Minutes of the Health Commission Meeting
Tuesday, June 13, 2006
101 GROVE STREET, ROOM 300
San Francisco, CA 94102
1) CALL TO ORDER
President Monfredini called the meeting to order at 3:15 p.m.
- Commissioner Lee Ann Monfredini, President
- Commissioner James M. Illig, Vice President
- Commissioner Edward A. Chow, M.D.
- Commissioner David J. Sanchez, Jr., Ph.D.
- Commissioner Donald E. Tarver, II, M.D.
- Commissioner Roma P. Guy, M.S.W.
- Commissioner John I. Umekubo, M.D.
2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF MAY 16,
Action Taken: The Commission (Chow, Illig, Monfredini, Sanchez, Tarver)
approved the minutes of the May 16, 2006 Health Commission meeting.
3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE
Commissioner Sanchez chaired and Commissioner Chow and Commissioner
Tarver attended the Budget Committee meeting.
Items for Approval
(3.1) CHN-SFGH – Request for approval of a contract renewal with Saint
Francis Memorial Hospital, in the amount of $240,000, to provide
outpatient tertiary radiation oncology care services targeting medically
indigent adults, In-Home Supportive Services workers and San Francisco
County Jail patients, for the period of July 1, 2006 through June 30,
(3.2) AIDS OFFICE-HIV Health Services – Request for approval of a
retroactive renewal contract with Catholic Health Care West–St. Mary’s
HIV Care Program, in the amount of $152,510, which includes a 12%
contingency, to provide primary care and supportive services to
individuals affected by HIV/AIDS, for the period of March 1, 2006
through June 30, 2006.
Secretary’s Note – Commissioner Illig abstained from voting on this
(3.3) BHS – Request for approval of a contract renewal with Golden Bear
Associates, in the amount of $81,782, which includes a 12% contingency,
to provide technical assistance to the Child, Youth and Family System of
Care, for the period of July 1, 2006 through June 30, 2007.
(3.4) BHS – Request for approval of a renewal contract with RTZ
Associates, Inc., in the amount of $226,800, which includes a 12%
contingency, with an annual contract amount of $135,000, to provide a
discharge planning and a housing system, for the period of July 1, 2006
December 31, 2007.
(3.5) BHS – Request for approval to accept and expend a grant from the
Social Security Administration, in the amount of $97,660, in the support
of the project entitled “HOPE – Reaching the Hardest to Serve: SSI for
Chronically Homeless and Mentally Ill People in San Francisco”, for its
third year period of May 1, 2006 through April 30, 2007, which includes
a sub-contract with the San Francisco Bar Association’s Homeless
Advocacy Project, in the amount of $62,458 for the same time period.
(3.6) BHS – Request for approval of a contract renewal with the Fred
Finch Youth Center, in the amount of $142,654 per year for a total
amount of $718,976, which includes a 12% contingency, to provide
Therapeutic Behavioral Services for adolescent, for the period of July
1, 2006 through
December 31, 2010.
Items for Discussion and Approval
(3.7) CHN-SFGH – Request for approval of a contract renewal with the
Regents of the University of California, in the amount of $1,700,000, 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, 2006 through June 30, 2007.
(3.8) SFGH-Health Information Services – Request for approval of a
contract renewal with Deliverex, Inc., in the amount of $790,000, to
provide medical records storage, retrieval and delivery services for San
Francisco General Hospital’s Health Information Services, Medical Staff
Services and Radiology Departments, for the period of July 1, 2006
through June 30, 2007.
(3.9) BHS – Request for approval of a retroactive renewal contract with
Progress Foundation, in the amount of $8,682,902 per year, for a total
contract amount of $9,724,850, which includes a 12% contingency, to
provide residential mental health services, for the period of July 1,
2006 through June 30, 2007.
- Commissioner Tarver asked if the documents were correct in saying that
Steve Fields is Board President. Mr. Fields said that he is president of
the corporation, which is separate from the Board. He is not a voting
member of the Board of Directors. The Board has its own officers.
- Commissioner Chow commended the agency on meeting its broad spectrum
of outcome objectives.
(3.10) BHS – Request for approval of a contract renewal with Central
City Hospitality House, in the amount of $1,145,088, which includes a
12% contingency, with an annual contract amount of $681,600, to provide
mental health socialization and wellness services, for the period of
July 1, 2006 through December 31, 2007.
