>> chairman: good morning. the meeting will come to order. welcome to the thursday, march 11th meeting of the public safety & neighborhood services committee. i'm supervisor gordon mar, and we're joined by supervisor safai, and we're joined by supervisor mandelman as the sponser of item number two. and supervisor safai for items three and four. i would like to thank sfgovtv for staffing this meeting. mr. clerk, do you have any announcements. >> clerk: yes.

in order to protect the public, board members and city employees during the covid-19 emergency, the committee room and chamber are closed. this precaution is taken pursuant to all local and state is ordinances. public comment will be available for each item on this agenda, both on sfgovtv and channel 26. you will have an opportunity to speak and provide your public comment and it will be available to you via phone by dialing 415-655-0001. once you're connected and prompted, enter the meeting i.d. 1874861805. and then press ## to be connected to the meeting. when you're connected, you will hear the meeting discussions but your line will be muted. when you're item of

interest comes up, dial *3, and a system prompt will indicate that you have then raised your hand. please wait until the system indicates you've been unmuted and you may begin your comments. best practices are to call from a quiet location, to speak clearly and slowly, and turn down your radio or television or streaming device. there are speaking delays that we may encounter between the live coverage of the meet and the streaming. and you may submit your comments by e-mailing me at john.carrollat l@.govtv.

all of this contact information is available four consultation on the front page of our agenda as well if you need to refer back to it. and, finally, mr. chair, items acted upon today will appear on the board of supervisors' agenda of march 23, 2021, unless otherwise stated. >> chairman: thank you, mr. clerk. it looks like supervisor mandelman, who is the sponsor of item number one is not with us, and is having some technical difficulties. i'd like to maybe call item two out of order. and so, mr. clerk, can you please call item number two. >> clerk: agenda two is an ordinance amending the police code to create a right to re-employment for certain employees laid off due to the covid-19 pandemic. if the their employer needs to fill the same

position or a substantially similar position, and to reasonably accommodate employees who cannot work because of a family-care hardship. members of the public who wish to provide public comment on this ordinance should call the public comment now, and i'll repeat it: 415-655-0001, i.d. 1874861805, press the ## and then *3, if you wish to speak. mr. chair? >> chairman: thank you, mr. clerk. colleagues, we referred this item back to committee in order to consider a final set of substantive amendments, based on the in put from the business and labor communities. when we first drafted it last june and it went into affect in july, and the many months since then. the policy idea behind the

back to work ordinance isn't new. it exists in collective bargaining agreements visit san francisco and the world. but this ordinance is novel and groundbreaking in extending the right to be rehired through a fair process to non-union work forces. and this legislation is needed and important. the right to recall, the right to re-employment, when employers begin rehiring has been a good-faith job effort for many workers. continuing this right for workers in san francisco is vital to a full and just recovery. and it is vital that we support businesses as they reopen. i think we can do this, and we must do this, while also supporting fair treatment of laidoff workers. with this new and finalsed finalset of amendments, we move

forward and strike a balance of what is fair and equitable. these amendments do two things: first, it will set industry-specific thresholds for which employers this law would apply to. we know that the pandemic has impacted different industries differently. and those pre-and post-pandemic are as unique as the businesses in our city. instead of applying a blanket threshold among all employers, we're incorporating the threshold set by our industry working retention thresholds. it means this law would have industry-specific definition for covered employers for the following industries: restaurants, hotels, grocery stores, custodial contractors, event concessions, finally, the

retail businesses. and other businesses who have 100 employees. [inaudible] and by incorporating the definitions of covered employers, it makes the implementation clearer and easier for both the city and for employers. on the second amendment that we're proposing, it is to narrow the rehiring requirements to only include positions with comparable job duties, paid benefits, and working conditions, or positions that the worker has previously been employed in within the 12 months preceding the layoff. this removes the

requirement to offer re-employment for positions an eligible worker would be qualified for or that may require training but it was not a job that the worker was previously employed in. this change gives them more flexibility to make those decisions while maintaining the worker protections we know are most important. put simply, this law is still based on a simple, time, and just idea that businesses rehire rather than replace their laidoff workers, and a public health crisis shouldn't be a cover for firing workers. we know that most employers treat their laidoff workers fairly, and this will ensure that all employers do so. with this change and the many changes we have made previously to this law, we have refined, tailored, and targeted this to meet the needs of our workers and the needs of our businesses.

colleagues, i ask for your support today, as i have a dozen times before for this policy. now made leaner and stronger and based on the wealth of input and rich dialogue we've had with stakeholders, including the san francisco council, the chamber of commerce, and the golden gate council. leagues, do you have any questions or comments? i can't see -- it looks like somebody has their hand raised. >> clerk: mr. chair, supervisor haney has his hand up. >> chairman: supervisor haney? >> supervisor: thank you. and thank you so much, chair mar, for your leader leadership and working on this critical policy to support our workers. of course, many of them

were laid off due to no fault of their own, and having access to the employment is so important for the recovery of our city. i'm very proud to support you on this. i had two questions which have come to me from some of the businesses in my district. and i just wanted to get clarity on how this works. one of the questions that i was hoping you could answer is about the notification process for employees for rehiring, and what qualifies as adequate notification? i had one business express some concerns that they were required to send letters, and that that would take a long amount of time. and it was delaying three ability to rehire and to actually reopen. can you speak to the process for notification of employees and

reemployment and what opportunities businesses have to do that, and how we're ensuring that that is happening in as an affective way as possible? >> sure. thanks for the question, supervisor haney. we did spend a good amount of time on coming up with figuring out the best language and protocol for the notification requirements when employers are ready to rehire for the positions that they laid off employees for, and through this ordinance are required to offer the jobs back to their workers that were laid off before considering new employees. and we did make some changes. originally the ordinance required a written letter to employees offering their jobs back, but through feedback and communication from many

employers, we adjusted that and changed it to allow for phone calls and even text messages and e-mails as a way to notify employees of the job opportunity to be rehired back for. >> that's great. thank you so much for clarifying that and making that change. i think that makes a lot of sense. and thank you for that clarification. and it would be great for us to be able to provide that clarification to any affected businesses. the other question that they had was around the penalties, and what the penalties were and whether there were any tax to the penalties. their question was if they were, for some reason, unable to contact somebody and they were sued, how the penalties worked for violating that, and what are the maximum penalties.

>> yeah. so this is also an issue that we spent a good amount of time discussing with the different stakeholders, including labor and business, around enforcement of the ordinance. and where we landed was enforcement of the ordinance is really mainly through private right of action. and so that -- so this is really not going to be enforced by our office of labor standards enforcement for a number of reasons. so there are no penalties that would be applied by the city. and it's really through a private right of action that enforcement will primarily happen, you know, if needed. again, this has all been in place for many months now, since july. as far as i'm aware, there hasn't been any -- this hasn't really led to any -- to any of that type

of enforcement. we really hope, i think, through education and the employers and employees about the law which has been happening, through oawd's work on that, that there will be compliance and implementation of continued compliance and implementation of this important law. >> thank you. and thank you again for your work in bringing together all of the parties and really targeting and refining this and making sure it has the greatest impact possible. and appreciate -- i wanted to make sure to get those questions and clarifications on the record there so we can help to provide that information to businesses that may be impacted. and i'm very supportive of this legislation, and thank you for your leadership. >> thank you so much, supervisor haney. why don't we go to public comment. mr. clerk, are there any callers on the line?

>> clerk: thank you, mr. chair. mr. barretto with the department of technology will be checking right now to see if we have any callers in the cue. by those who have already connected via phone, please press *3, if you wish to speak to this item, item number two. for those already on hold in the cue, please continue to wait until you're prompted to begin. for those watching our meeting on cable channel 26 or through sfgovtv, please call in now by dialing 415-655-0001, following that you would enter i.d. 1874861805. press ## and then press *3 to enter the cue to speak. mr. barretto, could you connect us to our first caller. >> mr. clerk, we currently

have no callers in the cue. >> chairman: great, thank you. operations. public comment is closed. colleagues, i would like to move that we continue this item to the call of the chair. mr. clerk -- >> on the motion offered by chair mar, that the amendments to be presented are in order. vice chair safai? >> aye. >> clerk: member haney? >> aye. >> clerk: chair mar? >> aye. >> clerk: mr. chair, there are three ayes. on the motion that the item be continued to the call as amended, offered by chair mar, vice chair stefani? >> aye. >> clerk: member haney? >> aye. >> clerk: chair mar? aye.

