County of San Diego HEALTH SERVICES ADVISORY BOARD 1600 PACIFIC HIGHWAY, SAN DIEGO, CALIFORNIA

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1 County of San Diego HEALTH SERVICES ADVISORY BOARD 1600 PACIFIC HIGHWAY, SAN DIEGO, CALIFORNIA Thursday, 3:00-5:00 PM 1600 Pacific Highway, Room 302/303 MEETING MINUTES Members/Alternates Present Members Absent/Excused Presenters HHSA Support Seat 2/Dist 1 Paul Raffer Seat 7/Dist 4 James Lepanto, Chair Seat 8/Dist 4 Toluwalase Ajay (alt) Seat 11/Cmty Paul Hegyi Seat 12/Cmty Judith Yates (alt) Seat 13/Cmty Henry Tuttle Seat 14/Cmty Greg Knoll Seat 17/Cmty Bob Prath Seat 1/Dist 1 (vacant) Seat 3/Dist 2 Judith Shaplin Seat 4/Dist 2 (Jack Rogers) Seat 5/Dist 3 (Jeff Griffith) Seat 6/Dist 3 (vacant) Seat 8/Dist 4 Kyle Edmonds, Vice Chair Seat 9/Dist 5 Adriana Andrės- Paulson Seat 10/Dist 5 Michele Davis Seat 12/Cmty Dimitrios Alexiou Seat 15/Cmty Phillip Deming Seat 16/Cmty Leonard Kornreich Karen Waters-Montijo, Chief Epidemiology and Immunizations Services Branch (EISB), PHS Jeff Johnson, Sr. Epidemiologist, EISB, PHS Patrick Loose, Chief, HIV-STD- Hepatitis Branch (HSHB), PHS Dr. Nick Yphantides, Chief Medical Officer, Medical Care Services Division Lauren Brookshire, Assistant Medical Services Admin, HSHB James Patterson, Budget Manager, PHS Administration Brett Austin, Director, PHS Lab Jackie Werth, Performance Improvement Manager, PHS Liz Hernandez, Assistant Director, PHS Saman Yaghmaee, Deputy Director, PHS Wilma Wooten, Public Health Officer (via phone) Victoria Ollier, Secretary, PHS Admin Kay Collier, Secretary, PHN Admin Minutes Lead Follow-up Actions Due 9/15/16 Jim Patterson Provide information on how MTS is earning MAA revenue. Completed 10/20/16 10/20/16 Lauren Brookshire/ Saman Yaghmaee Liz Hernandez/ Saman Yaghmaee Invite HIV contract providers and/or the newly formed HIV Planning Group to an HSAB meeting to weigh in on the multi-service procurement model recommended by the State HSRA for Ryan White funding. Send the Epidemiology Surveillance Report to James Lepanto, HSAB Chair. Completed Completed 1. Welcome & Introduction 2. Public Comment James Lepanto called the meeting to order. No public comment. 3. Action Items A. Approval of October 20, 2016 meeting Minutes Greg Knoll motioned to approve; Paul Hegyi seconded. All voted Aye.

2 Health Services Advisory Board Meeting Page 2 of Action Items (continued) B. Approval of Board Letters 1) Single Source Procurement of Epidemiology and Immunization Services Presenter: Karen Waters-Montijo, Chief, Epidemiology and Immunization Services Branch (EISB), PHS This Board Letter will be presented to the Board of Supervisors on 1/10/17, requesting authorization for negotiation of two single source contracts to be extended for one year, with 4 option years through 6/30/22 each. Cost will be approximately $450,000 per year for each software system, funded through Health Realignment. Approval Greg Knoll motioned to approve HSAB support of this Board Letter; Judith Yates seconded. All voted Aye. Background [See Attachment A, pages 9-10] Extensions of 2 contracts, with vendors Software Partners and Atlas Development, will assure that over 10 years of uninterrupted and effective services will continue in the community through software that provides electronic exchange of information with community partners. Software Partners developed the proprietary software San Diego Immunization Registry (SDIR) in 2002, and has provided support for the web-based registry of immunizations since that time. Medical providers in San Diego use the registry to forecast vaccine needs and support timely immunizations that prevent disease outbreaks. The registry encourages improved compliance with state mandated reporting requirements. Atlas Development has been engaged since 2003 in development and support for the Web Confidential Morbidity Report (Web CMR), an electronic disease registry using proprietary software for the systematic collection and analysis of over 17,000 communicable disease cases reported per year. Thousands of lab results and medical records are stored in the system. It is used by disease investigators and for planning and decision-making on a local level by 6 Public Health programs, linking to the San Diego Health Connect/ Health Information Exchange (HIE) system. San Diego leads the West Coast in disease investigation and reporting, and Atlas system is key to that success. The Atlas software is proprietary, but the company is stable, and in case of transition, the County holds a key with an escrow account in Iron Mountain. The County receives health information that must be reported to the DMV, but this information is passed on, not entered into the Atlas system. Regarding possible future changes in CMS (Centers for Medicare & Medicaid Services), CDC Center for Disease Control (CDC) guidelines are being followed as standards now, but Atlas tracks CMS changes with development of a 5-year roadmap.