- Commissioner Chow asked if the agency has been able to meet all the
contract objectives. Jackie Jenks, Executive Director, said that the
agency did a good job meeting its objectives from January to March, and
continues to do so. They tried to ramp up as quickly as possible. She
has no reservations about the goals that are put forward in next year’s
contract. Ms. Jenks thanked the Health Department for its support, and
she looks forward to a continued partnership.
(3.11) BHS – Request for approval of a new contract with Calvin Y.
Louie, CPA dba Louie & Pak, LLP, in the amount of $2,493,579 per year,
with an annual contract amount of $1,484,273, which includes a 12%
contingency, to provide fiscal intermediary services, for the period of
July 1, 2006 through December 31, 2007.
- Commissioner Chow asked how many checks would be written. Ms.
Antonetty said 708 checks a year would be written. Mr. Louie nets
(3.12) CHN-Jail Health Services – Request for approval of a contract
renewal with Haight Ashbury Free Clinics, in the amount of $3,476,478,
which includes a 12% contingency, to provide psychiatric and substance
abuse treatment services targeting inmates in the San Francisco County
Jail system, for the period of July 1, 2006 through June 30, 2007.
Mr. Goldenson said he is strongly supportive of the contract and the
services that haight ashbury has provided in the jail. However, he is
very concerned about hafc financial situation. The financial uncertainty
has impacted staff morale and resulted in some staff leaving.
Mr. Sass, DPH CFO, said that Haight Ashbury has had a difficult year.
They have embarked upon a turnaround plan, and certainly DPH would like
to see the agency survive. Mr. Sass meets with the agency regularly to
monitor finances. Mr. Sass said the Jail Health contract is the largest
contract Haight Ashbury has with DPH. It is in both parties’ interest to
see the Jail Health contract continue, with the understanding that
should things not work out for Haight Ashbury, DPH has Plan B that would
enable jail health services be transitioned.
- Commissioner Chow said the Health Commission received a letter in May
saying that Haight Ashbury contracts were underfunded, and he asked if
the agency feels comfortable that the it can carry out the duties of the
Jail Health Services contract. John Eckstrom, Chief Executive Officer of
Haight Ashbury Free Clinics, said carrying out the duties of the
contract is something they can accomplish. The point of his letter was
that contracts have not been adequately structures and therefore their
true costs were not being covered. Most of the reasons for this are
historical in nature, and the agency has been addressing these issues
through the turnaround. He has been working closely with Gregg Sass.
They are about one year into a two-year turnaround.
- Commissioner Sanchez said the alert that was issued in May brought to
the forefront some historical issues that DPH has been working with
Haight Ashbury on. His concern is that the agency is able to carry out
the commitment in the contract.
- Commissioner Tarver commended the turnaround effort. He hopes the
staff sees the Commission’s action today as reassurance to hang in
(3.13) CHS-PAES Dental – Request for approval of a renewal contract with
AmeriChoice, in the amount of $1,284,186, which includes a 12%
contingency, to provide fiscal intermediary services to the Personal
Assisted Employment Services for dental services, for the period of July
1, 2006 through June 30, 2009.
- Commissioner Chow asked what AmeriChoice’s administrative fee is.
Maria Martinez said it is 12 percent of the contract. Commissioner Chow
noted that this contractor is receiving almost twice as much as the
other contract that was approved for check writing. Perhaps the
Department should look for other opportunities to find local companies
that do this for less money. Commissioner Chow does not want to lock
into a three-year contract without looking at alternatives.
- Commissioner Sanchez asked if the unit cost has changed since the last
contract, and also if there is a possibility of getting a local firm to
do this. Perhaps we should look at a one-year contract. Mr. Sass said
that DPH would collect additional information from AmeriChoice to
justify the administrative fee, but AmeriChoice provides much more than
check writing services.
- Commissioner Chow asked staff to come back at the next Health
Commission meeting to ensure that the Health Department is getting fair
value for this contract when compared to agencies that do similar fiscal
Secretary’s Note – this item was continued to the June 20th Health
Commissioners’ Comments (at Health Commission meeting)
- Commissioner Illig asked why Haight Ashbury Free Clinics received a
COLA while other contracts for next year do not include the COLA. Mr.
Sass said that this contract is the only contract administered by Jail
Health Services, which had the funding to provide the COLA. CBHS
administers many more contracts and communicating with each agency and
setting the level of the COLA is much more complicated.
Action Taken: The Commission (Chow, Illig, Monfredini, Sanchez, Tarver)
approved the Budget Committee Consent Calendar, with the exception of
Item 3.13, which was continued to the June 20th Health Commission
meeting. Commissioner Illig abstained from voting on Item 3.2.
