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tv   BOS Budget and Appropriations Committee  SFGTV  June 16, 2021 10:00pm-12:01am PDT

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>> chair haney: this is the june 16, 2021 meeting of the budget and appropriations meeting. madam clerk, do you have any announcements? >> clerk: yes, mr. chair. members of the committee will participate via video
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conference to the same extent as if they were personally present. each perwill be allowed two minutes to speak. comments or opportunity to speak during public comment comment are available by calling 415-655-0001, meeting i.d. 146-144-3843, then press pound twice. when connected, you will hear the meeting discussions but muted and in listening mode only. when you hear your item call, press star, three. best practices are to call from a quiet location and speak
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slowly and clearly. if you submit public comment via e-mail, it will be forwarded to the supervisors and will be included as part of the official file. written comments may be sent via u.s. postal service to 1 dr. carlton b. goodlett place, room 204, san francisco, california, 94102. i will now ask our interpreters to provide this announcement in their respective languages, starting with our spanish interpreter, followed by our cantonese interpreter, followed
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[speaking spanish language]
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>> clerk: thank you, mr. chair. this concludes our announcements. >> chair haney: thank you. can you please call items 1 and 2 together. >> clerk: budget and appropriation ordinance appropriating all estimated receipts and all estimated expenditures for departments of the city and county as of june 1, 2021 for the fiscal years ending june 30, 2020 and june
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30, 2023. item 2, annual salary ordinance enumerating positions in the annual budget and appropriation ordinance for the fiscal years ending june 30, 2022 and june 30, 2023. >> chair haney: first up is the department of public health, and i apologize. i have a fire drill -- not an actual fire, don't worry, so we're going to start with the department of public health. welcome. >> good morning, chair haney and other committee members. grant colfax, department of public health. we've been requested to limit
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our presentation of the ask to the budget and appropriations committee. so this is our $2.8 million budget and represented in key areas across the department. as you can see here, largest expenditures are with zuckerberg general hospital and laguna honda hospital, largest skilled nursing facility in the country. in all, this supports 7300 staff member full time equivalents. next slide, please. one of our key investments as a focus in the department is to capitalize on our racial equity
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action plan. this work is led by dr. ayanna bennett. the racial equity action plan was developed across the department and in close collaboration with the human rights division. you can see this will catalyze the reimplementation across the department with many -- much work being done from policy and program development to providing extensive antiracism, racial equity, and implicit bias for all staff. this slide shows the request for investment of nonlaw enforcement security. this is led by our director of
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nonlaw enforcement security who has held meetings over many months with the sheriff's staff and d.p.h. department. this will better align the department with the better security across the field and includes staffing at behavioral health emergency response teams as well as maintaining sheriffs deputies presence in some specific settings. next slide, please. certainly, behavioral health remains a priority for the city and then the department, and as we continue to transform our behavioral health system under the leadership of our new behavioral health director, we will implement mental health s.f. and proposition c as you can see here in these line items. i'm very delighted to say that
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all key components of mental health s.f. will be funded under this budget, and we are clearly focused on overdose prevention efforts. we can go into additional detail than what is shown on this slide in overdose prevention. there are a number of initiatives that are already started, including our drug sobering center and our behavioral health pharmacy that are not shown on this slide. next slide, please. and then, despite our lifting -- the state lifting of the tiered colored system yesterday, an exciting day for the state and california. the covid pandemic is very much with us, and we need to continue to sustain investment in response and recovery from covid-19. we have thousands of san franciscans who are eligible for vaccine now who still need
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to get a vaccine, so we are continuing to invest in our disease response, our testing, vaccination, and showing that our largest item on this slide is our community recovery and engagement, which we know is so important as we continue to ensure that our community can stay as healthy as possible as we go into this next phase of our pandemic response. so that completes my presentation. thank you very much, and again, the executive team is here to answer detailed questions, and i hope that the board members are satisfied that we maintained within five minutes. thank you. >> chair haney: thank you. i appreciate you sticking to the time frame there. i'm sure there will be lots of questions. supervisor ronen? >> supervisor ronen: thank you so much, chair haney, and
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director colfax. that was an impressive sticking to the five minutes. i have a question about the behavioral health budget, of course, and the implementation of behavioral health s.f. so i see that the total amount for this, and i'm wondering, so are those beds -- that was for a total of 343 new beds.
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so those are broken-down to the two fiscal years. could you elaborate which beds you plan to acquire in this coming fiscal year and then the 22-23 fiscal year? >> yeah. i think i'm going to have chief financial officer jennie louie provide this information and you've got some additional staff -- and i've got some additional staff for the information here. >> in this upcoming budget, we've got 11.4 million supported crisis diversion, additional supportive care
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beds, and as the members know, we are moving forward with drug sobering, trying to procure additional beds for subacute and psychiatric beds. we are still looking to increase our bed capacity for the treatment beds that we're seeking, and i will defer to mr. wagner who i think has been working a lot in terms of the site acquisition, which i think goes to your question. >> supervisor ronen: yeah. if you could break it down one more time, jennie, just how many in fiscal year 21-22 combined and how many in 22-23? >> so in the prior year budget, we assumed operating costs for about 147 beds, and in this new operating budget, it's about 196 additional beds that we have, and we're in the process
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of looking for operating costs -- or looking for facilities so we can increase the capacity. >> so how many beds were you able to acquire in fiscal year 20-21? >> i don't have that number right now, but let me see if i can find it. i know we have started some, including the drug sobering center, but i don't have the exact number of what has come on-line. >> and supervisor, we can certainly provide that for you, but we'll send you the sheet with it. there are a couple of phases, as we discussed in previous hearings. as we're acquiring those large
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sites, and because of the nature of those transactions, they take time, we are also moving forward with buying beds on a contracted basis from existing sites in the short-term, so there's the short-term, where we've contracted for beds at existing facilities for boarding care. we have processed another site that's a residential-type site that's a pilot program for a new model of care for 20 beds. we are procuring locked beds, so we are bringing beds on-line now in these temporary sites, and we'll get you the exact number of how many that is, and then, as we acquire these sites, we'll begin to transition those into permanent on going sites.
