>> good morning. welcome to the june 25, regular meeting of the public safety and neighborhood services committee. i'm supervisor rafael mandelman. i chair this committee. supervisor walton has not been able to be here today. our clerk is john carroll. i want to folks at sfgov tv for creating this meeting. mr. clerk, do you have any announcements? >> thank you very much. in order to protect board members and public during the covid-19 health emergency. board of supervisors legislative

chambers taken pursuant to all local, state and federal orders. committee member will attend the meet thuing through video conference. public comment will be available for each item on the agenda. both cable channel 26 and sfgov tv.com are streaming the public comment number across the screen. comments are your opportunity to speak during public comment and they are available by via phone. once connected and prompted in the meeting i.d. the i.d. is (145)853-2772. press pound and pound again to be connected. you will hear the meeting discussion. you'll be muted in listening mode only. when your item of interest comes up, dial star and three to be added to the speaker line. best practices are to call from

a quiet location, speak clearly, slowly. everyone should account for potential time delays and speaking discrepancies between live coverage and streaming. you may submit public comment. you may email me i'm the clerk of the public safety and neighborhood services committee. if you submit public comment by email, i will include it in part of the legislative file. you could also send your written comments to our office in san francisco city hall. our address is room 244, one dr. >> supervisor mandelman: i want to make a motion to excuse

supervisor walton for the entire meeting an. call the roll call. >> on the motion to excuse walton and ronnn until she arrives. >> aye. >> there are two ayes.>> superve rk, please call the first item. [agenda item read] >> supervisor mandelman: back in october 2018, you will remember, mayor breed and i introduced legislation authorizing the city to opt into new state law which

allows san francisco, san diego and los angeles county for small number of people suffering from mental illness who might not otherwise qualify for traditional co conservership. it reflected the concerns and the intention that this be a pilot. after months of stakeholder meetings, two city hearings and series of amendments on june 11, 2019, just over a year ago n ags board approved implementation. enabling san francisco to

conserve individuals under the new program. i want to recognize the challenge in bringing any new program like this online. i want to acknowledge the incredible work our department of of health do everything for to care for the most vulnerable in our city. more than a year after hard fought battle, i am perplexed, very perplexed that not a single person in san francisco has been conserved under this new law.

throughout the fall, we were advised that the first petition for sb1045 conservatorship will be submitted by end of the year. i believe at that time, i was frustrated about how long it was taking. earlier, this year, prior to pandemic time, the housing conservatorship working group issued its first report. which we will be discussing here today. among other things, it shows city has not conserve anything with sb1025. since then, number of media reports draw attention to issue noting that the city has yet attempt to try a sb1025 with one individual while any trip out into the streets of san francisco will reveal many folks intoxicated, psychotic, continue

to deteriorate. we know that relatively few individuals -- that was attempt to pilot. the estimates were that as many as 100 people might be eligible. i believed it will be far fewer. as i said over the last few years, it's still worth trying. that does presume it will help at least one person. i'm hoping that today's

presentation and conversation can illuminate to get this program implemented. and how some understanding how we can make progress on these issues when each small progra programmatic change seems to take so long to actually put in place. we're going to hear from angelica from justice and behavioral services at the department of public health. wit >> i believe i am sharing my screen. everyone able to see that okay? >> yes, we are.

>> perfect, thank you. thank you so much supervisor mandelman. appreciate to be here today to get a report out on implementation how the conservatorship and the activities of the working group. supervisor mandelman, you noticed that you reviewed some of this. just to to give a brief overview, we're experiencing methamphetamine and opioid pandemic but not only in san francisco but nationwide. these are situations where serious mental illness is by substance abuse and people are deteriorating in our communities. unfortunately x existing laws tt we have do not account for active substances and have not had the tools to intervene in these cases. as you identified housing conservatorship was designed to be a tool to help address this gap. allows for us to place

individuals on a conservatorship for six months for individuals who meet strict eligibility criteria which in san francisco is estimated to be 50 to 100 individuals. we've had multiple opportunities to engage in voluntary services. senate bill 1045 was signed by governor brown in 2018. it was adopted by board of supervisors in june 2018. in october 2018 governor newsom signed senate bill 40 which added some important clarifications and additions to patients rights and due process protection to the legislation. this included clarification of the role of assisted outpatient treatment. the addition of a temporary conservatorship, reduction of the conservatorship length of

time to be from 12 months to 6 months and additional due process protections and noticing of individuals that they are on their pathway towards the housing conservatorship. i'm happy to be here to provide update on implementation of housing conservatorship as was noted. it takes lot of time to implement a new piece of legislation and particularly one that is as different as our existing conservatorship laws as housing conservatorship is. we used this opportunity to have regular meetings between the department of public health and department of disability and aging services. we worked closely with san francisco general hospital. both of these entities develop standard work flow ace talk about individuals on the pathways towards conservatorship and identifying other less restrictive options. there's been a great deal of

coordination between the superior court of california and city attorney's office. one of the important pieces to move forward with this legislation has been to both develop and have the court approve paperwork that is needed to be filed in these cases. there have been some unexpected delays around having that. i'm happy to report, as of last week, this paperwork has been approved. we have been working closely with zuckerberg san francisco general hospital to serve individuals who is on pathway towards conservatorship. starting at -- that will be eligible more housing conservatorship, we have to serve individuals 51-50 to notify them they're on pathway to housing conservatorship. i think this really speaks to the work that we've been doing leading up to this point in working with our pattern partneo

ensure an effect streamline process. we're hopeful we'll use this tool in the near future to support individuals. moving on to the activities of the housing conservatorship working group. as you will know, this was established in the health code. we had report that was due and submitted in january 2020. this group contains 12 members who are appointed by department head, board of supervisors and the mayor's office. the goal of this working group is to evaluate the effectiveness of the legislation. subsequent report will be submitted in january to both the board of supervisors and mayor's office and starting in january 2021, we have reports that we have to submit to the state legislature. many of the data points for this report focus largely on individuals who have been placed under conservatorship. as previously indicated, that has not happene happened in san

