Programming and actually providing what we would want to provide, which is real treatment on demand for everybody seeking it in a quick period of time and support for them afterwards. I am hoping some of what will come out of doctor blands work is a map of what would and you suggested maybe it is three or a total of double the step down beds. It doesnt solve Behavioral Health court problem. It is hard for us as policymakers to, you know, work and i assume this is true in the Mayors Office to come up with solutions if we dont have a real assessment of what the gaps are. It is true, i didnt focus specifically on justice involvement in this presentation. We could find out. There are experts that would know better than i. Supervisor mandelman we have that hearing. We will have a lot of conversations about the jail. It does send assessors to the jail. It is difficult even though they are in jail it doesnt mean be they are easy to find or sit down with. A lot of things get in the way of the assessment. Supervisor mandelman superv. Supervisor haney i wanted to understand this. Based on the july report on the availability of Substance Abuse treatment, is the assertion here that there is no unmet demand . No unmet demand. Which report are you talking about . The treatment on demand report . Supervisor haney yes. It is getting better, but im sure we are not perfect. Supervisor haney the treatment system is large enough there are treatment openings every day, it has priority placement, no wait list for residential treatment, residential step down. How do you then assess what the demand is and help us to understand how to plan to meet that demand . Isnt that part of what we should be doing under prop t. It doesnt say anything about demand. My assumption is then that. It may not be accurate. What we are using is 10 to 12 people a day. There are a lot that want residential treatment. We look at the beds we manage at 90 occupancy rate makes sense for that, whether people get discouraged in the intake process that is probably true even though we shorten it to four days. My concern is that, and this is not meant to be an attack on you, it may not be accurate. How do we get Accurate Information . If it says there is no wait for the various things or one week wait, yet what we hear from folks working within the system is that wait lists are much longer than this to the extent they are kept. This information to me is by definition inaccurate, disconnected from what people are experiencing on the street. Obviously, we dont have residential step down beds for everybody. We understand that a lot of people come out of residential treatment and dont have residential step down. We are getting reports as policymakers that seem wildly disconnected from what is happening on the streets and also even by your own admission likely inaccurate. Well, yes and no. What i mean is from the persons experience who comes in to ask for treatment as supervisor stefani mentioned. They are not turning people away. You are offering appointment and intake process. What we are measuring on the slide show is the number of days from initial assessment to time they are in the bed. That is as short as it has been. We want it to be best. We have a high population that is experiencing homelessness. Waiting four days might not be realistic. We patch it up to do what we can to put them in detox and hold them there, but when i say there are probably people dropping out during that period from their point of view it didnt work and makes them more hopeless and they may not come back again and i dont like that but that is how it is right now. Supervisor haney it feels mismisleading if we are not keeg track of people turned away or dont come back. We are making it difficult for people to access things for a variety of reasons we are not reaching effectively or it is not there when they need it we should not be saying that there is an unmet demand. We should be as part of these reports requiring a plan to meet the actual demand, not the people jumping through all sorts of hoops and wait many days and be there at the exact moment to walk in. I feel like it is being cooked to lead to one conclusion, which is that we are meeting the demand, not measuring demand in a real way. Last thing. Has there been an external evaluation of this in any way . Yes, these measures we did it for the aqro. They require it. Supervisor haney is there an outside independent evaluator that they do that every year . They come every year and look at our numbers. Their benchmarks 10 days. From their point of view we are doing great. From the San Francisco point of view we could do better. They dont count it as wait list if you give somebody an appointment within a week. That is different from being on await list that you dont know when you get in. If you come in a week you will get in, in some cases if you are suffering homelessness, that is just semantic. You cant come back to an appointment. From the point of view of our external quality review organization, it would be on demand. Supervisor mandelman thank you, doctor martin. Next up we are going to hear from the treatment on demand coalition. Good afternoon. I am representing the treatment on demand coalition. One alliance of Behavioral Health advocates in support of housing, criminal Justice Reform and health care. We recognize there are enormous barriers that people face in San Francisco when they try to access treatment for Substance Abuse and Mental Health disorders. We are here today to talk about the best ways to overcome those barriers. In 2008 San Francisco passed a ballot measure which stated there we go. In 2008 San Francisco passed a ballot measure which stated the department of Public Health would provide enough free and low cost medical Substance AbuseTreatment Services to meet demand and required the city to maintain funding for the services. 