tv Government Access Programming SFGTV March 14, 2019 10:00pm-11:00pm PDT
>> chair mandelman: and you have a daytime at hummingbird. >> they treat people all day until 6:00. >> supervisor stefani: and just to follow up, it's not just about what the city and county of san francisco can provide, if what you need from us in terms of how we invest our dollars, but i want to know what can our other hospitals be doing? what can we step up to do? that's the information we need. what can we ask kaiser to do? what can we ask cpmc to do? i want to know what we need, and then how we can ask the other places to provide it. >> we need more lsat, locked
subacute treatment beds. >> chair mandelman: what does that mean? what is a locked subacute treatment bed? >> so it means the individual cannot come and go as they please. >> chair mandelman: so they would be inappropriate at s.f. general, and we would have a hard time justify keeping them there, but they don't have a place to go, and they can't be released on the street, and we also don't want to send them out of county. >> right. >> chair mandelman: that's the point of expanding the healing center with the eraf dollars does. i know that supervisor stefani has a few more questions, but i know that supervisor ronen wants to follow up. >> supervisor ronen: yeah. instead of following the line that i started and i feel like
i haven't gotten a lot of answers for, i'll follow up with what supervisor stefani said. so hummingbird is -- it's a navigation center. and granted, it's a navigation center that's focused on people with behavioral health conditions, but it's a temporary place for homeless individuals to be. it's not a treatment plan. it's not -- it's not the stablize -- it's not going to stablize the individual or get them to a place. so what's next for the person? what are the exits for humming bird? where are those people who fill those 29 beds every single night go? >> so i would say it is a
stablizing force, because number one, it gets people off the streets. >> supervisor ronen: no, no, i understand that. i'm looking for a path that -- you know, i believe that everyone can get well, and that everyone with the right set of circumstance can be somewhat reintegrated into society, maybe hold down a certain job, maybe living in a housing situation that isn't as restrictive as a residential treatment program. so i guess if that's where i'm starting from, that is my firm belief, what is our past in san francisco to get that person there, and, and it worries me. while these are both very important, i don't believe that these are the two pieces that
are going to get a person to reintegrate into society and no longer go through that cycle on the street of where they get to eight 5150s, etc. so i'm just looking for a vision from our departments that say here is our system, here's how it works, here's how you get from point a to being back in society and having a chance at a life again and off the street. and i have yet to understand or hear that for?
gaps are, where, you know, the lack of coordination exists. it's incredibly complicated. to me, it is broken. and whole i have a lot -- i mean, a tremendous respect for everything single person that i'm look -- every single person that i'm looking at right now, and i believe we have some of the top people in the country doing this work, we've got to be the model for the nation. you know, the thing is we know we have a broken mental health care system in the united states of america.
this is not particular just to san francisco, and i want to recognize that. but we have such brilliant people here, we have such incredible programs, we have so much empathy in our city leaders, and we have a massive city budget. and we are the ones to do this right, and i just don't see the leadership, and i don't see the vision to get us there, and it's incredibly frustrating, and it's something that i hope that we can change in the coming years. thank you, chair mandelman, for giving me so much time. i really appreciate it. >> chair mandelman: i think -- and i'm sorry to take more -- a few more minutes from your hearing, supervisor stefani. you know, i've shared sort of a lot of the frustration that a lot of the people feel about the gaps in our behavioral health system and have talked
about it a number of times with the mayor. and i hope this director of mental health reform -- which i urged the appointment of that person -- will play an important role -- even though we play a role of oversight, none of us are mental health professionals, but i do want to applaud the mayor for her work on this and moving forward. similar to what happened in consolidating and making sense of our homeless services delivery to do something similar around -- around behavioral health and make sure that we're actually spotting the gaps and filling them. the one piece of the system that i notice nobody identified as a key critical need is in fact that community mental health dual diagnose -- dual diagnosis treatment capacity, which i think is, you know, again, there are all these different log jams but having the place for the person that is both schizophrenic and meth
using so that they can get the treatment that they find. supervisor ronen said those person are hard to engage in treatment, so if you don't have a slot, it's easy to engage that person for a really long time. whereas if we had a slot, we can bring in those folks and get them into beds. my understanding from talking to folks in that area is we haven't expanded our focus in that area in over 20 years. so even though we see it on the streets every day, we don't have the additional progress or p.r.c., nonprofit would be providing it, sort of the longer term treatment, transitional treatment term
placements. i have a question about this. so the interaction, coordinated entry, my fear that folks have a whole lot of stuff going on, whole lot of challenges have to get themselves to a place to be assessed for coordinated entry, and i'm kind of hoping that's not the case. but i want to understand if it those are the most vulnerable people, the people that are going in and out all the time might not get themselves to a particular place where they can be assessed and given the priority for coordinated entry, how we're thinking about that challenge. >> i guess i'll take that one. so no, people don't necessarily have to go to a place. if they do, that's ideal, but hot team is assessing people on the streets.