francisco. we use this opportunity to focus on two data points that look at the landscape of 5150s in san francisco. and in situations where the police were the ones placed an individual on 5150 and why that was the case. the data for this report is focused on fiscal year '18-'19. this gives a brief overview of the data we had available to us and i'll talk about the limitation and the work that we're doing to have a more robust report and data analysis and evaluation. this looks at data from the care management system. which pulls information from zuckerberg san francisco general hospital and psychiatric emergency services as designated crises facilities. we also were able to gather information from the san

francisco police department and i think what was important about this opportunity is that we were able to get client level data from both of these events to remove duplicates counts for individuals. there were roughly 3800 unique individuals that have been placed on a 5150 during fiscal year 18-'19. of note, 35% of the cases seen as p.e.s. are brought in by the police department and 64% of the cases that the police department shared with us were individuals placed on 5150 were treated at other facilities outside of psychiatric emergency services. this could be for a number reasons. including that an individual has comorbid medical conditions that need to be treated at the nearest emergency department. there's some situations where individuals request to go to a specific hospital and this would be included in that account.

>> supervisor mandelman: because the police data is in there, we believe that captures most of the things happening? >> yes, we believe that this captures most of the 5150s. certainly not all of them. one of the things that we have been working on during this interim time is to partner with hospital counsel of northern california and other local private hospitals to gather that information. we had success in having conversations with hospitals and we anticipate to having that information for this next report. which will give us a more broader and more robust view. one limitation around that is due to privacy reason, we won't be able to access client level data. it will make it difficult for us to understand the unique count of individuals. it will be really important to understand the amount of psychiatric crises that we're seeing in san francisco. >> supervisor mandelman: do you

have data overtime. can you compare 5150 up or down or year over year? >> there's been some changes in the electronic health records. there's some limitations to that data. we have that information from the psychiatric emergency services. >> supervisor mandelman: ,thank you. >> turning our attention to look more specifically at the population of individuals who might be on their pathway towards housing conservatorship. we pulled information, this is limited to the individuals who are seen psychiatric emergency services. we pulled information for fiscal year 18-19 for individuals who had four or more 5150. why we thought it was important because of the fifth 5150, we have to start serving individuals on their pathway to housing conservatorship. ewanted to understand the larger

potential option tha population. most individuals are between the ages of 40 and 50 are male and white or african-american. not surprisingly, most of the individuals have freak contacts with urgent and emergent medical services and have average 11.8 visits to psychiatrics emergency visits during that time period. they have low contacts with ongoing medical and psychiatric services. have high frequency of contacts with the san francisco county jail. while experiencing homelessness is not a requirement for coursing conservatorship, many individuals who are in this population are experiencing homelessness and have extended periods of homelessness.

>> supervisor mandelman: if you don't have an assigned case manager is there anyone who's sort of tracking you in the public health system? >> i appreciate that. certainly, this legislation is a unique opportunity to look at that more closely. there are certainly other programs like assisted outpatient that works with individuals who are also not agreeing with services at that time. there are some programs that do that in different ways. there are some programs that do that in different ways but not in the intensive and coordinated way with case management. >> supervisor mandelman: it strikes me, whether or not someone has an interest in intensive case management when

they're getting four or more 5150, we probably have interest in them having a case manager. >> absolutely. we want to make sure people have access to. this is where it gets complicated in terms of individuals consenting to services. which is why we have other programs that assisted outpatient treatment and housing conservatorship. for individuals who are not able to accept voluntary services that we have other options to support them. we briefly touched on this. we've been working with the hospital council of northern california and partners across private hospitals in san francisco to gather this data. we anticipate having this for subsequent report. department of justice receives information about 5150s.

we talk to them about the information they receive. we want to make sure information across systems and reporting are consistent and that we have comprehensive data. we've also been working with the san francisco police department and our just finalizing our m.o.u. to have access to the incident report. this will give us an opportunity to sampling of the report to better understand situations where police were involved. if there are alternatives, this is an incredibly conversation as we're looking at the racial pandemic that we're experiencing as well as the legislation of mental health -- to see what other opportunities can be afforded. we look forward to gathering that information. the other piece that is important for all of us from an evaluation perspectives and for the working group, is to gather information on the individuals

going through the process. external evaluator, will be partnering with service providers to be able to do interviews and surveys with those individuals to better understand what they are experience is during this process. this for individuals who aren't aware, we have regular meetings for the housing conservatorship working group. this is where information can be found about this meeting as well as past presentations and if there's any questions, member of the public are welcome to email

us at the email on the screen. supervisor mandelman i'm happy to answer any additional questions that you may have. >> supervisor mandelman: thank you. i do have a few questions. i guess the first is -- can you oexplain why this is taking a year? to the average san franciscan, that's an extraordinarily long time for a pretty small program. i thought it was perplexing, frustrating, whole lot of adjectives. it seems deeply wrong.

