BSCC
Board of State and Community Corrections
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Law Enforcement Assisted Diversion (LEAD) External Evaluation
Report to the California State Legislature
Submitted to
Board of State and Community Corrections
By
Aili Malm, Ph.D.
Dina Perrone, Ph.D.
Erica Magaña, MS
School of Criminology, Criminal Justice and Emergency Management
California State University Long Beach
1250 Bellflower Boulevard
Long Beach, CA 90840-4603
(562) 985-0438
January 1, 2020
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Table of Contents
Acknowledgements ............................................................................................................. 5
Executive Summary ............................................................................................................ 6
1. Introduction .................................................................................................................. 10
Law Enforcement Assisted Diversion (LEAD) ........................................................................ 10
External evaluation in California .............................................................................................. 11
Process evaluation ................................................................................................................. 12
Outcome and costing evaluation ........................................................................................... 12
2. Los Angeles County LEAD ......................................................................................... 14
3. Process Evaluation: Los Angeles County .................................................................... 17
Semi-structured focus groups and interviews ........................................................................... 17
LEAD LAC document data ...................................................................................................... 19
LEAD LAC client surveys ........................................................................................................ 19
The sample ............................................................................................................................ 20
Data analysis ............................................................................................................................. 22
LEAD Seattle vs. LEAD LAC .................................................................................................. 23
Goals ..................................................................................................................................... 23
LEAD core principles ........................................................................................................... 24
LEAD client eligibility and exclusion criteria ...................................................................... 25
LEAD referral process .......................................................................................................... 28
LEAD LAC implementation successes and challenges ............................................................ 30
Successes............................................................................................................................... 30
LEAD LAC challenges ......................................................................................................... 40
4. Outcome and Costing Evaluation: Los Angeles County .............................................. 54
Method ...................................................................................................................................... 54
Evaluation design .................................................................................................................. 54
Measures ............................................................................................................................... 54
5. LEAD San Francisco .................................................................................................... 55
6. Process Evaluation: San Francisco ............................................................................... 58
Semi-structured focus groups and interviews ........................................................................... 58
LEAD SF document data .......................................................................................................... 59
LEAD SF client surveys ........................................................................................................... 60
Data analysis ......................................................................................................................... 64
LEAD Seattle vs. LEAD SF ..................................................................................................... 64
LEAD core principles ............................................................................................................... 65
LEAD client eligibility and exclusion criteria .......................................................................... 66
LEAD referral process .............................................................................................................. 68
LEAD SF successes and challenges ......................................................................................... 72
Successes............................................................................................................................... 73
Challenges ............................................................................................................................. 85
Summary of findings............................................................................................................... 113
7. Outcome and Costing Evaluation: San Francisco ...................................................... 115
Method .................................................................................................................................... 115
Evaluation design ................................................................................................................ 115
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Measures ............................................................................................................................. 115
Participants .......................................................................................................................... 116
Group allocation.................................................................................................................. 116
Primary analyses ................................................................................................................. 117
Results ..................................................................................................................................... 117
LEAD effects on criminal justice and legal system utilization........................................... 117
LEAD effects on criminal justice system costs .................................................................. 119
Discussion ............................................................................................................................... 120
Limitations .............................................................................................................................. 121
8. Conclusion .................................................................................................................. 122
Summary of advice for future LEAD sites from LEAD LAC and LEAD SF ........................ 122
9. References .................................................................................................................. 124
10. Technical Appendix .................................................................................................. 126
Process Evaluation (Los Angeles County) ............................................................................. 126
Outcome and Cost Evaluation (Los Angeles County) ............................................................ 133
Process Evaluation (San Francisco) ........................................................................................ 135
Outcome and Costing Evaluation (San Francisco) ................................................................. 147
11. List of Acronyms ...................................................................................................... 151
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Table of Figures and Tables
Tables
Table 1-1: List of outcome variables and their department sources .......................................................... 13
Table 3-1: LEAD LAC focus groups .............................................................................................................. 18
Table 3-2: LEAD LAC interviews .................................................................................................................. 18
Table 3-3:LEAD LAC client survey sample ................................................................................................... 20
Table 3-4: LEAD LAC and LEAD Seattle eligibility and exclusion criteria ..................................................... 26
Table 3-5: LEAD LAC quarterly reported challenges ................................................................................... 32
Table 3-6: Officer procedural justice (n=67) ............................................................................................... 36
Table 3-7: LEAD LAC key themes ................................................................................................................. 42
Table 6-1: LEAD SF focus groups (n=20) ..................................................................................................... 59
Table 6-2: LEAD SF interviews (n=4) ........................................................................................................... 59
Table 6-3: Data documents ......................................................................................................................... 60
Table 6-4: Client sample demographics (n=75) .......................................................................................... 61
Table 6-5: Client self-reported criminal history .......................................................................................... 62
Table 6-6: Client self-reported drug use (n=75) .......................................................................................... 63
Table 6-7: LEAD Seattle and LEAD SF eligibility criteria .............................................................................. 67
Table 6-8: Timeline of encountered implementation challenges ............................................................... 76
Table 6-9: Officer procedural justice (n-74) ................................................................................................ 80
Table 6-10: Case manager procedural justice (n=74) ................................................................................. 82
Table 6-11: Client survey themes................................................................................................................ 83
Table 6-12: Approved LEAD eligible charges ............................................................................................ 100
Table 7-1: LEAD SF criminal justice outcomes by group ........................................................................... 117
Table 7-2: LEAD SF odds ratios for significant criminal justice outcomes ................................................ 118
Table 7-3: LEAD San Francisco program costs .......................................................................................... 119
Table 10-1: LEAD LAC training ................................................................................................................... 126
Table 10-2: LEAD LA baseline comparisons by referral mechanism ......................................................... 133
Table 10-3: LEAD LA baseline comparisons by group ............................................................................... 133
Table 10-4: LEAD LA after-matching comparisons by group .................................................................... 134
Table 10-5: LEAD LA costs by month......................................................................................................... 134
Table 10-6: LEAD LA pre and post-treatment cost of criminal justice services ........................................ 134
Table 10-7: LEAD SF baseline comparisons by referral mechanism ......................................................... 147
Table 10-8: LEAD SF baseline comparisons by group ............................................................................... 147
Table 10-9: LEAD SF after-matching comparisons by group ..................................................................... 148
Table 10-10: LEAD SF costs by month ....................................................................................................... 149
Table 10-11: LEAD SF pre and post-treatment cost of criminal justice services ...................................... 150
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Figures
Figure 1-1: Evaluation plan at a glance ....................................................................................................... 11
Figure 2-1: LEAD LAC enrollment numbers by month (December 2017-April 2019) ................................. 14
Figure 2-2: LEAD LAC social contact client enrollments by month (December 2017 – April 2019) ............ 15
Figure 2-3: LEAD LAC client ethnicity as of April 2019 ................................................................................ 15
Figure 2-4: LEAD LAC female client enrollment by month (December 2017 – April 2019) ........................ 16
Figure 2-5: LEAD LAC homeless client enrollment by month (December 2017 – April 2019) .................... 16
Figure 3-1: LEAD LAC and LEAD Seattle goals comparison ......................................................................... 24
Figure 3-2: LEAD LAC and LEAD Seattle core principles comparison .......................................................... 25
Figure 3-3: LEAD LAC referral process ........................................................................................................ 29
Figure 3-4: LEAD LAC successes .................................................................................................................. 30
Figure 3-5: LEAD LAC challenges ................................................................................................................. 41
Figure 5-1: LEAD SF enrollment numbers by month (November 2017-June 2019) ................................... 55
Figure 5-2: LEAD SF Social contact client enrollments by month (November 2017 – June 2019) .............. 56
Figure 5-3: LEAD SF client ethnicity as of June 2019 .................................................................................. 56
Figure 5-4: LEAD SF White client enrollments by month (November 2017 – June 2019) .......................... 57
Figure 6-1: Goals comparison ..................................................................................................................... 65
Figure 6-2: LEAD Seattle core principles ..................................................................................................... 66
Figure 6-3: Referral process comparison .................................................................................................... 72
Figure 6-4: LEAD SF successes ..................................................................................................................... 73
Figure 6-5: LEAD SF challenges ................................................................................................................... 85
Figure 6-6: Law enforcement cover sheet evolution .................................................................................. 95
Figure 7-1: LEAD SF 12-month criminal history outcomes by group post-treatment .............................. 118
Figure 7-2: LEAD SF pre and post treatment criminal justice system utilization costs by group ............. 120
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Acknowledgements
This report was funded by the Board of State and Community Corrections. We appreciate their guidance
and support of external evaluation efforts. We are especially grateful for the assistance of Colleen
Stoner and Daryle McDaniel.
We wish to thank our partners in Los Angeles County and San Francisco. This report would not have
been possible without the assistance of employees from several LEAD program partners. We are
indebted to these individuals for their time participating in interviews and focus groups, site visits, and
preparing and sharing data. Special thanks are due to program managers Angelica Almeida, Robin
Candler, Shoshanna Scholar, and Erica Shehane. The authors also thank the Seattle LEAD National
Support Bureau for their expertise and domain knowledge.
We would also like to acknowledge the valuable assistance of our colleagues: James Binnall, Priscillia
Hunt, Jerry Ratcliffe, and Michael White.
Finally, we would like to thank our invaluable research assistants: Demerie Aguirre, Alyssa Blanco, Elijah
Bueno, Andrea Carrizal, Caitlin Cardenas, Heleana Melendez, Alfonso Mendosa, and Gabrielle White.
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Executive Summary
Law Enforcement Assisted Diversion (LEAD) is one of the first U.S. pre-booking diversion programs
specifically aimed at individuals involved in drug offenses and sex work. LEAD redirects individuals from
criminal justice system involvement into community-based social, health, and behavioral health services.
To date, two peer-reviewed LEAD outcome studies and one peer-reviewed cost analysis show that LEAD,
as implemented in Seattle, WA, is an effective diversion mechanism for those involved in low-level drug
offenses and sex work—positioning LEAD as a promising program. LEAD has now rapidly spread to 37 U.S.
jurisdictions, with an additional six in the process of launching LEAD.
Our external evaluation team was contracted by the Board of State and Community Corrections (BSCC) to
conduct an evaluation of the LEAD program in two pilot sites, Los Angeles County (LAC) and the City and
County of San Francisco (SF). Launched in November 2017, the LAC and LEAD SF pilot programs are both
2.5 year initiatives designed to divert and serve people with behavioral health needs who have been in
repeated contact with the police for low-level nonviolent charges. This report provides preliminary results
(November 2017 through mid to late-2019) in the form of process, outcome and costing evaluations for
both sites.
This preliminary evaluation’s key findings include the following:
Los Angeles County
• LEAD LAC client enrollment fluctuated dramatically over the first 17 months of the program,
trending slightly downward in 2019. By April 2019, there were over 200 active clients, 58% of
whom were social contact referrals.
• By April 2019, 49% of active LEAD LAC clients were Black/African American, 26% Hispanic/Latinx,
and 22% White.
• The percent of female enrollees has been trending upward since program inception, and by April
2019, 69% of all LEAD LAC clients have been female.
