high point. we did want to highlight that for those who did not voluntarily seek services, b.h.s. has voluntary services. if you look at the table to the right, 56.2% of p.e.s. visits were on a 5150, involuntary hold, so that means a person was brought in against their will. we're just highlighting a point that it's a policy decision for the board to consider how can we help those who might be voluntarily seek the services that they need? the d.p.s. whole person care team pilot program is tailored for the high user group, and they're working towards better meeting the needs for this group, but we do think there's a discussion about the need for the behavioral piece, so we think that b.h.s. should appoint a liaison to the d.p.s.

whole person care team. and of course that the director of d.p.h. should continue to work with h.s.h. to increase the availability of medically intensive supportive housing since we know that most of these clients are homeless. so the report that we released yesterday addressed the behavioral piece in the jails? and what we've found was that most jail booking events involve people with a history of substance use. i think there's -- we thought there was a perception that most people in jails actually have a severe mental illness, but it's only 1.1% of booking individuals with a severe mental illness only, while it was a vast majority, 84.5% had a substance abuse issue, so where around 24% had both a

severe substance abuse and mental illness challenge. >> supervisor safai: can you go back two slides, i just want to go back to one point, on the cohorts of adults not stablized. >> yeah, sure. >> supervisor safai: it's a little hard to read on the screen. i think we talk about this a lot, and i think a lot of this information people suspect and have talked about in the public before. i just want to make sure i understand. so 5% of the individuals using the city's urgent and emergency services account for 52% of the total costs, and 90% of these users had a behavioral health diagnosis. so high users, if you go to the third column, we're talking about 237 people? >> 2,237 people. >> okay. how many of those with mental health diagnosis? >> it's a little less than

2,000 of those individuals have a behavioral health diagnosis. >> supervisor safai: but the 5% of the cost, that's the 2,000 -- >> the 2,239. >> so out of 44,000 people, it's 2,000 people that are costing -- >> more than half -- >> supervisor safai: more than half of the cost. >> okay. >> supervisor safai: i just wanted to over emphasize the point, because i think this is an important point to jump out. okay. please proceed. >> okay. so as we just summarized in the slide, that most people in the jail are using substances and we wanted to clarify this does not mean that they have a substance use diagnosis. that information is unavailable. these are people in the jails who either have -- have been prescribed withdrawal medication, have been given high risk of withdrawal or have been reporting that they're using substances. then we also looked at the average days in custody by

behavioral health status, and you'll see with those -- either they have a severe mental illness or if they use substances or they have both a severe mental illness and they use substances, they have a higher average stay in jail compared to those with none of those statuses. and then we looked at how does average day stay in jail change with the severity of the crime. so we looked at the most violent crimes, assault, homicide. we also looked at quality of life only, quality of life -- people are often booked on quality of life among other charges, not serious and violent, but other charges, and everything else in between, and the trend still continues. those with severe mental illness and/or history of substance use do tend to have a longer average day in custody. and finally, on the rearrest rate, we're seeing the exact same trends. so our takeaway from this is that the individuals who are struggling with both a history

of substance use and severe mental illness, they're certainly staying the longest, and they have the highest rearrest rates, so we would recommend more attention to that population and better research to understand better what's happening there. so our policy recommendations are that the working group to reenvision jail placement should consider the prevalence of substance use in county jails when identifying alternative programs and services. there is new funding coming from the medi-cal drug organized systems, and assembly bill 1810 effective as of june 18 will divert more individuals from jail to behavioral health treatment fee free for up to two years, so there does seem to be a state policy directing more people from jail into mental health treatment, so we thought that should be a part of the conversation. that concludes our presentation. we did want to thank d.p.h., jail health services, lisa

pratt for the tremendous amount of work that it took to complete this audit report, and the sheriff's team. that's really important. thank you so much. >> supervisor safai: thank you. and i will say the same thing. i failed to mention in my opening remarks that mental health and substance abuse disorder services provide services to over 30,000 san franciscans annually at an annual cost of just under $400 million. so this was not an easy task to undertake. i also want to thank the director of behavioral health services and the department of public health. i know with ye strongly worked conjunction with either team, and lisa pratt from jail services for taking the time to do this, as miss mcdonald mentioned. i do want to come back to the amount -- the 2200 patients that are in the -- that are taking the emergency services

