Skip to main content

tv   Planning Commission 7716  SFGTV  July 9, 2016 12:00am-2:01am PDT

12:00 am
>> good afternoon, the commission will please come to order and the secretary will call the roll, commissioner pating, present. commissioner show rks present. commissioner chung, present. commissioner sanchez, present. commissioner carsh nu, approval of the mchbts of june 21, 2016. i nut revised minutes to the right of you as i e-mailed you, i had left out section 6 and the minutes in front of you have that so apologize. >> commissioners, the minutes are before you with the new section 6 filled in. is there a motion for acceptance? >> so moved. >> and a second. >> second. >> let people have a moment to read section 6, if you had not and are there any further corrections to the
12:01 am
minutes? if not, we are prepared for the vote. any questions on 6? all in favor, please say aye. opposed? the minutes adopted >> item 3, directors report. >> good afternoon commissioners. welcome to fiscal year 16-17 and just wanted to-i bow many of you just had to open the newspaper or turn on the tv and saw lots of homeless coverage and in august we'll come back to you as we go through all the homeless coverage to bring updates on what we learned from the coverage and identifies areas of our speedometer that of course includes
12:02 am
mental health and substance abuse and supportive services to projeththe mayor announced and one is is the navigation center and encampment response team. in the report it talks about the navigation center and there will be several others opening this coming year and this has a interesting process where we move individuals there and it will become later a permanent location. this [inaudible] center building is own bide the ua local 3 a plumbers union so will be rebuilt in [inaudible] with 110 permanent homes. also, governor brown signed a no place like home initiative july 1 which provides 2
12:03 am
billion ovthe next 4 years for construction and rehabilitation for permanent housing for individuals with mental illness. this is [inaudible] secure the [inaudible] bonds to fund the competitive grant program to counties that meet minimum eligibility critear ai rchlt san francisco currently receives approximately $22 million in prop 63 revenue and expected that these revenues could decline between 7 and 10 percent to secure the bond funding so i'll meet with staff in the next coming week tooz figure how to manage that reduction in that process and what we usually do is a rfp process, reorganize the programs and potentially have more amounts of money available for some of the programs as a way to support new housing. i was able to participate with nancy
12:04 am
pelosi and congress people on june 29 including the ceo of [inaudible] bringing the family [inaudible] to disarm hate and this was to of course to confront gun violence by [inaudible] no fly, no bye. there was several hundred people at the event and heard a lot from individual jz community members working on violence prevention. today you will hear about the ehr update so just want you to know we are already working very hard on insureing that we are organizing the way we are looking at how to work with ucsf on the potential bringing in apex into our network and will hear more from that from
12:05 am
our it directed today. the asian pacific islander clinic and bayview hunters point health plan will [inaudible] part of a medical group [inaudible] provide primary care and specially care service for hospital and specially services. that provides us more expansion within our network. i'llened my directors report there and ask for any other questions from the report? >> commissioners, questions to the director-i was pleased to hear the director will bring more information concerning the initiatives and the manner in which the department will be coordinating with the department of homelessness over the next several months. that includes moving of course many of our own housing
12:06 am
programs over to the department along with the new navigation centers so think it will be very important for us to receive regular updates are happening and how we continue to serve those that need or services. could you let me know a little more or let us know a little more about what the governor is actually doing with those funds and exactly-i thought when you were introducing the topic we would get more money, but it sounds like we are getting less money. >> i'll let the policy director give a update on that. it is repurnsing the dollars. >> [inaudible] it is taking some of the revenues that come in already for prop 63 and that is tax on people
12:07 am
that earn $63 and that is tax on people that earn over a million a year and rerouting so it can secure larger bond funding, 2 billion dollar bond fund that will be available for counties over 4 psycholts for the next 4 years as they apply for supportive housing projects for folks that have mental illness, homeless or formally homeless. it is a application counties can apply for. overall can can be the same or more funding for san francisco in total but earmarked for supportive housing purposes. >> initially it removals from the prop 63 monies to create this fund for which there are grants for homeless funding? >> correct, counties get allocations based on a formula under prop 63 so it takes off the top an amount sufficient to secure the 2 billion in
12:08 am
bonds and [inaudible] on a competitive basis. >> thank you. other questions to the director? commissioner pating. >> we took a good advantage of the county of the first round of 400 million that came out of prop 63 so i would hope-my question is, other projects in the pipeline you can see taking advantage of this? my other commissioners-the funds from prop 63 are generally commingled with hud fun and private funds and other funds so the projects are very complex to bring together which usually the prop 63 aurfs 1 component mostly the service component. are there projects in the pipeline you can see are early applications for the-
12:09 am
>> i probably am not the best person to talk about the projects in the pipeline. director garcia and [inaudible] is better to speak to that but one criteria specified in the legislation is project readiness and that is among which the projects will be evaluated. i think they listed 5 criteria projects are evaluated on and project readiness is one of the 5. we know the homeless department is given the direction of 8 thousand new housing opportunities for individuals and so there is a pipeline for our regular housing area including most recently one of the propositions , thrfs a housing bond prop in the local election so when we sxh back in august we will get that information to share with you. our role because all our housing and i call it the bricks and mortar in the department ov2 thousand units
12:10 am
of housing will be transferred with staff to the new department and our role is maintained as clinical support service for wrap around serves for those individuals. we will be very involved and connected to that department to insure the individuals in the housing and navigation centers and shelters have the kind of supportive services they need for success. >> the other thing i might add is department of public health and the staff from the new department of supportive homelessness and housing were involved in discuzs with the state legislature during the development of the legislation and so some of the other criteria are those that san francisco would also do well on h experience priding supportive housing to reduce the homeless population and behavioral services to the population so they are aurlds areas we do quite well on. >> commissioners, any other questions?
