Expanding Treatment in San Francisco

London Breed
7 min readJan 9, 2024

Beginning this year, San Francisco and other counties across the state have a new conservatorship tool to help compel people into the care they need to survive and thrive. Our City Departments have worked hard to make sure we are ready right away to start implementing this new law which will help change lives.

The good news: when we talk about the individuals that will be helped by this program, it’s often those whose cases are the most heartbreaking. The people we see on our streets, day after day, unable to clothe or care for themselves. From a statistical standpoint, they may be few, but they occupy a disproportionate level of city services. By getting them into care, we can better help them, and better serve others with our robust services.

However, this is not the tool for everyone struggling in our city — it’s truly for the most severe cases. Still, by adding one more tool, we will be able to expand our range of services and help more people at different levels of need. When people talk about the need for treatment, it can mean so many different things. Some might need crisis intervention or a locked facility, while others might need preventative support or outpatient treatment.

Our public services are targeted to serve those most in need. Our goal is to have a network of care to not only help people on the street, but also people who are housed to keep them healthy and stable.

Right now, the San Francisco Department of Public Health (SFDPH) serves as many as 32,000 people annually with mental health and substance use disorder care through outpatient and residential services. This includes:

  • Serving more than 5,000 people with medication assisted treatment for opioid use disorder with buprenorphine and methadone. And we are ready to expand to help more. Right now, we typically can sign people up the same day they apply to one of these programs.
  • Expanding treatment beds by adding an additional 350 beds to the 2,200 we had, with another 50 in the pipeline. We worked to shape and support putting a State Mental Health Bond on the March Ballot to fund thousands more beds across the state, including in San Francisco.
  • Making pharmacy deliveries that serve shelters and permanent supportive housing and extending hours at our Behavorial Health Access Center, Behavioral Health Pharmacy, and other outpatient treatment sites. We have pharmacists walking our streets to deliver medication to reach people in treatment with barriers to medication access. With expanded hours, we have handled a 164% increase in clients at our buprenorphine induction clinic at 1380 Howard Street and are prepared to handle more.
  • Providing outpatient services at 14 DPH community clinics across our City, where people can get access to medications for addiction treatment. Approximately 25,000 people a year receive care for substance use or mental health disorders at our primary clinics. This includes Maria X Martinez Health Resource Center, which opened in early 2023 with a focus on our South of Market Area and people experiencing homelessness.
  • Providing contingency management programs, an innovative behavioral therapy that rewards people with small incentives, such as gift cards of low monetary value, for quitting stimulants like cocaine and methamphetamine. As the most effective studied intervention for stimulant use disorder, it saves lives, and we are growing these programs in San Francisco.

To connect people struggling on our streets to all these services, our public health street care teams are in the community seven days a week. These are dedicated medical and behavioral health professionals, as well as peer counselors with lived experience with addiction who are there offering care and support on the spot and connecting people experiencing homelessness and/or using substances in public settings to clinics and treatment. They are consistent and compassionate, but the reality is they often cannot get people to accept the care they need. Nevertheless, we do not give up on people.

For example, our street care teams will engage and support the same person for months building rapport and trust before client agrees to accept treatment and other City services.

Despite these challenges to getting people help, we will continue to send our teams out to offer care. We will continue to offer treatment for those who need it through both outpatient and inpatient services. We will use whatever laws or tools we can to compel people to accept care, so they get the help they need.

To learn more about the different levels of programs we have:

Crisis Intervention

For people experiencing a mental health emergency we want to get to them quickly to stabilize them with an emergency response that can meet their immediate needs. Once they get that immediate response and are stabilized, we can then work to get them the longer-term care and connections they need.