please shed some light where it is taking a year and we're still not in a place to have done a single housing conservatorship? >> as i mentioned, we've made great strides in just a week of the paperwork being finalized with the court to move forward with that. we're in a really hopeful place now. i completely hear and understand the frustration and all other adjectives that you shared regarding that. this is challenging that this represents a major change in conservatorship. certainly standing up a program like this takes lot of time and consideration. there are certainly details. we want to make sure we thought through and did so in a very thoughtful way. there were unexpected delays to have the paperwork finalized with the court. i know that our city attorney's office and working with the

court. i know that again, that has moved forward. i would defer to ann pierson with the city attorney office if she wants to add anything about the collaboration with the court process. i think that was our major delay to move forward. we need to have the paperwork available to us to submit the petition. >> if i may supervisor mandelm mandelman, i wanted to also highlight the fact that this is not a small programmatic change. the housing conservatorship legislation is from a legal perspective. it's a dramatic new type of mental health conservatorship that probably has not been attempted anywhere in the world, certainly not in the united states from the legal perspective, the rules that our city attorney had to take on was

really like climbing mt. everest. new declarations, new citations, i wish they were here to be able to speak about the amount of work that it took. they were ready to go to january. reached out to the court, met with the court in early february. once they met with the court, they learned that the court had some different interpretations of the legislation. the court required them to go back to the drawing board. this is all in collaboration with the public defender's office. there was a substantial revision that had to take place during the month of february. i know there was lot of long hours that were put in by our city attorney during that time. then they were scheduled to meet with the court early in march.

thought that everybody will be set to go. we sincerely apologize for the delay. i want to assure you that, department of public health and city attorney office absolutely prioritized the implementation. we're very happy that we're finally at the point where we can move forward. it really sort of legal unknown as we move forward with the court process. we'll have to see how things go. i know there will be other counties watching us. >> supervisor mandelman: can you shed some light on what' what te issue with the court was. >> my understanding, i'm not an attorney of course, from meeting with the city attorney' office,

the court has made the determination that for each and every housing conservatorship petition, they would have to make a series of findings. the finding that we made by the board of supervisors relating to the availability of services. that is actually in their interpretation of the legislation finding that they will need no make for each and every one of those -- every

petition. i think that was one piece and one form that needed to actually be changed. i know they can speak in greater detail if there's interest. if ann pierson is able to speak to that, that would be great. >> good morning everyone. deputy city attorney ann pierson. i was involved in this project in drafting the legislation. i have not been in involved firsthand since that time. i think you've heard a wonderful description of the process that has been undertaken by my office in collaboration with the public defender office and the court. three offices started working together to develop the form pleading that will be need to initiate one of these cases. i understand lot of work has gone into that. i'm sorry that the attorneys who

worked on it is not here today but they are in court now. there were lot of back and forth with the court to make sure there's an understand who's burden it was to prove the underlining finding to show somebody is eligible. i do understand that the emergency stalled those discussions little bit. they've gone forward to completion and that the parties feel that -- we are ready to bring a case as soon as there's an individual who meets all the eligibility criteria. >> supervisor mandelman: it sounds like availability of services finding became an issue for the court. last year, september of last year, there was an issue where there were 11 folks in the jail, unable to be conserved because.

they shouldn't been in the jail and they should have been in conservatorship and the placement. it took a significant amount of effort. we talked about the potential for up to 100 folks, there's 117 folks now who have been p.e.s. four plus times. it kind of begs the question of how we're going to convincingly make the case to the courts.

it's going to go into the next hearing we're going to have on behavioral health services and time of covid and we have services that we need to get a handle on our streets. it seem like we don't have the best --

>> what sb40 afforded us is the addition of conservatorship of 28 days. what we anticipate is for the 28 days individuals will be able to held on inpatient unit. which is not the case often for this population. they don't meet the level to remain at the hospital. this would allow people to be at the hospital. we have that time to stabilize them and engage them in services. our hope is they'll go to less options such as diagnosis program and substance abuse disorder treatment. >> supervisor mandelman: that sounds like holding acute unit up to 28 days. >> they can be held up to 28 days. it give us that time to stabilize individual so they wouldn't need to go to a locked

facility. >> supervisor mandelman: okay. how many of these do you think you'll be able to do in the next year? >> it's really hard for us to predict. again, housing conservatorship is always going to be last resort. i think this gives us an opportunity to engage individuals in services in a different way. certainly having the noticing that they're on the pathway to housing conservatorship. it's hard to know because it's really uniquely dependent on that individual and our ability to engage them and their number 5150 that they have in any given time. it's hard for us to know. our estimation is that 50 to 100 people might meet the criteria. >> supervisor stefani: i want to follow up on that last statement

that you made. you said you would stabilize them so they wouldn't have to go to a locked facility. i wonder what you mean. i don't think if that's always the case that people can be stabilized to go to a locked facility. do you mean with regard to drug addiction? i don't know what you mean by that. >> i appreciate that question. in a number of different ways, part of what we see is that mental health is exacerbated by substance abuse. this would allow us to have that time when they're not under the influence of substances to engage in services, develop that relationship with them and engaging motivational interviewing and talk to them about what treatment options are available and have that

institutional remission. >> supervisor stefani: is there any guarantee when they're no longer in a place -- no longer viewed maybe being subject to a locked facility that they enter somewhere else? there's no commitment to continue on. they're going to end unright back where they were. how do you guarantee they're in a place to deal with the substance abuse disorder that causes them to get in a place where people think they might require a locked facility. >> i think this will give us an opportunity to have a connect individuals and have wraparound services. we've had that opportunity to talk to them more about the services when they're not under the influence of substances.

we'll have that opportunity but also with them being under conservatorship and having regular court appearances and updates with the court, which they have to be minimum every 60 days. if give us an opportunity to leverage that and also for the conservator, and we're able to set them up. >> thank you. >> supervisor mandelman: i'm going to try it different way. you had a year to look at the population. there's broadest category somewhere around 100, 117 but not all those folks -- [indiscernible] some of them are plainly not going to be appropriate for sb1045

conservatorship. some of them you may try different approach. some folks it might be appropriate to have acute bed for longer period of time. some of them a month -- pursuing longer term conservatorship with a period of sobriety and aggressive efforts to try to engage someone into voluntary patient and treatment. they wilthere will be different approaches for different people. i would hope that we would have some sense, there's some stability in the population and some of the folks have been cycling around for a year now. we would have some sense of the -- some sense of ballpark of people that like to sb45 conservatorship. if it's something more than one,

i would love to know the scale. we're going to talk later in part about the shortage of beds that we have in the city. we have serious shortage of beds. the reason people are staying in jail too long, there aren't enough beds. we have a medi-cal reimbursement problem because we can't move people down to the next stage. what we're going to hear from the doctor coming up, some of his understanding and thinking on what is the state of our shortage of beds. we have a shortage of beds right now. if i'm a judge looking at san francisco coming in with a new program, san francisco doesn't have a plan to expand the beds to bring that population online. either this program has to be adorably cute in how small it

is. or it's not going to work. i don't think any of us want it to be cute. we want it to be meaningful as possible. that means more beds. when we have this conversation with the doctor, he says we need certain number of beds. we say what about sb1045. has been any thought about the additional need for bed capacity that implementation 1045 would require. i will say, you had a year to think about it. >> i appreciate that. i would defer to the doctor to talk about the bed modeling and his representation representati- recommendations regarding that.

