isn't interest in access to bed and timely access to bed. i think i will answer -- asked kelly to come up later to answer questions you had about that. i do know it is still complicated and we are trying to improve our data tracking system to more effectively track this measure. [please stand by]

within our programs. we also look at re-admission. we definitely look at re-admission. 70% were not readmitted within 90 days. that we know. and that 65% of p.a. discharges were not readmitted within 60 days. and lastly, client satisfaction. we -- >> that sounds like 35% of p.e.s. discharges -- >> that's true.

i was thinking about that. people would figure that. absolutely. well, yes. okay. our target -- right. our target of re-admission -- inpatient discharge our target is 80%. and we hit 74%. i don't know what our target is. but it's something we continue to work on. and i have some -- i'll get to kind of how we are trying to work on that. our client satisfaction -- we do conduct them twice annually for mental health and substance uses. also state mandates and they did show a summary score of 92% for both mental health and substance use. so our challenges. these are two of our major challenges. our workforce vick i -- vacancies. we have significant vacancies and that's after a survey that

we performed that was in december, i think. yeah. yeah. it's about 20% across both civil service and community-based organizations. we hear about the challenges in hiring and retaining staff. and especially when trying to hire bilingual staff, cantonese speaking and spanish speakers. we know there's a nationwide shortage of psychiatrist and san francisco is not immune. we have a 23% vacancy rate, which is growing, as more of our psychiatrists retire. engaging and treating people suffering from substance use and mental health issues, who experience homelessness, this is one of our challenges reaching this population for sure. our clinic -- client-based services are the bulk of our services. and they work well for those who

are able to participate at this level of care. we know that homelessness makes it challenging to attend appointments, remember to take medication, and participate in other clinic-based services. our intensive care management programs do field-based work. i know i have done it. but they're suffering from the same 20% vacancy rate across the board. so our current priorities. these are the things that we are doing. we're -- we want to meet clients where they are. we know. we're increasing outreach. these are the engagement specialists that we placed at the healthy streets operation center. they describe the -- they describe the harm-reduction therapy services, which is kind of a pop-up clinic. and they're going to be aligning themselves with street medicine. we're increasing our intensive care management. we have a short-term i.c.m.

linkage program. and our i.c.m. expansion and also we described these strategies to increase intensive care management flow from intensive care measure to outpatient to kind of open up more slots. we're expanding the hours of the drop-in center from 5:00 p.m. to 9:00 p.m., that offers us the opportunity to engage more clients and hopefully provide more linkage. we're placing two social workers in psyche emergency services. someone described that warm hand up needing a link to services. but the social worker is there to offer the warm hand up and offer other services. the four peer navigators really are tied to hummingbird. there are times, okay, we're getting to you hummingbird and then gone. it's really to help engage them and walk them over to help them

to connect. we are expanding behavioral bed capacity. in february, we expanded capacity of hummingbird by 14 beds. we just increased the number at the healing center by another 14. and we're creating 72 new residential step-down beds for substance-use ever ises. when they get out 50/50 -- -- rather than just going to the streets. and that's through h.r.360 on treasure island, too. we recognize that there's a critical need to collaborate with h.s.h. particularly to identify our overlapping, vulnerable clients. you know, housing is really important for wellness. lastly, the strategic planning announcement approaches.

we're really needing to work on workforce. for civil service really streamlining hiring with human resources and training in the system to provide a pipeline. also exploring ways to help support their hiring and retention of staff. our director of mental health reform dr. bland. we're looking forward to helping him look at our system, identify gaps and determine strategies to those close gaps, particularly for clients who experience homelessness. we are continuing our work to improve our services, but i want to highlight the work we're doing with our city partners, community and city partners to improve services for our shared populations. a good example is in the newspaper today, the critical incident training. together we're collaborating with law enforcement to provide training. it's really helped reduce the -- i don't know how you describe

it. but it's been helpful to reduce force i guess. that was in the newspaper today. and we're also moving toward having discussions about can we do more co-response, co-responding, co-location. we're definitely exploring that. for h. -- we're supporting age soft with clinicians and h.s.h., the collaboration, looking at our coordinated entry to see how our clients. so we can support our clients who go into coordinate entry and receive housing and then we can support them to keep them stable, so they can maintain their housing. and, of course, we are in process of hiring -- not hiring, in the process of identifying a parent director to help really create some stability and move the initiatives forward. our policy recommendations. we realize that as a navigation