12:11 am
if not we'll proceed >> student the next item. >> itedm 4, general public comment and have two requests. >> yes, first speaker will be ma tt asbone and the speakers note i have a timer of 3 minutes and when the buzzer goes off it means your time is up. i'm sorry commissioners there is a photo the public speaker asked me to pass around so it will come your way. mr. osborn. >> thank you for letting me speak. i had a prepared statement and too nervous to read it so will just speak from the heart. i'm a member of the lower haight community and run a business there and in the process becoming a medical marijuana dispensary. our neighborhood
12:12 am
is plagued with crime related to drugs for decades now. as a community don't feel we were given a fair chance to know this happened. the outreach done by the company in question in our pin didn't happen-many people didn't know until recently and have been addressing it since. sorry, i'm nervous mptd . there is a elementary school about 500 feet away from this, 600 feet away from this but due to something in the planning department that is unclear to me they are not hearing about the legitimacy of the business. we are [inaudible] as a matter of community health as we have a community on the mends from years and decades of pain. we have a community that is not trusting the system currently
12:13 am
because of things like the picture i'm passic around where 3 members from the planning department will decide the fate of this made public comment about a business they are still deciding on which doesn't make us feel confident. i just want to reiterate this is not a argument against medical marijuana, this is not about property values, this is not about, not in my backyard, this is about health and well being of a community that has felt they are under served, some discriminated against. it is about human lives because there are murders related to that i seen and hoping to come up with a way for it community to speak about their health and safety especially students at the scoom and community parks. the community wasn't able to be heard and i'm hoping for your help. i don't know
12:14 am
exactly what i'm asking for specificically about your help. if you like to speak to me i left my contact information and open to communicating in any way. thank you. >> thank you for alerting us and imagine staff will look further fl to this with you. next question? next speaker. brian brooks. >> grood afternoon and thank you for the opportunity to talk to the commissioners. we represent the lower haight merchants and residents on-twnt year residents and a lower haight resident and the medical disspencely we are trying to get more insight how the process occurred. back in 2006, [inaudible] 473 haight street
12:15 am
was issued a medical dispensary license because we had multiple dispensarys on the 400 block and it years of violence and murders and assaultsment they closed over the years. we had the vapor room closed which was a dispensary closeed by the federal government because they were 5 feet too close to the parkment we became aware of this- the community became aware of this issue may 19 when there was a flier posted about a hearing. we came down with [inaudible] and had two weeks and put together 60 signatures. in that time we have gotten 13 of the 17 businesses on the 400 block to go into opposition. ma tt shared a picture, this is the latest pr stunt by the organization, spark to reverse that situation. there is a lot of
12:16 am
[inaudible] lot of positioning and a lot of procedure that is being done in this certificate transfer process planning. the community had no idea this is happening. we walk the streets and canvas and everyone is like, really, we don't know this is happening. the company spark claimed they did outreach in a 5 block radius then on the website they said they did 300 feet door to door, which is different than 500 blocks. we have john mure struggling over the years. we want a dialogue because the neighborhood feels they have not been heard. we-this is definitely a health issue. we talk about crime, violence and homelessness, the 400 block lower haight is not the right place for this
12:17 am
so we would love to work with you the commissioners and spark to open a dialogue so people can be heard. thank you. >> thank you. again, we'll have staff work with you. there is one more. there is one more speaker, former commissioner [inaudible] it says health services update. >> so, public comment is now, right? >> yes. >> i don't know how to do this. thank you health commissioners. nice to see you. so, and represent today taxpayers for public safety, which will be related to the jail health update. i wanted to say before i begin i was asked by supervisor breed and your director to be cochair in the
12:18 am
work replacement project so i don't want to say i don't represent that either. so, at any rate i want to say i appreciate the report you will receive because through the leadership of supervisor breed and the board of supervisors, the mayor, the department of public health led by the director of public health, [inaudible] we have a new opportunity and a new framework to work with around jails that includes jail health because the agenda of inmates is really a very big social issue. as you know, health is a very important part of this. what you will see in the report is there is more detail, the framework is more clear and we have something to work with and really want to thank
12:19 am
the leadership for this. there are many more questions and we will come to you hopefully september, october with real recommendations, but right now at least we have some important data to work with, which a year and a half ago we did not. the other thing is the convergency nationally state wide and locally around homelessness and incarceration and relationship to poverty is more clear and punishment is taking at least a little bit of a second place. there has been a cultural shift and that is a good thing and brings about structural change. the 47 beds all that you heard about and will hear more about through had leadership of department of public helt is significant so please i want you to appreciate it and it will cost money
12:20 am
and so i just want to say we support that. i think the most compelling statistics you know, is that 65 percent spends less than 7 days in the jail. this is really important if you do a policy change. also, 86 percent are pretrials, meaning they are there awaiting justice. 86 percent. this is very significant. 2/3 people of color. it doesn't make sense. we have to do something and we can. the leadership is in place and we want to see that it gets done. >> time. >> the new idea i want you to think about is relief center. we need to think it about it the way you think about hospitals. the day you come in, we don't stay in the hospitals anymore and the jails are less than a
12:21 am
week for 63 percent. we need to know when you come in there is discharge planning. that is a new concept. please, listen for it. thank you. >> thank you commissioner. commission >> item 5 is the report back from the finance and planning meeting. >> commissioner chung. >> good afternoon. the finance and planning committee met today before the commission meeting and we had some really interesting discussions. one of the monthly contract report which is included in the consent calendar for approval, within there there are a couple items we discussed and so one of them is the san francisco community health authority. we were having conversations to see why there
12:22 am
is a 15 percent increase in the cost of like running the programs, when there is a reduction of number of services. of course we do think the infrastructure-the cost goes away. other items that we had a conversation is like [inaudible] there is a significant increase in the contract with data way so that any difference is 58 percent and that is part of-that is the ongoing discussion about it infrastructure improvement including -like the fire walls you can have. i guess like the state department
12:23 am
[inaudible] and so these are the costs that will help reduce the in the long run with like reducing the cost of running the department, but right now it is a huge increase as it stands. let's see, anything else here? and then we also have another new contract that has been added to the consent calendar for approval. it is the survey for patients and workforce experience and they are contracted to do a total of 5 surveys for the patient experience for sfgph so one per
12:24 am
year and then 3 employee surveys and 3 physician surveys that will be conducted every or year and it is a contract of 5 years. and we also have a presentation by the business office of contract compliance to look at-that is a ongoing presentation we have done aroun how to assess health impacts and how to measure outcomes [inaudible] and it is a really wonderful conversation to hear how far we have come and looking at ourselves as the
12:25 am
technical assistance and also provider to help build infrastructure with some the smaller organizations which might have great cultural competency, but lack the business infrastructure to run the organization and help them improve. we also have a presentation on the third quarter of revenue and finance report and it is great to hear that we are on track on our surplus. that concludes my report. >> questions to commissioner chung? was there public-commissioner sanchez >> it isn't a question. i guess it is in a sense. in reference to the
12:26 am
item pertaining to [inaudible] associates, as you read through it they have been involved in the new protocol since 85. they list the regional offices or offices where i guess they have centers or involved in the cohorts. i notice that none are on the west coast are in the mid-wist mid-west and know a multitude of surveys over the years we had a number especially a number of midwestern institutions in wisconsin and michigan and california and texas, this will be the first opportunity for this group to have a physical presence in the network here or are they the only group that met the
12:27 am
requirements per taining to the solicitation of the request? >> [inaudible] can respond to that but do know they are in san mateo as well. >> good afternoon commissioners. roland pickens director of health network. this contract is awarded after a rfp was put out. you should rest assureed to know [inaudible] gainee is one of the leading companies that performs this work for acute care hospitals arounds the country. they have several hospitals in california, they just happened to be based back east, but they are the predominant player in the area of patient and workforce satisfaction. >> so, in essence in the review we noted there are i assume some similar hospitals or solutions in california? >> absolutely and as director
12:28 am
garcia opponented out, san mateo uses them in the eeoceo [inaudible] zuckerburg is familiar with it. >> i didn't attend the meeting and sure it was answered there. when i read this i wondered here and didn't see a number of things, that is quhie why i thought i would raise it. >> we are looking forward working with them. one thing they provide is a much more detailed reporting capacity down to the individual units and cost center level which we didn't have before. >> i concur, this is a critical parameters in databases we will be undertaking as we take a look how we deliver the services and models. thank you. >> thank you. commissioner shan
12:29 am
sanchez, i know this company but it is noted here that they do 50 percent of all the u.s. hospitals. i did ask as commissioner chung how they would slice and dice and it sounded like they can compare against all sorts of different demo graphics. the safety net hospitals and coupty hospitals and universities and so forth. i think more to the question was whether or not-they were used to being able to survey for customer satisfaction within the melthal health field or children or jail health and it was inicated during testimony in the rfp process that actually-nobody had great experience, these people were the people who came up with how they would do it and this was one of the reasons they were awarded the contract.
