Skip to main content

tv   Government Access Programming  SFGTV  May 1, 2019 11:00pm-12:01am PDT

11:00 pm
that behavior change is hard. it takes an understanding first that there is a problem, and then it takes enough time to build trust in a relationship with someone to accept that change is needed or even possible. so wherever they are in their continuum of care, our continuum of care, whether it be involuntary services or voluntary services, we have to work with each individual to support the change that will help them move on with their lives. change does not happen in a straight-line, it is not linear. if you think about any time that you or someone else has determined to start dieting regularly, i do this every new year, even when we are committed to making a change, it doesn't always happen quickly. you take two steps forward and one step back and sometimes two steps back. there are relapses, and we have to work with each individual or family wherever they are in their stage of change, so with
11:01 pm
all of this, we also know that wellness and recovery as possible, we have seen people progress in their lives, build relationships with their families, friends, and community to continue to support their wellness. behavioral health has been the focus of several policies, both at the federal and state level. more people have health insurance now because of the aca they've expanded the number of medi-cal and the formerly uninsured beneficiaries. parity has increased the ability of individuals to access behavioral health services since health plans now are required to offer behavioral healthcare just as they do other medical healthcare. the drug medi-cal organized delivery system provided the ability to build a continuum of substitute services to clients
11:02 pm
can access services at the level of care that they need, so what is behavioral health services look like in san francisco? if i had to put it -- to me for my paper down to see if i can still read, there are three basic buckets, there is the adult and other adult -- older adult mental health services, children youth and family mental health, and substance use services, i know that there are other services in between that link and specialized services within these, with those are the big and basic buckets that we look at because each one of these, within each of these systems of care, there are levels of care. from prevention to early intervention and outreach, to outpatient services, we assist in these outpatient services, to residential treatment services, crisis programs, hospitalization and other involuntary treatments down to facilities which is also
11:03 pm
involuntary treatment. staff -- that is where the bottom of the upside down triangle which i hope you have all seen before, really that is where our involuntary services at that is where the most acute clients and the least number and highest cost services exist. what we try to do, and what we want to do is provide more towards a voluntary service and to prevent the clients from sinking down to the bottom of that triangle. there are many access points. we have a behavioral health axis center at howard which includes the treatment access program and the substance use services so you can come in to that site or call in for access to services, likewise, we have a lot of different partners, whether it be city partners, community providers, to be able to access service to refer into our services, and clients can self
11:04 pm
refer either through going to our community clinics to request services where they will be provided an assessment for care. i did want to point out, does highlight some innovative programming that sits within the triangle. recently there was an article about the assisted outpatient treatment services, which has been really useful in supporting i -- in supporting these clients there has been a collaboration between street medicine and our behavioral health pharmacy to support clients on the streets who receive medication to treatment -- referrals to hummingbird and transitional aids youth services which is being built to enhance this move for clients and a system where that linkage can be very difficult so we want to create a smoother transition.
11:05 pm
they all sit within this triangle. this is our budget slide. should i tell you when i'm turning the page? as i said, our budget is approximately $366 million. i am taking the opportunity to divide it up to a different pie chart. the pie chart on the left is based on system of care, and that is all levels of care from prevention all the way down to the beds, and you can see that the bulk of the budget fits within adult and older -- older adult services, and then a smaller amount goes into children mental health and substance abuse services. the second pie chart is looking at the budgets -- from the perspective of a funding source. if i had to -- the largest two amounts, the pieces of this pie
11:06 pm
are medi-cal and other revenues like healthy families, healthy kids or other revenues that are coming to our system for behavioral services and our general fund. the realignment dollars, which i'm still learning, but those dollars, from what i understand our realignment from the state, and those dollars we use to match with the medi-cal, which we need to provide. we also have a number of work orders that come from other departments for collaborative, basically to build synergy from our mutual clients to treat our mutual clients and we have grant funding. one thing i wanted to point out about this is really a lot of this, the services outside of the general fund are from funding streams that are subject to regulations regarding can be served and what services can be provided, an example of this is that medi-cal does not pay for
11:07 pm
outreach services, it does not pay for integrated care services if our client needs help getting to the doctors appointment, we will take them to their appointments but that is unfunded by medi-cal. that comes out of our general fund. if our client ends up in the hospital at jones with disco general, stabilizes for a couple of days and then the care manager has a close relationship , visits a client in the hospital, that is unfunded. we promoted because it is good care, but it is -- it draws into our general fund for sure. that general fund covers those services and cover services for people who actually are based on eligibility, recent immigrants, for example, would be unfunded and we would cover those services. this next slide to specs -- pixar expenditures. this is a fiscal year 17-18.