• While the percentage has been trending downward, 82% of all LEAD LAC clients were homeless
at time of enrollment.
• LEAD LAC was implemented with fidelity, held true to the LEAD Seattle model, and maintained
comparable goals and eligibility and exclusionary criteria.
• Throughout LEAD LAC implementation, the site faced case-management turnover, ambitious case
management workloads, high client-case manager ratios, and challenges to open communication
across the partners, which impacted perceived service delivery and accountability.
• LEAD LAC’s strong stakeholder investment and relationship building, primarily facilitated by
program management, enabled many client successes.
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• LEAD LAC Client Survey data demonstrate that
LEAD LAC officers and case managers carried
out their LEAD duties with procedural justice;
LEAD LAC officers and case
clients felt the LEAD LAC officers and case
managers carried out their duties
managers treated them fairly and with dignity
with procedural justice; clients
and respect.
felt the officers and case
• Outcome and costing findings are not managers treated them fairly and
currently available. The LA LEAD Project did with dignity and respect.
not fully understand the request of the
Evaluator to re-run criminal histories (RAP sheets) on all LEAD clients so post-LEAD criminal
histories could be assessed. Once the missing data were discovered, the Evaluators requested LA
LEAD re-run all RAP sheets; however, the data from the LA LEAD project was not available at the
time of the report submission. CSULB will complete the outcome and costing evaluation within
two months of receiving the necessary data.
San Francisco
• LEAD SF client enrollment fluctuated dramatically over the first 20 months of the program,
trending slightly downward in 2019. By June 2019, there were over 200 active clients, 65% of
whom were social contact referrals.
• By June 2019, 46% of active LEAD SF clients were White, 32% Black/African American, and 9%
Hispanic/Latinx.
• LEAD SF and LEAD Seattle goals and eligibility and exclusionary criteria were similar, with two
differences. Individuals with certain felony convictions within the past 10-years were excluded
from LEAD Seattle, however individuals with those convictions within the past 8-years were
excluded from LEAD SF. LEAD SF expanded LEAD eligibility charges to include specific, non-violent
vandalism, theft, and vehicle-related felony charges.
• LEAD SF referral process differed significantly from the LEAD Seattle model: law enforcement first
referred LEAD clients to the Department of Public Health clinician for assessment prior to
connecting with a case manager.
• LEAD SF was initially implemented with fidelity but began to deviate in year 2 with the
introduction of Healthy Streets Operation Center’s (HSOC) operations.
• Throughout LEAD SF implementation, the site struggled with (1) a lack of investment from law
enforcement, (2) questions about LEAD applicability due to Proposition 47 and the prevalence of
resources in San Francisco, (3) concerns about partner autonomy and open communication, (4) a
misinterpretation of policies, (5) unclear goals, procedures, and messaging, and (6) providing law
enforcement training in LEAD and harm reduction.
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• LEAD SF’s ability to build relationships and
collaborate facilitated both client and partner
shifts in perceptions of police, and significant
At the 12-month follow-up
client successes.
period, LEAD SF clients had
significantly lower rates of
• LEAD SF Client Survey data demonstrate that
misdemeanor and felony arrests,
law enforcement officers and case managers
carried out their LEAD duties with procedural and felony cases.
justice; clients felt the officers and case
managers treated them fairly and with dignity and respect.
• At the 6-month follow-up, clients in LEAD SF had more citations, but significantly less
misdemeanor arrests than the system-as-usual comparison group. This finding could be due to a
true reduction in the severity of crimes committed by LEAD clients, or it could be police officer’s
reluctance to arrest LEAD clients. However, because no LEAD flag on is the client’s record, SF
officers had low buy-in in LEAD, and the majority of officers would not know if an individual is in
LEAD, this finding is not likely due to police reluctance to arrest.
• At the 12-month follow-up period, LEAD SF clients had significantly lower rates of misdemeanor
and felony arrests, and felony cases. Felony arrests were about two and a half times higher (257%)
for individuals in the comparison group. Misdemeanor arrests were over six times higher (623%)
for the comparison group. And felony cases were three and a half times higher (360%) for the
comparison group. Notably, the significant increase in citations for LEAD clients seen at the 6-
month follow-up was
not present after a year
in the program. These
positive findings are
likely due to the harm-
reduction nature of
LEAD. LEAD participants’
case managers also
coordinated with San
Francisco public
defenders and DAs to
assist with active cases
as to not compromise
LEAD intervention plans.
• The lower recidivism for LEAD clients translate into a one-year criminal justice system utilization
cost savings of $3691 over system-as-usual comparison individuals.
• Case management and legal services per client equaled $1301 per month in San Francisco
compared to $899 in Seattle. However, since Seattle LEAD saw reductions in program expenses
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over time, there is reason to believe that LEAD SF will also see reductions in operating expenses
as the program becomes more efficient and client participation increases.
Advice for future LEAD sites from LEAD LAC and LEAD SF
• Committed stakeholders are key to successful program implementation. This involves the
careful selection of partners that are not only bought-in to the program but are also open-
minded, flexible, willing, and proactive participants in the implementation of LEAD. Sites should
ensure they have dedicated law enforcement and case management partners.
• Once dedicated partners are at the table, thorough and ongoing training on LEAD procedures
and harm reduction philosophies, especially for law enforcement, is necessary to securing buy-in
and improving program implementation. Additionally, it is recommended that both law
enforcement and case managers are able to spend time training with the LEAD Seattle Bureau,
especially prior to implementation but throughout to see how the program works in practice.
• Strong leadership and effective program management is necessary. Program management
should ensure that all partners have an equal voice/role in the implementation of LEAD.
Specifically, law enforcement should have some level of program ownership, as they are key
drivers of the program. Case managers also must be heard, as they can be easily overworked by
the sheer number of cases and the amount of paperwork; burnout can happen quickly.
• Program managers should work to ensure staff are and feel supported. Program management
shall ensure open lines of communication, as this is essential to developing good working
relationships among LEAD partners.
• Program management must also be responsive to ongoing challenges. Maintaining open and
working relationships with the LEAD Seattle National Support Bureau can help address
implementation challenges.
• Finally, sites seeking to implement LEAD should ensure that they have the necessary resources
in place (e.g., housing, harm reduction services) in place prior to launching the program. Sites
should work to utilize existing community resources, where applicable, to expand the nexus of
services available to LEAD clients. Both sites explained that more services than what is expected
will surely be needed.
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1. Introduction
The LEAD external evaluation team was contracted by the Board of State and Community Corrections
(BSCC) to conduct an evaluation of the Law Enforcement Assisted Diversion (LEAD) program in two pilot
sites, Los Angeles County (LAC) and the City and County of San Francisco (SF). This report will provide
preliminary results in the form of process, outcome and costing evaluations for both sites.
Law Enforcement Assisted Diversion (LEAD)
LEAD is one of the first U.S. pre-booking diversion programs specifically aimed at individuals involved in
drug offenses and sex work (Beckett, 2014). LEAD redirects individuals from criminal justice system
involvement into community-based social, health, and behavioral health services (LEAD National
Support Bureau, n.d.a). To date, two peer-reviewed LEAD outcome studies (Clifasefi et al., 2017; Collins
et al., 2017) and one peer-reviewed cost analysis (Collins et al., 2019) show that LEAD, as implemented
in Seattle, WA, is an effective diversion mechanism for those involved in low-level drug offenses and sex
work—positioning LEAD as a promising program. LEAD has now rapidly spread to 37 U.S. jurisdictions,
with an additional six in the process of launching LEAD (LEAD National Support Bureau, n.d.b).
LEAD has four core principles: diversion, harm reduction, housing first, and intensive case management.
At the point of contact, LEAD police officers exercise discretion in deciding whether to divert an eligible
individual (involved in drug offenses or sex work) to community-based services or process them through
the criminal justice system (LEAD National Support Bureau, n.d.a). The underlying rationale is that by
routing individuals involved in drug offenses and sex work away from jail and into health, social,
behavioral, and mental health services, their likelihood of reoffending will decrease, and criminal justice
costs will be avoided. The services will allow individuals to address the underlying reasons for their
criminal behavior, leading to long-term desistance.
The second core principle of LEAD is harm reduction. Broadly, harm reduction is best defined as “a
pragmatic yet compassionate set of principles and procedures designed to reduce the harmful
consequences of addictive behavior for both drug consumers and for the society in which they live”
(Marlatt, 1996, p. 779). In LEAD, harm reduction refers to reducing the harms associated with drug use
and sex work and providing individualized intervention plans for participants based on their immediate
needs.
LEAD’s third core principle is housing first. The housing first models seek to provide stability through the
form of housing, specifically permanent housing, without conditional requirements to enroll in drug or
mental health treatment (National Alliance to End Homelessness, 2016). By providing housing, clients’
lives will be more stable, allowing them to address problems, traumas, and struggles in their life (LEAD
National Support Bureau, n.d.a).
The last core principle of LEAD is intensive case management (ICM). ICM essentially services high acuity
clients with frequent case manager-client contact (de Vet et al., 2013). The goal of ICM is to improve the
clients’ quality of life through the development of individualized intervention plans and provisions of
services based on assessments of client’s needs.
LEAD was designed with six specific goals: (1) reorient, (2) improve, (3) reduce, (4) undo, (5) sustain, and
(6) strengthen (LEAD National Support Bureau, n.d.a). First, LEAD seeks to remodel typical responses to
crime, public safety, public order, and health-related problems. Second, LEAD aims to improve public
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safety and health by utilizing evidence-based practices, such as harm reduction. Third, LEAD reduces the
number of low-level offenders who enter the criminal justice system. Fourth, LEAD seeks to undo racial
disparities caused by the system. Fifth, LEAD aims to sustain LEAD funding through system cost-savings.
Sixth, LEAD hopes to strengthen police-community relations, through which LEAD can reconcile tensions
between the police, community, and civil rights organizations (LEAD National Support Bureau, n.d.a).
To meet LEAD goals, LEAD uses multiagency collaboration between law enforcement departments,
prosecutors, case management agencies, and state and local service providers. The LEAD diversion
process grants officers the discretion to direct those involved in low-level drug crimes and sex work
away from the criminal justice system and into harm reduction services (LEAD, 2015). Individuals enter
the LEAD program through two avenues, either as a pre-booking or a social contact client. The key
difference between the two is that pre-booking referrals are made when police officers witness an
individual committing a LEAD eligible offense. Social contacts do not have to be committing a LEAD
eligible offense at the time of referral, though certain criteria must be met. Once the officer decides to
refer to LEAD, the officer contacts the LEAD service provider and transfers custody of the individual to
the service provider, a process LEAD refers to as a warm-handoff. The individual then has 30 days to
complete an assessment before they are enrolled in LEAD. If a pre-booking client refuses or fails to
complete the assessment within that 30-day period, then the District Attorney has the discretion to
charge the client.
