digging. >> no, we require of our providers to submit monthly critical injury and we come pile them tare also discussed at what we call the discussion critical advisory committee it is sitting down and going through each one to look at that specific incident that required someone who couldn't self-care. >> so at the moment than a critical i wanted is someone behaving balanced or someone released from the hospital and goes to the shelter and can't self-care. >> correct. >> so what kind of care which is what type of care is generally required. >> someone who can't self-care or and right what typically

happens next. >> i'm spanking against the case our for our nurse kate someone being discharged from the hospital with the wound injury and they can't self-clean the wound injury it's on their leg and they can't reach their leg and need someone to get the medicine to do that or someone that is incobbling cognizant. >> we're talking about assistant care not the type of care the shelters typically provide we're talking about assisted care for post surgical or post trauma. >> those are some of the incidents we've encountered. >> it seems to me that is the

reverse problem so calling 9-1-1 to respond to problems in shelters and sro's and housing unit is an issue that level of energy care is not also required this is the reverse problem then bringing people from a medical facility into the shelter just continues to cycle. >> right. >> so are are there tyler san francisco general hospital and laguna honda where between the level of the hospital and helpful will of the shelters are there. >> supervisor kim wants to intervention only because there are presentations this is merely the first presentation it is describing the issue issue you're right before about the

rules to consolidate for the rules how their drafted being in existence we came up with the issue i know this is an issue every night at the shelters people entering the shelters that can't self-care so knowing often the response to call 9-1-1 or the other nurse now we have nurses in our shelter system can we develop a systemic progress understanding our demographics is intenseer he older than 10 years ago so 0 the purpose of the hearing has shifted more than about the proposed rules but the solution to the issue we're seeing no our shelters today, we have the department of public health to address a lot of the questions you're answering we're in the process of developing the solutions and this hamburger is an opportunity for us to have this discussion

in public and to hear from the members of the public on their feedback and thoughts how we can improve the system no answers and you asked a lot of the questions i've been asking forever the last couple of months and thank you ms. crumb i don't want to sound like we have the answers but we're about exploring options and we can talk about the resources readily available to address solutions to this issue. >> through the chair. >> yes. >> because my question is wait the magnitude of the issue. >> dpw will go through that. >> and then what are the alternatives to requiring the shelters i guess those are my anecdotal information is interesting but to focus on the issue i thank you supervisor christensen. >> thank you, ms. crumb and mr.

walton i do want to bring up the department of public health and just to give a little bit of background on data they'll be presenting today on the demographics of our homelessness e homeless population and the work we've done the studies to he'd some of the issues that was brought up electro the disclosed rule and in particular around self-care and so thank you for being here today. >> okay supervisors i'm here for barbara and i'm the deputy director of the health network and essentially i think we understand did needs in the shelter because people are aging loose and lots of housing issue dpw has been resolved resolved trying to address the health care needs in the sheltered one

of the first things we implemented even though medical reports or record this is the beds facility an mission street and essentially what medical focus who people are disregard in the hospital they go to a medical respite and stay up to thirty days one we try to make arrangements for the next level of care it would be permanent housing or shelter or could be in the partial housing that's one thing that dpw is working on we also tried to understand our medical homes and part of the medical home system to capitol hill the access to if people are in a shelter and needing health care they can go to one the medical homes one the medical homes that is on

6 days a week no appointment needed at tom wisconsin dell the area that invested a lot of time kate has worked at the shelters educating and this year we actually are lucky in that that study will be expanded to include much more comprehensive studies we work with the shareholders to see challenges and things of people being in the shelter and needing self-care that's some of the things we think are critical we're going to get more and more sick people in the shelters and how do we address the issue we look forward to working with the agency to address those i'm going to turn it over to kate

who has been there for the last 5 years and looking at and working with the shelters to address some of the health care needs and she's going to expand on the new molding model. >> so thank you for hearing me so there are sicker older people every year it seems to be getting the needs seem to be getting greater and the shelter staff are not equipped to take care of sick people can't transfer or shower them so when something is in front of them they don't have a choices but to call 9-1-1 that's a big issue as people get sicker we started to realize we have to make

interventions so we have one group that calls 9-1-1 and sicker clients we really pull together the experts in the 9-1-1 group it was shelter help that was me just the fire department and ems and h f a to strategy allergies out to help people get to the appropriate level of care versus 9-1-1 as i mentioned going in and out of the emergency room doesn't help anyone unless it's truly an emergency the work shelter groups i had to write it down we pulled together as a city i want to say there's some amazing people who are at the table and really worked together shelter directors and supervisors and on the placement

