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 mayor's office,

really trying to understand exactly the benefits of if we were to support sb1045 and current toreship and there are a lot of struggles for me as we continue to have this conversation. so, i have, i guess, some statements and some questions, particularly starting with, we had a mental health hearing and public safety neighborhood services. we have also had some reports from department of public health and i guess my first question is, because i've consistently heard from the department of public health that we don't have enough beds to adequately address the needs of people seeking voluntary services, am i right that is still the case? >> supervisor, i think what we discussed is important in terms

of adding, something as a landscape has changed in san francisco for who we are serving, we also have to respond to that and adjust our system to meet those needs. so adding the beds is an important part to us addressing the needs and what's important to note about this population is that because they are cycling in and out of crisis services, they are a priority for us and we are able to meet their needs immediately if they would accept those services, that we have beds available and place them in them if they are to accept them but not the case for this population. >> what's troubling as well, our entire homeless population is a priority. we have had major concerns and major issues with homelessness for a long time, and so as we talk about prioritizing, i'm not confident that all of a sudden we can adequately address the

needs of a specific portion of the homeless population. all of us, all of my colleagues, everyone in the audience, your department is extremely focussed on addressing homelessness. and so that's very concerning to me to hearsay that all of a sudden we can wave a wand and address another population. also the way we do 5150 here in san francisco i know it's determined by law enforcement, and we have been working very hard to decrease negative interactions between public and law enforcement and is there a way to change the policy for determining 5150 and making it completely medical? what's the conversation around that? >> so, i would just highlight, supervisor, that while law enforcement are able to place somebody on an involuntary hold

that it's not exclusively law enforcement that does that. providers are able to do that and receive training to be able to do that. so, it's not just law enforcement making that determination. i also think having a facility like psychiatric emergency services provides us with the opportunity to provide that immediate evaluation to see that is clinically indicated to be on an involuntary hold. >> as someone who definitely has, addiction runs in my family and we know that, and with supported by data, the majority of folks who do well and are able to stay in recovery are folks who voluntarily choose to go into recovery. and so with that said, what are your thoughts about that? because if we are talking 40 people and look at the data, we know that typically people who are forced into a situation to

try to seek recovery don't typically do well. what's the conversation and thoughts around that? >> so, i think while voluntary services are always a priority and something that is very important to us as the department and as a system, that there is mounting evidence compelling somebody into treatment under certain circumstances for some individuals they do benefit from it. and they don't necessarily fare worse than individuals who accept voluntary services, although that is the priority and goal for all of us. >> real quick, what's the measuring stick for be worse. >> sure. i am share articles that we have looked at, that individuals do equally well if they are compelled into treatment. also important to note for the services that we are discussing that would be offered to an

individual is that these services are not forcing substance use disorder treatment, but there is the expertise for individuals who are providing those services that they are able to work with individuals by engaging motivational interviewing and other tools to support individuals on that path to recovery related to their substance use. >> and when we say equally well, the data demonstrate the duration or how long? it's one thing to be put into a service involving things to do well for a certain period of time. are we tracking the long-term implications versus someone put involuntary recovery versus someone wlo choose it and was able to stay in recovery. is that data tracked in that? >> longitudinal data? >> i appreciate that question. i would have to look into it in more detail and circle back to you about that. the assisted outpatient treatment program, we do look at the extended data and for the

program thus far that we have had long-term impact of individuals continuing to accept voluntary services after the court process. >> and then as a person of color, always a major concern any time we put any system in place of incarceration or taking away someone's ability to be free, typically disproportionately affects black people and people of color. i know you can't give me a guarantee that won't happen, but what's been the conversation around that? because that is one of the things most disheartening, concerning, troubling for me and one of the biggest reasons why i'm not excited about this. >> i think it's incredibly important to discuss and don't want to minimize that or take that away from the conversation at all. and like you said, while i'm not