>> clerk: mr. chair, there are three ayes. >> chairman: great. thank you. supervisor mandelman has joined us. so i think we can go back to item number one. mr. clerk, can you please call item number one. >> clerk: agenda one is a hearing to discuss the san francisco housing conservatorship. those wishing to provide public comment, please dial 415-655-0001 and then enter i.d. 1874861805 and then press ## and enter *3 to speak. >> clerk: supervisor mandelman, thank you so much for your leadership on this and calling for this hearing. the floor is yours. >> supervisor: thank you, chair mar, and committee members, thank you for hearing this item

today. i want to take a the minute torefresh folks on how we got here. this conversation, and in fact this hearing, began back in june 2020. and at that time, we were about a year after the city -- the board of supervisors had opted in to sb1045 and learned that at that time not a single person had been conserved through this program. so i called for this hearing, and we heard updates. and then i asked to have the hearing continued for additional time to see what kind of progress the department of public health and the office of the public conservator might be able to make. and so we continued the hearing until july, and at that point we were updated there had been no

conservatorships. and so we continued until december, and still not a single person had been conserved under the sb1045. at that point we continued it until november, hoping we would hear that progress in november. you all may recall that we were then going into the winter surge with covid-19, and in light of all of that, and the many pressing demands from the department of public health, it seemed to me to make sense to not hear it in november, and we've continued it a few times since then. so i think here we are, ready to hear -- and probably at the end of the close of this hearing to file it. i did ask, way back in september, i guess, that at our next hearing on this that we have the directors of the relevant departments here the..

and i'm great that director colfax can be here from the department of public health. we do have joe neilson from the conservatorship in her place. as we will hear more about today, the city has now considered. [indiscernable] considered (indiscernable) sb1045, and this program is allowing folks to get additional health and support before we need to conserve them. i am grateful for the hard work that the department of public health and the public conservator's office has done to implement this pilot program, to remember that the purpose was to address the needs of a relatively small population of unhoused folks who repeatedly cycle through psych emergency, our other

emergency rooms, jail, back to the streets, and again, without ever getting the longer-term support and care that they need. unfortunately, in my view, through both state and local legislative processeses, the sb1045 opposition was successful in adding layers of process and complexity procedural requirements that intentionally made this program highly complex and difficult to implement. and i think we -- i don't know that we fully appreciated how complex the legislation had been made, but we knew from the beginning it would be slow-going, and the program's reach would be limited, even for a pilot. that said, i am concerned that here we are almost two years later about what our slow progress in implementing sb1045 may say about the city's broader ability to help the population whom we do

not seem able to help in other ways. again, it has been nearly two years since the board vigorously debated and ultimately opted in to sb1045. i said at that time that even this sba 45 only helped one person, it was worth doing. and i think there are additional folks who will get helped by this program over time. even those opting into sb1045 didn't believe it alone would be the solution to the crisis unfolding on our streets. i did think, and i still hope, that this legislation, this program, might be -- might show us one path to get care to a population that desperately needs it but too often cannot seek it,

and even rejects it. the story of 1045 is still being told, and i still believe we must do whatever it takes use whatever tool in the toolbox, including sb1045, to help everybody who needs conservatorship, as much as we can. i hope we can have an open conversations about some of the things that have slowed the progress and lessons learned. there are legal and practical challenges, improving that candidates meet the legal standard for sb1045 for short conservatorships. perhaps even more significantly, there is an obvious and significant lack of appropriate placements, especially in-county placements and board and care facilities and locked and other care settings. sb1045 does not address

those problems and was never going to be a cure-all for the crisis of addiction and other mental illness on san francisco streets. but as we emerge from the covid-19 pandemic, san franciscans are going to expect our city government, and our department of public health in particular, to address our other public health crises, in particular this public health crisis, with all of the focus and commitment that we've dedicated to the covid-19 response. in mental health s.f., we have a consensus framework for making that pivot, but we need to move far more urgently, far more boldly, on these issues than we ever have before. and the sb1045 experience so far causes me concern about our capacity to do that. first today we'll be hearing some opening remarks from director colfax, and, again, thank you for making the time to be. and then we'll hear a presentation from jill neilson from the department of disability

and aging services. and dr. angelica nata, the director of forensic services at the department of public health. so perhaps we could hear from director colfax first. >> good morning. good morning, chair mar and vice chair stefani, supervisor mandelman and supervisor safai. thank you for this opportunity to talk about how the conservatorship is in san francisco. as you know, under the direction of mayor breed, the department of public health is in the midst of transforming its behavioral health system to better serve people experiencing homelessness, serious mental illnesses, and substance abuse disorders. this transformation is already well under way, and soon we will welcome our new director of behavioral services and mental health s.f.,

dr. hillary coonan. it is a massive, multi-year effort. it encompasses the full spectrum, from preventive care to crisis response, sobering centers, overdose prevention, and expansion of treatment beds, medication and case management. our new office of coordinated care will help ensure that no one, no matter where they fall on that spectrum of need, will fall through the cracks. among the people we serve in this system are those so vulnerable, so gravely disabled that they can no longer care for themselves. for these clients who have reached that point, of meeting a 5150 hold, you have created housing conservatorship. it is an important tool, and just one tool in our tool kit. our goal is to always serve our clients in the least restrictive setting possible. but we also recognize that

in some situations, after trying all other options available, conservatorship is the most appropriate tool to use. we are grateful to you, and in particular supervisor mandelman, for your tireless work in crafting housing conservatorship legislation. and we also thank senator weiner for all he has done at the state level to make sure this tool is available to all providers in san francisco. we need a variety of options in order to meet our clients' needs. we fully support housing conservatorship as an option that can help them on the road to wellness and recovery. d.p.h. has strong partners in this work, and my counterpart, director shareem mcfad don, coulddon coud not be here today, but i want to thank her and her

staff for all they have done. and as supervisor mandelman mentioned today, you'll hear from jill neilson and the director of forensic, angelica nata. they have navigated several challenges, multiple challenges, in implementing housing conservatorship, which i'll talk about today. and they've been extremely creative in finding ways to serve people who may need this level of care. i want to thank them for their dedication to clients and to this work, including through a global pandemic. san francisco is fortunate to have civil servants such as these. the housing conservatorship also benefits from mental health. we're lowering barriers to treatment and making it easier to access and move through the system. we are constantly looking

for referrals. and we are expanding placement options for individuals who are conserved. it gives us an opportunity to build that pipeline with local hospitals and collaborate with us and share information about patients who could be eligible for these services. through the new street crisis response team, we are identifying more people in need of our services, while preventing unnecessary emergency room visits and stays in jail. in the covid-19 alternative shelter program, including the shelter in place hotels, we're able to find and followup with our clients in need of support. as you know, covid-19 has led to a slower turnover in parts of our system, as residential programs have reduced their capacity, and the pace that it takes to control the spread of the virus. they're discharging only those individuals who have a covid-19-safe place to go. but, as you know, the vaccine is bringing us

hope. and we are well on our way to a different future. as part of mental health s.f., and thanks in part to prop "c" funding, we are enhancing services and creating bed placements across our system of care. and, again, this is a massive, multi-year effort. with our partners at h.s.a., d.p.h. will continue to support housing conservatorship. we need all of the tools to conserve those most vulnerable in san francisco. with that, i would like to turn it over to angelica and jill. thank you again for this opportunity. >> chairman: thank you. thank you, director colfax. >> good morning supervisors, and thank you for having us here today. i'm going to go ahead and

reorient us to the conversation to go over the intention of housing conservatorship, and we'll talk about how we got here, and the work that has been done since housing conservatorship has been adopted, and jill will speak to implementing this legislation, as well as some other options we have developed to address the needs in the community. just then to give an overview, housing conservatorship is designed to support individuals who have significant behavioral needs, who are cycling in and out of conservatorship. they have refused multiply officers of voluntary services, and cannot be treated in other options, such as the outpatient as was noted, the criteria

for housing conservatorship is many. it includes individuals who have both a serious mental health need, as well as a substance abuse disorder, and it leads to impairment, and there is evidence of decompensation. as we indicated, the individuals have multiple 5150or involuntary psychic holds, and that is eight in a 12 months period. and individuals have had multiple opportunities and have been offered voluntary treatment options, and that we have been unsuccessful in engaging them in these options. to give a little bit of history about the legislation, as indicated, this was adopted at the state level as sb1045 in 2018, and subsequently adopted locally by the board of supervisors in june of 2019.

