San Francisco Community Clinic Consortium's Quarterly NewsletterRead More
San Francisco's Getting to Zero initiative aims to make San Francisco the first city to achieve the UNAIDS goals of eliminating new HIV infections, deaths due to HIV/AIDS, and stigma against people living with HIV by 2020. It relies on a three-prong strategy of expanded access to PrEP; (see below for a description) rapid initiation of antiretroviral therapy, or ART; and engaging and retaining HIV-positive people in care. At a report presented on World Aids Day, December 1, 2016, progress was celebrated, along with a recognition that San Francisco still has far to go, particularly since there are still significant disparities between populations.
"HIV Pre-exposure Prophylaxis , or PrEP , is a critical component of the Getting to Zero strategy for ending the HIV epidemic in San Francisco. PrEP is a co - formulated pill (emtricitabine/tenofovir[Truvada®]) taken daily and can reduce the risk of HIV transmission by over 90 %. PrEP complements other proven HIV prevention options, such as reducing the number of partners , consistent use of condoms, needle and syringe exchange, and suppressing viral load through use of HIV medication among those who are HIV infected. Current surveillance data estimates 12,500 SF residents on PrEP." (www.sfdph.org).
The San Francisco Department of Public Health has published a handy two page information sheet regarding PrEP. Please see the link here https://www.sfdph.org/dph/files/newsMediadocs/2016PR/AskAboutPrEPandHelpSFGettoZero12012016.pdf as well as Project Inform's detailed chart about how to get PrEP, which can be found at http://www.projectinform.org/pdf/PrEP_Flow_Chart.pdf.
shows that the number of new HIV diagnoses fell 17 percent in 2015, to 255, the lowest level since the start of the epidemic. The total number of deaths due to all causes among people living with HIV also fell, by about 10 percent, to 197. About 40 percent of those deaths were due to HIV/AIDS-related causes.
And San Francisco continues to do a better job than the U.S. as a whole in moving people through the continuum of care, from HIV testing to linkage to care to initiation of treatment to viral suppression.
But there are still notable disparities. African-Americans are the only group for whom new HIV diagnoses are stable or rising rather than declining, and blacks are more likely to be diagnosed late and less likely to be promptly linked to care. African-Americans accounted for 17 percent of all new HIV diagnoses in San Francisco in 2015, despite making up about 6 percent of the city's population.
Dr. Albert Liu of the DPH reported on behalf of the Getting to Zero PrEP committee that the city recently launched a social marketing campaign – "Our Sexual Revolution" – to encourage gay and bisexual men of color and transgender women to consider daily Truvada (tenofovir/emtricitabine) for HIV prevention.
San Francisco has taken the lead on access to PrEP. Informal estimates suggest that 6,000 to 10,000 people in the city may be taking Truvada for PrEP. However, to date major PrEP providers, including the San Francisco AIDS Foundation's Magnet program at Strut and Kaiser Permanente, have primarily served white and Latino gay men.
Dr. Oliver Bacon of UCSF and the HIV Division at SFGH gave a progress report from the Getting to Zero Rapid committee, which aims to get people newly diagnosed with HIV on antiretroviral treatment as soon as possible – ideally the same day.
Currently the median time from diagnosis to initiation of care is seven days and the time from starting care to treatment initiation is six days. Altogether, the time from diagnosis to reaching an undetectable viral load is 69 days – down from 131 days in 2013.
"Physicians around the city are quite willing to do rapid ART," Bacon said. "One of the major barriers to [rapid ART] is insurance status. If you have Medi-Cal or public insurance it's very easy to get rapid ART in San Francisco, but if you're eligible for commercial insurance or are uninsured, it's actually much more difficult."
The city has created the first directory of Rapid providers who can start ART right away, as well as an insurance navigation guide.
Reporting from the retention and re-engagement in care committee, Edwin Charlebois, Ph.D., from UCSF's Center for AIDS Prevention Studies, said that the city has received renewed funding from the MAC AIDS Fund for a linkage demonstration project. A pharmacy working group is exploring whether pharmacists can help identify people at risk of falling out of care.
Stigma is harder to measure than the number of people on PrEP or the length of time to viral suppression, but Austin Padilla from the stigma committee said the goal for the next year is to establish metrics.
HIV among young and old
A member of the audience asked where young people fit into the Getting to Zero plan.
According to the latest HIV Surveillance Report from the Centers for Disease Control and Prevention, young adults age 25-29 are the only age group to see an increase in new HIV diagnoses in 2015. In San Francisco this age group accounts for 23 percent of new diagnoses, while those age 18-24 account for 13 percent.
