Transcripts For SFGTV Health Commission 31516 20160321

This has been an enlightning and learning experience as we navigate ourselves through an ever changing complex, healthcare system, where the local and the state and the federal enter twine, i have been thankful to be part of the process, under Robert Garcia and her team, and my fellow commissioners in case people are wondering, i am, and i have been transferring back and forth, between valeo where the Stroke Center is, while i am in recovery that is the reason that i am no longer going to be. And although i have a local, business here in San Francisco, and i am committed to being in San Francisco and being a part of this community, i will continue to be a part of this community, and also i wanted to say that i wanted to make sure that as we move forward, with the work that we are doing here, at the Health Commission, that we take a serious look at how we can really look at the rate of healthcare disparities among african americans, in particular. It is an issue that is of serious concern to me. I would like to see us get to a point where we have Better Health out comes and as an advocate, i would like to be a part of that. And you will see me, continue to see me. The mayor understands my commitment to public service. And there will be something happening within the next week. I cannot say. But it is all good. And so i just wanted to thank everyone for their support, particularly as i have navigated my way through the healthcare challenges. So thank you. Thank you, commissioner taylormcghee. As we know, commissioner taylormcghee was during the Health Commission, four years ago, and has been an important contributor especially in advocating for the improved african, american health, initiative, that has been started by director garcia. And, and, for these numbers of year, we have certainly been trying to address that issue probably no more vigorously than we have in these last several years, which i attribute to the fact that commissioner taylormcghee has been with us and has been able to articulate the needs of that community so well. In her absence, we will continue to work on the initiatives, and bring it to a successful fruition and our thanks for the four years that you have spent with us, and given us your wise counsel. Thank you and we wish you well. Commissioners, item two, is the approval of the minutes of march first and to the right of your packets are the revised set of minutes that i sent you yesterday and they have a few extra comments from dr. Chow or comments that he asked me to put in, on page 8. And so commissioners the new minutes are before you and they were some additional explanations added to or as you will see from the underlining to note that we also had presented miss bear, a Public Health award, and in expansion. And i am hoping that these will be meeting with your approval, and so, the minutes are available now, for a motion for acceptance. So moved. Second. Second. There is a second. Oh, lets see, commissioners continue to look over the document to see if there are any other changes that they would like to propose. Seeing no further changes, we are prepared for the vote all of those in favor of the minutes as now written, and presented please say aye. All of those opposed and the minutes have been adopted. And the next item the directors report. Good evening, commissioner taylormcghee thank you for your service and it has been a Great Partnership and you and i have had and i respect your commitment to help equity. And so you have my commitment to keep work og that and thank you so much for your involvement and the encourage and you have attended. And thank you so much, and we look forward. And very excited to say that we just came from the board of supervisors, and about an hour or two ago. And we were approved. From a nine to two vote to seek the ability to negotiate with uc, for a new Electronic Health records. And so, we just want to give and i want to acknowledge all of the team and i do not see greg here but i do see bill kim and bill did a great job as well. Helping us with the board and really educating us, and you know he is really going to be leaving the ship for us, and he has the experience of implementation and he has been working on the Infrastructure Development and i think that he has been on the second day of the life of the new hospital. And things that are on green light, i understand, and working. So, that gives us an important step towards being prepared for the Electronic Health record. Our next steps, of course, is to allow for the mayor to sign this ordinance, so that we can then start having the conversations with uc. Bill and his team are working on the chart. And we will have two basic groups, one that will be working on the technical and implementation and the second group of the executives of the department at uc will be then and our lawyers who will be working on the contract itself. And as you know, within the ordinance, we do have the back up plan, that if we cant find our path through the uc, component, we do have a back up plan with another vendor. And so i wanted and greg just walked in and so i just want to make sure that he knows how proud we are for all of the work that he has done for the new Electronic Health record and the team and bill, shop and i think that we are moving ahead and as you know we have a lot of support from the uc leadership and the doctors in the department i want to thank them as well. We have and does not look like it today, but in the last couple of weeks we had bad weather. And the mayor lee, announced an expanded winter shelters and we will do that throughout the el nino storms and we are good at implementing these quickly. And what we continue to find the people who are not seeking healthcare but who really are in need of healthcare. And so our medical teams were highlighted in the chronicle just the other day, and so we are proud and i see barry, and along from the dr. , seven who is in the odd ens today and he has done a great job of leading that group. And another big, structure, structural decision for the department, of course, is the fact that the mayor and for the public and safety bond to the june, 2016 ballot and this will be for 272 million for the department. And 222, for the health, or for building five, and where we are going to integrate, many of our outpatient programming, prohe vied a much better space for dialysis patients and along with the urgent care. And then we will have 30 million for the building of an integrated Mental Health program, with primary care at south east. And then the 20 million because over the years we have had a prioritized process of identifying some of our clinics who need it and ada improvements and flow improvement and privacy, improvement and especially as we move towards Behavior Health integration, within our Primary Care Clinic and we will 20 million, and we will hear more about some of our updates on the capitol today as well. I do want to acknowledge that we do have a change in our environMental Health department, kusihing is the new director, richard was honored by the board this last week, and also on wednesday, march 9th, a group of staff crowded into the Health Officers office to cheer him on as he clicked the submission, and documentation box of the Public Health accreditation, on the computer, and signalled the completing of step there in the board process. The search for the written evidence of the work and so this will, and this was also, reported out today in one of our joint, conference committees. And i will end it there and if this is a long, director report this time and if there are any questions, i am happy to try to answer, thank you commissioners. Questions to the director . And the commissioner . Thank you, for the excellent, report. Regarding the california special legislative special on health, with the date now of the attempted suicide and end of life options now, solidified as june, 9, 2016, i would assume that at both the general and laguna honda or both, we need to look at policy issues and i just like to ask that one of the jccs that we will be able to review how we might be implementing that and looking at the policies that. I got to request that we have it here because it is a jcc. We start here, with that conversation, and then, the jcc can kind of refine some of those so that they are all talking together. As a whole, commissioner and i am sure that some of the other commissioners who are not sitting on the hospital, committees will really like to hear and i believe that our Deputy Director would be ready to provide for some of that. That will be fine, i think that this hearing will be nice. Absolutely. I would agree with the issue that did come before the commission, and certainly, the entire commission would benefit from understanding how we will be implementing it and also be informing the public that way. Okay. The second question is the two tobacco bills and one is at the city level and the tobacco 21 and now the state, i think that the state, copied us. We were first, and so what is the implication now of having two ordinances that may do, some what of the same thing, does that supercede our ordinance . Our directive policy will try to address that. And the details of that. Actually, i think that it is a little bit different and we will have to coordinate the two. I believe that the state level, legislation, prohibits smoking. By ages 21, ours prohibits purchase of tobacco and so we will have to look at how to make sure that the ordinance reflects what has been passed at the state level chl thank you very much. Sure. Would it be possible then to get a follow up on that at our next meeting in terms of the clarification . And providing that the governor is on the bill. The governor has 12 days to sign the legislation and there is no indication and we just had a call with the director of the Healthcare Services and there is no indication by them, whether he will or wont sign it. And so we will up date you as soon as we know. Thank you. Any further questions . No that is it. Questions from and i did want to note that the department has been certainly doing a lot of work and particularly, i think passing the number of the surveys, should be commended because those are really key and they were of concern as to whether or not knowing state surveyors and licensing that they would not find and are very complex and new building, with the new technology. That they would not have been even mo even, issues so to everyone that were involved. There should be or continue to be congratulated if the only real issue is that we have to have the dialysis unit up for 30 days and that i, and i would believe that it is not a real problem. We have our chief Operations Officer here. Sure. Tell us directly doctor. Why dont you. You