>> good morning, everyone, meeting will come to order. welcome to the may 13, 2019, i am supervisor ronen, seated to my right, supervisor walton, and to my left, supervisor mar. clerk is victor young and thank kalina and scott from sfgovtv. >> make sure to silence all phones and electronic devices. completed speaker cards to be included should be submitted to the clerk. items acted on today, may 21, board of supervisor agenda unless otherwise stated. >> item 1, whether the services

with wrap around services and adequate beds, mental health counseling, psychiatric and psychological services, and funding levels to serve the population serviced by the program proposed in the pending ordinance, 181402. and item 2, authorize proce proceedurees -- city attorney to institute judicial proceedings to establish housing conservatorship, evaluation of the implementation of the housing conservatorship program. >> thank you very much, and joined by supervisor mandelman,

the sponsor of these items. would you like to make the opening statements? >> members of the rule committee for hearing this today, and mayor breed, and even the most modest efforts are likely to face a tremendous up hill slog. never one to shy away from a fight, senator wiener is back with sb40, we will hear more later. i do not agree with him about everything but he is fearless and relentless and i am grateful for his fearlessness and relentlessness on this issue. i want to thank the department of public health and office of public conservator for month and years of service on sb1045 and

40, and how to make local implementation work. and thank my co-sponsors, supervisors brown and stefani. colleagues, there are two items before you to as required by sb1045, item 1 is a hearing on the sb1045 local implementation plan prepared by the department of public health and the office of the public conservator and resources available for implementation. item 2, authorizes creation of the housing conservatorship program here in san francisco. second, establishes the working group. and third, makes findings determining resources required to serve the sb1045 population are available to support the success of the program without reduction of voluntary mental health services nor reduction of services under programs. this ordinance is many, many months in the making. last year the state legislature

passed sb1045 authorizing five-year pilot program for san francisco, san diego and los angeles counties to seek temporary conservatorships. in san francisco, it will allow the office of the public conservator to petition the superior court to be the appointed caretaker for dual diagnosed individuals, wrap around care, service, treatment and management of the affairs for the duration of the conservatorship. and an act allows people gravely disabled by a serious mental illness. but laws written 50 years ago, co-occurring serious mental illness and substance use disorder. working with the san francisco department of public health, senator wiener crafted sb45 to address the legal pit falls that

exclude too many mentally ill people from care due to the fact the primary disabling condition is drug addiction. impacts of substance abuse on a growing number of unhoused people suffered from untreated mental illness. nearly half of all patients are brought there suffering from meth intoxication. and we know many of these individuals keep returning over and over again. we are seeing these same individuals show up in hospital emergency rooms and jails or worse, one of the increasing number of unhoused people dying from meth overdoses, twoen 2016 and 2018, meth was the most commonly found in homeless deaths. employing a public health response in a strict legal framework. any conservatorship must meet a

number of objective and sub jec testify tests. individuals considered for conservatorship must suffer from both a serious mental illness and a substance use disorder. they must have been placed on an involuntary psychiatric 5150 hold at least eight times in the prior year. county must have tried other less restrictive alternatives and a judge must establish the conservatorship is the least restrictive to provide for the care. these requirements appropriately set a high bar for a 1045 conservatorship, and estimates are likely to apply to fewer than ten people a year. even if senator's bill sb40 passes, the largest number of people will be certainly fewer than 50.

it's temporary and can be granted for no longer than one year. conservatorship automatically terminates unless renewed by the court. the potential person will be represented by a public defender throughout the process and has the right to a court or jury trial as well as the right to contest or petition to end the conservatorship early at any point. sb1045 was signed into state law in september. mayor breed and brought the legislation in november. since then, office of public health and public conservator have spent many long hours thinking through plans for implementation. and held three meetings with stakeholders to discuss the plan. i want to thank all those who participated in those conversations and those directly by email, call, text, twitter message, as well as here today. now, i at times over the last

several months have wondered if ever so many have spent so much time, energy and effort working through and fighting over a program that seems so modest in its ambitions. it is tempting, colleagues, i am sure, to conclude that this 1045 stuff is really just not worth the effort. clearly i think that it is. even if we only reach a handful of folks at first, i believe we must try to get those hardest to reach people, get care to the hardest to reach people, the sickest, and those least likely to voluntarily seek help. as the opponents realize, there is a larger principle at stake here. we all believe san francisco, well, i hope we all believe that san francisco must do more to expand access to voluntary mental health and substance use treatment services and i'm excited we have a mayor and board of supervisors who are singularly committed and pretty