External evaluation in California
Figure 1-1: Evaluation plan at a glance
Process Evaluation Outcome Evaluation Cost Analysis
AAcccceeppttss LLEEAADD
pprrooggrraamm
Group 1: Treatment Treatment Recidivism1,2 Cost estimation
(S(Soocciaiall ccoonnttaacctt o or r
pprree--aarrrreesstt))
LA: Eligible individuals
from control area Monitoring Recidivism1 Cost estimation
propensity score
matched
Group 2: Comparison
SF: Eligible individuals
from catchment area
not referred to LEAD Monitoring Recidivism2 Cost estimation
propensity score
matched
Treatment Phase Assessment Phase Cost-Benefit Phase
1 Local SF County criminal history data retrieval through SF District Attorney’s Office. Statewide criminal history data retrieval through
California DOJ.
2 Criminal history data retrieved through CLETS statewide system. Provided by LASD and LBPD.
Figure 1-1 provides a birds-eye picture of the LEAD evaluation, which consists of three parts:
1. process evaluation
2. outcome evaluation
3. cost analysis
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Process evaluation
In line with prior research on the viability of policy evaluations, we collected several forms of data and
used multiple methodologies to analyze the implementation of the Law Enforcement Assisted Diversion
(LEAD) program in both sites. The process evaluation seeks to describe LEAD development and LEAD
implementation. The process evaluation can inform other cities/counties/states of best practices and
challenges in developing and implementing LEAD. The process evaluation answered four research
questions:
1. Does this program model past LEAD efforts (Seattle, Santa Fe, Albany)? What are the similarities
and differences?
2. What was the nature of training received?
3. What were the barriers and facilitators to program implementation? How were barriers
addressed?
4. What are the perceptions of LEAD amongst the target population and LEAD stakeholders?
The process evaluation involves three components: 1) document analysis, 2) stakeholder
interviews/focus groups, and 3) client surveys/interviews. In the first component of the process
evaluation, policy documents relating to the implementation of LEAD were reviewed in both sites.
Relevant data included: grant applications, Operational Workgroup (OW) and Policy Committee meeting
minutes and PowerPoint slides, policy and procedure documents, protocols and forms used and
developed, MOUs, quarterly reports, etc. Data were analyzed using a content analysis, in which textual
data are coded. We employed a grounded approach to coding, deriving codes from the data.
In the second component of the process evaluation, data were derived from interviews and focus
groups conducted with LEAD stakeholders and implementers (e.g., law enforcement line officers and
leadership, legal teams, project managers/staff, case managers, service delivery administrators, etc.]
Analysis for this portion of the evaluation involved qualitative analyses of interviews/focus groups.
In the final component of our process evaluation, data were collected from client surveys via phone. The
phone survey/interview queried theoretically derived measures of program effectiveness, procedural
justice, and life satisfaction as well as demographic and attitudinal data.
Outcome and costing evaluation
The purpose of the second part of the evaluation, the outcome evaluation, is to assess the effect of the
LEAD program on recidivism. The outcome evaluation is designed to answer the following research
questions:
1. Does LEAD reduce recidivism?
2. Does LEAD reduce criminal justice system utilization?
To answer these questions, we collected administrative data on two groups (see Figure 1-1):
Group 1: Treatment
The treatment group includes all of the clients who successfully complete the LEAD intake assessment.
The treatment group has two sub-components, those referred through pre-booking and those referred
to LEAD as social contacts.
Group 2: System-as-usual comparison
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In the City and County of San Francisco, the comparison group is a matched group of individuals from
the catchment area (Mission and Tenderloin) who would have been eligible for LEAD but were not
offered the program. These individuals come from incident-level data provided to the San Francisco
District Attorney’s Office (SFDA) by the San Francisco Police Department (SFPD), San Francisco Sherriff’s
Department (SFSD), and BART Police. Prosecutors selected eligible cases based on crime type/reason for
contact. These cases were then reviewed by members of the Policy Committee to make sure they were,
in fact, LEAD eligible. We then used propensity score matching (PSM) to construct control group that is
similar in criminal history and demographics to the treatment group. We provide more detail about the
methodological and statistical techniques used to make this group comparable to the treatment group
in Chapter 5.
In Los Angeles County, the control group is a matched group of LEAD eligible individuals from a
comparison area – the Artesia Blvd. corridor. The Los Angeles Sherriff’s Department (LASD) and Long
Beach Police Department (LBPD) sent a list of LEAD eligible (based on crime type) individuals and their
Statewide criminal history to the Office of Diversion and Reentry (ODR) in the Department of Health
Services (DHS). ODR then provided researchers with the redacted criminal history data. As in San
Francisco, we used PSM to construct a control group that is similar in criminal history and demographics
to the treatment group. We provide more detail about the methodological and statistical techniques
used to make this group comparable to the treatment group in Chapter 8.
The two groups were compared on the key outcome areas. The key areas were measured using
variables collected from key LEAD stakeholders (see Table 1-1).
Table 1-1: List of outcome variables and their department sources
Variable Department Source (LAC) Department Source (SF)
Criminal Justice Variables
Number of felony cases CLETS SFDA
Number of misdemeanor cases CLETS SFDA
Number of felony arrests CLETS SFDA
Number of misdemeanor arrests CLETS SFDA
Days spent in jail ELP SFSD
Days that client was on probation ELP SF Adult Probation Department
or received any probation services (SFAPD)
Demographics
Age LA County Department of SF County Department of Public
Health Services (LADHS) Health (SFDPH)
Ethnicity LADHS SFDPH
Gender LADHS SFDPH
The final part of the project involves a cost analysis, in which expenditure data were analyzed to assess
LEAD costs and cost savings. The cost analysis was designed to answer the following research questions:
1. What are the LEAD program costs?
2. Does LEAD reduce criminal justice system utilization costs?
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2. Los Angeles County LEAD
LEAD LAC officially launched on December 1, 2017. According to the LEAD LAC grant proposal, the LEAD
LAC model is a community based diversion program that aims to improve public safety and reduce
future criminal behavior by people engaged in low level drug offenses. LEAD LAC is a result of a unique
partnership between the County of Los Angeles, including the Los Angeles Sheriff's Department, the
District Attorney, Probation, the Health Agency's Office of Diversion and Reentry and Housing for Health
divisions, the Department of Public Health, the Department of Mental Health; the City of Long Beach,
including the Long Beach Police Department, the City Prosecutor, and public defenders; community
organizations; and community members.
Figure 2-1 shows how LEAD LAC client enrollment has fluctuated dramatically over the first 17 months of
the program, trending slightly downward in 2019. By April 2019, there were over 200 active clients in
LEAD LAC.
Figure 2-1: LEAD LAC enrollment numbers by month (December 2017-April 2019)
Originally, LEAD LAC planned to operate for two years and enroll a minimum of 250 individuals: 200 pre-
booking and 50 social contacts. Figure 2-2 illustrates that while there were monthly fluctuations, social
contact referrals trended downward during the course of the project. By April 2019, 58% of all LEAD LAC
clients were social contact referrals.
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Figure 2-2: LEAD LAC social contact client enrollments by month (December 2017 – April 2019)
Figure 2-3 shows the ethnicity breakdown of LEAD LAC clients. In April 2019, 49% of active LEAD clients
were Black/African American, 26% Hispanic/Latinx, and 22% White. The remaining 3% was Asian/Pacific
Islander or missing ethnicity.
Figure 2-3: LEAD LAC client ethnicity as of April 2019
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Figure 2-4 presents the percentage of female clients by month. The percent has been trending upward
since program inception, and by April 2019 enrolled clients were 69% female.
Figure 2-4: LEAD LAC female client enrollment by month (December 2017 – April 2019)
Figure 2-5 presents the percentage of homeless clients by month. While the percentage has been
trending downward, 82% of all LEAD LAC clients were homeless at time of enrollment.
Figure 2-5: LEAD LAC homeless client enrollment by month (December 2017 – April 2019)
In the next chapter, we present the findings of the process evaluation in Los Angeles County.
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3. Process Evaluation: Los Angeles County
Process evaluations provide detailed information about a program’s underlying theory, model design,
goals, objectives, operations, service delivery, quality of services, and implementation barriers and
facilitators (Krisberg, 1980; Mears, 2010; Miller & Miller, 2015; Scarpitti et al., 1993). This information is
helpful in enhancing other sites’ ability to replicate a program with similar results. Researchers and
program evaluators can avoid committing a Type III error, as they will know if relevant components
were absent or added (i.e., incorrectly concluding that a program’s outcomes are attributable to the
program components when the intervention was not delivered as indicated [Helitzer & Yoon, 2002]).
Process evaluations contextualize impact and outcome findings by describing how and why an
intervention experienced certain results. They are key to understanding program implementation and
program outcomes.
Process evaluations utilize qualitative and quantitative methods to assess program implementation and
identify how and under what conditions programs work or do not work (Mears, 2010; Pawson & Tilly,
1997). Consistent with previous process evaluation research, this process evaluation employed both
qualitative and quantitative methods in the form of semi-structured focus groups/interviews, client
surveys, and content analyses of LEAD LAC and Seattle policy documentation (e.g., policies and
procedures). Data were analyzed and triangulated to fully examine the implementation of LEAD LAC and
identify the conditions under which LEAD implementation is successful.
Semi-structured focus groups and interviews
Semi-structured focus groups and interviews with LEAD LAC Project Management, case management
administrators, case managers, legal/prosecutor partners, senior commanding officers, and front-line
officers were conducted. The purpose of these interviews/focus groups was to:
1. Understand LEAD LAC roles,
2. Understand LEAD LAC procedures,
3. Understand LEAD impact on community relations and LEAD partner relations,
4. Identify obstacles and facilitators to LEAD development,
5. Identify successes and challenges to LEAD implementation, and
6. Identify best practices in LEAD development and implementation.
The focus groups and interviews were scheduled to occur biannually. However, staff turnover
challenges in case management meant that focus groups and interviews occurred less systematically.
At the scheduled focus group/interview, we obtained non-signature consent to participate and record
the interview/focus group. All participants had the option to keep a copy of the consent form.
Interviews lasted approximately 30-minutes and focus groups lasted no more than two hours, in which
questions were posed about mechanisms, contexts, challenges, and facilitators of LEAD LAC
implementation. The interview/focus groups were audio recorded, and handwritten notes were taken
when participants wanted to speak off the record. Participants had the right to skip or refuse to answer
any questions and to terminate the interview/focus group. Participants also had an opportunity to
request (during or after) the interview/focus group to review and/or delete audio recordings and
transcriptions (although none did so).
To minimize any risks to participants’ privacy, all identifiable data were redacted, and participants were
identified as their title and a number (e.g., case manager #1). Within focus groups/interviews, the title
and number correspond to the same person. However, this is not the case between focus groups and
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interviews. The title and number of a participant in one focus group/interview is not the same person in
a different focus group/interview. Because no record of who attended was maintained and the audio
files were deleted upon transcription, linking individuals across focus groups/interviews was not
possible. A total of 14 focus groups, ranging in size from 2-5 (See Table 3-1), and 13 interviews were
conducted over a two-year period July 2017-December 2019 (See Table 3-2).