and that -- that are in need of mental health and have severe diagnoses that are accounting for over 50% of the cost. i do want to come back to that conversation. i think the citizens of san francisco will, you know, out of our budget, almost $400 million being spent on behavioral health services, and are we getting the best bang for our buck? are we really using those dollars in an appropriate manner, particularly when 2200 individuals out of 44,000 are 50% of the cost for -- in our urgent and emergency services. so i want d.p.h. to speak and do their presentation, but i want to come back to that point. i also want to emphasize the point on the slide that was presented about the jail bookings and those involved in -- in our jails and their history of mental health and substance abuse because again, in terms of the amount of costs associated with that, and the

level of intensity of need that they provide, want to really hear what d.p.h. has to say about some solutions about that because i think much of the debate about incarceration and building a new jail and so on has also been -- there's also been a debate about mental health services, and i think this really underscores the need for a mental health and substance abuse services in the jail system. so mr. garembacetti, if you would proceed with your presentation, and then, we can proceed with those two points. >> okay. well, good morning, supervisors. i'm here to present some information about our system of care and also in response to the performance audit. before i start, i do want to thank the b.l.a.s and all the people who were involved for

their professionalism, response and diligentness that they took this work on, and you know, it took a lot of, a lot of effort to pull together. so i thank them, and also my staff, and all the staff at the department of public health who were involved in the process. so very quickly, for behavioral health services, you know, we have basically something that kind of propels us to do the vision, an overarching and arching goal. our goal is to really help people recover and be in recovery, and we want people to be in their environment, the least restrictive environment possible so they can get the best support and best care in the environment that they thrive in. as well as we want to make sure our services are welcoming, any door is the right door and also it's culturally responsive and linguistically competent and again, the goal for us is the wellness and recovery of the

individuals we work with, and we believe that recovery does happen. and for every story that we see on the street that we are sort of impacted, we have hundreds of other stories and thousands of stories of people who are succeeding and doing well in our system of care. so when we look at our system, it's important to know how the system of care is provided. [please stand by]

>> let me mention the amount of funding that is put to behavioral health services and when we think about the number, the numbers much higher because of the variety services we provide. >> the goal is for people to be able to transition within these levels of care. if they need something at a

higher level or lower level they will be able to move across the system as needed. i wanted highlight one client story. what we to is all about people and the relationships we build. we know it takes time for lovery -- recovery and lovery is possible. we had one individual, michael, who's in his mid-40s. he is homeless and lives on the street and he has not been part our system. this is not someone who's been in our system of care. he's not receiving services. we have received multiple numerous notifications from neighbors from local people from businesses about their concern

about this one individual. we know this that this individual presence and his behavior have impacted that whole neighborhood. immediately, as that came to our attention, we immediately looked at the background and found out more information. we deployed our engagement special to go out and meet and connect with this individual, to really understand what's going on and get as much information. we engaged with this individual and tried to about understand what the issues are and look at all these notifications coming and understand the patterns. through this process there was an event that occurred that this person was actually ended up being taken to psychiatric emergency services and was put on hold for 5151 psychiatric

manufacture services. because this individual was identified in our high priority case review, which we have this robust process that we look at these priority cases, immediately we are notified. we got involved and looked at the care of this individual and we followed it as far as what we will do upon discharge. this person got hospitalized. we provided as much information as possible but also came up with immediate planning upon discharge. what's going to happen if this person was discharged. we decided to immediate case conference with the homeless department with our behavioral health services and intensive case management and hospital staff. we brought in intensive case management staff to start this process while this person was in the hospital engage with this person while they were in the hospital and then work with the department to identify this

person with go to on discharge. this was a coordinated effort that we did together. then we had this information available and worked it out. he found out it person had family. we alleghenye allegheny -- we eh the family. they had come out to visit this person and they couldn't get this person in care. when the person was cleared from being able to be discharged from the hospital, everything happened from there. we the hospital with the intensive case management and the place to stay and went over and made sure the person was stabilized and continuously works and connect the person with the clinic. now this person i can tell you, there's been no notification after numerous daily notification we had no notification for several weeks and this person is still connected, still with the

