homelessness people face everyday and how this may be made more challenge by constricting stricter rules not only rule 18 appreciate the practices that will be brought up in the hearing as well and in many ways as supervisor kim said no point looking at trying to push square pegs through holes but looking at supportive practices that can help lift people out of poverty and address the causes of homelessness in our city it to you supervisor kim and i'm looking forward to this hearing as well. >> so thank you, colleagues. i forget to give the members of the committee a chance to make opening remarks we've started with ms. crumbing u crumb from

the human services agency. >> thank you for being here. >> any member of the public wish to speak on any item. >> at the thank you for having this hearing i am joyce crumb the director of the houses and homelessness division for the human agency i appreciate this hearing and appreciate the preempt we had with the supervisor kim and then our group meeting that we had with coalition on homelessness and e.c. s proifrdz just let me give you a little bit of background those are not in any rules in order to have a shelter facility we have to have rules and those rules actually went into effect in 1999 when we established the shelter grinds advisory committee and

when rules are broken and shelters or an infraction happens in a shelter you could not deny a percent e person access it has to in absentia trade and and hearing we're not adding new rules what we were trying to do with a concern we heard not only from our arbitrators that arbitrate guidance but during the shelter assess group although not a recommendation we heard numerous times that the rules in the sheltered are not applied fairly so we undertook this process with collaboration of all of our shelters and we began in july of 2012 gathering all of the shelter rules across all the

shelters in which we fund we had a series of meetings with our providers along with community meetings to get combating input from our community stakeholders rethought we were on the right track until i guess early december i got a phone call from one of the sdhd from the shelters expressing concern about this process of standard digdz rules what we found in this each shelter had a set of rules although many rules are similar the language and the sanitary period varied for instance in a small shelter it's a if a routine is broken and the same rule that a larger shelter has the larger shelter might impose

a longer sanction so we were trying to standard device the rule and give them a range allowing each shelter to maintain it's individuality and work within that system so that's why we got to the point of let's look at the shelter rules we thought we had the buy in of our shelters during the process we understand change and we also look at criticism at being constructive and to strengthen what we do so last friday when we met with the shelters the one shelter and supervisor kim and her staff and the coalition h f a made the

decision not to move forward with standard dizzying the shelter rules we have a shelter directors meeting on monday because all of the shelters were noted present at the meeting nor a part of a letter that went to my director we are going to have a constitution with tell them on monday but we will not precede with standard dizzying the rules as i mentioned to you on friday what came out of meeting on friday (clapping) thank you. >> were two specific issues that is bigger than h f a it's the rule around clients when arrive at shelters unable to have care and without established support as supervisor kim mentioned earlier shelter staff are not trained to

provide health care so what came out of friday, a small group decision that once h f a garthsd do not when an incident occurs in a shelter right of shelters providers are responsibly for submitting a critical incident report from 9-1-1 calls to some something that happens in the shelter that was critical to the daily operation in the shelters we're going to look at 6 months to a year of data to determine what type of critical incidents have occurred and which one of those critical incident surround see self-care of clients in someone is dropped off from a hospital into a shelter and managed to get a shelter bed in the night time can't get themselves up to go to the bathroom or have an accident this is critical because the

staff are not trained to handle an i want of that nature also what is most important in an incident it is self-care we do have the support of the department of public health and their public health nurse who's assigned to our shelter that's kate kate meets he regularly with the shelter providers to look at needs of the clients who the shelter have expressed a concern in they're not able to care for themselves they're fragile and there's a need for them to be move forward we've agreed to work on a plan i do know the department of public health will speak to that but their enabling more mental health nurses at the shelter to

help us in p in delicate situation that's our pay attention i'm happy to answer any questions you may have. >> thank you very much ms. crumb and thank you, mr. walton just a couple of questions in terms of the when - what happens if someone is not able to take care of them and the shelter can't address their needs how is that individual usually handled. >> i know that scott talks regularly with the shelters so i'm going to ask him to provide an answer to that question. >> thank you very much. >> good afternoon supervisors the rule itself was about the ability to end a recess evacuates the shelters work

closely with the nurse sport and the behavior roving team that supports shelters to try to address the issues in many case because of the alternative to call 9-1-1 they get returned to the hospital it's not an effective electrocution u solution but when a client can't move out of bed and the shelter staff are not trained to do that that's the solution that happens but what happens when those clients are identified there's a great deal of communication between the shelter provider and others often the hospital to try to determine what the solution is we want to avoid the client being asked at the hospital and they're saying the shelter and they get returned back to the shelter we work with the in home

services their hours are limited and not twenty-four hour a day so the clients may have problems outside of a caregiver. >> i do want to appreciate mr. walton and ms. crumb for the work they do they've been responsive to those concerns do you have a sense of what should happen what's the ideal situation in this case so the client is not returned to the hospital not an ongoing cycle. >> i don't think that's a question the h f a can answer we work closely with the care of nurse maybe she can offer a response kate. >> (laughter). >> you're on the hot seat (laughter). >> so the question is what do

we do when people go the the hospital. >> what's the ideal what's the outcome you want to see given right now it is sort of an ongoing cycle. >> it's complicated and each case is very complicated every time i get a referral for someone that can't take care of themselves that 3 involves a lot of parties not ideal for people to be 9-1-1ed out to the emergency room without someone on the other end advocating the emergency rooms are to treat trauma for instance if you have a chronic issue and you're in the er you're not going to walk out you you'll be attached

together so the ideal situation we have advocates like myself i was going to talk a little bit after those guys about the new nurses in the shelter and what that is going to look like. >> supervisor christensen has a comment. >> actually not a comment a few questions i'm a little bit perplexed the main question of this hearing was should we implement uniform shelter rules it sounds like that is no longer on the table so the primary function of the hearing doesn't exist on that issue i guess i'll per mreblthd because the stated problems is that shelter rules are not consistent but i'm not sure why i see that's a problem if you have shelters with people of different angles and sexes and mental conditions and physical

conditions if you have shelters of different size then why would you want the rules to be the same. >> because shelter clients have the ability to access outline 8 shelters so if they're at one shelter and break a rule and the penalty is different than the next one that's the complaints we were hearing that the shelter rules weren't fair. >> but we've past that so, now we're on to another topic when the nursing care in shelters. >> one of the topics correct and right so how many, huh? how frequent is this occurring so on average how many times per shelter or per month or year do issues related to requiring skilled nursing or medical assistance come up. >> that's the question is supervisor kim asked us last

friday we couldn't provide an answer we need to look at the critical incident reports to track the number of times 9-1-1 was called when someone was not being that couldn't self-care. >> that doesn't tells us which of those calls related to people that came out of a medical facility and in some cases it can it depends on the detailed the report is written up by the shelter. >> that's a lot of 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 loo