united with regards to that goal. but we could double the availability of voluntary services tomorrow and we should. and i still do not believe we would reach the population 1045 seeks to bring into care. friends of mine in recovery sometimes speak about hitting bottom. but the 1045 population hit bottom a long, long time ago. and while i agree that involuntary treatment cannot cure a substance use disorder, neither can you be in the treatment, if the meth addiction has the reason to feel or want anything other than the next high. for some people, involuntary is necessary, and you shouldn't have to go to jail to get that. that is the point of sb1045. it is a small pilot to help a few people and to test an idea that might be able to help more. i ask that you approve this

ordinance today and forward item two to the full board with positive recommendation. if you are not comfortable do that, i ask you send it forward without recommendation so we and all of our colleagues can discuss these complex and important issues as a full board. we will hear a presenttation on the plan from the department of public health and the office of public conservator, and the amazing simon pang from e.m.s.six who does incredible work with this population every day. the folks, the other folks presenting, jill nelson, as well as angelica alameda, justice involved behavioral systems with the department of public health. and available for questions, dr. antoine bland, new director of mental health reform who was until very, very recently the lead psychiatric emergency

services and i'm very excited that dr. planned is in this role. dr. grant colfax, shareen mcfadden, and kelly hirmoto, director of transitions of the department of public health. so, with that. >> can i see if any of my other colleagues have opening comments? no? no? i just -- make a few opening remarks. i wanted to start off by just saying how much we all agree that abandoning mentally ill people to wander the street without care or medication is morally wrong and dangerous and i agree with the mayor and supervisor mandelman that our system is broken. i think we have seen that in the last few hearings we have had on

the subject at the budget committee. and that i desperately want to help mentally ill people and people suffering from substance abuse who are very ill on our streets. be all know that when reagan closed the mental health hospitals in the 1980s we never created an alternative place for people to go and it's way pastime that we build a modern care system for people with mental illness and substance use disorders. i also want to make it clear that i believe that some people need forced treatment. i believe in conserving people in certain circumstances and i believe in the l.p.s. conservatorship process. i also believe there are changes that would make the l.p.s. process better. for example, it's a no brainer to me and i would change it, shouf happened years ago, that l.p.s. conservatorship includes

drug addiction. not sure why it has not happened at the state level. i would be open to broadening the definition of danger to self. under l.p.s. i had a year-long experience trying to help a mentally ill substance user in the mission district, an elderly woman lived at the 16th street bart station for two years and i learned that the only way we could have conserved her is if we had a broader definition of danger to self. she was clearly dying in the streets, but because she could articulate where to get food and that she could make it to a shelter, we were not able to bring her indoors. and that was -- that was hard, that was hard to watch. we eventually succeeded because we did basically the equivalent of intensive case management and got her to voluntarily come indoors. but that was a hard process.

but i want to say i'm looking forward to this hearing and hopefully getting a lot of my questions answered, but i've been very skeptical about 1045, and i'm not yet convinced that it is workable at all or even a useful law to address the people suffering from mental illness and substance addiction on our streets. we have been told that as written it will help five people, supervisor mandelman said maybe ten, and many proponents of the law admit it is specifically designed for those individuals addicted to methamphetamines. yet drug addiction experts, including health right 360 who we rely on in san francisco are opposing the law and say this will not work to help meth users. or meth addicts.

finally, before we get this hearing going, i want to say that while there are strong feelings on this topic on all sides, i want to echo supervisor mandelman and say i have no doubt especially given your deep personal experience with mental illness that supervisor mandelman's desire to help is absolutely genuine, and while we may disagree on the strategy, absolutely united in our desire to help people suffering from mental illness and substance abuse on the street. and i just want us all to remember that, as we are debating and talking about this strategy because this is really a desire on all our parts to help and to just make sure we are doing it in the most effective way possible. i just wanted to say that to you from the get-go, supervisor mandelman. and with that, would you like to run the hearing, or do you want

me to call the speakers up, however you want like to handle it. >> i'm happy to call folks up. >> all right. so, and we don't have that many people to call up, i think jill and angelica are starting and then simon. i believe we also have -- i did not identify her but we have the director of city-wide that can help with questions. and city-wide does case management for many people, including folks who are likely on our high users list. go ahead. >> good morning, supervisors. again, i'm dr. angelica alameda, and with the department of behavioral health services. share just an overview of our presentation.