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>> supervisor ronen: okay. i can't believe that you don't have it now, but if you would get to me by the next hearing what type of beds -- because i know we funded quite a few beds, and i know how difficult it is to acquire these beds. no fault, but i want to know what we've been able to, in the last year, acquire, so we can start to look at what we're budgeting and what we're able to pull off in a year and, of course, anything that we can do on the board to help facilitate and hasten the process, you know, we're all ready and willing to do anything we can, but it is helpful over time to see sort of what we're budgeting and what we're able to acquire, and any information
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available would be welcome. thank you. >> we're just scrambling to find the length of that for you. >> supervisor ronen: thank you. and then, the cost -- the mayor added [inaudible] for 17 in total in this upcoming budget here, and i just wanted to confirm that that will cover the priority that was designed in total for the city. so in other words, will the seven teams cover the complete needs 24 hours a day seven days a week? is seven sufficient to cover that? >> thank you, supervisor. i'm going to turn to dr.
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cummins to answer that question. [inaudible] >> we believe that that -- sorry for the feedback -- extra team will indeed be able to cover the projected calls and in the priority areas, and obviously, we are monitoring very, very closely to be sure as we implement and as we perhaps create more demand, that that will continue to be the case. >> supervisor ronen: okay. and we currently have four or five teams up and running? >> i believe it is four, and i will confirm with my team. >> supervisor ronen: okay. and so the design is to have those seven teams up and running by when? >> i believe, i will also just
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confirm by the end of the summer. >> okay. and -- and then, when all seven teams are up and running, can you remind me the number of calls that will be -- 911 calls that will be diverted to this team? is it 10,700 or 17,000? i just wanted to confirm. >> i believe it was 10,000, and i will confirm. >> supervisor ronen: okay. so around 10,000, and you will confirm. great. and then for the mental health service center, there was money in the budget to increase the behavioral health access center, but i'm wondering what the plan is to plan for the
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full opening of the mental health s.f. service center? i know that's sort of last in line in terms of the implementation of mental health s.f., but i'd like to know in the upcoming fiscal year, what's the process for deciding exactly what the mental health s.f. service will look like, what gaps in services it will serve, and how steele operate? >> so dr. hammer i think is in the best position to answer these questions. dr. cummins has been on the job just a couple of weeks now. we'll have to tag team, and i apologize. it's harder to do that here than in other settings. >> and thank you for your inquiries, everyone. so two things.
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i want to just confirm the 10,000 calls. the teams will be up and running this summer, and i misspoke about the seventh team. i will have to get back to you, but we will have it up and running by the end of the summer, which is fantastic. since we're talking about the mental health service center planning, i wanted to share with you we have a robust planning structure and implementation structure happening in the department of health. there is a strong execute governance team as well as subject matter implementation groups, so those groups are
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engaged in the matters you just describe, supervisor ronen, to figure out the design and timeline in this coming fiscal year as we first expand hours, which is very exciting, and then, we need to tackle the issues that you just described, but i want to assure you that the structure both due to the design and operationalization is in place. >> supervisor ronen: and how will the working group be involved in impacting that design? >> absolutely. i think we have a model for the work so far with the street crisis response teams. we present works in progress, bring questions around implementation and ask that group for recommendations. i know that we are still developing because the group -- we are all new, and the group is new, to figure out how best
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to structure both their involvement and getting timely feedback and then being able to act on their input. >> supervisor ronen: okay. and so the budgeted expansion of hours for the bhac is -- it will operate seven days from 9:00 a.m. to 7:00 p.m. is that correct? >> yes. >> supervisor ronen: okay. my understanding, and this was from greg wagner, so i know he's on the call, and greg, correct me if i am wrong, but was that the bhac was determined not to be the ideal physical building for the mental health s.f. service center because we don't own it and we couldn't make the sort of physical changes to the building that we would want to if we did own it?
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so are we still potentially looking for a new site so that we can adapt to the program site or vice versa or is that still on the table. >> greg, can you address the supervisor's questions, then? >> yes, supervisors. that's correct. so as you just discussed with dr. kahn, the program design comes first. we are moving forward with what we can on bhac, and that will be improve with access. we also -- all the services
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involved with the health service center that are envisioned would work as we had originally anticipated at 1380 howard, so i think it is going to be likely we are going to be acquiring an alternative site. i think there is -- and this is up for discussion -- conversation about how do you leverage multiple sites where you have a main access site, but then, we could leverage the pharmacy at 1380 howard, we could leverage some of the services there. that is still thinking in progress, but essentially, we've kind of moved into that more nuanced view of how that is going to work. >> supervisor ronen: okay. and so my understanding is as s.f. mental health service center is in design, the -- do
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we anticipate in 2021-22, we'll be able to complete the design and start funding in 22-23? i know you don't have a detailed map under development, but sort of big picture, what are you thinking here? >> i can take that. i think that timeline makes sense, that the design should be completed with -- with input and with collaboration with the implementation working group to have a clear inclementation plan for the following here. i think also -- implementation
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plan for the following year. i think also, as we move along, we will know what is needed for design for the other work we're doing. >> supervisor ronen: okay. so i don't see that here, but that site acquisition is not in this current budget, is that correct? >> supervisors, so in the current budget, we have, in addition to the on going prop c funds, we are requesting appropriation of the one-time dollars from prior year collections of prop c, and then, we have the prop a g.o.
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bond. so those provides funding that will be the source for our acquisition program, and so a lot of that is going to be identifying the needs for new beds, and as we identify locations, we would incorporate that into our acquisition strategy. i think with the budget that we've proposed, we have the ability to move forward with a healthy site acquisition program. >> supervisor ronen: all right. so i am looking at the budget, thank you. i had asked [inaudible] in advance for the mental health and behavioral health budget,
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and it's not in this budget, correct? and greg, i don't know if you know what i'm talking about. >> if it's what i think you're holding up, i believe it's toward the bottom. >> through the chair, jennie lui. i believe the one-time acquisition line item is under the bed, so those are the one-time dollars that we have, 7.7, and we're proposing another 76 in the first year of the budget, and 45 in the second year for additional new facilities. >> supervisor ronen: so it's not necessarily programs, but unlike the drug sobering acute block, there's not a line for s.f. mental health service center, but it's going to come
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from those acquisition dollars. okay. thank you. and then, the -- excuse me? >> and that would go for the appropriated budget for mental health care. >> supervisor ronen: could you tell me how many case managers in the three tiers of case management, how many in each category you expect to expand
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with the money budgeted here for the next fiscal year? so it's 8.1 million in this fiscal year and 8.7 million in fiscal year 22-23? and jennie and grant, do you have it now, and if not, can you get that by the next hearing? >> yeah, we can get that information for you. i think it's both civil and contracted cases. i think we [inaudible]. >> supervisor ronen: okay. that would be helpful, by the next hearing, so thank you so much. and then, i just wanted to see...if i had anymore questions here.