there were then amendments to the sb1045 legislation as sb40, which was signed by the governor in october of 2019. and then in june 2020, the forms were finalized by the courts locally, which then allowed us to be able to move forward with cases. i think this is important to note because it really wasn't until june 2020that we were able to move forward with cases. at this point, if they had more 5150s, we had to start noticing them, which we'll be talking a little more about. despite this, during the time leading up to being able to file petitions with the court, we worked tirelessly and collaborated with our partners across the system, including offering expensive training to hospitals, identifying individuals who may be on the pathway to conservatorship, and offering them services, and making sure there was active engagement for these individuals. i want to highlight that

we have staff tirelessly working on this. i have a staff member who is available to hospitals seven days a week, who takes calls on the weekends, about individuals who are there who may be on the pathway to support that individual, and also the hospital, around any documentation or paperwork that is needed. but i'm also happy to report that during this time, there have been 140 individuals we've been able to serve in less restrictive treatment options, including case management, assisted outpatient treatment, supporting existing providers who are working with those individuals to ensure that individuals had what they need to be successful in the community. and in total, 60 of thoseç individuals have since dropped off the pathway to being towards housing conservatorship and no longer eligible for the program, which is a great success. as i indicated, we also have to start serving individual with notice they're on the pathway to housing conservatorship starting with the 5150.

this is the most recent information to highlight individuals, again, who are on this pathway, and this is as of the end of january. there were 63 individuals at that time, who in the last 12 months had five or more 5150s, and that's when we need to start serving individuals that they are on the pathway to conservatorship. 10 of the individuals we're currently working to serve in less restrictive options, by engaging them in outpatient treatment and intensive case management. in total, seven have received notice they're on that pathway towards housing conservatorship. and so if we're unsuccessful in supporting them in less restrictive options, we'll be able to move forward with these

cases. we've had one individual we've been able to place on a housing conservatorship. as director colfax mentioned, mental health is san francisco, it will hopefully allow us to successful intervene so people will not become on that pathway. we know that it is important that we have additional placement options at different levels of care so we have flow through the system, rather than loading them on to one specific level of care, and it is exciting we're having this new in filtration and enhancement across our work. and, of course, our priority both ethically and legally is to serve individuals at the least restrictive option for them, and as best as we can to engage individuals involuntary services.

as director colfax mentioned, we know that conservatorship is an important tool in our tool belt. it is not the answer to everything. but there are many individuals in our community who would benefit from conservatorship, and we're excited to have housing conservatorship as a new tool to support individuals. this gives a brief overview of the pathway for individuals to get towards housing conservatorship. those who have a 5150 and have a mental abuse disorder, we begin to provide notice to individuals that they're on the pathway to conservatorship. throughout this, we are always trying to engage individuals in less restrictive and voluntary treatment options. starting -- part of the requirements for housing conservatorship is starting at the third 5150, and there has to be a documented offer of

voluntary services. we attempt to engage individuals that they qualify through the assisted outpatient treatment program, which we've seen huge success for, and we offer other voluntary services, such as residential treatment and case management options. however, if we're unsuccessful with this, at the eighth 5150 within 12 months, a conservatorship can be filed by the treating psychiatrist. part of the requirement of the health code is that (indiscernable) through the assisted outpatient treatment program has to offer documented offers of treatment to individuals three additional times before a temporary conservatorship is granted by the court. and then a individual is on a temporary conservatorship up to 28 days, and then there can be a hearing for a permanent one, which lasts up to six months and can be renewed. i'm going to transition at this time to jill neilson to talk about the

implementation challenges and some of the other work that we've done in the community to support individuals. >> thank you so much. good morning, chair mar, supervisors mandelman, stefani, haney, thank you so much for having us today. and i would like to really thank director mandelman and director colfax for acknowledging the hard work that the departments have invested collaboratively towards the successful implementation of this program. i'd like to add the city attorney's office to the list of departments that really deserve acknowledgment for hard work as they have moved forward a brand new, unprecedented law. and we have been very pleased to be working with the city attorney's office. we knew that the housing conservatorship program would only serve a small number of individuals, it does remain disappointing that we have not been able to help more vulnerable people at this point.

i do want to assure you that we are absolutely committed to growing the program, and we remain committed to implementation of innovation to do everything we can to make sure we are using this tool. i did want to share some of the challenges that we've experienced, and i also know there is interest to hear how the law might be improved. and these are some of the areas we could present possible opportunities for reform. the first set of challenges was the eligibility criteria is far too narrow. you may remember the original version of sb1045 looked very different than the law we're working with today. that version of the bill originally only called for three 5150s within 12 months, not eight. and it is not just the number of 5150s that is problematic, but ensuring that we have the appropriate documentation from the hospital. we have to have

documentation to support each and every one of those eight 5150s to ensure that the 5150s occurred within the proper scope of the law. it is really critically important from the legal perspective to have that documentation, as well as documentation regarding the notification of individuals, as they hre moving through their 5150 pathways. so the notification process must be provided to the fifth, sixth, seventh, 5150s, all of that documentation has to be done within the law or our office is not able to move a referral forward. another significant challenge is related to the voluntary service requirement. and, of course, that was in addition to sb1045. and that aspect of the law came into being in the

subsequent sb40 legislation. and the voluntary service requirement was furthered strengthened by san francisco's local ordinance. so sb40 essentially required us to have six documented offers of voluntary services, and the local ordinance added an additional three documented offers on top of that. and so although well-intentioned, these requirements are really excessive, and they do make it challenging for us to prepare a case. of course, the pandemic has also presented some implementation challenges for us as well. the noticing and the voluntary service offers have to happen in the hospitals. and right now hospitals are obviously stretched very thin as they work

tirelessly to handle the pandemic. there are always restrictions and presentations, and they prohibit us from having, for example, behavioral health staff that can assist with the involuntary service documentation, and they're prohibited from entering right now. it has been the implementation process increasingly more challenging. we have yet to have a contested case, but i did want to note that the city attorney believes that a future contested case could be quite complex and lengthy, unlike l.p.s. contested cases. and that is only to the extensive requirements that are found within the law. supervisor mandelman, i have heard you voice that you feel that the conservatorship is an underutilized intervention tool, an intervention tool

that really does have the power to help vulnerable people, and i believe that is what drove us to pursue housing conservatorship. if you could move to the next slide. this is a data slide that was recently published in a report by a researcher who studied california's conservatorship. and although the data only extends to 2016, but what you can see here is that across the state, conservatorship has declined. in the mid-1990s, the state had close to 16,000 individuals under conservatorship, that would be a one-year conservatorship. and in 2016, that number declined down to a mere 6,000 individuals. unfortunately, we don't have data since 2016 for this state. and that is likely owing

to the fact that we don't have a state office that functions as a home for conservatorship, which i think is fairly unique in the county programs that we operate. counties do not receive dedicated funding to operate their public conservatorship program, and we don't have the state office that might help us to -- it might help policy-makers to be seeking out best practices, to ensuring that policy-makers have access to the type of data that they need to make good policy decisions. our l.p.s. case load has remained stapled, but we know we can do better and it is a priority for the

city. next slide, please. thank you. i'm happy to have a opportunity to tell you about a program that the public health services -- we've already launched this unit pilot program. what we're doing is following the lead of los angeles county. they started a pilot to proactively leverage welfare institutions code 5352, and we are referring to that as the outpatient pathway. what is that? essentially the wic statue already allows us to move forward conservatorship to individuals while they're in the community and who are not in an acute care hospital. how this works is that psychiatrists who are working with individuals on an outpatient basis may

refer directly to the office of the public conservator. the eligibility is the same as with traditional l.p.s., conservatorships, which is based on the grade disability, which i'm sure you're all familiar with, food, clothing and shelter, but they can only refer people who do not need to be hospitalized. so that is a significant caveat. next slide, please. what you can see here is the traditional l.p.s. s. referral process, which is based on a series of short-term involuntary holds. the benefits of the outpatient referral pathway is that the referral is given directly to the office of the public conservator bye-bye by by

passing the short hold. considering that, we're in a pandemic, and keeping the hospitalizations low is a priority for all of us. i think there are a lot of individuals to not having spend extensive amounts of time in acute care studies. one of the biggest benefits is to the individual themselves because it promotes their ability, of course, to remain in the least restrictive setting possible. but i do want to emphasize that the referral pathway will only work for substantive individuals who are considered gravely disabled due to serious mental illness but who are not in imminent danger. we do need to have a psychiatrist who is able to attest that the grave disability will not change without the benefit of an in-patient acute care stay. next slide, please. so why haven't we leveraged the provision of the l.p.s. act earlier?