4) DIRECTOR’S REPORT
Mitchell H. Katz, M.D., Health Director, presented the Director’s
Civil Grand Jury Report on Emergency/Disaster Medical Preparedness in
The 2005-06 Civil Grand Jury issued a report on disaster medical
preparedness May 26th containing a number of thoughtful findings and
recommendations. While some deficiencies are noted, overall the report
highlights the City’s progress toward preparedness goals since the
2002-03 Grand Jury Report. Prior to the release of the Grand Jury’s
report on May 23rd the Mayor issued Executive Directive 06-03, Emergency
Medical Disaster Planning. This directive reinforces DPH’s role in
emergency preparedness and outlines the Mayor’s priorities for emergency
medical coordination, planning and reporting.
As reported to the Commission April 4th the DPH Office of Policy and
Planning assumed responsibility for the overall coordination of Homeland
Security and Emergency Response planning in 2005. The Office of
Emergency Services is responsible for coordinating emergency
preparedness and response for the entire City. DPH works closely with
OES in coordinating medical disaster planning, grant expenditures,
training and exercises. Dr. Katz will continue to keep the Commission
apprised of DPH’s activities and progress toward meeting its goals.
Assembly Passes San Francisco Long-Term Care Waiver
Earlier this year, the Department worked with Assembly Member Mark Leno
to introduce AB 2968, which would require the State Department of Health
Services to seek a Medi-Cal waiver to increase community-based care
options for San Franciscans with chronic or disabling health conditions
who would otherwise be homeless, living in shelters or
According to a review of residents conducted by the Laguna Honda Office
of Social Services in September 2005, approximately one quarter (over
250 residents) could instead be cared for in a community-based setting.
However, Medi-Cal reimbursement policies favor care in inpatient
institutional settings. As a result, alternatives to institutional care
for homeless, low-income Medical beneficiaries with chronic or disabling
health conditions are limited, and this population often must remain in
costly inpatient settings longer than medically necessary.
The waiver initiated by AB 2968 would change Medi-Cal’s reimbursement
rate structure to increase support for community-based alternatives to
institutional care in San Francisco. I am happy to report that the full
Assembly passed the bill by a vote of 76-1 on May 30, 2006. AB 2968 will
next move to the Senate Rules Committee for consideration.
Ryan White CARE Act Reauthorization
After a slow start, the Congressional committees with jurisdiction over
the Ryan White CARE Act have intensified their efforts to pass a
reauthorization bill, S.2823, this year.
Although the basic four-title structure of the CARE Act is preserved,
the changes proposed will significantly reduce CARE Act funding for San
Francisco over the next five years. According to our Congressional
delegation, Republican opposition to the “hold harmless” protection,
which limits a jurisdiction’s funding losses each year, was intense. San
Francisco benefits significantly from this protection, which the bill
would eliminate over three years. We are continuing to advocate for a
fourth year of protection. However, it is clear that the “hold
harmless,” which represents about one quarter of San Francisco’s Title I
award (approximately $7 million), will be eliminated at some point
during the five year reauthorization period.
Another issue of concern is a proposal to require that 75 percent of the
total CARE Act award to a Title I or state grantee be used for specified
core medical services that are defined in the bill. Several key HIV
services, including non-medical case management, transitional housing,
inpatient substance abuse treatment, food and transportation to medical
care facilities, are not yet included on this list. These services are
critically important to people living with HIV/AIDS in San Francisco.
On a more positive note, Congress has agreed to move away from formula
funding based on 10-year estimates of living AIDS cases--which
undercounts AIDS cases in California by approximately 30%--to an actual
living AIDS case count, thereby increasing CARE funding for the State
and offsetting some of the City’s “hold harmless” losses.
In addition, a proposed shift from CARE formula funding based on AIDS
case counts to funding based on combined HIV and AIDS case counts had
been a concern for California and other states that have not yet fully
implemented names-based HIV reporting (the CDC refuses to accept HIV
case counts based on non-names reporting systems). S.2823 includes a
proxy for actual HIV cases for these states. The proxy will count 0.9
HIV cases for each diagnosed case of AIDS. The Department will continue
to work with our allies in Congress to advocate for positions that
benefit San Francisco as this process moves forward.
Mayor Newsom Submits FY 2006-07 to the Board of Supervisors
The Mayor submitted his budget to the Board of Supervisors June 1st. The
Mayor made only minor changes to the budget the Health Commission passed
in April. The modifications include the elimination of co-pays for
pharmaceuticals and while the Mayor conceptually supports equalization
of residential substance abuse rates, he does not support them as a
budget measure. The elimination of the Worker’s Compensation Clinic is
still in the budget. Capital project funding includes 11.9 million for
the rebuild of SFGH. The Board of Supervisors will hold two budget
hearings, the first is scheduled for June 22nd, the second a week later
on June 29th.