thank you. ok. so, this is just an overview of our presentation for today. we just wanted to orient us to the conversation, discuss how we see bill 1045 fitting into the landscape in san francisco. so, want to start off by saying as was just discussed, we know the landscape has changed, not just in san francisco but california and nationwide. and when the act was passed, what we are doing now and the complex needs of individuals we are serving looks very different. what we know in san francisco, we have a methamphetamine and opioid epidemic. and there are individuals of complex behavioral health needs that are vulnerable and unable to care for themselves in the community. when they are unable to accept voluntary services, this often leads to cycling in and out of

crisis services and deterioration and can lead to dying. estimated 400 individuals who experience homelessness die every year, indicated, 35 individuals have, according to the medical examiner, 35% died subsequent to overdose and 52% of individuals had substances in their system. san francisco has a long history of being innovative and adapting to the needs of our community. and senate wiener saw this deep need and worked to develop the legislation to serve a small group of individuals through the housing conservatorship. so again, i work with behavioral health services. i'm, which is part of the department of public health and provides substance use and mental health disorder, treatment services across a range of treatment modalities. our goal is to support individuals on their path to recovery and wellness in a least

restrictive setting. >> thanks. good morning, chair ronen, supervisors, jill neilson with the department of aging and adult services. mission of my department is to support the well-being, safety and independence of adults with disabilities, older people and veteran. and the offers of the public conservator -- it's a privilege for the department to operate this critical safety net program for the city and i'm really fortunate to have a team of skilled and dedicated clinicians that serve as deputy conservators. great pride in the advocacy, assistance and oversight provide to our clients. individuals who do not usually have any other support system in their lives. before we dive into a complex topic, i wanted to clarify a

couple of terms to make sure we have the same baseline understanding. l.p.s., lanterman petra short, the three legislators who passed the hallmark legislation in 1968, and the l.p.s. act provides the legal framework and structure for mental health conservatorships today. the terms are the same, used interchangebly. office of the public conservator, overseeing it. distinguish from probate conservatorships, those are handled by a different division of the aging and adult services and will not be talking about those conservatorships today. >> thought it would be helpful to take a step back and discuss a case we see as potentially

served through the housing conservatorship, and somebody like melanie, not her name due to privacy reasons, this is the experience for some of the individuals. melanie is in her 30s, has schizophrenia. she's in crisis. seen running in the streets, taking her clothes off and vulnerable. she's placed on a hold. no longer under the influence of substances, mental health is no longer acute, stabilizes, a meaningful conversation, identify resources and able to take care of herself. legally she has to be released. not able to remain at the hospital. we offer her voluntary services, including case management and residential treatment but she tells us i'm fine, don't worry about it, and unfortunately what

ends up happening, she is released and relapses on substances and cycles back into crisis. and this is the experience that we see here on this next slide. for some individuals when they use substances, their mental health symptoms are exacerbated. they engage in harmful behavior or unable to take care of themselves. placed on an involuntary hold, stabilized, no longer meets the criteria to remain at the hospital. offered services, decline services and released to the community and the cycle continues and perpetual cycles for some individuals. and sb1045, it needs to happen at least eight times for us to consider a housing conservatorship. what we do know and see as providers for somebody like melanie, worse over time. each time the cycle continues and repeats, she deteriorates in the community. and at this time we don't have the tools that we need to help her.

