Transcripts For SFGTV BOS 20240704 : comparemela.com

Good morning. The meeting will come to order. Welcome to the july 28, 2023 homelessness and Behavioral Health select committee. Im supervisor ronen chair of the committee joined by vice chair mandelman and supervize sor when your item of interest comes up and Public Comment is called, those in person should line up to speak and those on the telephone dial star 3 to be added to the queue. If you are on the telephone, please remember to turn down your tv and listening devices you may be using. When your item of income comes upyou may submit Public Comment in writing in either of the two following ways. Myself the homelessness and behavioral select clerk at stephanie. Cabrera sfgov. Org. You may send your comments via u. S. Postal service to our office in city hall at 1 dr. Carlton b goodlett place room 244 San Francisco california 94102. Finally, items acted upon today are expected to appear on the board of supervisors agenda of september 5, unless otherwise stated. Thank you so much. Can you please read item 1 . Item 1. Hearing on department of Public Healths Behavioral Health Services Case management system; specifically examining how many Behavioral Health and Substance Use case managers are in the system, their work location, the process for providing Case Management at varying levels of need, frequency of case managers interacting with their clients, the caseload of case managers at every level of care, and the number of funded but vacant case manager positions exist in the entire system of care; and requesting department of Public Healths Behavioral Health services to report. For those remotely , if you havent done so dial star three to be added to the queue. Please wait for the system indicate you have been unmuted and you may begin your comments. Thank you so much. As the person who called the hearing, i wanted to make a few remarksopening remarks before i turn it over to the director of managed care at dph. When i wrote Mental Health sf about four years ago, i knew that it was redesigning our entire Behavioral Health system, and that implementing it was going to be a major challenge,b a major effort and it would take some time to do so. At the time, we didnt realize that a worldwide pandemic would hit us and completely divert the attention of dph for over a year to keeping us as safe as possible from that pandemic and so, aswe lost a good year of implementation. I do want to say, i believe that we are moving in the right direction and that dph is committed to redesigning our Behavioral Health system so that it flows as well as it possibly can amidst a privatize Healthcare System that is broken, a public system that is underfunded and a National Situation that is absolutely broken in every way shape and form. Still, we are working to become the best Behavioral Health system of care in the country and we are well on the way. Case managers are sort of at the center of the system because when someone is suffering from Mental Illness or Substance Use disorder, it is very difficult to keep appointments, to find and do all the paperwork to enroll in programs, to find housing, et cetera, et cetera, et cetera and the case manager sits at the middle of all the different Behavioral Healthcare as well as efforts to obtain housing. They often dont happen unless there is a case manager involved. Case management is extremely hard work. We have a workforce crisis in San Francisco but across the state and across the contry because the work is extremely exemtremely difficult and it is i think underpaid especially given so difficult it is. Looking forward to hearing from department of Public Health of the state of the Case Management system in San Francisco, whats going well, whats challenging, but i also received an email this morning from two licensed clinical social workers who i believe work at General Hospital that i wanted to read, because i think its very telling about how challenging the job of a case manager is, and how it becomes more challenging when the other parts of the system are not working as they should, or in the best way possible. This is just the beginning of a series of hearings about the implementation of Mental Health sf, because Case Management is so critical to a functional system, i wanted to call this out separately so that we could really focus on the issue today, but again, it is one part of the system that all has to Work Together so that we can really really see a difference for the people suffering from these terrible illnesses and so we can see the difference of a high functioning system on the streets. So, im just going to read this email very quickly. It says, dear clerk stephanie cabrera, thank you for forwarding it. We would like to submit the Public Comment for Behavioral Health Committee Meeting tomorrow july 28. Behavioral case managers carry a case load of the city most challenging residents working with clients who have pervasive Mental Illness often coupled with Substance Use. The work they do is exceptional. They are work against a broken system. No access to 24 hour shelter beds, no access to same day treatment, limited access to 24 hour Crisis Centers and notner acute inpatient psych bets in the city. We interface with Behavioral Healthcare managers when the clients come through the ed. More often then not, due to challenges mentioned above, we are left with the only option to send the client right back out into the same situation. Clinicians under paid over work recollect under trained and left to fight a uphill battle. The city needs to do better. We need to invest in resources most dedicated to helping those in need. Mejo indiscernible and indiscernible i want to thank them so much their testimony. I think they said it perfectly, and i know that dph, not only agrees, but is spending all their time trying to improve and perfect all those services at the same time while being underresourced so this is very challenging what we are all doing. I want the public to know that this board of supervisors certainly this supervisor is dedicated to working hand in hand with dph to address this, because we just cannot see a dif ference in our streets until we create a system that works smoothly. With that, i am going to call indiscernible department of Public Health and thanks so much for being here with us today. Good morning chair ronen, good morning supervisors mandelman and walton. Today im here to present on Behavioral Health Case Management system. Today just looking at the agenda, would address what is Case Management, the current state and looking forward. What is Case Management . It is a stand alone or in conjunction with intensive outletpaig treatment program, person specific and vary in intensity, length and location of where services are provided. Below are functions within the Case Management systems, which include care coordination, referral, medication support, benefit enrollment, professional support and housing support. We have three different types of Case Management that range from low to high intensity. Ill begin by describing low intensity Case Management. These are based out of various Mental Health and Substance Use Outpatient Clinics and serve indiscernible do not require high intensity Case Management and are doing well in their recovery but might need