So good morning, I'd like to call the health committee meeting to order from Monday, March 10th. Clerk, take the roll. Supervisor Tam. Present. Supervisor Miley. Here. First item is informational. Let me help system quarterly update. Good morning supervisors. Thanks for the opportunity to present once again. We will go in the following water. Sherry Johnson, who leads our revenue cycle, will present the financial report. Mario Harding, Chief Administrative Officer for St. Rose, will present specifically about St. Rose, and then I will present an overview report. So if that satisfactory, I'll ask Ms. Johnson to come up. Good morning. No, excuse me, I'm gonna walk us through the 2025 financial report summary along with our year-to-date highlights. And specifically around the operating revenue, along with the operating expenses, focusing in on the year-to-date variances. Good news is that we've had favorable revenue variance, and that has been associated with the higher volumes for outpatient and professional fees, in higher net patient revenue in that for approximately 37.1 million. This is collections has been higher than our plan. We've also received new supplemental program funding for the distinct partner nursing facility pass through approved, but not part of our budget. and that came in at 19.1 million. Also the EPP enhanced payment program for calendar year 2023 and 2025 came in at 5 million. The quality incentive program the QIP for 2023 and 2025 came in at 7.2 million. FEMA came in at 5.8 and that has been solely focused around our finance team pursuing our COVID relief. So that was a great news to get in for our COVID at 5.8. Unfavorable expenses have been associated primarily to labor costs at about 4465, and that's been associated with higher FTE utilization in that 227 along with FTEs, along with 21.9 million. That in turn gives us higher wage costs at 13.4 million, and along with that higher benefit retirement cost of 11.2 million. Something that we're watching closely is our materials and supply costs. Those keep going up. That's associated with a 6.5 million and that's again primarily driven around pharmaceuticals and non medical supplies. Next is our January 2025 financial report and the line of credit for the NNB. Well, good news is that we have improved and that's been related to cash flow. What we've had significant risk in is our cash outflows have increased and the NNB is projected to end as a payable of the 13.7 million this fiscal year. We've had strong patient receipts and lower AR days at 59.9 which has made an significant impact along with the supplemental funding above our budget. Again, that's that FEMA receipt of 5.8. The SNF passed through at 19.1, the EPP at 5 and the QIP at 7.2. Please know that the St. Rose funding support is not considered as part of our forecast. Rose presentation. Thank you. So this is a slide that really focuses in on our patient collections, which has been strong. Fiscal year 2025 patient collections is approximately 20.5% higher than the same period of 2024, which is great. Our John George funding remains low as the county smart care implementation stabilizes. In fiscal year 2025 so far we with the agreement with the county at 49.2 million that contract was signed in October of November. Partial payment was received in January of 9.2 million and as a reminder that fiscal year contract for 2023 was 72.1 million. So overall, we're doing really well on our patient collections. This just demonstrates our financial reporting for AR trending. This is a 90 day view. And AR days decreased by 1.4 days from December to January of 66.2 and down to 64.8 days in January. The professional has the same outlook. We decreased their ARDAs by 1.4 days from December to January at 3335.2, excuse me, and January ARDAs ended at 33.8. One of the things that we're really working on is our Enterprise CDI program launched and it addresses provider clinical documentation along with charge automation and uses of the Epic tools. Our pilot program started out with obstetrics, orthopedics and E&T, and now we have moved on to most all of our other practices. I'm going to spend a little time talking to you today about enterprise CDI and what it has to do with finance. Our enterprise CDI program is really about physician documentation. Doesn't matter if you're on the amputary side or the hospital side, documentation can lead to charge capture which leads to revenue. So when we spend time with our providers, one on one, talking to them in their clinic, it allows us to have a lot of different discoveries. So we developed an outline or a skeleton of how we need to meet with our providers, learn what they're doing, and then improve the system. So we meet with them, we have a discovery, we talk about what there are epic tools and how do they utilize them for efficiencies, we talk about how well they know about the charge capture and how it relates to revenue. One of the things that our providers told us is it doesn't matter, we're paid on the FQHC, right? And that was like a strong belief. And what we told them, well, those rates, our FQHC rates are dependent on our costs, which is also reported through our charge capture. So now we have all of our sick physicians raising their hands saying, I want to help, which is great. So learning through their knowledge allowed us to bring on some educators to help them learn how to do documentation or what nuances we needed to do to capture it. Those FTEs are budget neutral and they are working really hard with our providers and auditing. We also hired a CDI supervisor that started last year and again FTE neutral. They're leading the charge working with our provider scheduling time, answering questions and making sure that this program is sustainable. One way that we reach our providers is through an outreach of an email. So they ask documentation at Elmeah Health System. You can email us at any time and will respond to you about documentation challenges. We also meet with our providers on a weekly basis that are enrolled in the CDI program. And we're also working through our telehealth program, which allows providers to really provide better outreach to our community for services. So they don't always have to come in. What do we need to do to improve our virtual communication with our patients, our patients, excuse me. And then we work with our providers to develop lunch and learns twice a week. So now how do we know that's successful? Well, we get about two to five emails per week from our providers. That means we're doing well, but we do have low attendance in our weekly webinar. So we know we need to reach our providers differently. And then we ask our providers to rate us on a scale, a five-star scale. And so far, our orthopedic physician was really pleased with our CDI program. He gave us five stars. And he felt like our interactions with the team has been great. We were very motivated to make changes, and he saw steady progress week over week. And they've really have done well with their documentation and ensuring that epic has been designed to really leverage and move through the patient documentation quicker than what they were. So less screen time and more patient time. So we've gotten really good reviews for that. And that takes us to the end of the presentation. Thank you. Thank you, Supervisor Tam, do you have any questions on the financials? Thank you, Chair Miley. I have a couple of questions. Appreciate the presentation and definitely good news on several fronts like the patient collection. Do you think that the work on EPIC has contributed to that increased collection? The work with EPIC? Yeah, what do you think contributed to the, having over a 20% higher collection than in the past? Well, we have a different tactics regarding patient collections and different levels so when As you know, we have patient pairs deny claims quite often, right? And so instead of just writing that off if the pair says says it's not medically necessary, or if they say there's no authorization, whatever their rules are, we push back, and we leverage other entities to help us. So entities such as maybe cloud med that has maybe a lawyer or some nurses that can review the chart with us, and then send an appeal letter and really win and overturn that denial. So it's really about overturning denials and being persistent. Epic also allows us to put rules in their system so that things aren't just written off, they move and are escalated to the right appropriate person to pursue those. We've had most of our success in that space, but also redesigning Epic to support that. And I think giving our team confidence to say, I need help and not to see it as failure, but to say I need more resources or different levels of expertise to overturn these denials. And that's where we've seen. We've last month we've got paid for 2023 claims. Yeah, which is really good. That means we're pursuing it and we're persistent. At least you're not back five years. No, I get our money. Thank you. On the NNB, basically you're a line of credit. You're projecting that the end of fiscal year payable would be 13.7. I know St. Rose is separate. Does this NNB capture the funding that would go to St. Rose? Thank you. It did not in this visualization, but I think you're aware, supervisor, our intention will be to essentially draw down the balance of what's needed to get the full IGT via the NNV. And so that will play in, but we are looking for other sources as well. And so our hope is to minimize the need to draw on the NNV. we have sufficient capacity to allow us to draw down or to put up the entirety of the half that will allow us to pull down the full 30 million. Okay, appreciate that. The last question is on the physician contracts or services you're seeing large variances in psychiatry and your hospitalists. You know, we have some emerging programs. Like we have CARECORRT that we've contracted with BACS, for example, and we're talking about looking at geriatric psych over at St. Rose and then possibly at Alameda Hospital. How we anticipating that need with physician contracts at the point that we're at, particularly in psychiatry. I don't know that there's a definitive answer. Supervisor, certainly those you articulated nicely, some of the things that we're envisioning to try to bridge the gap around psychiatric and behavioral health care that exists today. So working with our partners with the county, Dr. Trouble and others, we're envisioning how we can do that. So in terms of the contracting and how that will anticipate and prepare for that, we can certainly come back with more details. I don't think today we're prepared to say the specifics of that, but you nailed it. There's a need and we are starting to have those conversations about how we're going to close that gap. I appreciate that. I mean, we keep hearing from Dr. Trouble that there is a shortage. And so having unf contract services is understandable. Yes, and so I received Friday the contract for our agreement with Alameda County Behavioral Health and so I'm going to be signing off on that. So we are about to put a bow on that one and so we will continue to work closely with Dr. Trouble and her team to make sure that we are indeed closing that gap. Thank you. Thank you. All right. Well, this is my first update on how many health systems since I've joined this committee, financials, very good financial report. I'm just trying to get an overall picture because generally as a board member I've received information when we've had the joint board meetings and trustee meetings but now this level of specificity is helpful. I think how often do you come to the committee? Okay, because I think maybe next time I might want to get a bigger overview of just how things have progressed over time. Just to kind of see the big picture, what has been your, because you point out a number of areas where revenue has grown, and then Supervisor Tam has asked some very cogent questions, which I do expect her to be asking. And I kind of want to get a kind of an overview of both how things have been, how you see things going, and just kind of paint a bigger picture. So we can just consider that. We'll do, thank you. Yeah, but I mean, I don't have any particular questions. I'm just pleased that the finances, at least from this perspective, are still very healthy. That is very much appreciated. And I think unless you're projecting any concerns because of the new administration in Washington, or any other trends out there that might impact your revenues, I think that's the kind of thing. I personally would like this committee to kind of be able to monitor. Okay, we'll do, thank you. Good reward, okay. the morning. Yeah, Mario Harding. I am the chief administrative officer for St. Rose Hospital. I've been at Alameda House system, actually, for almost three and a half years. I was overseeing Alameda Hospital San Leandro before I pivoted over to St. Rose November 1st. So I just wanted to give you that context and it's been what we're in our fifth month. I made sure I'm going the right way. So just want to share this with you. Just give you some perspective around both what I'll cover operational and both strategic. So as we are pulling back every layer of the the hospital with electo leaving, of course, out of the health system coming in. So what I have before you is really a map journey. It's really a framework, if you will, that our Board of Trustees approved prior to the affiliation agreement. So, and this is what I operate on day to day in terms of looking at how are we going to move the hospital forward from where it is. And just quickly, again, as we look at physician integration, this is really about looking at the existing medical staff, what services that we have, that we're sending out that we could bring back in. Also looking at our, we have several MOVs around the campus and but looking at the decisions providers in those medical office buildings to see how they, if there's any synergy between St. Rose and those providers. Also maximizing capacity, which really looks at our, we definitely have the capacity. Absolutely, we have more beds than our senses. So that is about increasing the systems to the hospital, whether through the ED or also through transfers, but through other partnerships. We also have capacity to see more patients through surgical volumes. As far as the market need, again, that's looking a bit of certainly what the keyword community needs, but also trying to align that very closely with H.S. and the county in terms of the services there. The last two interventional cardiology, we are a STEMI receiving center at St. Rose Hospital. In fact, we capture about 16% of the STEMI volume in the county. So from there, we are in the process of assessing the existing catholic equipment. It does need to be replaced. So there's a capital campaign campaign underway which I'll talk a little bit more about that. Capital freeze. Again, we early on we looked at what it would take to convert the electronic medical record which St. Rose is on med attack, AHS is on epic, right? So the initial cost was close to about 8 million if I'm not mistaken. So again, just early on, we just did not have the capital to put forward right now to do that, but that is something that we want to look at in the next two to three years to see if we can convert. That would just make it much easier. Patient. Singing patients across. So anyway, so that's the framework. I'm going to go into operational initiatives. There's quite a bit here, but I want you to just, just on the context of how we're approaching St. Rose and the tactics and strategy initiatives that we're looking at across the board. So these five buckets, streams, if you will, we're looking certainly at primary and specialty care on campus. There is some primary care. And as you know, H.S. has wellness centers both in Heywork and in Newark, and we want to capitalize on those. Yes, we're seeing some of those patients from the clinics at St. Rose. Some certainly come through our ED. But we know