SANFRANCISCOPUBLICLIBRARY 3 1223 08514 2967 Cityand CountyofSan Francisco Local Homeless Coordinating Board Shelter Monitoring Committee ShelterEnrichmentReport ExecutiveSummary ProcessOverview The ShelterEnrichmentprocessbeganonFebruary 14,2008,whenMayorNewsomheldapress conferenceannouncinghisinterestintransformingthetwolargestCityownedemergency shelters,NextDoorandMulti ServiceCenterSouth(MSC),throughexpandingthemedical respiteprogramandplacementofon-sitesupportiveservices, similartotheone-stopmodelof ProjectHomelessConnect.TheLocal HomelessCoordinatingBoardandthe ShelterMonitoring Committeebeganacommunityprocesstogetfeedbackonthemedicalrespiteandsupportive servicemodel proposed. Fivecommunitymeetingsand fiveon-sitesheltermeetingswereheld overasixweekperiodtogatherrecommendationsonmedical services, supportiveservices,and acr-p"tr>the*ritvR, Pnnnh/ofSanFranciscosheltersystem. -ommunityhighlightedkeyrecommendationsinall fourareas,the ces, supportiveservices,andaccess. Belowarethegeneralthemes nberofsleepingunitsintheemergencysheltersystemforboth SanFranciscoPublicLibrary Hies icesforhomelessshelterresidents, howeverdonotreplacegeneral Govcmmenl "enter withmedicalrespitebeds SanFranciscoFu'oiicLibrary homelesspeopleandmaketheon-siteservicesaccessibletoall 100LarkinStreet.5thFloor stayingatthesheltertheservicesarelocated SanFrancisco,CA 94102 irsleepingunitsareaccessedneedstochange[clientsstatedon REFERENCE BOOK ittheyhadtowaitinline5-8hoursadaytoaccessaone-day Not to be takenfrom the Library ntfocusedandtheonlywaytocreateclientfocusedandguided itinput shouldbealignmentwithContinuumofCareFive YearStrategic 'tandardsofCare. ionscanbefoundwithintheappendicesofthisreport. Theproductofthisprocessholdsmanydonatedhoursofclient, provider,andcommunitytime. Wewould liketothankeveryonewhocontributedtothe ShelterEnrichmentProcess. DOCUMENTS DEPT. MAY BerniceCasey, PolicyAnalyst Ali Schlageter, PolicyAnalyst 1 ShelterMonitoringCommittee Local HomelessCoordinatingBo£ FRANCISCO fl iUBLlC LIBRARY MonitoringCommittee LocalHomelessCoordinating awardSt.,2"dFloor 1440HarrisonSt.,2""Floor D incisco,CA94103 SanFrancisco,CA94103 REF 55.3642 (415)558.1825 362.582 gov.org/sheltermonitoring www.sfgov.org/lhcb Sa578 Cityand CountyofSan Francisco Local Homeless Coordinating Board Shelter Monitoring Committee ShelterEnrichmentReport ExecutiveSummary ProcessOverview TheShelterEnrichmentprocessbeganonFebruary 14,2008,whenMayorNewsomheldapress conferenceannouncinghisinterestintransformingthetwolargestCityownedemergency shelters,NextDoorandMulti ServiceCenterSouth(MSC),throughexpandingthemedical respiteprogramandplacementofon-sitesupportiveservices, similartotheone-stopmodelof ProjectHomelessConnect.TheLocalHomelessCoordinatingBoardandtheShelterMonitoring Committeebeganacommunityprocesstogetfeedbackonthemedicalrespiteandsupportive servicemodelproposed. Fivecommunitymeetingsand fiveon-sitesheltermeetingswereheld overasixweekperiodtogatherrecommendationsonmedical services, supportiveservices,and accesstotheCity&CountyofSanFranciscosheltersystem. Recommendations Throughouttheprocess,thecommunityhighlightedkeyrecommendationsinall fourareas,the overall system, medicalservices, supportiveservices,andaccess. Belowarethegeneralthemes statedthroughouttheprocess: • Donotreducethenumberofsleepingunitsintheemergencysheltersystemforboth singleadultsandfamilies • Increasemedicalservicesforhomelessshelterresidents, howeverdonotreplacegeneral accesssleepingunitswithmedicalrespitebeds • Increaseservicesforhomelesspeopleandmaketheon-siteservicesaccessibletoall people, notjustthosestayingatthesheltertheservicesarelocated • Thecurrentwaysheltersleepingunitsareaccessedneedstochange[clientsstatedon multipleoccasionsthattheyhadtowaitinline5-8hoursadaytoaccessaone-day reservation] • Solutionsmustbeclientfocusedandtheonlywaytocreateclientfocusedandguided solutionsistogetclientinput • AllrecommendationsshouldbealignmentwithContinuumofCareFive YearStrategic PlanandtheShelterStandardsofCare. A full listofall recommendationscanbefoundwithintheappendicesofthisreport. Theproductofthisprocessholdsmanydonatedhoursofclient,provider,andcommunitytime. Wewould liketothankeveryonewhocontributedtotheShelterEnrichmentProcess. DOCUMENTS DEI BerniceCasey, PolicyAnalyst Ali Schlageter,PolicyAnalyst ShelterMonitoringCommittee LocalHomelessCoordinatingBoard SS1ha3en8l0tFeHrraonMwcoainsricdtoo,SrtC.i,nAg2"9C14oF1ml0mo3iorttee SL1(oa44cn41a05lF)Hr5Haa5onr8cmr.iie1ssl8coe2ons,5sSCtC.A,oo29r"4d11iF0nl3aotoirngBe.rd (415)255.3642 www.sfgov.org/lhcb www.sfgov.org/sheltermonitoring LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May 12,2008 Page2 ShelterEnrichmentReport ShelterEnrichmentProposal OnFebruary 14,2008,MayorGavinNewsomheldapressconferenceatSt. Vincentde Paul's Multi ServiceCenterSouth(MSC)to"pledge [his]commitmentto improvethesheltersystem in SanFranciscothroughexpandedaccesstomedicalrespiteandon-sitesupportiveservices." By invitationfromtheMayor'sOffice,theLocal HomelessCoordinating Board(LHCB)andthe ShelterMonitoringCommittee(SMC)beganasixweekcommunityoutreachefforttoget recommendationsonMayorNewsom'sproposalofa"specific redesigncomponents [that] will focusontwoareas: expandedmedicalrespiteandplacementofon-sitesupportiveservices similartotheone-stopmodel ofProjectHomelessConnect." AttheirMarch meetings, boththe LHCBandSMCapprovedanoutreach proposal drafted by stafftobegina Shelter Enrichment process.Atthefirstoffivecommunitymeetingson March 19,2008, itwasclear from communityfeedbackreceivedthatashelterredesignwould needtoexpand pastthetwo large sheltersindicatedonFebruary 14,2008, MSC SouthandNextDoor,andthetwoareas, medical respiteandon-sitesupportiveservices. ShelterEnrichmentProcess LHCBPolicyAnalystAli Schlageterand SMC PolicyAnalystBerniceCasey planned the firsl TownHallmeetingonMarch 19, 2008. FacilitatedbyLHCB MemberDr.Chirstinc Ma. the meetingdrewover80participants. Thefocusofthe firstmeetingwastoget feedback on the proposalofimprovingthesheltersystemthroughexpansionofmedical respite,on-site supportiveservices,andaccess. Themeetingprovidedanopportunity forrepresentatives from theLHCB, SMC,TenYearPlan ImplementationCouncil (TYPIC), Human Services Agency (HSA),DepartmentofPublic Health (DPH), andtheMayor'sOfficetodiscusstheprevious communityworkcompletedonhomelesspolicy, specificallythecreationoftheTen YearPlan to EndHomelessness,theContinuumofCarePlan,theStandardsofCare, andtohearfrom policy makersonhowtermssuchas"respite"aredefinedwithintheCity&CountyofSan Francisco. ByprovidingabaseofwhatworktheCity&CountyofSan Franciscohadalready accomplished,thegoalofthismeetingwasto identifywhattypesofsupportiveservices consumersandproviderswould liketoseeinthesystem, utilizingaProject HomelessConnect (PHC)approach [servicesatonesite;utilizationofalargevolunteerbase;and financial and resourcebasedsupportfromtheprivatesector],theneed foran increase in medical serviceson- site, includingrespitebeds,andthemannerinwhichallservices, includingshelter, could be accessedwithinthesheltersystem. Atthismeetingandthefourmeetingsthatfollowed,aswellasthefiveshelter-specificmeetings thatwereheld,thefollowingsystemrecommendationswereraisedrepeatedly: • Donotreducethenumberofsleepingunitsintheemergencysheltersystem forboth singleadultsandfamilies • Increasemedicalservicesforhomelessshelterresidents,howeverdonot replace generalaccesssleepingunitswith medicalrespitebeds • Increaseservicesforhomelesspeopleand maketheon-siteservicesaccessibletoall people,notjustthosestayingatthesheltertheservicesarelocated 3 1223 085142967 .. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page3 • Thecurrentwaysheltersleeping unitsareaccessed needstochange [clientsstated on multipleoccasionsthatthey had towaitin line5-8hoursadaytoaccessaone- day reservation) • Solutionsmustbeclientfocused and theonlywaytocreateclientfocused and guided solutionsistogetclientinput • All recommendationsshould bealignmentwith Continuum ofCareFiveYear StrategicPlan and theShelterStandardsofCare. Therewere fourcommunitymeetingsheldafterMarch 19, 2008. OnApril 3, 2008, amedical servicesworkgroupmeetingwasheld. Thegroup identified20recommendationstoimprove clientaccesstomedicaland health services. OnApril 9, 2008,asupportiveservicesworkgroup meetingwas held. Thegroup identified29recommendationsto improveclientaccesstoservices inthesheltersystem. OnApril 23, 2008,anaccessworkgroupwasheld. Thegroup identified 20recommendationsto improveclientaccesstothesheltersystemasawhole. Thecommunity reconvened onApril 28,2008,to identifythekey recommendationstobe forwardedtothe LHCBandtheSMC fortheirreviewbeforebeingsentontotheMayor'sOfficeandtheBoardof Supervisors. ShelterEnrichmentRecommendations MedicalServices Atall thecommunitymeetings, itwasnotedthatadditionalmedical servicesare neededtomeet thehealth needsofclients. Iftheanswerisrespitebeds,therespite bedsshould beprovided in additiontocurrentunits, notwiththereplacementofany sleepingunitsatshelters. Manyspoke oftheneed forextended health clinic hours, moreclinicianson-site, moremental health services, theuseofamedical rovingteam, and healthtrainingforboth staffandclients. The followingarethe fivekey recommendations formedical services. Acomplete listof Medical Recommendations is located in Appendix 1 ofthisreport. • Havea roving medical team orvan thatcomestothesiteon a regularand consistent basis. 1 Mental healthandcounselingshouldalsobeapartoftherovingservice. 2. A mobile health vanwouldallow forservicetobeofferedatthesheltersopenedonly atnight. • Expand currenton-sitemedicalclinic hours. 1 Forlargershelters,theclinicexpandstofivedaysperweekatconvenienttimes, particularlyeveninghours. 2. Atresourceanddrop-incenters,clinichourscorrespond [and ifneeded,expand]to whenclientsaremaking [andwaiting for] reservations. • Have medicalstafftrain and educateboth clientsand staffon chronichealth issues, howtoensurea healthyenvironment,and provide basictreatmentforavarietyof common health conditions [aslistedbelow] 1. RequestthatDPH developcurriculum forshelterstaffthatwouldreviewtriage techniquesforwoundcare,epilepsy,asthma, pain management,occupationaltherapy, tuberculosis, hepatitis,and sexuallytransmitteddiseases. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page4 2. Inaddition,utilizingexistingprintedresourcefromNationalHealthCareforthe Homeless,distributeandpostpamphletsregardingchronichealth issuesatresource anddrop-incentersandshelters. • Increase"rest-beds" 1. A"rest-bed" [orhealthbed] isamedicalstep-downfrommoreacutemedicalcareas wellasastep-upincarefromageneralshelterbed. 2. Thepurposeofa"rest-bed"istoprevent[re-] hospitalizationandtomeettheneedof non-acutecare. 