>> i think this is a very important topic. i want to thank you for being here for us to have this conversation. i want to thank aaron mundy and my office for incredible

coordination, work that had to go into holding this together. i decided to request the hearing after visiting behavioral health court and drug court. i wanted to learn as much as i could as you quickly as i could about how the city responds to mental health challenges of our residents. the criminal justice system seem to present challenges and opportunities. i have been deeply impressed and inspired by the work of the collaborative courts and partners. but especially by their graduates. i was troubled by what i learned. i learned notwithstanding the amazing work b.h.c. does, its clients wait on average six weeks for placement and treatment. i'm told the wait times used to be worse.

six weeks is still too long. keep in mind, those wait times are with the extra muscle of district attorneys and judges calling on behalf program participants. i called for this hearing to shine a well-deserved spotlight on the successes of the collaborative courts and behavioral health court and misdemeanor health court. also, maybe more importantly to explore the challenges the courts confront in accessing appropriate services for participants. as we look to use our jail population and in the relentless and revolving door -- that cyclo many people between our streets hospitals and jails, the

experience of collaborative court offers hope that the cycle can be broken and illuminate some of the challenges. the challenges involve securing appropriate behavioral health services for b.h.c. participants, begs the question what about the rest of the jail population and others who may not be in jail and engage too frequently with the criminal justice system. i want to thank our presenters who are going to be before us shortly. in particular, jujharry of the behavioral health court. a number other people have work on this hearing and many of them are in the audience and available for questions, i want

to thank lisa lightman for her amazing work as director of the san francisco collaborative courts as well as chief karen fletcher with adult probation, dr. lisa pratt with jail health and group of folks from the san francisco public defender's office. first up we'll hear from the judge. >> thank you very much supervisors for giving us the opportunity to speak with you. i preside over behavioral health court at the hall of justice.

i also preside over mental health diversion. a new treatment court that was created by the state lawmakers last year. behavioral health court participants face serious and persistent mental health issues. more than 80% of our participants have co-occurring substance abuse issues. the participants in v.h.c. need significant services for a significant period of time. the median time in behavioral health court from acceptance to graduation for those who do graduate, is over two years. it's not a short period of treatment. takes time. good effective treatment does not happen quickly. it's challenging work and in a collaborative courts, where i'm part of a team, there are many dedicated people who participate for many different perspectives. i was asked today, i'm ready to

talk briefly about how a person engages in behavioral health court. a person who's a san francisco resident is arrested in jail and accused by the local district attorney of a felony. the defense attorney will ask the court for an assessment to be done by the jail staff focused on behavioral health court as a possible avenue. the assessment takes about three days for the staff to prepare. if the staff finds the individual clinically eligible and amenable for the behavioral health court process, then the lawyers and i weeks later will receive a much more comprehensive case presentation. the case presentation gives everybody more detailed information about the individual's social, medical,

psychological treatment and criminal history. it takes time to prepare because we warrant it to be thorough. in that case presentation also is recommended and initial treatment plan for the individual. either outpatient or residential. depending on the level of care, the needs of the individual. the next thing that has to happen in behavioral health court is the district attorney on the case and defense attorney. need reach an agreement what to do with the charges. that settlement is essential to make behavioral health court possible. that's how behavioral health court is set up in san francisco. the majority of the behavioral health court cases involval plea to a charge and formal probation is part of the settlement and

participation in the behavioral health court treatment is part of the settlement. if the level of care is recommended is residential treatment, this takes time as you refer to supervisor mandelman. you said six weeks, i want to be candid with you. in many cases it can take longer than six weeks from the referral to the possible treating agency then scheduling an interview by the target agency, then giving the agency time to make a decision to accept the applicant and then finally after acceptance, waiting for the beds to become available. all that takes weeks if not months to happen. once the person, the individual gets out and really is starting treatment, the treatment course typically lasts two years or longer. i want to let you know based on what i've seen in over two years, the individual really

need and benefit from this lengthy treatment. i'm not clinician. you will hear from clinicians today. based on what i've seen, the lengthy treatment is appropriate because it helps people who really are struggling with mental health and substance issues. what happens the person gets out and treatment begins, essential part of the treatment course is regular appearances in court either weekly, twice a month, maybe once a month and twice a week tuesday morning and thursday morning, also there's a misdemeanor behavioral health court component on friday morning. i'll focus on regular behavioral health court. starting at 8:45 in the morning tuesday and thursday until 10:30 maybe longer. we talk about every single individual who's coming back for a progress report.

