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March 14, 2003

  At its meeting on Thursday, March 13, SAVE PUBLIC HEALTH circulated the following draft of a letter that was later sent to Health Center Directors regarding the plan to cut Health Center hours in half, as well as patient visits and staff. On March 18 at 3:00 pm, the Health Commission will meet in 101 Grove Street, Room 300, to discuss the cuts outlined in the draft.
February 26, 2003
Barbara García, MPH
Community Programs Director
Patricia Pérez-Arce, Ph.D.
Primary Care Administrator
David Ofman, M.D.
Primary Care Medical Director

RE: Strategic Reduction of Primary Care Services

The Department of Public Health of the City of San Francisco is unique nationally in the comprehensiveness of its network of Primary Care Services which is dedicated to serve the indigent, uninsured, and vulnerable San Francisco residents. Eight of the 17 health centers that are part of the Primary Care Services of the Community Health Network are located throughout the City, primarily east of Divisadero Street, and the properties are owned by SFDPH.

While it is extremely difficult to think that any of these sites might close or reduce its services, as they serve unique cultural, monolingual, and geographic communities, given the City’s economic picture and the looming deficit in the General Fund, it is envisioned that primary care services of the Community Health Network will shrink, however temporarily. In this scenario primary care clinics and their Public Health Nurses, both community and SFGMC-based, will provide the most basic of safety net services and target health care access and management for complex and high risk patients to prevent costly hospitalizations. This strategy will enable DPH and the city of San Francisco to maintain open and viable the most basic of public health services for the indigent, uninsured, and underinsured residents, i.e., San Francisco General Medical Center and its Emergency and Trauma Units.

Rather than simply closing one or two health centers and selling the real estate they occupy, thus losing this asset to the City permanently, the SFDPH is proposing a radical model that will save the sites and will realize savings to DPH by significantly reducing the community based personnel, while maintaining a modicum of services at each site 2 to 3 days during the work week. This model will preserve all current buildings in order to allow opportunity for future growth.

This pattern of services would be possible through the creation of fully supported medical teams, bilingual and bicultural, to serve common populations of patients. Each team would provide primary care services at two different sites during the week. Staffing reductions would be planned to meet the goal of maximizing support staff-to-provider ratios and exam room-to-provider ratios. The industry’s ideal standard allocates 3 exam rooms to one provider with a full contingent of support staff in order to maintain maximal patient flow.

While this model would be an opportunity to create multidisciplinary medical teams supported by an operational infrastructure at all 8 community-based health centers, it would have a grave impact on primary care and the Community Health Network. In this model, rather than each health center having a unique Nurse Advice Phone Line, this line would be centralized to a Medical Care Access 24-7, 800 line, with ability to schedule next-day or same-week primary care appointments for targeted patients.

The criteria for pairing health centers include variables such as program size, i.e., staff size, serving similar patient populations, whether by ethnicity, minority languages, and/or sexual orientation, most common diagnoses treated and/or geographic location (neighborhoods served). The proposed pairings with what they have in common follow:

1. Potrero Hill Health Center and Maxine Hall Health Center

Operating budget in the 2 to 2.5 million range,
Actual FTEs: 18.8 (PHHC) and 22.98 (MHHC)// PHHC: MDs 2.3 FTE/ NPs 0.5 FTEMHHC: MDs 2.8 FTE /NPs 0.0 FTE
Number of Exam Rooms: PHHC: 6, MHHC:10 (through renovation)
Patient mix: PHHCMHHC: 40% African American, 20% Latinos, 20% European American, 10% Filipino/API
Most common diagnoses: HTN, Diabetes
Neighborhoods served: Potrero Hill and Western Addition Districts
Specialty services: PHHC: adult dental, podiatry, MHHC: PHNs, mental health (provided by UCSF/SFGH Psychosocial Medicine), adolescents, co-location with Westside Methadone Treatment Program

2. Southeast Health Center and Silver Avenue Family Health Center

Operating budgets in the 3 to 3.5 million range
Actual FTEs: 26.79 (SEHC) and 31.23 (SAFHC) SEHC: MDs 2 FTE/NPs .5 FTESAFHC: MDs 2.3 FTE/NPs .55 FTE
Number of Exam Rooms: SEHC: 10, SAFHC: 5
Patient mix: SEHC 80% African American and SAFHC African American, Latino, Chinese monolinguals
Revenues: Ryan White EIP (SEHC),
Most common diagnoses:
Neighborhoods served: Bayview Hunters Point and Visitacion Valley/Excelsior Districts (near OMI)
Specialty services: SEHC: Early Intervention Program for HIV patients, adult dental, Samoan PHN
SAFHC: PHNs, Ob-Gyn, copolscopy, children dental