intensive case management and now is even working on some of the core issues that person had as well as working with the clinic to engage in some activities. this is an example what it takes that it works. now i wanted -- i will let go the section i have around the audit. >> just before you do that, one other point is, you said some the recommendations that you don't agree with. you should highlight that. >> the four areas that i wanted to highlight, which kind of mimics what la toy where a -- la presented. it falls around case management, around transition to lower level of care and adults who did not stabilize. there were many recommendations and many identified areas that

we've already responded to. this these were important sections of the report that we have been working on already. the work started and it's continuing. i want to highlight this we welcome the audit. the audit allow us to look at the system much more in-depth. we learn a lot from the audits. we have multiple audits from the state and regulatory bodies. this audit was really welcomed. it helps us to look at areas to improve on and showcase what we have worked on. in the area of provider performance. we have our community-based organizations and we have civil service clinics. there's about 60 substance abuse provider organizations about 122 mental health prokerproviders te c.b.o.s. we to annual monitoring on the

same standard and same performance objectives for all of them. the civil service monitoring started about five years ago and it's been something that really is important because we want to monitor everyone on the same level. this monitoring has been going on an annual basis. we're excited about the business intelligence software that we have implemented. we can look at various live, time data. what is happen and who's getting what services and how many people are at what clinic. we're utilizing that. this is something that's been very helpful. what i would want to highlight since it was mentioned in a report, since the report from the b.l.a. was up to 15 or 16, 16 and 15 monitoring report

shown improvement of the civil service programs by one point more. if they were two, they already three. which means satisfactory, that means exceeding satisfaction. i'm very pleased to report that the year following already has been improvement. this year we noticed there was a further improvement. we've done lot of work around having training the staff as well as really looking the plans for the c.b.o.s. we gave them tools how to do that. we're going to be monitoring that. we did the same thing for civil service. we're doing that internal. we're looking at every clinic and also every staff per clinic. i'm very pleased to say this effort is working.

the next area is intensive case management. intensive case management, it is an outpatient level of service. it provides more services to the individual than it a regular outpatient clinic. it's basic the statement -- it's basically the same outpatient and the case load is smaller. they have more time and they can provide more intensive services. we wanted to look at our intensive case management because we agreed that this is an area that needs to be looked at. there's about 1400 intensive case management slots. to we need more slots? yes and no. yes and we've already acted on it. we're opening up 40 slots. we're opening 20 more slots for assisted outpatient treatment.

then the hope is that by looking at our reviewing and doing utilization managements, we can open up more slots. if we need to do have more, i think we should. at this time, i think we're doing lot of things and we have a consultants to look at our intensive case management. we are reviewing that closely and what we have -- we took on performance improvement project to look at how people from intensive case management transition to outpatient. this is a project we took on and the state is monitoring on that to make sure there's handoff it people make the connection to intensive to a lower level. we received two innovative grants that i'm pleased to announce, one is around pier linkage to help people transition from intensive

outpatient as well as wellness by peer support. we got those two grants. that would support further this effort. around intensive case management, we're on it. we're reviewing it. we're going to be doing utilization management on every single case. >> how many staff to you have that work on intensive case management? >> intensive case management is both -- there's south of market and there's hyde street west side community services and felton. there are about six programs all together. >> there's six for the entire city. how many staff is there? >> i don't know the staff for every c.b.o.s clinic. i can pull this. >> the reason i'm overemphasizing -- so it's.

hundred staff. the reason i'm asking the question, it seems to me that with 100 staff and the amount of patients that go in and out of those services, if we're talking about 2200 individuals that accounted for 50% of the uses of emergency care that need intensive care, they are a major cost to the system. i'm wondering who your strategies to deal with that? >> there are three approaches. one is to look at our current 1400 intensive case management slots that we have to make sure those people really need that level of care or could they be transitioned out, that's one. second is to assess anyone who's referred to intensive case management is that the right level of care for them. third, we actually need to address the issue of staffing.

not staffing to just increase it but to address the vacancies. we have 11 vacancies in our intensive case management system. those are both civil service and c.b.o.s. this is very hard work. not a lot of people want to do this work. when they to it's very intensive. it's the impact it has and the traumatic effect. that is hard. salaries is competitive and working in san francisco, they are being recruited. majority are all those vacancies are bilingual position. we need to address the staffing to recruit hire and maintain. then we can look at the current slots and also with the addition ones to make sure we can review who's coming in.