Table 3-1: LEAD LAC focus groups
Focus Groups (n=14)
Date Staff Classification Staff Count
11.09.17 Law Enforcement Officers 3
3.2.18 Project Management 2
3.12.18 Commanding Law Enforcement Officers 2
8.20.18 Legal/Prosecutorial Team 3
11.30.18 Law Enforcement Officers 3
12.11.18 Case Mangers & Housing Navigator 7
1.8.19 Legal/Prosecutorial Team 3
2.11.19 Project Management 2
2.11.19 Project Management 2
3.5.19 Commanding Law Enforcement Officers 3
11.18.19 Legal/Prosecutorial Team 3
11.20.19 Law Enforcement Officers 2
11.22.19 Case Managers 5
12.6.19 Project Management 2
Table 3-2: LEAD LAC interviews
Interviews (n=13)
Date Staff Classification Staff Count
12.14.17 Case Manager 1
12.14.17 Case Manager 1
12.14.17 Case Manager 1
12.14.17 Case Manager 1
3.9.18 Case Management Administrator 1
3.22.18 Case Management Administrator 1
4.11.18 & 4.17.18 Case Manager 1
4.11.18 Case Management Administrator 1
5.11.18 Project Management 1
9.17.18 Clinician 1
12.12.18 Clinician 1
12.12.18 Case Management Administrator 1
11.22.19 Case Management Administrator 1
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LEAD LAC document data
We collected various LEAD LAC-related documents for this study (See Table 3-3). Data were collected
from LEAD LAC Project Management. Policy-related documents included the LEAD LAC grant proposal,
LEAD LAC Key Stakeholder Policy Committee (KSPC) meeting PowerPoints, and LEAD LAC Quarterly
Reports. We also collected LEAD LAC policy and procedures document.
Relevant document data were also collected from LEAD Seattle to compare the sites and assess LEAD
LAC’s fidelity to the original LEAD model (see Table 6-3). Seattle data include LEAD’s core principles and
role documents, and policy/procedure protocols. Documents were collected from the LEAD King County
website and the LEAD National Support Bureau website. We were also in communication with the LEAD
National Support Bureau who provided additional documents (e.g., updated processes) and clarified any
confusions about the program.
Table 3-3: LEAD LAC Documents
LEAD Site Document Type Count
LEAD LAC Grant Proposal 1
LEAD LAC KSPC Policy Committee PowerPoints 9
LEAD LAC Quarterly Reports 10
LEAD LAC Procedures/Protocol 3
LEAD Seattle Policy: Goals and Principles 53
LEAD Seattle Procedure/Protocol 1
LEAD LAC client surveys
The process evaluation relied on LEAD LAC client survey data to contextualize qualitative findings.
Surveys were conducted to (a) understand participant perceptions of LEAD and LEAD partners, (b)
understand motivations for accepting LEAD, and (c) assess procedural justice. The survey was conducted
on the phone and posed a series of closed-and open-ended questions, lasting no more than 30 minutes.
Given physical signature of consent was not feasible as surveys were only conducted via phone, clients
gave verbal consent to participate and were asked if and where they wanted us to send them a copy of
the consent form. They were also asked to provide contact information for follow-up surveys to occur
every three months for one year. If they agreed to provide contact information, they could always
refuse to participate in the survey when later contacted. Participants received a $20 incentive, even if
they skipped a question(s) or stopped answering the survey. They had the option to receive their $20
incentive in one of four ways: (a) Venmo, (b) email gift card, (c) money mailed to a client-specified
address, or (d) pick-up from a LEAD office of their choice. They received $20 each time they completed
the survey.
Sampling
Potential survey participants are those over the age of 18, who LEAD LAC police officers referred to the
LEAD LAC program, and the LEAD LAC program manager then referred to a case manager. The case
manager or intake clinician informed the participant of the survey via a researcher-provided LEAD LAC
5x8 card containing information in both English and Spanish about the survey (e.g., purpose, incentive,
and contact information). Case managers distributed cards to all LEAD LAC clients. Clients interested in
completing the survey called us on a LEAD-specific phone line. Prior to commencing the survey, clients
were informed that their participation was voluntary, they could skip any question, they could stop the
survey at any time, and they would receive a $20 incentive. Surveys were typically conducted at the
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time of the call or scheduled at a time best suited for the client. In instances when calls were missed or
dropped, participants were called a maximum of twice a day over a four-day period.1
The sample
A total of 66 LEAD LAC clients participated in the LEAD client survey (See Table 3-3). More women
(63.6%) than men (36.4%) participated, and none identified as transgender/non-binary, with an average
of 39.7 years. The majority identified as Black (53%) followed by Hispanic (18.2%) and most were not
employed (61.2%). Their level of education varied; 29.9% have a less than high school education, 37.3%
are high school graduates or equivalent, and 22.4% attended some college. 63.6% of the sample are
suffering from homelessness; 31.8% are homeless alone, 7.6% are homeless with a partner, 1.5% are
homeless with children, and 22.7% are in a shelter.
Table 3-3:LEAD LAC client survey sample
Demographic # %
Age (Mean=39.7; Median=40)
20-29 24 36.4
30-39 8 12.1
40-49 10 15.2
50-59 22 33.3
60-69 2 3
Gender Identity
Male 24 36.4
Female 42 63.6
Transgender/Non-binary 0 0
Race
White, not Hispanic 11 16.7
Black 35 53
Hispanic 12 18.2
Asian 1 1.5
Other 7 10.6
Employment Status
Full Time 1 1.5
Part Time 25 37.3
No Employment 41 61.2
Education Level
Less than High School 20 29.9
High School Graduate or Equivalent 25 37.3
Some College 15 22.4
College Graduate 6 9
Trade School/Occupational Training 1 1.5
Housing Status
Homeless Alone 21 31.8
Homeless with a Partner 4 7.6
1 Note: The data presented here are the first survey the client completed (Time 1).
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Homeless with Children 1 1.5
Shelter 15 22.7
Live Alone 3 4.5
With Family 3 4.5
Other 25 37.9
As LEAD LAC diverts individuals involved in drug offenses and sex work, participants were also asked
about their criminal history and drug and alcohol consumption to gain a better understanding of the
LEAD SF client population (see Tables 3-4 & 3-5). More than one-third of the participants reported
coming into contact with the police within the last 30 days (37.5%). One-third also reported having been
arrested between one and three times within the last year. 21.9% of the participants reported having
one to three felony convictions, and slightly more than one-fifth (21.9%) reported having one to three
misdemeanor convictions. Of this sample, 31.8% percent reported that their longest time spent in
prison/incarcerated was less than 3 months, 31.9% reported between 3 months and 2 years (28.5%),
and 21.2% reported three or more years. Collectively, over the lifetime, 84.8% of the sample spent time
in prison/incarcerated anywhere from one month to five or more years. About half (49.2%) of the
participants also reported having traded sex for money, though only 29% of that group considered
themselves a sex worker/prostitute. Lastly, 65.2% of the participants responded that they had used
either illicit drugs, prescription drugs, or alcohol within the last three months. And, most participants
prefer to use marijuana (27.8%) or crystal meth (22.2%).
Table 3-4: Client self-reported criminal history
Question # %
Instances of Contact with Police Within the Past 30 Days 64
None 39 60.9
1-5 24 37.5
6-9 1 1.6
10 or more 0 0
Number of Times Arrested in the Past Year 62
None 34 54.8
1-3 19 30.6
4-5 7 11.3
7-9 1 1.6
10 or more 1 1.6
Number of Felony Convictions 64
None 31 48.4
1-3 14 21.9
4-6 5 7.8
7-9 3 4.7
10 or more 1 1.6
Unsure 10 15.6
Number of Misdemeanor Convictions 65
None 19 29.7
1-3 13 20.3
4-6 9 14.1
7-9 4 6.3
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10 or more 7 10.91
Unsure 13 20.3
Longest Time Spent in Prison/Incarcerated 66
Never Been 10 15.2
Less than 3 months 21 31.8
More than 3mos but less than 6mos 7 10.6
6 months -1 Year 4 6.1
1-2 Years 10 15.2
3-5 Years 7 10.6
5+ Years 7 10.6
Time Spent Behind Bars Over the Lifetime 65
Never Been 10 15.3
Less than 3 months 17 26.2
More than 3mos but less than 6mos 3 4.6
6 months – 1 year 5 7.7
1-2 Years 5 7.7
3-5 Years 10 15.4
5 or more 15 23.1
Traded Sex of Any Kind for Money 63
Yes 31 49.2
No 32 50.8
Consider Himself or Herself a Sex Worker 62
Yes 18 29
No 44 71
Table 3-5: Client self-reported drug use
Question # %
Used illicit drugs, prescription 66
drugs, or alcohol in the 3
months
Yes 43 65.2
No 23 34.8
Drug of Choice 36
Alcohol 5 13.9
Cocaine/Crack 5 13.9
Crystal Meth 8 22.2
Heroin/Opioids 5 13.9
Marijuana 10 27.8
N/A 2 5.6
Other 1 2.8
Data analysis
Several methods are used to analyze data in this study. First, thematic analysis was used to analyze the
focus groups/interview data and survey clients’ responses to open-ended questions about the LEAD
program. Thematic analysis is a flexible qualitative method used for “identifying, analyzing, and
P a ge | 23
reporting patterns (themes) within data” (Braun & Clarke, 2006, p. 6). Themes refer to patterns of
information within the data in relation to the study’s research questions (Braun & Clarke, 2006). This
type of analysis can use either an inductive approach or deductive approach. In an inductive approach,
the coding is data-driven; it is based on what the data reveal. In a deductive approach, the researcher
uses a pre-existing schema of codes to analyze and interpret qualitative data (Braun & Clarke, 2006).
This study uses an inductive approach; LEAD LAC thematic codes emerged from the data. Thus, all focus
group and interview data audio recordings were manually transcribed and coded based on emergent
patterns. We used NVivo, a software that facilitates thematic coding in the form of organization and
mind-mapping.
Second, both a content analysis and .pdf Comparison Report were performed to analyze the LEAD LAC
policy and procedural documents. The content analysis tracked Policy Committee and OW
developments and challenges throughout implementation. Then, the thematic analysis findings from the
focus groups/interviews were cross-referenced with the findings from the content-analysis to identify
any connections with staff reported implementation barriers and facilitators. The comparison reports
allowed us to track changes among the various iterations of procedural documents. The next sections
discuss the findings.
LEAD Seattle vs. LEAD LAC
LEAD LAC and LEAD Seattle documents were analyzed to assess whether the LAC model adheres to or
deviates from LEAD Seattle’s model, including its goals, core principles, eligibility and exclusionary
criteria, and core processes.
Goals
Figure 3-1 illustrates the goals comparison. The LEAD Seattle model has six goals. One, reorient
traditional government responses to crime, public safety and order, and health-related problems. Two
improve public safety and public health by utilizing evidence-based practices, such as harm reduction.
Three, reduce the rate of low-level drug and prostitution offenders cycling through the criminal justice
system. Four, undo racial disparities resulting from criminal justice system involvement. Five, sustain
funding by utilizing LEAD systems’ cost savings. Six, strengthen and improve police-community relations
(LEAD National Support Bureau, n.d.).
LEAD LAC has three goals. One, reduce the number of low-level drug offenders who enter or reenter the
criminal justice system. Two, end the cycle of housing insecurity and homelessness for participants.