10 years later, everyone knows this is not happening. We also understand that there is not just a demand for Substance Abuse treatment for Mental Health treatment, also. These are intertwined. From that ballot measure the treatment on demand proposition, the public is to receive reports for the need for treatment and what is available. We havent been getting the reports. It is time to ask the right questions. Those questions need to come from the communities that are affected by lack of access. When people are denied access to treatment the consequences are homelessness and incarceration. It is known if you have no access to treatment it makes housing less secure. Chronic homelessness is a cause and result of Substance Abuse and Mental Health disorders. People of color and lbgq are especially vulnerable to this. There is talk about people using Psychiatric Services often. You can see them on the street. Our goal is so they do not get to that point. The way they are treated they are stabilized without connection to services to help them. That is unacceptable. Back in march this year the San FranciscoHealth Commission declared incarceration is a Public Health issue. We cant leave this in the bureaucratic hallwayses of homeises unkept. 85 of jail bookings are those with Substance Abuse disorders. Why . The answer to supporting those people with Behavioral Health problems has never been policed. The answer is licensed professionals who understand the people they are working with. We must increase the staffing for case managers on the front line of the Public Health crisis the city has not addressed adequately. Intensive indicate managers and residential beds and housing with those in Psychiatric Care are imperative to change the Behavior Health system. We need a formal Communication System between homelessness and Supportive Housing. San francisco has a 12 billion budget. It doesnt take a genius to understand why there are so many homeless. Substance abuse is ignored by city officials. We need a assessment so we can focus the energy and resources to substantive solutions, the voices of effective communities. The treatment on demand Coalition Says it is time for the city to be act believe with a task force which is the first step to making this part of the public consciousness. We need a change now. When other places werent taking notice about h. I. V. And aids, San Francisco took a stand and said enough is enough. We took action. We held the government accountable for the problems they were ignoring. The treatment on demand coalition which is consisting of Supportive Housing providers, people who are members of the community affected, criminal Justice Reformers, and front line providers say San Francisco is better than that. Lives depend on it. Thank you very much. Supervisor mandelman thank you. We have been blown away from the excellence of your presentation. Thank you. Up next we hear from the executive director of health right 360. I am vicky eye sen. I am the ceo of health right 360. I worked in the field in San Francisco for 25 years. I have seen a lot of changes and policy shifts and the impact that has had on people, and i am a former consumer, former injection heroin user who found recovery from the safety net programs long ago. I am thankful they were there for me. Is there a way to get my slide deck up here . Thanks. While we are doing that i will Say Something that is not in the deck to give you a broad context. Two years ago prior to implementation of drug medical we had the same beds, 500 beds between the treatment beds and they were residential step down beds. About two years ago prior to drug medical we had the same number of beds that were full every night. They are full every night. Today you might have heard, im not sure if you read the paper, we had challenges filling the beds. What has changed . What has changed where we went be from a place two years ago where we had the same number of beds and the beds were full to today we have challenges keeping the beds full . I dont want to say that the sole problem is drug medical. We advocated strongly for it. We believe that it is parody. People with Substance Abuse disorder should have a stable source of funding. There are problems with it. I hope we can talk about that in the slide presentation. I will give you a snapshot who we are. We provide a range of services, substance and residential and outpatient settings. We have primary Care Health Centers with primary care, residential step down and some sober living, outpatient treatment for people with substance and some people through special Health Contract as well. Broad range of services. I want to give you a snapshot of the 9,000 people is pretty much all of them. We didnt count residential step down beds. We looked at the data request from you. We have 160 residential step down beds. We serve 9,000 people each year. Of that 6500 receive primary care, 1500 addiction treatment, 1900 Mental Health services, either through the primary care clinics or as part of Substance Abuse disorder. 