>> hi today we have a special edition of building san francisco, stay safe, what we are going to be talking about san francisco's earth quakes, what you can do before an earthquake in your home, to be ready and after an earthquake to make sure that you are comfortable staying at home, while the city recovers.

♪ >> the next episode of stay safe, we have alicia johnson from san francisco's department of emergency management. hi, alicia thanks to coming >> it is a pleasure to be here with you. >> i wonder if you could tell us what you think people can do to get ready for what we know is a coming earthquake in san francisco. >> well, one of the most things that people can do is to make sure that you have a plan to communicate with people who live both in and out of state. having an out of state contact, to call, text or post on your social network is really important and being able to know how you are going to communicate with your friends, and family who live near you, where you might meet them if your home is uninhab hitable.

>> how long do you think that it will be before things are restored to normal in san francisco. >> it depends on the severity of the earthquake, we say to provide for 72 hours tha, is three days, and it helps to know that you might be without services for up to a week or more, depending on how heavy the shaking is and how many after shocks we have. >> what kind of neighborhood and community involvement might you want to have before an earthquake to make sure that you are going to able to have the support that you need. >> it is important to have a good relationship with your neighbors and your community. go to those community events, shop at local businesses, have a reciprocal relationship with them so that you know how to take care of yourself and who you can rely on and who can take care of you. it is important to have a battery-operated radio in your home so that you can keep track of what is happening in the community around and how you can communicate with other people. >> one of the things that seems important is to have access to

your important documents. >> yes, it is important to have copies of those and also stored them remotely. so a title to a home, a passport, a driver's license, any type of medical records that you need need, back those up or put them on a remote drive or store them on the cloud, the same is true with any vital information on your computer. back that up and have that on a cloud in case your hard drive does not work any more. >> in your home you should be prepared as well. >> absolutely. >> let's take a look at the kinds of things that you might want to have in your home. >> we have no water, what are we going to do about water? >> it is important for have extra water in your house, you want to have bottled water or a five gallon container of water able to use on a regular basis, both for bathing and cooking as well as for drinking. >> we have this big container and also in people's homes they have a hot water heater. >> absolutely, if you clean

your hot water heater out regularly you can use that for showering, drinking and bathing as well >> what other things do people need to have aren't their home. >> it is important to have extra every day items buy a couple extra cans of can food that you can eat without any preparation. >> here is a giant can of green giant canned corn. and this, a manual can opener, your electric can opener will not be working not only to have one but to know where to find it in your kitchen. >> yes. >> so in addition to canned goods, we are going to have fresh food and you have to preserve that and i know that we have an ice chest. >> having an ice chest on hand is really important because your refrigerator will not be working right away. it is important to have somebody else that can store cold foods so something that you might be able to take with you if you have to leave your home. >> and here, this is my very

own personal emergency supply box for my house. >> i hope that you have an alternative one at home. >> oh, i forgot. >> and in this is really important, you should have flashlights that have batteries, fresh batteries or hand crank flashlight. >> i have them right here. >> good. excellent. that is great. additionally, you are going to want to have candles a whistle, possibly a compass as well. markers if you want to label things if you need to, to people that you are safe in your home or that you have left your home. >> i am okay and i will meet you at... >> exactly. exactly. water proof matches are a great thing to have as well. >> we have matches here. and my spare glasses. >> and your spare glasses. >> if you have medication, you should keep it with you or have access to it. if it needs to be refrigerated make sure that it is in your ice box. >> inside, just to point out for you, we have spare

batteries. >> very important. >> we have a little first aid kit. >> and lots of different kinds of batteries. and another spare flashlight. >> so, alicia what else can we do to prepare our homes for an earthquake so we don't have damage? >> one of the most important things that you can do is to secure your valuable and breakable items. make sure that your tv is strapped down to your entertainment cabinet or wall so it does not move. also important is to make sure that your book case is secure to the wall so that it does not fall over and your valuable and breakables do not break on the ground. becoming prepared is not that difficult. taking care of your home, making sure that you have a few extra every-day items on hand helps to make the difference. >> that contributes dramatically to the way that the city as a whole can recover. >> absolutely. >> if you are able to control your own environment and house and recovery and your neighbors are doing the same the city as a whole will be a more

resilient city. >> we are all proud of living in san francisco and being prepared helps us stay here. >> so, thank you so much for joining us today, alicia, i appreciate it. >> absolutely, it is my pleasure. >> and thank you for joining us on another edition of building

