City and County of San Francisco

agree with the finding, or 2. disagree with it, wholly or partially, a nd e xplain w hy. As to each recommendation the responding party must report t hat: 1. the recommendation has been implemented, w ith a summary explanation; or 2. the recommendation has not been implemented b ut will be within a s et timeframe a s provided; or 3. the recommendation requires further a nalysis. The o fficer or agency head must define what additional study is needed. The G rand J ury expects a progress report within s ix months; or 4. the recommendation will not be implemented because it is not warranted or reasonable, with an explanation. 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 3 Members of the Civil Grand Jury Jaime Guandique, Foreperson Peter Mills, Parliamentarian Phyllis Deets, Correspondence Secretary Jonathan Gohstand, Recording Secretary Ruben Ahumada Richard Bogan Victoria Hanson Rebecca Jordan Diane Josephs Steven Lei Patricia B. Levenberg, PhD Judy Nadel Charles Raznikov Elwyn Wong 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 4 SUMMARY It is h ard to know where to start, but it’s impossible to ignore where we find o urselves. On any given night, as many as 5,000 individuals can be f ound s leeping on our sidewalks a nd byways with 3,000 more in shelters. Of those, 4,000 a re also suffering a mental i llness t hat deepens their despair. Ironically San Francisco County is one of the richest counties in the United States. It’s not like our city agencies are ignoring the less fortunate. T he San Francisco Department of Public Health (DPH), Behavioral Health Services ( BHS) sees a nd t reats 30,000 annually. Y es, a great d eal o f good work is getting done, but what more c ould we do? As 2019 came to a close, the Mayor and Board of Supervisors (BOS), authorized legislation entitled ‘Mental Health SF’. This, coupled with the hiring o f Dr. A nton N igusse B land in March 2019 as Director of Health Care Reform is a significant achievement for our City. Serving the unhoused, the unemployed, frequently behaviorally c hallenged i s the purpose of some 7 ,000 dedicated staff members of the DPH. The department's f unding sources are complex, a mix of federal, state, and local streams all with specific constraints on where and how a $ 2.4 b illion budget can be spent. The resultant mix of a gencies, b oth public a nd private, coupled with a plethora of regulations, has created one of the more c omplex bureaucracies in m odern government. A bit more than half-way into the 2019-2020 San Francisco Civil Grand Jury’s ( SFCGJ) t erm, when our r esearch was well underway, t he coronavirus pandemic emerged. A few months later we learned that the pandemic would have a major n egative i mpact on the c ity's f inances. The jury is thus mindful that finding new funding will prove i mpractical. B ut it also m eans t he city must be wise, looking to achieve the best possible results with the resources a t hand. With the prevailing conditions in mind, t he SFCGJ set out to e xamine San Francisco’s B HS, looking for potential weaknesses and inefficiencies that m ight be addressed w ithout the n eed for additional funding. We make recommendations i n t he areas of hiring, organization, and public communications where we think more efficient administration, focused management, and just plain discipline will achieve better outcomes and thus improve service d elivery - without significant increase in expense. BACKGROUND The SFCGJ could not ignore the longstanding situation t hat exists on S an Francisco’s streets where its residents pass people in obvious d istress, high out of t heir m inds or coping with some 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 5 other aspect of mental illness and desperate for help. It i s routine for o ur l ocal n ewspapers to write about the street scenes as well as the efforts o f the DPH to address these people's n eeds1 . In late winter early spring, the SFCGJ began to look more closely at the delivery of S an Francisco City and County BHS. Our initial f ocus w as to u nderstand what appeared to be a delivery shortfall as anecdotal evidence a nd p ublic reporting indicated the incidence of u nwanted or threatening public behavior was growing worse. Then as our research progressed, the coronavirus pandemic erupted. We must acknowledge the D PH’s e xtraordinary efforts to meet the c hallenge, both in its hospitals and clinics. The coronavirus pandemic will have a substantial negative impact on San Francisco’s p ublic finances. In March of 2020 a report to the supervisors a nnounced a significant r eduction in revenue was to be expected. What had been a projected shortfall of $420 m illion f or t he upcoming t wo-year plan was forecasted to increase to as much as $1.7 billion. Recognizing that unfunded recommendations made by the SFCGJ would be difficult to implement, we chose to limit our report’s recommendations t o areas where we find room for improvement and for which changes would not necessarily demand significant a dditional investment. That said, we