January 2020 San Francisco Housing Conservatorship Preliminary Evaluation Report harder4l=co community Contents Executive Summary......................................................................................1 Introduction ................................................................................................2 The San Francisco Housing Conservatorship Program .............................2 Housing Conservatorship Partners .......................................................3 Housing Conservatorship Evaluation................................................................6 Evaluation Requirements ...................................................................6 Evaluation Methods ...........................................................................7 Evaluation Findings ...........................................................................7 Looking Ahead ........................................................................................... 11 Evaluation Next Steps ..................................................................... 11 Working Group Considerations .................Error! Bookmark not defined. Executive Summary San Francisco’s Housing Conservatorship Program is designed to serve individuals who are deemed unable to care for their health and well-being due to co-occurring serious mental illness and substance use disorder, using the least restrictive and most clinically appropriate treatment options. The Program was conceived in September 2018 through California Senate Bill 1045, and later amended in Senate Bill 40. Local implementation in San Francisco was authorized by Mayor London Breed and the Board of Supervisors in June 2019, and a 12-member Working Group was established to evaluate the overall effectiveness of the Housing Conservatorship and its impact on individuals and local systems of care. San Francisco’s Administrative Code (Sec. 5.37-1 – 5.37-5) sets the requirements for the Working Group’s evaluation, as well as a timeline for submitting a preliminary evaluation report. The Working Group is charged with reporting on the following: 1. 2. 3. 4. 5. An assessment of the number and status of persons who have been recommended for a Housing Conservatorship, evaluated for eligibility for a Housing Conservatorship, and/or conserved under Chapter 5; The effectiveness of these conservatorships in addressing the short- and long-term needs of those persons, including a description of the services they received; The impact of conservatorships established pursuant to Chapter 5 on existing conservatorships established pursuant to Division 4 of the California Probate Code or Chapter 3 of the California Welfare and Institutions Code, and on mental health programs provided by the City; The number of detentions for evaluation and treatment under WIC §5150 of the California Welfare and Institutions Code that occurred in San Francisco during the evaluation period, broken down by the type of authorized person who performed the detention (e.g., peace officer or designated member of a mobile crisis team); and Where a detention for evaluation and treatment under WIC §5150 was performed by a peace officer, an explanation as to why the peace officer was the appropriate person to perform the detention. Report Summary This report provides context on the background and implementation of the San Francisco Housing Conservatorship Program, as well as an overview of key partners and eligibility criteria. To the extent possible, the report includes findings available to address the evaluation requirements above. This is the first Housing Conservatorship evaluation report and, at the time of submission, no individuals have been conserved. As such, this report provides a baseline exploration of the findings that will be reported in subsequent annual evaluations—including a partial estimate of WIC §5150 holds in Fiscal Year 201819—as well as insights into the conditions necessary for successful data collection, tracking, and analysis. San Francisco Housing Conservatorship – Preliminary Evaluation Report Introduction In September 2018, California Governor Jerry Brown signed Senate Bill 1045 (SB 1045), the Housing Conservatorship Program, into law. SB 1045 created a fiveyear mental health conservatorship pilot program for adults with serious mental illness and substance use disorder treatment needs who meet strict eligibility requirements, with a focus on providing housing and wraparound services. SB 1045 was revised in October 2019 when Governor Newsom signed Senate Bill 40 (SB 40) into law. SB 40 made technical amendments to SB 1045, including adding a Temporary Conservatorship requirement, clarifying the role of Assisted Outpatient Treatment (AOT), including additional due process protections, and reducing the length of the conservatorship to six months. San Francisco Mayor London Breed and the Board of Supervisors authorized local implementation of SB 1045 in the City and County of San Francisco in June 2019, and established a Housing Conservatorship Working Group to evaluate the effectiveness of the pilot program. This report provides an overview of San Francisco’s Housing Conservatorship pilot and a preliminary evaluation based on the requirements outlined in Chapter 5 of San Francisco’s Administrative Code (Sec. 5.37-1 – 5.37-5). This is the first Housing Conservatorship evaluation report and provides a baseline contextualization of the findings that will be reported in subsequent annual evaluations to the Mayor, Board of Supervisors, and State Legislature from January 2021 to January 2023. The San Francisco Housing Conservatorship Program The intent of Housing Conservatorship is to help people who are deemed unable to care for their health and well-being due to co-occurring