there is a need for additional specialty care. So we're assessing what that could look like on the campus there. From some of the other specialties that could be pulled maybe from Newark and Hayward to a larger presence there. We're also working collaboratively with diversity of ASCAS. They've expressed interest have been on site. We'd love to have a footprint on the campus. So we're working with them and there's some additional work happening there. I'll go through these, just sake of time, but labor and delivery, as you know, we suspended labor and delivery and patient services there, February the 18th. So we're looking at a completely different model. That work is just underway, and that dog is helping to, we're looking to pull a consultant in from the outside just to help give some framework around that. But the model will be different than what we have seen in the past. Dentistry, pretty significant when you think about Alameda Health System, the presence of dentistry certainly on the Highland campus but also the Eastmont, Eastmont Wellness Center which just went through an expansion. We're working with Dr. Charmaine Eink who recently received a grant from the state to expand dentistry and part of that she really wants to expand in the south area which is Hayward. So we have the ability to do that with the space there. We've got procedure rooms. So that is one of the areas that we're looking at for sure. I'd mention operating procedural practice. And again, one of the things we definitely have identified as a need is GI for sure. We've seen GI out and there are efforts underway to look at bringing in a provider so that we can keep that in service in. The other part that is expanding our, as I mentioned, our cath lab, which that work assessment is underway. Oh, yes, sir. What's GI's did? Oh, I'm sorry. General, it's gastroenterology. Sorry. thank you for that. Some said with the healthcare acronyms. So yes. So again, we're looking at the opportunity to bring in specialties that have been limited. The volume has been low. So what can we do to bring those volume up? And then lastly, just about occupational health urgent care. It's just something that we think there is an opportunity to need there, you know, just in, from the employees that work there, but also possibly of contracting with outside entities for occupational health and then urgent care as well. So I'll try to go briefly through these, but this really gives you a sense. This is what I do day to day. When I moved into this role in November, essentially, I knew the financial constraint, which are still significant. We're five weeks in, sorry, five months into the affiliation and I'm looking at everything in terms of contracts, you know, staffing over time. These are things that I have to look at in order to try to strike a balance because as I mentioned it's challenging week to week sometimes payroll to make sure that we're able to sustain operations, understanding that we still have growth that needs to happen. So this just gives you a sense of how we're monitoring the organization every day, but every week. We look at our cash flow, certainly several times a week, but as a team, we clearly look at what our projections are going out for a month and a half. if I to, and I'll talk about this later, you know, dip into the line of credit that we have with with HS. So but operationally what I'm doing again is, you know, again, I am working with all the department leaders at St. Rose Hospital just make sure that they understand certainly the challenges were up up against and that you know because the HS is here you know they've been extremely supportive which you know as HS has been will continue to be but it's also about the Department leader stepping up as well to do what they can to help make sure that we're doing we need to do to move the hospital in the right direction. I talked about contracts again looking at every physician contract provider contract supplies and vendors to see where we can leverage with HS and that's what we've been doing. We'll go back to a vendor and say now Now we're part of the HS. So we want that level of discount that you would give to the to to HS extend at the St. Rose. So those are some of the things that we're looking at. Again, I've talked about referrals MRI services. Again, we do have an MRI on site there. and just want to continue to look for ways to take advantage of providing getting more volume there. Again with any organization as I come in I'm looking to fill some management positions but not all because there's just some departments are small and we can get by with our compromising operations. So that's part of the assessment that I'm continuing to do. And then just lastly, as when I think about operational updates, some of the feedback from the SART, the St. Rose staff, and again, we're five months in, we just wanna, we're doing everything we can, of course, make sure that there are, which they have been included into any HS meetings, right? They're a part of HS, so we wanna make sure they get to participate in our monthly department meetings, also our leadership desk, upshed all the staff there on the weekly base. So they get to chime in and hear what's going on across the health system, which is important. Some of the updates. So as you know, St. Rose, we have a 29-bed sub-acute unit. The unit actually did open on February the 10th, but only for, it's a short-term skilled nursing. You see the specifics there for commercial insurance, workers' comp and private pay. So, you know, per our initial survey with CDPH, we needed to get some patients in the facility there before we moved to what we call a distinct subacute SNF unit, which would require more intensive survey. And by doing that, we would be able to take more, certainly take Medicare, Medi-Cal. So I will tell you, it's been almost a month and it's been a challenge to get admissions there, commercial. There's plenty of Medicare patients, but we can accept those right now. So, as of this morning, I got sex that we have our first admissions. Again, this is commercial today. So once we're able to get enough patients, and I put on, you know, close to seven patients consistently, we will reach back out to CDPH, CDH, CS, I should say, approval for distinct. So we can get surveyed that then would allow all of the other patients' admissions to happen with Medicaid, Medicare, which again should fill the unit for sure. And of course, we're working with Kaiser. That's probably one's one of the healthcare organizations that expressed a great deal of interest and we're just trying to finalize the rates so we can see their patients there. But so anyway, the units it's open, but it will only be staff and we have admissions. Okay, I had mentioned early on about I'd mentioned about about interpersonal cardiology. So again, given the fact that our, actually our, interventional cardiology, our volume is up 11% to date compared to the previous year to date, which is, actually, which is great. I did, I had mentioned there's a correction on the slide. It says 23% at, really, that's 16% of Alameda County for us, Demi. And right now, as I mentioned, we're going through some work that was previously done by elect of just in terms of our cath lab, upgrading the existing equipment that's already there, but there's also the ability to expand in the room next to it. And that's exactly what we're looking to do. Fortunately, with the 3.5 million contribution from Alameda Alliance, that was given to the H.S. Foundation. We're going to invest those dollars into the cath lab. This is by far one of the areas that I say from a financial standpoint is doing well and we need to continue to have the equipment working consistently just, you know, and just make sure that we have the best equipment for patient care. I just wanted to give you just an idea of kind of where the service areas for St. Rose Hospital. I mean, you can see the primary service areas really Hayward, Union City, San Leandro, and San Lorenzo. Certainly where our discharge has come from. and you can see this came from H. Kaya County Year 2022. If you just expand that out in secondary service area really it captures certainly more you know, free month Oakland of course and Newark as well. So so again that's the opposite the areas where we have the ability to draw in more patients and but in order to do that, we will continue to have to look at the services that we provide. What's going to, you know, what will draw a patient to come up to St. Rose, what will require physician to refer a patient to us? The next slide is just wanted to share with you. This is a campaign that we're kicking off with, we've been working with the HS marketing team around this. And so we'll have, send this to all the residents. You'll see in those zip codes, households. And the newer version of the postcard, which I didn't include here, but it has QR codes on the bottom that will be in Spanish, Chinese, and Vietnamese. So, but again, this will go to all the households and those zip codes just so folks know, hey, St. Roses here, it's in a field of Alameda Health System. You know, quick, you know, again, we can get you in in 30 minutes or less. So, and again, the ED is, that drives about close to 9% to 10% of our impatient volume. And their volume has been up 3% to 5% year over year. So, we want to continue to push the ED when they need it there. Also, I want to just give you an idea, you know, of course, with an affiliation comes new logos, right? So, just gives you, this is our branding. So we're in the process of changing out the signs, mixed-through signs across the campus, as you can see. That's the logo there. Well, sometime in the future, you'll see this sign that's a bigger project on the hospital itself. But I just want to give you a sense of so you can start to see what's happening as it relates to the branding of St. Rose as an Alameda Health System affiliate. Okay, so I'm going to go into to the finance and on the virtual clouds where I have my colleague Christine, Kristi Rober who can help chime in if I miss anything here. But so just a summary of kind of since October of last year, right, where things have sort of progressed in terms of the finances, right? So again, as you know, we're, we're membership issuance agreement which really solidified the affiliation. I did mention the $15 million line of credit to support the operations which certainly needed. Again, St. Rose has its own board. It's a private hospital within a public health safety net system. So again, all of our financials, their major decisions go through that board first. Then they eventually make their way up to the Alameda Health System Board of Trustees. So just wanted to give you a little some timeline here. When we went into, and we'll talk about the budget for fiscal year 25, I mean, we had to put the budget together. There's nothing in place during the transition. There wasn't like a handoff, right? So we, essentially, we took the expenses from fiscal year 24 and tried to make adjustments as best as we could based upon the information that we had. And then we'll talk about the IGT which James had mentioned earlier as well. And what I was going to mention is, so again, we're into March now, again, our financials for the organization get review, we'll be reviewed at our board meeting later this month. We will be moving forward with an application regarding the stress hospital loan forgiveness. We absolutely need that given where the hospital is. And again, the cliche about turning this around over, not I can't say that it will take some time to turn the hospital around. And but know that we're doing everything we can to move in the right direction. So here just gives you an idea of what the budget, what we approved for fiscal year 25, is you can see there's a projected loss of 20 close to 23.7 million dollars. And part of that's driven by, again, as I mentioned, we're using our patient volume and expense run rate. The L&D suspension, of course, which occurred last month and then we're expecting, we're making every effort to get the subacute towards that distinct SNF status. We say April 1st, it may be, I'm going to say that date's going to be pushed out a bit because we just starting to get patients in. So again, you'll see the funding actually, particularly I think the supplemental funding is sort of reduced the revenue there, you can see from close to 120 million compared to where it was previously. So all those things in the expense categories, which again, salaries, purchase services, supplies, those are all the things I had mentioned previously that we're looking at day to day. I look at every invoice that comes into the organization. I sign off on every invoice, I sign off an every check that goes out of the hospital. So I have eyes on line of sight on what's happening. But still, you know, again, we will make every effort to, you know, understanding that with the match of the IGT funds certainly will help, but that's not until I think May if I'm not mistaken. The next slide just gives you a project of the cash balance. So as I mentioned throughout the week, and especially on Tuesdays, we have a cash flow meeting just to look at what funds we may need for the following week to help support payroll. So again, we are already borrowed close to $5 million from the line of credit so far. And again, it's every week, I guess, I'm looking at our collections, how much we paid a vendors and then payroll. And that helps to give some determination. What's coming in also from H. Quaw for some dish to make determinations about what to borrow the next? I'm making every effort not to dip too much into the 15 million, but HS understands that we certainly may have to do more. And when you look at the graph there, you can see the 15 million dollar, which is the line of credit, we get very close to that at the end of April. And the dotted line, of course, is the IGT match funding. We secure that, that sustains us. So, again, with the match and with the support from certainly from the Board of Supervisors to help us move that. So I think that might be the last slide I have. Certainly open it up to questions. And thank you. Thank you, Chair Meimey. That's kind of grim, but. So the projected 23.7 million lost, how much worse would it have been had we not had had you not suspended the the labor and delivery of February 18th? Oh, it would have been we estimate about a three million dollar loss with the LND unit so so that would have put that close to 28 million. Well, sorry. So five more. 27. Okay. 27 million. Just to kind of recap in my mind, that when labor and delivery got suspended on February 18th that the staff staff moved to other facilities within HS or? Most took surveillance packages. There was, I know at least one of the Arians that moved to High Line if I'm not mistaken. And we had one or two OB-Tex that left the resign. Once I stay through the 18th took a severance. They already had some positions lined up. So again, you know, a part of that whole process we were certainly and there were, there are, I think there are three nurses if I'm not, who are out on leave, but will come back into per-dem positions. So they'll work either, med-searched unit, probably could be the ED. So that's really kind of where everyone went to. So for the most part, most of those employees took us heverance. Okay. I'm hopeful that because of the shortage that they will have other assignments at other facilities. Yes. So I understand you're having gone through the turnaround at Almea Hospital the sniff units the skilled nursing facilities are You know for a lack of a better phrase they they tend to be more money makers for For the system So you're running into this chicken and egg situation with trying to get at least seven commercially paid before you could get the licenseeer but then you know the Kaiser is the Sutter's and you know I assume even Highland because Medicare pays like I know 100 or 220 days or something like that maximum. So I think it's going to be