Transcripts For SFGTV Government Access Programming 20240713

Good afternoon, the meeting will come to order. Welcome to the september 27, 2019 special meeting of Public Safety and Neighborhood Services committee. I am supervisor mandelman. To my right is supervisor stefani and mr. Walton. Mr. Clerk do you have any moniesnents . Clerk please silence cell phones. Your completed speaker cards should be submitted to the clerk. No eating or drinking in the chamber, please. Items today will appear on the october 8th agenda unless otherwise stated. Supervisor mandelman thank you. Can you please call the first item. Clerk hearing to analyze and understand the city progress in meeting the requirements and goals of propsis t. Lessons learned from the citys efforts to achieve treatment on demand and challenges to current efforts to expand access to treatment for Substance Use disorder. Supervisor mandelman i want to thank the providers, advocates and drug policy experts who have pushed the city. The members of the coalition have been on the front lines for many years. I thank them to bring this hearing forward. It was more than two decades ago this board passed the resolution authored by the supervisor adopting drug treatment on demand fo for indigent san franciscans. The average wait was 60 days and the citiesty mated 12,000 of the 45,000 in need of treatment was receiving it. In 2008 voters passed proposition t reiterating the city commitment to the policy and requiring the department of Public Health to submit an annual report to this board assessing demand for Substance Abuse treatment and presenting the plan to meet that demand and requiring the budget include the dph plan. So today in 2019, how are we doing . A walk on the streets of San Francisco would suggest not that well. I am hoping we can unpack that a little in todays hearing, move and look at facts and data and begin the conversation about the necessary next steps to make good on treatment on demand. What are the successes since 1996 . I know there have been successes. I have seen first hand the amazing work so many great providers are doing to change lives throughout the city. There is more to be done. I am hoping today we can explore not just the gap between our current reality and the promise of universal immediate access to highquality drug treatment and we can explore the gap where we support those coming out of treatment. In may at the budget and finance committee we held a hearing on the budget. At that hearing we learned 44 of the people exiting residential treatment go to streets or shelter. This is alarming. It suggests we need significant investments not only in treatment but step downplaysment to ensure it is successful. We have begun to do that in the current budget although not enough. Today we will hear from the department of Public Health and the treatment on demand coalition and health right 360, positive resource and from citywide. Colleagues, i ask unless we have clarifying questions we allow the presenters to get through the presentations then discuss at the end of first i think supervisor. Supervisor stefani i want to thank you for calling this hearing. I want to thank the treatment on demand coalition for the meetings that have led up to this. This is a topic that means a lot to me in terms of addiction and how much i have come into contact with it in my life in various ways. It is something i am very familiar with and care deeply about and i think we can do better at in the city and county of San Francisco, and i think there are successes. When i called the hearing before last year on 5150s afternoon we were looking at coordinated exits. It was after i called the police on an individual on chess nut street when i was walking down the street with my son and that individual was in clear distress. They came and took him to the hospital. We didnt know where he went. Next day he was on the street with hospital braces on. Did we fail that individual . What could we have done better . Today on my way to work this morning i saw an individual at starbucks on union who probably had slept out all night in the rain, barefoot, struggling, eating out of trash. How can we help this individual . The way this man assessed for us on this side and our constituents in a way that creates a lot of negativity. Our neighbors are losing patience. They are fed up with conditions. Some of them are starting to run out of sympathy. I dont think i will run out of sympathy. The purpose of the hearing is to understand what is happening so we dont miss opportunities to help the individuals in the state they are and when they are ready for treatment. I believe we must lead with services and treatment. I have said that before. I have been very open about my experience with addiction in my family. I have a brother 16 months younger who was a heroin addict and whose had every opportunity to get well with my family. I come from a big family. My parents tried to help him several times. He has not wanted help. That help has been offered after rehab, rehab, rehab. He struggled with addiction since 18. He is now 48. It has been hard to watch. It has been hard to know how to help, and it is frustrating. That manifests here in the city and county of San Francisco. I think all of us want to help those individuals as well. It is hard to help people that sometimes dont want help for addiction. I think that when we see what is going on it is hard to imagine this crisis being any more dire. I know how discouraging it can be to think how long we have been working on Mental Health. We had the 1996, prop t in 2008. It is still present. I know how daunting it is to walk