3 Health Services Advisory Board Meeting Page 3 of Action Items (continued) B. Approval of Board Letters 2) UCSD Single Source Procurement for Immunization Support Services Presenter: Karen Waters-Montijo, Chief, EISB, PHS This Board Letter will be presented to the Board of Supervisors on 1/10/17, for (a) authorization to submit a 3-year grant application to CDPH for the period 7/1/17-6/30/20 for immunization related services; (b) authorization for Clerk of the Board to execute the CDPH 3-year revenue agreement of approximately $1, 800,000 per year; and (c) authorization for negotiation to amend a UCSD contract to extend services for one year, with 4 option years through 6/30/22. The funding source for UCSD support is CDPH, with estimated unrecoverable annual costs of $356,564 funded through Health Realignment. Approval Greg Knoll motioned to approve; Paul Hegyi seconded. All voted Aye. Background The County Immunization Program provides technical training to organizations on national standards for vaccine handling and administration, conducts disease surveillance, coordinates distribution of vaccines from CDPH to manage disease outbreaks, and promotes adherence to the recommended lifespan vaccine schedule, among other work. The objective of the CDPH grant is to reduce death and disability from vaccine preventable diseases. UCSD has assisted the Immunization Program for 14 years with operational support toward this objective while evolving its skills capacity. Significant gains have been realized in San Diego County over these years. On 9/26/16, in anticipation of the UCSD contract expiring, a Request for Information (RFI) was issued by the County Department of Purchasing and Contracting on BuyNet for immunization support services. UCSD was the only community organization that responded to the RFI, and they met or exceeded all requirements, including capacity to coordinate Immunization information systems, manage data exchange with providers, conduct evaluation, and provide information services. 3) Non-Competitive Procurement of HIV Primary Medical Services Presenter: Patrick Loose, Chief, HIV-STD- Hepatitis Branch (HSHB), PHS This Board Letter will be presented to the Board of Supervisors on 1/24/17, requesting authorization for negotiation of non-competitive contracts with community based providers to procure (a) Ryan White HIV/AIDS medical and dental services for one year, 7/1/17-6/30/18, with 4 option years; and (b) County Medical Services (CMS) services for one year with 3 option years. Cost is approximately $4,191,303 for Fiscal Year 2017/18, funded through the (a) federal Ryan White Act, Parts A and B, and (b) Tobacco Settlement Funds designated for CMS. Approval Paul Hegyi motioned to approve HSAB support of this Board Letter; Greg seconded. Henry Tuttle abstained; all others voted Aye.

4 Health Services Advisory Board Meeting Page 4 of Action Items (continued) B. Approval of Board Letters 3) Non-Competitive Procurement of HIV Primary Medical Services (continued) Background There is universal treatment coverage in San Diego County for the 21,389 people living with HIV/AIDS. If patients are not covered by Covered Care California or Medi-Cal, the federal Ryan White Act and County Medical Services (CMS) programs fill the gap. These gap services are important because research has shown that access to treatment slows transmission of HIV. HIV/AIDS outpatient medical services and dental care that are currently being provided by community based providers through contracts with funding through the Ryan White Act are entering the final contract year. Because services exceed $1 million annually, authorization is required for renewal of non-competitive procurement that will provide continuity of these services. CMS is a County program of last resort for uninsured homeless adults. Since the County does not provide any direct medical services, this program covers the expense of necessary medical services through hospitals, community health centers, and private doctors. It does not cover preventative services. Contracts are negotiated with hospitals to provide emergency care services at lower cost for program beneficiaries. 4) Procurement of Services for Whole Person Wellness Pilot Presenter: Dr. Nick Yphantides, Chief Medical Officer, Medical Care Services Division This Board Letter will be presented to the Board of Supervisors on 12/13/16, requesting authorization for negotiation of one or more contracts for a one year period, 7/1/17-6/30/18, with up to 3 option years through 6/30/20, to implement the Whole Person Care pilot project. This pilot, known as Whole Person Wellness, will provide services to the homeless with serious mental illness. Cost is approximately $5,300,000 in Fiscal Year 2017/18, and will be funded through federal funds authorized under the State s Medi-Cal 2020 waiver, Tobacco Settlement Funds, Health Realignment, and HHSA fund balance as needed. Approval Greg Knoll motioned to approve; Paul Hegyi seconded. All voted Aye. Background The State Department of Health Care Services (DHCS) received federal approval for Medi-Cal 2020, which is a broad waiver to allow counties to implement innovative approaches to serve persons receiving Medi-Cal. One component of the waiver is for counties to establish Whole Person Care pilot projects. On 6/28/16, HSAB approved County submittal of a proposal to the State for implementation of a Whole Person Care pilot project. On 10/24/16, the County was notified that they will be funded. The next step is to procure one or more contracts to provide services for the local pilot known as Whole Person Wellness, which will provide intensive wraparound services, integrating housing and treatment for approximately 1,000 individuals who are homeless or at risk for homelessness, and are seriously mentally ill, have substance abuse disorders, and/or have chronic health issues. Twelve teams will deployed throughout the County, comprised of a Social Worker paired with a Peer Support Specialist, working with community partners for outreach and case management of services over a 2-year period.

