San Francisco relies on permanent supportive housing to get people off the street, and the “permanent” is key. These homes are not shelters or transitional housing, but places where residents can expect stability as they rebuild their lives.
There are more than 13,000 units of this subsidized housing around town. Some are hosted by private landlords, while SF and its nonprofit partners run more than 9,000 units, often in large buildings where onsite services such as healthcare or job training might be available.
But city officials, housing providers, and residents themselves say that a sliver of occupants with disruptive behavior, perhaps 3 to 5 percent, make the system difficult for their neighbors and require another layer of help.
What kind of help, however, is a work in progress.
The need for more intensive care came to the fore in March. Details emerged about a supportive housing site in Mission Bay, run by the local nonprofit HomeRise, in a building that opened in 2022 with 144 units and drew plaudits for its design.
In documents and testimony at a public hearing, neighbors and others said the situation quickly went downhill, with hundreds of complaints to the police about behavior that included drug dealing, residents damaging their own units or in mental distress, and sexually inappropriate behavior on the sidewalk outside.
Because there’s a police station around the corner, “this should be the safest block in town,” said Sup. Matt Dorsey, who called the hearing. “Instead, honestly, it is a public nuisance.”
The neighborhood has grown dense around UCSF and the Warriors’ Chase Center arena. A new public elementary school is due to open nearby in August 2025.
Neighbors at the hearing presented their side of the story, saying “virtually no progress has been made” to fix problems. HomeRise’s director of residential services Marcel Davis said his organization has worked with neighbors and addressed some problems by posting a “No Loitering” sign and having a disruptive tenant leave, for example.
During public comment, HomeRise CEO Janéa Jackson estimated 3 percent of the Mission Bay residents have more acute mental health needs and behaviors that “have serious nuisance impacts” for other residents.
Emily Cohen, deputy director for communications and legislation for SF’s Department of Homelessness and Supportive Housing, or HSH, noted an “increased acuity” of physical and mental health needs in the PSH population, and she estimated 5 percent of residents across the city were disruptive.
“I think if we can solve for that 5 percent, our entire portfolio would be far more stabilized,” Cohen said at the hearing. In the next breath, Cohen mentioned a new program that she called “enhanced care supportive housing.”
That program – a pilot within one Tenderloin housing site – has since launched, but it’s focused more on extra health services for aging PSH tenants with serious needs, “not disruptive behavior specifically,” Cohen told The Frisc, but she also acknowledged that “they can be linked.”
There are also calls for separate facilities. (Some people in the March hearing called it “PSH 2.0.”) But with the city deep into a budget crisis, it’s unclear how SF would pay for these places, and whether they would function more like a hospital or clinic and less like independent housing.
For the time being, HSH wants to meet the small percentage of disruptive people with services where they are, not send them somewhere else. The agency is “working on multiple strategies to layer those clinical services into the overall PSH model,” Cohen added.
One of these programs is barely two years old.
Making house calls
In 2022, in response to people who weren’t going to appointments or clinical visits, the public health department launched a home-visit program called Permanent Housing Advanced Clinical Services, or PHACS, to PSH residents with short-term care and connections to additional services.
“If … a client needs behavioral health support and isn’t leaving to get [it], but they would become more inclined to accept it if someone came and met with them on site, this team will do that,” said Tabitha Allen, deputy director at Tenderloin Housing Clinic, one of the city’s largest PSH providers.
The health department launched PHACS in 2022, and in its first year it covered supportive housing units for more than 5,300 residents across 69 buildings. The budget has increased to $8.9 million, and as of last month the program has served 847 clients, 20 percent with a psychotic disorder such as schizophrenia and 55 percent with a substance use disorder, according to DPH. PHACS has prescribed 9 percent buprenorphine for opioid use treatment. (It’s unclear how many of these were emergency cases of overdose.)
HSH referred questions about what it called “the PHACS service model” to DPH. When asked specifically about PHACS and the HomeRise Mission Bay site, DPH referred The Frisc to HSH.
If we can solve for that 5 percent, our entire portfolio would be far more stabilized.
emily cohen, sf department of homelessness and supportive housing
Bringing treatment into homes “has long been the model for providing services to people who have serious behavioral health conditions,” said Sharon Rapport, director of California state policy for the Corporation of Supportive Housing. Rapport was referring to a specific model, Assertive Community Treatment (ACT), in which a team of professionals — such as social workers, psychiatrists, nurses, and counselors — meets regularly with clients, who can call around the clock.
ACT workers typically see clients in their homes or encampments, where “support is needed rather than in staff offices or clinics,” according to an ACT program-building kit from the U.S. Department of Health and Human Services.
“If it’s 7 o’clock at night, and [someone named] Bobby needs to talk to somebody, he can call the ACT team,” said Emery Cowan, behavioral health director for the Mental Health Division of Solano County. “If it’s a crisis, they can connect to the mobile crisis team. The team goes out, and potentially if someone needs to be placed on involuntary hold, or they need to be taken to an emergency room or crisis center, the team will help them get there.”
Cowan has implemented ACT programs in North Carolina, Florida, and most recently California, and says it largely works when used with the appropriate clients: people with severe mental illness such as schizophrenia and bipolar disorder. It’s not specific to PSH, but the combination of ACT and PSH goes back to the 1990s, Cowan said.
By a razor-thin margin, California just passed Prop. 1. According to the California Budget and Policy Center, the measure requires 35 percent of the state’s Behavioral Health Services Act funding to go toward full-service partnership programs (FSPs), which use a “whatever it takes” approach to help people with complex needs. Solano County’s three FSPs are all trained on the ACT model, she said.