serious mental illness and substance use disorder, and to treat individuals with the least restrictive and most clinically appropriate intervention needed for the protection of the person. As of December 2019, San Francisco’s Office of the Public Conservator currently oversees the care of 625 individuals under existing law, the Lanterman-Petris-Short Act (LPS). The LPS Act went into full effect in 1972 and provides counties with the ability to seek conservatorship of individuals who are considered gravely disabled due to serious mental illness or chronic alcoholism. Conservatorship under LPS does not provide for mental health conservatorship due to the impacts of substance use disorder, outside of alcohol. Housing Conservatorship creates a new type of mental health conservatorship for these individuals who are not currently covered under existing law. Eligibility In order to qualify for conservatorship, which is authorized through court proceedings, an individual must be dual-diagnosed with a serious mental illness and with a substance use disorder as defined by the law, and have been evaluated for a psychiatric emergency eight or more times in a 12-month period under an involuntary hold under California Welfare and Institutions Code (WIC) §5150.1 In A WIC §5150 hold is issued to individuals who present an imminent danger to themselves or others, or are gravely disabled due to a mental disorder. 1 2 San Francisco Housing Conservatorship – Preliminary Evaluation Report addition, the individual must have been provided with opportunities to engage in voluntary treatment, and the Office of the Public Conservator must determine through their initial investigation and prior to submitting a petition to the court, that a Housing Conservatorship is the least restrictive intervention for the protection of the individual. San Francisco’s Department of Public Health estimates that this program may serve 50-100 individuals. Referral and Engagement A person may be referred for an evaluation to determine eligibility for Housing Conservatorship by the Sheriff, Director of Health, Director of the Human Services Agency, or their designees. Directors of agencies that provide comprehensive evaluation or facilities that provide intensive treatment, such as hospitals that perform psychiatric evaluations, may also refer an individual if the individual meets the eligibility criteria. Housing Conservatorship in San Francisco is designed to maximize engagement in voluntary treatment and other appropriate housing options before the Office of the Public Conservator submits a petition for conservatorship. This element of the Conservatorship exceeds current laws and practices under LPS conservatorships. Housing Conservatorship includes due process protections and the right to be represented by the Public Defender. Housing Conservatorships will terminate after six months unless there is a demonstrated, continued need for conservatorship services. The Office of the Public Conservator is required to submit a report to the court every 60 days to demonstrate the continued need for conservatorship. Furthermore, the Office of the Public Conservator must request termination of the conservatorship before the expiration date, if the person’s condition no longer warrants it. Similar to LPS conservatorship, persons will be provided with an individualized treatment plan, including wrap-around services, trauma-informed and gender responsive treatment, and placement in a setting that is appropriate to meet their service needs. The Department of Homelessness and Supportive Housing will provide permanent supportive housing to individuals who are currently homeless and able to live in an independent level of care. Housing Conservatorship Partners San Francisco’s Housing Conservatorship pilot is designed to be a collaborative and responsive program with regard to both implementation and oversight. Key partners include: Public Conservator The Office of the Public Conservator is responsible for investigating all referrals for the Housing Conservatorship program and determining that individuals who are referred meet the strict program requirements. The City Attorney will represent the Public Conservator in court for the Housing Conservatorship program. The Public Conservator has established a specialized unit within the program’s team of clinicians that will have responsibility for closely overseeing all individuals who are served by the Housing Conservatorship program. Care Team Implementation of the Housing Conservatorship pilot will leverage existing Care Team staff from the City’s Assisted Outpatient Treatment (AOT) program, including a program manager (psychologist), three clinicians, and two team members to provide peer and family support. 3 San Francisco Housing Conservatorship – Preliminary Evaluation Report Working Group In compliance with the Administrative Code, the City and County of San Francisco has created a Housing Conservatorship Working Group to evaluate the effectiveness of the pilot implementation. The Working Group is tasked with submitting this preliminary report to San Francisco’s Board of Supervisors and the Mayor’s office in January 2020, and an annual report thereafter from January 2021 to January 2023 to the Board of Supervisors, Mayor’s office, and the State Legislature. Facilitation and administration of the Working Group is managed by San Francisco’s Department of Public Health. The Working Group is comprised of 12 members, appointed as follows: • Kelly Dearman, Seat 1, representative of disability rights advocacy groups appointed by the Mayor • Jessica Lehman, Seat 2, representative of disability rights advocacy groups appointed by the Board of Supervisors • Simon Pang, Seat 3, representative of labor unions appointed by