>> good afternoon. the meeting will come to order. this is may first. good afternoon. at the meeting will come to order. this is may first, 2019 regular meeting of the budget and finance committee. i'm sandra fewer, chair of the budget and finance committee, i am joined by supervisor hilary ronen, norman g. and matt haney. may i have a motion to excuse catherine stefani and norman, please? and we can second it by supervisor mandel men and take that without objection. thank you very much. i would like to thank lawrence and kalina from s.f. government

t.v. for broadcasting this meeting. are there any announcements? >> please silence all cell phones and electronic devices. completed speaker cards are copies of any documents to being completed should be submitted to the clerk. >> thank you very much. please call item number 1. >> i don't one is a hearing on key mental health and substance use strategies and programs in the city budget identifying funding levels, gaps and opportunities for future spending. >> thank you very much. today is the third by roger prior to hearing at budget and finance focused on mental health and substance abuse. our presenters for today include the budget and legislative analyst department of public health and the san francisco police department, among others. mental health and substance use is a large and complex problem, and we have had multiple hearings on this issue recently, particularly as it relates to homelessness. today, will certainly questions about that will come up, i want to broaden the conversation to learn more about how departments are working together to spread allocations to address mental

health and substance use for san franciscans. with that, we will represent -- present our presenters today. i will ask for committee members to wait until each question is done to get into question and discussion. first we have our budget legislative analyst for presentation. >> chair fewer, would it be possible to make opening remarks >> absolutely, please do. excuse me, b.l.a., supervisor ronen. >> thank you. i appreciate that. i am the supervisor of the mission district, and because general hospital faces my district, we see every day the results of the broken mental health care system in san francisco. people recently released from the hospital, with wristbands still on, walk around the streets of the mission in a daze this happens every day. it is dangerous, and it is morally wrong. we have been talking in circles about a broken system for

decades. ronald reagan shut down the mental health hospitals over 40 years ago and we are still complaining about that, rather than taking decisive action. i believe all the medical experts that have spoke over and over again that forcing people into treatment does not work. we have to give mentally ill and addicted people dignified and effective treatment if we are ever going to see a change on our streets. everyone at city hall has to be honest about our part in failing to create a system that works. if we cannot admit our deficiency and our failures, how can we possibly fix them? i am literally begging you, please let this board of supervisors help you. we are ready and we are willing to get you the resources that you need to build an actual system that gets mentally ill people off of our streets and into effective and long-term care and housing, but we need

true answers about what's going on today and the disconnect between the various services that exist. i hope that during this hearing we can start to move past the convoluted and contradictory data that we've gotten from the department literally every single time i talked to a representative from the department, and we can start to identify the actual and true needs so we can fix our broken system. thank you. >> thank you very much. any other comments? nothing, great. i also want to mention that it is to our great disappointments that we have requested for the sheriff to be here today, and we have not heard back, and the public defender, also. those two departments are not here today, understanding the sheriff delivered many of the mental health and behavioral health services within the jails , and there has not been a response. that is very disappointing from our city perspective.

i would like to invite the b.l.a. up. thank you. >> good afternoon, supervisors. i am with the budget and legislative analyst office, and i'm joined by cajun trainer who is a senior in our office and we will present our report on mental health and substance abuse services as the third budget priority as part of the budget priority process. under the umbrella of mental health services and substance abuse services, areas of interest to that we heard from, the member of the board of supervisors, included outreach services, particularly at night, residential treatment beds for individual stepping down from being voluntary -- involuntary holds, taste if -- intensive case managers and psychiatrists to ensure immediate access to services, as well as measures to reduce recidivism among individuals with behavioral health diagnoses in the criminal justice system. i will hand over the presentation to cajun trainer who word on the report.