12:30 am
>> this was just-it was clarifyed because we have been through clinical trials where we had foreign companies come in and promise this and this and something didn't pan out and something did and don't want to go through that trial again. i'm glad this is here and you informed me- >> i want to highlight piece that we will have a survey for jail health which means all the folks inside like county jails would be surveyed and they have identified a couple different methods to survey, so i [inaudible] quite impressive with the approach. >> questions to commissioner
12:31 am
chung? if not, we'll proceed to the next item. >> there was public comment requested on item 6 which is consent calendar which we just reviewed the two items. >> motion came from the committee for the acceptance of the consent calendar. are there questions extractions? if not we are prepared for the vote on the consent calendar. all in favor of the consent calendar say aye. opposed? the consent calendar isa proved >> item 7 is resolution to commitment to trauma care and before dr. [inaudible] step tooz the microphone, i will note that the [inaudible] jcc did recommend approval of this resolution. >> good afternoon commissioners. this is a very straightforward commitment. it is one you approved before and comes in the context of a survey we
12:32 am
are about to undergo in august from american college of surgeons around trauma services. happy to answer questions. >> question to dr.urelic? >> what prompted having the resolution? >> it is a standard approach to the survey coming in august. >> [inaudible] >> not at all. >> i believe every 3 years you all get the same type of resolution you passed and not all have been here maybe for that cycle >> it is a requirement. i guess the accrediting body was to be assureed the governing body is committed to the trauma service. >> exactly so.
12:33 am
>> any public comment? >> i have not received cards. >> resolution is before you for approval. further discussion? all in favor of the resolution say aye. opposed? the relution is adopted. next item, >> item 8 is jail house service update. >> good afternoon commissioners. dr. lisa pratt the new jail health drerter and have been in my role 6 months. it doesn't feel that new to me but compared to dr. [inaudible] who was there 20 years i think i will be new for a while. the first part of every presentation is struggling with it, but not for bill. >> [inaudible] >> thank you. so, i want to
12:34 am
introduce the deputy director frank pat who joins me and tonia marron who is director of behavioral health service and reentry of the jail and also acknowledge kate [inaudible] cline who retired after 25 years of commitment and work in the jail throughout that time. so, i will give you a overview of jail health services and like you to former commissioner [inaudible] for setting the context for us a little bit. i will tell you some things i think are interesting about what we do at the jail and what makes the san francisco jail the national model it is in jail health and talk about some things and opportunity for us to refine and improve or enhance some the programs in the jail. this is where we sit in the san francisco health network, which really demonstrates the
12:35 am
commitment of the network to provide high quality healthcare to all san franciscans in order they live a vibrant and healthy life no matter where they are. when they are in the jail they are afforded the same good quality healthcare as any other ambulatory care or hospital setting. that is a new position for jail health with the advent in the network. this is our organizational structure we are a integrateed multi disciplineitary. consists of medical care based on the primary care model and behavior health that consists of a team of psychiatrist and psychologist, mental health. [inaudible] formally called frap, [inaudible] it spans for
12:36 am
hiv integrated services and there is reentry piece also. we have dental services, and provide a hybrid of inpatient and outpatient pharmacy at the jail. we have a $31 million budget. clearly our greatest investment is in the greatest asset which is our people. with about 24 million in salary and another 3 and a half million in indirect and direct care cost as well and 2.5 million in pharmacy services. we have 163 fte, not all listed here but i'll go over the broad categories. 3 nurse managers. we have among the physician staff we have 1.2 psychiatrist
12:37 am
in the jail. 2.4 primary care physicians mpt 8 nurse practitioners. we have [inaudible] psychologist and counselors and 3 pharmacists with farm techs, 1.4 edintest. administrative support and support staff that consists of [inaudible] that clean the areas in the jail. we have nursing coverage 24/7 in all jails and primary care presence 6 days a week with 24/7 coverage and behavioral health presence in every jail, every day of the week and 24/7 coverage for the jail as well
12:38 am
for behavioral health as well. sorry. we serve 15,000 patients in 2015 and this gets to what commissioner [inaudible] was saying about the data. i'm not sure-i'm sure and probably have heard dr. [inaudible] talk about the databases and have a bunch of databases we use in jail health and the sheriff has a separate system of data and it is very difficult to triangulate the data and have confidence in the numbers we see today. i probably spent 3 mupths of my first 6 trying to do that so i feel confident in the numbers i present today and can tell you where they come from if it isn't clear from the slides. we saw 15,000 patients last year and i'm talking calendar year not
12:39 am
fiscal year. the average census is about 1250. the difference between prisons and jails for those that dopet live in the world every day is prisons are federal and state entities and people generally serve long sentences there and jails are local authority. they are city or county and mostly these are people awaiting trial or service short sentences. reflecting is our population in san francisco we are 86 percent the people have not been sentenced or prearraignment or pretrial or precentance and have the remainder who are serving their sentence. of the entire population you see the percentage, 7 to 14 percent of seriously mentally ill. 65
12:40 am
percent of our people in the jails stay less than 7 days. this speak tooz the churn of the population and then on the other side we got 16 percent there 30 days or more. we have two different sources of sex and gender identity data. the first is from the sheriffs department and the sheriff takes that information from the identification from the person arrested or make an assumption. we ask our patients and different rates of response than the sheriff does and we have identified 61 transwomen in the last year and 17 transmen who came into the jail. this just sort of sets a historical context. that is a totally different color. so, i'm sorry you can't see, but what now looks
12:41 am
like gray green bars, there is a number hidden in the bar next to it so it is 21 thousand, 17 thousand, 16, 15. the difference between the two sets of bars starting from fiscal year 2009, we see a persistent and lasting trend of decrease in the jail population and the maroon bars up there, which are gray on my screen represent the people who are arrested who come into the jail. everybody who makes it to the jail is represented in these numbers at the top. the larger numbers. the lower number are the people who are there after a couple hours and undergo a more extensive intake assessment. both of
12:42 am
those sets of numbers have been declining since 2009 and that is as far back as i have data for. ethnicity data, the-for those participating in the reenvisioning the jail meetings the sheriff does not collect data around race and ethnicity that includes latinos. this is from the jail health system and we-which is called the jail information management system. we ask our patients-these are self identified racial and ethnic profiles and regardless there is clearly a overrepresentation of people of color in the jail which is consistent with jails across the country. just to take you through how our patients come into the jail and access care, quh they are arrested and sxh to the jail
12:43 am
that is treaug. the first thing they do when they walk into the jail is they are presented to a nurse who takes them through questions to figure whether this person is safe to stay in the jail. safe from a medical standpoint. sometimes people are injured in the process of arrest or while they are fleeing or prior to arrest or have been on the streets for weeks, months, years and haven't accessed hemthcare so the diabetes is out of control or blood pressure is high, have a fracture or sellueitis. these people we immediately call it refuse for booking and the arresting agency usually sfpd will take them to the emergency department and if it is mental illness issue or dpes, so those people don't stay but they come back typically. for
