When Chuan Teng looks at San Francisco’s approach to behavioral health care, she sees a fundamental flaw.
“Jail, the streets, psychiatric emergency services — these end up being the points of entry into the city’s mental health care treatment,” said Teng, a private consultant who until recently was the chief executive officer of PRC, formerly called Positive Resource Center, a local provider of mental health care and other social services.
She called it “mind shattering” that often, because that system of care can be difficult to access, people with addiction and mental health disorders might get help only after they’ve deteriorated. By then, their conditions could have cost them jobs or housing, or caused them to land in the criminal justice system.
“Why is it that people can’t just go out and find care, if they need it?” Teng said.
She and a cadre of San Francisco-based service providers see an opportunity to help that happen.
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Over the next year, counties throughout the state must draft three-year plans to redesign their systems of care in accordance with California’s Behavioral Health Services Act, an element of Proposition 1, which voters passed in March 2024. Changes at the local level must aim to reduce involuntary detainment and treatment, ameliorate homelessness, and increase government transparency and accountability. The ballot measure also authorized billions of dollars to fund treatment and housing for people living on the streets and facing behavioral health challenges.
As San Francisco health officials have begun thinking through their plan, Teng and other service providers have been advocating for it to include systemic changes to help people who keep falling into crisis — many of them cycling between homelessness and inadequate treatment interventions.
Ideas include diverting more people from emergency rooms, changing caseworkers’ roles to help them keep clients on track with treatment, and creating tools that let nonprofit staffers quickly place people in programs that fit their needs.
The state mandates that San Francisco Department of Public Health officials hear the groups out. In fact, the city legally must seek public input to ensure that a range of perspectives influences local health care.
The health department declined to comment for this story.
“Given that the County Integrated Plan includes a community planning process and stakeholder involvement,” a department staffer wrote via email, using the plan’s official name, “as well as public comment and feedback period on the draft Integrated Plan, we believe it is too early to interview.”
San Francisco’s behavioral health system is already changing, in response to pressures from within City Hall.
Since taking office in January, Mayor Daniel Lurie has reorganized and redirected street teams, restricted how nonprofits distributed paraphernalia for drug use, and tried to alter the city’s image to discourage the sale and use of hard drugs in public.
And Lurie aims to create 1,500 shelter and treatment beds by September. Last month, the state committed to giving San Francisco $27.6 million, authorized by Proposition 1, to establish 73 beds. Most of the beds will be converted from other purposes, and the health department has promised to first relocate the seniors who now use them to other long-term beds. Lurie is also trying to redirect money from permanent housing to homeless shelters, a move that critics say could backfire because many shelter occupants would have nowhere to go once their stays concluded.
Facing dire budget concerns — the city must close a two-year deficit of roughly $781.5 million that could grow to nearly $2 billion, depending on federal cuts — Lurie this month proposed slashing $200 million in funding to nonprofits, including those that serve people with behavioral health problems. He is also seeking deeper shifts in local bureaucracy to streamline service delivery.
Some of those structural changes seem to align with ideas from Teng and others who have met regularly since October, including with health officials, as part of the Behavioral Health Provider Collaborative.
We examine some of the ideas below.
The collaborative — which includes local organizations PRC, Progress Foundation, HealthRIGHT 360 and Conard House — has tried to analyze the city’s behavioral health system and recommend to city leaders how it could evolve to satisfy the mandates of Proposition 1.
The mayor’s office did not respond to a request for comment.
About 8,300 unhoused people live in San Francisco, according to a 2024 count. About 187,000 unhoused people live in California. An estimated 48% of Californians experiencing homelessness have complex behavioral health needs, according to a March paper by the Benioff Homelessness and Housing Initiative. The paper categorized survey respondents as having that status if they reported either regular illicit drug use, heavy episodic alcohol use, hallucinations or a recent psychiatric hospitalization.