through the city and see distress on the streets knowing we have to do more. We all share a sense of urgency. Was it aids, Mental Health or Substance Abuse we have not ignored it. We are a national leader. It also means we have often had to carve a path on our own. The rest of the country has the opportunity to learn from trials and successes and failures. As we begin to tackle the crisis it is important to take stock of the resources we have and what is currently going on. We need a better understanding of why this is happening despite our best efforts, why this crisis continues, why we have Overdose Deaths at near historic highs. I am happy mayor breed announced this hearing. I think understanding the system apcurrent resources and the gaps is critical to reach the populations we havent yet been able to serve. Before i conclude i want to say one more thing. We talk about Opioid Crisis and meth crisis. I want to call out the crisis as it relates to alcohol. It is socially acceptable. No one will say at a party or bar, would you like your meth or opioids. At a bar, you know, or party or on a radio show, it is common for someone to ask you what you like . Alcohol is a powerful, powerful drug. Because it is socially acceptable and readily available 24 hours a day, it is seemingly okay. Some of the estimates indicate a vast majority of those homeless with Substance Abuse issues suffer from alcoholism. Alcohol needs to be understood and given the same attention that meth and heroin get. It is one of the hardest drugs to detox from and we need to concentrate on it. I look forward to your presentations and hearing from the public. Thank you. Supervisor mandelman thank you, supervisor stefani. With that we will hear from Judith Martin from the department of Public Health, doctor Judith Martin. Thank you supervisor and chairman delman. I am glad to be asked to talk about this treatment on demand. It is a key feature of San Franciscos services, as you pointed out in your talk, San Francisco is always willing to provide leadership to the whole world and this is one of those examples. My presentation is going to include an overview of Substance Abuse treatment and trends in San Francisco and some things about proposition t, and then talk about part of the system that is very much with this and then the lessons learned. This is a slide that shows a lot of things. On the right is the jail map. Red dots are Substance Abuse treatment locations. The blue shows clients. The darker the color, the more people. The city and county of San Francisco Substance Abuse Treatment Services in 20182019 served 6005 clients, 99 which were adults. 56 were homeless. If you look at residential treatment that goes up to the 90s. I also included in the circles the Mental Health services. I am only talking about Substance Abuse services here. To point out that the Mental Health is more than norm. A third of the Substance Abuse people are also duly enrolled in Mental Health services, specialty Mental Health services. This chart is specific leabout people who made it and stayed in treatment. It is the people who are actually doing well. It does not include the people who are not in treatment and surveys show only one in 10 of them want treatment. It does not include people who might want treatment but cant access it for various reasons, including people experiencing homelessness and having trouble with our system. It also does not include very Robust Services offered in primary care in the hospital, in jail. We continue treatment for opiate use while people are incarcerated. We have a treatment medication start in the emergency room, in the hospital for people wh who e not in treatment and prerelease in the jail. Many Mental Health and primary care clinicians are also treating this disorder. This is a chart that shows primary diagnosis of those 6005 people and that means the chief complaint. The drug they identified as the reason they came in. Opiate use disorder is by far the leader for many years in San Francisco. Alcohol was frequently second and lately is neck and neck with methamphetamine. That is what other still lat means cocaine which is methamphetamine in our city. You can see that methamphetamine use disorder has tied and surpassed in some months alcohol use disorder. This is one of doctor coffins slides. He tracks Overdose Deaths. This is through 2018. I used to be able to say even last year that overdoses were relatively flat in San Francisco, but look what happened in 2017 and 2018, they started to climb, and this in spite of 1500 bystander reversals thanks to the programs in the community. The top black line is totally overdoses. Green is opioid overdoses. The red line is climbs is overdoses due to methamphetamine. The blue bars are estimates of the number of people who inject drugs, which is estimated right now to be 25,000 people in our city. So i am witching to talk about treatment on demand. Up heard about it you have heard about it from the chairman. These are the actual words in proposition t. It is really interesting proposition t mentioned the word essential services with regard to Substance Abuse, and there is an echo of that in the 10 essential benefits of the essential care act later in 2010 that provide hope and dignity and pathway out of addiction. It may lead to homelessness and criminal activity which maybe seems a little hopeful, overly hopeful, perhaps, because we know that homelessness wont be cured without housing. The best approach to criminal activity is decriminalization of drugs. It required the department of Public Health to maintain free and low cost medical Substance Abuse services. Residential