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you know what? if i do, i'll come back to me, but i know that a lot of my colleagues have questions, so thank you so much. >> chair haney: supervisor walton? supervisor walton? i will go to supervisor mar. >> president walton: sorry about that, chair haney. >> chair haney: no problem. >> >> president walton: and thank you for the presentation, dr. colfax, and addressing some of my questions. i just want to know about the racial equity improvement plan, and how are you bringing in more employees of color, particularly in higher leadership positions? is.
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>> -- positions? >> yeah. i think that's one of the key elements of the racial equity action plan, and i'm going to have mr. wagner respond to -- dr. bennett respond to that, and mr. wagner may have some information on that. >> i'm sorry, supervisor walton. i'm having a problem with connection on my phone, and i don't want to sign back onto address your question, so could you repeat it? >> president walton: yes. i want to know what's being done specifically in line with the racial equity action plan and hiring employees of color, specifically in higher leadership positions? >> so we're looking at data and
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reports about the implementation of that, and by the end of that month, we should be using some of those techniques. we've used some of the them so far and have had good results with the pilots that we've implemented so far. >> president walton: and what plans do you have to address the vaccine hesitancy in certain communities of color? >> yeah. so there's -- one, we have different groups working with different communities of color. there's certain groups working with d.p.h., ucsf. we're working particularly with the black community. we've had a long-standing program that is really leaning hard on our latinx staff, so
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each area where we're seeing hesitancy in the numbers, and we're looking in the numbers to see where groups are falling apart both geographically and racially and responding accordingly. so there is a plan for each of those, and we can give you the details at another time. >> president walton: great. i'd love to see the details of that plan so that we can address the problems in our community. and then, how are you complying with the language access ordinance? >> we have pretty significant access to language access just as a medical provider that's increasingly being used.
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so the telephone contracting service that is the back up, and roughly about 2 million on the civil service contracting side and 2 million at the translation side. >> president walton: and that's an appropriate level? >> i believe so. we've expanded those programs over the last several years, so i do think we're meeting the need at this point. i do say that there's contractors and other providers that we always have to be diligent. when d.p.h. is providing service in other venues, that we have to keep up that standard, but that's going to be an on going monitor. >> president walton: and as a department, how many empty positions do you currently have? >> that's -- i'm going to have mr. wagner provide details on
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that, and if that's okay, supervisor. >> president walton: that is. >> so thank you, supervisor. our budgeted general fund supported positions, we have 251 vacancies that's net above salary savings. we currently have the $20 an hour temporarily employees that we have hire to cover some of those vacancies. as you know, from prior discussions, when we're awaiting hires, we fill some of those gaps in clinical staffing with short-term or temporary. a total of 264 f.t.e. covered by those temporary sources as we work through our hiring plan. so between those two, it's 251 p.c.s. vacancies, and we have
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264 temp staff employed on a temporary basis. >> president walton: thank you. and how many mental health beds do we have for children who are under 18? >> we may have to get that afterwards for you. i don't know that dr. cummins or mr. wagner has that right now. >> president walton: okay. if you could get that to me, i would appreciate that. and in terms of juvenile hall, how many staff do you have working inside the hall? >> again, we'll have to get that number for you as quickly
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as possible. i don't know that we have that number directly on our fingertips, but we will make sure you've got it. >> president walton: thank you. and my last question, right now, you are supporting community health programs in certain communities. are you going to make sure that those community health programs are continuing to be funded, like potrero hill and the bayview? >> so we won't anticipate any reduction in services, and yes, we will continue to support the community health efforts that you described. just answering the juvenile hall question you asked, we've got approximately 10 f.t.e.s there, but we'll get back to you with answers to your questions. >> president walton: great.
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thank you, chair haney, and thank you, dr. colfax. [please stand by]
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>> like an extension of the contract, and if you could speak a little bit about how much that is and what the scope and services would be in the expanded contract? >> yes, i appreciate that.
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dr. ababa is one of our leads on the program, and can speak to that. and if there are more financial details, our c.f.o., ms. louise, is available as well. >> yes. so operationally -- thank you for that, supervisor mar. operationally, we're expanded the program. and the program has about a dozen more ambassadors that will specifically look at violence prevention in the asian community, and will be at different quarters throughout san francisco. and that will likely be in throughout san francisco. coming year's budget. i don't have the numbers on hand. i don't know if you do, jenny. if you do -- otherwise we can get back to you. >> we have $1.4 million budgeted for the expansion
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of scid. >> for next year, $1.4 million for the extension. would that envision to be, like -- would that -- spid would contract with people in the asian communities? >> i think they would actually hire in, but, obviously, the recruitment would be very important, and also to talk to the community's organization to stand that pipeline. >> okay. thank you. thank you, chair haney. i don't have any other questions. >> chairman: member safai? >> i have a few questions in a few different areas. one i want to start with, and i understand what
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d.p.h. is trying to do. i'm fully supportive of the conversation around reforming our justice-related acton justice-related activities and those on the front lines. i have in regards from frontline workers in general, over the past year as this debate has raised, about whether or not sheriffs to be there to protect staff and to protect other patients. so i just want to have an opportunity to kind of talk about that on the record for a moment. i understand the plan is to reduce the d.p.h. sheriffs by 11.4 positions, and you're going to be reorganizationing some of reorgg some of the staff.