11:08 pm
it is on the slide. we're looking at the total expenditures. the bulk of the services which they call nonpersonal services, 95% of those are our contracts with our community-based organizations, there are some other slices in there within their for our lease payment for city clinics that are not in city-owned buildings, things like that. the salaries and benefits are our civil service positions that i described earlier. material and supplies, pharmaceutical sit in the material and supplies get. you can see our work is such a sliver, the work orders interesting. the new work order with other departments, but mostly departments refer us because we can pull down the medical revenue, so we end up holding a
11:09 pm
lot of those contracts. okay. client serve -- clients served. in our clinical services, we touch over 25,000 lives, i know there are folks with homelessness who are here and the table on the left depicts the homeless population. in -- for our clients. of our clients in mental health services, about 21,000 our total clients, and 26% of them were designated homeless. this is avatar data, the electronic health data, the largest bulk of people were in the older adult services. i did want to point out, just because i'm a child psychiatrist that 194 -- 194 kids are actually homeless families. and substance use services, the
11:10 pm
90 7% of the clients are over 18 and of the 6500 clients, approximately, 58% of them are homeless. another thing to remember, and the reason is 2500 as we have been looking at the numbers and they don't add up and we have a 2,000% overlap of people who have disorders. in addition to the treatment services, behavioral health provides additional prevention, early intervention and intervention services, which actually, sometimes includes brief treatment, and that is to tens and thousands of san francisco residents through briefing, school-based programs, peer programs, vocational services, or drop-in centers. and fiscal year 17-18, programming reached 48,000 people. the next slide is demographics.
11:11 pm
we pay close attention to demographics, and we know that disparities exist within the system, for example, we know certain groups are overrepresented and others are underrepresented relative to the census. sorry, thank you. in december, this last december, we created a new office of equity, social justice and multicultural education to focus on equity, diversity and inclusion, which they are currently developing an equity work plan to address gaps across the systems of care. they developed an equity improvement work group that will look at root causes identifying disparities. there's a lot more around disparities, and i just don't have time to present today, but we are happy to presented at a later date.
11:12 pm
we have a lot of performance measures, and the b.l.a. touched on some, but there's a lot of them, some of them are state mandates, some of them are requirements of the care plans. i just wanted to highlight some significant ones. access to care, i know there isn't interest in access to bed and timely access to bed. i think i will answer -- asked kelly to come up later to answer questions you had about that. i do know it is still complicated and we are trying to improve our data tracking system to more effectively track this measure. [please stand by]
11:13 pm
within our programs. we also look at re-admission. we definitely look at re-admission. 70% were not readmitted within 90 days.
11:14 pm
that we know. and that 65% of p.a. discharges were not readmitted within 60 days. and lastly, client satisfaction. we -- >> that sounds like 35% of p.e.s. discharges -- >> that's true. i was thinking about that. people would figure that. absolutely. well, yes. okay. our target -- right. our target of re-admission -- inpatient discharge our target is 80%. and we hit 74%. i don't know what our target is. but it's something we continue to work on. and i have some -- i'll get to kind of how we are trying to work on that. our client satisfaction -- we do conduct them twice annually for mental health and substance uses. also state mandates and they did show a summary score of 92% for
11:15 pm
both mental health and substance use. so our challenges. these are two of our major challenges. our workforce vick i -- vacancies. we have significant vacancies and that's after a survey that we performed that was in december, i think. yeah. yeah. it's about 20% across both civil service and community-based organizations. we hear about the challenges in hiring and retaining staff. and especially when trying to hire bilingual staff, cantonese speaking and spanish speakers. we know there's a nationwide shortage of psychiatrist and san francisco is not immune. we have a 23% vacancy rate, which is growing, as more of our psychiatrists retire.