New Disclosure Initiative for HIV Prevention
The HIV Prevention Section of the AIDS Office is embarking on an
important addition to our citywide prevention efforts called the
“Disclosure Initiative." An important new direction for prevention in
San Francisco, the initiative aims to begin changing community norms
around the discussion of HIV status and normalize/destigmatize the
sharing of HIV status between people before, during and after they are
having sex. With more people disclosing HIV status and thus negotiating
sexual or drug use behavior that supports the health and sexual
health-related needs of both partners, we believe that we will continue
our success at reducing the incidence of new infections.
As part of this new initiative, there will be educational and
promotional materials, a new marketing campaign, a new website
(hivdisclosure.com), trainings for service providers throughout the
City, and staff on-call to offer interested community members counseling
and referrals to appropriate disclosure assistance services. All
programs in Prevention’s network of services are contracted (and being
trained) to deliver disclosure assistance services to HIV-, HIV+ and
people of unknown HIV status.
The "Disclosure Initiative" was kicked off June 8th with a community
forum about disclosure and the empowerment of the community around the
negotiation of sexual activity based on 'asking and telling' of HIV
status with sex and needle sharing partners. This first event is
specifically targeting gay men but the initiative as a whole is
inclusive of people from all behavioral risk groups. Speakers at the
community forum will include counseling staff as well as community
members. The forum will be an opportunity for our prevention partners
and community members to address issues around personal responsibility
and disclosure in hopes of normalizing our discussion of HIV status and
the ways we negotiate sex.
Issue Concerning HIV Testing Clarified
There was some confusion regarding DPH’s HIV counseling and testing
protocols reported in the Chronicle two weeks ago. Essentially, the
Medical Executive Committee, on Dr. Katz’s recommendation, rewrote their
procedure for HIV counseling and testing so that a specific form was not
required in order to perform HIV testing in the context of medical
treatment. The previously required form, when incorrectly filled out,
resulted in the laboratory throwing away the blood specimen and the test
not being performed. Consistent with State of California law, physicians
must still obtain informed consent from patients prior to HIV testing,
must place written documentation in the medical record that informed
consent was obtained, and must perform pretest counseling. Some of the
newspaper articles suggested that we had eliminated the need for pretest
counseling. This was not accurate.
It is true that some public health and advocacy groups are calling for
the “normalization of HIV testing,” in other words, making HIV testing
more similar to testing for other diseases. Without entering this
debate, I would say that “normalization of HIV testing” would require a
very different process then what we had done in eliminating a
bureaucratic form as well as a change in State law. Supervisor Ma
introduced legislation recommending that we maintain informed consent
and pretest counseling for HIV. This is DPH’s current policy and what is
required by State law.
Electronic Death Registry System
Beginning June 1st, the Office of Vital Records began implementing the
new Electronic Death Registry System (EDRS). EDRS is the state’s
web-based system, which was designed to allow easy certification by
physicians of the causes of death as they appear on a death certificate.
Under the new system, physicians will remotely certify the cause of
death using either fax or voice attestation. Remote attestation replaces
the hand written signature of a physician on the death certificate. The
new system is simple, convenient, and will provide us with more accurate
and timely cause of death information. The Office of Vital Records held
a training session with funeral home directors and staff to acquaint
them with the new system.
Katrina Health Fair
Last month a Hurricane Katrina Survivor Resource Fair was held at the
State Building, and drew a dozen different agencies offering services to
nearly 50 survivors of Hurricane Katrina. DPH provided free blood
pressure screenings and consultations for accessing primary care, mental
health and substance abuse treatment. Many thanks to David Nakanishi,
James Eskridge, NP; Linda Bosley Thomas, PHN and Bernice Casey for
volunteering to help at this important outreach event.
Project Homeless Connect
Project Homeless Connect XI was held June 9th at Bill Graham Auditorium
serving 2, 358 homeless people and drawing over 2,100 volunteers.
Homeless individuals began lining up for services the day before to
ensure they had the first chance at housing, clothing, food and medical
care. New services are added at each PHC, Friday’s addition was the give
away of 2,000 pairs of new shoes donated by Deloitte & Touche. A record
number of 117 housing and shelter slots were allocated on Friday, 192
replacement identification card from the state Department of Motor
Vehicles and 28 repairs to wheelchairs. During the event, staff and
volunteers picked up clients from five sites in the Bayview and bused
them to Bill Graham. PHC is looking to expand its outreach to all
neighborhoods in the City. We continue to have many staff that give
generously of their time and talents to this worthwhile program.