introduce our report with a d iscussion of the newly e nacted legislation ‘Mental Health SF’ and its intended improvements. METHODOLOGY The SFCGJ centered it’s investigation around i nterviews and analysis of published reports. To a lesser degree it employed site visits and real time observations. Some o f our activities: ● Examined six years of DPH periodic and incidental reporting ● Conducted two dozen interviews with d epartment d irectors and staff ● Surveyed local press reporting on DPH initiatives for t he p receding three years ● Reviewed Legislation related to behavioral health ● Examined formal reporting of other public h ealth agencies ● Extracted current data from San Francisco’s S F OpenData web portal. ● Conducted a Ride-Along with Emergency Medical S ervices ● Reviewed video transcripts of the H ealth Commission Meetings f or the past year. ● Made site visits of selected DPH f acilities This report concerns itself with administrative practices and organizational structure. Thus we were most concerned with identifying actual vs. b est practice. Our r eport reflects this research. 1 ‘They’ve been getting sicker’: Inside SF’s effort to help the toughest homeless cases 2 B udget Outlook Update (March Joint Report) 3/31/2020 Kirkpatrick, Budget Director 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 6 DISCUSSION AND ANALYSIS Mental Health SF This past year has seen a strong push by t he Mayor a nd the BOS t o address a reas of c oncern in the d elivery of BHS to San Franciscans. Below we note some developments. In March of 2019, Mayor London Breed appointed Dr. Anton Nigusse Bland to s erve i n the new position o f Director of Mental Health Reform. H e r eports t o D r. Grant Colfax, t he Director of Public Health. Dr. Bland’s mandate3 is to r eview e xisting programs looking for opportunities for reform and to improve efficiencies. In February 2 020 Dr. B land made a n e arly presentation of his progress. His report can be found in the report H omelessness a nd Behavioral Health4 . In June 2019, Supervisors Haney and Ronen spoke to t he SF C hronicle Editorial Board a bout a plan they were formulating to expand mental health c are to all San Franciscans5 . It w as an early draft of what would eventually become Mental Health S F. Four months l ater, in October, t he Mayor announced her own initiative titled U rgentCare SF6 . T he M ayor's plan appears to have been strongly influenced by the newly appointed Dr. Bland. A lso in October, S upervisors Haney and Ronen announced revisions in their own p lan w ith adjustments meant to g ain w ider s upport7 . By November the competing legislation p roposals had been reconciled t o a single p lan t itled Mental Health SF 8. It would guarantee ‘...mental health care to all S an Franciscans who l ack insurance o r who are experiencing homelessness’. In December, the BOS approved Mental Health S F (“the Plan”), a c omprehensive p roposal t o transform the City’s behavioral health system. The Plan’s purpose is to overhaul the d isjointed mental health care system to provide access t o m ental health services, s ubstance u se t reatment, and psychiatric medications to all adult residents of San Francisco who are h omeless, uninsured, or enrolled in Medi-Cal or Healthy San Francisco. To accomplish this, the Plan proposes to increase access to behavioral health services for San Francisco r esidents 1 8 and older; create a Mental Health Services Center to serve as a centralized access p oint open 2 4/7; establish a Crisis Response Street Team available 24/7 through a specific phone line to connect individuals i n 3 Mayor Breed Appoints Dr. Anton Nigusse Bland to Director- Mental Health Reform, 3/27/2019 4 SFDPH Mental Health Reform - Homelessness and Behavioral Health, Feb. 21, 2020 5 Editorial: S.F. mental health plan is a long way from fully cooked 6 Mayor London Breed Announces Comprehensive Mental Health Plan to Help City's Most Vulnerable Residents 7 Supervisors unveil revised vision for mental health care overhaul 8Mayor London Breed, Supervisors Hillary Ronen and Matt Haney Announce Plan to Move Forward with Mental Health SF 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 7 crisis with the care they need; and expand current mental health and substance use disorder services offered by BHS. The future of the Plan is uncertain. The legislation as w ritten will not become operative without either voter approved taxes, a single year b udget e xpansion of a t l east 13%, or a BOS appropriation from the general fund. Recently announced b udget c uts imperil the Plan’s implementation. The Plan calls for the creation of a thirteen-member w orking g roup t o recommend how best to implement the services the Plan envisions. That group was t o have been in place by June 30, 2020 and to issue its f indings by June o f the f ollowing year. As of the date of our investigation, this group has not been formed. Our research identifies two initiatives that were i n development before Mental H ealth SF w as announced - a Drug Sobering Center and Expanded Hours at Behavioral H