>> next speaker please. >> hello. i'm a san francisco resident. i want to express my concern about conservatorship. i don't think it support people with mental illness like 5150 like many others say. i agree our first priority and focus for resources should be providing housing and further voluntary services and voluntary treatment. thank you very much. >> next speaker.

>> [indiscernible] i think people are physically intolerable. as for people who -- [indiscernible]. thank you supervisor mandelman for having this hearing. second one, there are thousands of empty hotel rooms in san

francisco. the issue with beds, we can look at that. issue with money, we have $431 million in the budget for homeless services. we heard lot about data collection.

i am completely against -- >> your time has expired. >> thank you for your comments. >> next speaker. >> good morning. i'm a community leader in district eight. i'm really pleased that you're having that hearing today. the data presented shows how tragic the tragi situation is. these are people with severe mental illness. we all agree with that. hotel rooms are not the option.

when someone is in violent psychosis. it requires that we implement -- we put together the steps to take some people who are experiencing psychosis and treat them. starting with acute beds and with all due respect to those who are here today, i'm just hearing legal words. i'm not hearing any transparency around what is needed, what the estimates are, the beds. they're not giving you the right number. not initially during covid. our healthcare providers got the beds. they got lot of beds. only after we started seeing how many people were basedden estimates, how many showed up. we can begin to understand. we reserved enough beds to take care of those who will be ill.

that's right thing to do. other city have done this. i'm saying because i'm so frustrated. i look at this pro -- problem fy direction. >> your time has expired. >> thank you very much for your comments. next speaker please. >> hi. i think it's completely astonishing to be thinking of implementing sb1045. there's still not an alternative to policing mental health and substance abuse the racial bias and poverty bias among police is still very real. we needed an expansion of voluntary services.

resolving door will continue. in my work, i worked with people of mental illness. i can't give services. my med got taken by d.p.w. i don't have my meds or doctor number anymore. people want the help. they can't get it. i'm done. >> thank you for your comments. next speaker please. >> my name is lauren. i'm invested in the city. i'm heart broken by the city that i see in my city with

people experiencing homelessness and mental health. i don't support implementation of s1b1045. it's clear that the police are not the people to be providing services to mental health. as people said before me, i think the issues with 5150, the solution should not be responding to the calls in the first place. even that as being the pathway to having a conservatorship, is something that concerns me. i really think that if people were able to get housing to be stabilized, that would really help with their substance abuse issues. especially with covid-19 now, when people are in close quarters it's still risky.

putting people in hospital beds where they're close to each other, does not seem like a good idea. i woul would advocate for expann of more voluntary services. >> next speaker. >> i'm dr. ron cooper. after retiring, i worked in various venues here around the city. i have seen people who have been concerned. when you talk to them about getting services, they say, i'm not going to see a social

worker. look what happened to me last time, i lost my job, i lost my house and everything i owned ow. that's not unusual. post-traumatic stress disorder and reluctant to seek future psychiatric and social services. physicians who see them should be making those judgments. now a policeman, people who knew before, it's now become graphic, are not the right people to be making medical decisions. if you get a chest pain or head pain, you don't call your cop. you call a physician. if you don't like your physician, you get another one. one who will address your

problem. this bill is foolish. it will create more problems. thank you. >> next speaker. >> my name is ashley. i appreciate everyone putting this together today. thank you supervisor mandelman. i'm with the callers that are concerned about the safety of the city by not commending conservatorship process. i think it's open for debate. it needs to happen. if you look at next door, the chronicle, there's countless posts about assault, sexual assault, other criminal activity, theft and murder. while there's lot of concern for those who need help, there needs

to be equal concern through those house resident who are experiencing crime and still frankly, san francisco shouldn't be proud it has a map associated with it. needles everywhere. i feel compassionate for the people on the street that needs help. it cost a lot to live here. it's naive for people to think that housing is the only solution. look to other cities and countries. housing along with mental healthcare and drug addiction services. they have to go together. senator feinstein's idea of putting people in cal palace,

working with other counties other areas in the state is far more realistic than trying to carve out an area of the city that's expensive for those who worked really hard and pay lot of money to live here. i appreciate you taking the time and let's try to prevent more of those situations. >> next speaker. >> i'm an organizer. we have been opposed to this expansion of conservatorship from the beginning because it's a violation of people's civil liberty based on mental health disability, homelessness, and detention. we've advocated for easy to access services and housing in the community which contrary what the last speaker said, i believe it's totally possible for san francisco to provide.

we haves on of empty units and tons of money in our city. even now we haves on of hotel rooms. at this point in history, it's adopted by the board. problem with conservatorship are much more clear than they were a year ago. in california, 50% of covid-19 death have be in long-term care facilities. that includes nursing homes and psych hospitals. these institutions have never been safe. now they are deadly across the board. have anyone been conserved under that program? would they be still be alive today. think being this pandemic and putting people in hospitals for other institutions is just a horrible approach. at the same time, the mass uprising against police violence against black people across the country, highlights why this is

the wrong approach. black people are 5% of san francisco's population and that leaves 30% of people with with more 5150. this is out of proportion and it shows the racism of the system and it shows how increasing police contact with people and mental health crises will lead to more killing. we continue to oppose this expansion. we're glad no one has been conserved under it yet. >> thank you, next speaker. >> my name is gracecy. i'm a san francisco resident. we need to reduce all police interaction with people who are

mentally ill. we need to develop resources that don't involve police and provide housing and develop solutions or punish them for having a mental illness. if you are housed in -- you should be advocating for providing house and safe resources. they are working hard to survive. the city is falling us. thank you. >> thank you. next speaker. >> this is rachael rodriguez. i'm calling to share my thought about sb1045 how the

conservatorship now in an intermentation phase. i work everyday -- i work with these folks very closely and have over the past year since we've had conservatorship in process. i have sent these multiple times to try to engage in intensive case management services, to do residential treatment program, to crises program and to housing opportunities. these have not worked. these individuals have been unable to make these opportunities work because their illness is too acute. these individuals who deserve a chance at housing and voluntary services. however the current condition of their symptoms do not allow them to participate in it. we have tried and we've seen it fail.

thank you so much. >> next speaker. [indiscernible] >> before the speaker continue, can you hear me? we seem to be having a lot of chatter on this line. it's very hard to understand what's being said. can you speak more clearly in

your microphone? your time begins now. is there a caller connected to the line presently? next caller please. for any callers who may have eattempted to connect to this public comment period by dialing star and 3. it is your opportunity to speak when the system prompt you by telling you that your line has been unmuted. are there any callers connected to the line presently?