center expand, we need to have more medical and behavioral health services within these navigation centers and shelters to help kind of stabilize clients and connect clients and engage with them and help really get them thinking about is there a hope, do you have hope for change, or do you think this is the future? let's give you an opportunity to think differently if that's what you want. right. to expand the behavioral health respite beds. i know we have expanded them on site, but is there opportunity to expand them somewhere else in the city, too. is there an opportunity for that. and expanding mental health and co-occurring residential treatment beds. we saw an overlap of 2,000 people. and if treatment reages like this on this side and that side, it's going to be harder for client -- for these clients to get better. we need to integrate those services.

so because i started the presentation with the client, i also wanted to end with one. we continually need to fight the stigma that's attached to people who suffer from mental health and substance-use issues. we need to promote empathy, compassion, and understanding. thank you. i can take questions. >> okay. thank you very much. >> thank you for the presentation. and i -- i appreciate that you're new, so feel free to call up anyone to answer the questions. >> sure. >> because i want to start off by asking many of the same questions i asked of the b.l.a. so i have been frustrated and quite shocked at the extreme discrepancies that -- between the data i have been given from d.p.h. we had a hearing in march, where your predecessor had mentioned

that wait times for residential treatment for mental health and dual diagnosis was two to three months. i then emailed for follow-up information with d.p.h. and was told it's one to two weeks. and then i've been working and talking to our conservator jill nielsen, who gave me information saying for those people that are conserved, it's two to six months, up to a year. and then the b.l.a. report today had a range that some services are on-demand, which doesn't even fully make sense to me. i want to walk through the chart with you and that other -- and that for the other services, it's up to 30 days. and then when i talked to advocates, when i talk to the executive directors, that running these residential treatment programs, when i talk to the public defender's office, when i talk to the d.a.'s office, this doesn't correspond with their experience.

so i have to say it's been disappointing how little data is kept to begin with. it's been disappointing the different answers i get every time i ask the question. and it's unclear to me even what the methodology is. as the b.l.a. explained, i guess you're not even tracking today referrals or wait times based on when it is determined the person needs a different level of care and when that person actually enters that level of care, which is, you know, what i'm very interested in. so let's start off just responding to that and then i'll offer feedback >> if i understand correctly, you're talking about specifically about beds. it's not outpatient treatment you're talking about? >> well, i'm really talking about step-down at all stages, right. i mean, you know, whether it's, you know, how people are being released from p.e.s. with or

without referrals, what they're being released into a programs from when they're in the acute ward and how long they stay there and how much, you know, we're paying for admin dates, which means we don't have the step-down wait times we need. so let's start there. >> right. because i know that there's a focus on beds. and i appreciate your understanding understanding that i might not have the information. >> sure. >> i wonder if it makes sense to call kelly up to talk about -- kelly is our director of transitions to talk about the actual residential access to residential bed. maybe we go go through the chart on page 9 of the b.l.a. report. okay. the b.l.a. report. and then before we go through that chart, kelly, let me just ask you. so when we're looking at this

report, can you -- what are we tracking? what is the information we're getting here? from what point to what point are the wait times on this chart? >> sure. so on this chart ... yeah. so on this chart you're tracking -- let's see, one, two, three, four, five, six, seven, eight different levels of care on this chart. so that's why the wait times are so variable, because the waits for different levels of care. >> no, no, of course. i'm wondering -- my first question is what are we tracking with these wait times? like what i would like to see tracked, for example, is the minute a clinician decides this level of care is no longer appropriate for you.

