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 years budget we assumed some additional revenue in the food Program Based on sections relate to cannabis. In the current year the board of supervisors allowed to codify a new cannabis fee were able to charge. Im literally shifting the dollars in the program but its net neutral overall. Lastly, our initiative to expand our Specialty Pharmacy for the San FranciscoHealth Network would allow our patients to access specialized medications including hepatitis b, oncology drugs at two additional locations. Their expenditures would be the pharmaceutical expenditures would be offset but it increases actions for patients and theyve been trained to support our patients or give them a better outcome. So in terms of our overall balancing with last weeks initiatives and new initiatives proposed, what you see is weve essentially corrected for the lopsidedness and we are about 700,000 to the good in terms of our Budget Proposal and fully meeting our revenue and reduction par gets. Tash targets. Theres been a lot of creative thinking on our part but we are pleased to say were leading the proposed budget. With your approval today well submit our proposed budget to the Controllers Office and Mayors Office. Where the mayor will review it and submit his proposed budget on june 1 and then it will go to the full board or budget and finance committee and full board. Happy to answer any questions you might have. Thank you. Commissioners, questions at this time . My one question which ill give to director garcia however, was that we had discussed the issue of the tuberculosis control the last budget hearing. And im still work on it. I was going to be working with our budget folks to try to complete that. This would assure with all the changes in both the feds and ourselves that we had adequate resources for this important infectious program. Thank you. Commissioners. The budget is well explained and if there are no questions to ask, then we are prepared for a motion for acceptance and to move it to the Mayors Office. Ill note there was no Public Comment requested. Im sorry. Is there Public Comment . Oh, there was not. So moved. Second. Theres a motion to accept and move it forward to the Mayors Office. And theres a second . Is there a further discussion of the motion . If not were prepared to vote. All those in favor please say aye. All opposed . And the budget has been accepted and will be moved to the Mayors Office. Thank you very much. If i could, commissioners, just to acknowledge their hard work on this and to the staff who tried to maintain the initiatives this year so we can continue to manage our budgets. Yes. And definitely and we had comment on the clearing of the budget. I think the department and the finance people particularly took next issue of the lopsidedness of the budgets and also refined it so it is now an acceptable budget. Thank you. Commissioners, item 7 is an update from the gender Health Program and evaluation. Thank you. If you have any problems let me know and ill come over. I am a math person. Okay, everyone. Were having technical difficulties today. Good afternoon, commissioners and director garcia. Im julie graham the director of gender health sf. This is dr. Seth pardo. Hes our evaluator and well be sharing this presentation. Im very grateful to be back in front of you to discuss the incredible work of our program so well start with maybe we wont. So our Program Began with you all in 2012, the Health Commission approved the development of a program for people to be able to access surgeries relate to their gender identity. In 2013 my program was established. We called it Transgender Health services and subsequently changed the name to gender health sf. In 2013 medical lifted the discriminatory exclusions that had been in place that prevented people from accessing care and we got a location and became a for real Program People could walk in and meet with their navigators. So what we do so were the First Program in the nation to do this, to provide navigation and access to these surgeries. Were just going to click on this on the side. Were the First Program in the nation to do this for Public Health. We provide access to surgery and navigation and education. Were under im a gender specialist and nationally known expert in gender health. Our medical director is also a nationally known expert in gender health and we now have a very parttime Nurse Practitioner which is very exciting to us. As i said, our evaluator is under quality management. We had a patient Care Coordinator and two vacant positions were hoping to fill and the bottom line is our core staff. So Behavioral Health clinician and Karen Aguilar our hearts and heroes award winner, tamika godwin who is a peer Patient Navigator. How thats important because thats our model. The people who work at our program, by and large, identify as transgender or transgender binary and many of us have had the patients our having and so were experts in that way and in experts in terms of knowledge. The people doing surgeries for us are at zuckerberg and people we contract with because theres so few gender surgeons in the United States and were lucky to have a few in the bay area. Our referrals have now theyve started to get steady and moving back up is what theyre seem like but ill let you talk about that. I can demonstrate this and its a pleasure to present for you. The numbers are increasing annually and though the orange bar which are the surgeries completed are less over time a lot of is because the Program Takes great care to make sure the patients are prepared for surgery so everybody goes through the Education Preparation Program and through a rigorous assessment of their medical records to make sure theyre stable and ready especially in a vulnerable Public Health population. What is of note is over the years amongst all patients the number of surgeries completed is essentially hanging steady with this green bar in the middle. These are the number of patients who have discontinued or not been eligible. In the data some of the predominant reasons for eneligibility has been changing of insurance, mainly people get jobs, they get better insurance, theyre no longer on the health care and thats a good thing or change providers so theyre no longer in that work so its not bad theyre not eligible for this but moved out of the main service category. For all surgeries completed so far for gender health sf , most the surgeries completed have been in network another really great thing. Most have been for transwomen. You can see the blue and purple side of the pie chart represent both breast surgeries so mem feminizing mammoplasties and the vaginalplasties. Most surgery covered by the San Francisco health plan. 70 of the surgery covered by the San Francisco health plan and 10 for healthy sf. Out of network surgeries as julie mentioned, we are competing with a worldwide population who are in need of these surgeries and we have a concentration of the most skilled surgeons here in the bay area. Regarding the program flow and evaluation, julie can speak to the flow of the patient through the program if you care to have if youre interested in that flow. For this slide i wanted to draw your attention to the items on the left in the purple box. Those are where the evaluation are and we do a baseline of where patient in their quality of life and body address and Substance Abuse and other concerns in the evaluation. We says how the Patient Satisfaction in the preparation and Education Program and the support groups that are run by the near navigators and we followup after surgery to see how well the patients are doing after surgery and to see how well gender health sf is supporting the patient. In brief, the primary outcomes for the evaluation are surgery readiness, timely access, Patient Satisfaction and quality of life indicators and we hope to see annual relative improvement in surgery readiness where patients feel theyre ready for surgery following the preparation and Education Program add gender health sf and able to access them in a timely fashion and hope with advocacy they can continue to access the surgeries sooner and sooner so theyre not waiting as many as a year to two to access some of the surgeries for such a vulnerable population as has been waiting decades. For Patient Satisfaction we hope to see a minimum of 80 of our patients satisfied. Thats a standard threshold. We aim higher than that and finally for quality of life we hope to see relative improvement to baseline for quality of life indicators, psycho, social, wellness and decreases in body disphoria and for the outcomes were mostly on target. 80 of the patients served by gender health sf felt very or completely ready. We asked how ready do you think you were before the surgery which is a testament to the preparation the staff are doing for the patients. Over time, the wait times have increased for out of network surgeries and medical is now funding them and were now compete a Global Market and 69 were satisfied with their surgery experience. Some of the room for improvement is through the patient and Education Program to accommodate the unrealistic expectations. People have an idealized outcome for the surgeries and there say high complication rate upwards of 50 , 75 and when im waiting my whole life to access something that ive needed or wanted to have an amazing quality of life, its easy from a psychological place to think this wont happen to me but it does. And were working on making sure our patients are prepared for that and with the surgery experience there are active engagements with staff across gender health sf to increase sensitivity training to make sure the Patient Experience increases over time and we have seen outcomes for psychological and social wellness and connectedness and decreases in body discomfort and gender disphoria as we expected. One of the other issues about people being satisfied with the outcomes is theres so much misinformation out there its part of why we do what we do. Theres so much misinformation many people are disappointed they dont have body parts that are exactly the same as people who were born with peni