population does change. it's based on the the number of 5150s. every month it might look different. i can certainly say what we do know right now is that there's roughly 10 individuals who have more than the eight 5150s. that can be the current population. not saying all those individuals need housing conservatorship. i think that's important information. always trying to keep people at the least restrictive setting and knowing there's a variety of beds needed to support the overall needs of san franciscans. >> supervisor mandelman: you want to add anything? >> i would encourage all of us as we're thinking about our local needs to also be considering the state system which really plays a vital role within the broad population of people with serious mental

illness. we do have individuals right now who are waiting for state hospital bed. that is only level of care that is appropriate for them due to their unique needs. many counties are in the same situation that we are in. we really need t a solution. >> where we see the longest wait for individuals both at the jail and san francisco general hospital are for people who have complex behavioral needs as well as highest assault risk. there are really limited options for those individuals. >> supervisor mandelman: i'm sure the state needs to be pressed on this given their inclination -- over the next year is going to be to cut everything. >> just a quick question. do i have an idea in terms of state beds and what you just

said. it's so alarming and concerning and absolutely unacceptable. it really is. i'm just wondering if we have an idea of how many more state beds we need to address that population. it's not fair to them. we keep talking about it. this conversation is like groundhog day here in san francisco. i'm sure probably for other counties as well. as our department of public health what we need to be asking the state for to help us deal with this issue? >> this is ecertainl certainly complicated, there are limitations in our ability to advocate in terms of state hospital beds. i think any given time, we have hand full of individuals waiting for that highest level of care.

>> what are the limitations on our ability to advocate? >> just so we don't have control over how many beds we have access to at the state hospital. they are certainly impacted. their primary responsibility working with individuals found competent to stand trial on felony charges. depending on the flow, it impacts our ability to send individuals. as indicated there, more and more pressure to return that responsibility back to the county origin. >> thank you. >> counties ar have a wait list. it used to be that we had access to certain number of bed in san francisco county. and d.p.h. with provide more information on that change. at this point, we essentially waited in line behind every other county when we have a client that needs one of those

beds. >> supervisor stefani: we need to do better job of advocating us, advocating to the state about what we need. not just obviously here in san francisco but statewide. this is an issue that's not going away. people are suffering and this is unacceptable. >> agreed. >> supervisor mandelman: agreed. it's outrageous. i love to work with you on blowing up -- [laughter] it's impacting counties around the state but particularly san francisco. we don't have have -- we couldn't meet the need for first

state hospital. we don't operate state hospitals. i know you're committed to this. i love to work with you on pushing on that. >> great. >> supervisor mandelman: maybe we can take public comment at this point. mr. carroll? >> thank you mr. chair. just checking to see if there's callers in the queue. for those that have already connected to our meeting by phone, please press star and 3 to speak on this item. for those already on hold in the queue, please continue to wait until you're prompted to begin at the beep. for those who are watching our meeting on cable channel 26 or streaming through sfgov tv, if you wish to speak on this item, please call in by following the instructions on your screen. you will would dial the number on your screen. enter the meeting i.d., --

>> we have eight callers in the queue. >> supervisor mandelman: i will say some things about public comment. each speakers will have two minutes. we ask that you state your first and last name clearly. if you prepare to written statement you're encourage to send a copy to our city clerk. speakers are encourage to avoid repetition of previous statements. let's hear the first caller. >> this is jennifer, i'm a registered nurse. psych nurse. i worked at general psych emergency. i happen to sit on the housing

conservatorship working group. i wanted to say you guys raised up some serious issues today. thank you for that. putting people into locked units is the most expensive care. as you discussed, not always the best way to compel people into treatment. voluntary services are definitely more effective and housing is absolutely one of the biggest issues that will help mitigate people need for ongoing treatment and stabilization. the working group discussed whether or not the city and county can provide this. still does not determine how housing can be provided on ongoing basis for these hundred plus people. there's been lot of discussion about the lack of voluntary services, long waiting lists for housing and services and lack of treatment and supportive housing. what members have impressed lot

of concern about how we can implement this program applause of the limitation. the data that we looked at does not show whether people with multiple 5150 hold have been offered housing. it's difficult to assess whether or not they've had options to engage in services. i know covid hit in march and sheltishelter-in-place. we had time since before covid to address some of these things. there's an issue about disproportionate impact people of colour. demographic shows one third of people who have 51 of 50 are black. that is glaring disproportionate impact that cannot just due to substance abuse and mental illness. we want to make sure that the

detention for 5150 was performed properly and we need a clear breakdown of all the 5150s and who is performing them in addition to police officers and working group we discussed this but did not have adequate data from all the hospitals in the area that could say who was providing and performing 5150s. it doesn't give us an accurate count of the number of people. we might see the number higher than the 117 we're talking about. the group could be bigger than that. as we're talking about defunding the police and alternativings for treatment and funds, we need to talk about other ways of responding to 5150 to avoid police violence.