treatment slots. It didnt provide specific funding. It said we shouldnt reduce funding staffing or treatment slots. This protected our services during downturn in the economy. This is a timeline to place it you have heard some of this already. The department of Public Health treatment on demand Planning Council in 1997. From 1972 on ward we have had block grands federal funding from the state to the county. We have those. That was all there was in 1972. In 1995 the city budgeted 11 million in friends. Then 20 in funds. Then more was added. It is still around 30,000. Then proposition t in 2008 that is the same year the pair rod de year passed at the federal level. In 2010, the Affordable Care act made Substance Abuse treatment an essential benefit which means all of assurances that covered california exchanges have to include it. Also, the aca had an expansion of medical to include people who were poor. No longer did one have to have a disability or Young Children to qualify for the medical benefit. That means in 201400s of people suddenly overnight had insurance. That included Substance Abuse treatment under me dical. The state decided to take advantage of this increase. The expansion did affect people suffering from Substance Abuse dispore torsiodisproportionatel. It was to expand the services to the full care of proven treatments. This required a lot of work including suspension of the imd exclusion that was present for residential treatment. San francisco opted into the waiver. We went life in 2017 and have been adding programs to this organized delivery system. So the things we like about it. It has high standards, proven evidence based treatments, and they are provided diagnosis and assessmentses are provided by licensed providers. Placement to level of care is backed up by evidencebased assessments. It includes a a continue care. It is the external Quality Review Organization is an organization that the state contracts with to come and vertus to see how we are doing and specifically they are looking at it is made up at people who used to work in Addiction Treatment and peers and people with lived experience or family members. They do a lot of focus groups with consumers and providers. They look specifically at things that would be very consistent with treatment on demand. They look at the adequacy of services, change of services, timeliness, if people get into service after they ask for it. They look at engagement for the people staying in treatment long enough t to have an effect, and they include Performance Improvement be projects they approve. At the end of the three days they give us recommendations. Next year they come to see if we did them. There is a new level of quality review that is because it is a health plan. There is also extensive documentation. We have to have accountability we did what we said we did to be reimbursed to cost. These are some of the all of the treatment providers, 45 communitybased treatment programs. The bold ones indicate they were active with drug medical and we have a number of programs with u. C. S. F. We have some that offer methadone on site affiliated with u. C. S. F. We have seven methadone clinics, which is an unusual number for a city our side, if you count the va it is eight. Supervisor mandelman unusuaf our size. We have a lot of access to opioid treatment. Residential beds are increasing, and this has a lot to do with the mayors support of Substance Abuse treatment. I wanted to show that residential beds remain high. Some of the residential beds were reassigned to residential step downs. Residential step down is a new Service Based on wanting to continue care after residential treatment is finished while people engage in outpatient treatment which was pointed out people were discharged to the street. Once it is on the treatment it is unlikely you are going to participate in the outpatient care. You are likely to not come. This is protected housing. When someone finishes residential treatment they go to a residential step down bed and can stay there while in outpatient treatment and also some Recovery Support services. It is a new form of housing. Not housing first. It is residential step down. The average stay is seven months, but people can stay as long as two years if they have to. I also included respite which is cooccurring diagnosis. It is very low threshold which meets well with the need of people who are homeless. Also, there is additional beds coming in 1920 that arent on this chart. Supervisor mandelman how is there a decline in residential . Some beds were reassigned to residential step down. They are for after . Residential step down to support the out patient treatment. Are there fewer slots for. For residential treatment . If you are looking at this . We are adding more as you can see in 1920. These are the ones we have right now, yes. We have 186 now. The residential step down, but we think we need 300 or 400 residential step down. Soon it will be a bottleneck because people stay longer. Supervisor mandelman you need three to 400 more . No a total of three to 400 which is double what we have now for residential step down. That is an estimate. So we have maintained a fairly high level of admission for drug medical monthly admissions between 300 and 350. The then residential Treatment Access. How do you decide what is adequate and with 10 to 12 people coming in a day, we believe that 90 utilization is about right. It means you have some leeway to admit people urgently, and our daily vacancy now is 86 capacity. These are the beds we manage and authorize. The programs submit assessment to us that is reviewed by our authorizers and i should