Three, foster a public dialogue about LEAD model diversion efforts locally and statewide. LEAD LAC’s
goals are consistent with LEAD Seattle.
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Figure 3-1: LEAD LAC and LEAD Seattle goals comparison
LEAD core principles
Data were analyzed to assess whether LAC adhered to the core principles of the Seattle model (See
Figure 3-2). LEAD is advertised as an adaptable model, though specific core principles are essential.
These include having committed stakeholders, a harm reduction and housing first framework, intensive
case management, and meaningful police relationships (LEAD National Bureau, n.d.). Unlike the LEAD
San Francisco model whose core principles were created for and branded by the LEAD Bureau, LEAD LAC
does not have a specific set of core principles. However, based on the LEAD LAC grant proposal, LEAD
LAC is “consistent with the guiding principles of LEAD by providing voluntary, harm reduction, temporary
and permanent housing options and client driven intensive case management services” (p. 15).
Moreover, data from LEAD LAC focus groups/interviews, quarterly reports, and policy committee
meetings suggest LEAD LAC adhered to various other core components of the LEAD Seattle model. Data
indicate LEAD LAC has created and maintained meaningful police partnerships, collaboration across
agencies and service providers, harm reduction services, and maintained a housing first framework.
However, LEAD LAC has encountered challenges with maintaining a constant flow of intensive case
management services due to high case management staff turnover.
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Figure 3-2: LEAD LAC and LEAD Seattle core principles comparison
LEAD client eligibility and exclusion criteria
In Seattle, LEAD partners originally intended to divert low-level drug offenders (e.g., possession of
controlled substances or narcotics not exceeding three grams) in the Belltown Neighborhood where
illicit drug markets are prevalent (Beckett, 2014). However, partners were concerned that this eligibility
criteria would primarily bring in male clients, and partners expanded the criteria to include sex workers
(i.e., low-level prostitution crimes) to bring in female participants struggling with drug problems and
poverty (Beckett, 2014). Since implementation, LEAD Seattle partners continued to refine pre-booking
and social contact criteria (Beckett, 2014). One notable change was the increase from three grams to
seven grams, as the maximum for possession of controlled substances or narcotics.
The LEAD Seattle and the LEAD LAC eligibility and exclusionary criteria are essentially identical. In fact,
LEAD LAC added HS 1150 – possession of drug paraphernalia – to the list of eligible charges to ensure
that the charges were comparable. Drug paraphernalia was not originally included in the CA legislation.
The LEAD LAC partners had extensive conversations about the exclusionary criteria prior to LEAD LAC
launch. Most of the partners, including law enforcement, had considered the 10-year mandatory
exclusion for certain offenses as too long, especially given most of the eligible charges for LEAD are
misdemeanors. However, all of the partners could not agree to reduce that length of time. LEAD LAC’s
commitment to collaboration and consensus meant the 10-year mandatory exclusion remained. This
complements the Seattle LEAD exclusionary criteria.
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Table 3-4: LEAD LAC and LEAD Seattle eligibility and exclusion criteria
LEAD Seattle LEAD LAC
Prebooking Prebooking & Social Contact
• VUCSA (Violation of the Uniform • Possession of a controlled substance or
Controlled Substance Act) and other prohibited substance under 7 grams
Prostitution Offenses (most commonly HS 11350, HS 11377, B&P
4060)
• Possession for sale or transfer of a
controlled substance or other prohibited
substance where the circumstances indicate
that the sale or transfer is intended to
provide a subsistence living or to allow the
person to obtain or afford drugs for his or
her own consumption. (HS 11351, HS 11378)
• Sale or transfer of controlled substance or
other prohibited substance under 7 grams
where the circumstances indicate that the
sale or transfer is intended to provide a
subsistence living or to allow the person to
obtain or afford drugs for his or her own
consumption (HS 11379)
• Being under the influence of a controlled
substance or other prohibited substance (HS
11550)
• Being under the influence of alcohol or a
controlled substance or other prohibited
substance (PC 647(f))
• Prostitution pursuant to subdivision (b) of
Section 647 of the California Penal Code (PC
647 (b))
• Loitering with intent to commit prostitution
pursuant to subdivision (a) of Section 653.22
of the California Penal Code (PC 653.22(a))
• Possession of an opium pipe or any device,
contrivance, instrument or paraphernalia
used for unlawfully injecting or smoking a
controlled substance (HS 11364)
Social Contact Social Contact
• Verification by law enforcement that 1. Social contact referrals are those, in which,
the individual is involved with narcotics deputies/officers believe an individual has a
(possession or delivery) or prostitution. high risk of arrest in the future for low level
• Verification by law enforcement: Police drug activity. All social contact referrals to
reports, arrests, jail bookings, criminal LEAD must meet the same pre-requisites as
charges, or convictions indicating that a LEAD pre- booking arrest.
P a ge | 27
the individual was engaged in narcotics
or prostitution activity; or
• Law enforcement directly observed the
individual's narcotics or prostitution
activity; or
• Law enforcement has a reliable basis
of information to believe that the
individual is engaged in narcotics or
prostitution, such as information
provided by another first responder, a
professional, or credible community
members.
• The individual's involvement with
narcotics or prostitution occurred
within the LEAD catchment area.
• The individual's involvement with
narcotics or prostitution occurred
within 24 months of date of referral.
• No existing case in Drug Diversion
Court or Mental Health Court.
• No existing no contact order,
temporary restraining order, or anti-
harassment order, prohibiting contact
with a current LEAD participant.
Exclusionary Criteria Exclusionary Criteria
1. Amount of drugs involved >7 grams Felony Referrals
(except where an individual has been 1. A PC § 290 sex offender registrant
arrested for delivery of or possession 2. Convicted of or a juvenile sustained petition
with intent to deliver marijuana, or for a felony crime of Domestic Violence:
delivery or possession with intent to 1. PC §273.5
deliver prescription controlled 2. PC § 646.9(a) or (b) involving
substances, officers will consider other Domestic Violence
criteria listed here without reference to 3. PC §245(a)(4) involving Domestic
amount limitation); Violence
2. Does not appear amenable to 3. Arrested or convicted of pimping, pandering
diversion; or human trafficking
3. The suspected drug activity involves 4. Prohibited by means of an existing no-
delivery or possession with intent to contact order, temporary restraining order,
deliver (PWI), and there is reason to or anti-harassment order, from making
believe the suspect is dealing for profit contact with a current LEAD participant
above a subsistence income; 5. Candidate has been convicted of a prior
4. Appears to exploit minors or others in a strike offense or has a juvenile sustained
drug dealing enterprise; petition for a strike offense at any time
5. Suspected of promoting prostitution; Misdemeanor Referrals
6. Existing no contact order, temporary 6. A PC § 290 sex offender registrant
restraining order, or anti-harassment 7. Convicted of or a juvenile sustained petition
for a felony crime of Domestic Violence:
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order prohibiting contact with a 1. PC §273.5
current LEAD participant; 2. PC § 646.9(a) or (b) involving
7. Open case in Drug Diversion Court or Domestic Violence
King County District Court Mental 3. PC §245(a)(4) involving Domestic
Health Court; and/or the individual has Violence
disqualifying criminal history as follows: 8. Prohibited by means of an existing no-
8. Without time limitation: Any conviction contact order, temporary restraining order,
for Murder 1 or 2 , Arson 1, Robbery 1, or anti-harassment order, from making
Assault 1, Kidnapping, VUFA 1, or any contact with a current LEAD participant
sex offense (or attempt of any crime 9. Convicted of a prior strike offense less than
listed here). 10 years old
9. Unless more than 10 years has elapsed
since conviction on any of the
following: Robbery 2, Assault 2 or 3,
Burglary 1.
10. Unless >5 years have elapsed since
conviction on any of the
following: Assault 4 – DV, Violation of a
Domestic Violence No Contact
Order, Violation of a Domestic Violence
Protection Order, Burglary 2, or VUFA 2
LEAD referral process
The LEAD LAC referral process is consistent with LEAD Seattle, with the exception that LEAD LAC has two
additional referral avenues. Figure 3-3 compares these referral processes. LEAD LAC’s Routine Protocol –
LEAD LEO – follows the Seattle model. In Seattle, the referral process operates as follows. First, an
officer determines whether an individual is eligible for diversion into LEAD, based on a set of site-
established eligibility and exclusionary criteria. Second, the LEAD officer utilizes his or her discretion to
decide to arrest or refer the individual to LEAD. Third, once an individual completes the intake
assessment within the allotted period, the LEAD case management group works with the client to
develop an individualized intervention plan (IIP). Similarly, LEAD LAC officers identify a LEAD-eligible
client in their daily routine. Next, they pre-screen the individual for eligibility and complete the
screening form. Officers then obtain the candidates’ consent and contact LEAD LAC case management to
transfer the individual over to them (i.e., the warm handoff).
LEAD LAC’s additional referral avenues allow that individuals be referred to LEAD during LAC Sheriff
Department and Long Beach Police Department Arrest Operations (e.g., prostitution stings) and via non-
LEAD officers. Because LEAD LAC has LEAD-designated officers, this additional avenue allows non-LEAD
officers to refer the individuals they believe are suitable LEAD candidates. The processes operate as
follows. For the Arrest Operations process, officers and/or deputies who are participating in a planned
operation identify a LEAD-eligible candidate and then contact and transfer custody of the individual to
LEAD LAC officer. Then, the LEAD LAC officer pre-screens the candidate and if eligible, proceeds with the
rest of the procedures in Routine Protocol LEAD LEO process. In the Non-LEAD referral protocol, a non-
LEAD officer identifies a LEAD-eligible candidate during the course of their routine patrol. Next, the non-
LEAD officer contacts a LEAD LAC officer, who then pre-screens the candidate and if eligible, proceeds
with the rest of the protocol as specified in Routine Protocol LEAD LEO process.
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Figure 3-3: LEAD LAC referral process
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LEAD LAC implementation successes and challenges
To identify the implementation barriers and facilitators LEAD LAC experienced, we conducted a thematic
analysis of the focus group data and a content analysis of LEAD LAC policy documents, quarterly reports,
meeting minutes, and client surveys. Several themes and subthemes emerged from the data that
describe the implementation process (See Figure 3-4 and Figure 3-5). The major themes include
stakeholder investment, relationship building, client successes, staff turnover, workload, case manager-
client ratio, and open communication. These themes are categorized as implementation successes and
challenges.
Successes
Those themes categorized as successes are stakeholder investment, relationship building, and client
successes. These themes are interlinked, as accomplishments in one area can lead to success in another
(see Figure 3-4). These successes also indicate that LEAD LAC is on track to meeting two out its three
goals. Moreover, LEAD LAC’s successes reflect some of the key elements to successful program
implementation. Policy theories and research have identified conditions necessary for successful policy
implementation, and a key condition is having stakeholder buy-in. LEAD LAC data indicate that partners
and especially law enforcement were invested in the program.
Figure 3-4: LEAD LAC successes
Stakeholder investment
One theme that emerged as a success and facilitator to LEAD LAC implementation was stakeholder
investment. The theme arose in two different contexts: law enforcement investment and program
leadership. LEAD LAC law enforcement officers were particularly committed to the program.