11:16 pm
engaging and treating people suffering from substance use and mental health issues, who experience homelessness, this is one of our challenges reaching this population for sure. our clinic -- client-based services are the bulk of our services. and they work well for those who are able to participate at this level of care. we know that homelessness makes it challenging to attend appointments, remember to take medication, and participate in other clinic-based services. our intensive care management programs do field-based work. i know i have done it. but they're suffering from the same 20% vacancy rate across the board. so our current priorities. these are the things that we are doing. we're -- we want to meet clients where they are. we know. we're increasing outreach. these are the engagement specialists that we placed at
11:17 pm
the healthy streets operation center. they describe the -- they describe the harm-reduction therapy services, which is kind of a pop-up clinic. and they're going to be aligning themselves with street medicine. we're increasing our intensive care management. we have a short-term i.c.m. linkage program. and our i.c.m. expansion and also we described these strategies to increase intensive care management flow from intensive care measure to outpatient to kind of open up more slots. we're expanding the hours of the drop-in center from 5:00 p.m. to 9:00 p.m., that offers us the opportunity to engage more clients and hopefully provide more linkage. we're placing two social workers in psyche emergency services. someone described that warm hand up needing a link to services. but the social worker is there to offer the warm hand up and
11:18 pm
offer other services. the four peer navigators really are tied to hummingbird. there are times, okay, we're getting to you hummingbird and then gone. it's really to help engage them and walk them over to help them to connect. we are expanding behavioral bed capacity. in february, we expanded capacity of hummingbird by 14 beds. we just increased the number at the healing center by another 14. and we're creating 72 new residential step-down beds for substance-use ever ises. when they get out 50/50 -- -- rather than just going to the streets. and that's through h.r.360 on treasure island, too. we recognize that there's a critical need to collaborate with h.s.h. particularly to
11:19 pm
identify our overlapping, vulnerable clients. you know, housing is really important for wellness. lastly, the strategic planning announcement approaches. we're really needing to work on workforce. for civil service really streamlining hiring with human resources and training in the system to provide a pipeline. also exploring ways to help support their hiring and retention of staff. our director of mental health reform dr. bland. we're looking forward to helping him look at our system, identify gaps and determine strategies to those close gaps, particularly for clients who experience homelessness. we are continuing our work to improve our services, but i want to highlight the work we're doing with our city partners, community and city partners to
11:20 pm
improve services for our shared populations. a good example is in the newspaper today, the critical incident training. together we're collaborating with law enforcement to provide training. it's really helped reduce the -- i don't know how you describe it. but it's been helpful to reduce force i guess. that was in the newspaper today. and we're also moving toward having discussions about can we do more co-response, co-responding, co-location. we're definitely exploring that. for h. -- we're supporting age soft with clinicians and h.s.h., the collaboration, looking at our coordinated entry to see how our clients. so we can support our clients who go into coordinate entry and receive housing and then we can support them to keep them stable, so they can maintain their housing. and, of course, we are in
11:21 pm
process of hiring -- not hiring, in the process of identifying a parent director to help really create some stability and move the initiatives forward. our policy recommendations. we realize that as a navigation center expand, we need to have more medical and behavioral health services within these navigation centers and shelters to help kind of stabilize clients and connect clients and engage with them and help really get them thinking about is there a hope, do you have hope for change, or do you think this is the future? let's give you an opportunity to think differently if that's what you want. right. to expand the behavioral health respite beds. i know we have expanded them on site, but is there opportunity to expand them somewhere else in the city, too. is there an opportunity for that. and expanding mental health and
11:22 pm
co-occurring residential treatment beds. we saw an overlap of 2,000 people. and if treatment reages like this on this side and that side, it's going to be harder for client -- for these clients to get better. we need to integrate those services. so because i started the presentation with the client, i also wanted to end with one. we continually need to fight the stigma that's attached to people who suffer from mental health and substance-use issues. we need to promote empathy, compassion, and understanding. thank you. i can take questions. >> okay. thank you very much. >> thank you for the presentation. and i -- i appreciate that you're new, so feel free to call up anyone to answer the questions. >> sure. >> because i want to start off by asking many of the same
11:23 pm
questions i asked of the b.l.a. so i have been frustrated and quite shocked at the extreme discrepancies that -- between the data i have been given from d.p.h. we had a hearing in march, where your predecessor had mentioned that wait times for residential treatment for mental health and dual diagnosis was two to three months. i then emailed for follow-up information with d.p.h. and was told it's one to two weeks. and then i've been working and talking to our conservator jill nielsen, who gave me information saying for those people that are conserved, it's two to six months, up to a year. and then the b.l.a. report today had a range that some services are on-demand, which doesn't even fully make sense to me. i want to walk through the chart with you and that other -- and that for the other services,
11:24 pm
it's up to 30 days. and then when i talked to advocates, when i talk to the executive directors, that running these residential treatment programs, when i talk to the public defender's office, when i talk to the d.a.'s office, this doesn't correspond with their experience. so i have to say it's been disappointing how little data is kept to begin with. it's been disappointing the different answers i get every time i ask the question. and it's unclear to me even what the methodology is. as the b.l.a. explained, i guess you're not even tracking today referrals or wait times based on when it is determined the person needs a different level of care and when that person actually enters that level of care, which is, you know, what i'm very interested in. so let's start off just responding to that and then i'll offer feedback