we need, you know, a different level of care, a different type of care for you. to the time that person enters into that different level of care. what is that wait time? >> so that wait time is historically been tracked manually, because the transition to division is not in an electronic database in any structured, regular way. and we aren't linked to any of the other systems. like we're not in the clinical record, we're not in avatar. >> but it has been tracked? >> it's tracked. but we would have to do a manual calculation every single time. so what we do is we document the date that we receive a request for a placement authorization. >> and does that usually happen on the same day that it's needed? or determined that it's needed? >> it's variable i would say. >> how big is that variable -- that variable time period? >> it's not something that we've ever looked. we have to look at every single client record to see when a

doctor or the treatment team recommended a lower level of care. and then track when they put it into the placement tracking report. and then -- >> can you give us -- like could that be a difference of a day or a month? what's the ranges? >> because i've never looked, i really can't speak to it. i would imagine -- in general it's probably been a few days ideally that they would determine it as a team that the person is ready to step down to a different level of care, that they would then put in the request to us. >> so for me to determine how accurate this new data i'm given, can anyone answer that question for me from d.p.h.? >> from the physician determining that a different level of care is needed to the time that that information gets to transitions. the request is made. >> as i said, i'd have to look at every single client record. look at the last physician note

or the last social work note to see when it was decided that a person should be referred to what level of care. >> but that -- so that differs based on every single patient? like we don't have generally it's one to two days. or generally it's -- i mean, that's a pretty important question. >> i don't know. what she's asking is when do they decide that to when they do fill out the form? >> and when does -- so my understanding is the manual tracking that is happening starts from the day transition -- >> it's the form. >> gets the form from the physician saying that the level of care that they are currently in is no longer appropriate for them. they need a different level of care. >> that's correct. >> there's no one here who can tell me how long in general or the range of length it takes getting from a physician to transition? like -- i just want to know if this takes a day or it takes a week. or it takes ...

>> that's true. i'm -- again i'm just speaking as a physician. you know, depending on what hospital, where they are, who is making the referral. so i could make a decision saying, okay, we should do this. and then the form needs to be filled out and needs to be sent in. so knowing the flow from each unit or physician, that piece i don't think we can determine. however, whoever is making the referral, like if an agency is making a referral, they can actually track that, right. right? if i make a decision -- >> excuse me. >> i'm sorry. i'm sorry. >> i think that -- i mean, i think one of the questions is are you collecting this data also? >> well, she said -- manually. >> yeah. but trying to understand in a sort -- are you in any way collecting this data in a systemic pay that we can actually -- you can actually

tell us on average. are we even collecting that type of data? i mean, when you say you're doing it manually, that means everyone is just doing their own thing. or do you actually have a -- have you compiled data to actually give us a timeframe? >> we collect it in an excel spreadsheet. so when we get the form, we put the date that that's received, the request, who is the requester, what level of care is being requested and where they got authorized to, what level of care they got authorized to. but to speak to supervisor ronen's question, no, no one to track when in the hospital the decision got made, the doctor is recommending a lower level of care or alternate level of care. and when did they send the placement form to us. so that one metric is not

tracked. >> that's incredible! that's absolutely incredible. and it's infuriating. i can't even -- i don't trust the data that you've given me -- the five times you've given me, wildly different numbers to begin with. then what you're telling me the data i'm getting doesn't even tell me what the actual wait times are, because we have no idea. nobody in your department, in d.p.h. or general hospital can tell me how long it takes to get from a doctor, who determines that a level of care is inappropriate, to transitions? what kind of operation are we running here? >> hello, supervisor ronen. roland pickens, director of san francisco health network. i think the answer of the question would take a practicing psychiatrist on the floor at the general, because they're the ones who write that. and then the social worker puts the packet into kelly's spot. so we can actually have someone like dr. leery would know when

he practices, how long does that process take. he's not here today. but we can certainly get that for you. >> but dr. leery might have one practice and dr. song might have a completely separate practice. and dr. tell has another practice. >> yes. from my knowledge, that's not the case. they have a standardized process on the inpatient service in terms of how they do the referrals. >> you just don't know the length of time -- but nobody knows? >> i'm not a practicing psychiatrist. i don't fill it out. we have to have one of them come up here and answer that question, because they do it every day. >> you knew that this hearing was taking place. you knew wait times has been a major issue. >> absolutely. >> yes. and you're coming to us to present this information, you've had a huge b.l.a. report done. and you can't answer that simple question? >> if i had anticipated that was your question, i would have made sure -- >> that's obvious question. i see the director of d.p.h. is here. you have something to say?