950 receive detox services. This statistic says 61 of the clients experience homelessness that is of the total 9,000. That is everybody who has come to see the dentist or primary care or reproductive health. When you drill down to people for Substance Abuse disorder. That is 94 of those who come for residential treatment. Most people are experiencing homelessness. That number has been consistent for the period of time before drug medical. That hasnt shifted over the past two years. 94 of the people who come for Substance Abuse treatment are experiencing homelessness, most are sleeping outside, unsheltered. As a substance treatment snapshot we have 239 residential treatment beds if San Francisco. 16 in a program for Pregnant Services for women. Then 223 residential Substance AbuseDisorder Treatment beds. 178 are funded by dph. There are other purchasers who purchase beds for low income. Parole purchases beds. They are all for san franciscans, not all purchased by the county. It was difficult for us to pull data on what percentage of our clients have a reoccurring Mental Illness. When we pull the data it pulled a number that said 1495 people which is the equivalent of the people receiving addiction treatment. It was pulled by diagnosis. Some have more than one Mental Health diagnosis. At least half if not more of the clients we serve have a reoccurring Mental Illness. There is a perception we dont take those people with Mental Illness and we do. We take people who have been hospitalized or coming out of the hospital. Stand stand i have a whole slide and the next slide works through the intake process and it will show you where there are a lot of places to fall off and im interested in that, as well. For detox services, we can do the sameday placements because its an emergency service. They meet medical necessity, we can place them in the same day and we have the opportunity to do the intake work because ill walk you through that. Some clients come into and they sign in the morning and learn about the programme and we register them but they leave before they come back to complete the assessment. On the other side of the page, it has the overview of the orientation and screening process into treatment and its a parallel pass, the same doing both and based on what a person needs but a parallel pass for detox first or residential treatment. So follow me here. So the top little work flow is people coming in for detox. So a person for deto detox or withdrawal management, they come in and its conceivable if a person comes into for detox and theyre psychotic with no medication, theyre significanting aggressive or violent behaviour, net may not be taken into detox that day and i dont know if any of you had a chance to visit the residential houses but theyre big facilities. So if people are not able to be managed in that environment because they are aggressive or psychotic, well work with them to get them seen but we need to be stable. Its how theyre presenting. But for the most part, people walk in and we do a medicationassisted treatment assessment and that means theyre sent from the fifth floor to be seen if theyre at risk for withdrawal of any kind, so particularly true for people using alcohol or opioided because we have medications to address that and theyre sent to the fifth floor to be evaluated. The wait time at the clinic can vary and they could be there 45 minutes or two hours because its an openaccess appointments. They come back down and theyre assessed. We do the first part of their assessments to residential treatment and then theres a whole bunch of paperwork to do and then we transport people to the facilities. So they get through that process and theyre transported. At that time, if they express an interest than or i then or in dy stay in detox three or seven days ar we schedule them for a residential treatment assessment where all of the stuff on the bottom row starts. So if youre coming on from detox into a residential assessment, its fairly the process is a bit smoother because were transporting people from the detox to the residential and they have an appointment and we know theyll be seen that day, ok . So lets walk through that set of slights and then, the little arrows at the bottom show the places where people can drop. So a person comes in tor an orientation and often, i think its been habit we did change our practise and asked people to come in the morning and whenever you come in, theyll do an orientation for people and then if lots of people show newspapee morning, well schedule them for an assessment and if we find out they dont have medical, we need to send them to harrison street to get enrolled. If theyre enrolled in medical in another county, we send them to harrison street to have them transferred. So to the best of our ability, we send navigators with them and we have somebody who accompanies with them and if they cant, this is an absolute break point people are coming into treatment and anything you put in the way will make is a barrier, obviously. We send them to the medic laxerl office . What percentage is this. I have a slide to show you a percentage. It will give you numbers on the next slide. So then, we do an assessment on level of care. So coming