team and management and respite and hot team and i h ss we met and come up with recommendations the common determinants is having the shelters they prepared they had trouble with self-care one person sort of wheeling and dealing to get our nurses they'll be doing realtime two jobs taking katz and figuring out what to do it is not always a 9-1-1 an unadorable situation like leveraging the serviced when we talk about the care we can leverage the home and health care i've been doing with the goal of stabilize and

keep them from bouncing in and out of effective levels of care to have a healthy shelter stay this is not also possible other piece is the advocacy when that happens without the advocacy people bounce in and out of hospital and there's not a lot of dialog so for instance, if i have someone that is xhaepd and the shelter sends them out or the noose is aware that someone goes to an emergency room he advocate with the hospital sometimes, it is miting people that is difficult and prevention so people don't get

to the point they're unable to take care of them medication management and the nurses are on site full-time 40 hours and 36 hours one american people expert and one an emt to be on call for the short term management working with the staircase team with an enter disciplinary group with the same goals so social work and medicine together to come up with some sustainable solutions for folks my questions. >> thank you. i did have one question so kate how many staff do you have to do this amount of work you're talking about and are the turn off all electronic

devices. looking at the type of work that is necessary it seems like that are people are disabilities i'm wondering is there adequate staff and what's the staffing needs. >> well, i think we expanded the service from any think it was kate. >> and he history. >> so actively having additional nurses so we'll be evaluating things that are not just concentrate we have 70 people helping with that and also the medical respite 27 individuals who have been sdprard from the hospital we have a lot of staff we need to sit down and look at how effectively at the different programs working together to

take that pilot hopefully, we'll need additional nurses i'll by looking at the pilot to see how well, we do and go back and count the numbers that's something we don't have we don't have the numbers of people that are sick i guess the incidents tells you how many people are not in the shelters that who would need nursing care or more advanced medical care to figure out the care to match that hopefully that is what we'll do as we re-evaluate the model. >> thank you, supervisor kim and supervisor christensen. >> can i say one thing something you failed to mention the hot team is moving towards a medical model and my team is going to be working under the same department and working

together to transport to urgent care and working together as a a medical team the coalition is going to have a major impact. >> supervisor kim. >> thanks again for the presentation i apologize. i didn't ask you for this i was hoping you'd bring the medical health assessment our office requested in 2012 i know the data is a little bit old and helpful in informing our office on the demographics in the shelters and i know that we need to do another assessment to get the details on the actual services we need to provide at our shelter i think the data was informative even in looking at what the current demographics are and i have the presentation here

or the data you had presented to our office last year to address the needs even the 059.5 percent of clients in you'll our shelters at some point needs our medical emergency assistance that's a high percentage we're not talking about one or two clients a broad swath of our population that's homeless when they think about what we look at aerial shelter system and understanding our sheltered system is not set up to address the clinic tell hoping the changes i think we have to face realty and adjust the types of services and staff in place i know our office worked hard with barbara garcia to find the full-time nurses under our directorship in the shelter system and having spent a night

no one of the shelters there's no one on site so help the clients i saw and myself in i had medical needs and how important it is to have a nurse someone should remain in a hospital but unfortunately you you know there are people that are going to be in our shelter system and addressing that as a realistic some of the data points will be helpful to my colleagues or who had access to the data we've seen i also remember over 50 percent of our clients are between 40 and 59 that's a stunning number for a lot of people and i know that dph said we're angling in place on the streets so when our 40 your body maybe a lot older

than most 40 years old not living on the street so moving towards the solutions we might have to improve our shelters it's important to acknowledge this is historically the offer seer that manages our shelter system and how important that partnership of the department of public health i'm existing we're working on keep that in mind the respite shelter on st. anthony's moving from this site we're looking to expand the respite shelters to double almost double we're looking to expand another 20 beds i think this is important but i think what became clear in the discussions we've been having we need more services in our shelters as well

and the 20 beds will be filled fast it will be helpful to hear if dph and then perhaps go to the gentleman from the mayor's office on disability after sxrifrz have questions. >> supervisor christensen. >> i'll be quick at some point the medical respite shelters a great idea you've mentioned there are shuttles that offer up to 60 days. >> a medical respite opens mission street and is that about 50 beds to people are disregard from san francisco general hospital and need care their disregard into the respite and we have 60 beds.

