$2.3 million dollars

Close Urgent Care at TWHC, the primary access point for SF's homeless.

Close Disability Evaluation Assessment Program (DEAP), qualifying disabled for SSI, raising revenue, and connecting clients with healthcare and housing.

Cut shelter/outreach/supportive housing clinics by one third

Cut leadership

The budget cuts require the closing of Tom Waddell HC Urgent Care.

o        60 – 100 patients will not be seen each day Monday – Saturday

o        18,000 - 30,000 patient encounters per year will not happen

o        These encounters are not trivial and patients will seek care in other settings. The most convenient will be local hospital emergency rooms which will be overwhelmed by homeless and un-sponsored patients seeking care.

o        Some patients will give up on seeking care until they are much sicker and require costly hospital admissions or die.

o        Currently 50% of the medical clearances for detox are done at TWHC urgent care. Access to medical detox will decrease.

o        Opportunities for prevention and engagement of patients into primary care will be lost resulting in even more burden to emergency and acute and long term care

The budget cuts require decreasing the number of community site clinics by 1/3

o        80 – 100 patients per week will not be seen at outreach, shelter and supportive housing sites

o        4000 – 5000 patient encounters per year will not happen

o        These encounters are not trivial and very often are the only medical care received in the course of a year by the individuals receiving them

o        TB control for homeless people has also been cut and the TWHC cuts further reduce the chances of contagious Tuberculosis being prevented or identified early

o        Engagement “where people are” is an essential component of the health care for the homeless model and harm reduction approach. Each encounter not done is an opportunity lost to engage individuals into primary care, substance abuse and mental health treatment, and prevention services.

The budget cuts require eliminating the disability evaluation project (DEAP)
Read a description of Tom Waddell's DEAP Program

o        100 or more patients per year will not get Social Security for which they are eligible

o        City and County provides free service rather than collect $750,000 - $5 million or more in revenues from Medi-cal and Medicare

o        SFGH and other hospitals provide free service rather than collect revenues

The budget cut requires eliminating all administration from TWHC except for 2 medical director positions, a health worker supervisor, and a principle clerk

o        The loss of the current health center director means the loss of a nationally esteemed expert on health care for the homeless (current president of the National Health Care for the Homeless Council.)

o        The loss of the deputy director and health program coordinator means the loss of exceptional expertise in managing TWHC budget and programs which includes more than $5 million dollars of grant funded services including Federal health care for the homeless, Federal Ryan White Care HIV grants, numerous collaborations, partnerships, and contracts.

o        The medical directors will be forced to decrease their current patient care work, and decrease other work in support of clinical services (quality assurance, consultation with other providers,…)

o        Staff supervision will be inadequate. The remaining staff will still number over 100 and at the time they will most require direction they will not get it.

The victims of this budget cut will be the most vulnerable homeless people and the emergency services forced to care for them due to these short-sighted and foolish cuts 

Some Predicted results of current budget proposals

o        Increase in active TB cases in homeless people and increased transmission of TB in San Francisco

o        Decreased revenues, decreased number of patients getting medi-cal

o        Increased usage of emergency room and inpatient services at sfgh and other hospitals

o        Increased amount of preventable deaths in homeless people, many of these after prolonged expensive hospitalization

o        Overall care below community standards.

o        Very poor supervision of staff and predictable poor staff performance

o        Loss of federal and private grant funding due to failure to fulfill mandated reporting and expectations.

Frequently Asked Questions:

Q: The McMillan Stabilization Project is not being cut; won’t that take the place of most of these other cuts?

A: The McMillan project has been quite successful in reaching chronic homeless inebriates. The staff will undoubtedly stretch to provide some of the needed detox clearances and urgent care needs but this is likely to replace only a small fraction of the services. The long term goal of McMillan to reduce the burden on emergency rooms will be more than reversed by eliminating Tom Waddell urgent care.

Q: Mayor Newsom is committed to solving homeless problems; won’t the new homeless outreach team take the place of whatever is cut at Tom Waddell Health Center?

A: Proposing to cut $2 million dollars from the largest provider of health services to homeless people does not seem like a sign of commitment to solve a problem. The new homeless outreach team does not include medical services and is unlikely to be able to engage many people into the primary care services which are an essential component of ending homelessness. Medical illness is an important barrier to ending homelessness and these cuts are likely to increase the burden of medical illness on homeless people.

