Good morning, everyone.

This meeting will come to order.

Welcome to the regular meeting of the Public Safety and Neighborhood Services Committee of the San Francisco Board of Supervisors for Thursday, October 9th, 2025.

I'm Supervisor Matt Dorsey, Chair of this committee.

I'm joined today by Vice Chair Balal Makmood and Supervisor Danny Sauter.

Our always capable clerk today is Ms.

Monique Creighton, whom we thank for staffing us today.

And together we'd like to express our appreciation to Jaimea Shaveri and the entire team at SFGov TV for facilitating and broadcasting today's meeting.

Madam Clerk, do we have any announcements?

Yes, please make sure to silence all cell phones and electronic devices documents to be included as part of the file.

Should be submitted to the clerk.

Public comment will be taken on each item on this agenda.

When your item of interest comes up and public comment is called, please line up to speak on your right.

Alternatively, you may submit public comment in writing either of the following ways.

First, you may email them to myself, the Public Safety and Neighborhood Services Committee Clerk at M O N IQ E dot C R A Y T O N at S F G O V dot O R G.

Or you may send your written comments via U.S.

Postal Service to our office in City Hall.

Number one, Dr.

Carlton B.

Goodlick Place, Room 244, San Francisco, California 94102.

If you submit public comment in writing, it will be forwarded to the supervisors and also included as part of the official file on which you are commenting.

Finally, items acted upon today are expected to appear on the Board of Supervisors Agenda of October 21st, 2025, unless otherwise stated.

Thank you, Madam Clerk.

Will you please call the first item?

Yes, uh, the first item is a resolution accepting the report of the city administrator and adding the Department of Homelessness to Support of Housing, the Controller's Office, and Data SF to the previous designation that included the Department of Public Health, Fire Department, Health Service System, City Attorney, Treasurer, Tax Collector, and Department of Technology as health care components under the Health Insurance Portability and Accountability Act of 1996, HIPAA Persuant Administrative Code Chapter 22H.

Thank you, Madam Clerk.

This item was introduced by the Office of the City Administrator and Vivian Ho, the director of central office and engagement is here to present.

Thank you.

Good morning, Chair Dorsey, Supervisor Mahmood, and Supervisor Softer.

Thank you for having me today.

And my name is Vivian Poe.

I serve as the Director of Central Office and Engagement in the City Administrator's Office.

For this item in front of you, I took on the role of project manager, working very closely with our legislative team and the city attorney's office to prepare the report and the resolution.

Well, the purpose of this project is to identify city agencies that are subject to HIPAA data protections.

Before I begin, I want to acknowledge my project partner, Deputy City Attorney.

He'll be here soon, Arnouval Medina.

He's our HIPAA expert in the project and also representatives from departments who are subject to HIPAA data protections.

They are available for questions after my presentation.

So very quickly, our first slide here is a high-level summary of our project.

But for your background, in 2020, the city passed an ordinance creating Chapter 22H in our admin code, which designates San Francisco as a HIPAA hybrid entity.

That simply means that our city performs many, many different functions, and only some of them would fall under HIPAA.

So HIPAA regulations apply only to those with specific functions.

And because of this destination, our office is required to take a look of the functions performed by city departments every three years in order to identify those that are subject to HIPAA, which are called health care components.

In 2021, our office, the city administrator's office, issued our first report and resolution.

At that time, we identified six departments, including the Department of Public Health, the Fire Department, Health Service System, City Attorney's Office, the Treasurer and Text Collector's Office, and the Department of Technology as health care components.

Fast forward to today.

We have recently completed our second three-year report.

In this report, we added three more departments: the controller's office, the Department of Homelessness and Support of Housing, and Data SF.

And we have submitted the report and the resolution for the Board of Supervisors to accept the report and to designate it, those we just mentioned in the report as HIPAA healthcare components.

Next slide, please.

I'll move quickly very quickly on this slide because I just want to mention that healthcare components come in two categories.

Cover entity and business associate.

As you will see these terms repeating themselves in the report and the resolution.

Cover entities include health care comp uh health care providers and health plans that transmit protective health information.

In our case, those would be DPH, FIRE, HSS, as we mentioned.

Business Associates, on the other hand, perform functions for a cover entity that involve the use or disclosure of health information.

For us, those includes the city attorney, TTX, DT, and the three new departments that we just mentioned.

Next slide, please.

To give you a sense on how we put together this new report, we use two main paths.

Well, first, we reconnect it with the six departments designated back into 2021.

Through a very brief questionnaire, we confirmed with them that they still function as cover entities and business associates.

NICs, we decided a new online survey and invited departments we believe might handle protected health information to fill it out.

After looking at their survey responses, we had multiple follow-up discussions and meetings with four agencies, and ultimately determined that three of them actually meet the HIPAA definition of a business associate.

And those are the ones we added to this year's report.

And again, they are the controller's office, department of homelessness, and data SF.

And to designate all nine departments as health care components, including the six existing and three new agencies.

Well, that concludes my presentation, and I'm happy to answer any questions you may have.

Thank you, Ms.

Ho.

I don't have any questions, and I don't see anyone on the roster with um with questions or comments.

So Madam Clerk, why don't we uh open this up to public comment and thank you so much for your presentation and work on this?

Yes, members of the public who wish to speak on this item should line them now along the side by the windows.

All speakers will have two minutes.

It appears we have no public comment.

Thank you, Madam Clerk.

Public comment on this item is now closed.

And I would like to now make a motion to send this item to the full board of supervisors with our positive recommendation.

Yes, and on that motion to forward this item to the full board with a positive recommendation.

Umder.

Member Soder Aye, Vice Chair Mahmood, Vice Chairman Mood I, Chair Dorsey, Chair Dorsey, I have three ayes.

Thank you, madam clerk.

Item number one passes.

Madam Clerk, can you please call item number two?

Yes, item number two is a hearing on the treatment on demand annual report for fiscal year 2023-2024.

Thank you, Madam Clerk.

I'd like to welcome Board President Raphael Mandelman to the Public Safety and Neighborhood Services Committee.

This hearing was convened at his request, and before turning it over to him, I want to take a moment to acknowledge and thank him for his long-standing leadership on San Francisco's behavioral health challenges, particularly as it pertains to drug policy.

Earlier this year, the committee, this committee held a hearing on overdose prevention policies and how we might incorporate the recovery first ordinance and some recovery policies into that.

I think what we're working toward is a unified drug policy report that helps to educate unify everybody, but also educate us as policymakers.

Um I consider this hearing in many ways the part two of that, what we started earlier this year.

Um I'm grateful that we're continuing this conversation today.

Uh we have several presenters joining us from city various city departments and community-based organizations.

I want to thank everyone for being here, and I look forward to hearing their perspective and their recommendations.

And with that, President Mendelman, the floor is yours.

Thank you, Chair Dorsey, and thank you, committee members.

Um, I usually uh play the role of backseat driver or backup dancer to uh Supervisor Dorsey on many of the behavioral health and substance use issues that we think about at the Board of Supervisors.

Um I did get interested in treatment on demand uh pretty much uh from the start of my time on the board, and I continue to um be interested in in focusing attention on it and the report.

Um we have some, they're not new supervisors anymore, but they're um, you know, folks who may not have been part of this conversation before, and so I do think it is worth um going over the history a bit.

So it was way back in 1996, almost 30 years ago, that the Board of Supervisors uh passed a resolution uh providing for substance use treatment on demand.

And at the time, the Department of Public Health estimated that only 12,000 of the 45,000 people in the city who they thought needed substance use disorder treatment were receiving it, and that resolution committed to increasing funding for substance use treatment until capacity met demand, and uh sure enough, between 1996 and 2000 treatment funding increased.

Nonetheless, I think there was certainly a feeling among providers and in the advocacy community that San Francisco was not meeting uh the obligation that had been set forth by resolution.

And so in 2008, Supervisors Daily, McGoldric, Mirkarimi, and Peskin uh put proposition T on the ballot, and voters passed it with 61% support.

Um, and uh among other things, Prop T amended the city administrative code to state that the Department of Public Health must provide free or low-cost substance abuse treatment programs at a level sufficient to meet demand in San Francisco, and the um ballot measure required the Department of Public Health to prepare a report to the Board of Supervisors by February 1st of each year to um estimate the demand for substance uh substance abuse services in the prior year and identify gaps and outline um uh the budgetary needs that would be um involved in closing that gap.

The idea was that that February report was supposed to inform the mayor and board of supervisors' deliberations and that the city would achieve treatment on demand through that.

Um when I, after I was elected, uh folks from the treatment on demand coalition reached out to me and also to then uh supervisor now assembly member Stephanie and uh reminded us of the existence of this mandate and this report.

Now, the reports had gotten as sometimes these reports do, um, had become sort of uh I don't know, an exercise that nobody was particularly giving much attention to.

The reports were one or two pages.

They sort of concluded that the city had met its obligations to provide treatment on demand, went into a file somewhere, nobody really did much with them.

And um, starting in 2019, we did change that for good or for ill.

Um, and I have continued to call for these hearings ever since.

The reports do strike me as somewhat odd, actually.

And in some ways, maybe what's going on is an evolution of these reports toward Chair Dorsey what you were talking about, which is a more comprehensive look at the city's um response to the challenges of substance use disorder and the programs that they are pursuing, which could be quite good.

The problems that I have with these reports, and more so actually this year than in the prior years, is that they're not terribly clear on what on if we are actually meeting that 1996 or 2008 mandate, where we might not be meeting that mandate, and what would be involved in closing the gap between where we are and actually truly having treatment on demand for everyone who needs it.

Now, I know from the prior discussions we have had here that these are actually pretty hard questions to answer, and so I can also understand DPH struggling with how to address them.

Um Director Cunnins and I have spoken publicly and privately many times about one area where prior reports have identified a gap, which is um dual diagnosis populations, people who have a severe mental illness and an overlay of a substance use disorder, and for whom it is very hard, I think we will hear, I think DPH would ignore would acknowledge this, and I think we will hear from our criminal justice friends and our outreach friends and some of the recovery advocates and treatment on demand advocates.

It's very it's actually quite hard to get the right kind of treatment for some of the folks who have some of the most significant challenges again with this combination of severe mental illness and substance use disorder.

And in some ways, trying to identify the gap between where we are now and being able to meet the needs of that complicated population.

I'm not going to put words into DPH's mouth, but I assume it's pretty when we're as far away from meeting the need as we are, it's pretty hard to measure or even imagine how we would get from here to there.

And I can also understand the burden of trying to do that on an annual basis.

But I think not doing it at all, or maybe we are doing it somewhat through some of our modeling.

It's just not clear from the report kind of how we're actually handling those challenges just on the sort of 2008 mandate.

I think the other thing that's clear to me from the prior hearings, from some of what I saw in the slides from today's hearings, is that not everybody has the same goals for what the city ought to be doing about substance use disorder and what our public policies should be aiming at.

And so in the absence of shared goals, it's a little hard to set measures of success.

We have this measure of treatment on demand.

It seems like that is not necessarily the only or even the best measure of whether we are achieving what we want to be achieving in the area of substance use disorder, but it also seems like we haven't clearly set out what we're actually aiming at and the goals other than treatment on demand.

Because I still think treatment on demand is an important goal.

I do, and this is just this is not as I mean, I am not an expert, not a doctor, not someone, you know, in recovery.

Like I don't know, but it seems like to just random, you know, basic San Franciscan me and the people I represent.

I think that if someone is trying to get into treatment, it should be pretty easy to access the friction around that should be de minimis.

We want to, we want you just easily come into that.

That may not be that again, that's not the only measure.

I also want to know.

I think we I think my constituents want to know is that treatment effective?

Does it last?

Do we support you when you come out of that, you know, out of that program?

Do we have you at five years not using or using less, depending on what are what our goals are?

Um what is the what are we doing with overall level of use in the city?

Are more people using or fewer people using?

Do we have more overdose deaths?

Fewer overdose deaths.

And I could imagine a set of metrics that we would put in place to supplement the treatment on demand metric that would be, and I think this again may be somewhat where Chair Dorsey was going, that would be a better way of framing the conversation.

I think what's happening now is a kind of throw the spaghetti at the wall, tell us everything you're working on, massive report out of DPH, and other people talk about what they think is interesting or important in the substance use space, but it feels it feels like a very unfocused discussion.

I think it's a useful discussion.

I'm looking forward to it, but I think coming out of it, we've talked about doing this in the past.

I got like 14 more months here.

I would really love in that time to come up with a better, maybe more useful and maybe less burdensome framework for DPH to be tracking what we think is important.

Um, okay.

So we're gonna hear from lots of people.

We're gonna we're gonna start with um Department of Public Health, and that's gonna be uh Director Daniel Sai, I believe, and uh and uh director of behavioral health services, Dr.

Hillary Cunnins.

Um we're also, and there's no particular order to how people are presenting, other than some folks had time pressures that meant that they needed to get to other places.

So after DPH, we're gonna hear uh from assistant deputy chief in the fire department, April Sloan, who's um with community paramedicine.

I'm gonna talk a little bit about what they're seeing on the streets and the challenges they may be facing in getting um treatment for folks.

We're then gonna hear from uh Victoria Westbrook from adult probation to talk a little bit about what they're seeing for their population.

Um we're gonna have Olivia Taylor from the public defender's office to talk about what's happening for um justice involved folks and how what the challenges are in getting treatment there.

We did invite the district attorney.

I apologize, we invited them probably a little late, and so they are interested, but we're not able to send a representative.

Um we're gonna hear from Steve Adami from the Recovery Coalition, and then we're gonna hear from uh Justice Dum Lau, Justin Louie, and April Cronk from uh the treatment on demand coalition, and that will be a couple of hours from now, but I I hope this is you know useful, and um I think unless anybody else has anything to say up here, we'll start with Director Sai.

Thank you to the board and everyone for being here and holding this hearing.

Um, just want to start by saying I fundamentally agree with everything that President Mandelman you just outlined.

And what I'll attempt to do for the discussion here, you'll see the presentation doesn't really follow the detailed report exactly for the reason you mentioned.

I think we want to be very clear about the problems that we need to solve, what we are trying to achieve, what the actual levers are for that, of which treatment on demand and getting treatment for folks much more quickly, absolutely is one part of that, but it is not the only piece of how we actually address the crisis that we have, and we will walk through some of the things that we're doing and trying to move on this, and I believe we'll have questions.

So we'll try to do that relatively uh quickly.

So Claire, if you don't mind fast forwarding, you can just go forward, forward, forward, forward.

I just I want to pause on this epidemic and crisis piece because as you noted, we have many, many different um uh opinions in our community, our staff, our CBOs, advocates, I respect them all.

And I want to note at the end of the day, we have an epidemic and a crisis.

We're at close to two people a day dying from overdoses.

We have invested significantly as a city.

I fully acknowledge and note that a lot of care and a lot of treatment and a lot of really good stuff has been provided, and we have a massive gap, both in terms of um death and also mortality, morbidity, just when I'm out walking the streets with the team, like you can see with your own eyes what is working and what is not.

And uh we have a very fragmented system, we have all sorts of pockets of what we call treatment, and things don't always flow as one continual system that really helps folks move from where they are into a path of treatment and recovery.

Um, and so that is why we are all here, and I want to be very clear from the department standpoint from my standpoint from this mayor's standpoint, um, we are going to be evidence-based.

I'm a public health person, and our job, my job is to make sure we are pushing the boundaries of what we all do, and we're not continuing to do what we've done before in the same way.

So uh Claire, if you can go to the next page, please.

There are two goals in our department roadmap here.

One, I think President Mandelman, to your point and Supervisor Dorsey, Chair Dorsey, we need a system of behavioral health care that quickly gets folks from the street into care and to treatment into recovery.

Treatment on demand and the speed of getting into treatment is one part of that.

But the outcomes and effectiveness of those programs and how fast and well and effectively we can move from one part to another is also a really key part of that.

I would also note the overdose stats, which we are still at close to two people a day dying of an overdose, and there are incredible disparities in that black African Americans are dying at five and a half the rate of the general population.

Um so, Claire, if you can go to the next page.

There's a range of things that I won't get into too much here, but you'll see the treatment expanding treatment and having that be much more quick and accelerating and simplifying entry into care are very, very important components.

Dr.

Cunnins will talk about that a little bit more.

We have recently, for example, reduced the wait time to get into residential treatment from four days to three days.

Great.

And that's still three days too long.

When somebody is ready to enter treatment, it needs to be, we can't have all the barriers that we have up today.