12:44 am
those that do stay we parse them out. one track is subacute track so people at high rist for detoxing and people who are appear to or have a history of psychiatric instability. people have a complex medical problems or mobility issues. all these patients go into a specialized housing track, either a medical or mental health specialist housing track and remainder the patients go into a chronic care track to access primary care, sicitree and mental health, dental and pharmacy as a outpatient model. the way that works in general is by referral. a patient can self refer. the nurses can refer. the deputy sheriffs can refer and mental health staff can refer and we
12:45 am
can all refer to each other so any door is the right door which is ironic in the jail. any door is the rith door to access care and typically after the referral the patient either has a nurse assessment or behavioral health assessment. in terms of the numbers, last year so the triaunge, the people that first come in are 20,000 and turned away 613 and sent them to the hospital to be seen at zuckerburg general and return. 14,000 went through more robust intake process meanic they were there for a couple hours or more. 31 thousand nursing visits and [inaudible] you see the dentt visits and 200 thousand pharmacy fills. people don't come with
12:46 am
their medications and if they do they don't get to keep them. in terms of behavioral health services, title 15 mandates that we provide minimum standard for jails in california that we provide basically stabilization, reentry and crisis management for behavioral health. in san francisco we do much more than that consistent with and beginning with evaluation, patients are then sort of sent through the path to individual and/or group therapy, medication management is needed, substance use treatment as needed and that is also in partnership with the sheriff who brings in peer base abstinence only. support groups. we
12:47 am
have in preparation for people leaving assessment and referral to community streement, which is through reentry services and also crisis intervention. so, 36 percent of the patients who came in last year had contact with jail behavioral health services and these are the kinds of parsed out in the stabilization of reentry and crisis intervention. you see the numbers of visits. these are not unique patients, these are encounters. and then we place the 5150, 465 times. 330 of those resulted in admission to the sfg 7 l which is inpatient jail ward at the hospital. [inaudible] our next program
12:48 am
consists of two different programs. the first is screening and prevention and second is center of excellence which provides primary care to hiv patients. screening and prevention involved 8900 hiv, help c and [inaudible] and education was provided to our patients as well as overdose education. condoms are available throughout the jails as many know and have been for a very long time and then [inaudible] narcan is provided to people at risk of overdose. we provide narcan in the jail. the other track is center of excellence providing primary hiv care to our patients. we serve 345 unique patients with hiv last
12:49 am
year. medical case management which starts rolling after day 5 of their stay in the jail. 127 patients with 500 encounters. during that time consisting of psychosocial assessment and medication support and discharge planning which includes supply and establishing or reestablishing medical appointments, housing referrals, food voucher jz transportation vouchers, things patients need when they leave as they identify to us as a need. just a couple of things that are-since i'm new to the jail coming in in my experience things that are unique here and very powerful for our patients in some regard in the jail are use of methadone and bupomofeen is unusual in a
12:50 am
jail. we provide methadone maintenance for people when they come in. we know it works and saves lives and haveprieve prevalence of substance users so treat their disorder. bup mof 15 for detox for opiate user squz a bridge to maintenance when they leave to return to the community. we have prenatal and laboring support for women in the jails who are pregnant through partnership with ucsf. we have a obgyn who comes in. the birth justice projsaeckt unique volunteered service, so when women are laboring they have a [inaudible] with them who also provide prenatal education and post
12:51 am
pardm support in particular arount breast feeding who want to breast feed after they return to the jail. we have 4 clinical pharmacist clinics, anticoagulation, hi hypertension management, diabetes management and psychopharmacology. we recently entered into a agreement to provide antivieral tooz the hepatitis c patients in the jail and when they leave so they continue their treatment with medications provided when they leave the jail. that is just launching right now. in terms of behavioral health, all sorts of interesting things, but one of the most successful programs is around behavioral health court with a collaborative court and now this is expanded to include
12:52 am
the misdemeanor so people won't languish in the jail for long periods of time waiting to have their charge adjudicated if it is a misdemeanor, they can move through had system more quickly and into raprogram that provides appropriate support for them. meantering and peer support for people who in collaborative court is a program that is very special and been very successful in the jail along with trauma screening and treatment for transitional age youth 18 to 25 in the jail. we had the privilege of work wg a consultant, mary sorten and her team and i understand you will hear more about mary's report, but what we engaged with around her are some
12:53 am
opportunities for areas of improvements to leverage resources in behavioral health to cover ever expanding population of people in need of melthal health services. just identified 3 major areas, cauntsnuity of medication which is sometimes difcult to provide in the jail when people come in and some-when people have case managers and good contact with their outside psychiatrists we ought to be able to continue unless there has been a significant change in their health, their medication and part of our limit is 1.2 psychiatrist we have for the entire jail so some possibilities to increase the number of prescribers we are looking at are sigh atric nurse practitioners and also
12:54 am
leveraging the primary care providers as they do at community standard in primary care settings to also provide medication for patients with mental illness. we also identified we provide a lot of care to a pretty large population in the jail around behavioral health, and some of that is too much and some is too little so stratifying that care is representing targeting who we want to receive what kind of care is something mary is helping us to do in addition to using a more efficient and equally effective validated suicide assessment tool obviously incarceration represents a very high risk time for suicide and we see that in jails throughout the country. and then
12:55 am
strengthening and stabilizing our programs in the sigh atric shelter living units thrmpt is a opportunity for individual treatment plans and we do a lot of group therapys as well. and then just the last slide is really some other visioning for jail health services. there is a lot of churn, people are not there very long and it is a perfect time for public health intervention and we do not screen everybody currently so expanding the surveillance and treatment in the jail is a opportunity we have. initiating and coordinating, relapse and revention therapy around substance use is a another opportunity. we are looking to expand the [inaudible] medical case management to insure contty with their community
12:56 am
providers. we have somewhat siloed reentry programs hivisand bhs. there is a opportunity to integrate those more effectively. [inaudible] the opportunity for linkage across social service. our patients in the jail are patients in the community which is what the linkage piece is about. caring for them during what could be a time of crisis and transitioning them home is our goal at jail house services. thank you for your interest in the jail and time on the agenda and happy to take any questions. >> commissioners, was there public comment first? >> i have not received any requests for this item.