5 Health Services Advisory Board Meeting Page 5 of Action Items (continued) B. Approval of Board Letters 4) Procurement of Services for Whole Person Wellness Pilot Background (continued) Funding will additionally be used for housing and to develop a ConnectWellSD system module to link information for care coordination. This pilot and the County initiative, "Project One for All," will work to mitigate the high cost to Medi-Cal and other public systems due to frequent Emergency Department visits by the mentally ill homeless, in addition to lengthy acute hospital stays and jail bookings. State funding for the pilot is contingent upon approved deliverables that are met, with County funds used to obtain a match in equal funding from the State. Outreach approaches and incentives for landlords to house pilot beneficiaries are being fine tuned. Their willingness to house the pilot population is key. An evaluation plan is in place that will track retention, housing rates, and other program elements in addition to housing, such as impact on incarceration and recidivism. 4. Follow-up Action Item/ Presentation A. HIV/AIDS Multi-Service Procurement Lauren Brookshire, HSAB, PHS At the board's request, Lauren Brookshire returned to address questions that members posed on 10/17/16 in regard to changes in how HIV services are procured with community partners. Instead of contracting for each service, the County will contract for umbrella services under this model. Those vendors awarded multiple-service contracts in each of the 6 HHSA Regions will be responsible for subcontracting for individual services. By State mandate, the HIV Planning Group is not able to address the board's concerns, since it cannot be involved in how services are procured. The County, as grantee, must handle the procurement process to prevent conflict of interest, since service providers participate as members of the Planning Group. This procurement and contracting approach was a recommendation of the Health Services and Resources Administration (HRSA) following a site visit that occurred in HRSA made this recommendation out of concern about the high volume of contracts that exist and as a way to create efficiencies in the contracting process. The main goal of the Ryan White Act is to link HIV positive individuals to care. The new contract system is designed to address the issue of access to services, which has been a particular concern for North Inland and East Regions. Under the new system, dollars will be allocated to each Region versus each service, which should improve access in those Regions. Since this procurement model has been successful with Women, Children and Families services, it is anticipated that it will be successful with all Ryan White services. Since administrative costs are capped at 10%, it is anticipated that there will be no loss of direct services, and that capacity would be extended to serve more patients, since reporting and other program areas will be streamlined, resulting in cost savings. B. Public Health Services Cost Recovery Proposal James Patterson and Brett Austin Board of Supervisors Policy B-29 requires full cost recovery by departments, and departments are required to review fee schedules every 2 years. If full cost recovery is not possible, the Board of Supervisors must be informed of revenue sources that will cover net County cost.