11:25 pm
>> if i understand correctly, you're talking about specifically about beds. it's not outpatient treatment you're talking about? >> well, i'm really talking about step-down at all stages, right. i mean, you know, whether it's, you know, how people are being released from p.e.s. with or without referrals, what they're being released into a programs from when they're in the acute ward and how long they stay there and how much, you know, we're paying for admin dates, which means we don't have the step-down wait times we need. so let's start there. >> right. because i know that there's a focus on beds. and i appreciate your understanding understanding that i might not have the information. >> sure. >> i wonder if it makes sense to call kelly up to talk about -- kelly is our director of transitions to talk about the
11:26 pm
actual residential access to residential bed. maybe we go go through the chart on page 9 of the b.l.a. report. okay. the b.l.a. report. and then before we go through that chart, kelly, let me just ask you. so when we're looking at this report, can you -- what are we tracking? what is the information we're getting here? from what point to what point are the wait times on this chart? >> sure. so on this chart ... yeah. so on this chart you're tracking -- let's see, one, two, three, four, five, six, seven, eight different levels of care on this chart. so that's why the wait times are
11:27 pm
so variable, because the waits for different levels of care. >> no, no, of course. i'm wondering -- my first question is what are we tracking with these wait times? like what i would like to see tracked, for example, is the minute a clinician decides this level of care is no longer appropriate for you. we need, you know, a different level of care, a different type of care for you. to the time that person enters into that different level of care. what is that wait time? >> so that wait time is historically been tracked manually, because the transition to division is not in an electronic database in any structured, regular way. and we aren't linked to any of the other systems. like we're not in the clinical record, we're not in avatar. >> but it has been tracked? >> it's tracked. but we would have to do a manual calculation every single time. so what we do is we document the date that we receive a request for a placement authorization.
11:28 pm
>> and does that usually happen on the same day that it's needed? or determined that it's needed? >> it's variable i would say. >> how big is that variable -- that variable time period? >> it's not something that we've ever looked. we have to look at every single client record to see when a doctor or the treatment team recommended a lower level of care. and then track when they put it into the placement tracking report. and then -- >> can you give us -- like could that be a difference of a day or a month? what's the ranges? >> because i've never looked, i really can't speak to it. i would imagine -- in general it's probably been a few days ideally that they would determine it as a team that the person is ready to step down to a different level of care, that they would then put in the request to us. >> so for me to determine how accurate this new data i'm given, can anyone answer that question for me from d.p.h.?
11:29 pm
>> from the physician determining that a different level of care is needed to the time that that information gets to transitions. the request is made. >> as i said, i'd have to look at every single client record. look at the last physician note or the last social work note to see when it was decided that a person should be referred to what level of care. >> but that -- so that differs based on every single patient? like we don't have generally it's one to two days. or generally it's -- i mean, that's a pretty important question. >> i don't know. what she's asking is when do they decide that to when they do fill out the form? >> and when does -- so my understanding is the manual tracking that is happening starts from the day transition -- >> it's the form. >> gets the form from the physician saying that the level of care that they are currently in is no longer appropriate for them. they need a different level of care. >> that's correct. >> there's no one here who can
11:30 pm
tell me how long in general or the range of length it takes getting from a physician to transition? like -- i just want to know if this takes a day or it takes a week. or it takes ... >> that's true. i'm -- again i'm just speaking as a physician. you know, depending on what hospital, where they are, who is making the referral. so i could make a decision saying, okay, we should do this. and then the form needs to be filled out and needs to be sent in. so knowing the flow from each unit or physician, that piece i don't think we can determine. however, whoever is making the referral, like if an agency is making a referral, they can actually track that, right. right? if i make a decision -- >> excuse me. >> i'm sorry. i'm sorry. >> i think that -- i mean, i think one of the questions is
11:31 pm
are you collecting this data also? >> well, she said -- manually. >> yeah. but trying to understand in a sort -- are you in any way collecting this data in a systemic pay that we can actually -- you can actually tell us on average. are we even collecting that type of data? i mean, when you say you're doing it manually, that means everyone is just doing their own thing. or do you actually have a -- have you compiled data to actually give us a timeframe? >> we collect it in an excel spreadsheet. so when we get the form, we put the date that that's received, the request, who is the requester, what level of care is being requested and where they got authorized to, what level of
11:32 pm
care they got authorized to. but to speak to supervisor ronen's question, no, no one to track when in the hospital the decision got made, the doctor is recommending a lower level of care or alternate level of care. and when did they send the placement form to us. so that one metric is not tracked. >> that's incredible! that's absolutely incredible. and it's infuriating. i can't even -- i don't trust the data that you've given me -- the five times you've given me, wildly different numbers to begin with. then what you're telling me the data i'm getting doesn't even tell me what the actual wait times are, because we have no idea. nobody in your department, in d.p.h. or general hospital can tell me how long it takes to get from a doctor, who determines that a level of care is inappropriate, to transitions? what kind of operation are we running here? >> hello, supervisor ronen.