the Mayor • Jennifer Esteen, Seat 4, representative of labor unions appointed by the Board of Supervisors • Rachel Rodriguez, Seat 5, representative of organizations providing direct services to homeless individuals or families, appointed by the Mayor • Sara Shortt, Seat 6, representative of organizations providing direct services to homeless individuals or families, appointed by the Board of Supervisors • Dr. Mark Leary, Seat 7, an employee of a hospital located in San Francisco with experience in mental health and substance use disorders, appointed by the Director of Health • Dr. Irene Sung, Seat 8, an employee of the Behavioral Health Services program of the Department of Public Health, appointed by the Director of Health • Jose Orbeta, Seat 9, an employee of the Department of Public Health, appointed by the Director of Health • Jill Nielsen, Seat 10, an employee of the Human Services Agency, appointed by the Director of the Human Services Agency • Dara Papo, Seat 11, an employee of the Department of Homelessness and Supportive Housing, appointed by the Director of the Department of Homelessness and Supportive Housing • Sgt. Kelly Kruger, Seat 12, an employee of the San Francisco Police Department. appointed by the Chief of Police Other Partners San Francisco’s Housing Conservatorship pilot will leverage key partners from across the local system of care, and individuals will have access to a wide range of services that are responsive to their treatment needs. Key partners include the 4 San Francisco Housing Conservatorship – Preliminary Evaluation Report courts, the Public Defender’s Office, the City Attorney’s office, the Department of Disability and Aging Services, Zuckerberg San Francisco General Hospital, and the Department of Public Health’s Whole Person Care program. 5 San Francisco Housing Conservatorship – Preliminary Evaluation Report Housing Conservatorship Evaluation Central to the launch of San Francisco’s Housing Conservatorship pilot is ongoing and informative evaluation, designed to gauge the success of the program as it develops and highlight opportunities for enhancement. The following sections of this report summarize the pilot’s evaluation requirements, as well as proposed methods. Evaluation Requirements SB 40 and the San Francisco Administrative Code (Sec. 5.37-1 – 5.37-5) have charged the Housing Conservatorship Working Group with managing an evaluation of the pilot’s overall effectiveness. According to the San Francisco Administrative Code, this preliminary evaluation report to the Mayor and Board of Supervisors is to include: 1. An assessment of the number and status of persons who have been recommended for a Housing Conservatorship, evaluated for eligibility for a Housing Conservatorship, and/or conserved under Chapter 5; 2. The effectiveness of these conservatorships in addressing the short- and longterm needs of those persons, including a description of the services they received; 3. The impact of conservatorships established pursuant to Chapter 5 on existing conservatorships established pursuant to Division 4 of the California Probate Code or Chapter 3 of the California Welfare and Institutions Code, and on mental health programs provided by the City; 4. The number of detentions for evaluation and treatment under WIC §5150 of the California Welfare and Institutions Code that occurred in San Francisco during the evaluation period, broken down by the type of authorized person who performed the detention (e.g., peace officer or designated member of a mobile crisis team); and 5. Where a detention for evaluation and treatment under WIC §5150 was performed by a peace officer, an explanation as to why the peace officer was the appropriate person to perform the detention2. In order to promote the efforts of the Working Group and ensure a high-quality, objective evaluation, the Department of Public Health and Department of Disability and Aging Services have contracted with Harder+Company Community Research to lead the evaluation as an external partner. Harder+Company has worked closely with the Working Group to review the requirements of this evaluation, discuss appropriate evaluation methods, and develop protocols to gather necessary data and feedback from partners. This preliminary evaluation meets the reporting requirements set out in San Francisco’s Administrative Code. For a full list of annual reporting requirements, including those outlined in SB 40, please see Appendix B. 2 6 San Francisco Housing Conservatorship – Preliminary Evaluation Report Evaluation Methods Methods for this evaluation were designed in collaboration between Harder+Company Community Research, the Department of Public Health, and the Department of Disability and Aging Services, with input from the Housing Conservatorship Working Group. These evaluation methods were selected to address the evaluation requirements set out in local San Francisco ordinance, as well as in SB 40: • Analysis of client-level data. Evaluation of the Housing Conservatorship pilot’s effectiveness at the individual level will be largely determined using client-level data gathered from multiple local agencies. Using descriptive and inferential statistical analysis, these data will be used to examine changes in client outcomes and the overall demographic landscape of those conserved. • Analysis of population-level data. One of the potential indicators of the Housing Conservatorship pilot’s impact is the presence of any change in the total number of WIC §5150 evaluations and detentions across San Francisco. The pilot’s evaluation will track population-level counts of 5150s over time, beginning with a pre-implementation baseline from Fiscal Year 2018-193. • Individual client surveys. Surveys will be administered on a regular basis to