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It’s been the biggest surprise to me is to see
how engaged law enforcement has been in this
process. I had no way of expecting that.
…The biggest surprise to me is to
(Program Management, 3/2/18)
see how engaged law
The overwhelming support from the officers could be enforcement has been in this
the result of a couple of factors. First, LEAD LAC has process. I had no way of
designated, full-time LEAD officers, meaning that a
expecting that.
select group of officers are specifically tasked with
carrying-out LEAD. Second, officers with more experience and/or willingness to adopt alternative
strategies to incarceration were sought for LEAD LAC, as expressed in the officer’s comment below.
We wanted people that would, you know, be empathetic to the people that they’re dealing with.
So we picked one deputy that was older and had been on quite a long time and had a good rapport
with the community – and we picked a younger deputy who was a little bit – you know, less
experienced, but more of a hard charger that wanted to go out and do the right thing. So I think
it was a good match. That’s how we picked ‘em. (Law Enforcement Officer, 3/5/19)
Third, some LEAD LAC officers specifically sought out the position. This is important to note because
research shows that targeting champions within a department facilitates change (Rogers, 2005).
It seems like talking to a lot of the other agencies involved in LEAD, they have a – everybody does
it a little bit differently. We’re the only ones that I know of that have dedicated two deputies –
or two officers, however you want to word it – full time, just to this project. And that was because
that was of the way that the money was given to us, and it might have been the way that the
grant proposal was originally written, and that had to do with our chief at the time, was the one
who had written it. So when it came to us, what was already set in stone was set in stone and
there wasn’t really a whole lot we could do about it. But they did ask for my input as to whether
we should do it full time, or whether we should have people from the stations do it full time, or
maybe it should be a part time thing where they do that including their regular duties. Which, I
think my captain and I just believed it was best off if we just had two dedicated people. (Law
Enforcement Officer, 3/5/19)
Program leadership also emerged as a facilitator to implementation. LEAD LAC has had dedicated
program management to facilitate problem solving throughout implementation. Data show that LEAD
LAC Project Management stayed abreast ongoing challenges (see Table 3-4). Moreover, LEAD LAC
Project Management maintained continuous communication with the LEAD National Support Bureau to
improve LEAD operations. The Bureau was instrumental in helping LEAD LAC with issues regarding
support for harm reduction case management practices, case manager hiring and training, protocol
refinements, officer training, and communication techniques.
There’s this really strong level of trust I think between the partners and I think a culture of being
able to problem solve together in that culture I think is in many ways informed by [name
redacted/project management’s]’s leadership. (Project Management, 03/02/18)
Case managers and law enforcement staff had independent monthly calls with the LEAD Bureau to get
support in their relevant areas. The LEAD Bureau also visited the LEAD LAC site to meet with the staff
and provide relevant support. For example, between October 25-27, the Bureau conducted a three-day
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training with law enforcement, case managers, and the LEAD LAC Policy Committee. On June 2018, LEAD
Seattle officers visited the LEAD LAC site where they engaged with LEAD LAC officers, observed their
processes, and shared information and lessons about their respective program protocol. Further, the
Seattle officers also conducted a training with officers and case managers, which focused on
communication techniques and partnerships between service providers and law enforcement.
Table 3-5: LEAD LAC quarterly reported challenges
Timeline Presented Challenges Presented Solutions
Start Date - Building relationships and collaborative Challenge resolved at the prosecutor
6.30.18 engagement in the OWG due to staffing level
changes at the prosecutor's office
7.1.17-9.30.17 Mutual agreement over universal consent Partner agencies and departments
forms and data tracking processes each provided feedback regarding
consent forms and identified their
respective regulations. LA County
Counsel to the Office of Diversion
and Reentry created a draft to review
at OWG. Draft sent back to partner
agencies/departments for review and
feedback. Final document was
approved by all OWG .
1.1.18-3.31.18 Client to case management ratio. Available BSCC LEAD Extension (12 month roll-
resources were not enough to out period)
accommodate the rate of referrals causing HOPICS began process to hire new
delays in enrolling awaiting clients. case managers, clinical staff, and
Staffing challenges (e.g., hiring, turnover, program management
fit) at HOPICS case management
4.1.18-6.30.18 Client to case management ratio. Available BSCC LEAD Extension (12 month roll-
resources were not enough to out period)
accommodate the rate of referrals causing HOPICS began process to hire new
delays in enrolling awaiting clients. case managers, clinical staff, and
Staffing challenges (e.g., hiring, turnover, program management
fit) at HOPICS case management
7.1.18-9.30.18 Staffing changes, decrease in overall new Concerns to be discussed in
referrals, increase in social contact referral upcoming months
and decrease in pre-booking referrals.
Staffing concerns: hiring staff with
necessary skills & experience. Some staff
having trouble working with LEAD model.
Rate of referrals too high for available
resources - case management
10.1.18- Social contact referral decrease Partners expect increase in referrals
12.31.18 Slight pre-booking referral increase; due to increased capacity from
referral slowdown due to hiring and HOPICS and police-community
training of new case managers and winter relationships
holiday working hours at HOPICS
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1.1.19-3.31.19 Decrease in overall number of referrals Fill available client slots when other
due to full or close to full case clients are deactivated
management slots (i.e., case manager- Decrease law enforcement referrals
client ratio) days to 2 days per week
4.1.19-6.30.19 Full or close to full case management slots Fill available client slots when other
(i.e., case manager-client ratio) clients are deactivated
Decrease law enforcement referral
days to 2 days per week
Relationship building
A positive theme that emerged from LEAD LAC data is relationship building. LEAD LAC partners been
successful in building relationships among partners and with clients and the community. The
relationships created among partners and their collaborative nature throughout the implementation of
LEAD LAC have been instrumental in LEAD LAC’s success.
I think it’s really – it’s opened my mind a lot and I’ve learned how much better things can be when
there’s collaboration and that you don’t have to constantly argue with the person on the other
side of the table. LEAD people, they’re not in court, so there’s not an opposing counsel for that…
we’re actually working together. We’re calling social workers, we’re calling treatment facilities
and I’m doing all that stuff – or we’re helping defense attorneys write motions. So it’s really – it’s
shown how awesome collaboration can be and that you don’t always have to be fighting…
(Legal/Prosecutorial Partners, 11/18/19)
Two examples demonstrate the power of the police, prosecutor, and case manager collaboration:
Um, [law enforcement officer] and HOPICS – like, [case manager] did this thing of like, a vacator
of an entire history of sex work… he [the law enforcement officer] just like took it on himself to
figure out how to make this document, and he talked to law professors who sent it to us, he sent
it to prosecutors to look at, and ultimately created something new that hadn’t existed before and
that was generated by law enforcement. …they [the police officer, the case manager, and the
LEAD LAC client] went in and asked the court to consider – it was a commissioner there…who sent
them back, it was like, set another court date. And during that time, he [the law enforcement
officer] drafted this letter, got all these people to sign on to it, and then went with her [the client]
to see the commissioner again. And …the prosecutor dropped charges that were existing and
offered to go back… (Project Management, 02/11/19)
…There was another person they had picked up, and she was somebody that would have been an
arrest referral… found her in Compton… and she had a number of warrants. Like when I showed
up to this court date, her mother was there and her sister was there, it turns out [name redacted,
the law enforcement officer] had taken her phone that day and called mom and been like, ‘come
get your daughter, she’s standing outside.’ She’s young, she’s real young… And they went to
court with these outstanding warrants, the prosecutors, they walked in, told [name redacted],
that she’ll be in Lynwood… And the judge, you know, everybody wants to know why the cop is
standing in the courtroom, it’s just like – this doesn’t usually happen unless it’s very serious… The
judge is like, ‘What’s up, come on up here.’ And like, [name redacted, the officer] himself and me
and the case manager said, ‘We’re doing LEAD.’ After… we had to developed court guidance for
case managers because there had been like up until that point a lot more sharing of information
with the court than was appropriate and like, they hadn’t had the right structure in place so… we
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developed something that everybody signed off on, that they now use in a letter produced to the
court. (Project Management, 02/11/19)
In addition to maintaining positive working relationships, LEAD LAC has been proactive in building
collaborative partnerships with local community service providers to expand the nexus of resources
available to LEAD LAC clients.
DHS holds contracts with probably three dozen service provider partners that deliver what we call
intensive case management services all across Los Angeles County. So we work – and we – those
agencies partner with workforce development and entities like Homeboy and Chrysalis and some
of those players, CEO [Center for Employment Opportunities]. But -- and in fact Homeboy is about
to become one of our intensive case management service providers. So we have lots of
partnerships we do all this work through, collaboration with, community based entities. (Project
Management, 3/2/18)
For when it comes to homeless services and everything, so we got a lot of resources here, so I –
you know, so I don’t want to brag, but I know that the case management component of LEAD is a
very, very, you know, identified strength, if you ask me. I think the fact that the program is being
ran through the county, through DHS – regardless to who they chose to do it – it’s a strength
because the county got a slew of resources… So I think that’s a big strength. (Case Manager #1,
12/14/17)
I have went outside with a service provider because… I was invited to observe a human trafficking
operation with the LA County sheriffs, and once I got there, there were some three other service
providers there and again, my goal was to observe… So we gave a whole presentation on what
LEAD does and what we offer – I wind up leaving with five ladies. One of my ladies – after about
a week – she had a breakdown. And she called me and she was like, ‘I need to see a therapist, I
need to see a therapist.’ And our unit, CRC (Certified Rehabilitation Counselor) hadn’t scheduled
her yet. So we had to have a 24 hour crisis intervention. So she said that, ‘Well, I’m just going to
call one of these numbers that the other service provider gave me.’ So I was like, ‘Which service
provider?’ Well, when she told me, I was able to follow up with them, and I met with them – two
of them since then. So they offered co-location – they’re both in the catchment area, offered co-
location, and we’ve met with them to see how we could integrate and help all of the clients.
Saturdays, we go over and meet with some of the ladies to get reversed social contact referrals.
And on Mondays, they call for potential clients that need assistance. So even if LEAD can’t assist
with a social contact referral, HOPICS has other programs and services that they can. My
preference is to just use everything internally to help me track. And we can speed it along. (Case
Manager #2, 12/14/17)
Moreover, LEAD LAC has been successful in building and strengthening police-community relationships.
Interview and focus group data indicate a positive shift in police relationships with the client population.
Police have been able to build rapport with individuals experiencing homelessness. LEAD officers and staff
noted that prior to LEAD, individuals in the homeless encampments showed hesitation to interact with
and trust officers. However, LEAD has facilitated more positive officer-client rapport and partners have
seen a positive change in how this population of clients now views the police.
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Yeah. I was going to say something about -- I just think that there’s been a huge sort of sea change
in the relationship between the encampment residents and law enforcement. (Project
Management, 3/2/19)
Yeah, there’s been a number of success stories from what the deputies have said. …a particular
lady was hospitalized, and the first person she wanted to contact was the deputies, and even the
administrator was like, ‘We’re not calling the police.’ ‘No, I want to talk to them.’ And the people
from the hospital didn’t understand it. They didn’t get it until the deputies actually got there and
they were able to see the relationship that the deputies actually had with this particular homeless
person… (Law Enforcement Officer, 3/5/18)
Yeah, one thing that the guys had said, and
this is true, I know this is true – usually they
[community members] just see a uniform.