able to provide guarantees, i want to know that we are not talking about incarceration here, that that is important to discuss but a separate conversation from this. the other thing that i would note, having the working group is important so that we do continue to have those conversations. i'll note similar concerns arose when we looked at implementing assisted outpatient treatment and say from personal experience it's not something we have seen in practice but something that should always be at the forefront of conversations in our continued reports with the working group as well as with the board of supervisors. >> what's the definition of incarceration? >> i think in terms of incarceration, what i would look at in terms of what we are talking about, somebody who is booked into a county jail or facility related to criminal charges, whereas this we are looking at a civil court process. >> so, i would push back and say

that anybody in the custody experience where they can't get out, where their freedom is taken away, is probably considered incarceration. that would be -- that would be my thought right there. but, and so with that said again, you know, typically people of color are disprobl disproportionately affected and the negative outcomes of people with color. as we ask that, because even unthe current system of involuntary services being chosen, how is one transported to involuntary services? >> just to clarify in terms of being placed on involuntary hold, for the community -- >> that could be the case. say you are out and given the option to walk in the street, give an option of going to services or going to jail, how is one typically transported to

either service? >> so, i can share for something like our law enforcement assisted diversion program, another innovative program that we have where individuals are offered services at the earliest point of contact with law enforcement, certainly times when law enforcement may transport them to those services but we have built in providers who have vehicles to be able to pick an individual up and take them to services. >> when people are transported to involuntary services, they are not handcuffed and taken to voluntary services as well? >> so, i certainly can't speak on behalf of the police department. go ahead. >> i would like to answer that question. there have been a number of occasions when somebody that was conserved, i had a social worker call me up, and ask if we could escort them in a taxi to the next destination. and that's how we did it. >> and i'm asking these

questions, you know, not as a got you, and as someone who has visited, and had conversations with law enforcement, with our health providers and i do know of instances where even people who choose to voluntary choose service because at the point of contact it is with law enforcement that they are actually transported in handcuffs because that is the -- that is police department policy that if they transport someone they are taken in handcuffs. and would love to see when we have someone who voluntarily chooses service, to be the one to transport in all cases. not specific to sb1045, but this is -- i'm just having a conversation right now about who is happening, because as we talk about conservatorship, one would

have to be confident everything we say is going to take place is even possible before i could even think about supporting something like this, and we are not even close to that in a lot of aspects. i want to go quick and i'm not going to take too much time, but i want to go to -- on one of the slides connection to housing, don't have page numbers, but it says any individual who has gone through the conservatorship will be guaranteed clinically appropriate housing placements along the way. and i want to know how we are going to achieve that. because we are not achieving it now. >> good morning, supervisors, department of homelessness and supportive housing and supervisor walton, thank you for recognizing that there are thousands and thousands of people on the streets all of whom need assistance. we need more housing, we need more shelter, need more of everything, that's painfully

clear. however, i think we also need to focus on getting better at how we use the resources that we have. and i think one of the ways that we are doing that is through coordinated entry in which we are assessing individuals based on acuity and length of homelessness, so they are getting access to permanent supportive housing, the individuals who are the greatest risk of dying or getting very ill on the streets and we'll use a similar process to coordinate entry to work with individuals in the 1045 program. assessed, i don't think i need to assume, i think the current work that we are doing will show that individuals who are this ill will be at the very top of our housing queue and put into appropriate treatment placed on high needs, generally in a room that's got its own kitchen and

its own bathroom, fully adaptable or accessible and services on-site. >> follow up, go ahead. >> what you just stated and guaranteed don't equal the same thing. you talk about a process hopefully that we could -- but guaranteed is different than what you just said. >> we have over 1,000 units opening up on any given year. people are placed into the units are being placed due to, after being assessed. so, following an assessment in which the highest acuity individuals are being prioritized for housing, so these individuals will be guaranteed placement to housing. we cannot necessarily do it in the moment, but in 90 days we should be able to place what i would imagine would be a very,