Idea: Divert people from psychiatric emergency room detentions
It’s a common situation on the streets, in parts of San Francisco: An unhoused person’s mental health condition worsens until a passerby sees them in crisis and calls the police or the city’s nonemergency helpline. First responders might detain the person and bring them to a hospital for psychiatric evaluation. If they seem to be a danger to themselves or others, or cannot provide for their basic needs, hospital staffers may hold them against their will for an initial 72 hours, which may be extended.
After that? They often return to the streets, where their problems escalate again. Later, the cycle might repeat.
“That flow needs to be interrupted,” said Steve Fields, executive director of nonprofit Progress Foundation.
For four decades, his organization tried to interrupt that cycle through a partnership with Zuckerberg San Francisco General Hospital and Trauma Center. If someone qualified for detention because they couldn’t take care of themselves — rather than because they were an obvious and immediate threat to anyone — hospital clinicians offered them stays at Progress Foundation. There, they faced a less restrictive environment where they might live for about two weeks, with staffers monitoring them around the clock.
Perhaps most important, often when their stays concluded staffers moved them to progressively lower-intensity treatment environments where they had more freedom and shared household duties with other tenants. Socializing helped people gradually get better, Fields said.
“The goal should be reintegration into the community through a process of rehabilitation and recovery,” Fields said. He would also like to see the city scale up these lower-intensity options. “That’s the key to it, and that’s the part that we haven’t expanded in decades.”
Progress Foundation’s partnership with the hospital ended in 2018. Fields would like to see it resume and expand.
Diverting people from the emergency room into longer-term treatment settings lines up with statewide “best practices,” said Karen Larsen, chief executive officer at the Steinberg Institute, which conducts research about and advocates for policies regarding mental health and substance use. “And they’re absolutely the types of services that the state would want to see funded with Prop. 1 dollars,” she said.
“In a perfect world, somebody in a mental health crisis wouldn’t go to an emergency department for the most part,” Larsen said, “because that’s a pretty chaotic place.”
“And in San Francisco, they really need help,” Larsen said, referring to the people who cycle between hospitals and the streets.
When unhoused people struggle with psychiatric conditions, it’s common for them to seek care at hospital emergency departments, possibly many times in the lead-up to getting more comprehensive help. Some ultimately get treatment through what California calls “full service partnerships,” named for their diverse services and whatever-it-takes approach to helping people with severe mental illness.
Compared with their counterparts statewide, a greater percentage of full-service-partnership clients in San Francisco — many of them unhoused — have previously sought help through emergency departments, according to a 2024 report by California’s Behavioral Health Services Oversight and Accountability Commission. In the city, 87% of adult clients had at least one emergency department visit for psychiatric reasons in the five years prior to joining a partnership; the average number of visits per client was 38. Across California, 81% of clients had at least one previous visit in the five years prior to joining a partnership.
Idea: Case managers attached to the client, not the program
Case managers are the Swiss Army knives of behavioral health care. They might help people navigate one treatment program or find and enter others, or help them get food, identification, housing or doctor appointments.
And ideally, Fields said, the case manager would help someone through their full treatment trajectory, from diagnosis to stability.
“This is not the way that it is,” he said. “Not even close.”
That’s because a case manager often works for a particular local organization, advising and guiding within their sphere of influence. If someone they are helping leaves that organization’s program, the case manager’s connection with them ends. Sometimes one person may have multiple case managers among many service providers. Some programs don’t offer case managers at all.
The result: People seeking care must keep track of their own appointments and commitments, their long-term treatment goals and, sometimes, advocate for themselves with nonprofit staffers. That can be difficult for people struggling with acute mental health challenges or taking medications that affect cognition. Sometimes they miss appointments and lose their way, falling out of the system altogether.
“You’re always at risk of having nobody who remembers what the plan was,” Fields said. “And then they drop out because they don’t feel like they’re getting helped. And then they show up in the emergency room again, and again.”
Fields would like to see the city assign dedicated case managers who stick with the people they are helping at every step, from program to program. The case manager and person seeking care could build a rapport and potentially trust. With a full understanding of someone’s medical history, challenges and needs, the case manager might better direct them through recovery and would be well positioned to intervene if they began backsliding or abusing drugs.