But once they realize, you know,
They could care less what color you are. They
just think, ‘Okay, you’re going to shake me after they see you five or six times,
down. You’re going to take me to jail.’ But
and they’re [police] not shaking
once they realize, you know, after they see
them down and they’re not taking
you five or six times, and they’re not shaking
them down and they’re not taking them to them to jail that they can – you
jail that they can – you know, they can open
know, they can open up a little bit.
up a little bit. And that’s where they’re
And that’s where they’re starting
starting to make these – you know, open up
these lines of communication, especially with to…open up these lines of
the homeless community. Because now they
communication, especially with the
go into a lot of these homeless encampments
and people know them. ‘Hey, deputy such homeless community.
and such is here.’ They’ll see the car pulling
up and they’ll go up and meet him. You know, even with our homeless team, it’s not that common
because the homeless team is spread out throughout the county. So they’re running from one
fire to another, whereas these guys are more or less ingrained in this particular area. …So these
guys have developed a rapport that not even the homeless teams have developed at this point.
(Commanding Law Enforcement Officer, 3/12/18)
I have seen a change in the community relationships with law enforcement that’s profound. Like
the – people from an encampment walking towards a cop to say hi is just, like – I can’t even
imagine that happening for any other reason. The fact that, like, they come back, says a ton, like,
it really does build – I think – yeah, the community relationship watching people – watching cops
building trust in a population that has no reason to trust them and has every reason to run away
is just so deep. (Project Management, 5/11/18)
Client survey data also indicate that a majority of clients reported positive experiences and perceptions
of LEAD LAC officers (see Table 3-5). In particular, a large number of clients (n=74) perceived that
officers treated them with dignity and respect and that officers were fair, nonjudgmental, and polite.
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Table 3-6: Officer procedural justice (n=67)
Question Agree-Strongly Agree
# %
Perceived Officer Fairness 66 98.5
Officer Allowed Questions 65 97
Officer Answered Questions 65 97
Officer Explained LEAD Fully 55 82.1
Perceived Officer Care of Client’s Wellbeing 66 98.5
Officer Did Not Judge the Client 65 97
Perceived Officer Helpfulness 66 98.5
Officer Made Sure Client Understood Rights and Responsibilities 60 89.5
Perceived Officer Politeness 66 98.5
Officer Treated Client with Dignity and Respect 67 100
Quotes from clients via LEAD survey about LEAD LAC officers echo those results:
The police officers are very, very concerned about our well-being. (LEAD LAC Client)
The cops seemed to care… like I was a person. Felt good to talk to someone, to feel like a person
again. (LEAD LAC Client)
I contacted the officer on my own [to get into LEAD]. I got the number from a mutual friend. (LEAD
LAC Client)
In addition to officers improving police-community relationships, LEAD LAC case managers have built
meaningful rapport with their clients. The client survey data corroborate these findings. Clients were
asked to rate their experiences with their case manager using a series of closed-ended questions. Results
show that a majority of clients either agreed or strongly agreed that case managers treated them with
dignity and respect, seemed to care about their wellbeing, were knowledgeable about services, and were
fair, polite, and nonjudgmental (See Table 3-6).
Table 3-6: Case manager procedural justice (n=67)
Question Agree-Strongly Agree
# %
Perceived Case Manager Fairness 65 97
Case Manager Allowed Questions 66 98.5
Case Manager Answered Questions 63 94
Case Manager Explained LEAD Fully 62 92.5
Perceived Case Manager Care of Client’s Wellbeing 64 95.5
Case Manager Did Not Judge the Client 66 98.5
Perceived Case Manager Helpfulness 61 90
Case Manager Made Sure Client Understood Rights and Responsibilities 62 92.5
Perceived Case Manager Politeness 66 98.5
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Case Manager Was Knowledgeable about Services 60 90
Case Manager Treated Client with Dignity and Respect 65 98.5
Clients’ responses to open-ended ended questions echoed their experience with case managers.
Specifically, when asked what clients like most about LEAD, many positively referenced their case
managers:
Like that the case managers actually care, they care about your wellbeing. They give me advice,
good advice, my case manager teaches me life skills. (LEAD LAC Client)
They seem to really care about me. They are making a transition in my life. You know, I'm living in
my car and they're going to help me get a place and get a job. I'm just trying to get through some
situations in my life. Taking a new approach. (LEAD LAC Client)
I like the realness of the people. They're not judgmental. They're supportive and they don't make
me feel like they're judging. (LEAD LAC Client)
I like that the staff members are very quick to want to
help out. The ones that have their heart in it, they're
trying to help so I don't go back on the streets.
Whenever I need, they're willing and they offer.
I like that the staff members are
They're coming from their heart; they're genuine.
very quick to want to help out. The
They try to work as a team. Some places don't care
ones that have their heart in it, like that. They are trying to figure out how to make
things better. (LEAD LAC Client)
they're trying to help so I don't go
back on the streets. Whenever I
[I] like that the case managers actually care; they care
need, they're willing and they offer. about your wellbeing. They give me advice, good
advice, my case manager teaches me life skills. (LEAD
They're coming from their heart;
LAC Client)
they're genuine. They try to work
My worker has been very understanding with what
as a team. Some places don't care
I'm going through. She wants to make sure I'm taken
like that. They are trying to figure
care off, she even brought me some food. (LEAD LAC
out how to make things better. Client)
My case manager is always coming out to check on us. (LEAD LAC Client)
In fact, across the open-ended response from LEAD LAC clients, the support they received impacted
their perception of the LEAD LAC program. In particular, LEAD LAC clients highlighted how LEAD LAC
staff were nonjudgmental, provided individualized help, and a variety of services and resources (see
Table 3-7). Quotes from the clients echoing these sentiments are presented under client successes.
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Table 3-7: Client survey themes
Key Theme I Sub Themes
Support Nonjudgmental Staff
Individualized Help
Services and Resources
The LEAD LAC Case Manager has been critical to the success of their clients. And, their work combines
harm reduction principles with outreach and intensive case management. One case manager explains:
A lot of the clients are high acuity clients, and they’re clients who have been out on the street for
a long time. So it’s – it’s trying to help them adjust to moving back into society and not being
down where people can’t see. And, I think that’s the biggest barrier with our clients that’s
different from other clients that I’ve had in the past, is the level of the system that they need and
how much we do have to help them to get all the services connected, whether it’s transportation,
you know, food, clothing, it’s very – our job is very – our role is very extensive in the life of a client
where we provide services all the way around. So, it is different than my other job where they
come to the office and that’s it. And if they don’t, then they don’t, you know, like [name redacted]
said, like she said, you write a note, and that’s it. Here, it’s like, ‘Oh, they didn’t come. Let’s go
see. Yeah, I know they’re on such and such [street].’ You know, we go and do outreach… (Case
Manager, 12/11/18)
Client successes
Client successes emerged as an overarching theme in two contexts: small successes and connections to
housing services. LEAD LAC staff report that small wins are important celebrations and that these wins
give clients a sense of self-worth. The celebration of small successes is a practice of harm reduction.
Small milestones (e.g., taking a shower, getting a haircut) are wins.
So they run into her [LEAD LAC client] and like – that’s one example of where we’ve been able to
consistently look at it – this case through a harm reduction lens, in the workgroup. Because like,
the number of days she’s in recuperative care, that’s a day she’s not in the ER (Emergency Room),
that’s a day she’s not outside, and so like being able to see progress incremental over time… and
on top of that, like, [name redacted; LEAD LAC Law Enforcement Officer] sees her – perhaps
drinking on her bus bench, like a couple of days she’s on a bender outside, and he’ll check in with
her, like, ‘How are you doing today?’ And like encourage her, like she’s got this other resource,
and she’ll like – that is like – for a cop to walk up and see progress and sit with that person and
see them and be consistently affirming, not lecturing, that’s – I feel like our cops have done
something really interesting in their work, like they’ve really like changed their practices. (Project
Management, 2/11/19)
Case Manager #1: But as case managers, what I want everybody to look at is – this client, she
actually reported a crime. This time, she actually got medical assistance. To get her to leave the
environment, because that could have happened regardless, whether the DV [Domestic Violence]
happened or not. But this time she reported it. This time, she took back some control and went
to the doctor. This time, he was arrested. So looking at the bigger part of case management, if
case management wasn’t there, that wouldn’t happen. She would have no strength and no
empowerment to call the police whatsoever.
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Case Manager #2: And that’s what, for us, that’s a big accomplishment for her. That’s a big victory
for us and just her as a person to be able to do that. So when we go to this meeting, this interview,
like well why didn’t she -
Case Manager #1: It’s life changing for clients. It’s really life changing for clients, whether it’s
positive or negative. It’s life changing. Life changing to where I’ve seen a victim of domestic
violence lean from her husband to stay with her three kids, now she has permanent housing. I’ve
seen an elderly person now sleeping on a bus stop and now she checks in on a daily basis because
she needs to get to the doctor and wants to take her medication. I’ve seen a young man that got
referred and in another day, he was treated like VIP, he came in here and got a whole wardrobe,
got put in a hotel, got connected to the workforce, got employment. (4/11/18)
Data from client surveys also corroborate these findings. Clients positively regard case managers’ efforts
to help them with their day to day routines, especially in the form of individualized help as illustrated by
some client responses below:
They help me everything. Basically with everything I need to better my life. (LEAD LAC Client)
They are very respectful and helpful with whatever that I need. I can go to them and they will be
there for me and get my life back on track, with like the counseling and whatever you need. They
have it there. They help you get more focused and be more independent. (LEAD LAC Client)
In addition to celebrating small successes, LEAD LAC staff report that they have been successful in
connecting clients to health and social services, especially housing. LEAD LAC partners attribute their
ability to house clients due to the existing housing infrastructures in LA County.
I mean we’re actually doing fairly well, we’re buying up beds like crazy. So we’ve got a portfolio
around 1500 beds and so we’ve been able to make those beds available to LEAD, but we are
looking for a LEAD specific interim housing site. We want to look for one for men and one for
women, a separate interim housing site. (Project Management, 3/2/18)
I mean, having the Housing for Health system in place, so what’s in place that we’re tapping into
is this thing called the flexible housing subsidy pool. Which pays for the permanent housing for
the people that – the 160 people that will go through LEAD. So the interim housing piece is paid
for through the grant and some other resources, depending on how much we use and when. Right
now we’re drawing down grant funds. So having a path that exists, even if it wasn’t used terribly
well, that goes from like, street to bridge housing to permanent housing… (Project Management
5/11/18)
We’ve got 31 LEAD participants housed, included in – four of them, permanent housing. Which
includes four families. So we’re not even counting them in the 31. And in addition to that, there’s
how many people in interim now?... 19 in interim, we’ve got five apartment viewings that are this
month and the beginning of next month, like those people are going to move into permanent
housing. (Project Management, 2/11/19)
Client surveys corroborate these housing successes. When asked what clients like most about LEAD LAC,
many referenced housing services.