Liu said that the PrEP committee has identified youth as a high priority and the city is talking about establishing a fund to provide PrEP for young people. Oliver noted that Larkin Street Youth Services was one of the first to sign on to the rapid ART program.
The Getting to Zero meeting concluded with a discussion of HIV and aging. According to the DPH annual report, 60 percent of people living with HIV in San Francisco are age 50 and older.
"We quit our jobs, went on disability, and prepared to die – but some of us didn't," said long-term survivor Hank Trout. "Our golden years are turning into tin."
Vince Crisostomo, manager of SFAF's 50-Plus Network, said that housing is the biggest concern of older people living with HIV in San Francisco.
Dr. Monica Gandhi, medical director of the HIV clinic at SFGH, described a new program – dubbed Golden Compass – that will launch in early January at Ward 86. The program will centralize services for HIV-positive people age 50 and older, including cardiology and neuropsychiatric care, exercise and fitness for bone strength, vision and hearing services, and peer support groups.
"So much in HIV started in San Francisco and we need to be on the forefront of HIV and aging," Gandhi said. "As we work toward the [Getting to Zero] goal, we need to make sure people living with HIV are living better."
San Francisco Community Clinic Consortium's Quarterly Newsletter
From the CEO
I started my career as a probation officer working with juvenile and adult offenders. I planned to help each person I worked with to change their behavior and become model citizens. Many times I heard, “If only…” If only I had not been drinking, taking drugs, neglected my child, if only I had worked harder. My next job was as a mental health social worker in an alternative school for teens. Once again, I heard, “if only…” Wanting to make a difference, I became Executive Director of a health center, with the aims of changing people’s lives and changing the health care delivery system. Meeting with other health care leaders, once again I heard “if only”… we had more money, acted faster, knew more about the future. Today, nearly three decades later, (I celebrated 25 years at SFCCC on October 15) I still hear “if only…” from our patients, our Member Health Centers, and our community leaders. In all my years of service, I never knew a person who started out to be a drug user or alcoholic. I never met anyone who planned to be homeless someday.
SOS, Vet SOS, and our Member Health Centers and other partners offer a wide array of services to break the cycle of homelessness. Please read on and see how SFCCC is making a difference to prevent having to say “if only…”
SFCCC Health Care for the Homeless Program
Determining the number of homeless in San Francisco is a challenge. The point-in-time count of the number of homeless individuals in January, 2015, including a supplemental youth count, was 7,539, a 2% increase from the 2013 count and a 7% increase over the last 10 years. Since this is only a one-night count, this is a severe undercount of those who are eligible for Health Care for the Homeless services, which includes those who are precariously housed. The SF Ten Year Plan to Abolish Chronic Homelessness estimated the number of homeless to be 15,000. San Francisco is estimated to have the highest proportion of unsheltered homeless in the nation, with 511 people on the streets for every 100,000 residents. The 2015 point-in-time count identified the extent of various health conditions for people experiencing chronic homelessness in San Francisco:
Since 1988, SFCCC has led the SF Health Care for the Homeless Program, with the goal of addressing the health-related needs of homeless people and linking them to ongoing care and services. The SFHCH Program, funded in part by the U.S. Health Resources and Services Administration Bureau of Primary Health Care, is a collaborative network providing services at 48 sites in San Francisco and includes Street Outreach Services (SOS), our mobile outreach van. In addition to SOS (described further in this newsletter), our primary partner clinics include:
- HealthRIGHT 360, with sites at the former Haight Ashbury Free Clinic, Integrated Care Center, Lyon-Martin Health Services, and Tenderloin Health Services (formerly Glide Health Services and now a program/site of HR360)
- Mission Neighborhood Health Center, including the Mission Neighborhood Resource Center focused solely on serving homeless people
- North East Medical Services
- St. Anthony’s Medical Clinic
- SFDPH’s Tom Waddell Urban Health Center, Castro Mission Health Center, and Curry Senior Center
- South of Market Health Center.
Meet “Street Outreach Services (SOS)”
“The thing that lies at the foundation of positive change is service to a fellow human being.” -Lech Walesa
SOS is the mobile outreach component of SFCCC’s Health Care for the Homeless (HCH) program. Since 1988, SOS has provided high-quality, nonjudgmental health services directly to homeless individuals. Through our Vet SOS project, we also offer free veterinary care to the companion animals of homeless San Franciscans as a demonstrated highly effective method for linking their human guardians with health care services.