relatively low number of individuals on any given year into a permanent supportive housing site without having to break fidelity at all from the system of coordinated entry. >> to reiterate, state law requires, requirement at the end of the process that they are provided with supportive housing unit if they are ready. if they are not ready for a permanent supportive housing units, they are guaranteed another housing placement at the proper level of care. fundamental as spent of this bill. >> supervisor walton, can i just chime in here? 12 days ago at the may 1st hearing, kelly said 44% of people who finish residential treatment program are released back to the street or to shelter. so, following up, this is a major concern of mine as well

with supervisor walton, it's not just all homeless people on the street where clearly there is not enough housing. it's people with severe mental illness and substance abuse that don't get housing. 44% of the time when they leave residential treatment and that's the specific concern. can you respond to that? >> without seeing any of the data that miss hirmoto is referring to or knowing what clients are exiting, it's hard for me to respond. but what we should be doing, ensuring those individuals are being assessed in the coordinated entry system because they likely are also, you know, high acuity individuals. and coordinated entry system has only been up and running about four months now, so we are still working out a whole variety of -- >> i understand that, director, you were not at this hearing so maybe you didn't see this. this was 12 days ago, and the

director of transition told us that 44% of the people leaving residential treatment are released back to the streets or a shelter. that is -- you are the director of the department of homelessness. and that's an extraordinary figure. and that's why people like supervisor walton and i have concerns that we are not ready to implement this law. >> not to cut over, director, with all due respect, 1045 population are not exiting treatment because they are never going into treatment. so those folks are more acute than the people making it through and a shockingly large number of whom are not getting placed and so that's -- but i -- i mean, i would like to know. >> wait, wait, i'll give you your chance, supervisor mandelman, but what i'm -- but the point here is not, you know, it's hard to -- it's hard to

compare acuity, right? are those people more acute or cause more problems in the neighborhood or, like we have so many acute people on our streets and every one of them deserves and should receive the best quality care and should receive housing and intensive case management and all of these services. my concern is that 44% of people that we are spending an enormous amount of resources on and time, they are saying i want to get better, we don't have enough services in the system so when they are released to the street we know what happens 100% of the time, go back to declining, go back to using drugs, cycle in and out of p.e.s. and so the question is not whether they are more acute or less acute and i don't think we can make that determination. >> i think more acute matters and i think you can make the determination. >> i'm trying to make my point.

i'm not sure that you can, and i would -- maybe there's a doctor that can answer. we don't know who we are talking about, how do we know who is the most acute person. what i'm saying, the system -- we don't have a system that's working. when there is 44% of people who voluntarily are accepting treatment, go through an entire residential program and released back into the streets, then we have -- we have a problem and this is not the answer. we should be -- we should be creating a system that works for everyone. sorry, i want to give it back to supervisor walton, i didn't mean to steal your thunder, i wanted to add that stat that we heard 12 days ago from the department of public health to this discussion. sorry. back to supervisor walton. >> thank you. >> you want a response or --

>> sure, i'm sorry. >> that's ok. i do not disagree, supervisor, that there are significant improvements that need to be made in the mental health system, why mayor breed and dr. colfax hired dr. bland to effect some of the changes and excited to work with am and i agree we need to do a better job of ensuring people with high acuity are getting access to services and not creating the revolving doors. i don't agree that we can't -- we shouldn't try to fix, just because there is one problem does not mean we shouldn't try to fix another, what i'm trying to say. we are not talking about a large number of individuals who will be affected by sb1045, and i have seen too many people dying on the streets and i would say the vast, vast majority, the vast majority of people we engage with accept services, they want housing. that is absolutely true and i don't want to, you know, my concern -- i don't want to make