11:33 pm
roland pickens, director of san francisco health network. i think the answer of the question would take a practicing psychiatrist on the floor at the general, because they're the ones who write that. and then the social worker puts the packet into kelly's spot. so we can actually have someone like dr. leery would know when he practices, how long does that process take. he's not here today. but we can certainly get that for you. >> but dr. leery might have one practice and dr. song might have a completely separate practice. and dr. tell has another practice. >> yes. from my knowledge, that's not the case. they have a standardized process on the inpatient service in terms of how they do the referrals. >> you just don't know the length of time -- but nobody knows? >> i'm not a practicing psychiatrist. i don't fill it out. we have to have one of them come up here and answer that question, because they do it every day. >> you knew that this hearing was taking place. you knew wait times has been a major issue. >> absolutely.
11:34 pm
>> yes. and you're coming to us to present this information, you've had a huge b.l.a. report done. and you can't answer that simple question? >> if i had anticipated that was your question, i would have made sure -- >> that's obvious question. i see the director of d.p.h. is here. you have something to say? >> yeah. good afternoon, supervisors. and director of health. and i just want to, one, acknowledge that the team here is working extremely hard under, you know, very difficult circumstances to care for people. and i also hear your concerns about the lack of identified metrics that are very important through our system. and i think you all know that, as i have come on to the department, started at the department and with mayor breed's priorities, we're focused on ensuring clear metrics about how people flow through the system. whether the metric you're asking
11:35 pm
for, which is understandable, with one of the key metrics, we're looking at what are the outcomes that we agree on, are the gold standard for our system, right. once we're actually able to identify those, we will be able to both monitor how patients flow through the system, what's best for them and what's best for their family and the community. and then actually provide with you field numbers about how much are we spending as a community, and as a city in our system, because things are not following adequately. so dr. bland, who is our director of mental health reform, i have identified flow as a key piece of what he's looking for. and we link the clinical side to the programmatic and budget side. you're exactly right with the need to better link what clinicians say in the emergency room, what they're asking for. identifying that as the key data point as we look to improve our system. >> dr. colfax, with all due respect, first of all, i will start off by saying kelly is one
11:36 pm
of the only people in d.p.h. that i actually trust to give me genuine data. she's a complete asset to your department. works her butt off every single day. and so if there's anybody who is going to give me information that i can trust, it's kelly. so let me just say i just -- i just need to put that plug in. but there aren't a lot of people i can go to these days to trust and kelly is one of those people. i just want to put that on the record, giving, you know, the way you started this out by saying everyone is working very hard. i have no doubt that everyone is working very hard. but this is extraordinary. your departments a come before this board of supervisors recently several times and every single time your last director of behavioral health couldn't answer our basic questions about wait times. you have since said, and then every single time we get data from your department on these times, for residential treatment beds, we get wildly different information. so i don't even trust the
11:37 pm
information i'm getting from you to begin with. but i'm just trying to understand what you're actually tracking in this wildly divergent data you're giving me every time i ask for it. what i just realized is you're not even giving me genuine wait times, because you have no idea how long it takes when a physician determines that a lower-level of care is necessary and by the time you start manually inputting that intomannually -- per patient, we don't know what the time is. we don't know what that time is. that's extraordinary. you could not bring one person here today that could answer that question. this is not a trick question. this is a basic, basic question. and it's -- talk about an expensive question. we're spending $21 million, over $2,000 a day for patients being kept on the most expensive level
11:38 pm
of care at general because we can't find a placement for them in the community, which is more appropriate. we can't bill medi-cal for it, because it's inappropriate. so this should be the first order of business of information that you're figuring out. >> right. and i just -- >> a point of information to note that dr. colfax has been on the job for about three weeks. >> but -- this is not about dr. -- this is not about dr. colfax. this is about who have you brought to testify in front of us today, knowing how important this issue is to us, knowing that it's a priority in a report, knowing that there is a chart on page 9 with this data and i'm just asking what -- what are we tracking with this chart? and nobody can -- nobody can answer that question for me. >> so i apologize if the answers have not met what the expectations that were brought forward.