3. Clientshouldbereferredto"rest-beds"fromthehospital,urgentcare,respitecenters, out-patientclinics,and/orcasemanagerattheshelterandresourceanddrop-incenter. • Usealowthresholdmodeltoensurethatallmedicalservicesareeasilyaccessedand tominimizetheunnecessaryhurdlesforthatclientstryingtoaccesssitesand services. SupportiveServices BeforethefirstTownHallmeeting,servicesproviderswereaskedto identifytheservices offeredattheirsite. GiventheFebruary 14, 2008proposalofprovidingon-sitesupportservices, ProjectHomelessConnectmodelproposedbyMayorNewsom,asurveywasdistributedto serviceproviderstoassesswhichoftheservicesofferedattheDecember2007ProjectHomeless Connectwereofferedattheirsite. Onlyonesingleadultshelterprovidedover60%ofthose services. Fordetailsofon-sitesupportiveservicescurrentlyofferedbyserviceprovidersand dataoftheuseoftheservicesprovidedattheDecember2007ProjectHomelessConnect,please reviewAppendix2. TheApril9,2008 SupportServicesworkgroupmeetingalsodiscussedutilizingaresourcecenter modelforon-siteservicedelivery. TheMissionNeighborhoodResourceCentermodelwas presented. Thefollowingarethe 14keyrecommendationsforsupportiveservices. Acomplete listofthe SupportiveServicesRecommendationsis locatedinAppendix3ofthisreport. • Provide24-houraccesstomentalhealthservices 1. Employatherapistforeachsiteand/orprogram, availableMonday-Friday 2. Provideaccesstoamentalhealthprofessionalafterhoursandonweekends 3. Providementalhealthtrainingtostaff • Createanassessmenttoolwhichmeasuresclients' needs [upon intake] from mental health,nutrition,physicalhealth,employability,and housing • Createandmaintainsystem-wide,stream-lined housingdatabasewhich isupdated, complete,andeasyforcasemanagerstouse • Createaseniorspecificshelter 1. CreateashelterforGoldenAgeclients55 yearsandolder 2. Provideintensivecasemanagementservices,similartothoseprovidedthroughthe HomelessOutreachTeam 3. Identifyclients65yearsandolderwhomayneedadditionalservices • Provideservicesatonesitebutletallclientsaccessthoseservices .. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page5 • Providetrainingforcasemanagers [andothershelterstaff] toensurethatallcase managers [andothershelterstaff] havethesameinformation on resourcesand servicesforclients • Createan employmentprogram on-siteatthesheltersin partnershipwithaday laborprogram • Providemoreeducationalprograms,includingliteracy,GeneralEducation Development((ill)),computerskills,andvocational programs • Createaclientsatisfactionsurveythatcanassistin determiningifservicesarebeing providedsuccessfully 1 Provideincentivestoclientsforcompletingthesurveys 2. Provideassistanceandencouragementforcompletingthesurveys 3. Provideanalternate formofdelivery sothatclientscan sendtheircommentsdirectly totheCity&CountyofSan Francisco • Providespecificservicesforundocumented clients,particularlyhousingand employment • Establish betterclienttostaffratios 1. Suggested Ratios: CaseManagement25:1 and FloorMonitors20:1 • Raisehiringstandardsforstaff 1. Providetraining forexistingstaff 2. Provideannualtrainingsforstaff 3. Emphasisonconflictpreventionresolutiontrainingandothertrainingoptionsby removingsecurityguardsfromsitesandusethosefundstotrainstaff[NOTE: when thisitemwasdiscussed inthe largergroup, someclientsrequestedthattherebe additional securityguardsatsites] 4. Providehigherwagesforstaff 5. TheCity& CountyofSanFranciscoshould providehiringguidelinestoallshelters • Createashelterforwomenonly 1 Createmore sleepingunits forwomen;whilethere isaneed formoresleepingunits formen,thereneedstobemoreunits forwomenthatcorrespondtothepopulation sizeofhomelesswomenofSanFrancisco. 