District 2 Supervisor

Stopping the revolving door: Homelessness and coordinated exits

About a year ago, my son and I were walking down Chestnut Street when we saw a man in obvious distress rummaging through garbage cans with his pants at his knees. Sadly, this story is shocking to no one. To get him help, I called the nonemergency police number. After I spoke with the officers, they determined the man needed to be taken to the hospital. I am unsure of exactly what happened after this because of patient privacy laws, but the next day I saw him on Chestnut Street again, still in the same condition — only this time he was wearing a hospital bracelet.

Because of this experience and many others like it, I called for a hearing on the coordination of homeless services between departments with a focus on the 5150 process, which allows a person who is deemed to be a danger to himself, herself, or others, to be held for 72 hours at a hospital for evaluation and treatment. The crisis we see on our streets is not just about homelessness or mental health or substance abuse, but frequently all three combined. To help those living on our streets, we need shelter, crisis intervention, short-term treatment, and long-term care. If any component fails, the whole system fails. The hospital should not be a revolving door leading back to the streets. This crisis will not be solved overnight, but with a better-coordinated exit from emergency treatment, we have an opportunity to intervene when our unsheltered residents are admitted to Psychiatric Emergency Services and to prevent them from simply returning to the streets with no hope for better outcomes.


I toured PES at San Francisco General Hospital and two supportive housing sites. At PES, I saw the only place in the city that provides 24/7, open-access care for individuals experiencing acute mental health and substance abuse issues, either admitted voluntarily or on a 5150 hold. I met doctors and nurses who care deeply for their patients and wish they had more resources when their patients are released. The doctors and nurses at PES are on the front lines caring for those truly suffering, some with meth-induced psychosis, schizophrenia, suicide-risk, substance abuse, or a combination of issues.

At the two supportive housing sites, I met dozens of people who were formerly homeless and living with many challenges. Some had previously entered PES for treatment, but because they were able to secure permanent supportive housing with on-site services, they are now able to lead more healthful and successful lives and seek recovery from the issues they face. After these tours, one question kept coming to mind: How do we bridge this gap and ensure those experiencing homelessness who enter PES and then exit the hospital are able to connect to a pathway to permanent supportive housing and other supportive services?

After months of research and asking questions, I discussed the gaps in our system with the city’s mental health, substance abuse, and homelessness experts for several hours at the Public Safety and Neighborhood Services Committee. Here are some of the key takeaways:

One: PES admits more than 8,000 patients each year, and 68 percent of them report being homeless. That is about 15 homeless people who enter PES each day.

Two: Behavioral health services clients who report being homeless often face multiple severe issues. In fact, 26 percent of them experience tri-morbidity: co-occurring medical, mental health, and substance abuse issues.

Three: Addressing this crisis is as much about prevention as it is about treatment. Each week, the Department of Homelessness and Supportive Housing helps house 50 people. However, about 150 people become homeless each week. Living on the streets can lead to or worsen mental health and substance abuse issues, exacerbating the problem.

Four: San Francisco’s Hummingbird Place offers respite beds and treatment and recovery services for homeless individuals with substance abuse and mental health issues, but the facility only has 29 beds. Mayor Breed and the Board of Supervisors funded 14 of these beds with the recent budget surplus, a critical investment to treat those who are homeless and suffer from multiple behavioral health issues. I will continue to work with the Department of Public Health to determine how many more beds our city needs. I am also reaching out to other providers in the city to determine how they can help.


It is not compassionate to allow people to live or die on our streets. Those who are homeless and enter PES need places to go when they are discharged and a plan for long-term recovery. During my hearing, multiple potential solutions came to light.

First, we need more respite and treatment beds like those offered at Hummingbird, and I will advocate for this investment in this year’s city budget. Respite beds provide the time and level of care necessary for people to start recovery and a place where case managers can build a relationship with their clients in one place over time rather than having to find them on the streets. Additionally, extra beds where homeless individuals can recover will most likely prevent further PES hospitalizations, actually reducing costs to the city.

We also need to continue improving coordination of care once homeless individuals enter services. Last fall, the city implemented a coordinated entry system that tracks all people who experience homelessness in one database, but we need to ensure we have coordinated exits as well. A recent grant I cosponsored allowed the city to make a major step in this process by adding two social workers and four peer navigation workers to staff PES. These case workers develop relationships with people and help get them into Navigation Centers, treatment, and supportive housing. We need to prevent people from returning to PES and divert those that can receive less acute care.

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