Health Commission approves creation of Health Care for the Homeless co-applicant board after HRSA-driven changes

The San Francisco Health Commission voted to establish a Health Care for the Homeless (HCH) co-applicant board after staff incorporated a change requested by federal funder Health Resources and Services Administration (HRSA).

Holly Hammer, director of ambulatory care, and Beth Neary, HCH program director, told commissioners that HRSA's recent audit found the program's governance did not meet current federal expectations. Staff proposed an 11-member co-applicant board with a majority of voting seats held by patients served by the program, an ex officio nonvoting slot for the director of health's designee, and monthly quorumed meetings. Major responsibilities would include reviewing the HCH program budget and priorities, developing quality-improvement and quality-assurance work, recommending the HCH program director to the Department of Public Health director, and long-term strategic planning.

Neary said HRSA requested removal of a provision that would have allowed a co-applicant board's proposed members to be automatically seated if the director failed to ratify nominations within 10 business days; staff supported removing that clause to align the proposal with HRSA's emphasis on board autonomy.

Commissioners pressed staff on how the new board would affect the Health Commission's charter responsibilities. Commissioner Christian asked how the proposal would preserve the commission's oversight role. Staff and city attorneys said the co-applicant board would have direct authority over the HCH grant budget required by HRSA, but the city's broader budget process remains governed by the Charter: the department submits budgets that the Health Commission reviews and that are ultimately part of the Mayor's proposed budget and Board of Supervisors' appropriation. Greg Wagner, chief operating officer, and city attorney staff emphasized that the Health Commission remains the ultimate policy-making body and retains charter responsibilities for personnel and overall budgetary authority.

On concerns about board autonomy and potential harms from a self-perpetuating membership, staff pointed to bylaws provisions for member removal, the presence of a director's designee on the board to maintain communication, and the director's ability to terminate a co-applicant agreement with 60 days' notice in extreme circumstances.

The resolution was moved, seconded and adopted on a roll-call vote. (Motion and mover not specified in the record.) Staff said the director of health will appoint the initial board and the co-applicant body will thereafter run its own selection process consistent with the approved bylaws and federal requirements.

Next steps include posting and running the application process, seating the initial board, and establishing regular reporting to the Health Commission via the director's report and optional joint presentations.

Authorities cited in the discussion and reflected in the adopted materials include HRSA governance guidance for Health Care for the Homeless grants and the co-applicant board provisions in the HCH grant program documentation. The commission recorded the vote and passed the resolution.