Traveling in two specially equipped vans to sites throughout San Francisco, the dedicated SOS team creates “clinics without walls” at soup kitchens, on city streets, under freeway overpasses, and in parks. By going directly to homeless people, the SOS team builds relationships of trust and breaks down the barriers that keep homeless people and their companion animals from the care they need and deserve.
Each year over 1,000 homeless San Franciscans receive direct services, with most also getting connected to primary care and other ongoing assistance such as mental health and substance abuse services, MediCal enrollment, shelter referrals, and other support services.
Each year over 800 homeless individuals’ companion animals receive care, while their guardians get comfort from knowing the being most important to them is taken care of, and often then become motivated to take care of their own health needs.
As the San Francisco Area Health Education Center (AHEC), each year over 50 medical residents, medical students, and nursing students receive hands-on training from our skilled multidisciplinary team, helping to develop and inspire future clinicians to practice community-based health care. In addition, their and our volunteer providers’ in-kind services make SOS an extremely cost-effective program.
For more information about SOS and Vet SOS, visit our website: http://www.sfccc.org/street-outreach-services and http://www.sfccc.org/veterinary-street-outreach-services-vetsos
It Takes A (Pop-Up Care) Village
Our SOS program is a key partner in San Francisco’s new “Pop-Up Care Village”. Launched in the spring of this year by Lava Mae, organizers aimed for the Village to “bring access to more services and collective impact to more people on the streets where they're at.” And that’s exactly what we are doing! Turns out the pop-up model is so successful that we’ve added it to our regular repertoire of outreach services. SOS provides medical visits, hygiene kits, and over-the-counter medications to Village guests on a monthly basis while other service providers offer haircuts, showers, clothing, and more. Come see us on the last Tuesday of each month in front of the main branch of San Francisco Public Library!
A Day with the SOS Team
9:00 am: Outreach team members meet to discuss the clients they haven’t seen in a while. A few are doing well and have moved off the street, into shelters, treatment programs or with friends. Many are still struggling with homelessness, addiction, mental illness, and/or isolation. There’s lots of work to be done!
9:30 am: SOS is open for business! Loaded with staff and supplies, the SOS van hits the streets, targeting neighborhoods with high concentrations of homeless people and low concentrations of service providers. Two outreach workers leave the van to canvas nearby parks and freeway overpasses, while two team members, including a medical provider, wait in the van for clients who need help.
9:45 am: The first of several clients boards the van. She’s been sleeping outdoors for 20 years and has a long history of trauma, leading to poly-substance abuse and serial violent relationships. She has poorly managed asthma and is not connected to primary care, instead using the public emergency room when crises arise. The outreach staff provides her with non-judgmental and compassionate care and, then with her consent, connects her to a primary care clinic and drug treatment services. All SOS services are free of charge, and we ensure that the other places where we connect our clients are free for homeless individuals also.
10:00 am: The client agrees to see the SOS doctor, so she’s escorted into the van’s private exam room, which is a regular doctor’s office with an exam table, medical equipment, and a small dispensary. A USF nursing student takes the client’s vitals. The doctor examines the client, reviews her medical history, and provides her with an albuterol inhaler to use while waiting for a primary care appointment in a few days. The client smiles!
10:15-11:45 am: Staff sees 3 more clients for medical visits. Each client is connected to resources, and a medical visit, and each leaves with a bag of health and hygiene supplies which may include toothbrushes, tampons, sunscreen, drinking water, protein bars, and vitamins. Clients tell us that these “little” things make a huge difference in their lives. Each client will later receive appointment reminder calls or texts from SOS, and will be offered transportation assistance so that they can actually make it to their appointments.
12:00 pm: Staff enters their interactions into SOS’ new electronic health record (EHR) system to support continuity of care across all SOS locations and providers. (SOS was selected by our EHR vendor to receive free use of their cloud-based system, including training and on-going support! Yes, free—yet another example of our program’s cost-effectiveness!).
12:30 pm: Staff grabs a quick lunch on the road. Burritos, anyone?
1:00 pm: A UCSF medical resident meets the SOS van for the afternoon shift. As a program of the SF AHEC, SOS works closely with several academic institutions to train the future health care workforce. Yay for teamwork!
“Working with SOS has taught me so many invaluable things – not only have I developed hands-on experience and vital skills for my future career as a physician, but I’ve also learned the importance of serving the community and treating all individuals with respect and dignity." -SOS resident
1:30 pm: The van moves to a grassy hill where several homeless people are enjoying a bit of respite in the sun. Some are playing instruments or eating sandwiches, while others play with their dogs or sleep. SOS team members take the opportunity to distribute fliers about our monthly pop-up Vet SOS clinics, where homeless guardians’ pets can receive free veterinary wellness exams, vaccines and pet supplies. Oh yeah, and we always sneak in some human health referrals, too!