important to secure that licensure and yes if you can You know maybe thrive some people we have Kaiser supervisor Tim. Yeah, we we have you know Richard Espinosa He's the chief administrative officer for post-eversist for Alameda Health System Amazing work. He has been making calls we have even know, to see what we can do to waiver or to, I mean, we want to make sure that we get some traction around the patients. This is a new unit, right? Make sure we get traction around patients. And hopefully we can sort of close that gap in terms of the timeline. The staff are ready and I think with this first admission that's coming through this afternoon, this will, you know, I think it'll certainly open up. I think one of the things that also just up until last week, we got access, so it became a member of this. It's called a care portal network where you can see SNF referrals across the state. And that has helped us. So we've gotten referrals in, but those referrals, once we've vetted them, has not translated into an admission. So, but yeah, we're absolutely doing everything we can, including, you know, of course, HS to help move the dial. So we're going to get there for sure. And again, we've, we've, you know, done it, tremendous amount of outreach to other hospitals, CEOs, executive. So, but we're continuing to put the word out there for sure. I appreciate that. I have confidence, you will. So the last question has more to do with the IGT transfers. I'm looking at your projections and I know that recently the board through to supervisor Mark Hess in District 2 had allocated a million dollars from her budget but it doesn't seem like even with the I GT because you're at 8 million you're trying to leverage the match that you're going to be able to close the gap. Yeah so you know and I hopefully I have my numbers right on Christie, and of Christie's you can chime in. So my understanding is the match could get us close to maybe 30 million, I believe, with what AHS is also attributed towards that. So if we take that 30 million and apply it against the 24 that helps significantly. So Christy has her hand raised. I'll let her chime in because she's been intimately involved with this. I'm looking at 30 and 24. There's a six million dollar. Yeah. Yeah. I mean, I don't take it lightly, but Christy, if you want to chime in, please do. Sure. Can everybody hear me okay? Yes. Okay, thank you. So, with regard to the budget, we only included the IGT assumed at prior year levels, which was 14 million. And so we just based on the community support that we had received and the federal match putting up those community support that we had received and the federal match putting up those community support dollars and the federal match on that would bring us to 8 million. But we're in the process. AHS has agreed to donate the additional 14 million that we would need to put up in order to maximize the IGT. So that would bring the IGT support to 30 million, which would close that gap. I'm old, that 14 million come from the NNB. I believe the source of it is the NNB, but it's not James or Mario can maybe stick here. Yeah, that's great. I believe that's what I believe the board approved donating that 14 million to maximize the I GT. To supervisor Miley's point is your federal match on the I GT going to be potentially compromised with the federal administration? James says no, so we're... Yeah, I don't believe so. No. Okay. And obviously, we're helping to turn the corner on this in a very significant way. And so I want to also appreciate that we have to look at whether it can be sustained beyond this year, right? So- Absolutely. At what point will we know whether it's sustained-? If I may. Go ahead, Chris. Yeah, if I may, there's a couple of unusual circumstances that you're seeing in this particular year. One is there was a severance for the separation of electo. So that's an unusual expense that the hospital incurred. I believe almost $4 million, which you won't see as a continuing expense. Second thing is the, they received, St. Rose received some extra IGT last year that is not typically budgeted or spent. So they received an additional $5 million from Alameda County. They received, I believe, close to $4 million in extra private dish funds. So that's why you're seeing the big gap in the revenue year over year. We're assuming that the volumes will stay the same, even though we have seen just since H.S. took over an uptick in the volume in November and December. Those financials are starting to come in. So we're starting to see just by a volume increase when they were on a downward trend under electo. So the volumes are starting to come back. Mario and his team of leaders are working on improving the expense side of it. And then you won't see the continuing unusual expense that you'd seen in prior years with the separation of electo and that expense of $4 million. I appreciate that, and that's the severance part, but even under electoral, the trend was going down despite the contractual payments to electo, right? But over time, you're gonna run into this situation where you have to make certain capital improvements to bring up the volume based on what your market studies are gonna show. And you're kind of in a difficult position, like we can't even get epic right now at the $8 million cost that you talked about with St. Rose. But at some point, we need to do that. So I'm just trying to understand, how do we turn that, when do we know we turned that corner? Yeah, I mean, I would say, again, there are some of the things mentioned earlier. We we So St. Rose was a part of the beach of application that was submitted in December. So for both this gerosyc and a meta-psyc unit those you know When we look at from a future standpoint, that's probably maybe two to three years by this time If if we're given the go if yes, two to three from a construction standpoint. And, you know, again, I don't want the epic mediatek to be a barrier. I mean, we've got a team that's looking at really sort of how you do that on the back end. I mean, it's no different than, you know, when you come from a private or non-affiliated hospital, patients still come to St. Rose. Let's just say for X-rays and other things. And so we're looking at how to just make that process a bit smoother. It's usually more like any e-facts. And so there's some work happening behind the scenes. And we just actually met on Friday to just work through the flow of what that would take. So again it would be ideal yes but until that happens I don't want that to be sort of a crutch. We've got to get patients in. We've got to figure out how to you know get referrals. It's just a little bit more grime but we have to do it. So, so, so, and again, some of the things that I mentioned previously, you know, we are looking at, you know, St. Rose just has not had sort of this high sort of, or expansion, like specialty services there. So part of this too is rebuilding the connections in the community, particularly with providers. We're hearing from providers, they just, we sort of lost our way. That's the best way to put it over the years. And so we're figuring out how do we pull them back in to say we want you to be a part of this hospital in this campus. And so that's rebuilding relationships. So that work is way as well. But we want to assess the things that are moving out that we could easily bring back in and that will help tremendously. Okay, so great question. Thank you. Thanks. Okay, yeah, thanks for the presentation. In this update, it's been very helpful and And mind you, I'm not the sharpest knife in the drawer. But there I do have a few questions here. First of all, refresh my memory. So there is the same rose board as the approved things in the Board of Trustees. So the same Rose Hospital has its own board, which are comprised of H.S. as well as community members. And so it's a private board, of course. So the actions that happen then that board just feeds into the Alameda Health System, Board of, the Finance Committee, and the Fool Board just for transparency and awareness of what's happening within the hospital. But does the Board of Trustees... There's no board... Sorry, there's no Board of Trustees within St. Rose, just a Board of Directors. So, but ultimately, does the Board of trustees have the final say? So the St. Rose makes its decision. I would say, yeah, once it goes up to like the board of trustees for Alameda Health System, yeah, I would say they definitely have direction and James can correct me if I'm wrong. But if there are decisions, we try to make sure that those are caught at the finance committee, which then goes up to the Board of Trustees for review. And if there's anything that captures that may garner their attention they can certainly address. Because I mean I ideally we want everybody to be in harmony. Sure, absolutely. And I'm just going to give a sense. Ultimately, there's a buck stop with the Board of Trustees or with the St. Rose Board. I'm going to say with the of Trustees. Okay. And and that the same Rose Board is there any Board of Trustees who sit on the same Rose Board? You have any representation on that board? You know we are if I'm not mistaken and I'm trying to remember I think it's trusty Fox Freeman that we're bringing, but I can't remember. So right now, no, yes. Okay. Right. And I'm gonna be all over the place with the stress hospital. So you're hoping to get 17.6 million? Really, yes, which would be the, that would be the entire loan itself. Wifed away, correct. Okay. That would just be huge if that can be, waved by the state. So it's just, again, with all the stress that's happening with the hospital, the work that we have underway. It just gives us a fresh outlook. Get ourselves together and you know, sustain going forward without sort of having that burden. Oh, Christie, I'm sorry, your hands up. Yeah, I was just going to add to that on the Distress Hospital loan program. That has to be forgiveness has to be achieved in two phases. The first phase in year one is a deferment. So you apply for 12 months of deferment. It's basically driven off your financial ratios, which obviously at St. Rose makes us an excellent candidate for that deferment for the first 12 months. We will reapply it next year and then they'll look at it again to see if we're eligible for forgiveness. It is 17.6 million. Those payments are 290,000 a month, I believe. So payments are set to start in July. But if we can get this 12 months forgiveness, we can maybe get those 12 months deferment, then it would differ those payments for another 12 months to July of 2026. So if you're successful, what will they do for the bottom line for St. Rose? Just in terms of the lift of that loan. Yeah. Yeah, I mean, I Yeah, go ahead, Chris. I was just I was sorry, Mario. I didn't need to cut you off I just improved the cash the cash position. So if you're not having to make there's no interest on this loan So it just makes it just improves your cash. I see. Okay. Um, then with the primary service area, but 80% is San Lorenzo Hayward, Union City. So how does that compare with like Alameda Hospital and San Leandro hospital? It is it about 80% there or is like Alameda hospital is like 99% and San Leandro's like 95% yeah, I'm trying to get a sense Christy probably knows that because I got the slide from her and I can't think of the exact but it's. Christy do you have that? I know. If you were looking at Alameda and San Leandro. So when you look at all of the hospitals within Alameda Health System and then look at at St Rose, you you'll find that probably 70% of the service is in that is in the share. There's only most of the zip codes that provide business to each or feed each of these hospitals is shared in sort of the central market. And then there are some zip codes that are unique to St. Rose, like South in Work. And I'm sorry the file isn't up so I can't speak specifically to it but you'll find that you're not in competition. You're each pulling from that center market. Yeah, and I was just trying to get a sense because I know you're going to intensify your Marketing into that market. So I'm trying to get a sense by doing that Logically, that's going to increase the patient Yeah, I am a hospital which should increase your revenue. I just want to Been the case because you see that in San Leandro hospital. You see that? I mean, I was just trying to. I'm just trying to. That's exactly the thing. I'm trying to play with that. So yes, the primary patient volume at each of those hospitals you talked about, Alameda, San Leandro and San Rose comes from the catchment area immediately around the hospital. We've used the same strategy previously. So what San Leandro, we literally sent the cards out that Mario just described to that catchment area to essentially reintroduce San Leandro to that community to, and it worked. We were able to drive new business back to the hospital. So it's the same strategy that we've used successfully at San Leandro and at Alamedaa, which we're now gonna be using at St. Rose. Gotcha. All right. And then there was another slide where you talked about, let's see, where is it? It's basically dealing with economy of scale, trying to get vendors contracts that no maximizing what the HS has done in getting this similar kind of support at St. Rose. Is that going to go beyond just vendor contracts? Are you going to try to use your good logges to try to help St. Rose out. You know, Academy of Scale. Yeah, I mean, that's absolutely. I think that's one of the biggest vendors that we utilize is Vizian, which is a GPO, general purchasing organization, if you will. That's, I want me to help system use, but also was already in place at St. Rose. So now what we've done is say, now let's pull the contract and look at you, and quote you, many busy, and incorporating St. Rose and to the contract overall. So again, we get the AHS economy of scale and so I think some of our initial savings were projected close to three of four hundred thousand dollars by doing that. So but so that's just one of the major But there's so many other vendors and even physician agreements, right? That we can look at start So are just peeling apart and saying, you know, the opportunity is there and we wanna take advantage of whatever discount that you give to HS, please extend it. You have to extend it over to St. Rose. Yeah, and I do, you know, supervise your time. That's a number of great questions. And I do think it's going to take time. And I do value the fact that H.S. stepped in, due to the support of trustees approved it. I know you wouldn't have done it if you didn't think you could achieve success there. So definitely appreciate and value all of that. And want to be supportive of that. Thank you. And I'm confident we'll continue to have these quarterly updates so we can monitor how, you know, what progress is being made, as well as if there have been any setbacks or concerns unintended consequences, things of that nature. I mean, I think you just have to be transparent about that because I think we all want want you to be successful with the same rose. The other thing is I was impressed you look at every invoice. Every year. Is that right? Every invoice. 