>> i wanted to applaud i think the movement offering skilled nursing aid at locations is such a welcomed development and i mentioned that you will be collecting data for this pilot program i think there are to things not only the resources and the money that are saved when emergency services are diverted to non-emergency but i think about the care people must receive and it is better like auditors looking avenue people and not having the people k5r9d off to other locations so it's good for the people it so you would this intermediate needs isle i'll be interested 2, 3, 4

following what can be established for that need thank you >> thank you supervisor kim are there other. >> yes. our last city presenter is the gentleman under the mayor's office on disability it is in its been such a resource with our shelter system particularly for the growing population of our individuals about homelands that are disabled. >> thank you, supervisor kim and thank you members of the committee about having this hearing and evaluating and inviting our office to speak on the issue our office from the beginning has been involved in the shelter group assess meetings we've been supportive of the h f a to

create the rules part of it with the people p with significant disabilities we hear from and the antidotes should they arises month many of our folks due to age are trauma through the streets people with disabilities have a higher incidents of injuries especially what they're not able to defend themselves from other folks also consistency that's pelosi why our officer is involved the in trying to create a uniformed rule so people have come to the issues and have memory oishgdz understanding the importance i reilly's release we've shifted

the conversation and provided information as a initiate restoration of the uniform rules to provide clarity that helped foepgz to 70 self-care we've heard a lot of incidents with people with disabilities themselves and that's the residents that come to our office and say that the shelter is not the proper environment and patient have been dropped by shelter staff and for folks who have been xhaep there's no proper support they're interested in the discussion about the nursing system and nursing care and the medical for the outreach team i'd like to caution you that san francisco and the nation in general based on the homestead decision from

the supreme court chosen to people with disabled shouldn't be thrown into a hospital or into a nursing home but having management that creates a community support system we would like to propose this body brings the involvement of the department of aging and adult services they're the primary experts on the support that people with the seniors with cognitive impairment and chronic disabilities are able to provide to the city as supervisor kim said a homeless shelter is no the place to stabilize and improve the

quality of living current the respite she recalls are slated for individuals who have a medical crisis so a person that has a surgery or wound that is expected to heal they'll go to the shelter two months and be able to return and move on with their struggles of homelessness however, there are a huge number have been stainless in our shelters now that didn't have that option people that have aged disabilities and disabilities important 0 a long time were stabilized in their home and have the housing crisis they end up on the streets and not able to access their support services the in home support services have rules about hours

you can be attended to so being able to access the services in a shelter system is almost impossible on diagnoses you have medical costs or spend time because the diagnoses care is difficult in the shelter they may have transportation issues in getting into their diagnose center so i would like to caution us all in creating a more wider system of community support that looks like that people and keeping them in their community rather than for laguna honda or extending other shuttles serviced this for people not able to access them i suggest if i come up with a

solution off the top of my head a system with appropriate case management that will be stabilizing the individual and supporting them and a place for a permanent housing our office is here to support and we we were not knifed to the communications around 9-1-1 meeting or other issues but here to work with everyone and courage you to look at the adult serviced i'm happy to answer any questions you may have. >> supervisor christensen. >> supervisor kim thank you again for being here and we'll make sure that the mayor's office on disability is included in future meetings i apologize you were not invite and you described some of the barriers that the disabled person today.

>> what the ideal system looked like our department has the sense of the numbers beyond i guess the folks that come into the office and describe the situation you realty is it has a long waiting list and challenging for the city to get more unit online because of cost we're also competing on that crazy rental and housing market can you describe a vision of a healthy shelter realistically because the numbers of the community will ended up in the shelters at a certain up to this point in time. >> i believe that people that talk about the different types of shelter systems i'll focus on the smaller scale shelter system with a lot more case management

i am thinking of the unit i'm sorry the in take unit at the department the aging and adult services we have a lot of case managers that are specifically trained to take care of the aging issues and think of a congratulated shelter or environment that is smaller and assessable and provides more serviced and connecting people with disables and perhaps some modifications to the in home support services and working with the departments to be able to access the support along with the transit services that people need to survive in the community. >> thank you supervisor campos. >> thank you very much and i also want to thank the department of public health for its work just a question i don't know if it's a dumb question but something i'm trying to fourth how this works if you have

someone who has chronic serious illness who happens to be homelessness and staying in a shelter but certain treatment that is needed where you know their presents in that shelter and lack of access to the facilities or whatever it is is a problem and what point do you decide to hospital lists the person what point do you decide to do more than having them in the shelter system not only in terms of the what's the right thing to do for that patient but also i would minimal the cost of care if the person gets worse is also an issue i don't know how that worked but in our local we have something