>> thank you -- i will hand over the representation to kate trainer who worked on the report >> thank you. number of clients accessing substance abuse and mental health services has declined of the past five years, though that share of clients who are homeless has remained can't -- constant or increased slightly. twenty-six% of the roughly 21,000 mental health clients were homeless, and 58% of the roughly 6500 are substance use clients who are homeless. we are not able to break down the budget by level or intensity of care, but we can take a look at the actual expenditures by level of care. this slide shows actual spending on mental health services over the past five years, and highlighted in red is the level of care that the board expressed board expressed interest in regarding the support that is crisis service has -- crisis services, prevention and outreach, and residential

treatment. spending has increased for all three levels for the past five years. the most recent year available for substance use spending is fiscal year 16 and 17. the term is different for such spending because prevention and early intervention appears to drop fiscal year 16 -17° is due to the transfer of services to the new department of services and supportive housing. by contrast, substance use residential spending did increase in fiscal year 16-17. our first priority area, outreach services include activity that reduce stigma and address an increased awareness and access to services, screening, short-term crisis therapy and a few other services existing outreach programs include street medicine and shelter health team. they were -- they work collaboratively with other programs to help people explains in homelessness and it is a whole person care model. engage with specialists in these clinicians are distributed across three programs that respond to community concerns in

and areas considered to be hotspots, often soma, civic centre, and tenderloin. these are provided during business hours. outreach at night was a priority identified by the board and this generally takes the form of crisis response. crisis response programs de-escalate toxic situations in response to individuals who may have mental illness or be under the influence of a substance. they there are four crisis teams listed here. mobile crisis, child crisis, crisis response and crisis intervention specialists. s.f. hot, under -- provides targeted services for high-risk individuals were identified by the community. it does not operate 24/7, but does operate expanded hours. there are a few additional plans and the proposed budget for d.b.h. those include adding four new behavioral health engagement specialist to the street medicine team, adding a baby or just behavioral health clinician who are coordinate, and this new

clinician will provide evening and weekend coverage. additionally, extending the hours of the existing south of market drop in center, and harm reduction therapy center. this is a new model, so details of staffing are still being finalized, with the harm reduction therapy center would provide mobile van support allowing agencies to take counciling out to other neighborhoods. this would include evening and weekend hours. for individuals who present a danger to themselves or are experiencing an acute episode, one of the primary entry points to this system of care is psychiatric emergency services. during fiscal year 16 -- 17-18, 70 3% of all admissions involved individuals admitted involuntarily through the use of a 5150 or 50 to 50 hold. the number of individuals held involuntarily last year was 2,667. the 2018 audit from our office

from the behavioral health services found that clients do not consistently access care after discharge from psych emergency services. the department has existing plans and their proposed budget to add four new navigation specialist to engage patients while they are at psych emergency services, which will help to address the issue of keeping clients engaged after they discharge from psych emergency. once they have stabilized, they will be referred to the next and appropriate and least restricted level of care. this is not an exhaustive list of behavioral health beds, with summarizes residential treatment options for individual stepping down from an involuntary hold. and this time -- those details are available in our reports. there has been a lot of interesting wait times. one of the findings from our audit was that we do not

systematically track waitlist information. more recently, the department found wait times for mental health and dual diagnosis residential treatment programs are longer than wait times for substance use programs. the department has a project underway to evaluate whether existing wait times are due to factors related to referral and admission rather than number of beds available. intensive case management is a low caseload, high contact outpatient model typically an intensive case manager will have no more than 17 clients as compared to well over 40 clients or a traditional case manager. it allows people to focus on keeping on a smaller number of clients engaged. in our behavioral health added from 2019, the need for intensive case management exceeded the available capacity by 2-1, and we saw slight decline in the past three years of total clients served by existing programs, however as the director reported here, the division is working hard to address this. they are launching a new intensive case program for intensive case program for 40 clients in the transitional age youth system of care. they're also opening 200 new spots for intensive case management for adults, and they

have secured funding to facilitate clients stepping down from intensive case management which will enable them to make space for new clients. these programs should be coming online in 2019. i'm sure d.b.h. will correct me if i'm wrong. the shortage of psychiatrists is a national issue, but they do have several measures in place. these include a student pipeline in collaboration with meadows -- with medical schools, and implement a continuous recruitment for psychiatric positions through h.r. diversion is a primary method for preventing individuals from cycling through the criminal justice system. diversion programs in san francisco are collaborations between multiple departments, law enforcement assisted diversion lead, this is a problem -- program that allows law enforcement to refer individuals who are arrested for drug offences do harm reduction treatment at the earliest point of contact. post arrest, that pretrial. the collaborative courts are for those arrested unless serious