>> i'm a resident of san francisco, 30-year resident of san francisco. i want to agree with the caller who said that there is a population that simply cannot access the voluntary services because their need is too acute. that's what this conservatorship is designed for. i really appreciate hearing that from a professional who works with them day in and day out. i'm calling to say that it seems to me as if from listening to this hearing, the department of public health is doing everything they can to drag their feet and prevent this from working. even if they've been doing a banged up job, it's sure

depressing. supervisor mandelman said, supervisors have noted, we clearly have this disconnect between these people who -- conservatorship is what they need. they cannot manage to stay in the voluntary services. yet, we can't seem to connect them with that. i find it really -- as a person who finds it frightening to go out on the street because there's so many crazy homeless people. we have empty hotel rooms for them. i attended a meeting where housing -- homeless team members described the three populations. one of them is the travelers. that's the one that permanently on the sidewalk in my

neighborhood. >> i fully support what the supervisor is attempting to do. focus of this meeting is really very acute patients in the city walking around like zombies. i don't understand why you can't do for someone who can't do for themselves. the year that we have spent where we're talking about someone who had eight incidents

a year and we can't put someone into some situation which will certainly enhance their lifestyle and i don't understand the emphasis on the police and the racial implications.

>> also, work on making sure that there's common understandings of definitions and how to operate the policy. it is new, it is complex, lots

of interconnecting parts, but we've seen many times where even the definition of 5150 isn't clear, and there's lots of inputs into this, right? you've got outreach teams, you've got doctors in emergency rooms, you've got police officers. everybody has to understand how the program works, not just s.f. general. two, like to see some data improvements. not just in the collection of data and the emerging of data, which i know is a massive undertaking, but the consistency of who's reporting. i read in an initial report because -- >> clerk: your time has expired. >> clerk: thank you for your comments. before we go to the next speaker, to the remaining speakers in the line, you will

know when your line is unmuted when you hear the announcement come on the line. could we get the next speaker, please. >> hello. this is david mora. basic programs like behavioral health treatment aren't available to address and triage issues before they get more severe. you know, this is -- definitely feels like a groundhog day moment. i'd just encourage us as a city to find out how we can implement the services that

we've talked about so long in so many different meetings and also take into account that we have shelter in place and social distancing issues that, for example -- [inaudible] >> could we get the next speaker, please. >> my name is jennifer. i'm a resident of district 2. i would like to thank everyone fo for organizing this. it's been very helpful for me to learn about how agencies do

a housing and conservatorship. in district 2, we experienced a homeless encampment, and through that, we saw many of the unhoused populations suffer mental illness. i understand the issue of giving them proper care and access to volunteer services, but, you know, many of them are seriously mentally ill, and i remember hearing people yell on the streets, i'm going to kill you. as a resident, i feel very unsafe. i know it's not right to call the police, but i don't know who to call to get help. for people of any color to live with a state of mental illness on the street, this is not compassionate, so i strongly support housing conservatorship. thank you very much. >> thank you. next speaker.

>> hi. this is jessica with senior and disability action. i'm also a member of the housing conservatorship working group. i am really shocked to hear conservatorship being used as a tool for mental health. people ask what's happening in other countries. in other countries, people have voluntary services. there's a couple of things that we've seen on the work group. one is that there's still no evidence that housing and voluntary services are provided. there's been discussion on the working group about the lack of services, the long waiting lists for housing, the look of

coordination. the preliminary data doesn't show whether people with multiple 5150 holds have been offered supportive housing, much less engaging in services. we see nearly one-third of people with four or more 5150s or african americans with no clear explanation of why or how to address that. also, the city ordinance requires information about detentions by police and/or someone from a mobile crisis team or analyzed and shared, and that needs to happen. this makes me wonder how much money has been spent on

research and implementation, how much it spends on 5150 detentions by police officers rather than social workers, and how many could the funding -- >> that's your time. thank you. >> thank you for your comment. >> mr. chair, that completes the queue. >> supervisor mandelman: thank you, and i will close public comment, and i want to thank all of the -- all the folks who took time out of this morning to attend this hearing and call in and share their thoughts. i guess i have one final question, just in terms of next steps. it sounds like it notices that folks that have had five or more 5150s have started to go out. what do we anticipate is the

next steps on this, and what's the timeline? >> thank you, supervisor mandelman. so as you indicated, we started to give notices to the individuals who have hit their fifth 5150, so it's really a matter of supporting those individuals, again, trying to identify less restrictive options to serve them. then once they get to their eighth 5150, we'll be working with the hospital where they're at and the department of adult and aging services, and then, it'll be the responsibility of the triage to submit the paperwork and then submit that to the court. >> supervisor mandelman: what's the timeline for that? >> it could be next week, it could be next month. it just depends on when

individuals hit their eighth 5150. >> supervisor mandelman: then i'm going to move that we check back in on this in one month, so i'm going to continue this to our meeting on july 23. mr. clerk, please call the roll. >> clerk: on the motion to continue this to the public safety and neighborhood services committee -- [roll call] >> clerk: mr. chair, there are three ayes. >> supervisor mandelman: all right. then, the motion passes, so we will continue this conversation on the 23rd, and i hope have some good news on progress. i'd like to thank all the good folks that are working to make this happen, and with that, i want to ask our clerk to please call the next item.