at the staff meeting, i'm there, the prosecutor is there and defense lawyer is there and treatment team is there and probation department is there and sheriff's office will be represented. whoever needs it participate in the conversation on that day is there. it takes time to do this work. lot of people give input. i need to hear the information how each person is doing. some people do very well. some people are doing well in part, not so well in other parts. so people are having lot of trouble depending on what's going on at that moment in time. in that staff meeting i get information that helps me decide what to say in court. around 10:30, we start calling the cases. i are appraise those who are complying. supervisor mandelman you might have seen that. the honor roll. it's a feature of what we do in san francisco to encourage somebody, recognize good work, good treatment and encourage them to continue. or i will address non-compliance

based on what i learned in the staff meeting. my goal after working with the staff and the lawyers is to figure out the right way to address non-compliance. it can go from urging somebody to meet with your case manager, take your medication or doctor have you come back in two dayser a week. it can go all the way to a remanding an individual back in custody if i think the circumstances justify after discussing what's the right thing to do with the staff and lawyers. twice a year in may and in november, we have a graduation ceremony. supervisor mandelman again, you were present for one of the ceremonies. it could have been last november. thanks again for coming to see it happen. that's a typical course of

behavioral health court. the staff is taking care to tell me and lawyers how she and doing here we have some slides to help the supervisors get an idea with some numbers. i know numbers can be very helpful to get a picture what's happening in our local treatment courts. in san francisco, first slide, approximately 130 clients are currently receiving b.h.c.

services. give you a three-year snapshot from the beginning of 2016 to the end of 2018, 912 people were clinically assessed just about 300 a year. that's a huge number in my opinion based on the work that's required to do a good assessment. in the same period, 378 were clinically eligible for behavioral health court treatment opportunity. finally, 204 people were accepted into behavioral health court over the last three years. of the 204, what further information maybe helpful to the supervisors today, 48% reported they were homeless or on the streets or in a shelter before they were arrested. almost three quarters reported a history of being homeless.

i'm not surprised by that statistic. i'm sure it doesn't surprise you, homelessness contributes so much. either it's a contributing factor or clear symptom of somebody who's struggling with these issues. what's clinical summary, 56%, more than half, primary diagnosis are schizophrenia. 60% are psychotic disorder and finally 14% bipolar. 81% has co-occurring substance abuse disorder. of our graduate, 97 people over that three-year period, 44% were homeless before the arrest. when know finished, 82% had independent housing. i'm proud of it. i'll say it clearly to you based on the hard work of the staff as well as what is available to

help these individuals. 82% independent housing exit, 16% were still in residential treatment at exit. clinically it was helpful. very important fact, the median time of program is over two years, 747 days. longer snapshot from 2008 to 2016, almost 60% of our participants graduated. it doesn't mean they had perfect performance in treatment. in fact, the course of treatment shows progress is made and there can be relapse. it's very common given the significant issues that participants are dealing with. nonetheless with good help, almost 60% graduated. last slide for b.h.c.

this is proof that the work we do is making a real difference for the people that we're serving. 78% of b.h.c. participants avoided arrest within year graduating from our treatment. more than three quarters staying out of trouble. if you take a two-year view, 66%, two thirds are avoiding arrests after graduation. that's very good news. making a big difference in the lives of people who are living in san francisco. that finishes my brief remarks on b.h.c. i am prepared to say a few words about mental health diversion. i have other people waiting to speak to you. supervisor, do you want me to say few words? >> supervisor mandelman: there's going to be more on behavioral health court coming from them? >> yes, the clinical experts are here. >> supervisor mandelman: i have

question about your slides. others do maybe we should take questions on your slides. i'll go first. i do want to gush. having been in your court, -- to seeing the weekly how it works and then coming back for the graduation, you are ideal for that role. we've been lucky to have you there. so thank you for what you do. one of the things i wonder about with this program, could it be any bigger? are there people, other people who might benefit. in terms of sort of whether we're reaching everybody who might be appropriate for behavioral health court programming, i kind of wimbledoned t-- wantedto look a.