individuals conserved under the San Francisco Housing Conservatorship, to gauge overall experience and attitude toward the pilot program. • Family and stakeholder feedback. Given the nature of this pilot program, it is especially important to gather input from family members and stakeholders whenever possible. The evaluation will gather feedback, when feasible, from family members, service partners, and other stakeholders to gauge impressions of the pilot and suggestions for improvement. Feedback may be gathered through surveys, focus groups, interviews, or any combination of these data collection methods. Evaluation Findings This section details, to the extent possible, the evaluation findings required by San Francisco Administrative Code. These findings are currently limited, as the Housing Conservatorship pilot is in its early stages of planning and implementation. Conserved Individuals and System-Level Impact Evaluation requirements 1-3 outlined in San Francisco Administrative Code (Sec. 5.37-1 – 5.37-5) call for reporting on the number and status of conserved individuals, the overall effectiveness of their conservatorships, and the broader impact of the Housing Conservatorship pilot on existing services in San Francisco. At the time of this preliminary report’s submission, the Housing Conservatorship pilot has yet to serve any individuals. Therefore, findings are not included for these three evaluation requirements. Given the recent passing of the legislation authorizing the Housing Conservatorship, key partners including the Care Team and the Office of the Public Conservator are working together to solidify Pre-implementation baseline estimates do not include data from all psychiatric units and emergency departments in San Francisco. These limitations are detailed further in the following section. 3 7 San Francisco Housing Conservatorship – Preliminary Evaluation Report implementation plans, create the necessary protocols and forms, and obtain necessary approvals from the court. WIC §5150 Evaluations in San Francisco The evaluation requirements outlined in San Francisco Administrative Code (Sec. 5.37-1 – 5.37-5) also call for reporting on the total number of WIC §5150 detentions performed during the evaluation period, broken down by the type of authorized person who performed the detentions. Because the Housing Conservatorship pilot is in its pre-implementation stage, and due to the truncated length of this preliminary evaluation period, this report includes available data on WIC §5150 detentions performed in San Francisco during Fiscal Year 2018-19 (July 1, 2018 – June 30, 2019). This population-level data will be used in subsequent annual evaluations as a baseline comparison to examine any change in the total number of WIC §5150 evaluations and detentions across San Francisco. The comparison of data points before and after the implementation of the Housing Conservatorship pilot may be one useful way to measure to impact of the program. Data on the total number of WIC §5150 evaluations and detentions that occurred in San Francisco during Fiscal Year 2018-19 is derived from two data sources: (1) SFDPH’s Coordinated Care Management System (CCMS) database, which tracks the individuals seen at Zuckerberg San Francisco General Hospital’s Psychiatric Emergency Services (PES) department, and (2) a formal Request for Information (RFI) fulfilled by the San Francisco Police Department (SFPD) for all individuals placed on a WIC §5150 hold in Fiscal Year 2018-19 as a result of an emergency dispatch of SFPD officers. Data on some WIC §5150 holds are also tracked by San Francisco Mental Health Clients’ Rights Advocates (SF MHCRA4), though it was not included in this current round of evaluation. Current data from SF MHCRA only tracks individuals admitted to LPS-designated inpatient facilities after their WIC §5150 hold, and the integrity of these data cannot yet be verified. Moving forward, SFPD will work closely with SF MHCRA to review and assess available data, and determine how it fits with data from existing sources. WIC §5150 Evaluations Partial estimate of population-wide WIC §5150 holds in San Francisco for Fiscal Year 2018-19: 5,754* *Includes data only from Psychiatric Emergency Services at Zuckerberg San Francisco General Hospital, and from the San Francisco Police Department Data from the sources available indicates a total of 5,754 WIC §5150 holds that occurred in San Francisco in Fiscal Year 2018-19, attributed to 3,810 unique individuals. Because data on WIC §5150 holds came from two distinct data sources, a large number of cases and individuals appeared in both databases. (i.e. the case of an individual detained by SFPD officers and transported to PES). These duplicate records were matched by unique identifiers, then removed from the total estimate count. Details on this process are summarized in the table below. Exhibit 1. Number of WIC §5150 evaluations and detentions that occurred in San Francisco during the evaluation period, from available sources Data Source Unique Individuals Total 5150 Count 2,437 3,542 2,358 3,461 – Removal of duplicate cases -985 -1,249 Total unduplicated cases 3,810 5,754 SFDPH: Coordinated Care Management System (CCMS) San Francisco Police Department (SFPD) San Francisco Mental Health Clients’ Rights Advocates (SF MHCRA) are the county’s appointed patients’ rights advocates, pursuant to WIC §5520 4 8 San Francisco Housing Conservatorship – Preliminary Evaluation Report Approximately 35% of the WIC §5150 holds tracked in the CCMS database were officer-involved detentions and approximately 36% of the individuals reported by SFPD are estimated to have been held and evaluated at PES. It is assumed that the remaining 64% of individuals were held and evaluated at other