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will there continue to be staffing of the sheriffs at s.f. general? and how many will be there? the reason i asked that question is i've toured your emergency room, i'm toured your med psych room, and talking to the nurses and frontline workers there, and a lot of times they'll say it takes three or four staff to constrain one individual that might be having a psychotic episode or might be having other issues. and i've seen wounded staff members as a result of dealing with that. and i understand it is part of the job, but i wanted to give you an opportunity to talk about that because i think there is still a lot of anxiety and fear from frontline staff. >> thank you, supervisor, and having trained in the san francisco emergency room, i can assure you that safety for staff is paramount of my concern and the department's
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concern. there will continue to be sheriff's deputies in some areas of zuckerberg san francisco hospital. they have gone through an extensive process in talking to multiple take holders, including at zuckerberg emergency room. ensuring that concerns have been heard, and we're also bringing the department's approach to health care security in line with best practices in the field. i'm going to ask mr. price to provide more details in response to your question. >> thank you. dr. colfax. the existing staff in the emergency department remain at 24-hour coverage both in the emergency department and in addition
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with the 11.4 f.t.e.s that are reduced, there are still 4.6 deputies providing 24/7 coverage, to include vehicle coverage across the campus, as well as the supervision. we determined with the existing staff remaining in place in these high-risk areas, both the additional deputy service to provide support to them, the other component we've proposed is the psychiatric nurses, as well as technicians, that actually provide de-escalation support, mainly focus on de-escalating conditions. what happens is we're reacting to risk behavior, but we want staff that is trained to recognize
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behavioral behaviors, as well as environments that contribute to escalating behaviors. so that is the purpose of that intermediate support with regards to those psych nurses and staff, with, of course, support from the sheriff's departments in dangerous situations. >> right. so my question is: if this plan turns out to be not the most affective, is there flexibility to adjust as you move forward? >> there is a transition plan, where we'll actually have both the sheriff's departments and the behavioral response team in place that will give us that opportunity to actually study it, review it, and measure its success. additionally, the team has been a functioning pilot for about three years right now, and so it has been successful thus far. it has the ability to
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de-escalate patients, provide support for the clinical staff, as well as to reduce the number of incidents of crisis development, have proven its success, and so now here is our opportunity to actually expand that across the hospital 24/7 instead of the one shift, as it currently is. >> so for me, i'm all for looking at new initiatives. i know that we care deeply about reforming and keeping people safe and not having an environment that is as odds with creating a safe healing and welcoming environment. i understand all of those objectives. i think it would be important to have a real thoughtful check-in, have the opportunity for frontline staff to come and present their own experiences over the course of the next year. hopefully this will be the right outcome. i'm glad to see there will continue to be presence on campus to help assist
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behavioral health workers. and i think all of this is important. what will the staffing be in the emergency room and in the emergency psych room as it pertains to sheriff's departments? >> there are two 24/7 sheriff's departments. so there is a sheriff's deputy assigned in each shift in the emergency department. >> what is the current staffing? >> the current staffing is one per shift as well. >> just one? >> yes. >> in the immediate environment, how often -- do you know -- or how often are individuals called in to assist that one individual? how often are they requesting backup or assistance? >> well, based on the response and dispatch logs, there is probably on
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average four to five incidents per quarter in the psychiatric emergency services. which in all of those, it would require backup. and as i said, with the 24.6 additional f.t.e.s, there will be additional support to that deputy. >> thank you, dr. colfax. and mr. price. i just want to ensure that some time over the next year we have an opportunity have a check-in, in a public forum, to see how things have progressed to ensure that patients feel safe, workers feel safe, and workers have an opportunity to express any of their ideas. but i appreciate the opportunity to ask those questions. thank you. i wanted to talk about the overdose prevention methods that you have in the -- we have met with your team.
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we had asked for more detail. i don't think we have received that detail. but there is a proposal in here for street overdose response team for $5.4 million in the budget. dr. colfax, what will these individuals be doing? and what is the objective? i obviously know the number one objective is to reduce the overdoses that we're experiencing in the city, but is it simply to roam around the city with drug overdose prevention medicine and look for people who are about to experience overdose? what is the objective of this $5.4 million initiative? what would the scope of their work be? >> i want to emphasize how committed the department is to the pandemic of overdose deaths in san francisco. and preventing as many of those as possible going forward. i'm really pleased that dr. cunans has expertise in this area, and she is already putting some very
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significant changes into our system to better address this. so i'll let her talk about the details of this program. again, also, augmented by dr. hammers, as necessary. dr. cunans? >> thank you, dr. colfax, and supervisor safai. thank you for your question. so the context for this street overdose response team is that we know from the scientific literature is that people who experience one non-fatal overdose are at particular high risk for a subsequent, including fatal, overdose, as high as three or four times the risk, compared to people who haven't had a prior overdose. so what is happening nationally, and it is very exciting to see this now funded in san francisco, is really a targeted program to reach people, particularly those experiencing homelessness, following a non-fatal overdose. so by working together
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with the community paramedicine team, we will be able to reach and provide tailored treatments. in partnership with the street medicine team. that means that the person can be offered care and treatment and really linkage to ongoing treatment. >> dr. cunans, i'm sorry. just because we're on limited time, i don't want to interrupt you, but i'm trying to be succinct because we have a long day ahead of us. i guess what i'm trying to understand is, we have our wellness check teams, our crisis response teams, and now we have an overdose prevention team. what specifically are they going to be doing? what is this $5.4 million going to be spent on that is different from the wellness check team, that could come in, call in a
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paramedic, and refer someone to the emergency room? are they going to be carrying overdose medicine with them and administering medicine on the street? is that the main purpose of this initiative? >> so they will be carrying overdose prevention medicine, naloxone. they will be able to start people on medication, epanophene. and they will also be able to follow people assertively, if they do not immediately engage in affective treatment. >> when you say "follow people at assertively," what do you mean? >> continuing to reach out to them proactively, after that non-fatal overdose event. the team will continue to work with you and reach to you until you are in treatment or some other
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ongoing care. >> that same day, over the course of time -- so say i'm on the street, officer safai, you found me, i'm a candidate that is going to be overdose. you're staying with me until i get into treatment? >> yes. >> is that what you just said? >> yes. there will be an immediate response, a rapid response, at the time of the event. and then, i believe, within 48 to 72 hours, ongoing followup. >> and what are the gamut of options of programs that they're going to? >> so, really, any program that is available in the city, depending on the person's clinical situation and their interest. >> got it. so if someone said, i want to go to an abstinence-only program, would you refer them to that? >> absolutely. >> okay.