charges in and their post arrest but not pretrial. police -- placement into jail, a patient will be referred to the collaborative courts. there are three chords that are available for these diagnoses. those are the behavioral health court, adult drug court and criminal justice center. all courts are staffed with d.p.h. treatment personnel. mental health diversion was signed into state law and june 2018 by providing treatment instead of criminal penalties. this enables existing court system to diverge treatment -- diverge entergy meant a broader population of individuals earlier on in the process. again, post arrest, but pretrial for anyone with a behavioral health diagnosis. promoting recovery and services for the prevention of recidivism , this is a new matching grant from the state. it will allow funds to go towards substance use treatment programs with peer navigation elements and services, specifically directed at the

transitional age youth population. finally, it is not an intervention in recidivism and recidivism, with d.p.h. does provide support and linkage upon reentry. in terms of performance measures , they do not set targets for the number of clients spaces. it the mission is to serve all who need care. however, all the programs have a set of performance measures based on the type of care provided, his performance so performance measures for outpatient treatment programs differ from measures from residential treatment programs. some measures are more output oriented, others are client outcome oriented. this slide shows a sample of client outcome oriented measures for a selection of programs. for example, in the top left, and outreach engagement program that serves mental health clients and measures are 100% of clients in the care pen, 75% are enrolled in medi-cal, and 85% are enrolled in treatment. i want to highlight these are not systemwide objectives are

all programs, this is just a very specific set of objectives for one care plan. this program does have its own set of performance measures that it is held to. we include a sample of measures and programs. finally, in terms of opportunity for the board to impact funding, d.p.h. identified three needs. first increased outreach on health services in shelter and navigation centres. there has been an increase in shelter and navigation center beds, but the staffing for these programs has not increased accordingly. additional resources enable us to add nurses and social workers to serve shelter residents with clinical care and linkage to services. second, expanding access to respite beds. it is just the hummingbird facility at s.f. general. the program recognizes a successful model of keeping individuals off the street and engaging individuals would otherwise not seek treatment. additional resources here would enable d.p.h. to increase the number of beds at hummingbird. lastly, increase the number of

mental health and dual diagnosis residential treatment beds. although we are currently conducting a process analysis internally to identify all possible sources, they do believe it is likely that increasing residential treatment resources would contribute to decreasing wait times. any sources here would increase -- allow deviation increase in number of beds. there is no policy option here around recidivism, and that is because the collaborative courts report that the need is for a simile more residential beds and transitional housing. that concludes -- is for simply more residential beds and transitional housing. >> thank you very much. supervisor ronen? >> thank you. starting with the budget, there was an excellent op-ed in the san francisco examiner on april 28th by a nurse, who i think is here today, i think i saw her come in. it had mentioned that while

there was once 88 acute care beds at general hospital, you know, she had started working there in 1987, that there are now only 22 and 22 subacute beds i'm just curious, i know you said there has been, over the past -- i guess since 2013, there's been an up-and-down, but mostly, i guess, trend upward and spending on mental health services, but i'm wondering how that compares to over a decade ago. do you happen to have that information? could you get that to us? >> that predates my time here, i think we are working on that. >> i would love to see a historical luck. >> we can work on that for you. we don't have it immediately, though. >> that would be great. the second thing is i was a bit

confused by the report, because while it said on page 8 that s.f. hot team, you know, works five days a week, it did say that they do respond 24 hours a day, seven days a week to requests for a therapeutic transferred from within the system of care. can you talk about that, because i'm certainly not aware nor have ever seen that the mic i'm afraid i didn't speak directly with h.s.h. about that, but my understanding is it is simply a transportation service so they use mobile van resources, but i would have to confirm that. >> between what? between where and where? >> i can't answer without speaking out of turn, we would have to go back to you. >> it is best to direct that question to the department of public health or ace -- h.s.h. >> okay. then for the chart on page 9 of your report that talks about the different wait times, i'm wondering what the methodology

for those wait times, from what point to what point are you measuring that span of time? >> these are from d.p.h. my understanding is this is from the point that the transitions team receives a request. it is not the full cycle. it does not reflect the full-time from the point to the services requested to the point the service is received. the? starts when the transitions team receives that request from within their system. >> okay. , maybe i will ask d.p.h. with that gap of time is. and then -- i was pretty shocked to see the low numbers of successful graduations from the different behavioral health courts, especially given the

percentage of people in jail who have a mental health diagnosis. do you have a sense of why that is, number 1, and number 2, do you have a sense of why the participants in those programs seem to have declined over the years. >> again, best refer to the department on that. i'm sorry. >> okay. and then finally, sorry, i'm just looking at my notes here. from the report, your audit in march of last year where you showed that 74% of people leaving emergency site services were leaving with no referral up at all, or maybe with a piece of paper someplace or someone to go , that is a very large number,