hospitals and emergency departments across San Francisco. These population-level data estimates are significantly incomplete and carry limitations that are important to underscore. Notably, the data from SFDPH’s CCMS system only includes individuals seen at Zuckerberg San Francisco General Hospital, which is the designated facility in San Francisco for psychiatric crisis, and does not include data from other hospitals across San Francisco that assess individuals on a WIC §5150 when there is an urgent medical need or admit individuals for WIC §5150 holds. Given this limitation, the true count of WIC §5150 holds across San Francisco in Fiscal Year 2018-19 is likely higher, though it is not possible to approximate at this time. Moving forward, effectively tracking the true count of WIC §5150 holds across San Francisco will require a new and streamlined work flow, with involvement from multiple partners. Further, while the data currently available indicates the overall proportion of WIC §5150 holds initiated with SFPD-involvement, it is not currently possible to extract the type of authorized person who performed the remaining holds, as prescribed in the evaluation requirements. Efforts to resolve this limitation are discussed further in the final section of this report. Existing and proposed steps to narrow these reporting gaps and reduce limitations are detailed further in the final section of this report. Peace Officer Involvement in WIC §5150 Evaluations In addition to tracking the total number of WIC §5150 holds in San Francisco, the Administrative Code (Sec. 5.37-1 – 5.37-5) charges the evaluation with further examining instances where peace officers were involved, to address the question of why a peace officer was the appropriate individual to respond in these cases. Reporting on this question will be especially relevant in subsequent evaluations, as Mental Health SF reforms related to peace officer involvement in behavioral health crises launch across San Francisco. While the data currently available is insufficient to address this question on a casespecific basis, the records of WIC §5150 detentions received from SFPD do offer some insights into how and why officers may typically become involved in these scenarios. In the SFPD database, each record includes the reason recorded by the peace officer for the emergency call, with the most common reason listed as ‘Person Attempting Suicide’ (35%), although this does not provide additional insight into what the caller is saying to dispatch about a person’s presentation or behavior at the time of the call. Exhibit 1, below, lists the five most common reasons for these calls as recorded verbatim in the dispatch logs. 9 San Francisco Housing Conservatorship – Preliminary Evaluation Report Exhibit 2. Five Most Common Reasons Recorded for Emergency Call per Dispatch Logs Resulting in WIC §5150 Evaluation (from SFPD Database) Reason for Emergency Call Number of Calls % of Calls “Person attempting suicide” 1,198 35% “Mentally disturbed person” 401 12% “Check on well-being” 322 9% “Mental health detention” 81 2% “Fight or dispute (no weapons)” 24 1% Data from the SFPD RFI also includes the ultimate resolution of the emergency call, showing that 96% of emergency calls that involved a WIC §5150 evaluation resolved with the individual detained without criminal charge, while the remaining individuals were either cited for minor infractions or booked into the county jail once their psychiatric crisis was resolved. 10 San Francisco Housing Conservatorship – Preliminary Evaluation Report Looking Ahead Given the pre-implementation timing of this preliminary evaluation report, it is not possible to draw meaningful conclusions about the effectiveness of the Housing Conservatorship pilot, or about its impact on service systems and overall rates of WIC §5150 detentions across San Francisco. Rather, this report serves as a baseline for measuring progress moving forward, and for documenting considerations for improving evaluability of the pilot. Evaluation Next Steps Future evaluation reports will be submitted annually during the Housing Conservatorship’s pilot stage, and a number of considerations have surfaced to date around designing an effective overall evaluation strategy. The ability to gauge overall effectiveness of the pilot for those conserved will rely on quality data at the individual level. Moving forward, the evaluation team will work closely with the Housing Conservatorship Care Team and Working Group to ensure that, as implementation launches, data monitoring and tracking are prioritized as key elements of the process. Subsequent evaluation reports will likely rely on individual-level data compiled from several sources, in order to paint a full picture of effectiveness. At the population level, successful evaluation efforts moving forward will require significant improvements in the ability to track and analyze WIC §5150 holds across the entirety of San Francisco’s system of care. Developing data sharing agreements with local hospitals will be central to these efforts, as well as protocols to process incoming data and filter for duplicate records. Efforts to outreach to local hospitals for data sharing are currently underway with the support of the Hospital Council of Northern and Central California. Drawing meaningful insights from population-level data on WIC §5150 holds will also require exploring new avenues of analysis using available data, with guidance from the Working Group. This consideration is especially relevant when working with data on peace officerinvolved holds, and relevant analyses may include, for example, exploring the source and timing of emergency calls that lead to WIC §5150 holds by peace officers, gathering qualitative information from samples