back to when i said drug medical has and impact, its a managed system and the protocol says we do an assault and make a recommendation for level of care, send that to the county to bhs and they review it and they either concur or do not concur with that level of assessment. We say, we dont think that person needs residential or we agree with you. That process takes a minute for them to get back to us sometimes, as i think dr. Martin eluded to. But if we do an assessment and to our determination, the person doesnt meet the medical necessary thannecessity for resl treatment, that means they do have housing. If you ask the feds cms will say housing alone should not be a reason why you put somebody who has a Substance Abuse disorder in residential treatment and i think thats bureaucratic crazy talk, ok . Like, no one who works in that field thinks that makes any sense whatsoever but thats what the words are. So housing alone isnt the case. So flip that over, if a person is housed and based on kind of the level of their Substance Abuse, it may be the outpatient is the best place for them and thats rare that happens but occasionally it happens. We do an assessment. Band then we move them into outpatient and thats rare that happens. So then we need to get approval from the county if the person is not already in a detox bed, but if theyre coming in from the street, walk in from the strategy and want residential treatment, we do an assessment and they meet medical necessity, we send them to tap and tap has period of time for which they review it and say yes or no. If we dont put thatperson in tn the bed, we dont hear from that person for 24 hours and thats a place we lose people. There are times staff will triage somebody in, pretty sure theyll say yes and well work it out and weve been negotiating with tap to put them in a bed because we have the beds. Well work it out after the fact, but there are times when we cant do that and or its iffy and we dont put them in the bed and we may not get approval for up to 72 hours and thats a point we lose them. We can call them, but the folks that were working with dont have consistent phone plans and getting ahold of somebody to say your bed is ready now, its absolutely not optimal and i would think we lose a fair number of people that way. But then they come back in and we do the intake paperwork and it takes a long time and we transport to the facility. There are issues on our side, like if we cant run vans every hour and somebody is ready and have their bag of stuff and ready to go and they have to wait for us to transport them for two hours, they will walk off. That happens with a fair amount of frequency, completely understandable, no one wants to wait that waiting room. If they walk off, sometimes we dont get them back. So its another area of potential risk perform so then theyre placed if treatment. We review their level of care and were required to do that every 30 days. Max length of stay that they will cover is 90 days. So back to the question, supervisor, that you asked. We grabbed data from the first month as a snapshot and average time to and this had to do with approvals, not because we didnt have beds anywhere from same day and detoxes are all same day to 72 business hours, thats business hours. If you came in on a friday, that could be wednesday of the following week. The number of clients who needed to newly enroll in the last month was 14, so this was 14 people who had to be escorted to harrison street. How many do you think you lost . Im phoning a friend. Its phoneafriend. Shes guessing two or three. The staff do street outreach and its the same staff. The outofcounty transfers is 18 and i would add those together because its a group of people. You could say more than one a day if you spread it out over the course of a working month. The number of clients screened for level of care and what that means is people for whom we submitted a level of care assessment to the county and they said they didnt agree. We had to figure out what was happening and resubmit. Im just identifying some places for hurdle. The number of clients who exceeded episode limits. Drug medical will pay for two episode treatments in a year. The episod episodes could be up0 days. As advocates weve been fighting this because the nation o name e condition, people are uncomfortable and they leave and thats a whole episode and may well be they have a whole seasoned foepisode and theyve d their limit. Thats a pay resource. We dont have a bed issue. You have the stepdown beds. We do. So presumely at the end of 90, youre able to offer someone the next place to be and if you need to go beyond 90, do you go to the county an and ask, can yu keep them for another 90 and we pay for it . Most of the time we move to stepdown. Because the stepdown beds, i think i told you, we have 160 active now, and that is a gamechanger i in terms of treatment. Even before the length of stay was 90 days, it was six months. If you come in and youre unhoused, in San Francisco, you still dont have it at six months. So we work the day that you reported about the number of people who were being discharged into homelessness, that was way work prior to stepdown. Its most of the clients. It was horrible. So most clients have stepdown available for them and even if they have had a return to drug use in the last few weeks before the stepdown, well move