Conservatorship off to a slow start with just one person in court-ordered treatment

Nearly two years after a conservatorship program was approved targeting mentally ill residents suffering from substance addiction and living on the city's streets, San Francisco has only now placed the first person in court-ordered treatment.

In June 2019, the Board of Supervisors approved the controversial "Housing Conservatorship" pilot program allowed under Senate Bill 1045, which had been approved earlier that same year. But challenges in implementing the program, which was promoted by Mayor London Breed and Supervisor Rafael Mandelman, has prevented anyone from being conserved until now. The pilot expires January 1, 2024.

"It's been nearly two years since the board vigorously debated and ultimately opted into SB 1045," Mandelman said at a Thursday hearing of the board's Public Safety and Neighborhood Services Committee. "I said at that time that even if SB 1045 only helped one person, I believed it was worth doing. And I still believe that, but I didn't think it would actually literally be just one person."

He said that the "purpose was to address the needs of a relatively small population of unhoused folks who repeatedly cycle through psych emergency, our other emergency rooms, jail, back to the streets and again without ever getting the longer term support and care that they need."

Under the program, a person is eligible for The City to seek a court approved-conservatorship if they have a mental illness and a substance use disorder and in the past 12 months were held at least eight times at an area hospital on a 5150 for up to 72 hours for a psychiatric emergency evaluation.

Early last year, city officials blamed the challenging process of setting up the legal forms with the courts for the new program as a cause for the delay in implementation.

"In June 2020, the forms were finalized by courts locally, which then allowed us to be able to move forward with cases," Angelica Almeida, who oversees the Department of Public Health's assisted outpatient treatment program and the SB 1045 pilot, told the committee. "It really wasn't until June 2020 that we were able to move forward with cases."

Almeida said that as of the end of January they have identified 63 individuals with dual conditions who had at least five 5150s in the past 12 months, of which 16 had at least 8 and one is the one who was conserved.

She said she anticipated The City would ultimately end up conserving "at least a handful of more individuals" under the pilot.

Mandelman said SB 1045 was initially proposed as a solution for a specific sort of problematic behavior he is seeing in his district.

"I know of a number of these individuals by name in my district who are committing crimes, not because they are bad people but because they have a mental illness combined with a substance use problem, who are being 5150'd maybe not 8 times, but a lot," Mandelman said. "One such person set a fire in my district that burned three people out of their homes last week."

Jill Nielsen, deputy director of programs for the Department of Disability and Aging Services, which oversees conservatorships, said that the "eligibility criteria is far too narrow" for conserving someone under the pilot. She noted that SB 1045 was initially introduced to permit a conservatorship if a person had three 5150s within 12 months, not 8.

However, critics of the bill called for tougher protections against conservatorship under the pilot, including The City doing more to offer voluntary services and housing "before we take away civil liberties."

Nielsen said that it remains to be seen what will happen when there is a contested conservatorship, but that the City Attorney "believes that a future contested case could be quite complex and lengthy" because of the "extensive requirements found within the law."

"Although we knew that the housing conservatorship program would only serve a small number of individuals, it does remain disappointing that we have not been able to help more vulnerable people at this point," Nielsen said. "We are absolutely committed to growing the program and we remain committed to implementation and innovation to do everything we can to make sure we are using this tool."

But critics said the approach remains wrong.

"We know there are huge problems with conservatorship," said Jessica Lehman, executive director of Senior and Disability Action. "It is a significant deprivation of civil liberties.We need to offer people housing and voluntary services earlier rather than having people in crisis for years and then saying that they haven't made rational choices."

She refuted the characterization from 1045 backers that opponents of the bill succeeded in getting in amendments that made the pilot overly complex.

"It is great that we have as many protections as we do," Lehman said. "The people who have had multiple 5150s are disproportionately African-American men and the city must come up with a plan to address that racial disparity before continuing."

Dr. Grant Colfax, head of the Department of Public Health, acknowledged the "multiple challenges" in implementing the pilot but stood behind it.

"DPH will continue to support housing conservatorship," Colfax said. "We need all the tools at our disposal to serve the most vulnerable in San Francisco."

He promised improvements to the entire system of care are underway through Mental Health SF, a multi-year effort to transform The City's behavioral health system. The department recently hired Dr. HillaryKunins to lead Mental Health SF.

"Our system of care is expanding, lowering barriers to treatment and making it easier to access and move through the system," Colfax said.

Mandelman, however, said that the "expectations for Mental Health SF are very high" and he remains concerned that The City is "orders of magnitude away from having the response to the pretty serious behavioral health and substance use issues on the street."