of incident reports, and assessing the demographic characteristics of individuals evaluated and detained with officer involvement, compared to others. Working Group Considerations At the time of this preliminary report’s submission, members of the Working Group have identified some unresolved issues and considerations that are important to note, including the following: • Limitations around data collection on WIC §5150 holds from all local hospitals and emergency departments in San Francisco limits the Working Group’s ability to determine effectiveness of the Housing Conservatorship pilot; o Next steps: SFDPH is working with the Hospital Council of Northern and Central California to establish working relationships to gather these data from individual hospitals, and will also 11 San Francisco Housing Conservatorship – Preliminary Evaluation Report conduct outreach to the Department of Justice and San Francisco Mental Health Clients’ Rights Advocates to discuss available data and its limitations); • In order to fully respond to the evaluation requirement that calls for explaining why a peace officer was the most appropriate person to execute a WIC §5150 hold, further data should be extracted from existing police records, including information on whether the hold was initiated in collaboration with other professionals (e.g., clinician, case manager, etc.). It is the understanding of Working Group members that peace officers can be called by clinicians to assist with WIC §5150 holds to detain an individual for transport; o • Working Group members have a desire to better understand the process by which individuals served by the Housing Conservatorship pilot will be offered voluntary services and housing at initial engagement. Specifically, Working Group members have expressed interest in what types of services and housing resources will be offered, availability of those services, and what that process will look like; o • Next steps: Working Group members will receive regular updates on the experience of individuals served by the Housing Conservatorship, and these service experiences will be a focus of ongoing evaluation activities); Initial figures suggest a high rate of African Americans detained under WIC §5150 holds across San Francisco, when compared to the overall demographic characteristics of San Francisco. When this rate is examined within the larger context of a declining number of African Americans residing in San Francisco, the Working Group is concerned that a disproportionate number of African Americans could be conserved under the pilot program; o • Next steps: SFDPH is working with SFPD to identify if a sample of incident reports can be reviewed in greater detail to provide qualitative information to the Working Group. These discussions are also part of larger efforts through Mental Health SF to identify needs and alternatives to peace officer involvement in behavioral health crises); Next steps: The Working Group intends to make sure that the Housing Conservatorship pilot does not bring unintentional consequences or impacts for San Francisco’s African American residents, and this topic will be a priority focus of ongoing and annual evaluation activities); The Working Group held its first meeting in November 2019, and some members have expressed a desire for more time to gather data (as outlined above), meet, discuss, and evaluate findings before submitting a preliminary report; o Next steps: The Working Group added an additional meeting to review the report prior to submission. While data will not be comprehensive, the goal is to provide a preliminary report and move towards obtaining more comprehensive and complete data for future reports). 12 Appendix A: Housing Conservatorship Fact Sheet WHAT IS HOUSING CONSERVATORSHIP? In September 2018, the California Governor approved Senate Bill 1045 (SB 1045), or the Housing Conservatorship Program, creating a pilot program that allows for the conservatorship of adults with serious mental illness and substance use disorder treatment needs who meet strict eligibility requirements. Housing conservatorship is designed to help individuals who cycle in and out of crisis and are incapable of caring for their health and well-being due to co-occurring serious mental illness and substance use disorder. SB 1045 was revised in October 2019 when California Gov. Gavin Newsom signed Senate Bill 40 (SB 40) into law. SB 40 clarified the role of Assisted Outpatient Treatment, includes a Temporary Conservatorship, and reduces the conservatorship time to six months. The San Francisco Board of Supervisors and Mayor London Breed authorized local implementation of SB 1045 in the City and County of San Francisco in June 2019, and established a Housing Conservatorship Working Group to evaluate the effectiveness of the implementation of SB 1045. Conservatorship is an important benefit for people who need a high level of care, and an important tool in the spectrum of services and treatment that the City of San Francisco provides. WHO IS HOUSING CONSERVATORSHIP DESIGNED TO HELP? Housing conservatorship is designed to help individuals who cycle in and out of crisis and are incapable of caring for their health and well-being due to co-occurring serious mental illness and substance use disorder. Additionally, housing conservatorship is only granted if the individual has repeatedly refused appropriate voluntary treatments and is not eligible for other programs including Assisted Outpatient Treatment (AOT, often called Laura’s Law) or existing conservatorship options. If placed on a conservatorship, an individual will be provided with individualized treatment in the least restrictive setting to support their path to recovery and wellness and ultimately transition into permanent