i can tell you actually we have. we know that the city attorney's office has been representing the public conservator, and has been able to access it six times over the past two years, and we've used it for some exceptional cases. really, across the state, this provision is rarely utilized. and that is, of course, until l.a. county launched their pilot program over the summer. most often, though, what we see in this provision is it is utilized by family members who are seeking to preserve a loved one who suffers from serious mental illness. why haven't counties utilized this provision toa greater extent? likely it is because it is, frankly, difficult. in order to do so, you need to have all of the different shakeholders, the department of homelessness, the department of housing, the

public conservator, the public defender, the courts, we all have to work the significant and legal hurtles. what i can say is that our housing conservatorship program and the limitation process has really prepared us to leverage this l.p.s. act. we're working more collaboratively than we ever have. i'm happy to say we're ready to follow l.a. county's pilot program. next slide, please. so, we've already gotten started, and since the beginning of the calendar year, we have been able to conserve 10 individuals. i'll say the individuals that we are assisting have access to housing, as well as intensive case management. and what we have been doing is collaborating with behavioral health services to identify individuals who are

appropriate, who are considered gravely disabled and in serious mental illness, but, again, who are not in imminent danger. we're focusing on individuals who are housed, and who are known to behavioral health services. we're working collaboratively to stabilize individuals, really trying to prevent episodes of homelessness or greater crises. but this process in this early stage of our pilot has really allowed all of the different stakeholders to work through systems issues and streamline our process. next slide, please. so at this point, we are ready to pivot. we're ready to follow l.a. county's lead. with their pilot project, they're leveraging provision of the l.p.s. act is to assist clients who are unhoused and very vulnerable. we intend to continue our collaboration with the department of health, the department of homelessness

and public housing and our other stakeholders, and we'll be working through all of the hurtles because it will be another phase for us to adapt this model to assist individuals who are on the streets. but we're absolutely committed to doing so. right now we are conducting significant outreach in education with outpatient clinical providers. and, of course, we intend to evaluate the model and determine if this is an affective practice. next slide, please. what is the future outlook for our conservatorship program? i just want to emphasize that we will continue to build on our collaborations with the client on the policy level. and we're working hard to identify clients who can be served through the housing conservatorship program, as well as through our new outpatient

l.p.s. referral program. with providers, to help them understand our service models and how conservatorship can be a tool to help vulnerable individuals. and, of course, we continue to be focused on growing community-based conservatorship, and keeping individuals in the least restrictive setting possible. at this time, i think we are available to answer any questions that you might have. thank you. [please stand by]

>> thank you, supervisor. i'm going to ask angelica alameda to try to project that future. >> i appreciate that, and i wish i did have a crystal ball. i will say, i think, as joe has mentioned, we learned a lot in implementing this program and being able to move forward, certainly, not only conservatorships but in how we support other individuals in distress in the community. i think there's a lot photographer us to learn about the court process, what will happen with a contested case, and as you mention, this is an opportunity for us to gather

that information, looking past the pilot. as i mentioned, we've served seven additional individuals to the one who was already conserved who are on that pathway towards conservatorship. we're anticipating that, at this point, there will be at least a handful of more individuals who will get to that eighth 5150 that we'll move forward with, and it will help us understand what that landscape will look like. it is a little bit hard to anticipate what that will be because it's still an unknown on what the court process will look like, but jill, is there anything that you want to add to that? >> no. i think we will remain hopeful that we will see clients. given the number of individuals that are on the pathway to

conservatorship, we will be able to continue to assist those individuals. the success we had with the one case and the fact that it's not contested highlights some of the benefits of the program which is that we're working collaboratively with the public defender. that doesn't mean that we won't see a contested conservatorship in the future, but it's likely we'll see someone in the future that will contest the conservatorship process. >> supervisor mandelman: given that this pilot is going to be more of a pilot than we anticipated, you know, and more petite than i had hoped, there

is this population that maybe not what s.b. 1045 ended up addressing but was where s.b. 1045 started. and i know a number of these individuals by names,

committing -- >> and supervisor, i'll just say that, of course, this is an incredibly complex question, and certainly requires a myriad of response, and i think that there's a lot of opportunity that we have through mental health s.f. to support individuals. not that any one thing is the answer. we know that it's not cookie cutter, that everyone has different needs, but i'll just say, you know, certainly the enhancements of beds, in particular looking at slow thresholds, accessing the barriers to people in those beds will be the focus. coordinated care and individuals who are cycling in and out of the hospital, maybe not under the volume that -- not in the volume under s.b.

1045, but hospitals will be better positioned to serve those individuals. as you know, we've also implemented recently the street crisis response team program, and so i think more proactively identifying individuals, supporting them, and building those relationships so we are more successful to bridge them into the care that we need. those are some of the things that i would highlight, but it certainly requires all of the collaboration of all of our departments. but we also, in addition to residential treatment programs, we've seen a lot of benefit in terms of having shelter in place, hotels, for example, so that people can be located, and that has been very stabilizing for some individuals, so i think it'll be a complex collaboration across departments to support individuals who are in the

highest level of distress in the community and certainly causing distress to our community members. >> supervisor, if i may, grant colfax, director of health. i think your point is well taken. just to be condud about the challenges that we have in the population -- candid about the challenges that we have in the population, we have -- the balance around individual rights and autonomy and how that intersects with the need for treatment, our criminal justice system, and our health system, i think s.b. 1045 is an example where those challenges have been and where they're going. we've said 1045 is one tool in our tool box, but we need to be

candid on any given day, people with substance use disorders, mental health disorders, even with intensive outreach engagement, only a small number receive treatment. there is a large gap between people who are -- i do think there is quite a bit of space between those continuum that the health care system, law enforcement, and the justice

system are still -- and society at large are still working to figure out where -- what is that appropriate -- appropriate balance, and i -- just to be candid, i don't see that the behavioral health system has all those tools in the tool box to address that. i think this is a broader societal question beyond our health care delivery system while also being firmly committed, as i said, in the introductory mark of building a robust system of meeting people where they are so we can get them into care. >> supervisor mandelman: i hear that, and i think it's extremely important that you say that, and we hear what you're saying.

i think the problem is going to grow, and the challenges are going to go as the state tries to reduce the number of those that are in state prison and reduce the number from local jails. and i think what i'm hearing from you is that you're not sure the public health tools

you have is enough. s.b. 1045 was one senator's effort to chip away i think at reasonable people's expectations of those who will get care and the people need care will not get care. most people don't want this to be a law enforcement response, but most organizations are telling us they don't have the legal resources to absorb these challenges. and the alarm bells are going off. i think the expectations for mental health s.f. are very high, and i'm concerned that we're not going to get -- even if you make a great deal of progress in implementing mental

health s.f., that we are orders of magnitude away from having a response to these serious mental health crises on the street. i've got a few more questions -- unless supervisor haney wants to jump in on that. okay. i was wondering, on s.b. 1045, sort of a public health mandated party of sobriety might be needed for somebody

cycling through the system; that a period of incarceration was a way for a period to get away from the substance and think oh, i don't need this. i was sort of hoping with s.b. 1045, we might see what a period of involuntary sobriety for someone struggling with those issues might do. i don't know that this one person gives us the sample size where it would be worth exploring. >> and supervisor, there are times that individuals having

that space and certainly the temporary conservatorship for housing and substances can be helpful. we know that while wellness and sobriety is a journey, it's not something that can be accomplished during a short period of time, and having the wraparound services in the community makes all the difference. we've had 60 individuals that we've been able to serve in less restrictive options, and by using stress reduction techniques and other methods, we've been able to reduce their needs on psychiatric services. certainly, not cookie cutter. we need different options, and there's a lot that we can do and less restrictive options that doesn't require

institutional sobriety. >> supervisor mandelman: and i guess that, although there's some expectations between myself and my constituents i represent who want us to act aggressively with the most troubled and heavy users who may be the least successful in the more voluntary kind of harm reduction sort of approaches. s.b. 1045 may not be where we're going to pilot that approach, but we need to look at how we get services not just to people that are voluntarily accepting them and want to reduce their use, but how to get harm reduction services to people who continue to use and continue to wreak havoc in their lives and the lives of the people in the community.

i do want to highlight slide eight. maybe we can bring that back up. >> yes. bear with me just a second, supervisor. >> supervisor mandelman: 'cause i think it tells the tale, and i think it tells the tale that i am alert and aware that correlation does not equal causation, but the rapid and steep decline in permanent and temporary conservatorships starting in around 2000, you know, interestingly coincides with an explosion in mental health crisis on our streets, and i know homelessness is

complicated, and most people who are unhoused are not -- i mean, the vast amount of people who are unhoused are not candidates for conservatorship. but we know that people who do not seek care, they often end up on the streets, and i think this graph is related to that. you know, that same study that alex varner did also took a look at psych beds in california, united states, compared them to psych beds in other developed countries. it looks to me like -- i guess these figures are from 2011, so they're nine years old. i don't know if the story is terribly different, but california, at that time, in