When someone wants uh treatment and it's after 5 p.m.

or it's Friday night or it's over the weekend, uh, you know, folks are told to check in someplace the next day, and we are trying to address that through a lot more activity on the street and prescribers and docs being able to engage at all hours of the day and night, but we still have major gaps in that.

And we're also trying to be able to actually pull through folks in the system.

We get them into one level of care.

How do we ensure they have a place to step down to so that as they're going through say residential treatment, there is some place with structure and stability for them to go versus we keep rinse and recycling and kind of having folks and getting through one part of treatment and then discharging to the street without supports that that is not going to lead to the most successful outcome for those folks.

If you can move on to the next page, I'm just gonna tee up a few quick priorities and I'll hit one part and then pass it to Dr.

Cunnins and then open it for wherever we want to go.

There are four things that we'll just give updates on.

One, a big part of this is how do we much more effectively and proactively help address when we're meeting individuals on the street, regardless of whether they're housed or not, with our street health teams or range of our services teams, others, how do we more quickly help those folks get into care?

Treatment on demand, that whole concept is a really important part of that, and all the systems and structures and barriers that we as a city have put in place that make it very difficult, far too difficult to do so.

Two is expanding the actual capacity of the system for stabilization, treatment, and recovery.

And you will see how we've started to make major investments in actually having a structure of a system and also investing in a continuum, including residential step down and also additional recovery-oriented um settings across the continuum, in addition to the the existing services that the department has historically invested in.

And those are very important um pivots.

They are ands in my mind of things that we have uh moved to as a department.

Third is we know medication treatment and some other evidence-based approaches are um work.

We are doing a lot to get access to that anywhere on the street much more quickly.

Um we'll talk about that.

And when I look at the data, again, this goes back to your point.

We are much more quickly able to get people engaged on say bupenorphine.

When we're engaged in certain settings, we see great persistency.

But we also have a lot of folks who pick up their first script, are on medication for 30 days and then drop off and um start again.

And so this is not just about getting folks plugged into treatment or uh quickly, but it's figuring out how to make sure that there's actually continuation and outcomes from the range of things that we're um that we're doing.

And I can't see what the last bullet.

Oh, this uh with the closed caption.

I think it says improve stickiness, which is we keep losing people at various points because it's really hard to transition from one setting to another.

And so that's why I think I'm very appreciative when we have providers able to think about a whole continuum of stepping people from one service to another or being able to move kind of back and forth in their journey without having to refigure out where to go at every single point.

So these are all things that are nuanced and more than just the immediate treatment on demand pieces, but we we absolutely agree.

Speed and time to treatment is a necessary but not sufficient condition.

If it is too hard to get into treatment and effective treatment, we're not gonna be able to help folks.

And if treatment is not effective, and we need to better measure that, have better outcome metrics, we're all gonna be doing a lot of work without outcomes to show for it, which is what we ultimately care about at the end of the day.

And so maybe I will um we were gonna try to go through a few slides quickly if that works, unless folks wanted to jump into things right away.

Okay, we'll try to do this quickly.

I'm gonna hit the next one and then I'm gonna pass it to um uh Dr.

Cunning.

So I'm not gonna hit every bullet here, but um excuse me.

I want to note, we have actually been doing stuff, not just talking about uh new directions that we want to go in.

And the point of this page is just that everything we're doing has a clear logic to it.

How we quickly engage folks on the street, how in the first 23 to 48 hours we're helping to stabilize and have a place for somebody, how we're having helping to actually get initiation into treatment and move them through that uh path.

You'll see a range of bullets of things that are all new enhancements or things, including, you know, a range of things like crisis stabilization at A22 Geary, trying to find a better way to engage folks on the street, expanding a range of really important parts of the continuum, including with providers that are offering a recovery oriented setting, both at the, you know, with uh Elinor Fagan uh right off the street for folks uh and through an entire continuum, including uh residential step down.

Um and you'll also see that a lot of work is happening in a new way across departments that are not just DPH but also with HSH.

Think about how we actually have flow and outcomes through the the rest of the system as well.

There's a lot more work to be done uh there, but this is this is the direction we're going.

Claire, I'm trying to go quickly so we can get to questions folks have.

Um, a big old street the street teams has been to reorient and try to focus on more clear outcomes and objectives for what we're doing.

And there was certainly an article this morning folks may have seen of a lot of the things that we are trying to experiment and pilot with.

The goal is both for complex, very, you know, interdepartmentally engaged individuals.

How do we help get those folks off the street and into care?

And then also, what is the most effective way as we do general outreach for folks to get them plugged into care?

A huge amount of work that is no longer just you know independent departments separately but integrated together.

Um, and we continue to refine and tweak that uh to make sure we're actually able to improve outcomes.

Next page, Claire.

Uh I would also say, because this body has had many questions, that includes a lot of new coordination on how to better manage 5150s across departments.

I know April from FIRES here.

Uh it goes far beyond just DPH and FIRE, but with our hospitals as well, to make sure that we are more successful in making sure that folks that meet that level of clinical need and uh and need to be you know brought to care that we are able to do so effectively.

Next page.

And finally, we're part of the things that we're trying to do is to experiment with different ways to get folks quickly off the street, but also say there's a bet available if folks are willing to engage with treatment.

And I will be the first to say there's a lot to continue to tweak and improve, and there are a range of other models we want to consider, but these are all things of converting and transitioning how the city has historically thought about a range of settings to add much more of a clinical orientation and a focus on treatment around that.

Uh, we do as a department believe that is part of our core mission to make sure we can get folks plugged into treatment and our resources are oriented around that.

So I'm gonna pass it to Dr.

Cunnins now to quickly walk through the rest of the pieces uh and then uh go where we want.

Thank you.

Thanks.

Good morning, uh Board of Supervisors.

Thanks for calling this hearing, and I look forward to more conversation.

Before I jump into the more specifics about what's going on, I really just want to echo and amplify some of the things that Director Sai said.

We have been working diligently around metrics, have been in conversation with President Mandelman and others about how is it that we measure what we do, know what is and isn't working, and adjust.

And I think there's no question that there is a crisis of untreated mental illness and untreated substance use disorder that all of us who live and work in the city see every day.

And that may be ultimately the best metric of what we are trying to drive towards, trying to pull people into care, treatment, and recovery, and knowing that as the best and overall measure.

A lot of what we are measuring and have been measuring are smaller pieces along that journey, but clearly that is what the public sees, that is what we hold ourselves accountable for in this administration.

I also want to really clearly say that this under Director Sai, Mayor Lurie, that there are enormous opportunities to see what we're doing as part of an overall system.

We are working across city departments from street into care into recovery to really aim to create systems that work so that we don't lose people.

It's unacceptable when people drop out of care.

We have some but not complete mechanisms to help coach and coax them back into care and back into treatment and recovery.

So big picture, we have been pivoting, investing in new things, acknowledging where things have fallen short, and aiming to strengthen them, and we will absolutely continue to do that and put a critical lens on everything both that we have been doing and what we are starting to see that it's achieving the goals we're setting forth.

So, with that said, I want to go into a few more specifics of some of the new and modified pieces of again this system that aims to pull people into care, keep them in care, and move people towards recovery and health.

So we have, and you can see this is focused on this slide on residential folk treatment programs and approaches.

We have 400, more than 400 treatment and care beds budgeted to open from this year through 2028, and additional 140 beds that are being planned.

We have categorized them in the following sort of areas or buckets, recovery-oriented beds, crisis and treatment beds, and then note what is still to come in the pipeline along a different uh array of care intensity and types.

I'll just call out specifically the dual diagnosis beds that President Mandelman mentioned, which we have been driving towards for the last time period, and hopeful that some of those will soon open.

We do have some out of county beds, but do not clearly meet the level of need.

Next slide, which we have spoken with many of you about, is uh new promise of new state capital funding for a number of behavioral health projects, including the dual diagnosis program on 7th Street, a 16-bed enhanced dual diagnosis program, and very importantly and critically to helping us flow people into appropriate levels of care is 21 million to support expansion of approximately 90 new locked mental health rehabilitation center beds.

We will also be applying for additional state Prop $1 at the end of October.

Next slide.

I want to drill down into two important interventions that we have been also expanding, which is rapid access to medication.

Director Sai already mentioned this.

We have seen through a number of our intensive and really pivoted efforts, an increase in number of people starting buprenorphine.

You'll know that buprenorphine and methadone are medications that decrease risk of dying of overdose by 50%.

Our innovative new initiatives drove these increases, including a telehealth program for buprenorphine treatment, providing access to medications 16 hours a day, seven days a week.

Retention and care at six months is about 30%, and we've have to do better.

We are finding ways to kind to drive to keep people in that care through a number of different approaches, including taking the opportunity to shift to long-acting injectable buprenorphine wherever possible, which we believe holds the promise of improving retention.

Next slide.

We are also aiming and have made a number of system adjustments to provide and improve rapid access to medication treatment.

Many folks in the community have described to us the ways in which, and as Director Sai said, it is inadequate to not be able to provide care when someone raises their hands.

So in the case of methadone, we've made a number of changes both to increase entry into care and ease of entry into care, as well as ways to improve retention.

And you can see on the graph, we have successfully increased the number of people we are treating with methadone in the city.

There have been a number of pilot programs, including providing peer navigation supports, which I just want to highlight as a number of our partners are working on the street with peers and health workers to support navigation into care.

You can see some of the other innovations on that slide.

Next slide.

It provides immediate incentives or tangible rewards to incentivize positive behaviors.

So we are aiming to expand and have expanded the number of programs in the city to 12, including some of which are funded by Medi-Cal, which helps us, of course, at the local level, draw down state dollars and federal dollars to help fund these programs.

We have we know that they are highly effective and uh in our own internal data, seeing that about three-quarters of urine testing in the Medi-Cal programs were negative for stimulants, which we see as a very positive part of this program.

We will be expanding to five additional programs by the end of this year and aiming to increase the total number of people we reach through these intervention.

Last slide.

Actually, I'm sorry, I'm sorry, Vice Chair Mockmood.

Oh, did you want to go first?

Yeah, I'll go first.

Thanks, Chair Darcy.

Thank you for those, uh, for those presentations.

I'm wondering if we could um dig in a little bit on the gaps.

Um, and you you've touched on them, they're hinted at in the reports, but um one is wait times, and it sounds like there has been progress since last year and a reduction by a day.

You said uh, Director Sai that you know, from your perspective, zero is the right, you know, number of days to wait.

We've had some conversations about what is waiting, what does waiting mean and if there is a um appropriate place to be and to manage um detox, you know, is our goal really no wait time for residential treatment, or is it um being able to get everybody into a place where they can be until they can go into residential treatment in a reasonable period of time?

It just seems like there's a if we're figuring out what the what the right goal is and one of those things, and it seems like the second thing I was describing is a little more realistic, and we may not actually even be meeting that right now.

Um I don't know if you could just talk about it.

I'll start and I'll ask Dr.

Connors to jump in.

Yes, the latter is effectively what matters, and I but but I in for others, um, uh in many cases the uh there may be a few days before someone can get into residential treatment, but we can immediately get them into withdrawal management, and we buy a pay for, I should say, a range of withdrawal management uh beds from a range of different types of providers.

So if someone gets into withdrawal management and they're detoxing there, like that's totally fine.

I think the issue is though, even with that, there's not always immediate access, whether it be to withdrawal management or for some of the populations that you mentioned.

I think I was just uh a few of us were just observing some of the case presentations with uh with the court, for example, and looking at how long it takes to get someone into residential treatment, if they've got any sort of history or complexity, right?

Those are all uh challenges.

So, Dr.

Connard, do you want to talk a little bit about some of the other process improvements we're doing?

Yes.

Um, and we do have, I don't have that today, a measure of most people today are coming from withdrawal management into residential treatment.

That is um, and we will get that number.

So that is to your point, a place to be that is safe and therapeutic.

We also are in our work opening some new programs, including uh the work we are doing uh with our colleagues at Westside on the LNR Fagan, sort of the as an example of a stabilization approach that then could lead into formal treatment.

So that is thinking about spaces that can be used to stabilize and having no wait time access to those.

There are some times when entry into residential treatment is requiring a medical assessment to make sure their medical conditions are safe, and that can sometimes, and that is what we are also working on to happen rapidly.

We are really excited this year uh, thanks to Director Sai and work with the state.

Uh, as many of you know in this room, sometimes medical regulations seem to get in the way of doing what is right, uh, and moving rapidly through process improvement.

We are able to admit people to residential treatment, doing a very brief assessment, and then completing the longer medical required assessment over the first few days.

That's gonna further reduce um or increase our ability to get people into residential treatment very quickly that just uh went live in the last couple of weeks, um days, and we expect to see further change as that gets implemented, and we work that through.

So we're very excited about that.

Are we able to measure and describe how far we away from being able to get people into withdrawal management or some other safe place we are?

We um we have been working on this, as you know.

I'll just mention another uh thing that's upcoming.

We don't have good measures of people being turned away.

We don't have that well documented quantitatively.

We know and that and we are um aiming to capture that quantitatively.

I think that's the main critical measure that we have to figure out to in order to get at that number.

And turned away means you show up at 4 p.m.

or you show up any time, and the person who would do the intake is not there, or we don't have a spot for you, or too medically complex or whatever.

And making sure that in those cases the turn away means you're going somewhere.

Right.

So for example, someone comes in in crisis for withdrawal management with mental illness and substance use.

We now have A22 Gary.

So we have that as a possibility, and that is a 24-7 location, for example.

Sure.

But we do not have measures of that, and we have been striving towards that.

And presumably A22 gear is a pretty high level of acuity, and the sort of the bad scenarios that we're, I think, afraid of and that we've heard about in prior versions of this hearing is more like what I was describing, which is the nonprofit that is doing this just doesn't happen to have the right people on site on that day, or we're not open on the weekend, or it's nighttime, or whenever it is, and there's this I don't think we have my fear is that we don't have a sense of how big that box is.

Um just a two more comments, if I may.

A22 Geary is a very high level of care with nurses, a medical director, uh, and are seeing people who are pretty ill.

Um another innovation that's coming is we are moving our substance use treatment programs onto our electronic health record, EPIC.

The EPIC, which we converted on the mental health side about a year and a half ago, it's gonna give us additional opportunities for measurement, consolidated reporting, and much more visibility into some of the systems that I'm saying we don't are not able to measure right now.

Um, prior reports have pretty clearly identified dual diagnosis, monolingual non-English speakers, and um justice involved population is three areas where we think we're probably, I mean, there's there's the wait potential wait times for um withdrawal management, which is um everybody, I guess, but those three subpopulations as being areas we needed to do work.

They are hinted at but not particularly called out, and certainly not quantified in any particular way in this year's treatment on demand report.

And I'm wondering how we're gonna how we're thinking about trying, if we are, it seems like we're supposed to get you know, measuring those gaps.

So, yes, we have those gaps.

Yes, we are working through that in a few different ways.

In some cases, like on the dual diagnosis beds, we've got uh two sites we're trying to send up 20 to 30 beds, specifically staff for dual diagnosis.

But I think the other level we're finding is we want to sit down with our existing providers who we contract with and pay a lot to make sure that we have appropriate mental health support more in some of those settings, even if we DPH have to think about other ways to provide to to you know broker uh different folks working together to have that mental health support, and also how we're ensuring that our providers are removing barriers for folks that are willing to go into treatment and we want them in treatment, not least of which is hours of when you can do intake, which has come up as a major barrier.

Um, but also that folks with um you know involvement with the criminal justice system and so on, that sometimes leads to just a carte blanche, we're not gonna support folks, but those are folks that we're trying to make sure when they're we have folks in front of us raising their hand for care, we have to be able to get them into care in a system that we believe works.

So those are all the things that our team daily is working on.

I'm excited about the 20 to 30 dual diagnosis beds.

I've been excited about dual diagnosis beds for as long as we've been talking about expanding there.

Does the department have a notion of whether 20 to 30 additional dual diagnosis beds gets us what we need for this population, gets us to meeting demand as it currently exists, gets us to meeting demand as we would want it to be.

We've done, we've you know done some flow analysis.

I mean, our our beds analysis is a flow analysis, which has always struck me as maybe not exactly getting at the question of how many people do we think we want in these beds, but what what are you all thinking about that right now?

I mean, I I think from our I would say two things.

One, from our rough modeling, which we all know is rough, that will help substantially.

But two, I just want to keep anchoring back.