thank you for your time. thank you for the working group. we have a lot to talk about. >> supervisor mandelman: thank you. >> next caller. connect us to the next caller. >> i'm the policy and planning manager. we are part of the treatment on demand coalition and topic on conservatorship is especially important to us. i'm here to express our concerns with the findings in the preliminary report. in terms of racial equity, black san franciscans experience involuntary 5150 psychiatric hold at a rate that is

disproportionate to their population. those holds were largely performed by police. in terms of availability of voluntary services, the preliminary data examined by the housing conservatorship working group does not make clear whether or not people with multiple 5150 holds have been offered housing without a better understanding of the current barriers that exist. it will be impossible to implement this program in a way that does not exacerbate the current legislation. we are concerned about the effects of the expanding conservatorship through the 5150 process which is carried out by police personnel. many of our clients and community members are had

fraught relationships with the police. tension is growing. clients and community members find this process to be tension -- tense and healing. we need more beds, more outreach, more housing. all things should be easy to access. i will end with a hope we look through a housing source land while we try to address mental health. thank you so much. >> next speaker.

>> good morning i live in district eight. we are nearly two years from governor brown signing of this bill to a five-year trail. i don't have the vocabulary or history i have experience being assaulted by mentally ill person. subsequent to my assault -- why there's a lack of urgency. it's not particularly an accusation. this is life or death for some people. with whom does the buck stop? this was supposed to be the way we filled the gap. we're still having committee meetings with reports and zero

conservatorships. in covid world, companies are rolling out programs a money and details regarding racial justice. no one want to disproportionately impact people of colour. this must be examined and solved. we're told we're undersiege we don't have the right forms? san franciscans need governor to be better. we feel like it's groundhog day. i expect the answer is inaction to take to helping people. thank you. >> next speaker.

>> as both the san francisco police and covid continue to hit homeless people, blacks and whites, the mayor is proposing huge cuts to mental health. i think it's outrageous this has happened. it's particularly true when you look at the statistics that blacks probably less than 50% of the population are six times

overrepresented, 33% of those who go before 5150s. police need to be removed from all mental health calls. your conservatorship program cements police into mental health. it needs to be getting rid of. what we need is enough services and housing for everyone who needs it. not just honing in on a few people. thank you. >> next speaker.

>> hi, i'm a family doctor working at sf general. i'm working in shelter-in-place hotels for people experiencing homelessness. i'm also on do no harm coalition. i agree there's urgency for more voluntary services to be available. thus far, we need more beds, more housing. treatment for substance abuse disorders is longitudinal process. m. patients want to seek treatment but feel limited in what is available. when people do decide to take the step, there's no bed available, there's not an easy way to help connect people to the services. having more voluntary services

is the key. i also agree that the housing first model we're seeing in the shelter-in-place, hotels that people are really starting to take advantage of more instability their lives to deal with underlining health issues and substance abuse issues. we are moving forward that voluntary service will help prevent more substance abuse disorders in the future. taking people rights away is not the solution. it's a slippery slope and introduces much room for bias. which we're seeing in the data thus far. i was very concerned when sb1045 was passed and i do not support this program. thank you for your time. >> next speaker. >> 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 will engage with. i'm the first to say that we have a problem that we have some services for those people

who have the most severe, most complicated needs, that they don't want -- you know, as many people as we put on the streets say that's not how people want to engage, and that's what i hope we get to moving forward on in these main areas around that mental health s.f. legislation. >> supervisor mandelman: but i would just point out -- and i think i have a couple more questions, and i'll feed to the other members of the committee. you know, the meth sobering center was -- i mean, what is it -- many different people on the meth task force had many different ideas what the sobering center would be and what services it would have, from a place to get out the streets to more of an altern e

alternative to p.e.s. from what i've heard on the streets, there was a real need to reduce pressure on p.e.s. and how a sobering center does that -- i can see stories how it does a little bit on the margins, but unless it has more, unless it is built to deal with people in acute crisis, it may not achieve that, and i know there have been conversations over time about potentially an alternative acute crisis facility in addition to p.e.s. seems like neitheither -- my s is that we need that. if we don't, i'm happy to have that explained to me, but i do think it's -- you know, that's key to getting someone -- someone who's psychotic on the street is not going to go to a sober -- like, the sobering center is not an option.

they need to be taken somewhere else, i think, a. and i guess my last question is, i've heard from multiple people -- supervisor ronen, but also people within d.p.h., that this care coordination is among the most -- and i think this is right -- is among the most important functions that we should be trying to build out over the last year. we had that extended conversation about case management, but really keeping track of who needs our services, and what those services are and getting those services aligned into what makes sense is really critical, and mental health s.f. envisions that as an office of care coordination. i don't know if that is to happen in the next year, but what is your thinking if you had some resources, how you

would begin to build out care coordination in a way that we would feel? like, we would see in the data, we would experience in the city? not the full gold plated version of this because, obviously, we're not going to do that right now, but what's the obvious sort of beachhead plan that, okay, we're doing this? >> so with your permission, i'm going to ask our acting director, marlo simmons, to answer your question. she's been looking carefully at the office of care coordination idea and how we move forward on care coordination, building that structure, even before it's fully funded, so i'm going

to ask marlo to start. >> supervisor mandelman: great. >> good afternoon, everybody. marlo simmons, acting director of behavioral health within d.p.h. the legislation and how mental health s.f. talks about the needs, i think, is really right on and reflected a lot of the problems that we have in our system. one of the first things that we'd like to do is really build out a linkage function and what that looks like, for example, in the s.i.p. hotels, to supervisor ronen's example that she shares, is that the staff and hotel would have a place to call when they see a concern about a client, and that that call -- there is someone who immediately answers the phone, talks with them about what they're seeing, what's the best