1:45 pm: The team greets a previous client, Al, and his puppy, Trinity. Al says if it weren’t for SOS and our Vet SOS project, he doesn’t know where he would get care for himself or Trinity. The outreach team high fives each other and smiles big (seriously).
2:00 pm: A new client boards the van. He says that he lived in a house in San Francisco for many years but when his mental illness became more severe, he began spending most nights camping alone in local parks. Staff assists the client to complete registration paperwork and talk to him about his most pressing needs. The client says that he hasn’t seen his psychiatrist in 3 months and is out of medication. The staff notice a troubling head wound and the client reports he was assaulted while sleeping last night. An outreach staff member phones the client’s clinic to schedule a same-day appointment with his psychiatrist and coordinates transport. The SOS doctor treats the patient’s head wound and dispenses antibiotics.
2:30-4:00 pm: Staff sees 3 more clients for medical visits. Each receives customized referrals; one client needs a shower, another a family shelter for her and her son, and another a pair of reading glasses.
4:15 pm: The outreach team completes their charting, then heads back to home base, where the van is filled with gas, parked, cleaned, and re-stocked for tomorrow. Fliers are replenished, new cases of water and snacks are transported from the storage unit, vaccines are re-refrigerated, portable electronics are charged, and trash is emptied.
4:45 pm: Staff arrive back in the office, where they review upcoming plans for collaborations in San Francisco’s monthly Pop-Up Care Villages and quarterly Project Homeless Connect events. SOS is all about collaborating to best meet the needs of homeless San Franciscans!
5:00 pm: Time to go home and rest for another day on the streets. Great work, SOS.
Meet SOS Patient Advocate, John Sorensen
John has been receiving services from SOS since 2002. He says, “The SOS program takes care of people without judgment or bias about what people are dealing with in their life. Those interactions really make a difference.”
Since John moved off the street and into a residential substance abuse treatment facility, he now serves as a patient representative to SFCCC’s Consumer Advisory Panel (CAP). The CAP is comprised of patients who represent the clinics where SFCCC’s Health Care for the Homeless (and Ryan White Part C HIV/AIDS) services are provided. The purpose of the CAP is to offer suggestions for the improvement of SFCCC’s members’ clinical services, by people directly impacted.
Of his service with CAP, John declares,
“I want to give homeless people a voice. I want to stand up for services that have been critical to me. To help the next person that really needs it. SOS services gave me empathy and compassion when I was down on my luck.”
Way to go and thank you for your commitment, John!
Meet SOS MD, Linette Martinez
Dr. Martinez has been working as a physician in SFCCC’s SOS program for 17 years!
She has wanted to help other people ever since she was a child. Dr. Martinez values being able to take extra time to really engage with SOS patients in the field and appreciates working as part of a team to share the follow up responsibilities.
When asked about her most memorable patient care experience, she told us: “I once took care of a man who was struggling so much with alcoholism that we would often find him lying on the sidewalk and barely moving. One day he said that he had a lot of dental pain and when I examined him, I saw that he had a life threatening dental abscess. He declined transport to the emergency room, so I gave him antibiotics and SOS kept checking back with him. Eventually, we were able to admit him to the hospital. He later told me; “Your antibiotics saved my life” He later went into recovery.
Help us address the health-related needs of homeless individuals and their companion animals! Donate to Street Outreach Services and Veterinary Street Outreach Services today:
Every donation makes a difference!