so because of this cycling, somebody like melanie is left behind and her functioning is deteriorating and again, she's getting worse but she does not meet the grave disability criteria for the l.p.s. conservatorship we currently have. and i have to say as a provider, these are the cases i take home with me and i worry about. and something like housing conservatorship or sb1045 would be the mechanism i need to support her engaging in care. one of the programs i oversee is assisted outpatient treatment, lord's law, and one of the programs i mentioned earlier that san francisco has a history of implementing. program adopted by the board in 2014 and subsequently enacted in 2015. for individuals who have serious mental illness who are not engaged in treatment and are on a downward spiritual. what i think is important to note about this is it's really

focussed on serious mental illness, not the co-relationship of mental illness and substance use. ultimately, what we can do in these cases, if we are unsuccessful engaging in the services, petition the court to office them into outpatient treatment. however, an individual must meet strict legal criteria to be able, for us to be able to do that. one of the big criteria, two or more inpatient psychiatric hospitalizations or receive mental health help while incarcerated or acts of violence towards themselves or others. for somebody like melanie, she does not qualify for assisted outpatient treatment because she has not been hospitalized on an inpatient unit, she does not meet legal criteria. does not have a history of jail contacts and has not had serious violent behavior. but her psychosis is exacerbated by her methamphetamine use, but

again, she stabilizes while at the hospital and must be discharged. and again, while we offer here voluntary services she continues to decline these and says i'll be fine. >> l.p.s. act founded on the principle that mental illness is treatable and with care, individuals with serious mental illness can recover, and that's why the procedure is composed of multiple short-term involuntary holds in the state's welfare institutions code. 51 5150 hold, initiated for three criteria, specifically defined as the inability to provide for one's own food, clothing or shelter. most individuals who are held on a 5150 recover in 72-hour window. and they are released. it's only a small fraction of individuals who do not recover, continue to meet the narrow legal definition and are not released. definition only allows us to

assist individuals who are gravely disabled due to serious mental illness or chronic alcoholism. and once at the hospital, individuals receive a clinical evaluation. those who continue to be considered gravely disabled by the treating psychiatric and medical teams can be held up to additional 44 days, but at any point in that timeline they can be released. if the team feels recovery is unlikely, a referral for conservatorship will be generated. a public defender and due process protections, and the public conservator is responsible for carrying out investigation to ensure the conservatorship is the least restrictive intervention. it's important to note that the goal of an l.p.s. conservatorship, like a housing conservatorship, is actually to move an individual to wellness and recovery and to terminate the conservatorship, and by a

variety of treatment interventions and services that will continue long after the conservatorship has ended. whether thinking back to melanie, she's not eligible for l.p.s., but excellent care, hydration, and drugs pass through her system. when she's lucid, how she will obtain her own food, clothing and shelter and legally has to be released. offered voluntary services but will refuse them and when she returns to the streets she will use drugs again and then she's back in the cycle of addiction that angelica was referencing. we cannot compel her to use the services to assist her, we have no option but to watch her deteriorate and cycle in and out of the hospital. that's why we feel we need to

implement the conservatorship program. >> what were the voluntary services offered to melanie? >> later in the presentation we go in-depth offered to her. the same offered to anyone going through a housing conservatorship program. intensive case management, connection to residential treatment. >> all offered to melanie? >> that's correct. >> so intensive case management, residential treatment, and what was the third? >> counseling. >> counseling. >> okay. >> just, if it's possible to, i think we have about ten more slides. to get through the slides and then have questions.

great. >> we feel we have a tremendous opportunity at this moment. housing conservatorship program will be an important new tool to allow us to reach a small group of people. angelica explained how a client like melanie will not qualify for assisted outpatient treatment and how the limitations of l.p.s. in regards to assisting a client like melanie. we can do better for people like her. housing conservatorship program aims to provide a clinically appropriate alternative in the least restrictive setting possible. for individuals incapable of caring for their own health and well-being, and reach individuals like melanie due to co-occurring mental illness and substance use disorder. similar to l.p.s., only provided if it's the least restrictive possible. legal and ethical obligation that our office must follow. one of the most significant

differences between the housing conservatorship program and l.p.s. is the eligibility criteria. it's not grave disability as for l.p.s. here it's founded on multiple factors, and all of these factors must be met. they include the inability to air for one's own health and well-being, serious mental illness, substance use disorder, documented frequent 5150 holds, specifically eight in 12 months. and all petitions to the court have to show every other less restrictive alternative first. that the individual could not be treated through the outpatient treatment program and other community-based services were attempted but were not effective. >> take a second to look at the population and doing a dive into our data who we think would be

