Mark Essick SheriffCorcner Sonomtt @ounty James Naugle Assistant Sherif Iaw Enforcement D ivision

MADF's current practice of never using maintenance medication to treat opioid addiction is controvers ial. RESPONSE: The respondent disagrees wholly with the finding. Using Medication-Assisted Treatment (MAT) to treat opioid addiction has not yet been proven to be a best practice for local jail environments. It is more likely to be successful in a prison setting with longer incarceration terms. The State has funded a three year pilot program for San Francisco County Sheriff s Office to administer a MAT within their detention facilities. This pilot program will illuminate best practices and uncover pitfalts. We will be closely monitoring It piog.i.s of the pilot over the next three years and look forward to evaluating their findings " and basing our local decisions on what has been leamed. The Grand Jury Report enoneously states that "Addicts who enter the jail dependent on either street narcotics or a prescribed maintenance medication are taken off 'cold turkey."' The Sheriff s Office, through its contract with Wellpath for inmate medical services, provides methadone for maintenance to individuals who are already receiving it at the time they are admitted, and to opioid-addicted women who are pregnant when admitted. The Wellpath withdrawal protocblprovides support medications for withdrawal. Inmates are not taken off ,.cold turkey". In ute. are monitored daily by medical staff in a designated withdraw unit and are supportla *itt medications prescribed by a physician so that they can medically and safely withdraw. These medications are not used for maintenance at this time.

Inmates admitted on HIV/AIDS medications outside the lYellpathformulary are switched to alternative medications which may not be as elfective or well-tolerated. RESPONSE: The respondent disagrees wholly with the finding. Wellpath does not change drug regimens; they offer generic substitutions. If the prescribing physician feels a patient cannot take the generic, there is a mechanism in place to secure authorization from the Senior Medical Director to prescribe non-formulary drugs when appropriate.

The inabilityfor inmates to earn GED certification is a weakness in the MADF education progrum. RESPONSE: The respondent agrees with the finding. The Sheriff s Office has been aware of this gap and has been working to strengthen GED certification opportunities. The opportunity to earn GED certification will be available to inmates in August 2019 with the opening of Five Keys Accredited Charter School contracted to operate within the Sheriff s Office two detention facilities. Five Keys is the first charter school for incarcerated adults in the United States. The school is a fully accredited public high school program established by the San Francisco Sheriffls Department in 2003. Five Keys provides a range of educational programs and services including courses to obtain a high school diploma. This is an important addition to the Sheriff s Office Inmate Education Program. The Sheriff s Office has collaborated with local partners to provide educational programming to incarcerated adults at MADF and NCDF for many years, including vocational training, GED preparation, basic education, and college credits in math, English, counseling, and culinary arts. Though inmates received preparation for high school equivalency, education partners were unable to provide a high school diploma or equivalent credential. Through its unique partnership with the San Francisco Workforce Investment Board, Five Keys is able to offer high school diplomas or GED certificates to adults. We are excited to Iaunch this new program in August.

Discharge coordination is insufficient to ensure effective medical hand-olfs. RESPONSE: The respondent disagrees partially with the finding. Coordination is sufficient for effective hand-offs for medical discharges the vast majority of the time. The Sheriff s OfIice agrees that enhanced discharge planning support would strengthen hand-offs, but also acknowledges that we cannot ensure effective medical hand-offs all of the time because we do not have control over all aspects of the hand-off, particularly when individuals don't want to pursue medical treatment after release. Medical hand-offs for inmates going to another facility include complete medical packets for the receiving facility. Individuals who need immediate ongoing medical care are released directly to the hospital. Individuals with support (family, housing, insurance) are released with prescriptions and wriftcn instructions that may recommend further medical attention, for which the individuals are responsible. Inmates receiving mental health services receive comprehensive discharge planning and warm hand-offs to supporting organizations, including prescriptions and reentry services. Discharges for individuals who need medical attention and are experiencing a lack of housing or other support are more complex and may ultimately fail because the individual doesn't want to get or is not capable of getting the medical attention they need following release. The Sheriff s Office Detention Division works with County Department of Health Services to facilitate Medi- Cal reinstatements and provide access to care, and Wellpath discharge planners make appointments and provide instructions and links to available support. We cannot, however, require individuals to follow instructions or attend appointments after release. Another challenge we face are unanticipated court-ordered releases because the Sheriff s Office does not always have advanced notice and we cannot hold inmates beyond their release date for medical discharge planning. Going forward, additional discharge planning hours will be available for two years as a result of a U.S. Department of Justice (DOJ) grant awarded in 2018 for the purpose of improving access to and delivery of services to offenders with co-occurring substance abuse and mental illness when they leave incarceration to reenter the community. The Sheriff s Office is currently in the first year planning phase of the "Improving Reentry for Adults with Co-Occurring Substance Abuse and Mental Illness (CSAMD Program" and expects to begin implementation by December 2019. The grant will fund a 1.0 FTE Co-Occurring Disorder Specialist to help prepare inmates for transition to the community and a 1.6 FTE Peer Navigator/Case Manager who will work with the jail's discharge planning staff to ensure that participants receive a warn hand-off to services they need when they reenter the community. These grant-funded positions are targeting individuals with dual diagnoses (not medical discharges), but in doing so will make more discharge planning hours available for non-CSAMI discharges.