>> yeah. good afternoon, supervisors. and director of health. and i just want to, one, acknowledge that the team here is working extremely hard under, you know, very difficult circumstances to care for people. and i also hear your concerns about the lack of identified metrics that are very important through our system. and i think you all know that, as i have come on to the department, started at the department and with mayor breed's priorities, we're focused on ensuring clear metrics about how people flow through the system. whether the metric you're asking for, which is understandable, with one of the key metrics, we're looking at what are the outcomes that we agree on, are the gold standard for our system, right. once we're actually able to identify those, we will be able to both monitor how patients flow through the system, what's best for them and what's best for their family and the

community. and then actually provide with you field numbers about how much are we spending as a community, and as a city in our system, because things are not following adequately. so dr. bland, who is our director of mental health reform, i have identified flow as a key piece of what he's looking for. and we link the clinical side to the programmatic and budget side. you're exactly right with the need to better link what clinicians say in the emergency room, what they're asking for. identifying that as the key data point as we look to improve our system. >> dr. colfax, with all due respect, first of all, i will start off by saying kelly is one of the only people in d.p.h. that i actually trust to give me genuine data. she's a complete asset to your department. works her butt off every single day. and so if there's anybody who is going to give me information that i can trust, it's kelly. so let me just say i just -- i just need to put that plug in. but there aren't a lot of people

i can go to these days to trust and kelly is one of those people. i just want to put that on the record, giving, you know, the way you started this out by saying everyone is working very hard. i have no doubt that everyone is working very hard. but this is extraordinary. your departments a come before this board of supervisors recently several times and every single time your last director of behavioral health couldn't answer our basic questions about wait times. you have since said, and then every single time we get data from your department on these times, for residential treatment beds, we get wildly different information. so i don't even trust the information i'm getting from you to begin with. but i'm just trying to understand what you're actually tracking in this wildly divergent data you're giving me every time i ask for it. what i just realized is you're not even giving me genuine wait times, because you have no idea how long it takes when a physician determines that a

lower-level of care is necessary and by the time you start manually inputting that intomannually -- per patient, we don't know what the time is. we don't know what that time is. that's extraordinary. you could not bring one person here today that could answer that question. this is not a trick question. this is a basic, basic question. and it's -- talk about an expensive question. we're spending $21 million, over $2,000 a day for patients being kept on the most expensive level of care at general because we can't find a placement for them in the community, which is more appropriate. we can't bill medi-cal for it, because it's inappropriate. so this should be the first order of business of information that you're figuring out. >> right. and i just -- >> a point of information to

note that dr. colfax has been on the job for about three weeks. >> but -- this is not about dr. -- this is not about dr. colfax. this is about who have you brought to testify in front of us today, knowing how important this issue is to us, knowing that it's a priority in a report, knowing that there is a chart on page 9 with this data and i'm just asking what -- what are we tracking with this chart? and nobody can -- nobody can answer that question for me. >> so i apologize if the answers have not met what the expectations that were brought forward. i do think that we can provide useful data, perhaps not the complete picture at this time. i agree that we need to do better job. and i think the people who are actually giving you the information just a few minutes ago would agree, we need to do a better job of looking at our data and making sure that we're measuring the right things, in order to improve our system

across the behavioral health field. we are looking for a new behavioral health director. dr. sung agreed to step up and actually manage the system as acting director at this point, in addition to her other duties. and we're building the capacity to answer the questions that i agree, we need to answer ek effectively and efficiency. and as much as possible in realtime. dr. bland has just been on the job for two weeks and this is his priority as well. so we're looking across the systems. i do think, given -- we do have some answers in the transitions program and in terms of kelly's work. we're actually looking at how do we expand that perspectives, who are able to better understand what's happening in our system to give you the numbers you need to help us make the right decisions for the community. and again i understand the concern. we're using the data that we do have available now. if there was some myths on our part in terms of a question that was specifically asked and you don't have the data in front of

you, we will do better next time. and i apologize for that. >> okay. if kelly could come back, i want to talk about this chart. >> sure. >> so we have no idea what the wait time was -- >> yes. >> it could be a week, it could be a month, it could be a year. we have no idea. but once it hits you, this says that anybody who -- let's start at the top. the inpatient psyche services at general, those are the 44 beds on the 7th floor, right. seventh floor ward. that there's always beds open? >> that is not true. if there isn't a bed available at san francisco general, we have a contract for overflow with st. francis. and then if they fill, then we have an agreement with cpmc,