can come up here. The commission and the rest of the commission that everything is going in order. Maybe maybe you can come and just give us a two minute up date on where we are. It is worthy because this is such an accomplishment and because those of us who have gone to, even the routine, hospital surveys have real problems, and this is not routine, the opening up a brand new, and highly Technology Cal facility. So take some credit and tell us how you did it. Thank you. And i believe that i get to share a rebuild in transition up date later in the agenda. You are right i have never done this before, many of us who work at the hospital have never done this before. And i work with a remarkable team. And that just pulled it together from a clinical standpoint. And under the leadership of jeff smith, and terri salt, from the physical building side of things. I cant say enough about max under the facilities because he has a web corp that has pulled back on the staff and has had to step up and so then, you know the surveyors, were truly, amazed by the joy of our staff. And in talking with our front line nurses and our super users, around how excited they are, the pleasure that they are going to have in delivering care to our patients in such a remarkable building. So, i have been through many cdph licensing surveys. Obviously not for opening a building. But, the energy that we got from the Licensing Team from cdph like you could feel that they new the value of zucherburg San Francisco general and wanted us to succeed and i think that they were super pleased that we didnt let them down and i will share more with you later. Surely. I just thought that it was important to call out how amazing that the survey process went so far for us. And that you and your team all of these are the credit that you are, and that you are justly getting. Thank you. Thank you. Any further questions on the directors report . Or any of the other items that you may wish to address the director of . Otherwise, oh, i did want to commend that, i think that the work on the homeless, injure work that you have continued to carry out on the pier 80 and all, are beginning to be reflected in the public testimony that is coming out. The last thing that the work, just that was, was it yesterday or today . That was, just so important, showing we have medical services at fury and how important those are. And so, thank you very much. Thank you. We are going to go to the next item, please. The next item is four and general Public Comment. And i have not received any requests, so he we should move back on to the report back from the Public Health committee from today and commissioner, and chairs that committee. Okay, the commissioner . Yes, and we, and on the xh itty, and the Public Health, and the committee we heard two reports and one on the accreditation project and i think that you heard from the directors report that on march 11th, dr. Aragon pushed the button and submitted the documents for the Public Health accreditation, on board, this, we saw a small portion of this document which is about 500 pages of about 50 of the sections, so this is about 1,000 or so pages electronic document and i just need to commend the team for the compiling of the data which was very broad scale across the Public Health department. The good news is that the expectation is by the end of this year, we will be accredited. There will be a mock survey, done by our own consultant. And in june and then, by october the expectation is the reviewers will come through, and we have asked that the full commission receive an interim report in july, after the mock, survey. But in terms of our subcommittee looking at the status of things, and there was a lot of optimism and there were, in our own sort of preliminary surveys no major gaps. And the documentation gaps that were there, have been filled. And i think that it is just a lot of optimism and a lot of hard work and sweat that has gone to get us to this point and so it was an momentus moment and having pushed that button and now it is on the way and up to the board to start the process of review and then come back to us, and we mreef believe that t date was in october. So we will hear before that site visit and we can ask more questions from the full commission. The second item that we heard is the first of the Behavior Health reviews. We are now in a process of trying to review the Health Network revisions twice a year and so we heard the Substance Abuse today. And so with have about 7500 clients and the Substance Abuse treatment, and about 3800 of them are receiving methadone and 7500 are unduplicated and it does not include the people that go in and out of the can enter and the hot team, and so we have asked for a drill down on what services that 7500, people actually received and what is the dollar amount for those services, and to begin to understand our Substance Abuse services in more detail. In the interim, the 1115 waiver has been approved by the state which guaranteed or which mandates an expansion of the Substance Abuse services for medical as part of a demonstrati demonstration. And this means that there will be, more requirement for about 75 percent of our Substance Use disorder patients who received, medical, under the expansion for enhanced services which have greater accountability, attached to them so the department will be looking at in more detail what services our cbos will be providing, these clients, receiving these new, 1115, waiver moneys and are they receiving evidence pf based treatment and this will also help us, as they get the information from the cbos to then be more accountable us as a commission, about again, what are the 7500 people receiving, are they getting good out comes and how is the dollars can be spent. So we are going to give them 6 months to compile that and hopefully we will have more information on the report to the commission. So right now, we are just getting oriented and to be led with the 15 wave as the first step and so those are the two reports and if my fellow commissioners have anything to add, we will welcome that. Yes, commissioner singer . Do we have an idea, we have 7500 unduplicated Substance Abuse . I think what was brought out today is that the numbers are not correct that we are calculating. And so, because we have people in different systems, that are also, Substance Abuse, clients, in our Sobering Center which is in another division, we want to do a little bit more guiding into the data, commissioner singer because i dont believe when i ran Substance Abuse, we were at 20,000 clients and so i just dont think that the data is right. That was the nature of my question, and so i will ask it and you will come back to it later, it is kind of two other pieces of data, and one is what is the need, so, how many people do we have in this city who could take advantage of those services . And the second question, is, and i think that this is a smaller number, than that. If we had more capacity, how many people would avail themselves of it and so trying to figure out, are we, and where are we in meeting a demand of the population . And i think that we do really well in the methadone programs and we have on demand, and in the primary clinics the opiates i would say that the residential programming and the outpatient, programming but we can definitely look at the wait list that we have and the demand and we have a lot of work and i spoke to our cfo after the Committee Meeting today that we will need to get some of our analysts to really support our Substance Abuse side of the house, to see if we a better picture of the need. And also the cost. Yeah, that would be great. And look forward to getting the data. I think that it is worth mentioning that actually getting precise numbers is not trivial on this. Absolutely. Yeah. Thank you. Thank you. So, commissioner i also had a question about the demonstration waiver and it is titled drug medical and so i am trying to pdz, is this related to getting the medicine to them . Because the discussion sounds like we are delivering the care in ted and so maybe the title is misnamed or, i dont think that i am understanding totally, and as the 1115, waiver and you could help me out, practice pz and the rest of us, and it is just that another way that we are able now, to use funding and why is it called drug medical . I am going to, and it is the way that medical, designates the services and the services and i am going to turn this over, to her and see if she can give you a lesson, and how those are divided. Yeah. Maybe i am the only one. It is in fact, the unfortunate way that medical refers to Substance Use, disorder coverage, it is called drug million dollaedical and to comprehensive like we have for the mentally ill that we have. More coverage for the services that are not covered now, and a greater rigger in the provision of the services now that medical is covering them. Okay, so in fact it is not related to how one obtains drugs, but the delivery of the services that are in the benefit. No, it is really about the coverage of the Substance Abuse disorder of treatment by medical. Right. But i do think that it is reflection of how we have looked at and i worked for samsa and why it is so important to have the parity in the systems of care and San Francisco leaps and bounds ahead of many other counties and even, states. In really trying, and we really try to put some humanity into those programs to our Harm Reduction approach and accepting people because there is so much stigma, like we have seen in the Mental Health system and sometimes, even more, and in fact, the most recently, we passed proposition, 47, where the people with addiction were being arrested and put in jail. And so, i do think that this is an opportune time to main stream and also increase the medical services which have been care driven and really medicalized a lot of those services through the medical detox to our programs for opiates under the methadone. And so i do think that this is a great opportunity to be able to create some revenue, increase the accountability, of many of our providers, and also, improve their services to the clients. And i think that some of the questions that the commissioners have asked for is really important and we need to really be right about our direction on this. And so we will be working and because this is 90 percent, almost, 95 percent, contracted out to cbos it is really working what those contractors to insure that they are meeting the compliance and training them and getting them and the helping them with the staffing that they are going to need to draw down, these new federal dollars. All right. Just trying to close part of the loop of where you had indicated for example, in regards to that workforce that our former commissioner, and you were heading, and will