2011, had just over 20 psych beds per 100,000 people. was doing worse than the united states, which had somewhere between 30 and 40 psych beds for 100,000 people. belgium has nearly 180 psych beds per 100,000 people. netherlands, close to 150. germany, 120. switzerland, all of the european countries that i think we all would acknowledge have excellent health care systems have psych beds, psych hospital beds per capita that dwarf what we have in the united states and definitely dwarf what we

have in california. you know, i understand perhaps california and san francisco can do things differently, and maybe not everything needs to be -- and i don't know if those are acute psych beds or what kind of psych beds that we're talking about, and i'm sure it gets more complicated as we drill down and look at other options. but i'm sure after that budget and legislative analyst's report that we did on conservatorships back in 2019, and after seeing, hearing -- you know, understanding that we are, you know, very short -- after dr. nigusse bland's

report, i'm concerned, as i am concerned about our slow implementation of s.b. 1045, i am concerned about our slow implementation of bed expansion. in 2019, the mayor announced, and the board of supervisors approved the most significant expansion and dual diagnosis beds for people suffering from both serious substance use disorder and -- and some other kind of mental illness. and those beds were not purchased. now again, covid intervened and made some of the work more difficult, but we're

approaching two years later. in the last budget, we set aside money to significantly expand locked subacute beds and other kinds of beds not in a way that i think will dramatically alter either of those figures in alex varner's study of california or, you know, but we did fund an expansion. and i think we will find that we have not been successful in achieving those expansions in this year, and it causes me, again, because i have said, grave concern about our ability not just to move mental health s.f. forward but the reasonable expectations of san franciscans that we will take care of people who can't take care of

themselves. i have other things that i will pursue. i do want to thank dr. jill nielsen for highlighting the absenteeism of the state around conservatism and the need for conservatorship beds, and i plan to take that up with the state legislature, and i want to thank you for exploring that with you. this presentation is well and good, but still does not address the allege of unhoused people with severe mental illness, so it's a to be determined kind of a situation. and finally, not that anyone wants to look at revisiting our s.b. 1045 implementation legislation, but it does seem ridiculous that we demand nine

documented voluntary office of services rather than the six by the state, and i think we should look at that, as well. and i think that's all i've got. thanks, everyone. we'll continue talking about these issues. i'll invite you back in six months or so for an update on conservatorships, and we'll probably be talking a lot about beds now and between the summer. >> chair mar: thank you, supervisor mandelman, and thank you, everyone for your work and for your report. supervisor haney? >> supervisor haney: thank you, supervisor mandelman, for your questions, and thank you, everyone for your report and

your work. i have several questions on this. what is the cost on this? i know we have one individual who was conserved -- a lot of bureaucratic things need to happen to get that person conserved. is there a figure what it costs the city? >> supervisor haney, neither department received additional funding. we used what we had to put forward. utilized beds are ones that exist in our similar or are ones that people would have been eligible for, so it was no additional cost. >> i'm sorry, angelica. my office did receive two additional f.t.e.s at the time

the legislation was passed, and i believe the city attorney's office may have received some additional staff at that time, as well. the cost of our f.t.e.s, we could certainly get that to you, but i would tell you we are absolutely utilizing the staffing resources for other purposes, such as this new pilot project that we have already launched and to really expand the community-based conservatorships that keep individuals in community-based settings as opposed to most costly and less available locked psychiatric facilities. >> supervisor haney: i got it, but obviously, there are, i'm sure, trade-offs in terms of the time that's spent on this and all of that that do have some cost to it.

i'm interested in what we are doing for people with a bit more clarity for 8 + -- i'm looking at the chart on page 5. there are several people that have received 8 + 5150s, and eight people that we're attempting to be served. so we have 16 there, i'm not sure what's happening there. and then, we hhave -- in terms

of all of these people, are all of them being offered housing in some way, and how many of them are homeless? is i assume that all of them with homeless, or if it's not all of them, it's a large number of them. are they being offered housing? some of them were even on our coordinated system of entry. if somebody is waiting for housing, being on the streets, being 5150 multiple times, you know, it seems like pretty early on in that process, we need to get folks inside and having treatment happening that's in the context of housing or being housed? >> and supervisor, i can answer that. so in terms of the services

that are being offered to individuals, we receive information every month for individuals who have the four or more 5150s in a 12-month period so we can more effectively outreach and support those individuals, and we've had more success in reducing crisis contacts and supporting them in less restrictive treatment options. that includes assisted treatment and individuals can meet criteria for that, which includes intensive outreach and support from peer workers, intensive case management. a number of people had existing providers, so we partner with providers to make sure there are not any barriers that individuals are encountering or that providers are encountering

to create those barriers. in terms of the housing, i don't have the number in front of me, but there is, as you anticipated, a large number of individuals who have voluntary or psychiatric holds that are experiencing homelessness or housing stability. we are certainly supporting those individuals, and there are psychiatric individuals at housing services who support individuals going through coordinated entry if they're open to that, and then, of course, individuals have been able to be placed in shelter in place hotels and in congregate sites. that has been more complicated in times of covid, but we have had success for individuals to be placed in shelter in place hotels and for us to be able to support them there. >> supervisor haney: thank you. just respectfully, i'm not sure i got an answer to the question. of the -- i would count here,

70 -- or 80 -- 80 people who have five 5150s or more, one was a conserved. for the other 79 people, were they -- how many of them were offered housing, what was that housing? how many of them have been placed inside? was it long-term housing? it seems that first step, if people are clearly a danger to themselves or others and out on the streets and potentially in a position where they may be harming themselves, we want to get them inside. i'm not seeing, before we get to the eight even how we're ensuring that people are accessing somewhere to stay where they can receive treatment. >> yeah, and supervisor, i don't have the data in front of me, and i can certainly follow

up with you about that in terms of the information. so -- and just to clarify, so it was 63 individuals in total who had the eight -- sorry, five or more 5150s in the last 12-month period. it's six that have four or more 5150s. i believe they're being served in shelter in place or congregate sites right now. we partner with h.s.h. to support those individuals and have been successful with individuals going directly from services to those situations, but i can follow up with you with numbers for that. >> supervisor haney: okay. i would say the goal for this, supervisor mandelman -- and i don't want to speak for you here -- but we want to have

folks get to the point where they're not having eight 5150s, that we want to get them some help, some support, get inside, get treatment, so that we're not getting to that point because each one of these 5150s reflects in some cases law enforcement contact, in some situations where they're putting themselves or others in danger and obviously representative of many other daily situations on that. so the sooner that we can get them help and get them support -- i think one conservatorship we would not consider a failure if all along the way, they were getting housing, they were getting treatment, they were getting some other things. i think the goal is to get to a lower number at the end if we felt that the system is working. and what i'm trying to understand is how for somebody who has one or two or three or

four and definitely five-plus, that we are -- and there are all these requirements of documented offers assistance or outpatient treatment and such, how much of that is really central for a lot of these folks, which is making sure that they're inside and that they can receive treatment and support inside. i don't know how effective outpatient treatment is when somebody is homeless and still homeless. we kind of need both of these things to go together, so i really would need to know more about how, you know, about how housing is a part of this and a part of the offers that are being made. i mean, they're -- i absolutely agree, there are a lot of people out there, many in my district, of course, who need much better treatment, and in some cases, are not in a

position to make that decision for themselves, but i do think that intervening with people earlier in the process i think is better for them and better for everyone, and i think in some cases, it's going to mean that they need a bed for treatment and, admittedly, a long-term one. >> supervisor, if i may, i want to say we agree with you. since june, we've had 140 individuals that we've been able to serve that were on the way to conservatorship. 60 of which have significantly reduced psychiatric emergency contacts. i certainly can't speak for the department of homelessness and

housing, but for the people that i'm talking about, i can certainly get service records for those individuals and available housing. >> supervisor haney: what role are they playing -- if somebody has multiple 5150s on the path here to potentially a housing conservatorship, are there staff at department of homelessness and supportive housing that are making sure that person has access to a placement, is a part of this process from the beginning, is supports where they are, if they are in a shelter in place hotel or congregate setting? what role is that department playing? >> we've certainly partnered with them in implementation of

housing conservatorship, and again, supporting victims to go through coordinated entry while they're at psychiatric emergency services, and we've had close collaboration with them to be able to operationalize that. and certainly having shelter in place hotels during covid has been incredibly beneficial for that. >> supervisor haney: for the population that we are looking at here, i know that the -- when we were discussing this initially. -- initially, there was generally a sense that people who have substance use disorder, addiction, and often

to certain types of drugs even that, you know, when some people talk about drugs, what we're talking about in some cases is people who are addicted to meth. do you have data on what are sort of the broader needs and illnesses and disorders, etc., addictions for this population that is -- even the set of folks who are in the 63-plus, what their actual set of diagnoses are? >> we certainly have access to that information. i would say that, as anticipated, we see a high number of individuals who struggle with methamphetamine use. in terms of mental health diagnoses, and again, i don't have exact numbers, but a number of individuals have diagnoses related to thought disorders, like a psychotic disorder, schizophrenia, bipolar, things of that nature.

