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 FranciscoSubstance AbuseTreatment 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 y