11:39 pm
i do think that we can provide useful data, perhaps not the complete picture at this time. i agree that we need to do better job. and i think the people who are actually giving you the information just a few minutes ago would agree, we need to do a better job of looking at our data and making sure that we're measuring the right things, in order to improve our system across the behavioral health field. we are looking for a new behavioral health director. dr. sung agreed to step up and actually manage the system as acting director at this point, in addition to her other duties. and we're building the capacity to answer the questions that i agree, we need to answer ek effectively and efficiency. and as much as possible in realtime. dr. bland has just been on the job for two weeks and this is his priority as well. so we're looking across the systems. i do think, given -- we do have some answers in the transitions program and in terms of kelly's work. we're actually looking at how do we expand that perspectives, who
11:40 pm
are able to better understand what's happening in our system to give you the numbers you need to help us make the right decisions for the community. and again i understand the concern. we're using the data that we do have available now. if there was some myths on our part in terms of a question that was specifically asked and you don't have the data in front of you, we will do better next time. and i apologize for that. >> okay. if kelly could come back, i want to talk about this chart. >> sure. >> so we have no idea what the wait time was -- >> yes. >> it could be a week, it could be a month, it could be a year. we have no idea. but once it hits you, this says that anybody who -- let's start at the top. the inpatient psyche services at general, those are the 44 beds
11:41 pm
on the 7th floor, right. seventh floor ward. that there's always beds open? >> that is not true. if there isn't a bed available at san francisco general, we have a contract for overflow with st. francis. and then if they fill, then we have an agreement with cpmc, they take folks into the acute unit. acute care in general, you will not wait. >> okay. that's what on-demand means. so there's anyone who needs that acute care and can't get it right here in san francisco? >> that's correct. >> okay. >> well, there are times that every single acute -- if inpatient unit was full in san francisco, and you are a san francisco client, you start to go to the next available bed. so there are people who go to any medi-cal accepting facility in the region. we have folks that will end up at stanford or alta.
11:42 pm
>> it happens often? >> it hasn't happened recently. but it has happened, yes. >> has it happened this year? >> let's see. we have people that are in out of county hospitals, more because they were transient and got picked up in the out of county location. i don't know of anyone that fell out of county because of overflow. >> okay. so then the acute diversion units, how are you getting that service on-demand? go ahead. >> okay. so if an acute diversion unit, it's really designed to be what it's described as, an acute diversion. if somebody has been recently admitted within a three to seven-day span, they can be diverted to the lower level of care. and some people could be diverted from p.e.s. if they didn't immediate to be
11:43 pm
inpatient and a space in e.d.u.. the recent practice from psychiatric emergency services to refer people urgent care first and into the e.d.u. >> so i talked to steve fields, who is the head of the foundation, who told me frequently not a bed at the acute diversion unit. but this chart says it's available on-demand. >> it's been influx this year, due to the practice change of psychiatric services. so i think that's a variable number. >> i think if you did a point in time, would we have a bed in e.d.u., it -- it has really fluctuated through the course of this year. >> so this is inaccurate when it says that this -- that a bed in an e.d.u. is on-demand? >> i think that in this recent past, it's probably not as accurate.
11:44 pm
that's true. >> okay. well, you know, for the record, steve fields told me that three days a week they're filled. every single week. so once again i'm having a really, really hard time trusting the data i'm getting from d.p.h. and it's -- it's incredibly upsetting. >> it's frustrating for me. because i think we've heard frequently from progress that their e.d.u.s are not getting used to capacity, because of the practice going through urgent care. i'm getting a mixed message from progress. when we speak to them, they're telling me they don't have e.d.u.s getting used as directly as they could. >> so my understanding is that they used to get referrals from p.e.s., but that's no longer happening? >> that's correct. >> why? >> it was a practice changed to try and expedite moving people through p.e.s. more streamlined, because in order to go to an e.d.u., fair amount of referral paperwork that needed to happen. and a medication ordering issue that we looked into trying to resolve.
11:45 pm
and in the interim, there was a practice change to use urgent care as a pass-through location, where it would be easier for them to get medications. >> so is there not going to an e.d.u., where are they going when they leave p.e.s.? >> well -- well, i was going to say hummingbird is a more recent location that's been available to them. >> that's 29 beds. that's always full. >> it's more now full than it had been, when we first opened, western -- we were able to manage flow. these are the times of practice changes that we're trying to accommodate, to try and figure out a best-practices way of managing the flow. and i think it's -- what's made it challenging in some ways to get the data as well, is because a lot of new programs, new practice procedures launched in this last year. so that's contributed to the wait time discrepancies. >> okay.