mention that doctor bland is developing a public facing bed count that includes all beds, not just these. This was a Performance Improvement project we undertook when we noticed a lot of beds empty. It it was our initial pilot partner and that agency has 80 of our total beds. We postulated that the intake was taking too long. People were screened and told to come back. A lot of these people were experiencing homelessness, they dropped out during the intake process. We wanted to shorten that and undertook a Performance Improvement process at the intake and Treatment Access program at 1380 howard. This was the effect of it. The intervention was led by irene, our cmo, it ran through june and early july. You can see our target 14 would be 10 empty or 90 full. We are not quite there, but it made a big difference. So in some ways successes we have treatment in Opioid Epidemic not just in treatment settings but street medicine and primary care, hospital, jail. We have expanded levels of care to fit more continuum of services. Residential step down to address transitions to community for people experiencing homelessness. We have gender and pull tur culture specific programs. Some of the challenges are extensive administrative requirements in order to be accountable for reimburse meant and even when treatment slots are mathematically sufficient people experiencing homelessness may have trouble taking advantage of the usual Treatment Services. This makes low threshold a key access need. That is not drug medcalorie imbursable. We are expanding the behavior access hours. Supervisor mandelman wait a second. Low threshold access means what . It means the intake process you walk in and say i need help, socks, food, or whatever. Supervisor mandelman things you would do with folks like hummingbird. For example street medicine sees people at syringe access where they are coming to get a syringe for heroine accident, what about the morphine . We have Behavioral Health pharmacy unique in the entire country and can do miracles. That program has hit 500 people, and 140 stayed in treatment, which is really amazing. So going forward, we think hours should expand to the evening hours so we are working on that. Web based listing, i already mentioned. We are expanding drug medical to the other programs that are smaller, and some are Spanish Speaking and some for women more specifically to neighborhoods in our city. There are 212 new Behavior Health beds projected through 2020. Next year will be the third year of drug medical expansion. Every year we get stronger and learn more about how to be a health plan. Also, we have the external quality review process which is very familiar because we had treatment on demand all of these years. We have a continued performance on access. That is why i decided to stay in the 10 minutes. Supervisor mandelman thank you. Supervisor haney has a question. Supervisor haney thank you for your presentation. So i am kind of clear on where we are at under what is required under proposition t, is it your view that we have enough spots and enough treatment available to meet the demand . We certainly have enough to meet the demand for opioids. If we have enough for residential treatment varies from daytoday. Part of it depending on what other Housing Options are available. It is hard to distinguish between need for housing and residential treatment. Residential treatment is pretty restrictive, and not everybody who lives on the street can stay in such a restricted setting. That is why i am arguing for lower threshold beds to be increased. We know the development there is an anecdotes. It is said by our providers. The development of Navigation Centers provides a place for those that need a break from the street. They used to come to the Access Center to say they need detox. What they needed was a couple days off the street to crash. They were shelter seeking. A safe place to feed and watch them while they slept. Supervisor haney i apologize if i am blunt here, many of the folks in need are in the district i represent. To say that we are meeting the demand feels wildly disconnected from what we see every day, from what my constituents are telling me every day. How can our own analysis lead us to say that we are meeting the demand when i think common sense dictates that we have so many people who are not accessing care right now . Are we not measuring the demand correctly here . If someone cant access something at all because of weight times or because it is not the appropriate type of care, and then we arent counting that as part of the demand, of course, we will measure that we are doing fine. For anybody who is looking at what is happening, who walks through the district i represent would say we are missing our responsibility to provide for that demand by a long way. How would you respond . Doctor bland had a report that said 4,000 people who are untreated who have a need. For us to say we are meeting that already, i am confused. What you are saying is whose demand . The neighbors demand or the persons demand who wants treatment . I am trying to minimize this. There we go. We have in Substance Abuse we have the advantage of a National Survey, called the National Survey of drug use and health that comes to San Francisco every couple years and interviews people about specifically that. It includes that, and i made a slide. Supervisor haney just another thing. I walked around with some of the folks who do Harm Reduction outreach in the tenderloin, and one of the things i asked them is do you offer treatment spots to people when you are out here talking to people on the street . And they say what treatment