6 Health Services Advisory Board Meeting Page 6 of Follow-up Action Item/ Presentation (continued) B. Public Health Services Cost Recovery Proposal (continued) Fee schedules for the PHS Laboratory and STD Clinic have not been updated for 10 years, but have been under study for the past 5 years. Methodology for obtaining the revised fee schedules took an extensive amount of time, and included benchmarks using fees from other California counties. Going forward, PHS anticipates reviewing fees biannually. Jim Patterson showed projected fee changes, explaining that he would return on 1/18/17 to seek HSAB approval authorizing a Board of Supervisors Letter recommending these changes. PHS Laboratory fees were kept, raised, or lowered, since the Laboratory has instituted automated systems that have lowered costs. Several fees were also added, included Food Borne Examinations, Rabies Testing, and some Medi-Cal reimbursed fees. Most who pay Laboratory fees are internal HHSA clients or other County departments, such as Department of Environmental Health and Animal Services. Scripps and UCSD health systems also use Laboratory services. Fees to visit the 4 STD Clinics, at Rosecrans and in 3 Regions (North Coastal, Central, and South), will increase from $15 to $40. So that no one in the community is discouraged from seeking treatment, this increase will be posted on the website, along with a waiver option that has already been in effect for clients who are unable to pay. Visits will be tracked to gauge the impact of this increase. There was a thorough review process of these fee changes that involved 12 entities, and the proposal will also be approved by the Auditor and Controller Department prior to the HSAB meeting on 1/18/ Chair s Report A. Strategic Planning - Board Priorities Jackie Werth Jackie Werth provided a document that combined and outlined the HSAB strategy plan and goals, including objectives and "supporting activities" under each goal. This document provides a tool that can be used to determine Work Plan priorities for the next 6 months. [For a quick reference of goals, see Attachment B, pages ] Members were requested to highlight this framework document for areas of interest, and bring it with them to the 1/18/16 meeting, so that 2-3 areas could be selected by consensus. B. Advisory Board Membership Renewal It is requested that, via , all board members document their intent to continue serving. There will be 4 vacancies as of January 2017, which board members could help to fill: District 1, Seat 1 Has been vacant District 2, Seat 4 Jack Rogers is resigning effective 1/1/17 District 3, Seat 5 Jeff Griffith is resigning effective 1/1/17 District 3, Seat 6 Has been vacant Board of Supervisors: District 1 Greg Cox (Coronado and South County) District 2 Dianne Jacob (East County, including SDSU and La Mesa/Spring Valley) District 3 Dave Roberts (North County to Carlsbad, excluding Rancho Santa Fe, including Escondido)

7 Health Services Advisory Board Meeting Page 7 of Informational Items 7. Public Health Officer s Report No Committee Reports. Of the 6 current committees, the following changes are proposed: Integrate "Site Visits" into "Policies and Program"; Restructure both "Health Legislation" and "Budget"; Report "Nominating Committee" progress one time per year; Revamp "Annual Reporting/Strategic Planning" processes. (See "Chair's Report") See Attachment C, pages 13-15, for the complete Public Health Officer's report. Dr. Wooten reviewed the items in red text on the report. I.A. Cases of Zika appear to be slowing. Only travelers reentering San Diego have been discovered with the virus. The ninth spraying is today in one of their neighborhoods. II.A. The County is working with the Hospital Association and other stakeholders to determine what is causing stress on local hospital Emergency Departments. In early spring, Dr. Wooten will bring this information before HSAB to obtain feedback on this topic. III.A.1. It was suggested that the 1/19/17 HSAB Meeting would be a good time to review the Health Services Capacity Plan, since this is flu season and the Plan would be a good tool for the community. Dr. Wooten assured that the Plan would be ready to present on 1/19/17. VI. Four thousand refugees came through San Diego recently, and 2,500 were served by the County s Refugee Health Assessment Program. PHS applied for $500 thousand, but this amount was increased to $980 thousand to serve incoming refugees. VII.A.1. New EMS Medical Director, Dr. Kristi Koenig, will begin full time on 1/1/17. The Chief Dental Officer position is posted, with an open end date. VIII. HSHB just had a HRSA site visit, which completed the Programmatic component. This will be followed by the Fiscal and Contractual component audits at the beginning of IX.B.1. The impact of Proposition 56 is unknown, but it is anticipated that additional debt revenue for next fiscal year will be $1-1.4 billion from the increased tobacco tax. 8. s for Future Meetings January 2017 Spring 2017 TBD - Cultural Competence Plan Eat Well Standards Invite Dr. Nick Yphantides to talk about the new Medical Care Services Division Health Services Capacity Plan 3 Board Letters: Refugee Health Assessment Program funding EISB services funding Certification CHDP & CCS Fiscal Report to State - Budget advocacy for STD Control branch Emergency Department stress issue - Probable new realities of Medicaid changes: block grants and per capita caps Suicide Prevention Long-Term Care Integration Project, AIS (Aging and Independence Services) Surge Capacity Plan Epidemiology Surveillance Report 9. Adjournment The meeting was adjourned at 5:00 PM. Next meeting: January 19, 2017