11:46 pm
i can go back to that. so for urgent care, it says that -- that that -- that that service is available on-demand. would you know that? it's not run by d.p.h.? >> it's not run by d.p.h. every day there's a report that progress sends to us with bed availability. and it's tracked every day. >> okay. >> it's combined with what's available, with the use of p.e.s. was. you can see the crisis and bed availability. >> okay. and that -- in your experience, that truly is available whenever? >> i would say more often than not and similarly it's gotten harder to get availability on-demand as p.e.s. used it more as the disposition location. but historically it has had
11:47 pm
availability. it's the pass-through to e.d.u., it has a flow to it that other places do not. >> sorry. it would make sense to me that the acute diversion units are full more often if p.e.s. is now sending people to urgent care, in order to an e.d.u., because they're paying on the high level of paperwork. it seems like it's a passing off on responsibilities on to our urgent care, that clogs up the system, but doesn't relieve burden in the entire system. does that make sense what i'm asking? >> yes. >> that's an accurate statement? >> yes. i wouldn't say a passing on. i think having people stay long
11:48 pm
at p.e.s. is really not an ideal situation. people on p.e.s. are in the highest crisis for our system. urgent care are for people no longer on a 51/50 hold or a little bit more stable than people in 51/50 and really needing to be held in p.e.s. so what i think the purpose of that practice change was really to try and make sure that our crisis -- that our most at-risk crisis stabilization beds were always available. and i think -- we said that our use pattern -- since the practice change at p.e.s., we need to look at our use patterns to see is what really is needed another urgent care, because we are finding that enough people can be dropped off at their 51/50s, moved to the next level of care, be triaged appropriately from there. and because this practice change happened mid-year, i don't -- you know, we're kind of in the beginnings part of the data collection to determine whether that's the right level of care
11:49 pm
or not. >> okay. okay. now this residential treatment. i don't know really what the difference is between mental health and co-occurring diagnosis is. i don't know why it's separated. >> it's separated because the presentation of the client is a different and each of these three levels of care. everything that's here under the residential treatment, the co-occurring mental health are substance use disorder treatment or what the client is bringing to the table. so somebody who has both mental health and substance-use disorder issues, equally present, would be best served if they went to a program that was designed to treat somebody who had both of those co-occurring diagnosis. and mental health treatment program is really for somebody who is more purely dealing with a mental health diagnosis issue, without any co-occurring substance use. the substance uses are who -- doesn't have an underlying mental health diagnosis. y , so my understanding it's very rare to find someone
11:50 pm
nowadays without a dual diagnosis. is that true? >> no, i don't think that is necessarily true. we still see our share of folks who are truly mentally ill. >> without substance abuse. >> our goal is to intervene at this point, before turning to street drugs to self-medicate. when it's the right time to get in, it's ideal. >> the average wait time of up to 30 days for a co-occurring diagnosis and a mental health disorder, that -- kavooss told us in march it was more two to three months. if you -- if you lump all of the -- all of the treatment modalities that we have, which are 90-day programs, include the two year-long programs that we have, then it skews the wait
11:51 pm
time longer, because the wait to get into the year-long programs is generally longer then it is to get into a 90-day. so if you look at just 90-day programs, then you're going to see that the 30-day is kind of closer to the mark, up to years and push it a little higher. although it says it's up to 30 days for the mental health beds, most 90 days, some 365 days. >> right. >> so you're saying that kavoos says two to three months because he was including the year-long program? >> right. i would imagine if you include outlyre waits, people waiting for reasons probably not related to bed availability and but for reasons very distinct to people, we have some folks that wait very, very long for other reasons, that have nothing to do with bed availability. if you include those people in the wait timing it would make the wait times seem so much longer. >> so jill nielsen, our conservator, told us -- sent me
11:52 pm
a chart. she also couldn't access very much useful or reliable data. but she said i have a point in time, march 22nd, 2019, count of all the people conserved in san francisco. and of those 24 people, 22 of them had been waiting for a step-down bed for over 60 days. so how does that compare with this data and this chart? >> i would have to look and see what she was talking about. acute treatment bed which is not any of these categories. so people who are waiting for an i.m.d. or mental health rehabilitation, that wait time is long. too long. >> okay. so that's -- that's that. okay. so -- and so that's the reason why we're spending $21 million a
11:53 pm
year on unreimbursed admin at general, because we're generally waiting for these locked beds, that take -- that have a much longer wait time? >> yes. and i think the combination of people waiting for state hospital beds, which is really the people who are the longest stay, kind of worst cases that you hear are people waiting for state hospital. that's a challenge for us because we don't really control the way state hospital flows people into care. they -- a few years ago they switched to a one giant waiting list model for the entire region. and so while we used to control our own beds at this point in time, we no longer do. so we get in line with all of the other counties to get access to a state hospital bed. that has made it considerably longer for us to get a person in. even if i step 20 people out, no guarantee that i can get 20 people in. so that's been very frustrating for us. one of the things we're doing on our side is actually start to work with our community providers, like crestwood to see if they'd be willing to open a