i'm thinking of the numbers that assessed and numbers that are accepted. are we sure we're getting everybody who without to be clinically assessed? >> an important question. of course from the very start. my first reaction, supervisor, an individual is arrested, brought in custody and charged and when the defense lawyer takes over the case, whether it's public defender or private lawyer, the lawyer quickly gets an opportunity after meeting with the client to make decisions. what is my client showing? as i mentioned the first step to head towards behavioral health court is the defense lawyer in the case will ask the judge, not

me, a different judge in the arraignment courts, please order an assessment for behavioral health court. as a judge in behavioral health court, we're relying on the initial request for that assessment. what's the burden for assessment, that's really important. i mentioned in this step by step

process for behavioral health court, once we get some clinical evaluations and a case presentation with that more detailed profile, next essential step is the legal assessment of the criminal case involving the district attorney and the defense lawyer. as the judge, i don't have gatekeeper authority to override the prosecutor and say i think you're being unreasonable over your objection. i'm accepting the applicant into behavioral health court. those aren't the terms of behavioral health court as currently set by the m.o.u. in san francisco. >> supervisor mandelman: everyb? >> the prosecutor and defense lawyer need to reach an agreement. the defendant need to say yes i understand and i accept that too. it happens, supervisors. in the legal discussion between prosecutor and defense lawyer if the prosecute -- prosecutor says we're going to demand state

prison and given what happened and history, we're not going to offer probation, which is what makes behavioral health court treatment possible. if you go to prison you can't be in the program. the prosecutor takes that position. i've done this sometime, some conversations when i hear what's happening, urge the prosecutor, can you settle the case legally in a different way that would treatment only. what if you take two pleas, run them consecutively, the prosecutor says, judge, thanks for your opinion. no. we view the case this way. this will block behavioral health court. >> supervisor mandelman: it seems like it is possible there might be more than 912 clients who could have been assessed. >> it's possible. average 300 a year of course. the numbers are easy.

if they're working 50 weeks that's six new clinical >> supervisor mandelman: staffin g issues? >> i'm inviting you to talk to you jail health. [please stand by]

>> i want to participate in treatment.

as you know, supervisors, when we talk about treatment, what i've learned in two years, treatment cannot be forced down someone's throat. an individual needs to want to do the work. even if the decision to participate may be grudging, or with some firm encouragement. the threat of something in criminal justice. the individual needs to say i'm ready to participate. i want to do it. the clinical staff in my experience does not always get that commitment when they're doing the assessment. those factors can explain that big drop off from 900 to 378. another drop off, 378 to 204 can be explained by the legal settlement i described to you. if they can't agree on a legal settlement, that would make probation and v.h.c. possible then the case, although clinically eligible and amenable, can't go further.

>> if my colleagues don't have more questions on behavioral health court, i'm going to ask the mental health diverse. vice pressure stefani does. >> thank you for your amazing work. i too have observed behavioral health court. we are trying to pass laura's law, out patient treatment. i went to behavioral health court and was so impressed and having started my career as a prosecutor, i was most impressed by the fact that i was watching the d.a. and the public defender work together to come to the best outcome really for the department and also what i watched and what i think has still left an impression on me and i'm sure it did for supervisor mandelman and you see the good this hearing does, when

the individual came before the judge, i can't remember the judge's name at the time. watching that individual light up when the judge praised him or her for following through treatment and watching that individual just feel that someone believes in him or someone believed he could achieve wellness. until you see it you don't know how incredible o behavioral health court and this type of solution to criminal justice and sir.

>> it seems like, you know, changes in the law legally would allow us to deal with a bunch of people who maybe don't actually even need to go to jail and might be able to be diverted if we could accommodate those people and my suspicion is we don't have the appropriate resources in place. as we look at trying to find a way to have a jail population that is in the neighborhood of 200 to 300 fewer people than we do now, does mental health diverse offer us if we funded the service for mental health die visiodiversion.