them to the step down and then just intensify the outpatient part. So well try to take care of their same needs. You said youre fighting back on drug medical and how so. So i sit on two different associations, Provider Association and also just as an organization. Flight 360 is a large provider in the state because we deploy some of the records to fight fot we serve. Im sitting on the waiver work Group Designing a drug medical waiver and we sit on those and talk a lot about it. We talk as providers and consumers to the state. We talk to legislatures about it and they did not disagree on the two episode issue. The waiver is resigned and renewed over the next year. This is an opportunity to push on that and get cms, the feds to change that. And how as a county can we help you do that. The people making these rules do not understand addiction. Providers and counties are all in agreement with this and we sit on the same task force and push this is a major issue. The residential treatment, they ask for 30 day. Cms looked back and said if they can do it in int 30 days, why ae you doing it in 90. The current registration doesnt like california very well and theres a little bit goes with that. We need to assure the people we serve have access for at least 90 day. And when i say county, i mean the board of supervisors. We can have a conversation about that later. Supervisor hainey. Ill let you finish. Number of clients turned away are for not meeting medical necessity over a month is maybe three and fairly rare and number of clients in that same month who were not accepted due to level of risk having to do with a severe medical issue that they could not be managed in a nonmedical facility or a Mental Health issue that was they were at such risk they had multiple and recent suicide attempts and were not quite stable and in the past month was two. So just if youre curious or interested, these are the drug use patterns in our Treatment Programme this past year and remember that some clients identify more than one drug, so its not some use both drugs. You may wonder why is opioids 30 and why were martins numbers such a larger number. The numbers that the county has accounts for all of the people in the opioid Treatment Programmes and the narcotic Treatment Programmes. A lot of people who use opioids. Nothis is interesting to me because the number of people who come to us for alcohol is way up over the years. 20 years ago this would not have looked like this. So its a challenge we had aligning with drug medical and that we have made changes to. We increased our staffing and intake and i think we were given additional funds so that we have a team of 11. Workforce is a massive challenge for us and were retaining employees is a huge issue and if we dont have staff do the job, that causes our delay and ability to see people but we increase the intake staff by three and weve extended our intake hours and we start earlier and we are piloting evening hours directly at one of the residentials so that they will do direct intakes at the facility until 8 00 p. M. And pla this month its ten. Well see if a lot of people use that and that answers a big question for us, right . So as i said earlier, we have the patient safety, and they need to go to pharmacy because one of the things that happen is when you go up to the clinic and get a production, you need that filled and we need to walk people over there so we dont lose them. So were working to have our team accompany people to those things and then weve done transportation improvements, as well. Obviously people waiting around so people used to have to we puc pick up the detox clients and we pick them up as soon as theyre well and before them back to finish their paperwork. So areas of needs and this is specific to health 360 and not the system of care. So part of the issue, if we send people to the medic quarkal, oft would be great if we didnt have to send them away. We split staff and they work in intake and then go to jails two days a week. The jails would love us to be on site permanently. We have one person fulltime and one person at san bruno and theyre doing intakes and if they miss a person they pick them up. We would like to add more drivers if we lose people because theyre waiting for vehicles. Weve also been long been asking for a staff to be placed at zuckerburg General Hospital because there are a lot of people who come in and woe loved love to sometimes we send them to pes and we would help to repatriate them to the clinic to have better coordination when that happens. I want to echo what i heard dr. Martin saying is that we need services for people who are have ambivalent about drug use. I dont believe that the only option is youre on the streets or youre in treatment. That i think there are people am bilent anambivalent and they dot treatment but their only other option is to live outdoor. Thats terrible for their health and inhumane. We need to look creatively at of courses for people who may want to not stop using drugs or want to use drugs less or undecided. We do retain people in treatment who have had a return to drug use, but in the end of the day, the facility is for people on a path to reducing their drug use. And i think we need to think creatively about that group of people. I think what judy was say, there was 20 Million People with problematic Substance Abuse, 2 million get get