>> supervisor haney: because i think for us to understand how people are getting to this point so we can better serve them further upstream, i know there are a lot of things that, for supervisor mandelman, that we're seeking to learn also from this pilot, you know, a better analysis of how to prevent people with certain diagnoses that, when left untreated, let them to this level -- get them to this level and better diagnoses are. it would be good, and maybe you've seen this, supervisor mandelman, is it addiction or certain types of psychotic disorders that we are failing to treat further upstream to identify things very important. and i would love to see that

data. the other two things i just wanted to ask, is there -- is there data on who is doing the 5150s? do we have a breakdown of -- i know there were a lot of questions about creating a situation with greater law enforcement contact? what's -- do you have a breakdown of the percentage that was done by law enforcement versus others? >> supervisor, i appreciate that. that is certainly a priority of the housing conservatorship working group that we've been working hard to gather information. this is, of course, complicated, because there's multiple hospitals to work with to pull this information. unfortunately, we don't have the level of detail regarding who's initiating the 5150s from

each hospital. we do have information from -- and the police department has been very helpful in partnering around this to make sure we do have the information, but we do have information from the police department and the number of 5150s they completed in the last -- in the last year, and we also work to do a more in-depth analysis of the reasons that law enforcement were involved in those 5150s. i will say, i think a lot of this will look different in our subsequent annual reports because of the i ever willmentation of the street crisis response team, and again, the call types of 800 -- or the calls for the mentally disturbed persons, it'll be interesting to see if there's a change in the volume of 5150s, but also the number of 5150s

completed by law enforcement and assess that. >> supervisor haney: so to be clear, we don't have that information yet, and you expect we should be able to share that at some other time? is that -- >> yeah. it's, again, complicated for privacy reasons but also matching data to be able to have this. but we have information from the hospitals in terms of the total 5150s that have been completed, and i'm just looking at the report right now so that i can share that information with you. so what we have from san francisco general hospital is that there were roughly 9,0005150s that occurred in fiscal year 19-20. again, what is complicated

about this, it certainly does not represent 9,000 individuals. because of privacy reasons, we're not able to get person information from the different hospitals, so we don't have the details of how many of those are duplicates for individuals, so that just gives a highlight of the volume of 5150s that we're looking at, but from each of those hospitals, we don't have the details of the breakdown of what initiated the 5150 or even what was the reason for the 5150. >> supervisor haney: so if we don't have the breakdown by how many actual people they represent, but somehow, we're able to know if one person has gotten a certain number of them, i'm a little confused as to what data we do have. seems like 5150 is clearly a

legal process that -- i'm confused as to why we can't sort what actually did that 5150. it seems like we have to know the people who have multiple 5150s because that's how they get on the path to conservatorship. how do we not know how many people have 5150s but know how many they have? >> supervisors, we have a lot of detailed information from zuckerberg san francisco general hospital regarding certain information regarding individuals, and we've partnered with other hospitals to identify individuals on the pathway who they see on a regular basis, and we're able to gather information from those hospitals.

but when we're looking at the larger scale of individuals who may have been placed on a voluntary hold, those are information that we're not privy to them. but we're thinking of ways to obtain that information, again, through the hospital association of northern california. but it's a complicated issue and one contemplated in the l.p.s. audit report and thinking for individuals that are cycling in and out of crisis how the department of public health is able to access that information in a timely manner so that we can intervene. it is a big ask for the department of coordinated care and get ahead of people needing to be placed on conservatorship. >> supervisor haney: and do we know when our own -- i mean, i guess when hospitals -- well, i don't get in the sense -- i

think clearly, we need to have an opportunity to get more data. we've had some of these same issues around covid, and we've been able to get them to share in various ways that they haven't before. do we know -- we should be able to track, like, when sfpd does it and look at that data or the fire department or, you know, our own s.f. general hospital -- and i'm trying to understand -- like for these 63 people, for example, do you know, for the ones who have over five 5150s, do we know who did those 5150s specifically, or do we know just they had

more than five? >> no, we certainly gather that information. it is complicated to pull that, but we do have access to that information. and we do pull information from the police department, and so we know the volume of 5150s they have completed, and what hospital they took individuals to. for our analysis for the housing [inaudible] working group, we did a deep dive there, so we'll have some additional there in terms of who contacted them and what was the reason for the 5150. >> supervisor haney: got it. okay. i think that's very important to know. if you have 16 people with eight or more, you know, what percentage of those were done by the police versus other providers or others who have

that authority, i think, is really important to know, and i think it's something that was raised when this law was passed to appreciate the impact. well, i think we have a lot further -- most importantly, as you said, supervisor mandelman, the question is how do we serve these folks and get them the care and treatment and protect them and all of our residents, and how does this program fit into it? how does it make sure we're holding ourselves accountable to helping people upstream in the process? when somebody has eight 5150s, i think we can all agree that's a breakdown of how the system would work. how do we learn when the system

has broken-down at that level that we get somebody treatment and support earlier. and of course, when there are people that have that level of need and are not being served by the system as it is, how do we expand the options, the opportunities via this program to serve them better? i want to ask one last question, and i'm sure that supervisor mandelman has things to add based on what i've said, but when i -- when i was out -- i spent time out with, you know, paramedics and e.m.s. 6 and others, and one of the things that came up was not conservatorship but individuals that they came in contact with

that would meet the the criteria of conservatorship, and that's people that abuse alcohol. i wonder if you could weigh-in on people that have chronic alcoholism in a way that's causing a lot of contacts and 5150s and other things? i will say there was a huge frustration that i heard from our folks at e.m.s. 6 and others about not feeling that we had adequate treatments and placements for people having that issue? >> so supervisor haney, i just want to clarify what your question is.

are you asking specifically how we may or may not be using l.p.s. conservatorship for individuals with chronic alcoholism? >> supervisor haney: yes, and, i mean, it seems to be connected to the broader questions around conservatorship and a population that seemed to be underserved and how we approach conservatorship as it relates to l.p.s. conservatorship related to alcoholism, but even before it gets to that stage, how we are serving individuals with that diagnosis more effectively? >> so that aspect, i may defer to angelica on how behavioral health services are working with individuals with substance abuse and addiction issues. in terms of l.p.s. conservatorship, what i can say is, really, across the state,

grave disability due to chronic alcoholism is a rarely utilized provision of the l.p.s. act. and just from talking with psychiatrists, what i have come to understand is at the heart of what housing conservatorship was attempting to address, which is that when someone appears gravely disabled as a result of their chronic alcoholism, if they are hospitalized, during that hospital stay, they get the hydration, nutrition, and represent that they need, and then they clear up, and once they clear up, they're no longer considered gravely disabled. so the outpatient l.p.s. referral pathway that he was presenting on -- that i was presenting on earlier, our office is hopeful that there may be some individuals on the street that may have chronic

impairment that may be related to a diagnosis of serious mental illness that may be exacerbated by alcoholism. and we have individuals from the street medicine team or other clinics that know this person well enough to say this person is gravely disabled, and no matter what kind of rest, nutrition, hydration they get from a hospital stay, they're still going to be gravely disabled, and those are the referrals that we'll hopefully be able to move forward on this outpatient basis. really, for l.p.s. conservatorship, the referral from that licensed psychologist is really what makes the difference. we can't move a conservatorship forward if we don't have that referral, and they have to be, within their license, willing to come and testify in court, you know, that they have made

that referral within the provision of the law. what we have seen in l.a. county is they've had some cases where individuals have not contested their outpatient referral pathway, and so i see that as a glimmer of hope because you use conservatorship to some degree within the context of maybe the carrot and stick approach, which the carrot is we're going to have you in community-based setting with lots of help and support, and the idea of conservatorship being, unfortunately, an involuntary measure, but hopefully we can work with individuals, negotiate with them, and help them to meet their goals. so i'm optimistic, especially seeing what they're -- what they've been able to accomplish in l.a. i'm optimistic that just in the