we also assess people at p.e.s. and at san francisco, we are looking to expand that and laguna honda and working with the criminal justice system, as well. with you agree there's no need to having people go to criminal access points. >> so your department has to assign a priority level to each person. >> correct. >> and d.p.h. is sort of working on people with their mental health and physical health needs. what's the -- like, how do you -- so yesterday, i went -- there's a great new program at san francisco general. it's related to getting to zero, and h.i.v. and h.p.c. treatment. people get their treatment and
they get social workers who try to get them into coordinated entry. they were saying it's a little bit of a mystery to them how the prioritization happens because it's of course from their perspective, 80 to 90% of these folks are not only hiv positive but have mental health or substance abuse issues. so how does prioritization happen? >> so i want to point out that d.p.h. and h.s.h. work closely together to develop the prioritization tools, and it wasn't done -- and we use when available to us medical data to help eventually do the -- essentially do the data for the assessment. so the prioritization is based on a number of factors. length of homelessness, if somebody's in a current situation, but also looking at
acuity based on a whole variety of factors, and then weighting all of the information we have. i think acuity is the highest -- has the highest waiting factor. if somebody is very, very sick and needs to get into housing, you know, they might get prioritized over somebody who's become homeless long -- been homeless longer but doesn't have the risk to their safety and help. >> chair mandelman: and there's a good practice in place where d.p.h. and h.s.h. can continue those conversations -- >> yes. we're meeting at the macrolevel on those issues but also on a weekly basis at hsoc addressing specific cases because at the end of the day, as supervisor ronen pointed out, there's more
demand than there is supply, and we're not trusting just a computer to make decisions. there are human beings that get involved and discuss individual cases. very manically, as we get more -- eventually, as we get more information into the system, we'll be able to adjust the algorithm that's making the decision, so that we'll be able to consistently improve that -- that improve. >> chair mandelman: great. thank you. supervisor stefani? >> supervisor stefani: yes. thank you, chair mandelman. i think the questions from my colleagues clearly demonstrate that we're wanting to figure out how to do better, obviously. and i know that we have a presentation here that is going to, i think, expand upon some of the questions that we have.
i'm really interested in looking at the presentation. i think there's information that we might have questions about, but i would really like to continue with the presentation and see -- i have all the departments here so that we could find out where we're -- like i said, where we can do better and what you need. i think there are some more slides here that are -- >> chair mandelman: is there a clarifying question on this particular slide? >> it's a whole series of questions. >> chair mandelman: okay. let's keep going. >> all right. >> so this involves a 5150 process. so this is scenario of alex, who lives on the streets in the mission neighborhood and there have been complaints from
neighbors about his behavior. in this case, there is a call into police and hsoc. police bring alex into p.e.s. on a 5150 hold. as you know, that hold can be up to 72 hours. in this case, p.e.s. stablizes alex, and he is released within 24 hours. while he's at p.e.s., we will have social workers engaging with alex, and he will also then be referred if he's homeless to a navigation center and also plugged into outpatient services if he's needing them. everyone is referred to other services, whether it's an outpatient slot or hummingbird. p.e.s. is the largest resource for hummingbird services, so
that's been a big improvement in our system to have that place that's really close by for them to go. while that person's at d.p.s., they're plugged into the whole system. i want to pause, supervisor stefani because this is an area you really wanted to focus on. i'm joined by my colleague, mark cleary, from san francisco general, who really operates the p.e.s. process. >> chair mandelman: i have a question. all right. so my question is -- i guess i have two. one is -- so the recent audit of the behavioral health services system found that 38% of folks who leave p.e.s. are leaving without a referral. i think d.p.h. disputes that and disputed that in the
hearing. how do we -- is there any way that you can help us make sense of why the b.l.a. is quite convinced that 38 -- at least when they did that survey or that study that 38% of folks were getting sent out without a referral and d.p.h. think that's not happening. >> i'd be happy to address that. p.e.s., as stated again, refers everyone who leaves p.e.s. who's not being admit todted t inpatient unit to outpatient services. the 38% is a result of our faultily drop-down in our p.e.s. medical records. the 38% was attached to a category called discharge to self. it's an unfortunate vague and
general item on our drop-down m m m menu, which we've since corrected. they were being discharged on their own. they weren't being taken into a treatment program, they were being allowed to pursue ongoing treatment. they were also being released with a referral to the behavioral health access center or to t.a.p. we disputed this in the draft process and thereafter, but it wasn't changed, unfortunately. i've -- i have very direct knowledge of that process, and i'm very concern that that's the case. >> chair mandelman: okay. so then i actually -- so then, the other question is are social workers there 24 hours a day at p.e.s.? >> social workers are not at the present time in p.e.s. 24 hours a day. there's going to be the