and 17 million are not seeking it so it goes to supervisor waltons question, are we offering what they want . Is health right responsive to their needs but do we have services at every level of peoples need . And i think we dont. Thats the end of my slayeds. S. Supervisor hainey. You mentioned vacancy and talked about the steps youve taken to reduce those. Where does that stand now . Have those been reduced . How many vacancies are you at now and as a part of that, would you say that people who need treatment arent turned away while there are vacancies available for them while theres space but most of the people youre kind of losing, not turning away but are dropping off themselves because of the number of steps that theyre required to take that you described . The first thing is about the vacancies and are you turning away people when there are openings . Based on the data that judy showed, it was sharply down. We did a parallel practise Improvement Project in they were lookinwhich whywas it taking sot can we do in terms of hours, drivers, to improve that. Its come significantly down. With that said, i dont think we should have any vacancies. I dont think we should have any vacancies and we need more treatment beds because were full. Not because theyre not getting the treatment we have, if that makes sense. Your other question . Im sorry. Is anyone turned away due to lack of space right now . No. So the people who are not getting in are generally people dropping all of the at some point throughout the process . For the most part, yes. Or what were offering is not the right thing . I think a lot can get lost in the process. The wait is too long. Do you track where people drop off . 50 people who walk in the door, and are interested, how many are dropping off at each stage . I dont think we do because this has been a big deal for us for quite awhile. So where are the points and how many people come in and where do they go . But i dont know we have that clean data to show you, but happy to start collecting, its been on our project that we want to do. Two other things and i really appreciate the point you made about theres a set of folks who arent yet ready to go into the services that you provide and how are we serving them effectively. Do you provide any immediate detox or sobering situations that is not residential . Is that something if somebody came in to help right, they would access . So theyre not ready for residential treatment, even detox . Well, detox is a superlow barrier and its very different from treatment. Theres no groups. I mean, people are literally detoxing. They dont feel well or catching up on a ton of sleep and theres very little theres no demands on people in that. Its a super low threshold and no expectation. Theres no harm, no foul if you choose not to. It would be the majority of people who came to detox or people not seeking treatment, they needed time off the street and thats flipped with majority of people coming to detox are coming into residential treatment on that path, but we have no requirement that it should be, and so its a really low threshold service. People stay there three to certainlsevendays. Terms of how we think of demand, you have spaces in residential treatment for anybody who walks in your door, who wants that and who goes through the entire set of steps. What about before that in the sense that, do you think theres sufficient outreach, two people who may want to go into this treatment and what are you seeing in terms of how people are coming to you all and whether were meeting the demands that out there of people who might want to pursue further services from you . Sure. So i dont think were meeting the demand of people out in the community or out in the streets who are actively use drugs or have distribution at al drug us. We offer residential treatment, detox, treatment. Route. Right. Methodone, otps, but we dont offer, as weve talked about here, we dont offer early engagement spaces that they can come in people come into treatment if they desire to come in, they come in because theyre connected and somebody has engaged them and felt a personal connection to somebody who showed them, like, dignity and hope. Thats why they come in and those things happen, thats a long process of trust building. Is they should happen not just in intake or in a residential Treatment Programme but in other early engagement opportunities like drug consumption spaces. We see those as opportunities to engage people. Other spaces, where people using drugs or under the influence of drugs can be safely not on the streets. And so we think those are the things we should be thinking about as places for people to be where theres no judgment, no examination that you must go to treatment and theres no, oh, youve been coming here a long time and nothing like that, its just a space where people can be, that people can have links to dental care or do nothing at all but hang out and theres people around. If we get a person from there and get their teeth fixed, thats great. The toothache has been bothering them, and we think thats where one of the biggest gaps in the system is. Thank you. Supervisor walton . Thank you and thank you for your presentation. You mentioned the fact that there are times when you cant address the need right away and part of the waiting time is because you cant draw down the reimbursement