this then be of help to that, so that we would therefore have access to facilities and therefore, not have to have those jails . Yeah, i think that it will be another tool, it will not be that the entire solution. Because remember when someone is in jail, they dont have medical. And it is until they are able to get discharged that they will be aible to take advantage of those. Which is another, policy i would like us to take on, is you know, the facts that the people in jail dont have medical, therefore, you know we are not able to really create a Revenue Source for many of them. And that is why in every city and county, the jail service is very different, depending on how much that county, can really support their jailed inmates. But it will be a tool and many of the clients can benefit from the services and that jail, committee i think, just to let you know, that we had that first meeting last weekend and i think that we started off very good and we have 40 members of it and lots of enthusiasm and i think that a very Broad Spectrum of representation and so the first meeting went really good, but this medical program, i know will be another tool to help us and improve those services for those meetings and jail and keeping the people out of jail. Wonderful. Okay. Thank you. If there are any other questions, we will move on. Item six is a Health Commission election. Yes. Commissioners your preference and we had in the past deferred our elections until to hold the election into march. So that we could understand any of the, well, i should say, the appointment of commissioners because all of these got changed with the now, older charter. That allowed only a 90day stay for those whos appointments expired and so we wanted to be sure that we could, have a commission that has known who the Health Commission members were before we elected officers. And so we put it to the second meeting of march. And this near and coincided exactly with the end of the term. Of commissioner taylormcghee. And in fact we didnt know that taylormcghee was going to or be staying on the commission and therefore eligible for an officer ship or not. And therefore, we have placed on to the agenda that we would entertain the idea of delaying the election until there are a few changing. And of course we dont have a name replacement either for commissioner taylormcghee. But, that does not necessarily negate, and so it is the desire of the commission where to hold the election or to postpone it for until the next meeting . And it would be your pleasure. We will have it at the next meeting if the commission so agrees, or if the commission wishes to move forward. So i guess that it would be best to see if there is a motion to postpone the election until the next meeting . How do you feel that we should proceed. And if the commission wishes to proceed with the election, at this meeting and then we can proceed. Okay, so the item is the election. And there are two officers opened for election, the president and the Vice President. We will open the nominations for the presidency at this time. Commissioner chung . I would like to nominate dr. Chow to serve another term as our president of the commission. Any other nominations . I will second that. That is the way that we do it. I dont know. Yes, thank you, you are correct. If there are any other nominations, i move that the nomination be closed. Is there a second to that . All of those in favor . Say aye . All of those opposed. We will take up the vote. All of those in favor . I did read that in the sunshine act, if it is unanimous or by numbers and i do that and so i thank you for your vote of confidence and i hope to be able to continue to be worthy of that in the coming year. Nomination for the Vice President is in order. Commissioner chung . I nominate, commissioner singer, to serve another term as the Vice President. And your reception to that . Second. And i heard a second. Okay, are there further nominations. There are not further nominations and the motion for the nomination to be closed. I move that the nomination be closed. Is there a second to that. Second. All of those in favors of closing the nominations please say aye. Aye. All of those opposed . The nominations are closed and the vote is on the motion to have commissioner singer serve as Vice President for another term, all of those in favor of that, please say aye, all of those opposed. And are there any abstaining . If not, commissioner singer congratulations on a second term as Vice President. Thank you. That was a surprise. I didnt realize that was going to happen today, congratulations everyone. Item 7, is a Transgender Health Services Evaluation up date. Thanks, who is presenting . Good afternoon, i am the director of the Transgender Health service and this is dr. Seth pardo our evaluator and we are here to give you an up date about the Transgender Health services and talk about our evaluation plan. Some of you may remember that in november of 2012, the Health Commission made a historic decision and decided to cover surgery medically necessary general, gender surgery for transagain ter people. This is something that did not exist in this way anywhere else in the u. S. And then, director garcia appointed evans to create a program. The only models is in European Countries where there is socialized medicine, it did not exist, if the people wanted these, they had to pay out of pocket which meant that they are out of reach. In 2013, the department of managed healthcare, removed the discrimination exclusions that insures that medical will cover, gender related care. This is primarily for your reference, and this is Transgender Health services, the direction that we are headed. So we are under community Behavior Health services. And in truth i just want to give you a shout out to joe robinson, because without joe, i think that we would not have nearly what we have, around transgender, sensitivity, and services in San Francisco. So, i am the director and funded by the Mental Health service act. We currently have some vacant positions of a Health Worker three, and a social worker. For 17, 18, we have proposed positions for Health Worker and for another social worker. What we currently have is we have a peer Care Coordinator and we have the Patient Access navigator who is half time mhsa person and we are currently hiring two patient, navigators, that will be peer providers, to navigate the people through this very complex system of care. This is again, for your reference. And this is the budget that we have moving forward. And i am going to jump to what i think is more interesting. To me, at least. So, in 2013, we started in august, and we got 78 referrals into this program. And we were able to provide, 7 surgeries in 2013. And in 2014, we had 148 referrals into the program, and provided 36 surgeries. 2015, 60 surgeries and 135 referrals, the referrals went down, because we put an hyadus on putting on the public out reach because we did not have the staff that we needed to at that point in time. So if you look at the whole they think, we have had 361 referrals by the end of 2015, and we have provided 133 surgeries and you might notice that there is a discrepancy between the number of referrals and the surgeries what that has to do with is the people who want the access to genital care we have to refer them out of network. And there is a 9 month wait list and a three year, wait list for one of the other s. The surgeries that we are able to provide at this point in time in that work are hysterectomys and then an mascectomy, and the removals of the testes. And that all happens in network. What happens out of network are vaginoplastys and the falo plasty and the creation of it is basically the lengthing of the clitoris and permitting people to stand to pee, and if you look at this, 32 out of network and 68 in network. And if i look at our list of people who are in the cue waiting to have access to care, over 55 percent of them, are waiting for out of network surgeries. Our population, we are a Public Health population, and we have, we have transgender, and sexual and nonbuyary people, who are staying the stigma on a daily basis, we have the people that were kicked out of homes and living in sro and people are homeless in neighborhoods that are unsafe and we have a lot of people on disability and the people that are struggling with poverty, and the distress, and we know, already that there is already, healthcare, disparity, for gay and lesbian, and transgender people and people on public insurance, and the people who are socially isolated and people who are, in poverty for people of color, the people with behavior helialth issues and so our population, stigmaize, that interferes with the people being able to be set up for good outcomes. They go through a number of checks, with the providers and with the administrative, staff, and across the department, to see what do they need in order to be ready to be referred to actual surgeries . Assuming all things go well and the documentation is submitted as necessary, they get a referral to the San Francisco health plan, or their insurance provider to cover them for whatever surgery is being petitioned. And they will go through the surgery authorization process and then at the bottom, 6 00 here on this graphic, they will get referred to a surgeon and all of this in the first 12 months and then they get a referral to have a con sult with a surgeon that could happen between the first year and as long as it could be as long as a year and a half. And then they have a schedule date for surgery, which can be as long as two, two and a half or three years later. Now in this theory, if anyone goes well as planned and the patient is prepared for surgery and completes the surgery, they go through the cycle more than once, and they have to get an approval for each surgery, and then in theory, we are providing the providers in the San Francisco Health Network to have care provisions for the patients and hopefully in theory this should lead to the success and the increased quality of life and improve social, and decrease Substance Use and ultimately the creation of the best practices. For the purpose of the evaluation and information that i am going to share with you today. I am going to share with you phase one, the first phase is going to look at client outcomes. Now, in quite a complex evaluation plan that i have that is really technical, these are the nuts and bolts of the most important parts of what is relevant vapt to what i am talking about today, there are activities that i will be going over and doing the interviews with the clients and provide the reports to the staff and clinical staff. And part of those outputs that i will be sharing are information about readiness, access, and spasht satisfaction in the out come and the quality