our current sf? do you have that now? >> i do and i can tell you that i know our african-american citizens are overrepresented when you look at the presentation. when you do and evaluation projects, you look at a cohort, a certain time period and the last break-down that we looked at, african-american made up to close to 0% o 20% and the majory are white males over the age of 60. but we see there are disparities. the islanders population is underrepresented when we look at their population here, the greater population in san francisco. the latino population is about -- is fairly well represented, appropriately represented in terms of the way

their representation in san francisco. >> the majority of percentage, do we know if that's long-term or short-term? >> whether they've been on conservatorship for a long-neve? i do not have that but i would be happy to provide that to you. >> supervisor walton, in terms of demographics of who we see, those numbers are fairly consistent with whom we see as a department. >> how does this work for individuals in custody or for youth? >> how does it work for individuals in custody? so for adults in custody, we do work with the jail, the psychiatric service's division within the jail and we are conserving individuals while they are in jail and we are trying to move them out of jail as quickly as we possibly can. >> i would add that it's rare

that individuals who are on an existing lps conservatorship are brought into custody. i think we're successful there, but there are individuals who certainly are seen in custody who would benefit from being on a conservatorship and the jail is able to make those referrals. >> what about you? >> we are not conserving individuals under the lps act under the age of 18 and, actually, the age breakdown between 18-24 only makes us 2% of our lps caseload. >> thank you. >> thank you for your presentation, for your work. at the start of this, let me ask you some specific kinds of questions about the charts but at the beginning of this, i talked, i think, about the mismatch between san francisco, the reasonable expectation we

would have a mechanism in place that is not incarceration for taking care of folks who can't take care of themselves. the sense that is conservatorship in the public's mind. and the reality that other than conservatorship honestly, there aren't a lot of other ways to deprive people of their autonomy and liberty, short of incarceration. and so, the question i'm going to get to, and may ask for dr. leery's thoughts, as well. but whether we think we are conserving everyone who is potentially eligible under current law and how far off of that we think we might be and how we would begin to think about that question, we've talked about it. and then, there's a hint -- nobody wants -- i understand neither of your departments really wants to bite on this,

but there i is the idea, think, that the lack of placements is somewhat in some set of ways depressing -- maybe congressingg the conservatorships. and if we had placements, we would be conserving a far larger number. and i want to think about what we think that's doing. and then the last sort of big difficult question above your pay grade, but i'll ask you to answer is, you know, what changes in the lps law, san francisco should be advocating for? and that's potentially a question for dr. leery, as well before i get to those hard, challenging questions, i'm going

to ask some smaller, i hope, not as challenging questions. so there's the chart on page 4. i think it's appeared in different places and i'm looking at page 4 of the vla report. and, basically, the chart that describes the decline in dis-loaincaseload. i know you described an increase in caseload and i want to thank everywhere who has been doing the work. and i think in recognition of the crisis we're facing, herculean efforts, to refer people when it's appropriate and pursue the case and do the work to actually get the conservatorship sustained. but before -- up to 2017-'18, it looks like, you know, starting in 2012-'13, there were 820 and by 2017-'18, we were down to 45.

is it your understanding that that is attributable to the 30-day holds? >> yes. >> you think that's about the 30-day hold? >> back in 2012, the hospitals were using the temporary conservatorship process to be able to hold that cohort of individuals that need 30 to 45 days to recover. they didn't have any other mechanism to keep them in the hospital on an involuntary basis and so what would happen is we would -- just point out, i was not working in my current role at the time, but from talking with my colleagues, what i've heard is that the temporary conservatorship, which is really a seemless process, we submit the petition to the court and the court reviews the petition in camera and then the temporary conservatorship is granted.

