Good morning. The meeting will come to order. Welcome to the july 28, 2023 homelessness and Behavioral Health select committee. Im supervisor ronen chair of the committee joined by vice chair mandelman and supervize sor when your item of interest comes up and Public Comment is called, those in person should line up to speak and those on the telephone dial star 3 to be added to the queue. If you are on the telephone, please remember to turn down your tv and listening devices you may be using. When your item of income comes upyou may submit Public Comment in writing in either of the two following ways. Myself the homelessness and behavioral select clerk at stephanie. Cabrera sfgov. Org. You may send your comments via u. S. Postal service to our office in city hall at 1 dr. Carlton b goodlett place room 244 San Francisco california 94102. Finally, items acted upon today are expected to appear on the board of supervisors agenda of september 5, unless otherwise stated. Thank you so much. Can you please read item 1 . Item 1. Hearing on department of Public Healths Behavioral HealthServices Case management system; specifically examining how many Behavioral Health and Substance Use case managers are in the system, their work location, the process for providing Case Management at varying levels of need, frequency of case managers interacting with their clients, the caseload of case managers at every level of care, and the number of funded but vacant case manager positions exist in the entire system of care; and requesting department of Public Healths Behavioral Health services to report. For those remotely , if you havent done so dial star three to be added to the queue. Please wait for the system indicate you have been unmuted and you may begin your comments. Thank you so much. As the person who called the hearing, i wanted to make a few remarksopening remarks before i turn it over to the director of managed care at dph. When i wrote Mental Health sf about four years ago, i knew that it was redesigning our entire Behavioral Health system, and that implementing it was going to be a major challenge,b a major effort and it would take some time to do so. At the time, we didnt realize that a worldwide pandemic would hit us and completely divert the attention of dph for over a year to keeping us as safe as possible from that pandemic and so, aswe lost a good year of implementation. I do want to say, i believe that we are moving in the right direction and that dph is committed to redesigning our Behavioral Health system so that it flows as well as it possibly can amidst a privatize Healthcare System that is broken, a public system that is underfunded and a National Situation that is absolutely broken in every way shape and form. Still, we are working to become the best Behavioral Health system of care in the country and we are well on the way. Case managers are sort of at the center of the system because when someone is suffering from Mental Illness or Substance Use disorder, it is very difficult to keep appointments, to find and do all the paperwork to enroll in programs, to find housing, et cetera, et cetera, et cetera and the case manager sits at the middle of all the different Behavioral Healthcare as well as efforts to obtain housing. They often dont happen unless there is a case manager involved. Case management is extremely hard work. We have a workforce crisis in San Francisco but across the state and across the contry because the work is extremely exemtremely difficult and it is i think underpaid especially given so difficult it is. Looking forward to hearing from department of Public Health of the state of the Case Management system in San Francisco, whats going well, whats challenging, but i also received an email this morning from two licensed clinical social workers who i believe work at General Hospital that i wanted to read, because i think its very telling about how challenging the job of a case manager is, and how it becomes more challenging when the other parts of the system are not working as they should, or in the best way possible. This is just the beginning of a series of hearings about the implementation of Mental Health sf, because Case Management is so critical to a functional system, i wanted to call this out separately so that we could really focus on the issue today, but again, it is one part of the system that all has to Work Together so that we can really really see a difference for the people suffering from these terrible illnesses and so we can see the difference of a high functioning system on the streets. So, im just going to read this email very quickly. It says, dear clerk stephanie cabrera, thank you for forwarding it. We would like to submit the Public Comment for Behavioral HealthCommittee Meeting tomorrow july 28. Behavioral case managers carry a case load of the city most challenging residents working with clients who have pervasive Mental Illness often coupled with Substance Use. The work they do is exceptional. They are work against a broken system. No access to 24 hour shelter beds, no access to same day treatment, limited access to 24 hour Crisis Centers and notner acute inpatient psych bets in the city. We interface with Behavioral Healthcare managers when the clients come through the ed. More often then not, due to challenges mentioned above, we are left with the only option to send the client right back out into the same situation. Clinicians under paid over work recollect under trained and left to fight a uphill battle. The city needs to do better. We need to invest in resources most dedicated to helping those in need. Mejo indiscernible and indiscernible i want to thank them so much their testimony. I think they said it perfectly, and i know that dph, not only agrees, but is spending all their time trying to improve and perfect all those services at the same time while being underresourced so this is very challenging what we are all doing. I want the public to know that this board of supervisors certainly this supervisor is dedicated to working hand in hand with dph to address this, because we just cannot see a dif ference in our streets until we create a system that works smoothly. With that, i am going to call indiscernible department of Public Health and thanks so much for being here with us today. Good morning chair ronen, good morning supervisors mandelman and walton. Today im here to present on Behavioral HealthCase Management system. Today just looking at the agenda, would address what is Case Management, the current state and looking forward. What is Case Management . It is a stand alone or in conjunction with intensive outletpaig treatment program, person specific and vary in intensity, length and location of where services are provided. Below are functions within the Case Management systems, which include care coordination, referral, medication support, benefit enrollment, professional support and housing support. We have three different types of Case Management that range from low to high intensity. Ill begin by describing low intensity Case Management. These are based out of various Mental Health and Substance UseOutpatient Clinics and serve indiscernible do not require high intensity Case Management and are doing well in their