>> clerk: agenda item number 2 is a hearing on the impacts of covid-19 on the city's response to the behavioral health needs of unhoused san franciscans. members of the public who wish to provide public comment on this hearing should call 415-655-0001, enter the meeting i.d. of 14578532772. press the pound symbol twice to connect to the meeting, and then press star-three to enter the queue to speak. mr. chair? >> supervisor mandelman: and i would note that although she has stepped temporarily away from her desk, we've been joined by supervisor ronen who is the principal author of mental health s.f. >> supervisor ronen: thank you. >> supervisor mandelman: colleagues, i requested this hearing to give the department of public health to give the

opportunity the board to update the public on how the covid-19 has impacted the behavioral health system to respond to the health needs of people a. covid-19 brought life in san francisco to a screeching halt in all sorts of ways, and in many ways, that has led to the significant success we have had in flattening the curve, those early and aggressive steps to shelter in place have saved lives and allowed us to claim the lowest mortality rates in the country. so i in no way want to did etr

from the enormous success we have for the department of public health, but in this shelter in place, it's become clear that this new public health crisis that we're dealing with has only exacerbated the existing public health crisis of mental health that we're dealing with on our streets. any walk-through the castro, the mission have scenes of human misery that are shocking to all of us, and should be. you cannot walk-through these neighborhoods without encountering shocking numbers of people in full blown psychosis or very close to it, and that's sort of the tip of the iceberg. there's clearly a ton of untreated mental illness and substance use disorder all-around. and clearly, i am most focused

on the neighborhoods that i represent, but i am well aware, other neighborhoods in the tenderloin, but throughout the city, that have fared far worse. no one has been spared in shelter in place -- no neighborhood has been spared. so these problems are not new, but the urgency with which we most focus our attention on them is greater than ever, and the horrible paradox is that our fiscal resources are more stretched and will not more stretched over the coming years than they have been in decades. and so covid-19 has disrupted some of the very important initiatives that we were hoping would address the problem we knew we had three months ago, principally, mental health s.f., but the creation of the

city's first sobering center. there's a long list of programs, innovations, reforms that were supposed to go forward that my impressions that programs stalled or stopped. we must adapt our delivery of behavioral health services to fit within a broader covid-19 response that no longer allows sick and addicted people to

languish in public spaces even as we continue to fight the coronavirus. so i believe we can do this. indeed we must do this. it's not an option in 2020. i think it's essential, and so i want to invite, in whatever portion they want to present, the director of mental health reform, and the director of mental health and d.c.h., and we have marla simmons, the director of behavioral health services. and i see that supervisor ronen has comments, so i will allow her to give comments before. my hope is that our speakers will be able to -- will use their presentations to explain what's happened over these last

few months, i think it's important to explain why there are so many people out there, and then share your plans about h -- thoughts about how you're planning to tackle those needs over the next months and years given that we can't allow the current status quo to continue. so with that, supervisor ronen. >> supervisor ronen: thank you so much, chair mandelman. when this crisis first began, and d.p.h. was monitoring the situation extremely closely, well before the three months that we went in place, dr. colfax, the director of public health gave me a call and said hillary, i don't want to have to do this, but we're going to

have to delay the push and implementation of mental health s.f. because we have a crisis. i said of course. this is the biggest crisis of our lifetime, and we need to get a handle on it with all our resources in the city, and that's what we did, and that's what we continue to do. that totally made sense. but i want to remind everyone that mental health s.f. is the blueprint for mental health reform in san francisco. it was passed unanimously by the board of supervisors with the cosponsorship of the mayor, and it is the way that you take hundreds of disconnected, disjoined, oftentimes really fabulous services, and you create a system out of them,

where nobody falls through the cracks or very few people fall through the cracks, and you have a way to bring people back in when they fall off their treatment plan because they actually have for the first time because we don't have people on treatment plans right now. i want to say from the get-go so you can address this -- i read the powerpoint presentation a few minutes ago and have a ton of concerns about it. first of all, it doesn't recognize mental health s.f. as being the blueprint for fixing the mental health system in san francisco, which it is and is currently the law. what i would have liked to see is your initial thoughts during and amidst covid and the fact that it's diverted resources, etc. will be put into play.

instead, i see mental health s.f. as a list of initiatives, and that is not what it is and should not become. these disjointed efforts are how we got to this point in the first place. you have people cycling from jail to emergency services back to the street without getting back and getting worse when they're pushed back into the system in whatever way they'll be pushed back into the system. so i will be asking a lot of questions about that. i am currently working with ben ros rosenfeld to cost out some figures initially, and because

the mayor announced as part of her police reform measure that she wanted to create what's already the law in mental health s.f., the crisis mental health street team, we need to implement that, as well. i am glad to see there is a study being done about bed flow, and i think that's important and a necessary study to implement mental health s.f. i do not like that it's being talked about as an independent measure. hopefully, i'm wrong, and the presentation is just poorly communicated, but i do not appreciate or like that the department is thinking of mental health reform outside of implementing mental health s.f. because that is the city blueprint that has been

unanimously passed by the board of supervisors about how you effectuate mental health reform in this city, and its implementation is what we should be discussing right now and in the many months moving forward. so i wanted to make that clear from the get go. that's where many of my questions will be focused today, and i'm looking forward to working with the department, with the mayor's office, with supervisor mandelman, to implement mental health s.f. within the new realities of our fiscal situation and covid-19. >> supervisor mandelman: thank you, supervisor ronen. and i will say, i think at least in part, the presentation was crafted in response to sort of specific questions that i had asked around things like this. so i think a little bit of it

is probably my fault. but with that, i think -- who are we hearing from first? from dr. hammer? >> yes. good morning, supervisors, and supervisor ronen, i hope that we address your concerns in this presentation and our answers to your questions, and that we can confirm our commitment in the department of public health to -- our commitment to mental health s.f. and to moving forward with you all and, really, with the city to implement the different projects and the general kind of mental health s.f. that you just articulated, so i hope we move in that direction today. as supervisor mandelman said, i'm the director of ambulatory care for the san francisco

health network and d.p.h. it includes health services, primary care, adolescent health, jail health, and health of people experiencing homelessness. i'm joined by dr. simmons and bland, who are the director of behavioral -- who is the director of behavioral health reform. this morning, i will share with you the information on how behavioral health has been impacted by the covid-19 activation and also discuss with you our priorities as we look forward to the coming year. like everyone across the city, behavioral health services has been significantly impacted by covid-19. we have been in pull response mode with the citywide covid activation since the beginning

of the public health emergency. we have also continued to engage with our existing clients. almost all of our clinics are open across all of our multiple systems of care. we've engaged in outreach efforts to people on the streets, and we are integrating new services which are part of the covid-19 response. every member of the behavioral health services leadership and staff deserve recognition for how hard they've worked, the part that they've played in flattening the curve in getting us through phase one of the shelter in place order, and responding to the needs of the city in the face of this unprecedented global health crisis. we have some early success in containing the virus. very cautious sense of early success in this city during phase one of our response to the global pandemic, and we're now shifting our attention to

our behavioral health quality improvement and reform efforts and really looking to see how what we've even focused on the last few months aligns with the work we need to do to start moving forward on mental health san francisco. we -- we need to do this really comprehensive assessment of what's possible, given our new reality, as we begin our budget planning for the coming years. we know that resources available to mobilize new access, care coordination, crisis response and outreach efforts will need to be directly linked to our covid-19 work as we prepare for the next surge and also will be impacted by the budget picture that unfolds in the face of an ongoing response to covid and its dire impacts on the economy. next slide.