to see Case Management once or twice a month. The second level of case man agement is intensive Case Management. For example, you can find this level of Case Management at our intensive outpatient treatment programs. These are services are indiscernible risk of severe negative outcomes, for example at risk of incarceration. Many of them had many crisis episodes in the past of multiple indiscernible the most intense level of Case Management is the stabilization Case Management and one of our programs within dhs that provides the service is office of coordinated care. It is also field base and targets people that made Immediate Intervention of support, otherwise they destabilize the indiscernible so, this slide right here is showing what it takes, what is required to really have an effective Case Management intervention for those that require the need. This is strength and collaboration of coordination between many city agencies. It requires case conferencing between our partners, our indiscernible as well as our city Agency Partners. Having a account record where in real time we can see where clients have been seen, their current disposition and what kind of intervention would beImmediate Intervention would help support their recovery. Also, with other city agencies and partners we identify shared priority clients because many of these individuals are homeless and hard to reach so it is important to really Exchange Information with other city agencies in case they come in contact with these individuals and have idea how best to provide support to these individuals. We have a street base team that provide Case Management in partnership with all the street based teams across city and county of San Francisco, we have ongoing meetings to address the every day challenges and our best to address those challenges. On a daily we receive a file log from the Street Crisis Response Team and office of care coordination what they do is review the log to see which of the contacts made be scrt require a followup. And also, we need a indiscernible clinicians, Health Workers that help with this outreach and engagement and really helping clients get into care. So, what is our current state of the Case Management system . Currently our budgeted fte is around 221. Our vacacy rate is 28 percent, which represents about 63 fte and we serve close to 4,000 individuals. I just want to give a note that these numbers represent our intensive Case Management program, which is a second level and our linkage of stabilization program, which is the most intense program. So, the case manager client ratio for clients that have low intensity needs, case managers hold cases up to 50, so ratio of 1 to 50 and for individuals with intenseival needs, case manager ratio is 1 to 17, and for those that are most intense level of Case Management, the case load is 1 to 12. The frequency in which case managers try to interact with their clites, those with high needs is one to 4 times a week. Those with low needs, average of monthly or biweekly so once or twice a month. Here is a graphic showing where case managers are located. I like to emphasize most of our case managers meet clients where they are. However, we do recognize it is important for these individuals to know that they are programs within the community to become familiar with them and access them when needed. To emphasize, most of the case activities happen where we meet clients are they are at. Just to give a little statistics, 5 percent of case managers are located in indiscernible and 45 percent of case managers located at cbo. That is Community Based organizations. However, if you drill down for those population, most of the case manager programs within Community Base organizations. And chair ronen, you alluded to the method of San Francisco legislation and what that afforded us to do is create this office of coordinated care that never existed. As you also mentioned, this legislation was approved in december of 2019 , but due to the pandemic there was delay in implementation so this program is two years old and we never had this level of support, so this is a added support for the department to meet the needs of our clients. So, with the expansion we have been able to add around 45 fte to the office of coordinated care, and add an additional 13 fte to existing Behavioral Health programs. Just to give a little description of what within the office of coordinated care, we have our central triage Care Management which focus on individuals released from jail or discharged from hospital. The neighborhood base care that provide Case Management and outreach and engagement and that program is our best neighborhoods program. We also have a shelter and Permanent Supportive Housing Program and our Behavioral Health Access Program which is centralized Access Points for Behavioral Health services. When is Case Management offered . So, i just referred to the Access Program. Within the behavioral Access Program we have a behavioral access line, a 24 7 call center and we also have a Behavioral Access Center which is open during the day and weekday where we you can seek services. Depending how a client is presenting, high acuity indiscernible they refer to office of coordinated care. If the client that presents with moderate symptoms then they refer to treatment and case manageagement services. For Priority Service populations, indiscernible street teams and also we do follow with individuals that have been placed on 5150 and released, those referrals go directly to office of coordinated care. The office of coordinated care, they provide the most intense level of Case Management. For our indiscernible youth and family indiscernible those are referred directly to treatment and Case Management programs because the system of care they have a program called intensive care coordination where Case Management is of high intensity already. This individual had a long history of complex trauma and homelessness. The approach is this individual was linked to the bridge and Engagement Service team, which is part of office coordinated care providing the most intensive Case Management services and through advocacy and engagement this individual was placed in a shelter and connected to intensive Case Management program. The outcome through ongoing continued relationship and this person being stabilized, the client was placed in longterm housing. Another Case Scenario for client b, this individual frequently in crisis, difficult to locate by providers in the community, our best neighborhood which is our street based Case Management team supported the clients with frequent outreach and assessments which lead to multiple hospital visits. Ultimately this individual was connected to our stabilization program, which is our highest most intensive level of Case Management and placed in a shortterm shelter. The outcome, the stabilization Case Management Program Consumer outreach and one outcome is all 911 calls have been eliminated. For the client c, this individual struggles with bipoller disorder with meth use. There are multiple Behavioral Health<\/a> select committee. Im supervisor ronen chair of the committee joined by vice chair mandelman and supervize sor when your item of interest comes up and Public Comment<\/a> is called, those in person should line up to speak and