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great. thank you. last question, dr. colfax. our office is looking at food security, and we're -- food insecurity, and we're re-imagining how that is done in the city. i know that you and your staff have supported this over the course of time, but outside of the director of food security, it doesn't seem as though there is a tremendous amount of effort and energy put into this issue. and i'm hopeful that maybe we can take one final look before we finalize the budget, to have someone that then can support, maybe through some of the covid funding or some of the other additional funds that you have there, so that we might be able to look at how we can build out capacity in your food
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health division. so i just wanted to give you an opportunity to talk about food insecurity and the work that you're doing. >> yeah. i appreciate that. and certainly we have staff -- superb staff in the department who are focused on this issue. obviously food insecurity is a public health issue, and it relates to issues across other city departments. we would be very interested in exploring how to better coordinate our efforts with other departments, what staff needs are in terms of both analysis, strategic priorities, and then service provision. i think with covid-19, supervisors, as you pointed out, that highlighted the prevalence of food insecurity in relationship to the pandemic, and this is an opportunity to help us better coordinate within the departments. i will say we have a very large department. i have some incredible subject matter experts on
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food insecurity. we don't have the band width right now to expand those efforts as much as i think is potentially needed. and then i also think there is the question of the delivery of the food services, where does that live across the city departments -- >> we're definitely working with h.s.h. and economic and workforce development. >> yes. >> it is just a matter of you have this one-time extended covid funding. we thought it would potentially be an opportunity for us to do a little bit deeper work with your department and across departments. >> yes. i'm certainly happy to explore that. >> thank you. okay, thank you, mr. chair. i'm done. >> chairman: thank you, dr. colfax. >> thank you. >> chairman: thank you, supervisor safai. i have a few questions. you know, first, i do want to commend you all and thank you for your
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extraordinary work over the last year. you know, i just think, you know -- i know that we already have so many needs that are residents are facing as it relates to health and public health, and then for you all to do all of that and also respond in such a robust, coordinated, comprehensive way to this pandemic was extraordinary. and so i just really want to acknowledge that and thank you and all of your staff for your hard work and the way that you all went above and beyond and, i think, set the standard nationally and internationally for how to respond to the pandemic. i -- with that, i did want to get a bit more information about the ongoing covid response. i just checked, and we are, thankfully -- because
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we have such a high vaccination rate, we are at an average of 13 cases a day. and hospitalizations and deaths are way down, nearly flat entirely. and so i want to know a bit about the ongoing funding that is being requested for the covid response. i totally understand we have an ongoing covid response from a public health perspective, but there are some different aspects of it that i think would be helpful to better understand because these are very large dollar amounts. even putting aside the community recovery and the vaccines, what i see here is about $60 million for the covid response. $12.3 for the covid task force. $14 for the disease response unit. over $11 million for
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ongoing testing. can you describe a bit about the ongoing covid response? i understand the vaccine aspect of it, but i will suspect in the coming months we will be at such a high level of vaccinations that that continuing to spend over $60 million on our covid response that is not vaccine-related feels like a lot. considering the number of cases and considering some of the other urgent public health epidemics that we're facing that are taking so many lives now on a continuing basis, like the drug overdose crisis, which i think needs a lot more devotion of resources. >> so thank you, supervisor and chair for your kind words with regard to our response to the pandemic. i do want to just --
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yesterday was a great day, and we are in a good position right now with regard to covid-19. and i just want to emphasize that. i also want to emphasize that this situation could change very quickly. in fact, this morning i and a number of my colleagues were on a call with our infectious disease experts, and the delta variant is very concerning. while the delta variant is a variant that is much more infectious, it may be more serious in terms of the medical consequences. and we still have a number of people in san francisco who are not vaccinated, who are eligible. and then, of course, children under 12 are not eligible. as we move forward, these investments really ensure a coordinated response to address not only vaccines, but all of the other components that we know are needed to more robustly meet the needs of
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the community. i'm going to turn this over to dr. babba, who will provide a much more detailed answer to your questions. >> chair haney, part of the reason that we are having to spend this funding it is because we want to ensure that the gains that we have made are not lost, as dr. colfax mentioned. there are still ongoing threats, and we're seeing what is happening in the u.k. with the delta variant. so i think san francisco has been incredible in our response. we just don't want to lose that. and there are still a lot of pockets in the community and different sectors that have not been vaccinated. and remain, you know, susceptible to covid. so that means we need to have testing, isolation and quarantining, and contact tracing all moving forward. all of those programs have been scaled back considerably, and can get
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reenergized and scaled back as needed, but we're at the bare minimum to maintain this effort. and i'm happy to take any other questions. >> chairman: sure. i appreciate. there are 12 million for the task force. $11 million for testing. these are large, ongoing investments that are not directly related to the vaccination. is that -- i understand if something changed and we started to see a lot more cases or more hospitalizations. is a lot of that spending in preparation for that possibility? if we aren't seeing so many cases and we aren't seeing many
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hospitalizations, and we're seeing more vaccinations, and we're only increasing the vaccinations, what is really the role that these various sort of task forces that are not directly vaccine-related, what are they focused on if we aren't seeing that many cases or hospitalizations? >> so it is based on a set of assumptions that basically our case rates will stay at a certain level, which is considered about 400 to 100,000, that
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>> chairman: i really am yet to see anything that looks like a plan or
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strategy of the scale that is necessary to stop and strategy of the scale that certainly last year things were as bad as we've ever seen, and it looks like this year will be even worse. and i really want to understand how we as a city are responding in a way that we don't just assume it is going to be even worse next year. i know it is not entirely on you. there is a law enforcement aspect to this, there is a housing aspect of this. there is a whole other set of rules for various city departments. but at the same time, you know, the -- i appreciate the additional investments in the budget around this, but if you would compare it in any way in terms of scale, with what we are rightfully doing, and that i fully support on
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covid-19, i don't see the level of tracking and coordination and data and investments. and we have to be all hands on deck or this is just going to continue to spiral out of control. so i guess i'll give you an opportunity to sort of respond to that generally. some of the straight overdose response teams and such are welcomed, and i fully support. if somebody overdoses, we can't just bring them into the hospital or let them right back out with no intervention, on the streets. these folks need intervention. also, i'll note that most of the people who overdose in our city have an address. they are housed. and what we are doing in those environments, whether s.r.o., supportive housing, or just generally to prevent overdose, i want to also better understand. so i know we've just put a
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ton of energy, rightfully so, to stop fighting -- to stop covid-19, i think we now need to throw everything we have to stop this drug epidemic. so i would like to better understand how you all are thinking about that, and what we can do to be supportive of a response that matches the scale of the crisis that we're facing. >> well, thank you, chair haney. just to emphasize again, this is a priority of the department. we will continue to expand those efforts, both with regard to prevention, care, and treatment, and as i think you just heard dr. cunans say a more while ago, we're being more strategic on how we're focusing on people who are as highest risk for subsequent overdose. again, the level of morbidity and morality in the city to drugs,
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including methamphetamine and fentanyl, is unacceptable. i'm going to have dr. cunans provide more details and perhaps more specific additional data on additional programs we're funding specific to overdose work. dr. cunans? >> sorry. delayed unmuting. >> doctor: supervisor haney, i just want to concur with you absolutely that this is a crisis, and we need a whole of city approach to tackle the problem. i think, as you know, the problem got worse both because of fentanyl and because of covid. this is true nationally, and there was just recent c.d.c. or n.i.h. notification that there is
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a 30% increase in overdose nationally during the pandemic. i am really optimistic that we can turn this around, and that this year's coming investments, through m.h.s. and prop "c" really represent a big step forward. this is a targeted approach that will both reach with extra followup and street medicine for people experiencing homelessness, but we'll also work with people with housing. a number of the other initiatives, as you saw on the slide, that will also specifically target, as you point out, people living in single-room occupancy, as well as permanent supportive housing, with approaches that focus on risk reduction and connection to affective care. a number of the other initiatives, the drug
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sobering center as well as expanding access to treatment 24/7, methadone treatment expanded, assess to behavioral health services pharmacy, means we're looking for every possible way to make linkages and access to care easier and put information in the hands of people and tools of people to keep themselves safe. and you can see in front of you we pulled out both the initiatives that were listed in what dr. colfax showed earlier as part of the overdose plan, as well as the initiatives that are sort of bucketed with mental health s.f., drug sobering center and the expanded behavioral health pharmacy, particularly. i very much welcome the chance to do more here. i agree that we need to be
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creative, expansive, aggressive in working on this issue. as you know, i just recently arrived, and i have been coming up to speed quickly to find opportunities where we can do more and do more quickly. >> chairman: thank you. i appreciate that. and i'm trying to add up these various investments, and i think that they are important. and i fully support them. you know, i would say that, again, they probably all together don't even necessarily add up to the $24 million for operations sustainability that we've got with our ongoing covid response, which i support.