>> i guess what i would like -- the thing that jumped out to me the most, we always understood that individuals receiving emergency care, i don't think that's anything eye-opening to anyone on this panel. i think the thing that is eye-opening to me was that they accounted for over 50% of services use. what that means to the overall system and what we're spending almost $400 million on mental health services. which is a significant portion d.p.a.'s budget. it's needed. it shows up again in the jail system. something that supervisor mandelman talked about. we'll take a second vote to expand the amount. that's one of my other questions. it's something through, it it's something that you highlighted for me. is this a housing issue, is it

intensive case management issue? you can say all of the above. there needs to be a thoughtful strategy to reduce the amount of costs. since we're here to talk about cost and service at the same time, the amount of cost at 2200 individual us out of 44,000 are costing to the overall system. how do we reduce that cost and get the level of services for these 2200 individuals? this an ongoing debate over and over again. emergency care can't be the answer. how do we get out in front of that? what's the strategy? it's not 11 staffing positions. one of the things i will is for from d.p.h. to come back and make a smaller report and recommendation on how you plan to tackle really providing the care and it could be in terms of staffing, it could be in terms of expanding group homes.

supervisor ma mandelman's legislation to spend the places without use authorization. this goes to that. maybe we have to come back and take a look at our rh1 and rh2. in my district in particular, there's been a significant drop in the number of group homes and those that need those services. that's a major loss of services. i want you all -- not just to report respond to this report and give us the data. pinpointing town, working with the department of homelessness in support of offices, how do we tackle these 2239 individuals that account for 52% of the cost of mental health services. that is a significant number. >> this is a serious concern for us as well.

we're taking this very seriously. it is a concern. it is impacting our system when they are coming in. not all these cost are in behavioral health services. it happens in multiple systems. what we are doing -- >> before you say that t i'm sorry. the other thing that has happened to this audit happening, we had prop c, 61% of voters authorized that. 60% of that money was supposed to go for it. hopeful that will come in our fave. we had windfall. this body and the mayor have proposed. i think there's some overlap in designs. there will be a significant portion money allocated to the department of hu -- public heal. it seems to me, where is -- what

the efficiency -- have we taken a look at the level of services? here we go, we have a report, the b.l.a. did it. we have the numbers in front of us. go back and work with the department homeless in support of housing and our crea team ane back with a recommendation. this seems to be the glaring hole. there's legislative solutions before us. maybe we can expand that to include additional housing options. that seems to be a simple solution that could happen very quickly. >> i totally agree. it's to b -- it's got to be multiprong approach. we are looking at ways that we can support. this number that you mentioned,

the number of the 2000 -- because we reviewed people who have highest use of our system, we have case reviews and we're looking at each case by case. the numbers is about 500. the 2000 is a large number. 500 is even more focused one. out of that number it's top 100. >> say that again? >> that number there's about 500 that's higher priority within that 2000. which we know about. we're getting lot of data and we know who they are, how they're impacting our system and then also we're working -- we're coming up with plans various parties. >> i would like to see that in your follow-up report. >> that is about hundred. which we're doing much more high priority review. i think that's exactly what the intention is. we need to understand this group

and understand what their need are and mobilize the system that supports this. >> thank you. >> i want to acknowledge and recognize supervisor mandelman who joined us for this hearing. this an issue he made a priority for his upcoming term. >> we're all in this together. this is our community. we live in the city. we're impacted as a system and community. what you're sharing is our community together. we need to work together. around transition to lower level of care, people who are coming to psych emergency and discharged from psych emergency, they are getting hospitalized and we come up with a specific plan while they're in the hospital. to make that connection stronger and if they are not connected, to make that linkage happen.

people coming to psych emergency, this is a very serious area for us as well as it is for the whole city. psych emergency is just one area of our crisis response. we have our urgent care and we have westside crises. we have multiple ways that we engage and work with people in the crisis situation. we have our engagement specialist. psych emergency gets most attention. we've been doing lot of work on that. one by providing staffing within psych emergency services for linkage and referral if they are not connected. it's the reason why we created humming bird place is to have a place for people. now it's expanding. majority of the referrals from psych humming bird is from psych emergency service. that is is the type of