supportive housing at the end of the conservatorship process. The San Francisco Department of Public Health (SFDPH) estimates that 50 to 100 individuals will be eligible to participate annually. Currently, about 600 individuals are receiving care under conservatorship as provided in existing law, the Lanterman-Petris-Short Act (LPS). LPS conservatorship has been in place since 1972 and does not include substance use disorder as part of the criteria for being conserved. To be eligible for housing conservatorship, which is authorized through court proceedings, an individual must meet all of the following criteria: 1) 2) 3) 4) 5) 6) 7) 8) 9) Be at least 18 years of age; Be diagnosed with a serious mental illness as defined by law (WIC 5452(e)); Be diagnosed with a substance use disorder as defined by law (WIC 5452(f)); As a result of (2) and (3), the individual has functional impairments or a psychiatric history demonstrating that without treatment it is more likely than not that the person will decompensate to functional impairment in the near future; Be incapable of caring for their own health and well-being due to a serious mental illness and substance use disorder; Have eight or more 5150 detentions in a 12-month period; Have been provided with opportunities to engage in voluntary treatment, including an offer of permanent housing following treatment; Assisted Outpatient Treatment has been determined to be insufficient or, as a matter of law, the individual does not meet the criteria for Assisted Outpatient Treatment; Conservatorship is the least restrictive option for the protection of the individual. Under the law, a person may be referred for an evaluation to determine eligibility by the Sheriff, Director of Health, Director of the Human Services Agency, or their designees. Directors of agencies that provide comprehensive evaluation or San Francisco Housing Conservatorship – Preliminary Evaluation Report facilities that provide intensive treatment – such as hospitals that perform psychiatric evaluations – may also refer an individual if they meet the eligibility criteria. HOW ARE PATIENTS’ RIGHTS PROTECTED? Housing conservatorship strictly defines patient eligibility criteria in order to ensure appropriate application of the law and to protect individual rights. Housing conservatorship requires at least three opportunities to engage patients in voluntary treatment before a referral for conservatorship is made. San Francisco is committed to ensuring that a voluntary treatment pathway is offered at every point of contact with the behavioral health system. Additionally, housing conservatorship specifically defines the rights of the individual, including due process protections and the right to be represented by the public defender. Further, under housing conservatorship, a person cannot be ordered or forced to take medication. HOW LONG DOES A HOUSING CONSERVATORSHIP LAST? Housing conservatorships will terminate after six months unless there is a demonstrated, continued need for conservatorship services. This differs from LPS conservatorships, which terminate after one year unless the Office of the Public Conservator seeks a renewal. In all cases, the court and the person’s care team must end the conservatorship before the expiration date if the person’s condition no longer warrants it. HOW DO PEOPLE GET INTO HOUSING? Similar to LPS conservatorship, individuals who are served through the housing conservatorship program will be provided with wraparound care, treatment and housing in a setting that is appropriate to meet their needs. The City is committed to providing care and treatment as well as supportive housing on an ongoing basis, even once the conservatorship has terminated. San Francisco Housing Conservatorship – Preliminary Evaluation Report WHAT MAKES HOUSING CONSERVATORSHIP DIFFERENT FROM OTHER KINDS OF CONSERVATORSHIP? An LPS mental health conservatorship is a legal procedure through which the Superior Court appoints a conservator to authorize psychiatric treatment of a person who meets a narrow legal definition of grave disability by reason of a serious mental illness. This procedure is established in the California Welfare and Institutions Code (WIC) as the Lanterman-PetrisShort conservatorship or “LPS,” named after the state assemblyman and senators who wrote the legislation, which went into effect in 1972. In San Francisco, the conservatorship process is a close collaboration of several public agencies. The Office of the Public Conservator is located within the Department of Disability and Aging Services, in the Human Services Agency. The program works closely with the Superior Court and the Department of Public Health to authorize, carry out and oversee treatment for individuals under conservatorship. The program supports overall health and well-being through case management and service coordination. Senate Bill 1045 fills a gap in current law by creating a new type of conservatorship to serve a small group of people who have been offered but are unable to accept voluntary services due to serious mental illness and substance use disorder. The definition of “grave disability” that governs the existing LPS mental health conservatorship does not account for the effects of psychoactive substances other than alcohol. This is insufficient in today’s San Francisco, in which many psychiatric emergency encounters involve methamphetamine use. Patients cycle in and out of crisis because once the substance clears from their systems, they are released, often back into a triggering environment where the substance use starts again and leads to behaviors that put them or others in danger. Housing conservatorship seeks to fill this gap by providing an avenue to support these individuals to achieve