of care. Information that we can gather on quality of life changes. We would like to see improved health, quality of life, restored trust in the Public Health system. So here is some of the sprefk indicators that i will be looking at as the evaluator for the services for the four basic areas that we are looking at with regard to the output, surgical readiness we hope to achieve a ten percent relative improvement in the patients who are ready for surgery. Hopefully through the Education Program we should see relative to the year before, increase in those number of patients that say that they felt ready for surgery and i will show you the data that we have. Timely access and the same thing, and relative ten percent and improvement based on the year before. Patient satisfaction and we would like to maintain if not exceed the 80 percent bench mark, 80 percent of patients being satisfied and the quality of care and improvement in quality of life at the indicators before you here is some of the data and i just started and today we have the interviews that were conducted between 6 and 12 months after a surgery was completed. It could have included, and with regard to the general regards of the readiness, 26 percent said that they felt, completely ready for surgery. On average, over all, in the Network Services is the most of the tests services are picking about 25 weeks, from enrollment to their date of surgery, and about, 53 weeks for general surgies and those these are on average and how they split, for those who enrolled, verses those who actually had a consult for surgery. For the patients satisfaction over all we had 3 quarters and more than half of the majority of patients who reported being completely satisfied with the surgery out come. They said well, that feels pretty low. There were additional 13 percent of people who reported mixed satisfaction. So they were satisfied, but, or happy with the services but they were okay with the out come but. So i didnt include those in the complete satisfaction indicators here. But know that the additional 30 percent of each of the out come and mixed additional satisfaction and among those who provided information regarding quality of life, a majority of them reported improvements. For example, things like you know i never thought that i would have access to this, this totally changed my life, and i may have had complications but i have been waiting my whole life and this is the best thing that happened to me. Even though they had serious complications. Access to surgery and those who actually landed the consult with the surgeon and then you can see that there is a disparity and there was a difference. And the out of network, and verses those that happened in network and just taking way too long, for those that are seeking general surgeries, to access those services and just some of them i dont have the exact numbers right now, but working on that, and some of them are relapsing or having the housing issues or the other things that are getting in the way of being stable enough to Access Services when in theory, having access would stabilize them. And so it could be a catch 22. And we are trying to assess that out. I separated this by year to show you that over time, as Transgender Health Services Gets a handle on how to provide the services and though they need the services. So these are the challenges or some of the challenges that we are confronting. So our network does not have the capacity that it needs to have. We have surgeries happening in burliggame and when you think about a person who lives in an sro and on Public Health in the city getting to the follow up care this is not or does not work well. And they said that our need for genital surgeries is increasing. So the Network Capacity in the location of surgeries is a significant issue. Many of the patients that we see have trauma issues. So they smoke. Smoke is highly connected to trauma. More smoke, because it is a barrier to surgery and good outcomes. The same issue with obesity. We are in Substance Use. So those things we really need to address. People dont have a safe place to recover in, so after care housing is a significant issue. After care fa some of these surgeries is, and it is somebody has an falo plasty for three months they are going to be recovering and need assistance for a vaginoplaty is less, the people have a dilation protocol, if you dont have a safe place to live you cant do that. If you are living in an sro with a shared bathroom you cannot do the after care you need in order to have a good out come. We talked about nutrition, and we had to get people food. Because people have to wait so long, we have to do again, a presurgery three months before surgery to see if the person is still stable and the Health Insurance requires that as well. We are working with San Francisco General Hospital to create a gynecology clinic, so that the post surgery people dont have to go to green bra. We are working with dr. Hammer to do better medical and Health Coordination across dph and we started to do training for youth providers. Because we do have young people who are in need of support around their gender identity. We are going to restart a lot of things that we began and then had to put down for a bit because we have way too much to do for the people we have right now. Some things that are cool is we are going to have a residents. So much of what we do is very heavy and intense and so doing something that gives people a chance to tell their stories. And we are doing, Community Ride education and we have to fix the data base that is where we are headed. I am the director, seth is our evaluator and dr. Evan is here and candy is next to him. How do you close the gap between the wait time for innetwork and contract care. So they are a specialized surgery. There are not tons of surgeons who do that and it is a struggle across the u. S. In new york they send people to philadelphia. We need to train people and it is my understanding that it is a provider issue. It is a huge provider issue. How do we envelope more surgeons. I can have row land come and respond to that. Roland is doing the Business Plan on that and looking at how many people do we have seeking the services. We knew that you would ask that question and it has been a pleasure to work with the group from the beginning in 2013. And to see where the program has come from and where it is going. So, as julie mentioned. We have already, worked with our colleagues at ucsf, and to actually put together, what will it take to begin to. As we prepare to move into a new hospital we will have three additional operating rooms. And so it is also going to record, additional surgeons. Thank you for the presentation, i just have a question because i dont know, so i am asking. This data around satisfaction and timely access, quality of life. Do we have National Data to bench mark against . No, we are so far ahead, that we dont have it that is Public Health and international there is some data. It would be helpful as we gauge to have the highest standard, is that we can look at how we are doing with the Public Health groups it would be on the international level. Well, i will say that, we have a unique poll you lags that is one of the first to be investigated at a Public Health level. And one of the samples that have the data on the Patient Satisfaction or out come or the time to surgery are based on private clinic or university, clinics and so yes we have a unique population and that being said we do have a Sister Health department in boston, and new york that are tarting to engage in that kind of evaluation and we have the challenges with doing this, and namely that the Public Health record does not really track, gender identity for transpeople very well. If we dont know how many people we are talking about, it is hard to gauge some of these what is the constitution of the sample and how does it compare in San Francisco. I appreciate the sensitive and how, you know, how unique that is. But as we move forward to continue to look at that. That is the idea. And a lot of the people that we see will be screened out in the European Countries. That is an interesting, fact as well. And so those kind of backgrounds are helpful as well. I cant help but add. And tell us who you are. Dr. Evan. Mysterious one alluded to. He was in the newspaper. And the, and again, and our evaluation is in the very early stages, but the numbers that we have, actually are rather comparable, to international numbers, and that have looked at satisfaction and quality of life, and after these surgeries. Those systems are quite different than ours. But, i actually have the expectation that our out comes are going to be equally as positive as what is achievable with those other populations. And i think that the peer navigation model that we are working with, along with the specialized professional care model in the Mental Health end and the surgery end are going to result in satisfaction and quality out comes, that are come parable or actually exceed what we have seen in some of the European Countries, just the speculation, but i want to say that is what we are aiming for. Thank you. Commissioner singer . Thank you. For this. And i am going to take the discussion in a little bit different direction. And the spirit of it, is as follows. And i think that as the city, we are super proud of this program. And we are committed to it. And so, the way that my brain works is as you said, that we have, more demand than we can meet for our services. And i always try and figure out, okay, how can we meet the demand . And so, the nature of my question is going to be trying to at least push our collective thinking forward on that. And so, i guess the first questions is what is the demand . Like what, what is steady state for this in our population, do you think . We get approximately ten new referrals a month without doing out reach. We dont know how many transgender people there are enrolled in Public Health in San Francisco. Because of what seth said before about the Electronic Health records and i mean it is also just about stigma and who we think that there is 2500 people enrolled in Public Health. Who identify as transgender sexual or no one conning. Not all of those people want or need surgery, only a subset, do. It is actually kind of hard to estimate what it is other than we are thinking, you know, those numbers 140, 130, to 140 referrals a year is probably accurate. And do you think that a steady state or do you think there is some die maam i can because of our forward thinking policies that there is, and if you will, pent up demand that will then be at different basel rate. I think that is very possible. But we have not seen it yet. We have not seen it start to decrease yet. So, i mean this is obviously an area that is with