environment we need. place for people to get the support. what we're tracking who's coming in to psych emergency. there are no one leaves psych emergency without a referral plan. referral to link angle is the area we need to work on more strongly. that's where we need to have the staffing to make sure we're looking at at that time. when somebody discharges and they get their services in outpatient, we put that in performance objective to make sure that happens. >> i like little more clarity on that point. the support said something different. i like to give the department public health the opportunity to explain the discrepancy. >> we really value the report

and we value the recommendations. this is one area that i thought it was overarching conclusion. one example is ref to self. we said let's pull the data. refer to self. we found out no one was refer to self without a plan. we looked at several cases. we find out a person, for example already linked to citywide case management. it was refer to self to go back to citywide case management. not refer to self and go figure out what you need to do. we have process now that we contact the provider saying your

client is at p.e.s. and we want to notify you. when the referral goes back we can track to see where that linkage continues. we believe that this was a category checking as well as misinformation and that how it was documented. if you pull actual record it's a check box. it's refer to self to go back. not they were referred to self to go out with nothing. we have specific come up with performance objectives to making sure no one leaves without a referral. we have a plan to make sure when somebody is given a referral, we can track to make sure that linkage happens and whether they received services. there's a lot of things we started doing.

we agreed with scenarios that we ned to -- need to improve on. >> that's reassuring. the idea is it wouldn't be just referral. people don't leave with a referral. >> a referral is made. a goal is to make sure that linkage happens. we're doing a lot to identify who the people are and putting engagement specialist to identify that report. we can look at the data to say it did happen. if it didn't, let's send out where they are and find out how we can make that connection. just because someone is given referral and it doesn't mean they don't want to go there. we have to do lot of work there. that's a big area that we're

working on. >> supervisor safai has another question. >> supervisor safai: slow down for a second. this is lot of information. someone comes in for emergency patient care, what happens and what does d.p.h. to and how do they stay in contact with that person? it goes back to my original point about the people receiving over 52% of the care. to you document these people? are they in database? to you work with the department of homelessness in support of housing. to you have a history of these people? do they have a profile? is there a plan put in place?

i really want you to walk us through that. i want to see where the gap is in terms of at that time data c. i want to see what the plan is and you're describing. this is one of the areas, emergency psychiatric care, it's something that all of us on this panel talked about. i want to make sure that we really drill down on this and i like you to end with maybe a professional opinion on how the whole -- i'm glad the supervisor mandelman is here. i like him to speak about this. how the role of conservativeship plays in discharging those patients. how conservatorship change the outcome. walk us through it.

>> also i wanted to mention the doctor psychiatry is here. when someone comes into psychiatric emergency, they are brought in or they are self-admitting themselves. you have voluntary and involuntary admissions. immediate they will do an assessment finding out what is going on with this individual. we do know that about right now, majority of our people who are coming to psych me emergency are people under the influence and also homeless.

we make that assessment immediately as they're in, make that determination of making sure what to they need, what's going on with them and we have database to pull the reports about what the services are and are they connected or not. one new thing is that if they are in the high priority list, we get immediate notification that this person is at p.e.s. now. we have known about this individual and what their needs are. if they are in the psych emergency and they stay there -- if they are appear to be needing to be hospitalized after the assessment, of course they will be assessed and will be sent to inpatient unit. if they are not and they are sure at the time while they are being assessed, during this 12 or 14 hours if the person is

continuous exhibiting symptom this they are actually not doing well and they need hospitalization, of course, that will be course of action. if the person is not exhibiting that, they have now cleared, they are now no longer danger to self to others or they are not disabled then that time it needs to be a plan for referral to somewhere else. they need to be discharged. we do multiple things. if they're willing to go to urgent care, we refer them to under care. we make this referral. from there, they could to further assessment for additional day and refer them to one of their acute diversion units or housing unit. the person can be referred to humming bird because they may not be ready for something but they're willing to go somewhere because they want support. they will be referred to humming bird. they will be at humming bird again.