they take folks into the acute unit. acute care in general, you will not wait. >> okay. that's what on-demand means. so there's anyone who needs that acute care and can't get it right here in san francisco? >> that's correct. >> okay. >> well, there are times that every single acute -- if inpatient unit was full in san francisco, and you are a san francisco client, you start to go to the next available bed. so there are people who go to any medi-cal accepting facility in the region. we have folks that will end up at stanford or alta. >> it happens often? >> it hasn't happened recently. but it has happened, yes. >> has it happened this year? >> let's see. we have people that are in out of county hospitals, more because they were transient and got picked up in the out of

county location. i don't know of anyone that fell out of county because of overflow. >> okay. so then the acute diversion units, how are you getting that service on-demand? go ahead. >> okay. so if an acute diversion unit, it's really designed to be what it's described as, an acute diversion. if somebody has been recently admitted within a three to seven-day span, they can be diverted to the lower level of care. and some people could be diverted from p.e.s. if they didn't immediate to be inpatient and a space in e.d.u.. the recent practice from psychiatric emergency services to refer people urgent care first and into the e.d.u. >> so i talked to steve fields, who is the head of the foundation, who told me frequently not a bed at the

acute diversion unit. but this chart says it's available on-demand. >> it's been influx this year, due to the practice change of psychiatric services. so i think that's a variable number. >> i think if you did a point in time, would we have a bed in e.d.u., it -- it has really fluctuated through the course of this year. >> so this is inaccurate when it says that this -- that a bed in an e.d.u. is on-demand? >> i think that in this recent past, it's probably not as accurate. that's true. >> okay. well, you know, for the record, steve fields told me that three days a week they're filled. every single week. so once again i'm having a really, really hard time trusting the data i'm getting from d.p.h. and it's -- it's incredibly upsetting. >> it's frustrating for me. because i think we've heard

frequently from progress that their e.d.u.s are not getting used to capacity, because of the practice going through urgent care. i'm getting a mixed message from progress. when we speak to them, they're telling me they don't have e.d.u.s getting used as directly as they could. >> so my understanding is that they used to get referrals from p.e.s., but that's no longer happening? >> that's correct. >> why? >> it was a practice changed to try and expedite moving people through p.e.s. more streamlined, because in order to go to an e.d.u., fair amount of referral paperwork that needed to happen. and a medication ordering issue that we looked into trying to resolve. and in the interim, there was a practice change to use urgent care as a pass-through location, where it would be easier for them to get medications. >> so is there not going to an e.d.u., where are they going when they leave p.e.s.? >> well -- well, i was going to

say hummingbird is a more recent location that's been available to them. >> that's 29 beds. that's always full. >> it's more now full than it had been, when we first opened, western -- we were able to manage flow. these are the times of practice changes that we're trying to accommodate, to try and figure out a best-practices way of managing the flow. and i think it's -- what's made it challenging in some ways to get the data as well, is because a lot of new programs, new practice procedures launched in this last year. so that's contributed to the wait time discrepancies. >> okay. i can go back to that. so for urgent care, it says that -- that that -- that that service is available on-demand. would you know that?

it's not run by d.p.h.? >> it's not run by d.p.h. every day there's a report that progress sends to us with bed availability. and it's tracked every day. >> okay. >> it's combined with what's available, with the use of p.e.s. was. you can see the crisis and bed availability. >> okay. and that -- in your experience, that truly is available whenever? >> i would say more often than not and similarly it's gotten harder to get availability on-demand as p.e.s. used it more as the disposition location. but historically it has had availability. it's the pass-through to e.d.u., it has a flow to it that other places do not. >> sorry. it would make sense to me that the acute diversion units are full more often if p.e.s. is now sending people to urgent care, in order to an e.d.u., because

they're paying on the high level of paperwork. it seems like it's a passing off on responsibilities on to our urgent care, that clogs up the system, but doesn't relieve burden in the entire system. does that make sense what i'm asking? >> yes. >> that's an accurate statement? >> yes. i wouldn't say a passing on. i think having people stay long at p.e.s. is really not an ideal situation. people on p.e.s. are in the highest crisis for our system. urgent care are for people no longer on a 51/50 hold or a little bit more stable than people in 51/50 and really needing to be held in p.e.s.

