Addressing Homelessness, Mental Health & Substance Use on our Streets

While the last year has forced us to confront a public health crisis the likes of which we’ve never seen in our lifetime, COVID-19 is not the only public health challenge facing San Francisco. Homelessness, addiction, and unhealthy street behaviors have been a challenge for years, and while we’ve implemented a number of solutions and made progress during the pandemic, we still have a lot of work to do.

Last year we had to severely limit capacity in our homeless shelters and Navigation Centers and, not surprisingly, we saw a big spike in unsheltered homelessness and people living in tents. At the height of the pandemic, with shelters emptied out, there were 1,108 tents and structures counted in the City. However, the City responded quickly and we were willing to try new approaches that we had never tried before. As a result, that number has been more than cut in half, with 501 tents and structures remaining, which is now back below January 2020 levels.

As we emerge from this pandemic, we need to focus on three things:

  • Continue creating more places for people to go, whether that’s a shelter space or a place with more services to treat their underlying issues like substance use disorders or mental health issues.
  • Expand our outreach and coordination so that people are getting connected with the right services and placements that could get them the help they need.
  • Strengthen data and transparency tracking tools so that we ensure that our money is being well-spent and our resources are being allocated in the right way. If they’re not, we can quickly pivot away from what is not working and try something new.

Creating More Placements

In response to the pandemic, we’ve opened more than 25 hotel sites with over 2,600 rooms for unsheltered people who are vulnerable to COVID so they can isolate and shelter indoors. But these hotels were an immediate response to a crisis. We still need long-term solutions that ensure that the people who we have moved inside don’t end up back on the street.

To do that, we need to create more placements for people who are homeless that fit their needs, whether that’s temporary shelter, permanent supportive housing, or treatment facilities. Last year, I announced our Homelessness Recovery Plan, an ambitious plan for how we are going to continue forward to respond to homelessness. This plan is built on three basic elements:

  • Expanding housing options for our homeless, including investing in the largest expansion of permanent supportive housing in 20 years. In total, we’re creating 6,000 new placements for people experiencing homelessness.
  • Adding capacity in our shelter system, including both opening up our existing shelters, navigation centers, and alternative housing and adding new sites.
  • Using prevention and rapid rehousing efforts, like problem solving, time-limited rental subsidies, and connections to health care, employment, and other resources to end homelessness for people with a variety of housing needs.

We also know that many people require a response that isn’t just a roof over their head. Approximately 4,000 people who are homeless in San Francisco also experience challenges with substance use disorders and mental illness. Drug use and overdoses are a major issue that is only getting worse as the deadly drug fentanyl becomes more and more prevalent in our city.

The City has long had a program aimed at providing care to people facing addiction on the street. Now we’re moving to open a Drug Sobering Center, an innovative approach that will be the first of its kind in the nation, which will serve people who are intoxicated from drug use and shouldn’t be left alone on the street. This will fill the gap between existing services so someone who is high and possibly acting erratically isn’t left alone if they don’t commit to a long-term treatment facility. Instead they can be brought to the 24-hour Drug Sobering Center, where they can stay for a number of hours while being watched by healthcare professionals.

There will be on-site services that range from everything from snacks, access to showers, and peer counseling to referrals to medical services and transportation to medical and social services appointments. The idea is to provide a place for people to safely be off the streets to ensure they are not a danger to themselves or others, and then have the resources available on-site that they need to try to turn their lives around when they come down.

After recovering from a crisis, people experiencing homelessness, mental health and substance use challenges often need a flexible place to stay and recover so that they are not exiting onto the street but can transition into treatment or housing with supportive services. We’ve developed Hummingbird Valencia, a respite center, designed on a previous model that we know works, as a place where people who need additional help to stabilize or develop their plan to go into treatment, and housing with other social services. Professional counselors are on hand to guide those who are recovering, and the respite center will provide these wrap around services for short stays up to a few weeks, depending on the need.

Mayor Breed with members of the San Francisco Homeless Outreach Team.

Connecting People to Placements and Services

Just because placements and services exist doesn’t mean that they’re automatically going to be utilized. City government is often too difficult for residents to navigate, and that is especially the case for someone who is also going through the trauma of being homeless, or facing challenges with mental illness and addiction.

Many of these folks will never get connected with services if we’re not consistently meeting them where they are and helping them get the resources they need. That is the purpose of our Homeless Outreach Team (HOT), which is out every day, building those relationships and trying to get people off the streets and into housing.

However, the challenges that substance use disorders and mental health issues pose requires an additional level of care. When someone is in distress on the street, historically the police have been the ones responding, even though this is not their area of expertise. Nationally, we have also seen a number of high-profile incidents where the presence of police has ended up exacerbating the situation posed by someone going through a mental health crisis.

One of San Francisco’s new Street Crisis Response Teams.

