Key points:
- San Francisco Community Health Clinic secures apartment for formerly unhoused Sheila.
- Sheila, a double amputee, struggled with daily life on city streets.
- San Francisco spends over $1 billion annually on homelessness services.
On a cloudy summer day in July in San Francisco, a long-awaited goal was made into a reality for Sheila, a formerly unhoused woman who had been living on the city’s streets for years. Two case managers from San Francisco Community Health Clinic collaborated closely with a local housing agency to secure Sheila her own apartment, referred to as “permanent supportive housing.”
For Sheila, a double amputee, managing daily life while attending regular dialysis appointments is often exhausting as she navigates the city’s well-known Tenderloin District, located in the heart of downtown. But finally, after years of completing countless documents toward housing applications, Sheila met compassionate social service professionals who worked tirelessly to offer her the chance to restore her dignity. Sheila would not have to spend another night outside in the cold.
Permanent supportive housing refers to units reserved for residents who are eligible for government subsidies, including Section 8 vouchers. But for many of the city’s most vulnerable and aging residents, the wait for placement into a unit can take years.
For Sheila, housing is only the first step. Due to proper communication between agencies, her case managers collaborated effectively with the on-site staff assigned to Sheila’s apartment building. By working together, staff across multiple agencies successfully allowed Sheila to secure transportation to her medical appointments and travel to the DMV in order to obtain important documents. This is an example of how social services can be effectively delivered across different agencies using teamwork, collaboration, empathy, and trauma-informed care.
So why are leaders in the San Francisco government refusing to acknowledge methods that work? This is one of multiple questions posed at last week’s “Understanding Homelessness” talks at Manny’s, a community space in the city’s Mission District for civic engagement around complex social issues.
Like many cities across the U.S., social and economic issues persist. But the level of visibility of suffering, sick, and hungry people on the streets is a grim reflection of inequality, despite hundreds of agencies and city departments working tirelessly around the clock to address issues of crime, overdose deaths, and other social and economic challenges.
According to a recent poll conducted by Sextant Strategies & Research, nearly three in four voters approve of Mayor Daniel Lurie’s first six months in office. But the results indicate an ultra-mixed climate of optimism and fatalism.
Strikingly, Lurie was less popular on specific issues than he was overall. While most respondents agreed that he was keeping the city clean, keeping residents and businesses safe from crime, and revitalizing downtown, he scored less favorably when it came to providing shelter for the homeless, handling the overdose crisis, and addressing the cost of housing.
“Mayor Lurie is delivering results on the issues San Franciscans care about,” mayoral spokesperson Charles Lutvak said in a statement to the San Francisco Chronicle. “Our administration will continue to deliver on what we’ve been working on relentlessly since day one: tackling the fentanyl crisis and providing safe and clean streets for everyone in our city.”
To address the disconnect between city departments such as the Department of Homelessness and Supportive Housing, Kunal Modi and Sharky Laguana spoke during a moderated panel by journalist David Sjostedt, reporter for the San Francisco Standard who covers addiction and homelessness.
Kunal Modi is the director of Homelessness and Supportive Housing, hired by Mayor Lurie to spearhead the city’s responses to those experiencing crises. He emphasized the need to remain focused on the human element of these sensitive issues.
“As we do all the really important human work on the street operationally and in our shelters and permanent supportive housing, we can also focus on the systems and infrastructure so that we can do this work smarter in the future.” He is referring to the three core objectives established by Mayor Lurie at the beginning of his term. These are government accountability and transparency, crime and behavioral health, and economic recovery.
Modi was joined by Sharky Laguana, commissioner on the city’s Homelessness Oversight Committee. A former foster youth, today Sharky operates his own small business writing software to optimize existing systems to improve efficiency.
The lack of transparency around where the over $1 billion a year homelessness budget was going kept Sharky up at night. He began to notice an unsettling fact: despite years of interventions and shifting policies, the population of unhoused individuals in San Francisco always remained the same.
He developed a thesis and even produced a short video documentary to raise awareness and reframe the problem as a way to understand the complex system currently in place. “To the extent that we can know that number,” Sharky says, “that’s what tells us how healthy the system is. If you can imagine a pipe, if one person’s coming in and one person’s going out at the same speed, then what that tells you is that’s a healthy, sustainable system, you have people going in and people coming out.” But, for every one person that is “exited” from homelessness, another three enter.
“Inflow” refers to the amount of water going in — in this case the number of people seeking services. The analogy of the pipe helps to understand that when more water enters a pipe than leaves — called “outflow” — then resources are quickly depleted.
Sharky points to the “wraparound” services, meaning the network of care coordinators and treatment providers who work around the clock to assist an individual to become self-sufficient, that are initiated when a person engages with public agencies and nonprofit organizations.
The cost of providing these wraparound services is a key factor as to why the city spends over $1 billion a year yet is still unable to provide adequate relief to those who need it most. Services include ambulance rides, treatment planning, staff to provide linkage to community resources and make referrals for services after a patient is discharged, rental assistance, long-term medical care, and more.