so what i think the purpose of that practice change was really to try and make sure that our crisis -- that our most at-risk crisis stabilization beds were always available. and i think -- we said that our use pattern -- since the practice change at p.e.s., we need to look at our use patterns to see is what really is needed another urgent care, because we are finding that enough people can be dropped off at their 51/50s, moved to the next level of care, be triaged appropriately from there. and because this practice change happened mid-year, i don't -- you know, we're kind of in the beginnings part of the data collection to determine whether that's the right level of care or not. >> okay. okay. now this residential treatment. i don't know really what the difference is between mental health and co-occurring diagnosis is. i don't know why it's separated. >> it's separated because the presentation of the client is a different and each of these three levels of care.

everything that's here under the residential treatment, the co-occurring mental health are substance use disorder treatment or what the client is bringing to the table. so somebody who has both mental health and substance-use disorder issues, equally present, would be best served if they went to a program that was designed to treat somebody who had both of those co-occurring diagnosis. and mental health treatment program is really for somebody who is more purely dealing with a mental health diagnosis issue, without any co-occurring substance use. the substance uses are who -- doesn't have an underlying mental health diagnosis. y , so my understanding it's very rare to find someone nowadays without a dual diagnosis. is that true? >> no, i don't think that is necessarily true. we still see our share of folks who are truly mentally ill. >> without substance abuse. >> our goal is to intervene at

this point, before turning to street drugs to self-medicate. when it's the right time to get in, it's ideal. >> the average wait time of up to 30 days for a co-occurring diagnosis and a mental health disorder, that -- kavooss told us in march it was more two to three months. if you -- if you lump all of the -- all of the treatment modalities that we have, which are 90-day programs, include the two year-long programs that we have, then it skews the wait time longer, because the wait to get into the year-long programs is generally longer then it is to get into a 90-day. so if you look at just 90-day programs, then you're going to see that the 30-day is kind of closer to the mark, up to years and push it a little higher.

although it says it's up to 30 days for the mental health beds, most 90 days, some 365 days. >> right. >> so you're saying that kavoos says two to three months because he was including the year-long program? >> right. i would imagine if you include outlyre waits, people waiting for reasons probably not related to bed availability and but for reasons very distinct to people, we have some folks that wait very, very long for other reasons, that have nothing to do with bed availability. if you include those people in the wait timing it would make the wait times seem so much longer. >> so jill nielsen, our conservator, told us -- sent me a chart. she also couldn't access very much useful or reliable data. but she said i have a point in time, march 22nd, 2019, count of all the people conserved in san francisco. and of those 24 people, 22 of

them had been waiting for a step-down bed for over 60 days. so how does that compare with this data and this chart? >> i would have to look and see what she was talking about. acute treatment bed which is not any of these categories. so people who are waiting for an i.m.d. or mental health rehabilitation, that wait time is long. too long. >> okay. so that's -- that's that. okay. so -- and so that's the reason why we're spending $21 million a year on unreimbursed admin at general, because we're generally waiting for these locked beds, that take -- that have a much longer wait time? >> yes. and i think the combination of people waiting for state hospital beds, which is really the people who are the longest stay, kind of worst cases that

you hear are people waiting for state hospital. that's a challenge for us because we don't really control the way state hospital flows people into care. they -- a few years ago they switched to a one giant waiting list model for the entire region. and so while we used to control our own beds at this point in time, we no longer do. so we get in line with all of the other counties to get access to a state hospital bed. that has made it considerably longer for us to get a person in. even if i step 20 people out, no guarantee that i can get 20 people in. so that's been very frustrating for us. one of the things we're doing on our side is actually start to work with our community providers, like crestwood to see if they'd be willing to open a facility specifically for more violent offenders, that have issues that are very hard to manage in a regular mental health rehabilitation setting, so that we have a place to actually take them instead of waiting for the state hospital bed. the other population has stayed it incredibly long on the

inpatient unit, co-occurring and mental health. that's been quite a challenge to try and get the regional centers to take responsibility, that when some of these psychiatric issues stabilized, they should step forward to help us take the next placement down and it's been very hard to get partnership going on that. >> so since the hearing we held in march, my understanding is d.p.h. is trying to track data we heard in a more systemic and accurate fashion. >> yes. >> what's changed? what are you doing differently? >> so we are actually working with our proprietary software provider for placement. we have a bed census that tracks out of a product called s.f. get care. and we asked them to build in modules that track the wait times in the way that people are asking for the data sets, which is really what will we can control, which is the day that we get the referral, when we send -- when we get an actual complete package, that's another