response. and in that case, it sounds like someone should have come out and helped that client get access to medication or whatever services are needed. we've started that with the shelter in place hotels. it's very new, and obviously, to get people to use that kind of service, they need to know about it, so that's where you get the marketing campaign that's involved in the office of care coordination. you need to train the staff in what to expect when they get calls or what will happen when they call the line, and then, you need quality insurance when the staff calls the line, they get a person on the line, so they understand the response, there's follow up. so there's a lot of details at every stage. i think we also need to really expand the street-based outreach that we're doing. some of us talk about it as

relentless street-based outreach, and that is what it is with people. there's a lot we have to show that it works. with the care coordination, if you identify someone who's willing to engage, how do you get them in the front door? that's what we hear from people involved in the system, in the jail system, in the prison system, in the foster care world. it's helping people understand what's available, what's the best match for the client, and helping them actually get there, and that takes a lot of time and engagement and real conscious work and being aware that the services have high quality or meeting the needs of the compliantlients. and looking at the data, the outcome, what we're trying to

achieve. a lot of information around accessing where we are. so people like the folks at p.e.s. are able to say oh, here's the outpatient provider, so it's kind of a lot of glue in between of all the silos of services that you have. >> supervisor mandelman: so that takes resources? >> for sure. >> supervisor mandelman: dollars, and although it is a high priority for the department, i am -- my understanding is, you know, that it is not dp-- the best priority may not be included in

your budget. so if the two stated things end up -- and a place for people to land -- if the outreach happens, and they are brought in somewhere -- like, those things would all need to get added either in the next month by the mayor, finding money from somewhere else or, less likely, from the board of supervisors trying to find money to shake out of the mayor's office to pay for those things. i mean, i think what would be really useful for this supervisor -- i don't know about for others -- is for the department of behavioral health services -- similarly along the lines of what the doctor has

done with the beds, but to think a little bit along the lines of some way of measuring a meaningful move in these areas, and then a cost associated with it, and i would love to see what it is. i know that supervisor ronen -- may already have asked the controller for this, or at least in some ways, i'll ask the department to look for those. all right. i'll cede the floor. supervisor ronen, you have this. >> supervisor ronen: yes. thank you. dr. bland kept referring to a

team. who's on the team? >> yes. so i'm having problems. after this, i'm going to switch to a different network. if i lose you, i'll be back in. so lauren bruner, who you've heard from, is an analyst working with dr. bland, and there are executive leaders from the behavioral -- from the d.p.h., myself included, who sort of morphed from our early work prior to mental health s.f., from mental health reform weekly meetings to the mental

health s.f. legislation and the projects that we had already started working on with mental health reform and the new projects, so, yeah, but it's led by dr. bland and dr. bruner. and i'll be back. >> supervisor ronen: i can talk to dr. simmons in the meantime. so a lot of what you're describing in the dialogue with

supervisor mandelman, it sounds like you're putting the cart before the horse. i don't know if any of you can answer these questions because it's sort of dr. bland's main thing, but i do have a lot of questions about the bed study? to me -- and i think i'm agreeing with supervisor mandelman, at least as i understood his comments -- that how do you even do that study if you don't have a system in place? i agree with that, that the office of care and accountability -- the office of care coordination, that that's a different office that we're going to put off till later. the office of care coordination is the most important part of mental health s.f. because if you don't have an office where

care is coordinated, and you don't have a structured team of management, etc., where people check in, you can't have that, and we've never had that before. i just don't understand without that, what's in place? who's the management? what's the different level of case management? who are the contracts with case management? who's quality control? who makes sure the same set of standards are being placed up? what's the tracking system tracking which patient is assigned to which care manager? if someone falls out, how do they get back in? i've heard none of this system building in your talk or the way that you refer to mental health s.f., and it's really worry some to me, when i saw

d.p.h.s budget that was presented to the mayor, too, i have to say, i was actually shocked that there was nothing in there, with the exception of a vague reference to hiring more people in the h.r. department at d.p.h. -- very important -- in order to even begin implementing mental health s.f. because you recognize you need to hire different staff to make it happen, or at least repurpose. so this is, again, why i get so frustrated. it has nothing to do with dr. bland, who's incredibly talented psychiatrist and physician. if the fact that you're focusing again on these one-offs, you know, this bed analysis that doesn't fit into a system -- so it's kind of vague and random. maybe you can explain to me the methodology around it, and i'm

wrong about it. but the rising prices on our street, you know, from a gut level, it just makes no sense. and so, you know, it -- it -- it's extremely worrying to me nowhere in your presentation, nowhere in your budget submissions to the mayor, and nowhere in talking about your work in the middle of a global kri s crisis is there talk about mental health s.f. it's just extremely problematic to me. i'm really glad we have a meeting set up in a few days. i think it's next week, even, but i'm really shocked that there hasn't been more thought into what would the first phase

look like? you've told us that street medicine goes out with a hot team. and supervisor mandelman asks, well, where do you take them? where do they go? well, we don't know. it sounds like a year ago, when we had to take the reins ourselves to create mental health s.f. and not to say that you guys haven't worked really hard, because i know that you do every single day. as supervisor mandelman said, no one can underestimate the impact of covid, but i at least hope going forward that we're thinking about it in the same way, and from the presentation

and all the discussion and the drafts of mental health s.f. and all of that, that we're still in a place where it's hard to get answers to question. >> supervisor mandelman: before you answer, i would just say that this presentation definitely reflected conversations that i and my office have had with d.p.h. >> supervisor ronen: okay. >> supervisor mandelman: i did not ask for a report on mental health s.f. implementation. i asked for what's going on on the streets, and it was the thoughts that were in my head about beds and other things, which has overlap with mental health s.f. >> supervisor ronen: sure, and