dollars. Uhhuh. I know i was looking at the slide in what areas of need, but it seems like when you cant help some participants, its due to cost reimbursement and not necessarily due to capacity. So would you say a gap funding or some way to eliminate their wait time to able to help a patient right away is important for addressing the need immediately . Yes. I mean, i think in general, we have come to understand the managed care system that is drug medical, and you think the county has been a learning process. We know that somebody will be eligible. We would like to put them in a bed and we will work out the funding after the fact. And yeah one think that would be helpful. Thank you. I dont want to oversell it. There are times when there are other barriers. Like, if a person has a Health Condition thats not been taken care of, that puts them at risk, so we might need to have them seen to get medication if they have diabetes and dont have any medication, we need to make sure they get their medication for diabetes. Anything resulting in an Emergent Health issue, we have to take care of that before we put them in a residential bed and were obligated under licensing to do that and sometimes that is the issue. But absent medical or severe psychiatric crisis, absent that, we should able to put somebody in a bed. Thank you. Up next we have scott arye from positive Resource Center programs. You believe your presentation is already on the computer . And then to update folkses on where we are, these are very fruitful conversations but were spending longer than i had anticipate. We still have positive Resource Center, stonecall project and citywide and then public comment. And this is baker place, continucontinued program servic. Im dr. Scott arye, currently working as a director of Mental Health system. I think i want to begin with a quick history on baker places and pmc. C. Baker place was a nonprofit in the 1960. People were trying to get well and getting off of drugs and alcohol without using the system or going into the department of Public Health. What happened is that they began purchasing units around San Francisco and using each as their support system. They have been doing this all along since the 1960s and the reason think im pointing this out, its part of the adaptability and the agility of what baker place has brought. 2016, positive Resource Center, baker places came together under one roof and we merge. Baker place is a wholly owned subsidiary of prc and were located on 179th street, brand new offices over there. So part of what you wanted to start with is our continuum of care. As were addressing the treatment on demand and think about what does it mean and what is the definition of it. At baker places, we have a wide range of services and to me, this is a part of how we are addressing, making sure that people were not turning anybody away. So in our acute services and residential programs, you might be aware of the hummingbird space, a 29bed psychiatric respite. Ill be touching about this more later. As it pertains to this hearing, we have a joe healy detoxification and its located in hayes valley. We recently kicked off they just started the drug medical in march of this year and so we are in the midst of going through the growing pains of instituting a brand new system and a brand new way of doing things at the detox. Last but not least on the bottom, theres grove street house. This is a ninebed crisis stabilization unit. This particular perfor program n the Mental Health side of the system and a lot of people were addressing the ko cooccurring disorder piece. As a clinical psychologist walking into this, this is one of the first things you notice in the system of care, is the separation between the Mental Health and the Substance Use disorder sides. I think this is a part of how prc baker places is addressing, how do we make sure people are getting to the right place . More often than not, i believe ththe statistics are thrown arod 90 also, they have coexist tentt orders. Is it your Mental Health causing the Substance Use or the Substance Use causing the Mental Health . Its getting out of the dynamic of which came first, the chicken or the egg. Its presenting a new paradigm of how do we address this . This is through the cooccurring disorder sort of motto. In our Substance Use disorder concontinuum, we have two programs. Substances are providing with sensitivity to the population served. Theres a Substance Use disorder diagnosis. Ferguson place is hiv place diagnosis and part of the things were doing well are target populations and providing Residential Services to specific populations. This is sort of the antithesis of treatment on demand. A woman cannot walk up and say can i have your services. This is men designed for men who have sex with men. And somewhere in there is huh, maybe not every place should be treatment on demand and theres the cultural competency involved generating healing in these facilities thats different than one size fits all. Moving on again are the Mental Health programs, prc has programmes anmentalhealth progr. Baker street program, you have to have a Mental Health issue. You may be using substances, but specifically its a Mental Health only. San jose place and Robertson Place have been categorized and dual diagnosis. This is important because these are the programs that allow us to work back and forth with