our office is granted the authority to do our full investigation to determine whether the permanent conservatorship is appropriate. the tcons were submitted to keep people and they would recover and be determined no longer to be gravely disabled and they would be discharged with community service referrals. >> so i'm skeptical of that answer because of the chart on -- and maybe i'm misreading or misunderstand but if you look at the chart on page 6, that breaks out permanent versus temporary conservatorships. and there is certainly a decline in temporary conservatorships. although, it doesn't actually track that establishment of the 30-day holds. and the decline in permanent, you know, is significant. from 2012-'13 to 2013-'14, there's a halving of that number

and percolates in the 40s and then in '17-'18 something happens and then i believe what's going on is the political pressure around what's going on on our streets is building and we are starting to really -- and maybe some of the work around the high users of multiple systems and the work that dph is doing didn't there's leadership in the office of the public conservator figuring out if there's more people who would qualify for a permanent and it goes up. but that doesn't -- i mean, that explanation that we found another way of meeting the needs of people who need permanent conservatorships, i don't accept. i don't think that's right and i don't think that's what happened. i think the 30-day hold may have played a role, but i think there were other things going on during that period. i tend to think it was probably

around the lack of placements and i tend to think there may have been changes which inn in church that lead people to refer fewer folks. this is wild speculation but do you have any thoughts about that? i'm not trying to play a fam gaf gotcha. >> i don't know any provider working with the vulnerable adults who we work with would say we don't need more placements at all levels of care. the born in care crisis playing out on our streets in san francisco is integral to place individuals in community-based settings and keep them this sanfrancisco which would be ideal to placed them in their home county and we're not always able to do that because of lack of placements. i really appreciate your deep

nuance understanding of this time period. i don't have all of the answers personally and i can understand the frustration that you may have. i think what i want you to know, supervisor, and what i want the entire board to know is that we are extremely focused on improving our collaboration and finding every innovative way to support individuals today and moving forward. >> right. and i appreciate that. i also appreciate that every dph staffer that comes before this committee is in a nearly impossible position because you're explaining decisions made by people who were not you is there has been transition and change and you're trying to do the best you can with what you've got. but from our perspective, people who allocate resources and decide kind of -- and our asked by our constituents on a daily basis what the hell is doin goi.

we have to figure out what the hell is going on. and plainly, you know, we're -- it seems plain to me -- again, i'm a lay person in this, like my of my constituents, but it seems plain to me that people should be conserved who aren't. so getting to the more, like, theoretical aspects of this. and one of the things that sb1045 and 40 were get after was, you know, the need, the problem around this person and there's like a lot of this person, who can stabilize at general, probably get stable -- either gets temporarily stabilized in pes or stabilizes over a period of weeks, but that person either never get as conservatorship or gets a conservatorship extheand then

stabilizes but we have a belief or our system is built around the idea we push people to the least restrictive setting. my biased is coming out here. i'm wondering whether we are making a mistake and maybe compelled by the law, but making a mistake in pushing people, you know, into less restrictive environments that they're not ready for, too fast. and do we feel like we don't have the legal tools? this goes to, is this is change in state law that we need? you know, are we not keeping these people under more supervision and keeping conservatorships going longer because we don't have the legal tools and need to change the law or because we don't have the resources and need more resources? or is it a combination of both? if there were changes in state law around grave disability and

the definition of that, have you thought about what that would look like? >> i can respond to changes in state law. over the past couple of years, there been multiple bills that went forward that were focused on updating the definition of grave disability. l.a. county put forward a change to the definition of grave disability which really brings in the concept of sort of informed consent. and triking t tritryingtrying tg the priors witprovidingthe prove flexible. in my understanding, but that they primarily failed because they did not have funding packages attached to them. counties across the state, and again, this is my antidotal knowledge based on working with the state association, counties

are operating these programs on an absolute shoestring and that's why the budget proposal that i've referenced earlier is critically important. i mean, we have three programs that do not have designated state funding for the county operations. in san francisco, we are lucky. we know that. we have additional resources that our colleagues across state do not have. so i think that we already have some of the bills and they've been introduced. what we need to do is make sure that they pass at the state level and that they're funded appropriately because in order to actually implement them, it will cost the state and counties quite a bit of money. there's investments not just with staffing but the investments on the placement and treatment side. the state audit that campbell referenced earlier was a tremendous opportunity. we had state opportunities with us for three weeks and i am