addition of two new social workers that's going to be working in p.e.s. they're in the process of being hired at this point. our clinical model in p.e.s. has been to have required psychiatrists and psychiatric nurses, and they're extremely active in the prime -- access for arranging for follow up. >> chair mandelman: and they would work on something about is this person in the coordinated entry system? >> right. all portions of discharge. >> chair mandelman: so we're talking -- wouldn't the ideal wor world -- wouldn't a pretty significant number of the folks whogeneral.
and when i asked about people who are leave p.e.s. and do so, of course, at that point in time, they can't be held any longer. when they're determined -- on a 5150, i'm talking about, when they are no longer a danger to themselves or others and they're released. at that point, voluntarily, i asked whether you thought it's offer to bed or offered something else, they would go. because at that point in time, they can just go. there's nothing we can do, but if we were to offer services to them at that point, you made a statement that i thought was pretty profouns in terms of how many people you thought would accept -- profound in terms of how many people you thought would accept? >> well, i think that most people, once their psychiatric crisis has resolved in p.e.s.
and they're -- no longer meet the criteria to be held against their will and they're homeless, most of them would want to be able to accept a shelter. i mean that in the most generic of terms, a place where they could stay, a bed. >> supervisor stefani: and then, i asked how many beds you thought you would need to accommodate that population? >> you know, i actually don't remember what number i gave you because it's not a number that i have any confidence in. we need -- there's great need there, and it's -- i wish i knew the answer to that question, but it's a large number. >> supervisor stefani: right. and you gave me 200 to 400.
that's what i want to get, in terms of the numbers leaving the hospital, whether or not we have the services, whether or not we have the beds, those that are coming through the other bhac and whatever. you are the only people that can tell us what those individuals need, so that's really what i'm hoping we leave with today. >> and i would add that -- excuse me. >> chair mandelman: go ahead. >> the importance of having those patients have a bed is their clinicians, case managers can find them or having a greater -- have a greater chance of finding them in that location with sustained ongoing treatment. >> supervisor stefani: also, a lot of people going into p.e.s., they could be under the influence of alcohol or methamphetamine. and then, when they sober up to have the ability to transfer to a bed where you continue days of sobriety, where your mind
becomes more clear, where you get a chance to really, maybe at that point, think that i've had enough, and i do want to get help. the longer we're able to provide that type of environment for an individual who has substance abuse issues, and the longer we're able to provide a space where they're not on the street, tempted to use, the better it is and the most likely we are to be able to exit them into a treatment bed, so that's what i'm really hoping to find out, is that how many beds or what can we be doing at the time to help those people. a lot of people who are on 5150 holds do not have a mental illness. a lot of people are addicted to alcohol or are alcoholics or have a drug problem. at that point in time, i just want to be able to capture those individuals and be able
to provide them a place where they can go where it's not back out on the streets because you don't get well in the environment where you are sick. you don't get well in the environment where you're sick. with y we need to provide an environment where people can have days away from using meth, have days away from that first drink, have people that are interacting with them in that environment that are sober, people that are interacting with them that are case managers that tell them there's a better way, and we have an option for you, we have a treatment bed, progress foundation, whatever. i want that space for those individuals, and i feel like that's what we're lacking right now. i want to be told by the professionals, this is what we need -- even if it is pie in the sky, even if it is 400 beds. because even if we might not be able to do it as a city and
county, we can ask our partnering hospitals, we can ask other cities to help us. maybe they have beds, maybe they should help out, as well. that's really what i'm hoping we find out, and that's what i'm hoping that we as a city and county can figure out to provide that. >> chair mandelman: supervisor ronen. >> supervisor ronen: yeah. just to follow up on supervisor mandelman's question on the audit of behavioral health services and the statistic about 80 people leaving p.e.s. without a referral. when i asked severin campbell about that statistic and why it didn't change, she said yes, the people might be handed a piece of paper for a referral,
but the referral may be a waiting period of a few months. to her, it feels like the person is just released without any sort of follow up, which seemed reasonable to me. and i just wanted to get your response to that. this isn't be blaming, this is about figuring out what we need to advocate for. so we know the truth -- the more we know the truth, the more we know how to fix it. to me, that felt like a valid reason for not changing the statistic. >> when someone is kn. >> chair nuru: -- when someone is new to our system, what we do is provide them with a referral to the behavioral health access clinic or btac. they can go in and walk right in or call and speak directly 24-7 to a clinician on the phone or walk in and get an
assessment that day, and as was mechanicsed, they'll be asseted for level of care in the system. ousht washt care, whether it's residential or mental or substance abuse. and then, an appointment would being setup for them at some later time. it's relatively soon, and that's what -- that's what we do. >> supervisor ronen: does anybody track how many people go from p.e.s. to tapper-bhac? >> i know there are efforts under way to track that. i haven't seen data about that.