eligible and served through sb1045. 55 individuals are currently eligible. as indicated, not to say 55 individuals would be placed on a conservatorship program but an option that we can consider for them. all of these individuals have a current diagnosis of serious mental illness and substance use disorder and have eight or more involuntary holds or 5150 in the last 12 months. of note, on average, the individuals have 16.5 visits. 96% of the individuals also had a visit to an emergency department. 98% have experienced homelessness on average 8.9 years. 91% have significant medical needs, and that's just to say that again this is a population that we see deteriorating in the community that not only have complex behavioral health needs but medical needs that let to

the deterioration. 75% have been connected to mental health services in the last year, and these individuals and providers are outreaching them and attempting to engage them. 35% have had a visit to an acute diversion unit. what we do know for the individuals, unable to remain in care. and that the need for something like sb1045 is pronounced in our community. i want to take a second to pause and talk about the different numbers discussed since the time sb1045 was initially introduced. when it was first introduced, anticipated that it would serve up to 200 individuals but through the legislative process and criteria put into the bill, ended up being more like the 55 individuals we are discussing today. as we worked toward implementation. language around assisted outpatient treatment that unintentionally narrowed the

population to around five individuals. jill will be speaking about senate bill 40, back to the 40 individuals but ultimately what it requires us to do is consider assisted outpatient treatment as a least restrictive setting but not preclude from moving forward with conservatorship if that's the most appropriate. so, i wanted to show and highlight how we imagine sb1045 fitting into our system of care. as we discussed multiple times, an individual has to have eight or more involuntary holds to be considered for the conservatorship. at the point of contact with a hospital setting on an involuntary hold, offered voluntary services. we are ready to connect them to the services. if they do not accept the voluntary service, they could be referred to assisted outpatient

treatment. that has whatever it takes and wherever it takes approach to outreach and engage the individual, attempt to offer them voluntary services, if they accept, we would immediately connect them to. not only on the team assisted outpatient treatment have clinicians, but peer navigators to support that work as well. if they continue to decline the voluntary services and unsuccessful, we could petition the court for a court order. at that point, the court could determine if a.o.t. is insufficient or inappropriate for the individual, and then the case would be conferred to the conservator's office as indicated. and again, i want to highlight through the process and voluntary services at the forefront, and having the tools needed as a mechanism to support individuals and accessing care.

>> key part is the connection to housing and part of an initial court petition, the p.c. will be required to demonstrate clinically appropriate housing placement is available. and likely that over the span of an individual's total recovery period that each individual will have multiple placements, likely a combination of licensed care facilities, and community-based options. the hope is move each individual into permanent supportive housing once that individual is ready to live at that level. every individual ready for supportive housing will get a unit and if not, commitment of the program for the higher level of care. highlight some of the key provisions. three counties for the five-year pilot. local legislative body must opt

in, why we are here today. additionally, the bill requires any county that opts in to form a working group. this working group composed of advocacy organizations, labor, and representatives of city departments. carry out a critical oversight and advisory role with the housing conservatorship implementation. they will provide valuable input as to the, to help craft the evaluation of the program that needs to be carried out and that than locally here in san francisco to the board as well as at the state in sacramento. >> as an individual is considered for housing conservatorship, they will have access to full due process protections. one of the most critical aspects of the process will occur initially during the investigation phase and that will be handled by the office of the public conservator.

determine that voluntary services have been offered prior to any involuntary measures. procedurally, it will mirror l.p.s. procedures. individuals will be represented by the public defender and have the ability to request a jury trial from the outset and appeal the conservatorship at any time. as she mentioned previously, a bill pending in sacramento that is aimed at cleaning up aspects of 1045, so it better aligns with the bill's original intent. no expansion of the eligible population is anticipated as a result of sb40. notably the bill shortens the duration of the conservatorship from 12 mostly sunny to six months and requires the p.c. provides status updates to the court every 60 days to justify the continued need for conservatorship. and also clarifies that a.o.t.

must be attempted first and all who qualify for a.o.t. will get referred to the program before a petition for housing conservatorship is committed to the court. >> in looking at services that would be offered to this population, i think it's important to note that the individuals that are currently eligible for sb1045 represent less than 1% of the total population we serve in behavioral health services but are the most acute. and again, for some a.o.t. is not sufficient and conservatorship is the last and final tool to work with them. offer similar to assisted outpatient treatment, wrap around comprehensive clinical and pure based services to support recovery and wellness and prioritize community-based treatment and always considering the less restrictive option. as jill again already mentioned,

not only an ethical responsibility for us as providers to do so but a local obligation and requirement to the court to do that as well. this is just to highlight some of our work. we serve over 25,000 individuals a year and are the largest provider of behavioral health services in san francisco. our services range from prevention and early intervention to outpatient and residential treatment, and crisis and acute services. what's important to note about this, the level of care is dependent on the individual's needs, and they may be in different levels of care throughout their time being served by the department, depending on what their needs are at any given time. again, this is just to note the number of individuals that we serve. psychiatric emergency services is a crisis stablization unit.