really, really looking forward to the recommendations that they will be publishing, that we should have those recommendations by march. and i know that there's a lot of policy makers at the state level waiting, as well. i really urge the board of supervisors, if i may, to be working in tandem, in conjunction with the rest of the state. we operate under state law and because these are such huge issues involving civil protections and civil rights, i think it's a weighty enough topic that the state needs to take the lead there and we can take the lead by helping to partner and be a voice up in sacramento for bills we think are worthwhile. >> i completely agree and i think we're all hopeful in this audit will help to inform legislative change at the state level. a couple of things i wanted to remark on is certainly the psychiatrist thinks an individual is gravely disabled, it would be unethical for them

not to move forward with a conservatorship, regardless of constraints and options. that being said, we, of course, support the investments that are being made in treatment options so that we do have more of that. i think the other thing that's happened over recent years, that we've seen and was part of the catalyst for the housing conservatorship was the increase of met methamphetamine and that stabilization and it's deteriorating and i appreciate the opportunity, because i think it will make a significant difference. >> for a very, very small number, but yes. >> but very important individuals. and the other thing that i think you were commenting on is regarding the court's interpretation of grave disability and the way it is worded currently in the

institution's code is nuanced and up for interpretation. and so i think that having more clarity at the state level of what it means to be gravely disabled would be incredibly helpful because i think that is likely to impact a psychiatrist moving forward with conservative, depending on how the court interprets that. the other thing that think is important and related to these investments that we have is -- and we look at this across our system of care not just with conservatorships or facilities but to the point of are we moving people into lower levels of care too soon? is increasing our capacity and flow to move people back to restrictive levels if that's needed but giving people the opportunity to be successful at those lower levels of care? >> i wanted to ask about this little wrinkle in lps that to

read it allows for establishment of lps conservatorship based on chronic inebriation but it is my perception that we don't do much of that. my office keeps a list of people we hear about, how my constituents cannot understand how this person is still out there. i'm thinking of a 72-year-old man, who has been hospitalized more times than anyone can count, who everyone sees often with sores on his body, bleeding, going into stores and restaurants over years, ok? and the response i got fro froma doctor at dph, well, he might be reaching the point he might be appropriate for a conservatorship. well, the non-dph, non-city hall

san francisco response so that is that's insane. if that person were my uncle, my father, anybody in my life, i would want that person to be taken care of and we are completely failing. the underlying issue, there's probably dementia and who knows what other issues, but he is a chronic alcoholic and so, taking that -- we're not talking about a specific person, but -- except i sort of am. but why are we not able to use chronic eknee briation even though the law calls it out? >> it's do to chronic alcohol or mental illness.

>> so when that person gets describegetsstabilized and by te was taken in before a court under a petition for a conservatorship, he's not exhibiting grave disability that moment, even though is a chronic inebriate, the fact the language is in the statue, that presents us from making the case for conservatorship? the individual has to meet the same threshold of grave disability. but one thing i'll say, ang gelcandgelca and i did discuss , the individuals who have alcohol use as a primary use disorder, have an overarching, major mental illness. in addition, they may be using alcohol and additional

substances, as well. we have 4,000 in san francisco whsan franciscowho have an alcod we know the vast majority use alcohol and may use additional substances, too. you highlighted dementia and the way that our regulatory systems treat individuals who lack capacity, is that we have a divide between those with mental illness and those who have a cognitive impairment, deteriorating type of dementia and we do see -- in effect, i was involved in one case on the public guardian side and we were working to protect an individual who is a chronic inebriate.