12:57 am
>> doctor sanchez. >> i think that was a excellent update and unique insight and defined the parameters that have been in the past and those we are looking at now and in the future so want to commend you and staff for utizing and maintaining the data based on the realty of those we serve so thank you very much for sharing. >> thank you. commissioner chung. >> thank you for the presentation. i have a few questions, the first one is about specialty [inaudible] can you elaborate on what that is? >> sorry, specialty? >> specially services. >> we do have a couple of specialist that come into the jail, medical specialist that ob program is one of them and podiatry is another. all our specialty care is provided at
12:58 am
[inaudible] so other than those specialist. >> what i mean, it says here intake for specialized housing. >> that is either medical or mental health housing where people need more support. on the medical side if you have-if you use a wheelchair you can't be in a regular part the jail so we have a area that is a skilled nursing facility where people can help patients with activities and daily living. if they have appliances like a colostomy that is difficult to manage in a group jail setting or if you are on iv medications for example, that is provided in the specialized housing as is for the mental health patientatize is psychiatric observation so patients are under closer scrutiny and
12:59 am
provided more support in what is typically a precrisis time. that is what the observation is about. >> another question i have is you mentioned here that you referred 613 people to emergency department >> yes >> that is more than 1 a day. >> right. when people are- total of the year is about 850 so there is 150 in the jail over the year whos condition detearierates or warrants people get in fights in the jail and that is trauma. those initial 600 are those rejected from treaunge out of the gate
1:00 am
so say this person is too sick or complicated to be here now and need them to go to sfg to get stabilized. they are still under arrest and then they are brought back to the jail when their condition-the jail isn't the right place to treat a lot of medical problems so until they are in the right place to do that they stay at sfg. >> between that number and how many actually went to psych emergency- >> 330. that 330 is a great question. those are totally over lapping numbers because some of the 5150's happen when people are in jail a while so it isn't just when they come in, but they may get bad news, so they are in
1:01 am
crisis and 5150. there is a little vin diagram for those numbers. >> it is interesting i think there is a lot to [inaudible] >> for sure. >> and also there is currently-i know there is a certain person doing a hunger strike. in that situation how does jail health get involved? >> um, i can speak generally about that, which is there is a sort of graded policy how to manage it and prior to this job i worked at san quenten 10 years and had a mass hunger strike. there isn't a big body of medical literature around hunger strikes but we had a lot of experience recently between california and
1:02 am
department of corrections in guantanamo. we follow their weight and follow lab data very carefully. we follow the amount of urine may make because if people are drinking they can go 40 days and 40 nights. that is the biblical length of time but much longer. if they stop drinking people get into serious trouble very quickly. we monitor those parameters. their energy level, their ability to interact and if the patients have capacity at the beginic of the hunger strike meaning they understand what can happen and this is decision they are making and [inaudible] around this decision and others, then it is like
1:03 am
anything else, they can refuse any treatment and refuse food in the jail. they retain atotomy as patients. typically when it is difficult is when people get very sick and we are faced with difficult ethical questions about what to do if someone is unresponsive and how we approach that and we haven't had to think about that with the current hunger striker. that is something we could face. >> thank you. also, it fascinates me to look how we actually [inaudible] self efficacy. at the sheriff department or [inaudible] from my perspective is advocating for
1:04 am
themselves for safety reasons [inaudible] >> that is absolutely true. i think the public don't necessarily understand patients retain atotomy whether they are incarcerated or not. as long as it isn't a public health issue like acive tb they can refuse or decline treatment as they see fit. my job is protect that atotomy. >> commissioner pating. >> first of all, i want to thank you for the excellent report and for jail house services having toured, i appreciate how difficult your job is. the most difficult clients in the network and working environment having 250 coordinate service with the sheriff department and being at the whim when they are booked and discharged and working around those visits, you have
1:05 am
as much complexity as a hospital and integration as the outpatient system so you are key the system. i would like to look at your role in the health network. we have taken a focus on the jail. just a couple questions. of the patients more short term, which is 65 percent and clients more long term, which is i guess 15 percent are like over30 days and the rest are between, how does the services break down? do the short term services-are they less expensive oregon doing a lot of intakes? long term clients are they costing a lot? can you tell us in terms of the budget burden of each of those groups and whether there is a difference. >> i cannot tell you anything about the
1:06 am
cost in that regard and i don't know that we have the sophistication in the data systems to be able to address that in detail right now, but in general people who are there a shorter amont of time unless they have a serious injury or illness and end up at sfg they cost the system less because they are not there long enough to really get engaged t. we restart their medication, that is probably the biggest cost. those that are there longer, a long period of time, the short period is 7 days is more of a urgent care model and then for those who are there longer term we are into a chronic care primary care model where we look that screening and diabetics for eyes and feet and thinking about corectal cancer
1:07 am
screening and mamo grams and things where once a patient is stabilized you address in more a prevention aspect, more education about their illness and medication and how to engage around self management for whatever those illnesses are. that doesn't happen in the first 7 daysism s. >> can we look at it from those different perspectives? can i walk through the services-on one ends your services are vertically integrated and have hospital beds and post opsurgical units for people who receive minor procedures. subacute and have the regular clinic duties. in that respect, one thing i came away with is you look like a hospital, what are some things you do to make sure the integration goes well? i was interested in the
1:08 am
pharmaceuticals because i know that you did not get some of the pricing the hospital got and wonder-as much as we offer total care can we get some the cost efficiency of the hospitals? >> to speak to the first part the question, the vertical integration stops at acute care hospitalization so anybody who has anything beyond a skilled nursing need goes out and so that's-there is a opportunity to bill when they are inpatient so that is out of my budget. that is out of the jail over here. the 340 b or other opportunities pricings for pharmaceuticals is one that i'm sure joe exploreed a lot and one i
1:09 am
exploreed when i first started with the idea-we have our own pharmacy and it wasn't clear if that is something that we should continue to do, should we merge that with sfg and get our meds as a outpatient satellight. we talked a little about that with the pharmacy director and 340 b specifically excludes carceral settings from their pricing. there is no benefit to us. there is a lot of stuff we have to do to become staff members at the hospital in order to do this, which would have been great incentive if we got 340 b pricing and once we reviewed the regulations and saw this provision that excludes jails and prisons that stopped that movement. i dopet know why that
1:10 am
is historically, but it was pretty [inaudible] and that is where it ended with dr. woods. >> considering jail services in the other direction not vertically as the hospital or subacute, with 6 days stay i think you can be at hospital model where you see people doing acute triaunge and cleaning up and linking them. with regards to that, the recommendation of former commissioner guy, the release center for linkage opportunity. i didn't see it in the presentation and wonder what you have discussed to make sure you are a quick triaunge, get hooked up to the continuity of care because this is the only opportunity they get for quite a while or never before.
1:11 am
>> we are in the [inaudible] stages of exploring how to formalize the linkages. there is capacity in the primary care system and dr. hammer is happy to have us integrate our patients back into the system because they were served by the health center or establish care. we haven't form alized that yet and that is the last point to figure how to do that in a way that really is a warm hand off and not just we made a appointment tuesday, hope you make it because that historically doesn't work for this population. we are more likely to see them again then they make the primary care appointment >> most new clients come into you are probably unlinked and not part the system, is that correct? >> they are linked and out of care.