in the recent path, we were working with four changes to behavioral health services in san francisco. we were deep in planning, embarking on a community health [inaudible] that started with mayor breed's appointment of dr. bland as director of mental health reform and were aligned with the tenants and specific projects of mental health san francisco. [inaudible] >> yeah. so the thing that we were -- are you asking what we were already working on? >> supervisor ronen: yes. >> yeah, i think i'm going to talk about that a bit, but in terms of those things that came out of the mental health reform

work before mental health s.f. legislation was passed? >> supervisor ronen: yeah. >> yeah, so that optimization that you'll hear about today, really we'd been very focused on and gotten very far on. with the mental health s.f. legislation, we -- as you said, that was sort of a coalescing of several projects and gave us a sense of how to build the infrastructure really hinging on care coordination and access and optimizing access while really doing much more work inread of i instead of in clinic. >> supervisor ronen: and the bed optimization project and

bed sobering center, was there anything else that you were working on with mental health s.f. that's related to mental health reform? >> yes. so we were working on the -- redoing of our behavioral health access center, so a remodelling and expansion. a lot of street outreach work, both the street medicine and our street response teams, so is that what you're asking about? >> supervisor ronen: yeah. it's just -- i wasn't aware of a lot of community outreach on mental health reform prior to mental health s.f. >> yeah. i didn't say that was before mental health s.f. i said before covid-19, we were

working on we'll engaging many stakeholders to figure out how we would begin to develop many of the projects. they were complicated projects. like, the behavioral health access center, so how do you take a -- a fixed access center which is at the corner of 10th and howard, expand it to 24-7. how do we staff that? what are the roles of prescribers? those were the thinged we were working on and trying toen -- those were the things we were working on and trying to engage our efforts. should i go on? >> supervisor ronen: sure. >> so three general buckets of this transformational work. so the bed composite, developing our street crisis responses, and outreach services. before we want to go on, and

i'm not doing sort of an overview of behavioral health services, but just need to remind you that behavioral health services is a large and complex system, so we're both mental health and substance use providers with multiple systems of care, including transitional age youth, older adult services. we do a lot of prevention work, and we're also a mental health plan, which contracts with over 80 providers of mental health services in the city. with the covid-19 emergency beginning in february, providers, and our contracted c.b.o.s, like many others throughout the city, have shifted our attention, resources, and much of the staff to the response to t-- t

the covid-19 response. i do want to spend a couple of minutes going over the impact of covid-19 on our services and our clients and what we've been working on that's different over the last 17 weeks of the activation. we're really focused on our main strategic and budgetary priorities, which i think is also what you want to hear about. our mental health s.f. plans and covid response work is fully formed by our current economic forecast. there's still a lot of uncertainty, and what i will share with you today are those priorities that we think that we can and must move forward in the current budget picture. so pleased to say that d.p.h. was able to meet our general fund reduction target without cutting any services, but because of the current

situation, we're not able to provide any expansion. we remain committed to keeping the momentum that we had just started on mental health reform and mental health s.f., but given the very rough price tag on mental health s.f. and the financial situation, we understand it's unlikely to happen at all this year barring a significant new resource -- revenue source, so we'll focus on where we really think we can move forward quickly. we are working on ideas, and i know we'll be meeting with you, supervisor ronen, and really if we move into phase two and continue to flatten the curve, we'll see where we can make some reforms in mental health s.f. reform.

it's to be determined what's possible given our budget constraints. we're grateful for the tremendous support from the mayor and the board of supervisors and know that through collaboration and shared vision we will move toward this transformational vision articulated in mental health san francisco. finally, we'll have on the bond in november 20 -- this year, approved by voters will give us some funding for key facility needs, so space for the bed in the modelling project and other plans such as the sobering center and other expansions. next slide. these are our four main budget and fiscal priorities in the

coming fiscal year. these four priorities reflect our commitment to mental health s.f. and the covid-19 restraints. starting at the beginning of the public health emergency, we dramatically scaled back our public health services across ambulatory care. we shifted most of our encounters to telehealth, only about 20% of our visits to now over 60% of our visited being provided by telehealth. impressively, we've been able

to remain in contact with over 85% of our established mental health clients and have continued to see use of mental health services. we know from calls to our comprehensive behavioral health a access lines and visits to our kle clinics that acuity has increased because of covid, and we are concerned about the people that we've not been able to reach. some data is hard to interpret because of covid impacted changes to work flows. there's been impact on flow through the whole continuum of

care, though we haven't seen the increase in demand of acute services that we expected, but we need data so that we can understand why we're not seeing the increase in acute visits. we feel relieved to be moving into phase two. again, if we do not have the surge which we're now planning for, phase two of the shelter in place, we look forward to resuming many of our in-person visits, and we hope to reconnect with established patients who have been difficult to contact during our mental health outreach work. we look forward to continuing our care in the coming months while also, with the command center, preparing for the surge and adjusting our staffing

accordingly. there have been significant impacts in residential treatment since the beginning of the covid-19 public health emergency. i'll just talk a little bit about that, but we can go into detail if you want to hear it. review of our providers shows an increase in length of stay of residential programs. our providers have been reluctant to discharge clients into an unsheltered place. we saw a decrease in beds in both man tall -- mental health and substance abuse programs and also allow for isolation of clients while awaiting results,