he is definitely, by all accounts, everyone agrees gravely disabled due to chronic alcoholism. but when he is an acute setting, he gains the institutional sobriety. he still has a very significant level of impairment, but the impairment is due to a cognitive impairment. for this individual that i'm thinking of, it's no longer due to a serious illness. we have been working to move towards a conservatorship for this individual on the probate side, as well. so that may be in many instancee get thavedata -- but one may bee intervention that's more appropriate. >> it was reality we have so

many people cycling through jail and psych emergency and i have a number of these folks who get picked up and maybe make it through, say, get into behavioral health court or drug court or simply through a hospitalization get stabilized and never reach the point where we petition for a conservatorship for them and i think your understanding is that we probably couldn't because even if they have an underlying mental illness, the role substance use plays in their illness is such that they can be stabilized and not be appropriate for a conservatorship by the time they are brought before a judge. so senator weiner came up with sb1045 and it was suggested that that was the wrong way to do it,

the 85150 or some number of 5150s because you could put it in the law the way chronic inebriation is but that's doing us no good at all. i'm concerned sb1045 was way too small for the scope of the problem and we should be expanding it. but it seems like insofar as adding substance abuse like alcohol, it may not get us very far. >> i think what's important about that, an individual doesn't need to be placed on a 5150 but needs to be on an inpatient unit and that goes through a court process. >> under traditional lps. >> under traditional lps, right. so i think what housing county enforces iconservatorship enfort

cycling in and out. while it's important to account for others, it just adds that into lps. >> unless there are more questions, i want to get dr. leery up here for a second. but i do want to thank you for all of the work you do everyday and i want to implore you to use every tool in your toolbox to reach as many people as the current law allows to continue doing the outreach in the work and to encourage them to refer everywhere appropriate to work with the city attorney's office and do everything we can to push the limits of what we can get away with, actually. like i noticed that the petitionone of these charts shows a number of permanent

conservatorships and this is on page 6, temporary conservatorships and the number that were declined. we asked for and they were declined and we went from 12, and then one this '14-'15 and that success and that you have lined -- the system is not recommending people for conservatorship who judges are determining that's not a good idea. but i wonder if there might be some folks who would benefit, who should be conserved, who are not having to go with the court around having folks denied and make that case -- some harder cases. i know the cases you're doing are hard and take a ton of work. but we want to encourage you to get as many people into care and we should be advocate for changes in state law and whatever the governor comes up with lps reform, please let our

offices now what we should be advocating for. thank you. >> thank you. >> and then dr. leery, can you come up for a moment? so tell us who you are and what you do and why you've shown up today. >> i'm mark leery, the interim chief of psychiatry at san francisco general. i've worked there 30 years at the locked in-patient units and psych emergency and city-wide case management and the jail psychiatric program. i want to thank you for your deep interest in this issue and the way that you're looking at it in such ad manner. >> i think we're in actually, a

moment with opportunity because we're approaching it in different ways but i think it's not every member of the board, and certainly the mayor who all want to try to make progress on these issues. so i want to talk with you about the beds and kind of the choke points in the system and what's hard and why people are stuck. and one of the things that i understand, from prior conversations with you and from these reports and the conversation we have been having is that we do not have enough locked subacute beds for the need. that means people get stuck in jail. they get stuck at general, in acute care. and we just don't have enough and i'm wondering if you could tell us if you have any idea what the additional need is for

locked subacute beds to create more flow out of pes, to free up people, more flow out acute psych unit at general and out of jails and actually meet the city's needs and maybe be able to conserve more folks who need a conservatorship and shouldn't be returned to the streets until they're in better shape. >> well, i would start off by saying, i agree that absolutely, we don't have enough locked subacute beds for the patients that we have in san francisco. and it's a difficult number to -- to answer the question of how many we need, i'm not sure that i can do that, not being a statistician or epidemiologist but i can offer a good place to start. in recent months, we've had often about 20 people on our acute locked-in patients at sanfrancisco general waiting for