and they provide immediate evaluation and treatment of individuals. fiscal year 17-18, they provided services to unduplicated count of 3,674 individuals, which again in looking at the population who would be served through sb1045, that population is roughly 1.5% of the total population served at p.e.s. >> very much like l.p.s. conservatorships, housing conservatorships carried out with other entities, department of homelessness and supportive housing and courts. and some come from zuckerberg and other psychiatric hospitals in the city and would do so under the new model.

all tri aged through the program, psychiatric treatment program and other under conservatorship licensed care setting where they may be residing but provided by behavioral health services and community-based contractors. services that are provided are tailored to meet the needs of the individual, and this slide lists a range of services individuals may receive depending on their care plan, and it takes a multi-departmental partnership to provide the necessary services. they will all be provided with a strength-based approach and focus on empowering individuals. role of the p.c. to oversee the care plan in its entirety and make sure legal obligations are met. we have to ensure all services follow the least restrictive mandate, that really guides our work. other critical services will be

intensive case management, provided by c.b.o., such as city-wide, medical care from community-based clinics, perhaps like tom wadell. vocational support offered, and family services agency. comprehensive and holistic care, recovery in the least restrictive clinically appropriate setting. and services long after the termination of the conservatorship. this slide is intended to illustrate a pathway for services. it shows each individual likely offered multiple housing as they work toward recovery. to help individuals stabilize to a level of independence to allow placement in permanent supportive housing. self-care or acceptance of supportive services will be a significant marker in making that determination. access to permanent supportive

housing is the long-term solution for this small group of people that will be served through the program and housing program will facilitate our ability to get them the services that they need and to move them to that point. if we look back at the case example from the origins of the presentation, i wanted to describe a possible tailored service plan for a client like melanie. by the time the court has authorized a conservatorship, clinicians from my office would have conducted outreach with her and trying to engage her to actively participate in her own treatment plan and i think that one strength we have with the housing conservatorship program is the offer of permanent supportive housing. and hopefully that will help to really engage individuals in their treatment. the primary services will be provided through the licensed care setting where melanie likely would reside in the

initial phases of her recovery. very likely reside in a treatment setting like baker place, at least initially. precise placement identified by the transitions team in d.p.h., and over the duration of her stay, the transitions team would be conducting regular visits to ensure the quality of the treatment she received. and also connected to individual counseling and peer support, navigation, intensive case management. provided by city-wide, for example, and those relationships again are critically important because those are individuals who will continue to work with her once the conservatorship has terminated. so access to psychiatric and medical treatment through d.p.s. clinics, as well as money management, an important tool. department of aging and adult services, we operate a representative pay program and would manage her social security

income in collaboration with her case manager. if she decides returning to work is a goal for herself, we would connect her to vocational services. public conservator has the responsibility for overseeing the treatment plan in its entirety, and providing her with advocacy along the way. sb1045 will provide health care and housing to get back on track with their lives. our goal here is really to break the persistent cycle of streets, hospitals and jails. hopefully she'll be able to stabilize and recover and a permanent supportive housing unit waiting for her. >> wanted to talk about some recent investments made into the system, would benefit individuals such as melanie and the population for sb1045. what's important is to note that there is a priority for individuals to be placed in permanent supportive housing and

the department of homelessness and supportive housing as you know is working very closely to get as many units on board quickly that would serve individuals such as melanie. the healing center is having 14 new beds added so a total of 54 beds. new substance use recovery beds, 72 new beds added. mayor is committed to $1 million to stabilize residential care facilities, and i'm happy to announce on behalf of the mayor's office today that 30 new residential treatment beds are being added into our system of care, which is the largest investment in residential treatment beds in our last generation. additionally, $6 million have been added to increase street medicine teams. a.o.t. is in the process of expanding our team as well, so we have additional clinicians to work and engage individuals involuntary services as well as increase intensive case management capacity.

