility of entering into a risk-sharing arrangement with contractors. This opens the City to exposure. Commissioner Chow said that the artwork must be simple because residents are different ages with different abilities. Specifically he has concerns about the clock artwork because seniors generally do not want to “mark time.” Commissioner Monfredini asked if there is a shortage of steel, and is this a supply and demand issue. She also asked if steel for all three buildings could be purchased together and delivered at the same time. Mr. Lane replied that the steel is available but there is a great demand for it, and they are not in a position to negotiate. They will purchase the steel for all the buildings at the same time. The contractor who wins the bid will buy it all and store it. Commissioner Monfredini said that when floors are eliminated, then beds are eliminated. Is this going against what was promised to the voters who approved the bond initiative? Mr. Lane replied that the bond specified a replacement facility, not 1200 beds, but clearly throughout the process the plan has been for 1200 beds. He reiterated that without the bid information it is difficult to make a decision about bed reductions, but probably talking about a reduction of between 180 and 240 beds. Dr. Katz added that he has not given up hope. Steel might become more affordable again. Staff is doing its due diligence to be faithful to the bond and try to build 1200 beds. Commissioner Chow asked when an update could be given to the Health Commission. Dr. Katz said September. Commissioner Umekubo said the Laguna Honda Hospital Joint Conference Committee receives monthly status reports with good information, and thanked Mr. Lane for the excellent job he is doing. Commissioner Monfredini asked how confident staff is about the July bidding timeline. Mr. Lane is 100 percent confident. 6) PRIMARY CARE RESTRUCTURING UPDATE Barbara Garcia, Deputy Director of Health, Community Health Services, presented an update on Primary Care Restructuring. Over the past year, staff looked at productivity and staffing data and did a study the overlap of patients in Behavioral Health and Primary Care. Accomplishments include the McMillan Center and implementation of OBOAT. This work helped in the discussion of restructuring primary care in the face of diminishing funds. A new centralized administrative team will be created for Primary Care. Effective May 23, Michael Drennan, M.D., became the Chief of Service for Primary Care. He will be responsible for many of the duties that were previously assigned to David Ofman, M.D., including supervision of medical directors, overseeing credentialing and system-wide coordination. A Chief Operating Officer will be hired to work under the supervision of the Chief of Service. Many administrative functions that are currently dispersed at the various primary care sites will be centralized to this position. As of September 1, 2004, there will no longer be health center directors at the primary care clinics. The Director of Nursing position will also be eliminated as of this date. Nurse Managers will be reduced by half. Medical Directors will become the lead person at each of the centers. Health center director functions will be centralized and/or re-distributed among staff. Staffing levels will be re-distributed at eight primary care health centers to maximize efficiency, achieve savings and ensure equity in resources across the clinics. Staffing levels were set using a per-provider national industry benchmark. This proposal eliminates evening hours at Castro Mission Health Center and eliminates Tom Waddell’s urgent care center. The integration of Primary Care and Behavioral Health Services will continue. The contingency budget proposed a very ambitious integration plan, moving a substantial number of patients from mental health sites to primary care sites. If the Mayor and Board of Supervisors are able to eliminate the need for these cuts, integration will continue but at a slower rate. Ms. Garcia said that effective June 2004, all SFGH Campus-based primary care programs will be under the jurisdiction of SFGH. As of July 1, 2004, public health nurses will be assigned to Health at Home and Maternal Child Health.   Commissioners’ Comments Commissioner Umekubo asked what the structure for quality assurance is under the restructure. Ms Garcia replied that quality assurance would continue to be under SFGH Quality Assurance. There are also other quality issues they would like to work on throughout Behavioral Health. Commissioner Umekubo asked if there are opportunities to improve charge ratios and billings. Ms. Garcia said that Gregg Sass has formed a Revenue Enhancement Committee to ensure that all revenues are maximized. Dr. Katz added that the proposed budget includes an increased revenue projection for Primary Care. Commissioner Illig asked if staff is looking at community-based clinics in the City to establish benchmarks. Ms. Garcia said they are. Commissioner Illig asked if giving physicians and nurses administrative tasks would take away from client care, and would clinicians stay at clinics. Dr Katz replied that the Medical Directors are at the centers and will stay at the centers. The nurse managers will cover more than one center and will make sure that the protocols are the same throughout the system. There will be no roving among direct service providers. Commissioner Chow said that public health nurses have culturally competent language skills, and this needs competency needs to be maintained. Will public health nurses remain at the health centers? Ms. Garcia said that the transition would be sensitive to the language needs and centers would have public health nursing. 7) PUBLIC COMMENT Martha Hawthorne – nurse at Castro Mission Health Center. Grave concerns about restructuring process from start to finish. We don’t have the kind of staffing to replace lower seniority folks. Staff hasn’t been consulted and taken seriously. Worried about patient care. It will affect service. The opinions of the public health nurses are not taken seriously. Loss of revenue and loss of service especially for women and children. If only 13 of us are doing the work of the original 39 that will be a big loss in revenue. We see women and children and the diabetic grandmother all in one home visit. We like the structure we have currently. 8) CLOSED SESSION: A) Public comments on all matters pertaining to the closed session None. B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11) Action Taken: The Commission voted to go into closed session. The Commission went into closed session at 5:15 p.m. Present in closed session were Commissioners Chow, Illig, Monfredini and Umekubo; Dr. Mitch Katz, Health Director; Gene O’Connell, SFGH Executive Administrator; Don Margolis, Deputy City Attorney and Anne Kronenberg, acting Health Commission Executive Secretary. C) Closed session pursuant to Government Code Section 54956.9 and San Francisco Administrative Code Section 67.10(d) Action Taken: The Commission (Chow, Illig, Monfredini, Umekubo) approved a settlement in the amount of $25,000 in the Keith Smith v. City and County of San Francisco et al, Superior Court case #422-906, City Attorney File #040178. D) Reconvene in Open Session Action Taken: The Commission came into open session at 6:15 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.) Vote to elect whether to disclose any or all discussions held in closed session (San Francisco Administrative Code Section 67.12(a).) 9) ADJOURNMENT The meeting adjourned at 6:15 p.m. Michele M. Olson, Executive Secretary to the Health Commission, and Anne Kronenberg, Acting 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.