ealth A ccess Center (BHAC) at 1380 Howard Street which acts as an entry point t o substance abuse and mental health services. These two initiatives are as follows: A Drug Sobering Center is a recommendation o f the S an Francisco Methamphetamine Task Force as described in its comprehensive f inal r eport published October 2019 9. Creating a ‘trauma-informed sobering site’ was the number one objective of t hree most impactful recommendations. Note this w as published before the P lan. Three months after the plan was published, in March 2 020, DPH in a r eport to the Health Commission proposed a sobering center to be q uickly e rected on an empty site at Turk and Jones1 0. Since then, progress has been held u p because the site has been at the c enter of a neighborhood controversy1 1. We are able t o find t he chosen site mentioned in a H ealthy Streets Operations Center Report1 2 centered o n coronavirus response planning. H owever, we are not able to find what has become of t he Task Force’s intended s obering site. Expanded hours of service a t the BHAC. This initiative was announced b y Mayor London Breed in September of 2 019, in part as a r esult of Dr Bland’s reform effort1 3. Four months later the Plan described a Mental Health S ervice Center operating 24/7, in essence expanding access to services already provided at the BHAC. Currently, the BHAC is only open 8-5 Monday through Friday, making Zuckerberg San F rancisco General Hospital Psychiatric Emergency S ervices (PES) the sole emergency provider during off hours. The expanded hours of s ervice a t B HAC s till h ave n ot been implemented. S F Methamphetamine Task Force Final Report 2019 10 Drug Sobering Center Proposal: “Project 180’ 11 SF Says no thanks to free housing for homeless on tenderloin parking lot 12 Tenderloin Neighborhood Plan for COVID -19 May 7, 2020 Revision 13 M ayor’s Office Press Release 9/4/2019 Plan to Help Those Suffering from Mental Illness 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 8 These two service expansions, both solutions t o c risis conditions existing for more t han a year, were important enough to be announced as real p lans being p ut into action. The jury endorses the enactment of the Drug Sobering Center, and the e xpanded hours o f service as originally planned. They clearly fit into the strategy of Mental Health SF, a nd address an immediate n eed. W e are hopeful t hese move to the top priority in an incremental rollout of Mental Health SF. It’s a Big Public Agency San Francisco’s DPH is one of the city's largest single enterprises. It has a current annual budget of nearly $2.4 billion and employs nearly 7,000 people. B HS, a department within DPH, is itself the l argest provider of services to individuals with serious m ental illness a nd substance use disorders in the city. Its share of the DPH budget is $446 million and its staff count i s just under 700 full time equivalents (FTEs). Its services include prevention, e arly i ntervention, a nd inpatient and outpatient treatment. The need is equally large as well, for both sheltered a nd h omeless City r esidents. In t he case of the h omeless, 8,035 individuals were counted i n S an F rancisco's 2019 p oint-in-time street and shelter count, an increase of more than 14% o ver t he 2017 count1 4. A r eport from Tipping Point, 15 a nonprofit organization working in the area o f poverty a nd h omelessness, finds that “...of the 10,856 individuals who experienced homelessness in 2 016/2017 and accessed care at DPH, 58% had been treated for serious mental health d isorders and 63% had a history of drug or alcohol misuse.” In Fiscal Year 2018-2019, BHS provided services to 20,382 mental health patients and 5,975 clients with substance use orders.1 6 The proportion o f behavioral health clients w ho reported being homeless increased to 35% among mental health clients and 52% among substance use disorder clients. In this large complex public agency, SFCGJ found three areas where improvement could have a positive impact: shortened lag time in hiring, more d urable e xecutive placement, and increased discipline in web site publishing. A Hiring Bottleneck Vacancy Rate Among Intensive Case Managers. BHS provides i ntensive case management services to individuals with acute and chronic behavioral health needs who require significant 14 C ity Performance Scorecards, Homeless Population 15 Behavioral Health and Homelessness in San Francisco: Needs and Opportunities 16 Department of Public Health Annual Report 2018-2019 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 9 support to remain in treatment and successfully return t o t he community; t hese are the city’s most vulnerable population. An Intensive Case Manager (“ICM”) paired with an i ndividual in a behavioral health crisis is critical to a successful outcome. ICMs c an play a c ritical role in reducing the use of psychiatric hospital emergency services, hospital c are, and/or jail for high risk mentally ill individuals1 7. Without case management, at risk p atients a re more likely t o b e readmitted for