Report. Good afternoon, commissioners. The president did sign a continuing resolution for a twoyear budget framework into law and that will allow us to not have a Government Shutdown until fiscal year 2019. There are specifically in the measure the funding for extending the Childrens HealthInsurance Program for an addition four years. Reauthorizing funding for more than 7 billion to Community Health centers that includes the departments dollars for homeless services. It provides 6 billion dedicated opioid treatment and Mental Health service and funding to National Institutes of health and the child Home Visiting program. We are still tracking the 340b issue as well as the fact we know potential of cuts and future cuts in Services Including in cdc, samis a, nih and other areas and keep you informed as we know. Senator scott wiener announced a new conservatorship for addiction and homelessness as part of the definitions. We hope that we are in support of this with the senator and we can do a press conference the last week on that. Part of the legislation allows us to continue and weve been positive in being served versus being in locked facility. The Prep Campaign ink to address hiv disparity by reaching out to African American there was a new campaign in the fight against hiv to end the disparities impacting African American men and the focus is to prevent hiv infection and a new campaign launching will help close this gap by engaging black san franciscans to support in prep messages. Gender health recognized an event and i kind of see them of them in the audience. We want to acknowledge them and the mortality rate of black infants is more than twice of white infants and a growing body of evidence shows stress may be among black women caused by Racial Discrimination and as you saw in todays report some work is finding better results by focussing on those kinds of issues including working in the community and managing individual stress from the African American community. I do want to make sure we recommend the staff today. Director, i had one question off the present i guess the continuing resolution it then would not have the let it of another shutdown im trying so information how that works. I and tis we could have another shut down but this allows us to go forward with the initiatives. And on the report our congratulations for all those who have been recognized at the event. Thank you for the report and the next item. Public comment and ive not received any requests. Could i ask karen to come up to acknowledge her . Surely, please. I know you have experience now and if you can give the commissioners a little bit about your background and the work youve been doing for us. I did hiv prevention back in 1999 and have been working there since 2017 and looking for the transgender community. We want to acknowledge her for her award at the hearts and heroes. Congratulations. Thank you, sir. Item five is from the commit from today. President and members of the public, the Community PublicHealth Committee met this afternoon. We had two very specific items on our agenda in the child and adolescent health. Theres three items discussed in detail. Preterm birth and childrens oral health and child abuse. Next item was Food Insecurity in San Francisco and talked about hunger in the Faith Community and over the next few months and later in the year, data will be provided on the ethnicity and perform level and we look forward to hearing from them as a competition. That con cloud my report. Thank you. I was able to be present at the Committee Meeting and was struck with the presentation on Food Security which i understand will be expanded and be available for presentation to the full commission and understand the importance of food as one of the sociodeterminates of health and what the department is and as a Strategic Plan working on in order to move forward on that as an important pillar. So we will be agendizing that for a fuller presentation as part of the departments overview. Thank you, commissioners. The clerk item 6 is the budget and today youll vote on the issue. If you recall this with us introduced at the last meeting february 6. Very briefly and then ill turn it over to our budget director. As you know we had a hearing in our last Commission Meeting with a set of initiatives proposed for the budget. This is the second hearing well be requesting a vote to forward to the mayors and comptrollers office. The budget we submitted to you was roughly balanced, however, as we noted during the hearing it was uneven between years where we were over balanced in the first year and under balanced in the second leader and while we hit a target it created an issue because when were short in the second year it carries forward to the future budget and affects our ability to hit our longer term Financial Planning goals. So what weve come back with today for you is a second set of initiatives that introduced the items we were not prepared to bring to the last hearing, but furthermore corrects the balance to were hitting our target in each of the years and we should be in a good position for our ongoing to meet our ongoing general fund target. Ill turn it over to jenny with the initiatives. [no audio] hopefully members of the audience can follow along until we get a larger screen. So commissioners, as mr. Wagner said in the last hearing, weve submitted our base budget overview. We committed a number of proposals that didnt meet target and the concern on the initial proposal is we were very lopside in how we spread out our savings and how we met the target over two years. At this Commission Hearing were bringing forward a complete balancing plan. One that