so there was a challenge. there was a lot of admissions to programs early on and then no corresponding flow out, so again, the whole continuum of care has been impacted with reduced flow through all parts of the system. some programs even had to shutdown for a short time due to outbreaks. it's really, really hard to keep a residential program open when you have staff and patients who test positive. [inaudible] >> say that again? >> supervisor mandelman: have there been any positive tests at hummingbird? >> yes, there was. our first positive test was last week, and the outbreak management team of the d.o.c. has, you know, shifted their attention to hummingbird. we've been doing testing, and shifting to the hospitals to

address the positive cases at hummingbird. oh, this slide. okay. so i'm going to focus to the first of our four strategic and budgetary priorities for the coming year. >> supervisor mandelman: actually, i'm sorry. can i make you go back to the problems slide? >> the problems? yeah. >> supervisor mandelman: because i want to talk about the future, but i kind of want to talk about where we are, too, as well. >> okay. >> supervisor mandelman: so what does it mean when p.e.s. is limited to 18-bed capacity? what happened? >> so people coming into p.e.s., i think as you know now, there's a new work flow, so they come through the medical emergency room and have a rapid test before they enter that more congregate setting of p.e.s. we have p.e.s. medical staff

who are stationed now in the medical emergency rooms, so psychiatrists, nurses, and some -- because of this change in work flow, i think more people are leaving before they even get into p.e.s. that may account for the reductions in admissions to p.e.s. >> supervisor mandelman: so you come down in the e.r. before you even get to p.e.s. >> right, right. it's a -- this isn't optimal, but it's probably a three or four-hour long process as people are assessed and tested, and then, we await test results in the e.r. >> commissioner mondejar: so this seems like a problem for the e.r. >> this is a problem for the e.r., but i think a really impressive shift in work flows -- i mean, i remember the day being on the hospital incident command call and

hearing when the first person came into p.e.s. with symptoms and tested positive, how quickly the s.f.g. shifted their work flows and figured out how to dedicate space and staff in the medical e.r. so that people could be screened before they go to p.e.s. >> supervisor mandelman: so my suspicion -- because it does seem like lived experience of san franciscans is we are seeing a lot more people who are in psychosis on the streets. it feels like one possible thing that may be going on is that people who might otherwise be brought into an emergency room or p.e.s. are not being brought in because the system knows it doesn't have space for

them, and we are seeing that people don't stay for the full 72 hours, that that need to get people out of there is greater, so the cycling problem -- it seems plausible to me that the cycling problem could be worse during the covid-19, and there's seeming to be more people on the streets. is that a reasonable hypothesis? maybe i'm wrong. >> i think that's a reasonable hypothesis. i think we have to look at the whole of the city since shelter in place. so people who are housed and people who are able to work from home, we have much less -- much fewer people on the streets. i think that that -- that that

may result -- i mean, this is just -- again, you asked me for my hypothesis -- [inaudible] >> what's that? >> supervisor mandelman: little wild speculation on a thursday afternoon. go ahead. why not? >> that may result in fewer calls to 911, fewer interactions with people who are experiencing a behavioral health crisis on the streets. i think that our experience -- which i won't go into too much today, but with our alcohol sobering center, when we were able to close that really high risk congregate setting of our alcohol sobering center and move it into a motel setting so that people are not putting others at risk in transition if they were infected, that led to

a dramatic reduction in e.m.s. calls. so i think -- >> supervisor mandelman: because people were staying there longer or what? >> because people were housed. >> commissioner mondejar: oh, like, they're not coming down. >> they had a place to use. so -- and i'll talk about the criteria for offering people housing in our shelter in place hotels is based on femas medical vulnerablities, but we do know that a lot of the people in those motels have serious drug use or alcohol disorders. but i think what you started out by saying, supervisor, is correct. there's a lot more going on and

permitted for whatever reason. it just may be that people are sheltering in place. there's a lot less foot traffic, a lot less interactions. i mentioned surprising data that we aren't seeing more demand for acute services, and that goes along with, you know, on the medical side, we have seen a very curious and unexpected presentations -- decrease in presentations to the emergency department. >> supervisor mandelman: okay. thank you. >> okay. so i'm going to shift to the four main strategic and budgetary priorities. okay. we are on slide 7.

as we've mentioned, our behavioral health staff and a lot of our leadership have been deployed to work since the beginning of the public health emergency, and now, with the july 6 kickoff of the unified command structure of the citywide e.o.c., the emergency operation center, it'll promote more of a collaboration with h.s.a., h.s.h., and other partner agencies to continue to work together. problems, as we all know, have been impacted and worsened by the covid-19 pandemic. a few things we have been involved in and i think we started to see some success, our street medicine teams

[inaudible] to create an unsheltered homeless covid-19 street response -- street outreach program. facebook is connecting us with homeless people and responding to needs in congregate living sites and shelters. and when we encounter the people that meet the criteria for medical vulnerablities, we work hard to get them in a hotel or who test and meet criteria for testing and quarantine sites. we have some data from the work of those teams, which started in mid-april. so for the first six weeks of their work, they sheltered about 950 people.

about a quarter of the individuals who were screened had some sort of secondary follow up with a medical prior, so thissout reach work is starting to connect people. >> supervisor ronen: doctor, i'm wondering if there's been any results from dr. -- oh, my god, i'm blanking on her name. i can't believe i've done this -- cusel and the work that she's done. i'm trying to get a sense of

how many people are positive on the streets. >> yeah, i don't know the numbers from testing. i do know on the covid data tracker, of all the people that have tested positive, i think the last numbers i saw were either s6% or 4% of them. but that would be important information for us to know, and i can get that to you. >> supervisor ronen: okay. thank you. >> so the data tracker just shows, of all people who have tested positive, who are experiencing homelessness, but it doesn't show all unhoused people, how many we have -- yeah, what percentage are positive. we also are working with the

tenderloin plan and hsoc outreach services. our staff attends meetings and works to coordinate mental health services. there's meetings with community based organizations to help outreach in the neighborhood. i'm going to move onto our -- >> supervisor ronen: sorry. could i ask you one question on

that last slide? so is that only doing outreach in the t.l. or are they continuing to do outreach in the city? >> i believe they're outreaching in the city. let me see if marlo can confirm that. >> that's right. we can get numbers on where they're deployed day-to-day and we are they're engaging with people, so we can find that out. >> supervisor ronen: and does s.i.p. have the ability to refer people to care rooms? >> through the overall partnership. i'm not sure they're doing it directly, but working with our team members, i know they would be able to. >> supervisor ronen: and is that happening?