Those who engage with the city’s street crises response system — whether that is through an emergency room in a hospital or through one of the city’s hundreds of social service agencies — cost thousands of dollars per day in services. This includes paramedics, law enforcement, and medical transportation, salaries of hospital staff, social services staff including a case manager, and specialty care for physical and behavioral health.
This leads to unnecessary spending on services that a client doesn’t need but receives regardless. Simply put, the current health system is designed to treat disease, not prevent it. Yet countless findings based on concrete data indicate prevention works.
The key, says Modi, is to tailor treatment to the individual. Our current health system treats everyone the same without consideration for their unique and cultural needs. The majority of funding for programs comes from private donors, state, and federal sources who closely monitor how dollars are spent to ensure dollars are not spent on staff salaries and are being used properly toward client services.
For example, one of the biggest cost drivers consuming most of the city’s HSH budget is spent on people that already have housing, to cover expenses such as Section 8 vouchers. According to Modi, it costs $50,000 to $60,000 a year to place someone in temporary housing.
Government accountability and transparency is one of the three promises Mayor Lurie plans to address in addition to combating the crisis still visible on the city’s streets.
“We are pushing our regional partners to build inventory as well, because we cannot solve this alone in SF. We need to do this across the state in CA. Most of who we serve is from CA so the state has been pushing counties to build more interim housing. We are going to be proponents in the [state capitol] Sacramento to push other counties to do their part as well,” says Modi.
“According to Public Health, every individual is considered a data point,” says Professor Lily Cheung, educator at SF City College in the Community Healthworker Department and medical interpreter at San Francisco Zuckerberg Hospital.
Health data can then be measured and used to improve the delivery of services. But how patient information is collected is a major concern.
A core issue underlying the ineffective delivery of services across the system of care comes from the fact that every organization essentially uses a different database to store data. Law enforcement agencies such as SFFD and SFPD, the Department of Homelessness and Supportive Housing, and public benefit organizations all rely on different software and record-keeping methods.
These include EPIC — used by hospitals — Avatar, used by behavioral health clinicians, and the OneSystem, the city’s database of unhoused individuals’ shelter placement status, where each person is assigned a number. Simply put, there is no ability to communicate between agencies to support a person through the many stages of achieving stability.
Yet it is imperative to maintain privacy in regard to a person’s private health information, or PHI, or else face criminal penalties. Agencies are required by law to abide by HIPAA, referring to the Health Information Portability and Accessibility Act. For many unhoused folks, however, privacy is seen as a luxury rather than a basic human right.
In order to effectively measure the specific needs of the community, homeless advocates and social service staff deploy teams to outreach individuals on the streets, effectively “meeting them where they are at.”
To collect data, a “Point in Time Count” is conducted once every two years. But this method of gathering important information is dysfunctional and ineffective, as it only counts people during one night of the year and is not an accurate representation of the unhoused population.
Yet, the data from this survey is used to determine how dollars are spent that are provided by donors, city and county, and federal sources. According to the most recent PIT Count from September 2024, the total number of unhoused people in SF was 8,000. In reality, however, the number of people any given year is closer to 20,000. That 8,000 figure is “just a snapshot,” says Laguana.
While there is an abundance of data, there is a huge deficiency in the quality of tools available to measure this data in a way that can be quantified.
“If we want to provide the same level of services that we are continuing to provide and if we want to increase the effectiveness of the services we’re providing, then it’s incumbent on us to figure out as many ways as possible to be as efficient as possible to increase flow.
“If we can increase throughput, we can actually modestly decrease the size of the pipe and operationally still serve the same number of people. That’s the challenge we’re going to work through and this is the strategy that we’re working towards.”
A supervisor at San Francisco Zuckerberg Hospital’s emergency department described a case in which an individual had not just 100 emergency department visits but over 1,000 in a single year.
According to the Transtheoretical Model of Public Health and the Stages of Change, a person who will most benefit from the change — a person in crisis — has to want to make the change. Oftentimes this is caused by a cue to action, whether it is a minor or major life-threatening event, that finally persuades a person to seek the help they need.
“Sometimes the whole hospital is only allocated one shelter bed,” said the supervisor. “These are folks who are highly disorganized, many of whom are using substances, who have to present in one place, and that’s the only way they can access shelter.” This system ends up harming the people who rely on it, leading critics to doubt the mayor’s ability to deliver on one of his core promises.
“There is nothing progressive or kind to let someone struggle on the streets through that kind of crisis through ERs, hospitals and jails — there’s nothing kind about that,” Modi said.
Nonprofit agencies and government departments must work together in order to maximize and streamline systems to make them work together instead of in siloed databases that make it impossible for relevant information to easily be accessed to help someone in crisis.
Social service agencies provide crucial support to help those who are economically disadvantaged achieve long-term stability and overcome barriers to success. Many people who are eligible for public assistance are capable of benefiting from these programs to eventually move out of poverty to become self-sufficient.
But achieving this cannot and should not be done alone. “You don’t want people to get stuck in one part of the pipe — you want to help people move through the system. By helping them, we create more capacity to help people that need help that are not yet in the system.”
If Mayor Lurie wants to keep his reputation aligned with the pendulum swing of SF politics and maintain support from voters, it will require an all-hands-on-deck approach across multiple sectors.