those on the telephone dial star 3 to be added to the queue. If you are on the telephone, please remember to turn down your tv and listening devices you may be using. When your item of income comes upyou may submit Public Comment<\/a> in writing in either of the two following ways. Myself the homelessness and behavioral select clerk at stephanie. Cabrera sfgov. Org. You may send your comments via u. S. Postal service to our office in city hall at 1 dr. Carlton b goodlett place room 244 San Francisco<\/a> california 94102. Finally, items acted upon today are expected to appear on the board of supervisors agenda of september 5, unless otherwise stated. Thank you so much. Can you please read item 1 . Item 1. Hearing on department of Public Health<\/a>s Behavioral Health<\/a> Services Case<\/a> management system; specifically examining how many Behavioral Health<\/a> and Substance Use<\/a> case managers are in the system, their work location, the process for providing Case Management<\/a> at varying levels of need, frequency of case managers interacting with their clients, the caseload of case managers at every level of care, and the number of funded but vacant case manager positions exist in the entire system of care; and requesting department of Public Health<\/a>s Behavioral Health<\/a> services to report. For those remotely , if you havent done so dial star three to be added to the queue. Please wait for the system indicate you have been unmuted and you may begin your comments. Thank you so much. As the person who called the hearing, i wanted to make a few remarksopening remarks before i turn it over to the director of managed care at dph. When i wrote Mental Health<\/a> sf about four years ago, i knew that it was redesigning our entire Behavioral Health<\/a> system, and that implementing it was going to be a major challenge,b a major effort and it would take some time to do so. At the time, we didnt realize that a worldwide pandemic would hit us and completely divert the attention of dph for over a year to keeping us as safe as possible from that pandemic and so, aswe lost a good year of implementation. I do want to say, i believe that we are moving in the right direction and that dph is committed to redesigning our Behavioral Health<\/a> system so that it flows as well as it possibly can amidst a privatize Healthcare System<\/a> that is broken, a public system that is underfunded and a National Situation<\/a> that is absolutely broken in every way shape and form. Still, we are working to become the best Behavioral Health<\/a> system of care in the country and we are well on the way. Case managers are sort of at the center of the system because when someone is suffering from Mental Illness<\/a> or Substance Use<\/a> disorder, it is very difficult to keep appointments, to find and do all the paperwork to enroll in programs, to find housing, et cetera, et cetera, et cetera and the case manager sits at the middle of all the different Behavioral Health<\/a>care as well as efforts to obtain housing. They often dont happen unless there is a case manager involved. Case management is extremely hard work. We have a workforce crisis in San Francisco<\/a> but across the state and across the contry because the work is extremely exemtremely difficult and it is i think underpaid especially given so difficult it is. Looking forward to hearing from department of Public Health<\/a> of the state of the Case Management<\/a> system in San Francisco<\/a>, whats going well, whats challenging, but i also received an email this morning from two licensed clinical social workers who i believe work at General Hospital<\/a> that i wanted to read, because i think its very telling about how challenging the job of a case manager is, and how it becomes more challenging when the other parts of the system are not working as they should, or in the best way possible. This is just the beginning of a series of hearings about the implementation of Mental Health<\/a> sf, because Case Management<\/a> is so critical to a functional system, i wanted to call this out separately so that we could really focus on the issue today, but again, it is one part of the system that all has to Work Together<\/a> so that we can really really see a difference for the people suffering from these terrible illnesses and so we can see the difference of a high functioning system on the streets. So, im just going to read this email very quickly. It says, dear clerk stephanie cabrera, thank you for forwarding it. We would like to submit the Public Comment<\/a> for Behavioral Health<\/a> Committee Meeting<\/a> tomorrow july 28. Behavioral case managers carry a case load of the city most challenging residents working with clients who have pervasive Mental Illness<\/a> often coupled with Substance Use<\/a>. The work they do is exceptional. They are work against a broken system. No access to 24 hour shelter beds, no access to same day treatment, limited access to 24 hour Crisis Centers<\/a> and notner acute inpatient psych bets in the city. We interface with Behavioral Health<\/a>care managers when the clients come through the ed. More often then not, due to challenges mentioned above, we are left with the only option to send the client right back out into the same situation. Clinicians under paid over work recollect under trained and left to fight a uphill battle. The city needs to do better. We need to invest in resources most dedicated to helping those in need. Mejo indiscernible and indiscernible i want to thank them so much their testimony. I think they said it perfectly, and i know that dph, not only agrees, but is spending all their time trying to improve and perfect all those services at the same time while being underresourced so this is very challenging what we are all doing. I want the public to know that this board of supervisors certainly this supervisor is dedicated to working hand in hand with dph to address this, because we just cannot see a dif ference in our streets until we create a system that works smoothly. With that, i am going to call indiscernible department of Public Health<\/a> and thanks so much for being here with us today. Good morning chair ronen, good morning supervisors mandelman and walton. Today im here to present on Behavioral Health<\/a> Case Management<\/a> system. Today just looking at the agenda, would address what is Case Management<\/a>, the current state and looking forward. What is Case Management<\/a> . It is a stand alone or in conjunction with intensive outletpaig treatment program, person specific and vary in intensity, length and location of where services are provided. Below are functions within the Case Management<\/a> systems, which include care coordination, referral, medication support, benefit enrollment, professional support and housing support. We have three different types of Case Management<\/a> that range from low to high intensity. Ill begin by describing low intensity Case Management<\/a>. These are based out of various Mental Health<\/a> and Substance Use<\/a> Outpatient Clinics<\/a> and serve indiscernible do not require high intensity Case Management<\/a> and are doing well in their recovery but might need to see Case Management<\/a> once or twice a month. The second level of case man agement is intensive Case Management<\/a>. For example, you can find this