thing that comes kind of slowing it down, we need a certain body of paperwork to send to a facility, if we don't get all of the pieces that we need, the decision can't get made timely. we're trying to fine tune making sure that we get all of the pieces at the front end, so we can get a decision from a facility within two days. so that we know the wait is because there's not available bed and if there is a barrier, like there's only a particular kind of bed that can receive the client, that we document that. so we would be able to give a clear data set that the people who wait the longest are the people who -- like we know registered sex offenders wait the long post it a step-down bed. or somebody who has violent episodes unprovoked, that's a person who waits longer. you know that's the thing that caused the wait times. >> when has that changed? >> we're working with the vendor now. >> it hasn't happened yet. >> it hasn't. until then we're capturing the data as best as we're able in an

excel spreadsheet. >> similar to the way p.e.s. stopped referring to the acute diversion, my understanding is that general all together has stopped referring to residential treatment programs about a month ago? >> yes. i just recently heard that as well. >> what's going on there? >> i have not had a chance to talk to kerry at the hospital, to find out why she changed that practice. >> is there anyone here that can answer that question? the director of public health? did you hear the question? okay. the question that i asked is -- that i have heard that as of a month ago, that general has stopped referring patients to residential treatment beds and kelly just confirmed that that is correct. and i'm wondering why?

>> i will double check on that and we can have an answer by the end of this hearing for sure. >> okay. does anybody know? >> is that actually -- >> yeah. so let me check with the hospital. i'll let you know by -- as soon as i get an answer. >> okay. miss sung, you don't --, >> i just heard it when i arrive, kim taylor. >> let me -- let me get in touch with the c.e.o. of the hospital and we'll get you an answer from the d.p.h. site right now. >> okay. i have -- i have a bunch more questions. but i understand that supervisor heeney has to leave. if i could come back? >> that's great. so supervisor ronen, we have walton has some questions.

the police department must leave at 3:20. what i would suggest doing, we would hear from the police. can you hold your questions. we can have d.p.h. come back up to answer questions. would that be okay? >> yes. i do have a lot more questions. but, yes, sure. >> thank you very much. okay. supervisor haney. >> thank you, chair fewer. so i also wanted to -- i don't know who the right person is to direct this to. i wanted to revisit some of the questions i had around data quickly. so we heard a little bit about how some of the data is tracked manually, which it sounds like is on an excel spreadsheet, in terms of wait times and referrals, which i agree is concerning and a bit shocking. but in terms of where people go when they people p.e.s. or when they're in the system somewhere, and are understanding of outcomes for them, where they

are in the broader system, is that being tracked actively? the example that i gave is this 2,667 people who were 5150 or, if we do know exactly where those folks are. and outcomes for them. is that information we have? or is that part of something that we're in the process of creating? >> antoine bland is coming up to answer this question. >> i'm the current director for mental health reform. and the former medical director for psychiatric emergency services. and i'm here and dr. mark leery to help answer questions, with relation to p.e.s. can you please repeat the question at the time and i want to make sure that i answer that. >> so tracking of placements, outcomes, -- and brought to

p.e.s. is there some sort of central tracking database for those folks. and what happens to them, who is serving them, what outcomes are for them. and then by extension, do we have that for our system as a whole? so for that subset, which is a significant one, my concern is there is -- and this is i think part of your mandate here, is that we have a lot of different folks who are delivers services, a lot of contracting out at various levels. and the concern is, as you know very well, people really, you know, falling through the cracks, because we're not able to track where they are. and whether they walk out, you know, referred somewhere and they walk out the door one day and then we lose track of them and we don't see them again until they're 5150 again years from now. how are we addressing that sort of broader systemic tracking and

case management? >> thank you. this is such a really important question to ask. i'm certainly very concerned about people simply falling through the cracks and we're not able to meet them. what happens in most systems and our system also has its own constraints around our data processes. however, a common process for that data to be integrated in the ccms. and that data feeds from p.e.s. medical record, electronic medical record into ccms. some data fields that are coded properly, there's some data fields that we have learned recently, based on the previous hearings, that are improperly coded. i want to be clear that when an individual is in psychiatric emergency services, every individual is assessed for their needs and assessed for their after-care needs. the process for connecting them to those services has been less