the resource to make sure that we are planning appropriately for the future. And so, the first question is, how much more does it cost us to do things out of network . Than to do them in network . I dont actually know the numbers on that. I dont know, if that is an roland question . We can, it does not look like we have it right at this, and so we can track that. I mean, i think you know, we face these choices of, and in languages not usually reserved for this field, do we build the capacity or buy the capacity and i think that these two things are really related and it is worth thinking through, which is depending on your view of the basel, rate, if you will, you may decide to be more aggressive in buying capacity on the outside, because you have enough capacity inside when you get to that basel rate. Or you might decide the exact opposite, which is gosh we are spending 75 percent more on the outside. We are never going to be at our basel capacity. So, it makes a lot of sense and it is worth a lot of resources for us in the long term to build to capacity here in the short term. And you come to, one comes to very different answers depending on your views of what the cost is, and inside out and i would really encourage as part of your work, to think through those things. Because you may and we may end up in a space where we are five years from now, and we are not in the kind of environment that we are in today in terms of the citys resources. And we need to begin to make choices about programs. And the idea of trying to look as far forward to get the programs so that the dollar is allocated to the program, serve the most clients, doing that early, i think super important. So i would encourage you to think about the physics of that just as much as the physics of how well are we providing the service. Which you are spending a lot of time thinking about it and it is wonderful work. But if you and we do both, then we will be in a much better place. Absolutely. And one of the things that we thought about early on, is that you know, if you are in the stock ton where do you go in and so, creating a program at say, San Francisco general, to be able to provide this to all of california, for a while los angeles was thinking that they would send the people up to us and there is not this capacity and so the General Hospital could be a center of excellence that does something that serves people all over the state of california. There is a huge need. And it is certainly true that roland would rather have more out of Network Patients than to send more of our clients out of our network. And that is so true and this is also, a relationship that we have to develop with what you see and because part of the issue this into start it with when we didnt have our own surgeons in the budget, we put in a surgeon in with training. And also, being able to identify certi surgeons that have this expertise and so it is something and you can get those surgeons just towards the beginning of every physical year, and so we have to work them and we work closely with the first surgeon, and trying to kind of figure out, do we have enough capacity and sue, made a very, big commitment to us that she really wanted to see this as a center of excellence that we will provide for more than just San Francisco understanding that there are no other expertise in the general area. And i selected that Business Plan that you are identifying i think and also the commissioners are looking at how can we kind of look at our evaluation to kind of help us with that in terms of coming up with a police plan that we see to identify how we can bring more of those in network and knowing that it may be more affordable to have it out of network. Exactly, because you have the short term and then your steady state and you would rather take them and spend them on the other parts of the program. And so, the last thing that i want to make is i would not presuppose, what the answer is. Until you get the actual some sense of what your team believes that the steady state demand is. And more rigger around what are the costs between the innetwork and out of network. I go back to the fact that when the program started the idea was to have a center of excellence as sf general, be that with the uc faculty or our own. And so i would encourage that, with the elements that you are talking about, it is not merely the steady state in San Francisco, but what is the potential demand that i think that they need to look at from the business standpoint in which then, we would do, like you were saying, potentially, we would be accepting cases, for a center of excellence, which will be really, extraordinary for this city. The way that our budget increases it is not the steady state for the decade and it was the past decade that ought to be the planning assumption, so getting our act in order now on these things is going to enable us to be a much better provider, to many more patients. And clients, in the future. And if we dont, we are, you know, you end up in these pen itani pinches and we have seen them in the City Government, where no one wants to do things but you have to because it is the reality of the financial picture. Commissioner pating . Yes, regarding the scene and i am actually worried in terms of adverse demands and when you build an Excellent Program people are going to come. Is it true that it is a benefit . In all of the surgeries only 20 of them were healthy San Francisco, and early on, and in 2015, only 20 were healthy San Francisco and the rest is the San Francisco health plan. Could you get closer to the microphone . I guess that my question is we are looking at access to, you know, the treatment, surgery, and follow up, and difficulties, and Health Concerns and etc. , presented. But, i would like to, sort of find out if, if the, if the Health Providers themselves, if in fact if there is any movement to certification, pertaining to this pathway, based on patient need demand and etc. Etc. You mentioned that, some people go and some of the doctors there are stanford and some are ucsf and you can go he to philadelphia, and other programs medical schools, and maybe that have the different pathways, involved. And but i dont know. I have not looked at and yet there is a movement towards, board certification, within the department of surgery, so this will be an especially in the future. Would it involve obgyn and etc. Etc. It takes time. That is why sort of get, i dont want to get confused, but i get frustrated when the people make a statement surrounding statements about we are going to have a center of excellence and it is going to happen like this. Centers of excellence dont happen like that. Unless we have providers who are board certificated, for these unique challenges or you have an integrated program, with a multitude of disciplines and this is ongoing and it is ongoing and ongoing. And so, all that i am thinking about is you know, we have really made a unique step forward in saying this is, our population here in San Francisco, and we are addressing this as best as we can. But we have limitations. And in order to do this, we are going to have to have, you know, some interaction and dialogue, and some leadership, within these medical boards and the department of surgeries and the surgeons, and you name it and it takes time and they have specific, Training Programs and they have, you know, what we talk about accreditation and visitation and etc. , and the board certification and follow up and all of these things are part of the pathway and until we see some collective movement, i mean, uc has five medical schools, you know, the la program is great, and our program is great, and there are other, and you know, chapel hill and etc. And there are a number of programs and it seems to me that, the battle to be fought within our department of Public Health. Or our affiliation with one campus or one, you know, one, or what we also need a national dialogue, with those who really have the professional expertise in order to say, you know, we want to bring this before the board and we want to have it approved and go through a trust file and we want to make sure that we have the special ways to address this in the future. And i think that that would really be a major contribution, and i cant think of any place in the nation that perhaps, some of that dialogue could not start right here because you have stanford and ucsf and you have the collar ration, and you know, as we have the links going through, the others and we have Excellent Programs. But, that is another area i think that could help us you know, as a Health Department and as we have shown that here is the unique need and we want to address us in a comprehensive and confident way with the most qualified providers. And hopefully that will get the movement and dialogue in the future, does that make sense . Yeah. Some of them are gynecology. And if you are doing faloplasty you need to have an neuro surgeon and, this is complicated and there is no training, there is no place, there is no place that does this. There are well, in character there is a cadaver lab that is about to happen to train the people how to do these surgeries. It is sort of piece meal. I also am a part of the World Organization and part of what we have taken on recently is certifying people and we are developing the programs f for, therapists and we are at the beginning of creating it, to certificate people because we need competent people. Because there are people who are just starting to do because they see that there is money in it and they are not properly trained. I like it, that is helpful. Just briefly, that there are a handful of medical schools and university of miami is one of them that have started looking at certain, Training Programs for obgyn programs, for example or other kinds of surgical residents that are coming through. And a lot of interest in the medical community to take a hard look at how we incorporate this kind of education into our curriculum. To lead to a National Certification through surgery or whatever discipline it is from. That gives them a validation to the effort. Which i think enhances the quality of our programs that have been started here. And dr. , thank you for those comments, because when we first started this, and it was the transgender, law center, and it really took this on, around the benefit issue. And we could have not and we not be able to continue the level of need if we had, if they had not, fought for the rights of the benefits for transgender people, and so like i do think that we are in relationship with them in terms of the work that they are doing. And so i really want to acknowledge the staff that i know, and one of the things that we wanted to do, and this was the assignment to barry was to really bring and because we had the transgender