level of Case Management<\/a> at our intensive outpatient treatment programs. These are services are indiscernible risk of severe negative outcomes, for example at risk of incarceration. Many of them had many crisis episodes in the past of multiple indiscernible the most intense level of Case Management<\/a> is the stabilization Case Management<\/a> and one of our programs within dhs that provides the service is office of coordinated care. It is also field base and targets people that made Immediate Intervention<\/a> of support, otherwise they destabilize the indiscernible so, this slide right here is showing what it takes, what is required to really have an effective Case Management<\/a> intervention for those that require the need. This is strength and collaboration of coordination between many city agencies. It requires case conferencing between our partners, our indiscernible as well as our city Agency Partners<\/a>. Having a account record where in real time we can see where clients have been seen, their current disposition and what kind of intervention would beImmediate Intervention<\/a> would help support their recovery. Also, with other city agencies and partners we identify shared priority clients because many of these individuals are homeless and hard to reach so it is important to really Exchange Information<\/a> with other city agencies in case they come in contact with these individuals and have idea how best to provide support to these individuals. We have a street base team that provide Case Management<\/a> in partnership with all the street based teams across city and county of San Francisco<\/a>, we have ongoing meetings to address the every day challenges and our best to address those challenges. On a daily we receive a file log from the Street Crisis Response Team<\/a> and office of care coordination what they do is review the log to see which of the contacts made be scrt require a followup. And also, we need a indiscernible clinicians, Health Workers<\/a> that help with this outreach and engagement and really helping clients get into care. So, what is our current state of the Case Management<\/a> system . Currently our budgeted fte is around 221. Our vacacy rate is 28 percent, which represents about 63 fte and we serve close to 4,000 individuals. I just want to give a note that these numbers represent our intensive Case Management<\/a> program, which is a second level and our linkage of stabilization program, which is the most intense program. So, the case manager client ratio for clients that have low intensity needs, case managers hold cases up to 50, so ratio of 1 to 50 and for individuals with intenseival needs, case manager ratio is 1 to 17, and for those that are most intense level of Case Management<\/a>, the case load is 1 to 12. The frequency in which case managers try to interact with their clites, those with high needs is one to 4 times a week. Those with low needs, average of monthly or biweekly so once or twice a month. Here is a graphic showing where case managers are located. I like to emphasize most of our case managers meet clients where they are. However, we do recognize it is important for these individuals to know that they are programs within the community to become familiar with them and access them when needed. To emphasize, most of the case activities happen where we meet clients are they are at. Just to give a little statistics, 5 percent of case managers are located in indiscernible and 45 percent of case managers located at cbo. That is Community Based<\/a> organizations. However, if you drill down for those population, most of the case manager programs within Community Base<\/a> organizations. And chair ronen, you alluded to the method of San Francisco<\/a> legislation and what that afforded us to do is create this office of coordinated care that never existed. As you also mentioned, this legislation was approved in december of 2019 , but due to the pandemic there was delay in implementation so this program is two years old and we never had this level of support, so this is a added support for the department to meet the needs of our clients. So, with the expansion we have been able to add around 45 fte to the office of coordinated care, and add an additional 13 fte to existing Behavioral Health<\/a> programs. Just to give a little description of what within the office of coordinated care, we have our central triage Care Management<\/a> which focus on individuals released from jail or discharged from hospital. The neighborhood base care that provide Case Management<\/a> and outreach and engagement and that program is our best neighborhoods program. We also have a shelter and Permanent Supportive Housing Program<\/a> and our Behavioral Health<\/a> Access Program<\/a> which is centralized Access Points<\/a> for Behavioral Health<\/a> services. When is Case Management<\/a> offered . So, i just referred to the Access Program<\/a>. Within the behavioral Access Program<\/a> we have a behavioral access line, a 24 7 call center and we also have a Behavioral Access Center<\/a> which is open during the day and weekday where we you can seek services. Depending how a client is presenting, high acuity indiscernible they refer to office of coordinated care. If the client that presents with moderate symptoms then they refer to treatment and case manageagement services. For Priority Service<\/a> populations, indiscernible street teams and also we do follow with individuals that have been placed on 5150 and released, those referrals go directly to office of coordinated care. The office of coordinated care, they provide the most intense level of Case Management<\/a>. For our indiscernible youth and family indiscernible those are referred directly to treatment and Case Management<\/a> programs because the system of care they have a program called intensive care coordination where Case Management<\/a> is of high intensity already. This individual had a long history of complex trauma and homelessness. The approach is this individual was linked to the bridge and Engagement Service<\/a> team, which is part of office coordinated care providing the most intensive Case Management<\/a> services and through advocacy and engagement this individual was placed in a shelter and connected to intensive Case Management<\/a> program. The outcome through ongoing continued relationship and this person being stabilized, the client was placed in longterm housing. Another Case Scenario<\/a> for client b, this individual frequently in crisis, difficult to locate by providers in the community, our best neighborhood which is our street based Case Management<\/a> team supported the clients with frequent outreach and assessments which lead to multiple hospital visits. Ultimately this individual was connected to our stabilization program, which is our highest most intensive level of Case Management<\/a> and placed in a shortterm shelter. The outcome, the stabilization Case Management<\/a> Program Consumer<\/a> outreach and one outcome is all 911 calls have been eliminated. For the client c, this individual struggles with bipoller disorder with meth use. There are multiple Street Crisis Response Team<\/a> calls. The street base team, best neighborhood conducted outreach leading to this individual being placed in the single room occupancy. However, this