We we have a lot of beds we purchase today from a range of providers on the SUD and mental health side, and we spend a lot of money on that.

And part of what we need to do is to make sure that we're utilizing that spending and those beds to get outcomes.

So, where we've identified a need for more dual diagnosis or higher levels of care.

Like it to me, the answer is not always, hey, let's just go leave our current system as is and go buy a bunch of new uh new beds and build new beds.

We have to also make sure that the existing system is working better, which it does not always work as well as it needs to today.

That is a fact.

We acknowledge that, and I think we are saying that out loud because it requires a hard look, including a range of areas that we kind of dance around where we think we need to track outcomes, but at the end of the day, we don't have data that can point to things and the level of rigor that we want.

Those are the directions that we as a department are moving because that's what you should hold us accountable to.

Um, I certainly appreciate the department's emphasis on the street and addressing challenges on the street.

I think that is good, and I I think you know, I think you've been pushed in that direction in some ways by community and politicians.

Um I am curious about how you're thinking about the non street population of substance users who may need treatment.

Um, one of the things I heard in some of my conversations with people in the justice system is that they're actually finding that it is easier to get resident.

I mean, not easy, but it may be easier to get residential treatment in some cases than effective outpatient treatment.

Um, and how are you thinking about treatment on demand for people who don't also need a place to be?

So I think I would say a few things and then ask uh Hillary to jump in.

Um, one we need to think better about how we 26% of our overdose deaths are in permanent supportive housing.

We've had an increasingly complex set of populations in PSH.

I know there's a much broader policy debate around all the structures of PSH for the department for the health department's role, one of the important pieces is we need to find a way to actually uh help folks get care and move through treatment versus waiting to find them on the street when they're decompensating.

And so all of that speaks to a much more intentional, proactive approach, including in PSH settings and also doing a range of other things there.

So that that that is one thing I would say, many of the folks that we're engaged with are actually housed in some way, and as a city, we need to better utilize our resources and think about how those settings can be more effective.

A second thing I would note is that we also believe like uh we need a better structure of outpatient treatment that has a range of intensity, and I'm gonna ask Hillary to talk a little bit about that because there's some new state initiatives and funding that come with that as well.

Um, so what we do offer in the way of outpatient substance use disorder treatment as well as mental health treatment does exist.

We are aiming to incorporate more substance use treatment into our mental health treatment programs.

We have two levels of substance use disorder treatment outpatient treatment, intensive outpatient treatment and lower level.

There are opportunities, as Dan mentioned, to think further about expanding at the sort of even higher intensity of that.

So we think there's more work there.

We also want those settings to be delivering the most effective evidence-based care.

So for example, um uh the contingency management work that we are doing ought to be integrated routinely across outpatient sites as one of the tools.

Um and we are working to expand that both in sort of the licensed treatment settings as well as other community settings where people might be seeking other kinds of care and might be willing to get some help where even if they're not willing to go to uh labeled substance use disorder treatment program, we want to make it widely available.

Um I have a couple few more questions, then I'll get out of the way.

Um one relates to so as we as we think about if we if we do spend some time over the next year thinking about structuring these reports and figuring out what we actually want to be measuring over maybe not every year but some period of time.

I think that one of the things I would like us to be looking at is overall levels of use of um of the substances that we think are most disabling or causing us the greatest challenges as a city.

And I I mean you can tell me, but I think that's um, you know, uh fentanyl and opioids, um, meth.

Um I was intrigued but confused by the modeling discussion in the in the report about what it says and whether we could use it to figure out in 2030 if we have fewer people using these um substances than we had in 2025 in San Francisco overall, and other um Supervisor Dorsey and I have talked some about you know sort of efforts in some places to sort of measure the sewage.

Um how are you all thinking about measuring overall use in the population as another way of getting at how are we doing?

Yeah, I appreciate that.

I think all that goes to we have spent we not just the whole, not just San Francisco, but all across the country, so much of the efforts around behavioral health addiction, drug use, the intersection of these has been focused on individual process metrics or utilization of the first step of one service or another, which is good, important inputs.

What we care about at the end of the day are outcomes.

And I remember my federal role thinking about this quite a bit at CMS, the centers for Medicare and Medicaid Services, because when you look at physical health care, yes, there are utilization metrics like did you use the hospital or not or primary care visits, but there are also clear outcome metrics that are national validated metrics like percent of a population with HBA1C, meaning blood sugar control, or percent of the population with HDL LDL or um blood uh well uh actually a range of chronic disease, because it's you have actual outcome metrics that you can pull.

When you look at the um national validated metrics on behavioral health, most of them are just about uh so one of the most common ones is after a hospitalization for mental health, did you get care within a certain amount of time?

That is a very underwhelming metric, and that's kind of where the national measurement science has been.

So I say that with that context, but I think what we care about is from an outcome standpoint to use that parallel.

We would, I mean, we care about the overall incidence of uh uh use and also outcomes.

The science measurement wise is very poor around this.

And so as we've talked about how to do that, I think it requires some further exploration and utilizing some of the research support that we have here in the city, but we should be looking at that and we should be also finding a way to better define whether or not our programs are successful or how we're able to persistently kind of see people over time uh continue on their treatment and recovery journey.

And we not just San Francisco, no one has strong metrics around that, and I think that's a real gap that we need to work through.

I concur.

I mean, just looking at the report and thinking about this and thinking about the structure that we have, which is this treatment on demand framework, which is very focused on an individual at a particular moment in their treatment journey, which may have nothing to do with their ultimate success.

Yeah, I mean it's important, it's not nothing, it is a thing worth measuring.

We're having a whole hearing about it.

You do a report about it every year, but it seems like there are other things that get to the success for individuals over time that you know are hard to measure but would be good to try, and then figuring out measures of the community health that I think is like less use of this stuff, um, you know, and if we are doing the right set of things, and that is a range of interventions from you know, potentially uh medication assisted treatment, but also um, you know, education on the front end, um the right set of incentives, blah you know, on and on, blah blah.

Um, you know, you would want to see a graph that's going down in terms of overall use, and it would be good, I think, if we could figure out how to measure that and report on it in some kind of.

We'd welcome sitting together to think through that.

My last questions relate, and I don't have the numbers on me, but one of the things that has struck my legislative aids and struck me about this um as we were preparing for this report, and I do want to thank Bradley Phelps, who was working on this in my office and has since moved on, and Sophie Marie, who is in my office, who has picked this up from um Brad Bradley, um, is uh we've we have we're spending a lot more money today on substance use treatment than we were in 2019 when we started this.

And we have added by some measure a whole lot of beds.

And you can see year by year since the pandemic, an increase in the number of beds.

But if you compare treatment in 2025 to treatment in 2019, notwithstanding all that work and that increased spending, it doesn't look like we've increased treatment or do I have that wrong.

So I think um there's a few things I would note.

I think um San Francisco over the I'm gonna say a factual statement.

I'm not putting any judgment either way, but these are we try to look at the facts and figure out where we go from there.

San Francisco over the course of the past several years has added a tremendous number of beds of various sorts.

The unhoused population is relatively constant still, and there's a range of inflow and outflow dynamics for that.

And so we from a health standpoint are focused on trying to do more of the treatment pieces, and so the treatment budget has not expanded at that same rate as we've looked over the past um several years and we've kind of pinpointed what things have what what's been driving uh different uh pieces.

And so that is a um important discussion, especially as we think about how to utilize our funding.

Say that exactly.

But the treatment budget has not increased.

When I look at over the course of the past five to six years, the budget say within behavioral health, we did move different line items and collapse them all together in certain places, but it's not like we have seen a doubling of the underlying in the aggregate spending.

I'm sorry.

So I mean maybe you can't answer this, but it presumably different things were prioritized, other things were reduced.

I would be interested.

I mean, I we thought we were adding a whole bunch of stuff.

Um sounds like maybe we in the aggregate weren't.

No, I we to I want to be clear the spending has grown, but at a uh level that is more commensurate with kind of the growth of the overall program versus a doubling of uh spend.

So maybe my context is a little like when I look at some other pieces, I see a doubling of beds and capacity.

When I look at the treatment side, we have not doubled capacity, but we are trying to make investments increasingly, especially in this administration, things that we know work.

Um, I would be interested in uh kind of figuring that out a little bit more.

Um, all uh now get out of the way.

Thank you.

Thank you, President Mandelman.

Uh Vice Chair Mockwood.

Thank you, Chair, and thank you, Director Sai, for the uh presentation.

Um I have a couple questions for myself and then um for Supervisor Fielder, who's co-sponsor of this committee as well.

Um first um I think it's important to try to make progress on a problem uh to have a better understanding of the data and have targets.

Um I saw kind of a funnel of strategy on one of the slides, but I was curious whether do you have targets for how many patients we have to take care of right now?

How many you hope to move along that funnel year over year?

And if so, could you share those numbers?

So our targets are more in terms of, and actually, this is why the treatment on demand framework, President Man and we're sorry, it it's still a helpful framework because we are seeing quite a movement of we're not working with a stable meaning the same population over time.

There are people coming in and out of the city.

We want to make sure that um, and the need is very clear.

One of our principal goals is to make sure that for treatment and recovery services, we can quickly meet the demand for that to get people plugged into that because we believe that is the best way we from a health standpoint are able to support their best chance of making it through that treatment and recovery journey around that.

Now, the team has worked through and we can sit offline through more of the actual estimates of specific beds by services to be able to meet that demand and have quantified that at a more tangible level, but all of that is with the goal of trying to be able to quickly get somebody into treatment and actually through a range of settings.

So even the the range of beds that we've contracted uh with more recently have a goal of trying to be able to move folks, say from the street into stabilization through residential treatment and into 12 to 18 months of residential treatment.

But we're happy to sit down and follow up to talk through more at the um the quantitative uh bed targets we have by service if that's helpful.

I guess it to clarify beds and these things are solutions.

What I feel like we need is quantification of the problem to then better understand are we improving the situation?

Is the department not setting goals for how many people, not beds, how many people we are trying to help year over year?

That model has a vol it has a there's a number of people assumed in that that leads to the output of beds and it kind of varies by service level.

So that's something we we should we can sit down and talk through.

It's not just an assumption of beds, it starts from assumed numbers of people.

But I I really I want to be really clear.

When we have done that modeling, it is our best informed data-driven estimate.

We are seeing a highly um influx population with inflows and outflows, and I think that's a broader discussion as a city for us to think about, which makes it it's not a fixed peg that we are working through, but even with that, we have done our best to kind of model out the number of people and the additional number of people we believe on an annual basis at each level of care we think need to be served with an assumption about how many months at that service level, and that has defined a bed gap at each service level as an output.

I think that that information would be helpful in this context so we can supplement it with the beds that you're seeing as well.

Thank you for that.

On that funnel diagram that you have on slide, 10.

Um you walk through the respective strategies, five different steps.

Do you have context?

I guess continuing the last question.

What is for the people who start off a certain what is the drop-off rate to each stage so that we can better understand maybe where there's gaps or where the efficacy of respective programs are?

The ideal is that we have 100% at every stage.

Obviously, that's not likely the case.

Do we have context on percentage drop-off at each of these stages?

Yeah, I think so.

Um we have a sense of that in some programs.

As I was saying at the outset, I do not believe we track and have had our data systems built in that way.

We, and not just all of us, not just San Francisco have focused much more on just each level of care, how many people serviced.

We are wanting to see outcomes and flow through the system.

So there is an actual cross-departmental exercise going on now that is defining that because I not just for the DPH beds, but also for HSH as well, because we know that these things intersect uh quite a bit.

It is why we I think are excited when we have providers that are able to think about the entire continuum where you can get someone into residential treatment and actually help guarantee and kind of flow them through that process.

That is a that is what we want to see our providers able to help support.

Um last question on my part.

Um, we noted I think there was about 400 beds added since 2020 and about 400 more that you're looking to add.

Um where are those beds going?

Um are there plans to expand resources outside of the tender loin?

And the reason I ask is that there are a lot of people trying to get in recovery, and it's difficult representing the tenderline to see that putting people in the environment where they're surrounded by an open air drug market uh and open air drug use, it's difficult to be in that environment.

So, how is the city making sure that geographic equity is part of treatment on demand so that residents from the TL and other high need neighborhoods have access to safe recovery spaces across the city?

Yeah, I appreciate that.

I mean, that has been a big focus, and I would say it's it's both um where the services are being put and what type of services.

So of the 400 Samad, 270 some odd of those beds, don't quit.

Like I might be off by few, roughly 270 are in a continuum of uh recovery services, both from very close to the street with the Eleanor Fagan all the way to in the marina residential step down for 12, 18 plus months.

Uh, with the Alfred uh Wells uh marina in setting, really intent on helping pull people through successfully a journey of treatment and recovery.

We also know that at points we're trying to make sure we can meet people where the need is and quickly then pull them into a system of thinking about treatment and recovery.

So I the what you I mean, that's on our I very much undermines kind of at every single point of the bed calculus.

Okay.

Thank you.

Um next, I have uh questions from Supervisor Fielder.

Um on the data aspect, uh, the report was showing that the loxone distribution exceeds 158,000 doses in the fiscal year 23-24.

Does DPH, can you share how those doses were geographically distributed?

And whether overdose reversals increased in tandem as well?

I think we do we have that, or we can follow up on that.

Well, we can follow up on the geographic distribution.

Um we know that overdose reversal reporting is voluntary, meaning we uh often the naloxone gets distributed to other people, uh lay people in the community to providers, and we don't believe that the overdose reversal reporting, we know it's uh profound under counting of the number of times the naloxone is being used.

We can follow up on the specifics of what we've got though.

Appreciate it.

Second metric question was uh the report cited at a 32% increase in buprenorfin clients and the launch of on-demand telehealth for MOUD.

Um, how many of those telehealth patients have successfully linked to ongoing care after their initial visit?

So, um within six months, 30% are still engaged in treatment.

And so, I mean, the more upstream we one fundamental thing we always wrestle with as a department that we are trying to go as upstream as possible to to motivate and engage folks to begin something, those folks are in a range of places of where they are, and so um that 30% number of folks still engaged after six months, as Dr.

Cunning said, replaced that at least three and ten, but that's that's that's far too low from our standpoint, and a lot of the things that we're thinking about programmatically are how do we help more persistency?

Once we have someone engaged, how do we make sure they can be more successful?

And it's not just for bupenorphine, it's actually outpatient services.

I think some of the questions r relate to this and other treatment modalities to wrap around as well.

Got it.

Um third question is uh on the data is that in context of the street teams that we're discussed as well.

Um we tripled the number of street health care workers and integrating overdose response teams.

Um, what are the metrics that you're using to measure success of or retention in those engagements?

So I think there's a few things, and some of that is beyond just health, because again, the street teams are integrated across much more than DPH, all under the day-to-day direction of DEM uh emergency management.

One of the things I'll note is where we are seeing the most success is with our shared priority clients, of folks that shared priority meaning folks that are kind of at the top of the list for the level of complexity, acuity, lots and lots of engagement over time with many different city departments without a lot of effective progress and movement, and we are um uh more quickly getting those folks into care and able to help uh in some cases resolve various clinical situations.

So that is a very strong positive.

What I think we are still I'll be very transparent where we are still wrestling through is when we're doing general outreach, meaning we're not looking at just the shared priority list, we have differing levels of success success for willingness of people to engage in services, and that is something our team every day is trying to titrate and figure out.

Um I believe there's no one from SFPD or the DA's office here, correct?

Nope, nope.

Um maybe if you have context, um, if there's an arrest uh for someone who's struggling on the street uh that might be engaging with one of these programs, is there any tracking of whether those people were then subsequently offered services or linked to care?

So I want to defer that the exact tracking question to PD.

I would say though, that as part of our new approach, all of us departments every single week are sitting together trying to figure out how, but different departments having different roles were able to coordinate much much more.

But specific PD questions I want to defer to PD.

Is the Astrid system?

This is a question on my on my behalf specifically.

The Astrid system is that being helpful in particular different departments.

Theoretically, my understanding is that should be having a centralized database for you to know different touch points for an individual on the street across different departments.

How's that working?

So there's both one system, a range of things which are have been quite helpful in teams having street teams having a shared overall view uh of what's happening.

I would also say the mayor's office of innovation has also been leading an effort to um there are still gaps of how well different parts of our team can see and understand what's hope happening consistent with all privacy rules around that, but there are different departments that have different systems where those systems don't all talk to each other appropriately.