12 dollars and up. I do. Every check that goes $12 and up has my signature on it. Okay, very good. Level. I do. Every check that goes out $12 enough has my signature on it. Okay, very good. That level of scrutiny I think is extremely noted. And so, I think my last question is a broader question once again, Because you're about five months into this and it gets to the superficial to him's question. With the agreement, is there, and I'm not saying this because I'm concerned about it happening, but what if we're not successful? What's what happens? Yeah, you know, I mean, that's a great question. I hope and I'd have to think that, you know, me being in here three and a half years, when I look at St. Rose, and I look at Alameda and San Leandro, which were in the same place 10, 11 years ago. I have to think we can replicate that success. It's just, you know, it's going to take time. It's going to be pain points. And I've been sharing that with the leadership, you know, the things that got us to where we are today are not going to get us to where we need to be in the future at St. Rose. So we have to do things differently. And again, reimagine the services there. I just want to also mention just a couple of things that I overlooked. One, we are receiving transfers from Highlands from some of our other hospitals. So we're now in the mix to receive patients. So that's another way to increase our senses. And so we're pulling in from the ED at Highland to get patients over to St. Rose. So it's, there's a gradual increase that's happening there. I think the other thing I wanted to make sure I just mentioned is that we're certainly not, St. Rose. All of the hospitals have their own unique what they do. So, you know, we don't want to count up a lies in either hospitals we want to find, you know, certainly ways to share and collaborate. And so, you know, St. Rose has a cath lab and a MRI, St. Leandro doesn't. Alameda has a stroke center. So we have to capitalize on our niche, what makes us best in order to support the system as a whole. So we all have our place and lifting an elevated health system. It's just going to, like I say, make it take us a little while to get there. But we're on the right track to get us there. But we've got to remain steadfast in the work that we're doing. And what the docs, the docs is, what's the relationship with the docs at the different hospitals? Is it one network of doctors or is it unique or what's that look like? So St. Rose, of course, the docs are, they're all from the community, right? So they're contract, they're on medical staff, which, and they're, for the most part, they're, you know, again, they're contract, right? So H.S. is a little different because we've got employed physicians there. And so, but St. Rose, their community docs, they've been a part of the hospital for years. You know again, I'd like to be honest, I'd like to infuse some younger, you know, and that's just a part of healthcare, right? As the physician population sort of age out, you want to try to draw in others, you know, in that space. So, but it's a little, you know, right now the physicians that are at St. Rose, some groups do cover by contract. They cover Saint Leandro or Alameda depending on the specialty. So we have some of that overlap, but predominantly there are physicians that have been a part of that hospital physician. That's it. Oh, sure. It's important to acknowledge we value the community-based physicians that have sustained St. Rose over the years. And so we are actively working to engage with them to figure out how do we create synergies so that they feel comfortable sending their patients to St. Rose. And so their number of MLBs, Mario mentioned on the site, the physicians are working there. And so we're not getting all of that business. And we believe we can have more of that business come to same roles, so we're working on that. You asked about physician relationships across the system. We have what was known as the Alameda Health Medical Group, HMG. And so that is an entity that employed a lot of the physicians who work in the Alameda Health System. We are in the process of winding that entity down. Those physicians will be employed by AHS. We do have other contracted relationships, and so our primary model is an employment model. We are unique to a certain extent in that way, and then we can employ physicians. And so we're looking to integrate the doctors at the community-based physicians at St. Rose. They have contracted hospitalists that are there, and so we're working on making sure that we optimize that contract. And then as Mario noted, pushing some of the specialty services that don't exist at St. Rose today, that we have within the system, making sure that we make those available to St. Rose to the extent that we can, or conversely bringing those patients we needed into another AHS facility to get it. And that's the synergies, that's how we will optimize the continuum of care. Okay. I don't want to belabor it, There's just two more questions. So, H.S., particularly the Worma Chan campus is a trauma center. So is there any synergy between that and the rest of the network? Absolutely. So, you know, Mario mentioned that we are actively looking to transfer on our goal as four patients a day. I don't know that we're hitting it, but patients who are from that community who the level of care they require is appropriate for St. Rose. We're looking to move them there because we do have, you know, some flow issues at the Wilman-Channe Highland Hospital campus that we can address by virtue of getting patients to other levels of care such as St. Rose, Alameda, Sanli, andro, and so we're looking to move patients across the entire system in a way that really allows for the best care in the best location, hopefully close to their home. My final question, I think in the presentation, you mentioned that St Rose there's bed capacity. Now how does that compare with the other hospitals in the network? Like is the bed capacity at St. Rose 50% and at the other hospitals it's, you know, it's, there's, more of the beds are taken up. up so there's less capacity so I don't know what that look like. Now I understand the question I don't think we have the specific data but I can tell you that the woman Channel and hospital campus is the most impacted so patients are often not getting up to the floor as fast as we would like because they have to have a bed so if we can move move patients out of those beds and to one of our other facilities that has more capacity like St. Rose, it allows for full capacity to get patients out of the emergency setting, out of the intensive care setting and into a med surge bed. So that's what we're trying to do is to really optimize moving patients across the entire of the system. And so we can come back with specific numbers, but we have significant capacity at St. Rose. And to a lesser extent, the same is true at San the Andrew and Alameda, not so much at Hyde. And so we're trying to optimize the other facilities to create that poor capacity at the woman in Hollywood. All right. Always got thanks for the presentation. Thank you, Mike. This is my only second or third meeting on this committee. So I'm trying to get up to speed, but I've realized it provides your time to have all the answers. Let me just keep querying you, but thank you. Very good. Thank you. Thanks for your support. Absolutely. So I have one more presentation in the interest of time. I will be brief, but I do need to just start off by restating something that you said, supervisor Tam, and that is supervisor Marquez, basically made all of her discretionary funds to the sum of a million dollars I believe available for St. Rose to help us draw down the IGT. So with support like that from the Eden Healthcare District, from the city of Hayward, from the Alameda Alliance, those are the kind of, you know, it's one thing to have organizations talk about. They support St. Rose and they believe in St. Rose and supervise the Marques, the supervisors in general, and the other entities I mentioned really have stepped up. And so we are We are grateful. Obviously more will be required, but we've seen the support from the entities that I mentioned yourselves included that gives us the confidence. One of the questions was, what happens? How do we know we're gonna be able to sustain St. Rose? And nothing is promised, but with the kind of support that we've seen with the increases in volumes, ED volume is up, inpatient volume is up. We've seen increases that suggest that, it's not just the Hawthorne effect, it's not just because we're watching it. People are starting to choose St. Rose again, and we believe that's gonna be the difference maker, and so Mario's leadership, and helping us on a day-to-day, provide that level of scrutiny that he talked about, and also really just changing the perception of St. Rose. We are talking to Tiberosio Vazquez, which is one of the FQHCs in the Hayward area, and we are having ongoing conversations about trying to bring them on site, because we believe that there is a reason for them to choose St. Rose. And so we're working with their CEO to try to facilitate that. LaFamilia is already there. So we're looking to grow the relationship with LaFamilia. So really turning over every stone to make sure that we are not coming back to you with a different message about St. Rose. So I will go into my report. I am going to be very high level. Welcome your questions. Stop me if there's something you'd like for me to focus on a little bit more. So using our pillars on our first pillar of sustainability and I just wanted to talk about something and Mario mentioned it briefly. We recently opened expanded services for dental and ophthalmology at the Eastmont Wellness Center. This is significant. In the picture, you can see that Senator Errigin, we had a assembly member, Bonta, with us, as well as the physicians who are the leaders of those programs as we open this expansion, we are going to basically add 18 to 20,000 additional dental visits capacity by virtue of this work and also a dramatic expansion of the ophthalmologic services that are available to patients and doing it in the community and supervisor Miley you and I had a conversation about this but really taking the services to where the patients are and not making them come to one central location was really our goal and reinvesting in the East Oakland community. So really pleased and proud of this work. We recently relocated our pain procedure clinic to the Womachan Highland Hospital campus. You can see here this took place as of Monday March 3rd and we are going to be essentially co-habitating this service with the gastroenter, the GI services, gastroanalogic services, and increasing staff to make sure that we can manage the volumes there. So, we're really pleased that these patients who really have a vital need for these pain services are able to receive that service. Supervisor, Tam I did this for you. Alameda Hospital and what we're doing over there. There's been some question about our commitment to Alameda Hospital as we are bringing St. Rosanne and I just really, I take that to heart because we are extraordinarily committed to Alameda Hospital. So we have just synopsis of some of the work that's happening there right now and so improving the HVAC which is the heating ventilation air conditioning infrastructure as well as moving to our seismic retrofits. So all of this work will be part and parcel with meeting the 2030 seismic deadline to make sure that that hospital can continue to provide acute care services for the foreseeable future. So I'm making significant investments in Alameda Hospital. How many emergency rooms are still in service right now in Alameda? We've not changed the number of days. So the emergency department has the same level of service that it's always had at Alameda Hospital. I was talking about surgical rooms. Oh, the surgical, we are not doing, we have surgical capacity, but we have taken the elective procedures out of the facility. And so the number of rooms remains the same, but the number of procedures has gone down because now we're doing emergent or actually emergency procedures, anything that can be transferred out from a surgical perspective is being transferred out. Okay because I was told that the the reason some of the emergency rooms were not functional was because of the eight-fac system issues that you were talking about here. Sure and so and I just not to belabor it but you refer into the OR services, because you said emergency services. So I want to make sure that we're clear. Emergency services are unchanged. Surgical services, the rooms remain. And this work, because number two on the list, the humidifier system. That was one of the big challenges is that we couldn't achieve the right humidity level in the ORs. And so a lot of the procedures that we otherwise would have done We just couldn't because it wasn't. And so this sort of work will allow for those sort of procedures to be done there if the need arises. And so again, the same number of rooms are available, but we're changing our ability to do procedures at Alameda Hospital by virtue of this work. Thank you for those questions. Moving to the quality of care pillar. I want to talk briefly about CMS surveys and post-acute care, and this is my opportunity to crow about Richard Esponosa, who is the CAO for post-acute care. Mario mentioned him a moment ago, but Richard is phenomenal, and he and his team really do excellent work, and so five stars is the highest rating that you can achieve, and you can see that at both the Alameda facility and what's referred to a San Leandro's Fairmont. And so you can see that both of those facilities in the most recent reporting period, which was February, are five stars. And so they are rated the highest that they can be and they are in the top 10% in the state. So just really pleased and proud of that work. Congratulations. Thank you very much. I'm sure Richard is somewhere watching. Gidey, I want to talk about the staff and physician experience pillar. And this is kind of the issue of the day is immigration. And what are we doing to make sure that those who really deserve and need our care feel safe getting care at our facilities? Given the changes at the federal level, there has been somewhat of a chilling effect for people, both patients but also staff who have immigration status that could result in deportation. And so it's important to note we're going to comply with the law. We have no intention of defying the law, we're going to understand the law. And to that end we have made information available in multiple languages available in all of our facilities and we have essentially a dedicated hotline and people like Mario and myself will be available on call so we're a federal agency to arrive at one of our facilities to enforce an immigration action. The frontline staff will be able to call us and we will intervene so that they can go back to providing care. So really allowing them to to be the caregivers that they Signed up to be and we will do the work of interfacing with the federal agents. So We are very committed to making sure that people know they can get care and that we serve all regardless. One thing that Sherry mentioned, which I want to emphasize is telehealth, because what we saw the last time there were immigration questions like this, people chose telehealth because they felt safer using electronic appointments versus physically coming in. And so Sherry made note of the fact that we are increasing our telehealth presence and It helps in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are in the same and we are to the community. Finally the day of service. In January, on Dr. King's birthday, about 30 of our staff went, and we do this about two times a year, we go and package food for the community at the food bank. That is a critical resource, and we're very happy to support them. And with that, I will end my report and happy to take any questions or provide clarifications. I have no further questions, but great report. Appreciate all the work that you're doing, particularly as we deal with these unprecedented times or maybe unprecedented times that we've had. So let us know how we can be helpful be able to do that. And we're going to be able to do that. And we're going to be able to do that. And we're going to be able to do that. And we're going to be able to do that. And we're going to be able to do that. And we're going to be able to do that. And we're going to be able, but I wanted to give you a chance that we will continue to provide care at all. Thank you. Yeah, just a couple quick things. So appreciate this. The Eastmont clearly is near and near to me. I have an office at Eastmont. I've had probably been at Eastmont with an office since my days on the Oakland City Council. I'm out there every