13 14 Revenues Incr/(Decr) Dept Proposed Net GF Cost/ (Savings) FTE Change

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1 SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH FY PROPOSED BUDGET Health Commission Meeting Division Item Description Expend Expend Net GF REVENUES PHP A1 TB Control and Prevention Services Maintain Core Services , , , ,981 The DPH TB Control Program's Federal Center for Disease Control (CDC) funding was reduced in FY The TB Program is utilizing one time savings to cover expenditures in the current year, but will require additional general fund to support current activities to control TB outbreaks and maintain current TB program core functions including: direct clinical services, evaluation of referrals of TB suspects and high risk infected individuals, and maintaining city mandated TB screening in homeless shelters. SFGH A2 Increase Occupational Health Workorder Recovery , ,510 (616,813) 92, ,510 (612,704) The Occupational Health Services Dept at San Francisco General Hospital provides medical and occupation related health services through workorder agreements with City and County Departments. Rates charged to City Departments have seen only modest increases three times in 15 years despite increasing costs. The Department is proposing rate increases to fully cover direct expense for services provided but are equal to or below rates charged by area hosptials for similiar services. PH A3 DPH Baseline Revenue ,163,473 7,909,683 (4,746,210) ,428,915 7,534,104 (6,105,189) s to DPH Baseline Patient for SFGH, LHH and CBHS. Includes program expenditures for Delivery System Reform Incentive Pool (DSRIP) Category V HIV Transition Project to provide access to coordinated, integrated care to patients diagnosed with HIV who previously received care under programs funded by the Ryan White HIV/AIDS Treatment extension act of Additional program expenditures for related ITG's and Human Services Agency workorder for IHSS workers. A4 Environmental Health Services Fees , , , ,521 0 Annual and legislated increases in Environmmental Services inspection fees to cover related program expenditures. TOTAL REVENUE ,056,987 9,073,714 (5,016,727) ,457,223 8,698,135 (6,240,912) REDUCTIONS/SAVINGS PROPOSALS 0 L\Budget\1213\HC Summary May 7 Hearing Final 1 5/9/20136:12 PM

2 Division Item Description Expend Expend Net GF SFGH B1 Reprogramming of Behavioral Health Center (36.79) (6,731,713) (2,160,844) (4,570,869) (50.40) (11,141,360) (2,983,272) (8,158,088) Proposed programming changes at the Behavioral Health Center to maximize use of the BHC and strengthen its role in the system of care. Adding bed types that are in short supply allows DPH patients to be placed more quickly in the appropriate level of care and improves patient fow within the DPH network. CP B2 Community Programs Across the Board Reduction to CBO Contracts (4,765,369) (4,765,369) (6,978,038) (6,978,038) As part of its plan to address the Department s funding shortfalls, a total of $7,312,104 will be reduced from contractual services funding by implementing an across the board reduction to unmatched General Fund dollars, (i.e. General Fund dollars that aren t used to draw down additional State or Federal revenues). CP B3 Community Programs Request for Proposal Process (RFP) (8,843,948) (8,843,948) Through an RFP process, the Department will realign its contractual services to meet one or more of the following objectives: Essential services to meeting the Affordable Care Act (ACA) milestones; Services reimbursable under ACA; Services that directly help Hospital Discharge, and Services that support population health. DPH All B4 DPH One Time Prior Year Savings (2,400,000) (2,400,000) 0 DPH fiscal staff will begin the process of reviewing prior year project accounts and close out any unnecessary fund balances. The Department expects to have savings of about $2.4 million which can be returned to the general fund. LHH B5 LHH Transition Project Savings (776,449) (776,449) (535,065) (535,065) One time LHH Transition Project savings spread over two years which will also offset additional ongoing infrastructure positions. CP B6 Redwood Center Savings (400,000) (400,000) (400,000) (400,000) The Redwoood Center site was closed in FY09 10 for renovations. The Department of Public Health terminated the renovation process in early FY12 13 because of the financial and operational challenges posed by the remote site. Additionally, the site s designation as historical created limits to achieving the desired improvements. A portion of the operating costs budgeted for Redwood will be redirect to other programs and $400,000 will be used to reduce general fund support. L\Budget\1213\HC Summary May 7 Hearing Final 2 5/9/20136:12 PM