$ 10.00: Provides fuel for our outreach van
$ 25.00: Pays for preventative vaccines
$ 50.00: Supplies vitamins and toiletries to a homeless person for a week, or ensures that a companion animal will receive a microchip
$ 75.00: Helps distribute clothing, raingear and blankets to homeless people, or underwrites flea and heartworm preventative for companion animals
$100.00: Provides antibiotics and other urgently needed medications
$250.00: Helps underwrite life-saving urgent care services for a homeless person, or life-saving emergency care for a companion animal
Learn more about SOS and Vet SOS and view our institutional supporters:
The Center for Disease Control has free, on line learning modules regarding the latest science on vaccines. On
http://www.cdc.gov/vaccines/ed/youcalltheshots.html You Call the Shots is an interactive, web-based immunization training course. It consists of a series of modules that discuss vaccine-preventable diseases and explain the latest recommendations for vaccine use. Each module provides learning opportunities, self-test practice questions, reference and resource materials, and an extensive glossary where you can learn about:
- Diphtheria, Tetanus, and Pertussis (DTaP) Mar 2016
- Haemophilus influenzae type b (Hib) Jul 2015
- Hepatitis A Jun 2015
- Hepatitis B Mar 2016
- Human Papillomavirus Jan 2016
- Influenza (updated to reflect 2016-2017 recommendations) Oct 2016
- Meningococcal Feb 2016
- MMR Jan 2015
- Pneumococcal Feb 2016
- Polio Oct 2015
- Rotavirus Apr 2016
- Tetanus, Diphtheria, and Pertussis (Tdap) Mar 2016
- Understanding the Basics: General Recommendations on Immunization Feb 2015
- Vaccines For Children (VFC) Jan 2016
- Vaccine Storage and Handling Jan 2016
- Varicella Sep 2016
A recent article in "Modern Health Care" summed up the urgent problems of recruiting physicians for community health centers:
"The limited supply of primary-care doctors and other clinical staff dedicated to the field has increased competition among healthcare providers to attract these key personnel. Federally qualified health centers often lose out in the scramble.
The larger health systems and hospitals have the wherewithal to offer lucrative signing bonuses and financial incentives to prospective employees. Community health centers do not.
“In any given market, whether it be small or large, there are at least 10 different delivery systems a family practitioner can practice in,” said Travis Singleton, senior vice president at physician search firm Merritt Hawkins. “That wasn't the world that we had 10 years ago.”
Many factors fuel the trend. One of the largest came with the implementation of the Affordable Care Act, as millions of newly insured Americans gained access to routine healthcare. Other causes include population growth, an increased elderly population and the likelihood that as many as one-third of the current physician workforce will retire over the next decade.
The confluence of factors has raised the possibility of a shortage of primary-care providers over the next decade. The Association of American Medical Colleges estimates the shortfall will reach between 14,900 and 35,600 physicians by 2025, according to a recent report.
A recent survey on physician recruiting by Merritt Hawkins showed family physicians are the most sought-after specialty for the 10th straight year. Urgent-care physicians, a growing alternative, have moved from 20th most requested in 2015 to ninth in 2016. Average starting salaries rose 13% to $225,000 in 2016 from a year earlier.
The nation's 1,200 community health centers are expected to be hit hardest by the shortage, experts say. The 10,000 primary-care physicians now at community health centers will need to be supplemented by an additional 15,000 providers over the next 10 years."
Here in San Francisco, recruitment is made more difficult because of the high cost of living and the fact that the scoring that is used to provide Federal Loan Repayment, traditionally a strong recruiting tool for doctors coming out of medical school with thousands of dollars in debt, disadvantages high cost, high density urban areas.
SFCCC is working with local, state and national partners on a series of initiatives to ameliorate this problem. The California Primary Care Association (CPCA) has laid out the following priority recommendations and we will be adding local priorities and projects to address these issues.
CPCA Overarching Priority Recommendations
1. EDUCATE the public and key stakeholders about growing primary care access, quality, and cost challenges
2. IMPROVE documentation and communication of emerging primary care workforce problems and consequences.
3. SECURE additional investment and partnerships to accelerate primary care transformation within CCHCs including pilot projects, training, technical assistance, and shared learning.
4.INCREASE the number of primary care residencies in California with a priority focus on residencies in community health centers and medically underserved regions.
5. EXPAND loan repayment funds and provisions to incentivize new and existing providers to practice in CCHCs.
6. ADVOCATE for funds to expand medical schools targeting candidates committed to primary care practice in underserved areas
7. DEVELOPformal ongoing relationships between CPCA and other key advocacy organizations and build an inclusive broad-based coalition to focus explicitly on primary care access and workforce-related policy solutions.
8. DEVELOP state level public-private entity with the necessary expertise, capacity, and relationships to advance collaborative primary care workforce solutions. Convene a process for development of a multi-year strategic plan for California to strengthen primary care capacity and access.
9. ACCELERATE and expand payment reform and pilot projects that align financial incentives and regulations with new team-based primary care models.
San Francisco Community Clinic Consortium’s quarterly newsletter
Spring - 2016Read More
We couldn't be more proud of the amazing service and support our AmeriCorps members bring to our partner clinics and the patients they serve! Meet one half of our 2015-2016 San Francisco Community HealthCorps team in the first edition of our 15-16 Newsletter - Introduction to the 2nd half of our team coming soon!Read More
San Francisco Community Clinic Consortium’s quarterly newsletter
Winter - 2015Read More