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 chung . If not, well 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 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. 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 doesnt 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 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 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 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 ill go over the broad categories. 3 nurse managers. We have among the physician staff we have 1. 2 psychiatrist 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 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. Im not sureim 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 isnt clear from the slides. We saw 15,000 patients last year and im talking calendar year not 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 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, im sorry you cant see, but what now looks 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 those sets of numbers have been declining since 2009 and that is as far back as i have data for. Ethnicity data, thefor 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 wewhich is called the jail Information Management system. We ask our patientsthese 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 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 havent 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 dont stay but they come back typically. For 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 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 dont come with their medications and if they do they dont 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 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 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 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 aresince im 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 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 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 the misdemeanor so people wont 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 marys report, but what we engaged with around her are some 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 somewhen 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 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 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 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.