tuesday for 20 years. But tom Health Center when i started we had started that. But it was not very organized. But we had pieces all over the system. And so, bringing it altogether and making sure that we provide comprehensive services and remember that the transgender individual if they did not have dollars, there was no way for a surgery to happen. It is a very large spectrum of what the people would like to do in their lives. I want to acknowledge your work and i think that we are doing fantastic work for our Community Members and i get a lot of pressure about how fast we are not going. So that helps me also, to help to keep focused and to make sure that the staff is focused. And we have a lot of eyes on us in terms of our community wanting to make sure that we do the right thing i think that it is exceptional finding in the fact that we are able to respond and this is where we go. I am thinking, you know, hey, changes takes a long time. Those that it work, regarding certification and follow up and it is going to take the time and so what we are saying is it was started here and we have the excellent, and you know that is great. But i was, thinking of the long haul because it is going to take, you know, everybody together to institute and then to sustain it. And it takes a long time. And you, and along with some of the other commissioners have really given us some really important direction in terms of that, particularly to as to what the Business Plan, considering that we have the ability to do this right now. And we have to be smart, and so we take that direction and we will do a lot more work on this to make sure that we take those into consideration, but i do want to thank the staff and barry for the leadership to provide the necessary support, you know, that our clients need. And the question, the first question, that i have is, so what type of like, insurance that we take in right now, other than the uninsured . What we need to be, to become the providers of choice, because like for those specific patients, they actually do have the choice. They can just access some of these certify gons. And if they can take medical themselves they can access them, if they have medicare it is a similar situation. They might have to go through, you know, like the irp process. But, it is still, possible for them, you know, to like, access that without, you know, going through our system; is that correct . . So, if the people have the San Francisco health plan, they have to go through our system. Are you coming here . Medicare and medical, and so for the medical and medicare patients, if they do not have the San Francisco health plan, they are stuck. So their question becomes, you know, if they have medical or medicare, what makes them decide to have the San Francisco health plan. Verses going to another Health Center or clinic . Actually the San Francisco, health has been wonderful. They have, they have provided that, and pardon . They have provided access, to procedures that other medicals dont cover. Because they recognize that the people need to have these procedures, and that are medically necessary. And so i think that is a big piece of this. And there are folks that, and so for instance, they will cover the people with medicare, and anthem is not doing that. The same thing with facial electron sis, and the facial hair removal, people can get that through the San Francisco health plan. Medical does not cover that generally. So the San Francisco health plan, covers things that medical does not reimburse them for. Because it is medically necessary. And it is ultimately reduces costs in the long run because it decreases peoples gender dysphoria. And i wanted to bring that up because that is the standard that now that the california correctional, you know, like the facilities are using, that they have to provide the electron sis, like before, you know, they would provide, the reassignment surgeries to know, you to the, inmates and so are we doing something right and that is what i am trying to, and that is like, the go around in the circles to get to that point. And i think that is also, really important, to really recognize something that i think most people would take for granted is that we talk about genital surgery it is not just the surgeries that you stitch something together. You know there is the aesthetics of it and that is the functionality of it. And the community, of a very educated you know. Like in the abilities of the different surgeons. And you know, but, they really want or see themselves to have, and i think that is the other piece of the conversation that needs to be incorporate into this. And so it is not just one surgeon, it is what is available out there. And also, the other thing i think to this, is if it is great to be measuring the quality of life, for me. Personally, you know, i know how my life changed, you know, after my surgery. And how i took better care of my own health. And. We are looking at preand post surgery comparisons. And i believe that because we are so advanced and you know, pretty soon, we are going to have other, gender, information, surgeries that we, that we will be looking into covering. And are we, ready, you know, like for, to make those available . I am not even going to name the surgeries. So it is coming, it is. And thank you, for it, and the facial is coming and because that is important, and it is a big piece of what happens around the safety, you know that the people are assaulted and harassed and harmed because they are perceived to be an again ter other than they are, and so it matters. And we are going to figure out how to make that work for folks. So yeah. And it is not just about, rearranging the face. And thank you for doing all of the work that you do. And so how can the commission help to support this to, like, continue to let it grow and develop into. I think that you have asked us some really important questions, tonight. And so, that is, i think, really, informative for us, and for some of the direction to really think about the Business Plan. And particularly as we see, we have a window of opportunity, to really think about this. And also, to really get the evaluation to maybe, embrace some of this data that we will need. In terms of determining what the is it more affordable to bring in health surgeries. Or is it more costly, to have them out of the network . And i think that is a big question that we have to answer, and that is something that has, some difficulty because of the issue of one, just being able to give the data on the transgender individuals in our system, and looking at the pent up demand as we move forward with the managing that pent up demand. And so i think that, and what you have done tonight and in this discussion, i think that it is helpful for us for the Network Development and also, i think that they have dealt, very clearly, some of the needs and continual needs that they have, and one being a location, and which i am trying to work on, because you know, they really need to have a focused area in the hospital, area, because that is where many of patients are, and so we are making sure, that they will be part of the whole move that we have in the hospital, so, he has his eyes on that as well. So director, within that framework, that i think that you have described, well, the discussion that has occurred today, where, or would we then have the next opportunity to look at this . I mean that this is, and of course an Important Program but a very small part of the over all budget. And it often does not come. But as a topic, and certainly, as a potential, center of excellence, and for our community, it is a very important topic. And so, what would you suggest . At the minimum on the annual basis, i think that we should bring this forward, between now and in a year from now, if there is something important as an example we can come up with some projected Business Plan, with uc, to think about for next years budget. Yes. That not the one coming but the one after. I think that will be a very important time for us to come forward and so i would say, probably you know, december of next, and less than nine months so that we can have a little time to figure out how, the next and it might be within the presentation of the coming budget, next year. That this could be also, called out to say that this is where we are at this point. I think that it will be fair. Okay. Was there any public. I have not received any Public Comment requests for this item. I dont know, and sthurly. I was just going to say if the commissioners had questions. It is sort of along the lines of what the commissioner, singer talked about. One of the questions is how do you incentivize, providers to do this work and to provide more care, where do you get them since you have a lack of prohe vieders, how do you get them coming in . Obviously there is a need. How do you ensentivize them to do that snchlt that is a complicated question. So, one of the surgeons that we work with is actively training people, he is actively training other surgeons, because the needs is so great and that is a big piece of what we need, is that we need the people who recognize the need, and want to specialize in this. It is a very small number of, i can count the surgeons that do the faloplasty on one hand in this country. It is a very small number of providers. And we are really lucky that we have one of them. There needs to be training in medical schools. I think that it is a complicated question because it is not only incentivizing providers and surgeons, to be interested in this field, but, to be interested in this field in the public sector, we have found is really, something that is i think there is, and i think that the people are out there and i think that they want to do this. And it is fascinating work, and the people want to be, on the cutting edge of it. I think that is saying, this is great work, and we want to you do it in this highly diverse, setting in a setting where the people have many challenges. This is, this is, where we are really in the cheerleading mode. And saying, you know, i cant think of anything that i would rather do. But, how do i express that to colleagues . How do i express that to others . So, it is, and it really is, and it is explaining as i do when i am talking to primary care providers, this type of work is the most fun that i have all in my week. I do a lot of fun things. Some people dont necessarily look at it that way. But this is something that is truly fulfilling and sas identifying, and though this is going to, really, be something that is fulfilling. And that is, the message that we have got to get out there and to be aible to recruit and retain the new staff who need to be here to do that. Thank you. I would also love to add that with every year that goes by, with, the