Cities and counties across the U.S., as well as the state of Georgia, use ACT, but only a minority of California counties fund it, said Rapport. According to HSH’s Cohen, ACT isn’t mandatory in San Francisco, but some providers use elements of it and other “evidence-based case management.”
“This is something we want to explore as part of the strategic focus on housing stability,” Cohen added.
‘Stay until stable’
If San Francisco were to create a second level of PSH to address disruption, what would it look like? Answers get complicated. The Frisc asked HomeRise CEO Jackson for ideas. She suggested via email “two forms of housing: PSH for the general homeless population and specialized housing for homeless who have higher acuity support needs.”
The specialized housing would “offer assistance with mental and behavioral health, medical care, and substance abuse, allowing residents to stay until stable. Later, once stable, residents could step up into PSH with continued support from the same team.”
Compelling someone into specialized housing should only occur when it is legally justified and in the person’s best interest, such as in cases where they pose a danger to themselves or others and cannot safely manage their own care.
HomeRise CEO Janéa Jackson
Asked about Jackson’s idea, Tenderloin Housing Clinic’s Allen was supportive: “There needs to be different housing options, and there needs to be mobility and flexibility for people to move within those housing options.”
Rapport noted that a restricted setting where the purpose is to provide medication and treatment is residential treatment, not housing. “I think it’s a treatment bed,” she said. “They need medication or help getting stable or getting through crisis, and then they can live independently.”
About Jackson’s “specialized housing” suggestion, HSH’s Cohen said the agency is “in conversation with DPH about what that could look like within the PSH portfolio or if that is a separate type of housing that should be developed within the behavioral health care system.”
Cohen added it’s important to build “straightforward pathways back and forth” between a higher level of care and PSH to meet people’s changing needs: “Movement between the two types of housing will be essential to success.”
Jackson later added that people coming off the streets would need a mental health assessment via HSH’s coordinated entry system to determine the best place for them. Jackson also wrote that “it is crucial to respect individuals’ autonomy and rights.”
“Compelling someone into specialized housing should only occur when it is legally justified and in the person’s best interest, such as in cases where they pose a danger to themselves or others and cannot safely manage their own care,” she wrote.
But with SF facing a massive $800 million deficit in its next two-year budget cycle, Mayor Breed has asked all departments to come up with 10 percent cuts across the board, all while demand for homelessness services is surging. Beds, roofs, staff with medical and social-work expertise: It will be a struggle to maintain current levels of service, let alone add layers of “PSH plus.”
Still, HSH is spending a few million dollars on a tiny pilot program to add extra medical services inside a PSH site, in part with the hope that it can provide a few extra ounces of prevention.
Physical health, mental health
The Kelly Cullen Community, on Golden Gate Avenue in the Tenderloin, has 174 extremely low-income residents, many once homeless. Carving out less than $4 million from its two-year, billion-dollar-plus budget, HSH is launching an experimental program inside Kelly Cullen to give residents an extra layer of care.
Run by nonprofit Cardea Health, the pilot starts next month. Cardea CEO and cofounder Alexis Chettiar noted that medical, psychiatric, and substance use disorders can go hand in hand, but emphasized the program is focused on medical care and nursing. “We’re not there to remedy the behavioral health challenges that you were alluding to at some of the other (PSH) sites,” Chettiar said.
HSH’s Cohen believes it could still play a role: “Where unmet health care needs are at the root of disruptive behavior, this pilot could help address that challenge.”
For Joe Price, it doesn’t matter how it’s described. More health care, when and where he needs it, is a good thing. Price moved two years ago from San Diego to San Francisco. He had been homeless for more than 25 years when, about seven months ago, a shelter referred him to Kelly Cullen, and city services helped him get an ID, supplemental security income, and food delivery. “It’s strange. It’s nice. I like it,” Price said. “Stuff doesn’t get stolen no more.”
The 66-year-old, who mostly uses a wheelchair, is looking forward to the extra care: “Me, myself, I need help.”
At Kelly Cullen, Cardea Health will provide a medical director, a medical biller, seven home health aides, and more than four full-time nursing positions, according to the contract.
“Seven days a week, we have nurses and caregivers on site to support clients with getting out of bed, toileting – we help schedule transportation, we remind people, hey, you have an appointment tomorrow,” Chettiar said.
Cardea’s contract says the work can serve 40 to 60 tenants, but that’s only an estimate of how many tenants might opt in; Chettiar said everyone is eligible.
The cost is up to $3.5 million, but Chettiar said MediCal should start covering it fully by the end of the pilot phase.
Cardea Health caught the attention of SF officials with a similar program at a PSH site in Oakland, a former Days Inn. Among clients of 180 days or more, the program reduced emergency room visits and other medical admissions by 78 percent, according to the Alameda County Homeless Care and Coordination Services.
At Kelly Cullen, social worker site supervisor Clair Neff said 15 people come to mind who regularly cycle through emergency services and skilled nursing facilities. The idea is to stop those cycles and keep people in their homes. Around five tenants are hospitalized a week, often due to chronic issues such as diabetes, urinary tract infections, and catheter problems. “This program is going to be incredibly supportive because it’s going to be seven days a week, whereas right now we have four days a week for nursing,” Neff said.
The more residents who can live stable lives, the less disruption for them and for others. Stability also means savings: fewer medical transports, fewer expensive emergency visits, more predictable appointment schedules for case workers and others. And perhaps, more time, money, and resources freed up to address the small number of people – whether it’s three or five or some other percentage – who are putting disproportionate stress on the system.