Friday, errands out there as well. So I mean, anything to continue the enhancement of the services out there is just very much valued. So I appreciate the fact that wellness facility is now expanding its dental program. I appreciate you saying that. I've told the story. I used to catch the bus to Eastmont when I was a kid. I'd get on the 57 and go shop in there. And to be at the helm of an organization that is reinvesting in the community and making sure that care is available where it's needed, nothing gives me more pride. So I appreciate your commitment to Eastmont to that community and I look forward to the opportunity to show you what we've done with the place. Yeah, I mean, it's just really great. Excellent. Alameda Health System in County, the city, making that Eastmont a hub of community involvement and care and things that. In Asia. The, so there's one thing. Second thing is, everything's good with labor I'm sorry labor. How are things with labor and delivery? Yes, organized labor organized labor. Yes. Well, you know it is um Sure now I appreciate the question and we are in active negotiations with CNA right now as it pertains to Alameda and San Leandro. I think they're going well. Obviously, there's work to be done, but we're hopeful that we'll have a contract and emerge contract as our goals because that allows for us to optimize services and to move staff in a way that we couldn't under the prior separated contracts. And so that's a key objective. And so we are hopeful that we'll have a, we'll consummate a deal with them soon. We are an impact bar, we just finished impact bargaining. That's what allowed us to suspend the service at St. Rose. And so that was successful. I was grateful for your questions about the employees. We provided the severance packages that Mario made reference to. But we were also able to relocate some of the staff. And so we are confident that folks are gainfully employed. So it wasn't as if people lost jobs as a result of this because a lot of folks, you know, it's healthcare people work at different facilities And so they got a I think a fair severance package and they were able to then pick up additional hours at other facilities So all of that to say the work with labor continues It's never easy, but it's important They represent the majority of our employees and I think in the past four years We have a much better relationship with labor than might have been the case in the past. And it's not perfect, but I'm confident that we are being good partners. And we're always going to put patient care first. Very good. And let's see. The next update will be in what month? For this committee? Yeah. I believe that we're in March, June June? Okay. Do you want to mention anything about your pick of then coming up in May? I would love to. Thank you for the setup. I love it. The Soul of Spring is going to be on the 17th of May and this is our, OBR 4th and it gets bigger and better every year. It's at the Henry J. Kaiser Center. We this year will be honoring Dr. Michael Lenore with the Legacy Award. And I see heads nodding everybody in those. Michael Lenore, he is a pillar in the community and continues to do excellent work. And we will also be honoring Tabersio Vazquez Health Center as a community partner that we believe is doing excellent work and we're looking to create more synergies with, certainly at St. Roosevelt elsewhere. So thank you for the opportunity to give a plug. I would encourage everybody to consider joining us on the 17th of May at the Soul of Spring. Very good. All right. So that's a high five on. Yes, high five over there. Do we have any public speakers on this item? I have no speakers on this item. That speakers are right. Very good. Well, thanks for the update. Look forward to the update. Come June. Excellent. You know, just keep it. Thank you very much. You put a great work in. I really appreciate work that James and his team's doing and appreciate all of your trustees. Yeah, because you know, I've seen a lot. Oh, since I've been on the board of supervisors, so I know some of the, a lot of the history of the community. You have some context, yes indeed. Yes, exactly. Thank you very much. Appreciate your support. Have a great day. So let's go to our next item. Information update on behavioral health department overview, major initiatives. Good morning, Chair Miley, Supervisor Miley, and Chair Tam is nice, Supervisor Tam is nice to see you both this morning. This morning, I want to respect time, so I'll definitely will be differring to you all about any context or any questions that you'd like for me. But in terms of this, this has a lot of information and I'll try to focus on some of the questions that you've asked about in the past. So as we go through, there will be a departmental structure that we'll look at and I definitely want to attend to some of the critical initiatives and the landscape and the work as well as what will be happening beyond. This slide is just an acknowledgement of our mission and I think Chair Miley especially I've heard you ask questions in terms of impact to the federal government. We are monitoring that, but for us we will remain steadfast. We are still required to serve and we'll continue to do so despite some of the changes. But I'll speak a little later about how it will be impacting or how we're looking in terms of our budget and some of the operations. So this is just a respectful acknowledgement of our leadership team, our executive team who are each over various aspects of our department, including Dr. Aaron Chapman, who's here with me. He's our chief medical officer. But for again, this is for future reference. Yes, sir. Yeah. Do you mind if we ask questions as you go? Absolutely. So can I at one of our future meetings with you and the inter-magency director, can you bring in Kate Jones? Because I'd like to kind of drill down into some of the older adult stuff. Absolutely. We will bring, whomever you tell us to, absolutely. And I'm sure Kate will oblige. This is just a pictorial depiction of how our department is structured. Again, my office at the top is a very small portion of about 4% of our operations in terms of that. But strategic initiatives rolls up to my office and then again we have it out loud, clinical operations, Office of the Medical Director, Archive Medical Officer, Health Equity and Planet Administration and I'll briefly walk through as an update and just reinforcing how we're structured in terms of our requirement. This is visually walks you can walk through and again we've color coded it. This was a, This was a link here. It looks like that link has been removed. Or maybe on another slide, you can take a look at it on our website. But as you can see, clinical operations essentially is the types of services that will be being provided to our beneficiaries. With the exception of crisis services or acute services services, hospital-based, psychiatry, pharmacy, and integrated care, those are on the left side of the chart, as you can see. In terms of our health equity division, again, that's how we're monitoring our policy, workforce, peers, our family members, some of the things that obviously we're required to do in the support that we provide to our system for workforce education and training. And on the right side as every plan is required in the state of California, we have very key components that help us to deliver the services ourselves through the county, obviously with your support or through our beneficiaries. So that's quality management, our finance, mental health services act, and data services. And as you know, at the top previously, we're still connected. We also are required to have information system now and that operates through our agency, our broader agency, but nevertheless, this is our global the way we're structured. And we are required to be as transparent as we can to the state, they often visit and ask. So this is that context. This is just something we will be periodically updating and we have been updating our partners. And when the pandemic happened, we created a true North fit framework. And essentially, it was our way of stabilizing, despite what was happening, the state changes, the federal impacts, we focused on those areas to help govern the way in which we make decisions. And so that slide is around this as well as the how, those are the opportunities that we took and our mission of vision and values and some of the results based accountability and the path forward. So again, this is in terms of the structure, and this is, again, operating through the Office's Director, my office, and this is how we've been achieving a lot of different projects and work. This is just for visual learners, there was the picture, this again, just highlights the services that operate in terms of clinical work and integrated worth across our system. So again, just another opportunity to see that structure. In terms of health equity, as I mentioned, this also is something that we're continuing to monitor because as a managed care plan for our behavioral health, we're required to provide culturally and ethnically- services. That is just in our mandate, as well as in our structure, as the state. So we continue to make sure we provide translation services on a very basic level. So whatever does or doesn't happen at the state, we are still required at the, excuse me, at the federal level, at the state level to deliver this service and care to our beneficiaries. That's just required. And again, plan administration, as I mentioned as well. This I most certainly won't, because my eyes would be compromised as well, read through this, but this is again, what is on our website. So you can any person in the community, were required to be very transparent for a beneficiary has the right to access and find out who and when and how. And so this is on our website for those that are interested. I yes, supervisor. So your man is about 800 million. Correct. We are I will go through but at this we're about $770 million. Okay. And then on your chart here, how many CBOs do you have? When you look in totality of our CBO providers are employees, there are about 800 FTEs, but when you look at our providers, it's about 4 to 6,000 depending on the year. So in terms of the number of CBOs that could be anywhere between 3 to 500, if you include our individual providers, because we're also like an HMO required to contract to individuals as well. Okay. And I don't know if that's that level of details in the budget booklet, but it'd be good to kind of see the whole You know, because it's a big operation. It is a very big operation. Yeah. Yes. Thank you These are examples of the populations that we serve across the lifespan you mentioned older adults again for us It is at birth even we have perinatal and pre-nill programs for individuals and across the spectrum and I think as I've mentioned to your board on many of occasions again it's wherever the individual is whether they're in a community-based setting whether they're in a locked institution we're required to serve them and there are categorical funding and restrictions that will preclude us from using certain revenue for that, but nevertheless, we're still committed to doing that work. This, we thought, is something that we often provide to individuals they want to know. We'll give it as an example of what type of services fall within each system. So these are different examples. We are divided into five systems of care and again that's governed. We didn't make that term up. It is something that we are required to do so whether it's county supported by your board or subcontract through CBOs or hospitals. We deliver care in these type of examples, our adult and older adult, child and young adult system of care, our substance use continuum of care. And one of our newer acknowledgements is the forensic diversion and reentry system of care, because your board again supported and was spearheading the care for sales last in a policy to reduce incarceration, as well as to make sure that we are more collaboratively connecting with our partners and courts, as well as our other entities. And that system was created so that we don't have system gaps as a person navigates from being released from jail to outpatient, it's all in one system. And so they have the ability to wrap around services to them. Given the level of support needed in the pandemic, we also elevated our crisis services system of care. It used to be a division. And now it's much larger than that. Obviously you're aware of CAT. We're very pleased that the state has recognized the community assessment and transport teams and other counties come to us for models. We created that through the innovation dollars through image to say as a five-year pilot initially, but we shifted it for longer term support and now it is across the county. So those are just examples that happen in the crisis system of care. At the bottom for those that are interested to reflect now or later, there are certain requirements that were also required to deliver. So those operate across any age, any system wherever they are. And as you can see, accessing services employment, we provide employment services is actually an evidence-based program, nationally renowned IPS model, housing and homeless services, as you know, has transitioned now through AC Health and is the housing and homeless services. But we still clearly are mandated and do support that financially to make sure that we're delivering care for our beneficiaries. Psychiatry, nursing, and integrated care, which just means our federally qualified health centers. We will fund them, we fund care coordinators, wherever we have seen people who need support, we have expanded to make sure that they have the support that they need, as well as pharmacy. We operate our own formulary very much as you would Kaiser, where you receive information from state or federal government about drugs and we will then make that available to our beneficiaries. In many cases, we will pay them outright so that there's no cost either to the provider or the system because we are in that requirement, an HML. So with the crisis services system, it's countywide now. Yes. And there's a clinician working with every city's law enforcement as well as county sheriff. Good question. So as you can see it depends on the program but yes. So some cities have preferred to develop their own individual supported infrastructure which we support regardless. So we'll coordinate with the law enforcement whether it's met mobile evaluation teams, whether it's a clinician and law enforcement or it's pure mobile crisis outreach teams or in cat it is a clinician plus an EMS worker supported through our EMS services and a subcontract program. So yes, every city is either covered by the county and your support to us or it's covered by the local jurisdiction. And either way, we are required and coordinate here with them. And if it's covered by the local jurisdiction is Alameda P. Adria Health providing the funding for that term? Sometimes, yes, sometimes no. Some jurisdictions have elected to create their own systems. For example, even if that happens, behavioral health, my office has to certify them to initiate and drop release holds. So we will coordinate here, or we will coordinate with them to have them admitted to our facilities or our service delivery. So one way or another if a county or a city has created and funds their own, either we will coordinate with them or in some cases we will provide some partial funding in some cases. One last question. Why would a city decide to do it on its own as opposed to just like You know your office or department handle that good question So we have had I don't want to name some off of hand, but I'll be global So well actually maybe I will so for example out in in Fremont another area Is they they had a close relationship and wanted to work for example more law enforcement in that. And so they wanted to cultivate a different type of model. They also wanted to apply for and have