You mentioned the fact that there are times when you cant address the need right away and part of the waiting time is because you cant draw down the reimbursement dollars. Uhhuh. I know i was looking at the slide in what areas of need, but it seems like when you cant help some participants, its due to cost reimbursement and not necessarily due to capacity. So would you say a gap funding or some way to eliminate their wait time to able to help a patient right away is important for addressing the need immediately . Yes. I mean, i think in general, we have come to understand the managed care system that is drug medical, and you think the county has been a learning process. We know that somebody will be eligible. We would like to put them in a bed and we will work out the funding after the fact. And yeah one think that would be helpful. Thank you. I dont want to oversell it. There are times when there are other barriers. Like, if a person has a Health Condition thats not been taken care of, that puts them at risk, so we might need to have them seen to get medication if they have diabetes and dont have any medication, we need to make sure they get their medication for diabetes. Anything resulting in an Emergent Health issue, we have to take care of that before we put them in a residential bed and were obligated under licensing to do that and sometimes that is the issue. But absent medical or severe psychiatric crisis, absent that, we should able to put somebody in a bed. Thank you. Up next we have scott arye from positive Resource Center programs. You believe your presentation is already on the computer . And then to update folkses on where we are, these are very fruitful conversations but were spending longer than i had anticipate. We still have positive Resource Center, stonecall project and citywide and then public comment. And this is baker place, continucontinued program servic. Im dr. Scott arye, currently working as a director of Mental Health system. I think i want to begin with a quick history on baker places and pmc. C. Baker place was a nonprofit in the 1960. People were trying to get well and getting off of drugs and alcohol without using the system or going into the department of Public Health. What happened is that they began purchasing units around San Francisco and using each as their support system. They have been doing this all along since the 1960s and the reason think im pointing this out, its part of the adaptability and the agility of what baker place has brought. 2016, positive Resource Center, baker places came together under one roof and we merge. Baker place is a wholly owned subsidiary of prc and were located on 179th street, brand new offices over there. So part of what you wanted to start with is our continuum of care. As were addressing the treatment on demand and think about what does it mean and what is the definition of it. At baker places, we have a wide range of services and to me, this is a part of how we are addressing, making sure that people were not turning anybody away. So in our acute services and Residential Programs, you might be aware of the hummingbird space, a 29bed psychiatric respite. Ill be touching about this more later. As it pertains to this hearing, we have a joe healy detoxification and its located in hayes valley. We recently kicked off they just started the drug medical in march of this year and so we are in the midst of going through the growing pains of instituting a brand new system and a brand new way of doing things at the detox. Last but not least on the bottom, theres grove street house. This is a ninebed crisis stabilization unit. This particular perfor program n the Mental Health side of the system and a lot of people were addressing the ko cooccurring disorder piece. As a clinical psychologist walking into this, this is one of the first things you notice in the system of care, is the separation between the Mental Health and the Substance Use disorder sides. I think this is a part of how prc baker places is addressing, how do we make sure people are getting to the right place . More often than not, i believe ththe statistics are thrown arod 90 also, they have coexist tentt orders. Is it your Mental Health causing the Substance Use or the Substance Use causing the Mental Health . Its getting out of the dynamic of which came first, the chicken or the egg. Its presenting a new paradigm of how do we address this . This is through the cooccurring disorder sort of motto. In our Substance Use disorder concontinuum, we have two programs. Substances are providing with sensitivity to the population served. Theres a Substance Use disorder diagnosis. Ferguson place is hiv place diagnosis and part of the things were doing well are target populations and providing Residential Services to specific populations. This is sort of the antithesis of treatment on demand. A woman cannot walk up and say can i have your services. This is men designed for men who have sex with men. And somewhere in there is huh, maybe not every place should be treatment on demand and theres the cultural competency involved generating healing in these facilities thats different than one size fits all. Moving on again are the Mental Health programs, prc has programmes anmentalhealth progr. Baker street program, you have to have a Mental Health issue. You may be using substances, but specifically its a Mental Health only. San jose place and