it about like the homeless population or about people who are struggling with mental health or substance abuse issues. the vast majority of them are perfectly capable and should make their own decisions about the treatment or housing, but a small group of people are dying on the streets i have personally witnessed turn down offers, not only case management and shelter but in the hospital that we could do a better job serving and even if it's just one person that does not have to die on the streets i think it's worth moving forward with the pilot. lots of things need to be fixed but we can also fix the other problem of a small number of people cycling in and out of the system suffering. >> i would add on behalf of the mayor, housing is the number one priority and made significant investment, and we are making new investment, including the housing bond, and look forward to your partnership on that,

chair ronen. at the end of the day as mentioned, absent intervention these people will die. assertion we should wait and fix the entire system, we all agree needs to be fixed and more housing and resources for everyone across the board, including folks with mental health issues, we cannot wait for these people. we cannot let them die, it's not the appropriate thing to do. >> i understand and i have a lot mr questions about, a lot more things. i interrupted supervisor walton so i want to give it back to him. but the law itself requires that we have enough capacity in our system to that other people are not bumped, and i don't think we are honest about that in this discussion, which is not's your point is not true and i don't agree with that point and we'll discuss it more after i give my colleagues a chance to talk, but the law itself requires it and i don't think we are being honest. i don't think the department has been honest with the board of supervisors about the resources

that are available and i think we have showed that in every single hearing and it's been really frustrating for us. supervisor walton. >> definitely not asserting we cannot chew gum and walk at the same time but a lot of things are broken before i would jump into something like this because at the end of the day we are taking away folks' civil liberties and we have to remember that. so yeah, there are some major concerns with that. a slide that also talks about judicial process, all clients have been offered voluntary services prior to petitioning the court for sb1045. is there like a certain amount of time? how many times they have been offered service? can you talk me through that a little bit? >> so, the role for the public conservator to conduct an investigation and part of the investigation interviewing the

individual and ask them about their experiences, what services have they been offered. also working with our partners at d.p.h. access to avatar and l.c.r. system to check past hospital records, determine what they have been offered. and certainly if services have not been offered to make that recommendation, that's also in the statute. if we determine voluntary services have not been offered in a meaningful way, we would not petition and we would be providing recommendations back to the department of public health on additional service interventions that need to be offered. >> and the fourth bullet, it's going to seem nitpicky, but goes back to terminology. says client may request a jury trial or rehearing at any time to appeal conservative's

determination. aren't jury trials typically for people who commit felony? >> under d.p.s. statutes, they have the ability to request jury trials. 5 or 6 jury trials every year on average. >> and pending legislation slight, from a practical aspect, it says individual notified after the seventh voluntary hold of a possible future conservator petition. how would that notification take place? >> that was a recent amendment recommended by the senate judiciary committee. and what we are envisioning, the department of public health would notify the individual before the 5150, but no later than that time a conservatorship

petition could be forthcoming? >> how, you tell them -- >> during the 5150 hold. working with the courts with the city attorney to develop written materials and explaining what could be for the -- forthcoming. we'll be sitting down with the city attorney, as well as with the public defender's office. they will play a really critical role in terms of due process protections, and that's really what the notification is about. it's about providing additional due process protections for individuals. in response to your earlier question about jury, trial by jury, i'm not an attorney, so i cannot speak to when jury trials are implemented. only that we use them in l.p.s., and it's really so that there is

an opportunity for peers to weigh in. >> thank you. so, i don't have any more questions. i guess i would just say that, you know, i definitely believe in tackling some hard issues and putting some policies in place that are really going to address the needs of what the concerns we have in community, and the things we need to change. but i also know that we have to be very careful setting ourselves up for failure in the policies that we implement and approve, and sitting through this hearing, sitting through public safety and neighborhood services hearing, through budget hearings, i have not heard anything that tells me that we adequately have the ability to address the most acute needs and put in a conservatorship policy, typically in alliance with