i guess that, and i guess that that wasn't the topic of today's presentation, but the reason that it's triggering to me is because in the way that you're answering questions that supervisor mandelman is bringing up, the framework hasn't shifts in terms of how d.p.h. is thinking about solving these intractable problems that we haven't gotten a handle over in years, and so that's what's worrying me. i hear you, supervisor mandelman. it's the way that things are being discussed that makes me feel that we're not moving in the direction that i thought we unanimously passed legislation, deal brokered with the mayor, would be leading us. >> so supervisor ronen, i hear what you're saying, and i'm

sorry that our presentation and the way that we're talking about our work over the last few months during the covid-19 activation wasn't based in the language that i think we all did -- the language, the vision, the tenets, the different projects are articulated in the mental health s.f. vision. before february -- remember, this was incredibly complicated transformational work. you were the author and visionary working with us. it's expensive and requires a lot of infusion of not just staff and changing how people do their work, but also facilities improvements. when you talk about an office

of care coordination, when you talk about 24-7 access, those are huge transformational changing. i'm glad that we started it. we talked about the expand of bhac, how we would expand access to 24-7. we had started work on the street crisis intervention response team and how that was articulated in mental health s.f. you know, the work that dr. bland discussed, so not just the bed modelling, but how we

use this. but because there was this, you know, wellspring of support for, like, i said, major transformational change, we put our effort toward it. and now, here we are. so as i said, you know, if we are able to flatten the curve, and if we can pool some of the huge resources that we've invested in the covid response -- street outreach

response is hugely resources intensive. you know, it will take a lot of staff. we will have to hire staff for that and not for, you know, the clinical support that's needed for people if you put them in hotels. so i just want to be realistic that we can only do so much. i do take responsibility and really hear you about -- that we not only need to talk about, but start thinking about that our transformational work -- our mental health reform work is mental health s.f. until we do something, it's what we all were very excited about. the legislation -- we're moving toward something.

early april, we had a meeting date for the working group. we never had the working group meet, but we're focusing our energy of hiring a new director of mental health san francisco. those things need to happen before you can see what you need to see and what's urgent. so i think what we're trying to convey in this presentation is we've already started working on basically what's sort of -- i don't want to say low hanging fruit, but it's things that are directly related to our covid response and what we have to do right now and what we see as the start of building the foundation for mental health s.f. i think they are, the work that we're doing in the s.i.p. and the street work, that's the start of building that foundation, but we're not there yet, as you know. >> supervisor ronen: i really appreciate that. your response makes a lot of

sense to me. i'm happy we're having this conversation, and i want to thank supervisor mandelman for calling this meeting and having this conversation because it's starting to sharpen what's needed moving forward, and i hear what you're saying. and again, we were moving sort of in the right direction before covid hit, and it's thrown everything haywire. so i'm looking forward to getting together and talking about this in a different way in the midst of covid -- we're both coughing now, but i really appreciated what you said, dr. hammer. thank you. i'm done. >> supervisor mandelman: okay. thank you, supervisor ronen. vice chair stefani, if you

don't have any questions or comments, let's go to public comment. >> clerk: for those who have already connected to our meeting via phone, please press star-three to be connected to this item. for those already in the queue, wait for the prompt. the prompt will be, "your line has been unmuted." for those on-line or on channel 1626 to 415-655-0001, and then enter 1458532772. press the pound symbol twice, and then star-three to be entered to speak. do we have any callers? >> yes, we currently have three callers in the queue.

i will queue the first caller. >> supervisor mandelman: and i will repeat our public comment rules. speakers will have two minutes. we ask that you state your first and last name and you speak directly into the phone. if you've prepared a written statement, you can send it to the city clerk for inclusion into the file, and in the interests of time, speakers are encouraged to avoid repeating statements. let's hear the first caller. >> hi, can you hear me? >> supervisor mandelman: yes, go ahead. >> hi. my name is javier. i'm a san francisco resident and community organizer. i also represent the treatment on demand coalition. the pandemic has us in an unprecedented time in terms of health care, and as always, people that are suffering under the status quo are hit hardest by covid-19. the homeless population has now

hit fr moved from precarious on the streets. our communities have been asking for accessible treatment options for decades, and we have the tools to address this. i'm glad that we're holding a separate hearing on the city's response to unhoused people because we passed mental health s.f. late last year. this bill was to make mental health treatment in s.f. actually accessible at a time when we're having a conversation about reducing the police in our every day, our only conversation is finding out different ways to lock people up. it's embarrassing that our city orders its constituents to shelter in place to stay safe

when they don't offer how and then continue to complain about unsightly homeless people who our communities are offering solutions that aren't at the center of our conversations. we must implement mental health s.f. now and house people that are on the streets. we are facing rough economic times, and our approach is always to cut or slow down crucial change like mental health s.f. when the dot-com bubble burst, we cut mental health services. in 2008, we put mental health on the back burner again, and look we ahere we are now. >> clerk: the speaker's time is up. >> supervisor mandelman: thank you. next speaker. nrs

. >> supervisors, and you so called experts from the san francisco department, i'd like to bring to your attention that there are $12.78 billion budget. i know the san francisco health department washas a budget tha over $2 billion, but what i -- i've seen for is that a few supervisors have their heart in the right place because i've spoken to them, but when it comes to the san francisco health department, it's

pathetic. the director, grant colfax, he's all over the place. this is what happens with newbies. when they come here, it takes them about 500 years to understand san francisco. it is disgraceful to see so many homeless, and people assaulting people in the bus all over our city, and here, we are talking in generalities. one of the supervisors was right. we should take it upon ourselves to understand a few of the aspects, but the so-called doctor who is an expert, he's got something to do. probably to go to the planet juby-juby but not to attend the meeting, and that's not becoming of anybody who's professional. san franciscans are fed up. in the interim, you have a

supervisor and the mayor who spent all day yesterday cutting ribbons and doling out commendations. that's pathetic. we need to address -- >> supervisor mandelman: thank you. next speaker. >> good afternoon. my name is mary kate buckelew. i appreciate today's focus on mental health s.f. and coordinated care for people in crisis, and i wanted to talk about covid-19 and the impact on them, where entire families are sharing cramped and substandard rooms. they've lot significant percentages of income. i would estimate about a third across the board, and they're isolated from families,