Robertson Place have been categorized and dual diagnosis. This is important because these are the programs that allow us to work back and forth with 360. This is a big need is the longterm programs, a step down and where are people going to. At prc baker places, we have three different types of programs. The first is the assisted Living Program and this is Mental Health driven. You have to have a Mental Health diagnosis but doesnt many you dont have Substance Use. Many are doing the same thing, many are cooccurring disorders. We have our baker supported living disorder. This is another set of coop units and 34 clients are living with positive diagnosis and a Substance Abuse diagnosis and Mental Health diagnosis. These are the hoops to jump through. How do we get to where the open beds are . So, for example, what was happening in the Residential Programs, people would relapse and go out and use drugs or alcohol. One of the options at that point is to say, we might have to discharge you. The olden days, in the past, has been, well have to discharge you and here is a list of shelter, the emergency room and if you have trouble, please call these numbers, thank you very much. Im bringing up hummingbird because this has been a great resource for these types of incidents so that we dont lose people. It is a psychiatric respite where we can help people go, excuse themselves from the residential treatment for a little bit and get some respite and come back in. It doesnt require a new intake or a new system that happens. The hummingbird pe respite provs a soft, quiet space. We talked how people are lost going from p her here to there d this is where hummingbird picks up clients having difficulty navigating the system. Because were connected to them, we have to say because youre ready to for treatment, well connect with you. Its taking it upon ourselves to try to figure it what we do. One of the things weve been doing is working with Progress Foundation, another Residential Program and we have a weekly meeting called flow meeting and we go over all of the beds we have. We go over all of the referrals, who will be discharging from pes into the adus, from the adus and what treatment beds are available . So we talk and see whats going on here. That meeting is used for a back and forth of Progress Foundation may have someone who relapsed on drugs and alcohol. They might be men who have sex with men. We can let them though, give us that referral, well contact acceptance place and get them over there. It really is an interesting meeting that happens in the community. This is one of the strengths or successes, is that these relationships that happen outside of dph, that our agency is creating, i think its a big piece to helping us out. So when you were asking, what is it that we need, is that support to help build that . Lets see here, and barriers. What are we having difficult yeahs with . Ill mention two of them and theyve been mentioned, i want to say add newsum add ad naseum. Well be fighting over it with Progress Foundations. But what happens next . The staffing issue is the other one. We mentioned about the he high turnover, vicarious trauma, the low cost of living in sanfrancisco. When we last looked at it, 90 of staff in our agency lives outside of the city. And its really difficult to address that. When it is, our direct services is paying 21, which is 6 above minimum wage but its not enough. Thats a 45,000 a year job and it doesnt compute at this point in time. So it is something we are running into, is the staffing issue. And i think the other part thats related to the staffing issue and it goes in with the whole drug medical, is when we opted in for the drug medical, we are changing our assessment systems. Youre familiar with the american sit o society of addicn medicine . Previously were using different assessment tools to establish medical necessity. Drug medical says youre using this asam theory and model and this requires training of how to redo this and rethink an assessment. Part of this process is an authorization that needs to be required every 30 days by a licensed professional heeling arts, a license thed clinician. We would have to hire more licensed people. It turns into, where does that come out of the budget and fit into it . Trials and tribulations and getting going with the drug medical, it will be great but at the moment, we have a whole training force. Again, we just started in march, but it is going through and going mandatory Training Need to happen and looking at if its fitting what the state would like. So somewhere in there is the staffing issue related to the drug medical and the effects of the new system put on to the system. And i think thats all i have to say. Thank you, doctor. Next up we have mike decepalo, senior director of service and the stonewall project of the aids foundation. Thank you for having me. Im inspired by the response ans and challenges. Im the senior director of Behavioral Health services for the senior aids foundation and i oversee the patient Substance Use program and i oversee the syringe Access Service and other low Threshold Services. To a large degree, i can go off of a lot of what vica is saying, because my role as a professional is to act from the perspective of our program has been developed as a safety net type service. Soma project was founded in 1997, one effort first finished by the National Treatment on