i know if it's during the day, we will taxi somebody over to bhac directly to ensure that it's more likely that they're going to enter the system. >> supervisor ronen, we actually realize that data was lacking. we've started this fiscal year the rate for p.e.s. we do have some numbers to show you. a percentage do get admitted snoo psychiatry at san francisco general. we want to be able to get that same kind of information for p.e.s., and we're just now beginning to track it. >> chair mandelman: all right. keep going. >> and there was a question about how does someone with a
physical -- a homeless person with a physical health issue, how are they seen according to our system? so this last scenario is maria who's living on the streets of soma and has open sores on her legs. the d.p.h. street medicine team, headed by dr. zephen will encounter maria on the street and treat her abseses right there on the spot and then also refer her to primary care or urgent care. at the same time, s.f. hot workers would be call today the scene to begin to engage with maria. and at that point, maria is started within the coordinated entry system of h.s.h. in terms of housing options that might be available for her. and so again, the goal is treat her immediate needs on the street, make a referral back to a more permanent source of
medical care, primary care or urgent care, but then, also make sure she gets plugged into the coordinated entry system for housing priority. and just -- the final slide from d.p.h. before we turn it over to our colleagues from h.s.h. is to see all the investments we've made. as we begin to see this, these are the investments we've made over the past few years. dr. seven talked about the individual who was -- zephen talked about the individual who was in our first pilot program for low barrier medication. we started that in 2016 and it's now been expanded in 2018. we also started health fairs, and these are health fairs throughout the city in almost
every supervisorial district where we have our early prevention professionals. we also opened the hummingbird place in 2017 with an original 15 beds and now we've added 14 more, up to 29. again, hummingbird is always fun. we've started our hsoc coordination among our other three departments plus the police department skpp d.p.w. and hsoc has involved. it's really -- i think a really good working process where we're all together and prioritizing what's going on out in the community. we talked about the healing center, the collaboration between ucsf, and d.p.h. and -- >> chair mandelman: is that 54?
>> that's 54. we're also planning, expecting in july of this year, opening 72 new transitional housing beds for people with existing substance abuse treatment services. so this is just a down payment on all the work we know that still needs to be done. as barry and others have said, we know we need more, and we probably need more of everything. it's a question of what's the proportion of those -- that more, and we're really looking hard with all of our partners to figure it out and figure it out quickly so we can come back to you and say this is what we need. so i'm going to turn this over to my colleague and my partner, carrie abbot from h.s.h., and we oversee the coordination process from h.s.h. and susie
from h.s.a. so we are all working together, coordinating, to have the biggest impact possible. skbl supervisors, my name is carrie abet. i'm the deputy director of our programs at h.s.h. i'm going to go through our systems and how we coordinate with the other departments, and obviously, i am available or jeff is available to answer questions as we go. so these are the framework. entry, this is where we bring everyone in and try to bring everyone into the system and get them through the assessment process? straight outreach. that's our hot team. it's lrkin street and homeless youth alliance doing outreach on the street for young people?