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but our response as it relates to overdose is not at the scale that i feel -- or the immediate scale that i think that we need right now, that i think we can confidently say that we are going to stop this skyrocketing of the death and devastation from this epidemic. i definitely appreciate the commitment to it. do we believe -- or in your opinion, based on these investments, will we see a reduction in overdoses over the next year? are we confident that this is going to -- that these investments and this approach that we have here are going to have an impact in the next year? i just -- the level of acceleration and increase of this epidemic has happened so fast over the last few years, and this years s
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year, that i feel we are more likely than not going to be here a year from now having a similar conversation. and at that point we're going to be on pace for 1200 people dying. i mean, what more -- are you confident that these interventions are going to work and are going to slow or stop or reverse the -- >> chair haney, one thing i think is important to emphasize here, and i'll let dr. cunans answer with regard to the further investments and with regard to the reductions that you're asking about. but i think these are new overdose interventions, that unlike the covid-19 response, these are on top of a substantial ongoing
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investment in substance abuse treatment across the city. not only are the new treatments getting out there, we're reconfiguring lowering barriers to people, and engaging people in-care has much as we can. so i just want to emphasize that there are literally tens of millions of dollars being invested in substance abuse treatment, in d.p.h., and with our partners. this represents newer interventions specifically around overdose prevention, but a lot of the overdose prevention work, a lot of the treatment work and the prevention work are reflected in our baseline budget, and i'll let dr. cunans answer your question more specifically. >> chairman: that's fair. >> doctor: thank you. and, supervisor haney, i just want to say i think you're asking exactly the right questions, which is: what is the impact we expect to see? obviously, one cannot predict with certainty.
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i believe these interventions, as well as some of the interventions during covid will slow or flatten the curve. that's the first step we expect sto see. to see.and i'll call out the ste overdose response team in particular as an immediate and followup intervention for people at highest risk of having a subsequent overdose. this kind of intervention is being used nationally. it is part of what we launched in new york city, where we also were experiencing a steep rise, 50% increase in overdose deaths due to fentanyl, and we were able to level the curve. i think what has happened in san francisco is that fentanyl and covid have been fairly
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coincidentally, when provided a sort of the double challenge, which i think we can meet. and. >> pam: of what we canand part e restricting of some of the covid restrictions will also help our overdose prevention efforts. as to the what else, i want to ensure you that that is exactly what i and the department are doing, is thinking about what else we can and should be doing as all of these initiatives are getting launched shortly. >> chairman: this will be a top priority for me. it is great to see these investments. i'm going to keep on saying this, that this is just -- you know, we cannot stand by or accept
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anything resembling business as usual when we're experiencing such devastation. and i appreciate the additional urgency that is reflected here, and i think we all agree that we need to do more. and i appreciate the attention to it. on that note, you know, i am hopeful that we are going to see a state bill passed that allows us to open a safe consumption site or overdose prevention site. it is my understanding if that did happen, we would have that authority beginning in january. we have passed local legislation with the mayor to create a permitting process for those sites. i was a little surprised to not see any funding for potentially opening those
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sites in your budget. if there is state legislation that is passed that gives us the authority to open these sites in january, how are we preparing and ensuring that we have the funding available to immediately be able to open an overdose prevention site as soon as we have that authority? >> so, chair haney, overdose prevention sites have been a key priority of the mayor and of the department for some time now. and we will use existing budget to implement an overdose prevention site as quickly as possible, if and when it becomes feasible from the state and federal level. we are well-prepared to do that. so i just want to emphasize that going forward. so we're watching that bill eagerly, and hopefully with the new federal administration, overdose prevention sites can get up and running.
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i think it is a key component to the response that we need. we know these are highly affective. they save lives and they do not increase drug use or have collateral damage to communities where they are placed. so a very important key piece. i wish we were able to do it sooner, but we're looking eagerly forward to seeing what is going to happen at the state level, as well as the federal level. >> chairman: i appreciate that. that is very good to hear. i really hope we are not in a position where we aren't ready, you know, when we do have this ability. i don't want us to be in a position from the bill passes, and we say, well, it is going to take us another six or eight or 10 months, because we have known about this for a long time. we should be preparing. and, you know, i'm hopeful that we can move quickly
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once we do have that authority. last question -- and thank you for that update and your commitment on that, dr. colfax. it is appreciated. the last question that i have, you know, supervisor ronen brought this up as well, we are creating all of this additional street response, which is really welcomed and necessary, but equally important to that is when somebody is brought inside, either to the hospital or to another temporary placement or even just dealing with folks on the street, that they immediately have a level of tracking coordination, case management, that is intensive enough to meet their needs. and then, of course, on the back end of that, you talk about the actual placement for them. i'm wondering about that sort of middle part, that
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sometimes is the least visible part of it. but as you know, equally important to any of those other parts of it. when a street crisis response team goes out and spends four ours, or an entire day, trying to get somebody inside, it is so important when they're sent to the hospital, or wherever they go, that we have an equally probe bust robut response. can you talk a little about the investments in the office of coordinated care? do we have enough folks who are a part of that? what are the barriers to expanding it more quickly. one of the street response crisis team told me it is there, but sometimes there isn't necessarily someone who is there immediately once they do provide a street intervention, and how are we really prioritizing that middle part of the response? there is the street
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response, the treatment on the other side, but that middle part of getting someone from there to there is so important. can you talk about that transitional part of it and how much we're investing in it and how we're going to expand it quickly? >> yes. i'm going to let dr. cunans talk about the operational component. and then in terms of the investments, ms. louise will be able to provide the information specifically or follow up. >> yes. and i think the middle part, which can be invisible, is very much on our mind, and that connections to care will be handled by, as you point out, the office of care coordination and specifically care coordination and transition management team. that work is already in place, as you know, with the street crisis response
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team, where we have, and we're hiring additional case managers to do the followup that you describe as a key to success. once there is initial interaction, there needs to be followup and connection to ongoing care. the office of coordinated care is funded at $10 million annually at present. i think as director col fox alluded, we are very excited that all assets have been funded and will begin to be implemented this year, but i believe you raise an important point, which is: are the programs, as designed and funded, will they exactly meet need? i think as we implement, we will be asking ourselves, and you will, too, that question and we need to continue to assess
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to understand that the resources and program designs meet need as the other programs around it are being implemented. >> chairman: great. and then on the budget front, is that number an increase? you know, how much further do we need to get in terms of fully funding it? in terms of the office coordinating care. >> i'm going to defer to jenny louie here. >> that plan is basically the investment that we made in the prior year, and we're continuing to stand up that program in terms of service-level need. as dr. cunans said, i think we'll have to evaluate as we implement and determine whether or not we've had sufficient funding for the programs and the needs that we see.