And so the mayor's office has been leading a bit of a piece of integration on top of that to pull those things together.

But when I'm out with our street teams, like our clinicians or the hot team with HSH on their phones can literally pull up information about a client almost immediately, or when I've been out with our uh fire uh street crisis response team, like that that is incredibly valuable, but there are still gaps of what some of our teams are not able to see that prevent folks from knowing how best to triage an individual client or patient right before them.

What are the gaps that you'd like to see fix there?

I think there are gaps again between how well folks understand who has touched who between social services, human services, and health.

And sometimes we have multiple people running around trying to case manage the same set of folks, and that's not the most client-friendly or efficient way to run a system.

That's a thing we're working on.

Um next set of questions from Supervisor Fielder are related to funding.

Um given the complex funding mix uh for Medi-Cal, propsy, opiate settlements.

How does DPH decide where new dollars go?

Whether they go to expanding beds, opening sites, supporting workforce.

Um well, there's a range of pieces.

Some of the um spend requirements are statutory federal and state requirements for us for what we are required by law to ensure people have access to.

And so where there is a challenge of access, we are required to make sure there's bed expansion and present mannament reference, like some of the other local ordinance requirements around that.

But some of the other bed expansion pieces, the 75 million dollars we put into breaking the cycle of expanding a range of beds, those all were part of the budget process uh discussed with the board of supervisors, and so that is where a lot of the new budget requests kind of went through, which is the budget process.

Um, going into previous years of this report, um, the 2022-2023 report identified staffing shortages as a limiting factor in uh efficacy of this of this program.

Um, in the 2023 to 2024 fiscal year, there was 45 new hires.

Um, have those hires improved throughput or reduce wait times uh for residential placements.

Um, and at this point in the year, what is the continued um either staffing shortage or need for expansion that you see going forward?

I'm gonna ask Dr.

Cuttens to come, but there's a range of things.

There's staffing shortages for services that we provide civil service within DPH, and then there's a similar set of questions with our CBOs where we know less of the individual numbers and hires, and we do not run any residential treatment programs as DPH, and so um just to clarify kind of where the staffing numbers are versus the type of services.

But Hillary, you want to touch on that?

Um, yeah, thank you for the question.

In that report, we were exiting a period of uh profound staffing shortages, I think on the heels of COVID in particular.

Since that time, the staffing shortages that we hear again indirectly through contracted providers and our own uh services, has eased uh, I would say a great deal.

There there remain difficulties with workforce pipeline, uh, adequate pay, living wage pay, um, and um recruiting people with experience, particularly with complex, as we've been talking about over and over again, dual diagnosis and substance use disorder.

There have been a number of important initiatives, for example, the department funds, uh, some peer certifications, mental health certifications, and have begun to do billing for peer services, all and there are a few other initiatives that both in the department and with community-based organizations are aiming to continue to work on workforce shortages.

But just to be clear, so they were cut, they were there was a shortage during COVID.

Did you see an increase in throughput once those staffing shortages were solved with this to 45 new hires?

They are much less severe than they were during the time of that report.

And do you feel that there's need for more expansion to meet your goals?

I know that our providers continue to experience vacancies.

I can't quantify that for you.

They are more periodic and they are so sometimes there's full staffing, then folks might leave.

So it is I would say an ongoing, not as severe as it was during that report, but ongoing challenge for us.

Got it.

Going back to the funnel uh beyond increasing the bed count on page 10.

Obviously, discuss a couple different uh models for co-located mental health, SUD care, stabilization centers, respect by uh respite beds.

Is there a singular one of those that you think is gonna have the realize the most impact on treatment on demand in the next two years?

I'm not gonna point to a single one because I think they all need to work together as a system, but there are really two types of entry.

I mean, there's much more than, but two types of entry points I'll emphasize.

One is whenever someone wherever they are is ready for structured residential treatment, which is what some of the discussion at the beginning of this was, we have to make it easier and faster to get in, including through some of the um uh types of cases we discussed earlier, like dual diagnosis, monolingual Spanish speakers, et cetera, where it takes far too long.

But the other piece is we need in the immediate stabilization, like we need places where when we can someone is willing to come off the street and engage in some sort of um treatment or services that should not be as hard as it is today, and it often is.

And so we are ramping up, for example, both um Eleanor Faye Eleanor Fagan, which I believe I've I'm a few weeks out on the bed count that just started up, but I think we were at 28 out of I might be a few weeks off of my data point, so don't so these things are all ramping up, and we think have huge amounts of uh promise.

Same with restore around that, but um we want to see like how that impacts flow through the system.

So those are two different types of things that we think are really really important.

Last two questions from Supervisor Fielder focus on uh data uh and looking forward.

Um, so both of the reports provided uh emphasize improving data systems to meet the unmet need.

Sorry, can you say that again?

Uh the reports emphasize improving data systems to measure unmet need.

Um, what is the city's plan to make real-time bed availability and treatment slot data public so that both providers and community members can navigate the system efficiently?

Um let me first just refer.

We concur that improving data systems is a is a serious priority.

There's I mentioned the upcoming transition in electronic health record for the substance use system of care that will tremendously facilitate reporting uh and um more real-time data availability around a number of issues, including outcomes.

We do have um fine treatment SF, which shows uh bed availability on a daily basis.

We are working to improve that reporting and systems.

It's also being transferred to uh SF.gov, consistent with the city's approach, and we are working to strengthen regular reporting on that website.

Uh, last question.

Um, as we all know, overdose deaths remain high despite in the increased treatment access.

Um, what new partnerships or interventions, be them public health, community-based, or law enforcement, are needed to close the gap between treatment available and treatment utilized, many.

And I think part of what we outlined here is that it's not just availability of treatment.

It is how the different pieces knit together and how you move from one piece to another and how effective those programs are, and how we think about not just the DPH set of services in a silo, but how it fits across some of the other city department pieces.

I would also note that with the neighborhood street teams, very different way for the way the city is approaching things, is all of us have our different lanes.

I mean, health is not public safety, but the teams are now coordinated under DEM in a way that ensures there is at least thought and coordination in a much more cohesive way between cleaning and ambassadors and services and public safety.

Um we think that level of cross-department coordination is very important versus all of us just on our own working through things.

That concludes my questions.

Thank you.

Great.

Thank you, Vice Chair.

Um, Supervisor Sautter.

Thank you, Chair.

Um I wanted to just briefly ask about contingency management.

Seems to be promising, and I saw that you're expanding that to five new programs.

How much more opportunity is there?

I mean, is there still a lot of runway to expand that, or is are we pushing it about as far as it can go?

We think there's more runway.

There are to implement the program as consistent with the evidence, it does take some skill provider skills, um infrastructure.

So we are opening these next, we have opened five, we're opening two more.

We want to see increases in utilization, make sure we're getting it right, and uh absolutely continue to expand that service, that intervention.

Thank you.

Out of curiosity on that, what I mean what what does that mean in terms of people?

Like how many um I I mean the expansion in programs is cool, but what's how like what does that mean in terms of who's getting treated?

It's about so the numbers are still small now because it's a very intensive program, but I believe with the recent program expansions were at about 200, 250 individual clients served again for the programs for four of the specific programs where we have a certain level of tracking.

Um, 73% of the urine drug uh screens have come back, uh come back kind of consistently negative for uh stimulant use.

Uh the state has set an actual framework around the type of reporting needed, so we kind of are able to see that.

But it's uh in terms of percentages, like if your question is like it's a relatively small number because it is a uh is a very intensive intervention.

In that you are not, I mean, it's not just giving a gift card, you're also working with people and it's like there is it's like over a 12 or 16-week period, regular therapy sessions, uh case management, meetings, groups, like it is not just hey, give it like you are coming into regular structured uh contact.

I mean, it's it's a remarkably successful intervention, but you could also imagine many of the components of that also being pretty successful.

I mean, sort of an interesting like potentially studiable question of like which aspects of that are the most successful.

So it it has been looked at, and really the addition of the incentive to these other components is what improves its effectiveness, in part because people keep coming back, because it is appealing.

And this does feel like another area where it would be really great for us to be thinking about and have a sense of we're doing 200, we're gonna expand to whatever it is we're expanding to.

Gosh, we probably could do this for a few thousand people a year, and the gap between here and there is this, and of we either need to go to the state to get them to, you know, allow Medi-Cal to pay for this, or um, you know, agreed.

Yeah.

All right.

I mean, in general, and I do wanna.

Did you have more?

You got questions.

All right.

So our chair has some questions.

While we have uh I appreciate that we're actually went to contingency management because this is something that I wanted to um to ask about.

I know that the evidence shows that this is a successful intervention on stimulant use disorder.

It's my understanding that there are there are studies showing that that's it's equally effective, or at least it is also effective, I should say, for opioid use disorder for alcohol use disorder.

Is it is limitation of contingency management because of Medi-Cal?

And is there anything that we should be thinking about as policymakers and people who have the purse strings to expand contingency management to other things?

So the um the evidence around contingency management is not linked exclusively to just stimulant use.

Um pays for and covers contingency management exclusively for stimulant use and not opioid use.

And so to the extent we're drawing down Medicaid dollars, which helps us fund these things, um, the programs are around stimulant use.

We have been using a range of funding sources to try to expand out on pieces, but anything you want to add to that, Hilary?

Two things.

One is we are also using contingency management in the settings where people with opioid use disorder are being treated as additional treatment.

So both I would say formally for stimulant use disorder and informally for ongoing opioid use.

Okay.

That was actually the other thing I was gonna ask is are we are any of the contingency management programs serving other people beyond stimulant use disorder?

Just a word on the Medi-Cal restrictions.

The Medical program will only pay for contingency management in the context of a licensed substance use disorder treatment program, and so for example, if we want and do offer contingency management, for example, at a primary care location, uh, for example, at uh shelter or respite, we uh at this point at presently cannot draw down Medi-Cal dollars for that.

Okay.

If that policy were to change, is that a federal decision or a state decision?

It is a state decision that those restrictions are not um the federal government in approving that was not as prescriptive as were the state landed.

Should we, as a board, be thinking about urging our state policymakers to I think that is a useful discussion.

Okay.

That's all that's my question.

All right.

Thank you, uh, Chair Dorsey.

Thank you, Director Sai and uh Dr.

Dr.

Cunnens.

Um, I do want to actually do this sort of follow-up work on thinking through uh maybe potentially restructuring this report.

Um I don't know if it'll I don't know if we'll get that all done for next year, but I do think it's a conversation I've intended to have and will be following up to actually have so thank you.

Um I listed an order earlier, and I think we need to do some rearranging of it to uh get some folks who have to leave.

And so I think that we are actually gonna take uh the recovery coalition, uh Steve Adami, if you could come on up.

Oh, and then the other thing is um in order to get us out of here before 5 p.m., um, we are encouraging our presenters to try to keep their presentations under five minutes.

I'm gonna ask the clerk to set a five-minute timer.

Nobody's gonna cut you off at the end of five minutes.

If you go longer, that's okay, but it'll be a little marker for you that maybe it's the time to start thinking about wrapping up.

Well, Cedric is doing the recommendation, so you might as well extend it a little bit.

While they're loading our slides, let me get started.

Uh President Mandelman, Supervisor Dorsey, Supervisor Mahmood, and Supervisor Soder, thank you for having us today.

Uh, our group formed several years ago when I was the director of the adult probation department's or entry division.

Uh, and we saw the city falling apart in front of us.

All of us are formally incarcerated in recovery, and we felt like there needed to be a balanced response to San Francisco's drug and homeless crisis.

And during that time, we started advocating for abstinence-based solutions to the city's challenges.

I am excited to say that over the years we've put forth several recommendations, and just to highlight a few.

This committee and these hearings have led to the funding of the TRP Academy, which is an abstinence-based therapeutic teaching community for men, uh therapeutic residents for justice involved adults with dual diagnosis, the Nina Project, the Billy Holiday Center, and the expansion of abstinence-based treatment beds for women, the WTRP Academy.

Also, later today, we will be sharing five new projects that are part of the mayor's Breaking the Cycle Initiative.

You know, most of our work came from necessity.

Necessity drives innovation, and today that's what we're going to be sharing with you.

So thanks again for having us.

I'm going to turn it over to Cedric Akbar.

All right.

Good morning, supervisors, and thank you for allowing us to be here.

Who we are.

You got to get we got five minutes.

Okay, who we are.

We are a group of individuals in recovery who have been advocating for an advancing abstinence-based solutions to end San Francisco's drug and homeless crisis and overdose epidemic.

What we believe, we'll go a little bit off script here, because I've heard the word recovery used a lot today, and I think sometimes it's being misused.

And what I wanted to do personally for myself and I'm sure my colleagues will agree that for me, recovery is not merely the abstinence of drugs or alcohol.

It is a profound transformation of the mind, body, and spirit, and it's a way of life.

A continuous journey of growth, healing, and self-discovery.

Recovery is a spiritual process that empowers us to live in a new way guided by honesty, humility, and connection.

And listen to that carefully.

Connection, not individualism, but connection.

Each day in recovery is an opportunity to grow, to learn, and to become the person I always wanted to be.

Thank you.

And continuing on, treatment on demand.

We believe treatment on demand is a 24-7 access to drug treatment services, detox stabilization, and residential treatment.

Any barrier that prevents immediate access, including assessments, coordination, screening, and funding inhibit the individual's ability to seek recovery.

Okay.

Uh good morning, supervisor.

So of course they picked me to present all the problems, right?

So uh I'm just kidding.

Uh so look, you guys know me well.

I've been a recovery advocate.

I'm formerly homeless uh on the streets of the tenor line.

I'm seven years clean and sober.

So look, there's some truths that we have to grapple with that you guys all know, but it's good to talk about them again.

We have 8,300 unhoused people approximately in San Francisco, at least.

At least half of them are unsheltered, depending on who you talk to, somewhere between half and eighty percent are struggling with addiction or the co-occurring disorder of addiction and untreated mental illness.

Uh 950 OD deaths and permanent supportive housing since 2020, which should speak to the need that we need to ramp up more treatment and recovery services and make it more accessible to people, including people that are housed.

I think we're all interested in outcomes and data around outcomes.

I'm gonna skip over to this 88% failure rate in San Francisco Medical funded drug treatment.

We didn't just pull that data out of the air.

That would actually came from the San Francisco Chronicle, where they basically did a public records request and they found that 12%, 12% was the completion rate among people in Medical funded treatment in San Francisco, which is 50% below the national average.

So while I deeply appreciate Director Sai talking about recovery, and Cedric mentioned it, you know, in years past we would come up here and have these hearings, and recovery was not, it was being redefined into different things.

That's all changed now.

So we've definitely made some significant changes.

And I just want to end with this before we move on to the next thing.

Harm reduction plays a role.

We in the recovery coalition recognize that it plays a role.

It is a set of tools.

It should not, nor should it have ever have been our policy in regards to drugs because it has helped contribute to the 4,300 overdose deaths that we've had in the city in the last six years.

So while we're not saying to get rid of it, we need to make equal space and funding for treatment and recovery in the city if we're going to succeed.

And if we're not going to do it here, folks, I'm telling you now, I've been talking to the feds, they're doing it at the federal level, and that money is not going to be for harm reduction from the Office of National Drug Control Policy.

It's going to be for recovery services, and you may not see it here now, but two years from now you'll be feeling it.

Thank you.

Hi, everyone.

Um, this slide represents two continuum of cares that the Salvation Army in West Sides Positive Directions created out of necessity several years back.

Um it represents over 800 beds for people, and we offer four what we consider true treatment on demand at four various sites.

And so we just again, this was out of necessity, and it's great to hear that DPH has created their own continuum.

I'm really excited to share that the pivoting from services that really promote and enable addiction to services that actually help people get off of drugs and reclaim their lives, has been an incredible journey, especially with the Department of Homelessness and the Department of Public Health.

So there's five new projects that are funded by the city.

Two are funded by the Department of Public Health, and two are funded by the Department of Homelessness and Supportive Housing.

First, the Eleanor Fagan Center, which is ran by Westside Community Services and funded by the Department of Public Health, provides treatment on demand with medical and clinical services on site, and is really a spot for people that can literally walk in off the streets without a referral.

It is located in Supervisor Dorsey's district in the heart of some of the worst city problems.

And when you walk inside, the environment and the community that they've created, is incredible.

People are getting healthy.

The program is in ramp up.

People are doing well, people are getting off of drugs and beginning the process of learning how to live.

Working in tandem with that project is a program funded by the Department of Homelessness called Hope House.