individual chose to stay outdoors. We continued outreach support as well as street based psychiatry. The client agreed to a injectible medication to help stabilize the clients. Client remained with service and maintained housing and this individual is also connected to intensive Case Management<\/a> program. That program conducts outreach support and this person was recently placed in permanent Supportive Housing<\/a>. indiscernible i just want to echo what chair ronen said. This is very hard work. It requires frequent outreach, engagement, indiscernible identified the resources and in man y cases these individuals are homeless so sometimes you identify the resource but the individual may be hard to reach. A lot of times week after week sometimes the conditions worsen so it takes many hours, many weeks and a lot of times months before we can get this moderate outcome, so i dont want to minimize the outcomes because it take a lot of hard work and dedication. As you see in subsequent slide we indiscernible you have case managers carrying high case loads which can lead to burnout. Some of the challenges, we have 28 percent vacancy rate. Alluded to in the previous slide, which makes our case managers carry higher case loads then we would prefer. A lute lot of challenges and recruitment, you also alluded chair ronen, state wide in california we are faced with Behavioral Health<\/a> workforce crisis. It is hard to recruit, supply is lower then the demand and competing with neighboring large counties. And also people doing this work which is one of the hardest of Services Within<\/a> our system are not receiving indiscernible hazard pay and again with high case loads, constant outreach in the community and trying to indiscernible a lot of them are burned out and it is hard to recruit and retain. It is one thing we are trying to work on, but to this day it is very challenging to fill vacancies. Another limitation indiscernible we have many City Partners<\/a> that do street base work and might come in contact with some clients we have been trying to locate, however, because of federal and state legislation, we are limited to how much information we can share with Agency Partners<\/a> so the limitation we look to address in the subsequent slide ill describe some of the efforts to address this limitation. Lastly, limited Housing Options<\/a>. No matter how much we provide services to these clients and stabilize them and doing well in recovery, as long as they are homeless it is a high risk of stabilizing and high rivl risk indiscernible there is a huge challenge, because housing is basic need for human survival. So, looking forward, bhs we are going to new electronic record system called epic that help monitor clients through so regardless level of care we have a centralized system in which we can see what type of care these individuals are receiving, when last were they seen and help us really to indiscernible address the whole person need of these individuals. Currently, we are in the process of developing a mou for multidisciplinary teams. It is a mou between hsh, fire, dem, dph and the Mayors Office<\/a> and within the confine s of the law would allow us to share information across agencies, however we have to identify certain individuals within these agencies that have access to this information. Again, the intent is really identify shared clients, priority clients that we are aware of and can keep an eye on and also to come up with the best intervention that would help address the person need when contact is made. Also we participate in the care act, to indiscernible Court Ordered<\/a> care plan and care team in the community. Assessing and doing analysis, what this entails. We are looking forward to this because it also requires some Case Management<\/a> support for these individuals. Also, with regard to adding fte to the Case Management<\/a> system, we are about to publish a 1. 8 million request for proposal we anticipate will create indiscernible outpatient treatment and result with 5 to 7 new fte. Also recently received a Grant Funding<\/a> from Bridge Housing<\/a> that would add fte to the shelter Behavioral Health<\/a> plan. The Case Management<\/a> program that provide permanent Supportive Housing<\/a>, we are about to public a rfp to bring more case managers to support our clients in permanent Supportive Housing<\/a> and it is for a program called indiscernible permanent housing advanced clinical services. Thank you. Thank you. I have a number of questions but i want to see if colleagues have any . No. Thank you so much for the presentation. I have a few questions. So, ill start with the last slide that you just went over. It is great that we have new fte coming up, but if we already have 62 vacant positions and trouble hiring, is that actually going to happen . Are those positions counted within the vacant they are not counted within the vacant. So it is more vacancies. It is hard to see how we really move forward unless we figure out a way to hire and retain people. Do you have any plans or information about how we are going to hire and retain and fill these vacancies . Yes. Thank you for the question. Within bhs, less then 2 years ago under the direction of director indiscernible we have been able to create a new unit called bhs operations. And with that for example, recently for the positions the clinical positions, which we have a lot of them within our Case Management<\/a> program, we have been able to have that position opened continuously. That was never the case. Usually the position closes, we have to wait till it is posted again. One achievement we have made in less then 6 months is to have those clinical positions post ed on a continuous basis. Also, been doing what we call batch hiring, because this vacancies are only represent our case managers programs, however bhs is large. We have other programs with vacancies so we dont want to come to one another and have candidates in various programs, so we do batch hiring entails is programs that have vacancies that have a need for these positions. The managers come together, interview the candidate and see which best meet the need of their program. Also we had evening and weekday outreach events in which we describe the type of services, for example, Case Management<\/a> we are offering and describe the benefits and also just trying to pull people intoapplying for these positions. Those are some examples, but again, it is a challenge because we compete with other counties, it is hard work and postpandemic you have a lot of people wanting to work remotely. Also complete with the private Healthcare System<\/a>. There is a Behavioral Health<\/a> workforce crisis. One of the major priorities of our operations and address the vacancies, which is challenging. Do you happen to know the salary range for case managers . Yes, so for Civil Service<\/a> it ranges from aboutstarts 104 thousand up to 126 thousand. For cbo, Community Based<\/a> organizations, it ranges from 75 thousand to 95 thousand. Do you receive any help from oe rks oewd or central hr, not dph hrit seems it should be a priority. Im not privy to partnership with oewd but it is something we can look into to see if we can partner and do more outreach. With central hr, yes are, because working with our dph hr it is a collective of central dhr