2. Createawomen-onlyshelterinthe WinterShelterSystem • HaveGeneralAssistance(CountyAdultAssistanceProgram)workerson-siteatthe shelters Access Atthecommunitymeetings,throughcommunitydiscussionandclient'scomments, itwasclear thataccessto San Francisco'ssheltersystemneedstobe improved. In particular, peoplewere concernedwiththedifficulty forseniorsandthosewithdisabilitiesaccessingbeds,the longdaily waitspeopleencounterwhengettingareservation,andthe factthatempty bedsareinthesystem eachnight. Thefollowingarethesevenkeyrecommendationsforimprovingclientaccesstotheshelter system. Foracomplete listofalltherecommendations, pleasereviewAppendix4. • AnalyzetheCareNotCash (CNC) programs 1. TheanalysisshouldfocusonthenumberofCNCbedsunoccupiedeachnight. . LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page6 • Trackwhattypeofsleepingunitisvacanteach night 1. Theanalysiswoulddefinetheaccesspointtothatvacantsleepingunit: CAAP, CAAPPending,casemanagement,etc. 2. Trackwhere,whichsites,vacanciesoccur 3. Trackatwhattimessleepingunitsbecome"vacant" intheCoordinated Homeless AssessmentofNeedsandGuidancethroughEffectiveServices(CHANGES) • Increasethenumberofsleepingunitsthatthe resourcecenterhasaccessto make reservations. 1. Currentlytheresourcecentershaveaccessto38%ofthetotal units intheshelter system. • Allturn-awaysshould betrackedeach dayand nightatthe resourcecentersand at theindividualshelters. 1 Aturn-away isdefinedasan individualattemptingtomakeareservationatanytime duringthedayornightand notbeingabletoaccessasleepingunitatthattime. 2. Typesofturn-awayareclassified intwoways,a)an individual isunabletomakea reservationatXtimeastherenosleepingunitsavailable inthesystemand b)an individual isunabletomakeareservationatXtimeasthesheltertheyarerequesting doesnothaveanavailablesleepingunit [personalchoice]. 3. Thetrackingmechanismwouldnotewhethertheturn-awaywasbasedonpersonal choiceortheavailabilityofasleepingunit.Themechanismwould beusedatthesite throughouttheday,note ifthe individualwasunabletomakethereservation based onavailability,andatwhattimeasleepingunitwasmadeavailablewithin CHANGES. 4. Clientsshouldhavetheoptiontofilloutasurveydocumentingthetimetheywere turnedaway,whichsheltertheycouldnotaccess,andthereason. • Sleepingunitreservationsshould beabletomadeon-siteatshelters 1. TheStandardsofCareCity RequirementsSection 20.403 (a) Ensure24-hourclient accesstoashelterand provideon-siteshelterreservations forcurrentshelterclients. 2. Allowsleepingunitreservationsand reservationextensionstobemadeon-siteat shelters,notjustatresourcecenters. • Dropavailablesleepingunitsatanearliertime 1. Itwasreportedthatsomesheltersdrop"vacantbeds"as lateas 11:00PM, midnight, andtheearlymorninghours. • UsetheSF311 freephonelineasanotherwaythatsomeonecan makeashelter reservation24hoursaday. CommunityProcess Themostconsistentcomplaintaboutthecommunityprocesswasthe lackofclientinvolvement inthemeetings. Ms.CaseyandMs. Schlageterheldfivecommunitymeetingsatsheltersites, HospitalityHouse, DoloresStreetCommunity Services,MSC South,NextDoor,and Sanctuary. Inaddition,throughouttheprocess,theLocal HomelessCoordinatingBoardandthe Shelter MonitoringCommitteereceivede-mailsandcallsabouttheprocess. Twocommunity organizations, HumanServicesNetworkandtheCoalitiononHomelessness,submittedwritten recommendationsontheShelterEnrichmentprocess. Bothletterscanbe found inAppendix5. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page7 Continuum ofCarePlanand theStandardsofCare Inrecognitionofthecommunityeffortsthathavealreadytakenplace, it isimportanttorecognize thecrossoverbetweentherecommendationswithinthe ShelterEnrichment, ContinuumofCare Plan, and StandardsofCare legislation. InAppendix6,thereisabreakdownofthemedical, services,andaccessrecommendation intersections. BudgetConstraints OnApril 15,2008, MayorGavinNewsom submittedtotheBoardofSupervisorsaResolution declaring ittobeofficialCitypolicythatnonewset-asidesorothermandatoryappropriationsbe