>> the way you asked the question, does mental health diversion offer some possibility to provide treatment to the people that we treat and work with in san francisco? yes. it's working. it's a new law signed at the end of june and there was an amendment that came into effect january 1st. since august of last year. so for eight months, we've had 166 referrals to mental health diversion. it's different from b.h.c. in a few respects. as the judge, i'm the gatekeeper. the prosecutor can express an opinion should the applicant be brought into mental health diversion. but it's my decision to accept someone or not. under the terms of this statute, which makes it extremely attractive, to the client and the participants as well as to lawyer, if the individual wants in mental health diversion,

successfully finishes treatment, then the law says the judge must dismiss the case. the huge benefit, legally, to the participant. this statute has its own specific terms. it requires, for example, a recent diagnosis, recent is not defined. by a qualified mental health expert. that is not defined. i have a good idea what a qualified mental health expert is. but the lawmakers in sacramento didn't specifically define it. it must come from the most recent volume of the psychiatric association, the bible, the d.s.m.5 at this point. there are only three specific diagnosises excluded by statute, border line disorder and pedophilia. every other possible diagnosis in d.s.m.-5 are eligible for consideration for mental health

diversion. the law also requires that there be a treatment plan or treatment program described that the gatekeeper judge can evaluate, is it appropriate for the individuals' needs. everybody is different. we have to see what the treatment program is. candidly, so far, that takes time. it's not easy always for the defence lawyer to tell me what are the details of the treatment plan? now, to make this possible on the front end, we have people in custody and we have people out of custody who can apply for mental health diversion. in custody, we have an assessment for the purpose. this assessment is more comprehensive than the b.h.c. assessment and so this assessment takes two weeks at this point. clinical staff may discuss with you the two-week requirement for that m.h.d. assessment. if a person is out of custody

and interested in diversion, but some individuals are out of custody because they posted bail or their judges released them so they're out. the department of public-health, who is here, has been helping significantly to evaluate for the purpose of m.h.d., out of custody applicants. i get that information and i ask the defenc defense lawyer, givee initial evaluation for m.h.d. do you want to go further. if the initial evaluation says clinically appropriate there's a d.s.m.-5 diagnosis. we have an idea for a treatment plan. we think this person is eligible and amenable many of the application process now takes time. it takes some times three, four, five appearances in my court before both sides have all their information together. i've accepted 35 people into

mental health diversion at this point out of 166 referrals. i have denied 50 applications. i have 50 pending. i have one individual accepted in and terminated later on for conduct that justified termination, in my opinion. i have one individual who came in and successfully completed mental health di diversion. that person was in treatment for a year before i met the person. why do i deny applications for mental health diversion? the statute raises a number of issues. if there's no connection or nexus between the criminal conduct and the problem, and i hear from both sides on the point, i have to make a decision. sometimes i've said to the lawyers and the applicant, the defense lawyer and ap applicanti don't see that connection so

i'll deny on that basis. the statute requires me to ask the question, based on everything brought to my attention, do i think there's a reasonable possibility of a serious crime being committed by this individual in the future? it's not easy to pro dictionary thpredict thefuture. i look at criminal history and sometimes, more than a few times, when i've denied the application, i've said for this reason i'm denying the application. i also need to look at, because the statute makes me ask, how has this person done in treatment previously? not just right now. but in the past. other treatment opportunities, well done, not well done. finish successfully, failed to finish. medication compliance historically or lack of compliance historically. if an individual in my assessment, given what i'm told, has failed from treatment, one rae from treatment, not taken

medication on the past, in the terms of the statute i haven't accepted that individual for those reasons. so, it's not easy to get into mental health diversion. i went to a meeting last friday in sacramento. 24 countries were represented. a lot of judges and staff. in my opinion, san francisco with 35 participants right now in mental health diversion. we are leading, believe it or not, leading what other counties are doing and mental health diversion. trying to implement this new treatment statute and i want to emphasize with no money from the state. i hope the state did listening to me. no money from the state. it's not easy but the treatment team has tried in good faith to find existing resources to make