70 4%. do you think that the four. navigators, i think is what you call them, that d.p.h. is requesting in the budget would meet that need so that we would actually have the majority of people leaving hospitals with some meaningful, handholding so that they are not recycled back, on a hamster wheel, into the system? >> i will ask someone from our office was project manager on that audit to address your question. >> sure. >> good afternoon. the number of visits that ended without a referral was close to 38%, and i think the response so far -- >> could you clarify? there are two lines. self with an outpatient referral and itself without an outpatient referral. >> right. >> what does self with an

outpatient referral mean? if they are not going immediately into a program, which everyone else on this list is, then my sense is you have been given a piece of paper with a program on it. >> right, with a referral, in the department can speak and more specifics to this, but our understanding is they have an appointment with their psychiatrist, or there is an imminent plan for what happens after they are discharged. maybe these patients don't need to be admitted to a residential treatment facility or any other program. they are stable enough to go home and then meet with their psychiatrist at a later point. so the group that we had concerned are those clients who are discharged from the hospital without a referral or without a linkage, and just trying to better understand the reasons around that, and some of the explanations we have gotten so far is that some people, they might not have a referral in the system because maybe they are covered by a private insurer, and there are other people who maybe they don't accept services

, and that is beyond the ability of d.p.h. to address if someone does not accept treatment, and then, you know, either than that, it is trying to think about asking d.p.h. to dig deeper into the data and into those cases to understand what is happening. there is one explanation that some of those clients are given -- or are referred i referred to intensive case management, but that enrolment process does not happen in the hospital, so then it is another visit that has to be scheduled to go to bhs to enrolled in intensive case management, and then after that, you get a service plan, that results in a delay which might create a risk for someone who just had a psychiatric emergency , i hope that clarifies that point. >> that is definite helpful. i'm wondering, is there any data for the 70 4% of people who are not released immediately to another program -- for the 74%

of people who are not really simulate to another program but maybe have an appointment date at some later time set up, were leaving with no referrals, do we have a sense of how many of those people and at back in the hospital or end up back using some service within the behavioral health hodgepodge of services throughout the city? >> so we don't have -- so many people moving out of the hospital, house into they engage in outreach that data is a little unclear. because typically appointments are scheduled within one week or two weeks, so you will see that pattern, and we do see client engagement at the outpatient level, but in terms of tracking exactly what happens for those cohorts who are in psychiatric

inpatient, that we don't have, and that would be a great question for the department to explore. >> okay. of that data that you do have, what does it show? >> i would have to refer back, but i can maybe get that now and come back to you. >> okay. that would be great. thank you. >> supervisor madeleine? >> i think that data would be very interesting. i have asked in various forms for that from d.p.h. one tidbit i got was that i think that over a four month period, nine people visited 168 times, so that is a little of indicator of the churn, something like 12% during the four-month period i think were people who were coming back more

than once, but i think getting information on how many times people are coming back. >> right, i will say to that point, i think there are different types of clients that d.p.h. is treating. there is the multiple system which i think more speaks to the population you are describing, and that is definitely a high-volume incidence of visits. i do think in terms of client engagement at the outpatient level, at lower levels of care, that might be a different question. we definitely in the report have numbers on the high use of multiples and i will get this on the outpatient level. >> does this have the churn information? >> the audit report has the return. so it is the top 5% that accounts for over half of the cost of psychiatric emergency

cost, psychiatric emergency and psychiatric inpatient. >> that doesn't get you -- >> it includes the hospital. >> sure, but i think i kind of want to know, i know this is what you're asking, i kind of want to know how many people are just coming back and how often do they do it over the course of the year. aside from the human cost, there is a public cost in terms of spending. bills are high, so we are spending a lot of money for each of those emergency visits. if 10-2030 folks are getting just a tremendous amount of resources, these are resources that are not available for other better interventions, at those people are so are not having their needs address clearly. could you focus more resources