granted other funding sources. So whereas in Alameda, for example, the fire department wanted to really spearhead some different types of innovative programming. So in both areas, we would designate and allow them to support if they feel there's a different idiosyncratic need that the city jurisdiction wants Providing that there's no harm done. We will support them in that so it just literally depends on some cities have opted to Want to rely more on X service i.e. Fire Department or law enforcement whereas others did not so we tend to be very Nimble in terms of looking and meeting with them. In an Oakland, is it just macro? Oakland is the only one, yes, that operates its own macro. We county are there in Oakland, and for them, they have, as you know, it is purely pure base. It's no, there are no clinicians there. So they work with us pretty upsensibly because as you can imagine clinicians can provide preventative support, they can arrive on scene to support but they're not able to without a clinician initiate or drop a release a hole. So it becomes more acute, we will step in but yes, Oakland, Macro is another example. And then my final question is do we have a preferred approach? That is a wonderful question and I'm trying to be respectful of our county partners. The actual approach that I think it was two years ago we came to this health committee maybe three years ago and it is not the most salient response. It's an eclectic version. What we found in Alameda County, because it is so diverse, first and foremost, you have to have service levels at every area. So in other words, cat is our preferred approach when there is a medical crisis happening on the ground. And so at the highest level of service, just shy of medical intervention, you'll need that clearance from a medical personnel. So we think that's appropriate. For outreach teams, we think that's at the very most less crisis level or severe level. We think the most appropriate approach has to be outreach and follow-up and post-care follow-up. So for us, we endorse any program that can sustain post-follow-up treatment. So once a person is attended to address, there needs to be crisis units or supportive people who wrap around them so that they don't recidivate. We endorse and work with our county partners or city partners who are developing that to make sure that they include that. If they're not able to provide, again, the highest level of care will work with them and serve in that role or the lowest. In the middle. and the city partners who are developing that to make sure that they include that. If they're not able to provide, again, the highest level of care will work with them and serve in that role or the lowest. In the middle, it depends. We have recognized that some cities, for example, as I mentioned, would not prefer to rely on law enforcement. They just don't want that relationship in, in some cases, some law enforcement offices would prefer to rely on behavioral health were operated in their own way. So for us, require that they basically work with us to determine what actually they're trying to achieve and what actually they are supporting. Either way though we are required as a system to be to be able to respond and support them. So we found that. But for us you have to have an ability to either access higher level, you have to have an ability to follow up post crisis and engage and coordinate care to other systems. And you really should be able to navigate the space, not relying just on law enforcement, but you also need to be able to access and have relationships with the crisis units, residential treatment facilities or hospitals. So for us, I think it's a capacity as opposed to an exact model just because Alameda is so different. I even Berkeley operates a zone mobile crisis unit with whom we coordinate. Thank you for that. If I may just follow up on that. I understand Alameda's model and actually the county and your office help initiate a lot of the piloting. But there's been a lot of talk in Oakland given their budget woes. They seem to want to switch to the county but it sounds like it's already with the county, especially the CAT program. But what aspects, for example, of the macro program would it make sense for the county to take on if Oakland could not? That is a huge question. Given that I believe there's an investment about $10 million is dollars that's a very significant cost. What we're finding in Oakland and the data bears that out either for homelessness or for high need is it's the post crisis care that is really critical. So although the macro is looking to intervene at the time of crisis we would look to see and I certainly we would work with our executive leadership. I don't know that they've approached us directly. I'll look over at our chief medical officer, I don't think so yet. But it would be with Stephanie Lewis, who is our executive leader for crisis services. To what degree we can support them in the aftercare and the referral and the pathways and then networks because we do have a pretty robust team in that way and that would be something we would be looking at. Not necessarily arriving at crisis but post-crisis and we would have to see but they've not approached us directly I'm not aware. I appreciate the honesty. Thank you. Yeah, because I appreciate Supervisor Tim bringing that up, because we know Oakland and probably they've talked to both of us with their budget, their fiscal crisis that they're experiencing and their structural deficit that they have and that they've had, they're looking to see what more the county can provide. And so, if they haven't approached us, we're gonna be letting them know to approach you. Thank you. Thank you. Appreciate that. Thank you. Given,'s a perfect subway. This is again just a snapshot to where we are in our current fiscal year as you know We are you ask the question where we are $770 million at this point. We look to likely depending on the board process We know that there will be some growth in the next year, but again, that subject to approvals in terms of your board and other activity. But this is where we are as a snapshot now. We have changed in previous years, we used to operate between 85 to 80% with CBOs delivering the services that has shifted somewhat to some degree. So now we're at 79% of CBOs provide the mental health services. Now still 100% are provided by CBOs. So that's just I want to acknowledge that that has shifted. The county has taken a little bit more on in terms of mental health services. So your point is very timely. So again, this is what I just described. Prior year we were at $697 million. This year we're about approximately $770 million. And the total allocations for our CBO partners, as I mentioned that 4 to 6,000 is about 65 percent of our budget. So mostly we truly are in HMO where we are delivering the service and or contracting through entities to do the work. And I'll speak to this a little bit in later slides but we have been providing a lot of this information to our public state holders, your board periodically as well. we we're also going to be required, which is a good thing through BHAC to have transparency about our budget, that we will have to list sources, and we have been doing that in Alameda County for many years, so we're well underware of being compliant with that requirement, but this shows you that clearly the first primary source is MediCal, which is federal obviously, and then MHSA is our secondary, and there's other sources that help us to do the work that we do. And for the most part, everything to the left, my left is categorical funding, and to the right, certainly has restrictions restrictions but it does a little bit allow us some flexibility. But for the most part, County General Fund obviously has the most flexible funding opportunities. As you can imagine, it's our smaller resource though, it's only 8% of our budget. And image to say previously provided a huge amount of flexibility because it did not restrict whether you had insurance or not, where you were in your mental health prediction, we could support you, it will be changing obviously. And so you can see 2% is federal as well, grants in other areas. So Dr. Trudeville, are we concerned about any of the medical? We are certainly watching that and you are reading my mind because we have been meeting for several months now and I'm going to, if I may advance ahead to answer that question that is exactly what we're looking at. So as you can see, we have extrapolated what that means. So since medical is about 30% of our budget, that is a huge impact. So how we are factoring that is right now, thankfully, I believe it was last week, late last week, there was injunctions and an inability of the federal government to do some of the proposed changes to Medi-Cal. So we are very pleased at that more to worry at this point What it would mean though, our ability to match programs and do some expansion would be inhibited. It also would mean, for example, as you know, BHSA, as we transition, certainly has a revenue source. But what we often do is decrease reliance on BHSA by matchingi-Cal and the federal sources. Should something occur there, we would have to decrease that ability for us to draw down Medi-Cal. Right now we track back to how programs are funded, where the changes are. Our biggest concern for us is around our substance use block grant. $9.1 million, although it seems like a relatively small amount, 1.3, it's used to deliver 100% of our substance use services. And so we are monitoring our ability as a county department to step in to provide services. It is a blessing and a curse in terms of the workforce crisis because we will be leaning on our providers to support some of the vacancies and looking at how we can support by continuing to maintain those services irrespective of what happens. MALL also is affected. That's the pre-engagement of individuals with Medi-Cal and certainly our ability to, you cannot Subplant, obviously, image of say precludes that. You can't use it as a plug of hole. It's illegal. BHSA also will require that, but it's going to be more it's more highly restrictive. So for us, it means that expansion that we have not already banked for is something that we're conservatively thinking is not the right time. The other thing we're looking at is making sure our documentation and training our providers so that what will eventually be included and gone to the state and then of course goes the federal government would be allowable expenses. As you know the federal government is issuing to their own employees certain words that have to be removed because we're in California. We may need to conclude those words, but we're working with the state if there's any changes. But the good thing for us is that the state is our bypass in terms of the revenue that we bill around federal and other sources. That is a really good place to be quite frankly, as compared to other states, is in California. And if there is interest on how our $770 million is broken down, you can see how the revenue ties to services. You see, for example, outpatient is where we have most of our services, 260 million, which is about 33.9%. Some of our full service partnerships are 40 million at this point, and BHC will require that we increase that, but we've tried to be very transparent in terms of what this means in terms of not only the percentage, which is the far right, but also what this means and dollars actually. So in addition to watching the federal landscape doing some initial projections on what that could mean for us programmatically in terms of our budget. Obviously this is where we are in terms of the current land state. There is continues to be for our beneficiaries, these primary issues that are impacting them. And as you can see, what that means to them in general. But if you look at the last bullet and I'll explain that a little bit further We are watching and we'll have to watch the shift from image is say to be a just say because image is say did allow for Across the care continuum Prevention early intervention on to some more severe mental illness It will allow for substance use which is which is fantastic to address i.e. the substance use that we're seeing However, it will allow for substance use, which is fantastic to address IE, the substance use that we're seeing. However, it will technically require symptoms or diagnoses that are actually more far advanced or on their way. So that is a trade-off that we will have to monitor by focusing on people downstream, as opposed to upstream. So I was waiting for you to get to that. So, I know it's come up in other conversations. What type of funding are we talking about in terms of this decrease? It's the tune of $10 million, $20 million. What kind of money are we talking about? Great question. So specifically for BHA, BBHSA, to ship from image essay to BHASA, it will mean a $50 million approximately. At last check, we were about $55 million decrease in the services that we previously provided. Specifically for us, it's about $26 million in prevention dollars. So that is a significant change. Now might some of those individuals be eligible for a full service partnership? We believe so. However, we also know that not every service, i.e. school-based service or other things can be supported as an FSP. It just won't work. Okay, because I know we've talked about this in the past year or two. And I believe I've mentioned it to the Interim Agency Director as well. And I know the board's going to have a work session on Measure W. Because what I think the board needs to hear is not just what the needs are for homeless services, but what are your needs, what are the needs of other county agencies and departments. And so we can consider whether or not when the measure W monies become available. If we want to allocate any portion of that escrow money to this or any ongoing portion of that escrow money to this because I've been very clear. I'm speaking about as myself, I don't want to see a diminishing in these services because of requirements that we have to fulfill under the law downstream. we still need to do the upstream services. We can't have, you know, we can't, it's not like Wacomoll, we can't put it down here and have it pop up there. What we've been doing with prevention has been very successful. So I think it's not either or it's got to be both. So I'm going to raise that when he kids to the boards work session with measure W. So, but that's what I'm asking that question. How much are we talking about? Thank you. Thank you for the context. Let me underscore that that is an important, even though I know the board under supervisor Carson's direction wanted us to shift an earmark to funding for AC, I mean, almost near and coordination programs. I'm hopeful that we have a bigger context. We have that perspective when we talk about our budgeting and I know it's keeping Anika awake at night looking at different sources and what how prop 35 fits in and the threats to MediCal and what that means for the Medicare funding so I'm sure she's working very closely to make sure that your department's needs, which frankly are the largest in the county, are met. Thank you. Thank you. Thank you, Bob. I will start slightly to that end with some of the very new and the critical initiatives all are required and all are incredibly important and we've really tried to also include and embed links for people that are more interested in learning more. But again, I believe your board will hear an update around the opioid settlement planning. We're very pleased. I think we provided to the health committee some updates as well. I believe during a prior session with the board around the opioid settlement. So we have a lot of updates and services that we'd like to bring to your attention. As you know, we are very grateful that you have approved our ability to use Epic and contract with them to move forward, as you mentioned, as was mentioned by our AHS partners, for us as behavioral department, every county that touches