Smoke Free Bus Stops
Alyonik Hrushow from the Tobacco Free Project joined Supervisor Fiona Ma
and staff other city agencies in late May to welcome a new law aimed at
protecting San Francisco bus and transit riders from second-hand smoke.
The new “Smoke-Free Bus Stops” ordinance prohibits smoking at all city
bus, train and cable car stops and shelters. The ordinance was authored
by Supervisor Ma and signed into law by Mayor Newsom on April 20. Many
people exposed to second hand smoke suffer immediate symptoms including
breathing problems, eye irritation, headaches, nausea and
life-threatening asthma attacks. We welcome the protection this new law
brings to the public.
Best Practices in Cultural Competence
A grant from the California Endowment funded the Department of Public
Health’s five part training series on Best Practices on Cultural
Competence. This final event featured four programs recognized as Best
Practices in Cultural Competence and 11 honorable mention programs for
their efforts to advance cultural competence in the Department of Public
Health. The awardees and presenters were:
- Newcomers Health Program for Staff Development & Service Intervention
(Patricia Erwin, MPH)
- SFGH Ethnic/Minority Psychiatric Inpatient Programs for Service
(Francis Lu, MD)
- A Dialogue on Differences-Silenced Voices: A Series of Monologues for
Training and Communications
(Jenjii Perault, N. Bruce Williams, Victor Damian & Janet King)
- Community Response Network for Community Collaboration & Linkages
(Collaborative: Sal Nunez, PhD, Roban San Miguel, LCSW & John Torres and
Honorable Mention Programs:
- The IMD Alternatives Program (CBHS)
- Many Men, Many Voices (3MV), Black Coalition on AIDS (HUH)
- Chinatown North Beach Mental Health Services (CBHS)
- Richmond Area Multi-Services (CBHS and HUH)
- Black History Hair Care Seminar -Collaborative Program Activity
Therapy and Nursing Beauticians (LHH)
- Filipino-American Counseling and Treatment Team (CBHS)
- Instituto Familiar de la Raza (CBHS & HIV/AIDS)
- Asian Focus Units Ward C4 & G4 (LLH)
- Community Behavioral Health Services/ Cultural Competence Plan (CBHS)
- Pediatric Asthma Clinic (SFGH)
- Videoconference Medical Interpretation Project (SFGH)
Naomi Gray Leadership Award
Jimmy Loyce was honored Sunday at the annual Black Coalition on AIDS
“Freedom” Brunch as this years recipient of the Naomi Gray Leadership
Award. Naomi Gray is a former member of the Health Commission and is a
current resident at Laguna Honda Hospital. Ms. Gray herself presented
the award, which recognizes leadership in addressing the health related
needs of the Black community. The award is presented to an individual
who has demonstrated a lifetime commitment to improving health in Blacks
through public or community service. Dr. Katz congratulated Jimmy for
winning this prestigious award.
Shape Up San Francisco
Last month, Mayor Newsom hosted the Mayor' Challenge: Shape Up San
Francisco Summit urging city employees, elected officials and business
leaders to collaborate to address the public health epidemic of obesity
caused by physical inactivity. During this conference, he challenged all
city staff members to do their part, whether it is walking at lunch, or
just taking the stairs instead of the elevator. A group of SF city
employees decided to take it seriously by swimming, biking and running
the talk: they took on the Escape from Alcatraz Triathlon. The Mayor's
Shape-Up Challenge Team included DPH Senior Health Program Planner
Christina Carpenter, SFPUC Regulatory Specialist Lori Schectel and SF
Department of Human Resources Finance and Information Systems Director
Jamie Austin. They placed 20th out of 47 relay teams in the grueling
Escape from Alcatraz Triathlon. Christina swam 1.5 miles in cold choppy
water from Alcatraz to Marina Green, Lori rode her bike 18-miles through
the hills of San Francisco and Jamie ran 8-miles including the 400-step
sand ladder at Baker Beach. Their finishing time for the race was
Community Health Network, San Francisco General Hospital Credentials
Report, June 2006
07/05 to 06/06
Changes in Privileges
Current Statistics – as of 06/1/06
Affiliate Professionals (non-physicians)
Applications In Process
Applications Withdrawn Month of June 2006
2 (07/05 to 06/06)
SFGH Reappointments in Process July 2006 to Oct. 2006
- Commissioner Monfredini congratulated Dr. Katz and the Department on the
defeat of Proposition D. She thanked Commissioner Illig and John Kanaley for
their tireless work after hours as well.