It's the city's first abstinence-based shelter ran by the Salvation Army.

It is 60 beds and a beautifully remodeled building.

Also, working in partnership with several other programs to help people move through the continuum and build on the success they had in early recovery.

Two other quick programs, uh Wells Place, a recovery housing program in the marina for 60 adults that are completing residential treatment, also funded by the Department of Public Health.

And what I think is the most important program on this list is James Baldwin Place.

We often hear conversations about the need of permanent supportive housing, whether it be sober or drug tolerant.

And what we leave behind is the actual data behind most of the people in recovery.

So Destiny just presented two systems of care where people coming off the streets can actually live for up to four and a half years.

So the three criteria to live in government funded housing is you must be chronically homeless, disabled, and you cannot earn more than 30% of the area median income.

The challenge that we've seen, and the data that we've collected, which started with a report that we submitted to the Board of Supervisors when I was the director of the re-entry division, was on the housing needs of justice involved adults.

So the people that are going to treatment and going to post-treatment housing are no longer chronically homeless.

They're working, even if they had a minimum wage job at full time, they earn more than 30% of AMI.

And so our message to them was oh, you need to go back to the streets and use drugs so you can get housed.

What a horrible thing to say.

So the Department of Homelessness and Support of Housing issued an RFP last year, and we've responded.

And that was the program that was created, James Baldwin Place.

It's ran by Positive Directions.

It is an independent living program for people who are exiting step down housing who are not financially stable to afford market rate rent.

What we feel is the biggest gap in our system is more beds for people to achieve independence, and that was the first step in the right direction.

And last, the Department of Public Health funded more detox and treatment beds at the Harbor Light Center.

Now I'm going to turn it over to Cedric and Craig for our recommendations for this year.

And but doesn't seem like the treatment is happening.

I know one thing for certain is that when I interview people that come to our program, the first thing they tell me that I was referred here because I could have housing.

And what providers do, and I think what the city has done is promote more housing than promoting recovery or reporting, you know, supporting substance use and getting the help that you need.

And I just truly believe that we have to change that and be able to promote more sobriety, promote more recovery.

Go ahead.

All right.

So we have a few recommendations that we'd like to share with you guys in regards to these areas.

The first one, which is a big one for a lot of us, because of what just happened recently with the guy from Urban Alchemy, what happened in front of Eleanor Fagan facility is to shut down open air drug markets, prosecute drug dealers, and restore public safety.

That needs to happen.

We need to quit pussyfooting around about it.

We need to really make some efforts to make that happen.

The second one is that we need to revise HSH and DPH's program policies to align with more absence-based solutions and programs.

The next one is to reinvest in absent-based solutions and decrease funding for services that enable addiction.

Address wage parity between government employees and nonprofit providers because those are the ones that's getting shot.

And they're the ones that are in danger.

The frontline people that are out on the streets doing this work, the outreach workers and those people who are out here dealing with these situations, and they can't afford to live in San Francisco.

Um services are sequenced.

Now this is a big one.

People using illicit drugs should be required to go to treatment before in place in government funded housing.

They need to have some type of stability before they go into government coming out.

Because what we know with our eyes and what we see every day is that people have housing, but they're still using and they go out in the streets and they don't even go in their houses.

They go out on the streets and be out there all day getting high.

Um, fund a therapeutic community in jail.

We had had it before, I don't know what happened to it, but it no longer is any kind of therapy.

We used to call it pre-treatment, right?

To prepare people for treatment when they leave out of jail and go into the community.

And our last one was reform mental health diversion through a local ordinance.

The way mental health diversion is set up, every time I catch a case, I can say I got mental health issues and put me in diversion so I can get back out on the streets.

And so that needs to be really paid attention to and looked at very closely about who's going forward, talking about they got mental health issues because everybody knows that's all you gotta say, and you'll get treated differently, and your crime gets put on the back burner.

This is not a good way to do this, it's not a good way to do this.

There's no accountability when you allow that to happen.

So those are things that we recommended that need to be looked at very seriously.

Thank you.

And the last one, we would love for our city to have a citywide recommitment to addressing the root causes of street level violence, which includes addiction, open air drug market and selling, untreated trauma, systematic, disinvestment of people of color in this city.

Alright, thank you, um, recovery coalition.

Uh, I um thank you for participating in this hearing.

Thank you for participating in our prior treatment on demand hearings.

I I think you guys have to get out of here by noon.

Um, but um but I also want to just note I've I've seen you in these chambers over the last seven years, and I I do think uh it just I always want to acknowledge like the ways in which you have changed um the conversations that happened in this building around uh addiction and recovery.

Um, the particular programs that you were helping to set up to support abstinence and support recovery, but also just your contribution to the conversation.

I think has been profound and important and is ongoing.

Um I think that my colleagues have some questions, so I'll let them go.

Vice Chair Mockworth.

Thank you all for your presentation.

Um, Tom, I had a question actually on one of the slides you presented that medica on I think page slide three.

Medical funded drug treatment in San Francisco had an 88% failure rate in San Francisco.

That seems exceptionally high.

Do you have thoughts on what contributes to that high number?

What can be done about it, and either for yourself or if DPH is still here, what's their thoughts are as well?

Yeah, uh, that's a great question.

So there's a few different things.

So, one uh uh director Sai kind of alluded to, uh, and Dr.

Kunin's was about speeding up the process around Medical approval to get people into treatment.

I think that that will help because you're streamlining the process, right?

But there's a few different things that contribute to this.

One of them is just the open drug market.

The actual draw of knowing that you can walk out of your program today and walk up the street and buy fentanyl on the street for five bucks where all your friends are, and you're the community that you were part of at that time, and it's still there.

Uh, and I think also you have to look at who are the providers providing the residential treatment program.

I think that that's key.

Uh, you know, we've had this kind of same bank of providers providing addiction treatment in San Francisco for a number of years because there doesn't seem to be anyone else that can scale to meet the need.

There are now other options out there that are available that can scale to meet the need, and I think it's very important for the Department of Public Health and for City and County San Francisco and the mayor uh to start considering alternative service providers to provide treatment that's more comprehensive that focuses more on long term recovery and abstinence as opposed to uh kind of this low barrier approach around addiction treatment.

For example, I'll just give you a quick example of why things fail.

There's one treatment provider who I won't name that basically when someone relapses in their program, the person gets to remain in their program and continue to use inside their program amongst everybody else that's trying to stay sober in that program.

That type of thought while compassionate puts everyone else in that building in danger of relapsing and all that work and all the money that we're building Medical to pay for treatment is literally wasted and thrown out the window.

And so we need to actually either create more resources or change the rules and have more accountability and more structure in some of the treatment programs that we're running that collect Medical funding, and then I think you'd see the outcomes improve.

Would you say then um supervisor?

I have one additional comment.

Prior to Medical funded treatment and these new evidence-based models, therapeutic teaching communities dominated this space where the method of treatment was the community itself.

Most of us are from Delancey Street, where there was hundreds and hundreds of residents, and we operated on the model of each one teach one, and the programs were the premise was based on accountability that we know people are gonna make mistakes and there are opportunities to learn.

The Medical model is your relationship with your doctor or your clinician.

So you have several people housed together, up to a hundred in some of these programs, and everybody's accountable to somebody else instead of your peers.

That's why the opening of the TRP Academy, which is now funded by the probation department, was the first step for the city to really branch out and talk about the value of therapeutic teaching communities.

In the 50s, there were really prevalent mental health community, and then merged into the recovery community with programs coming out of the 60s like Phoenix House and Delancy Street, MSD Foundation, and others, and they really are client-centered and community-centered where Medi-Cal models are just a lot of individuals dealing with a lot of different issues and not really part of the treatment community inside the program.

So if I'm hearing you correctly, the two problems here are one that uh the Medicall model doesn't take a community-based approach, and it takes a more medical-based approach, and that's what's been lost.

And then two, Tom, you noted that there could be state legislation that could maybe seem like state registration might be required to streamline some of the the bottlenecks that Medi-Cal is in.

Absolutely agree.

So we can we are limited in what we can do at the at the city and county level, and we're doing more at the city and county level.

Think you just saw with AB 255 the impacts of not passing certain state legislation or having certain state legislation, how it affects communities across the state.

So, yes, that would be the next logical step.

Thank you.

Thank you, Vice Chair Machmood.

And um, I would just want to say I just express my appreciation to everything you've you're you have been doing, and I know for some of you this there was a time that uh you were the lonely voices out there, and I think um we're seeing the change you've been calling for, and I just appreciate everything that you do.

Thank you President.

Thank you, Chair Dorsey.

Um, we will let you get on to your next thing.

But um, I am especially interested in um the line in one of those slides about uh therapeutic teaching community in jail that prepares people for when they exit because it's my strong suspicion, it's not just a suspicion, it's sort of informed that since COVID the jails have become, I think, less good at supporting um recovery at providing programming, that that's just been a thing that has kind of fallen away.

And I think that if we're gonna address these challenges, like getting into the jails and doing more work there is pretty important.

Um, you know, with a lot to do there and a lot to do in all these other areas as well.

So thank you.

Appreciate it.

Thank you all.

All right.

Um, so next, I believe uh we're gonna get uh April, um, from the fire department, and that's assistant deputy chief, April Sloan, uh, from the community paramedicine division of the San Francisco Fire Department or April Assistant Chief Sloan.

Um I think it was probably shortly after I started in this building that I got to do uh ride along and with uh with you when you were EMS six.

Um it's good to see you still working in this area and working on our way up through the department.

And I know you all are kind of seeing a lot on the streets, and we thought you might have some thoughts on areas where the city could be improving its response to um addiction among folks uh who you are interacting with.

Thank you so much, President Mandelman, Supervisor Dorsey Supervisor Mahmood.

Um I'm the assistant deputy chief of community paramedicine, as uh President Middleman stated.

So underneath me, I have the street crisis response team.

I also have captains that deal with more acute clients on the street, such as high utilizers and overdose survivors, and they partner up with the neighborhood street teams.

Um this first slide here.

You know, this is a hearing on demand.

It might seem kind of odd to get a first responder's perspective, but I want to point out that uh the first resolution here was for a hybrid HIPAA um act, and that really does show that SFFD is part of the continuum of care for the people that we serve.

Uh and I do want to recognize how far we've come.

I want to thank Director Sai and uh Dr.

Kunins for their very, I want to say frank assessment of the system and also um their work with us.

Um I stole the slide from Darrell Papo.

You can see community paramedics are actually part of the whole person integrated system of care, um, their established pathways to treatment.

I know who to call if I need to access them, and DPH proactively reaches out to us for to let us know when they have new programs and how to refer.

Um, actually, back up one more.

Um overdose prevention group.

So my section chief Mason, he sits on that group, he works with Dr.

Haum.

Uh this has enabled enabled our department to receive some SANSA funds for stigma, 5150s, and bupenorphrin.

So every ambulance in San Francisco and Street Crisis Unit, they carry bupenorphan and they can offer it immediately after an overdose or if they encounter somebody in withdrawal.

Uh now, data.

A little bit wonky here.

This is Rhode Island criteria.

This is how an actual overdose is defined.

It's pretty rigid as data is, um, and I I want to say it's not reflective of the field and what we see on the street.

So while it is a good measure, it is not a perfect measure because it requires that a paramedic document that there was an arcan given that they use a particular word to describe their state and whether or not there was improvement.

So if those things are not met, it is not classified as an overdose.

So for that, what I want to point out is so these are the Rhode Island overdose uh charts recorded by SFFD for 2023, 2024, and 2025.

They are going down.

That is great.

We want to see that.

But I want to point to some data that I think actually shows the bigger picture here.

So these are daily averages for 2024 for overdose, and then I'm using my division as a proxy.

So overdose means an overdose response on the 23 card, meaning the call taker has to tell the dispatcher that there's an overdose involved.

So there's approximately 19 per day in 2024.

The community paramedicine division, so that's street crisis and my captains, which we are largely funded by Prop C, which is for people with serious mental illness, substance use disorder, and um experiencing homelessness.

We run about 56 calls per day.

So we run the psychiatric or behavioral health crisis calls and the well-being checks.

And what I want to point out is that a lot of our funding and for good reason comes to us because we deal with response to substance use disorder.

So if you add up the two right here, that's 75 per day.

We run about 350 calls per day.

That is a big chunk of time that San Francisco first responders are responding to people with substance use disorder.

Um, and so for that I have you know two things I would like to point out that I think might be helpful to us to improve people's outcomes.

So for my division in particular, uh, Dr.

Sai mentioned that three-day waiting period.

It would be super helpful if we had a place to bridge somebody on the night, on the weekends, without fail, it happens Friday night on a three-day weekend.

It is really frustrating when we have somebody who says, I want treatment right now, and we don't have a place to bring them.

Um as noted, withdrawal management needs to be on site to get them through that period until we can get them through an intake.

That's specific to my division.

On the EMS side, the ambulances and the engines that are responding directly to overdose, because Street Crisis does not go to overdose responses.

That first picture I showed you with the engine, the ambulance, the rescue captain, all those people, those are the ones who are going to that.

And our only option is to take them to a hospital.

Specialized care within a hospital is not a new concept.

We have heart attack specialty, we have stroke specialty, but pediatrics, we have trauma.

Also within San Francisco, we are the only city that has transport to alternate destination for ambulances.

The first one being the sobering center, which has been around for many, many years, and that's for alcohol.

And then the second one, which just opened on uh the first of this month, the Geary stabilization unit.

I believe that an opiate or a post-overdose receiving facility would greatly benefit people in their outcome to route them to the correct place to get the treatment that they need, as well as reduce ED overcrowding.

And sorry, what's the facility that opened recently?

The Geary stabilization.

GSU.

A twenty two Geary.

Yeah.

So to finish up, post-overdose receiving facility for EMS, I think would greatly improve people's outcomes and access to treatment.

And to your knowledge, I mean we might invite public health to come back up, but to your knowledge, I mean how what are the conversations like with public health?

So we have it's it's there's a we have scope.

We have so we can bring somebody there, and there's the other talks about other things for things where people are either 48 hours post-overdose or intoxicated.

The level of acuity needed for somebody who's post-overdose is different.

You know, um, we work really closely with scope.

Um we did four referrals last month, that's actually pretty low for us.

But um they are more comfortable with people who've been cleared in the ED, and then discharged to them.

So sorry, so if you um revive revive someone or someone is to or you take someone to I mean, if an ambulance revives an overdose, someone who's overdosed, they're going to take them to the emergency department.

Okay.

That is your only option.

And you're suggesting that it would be good to have another place.

A place that specializes in actually an emergency room is not set up to um provide the long-term assistant needed for somebody with substance use disorder.

They will treat the immediate problem and then they will be discharged.

Okay.

Um thank you for your work and your presentation.

Um I might invite Dr.

Sai to come back up.

Um I mean, the conversation about places and having enough places and the right kind of places is an ongoing one, and you're working on a lot of places and have been, and your department has been working on a lot of places.

Um, but this need for, I mean, we were talking earlier about sort of the losing the people who are ready to go into treatment, but we don't have the place to manage their withdrawal, or they're not you know, there's some there's some issue there as being maybe a thing, an area where we're losing a lot of folks, and then this sort of idea that potentially we could have somewhere to take people who um have overdosed that is not the ER, like where how are you all thinking about that at DPH among all the other things you're trying to get stood up?

I think that's a good area of continued discussion.

One of which is, for example, even um April's mentioning the scope sobering program.

It has been historically geared more towards, as you noted, post-overdose for someone about to start MOUD.

Medication for assisted treatment.

We would like to broaden the scope of scope to be a little bit for anyone kind of struggling with some of the opioid use disorder, so that um it's a broader uh space uh for folks.

That is one example of broadening what we can do so that EMS and others can drop off.

It's voluntary, of course.

Um I think we can have continued discussions and thinking through the overdose scenario.

I would love to, I actually don't know if there are any state or other licensing pieces, but we are generally supporting that.

We are very supportive of to the extent we can wanting to triage folks.

Geary, for example, October 1, we got state certification to be the alternate transport site, as April mentioned.

So EMS can now take someone directly to A22 Gearie instead of the emergency department as of nine days ago.

That's great.

And so we're in the first week of really piloting that.

I think we should explore additional opportunities of the sort.

Fantastic.

Thank you both.

Thank you so much.

If my colleagues don't, do you know?

All right.

If my colleagues don't have anything more for um for April Sloan, then we will go next to the public defender's office.