1:12 am
>> they have seen- >> we got a lot of kaiser patient squz a lot of patients dph patients and [inaudible] patients, we have a lot of ppo patients and they typically just have been out of care for the last time they picked up med in jan or february. there is real opportunity to make that connection if we can get-it has to be fast and the idea of diversion centers must have that kind of capacity if we don't have the patients in the jail we have to make sure we get that hit when they are in front of us. >> [inaudible] >> thank you, we need it. >> the last two questions is
1:13 am
medi-cal. when people go into prisons, they lose their medi-cal. do people lose med i-cal in jail? >> they lose kaiser coverage as well. >> do they resume when they get out? if they are in more than 30 days do they lose it? >> [inaudible] >> one thing we have done is worked with the sheriffs and social services during the aca process was to really have a process for them to get reinstated on the medi-cal. it goes on pause and isn't shut off which is what happened before. that was a legislative issue. also we worked hard with the state to insure individuals in the hospital got medi-cal coverage and because that was not-we were
1:14 am
covering those costs as well. >> if you were not on medi-cal or coved california there were [inaudible] to get on those is that what you are saying? >> they tack that as soon as they come into the jail. >> thank you. >> that is part of the dist charge process and reentry process that is important. >> do you have a question on this? i have one more on psychiatrist. 1.2 for 3 sites? >> there are 5 and one, two and four which are colocated downtown and 5 is san bruno which is the bigest jail >> it seems like a lot of territory to cover. >> it is a lot of territory. >> i'm done. >> [inaudible] commissioner carson. >> thank you for the presentation. i
1:15 am
had a couple questions, when i visit ed the jail there was talk about [inaudible] is that no longer something that- >> i think again this is sort of a early exploration but one of the opportunities for telehealth that would be a fabulous solution is telepsychiatry. we have as you know the conversion from health right 36, the behavioral health positions which include psychiatry neither of the psychiatrist are coming over after the conversion. psychiatry is the safetynet is a challenge and it is a impacted specialty and one we absolutely cannot do without. we have been in talks with uc around just very early stages the opportunity
1:16 am
for tele-health and there is a little technology that has to be put in place to do that as well that has a expense associated with it but it might be a great solution for us for psychiatry and other specialties as well. tele-psychiatry aligns so easily to tele-medicine, it seems like that is a waste if we can't figure how to make that work. >> the other thing, so, since it is the primary care model effectively and i anticipate that you will be part of the network dhr, is that correct? >> we will. >> so, some the questions that like cost issues, like how much does it cost to provide the services should be captured by that over time and
1:17 am
outcome measures. that would be important for us to see how those services impact outcomes with that population. my last is a comment. as you described the population that they come in and leave and transient, it sounds a lot like what we have talked about with homeless population. i wonder how connected you are with lessons learned out of those populations to use-for them to also get some of your lessons learned into their population? >> perhaps estimate what the homeless pertage might be in the jail. >> i was going to say 30 percent and--
1:18 am
>> [background speaking] >> that seems to be a underestimate if you include marginally housed people. i would say the first lesson is these are the same patients, so the opportunity for integration with homeless services is huge here and also providing care for those patients in other than, please go to this clinic in this neighborhood on this date, which is really what homeless outreach has been doing, just taking care of patients where they are. that opportunity is one that we need to leverage as well and figure how to connect them to the people out there with them with when they are not in
1:19 am
with us. probably the greatest lessons learned that we have been able to take away from is just the fundamental philosophy how to approach the patients. it isn't quite operationalized effectively yet but as we grow into a new approach to managing the homeless population that is also the jail population, that is also the mentally ill population-we triangulate around these people and support them in the appropriate way to do that for them where ever they happen to be at the time. >> warm hand offs. >> [inaudible] >> a couple questions around the integrated services. you mentioned 2015 there were 8900 tests done. out of the 8900, how many had been
1:20 am
positive? >> that includes hiv, hepatitis c and sti but 7 new hiv positive patients. it is harder to know who had a new hepc diagnosis but greater number than 7 and tons of chlamydia and gone reea and syphilis. >> director garcia. >> i wanted to thank you commissioner guy for coming. she talked about the jail reenvisioning and this is how we'll try to make recommendations including how to help people get into supportive housing and so sthra great deal of activity and lots of great ideas. very integrated group and want to thank commissioner guy for her leadership along with the sheriff. i
1:21 am
just want to note that i believe that part of the issue of why we are the best in jail services is when you think about the type of generalfund we put into the system and when you think there is no revenue at all and it sits on general fund of any county, that is one the problems we have in providing a kind of equity in terms of these individuals. particularly as you know that people of color are the ones getting arrested whether that is a right equity way but medi-cal is something coeen and i have been looking at is can we kbet individuals covered in medi-cal as they continue in jail since they are there for copal days and gets complicated getting back into care. that is apologist question i think we nude advocate for and by the way, children in our youth guidance center have the same issue so thought maybe we should try the kids first and get to adults but that is a problem
1:22 am
when we have to use our general fupd and we are a very generous city and county so we are able to provide the type of services. not all counties have that type of general fund to provide that and that is why you see differences in different counies. we vajail in the hospital called 7 l so when the individuals are acute and have to go to the hospital we have a jail system in the hospital so that is a another area that we focus on. >> is that medical and psychiatric? >> both. also, i just want to acknowledge the fact we have dr. pratt as the dr. in charge. you heard her say 10 years working at san quinton and worked at community based organizations including baker place for detox programs so has a deep understanding of the populations we serve and
1:23 am
how lucky are we after having joe [inaudible] to have dr. pratt. i just want to acknowledge robert who helped recruit her. i want to thank her for making the choice to work for us. andologist her staff who have done incredible work and very committed. frank and tonia are commit today the population. i thought if we have kate [inaudible] i want to acknowledge her because she is leading us and-[applause]-as a leader in jail health service particularly those with hiv i want to acknowledge her and have the commission acknowledge her today. >> thank you. i want to echo the comments of welcoming you and want to just reflect for a few short seconds that our jail house wasn't in this
1:24 am
condition when we were [inaudible] back 20 or 30 years ago for nearly a decade and if nothing else that made the city much more away of the need to really take care of this population and dr. goldensteen assisted in doing this. one of the other things we have been asking for i believe and while the commission has been looking at for example public health accreditation as being a positive move to move us into being able to be measured with the rest of the country is that if we believe that our jail system is moving along on a track that jail system and there should be consideration like perhaps we do with hospitals to relook at
1:25 am
the accreditation process that would then help the commission and understand how we are managing with the rest of theunts country or state. [inaudible] there may be others but encourage we also look for yard sticks that help validate what we are doing and your fine work you are doing. >> great. >> any comments otherwise? if not, thank you again and- >> thank you so much for the opportunity. [applause] >> there is no public comment and item 9 is, what is collective impact. >> dr. aragon. >> welcome back to the united states. >> thank you. good afternoon
1:26 am
commissioners. my name is tomas, aragon the health officer of city and coupty of san francisco and director of population health division. today what i will talk about is what is collective impact. it will be a conceptual overview. you received a detailed update but many of these areas so won't go into detail about the specific initiatives but will give a high lechbl overview. i want to start by saying back around 2011, [inaudible] were working on community health plan and health service master plan and a article came out in stanford social innovation review entitled collective impact and it got people
1:27 am
thinking about how we work together as different sectors of society to solve complex problems. collective impact is not new, it is the reframing of how we act collectively with focus and intention to solve complex social problems. the first one i want to show you is-this is actually a slide from australia and the date is 2014. you see from 2011 to really in a few years the concept of collective impact is known globally and inspired a lot of people to figure how to work together. what i will try to cover today is what is collective impact, why has it captured imaginations world wide, what does it mean for san francisco, what
1:28 am
does this mean for our organizations, for our staff, what are limitations of collective impact and how dus collective impact comp lment public approaches to improving population helt. drether garcia and myself are part of leadership training with [inaudible] called emerging leaders in public health and as part och that leadership fellowship we decided to transform how we do leadership training in the health department. at the top it says pub lb health leadership is practice mobilizing people, organizations and communities to tackle public health challenges. what you see in the house being built, the 4 component what we call the lead initiative, has the first one the
1:29 am