spots . We dont have anything to offer anybody. There is Nothing Available and people only get into treatment on rare occasions. It feels like there is a huge disconnect from what is in the report around the idea this is available for anyone whenever they want it and we are meeting the demand from what is happening in our neighborhoods and on the streets, particularly for people who not just outpatient but residential. All of the things here. I am having a hard time understanding the disconnect. It says that i thought as part of the report we need to present assessment of the demand as well as plan to meet that demand. Is that not in the report because our conclusion is that it is being met . Treatment is more accessible now than it has been before. It doesnt mean we have the answer for everything, but we have timing measures. For example the benchmark for methadone basis is three days. That is available on the same day. In terms of residential treatment, the average is 5. 9 days. Median 4 days. That is a huge difference from what it used to be. We try to make it shorter. I want to show you this. The National Survey for drug use interviews random people and then extrapolates that to the city. Based on dsm criteria, the diagnostic criteria for addiction. They estimate this that there are 8,000 plus people in San Francisco with opiate use disorder. We know in methadone treatment we have 4516. That includes methadone treatment. We can count it. It including every prescriber in the whole city. That shows an extra 2000 or so that people. That means that we have 3669 people who arent in treatment, right . So if they are not in treatment and all of the open slots we have capacity for up to 13,000, why arent they in treatment . The National Survey asked that of people who arent in treatment, how much want treatment . 5 perceive the need for treatment who arent in treatment when it is freely available, right . That means out of the 3,600, 370 want treatment and arent getting it. Why arent they getting it . This is an important question to ask for treatment on demand. When it is available on a walkin basis on the same day, yet uv over 300 people not getting treatment, why is that . I think the answer to that has to do with people experiencing homelessness, and also not liking our system. I think that, for example, street medicine a lot of people that came to get the drug who were recruited had been in the methadone clinics before. They didnt want to go back. There is the argument for very low threshold centers that give people what they need without a lot of requirements. There is a big argument for that aside from the treatment. This is by diagnosis. We could do a similar thing for methamphetamine. We couldnt look up cures to see who is in treatment. It is not exactly the same thing we say would do for residential access. What we are doing is looking at the beds we manage and trying to keep 90 occupancy to get the ability to keep admitting people. Do you track wait lists . Do you have wait lists . We dont have wait lists. We have a process of admission that sometimes if you are homeless ends up being await list. If you are homeless and you say i want treatment, they do a screen, you might need treatment, come back in three days for intake. That is not going to work. That is what we are working on to expand hours of intake. Right now sometimes we admit people to detox because tha ths a crisis service. They can get in sooner as a place to stay until they are admitted. It is not detox. It shouldnt be used that way. Maybe in the future hummingbirds can be used that way. It is a place people can be safe during the intake process if they are homeless. Commissioner walton thank you for the presentation, doctor martin. I want to make sure i heard you correctly. You say we have 300 plus people we know need treatment that want services, but your thought process the reason they dont seek our treatment is because they dont like it . Or cant access it because they cant get there. They have stuff. They dont know where to leave it. They cant keep an appointment. Isnt it our job to provide a Service People would like . That is why the doctor started doing the street medicine as a Restorative Justice approach. People are on the street homeless, this is how we take care of them. Is that what you are asking me . Commissioner walton i am trying to understand why we have 300 plus people and you gave the people of the fact they are not seeking the services because they dont like it. That is a problem for me when it is or job to be sure we serve them. If it is because we dont like our services . What are we going to do to make them like it so we are meeting the needs of individuals that we are supposed to serve . I think that is the right thing to work on. I think one of the answers is an open door that doesnt have a high barrier. What are we doing about that . We are meeting people where they go, to theiren campments to syringe access and offer treatment. We are doing pretty well with opiate use disorder. Maybe some of those reached are the 3770. The 370. It includes people in homes. I assume some of them are in the safety net at least. I speck limit homelessness gets in peoples way. Commissioner walton my questions are based on your statement. I want to make sure we are very intentional about the type of services we are providing if we know there are people with Substance Abuse issues that want treatment but they are not seeking our treatment which is free and meets the demand, there is something to do differently. I want to hear what we are going to do differently and how we are not going to have that issue again. I think