length of a couple of months, we have been able to help clients that are homeless, at s.i.p. sites, many of them were formerly homeless, get them stabilized in housing, and they may destabilize them again. so we're using conservatorship to come in and stabilize them again and prevent another round of homelessness, so these are innovative tools at the local level to really chip away at this problem. san francisco's not alone in the problems that we're experiencing, and i think we need to have both local innovation and hard work at the same time we are looking at

larger scale policy reform. >> supervisor haney: thank you. and i know this is sort of a bigger issue, and it's something i'll bring up when we have d.p.h. come to the board around the budget, but really trying to understand the -- and, you know, i think that with everything, we want to serve these folks not with a conservatorship whenever possible, but it just seems the people that are experiencing chronic alcoholism and/or that are homeless, we're more limited than some of the folks who are out on the streets than people with chronic alcoholism, and we're not meeting those needs. thank you so much for all of your work, and i'll pass it back over to you, chair mar, and thank you for answer my questions, and i'll look forward to more of the details and data which i think is helpful in understanding this

program and we as policy makers can better target our services to address the untreated illness and untreated addiction that is clearly in our city that this program was designed to solve for. in some part, we have a bigger challenge here that we really need to meet, and i think this is a program that we could better use to serve this population upstream. thank you. >> chair mar: thank you, supervisor haney. you know, i actually had some -- also had some questions about just how housing and permanent support hiv housing fit into this work to expand involuntary conservatorship to help those that are experiencing homelessness and the most severe mental health

disorders. most of these folks are experiencing homelessness, as well, and then, you know, it's clearly impossible for someone or very challenging for someone to get out of crisis when they do not have housing or stable housing, and if we want to help people, we should provide services and voluntary housing. and to say that someone has refused services without voluntary housing is -- i would like to hear how offers of housing or permanent supportive housing fits into the work, either the noticing for 5150s or direct inventions.

>> chair mar, i'm going to have to leave at noon, so if you would allow me to make a final statement. >> chair mar: yeah, go ahead. >> supervisor mandelman: i want to just, again, thank the folks from d.p.h., office of public conservator. i think it is challenging when you receive information from policy makers that is directly in conflict, and i'm going to disagree with some aspects of what supervisor haney suggested, and in this regard, i want to be clear that i think we're pushing you in different directions. i think the upstream interventions are critical. i think everyone supports upstream interventions, and i think it is important to get people who have mental health

issues, who have mental health issues and substance use disorders who can be helped with less intrusive approaches to get that help. i don't believe there's any disagreement on the board about that. i believe there are people who need more aggressive interventions, more intrusive interventions, and i think we can see in the studies of acute psych beds in other countries, we can see in the graph of what's happening with our own rate of conservatorship in this state in the last 20 years, that we are out of step and failing to realize that there are people who cannot make decisions for themselves. i don't think -- i think it is a failure, of course, for someone to be 5150'ed eight times, but i don't think the failure is we have failed to offer the correct mix of voluntary services necessarily, but i think it is far more

likely, as a practical matter, if we're going to get help to some of those folks, we're going to have to give them help without them wanting it. supervisor haney asked to what extent that population is suffering a meth addiction. i think it's greatly that population is suffering from meth addiction combined with masking a significant mental illness. it is a hard thing to get a handle on those folks and the needs that they have. and i think expecting if we just provide the right mix or approach for a voluntary service, these are not necessarily folks who are going to do well in permanent supportive housing. that's not the intervention that will keep them healthy. i think they're going to need conservatorships for a very long time, and their

individuals with meth and other substances, who need that help. and i don't want to let d.p.h. off the hook by saying they just need to focus on the upstream interventions. i think we are so failing the people who are the sickest and the most acute illness. i think it's somewhat like looking at the problem of cancer and saying well, we can avoid cancer by having better nutrition intervention than eating better. well, that may be true, but when somebody has to have the tumor removed, they have to have the tumor removed, and while it's expensive, we need to bite the bullet and do it. i don't think s.b. 1045 is as successful as we would have like it had to have been, but it's not because we haven't offered the right mix of services, but we haven't gotten conservatorships to people who i think need them who are on a

revolving doors. 95% of the 4,000 unhoused people who were identified on the streets in dr. nigusse bland's report had an alcohol issue, and conservatorship in its traditional form as used by health departments across california has not gotten the folks the help they need, but neither has voluntary services. i think we are falling down massively as a county and as a state in getting help to people who cannot recognize their needs, and i think at the lunacy to recognize that some people need to be taken care of and don't know it and aren't going to accept it.

and with that, i have to go to my noon meeting. i thank you, supervisor mar, for allowing my interruption. i thank you for your work and wish staff luck in meeting the needs of competing policy makers who may disagree. >> chair mar: thank you, supervisor mandelman. supervisor haney, did you have a sponsor did you have some additional questions? >> supervisor haney: yes, i just wanted to respond clarify. i know that supervisor mandelman had to go, but i do feel the need to put this on the record. obviously, there are people who are in such a dire condition and dangerous, in some cases, that some form of involuntary treatment may be needed, and i don't know if this is -- is needed, i should say.

where i want to clarify and what i was saying, and i don't know if i want to disagree with supervisor mandelman on this or not, but i don't think that is a static number. i think we should do everything possible to prevent people from getting to that point, and there are things we can do to keep them from getting to that point. i think there are persons that we can help with that. i grew up with him. he's currently living on the streets. a couple of years ago, he was working at phil's and was on medication. he slid off of medication and became addicted to meth, and i believe we could have prevented

him from getting multiple 5150s, that it wasn't a foregone conclusion that he was going to go down that road so that he didn't get to this point where he's in such an extreme and dangerous state. but yes, of course, there are people who are in that situation currently who also need our help and, in some extreme cases, involuntary treatment is something that is on the table and is needed in extreme cases. but our goal, ultimately, should be preventing people from getting to that level and for many, we can prevent them. for example, something as simple as we don't want people to use meth. we want to prevent them, we want to help them sooner so they don't use meth. of course, that is our goal, and to the extent a lot of these folks are meth users, we want to prevent them from becoming addicted to meth at such dangerous levels. any way, i'm sure that my

friend, supervisor mandelman, and i will continue to work together on this at all levels, and thank you for your work. >> chair mar: thank you, supervisor haney. if i could just go back to my question, and yeah, i think we could all agree the goal is to prevent folks from getting to the point where involuntary conservatorship is necessary. so i just had a question about how permanent supportive housing fits into the engagement with folks that are on the path to have the conservatorship, you know, the 63 individuals that had the five or more 5150s. >> and chair mar, i appreciate the question. i'll just say we, of course, agree and recognize that housing can be an incredibly stabilizing factor for individuals and individuals who are struggling with both mental

issues and substance use. as that, the department of public health do not oversee the public housing options that exist. i can tell you a little bit about our work, and i would defer to h.s.h. to talk more about how they navigate that. so for individuals, when they are at emergency psychiatric services, they are technicians that help them complete entry if they're willing to do that if they have not already done so. we have access to shelter in place hotels for individuals that are eligible for that, and, of course, that eligibility changes. but the team is very well versed in that so they can offer that and support them in transitioning to a shelter in place hotel. we think it's incredibly important once they are there, to stay there, so we have a lot

of wraparound services that we offer them. i will highlight that, in addition to that, individuals are able to move to permanent supportive housing in this process, and that is a promise for them. and so we work very closely with the department of public health to ensure that happens. >> chair mar: thank you for that. and with the outpatient referral pilot, you said there were ten individuals that have been conserved through that pilot program so far, but most

of them, it sounded like, were housed, but then, the plan is to expand -- or the plan is to expand it to -- to -- to unhoused folks, so is there a similar -- or can you just describe how housing or offers of housing is a part of this program, as well? is it similar to how you're handling the housing conservatorship pilot? >> thank you, supervisor mar, for the question. we already have individuals who have access to housing to prevent them from reexperiencing homelessness to prevent a real crisis from happening and to stabilize them. we are in the process of

pivoting to serving individuals who are unhoused on the street, and the process would be the same as our l.p.s. we determine the most appropriate level of care, and our office does that in collaboration with behavioral health services and their input as well as the transitions -- the transitions department of department of public health, excuse me, and they have expertise in identifying the most appropriate level of care for individuals, and we do everything we can to have individuals in community-based settings, which might be boarding care, which might be a permanent supportive care unit, but some people will need more care. so we will work with transitions, and we are working also with h.s.h. in fact, my staff are meeting with h.s.h. right now around housing options for some of our

conserveatees. we have to demonstrate to the court what the care plan will be, and the court gets very involved in these decisions. they care very deeply about our conservatees have, and where they're living in the facilities. so anyone in a conservatorship will have housing at the most appropriate level for them. >> chair mar: great, thank you. just thanks again, miss alameda and miss nielsen for all of your work and the presentation and discussion this afternoon. supervisor stefani?