actually corrects for the lopsidedness using appropriations and prefunded appropriations for project in year one. That should hopefully address that issue as well as an additional handful of issues wed like to bring forward for your consideration. Most significantly is the Electronic HealthRecords Initiative we brought forward and we have paper copies here. Let me walk you through this table. The first line is an updated projection of what we feel the project will cost from 17, 18 through 1920 and from mr. Kims presentation last year when he updated on the project basically the bulk of implementation has begun for 1920. The numbers were updated after we finalized the contract with epic and enabled us to figure out what were the services we were getting from epic and other services and were expecting well have 247 million worth of costs related to i mplementatio and this is the updated number from the fall and winter once we finalized the contract. The second set of numbers you see and so many commissioners may remember over the last several years weve tried many strategies to fund this Program Given we were progressing 377 million over 10 years when it was something we cannot do overnight. To summarize we did a combination of some base project funding. We did some onetime appropriations and project funds and additional infusion of base project funding and also had a mechanism we started in 1517 and we were able to capture the onetime revenues youve seen in the Financial Statement relate to costreport issues favorable costreport issues that were able to recognize its not money we feel comfortable budgeting or baseline budget but it is a revenue that we see fairly often but not always in our Financial Statements. And we believe we have 244 million in appropriations available for expenditures which is a couple millon million shy of what we had and the project expenditure and work in the baseline were things done before the budget. And last week we had an issue with our funding with the affiliation agreement where they believed in several years ago they could actually hold their affiliation agreement flat to help support the procurement of the Electronic Health records but recently this fall with updated projections they didnt feel they could maintain that agreement with us anymore and so theres a 10. 3 million issue we had to contend with to make sure we continue to support the services that you it provides for us. So that 10 million issue basically combined with our shortfall and our deficits over the last three years results in a 12 million shortfall in just looking at the issues. And then as we mentioned before, in addition to this issue we also had the issue of being lopsided in terms of our balancing in our initial Budget Proposal. So what we are proposing to do here is to shift the funding of the project earlier into fiscal year 1819 instead of 1920 and allows us to move dollars and enables us to reduce year two by 10. 3 million and reduces an additional 10. 7 million of ongoing costs for the h. R. Project because weve already prefunded the e. R. H. Project in the future im sorry, earlier. So what this does is overall all see we will actually have a balance of money for the next two or three years we expect to fully expend by the end of 1920 but we do believe we can provide the appropriation of 247 million over the next three years. This is something that we are going have to watch because we didnt reduce our ongoing appropriation and it does make that project a little bit tighter because we are projected to be at zero at year three but its something at this point we believe we can manage. I know i threw a lot of numbers at you. Do you have specific questions on what i just walked you through . In regards to the ucsf changes, has there been a review with ucsf in terms of what the affiliation agreement is expects in the future to have made assumptions or hope for promises and then to come in at the budget time to say that we actually cant fulfill that and there may be very legitimate reasons would seem to be a shortsighted type of process rather than one that should have had a more continuous dialogue that allows us because this is a longterm project, to understand and Work Together to manage all the sources of funding recognizing there was good will in coming in to say they would participate in the h. R. Process. Yes, thank you for the question. We have been work myself along with a Hospital Executive team, dr. Erlach on her staff and what the directions entail and youll see the funds removed from the project from the affiliation agreement and in addition we discussed at the prior hearing theres an assumption in the mayors deficit projection we will fund the nonphysician staff on an ongoing basis and between the two sources we believe that there is efficient funding that we will not sufficient funding we wont have to come back for an ask. It will be a process well have to work through and already started with u. C. So that process is going to be some added layers of oversight and collaborative financial management. So well be looking at enhanced process to evaluate whether those need to be refilled. Well be looking at opportunities both now and through the e. H. R. Revenue process and the fees woul offset the need for an affiliation agreement. We are going to be looking at whether theres opportunities to streamline consolidate, identify efficiency in the affiliation costs and the below the line items in the agreement. Theres layers in this but theyll be putting in plis a process well put through the next 18 months and beyond to make sure were including the same level of i guess certainly or oversight in the projections for