>> yeah. that is happening when someone has medical vulnerablities, then referrals are made to the s.i.p. hotels. >> supervisor ronen: but you have no idea how often or where they're outreaching? >> i don't know off the top of my head. i can find that out for you. >> supervisor ronen: okay. sorry. continue. >> so this is related to the information that we just discussed and our ongoing mental health work. this is something we were starting to work on precovid, so we're excited to look and

see how we can build on successful programs to do street outreach, and i think one of the things that we've really learned in terms of how we engage with people during covid-19 and before is -- is really getting out of the fixed environment and street outreach. i think this covid outreach and crisis response is aligned with the mayor's vision of responding and interaction to crisis with trained behavioral outreach teams. we really need to expand that work, and that's something we will be focusing on as one of our key strategic priorities in the coming -- in the coming fiscal year.

so to start, i'll talk about our continuing focus on the shared priority clients, so this was an interdepartmental effort which grew out of whole person care, and i think you know about that, but i want to share some information with you. this was launched last fall, and we're continuing to work on

it and see some progress on it during the covid-19 pandemic. shared priority is a joint effort. many agencies, including d.p.h., h.s.a., h.s.h., and e.m.s. 6, we track and report on multiple program measures related to the overall goals of connecting those with the -- ho those individuals with the most complex needs in housing and health care. so of those on the initial list, 111 have been housed. of the original -- in the area

of benefits enrollment, there have been 535 benefit enrollments among the 237 people, and that's -- [inaudible] >> now, what's for the -- [inaudible] >> supervisor mandelman: -- on sb 1045 1k3 people are getting 5150'ed, and i guess i was a

little surprised to see they're now being referred. it looks like 24% are getting aggressive case management, but it does seem that there are some sort of metrics for people that are distressed and showing us that they are distressed for whom tracking and management should not require them signing up. short of the loss of autonomy that's involved in a conservatorship, you get a

certain number, and there's a person in the department of public health who's going to be kind of tracking what happens to you and get out there to engage with you whether or not you've said yes. again, doesn't this make sense? >> no, that does make sense. i think that was behind of our use of the hmiot funding to contract with citywide linkage services so the clinicians can provide citywide case linkages. here's a number or you're going to meet a person, and you can

go to her clinic tomorrow or next week or in two weeks for your case management. that's why link yaj is an important level of -- linkage is important care and why we're hoping to expand on that. i think that's really, really important. >> supervisor mandelman: so there are currently in our system -- currently people in our system who get assigned a linkage manager even if they've not said yes, i want to participate in that. >> right, and we have to hear

from angelica how those people were counted in the data that she presented to you. >> supervisor mandelman: and i don't think she -- i don't think she presented on the linkage case project, but how many are getting linkage case management? >> so again, it's voluntary, so those who are open to continue working with us or whom we can -- >> supervisor mandelman: i guess i'm saying something a little bit different, and this may be part of it -- i mean, i think it is part of mental health s.f. -- let me just finish. but it seems like there's a set of folks who we don't have to

call it case management, but we have to -- but they have to be on somebody's desk. they have to be on somebody's to-do list. there has to be somebody who's keeping track of wow, they just got over four 5150s. they're going to know when they get their fifth. it seems like an important thing, so as we build out a better mental health system, it seems like an important piece, and i think provider ronen wanted to comment on that. >> supervisor ronen: thank you, chair mandelman. i'll talk about this case management component.

it's not a small thing that i say that our guide to mental health s.f. we've had these one-off initiatives that are not connected or coordinated into a system over and over and over again, and we have filed to me meaningfully address mental health reform. and my worry about the way that dr. hammer, who i have just so much respect for, i just literally bow down for. you know this 100 times better than i do, and i want you to know that. i want you to know this from the get-go.

i just truly, truly appreciate you, but i am frustrated to hear there's mental health reform and then there's mental health s.f. because what it feels to me like it you're, again -- like it you're, again, doing what we messed up on several times in the past. you have these disjoined initiatives -- disjointed parts that are apart from systemic change. for example, i'm going to get to the different levels of case management in mental health s.f., what it's going to look like when it's up and running. i'm going to give you an example. matt haney staffed a s.i.p. hotel one day. when he was there, an individual at the s.i.p. hotel

who had previously been at a navigation center successfully. he was shouting at the staff, someone stole my meds, someone stole my meds. the staff was working hard to get him back on the right floor, but on the way up to his floor, he kicked a resident's dog. and because of that, he was kicked out of the s.i.p. hotel, and matt saw him on the street several days later with all his belongings later, screaming at the top of his lungs. now if mental health s.f. would have been in play, we could have easily provided him replacement meds like that and connection to a mental health

professional to get him stably back on his meds. instead, someone who had done well in a navigation center and a s.i.p. hotel for months on end was thrown out on the street without contacting any professional whatever. that happened during a public health crisis in a s.i.p. hotel, and that is the kind of disconnected mess that is emblematic of our mental health system here in san francisco, and that's what mental health s.f. is designed to fix. it provides the connection, so it is very important for me that the director of ambulatory care doesn't speak as mental health s.f. as separate from mental health reform but it is

the mental health reform that we are doing here in san francisco. under case management, there's three levels of case management. case management for people that need lieu acuities to stay on their plan, intensive case management for people that have additional -- who voluntarily want case management but have additional barriers to care, like incarceration or activity in the criminal justice system, they're unhoused, etc., etc. the third level of case management is what's called critical case managers that have an incredibly low ratio of clients to critical case manager to deal with those people who don't want a case manager or who don't want any case management services, and they go and develop trust over time with that person. what i'm saying is all of these

components have been deeply thought out in mental health s.f., have been designed by the frontline care takers who literally sat in a room for, like, 100 drafts of this legislation, creating the system. my problem is that d.p.h. is not thinking about mental health reform as implementation of mental health s.f., but thinking about it in a silo with all of these other things not corrected to each other, and it's just recreating the errors of our past. there's a shift that needs to happen in our d.p.h. team that needs to happen. i'm glad we're meeting soon and we can talk about it, but the fact that there's still a director of mental health reform who is doing work separate from mental health s.f. implementation, and i will

not stand for it.