3 Division Item Description Expend Expend Net GF CP B7 HIV Administrative Savings (3.24) (422,352) (422,352) (4.00) (513,780) (513,780) The Department has identified proposed administrative savings equal to $422,352 in FY, and an annualized amount of $513,780 in FY. An amount of $102,075 represents contractual savings from the Native American AIDS Project (NAAP) which closed in December, 2012 at its own discretion. At that time, all clients were transitioned to existing programs. Additionally. 4.0 admimistrative positions have been proposed to be deleted. TOTAL REDUCTIONS (40.03) (15,495,883) (2,160,844) (13,335,039) (54.40) (28,412,191) (2,983,272) (25,428,919) INFLATIONARY DPH All C1 DPH Pharmaceutical and Materials and Supplies Inflation ,178,580 1,178,580 3,516,288 3,516,288 Annual request for increased expenditure authority related to materials and supplies. Pharmaceuticals continue to be the primary treatment modality for the prevention, mitigation or cure of disease. Drug therapy cost increases have exceeded the inflationary rate for other goods and services for the past decade, and increases in the utilization of novel therapeutic agents are expected to continue into year 2013/14 and 2014/15. Higher food costs have resulted from increased gas prices and the severe nation wide drought last summer. Laundry and linen costs will rise by 2.5% as there has been no COLA adjustment since SFGH C2 Mandated Salary and Fringe Increases for UCSF Affliation Agreement ,375,168 5,375,168 11,070,812 11,070,812 This request is to fund the projected increase to Faculty, Staff and Interns & Resident salaries and benefits under the UCSF/SFGH Affiliation Agreement. The, faculty, staff and interns & residents working at SFGH through the UCSF Affiliation Agreement are essential to the operation of the hospital. UCSF is contractually obligated to implement salary and benefit increases for staff in accordance with negotiated employment agreements (MOU s.) L\Budget\1213\HC Summary May 7 Hearing Final 3 5/9/20136:12 PM

4 Division Item Description Expend Expend Net GF HUH C3 Annual Rent Increase for Direct Access to Housing (DAH) Master Leases and Rent Subsidies and 3rd party rent payment , , , ,683 Through an integrated housing and healthcare approach, DAH provides high quality housing for homeless persons who have been living on the streets, individuals revolving through costly emergency care settings, and Health Department clients exiting higher levels of care. The master lease sites incur annual rent increases as required by their lease agreements. The non profit owned housing sites incur annual operating subsidy increases as required by their City contracts. Therefore, the Department is obligated to fund the proposed increases to adhere to these agreements. C4 Healthcare Data Exchange System (HDX) 810, , , ,000 The Siemens Healthcare Data Exchange (HDX) system is the application utilized by DPH Hospitals and Clinics for On line Eligibility verification for Medicaid, Medicare, Healthy San Francisco, San Francisco Health Plan and Third Party Payors. This Program change will increase the annual contracted system usage fees in order to provide a fixed monthly and annual fee for the service in anticipation of significant eligibility transaction increases related to Healthcare Reform implementation. 0 0 TOTAL INFLATIONARY ,513,748 7,513, ,091,783 16,091,783 REGULATORY SFGH D1 Emergency Department (ED) Clinical Decision Unit (CDU) ,977,214 2,977, ,753,826 3,753,826 To establish a dedicated Observations/Clinical Decision Unit to remedy regulatory non compliance of unmonitored patients on gurneys in the hallyways of the ED. This will also free beds in the ED for additional patients, reduce the leave without being seen (LWBS) rate, and allow more precise, quality of care. SFGH D2 Regulatory s to Pharmacy , , , ,712 Program changes required for regulatory compliance with Federal 340B pharmaceutical discount pricing. $4M in 340B drug cost savings at risk. In addition, regulatory enforcement has determined that we can no longer procure pharmaceuticals for non FQHC clinics through 340B and we will need to provide alternatives. L\Budget\1213\HC Summary May 7 Hearing Final 4 5/9/20136:12 PM