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>> chairman: okay. because we are increasing a lot more of the street response in various ways, with all these different street criteria, and that is welcomed. but then it doesn't seem we're necessarily increasing the office of coordinated care in a commensurate way. and so i just worry that, you know, obviously the street crisis response team is really important, it is much more visible, but for all of the work they do out there on the street, if there is not the follow-through, we're not actually creating a system that works. i appreciate that. i'm done with my questions. thank you for those answers; i appreciate it. supervisor safai? >> thank you, mr. chair. sorry, one more question that i wanted to talk about, and dr. colfax and i have spent a number of months talking about our
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local emergency response coordinating and response oversight with regard to paramedics and emergency services. i really appreciate the response and the crisis response team, the wellness team, and the investments in getting more paramedics in a very specified way, but there is still a significant shortage when it comes to paramedics in general. and the call center, the station that houses a lot of the paramedics, station 49, and even some of the private operators -- i think we're still down by 15 to 20 paramedics. calls are still backing up. and i know, again, similar to my question about covid recovery money, there is the ability to see a way if we can use some of this one-time funding to increase the number of paramedics that are
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responding to regular calls. and i just wanted to give you the opportunity to talk about that because we get calls consistently when the backlog starts to back up and our emergency response is impacted and the calls for service are impacted. >> supervisor, i appreciate the question. in terms of paramedics, i would really feed to defer to fire in terms of the paramedic staffing. we are transferring the ones that -- the ones that will be transferred to d.e.m-- >> -- >> i can't really speculate on the paramedic staffing -- >> i understand that. and we worked together on
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that, but in the interim, there is still a lot of money coming into your department that has flexibility, with regard to covid recovery. and this would not be, in terms of the hundreds of millions of dollars that are coming in in some of the areas that might not be fully utilized over the next year. we're talk about a $3 million or $3.5 million one time, so we can get the response times right. it may be where it is done through the fire department, but it might be from some of the monies flowing through d.p.h. what is your response to that? >> the citywide response to covid-19, a number of funding streams are coming through. our budget represents our estimate of what is needed to support the department, and other departments are also utilizing covid-related funding.
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i'm certainly happy to have that conversation and understand in a little more detail, but i also think our covid response, to be affective, needs to be integrated with other departments' responses. if there is a deficit with regard to the paramedics and our covid-19 response, we would want to do everything we can to support that effort, along with the overall city efforts that continue to be led by the department of emergency management. >> okay. great. we'll continue these conversations as we dive into the budget over the next few months. thank you, mr. chair. >> chairman: thank you. not seeing any other questions or comments from colleagues, i do want to thank all of you. ms. cunans, dr. colfax, dr. babba, we thank you for your leadership and
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answering all of these questions. and i'm grateful for your past work over the last year and moving forward. we have a couple of items that relate to d.p.h. that we want to also call before we let you go. so, madam clerk, i believe we have -- we're going to start with -- we items 3, 4, and 5, but we're going to start with item 3. >> clerk: yes, mr. chair. item 3, ordinance amending the health rates and rates for other services provided by the department of public health, for 2021 to 2022, and 2022 to 2023. members of the public who wish to provide public comment should call 415-655-0001, i.d. 1463144843, and then press pound twice. if you have not already done so, please dial *3. a system prompt will indicate you have raised your hand. please wait until the system indicates you have been unmuted and you may
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begin your comments. >> chairman: great. mr. colfax? >> yes. with regard to the rates, i'm going to turn this over to our chief operating officer, mr. wagner, to provide details on this. thank you. >> thank you, chair haney, members of the committee. the patient rates coordinance is annually or bi-annually submitted ordinance to extend our authority to set patient rates for services received in clinical settings. the current ordinance is essentially extending the existing rates for an additional year. there are a couple of minor clean-up items you'll see amended in the ordinance, but essentially it is status quo. the rates are based on an engagement that we did about a year and a half ago with delight consulting to evaluate our patient rates compared to the industry.
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i'm happy to answer any questions if you have any. >> chairman: supervisor ronen? >> yes, thank you. i know that a couple years ago we fixed the problem of out of network charges, general for emergency treatments, and i just want to triple check that that solution that we developed continues in these new patient rates? >> supervisor, can you hear me? >> yes. >> okay. my technology is being a little weird. but, yes, that is correct. the changes that we put in place, including in-network -- if you're an out-of-network at our facility, we'll treat you as in-network, and an out of pocket cap, that patients at all income levels remain in place and monitored. >> fantastic. thank you.
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>> chairman: thank you, supervisor ronen. not seeing any other questions or comments on this, we have to open up item 3 for public comment. for folks who are tuning in from the public, if you want to give comment, this is only on item 3, which is patient rates for the upcoming fiscal years. madam clerk? >> clerk: checking to see if there are any callers in the queue. members of the public who wish to provide comment, please press *3. mr. penna, are there any callers who wish to comment on item number three. >> we have four callers in the queue. >> clerk: thank you. please unmute the first caller. welcome, caller.