and problem solving, which is where we, with our home ward bound team or in our access points or now working directly with the hot team offer people the resources to choose something other than going into the homelessness response system. we try to connect people with family, we try to help them get back to the last place they stayed to prevent them from going on the streets? we have our transitional happened housing, we have permanent housing, and we have our housing ladder. that's where we move people in different settings if they no longer need intensive services. starting with the san francisco homeless outreach team. this is connecting unsheltered
san franciscans with medication, services and shelter. it's a multidisciplinary approach. we have a hot dispatch that both hsoc and 311 access? they work in every district in san francisco? they work directly in the b.a.r.t. stations and muni stations with b.a.r.t. representatives. they're really excited about the new movie, the public about library support services for homeless services. we also have the encampment response team going out and working with people in larger
encampments and now also working with people who are staying in vehicles who are unsheltered. a couple of collaboration points with hud, and hud, i would say collaborates with every system in san francisco. they are sort of famously mobile, and they are extremely well educated on resources and good at finding them kind of with whatever presents. a collaboration point, they're deployed in partnership with street medicine? our hot dispatch and supervisor worked directly with dr. zephen to figure out where they're all going this week and how they can support each other? they're in constant contact and it's a really -- it's a really beneficial relationship to both of our departments and to the clients that they're interacting with. another collaboration point, the encampment response team wor works with d.p.h. to provide very specific health resources to people in the encampments?
that includes health fairs, getting people vaccinated, getting people medicated if they are lacking critical medications. they give people access to medical treatment, appointments and referrals, and they bring all of that out to the encampments or to other places where homeless people might be congregating. coordinated entry. so here's our system map, and it's -- we have tried to incorporate how the other departments work within this map with us? so people come to us because they are seeking assistance or because we encounter them out on the streets, an encampment or of course coming and seeking shelter. our street outreach and our mainstream systems, the mainstream systems including hospitals, including the criminal justice system and
including h.s.a. benefits program? they come in to coordinated entry access points, and those access points, again, can be the ones we've setup on 10th street, 121 10th street and jennings. people can walk into those spots. we have people going into the coordinated access shelters and the hot team, and they are just deployed where we ask them to go. so we've tried to make coordinated entry citywide. the coordinated entry access points and the home ward bound staff do problem solving, and then, those who were not able to problem solve for, we do prioritization assessment. we started with a lens of who is most in need of permanent
supportive housing, and through the whole process and homeless person care, we've been looking at how we're using them so that everyone who comes into an access point or who encounters mobile assessment staff can be prioritized for medical care, for psychiatric care, for substance abuse treatment and for shelter and housing and for benefits outreach and eligibility. so we currently have, we're working toward a set of common questions that we ask everyone. and then, if they indicate critical health needs or they have no income or they've lost their income, then, they have the add-on for those other systems. we started this last summer and
we are working very closely on developing it, but it's still our future state. it's making sure people have access to all systems. >> chair mandelman: how many people are in the coordinated entry at this point? >> it's just over 6,000. last time i checked, there are 4,700 something adults and there were over 1500 family members with kids. >> chair mandelman: how does your prioritization change with life experience? so someone is entered into coordinated entry, and they're homeless, but you know, maybe they've been hospitalized once? but then, over the next year, say, there's a lot of 5150s, other kind of hospitalizations. how does that information get into the one system to potentially change -- would that information centrally change their rank, their
priori prioritization, and is there a way their information gets added to the one system. >> yes. so people can be reassessed, and we try to gep that to evke every 90 days. a lot of people want to be assessed more quickly? >> chair mandelman: is there any automation to it? >> yeah. so right now, if -- like, if someone's at psych emergency services or they're at s.f. general and going to be discharged to apparently homelessness, d.p.h. and ucsf has the ability to look people up in the one system to determine whether they're homeless, and they have the ability to make notes and to, like, put sort of a be on the lookout kind of alert. they don't currently have the
ability to change the assessment -- the assessment sort of clock, but they are working really closely with our partners at episcopal community services on coordinated entry, so if someone needs urgent attention, we can bring the mobile access point back to them and reassess if we need to. we're also looking at how our assessments are prioritizing people that d.p.h. has considered to be really high needs. we did a data comparison between the high users of multiple systems and we're now doing a pilot with people -- now, like, street medicine and other people in the system, saying this person should be prioritized and i don't see
them in this pool. we need to understand, was the person not accurately self-reporting, is there something in a we're missing about the life experience that we need to then incorporate into the prioritization? so that's a pilot where we're trying to, you know, relook at clients who didn't initially get prioritized and priority jies the ize them in. >> chair mandelman: are you finding there's significant overlap between the users and folks with high priority in the system or are you doing things to make that lineup better? >> well, that's why we need to do work in the system.