5 Division Item Description Expend Expend Net GF DPH All D3 Electronic Health Record (EHR) Meaningful Use (MU), & Virtual Desktop Interface/Infrastructure (VDI) ,862,681 6,862, ,780,988 4,780,988 Program Funding for ongoing development of Electronic Health Records and related Centers for Medicare & Medicaid Services (CMS) MU Incentive Program compliance efforts, transition to ICD 10 (International Statistical Classification of Diseases and Related Health Problems) and Virtual Desktop Interface (VDI). SFGH D4 Neurosurgery Attending , , , ,384 To fund regulatory compliance staffing required for Level One Trauma Accreditation. Additional.58 attending time will consist of Medical Director;. ereferral Reviewer; and clinical time. As a result, there will be 2 additional clinical sessions/week; thus, increasing annual visits by 440/year. SFGH D5 Anesthesia Tech 204, , , ,488 This program funds mandatory staffing required to meet regulartory compliance as articulated by The Joint Commission in the last accreditation survey of the hospital. 0 0 TOTAL REGULATORY ,221,663 11,221, ,086,398 10,086,398 BUDGET NEUTRAL CP E1 Children, Youth and Family Services Enhancement ,243,409 4,243,449 (40) ,636,713 3,636,713 0 In FY12 13 the State realigned mental health funding, and included an increase to support services related to a State settlement (Katie A), requiring a specific array and level of behavioral health services for children in foster care, or at risk of out of home placements. The proposed funding reflects the actual State Realignment increase to support these services ($1m), plus an equalivalent increase in Federal Short Doyle MediCal. L\Budget\1213\HC Summary May 7 Hearing Final 5 5/9/20136:12 PM

6 Division Item Description Expend Expend Net GF CP E2 Substance Abuse 2011 Realignment ,096,350 4,096, ,316,079 2,316,079 0 In FY12 13 the State realigned substance abuse funding. The proposed funding reflects the allocation increase, including funding for Drug MediCal services. Additionally, $540k will be used to support eligible services currently funded by City General Fund monies, $430k will be used to support current substance abuse medication funding levels, $460k will be used to fund four substance abuse counselors to work in Children's behavioral health clinics and COPC clinics, and the balance of funding will be used to support misc. services, including backfilling prior year State reductions and a Vivitrol evaluation pilot started in FY E3 Medi Cal Funding for Pipeline Housing Support Services 132, , , ,501 0 Medi Cal funding for supportive services for the tenants of the Rene Cazenave Apartments (RCA). RCA is DPH s newest pipeline development that will start this summer. While support services are voluntary, experience shows that the majority of tenants will participate in on site services, which may include case management, support groups, oneon one counseling, and linkage to a variety of community based benefits, employment and social services. TOTAL BUDGET NEUTRAL ,472,052 8,472,092 (40) ,264,293 6,264,293 0 EMERGING NEEDS DPH F1 Investments fo Healthcare Reform ,249, , , ,369, ,789 1,549,995 Healthcare reform will transition the healthcare industry from a volume based payment system to a value based payment system. In order to effectively manage costs, maintain revenues and provide quality care, DPH must make significant investments in its infrastructure to ensure that it minimizes its exposure to financial risks. In FY 13 15, DPH will focus on the following areas: Managed Care, Integrated Delivery System and Regulatory Reporting and Support for Federal and State Programs. COPC/ CBHS F2 Establish Clinic Managers in CBHS and COPC Clinics , , , ,355 Phase in of COPC and CBHS clinic managers to strengthen administrative capacity and ensure that each COPC and CBHS clinic is able to respond to its changing requirements and treatment models efficiently and effectively on an ongoing basis. L\Budget\1213\HC Summary May 7 Hearing Final 6 5/9/20136:12 PM

7 Division Item Description Expend Expend Net GF COPC F3 Establish Weekend/Evening Clinics to Maximize Access , , , ,246 Increase access to primary care with weekend and evening clinics through staffing expansion. CP F4 Young Black Women Health Initiative ,468 76, , ,587 This is a pilot initiative intended to improve the health of African American women before pregnancy, and reduce disparities in pregnancy and birth outcomes through improved access to high quality pre conception health care for women of reproductive age. SFGH F5 MD Access Initiative ,247,916 1,247, ,451,451 1,451,451 In recent years, increased demand stemming from Healthy San Francisco, the economic downturn, the need to keep capitated Seniors and Persons with Disabilities (SPDs) in network,and the external regulatory mandates regarding wait times for ambulatory services, have significantly impacted specialty services at SFGH. This initiative will address issues of capacity, access and wait times in the ambulatory arena. SFGH F6 UCSF Affiliation Agreement Services , , , ,851 UCSF Affiliation Agreement services necessary for SFDPH to address the health needs of San Franciscans, with a special emphasis and commitment to serving the City s most vulnerable, diverse populations. Urgent Care Cardilogy, 1M GMC Medical Director, HIV Hep Co Infection Clinic Ward86, 4M eye Clinic, Audiology, and Sleep Study. SFGH (UC) F7 Orthotics and Prosthetics M/Cal SPD and SFPATH , , , ,200 To fund increased Orthotic and Prosthetics medical supply costs for M/Cal Managed Care SPD's and SFPath. LHH F8 Clinical Pharmacist Clinics , ,823 (64,871) , ,964 41,569 This program will serve as an anticoagulation clinic for residents receiving warfarin to reduce medication complications and inpatient hospitalization by implementing a systematic process of medical therapy management services. This program will also include a transition clinic for residents who are being discharged to independent living. This will impact clinic visits per week for the pharmacist run anticoagulation services and 10 clinic visits per week for the transition clinic. L\Budget\1213\HC Summary May 7 Hearing Final 7 5/9/20136:12 PM