us in the Bay Area have already made the transition or are making the transition now. And we have been planning for this about 10 years now for a decade. So we have been scrolling away money even with some of the changes in legislation. And we've also researched a varying amount of different types of EHRs, Anasazi, NXGN, NETS Mark, Avatar, Clinicians Gateways, which we have. So we're very pleased that where we will be to communicate both with our healthcare partners as we've been funding some of that work, but to improve care-delivered coordination as well as our CBO partners. So we will internally also be hosting listening session for our CBOs because for many years, some of them since our legacy system is about 30 years old, even with the bridge that we provided through smart care, they will want to weigh in. And so we will be honoring them while the AC Health IS lead the conversations with Epic. And we have been assured that we'll be included as well. As you know, we will be providing the, I believe the full board or a majority with a care court update. We're very pleased that that is where we are. The state is actually reached out to us because they have seen a difference in elevated county as compared to I know statewide, we were the second cohort group, but we are actually ahead of most counties in terms of involving and bringing in individuals for care court and adjudicating them through court as compared to others who have been a year long. So the state is interested, they are working with us to plan a site visit to understand why is different here. So we already know part of that is that we've been working in a very plan full and have been working with our courts, our probation, our law enforcement, our CBOs, our health care providers yearly and we have a fantastic consultant group that's also working with us. But we think it's made a difference as well as our family members and our clients were at the table when we develop some of the programming, but it's clearly taking positive results to that. The African American Wellness Hub, we hope at some point to update you, as you know, I believe GSA has been providing updates. We're still moving forward. We're pleased we purchased that building. And again, despite what does or doesn't happen at the federal level We're already prepared because the state requires us to look at our data look at how we serve people and improve outcomes So we will continue to support that project as well Our strategic plan and system development opportunities are again a well underway We did not know when we launched our strategic plan three years ago and it was completed recently. We took our time to get stakeholder feedback that there would be probably 638,000 and seven new laws that came out on being exaggerating a bit. So we are actually interpreting the new laws even as they come out. So we're still socializing that across the county to stakeholders who've not heard about it. And finally, our health equity dashboard. Again, this is a link. This is actually posted. People can take a look either by district or for your board or by demographic, by race, by age, to see who's being served, where they're being served, and where the numbers fall in terms of our medical beneficiaries. Again, this is all our opportunity to be as transparent as we can. Dr. Trevo, could you also add to this list, we've been in conversation with the sheriff about the delivery of behavioral health services out at Santa Rita Jail and she has brought into our attention the fact that we potentially still have the capability of having a unit that can provide that comprehensive services at Glenn Dyer here in downtown Oakland. So I'm very interested in revisiting that you know that pathway gets to serve this product to my attention. Absolutely absolutely and that's a perfect said way as you recall we did we paid for and our GSA partners did the Fisability Study on Glendir, so we're absolutely ready. And I think we have the data to do that. And it is actually on our list of many. That was just an update. So this is an overview, as you can see, the forensic services redesign. These are not all of the legislative changes in the initiatives that we're working on, but there are a few. there's some that are incredibly time-sensitive or that we wanted to attend to. And again, the forensic services redesign is ongoing as you know that includes care first, it includes the work of the jail as well as some of the other initiatives. Where's that on the list? The forensic services redesign. So that one is, yes, that one is purple. I apologize. My advancement is very excited. But in any case, yes, that includes that. So that's something that it's not a time sensitive because we've been slowly implementing that work, but it still remains all of these are priority. And so yes, we will definitely be willing to have those conversations. I'll just highlight a few, the ones that are highlighted, obviously CalAIM is something BHSA, Prop. 1, obviously Cure Court, which we hope to provide your board with an update. I've mentioned settlement, our strategic planning, our EHR now is really critical because it helps, obviously, the more updated we are. And I mentioned that was an exaggeration, our legacy systems were about 30 years old. And I've mentioned it before, we literally had a system with a black screen and a yellow blousing cursor. So it was that old. And so we have been incrementally bringing it back up to space. So we're now in a position, thankfully, to move forward with improving that. And we think there's gonna be a direct revenue correlation to that. It'll be better able to track and build once we get through the gray zone of course. SB 43, we will be providing you with an update soon, as well as beach ship and other opportunities that we have been providing you updates with. And clearly our settlement implementation, as your board knows, we are in agreement. There is not a consent decree. There is one in Babu and the jail, but there's an agreement that we have to hold true to, to make sure that we're in good faith moving forward. Our report was most recently provided, and it looked very positive in terms of that, and we are anticipating another report to come to give an evaluation on how the county and where we are in terms of our settlement implementation. This, I won't reiterate this, but this is just a summary of what those critical, maybe time-sensitive ones are, as you can see, they're highlighted because of, again, when they're when they're quote do or where they are in a radar for example SB 43 we will implement it as you recall president Halbert asked us by 2026 absolutely by 2026 we are working but minimally at January 1st it has to be implemented and BHSA is corresponding that July. So these are just a summary of some of that work. We have developed a stop light approach for the last several months, probably years, to really track where we are. That's why we've been able to deliver so much and are really proud of our employees and our team members. And this is something that we will be using and continuing to socialize our providers to as well. And it's very simple for those of us that played red light green light. It means that for those priority ones, we have a bit of ongoing. And so if you see, if you look at green, again, it's ongoing, future, this is something we're working on. bit is ongoing and so if you see it if you look at green again, it's ongoing future This is something we're working on red obviously is urgent immediate time sensitive and yellow We've either already implemented or we are nearing a point of having that Urgently need to be implemented. So we're it's all underway But we there's just a lot so we've been trying to synthesize this with our public, our CBOs, our community, so they get a better sense of, so what are we working on and how critical is it at that point? And I won't reiterate our strategic plan, but again, there is a link at the top to hear more about it. but as you recall, these were the feedback highlights to the left that we received largely from the public and the community and our partner organizations. Certainly, we weighed in as a department, but it mostly came from the outside. And the proposed direction was the areas on the right. What was interesting, I'll point to what's most notably is the strategic direction of recommendation to collaborate and increase employment. There was an acknowledgement from our stakeholders that not only are people suffering from housing, they need a way to maintain the housing. So could the department work strategically to increase employment or the connection between employment and housing opportunities? So that we thought was actually quite a limited issue. It wasn't just around the housing need, it was a way to sustain the housing. Looking really to evaluate and improve, this will fit obviously with our requirements at the state, which I'll briefly mention, and some of the re-entering criminal justice. But again, this is essentially from our strategic plan what was recommended. And as you can imagine given the semi-the changing in law in legislative requirements, we are trying to interpret what that looks like. This slide is a summary. There's a lot. And so I've used this prior meetings before, but if the ones that are around system integration for us are, in our opinion, our CalAIM care court SB 43, which again changes the way a person can be placed on a hold, a psychiatric hold for adults. That's the law that will be implementing by January 1st of 2026, peer certification and EHR in our billing. That will help us better integrate across our system. The population focused areas that we're working on are the ones that you see highlighted there. The ones that we really believe are opportunities for more community engagement are also listed. And the purple coating is just acknowledgement that one or more may may appear twice. But again, we're trying to socialize these way to understand it because the community and our partners are asking us, so what does this really all mean? This is another tool that we're going to be hoping to use because we think it will be helpful. This is a visual depiction of it. We had planned to place this on our website or a variation of this to track. And as you can see, each of those not on this, but our actual links and our team have coordinated information that the public can click on to learn when we started it, how it's going, or what are some of the key laws, some of these also connect to the state websites and others. So we thought this was a helpful tool. We'll be creating another one for the next, the future, obviously, in several integrals. But there's a lot happening behavioral health. So again, this has really helped us to be very intentional and we think it'll help people understand when we started and how things are moving forward. So how we will be putting all of this together is very important to us. And one, I believe Supervisor Miley has seen something like this before. We are trying to help people understand, again, how they all relate to one another. And at the end of the day, all of these initiatives, Prop 1, CalA and B chip, which is again the infrastructure grants that helped us build capital, which I'm very pleased we have received about 40 million to date. This is us just counting behavioral health of in capital funding and we have other projects that we're looking to get feedback from the state of which you met with and heard from AHS. We've submitted proposals for a med-site unit with a 20-bed facility over at AHS, 100 substance use residential beds in addition to detox and work with our UCSF and chill partners. The ones that we have gotten will be funding about 32 adult residential 50 residential for substance use crisis residential treatment facilities 100 locked beds because we do recognize the need here now in the county as for supportive housing and crisis stabilization units. So again, that's about 248 new beds that will be added. The state obviously and we are also tracking our progress toward it and so there are ways in which the state will be evaluating Ellemont County's compliance and or success. These are examples of ways that the public can look into that. We will be hosting on I believe the coming weeks, an EQR or an external quality review by the state that looks at both our mental health and substance use program. That's a huge change and they'll be evaluating us current state. So that will be welcoming their feedback on that. The Health Equity Dashboard, as I've mentioned, is a way for us to evaluate as well as the recent mobile crisis report completed by Indigo Project. So they looked at all of our mobile crisis services, again, which ties in very much the earlier conversation about what Alameda has, what it doesn't. But that report, there's also a link, describes what is needed, what's going well, and what the county should focus on. So we've really been doing a lot of hard work around that. And finally, the state of California on last month just recently launched its own accountability dashboard. And the last few slides that I just wanted to bring your attention to is this is how the state will be evaluating success. They have statewide behavioral health goals. If you see the arrow up, it shows they will be looking for the care experience, access to care. So literally how easy is it for an individual to receive services, to look for services, prevention and treatment of physical health systems, quality of life, social connection, engagement in school and in work. Now what's important to note is as you can see, some of this is non-behavioral health data. So although you will see statewide behavioral health goals, their expectation at the state level is that all parties will really be coming, given the critical nature of behavioral health, what's happening, and the impact to other systems together to track this. So if you look to the right, I want to highlight, of course, our department, for example, at the bottom, is not responsible for removing children from home. But the state is evaluating the degree and the impact of that. And that is on the goals for reduction. Suicides, overdoses, untreated behavioral health conditions, institutionalization, homelessness, and justice involvement. So we will be the first out of the gate, the canary in the coal the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the police and the states. When I say the state I'll say offered through Governor Newsom's office was provided in the previous slide but these are the metrics that they will be evaluating all counties against. So it's a very complex time that we are. And finally in terms of the initiatives that are often or has come to our attention that we thought would would be very helpful for you to have that overview. Again, the current state, as I've mentioned before, for images say, is different. Prevention is there. It's a continuum of services. It does not have SUD, and it's around wellness and cultural linguistic programs, which I believe many of which have spoken to your offices about, outreach programs. So that's really in addition to the services, image to say, confunds now, those are really the way to understand it. As of July 1st, in next year, the transformation means that it's really targeting people with the most severe mental illness and it focuses on housing resources, navigation, and subsidies. And so the expectation is that behavioral health departments who have been managing the housing, for the most part, are getting a little different, but who have been housing and managing the housing services for those with housing needs will also focus on how those individuals are supported, resources, care coordination, and such. The positive aspect, because we've all accepted, it is in law, is that it will include substance use. It will also include mental health or substance use as a diagnosis only. Previously, we could not do that. An individual, for example, was in the community in the street suffering from what what was clearly a