and bph coming together to be intentional and address these vacancies. Is this 26 percent vacancy, is that typical or is this higher then normal . I know typical is hard, because theremaybe i should say, prepandemic were vacancies this high . I would say there is a trend. It is normal trend. Post pandemic it worsened and again, the mental needs of individuals especially those with homelessness increased so you are dealing with higher acuity and you have case managers that have high case loads and doing this work like i said, i cant emphasize this enough, difficult. Retaining staff is sometimes a challenge. It is getting worse, but we have to aggressively be proactive in the actions to make sure it doesnt get worse then it is now. Do you all have a sense how many of these 63 positions not counting the new ones but the 63 vacant you are going to be able to hire this year . This yearwe are hopeful. As of last week, we just hadone of our programs has 10 clinical positions they are trying to fill and just had interviews last week. Because like i said, through the partnership with bhs and hr we have been able to have the positions open on continuous basis. The success we have seen is we get more names, more individuals that we can interview, but again, we have to move fast, because someone with have apeople apply for different jobs every day and if we dont move fast to offer jobs we can lose them so that is part of the strategy, how can we in a timely fashion really do the interview, the exams, job offer, medical screening and get them onboard. Are 63 vacancies, those are just for Civil Service<\/a> positions . This doesnt count the non profit . It is both. It is a combination. Okay. However, i want to emphasize that within our cbo programss you have vacancies as high as 45 percent. They have their own challenges. Is the city helping the non profit hire . I dont know why you would apply for a non profit position if there is so many vacancies with the city and you get higher pay, better benefits, pension. Im just curious, is the city helpingcan you break down that 63 vacancies . How many of those are Civil Service<\/a> versus non profit . I would have to pget back to you. Could you get back to me on that . This is one big area of followup that i want to do after this hearing, because we cant improve the system unless we have the staff in place to do the actual work. Indeed. I dont feel like this is just a problem for dph. This is city wide problem and should be a priority for oewd, the mayor office and hr in general and we should work collectively with dph hr and you and the non profit leadership to figure out how to conquer this, because i dont see how wei dont think if we fill these 63 positions we will have enough case managers to do everything that is necessary, but at least we have to do that. If we got these positions funded we improve without them. Right. I will definitely be following up with you and the other agencies on this and it would be great to know the breakdown of non profits, different strategy, different animal and we might have to talk about bringing those non profit salaries up because they are very low. Considering how difficult this work is and how competitive the field is. Well followup on that. Do you want to chime in or should i go with the rest of my questions . indiscernible go ahead. Building off the question i think you are suggesting which is, i think in my experience following supervise r ronens effort and having my own over the last 5 years, we on the board tend to think about wanting to understand how sort ofwhat would the good situation be, where are we now,er and what is the gap between those things. I think that understandably, Like Department<\/a> of Public Health<\/a>, other city bureaucracies look what we can do, the gap between where we are and what we think we can realistically do in the year so i assume you are showing a daunting gap you need to fill from a hr perspective but i have the question that, which you probably cant answer, but i am curious if you have thoughts onsuming assuming you had all these positions filled, would we be in a situation where by in large people who need Case Management<\/a> in city and county of San Francisco<\/a> are getting Case Management<\/a> at the right level, or would we be awhere i think i suspect would be relatively small portion still of people who need Case Management<\/a> are getting the right level at the righti mean, theres huge need, it can feel endless but it isnt endless and deis helpful to think how big is this gap. I dont know if you have thoughts about this, but you aim a at a target, if you succeed you have the additional positions, everyone is doing their job, does that mean everyone on the streets across the city would get the right set of touches that we would be making progress on getting folks with severe Mental Illness<\/a> and addiction off the streets and in a better place or not really notice it because the problem is just so damn big . I have a few thoughts. Filling vacancies would help because you have clinicians carrying high case loads and burning out so that is one benefit. One challenge is that the clients or individuals that have challenges have indiscernible cant force them to accept services so part of the Case Management<\/a> work is engagement so if a individual experiences homelessness indiscernible it is hard to reach and engage. It is most definitely definitelydefinitely benefit as a system to fill our vacancies, and also we need to improve our workflows with our partners like the hospital, the jails, and we currently we are doing that because we need to improve efficiencies and not just fill vacancies. So, do you have any way ofthis whole structure is built about Getting Services<\/a> to people who either will easily accept services or with good consistent persistent high quality folks reaching out on a regular basis accept services and you hint at the realty that there are some people who even at highest level of Case Management<\/a> is not going to be able to reach. Does dph think or have a notion of how large that population might be in San Francisco<\/a> . It is hard to quantify. I got a chance to talk to you and go through this presentation ahead of time, so we ran out of time in that meeting, but in that meeting you said that pretty much everyone getting out of jail who has a Behavioral Health<\/a> issue or indiscernible or emergency room at general is connected to a case manager . We ran out of time so let me add context to that. Perfect. For example, with San Francisco<\/a> General Hospital<\/a>, with the help of dph Information Technology<\/a> team, they have been able to build a system in which we specifically office of coordinated care can see when someone is placed on 5150, where a person is at and when they are discharged. Sometimes they are discharged middle of the night and weekdays, however the goal is we follow up with everyone on 5150 and what we also assess is if they are already connected to care and if they we contact the case manager to let them know the individual is hospitalized and if they are not connected to care, that is when the office of coordinated care will do outreach follow up post 5150. Same with jail, we have jail health service. Matter of fact, the past 6 months we concluded designing a workflow they notify