addedtotheCityCharterunlessthemeasurealsoidentifiesorprovidesaspecific,adequatenew sourceoffunds.The issueoffundingwasaconcernthroughoutthisprocess. Torespectthe communityprocess,thekeyrecommendations formedical,services,andaccessshouldgo forward. The Human ServicesAgency, DepartmentofPublic Health,andotherpolicybodies shouldworkwiththeMayor'sOfficeandtheBoardofSupervisorstoidentifyappropriate funding, ifpossible. Thefollowingrecommendationsarebeingproposedas lowcostornocost; however,abudgetanalysiswouldneedtobeconductedbytheCitydepartmentsidentifiedbelow todeterminethecost: • Havemedicalstafftrainand educate both clientsandstaffonchronichealth issues, howtoensurea healthyenvironment,and provide basictreatmentforavarietyof common health conditions Implementation: a) UtilizingNationalHealthCarefortheHomelessfreetrainings; b) DPHcouldworkinpartnershipwithlocaluniversityhealthprogramstoprovidea curriculum-basedtrainingtoallemployees • Increase"rest-beds" Implementation:AccesstobedrestismandatedwithintheStandardsofCarelegislation • Createan assessmenttoolwhich measuresclients' needs [upon intake] from mental health,nutrition, physicalhealth,employability,and housing Implementation: HSA andtheDPHcouldcreateastandardizedassessmenttool, in partnershipwiththeShelterDirectors, incorporatingexistingtools • Createand maintainsystem-wide,stream-lined housingdata basewhich isupdated, complete,and easy forcasemanagersto use Implementation: WorkinginpartnershipwiththeHSA, DPH, andcommunityhousing organizations, createawebaccessiblelistthatcanbeaccessedbythecommunity. Need: IdentifyanexistingstaffwithinHSA orDPHtotakethelead. • HaveGeneralAssistance(CAAP)workerson-siteattheshelters Implementation:Apilotprogramatalargeshelter, e.g. MSCSouthorNextDoor, where aCAAPworkerwillworkon-site20hoursaweek[minimum]andtrackoutcomes. • Providetrainingforcasemanagers [andothershelterstaff] toensurethatallcase managers [andothershelterstaff] havethesameinformation on resourcesand servicesforclients Implementation: Employingasimilarmodelfortrainingstaff[listedabove], HSA and theDPH, willprovideannualtrainings. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page8 Need:AnanalysisoftrainingneedsidentifiedthroughHSA'smonthlyShelterDirector's meetingsandtheincorporationoftheninetrainingareasrequiredbyallstaffwithinthe StandardsofCare. Createaclientsatisfactionsurveythatcanassistindeterminingifservicesarebeing providedsuccessfully Implementation:LocalHomelessCoordinatingBoardandtheShelterMonitoring Committeewillworkwithcommunitygroupsandclientstoidentifyincentives. Need:Self-addressedenvelopestothecontractmonitoragencyshouldbeprovidedwith eachsurvey. TheLHCBandSMCcanprovideananalysisofeachsite'sresponses. Trackwhattypeofsleepingunitisvacanteachnight Implementation: ThisinformationisalreadyavailablethroughHSA. Need:Areportshouldbedoneonamonthlybasisandthatinformationprovidedtothe LHCBandSMC Allturn-awaysshould betrackedeachdayand nightattheresourcecentersand at theindividualshelters. Implementation:LocalHomelessCoordinatingBoardandtheShelterMonitoring Committeewilldoquarterlyturnawaychecks. Inaddition, contractmonitorsshould workwithagenciestoprovideatrackingtool. Forexample, theHumanSer\>icesAgency hasprovidedsiteswithatrackingsheettorecordturnaways. Increasethenumberofsleepingunitsthattheresourcecenterhasaccesstomake reservations. Implementation:Aftercompletionoftheaboveanalysis, theHumanServicesAgency shouldreassessresourcecenteraccessallocation. LocalHomelessCoordinatingBoard ShelterMonitoringCommittee ShelterEnrichmentReport May12,2008 Page9 Appendix 1 Medical Services Recommendations