treatment, thus increasing t he BHS’s workload and o verall costs. In its 2018 Performance Audit, the Budget and Legislative Analyst O ffice found the need f or ICMs exceeded the available ICMs by a f actor of 2 t o 1 and r ecommended an i ncrease in I CM staffing1 8. To date this increased staffing has not happened. The External Quality Review Organization ( EQRO) R eport f or Fiscal Year 2019-2020 made to BHS provided a glimpse of the continuing ICM s hort staffing 19. The authors highlight ICM access as one of its performance measures study topics. T he report indicates that timely I CM availability during transitioning, (step-down, when a patient m oves from a higher level o f care to a lower) remains of concern. The DPH Mental Health Quality Improvement Work P lan for two years (FY 2018-20192 0, FY 2019-2020 21) has identified ICM staff shortages as an issue contributing to e xtended wait times for clients to be paired with an ICM. In a March 2020 DPH SF H ealth Network presentation, the average wait to enter into ICM care is ‘more than two m onths’2 2. BHS’ is currently striving to reduce wait time for at least 50% of clients to one m onth. Hiring is a significant bottleneck: In an April 2015 C ontroller’s a udit, t he average lag t o h ire a registered nurse was 200 days2 3. Four years later, in M arch 2 019, t he BOS Government Audit & Oversight Committee heard from the DPH Human Resources D irector t hat s ame measure h ad only been reduced to 165.5 days2 4. In the later report, t he lag t ime for non-nursing s taffing was 235 days and peaked at 300 days. The COVID crisis demonstrates the possible: O n M arch 1 7, 2020, t he initial surge i n t he COVID-19 pandemic began overtaking the capacity of city services, and t he Mayor temporarily waived provisions of the Civil Service Commission a nd t he City Charter to expedite the hiring of 17 UCSF Citywide Case Management Programs 18 Performance Audit of the Department of Public Health Behavioral Health Services, 4/19/2018 19 FY 2019-2020 Medi-Cal Specialty Mental Health External Quality Review 20 DPH Quality Improvement Work Plan 2018-2019 21 DPH Quality Improvement Work Plan 2019-2020 22 SF Health Network Mental Health Services Capacity 23 How Long Does it Take to Hire in the City and County of San Francisco? 24 Presentation to BOS GAOC, 3/5/2020 Michael L. Brown Director of HR,Current State of RN Hiring 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 10 health care p rofessionals necessary to respond to the p andemic2 5. T he Mayor c ut the bureaucratic steps in the hiring process, slashing the time it takes t o hire a n urse f rom more t han s ix m onths to just 45 days or less. When the need is imperative, the hiring process can b e s treamlined. The D PH Human R esources must carefully consider how the existing p rotracted process is inhibiting filling approved and funded client service positions. A Problem of Executive Turnover In the four plus years since the retirement o f Director of Behavioral Health, Jo Robinson, the department has had four different directors. ● While Dr. Marcellina A. Ogbu continued as SF Network Deputy Director, s he w as named to replace Ms. Robinson as Director of Behavioral Health in April 2 016 in an acting capacity. ● Ms. Ogbu held the position for just eight months. She w as replaced by Kavoos Ghane Bassiri in January 2017. Mr. Bassiri left Richmond A rea Multi-Services ( RAMS), a mental health agency serving San Francisco’s Richmond D istrict, t o take the director's position. ● Mr. Bassiri served for twenty-seven months. In M ay 2019, D r. Irene Sung was named to replace Mr. Bassiri in an acting c apacity. Dr. S ung h ad previously served as Chief Medical Officer of BHS. ● Dr. Sung held the position for nine months. I n February 2020, Marlo Simmons was named to replace Dr. Sung, also in an acting capacity. Ms. Simmons had been serving as Deputy Director of Behavioral Health. In that four year period, the turnover rate for B HS d irectors hovered at 100%. Noting t he brevity of the service terms, and three of the four a ppointments a s ‘acting’, it appears the D PH has been unable to e stablish stable leadership for the BHS department. Reported executive turnover in the healthcare industry has trended up and is currently at 19% 26. DPH’s record for this position far exceeds the norm. Another factor may be at play. The Director of Behavioral Health r eports to the Director of Ambulatory Care, who in turn reports to the Director of S F Health N etwork w ith ten other d irect reports. That position is one step down from the Director of D PH who h as e ight direct reports. Press Release, Office of Mayor London Breed, 3/17/2020; Expedited Hiring of Health Professionals 26 Workforce at Risk: Addressing Healthcare’s High Turnover Rates for Executives 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 11 Despite t he fact that the Director of Behavioral H ealth leads a 700 e mployee team, manages a near half billion dollar annual budget, and oversees one of t he largest departments in t he DPH, yet r eports three levels away from