- Commissioner Chow said his confusion around HIV testing reported in the
newspaper was that pretesting counseling was not required. He appreciates Dr.
Katz clarification. He also asked if it has always been true that treating
physicians can obtain verbal consent from patients, rather than having to get
written consent. Dr. Katz said that this has always been the law. Commissioner
Chow asked if this is true at the clinics as well. Dr. Katz said it a doctor is
a treating physician, oral consent is what is required. If a patient is only
going for an HIV test, written consent is required. There is a separate State
law with a separate protocol for pregnant women.
- Commissioner Illig asked if AB 2968 is the same bill that was addressed in the
HMA report. Dr. Katz said yes. Commissioner Illig asked what this would pay for
that is not included in the current waiver. Dr. Katz said it would do a few
things that the current waivers do not. One limitation of the existing waiver is
that it is $115 per day and cannot be used for anyone in independent living,
cannot be used for rent and excludes IHSS. So the current waiver is not very
effective. The new waiver sets a higher amount as the fiscally neutral level,
and would fund people in assisted living. Commissioner Illig asked when the AIDS
Office would be able to update the Commission on its Call to Action. Mr. Loyce
said they are almost ready to present this, and will come to the CHN JCC in the
next few months.
- Commissioner Chow thanked the Department for its work around best practices in
cultural competency. He is hoping that one outcome of this training would be
more detailed descriptions by program managers of agencies’ cultural competency
when each of the contracts is renewed. With regard to the Grand Jury Report,
much of the emphasis was on the need for a helipad. Commissioner Chow said the
Health Commission has consistently supported a helipad, and asked the status.
Dr. Katz said the EIR is in the Planning Department, they are estimating that
the Planning Department would be issuing the EIR in the next few months.
- Commissioner Monfredini said the delay with the helipad has been that the
issue is stuck in the Planning Department.
5) JAIL HEALTH UPDATE
Joe Goldenson, M.D., Director, Jail Health Services, presented an update on Jail
Health Services, with the focus on transitioning Jail Health clients back into
the community upon discharge.
Jo Robinson, director of Psychiatric Services, discussed mental health services
for jail clients. They recognize that continuity of care with community
providers is very important to this clientele so when they know that the client
has a case manager or provider in the community, they invite that person into
the jail when the client is in custody. Jail Psychiatric Services makes several
successful mental health places, to places such as acute diversion units, dual
diagnosis residential, outpatient placements, assertive case management
placements, Behavioral Health Court and many other placements.
A few years ago Jail Health Services lost two discharge planners. As a result
they have had to change the way they do discharge services. They used to do a
lot of hands-on and hand holding work with clients, taking them to appointments,
taking them to placements, etc. Now they are able to provide information about
the programs and how clients can access these programs. Discharge planners begin
to work with sentenced inmates 30 days prior to their release.
Patients needing medical follow up are advised if they have a pending
appointment at SFGH or are instructed how to see a neighborhood clinic. If
needed, they are given a medication prescription. Jail Health provides a
two-week supply of psychiatric medication.
Kate Monaco Klein presented the Center Of Excellence Discharge Planning, a
program of the Forensic AIDS Project (FAP). The goal of Discharge Planning is to
successfully transition clients from jail into community, rather than to create
a parallel system of care between jail and community. Discharge planning begins
with the first encounter in the jails between the FAP case manager and the
client. When leaving the jails, a client receives a medical care appointment
with a primary care provider, a post-release case management appointment, a GA/SSI
appointment, a substance abuse treatment referral, as necessary, ADAP
recertification or enrollment and a letter of diagnosis and most recent test
results. The primary care provider receives a current list of medications,
copies of medical records, lab results and a direct communication from a FAP
clinician or an RN. Ms. Monaco Klein said it is the intensity of the
relationship between the Center of Excellence team members and the HIV positive
clients that solidified the relationship of the clients with the HIV/AIDS
Dr. Goldenson presented the new initiatives. Through a grant Housing and Urban
Health received from the Department of Justice, 15 transitional units will be
available for people leaving jail or prison. DPH’s proposed medical respite beds
will be available for people with significant medical problems. Jail Health has
started a discharge clinic to attempt to address the problem of people who leave
jail with medical appointments but do not show up for these appointments. A
nurse who works at a primary care clinic will be at the discharge clinic 1-2
mornings a week to establish a personal relationship with the clients. And
lastly, improved linkages with the VA hospital. The VA opened a clinic at 5th
and Mission and is very interested in working with Jail Health around inmates
who are veterans.
