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 work and works well. There is data there on the programs we have. Finally, theres a lot of things here that we know, so i would say putting together a Behavioral Health task force would be a great way to be able to dig into these ideas, get the best thinking on the table and really, then, to start to look at mechanisms and ways to pilot these service. Many providers, some of whom are in the room, have targeted or have piloted these services with success. We have successful models in place. We need for resources to actualize them further. Thank you. Thank you. So next up, our final presentation from dr. Fu dr. Fumi nitsuwishi from Case Management. Thank you for the opportunity to talk about citywide and to participate in this. Im a psychiatrist and the executive director of citywade Case Management. We are part of ucsf and ucsfg. So i think i would lic like to t with thre three questions. Every door is the right door. But who needs the most help in getting to the door . What are the doors and how does an agency like citywide help unlocking these doors . What are the challenges and opportunities. So let me start with telling you about citywade. Citywide. Weve been around since 1980, and under the department of psychiatry since 1985. We rate based on contracts, mostly from dphbhs. We have locations. The main on six and mission. The most help knocking on the doors . I think folks ha are duly diagnosed, ha have substance disorder are the folks who need the most help. We need people with severe quadruple diagnosis. I totally made this up. Weve experienced severe mental challenges, talking about legal challenges, food insecurity, about housing insecurity and folks who experience social injustice in a big way. And also, i want to say folks who experience trauma. And i dont mean ptsd. Im talking about traumatized relationships with our system of care. Im talking about folks ha have a very, very hard time coming tg and knocking on the right language and getting in. Those are the folks who need the most help. So how does citywide or an agency like this go about helping these folks . We have intensive clinical Case Management. Its a long name. How do i define icm . So what is icm . We are trained clinicians who are case managers, psychiatrists, nurses, employment specialists, peer specialists who work as a Team Together and were highly mobile. please stand by . Number one, what we do is engage clients. What that means is that we ask the question of what do you want rather than why dont you do something that we think you need. Number two, we help them enter Substance Abuse disorder treatment, which means sometime we need to do advocacy work to make sure our clients who may have been banned from treatment because of prior behavior, this is reality, too, to make sure she can have a second chance. We help them stay in treatment, which for some folks it means we help them accept medication long acting injectables to make sure that, you know, if they are feeling paranoid they dont leave the program because they are scared of the setting. We also help think about transition. Getting out of treatment is a big deal. Any transition could be potentially traumatic and difficult. We want to usher then. Our folks tend to go in and out. They relapse and reenter the system of care. What we do at city wide is hold them throughout it. We are their family and their constant. I am actually going to skip a few slides to show you something because i think this is really i was not going to cover this, but i think it is probably helpful because we have been talking a lot about this. What is the treatment that has to happen before the treatment . That is the treatment that we call pretreatment. This is the treatment of folks not quite yet ready to enter treatment, and yet it appears they are in distress, their homelessness seems distressing, and so i think and that is where we bring in pretreatment. That is heavy on outreach, heavy on Crisis Management and Harm Reduction. It is about engaging the client, whatever it takings. It is about being where they are. Unfortunately, as you can tell, pretreatment does not cannot be reim percented by medical. That is what we need to think about. Let me go back to my slides about the challenges and opportunities. There are a lot of challenges and opportunities. Number one, engagement. When you use medical billing with documentation requirements and intakes and forms and so on, and put it together with working with superacute clients, very difficult. What i would argue for are other form of reimbursements that are less restrictive and reduced caseloads. It takes reduced caseloads to really do the work. To the bottom, the issue of accessing services for justice involved population is a topic of its own as supervisor mandelman pointed out. In terms what would it look like if icm were extended to everybody who needed treatment . That is a big topic that is entire system is working on. I think, number one, we dont have enough icm slots. We need more slots with a flow that works. One of the Simple Solutions is to actually integrate the icm so they contain an Outpatient Clinic within it to transfer clients within the clinic is easier. Clients have Agency Relationship which is hard to transfer to a new agency. I think that would be something, and, as a matter of fact, not a lot of icns have those foughts. Safety is a big deal. As a matter of fact it is really linked to retension as well. Retention as well. To think about improving the system we need to go toward the quadruple aim to think about client outcomes, what happens to clients. We also need to think about experience, how is it that the setting of the clinical sets is welcoming to them and so on. We need to think about resources. We also definitely need to think about our providers. Thank you. Supervisor mandelman thank you. Colleagues, any questions . I will have you come back for a second. There is a fair amount of talk about well, beginning of the conversation about these 4,000 folks who were identified as priorities, folks who are homeless and have serious Mental Illnesses and 95 have alcohol use and many have Substance Abuse disorder and something in the high 30 are users of the systems, low 40 , in that range. I think we dont do we know how many of those have a case manager . This might be a question for dph . I dont think we have that answer . Supervisor mandelman if you have 1200 and there are 4,000 we know we are far short of providing Case Management even for the folks who we would prioritize in an ideal system. Right. I think you may know about this, but i want to make sure that can you put the screen up . Within citywide we have a range of services, some teams are more mobile, have smaller caseloads, general funded and mhsa funded. Their ability to address the high priority is different from the 251 caseload. I dont think we know how many of those folks are case managed, some are. Supervisor mandelman priorit even all of th