sb1045, and 40 more, but a lot of work we have to do as a city and it's really concerning to me as we continue to have this conversation. i just wanted to say that. >> thank you. supervisor mar. >> ok. thank you. we will be giving an opportunity for public comments shortly. thank you. just asking questions and then we will open it up for public comment. thank you. >> thank you. chair ronen. start by thanking, really thanking you and supervisor mandelman for all of your leadership on these important issues and sort of leading this important public sort of discussion about how we could best address the mental health and drug addiction crisis in our city and how we could better support members of our, in our community who are really suffering and need support for

their welfare and the welfare of the broader community as well, and i think also this discussion, you know, this morning is particularly about whether expansion of conservatorship and sb1045 would be a helpful or the best approach to do that. i know we have a lot of folks here who wish to speak during public comment and looking forward to hearing all the perspectives on the complex issues. i'll keep my comments short. had a few questions, kind of following up on some of the questions and points supervisor walton had raised. so i just had a question about whether, or how many, whether there are people who are currently conserved in jail, and if so, how many, and why? why are they in jail?

that are promoting their safety. >> i would add the wraparound services being clinical services. i can say for outpatient treatment we have had significant significants in jail contacts for individuals who participated in the program. >> thank you. i had one other question or set of questions. it is a question of how has in the implementation plan, how have we shown that no voluntary services will be reduced as a result of implementation of

sb1045? >> i don't know that we highlighted. we are estimating so we would potentially serve two to three individuals max every single month. the individuals population that are described are those within the system. we know who they are, and 55 is the outer limits of the eligible individuals we might reach. that does not mean we would serve 55 at any one time. we think we would move forward with the housing conservatorship two to three times max during any particular month. sb40 is shortening the duration. we would be pulling individuals who are high utilizers and helping them to use services in a more effective and efficient manner.

>> with intensive case management to increase capacity we would insure we are adding services needed to support this population. >> how much would it cost to provide services for a individual under sb1045 including the guaranteed support of housing that comes at the end? >> i am sorry. i do not have access to that information. certainly we would be happy to follow up and we could pull that information together for you. >> i would add that we are happy to follow up regarding that information. these are individuals known to our system cycling through crisis services. they are already costing the system of care existing dollars to support them. >> it is my understanding state law requires we have sufficient funding for this. i guess the question is if the funding has been set aside for

this for implementation including the permanent support of housing that comes at the end? >> i was going to say that i don't think we don't see a separate population to be served. they would be served through the existing system so there is not unique funding. with the expansions of services we know are needed throughout the system they would flow through and be eligible for the services regardless. >> thank you. >> supervisor mandelman? >> thank you. i want to drill down on a couple issues and talk more about them. there is a question of capacity in the system, and i don't know if the director is still around. there he is. i will bring you back up. i apologize.

your goal so you don't have enough housing units for all of the people who are homeless? >> that's correct. >> so you would ask us presumably to find revenue and build and buy a lot of housing units to house people who are stuck at various places in the system or not even in the system at all? you don't have to give us policy direction it might make your job easier. given the scarce resources, you have spent a lot of time over the last couple years trying to set up a system that allocates scarce resources, presumably according to need. is that correct? >> that's correct. >> you are doing your best and you may not have arrived there yet, but you are trying to figure out who has the most acute and severe needs to get those people off the street and into care fastest.

>> that's correct also. >> do you have any doubt at all the population we are talking about, sb1045 population would be at the very top of that acuity need list? >> no, no doubt at all. >> so if your systems are working correctly and you are trying to get the systems to work correctly. there may need to be further conversations to make it work better for those in drug treatment right now. the small number of 1045 people not in drug treatment currently because they aren't able to access it would be at the top of the list and you believe should be at the top of the list and not necessarily displacing other people at the top of the list? >> that's correct. >> okay. thank you. i am done with you for the moment. i want to talk a little bit about 5150. there may be people to address this.