8 Health Services Advisory Board Meeting Page 8 of Supplemental Information There was no Aging and Independent Services (AIS) Update, but this topic prompted the following discussion. The Community Care Transition Program is ending in January. It was a program that penalized hospitals under the Affordable Care Act for high levels of patient readmission. Medicare has refused to extend the program, but AIS and Palomar Health have entered into a contract to continue incentives that were working for the Palomar system. There are already incentives in place for hospitals countywide, and more incentives need to be aligned at all levels, but there are also barriers to providing economic incentives to reduce readmissions: Currently, San Diego County hospitals do not have sufficient availability of beds, since many health issues are more acute and require longer stays, which slows the volume of readmissions; Physicians can bill more if they readmit, so hospital incentives would not affect change on physician behaviors; Hospitalists are salaried and care for patients, but they are not admitting physicians; Careful patient care coordination would be required to minimize readmissions; Current national political elections may change Medicare and programmatic expectations. If revisited, this discussion should be continued after the presidential inauguration in January.

9 Health Services Advisory Board Meeting Page 9 of 15 ATTACHMENT A Epidemiology and Immunization Registries Atlas Contract WebCMR (Confidential Morbidity Report) Used in Epidemiology since 2003 to register all disease reports submitted to Public Health Services Accepts electronic reports from hospitals and labs Documents disease investigations and stores medical case report Facilitates collection, management, and reporting of public health information for disease control activities Used to manage data for the Childhood Lead Poisoning Prevention Program Estimated cost is $450,000 per fiscal year o System license, hosting, and maintenance o Development of new modules (e.g. Zika, CLPPP) o HIE Interface development o Alerting and electronic filing cabinet Software Partners Contract San Diego Immunization Registry (SDIR) Developed in 1993 as the local Immunization Information System Web-based system since 2004 Documents immunizations given and forecasts vaccines due Used by medical providers and schools Estimated cost is $450,000 per fiscal year o System maintenance o System updates (e.g. new vaccines or changes in the immunization schedule o Interface development o Quality assurance WebCMR has additional functionality: Specialized modules Custom workflows Custom reports for childhood lead poisoning disease Custom reports for local reportable conditions Extensive auditing and quality assurance capability Surveillance data infrastructure Having a locally controlled system allows system administrative capability: Manage and authorize users Perform system, workflow, and staff audits Implement flexible solutions within the system 19,000+ disease reports registered annually 40,000+ medical records and lab reports attached to cases

10 Health Services Advisory Board Meeting Page 10 of 15 Page 2 ATTACHMENT A Epidemiology and Immunization Registries Atlas Contract WebCMR (Confidential Morbidity Report) Used by 6 Public Health Programs Epidemiology, TB, Immunizations, Public Health Lab, Border Health, Childhood Lead Poisoning Prevention Program Electronic lab reporting with 6 labs Part of Public Health Hub for San Diego Health Connect (HIE) Accepted by California Department of Public Health as local disease registry Electronic Lab Reporting Live with Scripps, Sharp, Rady s, Palomar, Tri-City, Quest Testing with Kaiser, UCSD, Tri-City, Planned Parenthood Connecting the health care community Enable Meaningful Use reporting by providers E-Linkages with San Diego Health Connect HIE E-Linkages with other disease registries (e.g. death) Expanded exchanges with California Department of Public Health Syndromic surveillance for detection of events Meaningful Use Stage 3 (2018) Software Partners Contract San Diego Immunization Registry (SDIR) System Advantages: SDIR has roster report used by some schools SDIR has audit trail to identify, who, when and what has been done to immunization record SDIR has function for QA reports on the incoming data to identify errors SDIR has a matching function (Master Patient Index) SDIR has bidirectional query capacity, allowing medical systems to electronically obtain patient records from SDIR Outcomes: Mature system to track immunizations in 600+ sites, including community health centers, public health centers, and pediatric practices in the county Integral part of Public Health Hub associated with Health Information Exchange Opportunities: Continued expansion of participation by local providers and pharmacies Future ability to use SDIR to determine coverage rates Interoperability with California Immunization Registry Ongoing Quality Assurance of data coming into the system via interfaces

11 Page 11 of 15 Health Services Advisory Board Meeting Attachment B Chair s Report HSAB Fact Sheet and Goals

12 Page 12 of 15 Health Services Advisory Board Meeting Attachment E Chair s Report HSAB Fact Sheet and Goals

13 Page 13 of 15 Health Services Advisory Board Meeting Attachment C Public Health Officer s Report

14 Page 14 of 15 Health Services Advisory Board Meeting Attachment C Public Health Officer s Report

15 Health Services Advisory Board Meeting Page 15 of 15 Attachment C Public Health Officer s Report