And that is Olivia Taylor.

Hello.

Good morning, supervisors.

Tell us about treatment for the justice-involved population.

Okay, um, so I'll just start by introducing myself.

My name is Olivia Taylor.

I'm a deputy public defender.

I'm also the staff attorney from the public defender's office in both drug court and the community justice center, which we call CJC for short.

They're both collaborative courts that are focused on treatment.

Um drug court is a collaborative court specifically for people facing criminal charges or who are on probation who have serious substance use disorders.

Drug Court provides justice-involved individuals with intensive inpatient and outpatient treatment, which is monitored by case managers from the San Francisco Department of Public Health and by the Superior Court.

CJC has a little bit of a broader treatment mandate and serves many people who struggle with substance use disorders, mental health disorders, and need to address other collateral issues, such as homelessness, unemployment, and access to public benefits.

Uh that also that program also works with the Department of Public Health as case managers and with the court.

I have staffed both of these courts for the past 15 months, and during that time I've witnessed a very significant disconnect between the concept of treatment on demand that is often spoken about in the political sphere and the treatment that's actually available on the ground.

Most drug court participants start out in the jail and go directly from jail into residential treatment.

So I'm very familiar with the different residential treatment programs, including some of the people who've already spoken today.

And all of these programs are extremely popular.

My in-custody clients usually are waiting at least a month, if not longer, from the time that they are granted the opportunity to participate in a court like drug court until they're actually transported into treatment.

And as has been mentioned by other people earlier this morning, there are very few treatment opportunities available to them in the jail while they are awaiting entry into treatment in the community.

The programming options for monolingual Spanish speakers are even more limited.

My Spanish speaking clients often wait at least twice as long to get into residential treatment programming because there are, as far as I recall, I think two to three programs that actually serve monolingual Spanish speakers.

When it comes to other languages, there are even fewer opportunities, and it can be very, very difficult to place those clients into treatment programs.

I have clients that wait between three and six months in custody after being granted by a judge the opportunity to go into treatment while their case manager is applying for them, while they're on a wait list, and waiting to be transported to these programs.

And like I said, there just isn't dual diagnosis programming available in the jail for them.

That is not just the case for people that are waiting in San Francisco's jails, though.

I have clients who are referred out of custody to both drug court and CJC.

And my out of custody clients are also having to wait long periods of time to get into residential treatment.

Of course, I don't have data to present to the court, but not to the court to the to this body, but we got a promotion.

But I anecdotally, from my experience working with these clients, I have clients who are showing up to programs like Health Right 360 every day at 8 a.m.

trying to get a spot in those programs, and they're being turned away regularly because the program is at capacity.

And so I think there really is a disconnect between treatment on demand and the reality on the ground.

My experience as a public defender working with people who are desperately wanting to access treatment and of course have very real incentives to access that treatment from the court, is that that treatment is not available to them at the moment that they need it most.

There is significantly more demand for program beds than there are program beds available.

It is my belief that the city needs to allocate significantly more resources to these types of programs in order to make this ideal into a reality for treatment on demand.

In particular, I think that we need to increase Spanish language and other non-English speaking program opportunities for uh justice involved individuals and non-justice involved individuals, as well as more dual diagnosis programming.

I also believe that we need an expansion of step-down programming, as has already been mentioned this morning, as well as sober living environments and other forms of supportive housing for individuals coming out of a treatment setting, because that is an uh a very critical point in the treatment process, and you do see people who relapse once they come out of the very structured environment of residential treatment.

Um so thank you to Supervisor Mandelman uh for inviting the public defender's office to present today and for allowing us to share our experiences with regard to our clients' ability to access drug treatment.

I am very happy to answer any questions you may have.

Thank you, Ms.

Ms.

Taylor, for your work and for your taking the time to come over and uh be with us today.

Um, this is consistent with what we generally hear in response to these treatment on demand reports.

Um, and I'm often struck by what just seems like a wild mismatch between the presentation that we get from the Department of Public Health about general availability of treatment, but uh you know, with some uh areas where we might need to do some work versus not, you know, from the in the criminal justice context, seemingly not even close, long, long waits, not just a dual diagnosis problem, uh problem for everybody, definitely more of a problem on the dual diagnosis side.

Um the I mean I can imagine a reason for that, which is that outside of the criminal justice context, this stuff is all voluntary, and so we can manage if we if we just slice out the justice-involved population, that well, maybe we are somewhere in the neighborhood of meeting treatment on demand for the people who are voluntarily seeking treatment who do not have complex diagnoses, that doesn't seem like the right way to be looking at this, and it does seem like there's a massive gap on the criminal justice side that if we were if we're actually serious about addressing this problem in society since people go in and out of the criminal justice system, we would be using the criminal justice system as an opportunity.

I mean, that's not exactly the right way to say it, but if we have people in the criminal justice system who are getting the nudge to participate in treatment, that um the goals of our treatment on demand policy would be um well served by actually getting adequate treatment there.

And if we aren't measuring the gap there, and think on some kind of cadence thinking about whether it's every year or not every year, but thinking about how to close that gap, we're not living up to what we've we've been, what we're supposed to be doing here.

Um I think you've just sort of ticked off the areas that uh several of the areas, I think maybe all of the areas that have been previously identified and prior treatment on demand reports, dual diagnosis, justice involved, monolingual Spanish speakers.

Um I noticed those are not clearly called out in this year's report.

My frustration with the prior reports was that it didn't actually provide any sense of scale for those problems.

My frustration with this year's report is that it doesn't really um address them directly at all.

Um but I'm glad you're here, and thank you for trying to get um get treatment for uh for your clients.

Um I don't know if my colleagues have any particular one thing that I did hear in talking to, I think I said this was that it has actually gotten maybe easier in the collaborative courts to get um residential, uh this presumably is for outpatient, I don't know, for uh for out-of-custody people.

Easier to get residential, harder to get good um non-residential treatment options for people.

I don't know if that's consistent with what you're hearing or seeing or.

I think the vast majority of the clients that I work with are starting out in custody and and the typical, I would say 99% of cases, people are gonna be going directly into residential treatment.

Um, but eventually they're going to go into outpatient, as as you've all seen from the models, you know, that's that we don't stop treatment, right?

Uh, and particularly in drug court, the court uh wants before an individual has graduated from this type of program for that individual to be living independently in the community, working to support themselves or receive benefits of some kind and engaging in outpatient treatment.

So there are I think I think there are not enough outpatient treatment options, um, but my familiarity is is most sort of with the residential system because that's where people are the justice-involved people are typically uh entering.

And um, and I also do appreciate your bringing up the issue of uh which came up with the recovery coalition, but the availability of treatment or other support for recovery in the jails themselves, where it feels like we're maybe not um, not maybe we're I don't think we are where we want to be.

Um, and maybe um we can hear from DPH a little bit there about their thinking of what's available through jail health and if they have thoughts on gaps there.

Um, but all right.

Thank you.

If my colleagues don't have anything, nope, they're just eager for our next presenter.

So thank you so much.

Thank you very much.

Um, and I think next we're gonna hear from Victoria Westbrook, uh, re-entry division director of SF adult probation.

Nope, not Victoria Westbrook.

Oh, there's Victoria Westbrook.

Hello.

I'm here literally just to cue up Victoria Westbrook.

Okay, thank you for having us.

Jeremy Valverde, uh assistant chief of adult probation department supervisors, thank you again for your time.

Um just wanted to highlight a couple things before Victoria gets started, and she could speak on us with more authority.

But um back in 2012, the department um using funds from realignment heavily invested in individualized treatment um options and needs of our clients to some success.

We have um supported a pattern of doubling down on that effort with our own departmental budget, and we have done so since again um fairly effectively.

Uh, and I I'll just sort of say I think it's maybe helpful that we're wrapping this up because we sort of sit in the middle of a lot of these conversations.

Our focus tends to be relational or relationships, and by paying attention to these relationships, we can better identify the treatment that's individualized that works for our clients and all of San Francisco's San Franciscan seeking a safe place to engage in recovery.

I'll highlight one more thing before I turn it over.

Victoria will talk about our uh mobile cask.

It is a mobile unit that we intend to deploy.

It's hopefully just some of your districts soon with your advanced notice and hopefully support.

Um that will bring the services that we provide to the community directly.

We will park it in the communities, we will engage the people in the communities to provide referral services and services directly coming soon.

So thank you for your time.

Thank you.

Thank you so much.

As Jeremy said, I'm Victoria Westbrook.

I'm the re-entry division director for adult probation.

Just to give a little timeline.

So in 2008, adult probation and the senior ex offender program joined forces to create and held a recovery summit.

Out of that recovery summit afterwards, because we wanted to continue the conversation and really address what was going on in San Francisco.

We formed the recovery summit working group.

That group met regularly.

It consisted of people in recovery, people working with substance use disorder and substance use disorder treatment facilities, as well as loved ones who had been impacted by others' drug use.

One of the surveys were for current or former drug users, and the other one was for loved ones affected by someone else's drug use.

Over 500 people completed the survey, and based on the data we collected, in addition to input from the recovery community, we developed seven recommendations.

Most of those, well, the primary recommendations centered around including voices of people in recovery when having policy discussions.

Also extending drug and alcohol treatment, 90 days for people who have struggled with chronic substance use disorder for five, 10, 20 years or more.

90 days wasn't an adequate amount of time.

That's what we were running into.

People were going in and out of treatment.

We wanted programs to be funded that were culturally responsive to people of color.

And primarily we really wanted to expand the options for treatment.

In San Francisco at that time, the primary mode of or form like foundation for treatment was harm reduction.

And we knew in the working group that abstinence is the ultimate form of harm reduction, but there was this false dichotomy that emerged in San Francisco that kind of pitted harm reduction versus recovery as two opposing philosophies rather than complementary strategies.

And like the coalition said, recovery wasn't talked about.

We weren't seeking to diminish or eliminate any of the services.

We just wanted to expand the options that were present and available to people in San Francisco.

So we took these findings and recommendations to the reentry council.

They voted unanimous unanimously to support us bringing these recommendations and findings to the city.

And then in 2021, we were before this very committee and presenting what we found and what we thought would be helpful approaches to increasing our response to addiction in San Francisco and to improve outcomes.

During the 2020 shelter in place overdose deaths escalated dramatically as a department, we chose to take decisive action within our scope of authority.

While we lack the capacity to open a licensed residential treatment facility offering extended abstinence-based programming, we leveraged our existing expertise in transitional housing.

As was talked about prior previously, we launched the Positive Directions TRP Academy.

It's an abstinence-based recovery-focused transitional housing program designed to fill this critical gap that we identified.

Unlike our other drug and alcohol-free housing programs with stays up to one year, the TRP Academy operates as a phase system with intensive programming for the first six months, followed by an extended transition phase lasting up to two years.

In this program, medical assisted treatment is not accepted.

And we wanted to offer this abstinence only option for individuals who request or need this approach.

The data and the recommendations from the Recovery Summit Working Group validated what we had already knew that one size doesn't fit all.

Successfully addressing addiction and exiting the criminal justice system requires comprehensive multi-domain support and extends far beyond cessation of substance use.

So we developed this re-entry care and treatment network that was really an approach that was innovative and symbiotic, joining together multiple re-entry services to ensure a holistic approach.

What we learned is that effective interventions must address housing, employment, mental health, family relationships, education, and community integration, the whole full spectrum of criminogenic needs that drive recidivism when left undressed, and these are the same things that must be addressed for people to successfully move into recovery.

And you know, addiction isn't just about the drugs that we used, it's really about learning how to live in a way that creates healthy and productive movement in our community.

Sorry, I'll go back.

There you go.

Um I won't go over all of these, but these are the re-entry outcomes for fiscal year 24-25.

I did just want to note that there are some keys to our model.

One of them is the community assessment and service center.

It's a one-stop shop behavioral health focused re-entry center.

We are the first of that kind of reentry center in California.

During fiscal year 24-25, there were over 16,000 visitors to the CASC, which equated to only 270 unduplicated clients.

So that shows that our services and programs, clients come repeatedly keep engaged, and you know, because we know that the more consistently and that clients participate in programs, the more impact that they have.

In our housing programs, we require participants to save money, they we don't take it, they get it back when they leave the program.

Last year they saved over $700,000.

Over $200,000 of that amount was saved in the TRP Academy.

Again, this is the community assessment service center.

It's very it's central to our model.

We really work to decrease barriers for our clients and other justice-involved people to increase access.

And like Jeremy said, we continue to create and innovate to develop programs and services to increase access.

One of our hardest populations is our unhoused population.

And it's really going to help quickly um create referrals and connections to the programs and services that this population needs.

I just want to say before I stop that you know we don't do this work together, we do this in collaboration with a number of community partners, and we what we know is that the collaboration collaboration between community-based organizations and various city departments is really where the biggest impact and the best solutions come from.

Thank you very much.

And if you have any questions, I'll answer them now.

Thank you for your uh presentation.

I guess at a sort of very basic level, we heard from the public defender um harrowing tales of trying to get uh folks who are in jail or um out of custody uh into appropriate treatment.

What's the experience of adult probation in accessing the right kind of treatment for the people under your charge?

So we actually fund um, I mean, our our clients use a variety of treatment programs, but we actually fund um beds at Salvation Army through a work order with DPH to help increase the um access that our clients have to residential treatment beds.

Uh additionally, we have the Billy Holiday Center, which is a re-entry navigation and stabilization center that provides a way for people to go stabilize and start withdrawal management to either on their way to a treatment bed or on their way to one of our other programs.

So it makes them ready to start doing the programming that we have in other programs.

Uh we find that the really the continuation of care, the continued structure, is what best serves our clients.

We also have outpatient uh drug treatment offered at the CAST through UCSF citywide.

So are you basically saying that more or less with the resources that are out in the community and what you are able to provide through adult probation, you are able to get the treatment you need within a reasonable time frame for the people who you are?

It's better than what they could access on their own through DPH, but we still have wait lists.

And that's just there's just not enough money treatment.

Do you have sense of the scale of the wait lists?

Um, well, our wait list into treatment beds right now, I think like directly into treatment beds is about the last time I looked, it was like 10 or 11 people that's going into like full formal residential detox and into treatment beds.

How long does someone stay on that wait list?

It really depends on, you know, we can't, it's hard to say because we don't know, you know, if somebody's gonna relapse or they're gonna break program rules, or but it's not treat-I mean, that is not treatment on demand for at least people who are in adult probation.

No, I mean, really, our most of our housing programs also have wait lists, but the wait list to get into like the Billy Holiday Center is very small, if any, which provides um a place for clients to be on their way to the next step.

We're very excited about um the Eleanor Fagan and Hope House, which will also increase the ability, the movement through our programs and also places for people to start off.

Thank you.

My colleagues don't have any other questions, we'll let you sit down.

Okay, thank you.

Obviously, Director Tullock, thank you for being here.

Thank you for having us.

All right.

Um I know that uh uh Dr.

Cunnins needs to leave.

Um so if you could just pop up here for one more quick question and then get off to your afternoon of uh of meetings.

Um, we didn't really, I don't think we asked you to be prepared to talk about what's happening in the jails, so it's not a fair conversation.

It may not even be under you, um, but I mean, one of the things that just seems so obvious about this exercise that we go through is that we aren't measuring the gap on at least not in a way that we're presenting in the Freedmen on Demand reports around in jail and then not in jail but adult probation, or not in jail, but um pretrial or whatever it is, that we just it's a black box of uncertainty, but seems bad.

And um, I don't know if you have any thoughts about that, but it seems like a thing that in our follow-up conversations we should go into more.

Yes.

Yes, all right.

Um it's um I mean, I just want to acknowledge that hearing from the public defender and in our many collective conversations with the courts, that there are um a number of challenges that need solving where I believe there are multiple contributing factors, and we more precisely have to tackle those around I think a number of the issues we've been talking about, but they're um including looking at data together, including to understand what's driving those data and the different parts of the multiple systems that are working with these folks who who very much need to be in effective treatment.

I mean, as I as I said um to Ms.

Taylor, I could imagine I can imagine a story or a narrative of why the general availability to people voluntarily seeking relatively um uncomplicated treatment out in the world might be very that that the availability of that might be quite different from the availability in the environment of induced demand where we are um either encouraging or demanding that people get into treatment on um who are justice involved.

Yes, and and uh including some of the support, which as you and I have spoken about, which have been diminishing, for example, state hospital level of care, uh rolling down need to community level where community providers have not historically had the preparation or ability to care for folks with very profound forensic histories.