there is concern about what i have heard that this legislation is going to promote more 5150s and more encounters traumatizing encounters between police and folks on the street. i don't believe that is the case, but i want to know what is in place to make it unlikely that that happens or if that does happen that it will become a bar to that person being conserved? how are we going to know? one question is whether people currently arriving at psychiatric emergency services are being inappropriately brought thereunder 5150. doctor bland. >> good morning. >> you were at psychiatric emergency services until about a month ago or maybe two months ago? >> there about. thank you for the question. i want to make sure i understand

the context the concern about the over use of 5150 and the second question about people coming to pes. >> what happens if some police officer treats somehow reads in the paper sb1045 is implemented locally and decides to go and start 5150ing people not appropriate in hopes of getting them in housing conserto have ship. >> -- conservatorship. what would happen if that were going on? >> that is a important question. we are trying to help the people that are most affected and having been in pes as a physician and psychiatrist and seeing these individuals cycling through services, i have been increasingly concerns about the limits and constraints of the system to meet their needs.

the welfare institution codes for the act has several checks and balances in place in that individuals can be placed on the 5150 when they -- 5150. someone observed behavior concerning it to be dangerous or behavior that suggests the person is not able to make use of food, clothing or shelter. when a person is placed on 5150, it is important to understand that is simply a petition for evaluation. that person must be taken to the nearest emergency or evaluation facility as designated by the county. many cases in psychiatric emergency services. at that point we have an obligation to provide timely assessment of the individuals. psychiatric emergency services is the only place to be seen by

a psychiatrist when a crisis 24 hours a day seven days a week. we take great joy and pride in providing that service to the citizens of san francisco. when they identify someone meeting those criteria. at this point where they arrive our goal is to understand the validity of the concerns. we have to spend time doing evaluation of the person directly was well as looking for collateral information or resources to confirm the concerns expressed in the community. it is an ongoing process, often not easy to collect that information at various points. it comes to the team of the physician whether or not the person will continue to need to be detained much longer. i will say the last part of the checks and balances around the lps is individuals who place someone on the involuntary

psychiatric hold without adequate criteria can be subject to criminal and civi line for te action. >> while you are up here. i wonder if you could talk a little more about the potential benefits of involuntary periods of sobriety for someone struggling with methamphetamine addiction particularly 1045. frequently experiencing meth induced psychosis. there is argument about whether compelled treatment can work and we hut up studies treatment may have possibility. short of that, what 1045 would allow us to do is just even before compelled treatment would allow compelled sobriety, i believe. that is one of the reasons why

it is attractive to me. as a doctor, can you talk a little bit about your thoughts on involuntary treatment, sobriety, that kind of stuff. >> thank you. i think it is important to understand that referring individuals for an evaluation and treatment in the hospitals is not equivalent of incarceration. this is treatment. we are there to help people get better. many individuals do actually recover. addiction is a chronic brain disease. it is fundamentally changing personality emotions and behaviors and interferes with ability to make decisions. there are elements of the process typically people are in denial. they feel loss of control to limit ability to recognize how serious the problem has become for them. in substance abuse treatment we have had varying opinions around

a client-centered approach to treating addiction, and what is clear is that contrary to popular belief there is a mounting amount of evidence that suggests involuntary compelling treatment can be helpful for individuals suffering with substance abuse disorders. i think that there are opinions and philosophies and then there is data. that is what i want to come back to. what does the data tell us? there is data for mandated patients that challenges that individuals must be ready or motivated to change before they are able to change. the key factor in the treatment is length of time an individual is able to be retained in treatment. it is important that the person

is able to reach sobriety to begin to be able to change. compulsory measures reduce the treatment dropout as with other serious mental illnesses involuntary hospitalization may be necessary to stabilize, assess and come up with appropriate plan for an individual. similar to outcomes for coerced treatment for users of other drugs, moderate outcomes are also seen for methamphetamine users who are reporting they have felt compelled or pressured to treatment. for the most part the outcomes have very much similar to individuals that would have sought treatment voluntarily. the strongest predictor of success for an individual in addiction services under compulsory mechanisms or voluntarily is the number of