executive leadership. One would not find a parallel in a p ublic company. The reasons behind this turnover are not stated. I t is p ossible that s tronger leadership, organizational realignment, and greater recognition could b ring about improvement i n stability and visibility. Public Visibility During the Jury’s research, we accessed the S FDPH.ORG website extensively. W e found it t o be inconsistently organized, however our chief concern i s its lack of m aintenance. We n ote that Laguna Honda, Zuckerberg General Hospital, and SFHIV, a ll agencies w ithin DPH, h ave their own web domains which are contemporary, organized, and appear to b e w ell-maintained. These are largely client service focused. SFDPH.ORG, w hile also providing n otice of c lient s ervices, is the p ublishing site for ongoing reporting of t he department's activities. We note the 2 017-2018 SFCGJ in it’s report C risis Intervention: Bridging P olice and Public Health2 7, a lso describes difficulties using the SFDPH website. Most inexplicable is the inconsistent accrual of o ngoing periodical r eports - the s imple a ddition of the next publication in a series of regularly reported e vents. We encountered m issing reports, reports misfiled under the wrong date, search requests not returning a r eport we could f ind posted when we found it’s location. This indicates a lack o f routine administrative discipline. We f ound attempts to make phone connections with DPH p ersonnel challenging. T he D PH home page SFDPH.ORG presents no point of entry t o a phone directory. If t he search term ‘phone directory’ is entered into the DPH home page search box, of t he four r esults, only one provides a phone number - and that is a single number - the main number for t he San Francisco Department of Health. Upon dialing the number, an a utomated voice a nswers, in part saying “...there is no operator”. On one occasion, a juror walked to 101 Grove Street, a nd asked to be d irected to t he DPH O ffice of Human Resources. There was not a person nor a directory in the lobby that indicated where the O ffice of Human Resources was located or the name of the director. F inally, after s earching, the j uror found the office but no one could i dentify t he name of the director until finally a n administrator came to the rescue. C risis Intervention: Bridging Police and P ublic Health 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 12 Correcting these weaknesses in DPH’s public v isibility is not primarily a matter of money. Improvements can be made by tightening internal procedures and improving p ublicly visible directories. CONCLUSION The economic impact of the coronavirus pandemic on the c ity finances will force hard c hoices for years into the future2 8. The homeless, u nemployed, and uninsured rely heavily on city hospitals and clinics for behavioral health care. Given t he consequences of the coronavirus pandemic, these services will be even more in demand i n the months ahead. The SFCGJ has written this report fully aware o f these headwinds. W e have kept our recommendations focused on improving processes and strengthening the SFDPH organization and administration. At the same time, recognizing that the Mental H ealth S F Legislation remains central to the city's plans to improve delivery o f behavioral health s ervices, w e a sk t hat two of its proposed developments; the Sobering Center, and Expanded Hours program at the B HAC be considered as items of the highest priority. Given the depth of crises w itnessed every d ay on our streets, we urge city administration and t he DPH to give their favored a ttention t o t his report and our recommendations. FINDINGS Based on the facts set forth above, the SFCGJ h ighlights here i ts principal findings. Finding Findings Required Responses # 1 High staff vacancy rates inhibit the ability to Director of P ublic Health care for individuals with mental illness and Director of H uman Resources substance abuse disorders. The shortage of Intensive Case Managers is Director of P ublic Health chronic. Director of H uman Resources 3 Lengthy and inefficient hiring protocols are Director of P ublic Health contributing to a shortage of Intensive C ase Director of H uman Resources Managers. M ayor London Breed Announces Updated Budget Impacts as a Result of COVID_19 2019-2020 SFCGJ: Strengthen our Behavioral Health Services 13 4 The position of Director of B ehavioral H ealth Director of P ublic Health has been filled with five different i ndividuals in San F rancisco Health five years. Commission 5 BHS’ scale of operation in terms o f staff c ount, Director of P ublic Health budget size, and public impact are not r eflected San F rancisco Health in its deeply nested reporting position in DPH. Commission 6 Regularly published DPH reports are n ot Director of P ublic Health consistently published on the department web site. DPH Headquarters at 101 Grove S t. provides n o Director of P ublic Health public directory of offices.and services. DPH website provides no public directory of Director of P ublic Health phone numbers.