enhanced visibility and love, that we provide, to the Younger Generation of transyouth, that they have an opportunity to grow up and access resources that generations before them, just did not think that they could ever access. Because of such stigma and discrimination and as we support the next generation of transyouth, i can already share that there are a number of my peers that are going into medical school for the purpose of being the next primary care provider or to be the next surgeon who will take care of their community. And so it is a wonderful thing to witness. And i think that, i dont think that it is unreasonable to suggest in the next decade to the next generation, we will see the transyouth of today becoming the providers of tomorrow. Thank you. So thank the presenters for bringing forecast the work that you are all doing. We are pleased with where you are going. I think that you have heard of where the commission and the department is interested in the future with you all. And we will look forward to that report. So, if there are no further questions, we move on, with our request for presenters. Thank you. Item 8, is the zuckerberg San Francisco, general rebuild up date. Building, 25. That is the new building. So are you following a different set . We had updated the, okay. The first, slide, to, and there was a typo and so we corrected that. And but i am not sure why they are not showing up. I am happy to go ahead and you all have the document . Yeah. And i think just for the billing and there it goes. It is broken down by going from top to bottom, and we hit those. In order to launch the survey on february 22nd, and we have the deliverables for operating safe, patient care and those, facility construction, related issues are going to take us out into about, may 15th. And may, 13th. And to make this in the processing is the right size and it it is installing all of the appropriate, way of signage and so there is a list of about 45 items and we are working through those. And the next chunk of the 5 lines, relate to it tracks. And all of those are on, on track, except for slightly over on to facilities. And that is related to our real time location services. And our arrow scout, implementation. And i have been assured by bill kim that we will makeup lost time, and be fine with that. Implementation. Let me go back one second to orient those who are not in the j. Cc and because i know that the commissioner singer chow and sanchez are familiar with this document. The gray bottom line, is our base line and our green line is current status. And so, we it is at a glance you should feel really good that we are, we are on time, and on target, for a may, 21 move in. The next item is hr staffing. And we added 119 positions to building, 25, operations and those have been hired for. And the work flow design and validation is, and it is on track, the Workplace Organization on track, and i am going to say more, in a moment, about orientation training, licensing and our patient moves. So, our more detail around the elements that keep us on track for a may, 21 move in, includes the board of pharmacy survey, which we had last week. And we had a successful, board of pharmacy, survey. The licensing validation is going to, and we requested for the week of may, second, and we anticipate, our california, department of Public Health, license to be issued, by may 6th. And several weeks before our move in and our actual, patient move, and some of the activities related to that include, the move orientation. And where all of our staff, who are part of that, particularly leadership capacities, gathering on march 30th. And we will have a mock move simulation on april, 9th to test out our flows. And to test out elements like, when we take a patient over, and in a bed, and the move date is may, 21 and we are going to participate in the activities around the census reduction and so making sure that any patient that is lower, level that we can find appropriate placement for them. And any elective surgeries that will be, anticipated to stay after surgery, we would not schedule those, and those are referred to as a come and stay, and any type of an he cannive or a schedule, and i should say a schedule csection or a schedule labor, induction and we will not schedule those during the time and so those are the activities during the census reduction week. Tomorrow is going to be our first full day in the life activity and this is where the department interact with each other, to similar you late a patient experience. And so a patient, coming into the emergency department, needing to go to the operating room, and then, being taken to critical care. And so those are the flows that we are going to practice tomorrow. And then, again on april, 20th. And so we did a lot of preparation to have as the successful of a licensing sur fa that we had, and we did a truncated day in the life in early, february and then we, did have a mock, survey, where our consultants and fdi, acted just as if they were cdph, survey ors and prepared us for, the actual licensing week of february, 22nd. And you all heard this already. I am just going to briefly say that, we had two findings, one was the failure of not having the board of pharmacy come out and that has been taken care of. And we anticipate, our license from the board of pharmacy, by march 28th. And then this issue of having, 30 days of water, quality control, data for our dialysis, machine. And we anticipate that being taken care of by the end of april. So, that is the current state of our new acute care and trauma center. I am super excited that we are on track and i am happy to field any questions. Mark is here to go over the construction budget, really . This is complexity on complexity on complexity and so congratulations. It was just commenting that we dont clap very much at Health Commissioners and i wanted to clap for the last presentation, thank you. Thank you. And i mid ask, why, you need 216, infusion, pumps dont we already have them. So this was actually, interesting, and i should say more about this. There were two items that the Pharmacist Survey ors from the California Department of Public Health observed, in addition to the lack of a stocked medication, because we didnt have the pharmacy, license yet. And we cant have the crash carts in two places taking care of the population and so we have to double up and so that was a good catch that she shed the light on and the second issue is that we have the different types of pumps in building, 25 than we currently have and they operate on a wireless system and so, she is requiring us to have those installed, and tested, and ready and waiting for the patients and so that, again was a really good, catch and we are working on that. We have the pumps and we need to install them. Is that what it is. So we are getting nem from baxteare, and that has been a miracle that they are delivering them and we are going to have them, soon. And that is going to allow us time for implementation and then testing because they are on the wireless platform. Thank you. You want to proceed, with the you are going to do the. No i want mark to come up. Right here. So the budget is pretty straight forward and there are about, 24 Million Dollars that are still being held back and mostly payments for the general contractor. But we really then, have been very lucky to hold this program, so precisely to the budget, and i think that that is just the tribute to the terri, and the ron and the everyone on the team that really have focus on this program. Andp there were four where we planned on five and we cut that back and so any of the savings that come from the reduction of the sale, will be put back into the program, there is also about, 12 million, and 12. 2, million in interest, earnings that we have to go to the board. And to apply against the project. And any questions . Mark it would be good to talk about the final process that we are going to for the closure. Of all of it, and for you the contractor. And what happened. There is a final negotiation. Ofttimes, on some of the larger and particularly on the larger projects, you get into, the situation where the subcontractors usually that are under the general contractor, see this as the last chance to sort of ask for money, whether they deserve it or not, or if there is a merit around it, this happens on just about every project, and dr. Chow remembered the soar project and we had a similar situation, where the subcontractor because the building was occupied, and thought that they were owed more money than we thought. And so we kind of go through that negotiation. And barber is right, we still need to go through that. And we anticipate, that probably there will be, some subs asking for additional money. That most of the larger projects tend to do that and we tend to go through that process, over the next two or three months. Probably one or two more just to close this out. I think that probably close to the opening. Of the move and so that we can give you an up date on how well we are doing. And i think that probably, we have to go to may. I would probably say that we might want to do the first week and the second week of may. And to be able to really get crisp in terms of where we are. And then the post review. And as we did with laguna and we looked at the beginning and the post process of what happened, as the move happens and how well we are settling into the new building. Yeah. And any, and i think that it would be good that we were able to say with confidence that as this shows that we are not only, well within the budget, we are delivering the essentially, what was promised. Absolutely. Thank you. Further questions from the commission on the presentation . Was there any Public Comment . I have not received the requests for that item. Okay. So, if not, then we can go on to the next item. The next item is the 2016, Public Health and safety bond up date and i am locating it. Mark is going to present also. All right. Thank you. So, this is the report that was done earlier on march first, to the budget and finance committee. And that would be appropriate to bring it to the full commission. Keep in mind, that over the last two years, bar bra, and greg and i have seen the scope and the budget v this thing, change five different times starting out in 2014, at 535 million. And covering about, 7 buildings, and some additional buildings on campus, and then getting cut back by 100 million, and going all the way down to zero. And we were told that we were not going to get anything. And then, becoming the bond that it is today, and at 350 Million Dollars, shared. Between the Fire Department and hsa. And with the budgets that you see here, and the 222, and that barber mentioned earlier for building, five and existing hospital and the 50 million for the