months that person spends in treatment. the longer in treatment the more likely they are to be successful. >> than thank you, doctor bland. that is it to moore questions. -- that is it for my questions. we are deeply concerned about our behavior health system in san francisco. a couple things give me hope. one is that -- three things. while our system is not ideal, i think it is probably better and doing more and trying harder than any other system in california. i think i am on a daily basis impressed by the efforts made by people like anton bland and the folks through the systems and conservator office trying to do heroic things and kelly in a system that is not ideal, but

people are trying so hard to make it work and going above and beyond. what gives me hope. we have a mayor and board of supervisors committed to new investments. this sheet every sept investments is high -- sheet every sent investments. in opposed the 14 new healing center beds. those are critical. some of the folk opposing the implementation opposed the 72 new substance abuse recovery beds. those are critical and give me hope. the 30 new residential treatment beds are the first new mental health or dual diagnose beds in the city since 2008. it is the most significant investment in that type of treatment facility or those kinds of beds in a generation. the fact that we have pioneered

the humming bird navigation center, i want a hummingbirds in my district. i am eager to see more capacity. this is potentially an exciting time for san francisco to show the rest of the state and country how to do this right. i have a lot of hope and gratitude for the people who are doing the work. thank you. >> thank you. i have a number of questions, but absolutely i want to echo supervisor mandelman and the gratitude to all of you who do the work on the city side and in the public. this is some of the hardest work that anyone does out there, and to dedicate your life to this type of work, you are heros and we just appreciate you immensely. i completely agree with supervisor mandelman on that point. i have a number of questions. we will get to public comment

right after i ask these questions. stay tuned and thank you for being patient everyone. i am wondering, i noticed -- let me back up. if someone could come up maybe jail and walk me through -- maybe jill and walk me through what this would look like what a -- how this would work. let's take melanie. melanie has not accepted voluntary services 5150 for 10 times. this law goes into effect, and the next time she is 5150, where will she go? >> are you asking me to provide a pathway for her, assuming sb40 passes at the state level?

>> i will talk about sb40 later. i am concerned we are having this discussion with sb40 pending. i am assuming that 1045, you know, that this legislation passes and then i am assuming whether it is the police. under sb1045 we would be engaging angelica's team and other folks from the sf hotted team would be engaging with melanie. a client like her is homeless on the streets, trying to engage her in voluntary treatment which she has refused. at that point aot would make a referral to our office and practically speaking, when we receive referrals for lps we are evaluating whether an individual might be eligible for aot. assuming that the referral that

we are able to meet the statutory requirements under sb1045, we would conduct our own investigation, which as i explained before would include looking at clinical records, it would involve interviewing her directly, interviewing service providers that worked with her. we would also be trying to determine if there are any family members or other support, informal support to pull into the care plan. >> is melanie homeless? >> yes. >> melanie is living on the streets and schizophrenic and taking meth. let's take out the aot part for the moment. but she is eligible for 1045. who is going to go find melanie and what is going to happen? >> what we are envisions is

that we would work through some of our existing programs for example sf hot team where they are doing considerable street outreach. >> let me walk you through. i want to understand how this works. the hot team finding emily. what do they do? >> specifically you are asking how to motivate an individual to come to court? >> okay maybe that is what i'm asking. i want to walk through what this is going to look like. >> are you going to propose? >> we would have to provide melanie with notification we would be petitioning for

conservatorship. >> before melanie is conserved she has to questio to go to cou. she doesn't want services and hasn't engaged with you before. how will we get her to court in. >> a critical player is public defender. he would meet with her before the hearing. >> if we know that in order to conserve her involuntarily that she has to go to court and she doesn't want to go to court, the public defender is going to convince his or her client to do something he or she does not want to do? i do not understand how this works. you are going to ask? is there anyone from the public defender's office here? >> i am in aot. angelica has experience with the public defender's office and street outreach.