- Commissioner Monfredini asked if the population served has changed much from
last year. Dr. Goldenson said overall it has been much the same, although there
was a slight increase in the number of women served. Commissioner Monfredini
asked about increased efforts to improve medication compliance upon release. Ms.
Robinson said the jail is required to give two-weeks worth of medication, but
people must be willing to take the medication. Commissioner Monfredini asked if
the 15 transitional units that will be available through HUH are beds. Ms.
Robinson said they are rooms, not beds.
- Commissioner Tarver said the average entry into outpatient psychiatric
services is often two months. How is the gap bridged when people only have
two-weeks worth of medication? Are there any policies around prescription
refills? Ms. Robinson said clients receive the actual medications, not a
prescription. With regard to appointments, Ms. Robinson said they are using
CBHS’s open access of care, and they have not had any problems getting the
initial appointment for clients. It is true that it takes a long time to get a
second appointment. Commissioner Tarver said that capacity limitations result in
an inefficient system. It would be an improvement to set a policy to have
behavioral health appointments booked before release. Ms. Robinson said they
have found that open access works better for this population, at least for the
first appointment, until they establish a relationship with a provider. She will
follow up with Commissioner Tarver.
- Commissioner Illig noted that there is no data in the report about the age of
the jail population. Dr. Goldenson said most of the patients are younger than 40
years old. It is not necessarily a healthy population, given the level of
substance abuse, but the long-term impacts of lifestyle choices have not fully
developed. Commissioner Illig asked how to improve clients’ connections with
Primary Care. Dr. Goldenson said that a few years ago, they had a program with
Primary Care where discharged clients had priority appointments. This program
ended as a result of the large number of people who failed to keep their
appointments. He is hoping to rectify this problem through the discharge clinic.
Commissioner Illig asked if the database of DPH beds that will be developed by
RTZ would be accessible by Jail Health Services. Ms. Gray said the database will
include every bed in the Department of Public Health, and Jail Health will have
access to the beds that are controlled by the database.
- Commissioner Chow asked if it is still true that people do not keep
appointments at Primary Care Clinics. Dr. Goldenson said they make appointments
for mental health patients and AIDS patients but, until the discharge clinic is
up and running, do not make appointments for primary care visits. Commissioner
Chow is concerned with people who have chronic diseases and an ongoing need for
medication. Dr. Goldenson agrees that appointments are the way to go, but case
managers are crucial to making the transition—to meet the person upon release
and take them to the clinic. If the budget continues to look good over the next
few years, they would like to get some case managers back to work with people
with serious medical problems. Dr. Katz said that it is fortunate that within
this population the incidence of disease besides HIV or mental illness is fairly
small. The Urgent Care Clinic is one resource. Dr. Goldenson added that almost
all of their clients on insulin have a regular primary care provider.
Commissioner Chow is concerned that we give very good care in the jail, yet only
provide information about how to receive care in the community post-discharge.
The process needs to provide a level of confidence that continuity of care will
exist. Dr. Katz said they will pursue this issue further, and he feels that the
Urgent Care Clinic is a good resource.
- Commissioner Sanchez thanked that staff for the report. He was especially
interested in the discharge clinic and the fact that the VA is coming off of the
hill and into the community, and being part of this new model. Different schools
of public health are looking at violence and the forensic population, and could
be a source of interns.
6) MOSS ADAMS REPORT ON PRIMARY CARE
Gregg Sass, Chief Financial Officer, presented the findings from the Moss Adams
Report on Primary Care Clinic revenue maximization. This review was conducted,
at the request of the Board of Supervisors, by Moss Adams LLP under contract to
the Controller’s Office as part of the City Services Auditor Charter mandate.
The study analyzed potential improvements in the health clinics’ billing
procedures with the intent to identify revenue maximization opportunities that
do not add extreme cost to the City General Fund. The study focused on the
following six clinics: Castro Mission Health Center, Maxine Hall Health Center,
Balboa Health Center, Curry Health Center, 1M General Medicine Clinic, and 5M
Women’s Services Clinic, though some of the findings relate to the entire
Joann Sutton, Moss Adams LLP, reviewed the revenue opportunities identified in
- Increase physician productivity - $1,600,000
- Revise billing codes and improve billing practices - $206,000
- Schedule patient orientation visits together with physician visits - $72,000
- Patient registration improvements - $244,000
- Charge for free family planning services at Balboa Clinic - $13,000
- Bill for introductory Medicare services - $35,000
Mr. Sass presented DPH’s response to the recommendations, as well as an overview
of other revenue enhancement efforts DPH has undertaken. In general, DPH is in
agreement with the findings. DPH agrees that increasing productivity offers the
greatest potential for revenue maximizations. DPH also agrees with the
recommendation to update the Charge Master Description. He noted that the Moss
Adams report does not include any recommendations related to the DPH patient
registration and billing practices. Mr. Sass commended the work of Diana Guevara
and Patient Billing Services, which has resulted in improved collections and
reduced accounts receivable.