the affiliation agreement that we are in other items were bringing before the commission and the Mayors Office and fiveyear Financial Planning process. So im confident its going to be work but confident everybodys on board between the Central Office and Hospital Administration and the deans office that you see everybodys committed to continuing to work through this to make sure that we can live westbound the appropriated dollars. Commissioners, any further questions . We felt it needed some explanation. Director gars yeah garcia, do you want to make comments on this . We know about their commitment and asked for an audit on the costs so we ensure what we are providing will be sufficient. I think its the same as any other organization as well. I think well work through that and as you know we are very dependent on these services and we want to make sure theyre qualitative. We will continue to provide the oversight. Theres actually codependents here. I wonder if anybody from either the hospital or ucsf would like to make comments concerning this . Good afternoon, commissioners. We have worked closely with the university to look at the costs and revenue opportunities. Weve been doing that ever since i got to the hospital actually two years ago. So i feel very confident that Going Forward well be working together collaboratively on costs and revenue to make sure its all controlled and maximized as appropriate and im happy to answer any questions. Commissioners . Thank you very much. The clerk youre welcome. Thank you. Well move on with the presentation. If the commissioners have questions even related back to the h. R. , we can take them up again as we move forward with the remaining changes in the budget. The next initiative is also an i. T. Project relate to the Controllers Office of Financial Systems project also known as f. S. P. The went live july 5 and as the system has a lot of capabilities as youve seen with the different ways to report on the budget theres also been challenges and the implementation of the new system. Most significantly for us was an interface between the Financial System and our procurement system. We were the only city to implement the procurement module and upon implementation we saw many links were broken, essentially. So we lost a lot of our automated capabilities so theres the shortterm issue of keeping the trains running and making our payments and making orders on time and reconciling systems and its requiring extra staff and weve been work with the Controllers Office to understand the i. T. Issue but we feel well need to create a new interface between the two systems to be able to automate it in the future. Obviously we are not interested in doing manual reconciliation moving forward. So its a onetime increase in the funding we have for a project we expect to use over the first 12 to 18 months of the next fiscal year and theyre continuing to create the modules. Theres also other areas in terms of payments where we have manual reconciliation in part due to the conversion issues and were reviewing the entries and making sure theyre all appropriate. And want to make sure we have all the staff for a yearend close which happens in august, september and october of 2018. The budget proposes to create a pool of staffing and allows us to give support for our operations and also proposes for consulting for us as well as a work order through the Controllers Office who can help implement better interfaces and modules for the Financial System. Then the last emerging need is related to the transfer Emergency Services for our department. As you know, weve been planning the transition for years and it became effective july 1. Prior to the transition we did a study on the staffing and program and there were significant issues and there was an additional need for increased analysis and metrics, policies and procedures and proposing a pool of Temp Staffing to let us do more discovery on what our operating needs are and then well evaluate the costs in the future. Next in terms of solutions, we have a onetime revenue related to a 2009 claim for the Mental Health state plan amendment. This was an adjustment made to our claims and proposed around 2009. After several years it actually we were told to submit our claim and we expect payment. So wed be pleased to recognize 8 million one time to help offset some of the proposed budget. The rest of the items are budget neutral and a few years ago we pi pilot piloted a new treatment for hep c to cure patients and the revenues would be sore i have, the expenditures of this very expensive treatment which is about 90,000 course is offset by medicare dollars. The pilot has been very successful and laguna hondawood wish to double it from 11 patients for a total of 23 and our request is really just to increase our pharmacy budget offset by revenues. Next is our environMental Health fees. As you know, we bring our fees forward for your view every year. This year what weve actually added weve added additional positions for additional inventory and our costs are not for new positions but they are for the work orders for tax collectors to implement a new online permitting system. It will have great impacts on our clients and the people we serve because it will obviously provide greater convenience. People dont have to bring their payments over. They have to come down in person. They can do all of it online. And then also just helps with our internal staff and reconciliation and it minimizes the the paper work on our side and an exciting change on the expenditure side. On the revenue side, were projecting minor changes based on inventory and one significant change we did do was that last