on those people in a different or smarter way and get them off? okay. so i guess this is how city budgeting works, but the department of public works asks for the 19-20 budget and it seemed remarkably modest to me given that it feels like we have a crisis. i'm hoping that that is the department responding to the edict to reduce spending and not expand spending, what i do hope that by the time a budget comes to this board of supervisors that -- this is not really for the b.l.a., but that in general, that kelly and folks are thinking about how to significantly expand the ability

to take people out of an inpatient acute hospitalization and not just send them back out onto the street. it has been disturbing in these hearings. i know it was back in the behavioral health hearing where we learned that even people who are coming out of an acute hospitalization, not just the folks -- the churning is terrible, that is horrendous, but the fact that we would admit someone for an inpatient hospitalization of many days or weeks, and then we would discharge that person not to a home, and maybe not even to a hummingbird, i hope we'll at least discharging them to a hummingbird, but our discharge planning seem so unable to address the needs and we are not even trying, clearly. i think that means that we don't

have a system that is doing enough to give people a place to land when they are coming out of a medical experience. anyway, that is neither here nor there in some ways, but i know the mayor's office is working on this and we'll have proposals. i was curious about your ability to get hot data. i have not been able to get hot data, and, you know, i've seen very little bit of information about what is happening in my district, and i was wondering if that ever came in. or how we are ever going to figure out, as we are deciding what is a good use of resources, it is hard when we don't know what we are getting for our money. just a thought, and supervisor ronen raise this as well. there are wait times and then there are wait times. and you suggested that those

maybe short what is in your slide, maybe on the short end of what is real, we have heard in one of these earrings -- hearings that if you are a diagnosed person that has some pretty serious psychiatric as well as substance use needs that the weights are more like three months, and i think even within that population, my understanding is, you know, the weights can be even longer because each of these people is a unique and distinct individual , and as you add on additional factors, other kinds of illnesses, a history of involvement with the criminal justice system, that the weights can be even longer, and then we may have some programs, we have some folks who recently don't have programs that are appropriate to their needs. anyway, i guess you don't have to say anything about any of that. those were just some observations i had based on your presentation. thank you. >> i think that is a perfect

question for d.p.h. and their office. supervisor haney? >> thank you. i will try to ask questions that are appropriate for you all, and i know you all have a lot to say i'd like to sift through the use and make sure i'm asking you all ones that you have a perspective on. just so i understand, and this is picking up a little bit on the line of questioning, in your report for the 2,667 individuals who were held in a 5150 or 50 to 50 during 17-18, what sort of information do we have about those individuals, where they are now, where they were sent. in the report you have a set of beds that are just generally available in terms of capacity, but he didn't see any sense of where these individuals are, where they were referred, where they are now, i also, in a similar, a supervisor mantle men said, you list the number of people who were held in 5150 but

not the total number of visions, i didn't see the total number who were serving in general and just the total number who were 5150 or 50 to 50, so what information do we have? is there a centralized tracking system for all of these folks who are coming in, clearly at a level of need, and would be great to know where these individuals are and how they are being served, and where exactly they were referred to. is that information available? >> i believe through the court needed care management system run by whole person care. this is where we got that data from. they are an excellent source of information i do believe they track where each individual is now, so i would defer to them. i'm not sure if they are here today. >> okay. that would be great if d.p.h. wants to provide that. it would be good to understand. >> sorry to interrupt, that is just some data, that is not

everyone who is 5150. >> this is correct. >> maybe -- i know we will have a lot more questions for d.p.h., but that's an important distinction. >> okay. that is important for me. similarly with some of these numbers, these numbers are particularly astounding to me. if you had 2600 people who are 5150 or 50 to 50 in a year, and 20 beds, it seems like a lot of what would be happening is trying to, a bottleneck in terms of places to people do for people to go, we have serious capacity issues. similar around data, is there a centralized waitlist for all of these beds that are available, or that exist so that if you come in in whatever capacity, is there a way, you know, if you have to wait 30 days or 1-7 months, then you maybe on the

street, how exactly are all these people keeping track? this could be for d.p.h., but it is showing wait times and such. did you have a sense that such a thing existed? >> i do not have a sense that there is a centralized waitlist. >> okay. the residential care facilities, do you know when was the last time we added more of those beds , has that number been stagnant for a while? or has it gone down? >> i will wait and revisit these questions. thank you for the report. i appreciate it. >> thank you very much. >> sorry, i had one more. slide 11 on performance measures , i'm trying to understand its significance. these are goals of the department and they were brought together when?