lock subacute care. and that's just the one time, a snapshot, on any given time. and as you saw from the report, they wait an average of 51 days. so if you multiplied the 20 patients times the fraction of a year 20 days is, it would come out to about 120, 125, something like that. so that would be, think, a reasonable estimate. we might not need that many. we might need more. it's hard to tell, but it's clear we need more beds at every level of care and i think we always want to emphasize people getting treatment at the least restrictive setting they can be

successful at. so we need beds at every level and that's a crucial point but things like supportive hotels and supported housing. but the biggest choke point, people that need lock subacute care, there aren't other options to creatively put together to treat them successfully. people that are less severely ill, we can be more creative and different options can be successful. but i think ultimately, the lock subacute treatment bees are the biggest choke point. >> do you know the cost of those beds. >> i don't. >> they are quite expensive, quite necessary, but even as i said, even just the mayor's proposal to expand our st. mary's capacity by 14 beds in this last year's budget was

something people were coming after as an investment in incar ratioinincarceration or the wrog level of care. but you know, you can get more community beds for the price of a lock subacute bed but from my perspective and what i've heard from you, we need to make the lock subacute beds a priority this year. >> i would agree. lock subacute beds are less expensive than acute psychiatry beds. >> one other question, not exactly on topic here, but pes is on diversion how much of the time these days? in recent months about a third of the time, 35% of the time, which is way too much for our system. our goal is to never be on diversion. we want to accommodate anyone

who needs emergency psychiatric care. >> it strikes me that, again, our inability to get care for people on a longer-term base exist we're nobasis,we're not tn the wrong place. >> right, half of our visits to pes are return visits by people that have been there at least one time before. >> so when pes is on diversion, are they able to be seen at our other hospitals? because i know you and i have had this discussion before and i'm wondering where there might be issues with that. >> so it's far from an ideal situation. when we're on diversion, what happens is that police and ems will bring people that are placed on a 5150 to the nearest

community hospital. >> to an er. >> to the nearest community hospital, correct and no hospital -- we're the only psych emergency system. no other hospitals are equipped and they don't have the facilities to take care of someone on a 5150 over a period of time. as soon as we get off of diversion, which is not as often as we would like, then we bring those patients to esfg. >> did those hospitals at one time have the ability to take care of emergency psychiatric patients? it seems like there was a time there were bees at our community hospitals and now there are not? >> well, there definitely were acute inpatient beds at a number of the hospitals. st. maries had an adult unit and

mount zion had one and that closed. what would happen when they had units, i think often people would get admitted to an acute unit when all they needed was an emergency psychiatric visit, not inpatient hospital visit. if i could just -- i just want to underscore something that jill said about the communication. i think that we have a really great partnership with the office of the conservator and we have open communication -- the theconservators meet with us once a week i it's a good partnership and i want to underscore that. >> thank you, dr. leery, for your work is i want to encourage you to come to us as you see

additional opportunities and i hope that people are not self-regulating and not referring people for conservatorships when they think those are appropriate because they're concerned about the lack of placements. >> well, i mean, if i could address that, to be as real as possible about it, i think that i would underscore what angelica said, we keep them in pes as long as we have to, if it's clear-cut, we keep them in pes as long we need to. we admit them didn't they have to wait days, we do that, if it's a clear-cut case. but the lps law, as you know, is not precise in terms of what defined grave disability. and so, there's a huge gray area and if we mow tha know that we t

have the inpatient bed capacity, then we're less likely to admit someone or to refer them for a conservatorship, knowing that will put us in a position to treat the people with acute emergency conditions that we absolutely have to. >> you're in triage mode. >> yes. >> thank you for your interest. it sustains us, so thank you. >> thank you for your work and thanks to everyone at general. so with that, we'll open this up for public comment. if there are any members of the public who would like to speak on this item, please line to your right, our left. and seeing no public comment on this item, i will close public comment. and i will make a motion to have this hearing heard and filed and

take this without jokes. objection. great. mr. clerk, any other items before us today? >> that concludes or business for today. >> then we are adjourned.