  • 24/7 Comprehensive Mobile Crisis Team provides 24/7 service to adults and children experiencing acute mental health emergencies and provides psychological first aid to people at the scene of critical police and fire incidents such as shootings and pedestrian accidents. Care is provided in person and over the phone. The team answered 3,000 calls for service and responded in person 700 times.
  • Street Crisis Response for people experiencing a mental health or substance use crisis in the community. These teams have expanded dramatically and have responded to over 35,000 calls for service since the first team launched in November 2020.
  • Crisis Stabilization and Urgent Care Access for people experiencing a behavioral health crisis to stabilize them and transition them to appropriate level care.

Outpatient Treatment

Primary care and specialized behavioral health care settings help people who need treatment and support but are not in residential care setting. This is the overwhelming level of population we serve, and it’s critical that we have a wide range of access points for people to reach services. These include:

  • Approximately 55 specialized outpatient mental health and substance use treatment sites offering services that include medication-assisted treatment, counseling, care coordination, and peer support.
  • Neighborhood primary clinics offering behavioral health care, including medication, care coordination, referrals to specialized clinics and services.
  • Specialty clinics for specific populations, including youth, seniors, and the LGBTQIA+ community.
  • Intensive outpatient programs providing multidisciplinary treatment (social worker, psychiatrist, health worker, nurse) that offer team-based care for people with complicated mental health and substance use needs.
  • Contingency management behavioral therapy programs to address stimulant use.
  • Opioid use disorder treatment programs with mental health and substance use counseling, wrap around services, and other health care interventions.
  • Alcohol use disorder programs, including medication assisted treatment.

Residential Treatment and Care

Live-in mental health and/or substance use programs where people can address behavioral health care needs in a safe and supportive setting range in service levels and duration, from short-term crisis beds like our drug sobering center to long-term residential care beds like our step-down residential facilities for post- treatment living on Treasure Island.

Our approximately 2,550 beds for mental health and substance use treatment and care include programs for:

  • Beds for people who are struggling with both mental illness and substance use disorder.
  • Crisis stabilization beds for people experiencing a behavioral health emergency.
  • Voluntary residential and locked residential treatment beds.
  • Withdrawal management and respite beds for people in withdrawal for substance use and need a safe and supportive environment before they initiate care services.
  • Drug sobering center like SOMA Rise, which provides 25 beds for people intoxicated on substances and need to recover in safe place indoors.
  • Alcohol sobering center for people intoxicated on alcohol and need a safe place to recover indoors.
  • Managed alcohol program for people with severe alcohol use disorder
  • Transitional supportive housing: Step-down programs for people to stabilize in a supportive environment after exiting a residential program and in outpatient treatment, including our new 70 beds on Treasure Island.
  • Medical respite programs for unhoused people with serious health issues to stabilize out of the hospital, receive behavioral health care services, and get connected to ongoing care and social services.

Proactive Care

Our work isn’t just about responding to those who have fallen into crisis. To keep people in our system of care once we’ve engaged with them, we have proactive strategies to keep them from falling through the cracks. This includes:

  • Providing ongoing care through our Office of Coordinated Care (OCC). The OCC provides case management, care plan, counseling, and connections to ongoing care with a focus on people with complex behavioral health care needs, including people experiencing homelessness; people leaving hospital inpatient, emergency department, and psychiatric emergency settings; people leaving jail, including reentry planning; people with high utilization of multiple systems and high behavioral health needs; and people living in the HSH system: shelters, navigation centers, permanent supportive housing
  • Ensuring access for treatment and care programs. We’ve expanded hours and staff at Behavioral Access Center, a self-referral site to get placed in treatment and care programs. We also have 24/7 Access Line and we’ve expanded hours at Community Behavioral Health Services Pharmacy that delivers medications to supportive housing, shelters, and other high-risk settings.
  • Expanding access to medication assisted treatment clinics by increasing hours of operation, staff, peer support groups and other services.
  • Deploying post overdose engagement and support programs to get people into care after a recent overdose, both housed and unhoused.
  • Running a robust network of street care engagement and coordination to get people experiencing homelessness into programs to address behavioral health care needs. These include neighborhood-based teams and street-based teams in outdoor settings and at community pop-up clinics.