us when they have someone in custody that might need care and when that person is discharged. Again, the challenge is when that person is released from jail, right . These are challenges, but yes we have a system, have a line of communication with jail Health Services<\/a> as well as San Francisco<\/a> general as to when these individuals are in custody or in the hospital discharge or released. During the day and week days if someone is released from jail or about to be released from the hospital after being 5150, does a case manager meet that person . If there is a need, yes. As you know, we have limited capacity. I want to be transparent. Not every time we can provide that real time response, but that is definitely our intent and our charge as a system. Got it. Let me ask supervisor mandelmans question, if we were fully staffed, would we be able to meet that charge . Again just during the days and during the weekdays . I believe so. To increased extent. I cant predict the future to say every Single Person<\/a> in real time. Yeah. I also agree with supervisor mandelman, how do you decide if they need that person to be met . I imagine, sure thereeveryone needs to be met, right . How do you decide when someone needs to be met versus not . Like, i said, with this system our office of care coordination they have the client profile and how to present it. Clinical assessment has been done while the person is in the hospital, so that is how you are basically making with limited resources you are making the judgment, lets get to the people with the most severe cases, lets try to meet them. In a ideal Case Scenario<\/a> you would meet everybody but you dont have the resources. We do a followup. If you get released in the middle of the nights doesnt mean because we are not there we wont conduct a followup. Part of the Program Design<\/a> model is followup post 5150 for example. How often do you find the person postwhen you are not meeting them at the point of discharge, do you keep statistics on how often you are actually able to follow up with them . I can check in on that. It is hard to reach. Exactly. Hard to reach population. indiscernible yeah, i dont thinkokay, thanks for all the qualification and i think the qualifications make it clear that we are not doing that and that that is the ideal. I guess i just want to make sure that we are working towards that ideal, because that is the ideal that feels like we are going toif we do that, well start to see the difference. Right. Also, as you alluded to, indiscernible that is a new program, a program we never had and less then 2 years and that is ourcharge. They have a higher hch this is in Mental Health<\/a> sf . Exactly right. That is the intent. The new program where you have to build workflows, build processes, hire staff. Im with you. I just want to make sure that thats the intention. Yes, it is. Okay. Well keep following up on that. So, you also told me there is a two month wait list for people needing Case Management<\/a>. Is that for the lowest level, for intensive or is that linkage . Where is that i described low intensive and most intensive so that is for intensive. It is when the low end, the most intense. Okay. And so in the mean time, someone who needs intensive Case Management<\/a> might be touched by the indiscernible im trying to understand what the best team is. Are all linkage case manners part of the best team or just some of them . Some of them, because of the expansion. However, with our adult system of care, we also had linkage programs in existence. Okay. Can you describe what the best team does . How they are dispatched . Where they are . How many of them there are and what they do . Right. So, the best team office of coordinated care is 46 fte. The combination ofthat program is made up of a team the Care Management<\/a> that has interaction with hospitals not just San Francisco<\/a>, hospitals overall, as well as the jails. They have the street based team, which is the best neighborhoods, then you have the shelter Behavioral Health<\/a> team, and you have our centralized Access Program<\/a>. As you saw on one of the slides, we deal a lot with referrals and the referrals lets us know what needs Immediate Intervention<\/a> and also what requires followup. That slide where you have referrals coming from the streets, from the hospitals, from the jail, thats how we assess and also again for example, the file log, that is how we assess where we need to be and provide that Case Management<\/a> intervention. So, the ratio is 1 to 12, so if im a best case manager, i have 12 clients, ideally, and i am constantly triaging the 12 clients. Some of them im not sure where they are because they are homeless, some i have their telephone number and check in on them every day. Some are in a shelter, so i go and visit them twice a week. Is that basically what that person is doing all day every day . Yes, and the needs vary. indiscernible mixed with Mental Health<\/a> and Substance Use<\/a> challenges so some clients needs are more intensive. People with higher case loads. What you describe is what they are doing and many cases and more. Because they are trying to advocate with other systems for example housing and et cetera. Is that temporary until they pass that person to a intensive case manager . Intensive case manager. So, their client load changes over time . Yes, and also what you described even the intensive case manager level of care, which is the one prior to most intense, they also do some of that work, because the client indiscernible risk of crisis of stabilization or incarceration. Okay. I just have one other main question. Housing priority. So, we know that if you have a serious Mental Illness<\/a> or Substance Use<\/a> disorder it is all most impossible to stabilize if you are homeless. If you are living on the streets. What kind of priority do people with these Behavioral Health<\/a> illnesses get for housing . Do you knowthat intersection and how that works . I never had that clear. We have department of homelessness and Supportive Housing<\/a>, and a lot of our housing programs that designBehavioral Health<\/a>clinous are managed by that department. Naturally, because a lot of the clients seen within the Case Management<\/a> programs expressing homelessness. Right . So, that is a priority of clients we are trying to place. Secondly, in the portfolio of Services Managed<\/a> by hsh, for example, there is a program under the Mental Health<\/a> service act that requires that people regarded as full service partner, which is also intensive case manager level of care, those sets of units should be reserved for them. As you know, working across departments takes coordination, takes workflows, and because of the limited Housing Options<\/a> in the city and county of San Francisco<\/a>, we are also competing with other systems, so i say it is a work in progress. There are lots of improvements that we can do to really open up the pipeline, but at the end of the day it is Still Limited<\/a> number of Housing Options<\/a> that we have. I think we just got a followup hearing. I think i want to bring in hsh together with dph to talk about how that coordination is happening, and what needs to be improved and what timeline it is being improved, so ill call that hearing right when i get backright when we