demand process. At that point, it was a Methamphetamine Program for gay, bi and transmen and also looking at methamphetamine for transmission. So part of our services at the aids foundation and stonewall, in particular, are to look at the intersection of Substance Use and sexual health, hiv infection and transmission and to look at acv and other disease processes, as well. I think its important to look at, in what ways, for example, is stonewall as an outpatient Treatment Facility different than other facilities . I would say that, with know, the philosophy of stonewall is Harm Reduction, the philosophy that the city and county has had for two decades now. I think the way we apply Harm Reduction is different than applied by a lot of other organizations. And i think primarily, the philosophy of care at stonewall, if our participants are not successful, we are not successful. So when people bail out of care or are unable to Access Services or unable go to our services, then we look at in what with are we failing or not meeting where they are . What happens, our programs are expanded broadly and for example, we have 27 groups, approximately, a week, for our outpatient Substance Abuse program and half of those groups are available to people on a walkin basis. Meaning they dont have to enroll in the program or answer any those nosey questions and tn come in and feel an accepted for who they are and we can develop a relationship, that the kernel of the round is love and compassion. And from that place of developing that relationship, we can decide together in what ways we might be able to be helpful to them. For some of those people, they decide to enroll in the Outpatient Treatment Program and when someone enrolls, its generally 16 to 1 month 18 montd its a big commitment of resources. So we appreciate the funding to offer that service. But there are many mean dont relate to treatment in that way. They may not be ready for treatment and some people come into our low threshold or easy Access Services and to define those things, because weve been talking about low Threshold Services, maybe theres massage or acupuncture or book club where theres lots of food and refreshments where we read a paragraph and people talk that paragraph means to them. It could be Harm Reduction and how to take better care of yourself. So what happens, folks make improvements in their life. We have conversations about them about minute details, including how much they may be loading in their rig if theyre loading methamphetamine, for example. There are very few providers in our system of care willing to have those conversations. There are also very few places where people who are not willing or able to get to treatment or dont want treatment can have those conversation. When we talk about low Threshold Services and the need to have places to go to feel safe, precisely these moments make critical changes for people at the interchanges having problems with and folks on the streets that are homeless, marginally housed, et cetera. So i think we talking earlier about Behavioral Health work group and a im excited about ts and i would like to participate and i think we should do it. In terms of systemic gaps or barriers, we need dropin centers, Overdose Prevention centers, more street outreach and low Threshold Services. People were talking earlier about the issues of medical and i wont get into the details about that. Those are in my slides, but it doesnt cover limitations. So this is not a low threshold, so the reason were able to offer the low Barrier Services is because we have city funding through Behavioral Health service, city funding through Community Health equity or promotion or former hiv prevention and own resource. The funding through hiv and unreinstructed fundraising that the organization does allows us to offer what we call the love. The love is throw Threshold Services we cant get them to pay for. There are exceptions to that. So we need ways to be able to have the will to be able to fund some of the services or look at innovative ways for those types of services one of the things happens, well integrating the behaviour center with the Harm Reduction center and its one facility where we offer syringe access. So there ought o all of this, fn get clean syringe and access and thats an important thing to offer. But the opportunity it allows us is expanding beyond gay, bi and trans men and well allow a prop for all for all participants in october. We need more resource, basically. When were asking the question about, do they have enough money for the beds for everyone who wants access to care . We do not have enough money for the folks who come in for services. We have a wait list for folks who want to access a councillor and they can walk no one on one immediately and access groups immediately but what they can not access is a councillor. There are times where there is a onemonth to threemonth wait list and there have been times its up to six months for the service. We need more money to have more treatment on demand. Its just not funded at this point in time. I know my time is out, so i will continue to move it fast. Thank you. Sorry about that. So what works is Harm Reduction. I think from a Harm Reduction perspective, multiple tracks, accepting people to continue to use called Substance Use management and people who want to stop using one but want to use targeted abstinence. That wor