Q: Why not cut primary care and urgent care equally at Tom Waddell and keep urgent care open?

A: Before this round of budget cuts urgent care already faced major cuts because of several years of increases in staff salaries without any increase in budget.  Urgent care is a moderately more expensive activity compared to standard primary care due to the need for enhanced nursing staffing for triage and follow up care and the need for replacement costs of staff time on vacations, leave etc. Since our primary commitment is to the continuity care of patients we have already committed to treating we cannot  (and should not) cut primary care services. A secondary but essential commitment is to the grant funders who fund us to provide primary care to special populations such as homeless people, People with AIDS, Opiate addicts in our OBOT program, etc.

Q: Isn’t there a community based organization already providing disability advocacy and evaluation services which overlaps with DEAP?

A: No. An existing project exists which assists patients already receiving services in the community behavioral health system to obtain benefits. DEAP assists patients who do not have existing connections and as an important adjunct can engage patients into primary care and provide mental health treatment.

Q: Isn’t it great that we are cutting administrators and saving services?

A: It would be great if it were true. Unfortunately any organization requires management to solve problems, supervise staff, plan and implement programs, improve quality and productivity, etc. Tom Waddell is a large community health center and health care for the homeless program. Its staff size is 3 –5 times that of the closest other health center and its operations are 10 times as complex. The cuts don’t change this. Sources of funding are diverse and allow for essential services to targeted populations. These funding sources require extensive attention to compliance, reporting, planning and collaboration. The administrative cuts will make this level of administration impossible and proposals to manage such matters centrally by already overburdened administrators who are unfamiliar with the details in these grants and projects will fail. Clinicians will inevitably be pulled away from patient care to fill in this void and productivity will fall. Funders will become dissatisfied with the work and $ will go away (often to other cities with better administrative infrastructure as we have recently seen with Ryan White Care Title I funds.) The central administration that we now are told will provide support are the same administration that has had a very poor track record at collecting revenue from the billable sources of revenue currently available.

Q: If anything is restored to the TWHC budget won’t that mean less for other health centers primary care or community based organizations?

A: This is only the case if we continue to believe the zero sum solutions put forth by DPH administrators. There are many creative ways to maintain if not expand these essential services. The closed planning process prevented anyone outside of the director’s office to help find these creative solutions. Within the department of public health I’d suggest starting with a close look at the affiliation agreement with UCSF for services at SFGH. Primary care services are provided at SFGH by trainees and faculty with part time commitments to primary care. This is not the best or most efficient model for providing primary care and certainly leaves out a large number of vulnerable people who cannot negotiate the institutional setting of SFGH. (It is also not the best model to teach trainees how to practice primary care in the real world.)

Q: Won’t the committed and skilled staff at Tom Waddell find ways to make up for the cuts? Can’t this all be rebuilt after the economy in San Francisco improves?

A: Unfortunately these cuts are a giant step backward. Experienced and idealistic staff will leave, grant funding will be lost, collaborators and partners will become discouraged and quite possibly get sucked down with us.

Q: Don’t these cuts require Bielenson hearings?

A: The director of the department maintains that these cuts will not cause service reductions and do not require hearings. This is a dishonorable lie. Hearings should take place and a full examination ought to occur of why these predictable economic problems were not planned for in advance and efforts made to minimize their effects on patients. The role of the Director of Public health should be examined carefully in these failures. (Note: Tom Waddell was indeed a major focus of the Bielenson Hearing, and the Director was grilled on these questions.)

Q: Wouldn’t it be better if these services were privatized?

A: At present the expertise exists at Tom Waddell Health Center. No community health center in San Francisco has had the innovation and ambition shown by Tom Waddell over the past 10 years. It’s  track record, productivity and efficiency, and commitment to the collaborative process have made us a sought after partner and fundable program despite the misgivings of many funders to work with city and county agencies. Ironically it has been the stability of our leadership which has been a major factor for our partners.

Q: What should happen?

A: Restore the cuts. Commit to urgent care and fund at the level to keep services open 7 days per week and 12 hours a day on weekdays. Restore services to community sites and set up a cross department multi-program task force to examine where to deploy staff to make biggest impact on homelessness. Fund DEAP which is a no brainer- it has long and short term impact and currently brings more revenue to the department than it expends.