we have data on these individuals because they're in our system. once they enter the system, we pull the record. if they never been in the system, we look at see what we need to do to prevent this from happening. at that time, if neither of those work, the person says, i don't want to go to humming bird, we need to give referral. we need to make sure there's linkage. if they're connected, we call the provider and letting them know they're at p.e.k. once we get the referral and they're ready to go, if they're in high priority, there are multiple things in place. we know this person is going and we need to activate the engagement specialist to maintain this person beyond discharge. that part is a part that we can do much better and much better work. i think i covered as far as what

happens from p.e.s.p. there's a group of people their mental health condition is not necessarily where they need hospitalization and the influence of the substances who has made the behaviors and symptoms or activities appear as if it's mental symptom, if that clears you and the person is more logical and knows where to go for food or chooses their own place, we have to make sure we put things in place. if the person keeps coming back, this may become one of the people we have to track. >> supervisor safai: when you say they keep coming back. how many times it take before you make an analysis? >> basic anyone who comes back again, there's two ways we're looking at it. one thing we're looking is to

say if that person came back and ended going to the inpatient unit, what did we miss? if they come back and they are still not needing hospitalization, then that list is reviewed. the hospital has a at tha a daty look at. we have made that effort even more stronger by saying to p.e.s. if someone is willing and ready, let us know. we'll make that happen. we'll make that immediate activated. we've done that number of times. it's a voluntary service. no one can be forced into

residential substance treatment or detox. if they are saying they are willing, we are immediately engaging with treatment access program or substance abuse provider say, we have someone we need to come to detox. we are doing all of that but again the person cannot be forced into that. if not, then we have to work back and forth. it's a pross. it's a relationship. it's a trust. it's something that we have to constantly be relentless and motivated to keep engage. >> supervisor safai: i wanted to just have you speak about conservatorship piece. i want to allow supervisor mandelman to jump in. >> supervisor mandelman: two questions.

your list of high users, are you able to access data from the other hospitals in the city? if someone is taken to st. francis, does that feed into your detention whether that person is a high user? >> the database it i pull from may not be there. we are working with whole person care as well as working with emergency group has eddy system. we can pull that data. we do need to work with system providers and other hospitals to give us at that time an data an. that one individual that i shared never hit our system but had gone to st. francis emergency many times. we actually didn't know about it until we had to follow that information. once we to this unified system

as well as this collaboration within the data sharing and emergency room reviews that we do with people who are using the system that help us a lot. it's something that needs to be improved. >> supervisor mandelman: the other question that keeps coming back, 5150, they don't need to be there for the full three days because their symptom clear. it's taking up a ton of space and you have people sitting in chairs. i've heard the idea of having sort of some other kind of separate, essentially meth sobering facility this will be place to send that particular set of folks. they need to be in a loxed facility. they need to have tricks around but they artrick --doctors arou. is that something you're interested in having?

>> we do have detox. we have substance treatment, we have urgent care. humming bird is a place that someone basically we could take people breaking down every barrier possible to be there. there are places that it will be helpful to say, they're not meeting criteria there. >> supervisor mandelman: there's issue what to do with the pers person. you need more humming bird and you need more all of that. i'm wondering whether you need another 5150 facility for people who is coming in with a meth

issue. >> i will have the tric doctor r that. >> my name is dr. mark leary. this issue of how to address this really crucial patient population, people that use meth repeat think anedly and heavilye are several ways to address it. i think that most cost efficient way for our city to address it will be to be able to treat the patients that are now waiting on our inpatient unit at san francisco general at the appropriate lower level of care which would create bed space on acute unit at san francisco general. we can admit those patients who are suffering from the meth

induced psychosis for two-day stay and then discharge them if that was appropriate thing to do. it this is not my decision, i would think it will be costly to open a second unit. having them to be admitted in inpatient, if they needed 36 to 72 hour stay, we allow psych emergency to stay open for the people that need psych emergency services on a shorter basis. >> supervisor mandelman: i wanted to hear your opinion o on the role conservatorship with

play with this overall population. >> the population of people that use meth repeatedly, there's a role for conservatorship. the key thing, i'm very supportive of the state legislation and the local initiative supervisor mandelman is supporting and authoring. this group of patients can be treated on an involuntary basis for a relatively brief period of time to try to break that cycle and get them involved in treatment. i think it will be important to do that. you should be able to do that. to answer the larger question about conservatorship and its value, we try to treat everyone in a voluntary way whenever possible. there's a role for involuntary treatment and conservatorship. it's only helpful if there are treatment resources available. if our case managers don't have