11:54 pm
facility specifically for more violent offenders, that have issues that are very hard to manage in a regular mental health rehabilitation setting, so that we have a place to actually take them instead of waiting for the state hospital bed. the other population has stayed it incredibly long on the inpatient unit, co-occurring and mental health. that's been quite a challenge to try and get the regional centers to take responsibility, that when some of these psychiatric issues stabilized, they should step forward to help us take the next placement down and it's been very hard to get partnership going on that. >> so since the hearing we held in march, my understanding is d.p.h. is trying to track data we heard in a more systemic and accurate fashion. >> yes. >> what's changed? what are you doing differently? >> so we are actually working with our proprietary software
11:55 pm
provider for placement. we have a bed census that tracks out of a product called s.f. get care. and we asked them to build in modules that track the wait times in the way that people are asking for the data sets, which is really what will we can control, which is the day that we get the referral, when we send -- when we get an actual complete package, that's another thing that comes kind of slowing it down, we need a certain body of paperwork to send to a facility, if we don't get all of the pieces that we need, the decision can't get made timely. we're trying to fine tune making sure that we get all of the pieces at the front end, so we can get a decision from a facility within two days. so that we know the wait is because there's not available bed and if there is a barrier, like there's only a particular kind of bed that can receive the client, that we document that. so we would be able to give a clear data set that the people who wait the longest are the people who -- like we know registered sex offenders wait the long post it a step-down bed. or somebody who has violent
11:56 pm
episodes unprovoked, that's a person who waits longer. you know that's the thing that caused the wait times. >> when has that changed? >> we're working with the vendor now. >> it hasn't happened yet. >> it hasn't. until then we're capturing the data as best as we're able in an excel spreadsheet. >> similar to the way p.e.s. stopped referring to the acute diversion, my understanding is that general all together has stopped referring to residential treatment programs about a month ago? >> yes. i just recently heard that as well. >> what's going on there? >> i have not had a chance to talk to kerry at the hospital, to find out why she changed that practice. >> is there anyone here that can answer that question? the director of public health?
11:57 pm
did you hear the question? okay. the question that i asked is -- that i have heard that as of a month ago, that general has stopped referring patients to residential treatment beds and kelly just confirmed that that is correct. and i'm wondering why? >> i will double check on that and we can have an answer by the end of this hearing for sure. >> okay. does anybody know? >> is that actually -- >> yeah. so let me check with the hospital. i'll let you know by -- as soon as i get an answer. >> okay. miss sung, you don't --, >> i just heard it when i arrive, kim taylor. >> let me -- let me get in touch with the c.e.o. of the hospital and we'll get you an answer from the d.p.h. site right now. >> okay. i have -- i have a bunch more
11:58 pm
questions. but i understand that supervisor heeney has to leave. if i could come back? >> that's great. so supervisor ronen, we have walton has some questions. the police department must leave at 3:20. what i would suggest doing, we would hear from the police. can you hold your questions. we can have d.p.h. come back up to answer questions. would that be okay? >> yes. i do have a lot more questions. but, yes, sure. >> thank you very much. okay. supervisor haney. >> thank you, chair fewer. so i also wanted to -- i don't know who the right person is to direct this to. i wanted to revisit some of the questions i had around data quickly. so we heard a little bit about how some of the data is tracked manually, which it sounds like is on an excel spreadsheet, in
11:59 pm
terms of wait times and referrals, which i agree is concerning and a bit shocking. but in terms of where people go when they people p.e.s. or when they're in the system somewhere, and are understanding of outcomes for them, where they are in the broader system, is that being tracked actively? the example that i gave is this 2,667 people who were 5150 or, if we do know exactly where those folks are. and outcomes for them. is that information we have? or is that part of something that we're in the process of creating? >> antoine bland is coming up to answer this question. >> i'm the current director for mental health reform. and the former medical director
12:00 am
for psychiatric emergency services. and i'm here and dr. mark leery to help answer questions, with relation to p.e.s. can you please repeat the question at the time and i want to make sure that i answer that. >> so tracking of placements, outcomes, -- and brought to p.e.s. is there some sort of central tracking database for those folks. and what happens to them, who is serving them, what outcomes are for them. and then by extension, do we have that for our system as a whole? so for that subset, which is a significant one, my concern is there is -- and this is i think part of your mandate here, is that we have a lot of different folks who are delivers services, a lot of contracting out at various levels. and the concern is, as you know very