That is why we’ve launched our Street Crisis Response Team, a new, innovative approach for responding to non-violent 911 calls relating to mental health and substance use. These teams consist of a community paramedic, a behavioral health clinician, and a peer counselor who are specifically trained to help de-escalate situations, address the immediate needs of the person in crisis, and get them connected to services to try to address their underlying issues.

We have now launched three of our first six teams and they’re currently serving the Tenderloin, Mission/Castro, and Bayview neighborhoods. In the early months of operation, this effort has demonstrated the positive impact of implementing alternatives to a police response: 20% of all 911 calls about street disturbances related to a behavioral health crisis have been diverted to these more specialized teams. Of these encounters, nearly a quarter required transportation to higher level care facilities, and the remainder were de-escalated with many people being connected to ongoing wrap around services.

This approach not only better addresses the needs of the people in crisis, it also helps ensure that the people who are in need are getting connected to the resources that we have ready to help. Additionally, it frees up our police officers to focus on crime and public safety.

Member of San Francisco’s EMS-6 team checks on the health and well-being of a person needed medical attention.

The Health Streets Operations Center (HSOC) was launched in 2018 to respond to the rise of tent encampments and unhealthy street behavior in the City. It is comprised of multiple City departments working together to coordinate responses relating to encampments, people living in vehicles, and other challenges.

Over the past year, HSOC has been effective in decreasing the number and size of the encampments on the streets. At the beginning of the pandemic, we had to close many of our shelter spaces in response due to social distancing, and not surprisingly the number of tents on the street skyrocketed. But HSOC’s systematic, persistent approach, coupled with new placements being opened in alternative housing options like hotels, helped get people out of tents and into placements.

In fact, there are currently fewer tents and structures on the streets now than there were before the pandemic began. The number of tents and structures that existed at the height of the pandemic has now decreased by more than 50%.

Before and after an encampment resolution in the Mission. This was part of an effort in the Mission where the City offered hotel rooms, access to safe sleep sites, shelter, and services to people experiencing homelessness.

The challenges we face with tents are now different than they were over the past year. For many people who are homeless, a tent is a last-ditch effort to find some shelter when no other options exist. These are the folks that HSOC staff are trying to help into a better situation. However, what HSOC is now finding is that the majority of people in encampments have been helped inside, and many of the folks who are remaining are using tents for other purposes.

For example, HSOC’s data show that between 10–15% of the people they are now interacting with in tents are already currently housed in the City’s portfolio of housing and shelters, yet they’re continuing to set up tents on the streets. The reason for this vary — some people find the shelter visitor rules too restrictive and other people are using tents for more nefarious reasons like engaging in criminal activity or drug use.

I want to be very clear that this will not be tolerated. If someone is currently housed and they’re continuing to set up tents on the street, the City will respond by ordering that the tent be removed or we will remove it. There is a big difference between someone who is out of options resorting to a tent as shelter and someone who is housed choosing to go out and still set up a tent. We will continue to try to help people get connected to shelter, but we will not allow people who are already being helped to then camp out, block sidewalks, and cause issues on the street.

Tracking Results and Analyzing What Works (And What Doesn’t)

As we move forward with these new efforts, we’ve set up detailed processes to track and analyze what is working and what is not. We know that it is not enough to simply create these programs and get them running — we also need to constantly analyze where we’re having success, and where we are falling short, so that we can reallocate resources. Here’s the thing about the new approaches we’re trying: some of them will fail, but that does not mean they were a failure because we can learn from them and move forward.

To give you a sense of the systems we have put in place,

  • HSOC conducts regular tent counts to show whether conditions on the street are improving or getting worse.
  • The Street Crisis Response Team tracks every interaction they have and the result of those interactions. This allows us to alter our approach when needed, and also compare the challenges in the different neighborhoods where the teams are operating to see where resources need to be shifted.
  • The Drug Sobering Center will similarly track the results of the clients they serve and what the outcome of those interactions were.
  • We have launched a new tracker for our Homelessness Recovery Plan, which will allow us collectively to understand the impact of our investments and change course when needed, so that as many people as possible access housing.

All of these efforts are working together. The Drug Sobering Center will provide another option for the Street Crisis Response Team to bring clients to in order to address the immediate issue they’re facing. The new placements through the Homelessness Recovery Plan provide placements for HSOC to provide for folks currently camping on the street. The Street Crisis Response Team can help police deal with challenging situations they’re not equipped for and let them focus instead on public safety. The police can help HSOC respond to issues that at first appear to be relating to homelessness but are actually related to criminal activity.

We still have a lot of work to do to get people the help they need and make our city shine. But we’re putting the pieces in place to make that happen. And as we emerge from this pandemic and start our economic recovery, I’m optimistic that our approach will show a meaningful change on our streets that benefits those most in need as well as the City as a whole.

45th Mayor of the City and County of San Francisco

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