this possible and they've done it in a significant way. so, there are fewer marks about mental health diversion, supervisor. >> to what extent is unavailable of appropriate services a barrier to diverting people at that stage? >> generally, for the treatment courts, unveil ability of resources is always significant. even though we provide an excellent service, in my opinion, it's not perfect. there are times when the defense lawyer and the client are both frustrated because it's taking so long and always wish we had more. and i know my staff would like more. but i also want to say you may hear this from the other members about to speak, the best solution would be a comprehensive look at what is needed for the whole treatment

course process. so if i said to you, supervisors, give us money so we can open up 30 new treatment beds. why think i would be speaking fairly to the spirit of the whole treatment goal and what is needed to make treatment really work. what is needed to make it really work is a detailed look at all the different pieces of treatment. if you give money just to one part or two parts, but there are eight or 10 or 12 essential participants along the way, then it's still out of whack. and so, i'm inviting -- my answer to the question is unveil ability of resources is always an issue and i hope that you are able to take a deeper look at the whole picture of treatment needs. >> i see vice-chair stefani perked up because it's similar to a conversation we had at the

budget committee or public safety neighborhoods. it was one of our prior hearings where we were looking at bee haibehavioral service needs ande sense we don't have a handle on what we need. so if we were to ask. >> i know you are going to hear perhaps from katie miller about this concept of the comprehensive needs assessment and what is possible. for me, what i've seen in two

years, i'm asking that you consider offering more case managers because they do the treatment work. i'm just a judge. i sit in the courtroom. i don't treat anybody. i try to say the right thing based on what the treatment team tells me. i don't treat people. the case managers, the managers who do the hard workday after day and week after week trying to supervisor and help the individuals more case managers. i know you understand that if a case and supervisors to work with the case managers can do more with one. and finally, to answer what am i

specifically looking for, more treatment beds. it's so frustrating and two weeks go by and a month and more and more. >> yes, for mental health diverse and more. i won't sign a release order for a person in custody who is supposed to go to a program for treatment if there's no program for treatment. that would be a longer discussion. why do i take that position and why don't i release earlier and hope everything is ok. in cander, i'm telling you where i'm coming from and also why i'm saying more treatment beds will make a difference because i'll

sign that release order when the bed is available. i won't sign the release order if the bed is not available because i'm concerned for the individuals' safety as well as the lick safety. give us beds. >> vice-chair -- >> can you put a number on beds? wish list? pie in the sky? >> i've opened the door to it and i certain understand you'd like to get a specific number and i'm actually going to offer that question to anybody who follows me, supervisor. i'm going to pull a number. give me 50 treatment beds. >> that's amount, it's expensi expensive. please talk to the clinical professionals who says judge

dorfmann is below given our populations. supervisors, you've been very kind to me to let me speak far longer than i thought i would be and row lease me in a turnover the -- without the treatment beds and i know address -- you have people that go into a prom and you hope it will work and you will handle maybe complicated needs they can't and then you in behavioral court are

left with how to struggle with these particularly complicated challenging folks. >> and someone is in custody, supervisor, on your hypothetical in desperate need of comprehensive professional treatment. they're not getting it in jail. although the jails do what they can in san francisco. that's a conversation also. real treatment happens out of custody. >> and that we sometimes have few or no slots available for the most difficult challenging and complicated, complex, whatever word you want to use cases. that's a real challenge. you need 50 or 100 or 150 treatment beds and it's not just a number. there's a qualitative issue around some of the beds that can handle someone who most programs are not going to be able to --

>> you are right. supervisor, i want to raise an issue that the clinical team can answer farber than i. we have treatments in san francisco. they're quite a number. they're not all the same. it's not everyone is the same and this one has two beds and this one has 20 beds and this one has 100 beds. it's not how it works, supervisors. there are programs that focus on drug treatment, duel diagnosis treatment. those particular beds are so important given the question you were asking that more complex needs, if part of the answer to that is more duel-diagnosis beds with good professionals who can do it, it goes back to my request respectfully that you look at a comprehensive needs assessment.

there's so much that goes into providing what each individual needs. >> so you have a 58% graduation rate. is some chunk of the 42% people for whom you could not find the right placement you just didn't have the right program and you could have imagined there would have been a program and i wished there was a program that was assertive or had the ability to handle folks with greater needs or something like that? knife i have an easy answer. the more complex answer is, if we had more comprehensive services, more opportunities to address people with real difficult multi-layered problems, maybe. with those extra top-level services the graduation rate would be higher. we can only guess. i'm offering it because i

believe it. a simpler answer is the 42% who did not graduate, because they were terminated and they have to back to regular criminal court given a new criminal act alleged by the prosecutor. >> everybody is good. good luck with the trial. >> thank you for the opportunity to speak very much, supervisors. thank you christine king. >> up next, tanya marra, the director of jail health and reentry services for the department of mental health.