>> these are for 18-19. these are current performance measures in place. >> to be have any data, presumably we have performance measures over several years, and we have data on how they have been performing against the performance measures. >> in the report appendix we have a sample of specific programs and providers and how they have stacked up against the performance measures. i think it is appendix c. >> i think it is appendix d. and e. >> if we are broken up by different program and vendors, i believe we pulled the performance measures from the vendor contracts. >> each year, at the end of the year, d.p.h. does a contract monitoring report, and that is when they compare performance against what their benchmarks were at the beginning. >> for each contract. >> for each contract. do they do it for the system?

>> they don't do it in the same way for the system, well, they do for outpatient programs, they do have that data for that. >> i looked at this late last night, so i may have missed, or it may not be in here, but these goals all seem like good goals, but it does not, i do not know whether, in fact 100% of some of those clients have a community care plan, or for a.d.u. clients , 80% of clients are discharged to a less restrictive level of care or whatever. it would be interesting to know how the system does, if these are systemwide goals, it just seems like they should be. >> what is a community care plan , by the way, through the

chair. >> this is for the program -- no other comments. our next speaker is the director of behavioral healthcare department of public health. welcome. >> thank you. could i just ask a quick question before? >> dr. sung, i didn't see dr. grant here.

is he here? i think he is on his way. >> okay. and is the new director of mental health here. >> yes, he is. >> great, so he might hear from you at different points. great. thank you. >> my apologies, it is taking some time to pull it up.

>> thank you. thank you, very much. my name is irene. i'm interim director of behavioral health. i know there are a lot of questions that are going to be asked. you would like us to respond to them. i have been interim director for a month and a half. i have a lot of people with me, so hopefully if i can't answer the questions, i will get the right people here to answer the questions for you. >> excuse me. do you have power points for the rest of the committee here? >> yes, we do. >> thank you very much. >> sorry to interrupt you. >> no worries. i will start by providing an overview of behavioral health services and try to include as

much information as i can given all its complexity, and then also, i will have time at the end for questions. i do want to start with who i am i have only been interim director for about a month and a half, but i have been with the department for over 20 years, starting in 1995 after graduating in psychiatry at ucsf i came to work in the mission district as a staff psychiatrist i worked in bayview's hunter point where i did field-based psychiatry and school and public housing, i remember meeting parents at burger king in the western edition because they did not feel comfortable coming into the clinic and they did not feel comfortable me coming to their homes. i had those experiences that i held in my head. i worked at a c.b.o. in residential treatment and also in special programs for youth in juvenile hall for short period

and also i covered a jail psychiatrist when they were low on psychiatry. i have worked all these different levels of care within my 20 plus years with the department, and i say this because i really want to let you know that first and foremost i am a clinician, and, though i am here to talk about the system and budget, our services are really about people. that we don't just treat numbers or diagnoses, but unique individuals. behavioral health services is the largest provider of mental health and substance use prevention, early intervention, treatment services in the city and county of san francisco. our budget is approximately $366 million. we have 809 budgeted civil service f.t.e., so that is not just in clinical services, that is including billing, i.t.,

compliance, quality management, so it is all the infrastructure that we need to keep the system running and/or substance use plans going as well. we have over 80 community-based organizations contractors who provide a large bulk of our direct services. i did want to move to an understanding of some key concepts which i feel are very important. many of our clients suffer from long-term chronic conditions such as schizophrenia or complex trauma that can span generations it is really not unlike diabetes like diabetes, there is no cure, often, but treatment can help manage the illness and prevent complications and the negative outcomes. also very important to remember

that behavior change is hard. it takes an understanding first that there is a problem, and then it takes enough time to build trust in a relationship with someone to accept that change is needed or even possible. so wherever they are in their continuum of care, our continuum of care, whether it be involuntary services or voluntary services, we have to work with each individual to support the change that will help them move on with their lives. change does not happen in a straight-line, it is not linear. if you think about any time that you or someone else has determined to start dieting regularly, i do this every new year, even when we are committed to making a change, it doesn't always happen quickly. you take two steps forward and one step back and sometimes two steps back. there are relapses, and we have to work with each individual or family wherever they are in their stage of change