3. Ocean Park Health Center and Chinatown Public Health Center

Operating budgets in the 3 to 3.5 million range
Actual FTEs: 26.28 (OPHC) and 29.5 (CPHC) OPHC: MDs 2.18 FTE/NPs 0.2 FTE CPHC: MDs 2.15 FTE/NPs 1.2 FTE
Number of Exam Rooms: OPHC: 8, CPHC 7
Patient mix: OPHC 60% Chinese, 20% Russian Speaking, 15 % English speaking, 5% Korean speaking; CPHC: 95% Cantonese speaking, 5% English speaking
Revenues: Ryan White grants
Most common diagnoses:
Neighborhoods served: Sunset/Richmond Districts and Chinatown/North Beach Districts
Specialty Services: OPHC: PHNs, mental health (provided by Sunset Mental Health)CPHC: PHNs, cancer support, mental health, children dental

4. Castro♦Mission Health Center and Tom Waddell Health Center and Homeless Programs

Operating budgets in the 4 million (CMHC) and 10 million (TWHC & Homeless Programs)
Actual FTEs: 33.38 (CMHC) and 52.32 (TWHC)CMHC: MDs 5.5 FTE/NPs 0.125 FTETWHC: MDs 9.5 FTE/NPs ??
Number of Exam Rooms: CMHC:10, TWHC:
Patient mix: CMHC (50% Latino Spanish Speaking, 45% LGBTQ youth and adults, 45 European American, 4% African American, 1% API); TWHCAfrican American, Latino, LGBT)
Revenues: Ryan White Grants
Most common diagnoses by proportion of visits:HIV, diabetes, Hep C
Neighborhoods served: Castro/Mission Districts and Tenderloin/SOM districts
Specialty Services: CMHC: PHNs, mental health (in its budget), acupuncture (Ryan White), HIVTWHC: Homeless programs (20 off-sites including shelters and SROs), HIV, HIV dental

Currently, of the 8 health centers paired above, Maxine Hall Health Center is undergoing extensive capital improvements which will increase the number of exam rooms to 9 and create a patient learning conference room. Tom Waddell Health Center is also being renovated to create a dental clinic in the 2nd floor and increase the space for eligibility and urgent care. Silver Avenue Family Health Center is next in line, again to increase the number of exam rooms to 10, create a patient learning conference room, and install an elevator which will allow patient access to the 2nd floor. Castro-Mission is scheduled for ADA renovations in FY 03-04. The UCC will be expanding its hours in the next fiscal year in order to meet the expected increase in the number of patients diverted from the ED.

Taking 10 exam rooms as the standard for each of the 8 health centers each medical/operations team would consist, as an average, of :

Medical Personnel

3 Primary Care Providers: 1 or 2 MDs and 1 or 2 NPs qualified to be Medicare providers
1 Charge Nurse
2 RNs (and 1 phone advice nurse if no centralized line is obtained)
3 MEAs (vitals, phlebotomy, medical supply ordering, EKGs, etc.)
4-6 HWIII/II (d/c appts, setting up exam rooms, appointment making, medical records support)
1or 2 Medical Social Workers
1 Outreach worker
2 Medical Records Clerks (one a supervising technician)
Public Health Nurses may be centralized in one or two health centers and deployed throughout the City based on language need, patient panel mix, and/or acuity of patient.

Operations Personnel

3 Registration (2903s) 1 Eligibility (2908) /Appointment Clerks
3 Clerical Staff (reception, materials and supply ordering, Point of Service entry of encounters, office work, answering telephones)

Administration: Oversight over the operations and services of 2 sites

1 Health Center Director
1 Medical Director
1 Nurse Manager
1 Operations Manager (more than a Principal Clerk)

The mental health, substance abuse and other specialty services’ staff would be allocated based on specific need-based criteria. Dental services are in the process of consolidating services to one location or two, depending on whether children and adults continue to be served.

Pediatric, including youth, services, a specialty practice, are currently being provided through 4 satellite clinics of 4 health centers (CMHC, CPHC, SAFHC, and OPHC), through children’s and family practice clinics (CMHC, MHHC, SAFHC, CPHC, PHHC, SEHC), at SPY, and CHPY clinics. Many of these patients also receive care at SFGH’s Children’s Health Center.

Assuming that 50% of the current staff of these 8 affected health centers will be retained in this new configuration and 50% of the positions eliminated in order to achieve General Fund savings, then approximately 50% of the patient visits at these 8 health centers will be "lost," as follows (numbers include visits to all professionals, not just primary care providers)....

The 8 affected CPC Health Centers provided 190,333 patient visits in FY 01-02. If half these visits are not provided, this translates into 95,166 "lost" visits, which in turn translates into 18,697 patients (at 5.09 average visits per patient per year for FY 01-02) who will not be provided primary care services. About 27.5% of all primary care visits would be "lost" through the proposed reconfiguration.

The loss of over a quarter of primary care visits would have profound implications for the delivery system network, particularly since the network already has significant problems meeting the demand for primary care services. It will be difficult to maintain the full scope of specialty and other network services that depend on managing patients in primary care settings, and utilization of emergency and acute care services would predictably increase. Primary Care would probably prioritize the most high risk, complex patients and the uninsured, as these would have the fewest alternatives. Lower priority patients would need to be referred elsewhere, or placed in long queues. Many would not be able to access primary care services, since the entire safety net has significant access problems for primary care.