Larsen called this “an intriguing concept. I could see why that would be better for the clients.”
It could also come with bureaucratic obstacles. “Our systems are so much about billing, and billing is tied to an organization. It seems like that could be complicated,” she said.
On the other hand, it might be easier for itinerant homeless people “to stay attached to a human being than an organization,” Larsen said.
That can be difficult when people struggling with homelessness move around, said Robb Layne, executive director of the California Association of Alcohol and Drug Program Executives, which advocates for policies that help people with substance use and co-occurring mental health disorders.
People without secure housing “don’t realize that if they move spaces, they’re moving case managers,” Layne said. “That individual is required to sort of find them, connect with them, offer them services, figure out what their diagnosis is, stabilize them.”
Layne said changing the relationship between case managers and clients could help, “but it won’t fix the problem,” which is that this work is underfunded. And that could worsen under President Trump, who recently revoked funding for addiction services and mental health care.
“As we see the federal government reducing eligibility and cutting access to services by removing programs, California’s going to have to decide how much we’re going to backfill,” Layne said.
Idea: Web portal to speed service delivery
Teng, of PRC, agreed that changing the case manager’s role could help people find their way through treatment.
But she was hesitant to endorse a version of the strategy that would hire droves of new case managers.
“What I’m more interested in is figuring out how to optimize the system,” she said.
Every day, staff at organizations across the city work the phones, calling each other to figure out where their clients can go next for the services they need, and whether those programs even have space to receive them.
It can be time-consuming work, Teng said. But maybe it doesn’t have to be that way.
Those staff should have access to a website with thorough, real-time information on all services, their availability and eligibility criteria, she said — the city offers a version of this, but it is less robust than Teng envisions. Case managers could log on, quickly assess their clients’ options and apply to place them. That could free them up to do other work, like helping more clients.
“It seems like there is technology out there that could lend itself to this type of exercise,” Teng said, adding that a booking service like Airbnb could serve as inspiration. “It doesn’t seem like we’d be creating something from scratch. There are so many search engines out there, there’s coding that’s already been done.”
“The web portal is a really great idea, in concept,” Layne said. But he likened it to larger, often statewide systems, which have in many cases suffered from being unable to keep their data on treatment beds current.
Outdated information on bed availability “can quickly discourage clients seeking care,” Layne said. “If the first place someone is sent can’t actually help them, they’re far less likely to try again.”
Many states have created digital registries tracking inpatient bed availability in hospitals and treatment programs for people with mental health and substance use disorders. A 2019 study of 17 states’ registries found they helped people get beds faster but faced obstacles that limited their effectiveness. Some hospitals resisted uploading bed information, possibly because staff worried they would lose control over who got beds. Sometimes staff didn’t know how to work with the registries or lacked the time to keep them up to date.
And for people with complex conditions, a registry might not offer case managers enough information to determine whether a particular setting would be appropriate.
When case managers seeking placement for clients call around to other service providers, they often discuss symptoms and other factors to ensure a good fit. Without a phone call, “if somebody just shows up, it wouldn’t be shocking if someone says, ‘We actually can’t serve that individual because their conditions are too severe, and the only space we have available is next to somebody who has that same exact condition, and they’re violent.’”
Larsen said that “in theory” a web portal “would be amazing.”
“And it gets really complicated, really quickly,” she said.
That’s a good reason to prototype it at a small scale, Teng said.
“Instead of building a new comprehensive system for every different city department, with all these different data inputs,” she said, “maybe you pick one major service provider in a county. Have them use it and update it for their own beds, their own resources. See if we can create a minimally viable product that actually works for them and accelerates access to service for clients.”
If the prototype worked, the next step would be to extend it to other organizations and tweak it to fit their needs. Eventually it might make sense to adopt it countywide.
Idea: Indefinite stays in communal housing for some people
Some unhoused people struggle to manage their disorders outside of communal settings. To get them off the streets for good, the city should scale up that type of housing, Teng said.