recovery but might need to see Case Management once or twice a month. The second level of case man agement is intensive Case Management. For example, you can find this level of Case Management at our intensive outpatient treatment programs. These are services are indiscernible risk of severe negative outcomes, for example at risk of incarceration. Many of them had many crisis episodes in the past of multiple indiscernible the most intense level of Case Management is the stabilization Case Management and one of our programs within dhs that provides the service is office of coordinated care. It is also field base and targets people that made Immediate Intervention of support, otherwise they destabilize the indiscernible so, this slide right here is showing what it takes, what is required to really have an effective Case Management intervention for those that require the need. This is strength and collaboration of coordination between many city agencies. It requires case conferencing between our partners, our indiscernible as well as our city Agency Partners. Having a account record where in real time we can see where clients have been seen, their current disposition and what kind of intervention would beImmediate Intervention would help support their recovery. Also, with other city agencies and partners we identify shared priority clients because many of these individuals are homeless and hard to reach so it is important to really Exchange Information with other city agencies in case they come in contact with these individuals and have idea how best to provide support to these individuals. We have a street base team that provide Case Management in partnership with all the street based teams across city and county of San Francisco, we have ongoing meetings to address the every day challenges and our best to address those challenges. On a daily we receive a file log from the Street Crisis Response Team and office of care coordination what they do is review the log to see which of the contacts made be scrt require a followup. And also, we need a indiscernible clinicians, Health Workers that help with this outreach and engagement and really helping clients get into care. So, what is our current state of the Case Management system . Currently our budgeted fte is around 221. Our vacacy rate is 28 percent, which represents about 63 fte and we serve close to 4,000 individuals. I just want to give a note that these numbers represent our intensive Case Management program, which is a second level and our linkage of stabilization program, which is the most intense program. So, the case manager client ratio for clients that have low intensity needs, case managers hold cases up to 50, so ratio of 1 to 50 and for individuals with intenseival needs, case manager ratio is 1 to 17, and for those that are most intense level of Case Management, the case load is 1 to 12. The frequency in which case managers try to interact with their clites, those with high needs is one to 4 times a week. Those with low needs, average of monthly or biweekly so once or twice a month. Here is a graphic showing where case managers are located. I like to emphasize most of our case managers meet clients where they are. However, we do recognize it is important for these individuals to know that they are programs within the community to become familiar with them and access them when needed. To emphasize, most of the case activities happen where we meet clients are they are at. Just to give a little statistics, 5 percent of case managers are located in indiscernible and 45 percent of case managers located at cbo. That is Community Based organizations. However, if you drill down for those population, most of the case manager programs within Community Base organizations. And chair ronen, you alluded to the method of San Francisco legislation and what that afforded us to do is create this office of coordinated care that never existed. As you also mentioned, this legislation was approved in december of 2019 , but due to the pandemic there was delay in implementation so this program is two years old and we never had this level of support, so this is a added support for the department to meet the needs of our clients. So, with the expansion we have been able to add around 45 fte to the office of coordinated care, and add an additional 13 fte to existing Behavioral Health programs. Just to give a little description of what within the office of coordinated care, we have our central triage Care Management which focus on individuals released from jail or discharged from hospital. The neighborhood base care that provide Case Management and outreach and engagement and that program is our best neighborhoods program. We also have a shelter and Permanent Supportive Housing Program and our Behavioral HealthAccess Program which is centralized Access Points for Behavioral Health services. When is Case Management offered . So, i just referred to the Access Program. Within the behavioral Access Program we have a behavioral access line, a 24 7 call center and we also have a Behavioral Access Center which is open during the day and weekday where we you can seek services. Depending how a client is presenting, high acuity indiscernible they refer to office of coordinated care. If the client that presents with moderate symptoms then they refer to treatment and case manageagement services. For Priority Service populations, indiscernible street teams and also we do follow with individuals that have been placed on 5150 and released, those referrals go directly to office of coordinated care. The office of coordinated care, they provide the most intense level of Case Management. For our indiscernible youth and family indiscernible those are referred directly to treatment and Case Management programs because the system of care they have a program called intensive care coordination where Case Management is of high intensity already. This individual had a long history of complex trauma and homelessness. The approach is this individual was linked to the bridge and Engagement Service team, which is part of office coordinated care providing the most intensive Case Management services and through advocacy and engagement this individual was placed in a shelter and connected to intensive Case Management program. The outcome through ongoing continued relationship and this person being stabilized, the client was placed in longterm housing. Another Case Scenario for client b, this individual frequently in crisis, difficult to locate by providers in the community, our best neighborhood which is our street based Case Management team supported the clients with frequent outreach and assessments which lead to multiple hospital visits. Ultimately this individual was connected to our stabilization program, which is our highest most intensive level of Case Management and placed in a shortterm shelter. The outcome, the stabilization Case ManagementProgram Consumer outreach and one outcome is all 911 calls have been eliminated. For the client c, this individual struggles with bipoller disorder with meth use. There are multiple Street Crisis Response Team calls. The street base team, best neighborhood conducted outreach leading to this individual being placed in the single r