and $3.2 million added to intensive case management, mobile harm reduction counseling, transition out of crisis services, and social workers and psychiatric services to support discharge planning. i want to turn it over to simon who will also talk about his experience in cases and a case example that would be served as well through sb1045. >> good morning, chair ronen and the members of the board of supervisors. my name is simon pang, part of e.m.s.six, a unit that responds to frequent 911 users, shepherding people to detox,

treatment, health and mental health care and supportive housing. senate bill 1045 written to save the lives of a small number of people who are dependent on 911 for their daily survival. individuals that have such severe substance use disorder and mental disorganization that they cannot perform basic acts of daily living. individuals that have continuously refused shelter, treatment, and housing. these few individuals will use until they are incapacitated, stumble out of an emergency room as soon as they can walk or rolled out of an e.r. in a wheelchair and use some more. it is a vicious circle of misery. i'll give four examples. a man i'll call john died in an e.r. >> sorry, if you can -- there will be an opportunity for

public comment and we don't allow audible noises while someone is speaking, so please, if you want to react and show your reaction, if you can give us thumb's down or supportive fingers, but we will give you time to speak during public comment. >> a man i'll call john died in an e.r. having been found with hypothermia by paramedics. he was a user, and sometimes willfully in continent. more than 100 emergency responses the year before he died. for acute emergencies or because a bystander saw a legless person covered in excrement who could not get back to his wheelchair. every time he had a bowel movement a nurse would have to clean him. he would leave hospitals with insulin and wound care supplies. and throw them away.

in the year that he died, e.m.s.six engaged him 48 times to offer shelter, substance use treatment, or to help him get documents because without an i.d. you can't get housing. but this is hard to do when someone is under the influence, hospitalized, or soiled with excrement. when he was clean and sober, he would refuse to participate. john was not able to be conserved under current law and he did not qualify for assisted outpatient treatment. another meth user, frank, sits in his wheelchair and excrement all day. he has an abscess on his back side that has tunnelled down to the bone. sometimes he will try to get out of his wheelchair to defecate in the open. they find him covered in feces,

wound exposed, unable to pull up his pants or get back into his wheelchair. and the last two years he has activated 911 122 times. my team, e.m.s. six, met with him 99 times, offering him shelter, navigation center bed, assistance activating benefits, referrals to treatment programs, he refused it all. time and again i have been dumbfounded, having been told he was allowed to leave a hospital because he could not be kept against his will. richard, another meth user, used 911 208 times in one year. he rides the bus all night, usually soiled in excrement and asked people to call 911 because he thinks he's having a life-threatening event and he's

scared. he'll stay in the e.r. for an hour or two, then he'll just walk out. hours later he activates 911 again. this happened four times in one day. richard was provided with a free room with in-home supportive services and a case manager. he never used the room. yet medical and mental health doctors let him leave they're hospitals because they believe he has a plan what he says, i'm going to see my doctor at her office. i get food there. and i'm going to the beach to meet some friends. but he never goes to see his doctor, unless escorted there, and there are no friends. another individual hospitalized for a life-threatening condition 21 times since january of this year. yet he insisted on leaving so he

could use meth and heroin. we were told doctors could not keep him against his will. he has been released and readmitted the very same day. admitted january 2nd, released january 2nd. admitted january 3rd, released january 7th. admitted again on january 7th, released january 8th, admitted january 9th. you get the picture. he died a few days ago. had he been conserved and gotten sober, might he have chosen a different path? while it is true that there are not sufficient quality services for all the people without homes in san francisco, for the population affected by sb1045, every service and resource has already been offered but they are continuously refused. we need a tool that can provide temporary respite so that free of substances a person's mind

may clear. their body may heal. given the possibility of rediscovering the desire for a better life. thank you. >> thank you, simon pang. i have a couple questions, i don't know if anybody has questions. or if you want to run questions. >> ok. do you want to start, or you want to start, since this is your hearing. >> i'm fine letting sunny walton start. >> supervisor walton. >> thank you chair ronen, and thank you for this report from d.p.h. and from testimonial from the fire department. this is a serious issue, of course, and there are a lot of questions that come from me about conservatorship and i've been talking to supervisor mandelman, the mayo