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hello, caller? ms. penna, perhaps we can go back to this caller and take the next. [inaudible]
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>> clerk: thank you for your comment. ms. penna, are there any other callers in the queue? >> one more caller in the queue. >> clerk: thank you. welcome, caller. this is public comment on item 3. ms. penna, are there any other callers in the queue? >> no more callers in the queue. >> clerk: thank you. >> chairman: public comment is now closed. i want to make a motion to move item 3 to the full board meeting on july 13th with a positive recommendation. is there a second?
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>> second. >> chairman: seconded. roll call, please. >> clerk: yes, on that motion. [roll call taken] >> clerk: mr. chair, there are five ayes. >> chairman: it will go to the full board with a positive recommendation on july 13th. madam clerk, can you please call item 4. >> clerk: item 4:
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resolution authorizing the acceptance and expenditure of state funds for fiscal year 2021 to 2022. members of the public who wish to provide public comment should call 415-655-0001, i.d. 1463144843, and then press pound twice. then press *3 to line up to speak. please wait until the system indicates you have been unmuted and you may begin your comments. >> chairman: great. dr. colfax? >> yes, i, again, will turn this item over to our chief operating officer, mr. wagner. >> thank you, chair haney and members of the committee. this item is another annual item that comes before you. as you know, we've received a large number and dollar value of grants for various services. many of these grants are recurring, meaning that we receive them each year.
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and rather than bringing them as individual except and expend items, in cases where they are recurring grants, we bring them as part of the budget process as a package for your approval to continue to accept these funds and appropriate them in the budget to continue the existing services. >> chairman: is there a b.l.a. report on this item? >> chair haney, this is dan gossam with the b.l.a. there is no b.l.a. report on this item. >> chairman: madam clerk, can we open this for public comment? again, this is only on item 4. >> clerk: yes, mr. chair. d.t. is checking to see if there are any callers in the queue. members of the public who wish to provide public
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comment, please press *3. please wait until the system indicates you have been unmuted. ms. penna, are there any callers who wish to comment on item 4? >> there are no callers in the queue. >> chairman: public comment is closed. i want to make a motion to move item 4to the full board on july 18th. with a positive recommendation. is there a second. >> seconded, safai. >> chairman: seconded by safai. can we have a roll call, please. >> clerk: yes, on that motion. [roll call taken] >> clerk: there are five ayes. >> chairman: it will go to the full board with a positive recommendation on july 1st. can you please call item 5. >> clerk: ordinance amending the business to
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update emergency medical services fee to reflects amounts currently authorized and charged under annual adjustment provisions, and to require that the fees be paid to the department of emergency management, rather than the department of public health. members of the public who wish to provide public comment should call 415-655-0001, i.d. 1463144843, then press pound twice. if you have not already done so, please dial *3 to line up to speak. a system prompt will indicate you have raised your hand. please wait until the system indicates you have been unmuted and you may begin your comments. mr. chair? >> chairman: i forward to you, d.p.h. >> yes, thank you, chair haney. i will defer to, again, mr. wagner on this one. >> thank you, chair haney. this item relates to what was discussed earlier by dr. colfax and supervisor
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safai, regarding the transfer of the lensa agency from d.p.h. to d.e.m.. there is a transfer of function proposed in the budget. we do collect fees, and as the function is transferring from d.p.h. to d.e.m., it requires an update to the administrative code to reflect that those fees will be paid to d.e.m., instead of d.p.h. so this is an administrative code change that provides the ability to continue to collect the fees through d.e.m.under the new proposed structure. >> chairman: great. supervisor safai. >> yeah, i just wanted to say, because this is on the record today, over the
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last number of months, six months or more, we've been working with the department of public health. we've been working with the fire department on this oversight. and finding the right place and area for this oversight -- i've said this before, and i think dr. colfax agrees, there are so many different central missions to the department of public health, but responding to emergency services in the context of 9-1-1 or 3-1-1 calls, and then that oversight of that agency historically has rested within the department of emergency management. and i think that, you know, d.p.h. will continue, obviously, with all of the different proposals of crisis response and wellness calls and checks and working and coordinating with other departments, but i am firmly in support, and have been working on this transfer and believe that it is the right place for ultimately lensa to rest, which is in
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the department of emergency management. so i appreciate the work of dr. colfax and his team in this process. and so i just wanted to get that on the record and thank dr. colfax for the collaboration. thank you, mr. chair. >> chairman: agreed. thank you. madam clerk, can you please open this up to public comment. >> clerk: yes, mr. chair. i do want to clarify that public members are allowed one minute to speak on all items on this agenda. members of the public who wish to provide comment on this item, please suppresses *3. for those already on hold, please wait until the system indicates you have been unmuted. ms. penna, are there any callers who wish to comment on item 5? >> there are currently no callers in the queue. >> clerk: thank you. >> chairman: public comment is closed. i want to make a motion to move item 5 to the full
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board on july 13th with a positive recommendation. >> seconded. >> chairman: seconded by supervisor safai. roll call vote, please. [roll call taken] >> clerk: there are five ayes. >> chairman: okay. this will go to the full board with a full recommendations on july 13th. i believe that is the last of public health-related items. i want to thank you all. [please stand by]
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benefits and support which used to be the department of human services and attempt to change the name was really to eliminate confusion between the department of human services and hsa. so we decided to rename it and re-brand it department of benefits and family support, which is all of our benefit programs, work force programs and child welfare services programs. so that is the department i will be discussing in detail for my
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budget presentation. next slide please. okay. so this shows you a breakdown of the proposed budget before you for the budget year and budget year plus one. really the overview or take away here is a couple of things. one, the overall human services agency budget, about one third is the department of disability and aging services and 20% education. about one third department of benefits and family support and the rest is the administrative infrastructure of hsa that provides support to all three departments. the other takeaway, there's really almost a status quo budget in terms of the prior year changes within the budget infrastructure as you know with
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the budget balancing directives from the mayor's office. next slide please. the case loads reflect the core work, you can see the case loads in foster care. there are a couple of things i want to highlight. the first is the sharp increase for most of these programs not for foster but the benefit programs during the pandemic. clearly because individuals, households, families lost their jobs, lost their income ask and turned to our programs for health insurance and income because they lost their jobs and
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were you inially eligible. although i'm never pleased with case loads grow because that means the need is growing but i am pleased during a pandemic response when close to 85% of our staff were working remotely, our programs were able to respond to the increase need. moving forward, we're projecting flattening or slight decrease in anticipation of a better economy and work with household families and individuals and getting them back in the work force. foster care is not a benefit program. foster care of course is the payments we pay to providers to take care of our kids who have been victims of abuse and neglect have been trending down for two decades, doing a lot more preventive work and reunion o