>> we have major gaps. we also know that we don't have funding right now, and so what we've done, and i think what i was trying to articulate is during covid-19, we basically moved our existing resources over to where they were urgently needed. one of the issues -- i'm going to ask angelica, your previous presenter, to speak to that because she's the behavioral health leader -- we've started to develop the behavioral health system of care to assist people at s.i.p. hotels, so i think she can speak to that experience that you talked about, and how we aim to do better both, you know, after covid-19 but then during, while we're working with it -- with the resources that we have. i mean, that's really been what i see as the amazing thing, is

that we've been able to put together these street response teams, that we've been able to staff these hotels where now almost 2,000 people, and that number's growing every week, are housed, and we're providing whole person services to them. you're right. we should have had something to offer that individual if he couldn't stay safely in the s.i.p. hotel. the s.i.p. hotels are really, really challenging to manage because of all the risks involved in bringing people into a new setting in individual hotel rooms. i'm going to ask angelica to talk a little bit about what we're developing in the s.i.p. hotels, and then, we'll go on. >> sorry.

i was speaking on mute. thank you, dr. hammer. supervisor ronen, i appreciate in terms of what you're saying about the need for coordinated services, and that those services need to follow the individual and not the other way around. i think the opportunities with having shelter in place sites have been many and inspired by the s.f. legislature. this includes d.b.h. providing more of the critical case management that you were talking about and engaging the individuals over time. we also are staffing a consultation line for both the staff at the sites and also medical providers so that we can consult on cases, be

proactive with individuals in connecting them to appropriate services. i think it's been remarkable how quickly we've been able to pivot our services to support our needs and building those collaborations with our other city partners. and so i think this, again, has been an opportunity to help bridge the gap and to have that collaboration which isn't to say that there aren't more gaps for us to feel, but i think this is a microcosm for us in mental health reform, and i think we're very much looking forward to the outcomes of this project in how we can model and expand this across our system

of care. >> supervisor mandelman: okay. let's keep going. >> okay. let me go to the next slide. >> supervisor mandelman: ah, dr. nagusabland. >> supervisor, i want to let you know that i have a hard stop at 1:00 p.m. i'd ask that you keep your questions until i get through this, and then, i'm happy to answer questions until 1:00 p.m.

with this charge, the mental health reform team has worked within the department of public health and within the broader behavioral health community to define the vision goals and target population for the team's reform efforts. here's some of the notes on what mental health was working on and continues to work on as we also advance the mental health s.f. planning process. we've used our -- >> supervisor ronen: sorry. this is hillary. who's on the mental health team? >> these are people appointed to work on the team, appointed in 2019. supervisor, i ask that you allow me to continue, otherwise, i have to leave at 1:00 p.m. >> supervisor ronen: i'm just asking the names. >> i will be happy to provide that to you after the meeting.

i'm sure that everyone realizes child care issues during covid-19. i have a one-year-old that won't wait. we have worked collaboratively within the department and with our stakeholders to set measures how we would impact the population. we had -- as mentioned by dr. hammer, the shares party pilot and -- shared party pilot and the wraparound services was initiated as a component of the mental health reform work as well as our city's first public

facing bed treatment website. shortly before the enactment of the mental health legislation, we were advising on the department's development of our city's first sobering center. and i am happy to present the most recent work about analyzing our system's flow needs. i must emphasize this is not a competition. this is complementary to the city's efforts in getting help to people suffering mental health issues in san francisco. we're also preparing to engage with the implementation of working group when our system resources were required to shift and pivot to the coronavirus response, so we

anticipate continuing to advise in that process for our shared vision for mental health s.f. now specifically with respect to the bed modelling project, and the work that was done there -- can you go back to that previous slide? thank you. the purpose of the bed optimization project was to improve ancient flow due too the beds that -- improve patient flow due to the beds that were available. a level of quantitative data analysis is the first for d.p.h. in early 2020, the d.p.h. mental health reform team engaged an experienced vendor to develop this management

tool. together, we discreetly tested a tool to help us decrease boarding of patients in inpatient psychiatry beds. if we can make 17 beds available when those patients are ready for those services, the entire system will flow more smoothly. let's advance to the next slide. we built the simulation model using information from the ccms, the behavioral health electronic medical record, information gathered at meetings, and input from stakeholders. we compared patient flow from

2018 to 2019 from 7,000 behavioral health clients. we compared the model results from more informative models so that it reflected actual usage efforts of bed utilization. the team identified capacity issues in our 12-month mental health residential treatment programs. in each scenario, to resolve the bottle neck, we added one additional treatment bed at the time in the treatment category until we reached avoiding thresholds of one day or less. this is how we arrived at the

recommendations of the number of beds for each level of care that is added can reduce our clients' wait times to zero. let's go to the main menu. >> clerk: please continue. >> okay. here, i'd like to summarize by highlighting the four recommendations for the benefit of the public. we recommend in investing in these additional bed categories with the recommended increase to achieve a boarding time of zero. we've also highlighted the actual cost of operating these beds based on our most recent data analysis on an annual basis. this does not include the startup cost for initiating these beds but the cost on an annual basis. second, i'd like to highlight

as our recommendation that we complement all behavioral health bed investments one to one with long-term housing placements. this may include permanent long-term housing to better serve the people experiencing homelessness to utilize the system of care. create a robust wait time and place to place data tracking system to better understand barriers on the patient's wait experience. invest in facilities with six beds dedicated for use by d.p.h. clients. rather than being shared with other health systems. currently, d.p.h. does not have fixed beds set aside for its

patients at a number of facilities. this makes it hard to place patiented in a timely manner as we are competing with other counties and cities for a limited supply of beds. and lastly, i want to emphasize this model. mitigate against data limitations that we encountered in this project and explore other projects that would improve our patient experience. finally, it's my expert opinion that by continuing this data informed process for calibrating our capacity for our behavioral health system, we will be able to achieve our ideals to provide optimal care for all san franciscans who need it. thank you, and with that, i have a few moments for questions. >> supervisor mandelman: thank you, doctor.