Just also acknowledge the colleagues from probation who I know have left the room.

We have had um very close collaboration with Chief Tullock and her staff in order to facilitate some of the needs and pathways into entry to a diversity of treatment approaches, and I think my sense from them and in the presentation that Billy Holiday has been a key linchpin in entry into care and reflects some of the investments around trying to have even if there are things that need taken care of before entry into residential care, there is a waiting air space that is therapeutic, conducting assessments, conducting initial supports and stabilization, which has been uh uh fairly effective.

I think is I think they would, if they were still in the room, I think their guide would also agree to.

Oh, I didn't see you all there.

I hope you agree uh with that, and it's been a very productive collaboration.

All right.

Thank you, Dr.

Connens.

Thank you for um staying with us until now.

And um I understand that you do need to head out.

So thank you.

Um so lastly but not least, by any means, uh, we're gonna end this hearing uh where these hearings started 20 and you know in 2019 with the treatment on demand coalition.

Um so if folks could come up.

All right.

Good afternoon, chair, supervisors.

Um, we'll make this as quick and efficient as effective as possible.

I know you all have lunch coming up, so um, want to respect that.

I'm the overdose prevention outreach coordinator at Tenderloin Neighborhood Development Corporation, and we're a member of the treatment on Demand coalition.

So I'm here with my colleagues, justice from the SF AIDS Foundation and Apple, uh, our community member and activist for dignity and liberation.

Um, I want to just first say that, you know, these issues we've talked about today, they're all deeply important.

Um, and for us, I think both professionally and you know personally, these are important issues, and we appreciate the ongoing dialogue with the board, the staff at DPH, and we just acknowledge people engaging as a community here, I think today, recognizing that we all share this, you know, the same goals of safer, healthier, more supportive communities.

And the opportunity to share an update on where we're at, elevate community perspectives on current progress and challenges towards implementing treatment on demand in San Francisco is very much appreciated.

I'm gonna just mention here as background, we have a coalition of nearly 50 local organizations.

This ranges from behavioral health providers to public health experts to people with lived experience, and we think that together we can actually advance, right?

This proposition T that was passed in 2008, and that called for San Francisco to provide sufficient capacity and quality of care to meet the need for publicly funded behavioral health treatment.

I wanna just give a sense of you know what our community has been feeling, these headlines, they reflect just a sample of what folks have been experiencing when reading the news and out in the real world.

And despite, you know, our city's expertise and compassion, San Francisco does remain in a behavioral health crisis, right?

And disproportionately affects people who use drugs, those navigating homelessness and poverty, and the neighborhood's businesses and workers that are most impacted by this substance use.

And we want to make sure that we're grounded in our work together here in public health and the framework that public health has provided us in emphasizing evidence-based care, compassionate and community-informed responses to substance use.

We believe that this framework allows us a shared foundation for policies and programs that reflect the realities of people who use drugs, and we help in this way to promote access to the health programs and the continuum of care our infrastructure already has.

Just to kind of um give a sense of our treatment infrastructure, who's accessing it, how are they accessing it?

I want to make clear that SAMHSA and their 2024 national survey on drug use and health, showed that 96% basically of people that have a diagnosable substance use disorder, they don't perceive, they don't perceive they need treatment.

So we have that huge proportion of folks, then we have four percent roughly that you know know they need treatment, but they're not seeking it, right?

So 95% of folks uh as a nation, can we force these people to, you know, 40 million people into treatment?

Substance use disorder we know is a chronic recurring condition, and we have to engage folks repeatedly with many different opportunities and accessible pathways in order to really make a difference on these 95% of folks, 99% I would say, because the folks that want it also aren't really seeking it, right?

So there's an opportunity here to I think bridge the gap between the abstinence-based programs that we want and the harm reduction strategies that uh we've long had in the city and treatment offerings, um, they can be more accessible, they can be more palatable, they can be more grounded in people's preferences, their goals, and their own experiences for what they want out of that treatment, and we got to do that engagement.

Um, with that said, we have made progress towards treatment on demand.

So, as you can see here, we've definitely expanded access to marginalized communities.

Um we acknowledge this, and I think specifically it's been around permanent supportive housing and the targeted outreach that we've provided to both black and brown communities.

In addition to that, residential treatment capacity has increased, as Dr.

Kunan's touched on, as well as Director Tai.

Um, outpatient participation has grown, and these programs, these new programs like Restore and Beam that work with folks from the street into outpatient sort of settings, that has been a success in our view.

At the same time, we know, right, there's barriers that persist, and we want to name them.

There's been, you know, access to medications for opioid disorders, but it's been uneven, right?

It's been uneven, and that can be improved.

Overdose mortality, that, you know, is increasingly seen in older adults.

So just noting that.

Residential treatment wait times, we've talked about four days too far, or sorry, too few low barrier drop-in spaces as well to support movement along our city's continuum of care.

And then last but not least, overdose prevention centers and wellness hubs.

They were removed from the overdose prevention plan.

Want to note that, and it was without really an explanation or community process.

To expand on this a little bit, there are some data gaps we are acknowledging here around treatment on demand.

What does it mean to actually have treatment on demand, right?

Current estimates, they don't reflect people's substance use patterns.

So we have estimates, but they don't quite capture the sort of the complexities.

It's incomplete measure in some ways.

It doesn't reflect their use patterns, the preferred routes in which people are using, and importantly, to get a more complete and precise measure, we need to know what their service-seeking behaviors are.

So policies prioritizing, you know, accelerating people from street to treatment.

If we're not addressing whole people needs, it's gonna undermine the trusted relationships people already have with their providers in harm reduction specific relationships too.

And you know, we've gotten a report from the BLA with some initial recommendations using the four pillars approach.

So I think the city does have sort of a um scaffold for how we can roll some of these solutions out that will later go into solutions, you know, as far as the coalition having provided solutions over the years as well as our new uh recommendations.

So these recommendations from the four pillars report, um, they reinforce many principles.

Um we've talked about so cross-departmental coordination, early prevention, expanded access to medications and drug checking, uh housing as a foundation for stability, and safe consumption sites to save lives.

And so now what I'll do is I'll pass the mic to Apple.

Um since we have time, we're not gonna leave her testimony till public comment, but she's gonna talk a little bit about her perspective as someone with direct lived experience with our treatment system.

Thanks, Kevin.

Good morning, supervisors, DPH leadership, and all present.

My name is Apple Kronk.

I am a person who has coped with substance use disorder and survived on the streets for over a decade.

I support the treatment on demand coalition in their recommendation to expand treatment options that are voluntary and readily available when a person seeks it.

It is a pivotal and precious moment when someone who has a substance use disorder decides they want help.

If that opportunity is not met swiftly with compassion and open doors, it is often an opportunity missed.

I know what it's like to want support around substance use only to not have the resources available.

Conversely, I've experienced being pressured into mandated abstinence when I wasn't ready.

And at that time, I did what most people would do when forced into a corner.

I ran.

Being met with demands rather than dignity pushed me further away from the help I needed.

And the shame I felt drove me into isolation.

The most dangerous place a drug user can go.

I nearly died from an overdose on three separate occasions and only survived because somebody with naloxone ended up finding me.

What is startling is how often it's shown to happen after a person goes through a forced period of abstinence, which they aren't ready for.

One Massachusetts stat Massachusetts, excuse me, statistics states that people who go through a mandated period of abstinence after an arrest are 41% more likely to overdose compared to people who go through voluntary treatment for the same length of time.

I now celebrate three years, nearly three years sober.

I want to stress that harm reduction never opposed my path to sobriety.

Rather, it enabled it.

It kept me alive and healthy and free of deadly infections until I was prepared to take that step.

If it weren't for these basic needs being met, I would not have lived long enough to have gotten the chance to be in my recovery journey.

It's also relevant to mention that if it weren't for having finally obtained shelter from the streets while I was still using and discovered that I was pregnant, I never would have made the medical appointment that led to getting me getting medically assisted treatment.

If it weren't for this, my daughter likely would not have survived.

That's why we must continue to support housing first and give people the opportunity to stabilize without giving them ultimatums about their substance use.

If you extend the hand of compassion and understanding while meeting people where they are, people will be more willing to accept the help.

When you offer substance users dignity and autonomy while celebrating every goal achieved, no matter how small, that's how you provide hope for the future.

Understand that recovery takes time.

It can only be taken a day at a time, and there were almost always be setbacks, but they should not have to come at the cost of somebody's future.

And I do want to thank DPH for everything you've done to support meeting the goal of treatment on demand, improving outreach efforts, and expanding treatment beds.

It's critical not only that treatment options are available when people need it, but that these options are as diverse and individualized as the people being treated.

What works for one person may not work for another.

Therefore, all options must be on the table.

Importantly, we must connect them to the services that meet their specific needs at that moment.

Whether it means getting them through the doors of residential treatment that same night, or if it's not what they want at the moment, ensuring that they have the available resources to continue using as safely as possible so that they have a tomorrow and a chance to be ready on their own terms.

If we can at least succeed at that much, I think then and only then we can talk about how to better support long-term sustained recovery.

Thank you for listening.

And now I will pass it back to my colleague, Justice.

Thank you, Apple, for reminding us and telling us about your experience.

I really appreciate your vulnerability in this space.

And it's a good reminder for us of all the tools that we use and how they can all be helpful for anyone in this city who might be struggling with a similar thing.

We have some additional slides here.

Also, thank you.

Some prior treatment on demand coalition recommendations around centering the experience of people who use drugs in program design so that services can reflect their needs and preferences of lived experience.

Something else that I want to touch base on here is ensuring the low threshold evidence base and culturally inclusive care is fully staffed, funded, and voluntary.

Obviously, harm reduction has been a policy of San Francisco for a long time, but a lot of that staffing and programmatic services have been systematically underfunded for a long time.

And it seems to me that the failure of funding has indicated to people that these programs don't work, which is simply not true.

The programs are working and they do a great job.

We just don't have enough resources in order to do them to scale for the demands that we need in this city.

I won't go into everything on this slide in the interest of time, and I'll be reaching out to you all for uh individual meetings so we can dive into these things a little bit deeper, but I'll move on for the sake of that.

Some of our new recommendations are listed here.

Um I'll touch on some of them as well.

One is to integrate harm reduction treatment and recovery systems for person-centered continuous care.

I know I said this earlier, but it's something that is so important to reiterate that this person-centered care really helps enable and create a system of trust in a system where people feel systematically forgotten and ignored.

So having a person centered approach really makes sure that these systems began to be trusted on a larger scale, right?

And so people go and tell their friends they had a great experience rather than saying they're telling their friends, wow, they tried to force me to do this, and this XYZ, you really shouldn't trust them.

Sustaining housing first is also extremely important.

It is a baseline for a lot of folks to be able to have a safe place to be and to exist and to know that people are there, supporting them in their journey and making sure that they are, you know, not ODing and all of these things is extremely, extremely important.

And I also want to mention that in honor of treatment on demand, we should ensure that we're not doing anything to defund any of the tools in our arsenal.

All of these tools should be available, as many folks have said today.

And adding any barriers to care will not help us with any of these problems.

When the hoppers with overdose won't help us with retaining people into treatment, it's really, really critical that we don't try and defund these tools, but we really try to ask for a larger pot, right?

That's really what we're asking for here.

And it's absurd to suggest that you know ending housing first might be a solution because that is how people are enabling drug use, right?

That is just simply untrue.

And I think points to one of our commitments here, which is a commit to ending stigma and misinformation that undermine care and harm people who use drugs.

Um I'll move on again.

So we have a couple of more recommendations here.

I want to really point out to apply the same transparent community-driven process to develop another overdose prevention plan because the 2022 plan was creating this really beautiful community input.

There are a lot of community stakeholders, and I think that plan really encapsulates what a lot of people in the city want and need.

So the revisions of the 2024 plan that were given with not really any community input or explanation really hit us in a weird sense.

And so we really just want to ask to have a more transparent process in doing that.

And something else we'd really like to say is that having a publish some service linkage and care access metrics that are tracked post-arrest by law enforcement.

I know we talked about that a little bit with DPH's presentation, and I think there's some more coordination that we could use with DEM and SFPD and DPH to really get all these teams working on a similar system so that way we aren't uh, you know, recreating the wheel and are re-talking to these patients and and redoing um duplicative work.

And I'll pass it back to Kevin.

Thank you.

So just to finish off here with some further considerations that we can take as a city, um, take into sort of our toolbox here.

Uh we can, as mentioned, expand contingency management programs, right?

We can diversify sort of um the substances that we use, contingent contingency management programs to um help our residents.

We can diversify treatment outcomes to reflect residents' goals, you know, clients' goals and what they're hoping to improve on in terms of their substance use.

Um, and we can also authorize an additional sobering center.

Um, these are all doable.

On top of that, I would say that the city uh should resume approving new surrender service programs and end the pilot restriction on safer use supplies.

Other cities we know, like New York, Providence, Burlington, they're all successful in terms of their implementation of overdose prevention centers.

And I just wanted to hand the mic over a second to um Apple to talk about overdose prevention centers.

If you could.

Thank you so much.

I want to take a moment to reopen the conversation on this public health solution that we feel should have been adopted if done right, and if done right, has the potential to shift the paradigm in our city and lift us out of our current epidemic of drug overdose and human suffering.

Let's talk about opening another safe consumption site.

And I say another for a reason.

Often called the linkage center, the tenderline linkage center, was open in 2022, and wall open 333 overdoses occurred on site and were immediately reversed.

Nobody died.

That means that 100% of would-be fatal overdoses were prevented in that controlled environment.

To put that differently, in a very real sense, people died when they used outside the protective, excuse me, protective walls of such spaces.

I know that not just through data, but by witnessing quick trained responses myself while I was there that turn tragedies into second chances.

We know addiction and substance dependence can't be coerced away and willed away through punitive measures.

It's not a debate, that's reality.

People use in hidden unsafe places because they are terrified of arrest, overdose, or abandonment.

The safe consumption site model doesn't compete with treatment.

Rather, it serves as an entry point for it.

For those who want it, it does not compete with prevention either.

It acknowledges the reality that drug dependence already exists and cannot be solved overnight.

We know that harm reduction serves as a bridge, not a detour.

People who feel safe are more likely to trust, engage, and accept help over time.

In San Francisco, the cadence of fatal overdoses, particularly involving fentanyl, remains unacceptably high.

The more people we can bring into contact with care in environments that don't kill them, the better the odds.

The tenderloin center was that bridge.

It saved lives, fostered trust, and created a proven proof of concept.

The data 33, 333 reversals, zero deaths, and 124,000 visits shows what's possible when you lean toward fostering safety and showing tolerance in a welcoming communal setting, whether than rather than driving substance users into isolation and abandonment.

And I don't I don't pretend this is perfect.

The linkage to treatment arm had constraints.

Relatively few visits translated into confirmed placements, um, treatment placements.

The question is, are we just saving lives so that people overdose again?

It's understandable, but every moment somebody is alive is an opportunity.

And life versus death is always worth fighting to sustain.

If we are not willing to give every reasonable solution a shot, then what are we doing?

The caveats from what the previous attempt, the Lickage Center, has taught us, lies in how aggressively we build warm handoffs, low barrier access, and wraparound supports.

So today I'm urging that this year's treatment on demand hearing elevate the conversation.

Let's move toward opening another safe consumption overdose prevention site in an area with high rates of overdose and low access to services.

The new site should be um, I'm sorry.

The new site should be low barrier, community trusted, and integrated with on-site overdose reversal, hygiene, basic service access, showers and rest space, real-time harm reduction supplies, warm handoffs to treatment, housing and mental health, radical hospitality approach, dignity and trust will be the magnet that draws people in.

Community oversight, transparency, monitoring, and evaluation.

And such a site does not replace treatment.

It enhances the possibility that people will accept treatment in their terms.

It's not radical, it's evidence-based, humane, and necessary.

Thank you, Apple.

Um, and just want to follow up with we can also explore uh in addition to overdose prevention centers, safe supply, safer supply strategies, um, that promo that promise uh sort of an approach that's harm reduction-based for um dealing with unregulated drug markets.

All right, and then to close out here, want to urge San Francisco to, you know, ground itself in treatment on demand, particularly through a public health framework that prioritize evidence, compassion, and community well-being.

We affirm public health as the foundation for addressing substance use and related challenges that our community faces, and it's critical to educate right all San Franciscans, including both community and providers on how and why substance use treatment and recovery are public health issues and to highlight how stigma and misinformation can negatively impact health outcomes.