8 Division Item Description Expend Expend Net GF LHH F9 LHH Neurobehavioral Health ,630,707 1,630, ,120,925 2,120,925 The LHH neurobehavioral day program will create a structured therapeutic day program for cognitively impaired SNF residents with complex behavioral symptoms. Residents will be receive activities and programming utilizing LHH community space such as the farm, wellness center, art studio and wellness center, for structured activity. The goal is to provide meaningful activity designed to promote resident success and enhance the skills of the staff. PH F10 Sexual Reassginment Surgery 300, , , ,000 Funding for a new program to provide certain specified sexual reassignment (SRS) services to eligible uninsured transgender adults. 0 0 TOTAL EMERGING NEEDS ,103, ,885 5,317, ,292,932 1,011,753 8,281,179 TOTAL ALL PROPOSED INITIATIVES ,872,181 16,170,847 5,701, ,780,438 12,990,909 2,789,529 Structural Requests LHH, SFGH, COPC, LHH G1 Porters , , , ,700 Adequate Porter staffing is needed to meet regulatory requirements, to facilitate patient flow and to ensure a clean and safe environment for our staff and patients. The current budgeted staffing levels are not adequate to meet the needs at SFGH, LHH, COPC and Jail Health. Adding these permanent positions to the budget also addresses Collective Bargaining concerns around using as needed staff for permanent work as well as addresses structural funding issues around growing as needed salary costs. SFGH G2 SFGH Nursing Services ,643,738 1,643, ,356,894 2,356,894 Permanent RN positions to replace the equivalent use of P103 in the Operating Room for scheduled operating room hours and related backfill. Permanent RN Positions to replace the equivalent amount of P103 being utilized in the Urgent Care Center for baseline Scope of Services This addtion to the budget would also address SFGH salary budget structural issues and Collective Bargaining concerns around utilizing as needed staffing for permanent work. L\Budget\1213\HC Summary May 7 Hearing Final 8 5/9/20136:12 PM

9 Division Item Description Expend Expend Net GF SFGH, LHH G3 Patient Care Assistants Patient Care and Patient Safety ,250,938 2,250, ,148,709 3,148,709 Permanent PCA Positions to replace the Equivalent use of the as needed / registry Patient Care Assistants. It is apparent that the need for the pool is constant and is consistent with the volume of patients requiring coaches and close observations. Nearly all employees in these registry and as needed postions already work hours/week, equal to the hours that permanent staff work. It is therefore more administratively efficient and cost effective to increase and hire permanent positions. This would also address SFGH's salary and contract structual issues and Collective Bargaining concerns of utilizing temp staff for permanent work. LHH G4 LHH Escort Team , , , ,825 LHH cares for residents with complex medical issues, chronic illnesses, and cognitive impairments. 70% of the residents are in need of escort services to clinic appointments at SFGH or other sites. A creation of an escort team can deploy designated staff to assist these residents with off site clinic appointments and registration. LHH G5 LHH Coach Team , , ,565,622 1,565,622 58% of the LHH residents have some type of dementia or cognitive impairments. Some with manifested safety risk behaviors would require oneon one care. By establishing a coach team the staff would be able to provide more customized support for those at risk residents. PH G6 Public Health Operations Structural Funding 307, , , ,208 The program request is to fund key infrastructure positions for the Population Health Division to support reorganization and integration efforts in health protection, health promotion, disease prevention and disaster preparedness. DPH G7 Premium Pay, Holiday Pay, and Salary Savings. LHH Materials and Supplies Structural Fix 0 0 8,495,193 8,495,193 DPH will continue to work with the Mayor's Office to identify specific structural fixes to the DPH Budget (i.e LHH materials and supplies and attrition and other special salary costs at the hospitals. No write up is available. TOTAL STRUCTURAL CHANGES ,844,973 5,844, ,286,151 17,286,151 Total All Initiatives and Structural ,717,154 16,170,847 11,546, ,066,589 12,990,909 20,075,680 L\Budget\1213\HC Summary May 7 Hearing Final 9 5/9/20136:12 PM