stability, prevent further deterioration and transition into permanent supportive housing. HOW WILL HOUSING CONSERVATORSHIP BE EVALUATED? The Department of Public Health will work with an external evaluator to provide reports to the Housing Conservatorship Working Group and the State of California, in accordance with the Health Code and Welfare and Institutions Code. For questions or information, please contact housing.conservatorship-workgroup@sfdph.org Appendix B: List of Data Points Required for Evaluation San Francisco Administrative Code 1. An assessment of the number and status of persons who have been recommended for a Housing Conservatorship, evaluated for eligibility for a Housing Conservatorship, and/or conserved under Chapter 5; 2. The effectiveness of these conservatorships in addressing the short- and long-term needs of those persons, including a description of the services they received; 3. The impact of conservatorships established pursuant to Chapter 5 on existing conservatorships established pursuant to Division 4 of the California Probate Code or Chapter 3 of the California Welfare and Institutions Code, and on mental health programs provided by the City; 4. The number of detentions for evaluation and treatment under Section 5150 of the California Welfare and Institutions Code that occurred in San Francisco during the evaluation period, broken down by the type of authorized person who performed the detention (e.g., peace officer or designated member of a mobile crisis team); 5. Where a detention for evaluation and treatment under Section 5150 was performed by a peace officer, an explanation as to why the peace officer was the appropriate person to perform the detention. Senate Bill 40 1. An assessment of the number and status of persons who have been conserved under Chapter 5 (commencing with Section 5450), the effectiveness of these conservatorships in addressing the shortand long-term needs of those persons, and the impact of conservatorships established pursuant to that chapter on existing conservatorships established pursuant to Division 4 (commencing with Section 1400) of the Probate Code or Chapter 3 (commencing with Section 5350) and on mental health programs provided by the county or the city and county; 2. The service planning and delivery process for persons conserved pursuant to Chapter 5 (commencing with Section 5450); 3. The number of persons conserved pursuant to Chapter 5 (commencing with Section 5450) who are placed in locked, acute psychiatric, hospital, rehabilitation, transitional, board and care, or any other facilities or housing types, and the duration of the confinement or placement in each of the facilities or housing types, including descriptions and analyses of the various types of confinement or placements and the types of onsite wraparound or other services, such as physical and behavioral health services; 4. The number of persons conserved pursuant to Chapter 5 (commencing with Section 5450) placed in another county and the types of facilities and the duration of the placements, including the types of onsite wraparound or other services, such as physical and behavioral health services; 5. The number of persons conserved pursuant to Chapter 5 (commencing with Section 5450) by the conserving county who receive permanent supportive housing in any county during their conservatorship, whether permanent supportive housing was provided during the conservatorship, and the wraparound services or other services, such as physical and behavioral health services, provided; 6. The number of persons conserved pursuant to Chapter 5 (commencing with Section 5450) who are able to maintain housing and the number who maintain contact with the treatment system after the termination of the conservatorship, including the type and level of support they were receiving at the time they were conserved pursuant to Chapter 5 (commencing with Section 5450); 7. The number of persons conserved pursuant to Chapter 5 (commencing with Section 5450) who successfully complete substance use disorder treatment programs; San Francisco Housing Conservatorship – Preliminary Evaluation Report 8. The incidence and rate of persons conserved pursuant to Chapter 5 (commencing with Section 5450) who have been detained pursuant to WIC §5150 subsequent to termination of the conservatorship at 6, 12, and 24 months following conservatorship; 9. An analysis of demographic data of persons conserved pursuant to Chapter 5 (commencing with Section 5450), including gender, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, marital status, and sexual orientation; 10. A survey of the individuals conserved pursuant to Chapter 5 (commencing with Section 5450) and an analysis of the effectiveness of the placements and services they were provided while conserved; 11. The substance use relapse rate of persons conserved pursuant to Chapter 5 (commencing with Section 5450) at 6, 12, and 24 months following conservatorship, to the extent this information can be obtained; 12. The number of deaths of persons conserved pursuant to Chapter 5 (commencing with Section 5450) within 6, 12, and 24 months following conservatorship, and the causes of death, to the extent this information can be obtained; 13. A detailed explanation for the absence of any information required in paragraph (11) or paragraph (12) that was omitted from the evaluation. harderco.com Harder+Company Community Research works with public- and social-sector organizations across the United States to learn about their impact and sharpen their strategies to advance social change. Since 1986, our data-driven, culturally-responsive approach has helped hundreds of organizations contribute to positive social impact for vulnerable communities. Learn more at www.harderco.com.