clinics and that split, between the south east, for 30 million and then 20, for a number of clinics from the system. And then, you will see the 58, for the fire. And 20 for the hsa. These are some of the things that we will be able to achieve with the money that we are going to be doing the selective seismic improvements and the hospital and consolidating some of the urgent care severings out of the building, 8090, and increasing the dialysis from 13, and the chairs and relocating out of the building 100 and moving the public, lab that is above us, and out of this building. And to the building five and so it is a safer building. And also, a lot of the improvements that we will be making on the seismic side meet the requirements for the ucsf, region policy. Here is our schedule which is aggressive and we took advantage of something ha we started back in 2008 was to get the prebond, fund and then when that first sale will happen, those proceeds will then pay for the money that were up front and so we have got about 12 Million Dollars. And we have been working on a lot of the design and programming now. And that is why we are able to get in the construction and the seismic work so quickly. And 2017. I talked to logan about the Health Centers and the south east and it will be, and doing two things, there. And one renovating the existing facility and the patient, flow, and making it work well, and better, and locations, and more privacy, and also, it will be adding, to the south, and on the city property, a new approximately, 20,000, square foot facility to bring in the Mental Health Service Component which is something that the director garcia has been focused on, mirroring the primary care, and the Substance Abuse, and the k dentistry and etc. Here is just a map of the ten basic clinics throughout the city. And then, here and here is their schedule, and a little bit later, starting, and then, ending, wrapping up, between 2019, and 2020. This is just for your information, and this is the fire component, and the ambulance, appointment, and which is the 44 million, and there is some fistations throughout the city, and the Homeless Service sites to get 20 million to do into the bond. And then here their schedule and so the next steps, we have been through the Bond Committee that prepares what the voters get, and the february, 29th. We are going through the ballot arguments right now, and so the mayor will be doing them and several commissioners will be doing them, and the fire chief, and they will be happening between the 17th, through the 22nd and we have got one, official endorsement and so far from the San Francisco chamber board, and directors voted to approve the bond. And on saturday, director garcia and i in the campaign, staff went through harvey, mill, and alex, and the Central Democratic Committee and that will be happening every saturday between now and the end of may. And we only have 84 days between now and june 7th. And so there is a lot to do. Out there, and on the campaign trail. Questions . All right. Questions . On the bond issues . I guess that part of the question, might be that in different areas or different organizations, or even, different communities, we are not even going to say too much except for the south east it sounds like. What could we say about the Health Centers . Because they do carry, you know, ai fairly good geographic area, and so some of them are within, certain districts like either, so is there any idea, that or what, what are we going to be able to help inform the public . I would think that one of the things that told the extremely high was both the seismic and they did the polling and as well as, doing improvements city wide through the clinics. And when we originally started the bond, program, we did not have that component and so i think that having this component, into the bond is actually going to help us, and i think that some of the things that we will probably do, is we will probably suppliment the castro, Mission Project and we have had the Additional Fund money to do that project right. And to look at the second floor, and to make sure that we are doing sort of the whole, family at risk, individuals, and family, and being able to treat them with that integrated care, that the director garcia wants and also we will revisit, the maxine hall and suppliment that project and probably look, possibly to the west side or even into the china town, at those clinics and we are actually studying that right now, we had a meeting last week, to look at all of those ten clinics to see where the money and the funding would make best sense. Yeah, because it would be nice to be able to, inform people that you know, lets just say that china town, we are going to do seismic here and over there. And not that, you could do it for, everybody, and some of the clinics already have had their up grades as you have pointed out. Correct. And it would be nice to be aible to then, bring it back down to the people, if we are able to get some of the further information. Without getting real specific. But, saying that this is our intent and it goes out to, 2021, any way. But, that these will be, you know, it is like the library ponds, right . Exactly. One of the constraints that we had, commissioner chow is that we could not, because of the 20 million was added so late in the process, like 2 weeks before we went to the board on february, 23rd. And in order to put projects on the ballot, with he have to have clearance and the clearance from the city planning and we were able to do that on building five and 8090. And south east. Because we started so early, and when they added the 20 million for the clinics, program wide, we could not mention, specifics. Otherwise we could not put them into the bond and so, that would now be a con trant that we had. Thank you. Questions . Dr. Chow, we have done a lot of, and we have done a lot of planning around our capital needs, for our clinics. And so, we have a list who we have already been working on many of those. So, we can prioritize, the clinics pretty well in terms of what clinic comes up next and what kind of areas. So we cant do that directly but yet, but we will. Thank you. Commissioner pating . First i have no comments on the safety bond, very much in support of the initiative. And just very happy that we have this leeway in our, and i g he is in our over all that we can propose a bond like this. And so thank you, for forwarding this. My question is actually to director garcia. Assuming on are if this bond were to pass, and there would be money to improve the clinics, would there be the opportunity for the commission to review the plans. For improvements for the clinics and are those already have been i guess preestablished or preread in. There is no magic to it, it is just the process of what we have done before and with we are going. And so, examples could be elevators. And to familiar that they are counseling rooms and the flow is different now in terms of looking at tbased services. And so those are the things that the primary care also is prioritizing and so we go from, the way to redo it, and that the user of the facility, really helps to drive the direction that we are going and the improvements that improve the patient, satisfaction and over all wellness and welcoming of our clinics. And our primary care providers have all of that in the process, and so we have to think about and help to transform to the clinics for sure. We will add an extra zero to that. I wish that i could. We dont have the machines in the back there. But, also. Keep in mind that you were in the ten year capitol plan, we are also back in six years, and in 2022. And with an additional amount, for the clinics, and so there is another, bite out of the apple. Down the road a little bit. And that is how we have done most of our clinic operations, prior to bonds, it is really, trying to look at incremental support. For our clinics in terms of all of those things that you have talked about that will make us competitive in the future. But, it is just a limited amount and so we have to prioritize, the sieismic safety and move frm there. I think that we did heard that you said that there is the issue of safety and flow that will be one of the priorities for clinic, upgrading. Is that right . Yes. Is there any Public Comment . I have not received any requests for Public Comment for this item. Okay. If not, then, thank you for the presentation. Thank you. And we will look forward to more information. We will move on to other business. Item ten. Commission . There would be the opportunity to bring up other topics. And again, probably noting that we are going to have our Planning Session the second meeting of april. Yes. So. 2 to 6 00 p. M. And all of you have given that okay for your calendar. Right. Thank you. Does anyone wish to add anything to other business right now . If not, with he will move on to the next sit em. 11, is a joint, conference, committee report, back and we are looking at the march, 2016, lhh jcc meeting. Reporting on the joint commission, i think that the conference committee, we discussed the report, and the health at home report, and a very important review of the general acute care hospital, licensing survey, up date and regarding that item, i would like to say that we were very satisfied that the staff, appears quite ready for the general election and the survey which is coming on up and it should be in the next three months and anticipating the survey and they have been running the mock surveys already. And assured me that they feel prepared. We also looked at hospital wide policies, and some standardized protocols for the assessment and the management of the acute patients. And the privileges. And so that is what we covered and then there was a closed session afterwards. Okay. Anyone want to add further comments to it . Or ask the questions . If not, we can proceed to the next item. Item 12 is the community, setting and you have already gone over that. And but, we are happy to hear more. Right, and i think that we added more today. And so, great. Great. So you are there there for the adjournment. We are prepared for adjournment and the motion is in order. Motion, and yeah. And the motion and second have left hand heard, all in favor, please say aye. All opposed. This meeting is now adjourned. Thank you. The office of controllers Whistle Blower Program is how City Employees and recipient sound the alarm an fraud address wait in City Government charitable complaints results in investigation that improves the efficiency of City Government that. 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And anticipate that also known as will be here in a mom the citys dhs and representing his office as well as the Planning Department and Planning Commission and well be joined joined by joe duffy