some of the people in the high users turned out to be housed, and they have had a history of homelessness in d.p.h. records, so they didn't hit our priority status. that's good. i think that's the right outcome. some of them had not yet been assessed, and so they are put on our list of people given our assessment staff, like, you need to go find these people. that is what we know about them? and then some folks had not reported their own disabilities in a way that would trigger status. those are the folks that are trying to figure out if they are seeking housing and they're seeking services, but they are not self-reporting, and d.p.h. has reported a higher level of acuity than they have reported, how do we get that reflected in the prioritization?
right now, we have kept d.p.h. referrals into what used to be the direct access to housing, the really higher needs direct housing, we've keep referrals for people who might not have triggered the prioritization and the assessment while we fix it. mandel than >> supervisor mandelman: thanks. >> thank you. >> so the priority gets people into a priority section. that's for the priority housing and about half of the navigation center beds. if you're priority status, we can place you in a navigation center? we have other centers for other uses and then, we have our temporary shelter system. we -- another collaboration point about coordinated entry and assessments is we are also working with d.p.h. about how to respond when we assess
someone as needing a higher level of care than permanent supportive housing. we have -- so they can -- they will show up in priority status, and we will also know that they have not been able to maintain indepentadent housing thus far, and we're working so that that's kind of a seamless handoff so we're not losing those folks back to the streets. problem solving, one of the core components of the system. collaboration point on problem solving is that this is often our first encounter, so we're trying to setup our first encounter at a point where we do an immediate triage,
engagement, and connection to the needed services. temporary shelter, this is an inventory of the temporary shelter system. we have the traditional emergency shelters. also within that category, we include the transition age youth shelters, the adult winter shelters, the stablization rooms, and the family rooms. stablization rooms, again, being a tool we have for the hot team, if someone is not going to be able to do well in a congregate shelters. navigation centers, we currently have about 500 beds? that changes a little bit. that he ae w that's why we have the approximateli
approximate sign. shelter beds for everyone, this is the mayor's initiative to bring 1,000 shelter beds. our goal is to bring on 1,000? these are still low barrier and have services on-site but are doing more to try to leverage the other services. a collaboration point about shelters, we have shelter health working in our tradition shelter sites. we have clinics within the navigation centers. we have joint referral system between rumming bird -- hummingbird and our shelter systems. all of these services and connections are in the shelters and navigation centers. we also through whole person center are intending to expand our coordinated assessment.
housing and housing ladder. so we have rapid rehousing. typically not for folks with serious treatments and substance abuse, but somebody who doesn't need these additional resources get put into permanent supportive housing and receiving services that they don't need. we have about 200 in our current system, more than 400 through the heading home for families. we have 500 new planned for rising up for youth and about 40 more for adults that are launching this month. currently supportsive housing, we have 6,700 units for adulting. some of those are the housing first units that were established by the home services agency and you now are
h.s.h. and some are the former direct access to housing. we're bringing on over the next several years, no place like home funded capital unit for additional permanent then supportive housing for people with serious mental abuse problems. the housing ladder, we have the moving on initiative. we were able to house 175 people using housing choice vouchers, moving them to scattered site apartments, privately owned units where they now have their own lease and can stay indefinitely. we provide light services mostly for the first 12 months to help people transition. we had a waiting list of over 800 people interested in that program. really helpful having some people involved in movable supportive housing.
it's currently on hold because of the lack of housing vouchers, which is a little bit devastating and there's so many people interested in that opportunity, so i'd just like to keep that out there as something that is really critical to our system and we're trying to figure how the how to bring that in. next month, the tenderloin housing clinic is starting residency at the bristol. these are larger units, in a nice building and will not have the intensive housing. and there are in addition to the bristol, there are a couple of existing step up buildings within the portfolio. so transitions point, we work
with transitions, the intensive case management programs, acas conferences with d.p.h. we also work really closely with in-house support services through h.s.a., through daas. we have done some really exciting pilots, one of them at the kelly cullen supportive housing site, where we try to have clinicians with in home support services. one of the few reasons people lose permanent supportive housing is hoarding and cluttering and sort of inability to maintain their unit. so ihss is a critical part of housing andci critical partnershi