get back from our legislative break. Okay, i have no more questions. Do you have anymore questions . Okay. Great. Thank you so much. Thank you so much. Appreciate it. Thank you. Can we now open this item up for Public Comment<\/a> . Yes, any members of the public that would like to comment on item 1 . Please line up along the curtain wall. For the members joining online, dial star 3. For those on hold, continue to wait until the system indicates you have been unmuted. Welcome, you may approach the podium. Floor is yours. Before discussing case managers and imagine there are high burnout, turn over and depression, lets look at the potential case load you were going to build 4 thousand new units of Public Housing<\/a> starting in 2019 but instead 3 thousand homeless died. The absence hasnt left public resource available for reallocation despite the 50 percent reduction in homelessness. Where housing is concerned it will require 8 and a half centuries to complete, 85 thousand new housing yount demanded by sacramento. I like to see case manager ares too but with patient situated far from Retail Stores<\/a> and far from drug bazaars as reported many adicts and mentally ill are not seeking treatment unless mandated for street people but environmental conditions must be supportive not lax. We dont want to see local psychiatrist dispensing drugs in a care free fashion similar to the millions the city distributed in charitable untraceable gift cards of value during the pandemic knowing lawful Chemical Companies<\/a> historically and present ly perperch wait addiction. Why is anyone required proof of indiscernible proof of payment of fees and evidence of valid permit indiscernible but why do you allow anyone residents in San Francisco<\/a> california without proof of anything without a passport, visa or id, no birth certificate, no background, no fees collected just a court date often are not met, pitch a tent on the sidewalk where you like and the court says you cant be bothered at the coast of local residents of billion dollars annually. Is that two minutes . That is two minutes. Thank you for your comments today. Any other persons here in the chamber that would like to speak to this item before we go to the online caller . Seeing no additional speakers in the chamber, wellwere you intending to speak to this item . Okay. Thank you. We have one caller in the queue. If you would like to speak to this item dial star 3 to be added to the speaker queue. Confirm. There are no hands. Zero speakers in the queue. Okay. Public comment is now closed. I want to thank dph for this really thoughtful hearing and presentation. I see three followup items from this hearing. Number one, putting more emphasis in dealing with the workforce issue with the whole city stepping into help. This is justwe cant make progress until we fix this piece of it. So that involves getting people hired and recruited, which i think will need to bring the office of Workforce Development<\/a> into as well as the City Hr Department<\/a> and i will followup outside this setting to do. We really have to fix this major salary disparity between Civil Service<\/a> and the non profits. I dont see how the non profits are ever going to fill these vacancies and they have 55 percent if im right, if i reectly of the case managers to the 45 percent that are Civil Service<\/a>, so i dont see how we fix this without fixing that salary disparity, so i think we need to look at that. I know the mayor did in this last budget cycle give an additional sort of bump in salary to homelessness and Behavioral Health<\/a> workers recognizing this is a major problem. I think we have to go further then that, and kind of look at that and talk to the Mayors Office<\/a> and dph and Budget Office<\/a> about perhaps we can move outside the city budget process on this, because i just dont see how we move forward if we are notif those non profits are not able to offer competitive salaries. And then secondly, this housing issue. I justobviously we dont have enough housing for everybody that needs it in San Francisco<\/a>, but i just think were spinning our wheels and that the rate of return of all of this work is neg lijable if we dont have housing for people that are very ill and so, we have to prioritize people with Mental Illness<\/a> and Substance Use<\/a> disorder who are rightfully spending a lot of money to help get stabilized, clean and back into living productive healthy lives. They cannot do that on the streets. It is impossible, and so why are we doing all that work if we know that just like the social worker sent that email, when they are putting people back in the streets . It doesnt make sense, and i never fully understood and think dph used to be in control of a lot more housing then it is now and ever since we made that change to hsh, there is just never been in my opinion the proper prioritization and are linkage with individuals experiencing Behavioral Health<\/a>, significant Behavioral Health<\/a> challenges rchlt i will be calling a hearing at our first meeting coming back that asks the department of homelessness and Supportive Housing<\/a> and dph to detail how they Work Together<\/a>. The departments Work Together<\/a> and how we insure that people suffering from these illnesses are getting prioritized for housing. So, this is really fabulous. I will say, i think dph has the right goals, it is just getting there with the multitude of challenges that we are facing. We didnt in my opinion before the leadership changes, before the beginning of the implementation of Mental Health<\/a> sf, we didabout didabout didnt have the basic structures in place to get to the goals and now we do. We are starting to build them, and thats enough exciting progress, and as long as we keep moving in the right direction, i believe we will get there, it takes time, energy and focus but believe we are moving in the right direction. If this was just a hearing on Case Management<\/a>, just like the social worker said in their email, that only works if you have treatment on demand, if you have enough housing, if you have the challenges that you talked about, the data sharing that works, and if you have the right staffing, so we need to keep working on those issues, but the optimization report is coming. We still do not have a 24 hour, 7 day a week, we have a phone line, but dont have a place, clinic where people can go. We constantly have this challenge on things work well on days and weekdays, but night not nights and weekdays. We have a way to go but feel optimistic well get there if we hammer away on the structuress in place and getting all those challenges and these pieces right. Again, thank you so much to dph for coming out and the presentation and for colleagues for being here on a friday before our break. You guys are the best, and with that, im going toim going to make a motion toi forgot what it is called. To continue to the call of the chair. Thats the language im looking for. Thank you. If we can have roll call vote. On the motion to continue to call of the chair, mandelman, aye. Member walton, aye. Chair ronen, aye. You have three ayes. Motion passes unanimously. Thank you. Are there any other items on the agenda today . No other items on the agenda. The meeting is adjourned. 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