schools, and community as they're dealing with extra stressors, like threats from their landlords, particularly for undocumented families, and putting food on the table. our demand has sky rocketed. our systems are all manageable with immediate, accessible and informed connections, i these are the cities most vulnerable families. they're people of color, low-income families, undocumented families. as we do our system planning and evaluation of the impacts of covid-19 on people in crisis, i urge you to consider

these families who are not as visible as some of others in crisis but who are truly facing unprecedented barriers. thank you. >> supervisor mandelman: thank you. next speaker. >> clerk: caller, go ahead. >> good afternoon. my name is carolyn kennedy. i'm a resident and community leader in district 8. thank you, supervisors, and thank you, d.p.h., for speaking. it's estimated that nearly half on the street suffer from behavioral health and substance abuse issues. and as supervisor mandelman says, this is a health crisis that's visible on the streets of our city. i thank you again. this hearing has provided much information about the problem

and about d.p.h.s response to the problem. we still desperately need mental health services to address the tragedy we see every day on our streets. we need to maintain and add to the funding for these critical services. supervisors, please take away one message from today's hearing. your constituents are sad and frustrated by a city where people are on our streets in full blown psychosis, where mentally ill people are harming themselves and others, where residents are being attacked and dying by those who are mentally ill. please know that residents in your districts want these services included in the 2020-2021 budget, and the department of public health, please provide us with clear budget figures regarding what's needed to fund enough beds to treat those in crisis so that we can lobby for them. i applaud the work you're

doing, i applaud the work of mental health san francisco. please sure that we can get those on the streets suffering psychosis into the service that they so need. the ones who are so severely mentally ill, that this is the right option for them. thank you very much. >> supervisor mandelman: thank you. next speaker. [please stand by]

thank you. next speaker. >> mr. chair, that completes the queue. >> great. well, if my colleagues don't -- well, public comment now closed. i want to thank all the public commenters for sticking with us through these four hours and calling in. and i see of my colleagues, so i will make some concluding remarks.

mainly in thanks to our folks for doing the thinking that went -- that underlay their presentation today. i think there is broad agreement i think, across the board, supervisors, mayor's office, department of public health -- i think there is a lot of shared understanding about how we need to fix our -- certainly our overall broken mental health system or at least -- yeah, we can call it broken. and the need to not wait another year. and so i think i am grateful to the doctor for the work he has done, and particularly for this bed study. i would like to encourage the department to do a little more

thinking about these buckets that are still -- pockets that are still -- at least in this presentation, fairly generally described. particularly street crisis response, outreach and care coordination to improve outcomes. i would love it if the department could spend some time thinking about how to make some significant moves in those two areas over the next year. and to do that, i think you're going to need the money to do it and it would be great to have, you know, some dollar figures attached to the projects that you want -- that you could undertake to make significant progress in those two areas. the area that i don't think i really saw reflected in the presentation today that i would also like to have additional thought on, is how we're going to -- where we're going to take

folks over the next year when they are -- or the next couple of years, when they are in psychosis, intoxicated and cannot remain out on the sidewalk in the state that they're in. as we've talked about, we can have great crisis outreach teams. those teams are going to need places to take people. and again, i think the time to start working on that, we cannot wait. we cannot go for another year with conditions on the street deteriorating. people in distress, visibly in distress, extremely sick and more of these folks out there than ever and not be able to at least tell san franciscans that we're engaged and moving as quickly as possible to a better status quo. so i actually want to continue

this hearing to the call of the chair. but it's my intention to have d.p.h. back at one of our two july meetings, because i would like to have more of that detail and maybe some dollar figures attached. and i do have at least a couple of additional questions about the -- you know, the results of the bed study, for example, you know, how does that proposed increase in funding relate to the existing d.p.h. budget for beds? because my understanding is the existing budget for beds does not actually account for all of the beds we buy over the course of a year. so if we're adding $10 million to a budget that already doesn't account for -- for the beds that we need to buy over the course of the year, i'm not sure that's guaranteed we'll be making progress toward the number of beds that we need.

anyway, maybe somebody can explain to me that aspect of the budgeting and maybe we can have craig wagner talk to us about that. and i'm wondering how the bed study relates to the beds we don't use. we know we have beds in the health facility, s.f. general, a number of locked beds that aren't in the budget. i don't think we budget for them, i think. so there are questions i'd like a little bit more information about. seeing supervisor ronen? do you want to unmute yourself? >> supervisor ronen: yes, thank you. i really just don't think we have the opportunity to ask enough questions about that bed study, so i would recommend that create a time where the doctor can be here with us so that we can really ask questions about it. >> yep. so i think we need to have d.p.h. back to this committee in

july. i did not anticipate that my housing conservatorship hearing would last hour and a half. and then we certainly did pepper presenters with questions as well. so the whole hearing has taken longer than anyone anticipates, but i think that is part of what happened here. he was around for three hours, so -- all right, with that, i will move that we continue this hearing to the call of the chair. and mr. clerk? if you could call the roll? >> on the motion from chair mandelman that the hearing be continued to the call of the chair? ronen aye. stefani aye. chair mandelman aye. mr. chair, there are three ayes. >> supervisor mandelman: great. then the motion passes. mr. clerk, do we have any

further business? >> clerk: that concludes this committee's business for today. >> well, then we are adjourned. thanks, everyone.

>> i am miguel bus bustos this d this is meeting for june 16, 2020. i welcome the members of the public streaming or listening via by phone and live and to the staff who have helped to make this meeting happen this afternoon. following the guidelines set forth by the local state officials during this health emergency, the members of the commission are meeting remotely to ensure the safety of everyone, including the