foundation is trauma system squz think you received talks on that. the concept is designing a heal ing organization. iment provement the idea is designing a learning organization. the two pillars are cultural humillty which is about tranlz forming the workforce and collective impact which is about transformic clunties. those are 4 components. you see how collect chb impact fits into a broader framework that director garcia is promoting. so, what is the idea about tackling complex essential and health problems? the way we think about things is problems and solutions can we simple, complicated or complex. the comicated problems are those with technical solution. the complex problems are problems that are very
1:30 am
difficult to solve and involve complex social interactions in society. some people call these wicked problems. there is no off the shelf solution to pull off the shelf and apply. what does it mean as a organization in terms of-how we work with other organizations arounds some of the complex problem snz one of the most important things about addressing the problems is the idea of humillty. the idea that we don't have theer swz. collectly hopefully through trial and error and integrating science, scientific evidence, community wisdom and community voiz and community evidence that we iterate to solution that will work for us. that means we have to be a lot more adaptive, flexible and willing to iterate. it also means we have to have a mindset we
1:31 am
continue to learn. we will share solutions. also means having principles of practice and i'll talk about that in a moment. the other important thing about the idea of coming together is there is a huge emphasis on relationships and figuring how to work together with diverse populations. you can imagine the way things were in the past or traditional approaches for solving complex problems. often times you have organizations, non proft organizations that go after funding and they work separately and disconducted and we describe that as isolated impact. the idea is if one organizations figure how to do it, we just scale up that solution. that is the more
1:32 am
traditional way of thinking about this. really the way that we should be thinking about this is all of us working together. not competing, but working together to have collective impact and that collectively we'll be audible to solve the problem. that is what this diagram depicts. so, in 2011, john cania and mark craimer came out with a article called collective impact. they articulated or reframed what they considered to be successful conditions for collaborative around the world that were achieving the transformation of complex social problems. they came up with thought they described as
1:33 am
5 conditions. the first is have a common ajendsa and the idea is have an agrud upon shared vision for change. having a common goal. the second criteria was to have shared measurements. now, one thing i want to point out is for me it second condition here is really about continuous improvement accept that you think about doing continuous improvements really at a social scale with diverse agencies coming together. that is continuous improvement condition. the next is mutually reinforcing activities that you bring people aroun the table who are already working on these solutions. they are already inspired to work in this area but they have part of the solution. bringing them around the table so that we can develop a common goal,
1:34 am
shared measurements and learn together and share our best practices. for me, that third area is about transformation and that is about transforming complex systems and there are two transformations. there is transformation you try to achieve in the community and also and in the collaborative. the fourth area is the idea of consistent and open communication. that condition is really about building trust and transforming relationships. the last condition is what they described as backbone support and backbone support being in my opinion one of the most important things that are needed. you need to have both the administrative, data analytic and also the strategic project management support so
1:35 am
you can pull off all this coordination and alignment. some the collective impact initiatives are huge. for example, there is some that involve hundreds of organizations. here in san francisco we don't have something that big but some can be big. part of the-i would say the last one is so-it is very very critical. foundations have now to xh to realize it is not about funding solutions, because often times the solutions are not easy. you is to discover the solutions with the stakeholders working together. it is also about finding the backbone support so you have the infrastructure for the alignment coordination, learning project management, the data. that is a very important condition. the thing i want you to take away is when i first looked at this, the way i
1:36 am
thought about this, this is just quality improvements applied at a social scale. at the health department we already have a lot of expertise to really contribute in a big way to collective impact and so that is what excites me about collective impact is we have the tools and expertise to make the big contributions. now, as you might imagine there are some people who would-are critical of collective impact because they say there are a lot of gaps and limitations and the intention of the slides conditions are not to be comprehensive. it is very concise and resinated with common sense like it resinated with me as a quality improvement model. since 2011, taking into account all the feedback that occurred around collective
1:37 am
impact, sfg which is consulting firm and think tank in san francisco, they are really the folks who are behind the idea of collective impact and geped principles of practice. designing and implementing a initiative with priority based on equity including community members, cocreating with cross sector partners, use data to continuously learn adapt and improve, cultivate lead ers unique system leadership skills, focus on program and system strategies, build a culture that fosters relationships, trust and respect, customize for a local contact. the way to think about collective impact are the 5 conditions and principles of practice coming together. so, because you're bringing together partners to
1:38 am
work together on comp plex problems, you have to a little patiences. sometimes there is frustration because you work together. on the lest side you see components of success and on the top you see what they describe as 4 phases. i won't go through the chart but want to read one quote from one of the articles. once the initiative is establish, phase 4 can last a decade or more. collective impact is a marathon, not a sprint. there is no short cut in the long term progress of social change. you'll see in some of the initiatives that i summarize you see that some of the problems are problems we won't solve over night, it will take years to really make a impact, so we have to have the peristance,
1:39 am
but also the patience. so, temrack institute in canada put together the slide to-when i started the traditional model is about competing and coexisting. collective impact is really on the right hand side focus on coordination, collaboration and integration when appropriate. so, i'm going to just list here-i listed some of the collective impact projects occurring in san francisco and know there is more but this is aicismal of collective impact projects the san francisco department of public health is involved in. you had several presentations on vision zero. they are getting traffic deaths down to zero by 2024. getting to zero-getting
1:40 am
h eeurfx v death infection and stigma to zero and i'll say a couple words about both of those. the san francisco health improvement partnerships which you also heard about which is coming together the hospital counsel ucsf, department of pubhook health, ethnic groups and foundation tooz focus on the health of san francisco, we use that for the health care service master plan public health accreditation u community health imprubment and hospitals use it for community benefits requirements. i'll talk about that for a second. the preterm birth initiative is a large grant with ucsf that we have staff here at the health department working on. the our children and family city wide initiative focus on family wellness in
1:41 am
san francisco. the last is black african american health initiative. i want to briefly acknowledge [inaudible] bennett quhoo is right there who will be a key leader in the black african american health initiative and i do also want to acknowledge some of the other leaders working in that beside [inaudible] dr. ellen chin working on heart health and blood pressure control with primary care clinicsism dr. lisa golden working on breast cancer screening across primary care. judith martin working on alcohol use for mens health and then dr. yana bennett and susan [inaudible] working on chlamydia screening. i have given you a ovview on collective impact and before i a brief summary of 3 of those areas, i want to just show you
1:42 am
operationally how we actually do the work. we take what is the described as a results based approach. operationally this is how we do it. you see population helths improvements mpt we are trying to improve health in the community. the population based health and you hear about this all the time. hiv infection, syphilis rates. but what we have control over is the specific programs that we can actually control. there is really two levels of thinking about this, there is the assets we control, which are programs, systems, program services or systems that we control and there we focus on the performance measures you often hear about and we are trying to
1:43 am
contribute to a population health improvement with community health indicator. a individual organization may operate optimally. they may provide the best services for their clients and patients, but they may have a limited impact in the population. if all of these organizations are all working together, the theory is that collectively we will make a difference. that is the idea there. population health improvement is community level, performance improvement is the agency level or program level. at the ends of the day for clients and people we are service we ask 3 questions, how much did we do? how well did we do it? and is anybody better off? it is always focus ed on improving health and
1:44 am
wellbeing of people. i gave you a appendix that goes into more detail how the results based approach aligns with the management system we are using. i want to show you how it works getting to zero. the goal in getting to zero or common agenda is zero hiv infections, deaths and zero hiv stigma and discrimination. there are 4 strategys being implemented across the city, the first is called rapid to support for persons newly diagnosed with hiv. retention and reengagement of persons living with hiv and to make sure they are getting high quality care. preexposure prophylaxis is reduce hiv transmission or acquisition among those that are hiv
1:45 am