>> the public defender plays a crucial role and there is not one person from the public defender's office here? that is shocking. can we get someone from the public defender's office here? as you said several times throughout the hearing. they play a very important role. i am surprised we don't have a representative from the office. you are saying the public defender is going to convince melanie to go to court to face a judge to be involuntarily conserved even though she doesn't want any voluntary treatment? >> our experience without patient treatment because we engage with individuals in the community and support them, if they want to attend court we will escort them to court. >> what if they don't want to? that is the point.

they don't want the services. that is where i have the questions. i don't understand how the law will work. if they don't want services, then how -- the only thing i heard we are going to use the public defender to convince the client to go to court? i don't understand how that will work. >> i was describing the process up until the conservatorship. are you asking how to provide the services when the conservator ship is authorized? >> no how do we get one who doesn't want services to go to court to face the judge to be conserved. >> i would add as a provider who does this work and my experience is that when we filed the petition with the court and working with the public defender's office we meet people where they are comfortable. the public defender will meet them in the community to

understand the individual's desires to represent them. >> we have engaged -- i would love to hear from you, simon. >> i am not an expert. this is my experiences in these matters. step one. how do we meet someone? we have a member that meets with the homeless. they are activating 911. we meet them in the hospital, ask what they are connected to. do you have a case manager, social worker, an id? we try to get them to meet us. when discharged from the hospital or pes we meet them or buy them a sandwich. we say let's go to the dmv and get this done. where are you staying? we will get you shelter tonight. the point is i don't want shelter. we will get a navigation center bed. i don't want that. they might take it but they are

kicked out of the navigation center bed a couple days later for failure to show up. that is what i mean by refusing. >> that is my while point. i am trying to understand if the while point is we can't engage this person. >> i will get there. >> sorry to interrupt. >> now we reach the point where we go on nonemergency basis to outreach on the street. we recognize this person at this moment is gravely disabled. they cannot care for themselves. then we can call the police. in my experience the police have not been the best people to evaluate someone. i will call mobile crisis or street medicine. there are two psychiatrists and they will evaluate that person and put that person on a hold. then they will go to one of the emergency rooms in the hospital

or pes. preferably pes. they will evaluate them for eight to 10 to 12 hours, clear, be able to site a plan, be released. they go back to the street. they repeat. that is the first 5150. we are working with all of the city agencies. we contact the department of public health. we will say this person is really in crisis. the department of public health will say you are right this person has had this many holds. they will send somebody out. i don't know if you want to mention names who work for the department of public health. they would come out. next time they are at the hospital i will call to say this person is at the hospital again. this is the sixth 5150 in the last number of months.

they will talk to that person and say you are in crisis we are trying to get to the residential treatment plan and you don't want to go. i have to tell you that eventually this might lead to a temporary restriction of your freedom. this has gone too far. this is the people i talked about in my testimony. this is who we are talking about. now on that eighth time they go to pes and maybe then pes is going to realize this is the eighth time. all of the boxes have been checked off. we will hold this person. at the general hospital at a hold. there is a room in building 5, sixth floor where there is a judge presiding overall these cases in a weekly basis. they have an assigned public defender.

i have been there for these individuals. one they are at the hospital detained, i guess that someone calls up the public defender to say this person is on the docket. please go see him, there is going to be a hearing. >> if i hear you correctly while the person is on the 5150 hold, they will be taken upstairs to the sixth floor to the judge to start the conservatorship process? >> eventually. >> i was not clear whether you were asking about preconservatorship process, how we are moving someone towards conservatorship? >> sb40 will change. >> that has not passed yet. it is not the law. if you are asking us to pass this without sb40, can you tell me if we pass this law today, the whole board passes it, mayor

signs it into law, then tomorrow you go to try to get melanie conserved under this law. how do you get melanie to court. [please stand by]