Service provider PRC offers communal housing for people struggling to overcome addiction, with staff available 24/7. The settings each have about a dozen tenants, who attend various types of group sessions throughout the day and otherwise help each other. “You’re buying groceries together as a household, though you can buy them alone if you want,” Teng said.
The organization’s funding covers up to 90 days per tenant. After that, staff try to find them somewhere to land. But Teng would prefer that tenants could stay indefinitely if they needed that.
“The amount of change we’re asking people to make within a 90-day period is a lot,” Teng said. “In reality, that’s not sufficient for many people.”
“And then to drop that person into independent living, where they don’t have the support of professional staff who are checking in with them, organizing them into a schedule, reminding them about meds” can be destabilizing, she said. They can lose ground on their recovery and might fall back into drug abuse.
The obstacle to implementing this idea is simple: cost.
“It sounds a lot like board-and-care homes, which already exist,” Larsen said. “I think we’ve lost thousands of board-and-care beds over the past few years because the funding structure is not such that supports sustainability.”
Idea: More affordable housing to receive people after treatment
There’s an even bigger problem that, though outside the behavioral health system, is preventing many people from fully recovering: lack of affordable housing.
“You’ve got people in care right now who complete treatment, who have no stable options,” for where to live upon leaving their programs, said Wesley Saver, director of policy and public affairs at nonprofit HealthRIGHT 360.
“Which means they end up back on the streets or in shelters,” he said.
San Francisco needs more housing “at a price point that someone on SSI can afford,” Teng said, referring to Supplemental Security Income, a federal program that pays older adults and people with disabilities who have little or no income. The maximum monthly SSI payment for a single adult is $967.
“That is the giant gorilla in the room,” Teng said.
Proposition 1 mandates that counties direct more of their state-provided behavioral health funds to housing programs. But Larsen said more could be done.
“The SSI rates haven’t been updated since maybe the 1960s for people living with behavioral health conditions,” Larsen said. “And so, the real answer is probably at the federal government level, and increasing those SSI rates” so that recipients can more easily cover rent.
SF officials must seek community input for care plan
Proposition 1 was among last year’s most controversial political issues in California, and it passed by a slim margin. Community groups throughout the state warned that by forcing local governments to shift their behavioral health spending, the ballot measure could end up siphoning from other vital services, endangering them.
It’s too early to predict the impact in San Francisco; that will be determined by the city’s plan for satisfying Proposition 1, due to the state by July 2026.
The state requires local health officials to proactively involve broad swaths of San Franciscans in crafting that plan. The goal is to ensure that “the voices of the community are driving the process from beginning to end, not just at one single community meeting,” said Jessica Cruz, the California chief executive officer for the National Alliance on Mental Illness, which had advocated that the engagement process be made part of the measure.
In public meetings, focus groups and other settings that must be documented, the government must seek input from service providers as well as people who have gone through the care system, families of people with disorders, LGBTQ+ people, domestic violence survivors, representatives from hospitals and other health care organizations, unhoused people and others.
Many of the groups “are disproportionately represented in our homeless services, in our hospitals and in our criminal justice systems,” Larsen said. “So having those folks around the table makes sense.”
For counties that do not fulfill Proposition 1’s requirements, state officials can “provide technical assistance” as well as carry out “corrective action,” including fines and penalties, said Anthony Cava, media relations manager at the California Department of Health Care Services.
San Francisco’s final plan must contain an accounting of all local behavioral health spending. And it must show how spending will shift from 2026 to 2029 to try to meet the state’s goals of improving access to care and reducing homelessness, institutionalization and cases of untreated addiction and mental health disorders.
It will be a major increase in government transparency, said Fields of Progress Foundation.
“The state will be collecting this data for the first time since the end of the 1980s,” he said. “It’s a financial accountability system.”
Like many media organizations, the San Francisco Public Press is experimenting with artificial intelligence tools that aid the creation of images for use in some stories. Nearly all our visual content is produced by humans.
The Public Press is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center and newsrooms in select states across the country.