negative. and ending stigma. if you look that bottom table number 1 that is population based indicator. we know for example in 2015 we had 255 new infections and in 2012 we had 453 so since 2012 to today there is 44 percent reduction in new hiv infections and this trend that got everybody excited about the idea of getting to zero. seeing it go down. we had a historical graph you see it was much higher. the idea is we like we can do this. we are moving in the right direction. we want that to get to zero. that is a a population health inicator so imagine the strategies happen at the program and agency level. now, number 2 and number 3 are examples of really
1:46 am
performance indicators. the first is time from diagnosis and first care. the second one is first care to vital suppression, also in days. you see from 2013 where it took 104 days to get the patient vierally surepress from 104 is down to 52. that is 50 percent reduction in getting people vierally surepress. moving in the right direction. we see endicators in the population level and program level are in the right direction. the program level is what people comthe lead intcader and contributed to the population indicator. we focus on the program because that is what we can control and expect it to improve at the
1:47 am
population level. at the population level it is a combination of all these things, social marketing and people changing behavior. that is what i wanted to cover in detail to give concrete example of those conceptsism i won't go indetail for vision zero. the numbers have not chaimpged dramatly in the past year but this is from the most recent report and can go and get the most recent report for 2015. in 2015, 31 people were killed in traffic collisions. 21 were pedestrians. 5 riding motorcycles, 4 bikes and within person driving. there is a lot more stats in the updated reports. i won't go through that. the last one i want to mention is san francisco health improvement partnership. at the very bottom you see we have a common
1:48 am
agenda. at the bottom we have draft shared measurements under behavioral health access to care and eating and physical activity. now we are in the process of finalizing theenedicator said we will focus on and deciding how to address those. those are 3 examples that were intimately involved in. the last thing i want to do is just describe how does this fit in with the other public health tool s we use to improve population helt. we have 3 core ways doing this. at the top is idea of health impact assessment. all these approaches you see they are system approachesbecause we work with communities. at the top is health impact assessment. we ask the question, what is non health
1:49 am
impact of programs -what is the health impact of non health programs policies or proposals. if someone proposes to build a freeway in a certain neighborhood, what is the health impact or the health impact putting bike lanes for example. the idea there is that if you go from left to right you see there is multiple impacts. collective impact is the reverse of that. we are saying, let's bring people together, the mutually reinforcing activities to focus on a specific health impact and goal so just the opposite. the last one i want to mention is called community based participatory research and san francisco is very active in this area. that is where you engage the community to come up with the quigz and solution and work with them to address the problem. a lot of
1:50 am
our tobacco control initiatives work wg youth groups is done through this approach where they identify the problems and do the research and learn how to take a idea through policy makes and getting something passed with legislation and board of supervisors. those are the 3 praimary ways we work with communities to transform health. what i covered today is collective impact. collective impact is not anything new, but it is really a reframing how we work together with focus and intention to transform complex problems and, it is a important pillar in our lead training initiative that director garcia is leading with the health department. that is my overview and i'm available for any questions. >> thank you. commissioners, questions to dr. aragon?
1:51 am
>> there is not public comment requests. >> thank you. >> dr. aragon, the first question-i mean the idea of collective impact is something that we have been using for a number of years in the city and bringing together a number of different organizations for different topics, right? particularly--and this sounds like you have interwoven it to a lean process, which the department has used now as its key metedology for developing programs in your scenario here, is that right? >> yes, they really comp lment each other. lean has a focus on methodology to improve processes and deliver on results. when you engage the community, you don't start with focusing on process, what you
1:52 am
focus on is what you are trying to accomplish which are results. you focus on results and then you say, how do we get there and yes, improvement methodology will help but you don't start. where you work with staff and focus on improving process, the lean approach is really provides the tools to improve the processes so they compliment each or. it is just where you start. that is reason quhie i-one thing that excites me about continuous improvement is as we engage with communities we wim have better tool tooz help thel. we will be able to provide that value as we engage with different agencies around these complex problems. >> if we can go back to your first one
1:53 am
that you have. it showed all the 3 areas. 4 areas. >> there we go. >> this is one of your tools to create this-the house here. >> right. continuous improvement we focus on that at a organizational level but tools we can use that with communities to help improve their processes. again, continuous improvement and [inaudible] internal to transformation but we engage with our patients in communities. collective impact is about outside working-the health department work wg other agencies on complex problems so vision zero about traffic injuries we work with police department and mta
1:54 am
and department of public healths and walking group jz, all the organizations come together and focus on a common issue. >> department of homelessness-it is one of the collective impacts? >> sleuthly. absolutely. the >> the complex cuply in many different areas. the clinical analogue of this is coordinateed case management. you have a complex patient and you need a- you have different providers who are coordinating care around a complex patient. take the idea of coordinating case management and scale it up to a social scale. that is what collective impact is. when you look at it carefully people are familiar with it but the things we bring to it
1:55 am
now with more rigor especially with continuous improvement and relationship building and trust component. you have to acknowledge these are complex issue squz have to get to a solution and build trust and transform reslaigzships. . >> any other questions at this time? >> i think the answer is what is collective impact and the answer is the most important thing we can do at this point for population health. with that, i just want to thank you for all that you are doing. when i inquired about the collective impact project particularly in the budget i'm impressed how much financial leverage we get out of these in terms of the not how little because i know we invested a lot but a relative benefit we get for the dollar we put in we get a lot of financial leverage. my
1:56 am
question may be to udr. aragon or director garcia, are we funding directive impact out of sur plus funds, the mayor comes windup a good idea or department comes up with a good idea so get backbone funds to fund this or is there a line item to fund the collective impablth because it should be a ongeeing structure? >> i think both areas. one thing we want today look at is we could look at lean and look at it separately, cultural humillty. we tried to bring the training components together because we felt each had a important contribution particularly as we are a delivery system and we are responsible for all the health status of all individuals in san francisco. using both the lean process,
1:57 am
collective impact, trauma and [inaudible] because that is who we serve, individuals who are traumatized by a variety of different social determinants and cultural humillty as well is one of the ways of looking at workforce transformation particularly reflecting whom we are serving in the workforce. so,-all this is funded as of today, the 3. collective impact is a example getting to zero 3.2 million from the mayors office and that will have some of our backbone in. we have to to fund each separately but there is a background growth we want to continue to support and have done that through public health accreditation to insure they have quality improvement staff and we have been bringing in at
1:58 am
least 2 million of new infrastructure for public health so they have backbone for the staff necessary. when we looked at public health division, what we found is epidemiologists were funded by hiv. i think you had one epidemiologists or 1 and a half when you think of all the other public health demesnes. we are looking how we grow the backbone of public health division and had $1 and a half when you think of all the other public health demesnes. we are looking how we grow the backbone of public health division and had to dollar. how do we provide backbone to any public health. we have the zika issue and had to deal with ebola issue. we have to contend with different areas.
1:59 am
part of the commitment i made to public health division as we go into the thirds year oof 5 years is to try to build the backbone of our public health division to participate in many activities you usually don't see public health departments do. >> we get efficiency as we do more. we have collective impact case management division that run the projects. interest is make sure you don't get hammered by funding when you feel they are essential to do them. that is the intent. >> absolutely. i asked for a 5 year funding plan for this. you caen just start lean and think tomorrow it is done. this is going to be for a decade-this has to be interwoven into our work so we have a working process of 5 year commitment. at least to plan out and tine continue to look
2:00 am
at that. i don'ts worry how to make investment especially in the days having more revenue, with competing things like electronic health records but we have been able to fund this. when new organizations as a example, there is a new several new researchers out of ucsf that feel they can get to cancer issues and get to provide for that. that is one thing we talked about that it is important for them to have a backbone and have funding to bring people together and work with all the other groups in the community versing starting new with the same group of people and that is what we found with health improvement process which we had hospital counsels in the plan separately coming to this commission. we had the community groups coming with their plan and public health and