what we are going to do differently is try to approach people in a less not expect people to come to us but go to them to do out reach. Support them during the intake process so it is more welcoming, and i also think that while people arent in treatment, even the people who dont want treatment, we should protect from the ravages of the disease. That is why we have Harm Reduction in the city. That is another whole effort that developed with treatment on demand. We had the Harm Reduction policy which kept a lot of people alive to make sure they dont get needle related illnesses or overdoses. I think also the people who the 3,000 or so who arent aware or dont perceive the need for treatment, i think that is where the screening helps. We are doing this now in the emergency room. If they need treatment it is offered. Where do they show up . You look to where they are and go find them. Commissioner walton do you think we have adequate staffing within the system to meet the needs to provide treatment on demand . I think that one of the challenges has been keeping staff. The turnover of treatment staff in Substance Abuse is pretty high. We thought about some things to do. I am not sure that they take money so we dont always do them. Because of the income disparity in the city, it is hard for working people to live here. It makes it less attractive to work here. I think the very least we could do is offer our contracting partners the same level of salaries as u. C. S. F. And the city has to be on parody. I think that would be a good place to put some money so our providers could be able to hire people and keep them. Commissioner walton it sounds like you have the answer to what we need to do to adjust that turnover. What are we doing to institute some of these great ideas . I mean we are talking about it. I have no idea if it will ever happen. Supervisor mandelman we have to give you money for it. We have to put it in the budget to see if it is approved. That is usually the way it happens. Commissioner walton there is give and take, too, we can talk about that as well. It seems if we know that we have steady turnover consistently we need to figure outweighs to keep folks ex imed about working and providing the services. It is amazing work force. All of the contracting partners are excited about treating people and inspired by their work when they see people get better. It is a good field to work in, very warding, but you need to earn a living. Supervisor mandelman superv. Steftestify when a homeless supervisor stefani when a homeless person comes in for treatment and they want treatment in that moment and we are not able to provide it and they might have to wait three days, and i cant live with that. That moment for someone especially someone living on the streets suffering from whatever Mental Health, Substance Abuse alcohol or whatever. That moment when somebody is ready to ask for help, we have to provide it. Three days that person could be dead from the disease. I just cant imagine that we cant figure out how we get that person to safety and hold that person in that moment of surrender so they get the help they need. It is for you to tell us so we can budget so we are effective as legislators and policymakers up here. We need to know what we can do so people dont die while waiting for treatment. I think, too, if someone came into the hospital with a broken arm or broken leg they wouldnt send them home to say come back in three days. Addiction is a disease and something when someone is ready, we have to be able to help them. I think about that person i saw today on the street. If that person walked into whatever facility we have and we turned him away, i want to know what we can do to make sure that we are taking care of that individual. I am not placing blame. I just want to know how we help those people get from that moment they want help to not letting them go until they get it. Certainly in terms of opiates we have that crisis approach if you get there by noon you get your dose. Supervisor stefani alcoholil disease, and if someone comes in and they are done, i cant take one more drink, what are we doing as the city and county to say to the homeless that 4,000, 90 are struggling with alcoholism. What are we doing to get them into any type of treatment at that point in time . With alcohol we need to make sure they have medications for withdrawal. We consider withdrawal management a crisis service. Our goal is to get them in within 24 hours. That is detox withdrawal management. It is easier to get into detox than residential treatment. It is longer process for assessment for residential treatment. Supervisor stefani can we have a process where they go and when they are in detox we have a place ready for residential treatment. Sobering centers are used in that way. If they are willing to go to detox sometimes the nurses will start the detox at sobering and admit them when the person is ready for the detox. Again, only one in 10 want that. Supervisor stefani for the one that does, though, i want to know what we are doing when they seek treatment we dont say come back in three days if you are homeless because the likelihood of them coming back is unlikely. I agree we need a place to keep them safe. Supervisor mandelman i want to first of all, thank you for all of your work over many years on these issues, an and i also e questions. I can accept and it makes sense to me for the person who is seeking treatment, a homeless person, outreach worker says do you want to go to treatment and they say, yes, there is a relatively short wait. It sounds like that could be several days and supervisor stefani, that is not