a place to go to meet the patient, whether it's a hotel, whether it's treatment setting, whether it's bed where they are staying, then the conservatorship isn't all that valuable. it may have some margin value in terms of allowing involuntary medication. that's only helpful if the patient comes in for services. >> supervisor safai: if you can stand ton that little bit. do you mean place of resident, place that they can -- housing. i wanted to make sure that's what we were talking about. we weren't talking about an institutional setting. >> not necessarily. >> supervisor safai: you can do conservatorship through a group home? >> yes. one great step forward in the city in this past year has been the post acute community conservatorship that's been a partnership with the office and the court system and public defenders and district attorney to allow people to be discharged from acute hospital care into

the community with the conservatorship in place and a link to treatment and housing. >> supervisor safai: the data that i have, in the last 10 year, we've lost 300 boarding homes have closed in san francisco. i think that -- crust going to be to the legislation, we're trying to move in a different direction to facilitate the expansion, the re-expansion of that. >> when we say we've lost civilization rooms, we lost border homes and supportive houses, our residential care facilities and those we've lost 195 in the last four years. what happens is lot of these are

owned by parents and they choose not to operate them anymore. their kids decide not to continue this service or sell the facility. we are losing that lower level of civility and support for people who could be in the community and still have that intensive case management. >> it's a crucial level of care that can stabilize patients with serious mental illness for many years at a time. >> thank you.>> supervisor safal man did you have any other questions that point? that's what we were looking for. you can continue.

>> i wanted to end by saying that we take this also very seriously. we are concerned also how our emergency rooms are being used and how we can coordinate the care best. that's why we have implemented strategies whether it's operation centre, humming bird place or engagement specialists. sb1045 has a possible tool to use. there are multiple ways we are trying to address this and coordinate the care. i think we've highlighted around the individual who do not stabilize. we're working closely with department of homelessness in support of housing. we have regularmeetings. they are right there. we are meeting regularly to review cases as well as find placement for these entry

systems. this has been really effective. the case that i mentioned earlier the individual is if i didn't have that support from them to offer immediate place for that person, i think this plan would have not worked. but because the intensive case management and the housing was right together, we were able to make this more effective. then with the whole person care, which is a competitive grant that we received we're looking at the data and coordinating our efforts. i want to highlight the behavioral health workforce. that's a big issue. currently in our civil service system, i looked just yesterday, we have 30 behavioral health clinicians positions vacant as of yesterday. that's a lot. >> supervisor safai: i wanted to emphasize the point.

>> it's multiple reasons. it's people are not applying. people applying taking other positions. people not wanted to do this work. it's a lot of work. people have to be really committed to public health. those people are working extreme hard and dedicated. we want them to stay with us. i want to say the population has changed. we know the opioid epidemic and the meth use has change the dynamics. we have majority of people coming to psych emergency with methamphetamine use or substance use. that is huge. this not something that just happen -- it's been going for years. also because i meet with other directors across counties these are regional issues. we work with each other. these are regional issues.

we have individuals that go through multiple counties. we have to see how we can best coordinate. i also wanted to mention about the lower level of care, the reduction of that. question came up when we met around out of county -- >> supervisor safai: i was going to ask you end on this. >> i maybe want to mention one thing and i'll go into additional things that we've done is our lead and law enforcement assisted diversion has been effective and street medicine expansion. basically bringing treatment into the streets. we know we're very good with services with people coming in and want the services. we need to do people who are not seeing what we offer. we need to be more versatile and more on the street. drug med cal is evidence-based

and specific model we can enhance our system of care. providing substance services is higher level. on the issue of out of county. this is a very important issue. i looked just november alone, i looked at the data, i wanted to see how many people that we serve in our system, mental and substance use they have a med cal that it not assigned to san francisco. 104 individuals were in our system who do not have a med cal assignment in san francisco. it's 141 service utilization because we have some people using multiple times. they are coming into the urgent care twice. >> supervisor safai: what's the cost to san francisco for this?

>> in the mental health section of it, which we can bill the federal portion for the services, not the county portion. we don't get the county portion. we can bill the federal portion. however, for the substance use. nothing. we do not get paid by any sort of services when it's out of county. there's no other mechanism so we are using general fund. what we are doing e we trying to see if the person is really living here to have med cal to transfer. we helped transfer 25 of those individual med cal to our system. >> supervisor safai: this is where i think working with the department of homelessness in supportive housing coordinating on this particular point. it's not a large number of individuals but i think was one of the intention of creation of that tent. i