>> supervisor stefani: thank you, chair mar. just really briefly because i could have many questions around this, but i feel like we've covered this hearing so many times and this issue so many times. with regard to housing and the questions that were just being asked, i think it's really important to understand that addiction is a disease of isolation, and we're hearing about the care plans under conservatorship, but sometimes those care plans have to include more than just harm reduction. they have to include absence based recovery. i just want to refer everyone to the hearing that i had a month ago on february 11, that had recommendations from the recovery summit working group telling us what worked for

them. they had recommendations to the department of public health. include the voice of people in recovery making public policy around this. extend drug and alcohol treatment stays, create specialized drug treatment programs, and expand paid peer specialist opportunities. i think we cannot solve this problem when it gets down to the gravest of those that are suffering from alcoholism or alcoholism and drug addiction, mental health, we cannot solve this problem unless we are listening to the voices of addictions who have been through it, who have come out the other end, who are clean and sober and are in abstinence based programs. that's all i'm going to say. i've said it many times, but

i'm going to keep saying it, so thank you. >> chair mar: thank you, supervisor stefani. i think we can go to public comment right now. mr. clerk, are there callers on the line? >> clerk: thank you, mr. chair. we're working today with javier beretto from the department of technology who's coordinating our calls today. for those who have already connected, press star, three to enter the queue to enter public comment for this item. for those already in the queue, wait for the system to indicate your line has been unmuted. if you wish to speak on this item now, call in following the instructions streaming on your screen. call 415-554-0001.

press the following code: 187-486-1805, and pound twice to be connected to the meeting. >> i'm calling because i'm the parent of a 46-year-old male who is in voluntary intensive case management and has housing, but he's using this harm reduction. he is a serious alcoholic. he has been once on outpatient conservatorship, and he refused to take his medication, and they just dropped it.

he has had 100 5150s in the last year. i want to know how people housed with so many 5150s and housed in an inpatient unit is not under some sort of treatment because he's now out someplace, running around so drunk, that the police know him, bring him to the hospital, and it's just a merry-go-round, so this is a statement that some people need to be conserved even if they are not homeless. that's all i have to say. >> clerk: thank you very much, speaker, for sharing your comments. mr. beretto, could you please bring us the next caller. >> hello, supervisors. this is jessica lehman.

we talk about people being unable to care for themselves, and we need to remember that this is subjective. we need to offer people housing and voluntary services earlier rather than having people in crisis for years and then saying that they haven't made rational choices. for example, if somebody has a pet, and that's what keeps them going while living on the street, then maybe refusing a residential treatment program that requires them to give up their dog is actually rational. it is great that we have as many protections as we do. the people that have had multiple 5150s are disproportionately african american men, and the city needs to come up with a plan to address that racial disparity before moving down that path. the biggest issue is we just don't have the housing. we can't conserve people, and we can't meet their needs until we increase housing options. many people that get a 5150 and

go to emergency services don't get a coordinated entry, and if they do, getting a referral is not the same as getting housing, of course. we need to work with people directly affected to create solutions rather than pushing a traumatic experience on people because we don't know what else to do. thank you. >> clerk: thank you, director lehman, for your comments. mr. beretto, are there any further callers? >> operator: mr. clerk, there are no further callers at this moment. >> supervisor mar: thank you. public comment is now closed. yeah, thanks, everyone for this very informative hearing and discussion about new ways to serve the most severely impacted residents, you know, with mental health and substance abuse disorders. i think supervisor mandelman

indicated his desire to close this file today, so i would move that we file this hearing. please call roll, mr. clerk. >> clerk: on the motion that chair martha this matter be heard and filed now -- [roll call] >> clerk: mr. chair, there are three ayes. >> chair mar: okay. thank you. thanks again, everyone. mr. clerk, can you please call items 3 and 4 together? >> clerk: item 3 is a hearing requesting departments to report to determine how many households do not have internet service, which neighborhoods they reside in, and how many of these households have children under the age of 18 and are studented of the san francisco unified school district, and determine the racial and ethnic makeup of these households,

including how many are foreign born and non-english speakers and english learners. and item 4 is a resolution urging the adoption of certain sections in the october 2020 economic recovery task force report that recommend the city pursue economic justice, provide high quality computers to vulnerable populations, bridge the digital divide with affordable connectivity and internet service, and building technology capacity of news users, small businesses, and nonprofits, and seeking the department of technology to provider a literature review of the past 20 years of the city's efforts to close the digital divide and provide the board with a written estimate of the cost for the implementation of the three sections proposed for section. members of the public who wish to provide public comment, call

415-655-0001. enter meeting i.d. 187-486-1805. press pound, and pound again. press star, three to enter the queue, and wait for the system to indicate you have been unmuted to provide your comment. >> chair mar: thank you, mr. -- supervisor safai. the floor is yours. >> supervisor safai: thank you, chair mar. thank you, colleagues. appreciate the opportunity. before i get into that, i just want to thank supervisor stefani for her comments on abstinence. i know that's something we've

been working on. i think we need to continue to push that conversation and how we think about treatment and substance abuse in the city, so thank you for those strong comments. on this topic, the city has been trying to solve the digital divide for more than two decades. the internet revolution started 30 years ago, 20 years ago, and the city has yet to begin to really bridge that for our most vulnerable. there have been many attempts to solve this problem, but none of the solutions have had the desired impact that we as a city are seeking. some of our most successful efforts in closing the digital divide have come during this pandemic, ironically, and this resolution seeks to honor the commitments that all organizations, private sector employees, and companies have been doing to bridge the

digital divide. currently, one out of eight san franciscans do not have access to the internet. many do not have appropriate devices to access the internet, nor do these individuals have effective electronic literacy to use these devices to enhance their daily life, and this is a problem that's been underscored day in and day out. today's hearing is set to give an overview where we as a city are in the digital divide and where we're going. my office has been working closely with the department of digital technology, and we appreciate the work that they've been doing over the years and the mayor's office of housing and community development in talking to our many providers, community organizations, and advocates. while the digital divide will not be solved today, i hope that today's presentation creates the start of a conversation of a blueprint on

how we can begin to solve this problem. this hearing will not be the last one, and we will continue this conversation. however, the results that we're hearing from this divide will help craft pertinent legislation that will help put us on track to closing the digital divide. while i know there's not one magical solution to this problem, which office is aware that the world is accessing digital information in the world through their smart phones. i've heard how 5-g technology could improve technology.

[inaudible] >> thank you so much, supervisor safai, and chairman mar for calling this hearing. my name is rudy reyes. in addition to being the west

region vice president and associate general council for verizon, i'm a long time 20 year resident and citizen of san francisco, and i live in forest hill west portal area with my husband and fourth grade son. so this issue of digital equity and inclusion calls for urgent action both by industry but also by all levels of government, federal, state, and local. if you could go to the next slide, christine. at verizon, we've made digital equity one of our top priorities. it's absolutely essential to this success of our community,

our city, our state, and our country. in short, we're all in this together. the digital divide has been studied for 20 years, and we need to address it on three pillars. we need to increase broad band affordability, we need to address broad band adoption, and we need to address broad band access. greater access to broad band, more competition, more choices, fosters greater accountability, adoption, etc. and supervisors, time is absolutely of the essence.

countless things that would formerly take place in our community or our schools are now taking place in our homes. we have the opportunity to deploy 5-g citywide including in digital equity zones, and we have shared that plan with the city. we've been talking with the city for two years. if we could overcome the local challenges, which i'll discuss in a moment, our plan is to deploy citywide, and that includes, supervisor safai, in ingleside terraces, but also in ingleside. that means not only in forest hill, where i have the privilege to living, but also in portola. not only in russian hill, but also in the outer mission and in the crocker-amazon. not only in the pacific heights and chinatown, but all the way down the third street corridor to the bayview and hunters

point and beyond. and we're not seeking any subsidy from the city or the government for this bill. this is all provide capital investment, and we will cover 100% of the city's reasonable and actual costs. so -- next slide, please, christine -- although 5-g has countless applications for big business, big enterprise, and consumers of all stripes, perhaps the most impactful and immediate and tangible solutions for our city is that 5-g will enable fixed wireless access for the home and small business. those markets are ripe for competition, particularly now as so many people are working and schooling from home during this extended pandemic. consumer demand is very, very

high. we've never seen it higher for reliable high speed broadband access in homes and small businesses. so fixed solutions like 5-g home are a game changer. it solves what we've been talking about in kmupgss for a generation, the last mile for deploying