exactly treatment on demand. There might be work to do there. I am more troubled by the access to treatment for the justice involved population which we had a hearing on several months ago. What we hear from Behavioral Health court and drug court is that they have a very hard time accessing appropriate services, appropriate Treatment Services for people in james or in one of those people in james or one of those courts. Part of the disconnect may be the treatment we are relying on to meet the treatment on demand goals might not be the most appropriate place for someone in Behavioral Health court. I know there are some folks going to health right. Can you talk about if the overall picture is better than what it was in 1996, there are pockets of the picture that are pretty not great sarfor folks in Behavioral Health court. Can you help us understand and if we were being more aggressive around kind of trying to leverage people into treatment through Behavioral Health court, that would just add to the backlog right now. People dropout of Behavioral Health court because they cant access the services. Can you talk about the disconnect between the numbers you are presenting and three day or week long wait which is the problem and many weeks wait which is happening for the justice involved population . A lot of people in the justice involved population would qualify for medical unless they are incarcerated. I think some of those folks that are coerced to treatment are coming in through regular medical. There are specified beds. There is one whole Residential Treatment Program that is and 90 methamphetamine primary drug in those beds that is specifically for prop 47, for example. There is ab109 beds. I believe health right has some of those. There are a lot of people who are in treatment because somebody holds it over them sort of. For example Child Welfare the women in the residential treatment for women which is drug medical are there because the case worker says they have to be there. It is an area there is not parody. If you broke your arm the judge wouldnt decide how long you stay in reman. It is a difficult area to be evidence based and assessing, but we think that the moment every union fiction where the mother and children are put together again i in peri medical care is important. We take that into consideration. Each case worker is slightly different so you cant predict very well. I think the courts, some of the courts have their own person to do the assessment and points the direction where people go. Some get in faster than the ones we manage. Supervisor mandelman if you talk to the people in those courts da or pd, they will say and have said here that they dont have nearly enough access to the appropriate kinds of treatment. It may be in a narrow sense we are close to meeting the treatment on demand goals. If you are affirmatively seeks treatment and not coerced and raising your hand and you have a fair amount of agency and being able to access what you need to access while the slot opens up we are in a better space than we were in 1996 around that, but if you are coerced into it and you may need a higher level of service and you may have committed some crimes and there may be concerns about forensic concerns that my belief, but it is not i guess what is troubling it is not necessarily out of the report. I have a hard time assessing how big of a problem this is. Maybe treatment on demand is not entirely the correct framework for thinking about it. Being able to provide Substance Abuse Treatment Services for everyone that we as the city want to get it to and making them the right services that are most likely to lead someone to stick with it. We are further than the treatment on demands reports are suggesting. I will say that more definite. We are further away than the treatment on demands report would suggest. Then i will let you respond. If there is a significant wait the Department Anticipates these things, sees them, then responds. The stop down beds came from the department. If i am on the street and i am thinking about treatment and my friend just went through treatment and now they are back in the park with me because they got through the 90 days or got to stay longer, but there was nothing to go to afterwards, to disrupt my life, leave my friends and go through a tough process, if i am just back in the same place isnt going to sound superappealing. I might be part of the 370 who like if there were a path that wasnt just treatment but were treatment to something, that i would then. Again, not exactly treatment on demand. That is not what they were worrying about in 1996 or 2008. We need to define it to include support for people who have gone through the immediate treatment and need support and sobriety for a while. Some kind of living situation to support you after the 90 or how ever many days. We need to redefine treatment on demand to include that or expand the priorities of the city to be not just treatment on demand but the additional elf of support which you are working on. I am saying this is a problem that we need to work on. I guess, you know, another question for me and this was hard for on the Budget Committee is for us to understand the scale and scope of the gaps and how much money it would actually take to fix them. I know this is part of doctor blands charge. In thinking what we need to do for folks on the street who either are voluntarily seeking treatment or are going to be kind of produced in that direction through some criminal justice involvement, i still dont think i have any concept of what it would cost to what the distance between where we are in terms of spending