substance use and toxication. MHSA couldn't be used to serve that individual because of the restrictions. So that's the benefit that we now can use that funding to support them or those programs can admit those individuals now. It also aligns with traditional county behavioral services. It depends on your perspective as to whether this is a positive change but what is new is with something old I can't recall but it actually takes us full circle to how it used to be many years ago. For those of us around 20-30 years ago you can see that now it's targeting more severe when in 1991 the state realigned to the counties counties and around healthcare and behavioral health. It also includes treatment and early intervention, and again, markedly noticeable here is the omission of early intervention, excuse me, prevention and that the state is still farating out through H.K.I, through Public Health Departments, how they'll be administering workforce and prevention. But it is important to just be realistic. We as I mentioned before to your question, Supervisor Miley funded about $26 million in prevention. With this shift, the statewide allocation is anywhere between six to eight depending on where they will be. So for an entire state for prevention, that is what every county at some point will have access to. That's significantly different. So I want to acknowledge that. And so as you can see, this is just again a different way to look at that. We went from population-based, mild to moderate, and severe, through image-to-say-and-it will go more toward severe. It is more focused on downstream and individuals having practical support, which for some will be great for others, as you've mentioned, and I think Asyn Quiried, it will be complicated. So for us, system engagement will be critical. So any time we can, we are launching opportunities for listening sessions, feedback sessions, surveys, we are really getting our providers to give us feedback, community members, stakeholder groups from every layer. And for us, we think it is required because we will not be able to continue to make these pivots in a good way, less we are up to date, and we give information, including if there are any impacts, federal and other. We are continuing to do communication updates and send that out. Our department has, as you can imagine, again, those four to six thousand individuals were making sure that those providers get those updates as well as our community and system and our clients. And obviously, we will be analyzing the impact to all of these changes. And I did participate in a process legislative with the Legislative Sacramento last week. And I believe the state set legislature is also hoping to look at what's the impact to all of these changes. And so we're gonna have to look. Our data will be critically important because not only will we be evaluated, but we also will need to look to see what the changes have done in Alameda County. And so essentially this is what we're looking at. A lot of what I've already described to you. This is just a reference to an earlier slide. We have much more to do. We are trying to map our system. We have had stakeholders ask for a system map. We have provided some, but it's going to change. Obviously, the way our system is lying according to our requirements in regulatory areas. And this is simply an acknowledgement. It's a lot. And I appreciate the camaraderie we have with our executive team. And they're holding with me and with our other team members a lot of this information. I continue to joke there's a four there. I don't know if it just means that that person can only carry four things at once, but clearly we will have to be accountable for all of this. And we're really pleased in terms of and we hope that you would be as well. So far we are getting fantastic feedback from the state. And even this morning I got an outreach from DHCS to what I be part of a panel to share an Alameda County and give feedback about what it could look like for our health care and behavioral health working together collectively. So I thank you. I'm very comprehensive so see if you press your TMS additional questions and I know I have a few more. Thank you, Chairman Reilly. We obviously interrupted your presentation and asked them along the way. I just have three major questions. You have the largest budget, your department in healthcare. And then unlike other departments, yours is extremely intensive and it helps a number of other departments. The $770 million, which is almost like close to 2,000, 63%. How does that compare with other counties in terms of expenditures in mental health? Great question. We've done a similar analysis and I think we're, we compare it ourselves to Sacramento in terms of not just budget size, but population and what their diversity looks like, their pictures, as well as Santa Clara. I think for us, we represent a appropriate maybe to some degree right in the middle in terms of the size. We're technically considered a large budget compared to other counties in the Bay Area, I say. We aren't the highest. I think Santa Clara and others may be higher, but we also comparatively have a smaller number of positions, employees doing that work. So it says a lot, I suppose about our efficiencies in terms of that. But what we are seeing is our county, sisters and brothers are also having to expand to meet the need because that is growing tremendously. And so we are large, comparatively large. And as you can imagine, we don't obviously compare to LA. They're their own, they're three billion. They're a whole, yes, yeah. A whole universe and in themselves. I appreciate that. And in your listing of the programs, and I know you went through this review of your department primarily for Supervisor Miley's benefit, right? Yes. But you're obviously very responsive to some of the discussions the board had last year with, and the year before, on the forensic forensic program which covers both the in custody programs that so you have allocated like 54 or $55 million. And we as a board are sensitive that we throw a lot of things at your department and the state throws a lot of things at your department that are unfunded mandates. So I'm hopeful that all this positive feedback that we're getting on care court might translate into some hopefulness with funding. But when we look at the last graphic that you showed on, you know, the tilting of the scales. You mentioned that it's about five to six million dollars that you're seeing being shifted from prevention to basically through the MHSA to BHSA. Do you anticipate requesting that through the budgeting process, the backfill it and with some of the dollars that we've been talking about with like Measure W? Great question. I think so to make sure I'm responsive to your question. So locally only we fund approximately $26 million of prevention. That $6 million that a reference is what the state once prevention is ending is prepared to pay for everyone. So technically it will now be a not allowable expense for us to do that prevention work. I'm pleased to hear and I believe Director Chauva as well as Inter and Director has mentioned your board's consideration of what that could look like. We would appreciate any support. I honestly, our providers, I think the community would appreciate it. But technically, because we're an HMO, we're a plan, we're not able to rob Peter to pay Paul for lack of an elegant way. So for example, it would literally mean for us to cut services to where now the state is moving downstream in order for us to add funding. In the budget cycle, we're operating within our means. We're looking at revenues and we're also looking at unspent dollars to help carry us through. So in this iteration, we've not, with very modest expansion, as I mentioned, there'll be maybe 10 million or so increase. We've, for the most part, are pivoting exactly what the state is requiring us to do. So we haven't added a significant ask for your board to fund or to approve. We're really trying to color within our lines. I have one piece that I would add is around the cost of living adjustments. As you know, your board has approved the Acmea as well, which is a great opportunity. So we're working with the CAO's office around personnel of current county employees. Those are probably factors that we'll be looking at to see the degree to which is appropriate. Annika, you had a question. Thank you. Yeah, I just wanted to add that with regard to the prevention piece, the new Behavioral Health Services Act plan isn't due to go into effect until next fiscal year. And so we have some time over the course of this next year to do some planning. And it'll be something that's of interest to all of our departments. And so to the extent that behavioral health as a plan can't fund those specific things we have other ways to think about how to make sure that the critical services are continued. Yeah when we say we have time we usually don't. No we're starting now. We've been having all the conversations. I appreciate that. Here's where I'm going with this. So we are being asked to shift funding from MHSA to BHSA from prevention essentially to housing. By the generosity of the voters now in the county, they also provided some measure, measure W for housing. So I'm hoping that if in terms of like, I know you can't rob Peter to pay Paul, but if you're being forced to shift funding from prevention to housing, and since we already have funding from forehousing with Measure W, maybe we can shift some of it to prevention. That's where I was going to go. I understand. Thank you for clarifying the question. I would say the way that BHA just says structured is that the new allocations will be 30-ish percent housing, 37% for services and supports, essentially, for the highest-need full-service partnerships, and then the remaining 30% for everything else. With an additional 10%, I think I've mentioned it to you, kind of use them, miss missically is the tie the now we will provide to the state. The housing supports have requirements so for example and the state is with as you've mentioned the beach beach connect they're rolling out primarily to behavioral health departments to figure out how they can cover that gap. Our task now, which we've been working on, is to evaluate literally program by program, which if any, meet the housing needs, so could be supported appropriately. So we wouldn't be robbing, we would be aligning ourselves with what the state says through that. What we also know, and I think I've mentioned it to your board, although the state is allowing for capital or subsidies, they are also talking about supportive housing, where you can only have supporting housing if you're looking at the services. So our mind is trying to figure out, and we've been planning on to what degree we can have coordination of housing as well as part of the housing. Because otherwise we will, we don't want to set our beneficiaries up for failure. We will increase all these housing slots but without the services. And even our current cadre, I don't want to speak for our housing partners, but our current number of housing organizations, it's not enough. Because when you look, as I mentioned, we've about four to 6,000 different providers, we will need a lot more help to provide service delivery. So we're looking at to the extent that the housing bucket will allow us and all the other counties are doing the same thing. Again, there are as a little different in terms of how it's functioning, but we're looking at how we can fit in that way and what can't fit and what's not eligible, that will be something that will have to provide to your board so you're aware of that. And certainly with the whatever discussions are happening for Measure W, we'll definitely entertain that. So thank you. So as I can say, very comprehensive presentation and I have another meeting I have to get into. So I just wanna flag these items and you can come back either at our next meeting in March or sequence responses in as you bring updates. The forensic services system plan, it's not fully financed. Correct, we've approximately 14 million, we were able to find. You know, I've been a broken record on that for maybe five years. I'd like to get an update on that and yeah, I'd like get an update really specifically on that because I really feel once again maybe we need to fully finance it so we can move that along. Also, the status of your hires where where you with your hires, and also your opportunities to engage with local universities for internships and a pathway to get into your department. Additionally, I'm very curious because it's as much as you can point it out and I've pointed out and you've acknowledged you've got a big budget close to a billion dollars and that quite but it's getting there. A lot of employees, a lot of CBOs. I'm very interested in knowing and you probably wouldn't have this data at the moment, but knowing how many of your employees, you know, where do they live? Of all the CBOs, their employees, where do they live? What type of return are we getting indirectly for the investment we're putting into all the CBOs all these employees your employees because often we don't see the indirect return for our investment if we know the direct return the fact that people have jobs people providing services Are they residing especially the cost of living? If we have if we have I five thousand people that are connected with behavioral health are 90% of them living outside the county for instance I'm just curious to see some of those data and we don't have to you might not have this data in the near future, but very curious to see that. I think through social services, we've been tracking this assessment center and the evaluation from the state, not on that committee anymore, but the social services agency received the evaluation. I thought Pover Health was also going to be part of that evaluation around juveniles and the assessment center. We'd like to either know that in this committee or in social services. Although we're not part of that, we are planning to attend the, I believe they're providing you an update in a future event. Yes. Because I know, I think I asked for that when I was on the committee, but I wanted to flag that as well. And is there anything else? Oh, John George, we've been told, this is going to work with John George, and I know when I talk to the. I said, well, you know, Dr. Trevor worked with John George and ended up the fact that some people from John George are still being released into the community and how we can provide a better way of rectifying that, working with Alameda Health Systems in the Sheriff's Department and then the piece is, Rootsdale has his trailer out there at Santa Rita Jail. And I don't know how effective that's, the fact that it's there helps, but it's not the most effective ability to provide services. The folks who are leaving Santa Rita Jail don't want to get the services in the jail, but the road's trailer isn't sufficient enough to provide the level of services that are needed. I'd like for that, I think that's part of maybe the forensic piece. Yes. That to be flagged as well. So those are some of the things. I'm going to see enough from now because we have to get to another meeting And I do want to hear if there's any public comment. Thank you. Okay, thanks I have no speakers on the side of no public speakers. All right. Well, thanks. This is great. Do you follow football doctor? I do yeah, you know the Eagles won the Super Bowl. I do. I do. I lived in Philly. My husband's from Philly. Yes. So the behavioral health department. I think of you as a Philadelphia Eagles. So depending on the year. Yes sir. Let's win the Super Bowl. I knew you got your something to talk players there. Let's win the Super Bowl. Thank you. All right. Okay, let's see. Do we have any speakers or non-agentized items? I have no speakers of non-agentized items? I have no speakers for public comment. Okay. Thanks. All right. So the Health Committee meeting for March the 10th is adjourned.