than ideal. i appreciate earlier that one of the b.l.a. analysts reported also around there's certain individuals coming to p.e.s. who may be privately insured. another factor is we have to respect the patient's choice, an individual may choose to decline those referrals at any given point in time. in terms of what we need to do around our data collection process, we're certainly excited to be going -- that the hospital system is transitioning to epic, which allows us to communicate more efficiently and directly with our outpatient health services. it is a major goal for ours to make sure no one falls through the cracks, because we're unable to communicate in realtime. >> so my understanding is that it doesn't exist right now, to the extent that it exists it's not entirely reliable, some

folks may be in it, some folks not. some folks might not be totally updated for. and that we don't have single way to keep track of the folks serving, many of them touched by multiple service providers and referred in various ways or comfort from multiple visits for a variety of reasons. >> every person who receives services is enter into the the common medical record for the hospital system, which needs over into the ccms system. the challenges in terms of which data fields and information is being pulled across the systems is one factor. the other side of this is the outpatient behavioral health system record, which is avatar. all of our p.e.s. records, received services in p.e.s., whether they're connected to an outpatient behavioral -- and so the information is collected, it is in a -- it does come together at some point. however, we want to certainly be

able to really consolidate that as much as possible. >> great. okay. thank you. thank you for that. i have another came of general question along the bottlenecks are. maybe a little more general. we obviously -- anyone who lives in the city and certainly number my district, there's just a tremendous need around mental health and substance abuse-related treatment and services. and understanding where the -- where the capacity needs are and how we can more aggressively address those. i think is something that i'm trying to get out of this hearing. i'm not seeing the level of

planning and strategy around meeting the capacity. and really understanding where that need is. so, you know, there was supervisor ronen quoted an article that said, you know, there are a few places to discharge mentally ill outpatients, few facilities where they can't do harm to themselves or others. and, as a result, we're releasing folks back out on to the street or very little connection to services. where would you say the greatest need is in terms of expanding capacity, where -- when you were at p.e.s., do you think you would have liked to have a lot of people sent to or have access to, that you weren't able to because of capacity? when i look at a number like near 3,000 that have been 5150 or 5250 and a few beds, it looks

like what may be happening then is that we're finding ways to quickly determine that people have been stabilized, and sending them on their way, because we don't have the ability to send them to escalated levels of care. because of capacity issues. so wouldn't necessarily be reflected in a wait list. it would be the way we have to do things, because of the triage that's taking place. can you speak to or somebody around the capacity that is really needed. for people who look at what's happening out in our city and our streets, and even what's coming into the hospital. it doesn't look like the beds are near the level they need to be to serve all of those folks effectively. >> this is where we went into our policy recommendations and that was the last page of our

slide. because we agree that bed capacity could be increased, right. which is why -- the idea of increasing the psyche respite beds or the behavioral health respite beds. we can start pulling people in. those are the folks that aren't really wanting direct service care, but it's a place where we can engage them and start the process. and certainly co-occurring treatment beds. the outreach services -- i mean, a lot of this is what dr. bland was talking about, unless they're in involuntary status, we have need the opportunities to meet them where they are, to engage them in services. that's why i feel like our -- one of our greatest opportunities lies. do you have something to say? >> i would agree with that.

we want them to know where to go. and many of those people are coming to psychiatric emergency services, which i think accounts for some of the return rates that we're seeing. we're as more and more individuals come to p.e.s., we certainly want to maintain

access for an individuals and so we had to do some efficiency projects. and looking at where's the most appropriate place for an individual who is no longer in the crisis state, to continue their care and continue their ongoing stability. and that was the impetuous for the pilot program. it's moving people from the most acute setting, which has the own risks to a more appropriate setting where they can continue on the care continuum. now the great thing about the project, it clearly increased the volume of activity that occurred at the urgent care clinic, significantly i would say. they can speak to that, steve shared the data with you. the challenge is how do you again develop an efficient process to move people through from the urgent care clinic into the acute diversion unit. that's something i'm very much interested in partnering of steve.