i do have some questions, and thank you for your work on this analysis. i'm wondering about sort of what's included and what's not included. so does -- last year, there were stories about people who could not get help because they were stuck in jail. i'm wondering, would that story be part of the bed flow analysis, the wait times included here? >> yes, we do account for people included in our jail psychiatry unit as part of this analysis. with respect to the expanded

conservatorship, i want to be clear. are you referring to the housing conservatorship? >> supervisor mandelman: let's start with the housing conservatorship. >> it's been estimated that between 50 to 100 people are likely to meet the criteria for the housing conservatorship possible. our recommendations for those 31 new treatment placements i think will significantly improve access to this treatment resource and significantly reduce waiting time for people in the jails as well as the hospital psychiatry unit. >> supervisor mandelman: i gueget it.

i believe that each one of these beds is desperately needed. i suspect that the model underestimates the need. i suspect if we loosened up the flow, there's more need out there. i don't think sb 1045 is going to generate 50 to 100 skefsh to ha have -- conservatorships. there will be additional needs, and when we had that report prepared on p.s. conservatorships, one of the things that i speculated on and seemed potentially reasonable to some of the folks at s.f. general when we talked about it was the system self-regulated,

that we do not refer -- that the number of referrals for conservatorships had gone down between 2012 and 2018 in parallel with the reduction of the number of available beds, suggesting that there may be some relationship between not referring people to conservatorships and the number of beds. i think this proposes a minimum starting point, and i think we are going to need to do continuing ongoing analysis going forward because i do think the need is greater even than the $11 million that we need to spend. that is not included in the budget, by the way? >> that is right.

this is one of our most important parts in the process is where do we start to allocate resources. the important thing is to use the data in this way to understand where do we go next with our next investment in services and beds? i want to highlight the importance of d.p.h. having these facilities itself so they can define the movements that take place. >> supervisor mandelman: there's several priorities here, but this is the only one that has dollars attached to.

i understand supervisor ronen has requested some numbers about some of the other investments that we might make, but actually nowhere in d.p.h.s identified priority is a -- in the immediate crisis response either as an expansion of p.e.s. or sobering or some other place where folks that are in psychosis could be brought to. it's hard to do it without it being a crisis stabilization unit or facility, but has there been any work done or thought about that piece of the mental health need, and what are you doing about that? there's been an analysis for the next stage, when we're getting people in care, solving

their problems or trying to solve their problems over a longer term. but when we started this hearing was with the sense that there are a whole lot of people out on the streets that don't have a place to be, or at least they're not being taken there. and i can see an amount that has yet to be determined with crisis intervention folks, but if they don't have a place to take that person, that's a problem. i'm wondering if you or anyone else has any idea what we could do in the coming year around covid problems and expanding that capacity? >> supervisor, i'm going to defer to dr. hammer to continue on that conversation piece. i am happy to make myself available for further conversation about this. i must sign off now, but i'm

very happy to return to you and add more after her response. thank you so much. >> supervisor mandelman: thank you. dr. hammer? >> so we started to, in work with our finance steteam, i th you know, before covid, started to develop a business plan for the expansion of our street outreach teams and the office of care coordination. everything has expanded with covid-19, so some of what you're asking is part of the cost analysis with the covid-19 activation? it's part of expanding our

staff in the hotels, expanding our street presence, working with c.b.o.s to see if we can do contract modification so that we have more workforce to draw on so that we can get the successful programs that predated covid-19. i don't have a cost on it right now. as i try to articulate, a lot of what we have quickly put into place, more quickly than anybody expected, during phase one of the activation, i think it's given us sort of a foothold, a building and expanding into those areas that i talked about. >> supervisor mandelman: although that doesn't -- i hear that you're doing the work on the -- on the street response,

but i guess i'm still missing the where folks in crisis would be taken, you know, over the next year if we don't have adequate capacity in p.e.s. >> right. we -- we -- i mean, i think what we need to really focus on is with some slight reduction in capacity at urgent care. we've been able to maintain most of our capacity in our diversion units and a.d.u.s, but yes, that's our biggest concern is if we expand our street outreach work, and it's 24-7, and it really moves us toward of vision of mental health s.f., which is more behavioral health teams on the street interacting with people and trying to engage them and

bringing them into care, the big question that comes up is where do we take them? where do we take them that's not p.e.s.? and we have very few options right now. we are optimistic about the expansion of hummingbird, that hummingbird will be another option, but as you know, beyond p.e.s., we have urgent care

options. >> supervisor mandelman: over on the -- you know, in the sort of homelessness side, we've spent -- you know, we have significantly increased over time, although maybe not enough, the number of outreach workers, but the thing is they don't always have places to offer people. we could easily replicate that conundrum by having really fantastic crisis intervention teams that could go out and have a conversation with people on the streets but have no place that they could take that person. well, it strikes me as where we are now, and strikes me as completely unacceptable, and i would move to hear -- you know, it doesn't have to be right

now, but i would love to hear the best thing from the department of public health on how to manage people in crisis, in psychosis. they might need to be in a licensed psych health facility like door. but i just think my hunch, based on the world that i live in and see, is we don't have places for people in crisis right now, and we need places for people in crisis. the immediate response, before someone ever gets referred for a conservatorship or a voluntary bed, that we need to have better placement. this came out of the report

from the task force about the sobering centers, as well. and this is not the budget committee. this is the public safety and neighborhood services, but last year, in budget, we said, tell us what you need and how much you need to do it. what we got back was thank you so much for the question. we're not quite ready to tell you that, but we will be in the future. well, a year has gone by -- you can't diminish the impact of a global pandemic or people that

are in psychosis or serious intoxication indication that are out on the streets. >> i think that's the crux -- to me, that's the at the heard of where we know we have to do better. if we have unused beds, if we have unused treatment facilities, we have to ask ourselves that if we build it, will they come question? i think that's why so many of us were so excited about the drug sobering center model that we were looking forward on piloting is it seemed like we were based on what we were hearing from people -- people who would be using it as well as the harm reduction community is this is what people needed. again, it was a pilot, and it was a suboptimal not permanent place, but it was good ideas about what people want and what they w