>> hello. >> good afternoon, supervisors. thank you for holding this hearing today on the justice-involved bee hair yearal health population. it's a topic near and dear to me. while driving my 6-year-old son to cool thi school this mornings telling about what i talk to him and he said mommy, please, stop talking. let's hope that you find me slightly more interesting than he did. so, when i started doing this work 15 years ago, some residential treatment programs refused to take patients from the jail. they saw them as dangerous and different. we have come a long way since then. today, we are having this

hearing and the health commission has passed a resolution stating that incarceration is a public-health issue. the d.p.h. in collaboration with the criminal justice partners has a role in preventing criminal justice involvement, treating justice-involved patients and addressing the far-reaching effects of incarceration on our patients, their families and our community as a whole. additionally, d.p.h. has many civil service and c.b.o. programs beyond jail halls dedicated to serving the population including drug court, community justice treatment center, behaval health court and city wide forensic, just to name a few. i am confident that tomorrow will bring us even greater expertise in serving the justice-involved population.

now to get into a little bit about the experience of someone with a be behavioral health disorder moving through the jail, everyone arrested is asked questions when they walk in the door that are designed to identify if they might have a bee hair year health or mental healing disorder. any yes answers to those questions result in a referral to my jail behavioral health staff. we do a more comprehensive assessment to determine what that person's needs are while they're in custody with us. and i put this slide together because i wanted to show that the way our system of care is set up in the jail, very much reflects the system of care that exists in the community. we have treatment available for patients at every level of a a cuity. for someone that could get --

all the way up to hospitalization. in terms of treatment in the jail, a lot of it reinvolved around housing and so i've included information about where our psychiatric patients are housed. they can be in general populations if their symptoms are under control. they're stable and not vulnerable. they can be at the next level in our psychiatric shelter living units. i want to high lie a new program we just started in collaboration with the sheriff's department where we have dedicated deputies assigned to the psychiatric shelter living units that have received additional training and working with patients with mental illness. and they work as a team with my staff to provide interventions and support to the patients. they support our group program, the groom be support we do for our patients and it's really resulted in a significant drop in incidents both use of force,

safety self-placements and issues with med non compliance that can result in hospitalizations and it's been really effective out of county jail 5. i thank sheriff for her leadership on that and we're excited to expand it. we have our acute housing, our observation unit, which is sort of a subacute right before someone might need to go to the hospital. it's a challenging population we work there. we have our safety cells which is where we do our assessments for hospitalizations. of course, we have at our highest level of care our unit at san francisco general. i can say that as someone that goes to a lot of jails throughout the state, we're very fortunate to have a jail unit at the hospital to treat our patients that are meeting 5150 criteria. lastly, i want to highlight that reentry planning and linkage to community treatment happens at all points along this triangle.

most importantly, i want to say that i think we are the only county in the state that allows conservatorship to be initiated from jail. this is some of the s b-1045 hearings. it's allowed us to get some of our sickest patients into the level of care that they need. i'm grateful our department of aging and adult services has worked with us on that. in terms of the referral to bee haibehavioral health court, when the person is housed post arraignment when they moved forward a little bit more in their legal process, and the same with mental health diversion referrals. >> how many conservatorship referrals have you done? >> last year we did 22. which is quite a bit higher than the year before. we almost doubled the number.

i foresee that continuing to grow. this next slide talks about our access to treatment. we have a reentry team that works as part of our buy hear yoral health team. we're all working from the same patient information. if my jail bay -- i'm speaking talking about the weight on the d.p.h. side. from the moment the referrals is done o