>> the bicycle coalition was giving away 33 bicycles so i

applied. i was happy to receive one of them. >> the community bike build program is the san francisco coalition's way of spreading the joy of biking and freedom of biking to residents who may not have access to affordable transportation. the city has an ordinance that we worked with them on back in 2014 that requires city agency goes to give organizations like the san francisco bicycle organization a chance to take bicycles abandoned and put them to good use or find new homes for them. the partnerships with organizations generally with

organizations that are working with low income individuals or families or people who are transportation dependent. we ask them to identify individuals who would greatly benefit from a bicycle. we make a list of people and their heights to match them to a bicycle that would suit their lifestyle and age and height. >> bicycle i received has impacted my life so greatly. it is not only a form of recreation. it is also a means of getting connected with the community through bike rides and it is also just a feeling of freedom. i really appreciate it. i am very thankful. >> we teach a class. they have to attend a one hour class. things like how to change lanes,

how to make a left turn, right turn, how to ride around cars. after that class, then we would give everyone a test chance -- chance to test ride. >> we are giving them as a way to get around the city. >> just the joy of like seeing people test drive the bicycles in the small area, there is no real word. i guess enjoyable is a word i could use. that doesn't describe the kind of warm feelings you feel in your heart giving someone that sense of freedom and maybe they haven't ridden a bike in years. these folks are older than the normal crowd of people we give bicycles away to. take my picture on my bike. that was a great experience. there were smiles all around. the recipients, myself,

supervisor, everyone was happy to be a part of this joyous occasion. at the end we normally do a group ride to see people ride off with these huge smiles on their faces is a great experience. >> if someone is interested in volunteering, we have a special section on the website sf bike.org/volunteer you can sign up for both events. we have given away 855 bicycles, 376 last year. we are growing each and every year. i hope to top that 376 this year. we frequently do events in bayview. the spaces are for people to come and work on their own bikes or learn skills and give them access to something that they may not have had access to.

>> for me this is a fun way to get outside and be active. most of the time the kids will be in the house. this is a fun way to do something. >> you get fresh air and you don't just stay in the house all day. iit is a good way to exercise. >> the bicycle coalition has a bicycle program for every community in san francisco. it is connecting the young, older community. it is a wonderful outlet for the community to come together to have some good clean fun. it has opened to many doors to the young people that will usually might not have a bicycle. i have seen them and they are thankful and i am thankful for this program.

a principal analyst recently appointed as acting administrator responsible for developing all of the rates and charges for the water, power services we provide. >> the main things i work on are rates. it is really trying to figure out how much money we need to fund our operations and maintenance and thinking how to collect the money in a way that is fair to customers and sincentives for water conservation or installing stormwater management on their property. >> i nominated erin for the many accomplishments she has provided

especially for the financial sustain ability. the reality required a lot of work retooling policies, financial planning as well as many rating and charges. er ron served in the projects including update to water and sewer rates, update to 10 year financial plan as well as setting the budget for fiscal 2019 higher 2020. >> i am pleased with working here. i feel like we have tons of work to do. it is important work. it has a direct impact on people's lives. >> she has a unique ability to get to the root cause of the issue and help develop consensus around a solution. not only is it troubleshooting what the questions are, but also coming up with what are the alternatives. >> i think a lot of the

satisfaction from the job is looking back over the past few years and seeing cereal concrete change we have been -- real concrete change and that gives me pride. >> the team very much appreciates her hair color and the world of finance and accounting tends to foster conformity and boring guys like myself. i very much admire the fact that she walks her own walk and creates her own path, and i think we all can learn a little bit from her. >> i and a principal revenue and rates analyst in the financial planni

nni >> clerk: this is the fire commission meeting of november 13, 2019, and the time is 9:01 a.m. roll call. [roll call]