Community clinics do not represent the major source of collections in the DPH
system. That said, collection in the Health Centers have grown 52 percent over
the past six years.
Mr. Sass said the most important component of the Moss Adams report is
increasing clinician productivity. DPH does not believe it is possible to
achieve a benchmark of 4 visits per clinician hour worked. Interviews with
public clinic directors in other counties in California and in other states
found that most public health primary care sites have visits per clinician hour
in the 1.6-2.5 range. Several DPH Health Centers have clinician productivity
rates greater than 2—the average is 2.08.
Efforts underway at neighborhood health centers to increase clinician
- Monitoring and feedback on clinician productivity at the neighborhood clinics
- Consultations to redesign the patient intake and treatment processes
- Renovation of DPH clinics to increase the number of treatment rooms
- Implementation of Open Access at selected clinics to increase volume
- Upgrades to computer network to improve connectivity
- Formation of a revenue enhancement task force
Ms. Sass said that DPH agrees with Moss Adams’ findings about the Charge Master
Update. It is clear that a complete evaluation is needed, not just at the
clinics but also at the hospital. He is working with the Controller’s Office to
see if this review could be funded by Proposition C monies.
- Commissioner Illig asked why medical directors have higher levels of
productivity than other MDs. Ms. Ogbu said that they have fewer clinics that
other doctors, and also tend to run urgent care clinics, which see more patients
- Commissioner Tarver asked if there are differentials between clinics in terms
of time spent on administrative duties. Ms. Ogbu said they are trying to set a
department-wide standard of 75 percent clinical duties and 25 percent
- Commissioner Monfredini asked Moss Adams what could be done to increase
clinician productivity. Ms. Sutton said the non-clinical duties physicians have
had to pick up have increased dramatically over the past five years. New
regulatory requirements have added to administrative duties. Keeping a clinic
open longer than eight hours increases productivity, but is very taxing on
staff. Medical residency and training programs offer an opportunity to increase
clinic productivity. The strongest barrier to increased productivity is the
shortage of administrative and support staff. Open access also allows for an
increased number of patients to be seen on a daily basis, which increases
productivity. Commissioner Monfredini asked if the recommendation about nursing
orientation visits has been implemented. Mr. Sass said this recommendation
relates only to the 1M clinic, and he believes changes have been made.
- Commissioner Sanchez said this report was very enlightening. He noticed that
there were differences between the teaching clinics and the non-academic
clinics. There are many things that could be done to move forward with the
clinics. We have a mission to serve the most vulnerable, and we do so through
- Commissioner Chow said the report provides guidance to policy makers and
staff. It is clear that DPH needs an adequate charge master. His concern is that
there are different charge masters at each clinic. While primary care clinics
have a lot of autonomy, this should not result in silos. There needs to be some
uniformity of administration, in terms of charge masters, how encounters are
classified, etc. Commissioner Chow said that DPH was criticized for cutting
staff while at the same time not going after revenue aggressively. This report
shows that this is not the case.
- Commissioner Tarver said this report will incentivise the Department to do
some creative thinking, and he urged that the providers be included.
Commissioner Tarver said that many clinic patients are medically complex, and
their visits are not straightforward. This impacts productivity. He also
encouraged using the sites that have the highest levels of productivity to
develop best practices that could be applied to other clinics.
7) PUBLIC COMMENT/OTHER BUSINESS
The meeting was adjourned at 6:00 p.m.
Michele M. Seaton,
Executive Secretary to the Health Commission
Health Commission meeting minutes are approved by the Commission at the next
regularly scheduled Health Commission meeting. Any changes or corrections to
these minutes will be noted in the minutes of the next meeting.
Any written summaries of 150 words or less that are provided by persons who
spoke at public comment are attached. The written summaries are prepared by
members of the public, the opinions and representations are those of the author,
and the City does not represent or warrant the correctness of any factual
representations and is not responsible for the content.