We also want to recommit to policies and investments that prioritize care, compassion, and evidence over punishment, ensuring that people who use drugs are treated with dignity, respect, and access to the full spectrum of care.

And so with that, thank you for your time and leadership, and we're welcome to any questions.

Thank you for your presentation.

If there are no, oh, I've done.

Thank you, President.

Um, I'm having trouble, and I want to hear your thoughts on this, squaring up the really striking statistic you shared on one of the early slides of, you know, 95-96% of people not perceiving the need for substance use treatment, but then you know the the viewpoint that these programs should be voluntaries.

How do we get from you know overwhelming number of people not feeling that um that need to folks doing that voluntarily?

And that's I know there's a long answer to that, but I just I want to hear how we how we close that gap succinctly.

Yeah, I can speak to that a little bit.

I think a lot of this requires like trust and relationship building.

And for us, a lot of the things that we think uh is that harm reduction provides a low barrier, low access point of connection for folks, right?

And as Apple mentioned, it extends the lifespan of folks to be able to have more opportunities to get into that treatment, right?

And so the the goal of Harmadech is meeting people where they're at, which may be not ready for treatment, and continuing that journey with them until they get to that point.

And there are points along that path where people push and pull, and there's some ebb and flow there, but it's really about extending that lifespan and having connection for folks.

Um it has been said that the opposite of addiction isn't sobriety, but it is connection, and that's really what harm reduction provides.

It provides connection for folks to feel like they are accounted for and cared for in a space so that they don't isolate and then have worse health outcomes, if that makes sense.

Thank you.

Um can I say something on that?

Um, so when I hear recovery, I really I like SAMHSA's definition of recovery, which is taking steps toward um a self-directed life and making progress in that way.

And I think what needs to be understood is that any small achievable goal is something that should be celebrated.

Like it can't, you know, even if somebody doesn't think they're ready for treatment, like Justice was saying, it's about building that trust and building that connection.

So when they are ready and a hand is extended, they feel comfortable accepting it.

Like I I wasn't ready for treatment for a very, very long time until I was ready, until that moment where I was done.

And somebody met me where I was at with compassion and was like not judging me and telling me, okay, we're gonna get you what you need, we're gonna get you the medication you need, and we're gonna help you.

It's just about building that trust and having that door be open.

So and I think that you know, it's not logical to think that everybody is gonna just stop using drugs and everybody's gonna become abstinent.

We can't treat everybody into abstinence, people are going to use drugs, and that's why harm reduction strategies are necessary because people need to stay alive and they should have the right to stay alive regardless of what they're doing.

Just because you don't like their lifestyle, you can't deny them the tools to be safe and healthy.

All right, we should go to public comment.

Madam Clerk, can we open this up for public comment?

Yes, members of the public who wish to speak on this item should line up now along the side by the windows.

We're gonna ask uh that you limit your comments to two minutes, please.

First speaker can come up, please.

First speaker, hi.

That's hard to imagine I'm the first speaker.

But uh, thanks for the hearing and thanks for uh all the good work.

My name is Brian Webster.

I am a semi-retired project manager and uh organizer living in San Francisco.

I came to San Francisco in 1981, straight from uh Lane County jail in Eugene, Oregon, where I entered the uh DeLancey Street Foundation.

I was a resident of Delancy Street for five years, and I'm still a graduate in good standing.

I have uh experience, uh, you know, ups and downs, and I'm an alcoholic and drug addict, but I do not represent any uh anonymous organizations or fellowships or any organization uh for that matter.

But um I have been clean and sober for uh one day at a time for over 30 years.

Uh I prepared a uh document to submit to the uh committee and to uh Matt's office.

I've been threatening to give him this for a while.

Uh it's uh called Beyond Government Programs, the pivotal role of community-driven addiction recovery services in San Francisco, how peer support groups and innovative nonprofits expand access to recovery.

So I just like to say that this phrase, treatment on demand, just sounds wrong.

It just sounds backwards on its face.

I have a lot of respect for the uh tenderloin neighborhood development corporation and the organizations with the treatment on demand coalition, but um there are hundreds of uh recovery meetings that happen every day throughout San Francisco through Narcotics Anonymous, Alcoholics Anonymous, organizations like Delancy Street that have no, where the federal budget, the state budget, the city budget has no effect on their operation or their effectiveness.

Thank you for commenting.

Thank you for people in recovery, um, responsible for their own recovery.

Okay, thank you.

Thank you.

Next speaker, please.

So okay if I talk here, okay.

Um I just want to say one thing before I read what I what I typed, but um, and I wish there were still people here that left earlier to hear this, but abstinence may be one way um one way people can get uh clean, but it's not the only way.

Um my name is Ray Orfiano, I'm a resident volunteer.

Um and I live on 10 in the tenderloin on the corner of Golden Gate and Leavenworth.

I specify my exact location because it represents what most people think of when they imagine the tenderloin, an area associated with drug dealers and individuals struggling with addiction.

As someone who has been in recovery from alcoholism for four years, I can confidently say that I wouldn't still be here today if it weren't for the treatment I received.

While some treatment options are available, they're not enough.

Many people want help, but when they seek treatment, they often find that there are no available beds or spots for them at that time.

I strongly encourage you to back the recommendations and requests put forth by the treatment on demand coalition.

By doing so, the city can take critical actions that align with its commitment to ensuring accessible treatment for all residents in need.

This includes developing comprehensive programs, increasing funding for mental health and addiction services, and providing resources that make treatment readily available to anyone who seeks help.

It is vital for our community.

We move forward decisively to support those who are struggling, ensuring that there's no one left behind in their journey towards recovery.

Thank you.

Thank you for your comments.

Next speaker, please.

Hey, good uh good afternoon, supervisors.

My name is Curtis Bradford, and I'm gonna go a little off of what I was gonna say earlier.

I've changed everything I want to say based on what I heard today.

I'm gonna talk about three things.

One, I want to talk about the definition of recovery, two, I want to talk about this idea of uh housing first, and three, I want to address the efficacy of permanent supportive housing.

One, there the arrogance of someone claiming that there is only one, their version of recovery is the only legitimate version of recovery, is really offensive to those of us who maybe found recovery in another way.

I'm celebrating 15 years clean and sober coming up, and I did it through harm reduction.

If I hadn't done harm reduction treatment for two years to get me to a place to choose abstinence, I never would have, I would have been dead, I wouldn't have been here.

Literally, I would have died, right?

Like there's no way I would have made it.

I I tried abstinence-based, couldn't do it.

Harm reduction kept me, saved me alive, gave me a path to recovery.

Abstinence is not in contrast harm reduction.

Abstinence is a goal of harm reduction in the end, but it's a trajectory, it's a it's a progression.

It's not one over the other, and and certainly not the only legitimate version of recovery.

Two housing first.

I got housing first.

I was living in permanent supportive housing.

It required that to happen first.

I was in there for six months to a year before I was able to make those first steps towards recovery.

Why?

Because I needed to get some health coverage first.

I needed to get medication from HIV, I needed to do there were a lot of steps that had to happen, and none of that could have happened if I hadn't gotten housing first.

So the social worker in my housing first, that's what did it.

And when we talk about permanent supportive housing, it's the lack of resources that doesn't allow for even greater efficacy of permanent supportive housing.

They could do a lot more with more resources.

But when we talk about some of the failures in permanent supportive housing, we're not mentioning the tens of thousands of us who actually did successfully transition through permanent through housing first model, and thousands of us who found recovery and abstinence through the through the housing first model.

So there's thousands and thousands and thousands and tens of thousands of success stories.

Permanent supportive housing, housing first, harm reduction saves lives.

Thank you.

Thank you for your comments.

Next speaker, please.

Uh hi.

Good afternoon, supervisor.

My name is Tammy Wong.

I'm referring I'm representing to T C A mean it's tend toi, tiny, um.

Tend the uh no, tenderly tiny rye association.

Uh they just left.

Yeah.

And then I present that.

I'll continue on our case, Soviet have a first step to meet need for the people to behave.

Challenger in our culture, diverseity.

We need uh you city on acceptable option to help people to get the mental health, and subtle you support they should.

I also to support our community.

Thank you.

Thank you for your comments.

Next speaker, please.

Good afternoon, supervisors.

I'm Laura Thomas with the San Francisco AIDS Foundation.

I want to start off by thanking Supervisor Mandelman and your staff in particular for your continued um focus on this issue for continuing to ask hard questions and push for answers, and in particular pushing for better services for all San Franciscans.

So thank you.

We've been doing this for for a minute, um, and I I appreciate uh all of your attention on this.

Um, you know, the treatment on demand coalition, which, as Supervisor Mandelman mentioned, was created uh in part because of this hearing.

You know, what we have been saying for years is that no one should be waiting for services anywhere along the continuum.

And you know, we there are many ways to enter into pathways to recovery, and it is really important that those entries be as easy and as seamless as possible.

You know, we don't want there to be friction, we don't want high thresholds, people should be able to walk in in that moment when they want a different relationship with substance use, a different relationship with what's going on in their life.

It should be as easy as possible.

And we really appreciate the work that the Department of Public Health has done, particularly over the last five years to make services um more expansive and more accessible, but we're still facing, as we have just heard, some really um uh substantial barriers.

I also want to raise some concerns that we make sure that as we are changing our policies, that we are not creating any unintended consequences that actually increase harms and that um uh negatively affect people's health outcomes, that we're keeping our eye on how we get to zero with HIV, and we're not uh changing policies that result in people being less able to access HIV prevention and HIV testing.

You know, science and public health is currently under incredible attack at the federal level, and we need to be clear that here in San Francisco, we stand up for science, for evidence-based approaches, and for compassion for all San Franciscans.

Thank you.

Thank you.

Next speaker, please.

Good afternoon services, uh supervisors, and thank you for your time.

Um I'm LJ Lara, a client receiving treatment and housing services through a San Francisco program.

Since 2020, San Francisco has expanded its residential and treatment care that allows people to access mental health care and substance use treatment.

I asked for continued and expanded support for sustained housing while enhancing recovery housing options.

And I also ask that we honor uh lived expertise with trauma-informed care with targeted workforce development and hiring of peers and ensure no one loses housing for engaging in treatment.

I found myself in grave need of these services after some traumatic experiences that were not correctly handled.

I went from an active professional member of the city to a man in a very dark place spiraling down with exasperated mental health issues and new substance abuse issues.

I believe I was one of the lucky ones who got into treatment the day after I tried to get into a program.

I have and continue to receive services that have turned my life around.

The housing, education, therapy, and mental health services have been vital in my recovery.

I am thriving and growing back to not only the man I was, but even stronger and more grounded.

Unfortunately, I have lost my permanent housing, but I hope that will fall into place when the time is right.

I feel so much better, and I have hope again for the future, which seemed lost.

Again, I ask for stronger care through supportive housing with integrated mental health and substance abuse treatment with an importance placed on employing people with lived experience and trauma-informed care.

Thank you, board, for your time.

Thank you for your comments.

Next speaker, please.

Hi, um, my name is Desiree Brown, community organizer with TNDC.

Um, and I just want to um say in order to address our city's public safety concerns, being a community organizer, I feel like one thing that is very important is to kind of bridge the gap of all the organizations that are doing the work, um, and just kind of bring them together with the work that DPH is doing, um, with the treatment on demand work that's being done with the different organizations.

Um, I feel like as a community organizer, that is a way to really speak to people.

I feel like I um I appreciate DPH for having the community meetings with us, but I feel like we can have more.

Um, I feel like as a community organizer, um, me personally as well as other organizations and other community organizers, we should be like coordinating something with DPH because everybody is doing different work in the TL and in San Francisco, but I feel like it can all come together in one way.

And I feel like it's instead of maybe trying to look at what could be eliminated, maybe looking at like what organizations are doing and like what DPH is doing and how we can collaborate together.

So there isn't like any gaps with re-entry services or people trying to get treatment, um, or just like even discharge services, those people are not lost within the city.

Um, so yeah, I feel like just kind of bridging that gap and just bringing us actually in maybe like the ideas and the action plans that DPH are trying to do will be great.

Thank you.

Thank you for your comments.

Next speaker, please.

Um, hi, good afternoon, supervisors.

My name is Andy Stone.

I'm with the San Francisco Aid Foundation and the HIV Advocacy Network.

Um, we are a group of grassroots uh HIV people living with HIV, LGBTQ folks, many of whom are people who use drugs and/or people who are in recovery.

Um, and we just want to highlight from an HIV and LGBTQ perspective um the importance of harm reduction and treatment services for folks that are grounded in evidence that are evidence-based, that are grounded in care and dignity.

Um, this is an extremely important issue for our community.

A lot of uh people, like the number one cause of death for people living with HIV in San Francisco is now overdose.

Um, this is a huge crisis that we're facing in terms of the overdose crisis.

We need uh compassionate responses that are evidence-based that treat people with dignity.

Um, and yeah, we strongly support all the recommendations put forward today by the treatment on demand coalition.

Thank you.

Thank you for your comments.

Next speaker, please.

You know, we can't even uh stop people from uh from smoking cigarettes in their rooms.

You know, there are things that are unenforceable.

Yeah, you know, since the beginning of humanity, people have been using substances, even uh our pre-human precursors used substance and sometimes got in trouble for some of them who went through to Lancy Street and we reestablished their connection to modern humanity, which which I'm I'm grateful for.

I heard a city official once talking about the race problem said it took us 400 years to get into this problem, and I'm willing to work another 400 years, whatever it takes to get us out of this problem.

And I have to say that's how I am with the with substance abuse, and I do support the continuum of care.

Thank you for your comments.

Do we have any additional public speakers?

That concludes public comment.

Thank you, Madam Clerk.

Public comment is now closed.

President Mandelman.

Thank you, Chair Dorsey.

Thank you, uh committee members for your well, thank you, uh Chair Darcy for your co-sponsorship.

Thank you, uh committee members for your participation.

I want to thank all of our presenters as well as uh members of the public who came out uh to speak.

Um I mean, I think there was a lot that was interesting both about the report and about the hearing.

I also think that neither the report nor these hearings are accomplishing what people anticipated in 2008 when they put property on the ballot.

And I look forward to ongoing conversations with the Department of Public Health and other stakeholders about how to uh try to get some measures uh and greater clarity and specificity about um you know where we're trying to go and how far away we are from those goals and what the gaps are and how much it would close it would cost to close them, and I and that you know may not be an exercise you can do every single year in its totality, but I don't think we're doing it at all in some ways.

And um that uh I think is is not good and doesn't help us get um to a better place.

So I'm grateful for all the great work the Department of Public Health is doing.

I'm grateful for the fact that these reports have grown from um two pages that didn't really mean anything to you know what is now sort of a semi-comprehensive look at kind of their priorities and what they think they're working on, but I still think there's just um a gap there in terms of uh thing treat goals around treatment availability and how far away we are from meeting them, other goals around substance use disorder and how far away we are from meeting them.

And I'm hoping working with our chair and uh the department and others that maybe we can uh get a little closer over the next year.

Thank you.

And I would request that this hearing be uh heard and filed.

Great.

Thank you, President.

Mandelman, I would just um close by expressing my gratitude to you for your work on this and my gratitude to everybody who um was here.

You know, to the extent I think um we as policymakers and as a city struggle with with measuring some of the outcomes and trying to figure out what is the solution that's gonna work um for everybody.

Uh I'm reminded of a uh conversation I had a couple months ago with a reporter who quoted a clinician who said something that has just really stuck with me, and that's you know what they say, you've talked to one addict, you've talked to one addict.

The reality is there is no one thing that works for everybody, and I think that is something that is has been uh increasingly apparent to me during my time as a policymaker, but it also maps to my experience as a person who's spent most of my adult life in recovery.

Every journey is different.

Um, and it has to be a multitude of approaches.

And we're and if we're in search of the thing that's going to work, we're we're gonna find that there is no one thing.

It's gotta be everything.

Um, so with that, I would uh in uh make a motion that this hearing be heard and filed.

Yes, and on that motion that this item be heard and filed.

Member Sauter.

Member Sauter, aye, Vice Chair Mahmood, Vice Chair Mahmood, aye, Chair Dorsey, Chair Dorsey, aye.

I have three ayes.

Thank you, madam clerk.

The uh motion passes.

Madam Clerk, are there any more items before us today?

That concludes our meeting agenda.

Thank you.

Everybody, we are adjourned.