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That they're giving me an opportunity to get off the streets and a new way to start living. I like
that they provided me housing that I was comfortable with and the things I need to stabilize
myself. (LEAD LAC Client)
The fact that I’m finally going to have my own place and be more independent than I am now.
(LEAD LAC Client)
The fact that it did get me housing. I am sitting in my apartment right now. (LEAD LAC Client)
Actually, what they offer. They offer a lot, mostly the housing. The housing is great. (LEAD LAC
Client)
They're very helpful and help people with transitional housing and get you off the streets. People
been out there so long, and they don't know how to go look for resources and LEAD helps you
find those resources, whatever you need help with. They are very compassionate about me and
take time from their day to take me places. (LEAD LAC Client)
LEAD LAC challenges
While LEAD LAC had significant successes, four themes which are challenges emerged from the data:
staff turnover, workload, and open communication. These themes are interlinked, as challenges in one
area could lead to challenges in another (See Figure 3-5). Subthemes also emerged that impacted staff
turnover and workload - including the high case manager-client ratios, the lack of petty cash, the limits
of transportation, and the frequency of meetings and trainings. Within open communication, the
challenges of data sharing and LEAD partner expectations of case management staff emerged.
Notably, the LEAD LAC project management was very aware of each of these challenges as they arose.
They had repeated conversations with their partners at every level, heavily relied on the LEAD National
Support Bureau for assistance, and “took like really concrete gestures of commitment to seeing things
from their [each partner’s] perspective” (Project Management, 12/06/19)
P a ge | 41
Figure 3-5: LEAD LAC challenges
Staff turnover
LEAD LAC underwent numerous staffing changes with their case management provider. The site
experienced high turnover of case managers. The staff were either terminated or resigned from their
LEAD positions. The site also struggled to hire new staff to fill those positions.
Everyone in our community and our network of case providers is saying it is so hard to hire right
now, because everyone is just poaching from other people, like, we need an infusion or sort of a
new pipeline of workers to help us do these services. It has been a major issue. (Project
Management, 3/2/18)
…we had enough case managers at some point to keep up with the number of referrals, but now
we don’t, because we had these losses over the last few weeks. So now, we all have more people.
And it’s shifted back to someone who’s new, hopefully we’ll find some good people, but we also
have a housing navigator. (Case Management Clinician, 9/17/18)
Unfortunately, as of 11/22/19, LEAD LAC lost their housing navigator.
To address the staff challenges, LEAD LAC project management hired a temporary clinician to guide and
trouble-shoot day-to-day operations for the case manager team and had the LEAD National Support
Bureau make multiple site visits. The case management agency also hired a full-time clinician to provide
clinical supervision to the LEAD LAC case managers (e.g., guiding case managers with high acuity clients).
So I provide clinical supervision to the staff – or the case managers, to kind of deal with their high
acuity to low acuity clients, more-so their high acuity clients, so I meet with them on a bi-weekly
basis for an hour. They – you know, address their more challenging clients with their caseload. If
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I need to do outreach with them to go provide any mental health services as far as assessing or
getting clients linked to mental health services on a community based level, I do that type of
outreach. I also keep track of their notes, are they writing effective notes in CHAMP, do – you
know, the verbiage that they’re using, kind of showing the work that they’re doing, because
they’re doing a lot of work, and so we need to snapshot that and get a picture of the work that
they’re doing. And then also reviewing their psychosocials, their ISPs, making sure that their goals
tie into their psychosocials, making sure that these are goals that the clients want to work on
(Case Management Clinician, 12/12/18)
Staff turnover also emerged as a challenge to keeping up with client management and connecting clients
to services in a timely manner. The open-ended responses in the LEAD client survey also identified this
additional theme (See Table 3-7). Specifically, the clients were concerned with the availability of their
case manager and the time it takes to receive services, especially housing.
Table 3-7: LEAD LAC key themes
Key Theme Sub Themes
Services Connection Wait Time
Staff Availability
I just feel like we need a little bit more hands-on with the case management. But their caseloads
are a lot for one person. And, need better collaboration and communication between LEAD and
Brilliant Corners. Brilliant Corners doesn't respond to case managers, and they don't realize how
that affects us. (LEAD LAC Client)
They gave me hope and ultimately didn’t follow up. It was devastating to not get any follow up
help. (LEAD LAC Client)
Because I had a case manager who left, I got switched to another one, and I fell through the cracks.
(LEAD LAC Client)
[I don’t like how] when I call to ask questions and nobody answers the phone. (LEAD LAC Client)
When they first came out (LEAD), they were really slow. Some of my friends in the program are
barely getting their places and I’m getting my housing before them. I think because it was new,
they (staff) were trying to figure out how to go about it. (LEAD LAC Client)
It’s taking a bit longer than anticipated to get a place. It’s 6 or 7 months, and I’m still waiting.
(LEAD LAC Client)
I don't like how long it has taken. I wish it would be faster to get housing. (LEAD LAC Client)
Some of the LEAD LAC Partners attributed these staffing challenges to the hiring process. The case
management agency hired case managers on a client enrollment basis, meaning that as client
enrollment increased, new case managers were hired. This was regarded as problematic because client
enrollment grew quickly in the first few months and case manager-client ratios led to some difficulties in
P a ge | 43
enrolling and connecting clients to services in a timely fashion. LEAD LAC Project Management later
explained that there was never a hold on case manager hires.
Project Management: What we do on our side is so their payment is based on participants and
slots. Like, they basically have up to 160 slots and they get – we add another 20 when they’re
about to bring somebody on. We open it up before we have participants in the slot as like, health
relief basically, is what they are. And so that means like there’s a funding stream for 20 individuals
that starts going into the program. So to that extent, we like plan it out, it’s part of, like, county
budgeting because the expenditures get incurred as they bring people on. You know, you can
project out, like, what the costs are on the other side, for the permanent housing or interim, either
way. (5/11/18)
The infrastructure has to be in place. You have to have the case managers in place before – well
before. Because we already saw this on the front end of this. When I got involved, one of my first
question is – okay, we have certain people that are here in place, we have people from the DA’s
office, DMH, ODR, all these people – and they have I think one case manager or supervisor… So
my first question was, are you guys hiring? ‘Well, we’re working – there’s two that are in the
process.’ Two?! And that was my question at almost every meeting – when are we going to get
these people online? When are we going to get these people online? And they started adding
them, but like I said, they got overwhelmed quick. They just hired two more, so now I think we’re
looking at four to six case managers, with 20 per manager, that’s – I don’t know. Even 20, I think
20 is a pretty big caseload for one case manager, seeing all the paperwork that they have to do
and all the stuff that – it just seems incredible how much work they have to do. I think a more
manageable number would be ten cases per case manager, and you’re thinking, you know, talking
about thousands of people that may be in line for this program. That’s a lot of people.
(Commanding Law Enforcement Officer, 3/12/18)
In more recent interview, case managers referenced staffing changes as a challenge in that they have
had to take on additional cases to cover for staff who are on leave.
Interviewer: So what would have helped you then?
Case Manager #1: To have full staff.
Case Manager #2: To have full staff.
Case Manager #1: And not cover other people’s caseloads, because we are…: Because we are –
we have 26 people.
Interviewer: How many people do each of you have?
Case Manager #2: 26.
Case Manager #1: Right now. I have 24.
Case Manager #3: Right now, I have 24.
Case Manager #4: I have 26.
How much do you have?
Case Manager #6: 26 – 26.
Case Manager #1: I think we should have more than 24 or 5 – well, they took over [name
redacted]’s caseload and –
Case Manager #4: We’re normally just 20. But with [name redacted] gone –
Case Manager #3: That’s not the norm. (11/22/19)
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Relatedly, in a recent focus group, officers referenced the ongoing staff shortage issues in terms of being
able to make referrals. Officers reported that they have been unable to make referrals for about two-
three months because the resources (e.g., case management or housing) are simply not available at the
capacity that is needed. This in turn has concerned some officers who feel that partners might perceive
them as not meeting their job requirements
We’ve adjusted our time, right, and we’ve literally said, ‘We’ll give you time to adjust.’ I would
guarantee you, we would put down a total of two to three months, if you take the whole time
together. That way we adjusted for them to get their stuff together, you know, where they lost
case managers, some left, some came – they were overwhelmed, And, we said ‘Hey, you know.’
But the problem is, we’re always afraid that they’re going to say like, ‘Well, law enforcement
didn’t meet their 300.’ (Law Enforcement Officer, 11/20/19)
Workload
Workload emerged as a challenge to implementation in six contexts: case manager-client ratio,
paperwork, frequency of meetings and trainings, the lack of petty cash budgets, and transportation.
Case manager-client ratio. Case managers reported feeling overwhelmed with the case manager-to-
client ratio. Further, case managers noted that the high caseloads interfere with their ability to provide
intensive case management services. These challenges are concerning but not surprising. It is well
documented in the social work literature that social work-related positions are prone to burnout, often
because of high workloads and related stress (Knight, Becan, & Flynn, 2013; Loyd, King, & Chenoweth,
2002). Some case managers expressed that there is simply not enough time in a given day to meet their
clients’ needs.
Case Manager #1: Now, we all have 20 clients. So at some point in time, within that week, that
hour, you’ve gotta make sure you know where these clients are. So that maybe – you may start
on one client in the morning, and you may end up with two or three in the afternoon, but you
gotta get back to number one.
Case Manager #3: I work six days, 12 to 14 hour shifts.
Interviewer: What would you propose differently?
Case Manager #4: Okay, I -
Case Manager #1: Ten intensive case management clients. Not 20… Half the clients. (12/11/18)
We’re supposed to work eight hours. We should be on 12. Because it takes 8 to do the work. It
takes four hours probably to do the paperwork. And then we travel. Like she was saying. I have
to start my day – I plan my day on Monday – I go through LA…But at the end of the day it’s a big
hole in me because I didn’t finish where I was supposed to because of time. And they don’t take
into consideration time. (Case Manager #1, 11/22/19)
Case Manager #2: We go to court appearances, if they have to go to court, we have to escort and
go with them to court, DCFS court, whatever court, wherever it is, Pomona, Compton, Inglewood,
whatever – and then, like I said, the housing visits, being out in the field, taking them to lease
signings, and some of them live –in El Monte… in Lancaster, clients in LA, clients in Long Beach, in
Compton – everywhere. (Case Manager #2, 11/22/19)
And, I think the frustrating part about it too is when we ask for time, it’s just like, ‘Oh, it’s just time
management. You’re doing something wrong.’ Like, it’s not – I don’t think they understand what
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it really is day-by-day. And I know that there’s stuff that comes up, and it’s not really an
emergency, and it’s not really a crisis and you know, you talk them through it – but it’s always just
been, ‘Your time management is horrible. And you need to work on it.’ ‘That’s not my fault that
you can’t work in eight hours.’ That’s basically what it is. And, when we ask for extra time,
because we have extra added work, extra added clients, extra added notes, extra added whatever
– we don’t get it. And we’re still held to that eight hour time to complete everything a week.
(Case Manager #2, 11/22/19)
Other LEAD LAC partners also expressed concerns regarding this case manager-client ratio.
I mean I – in general terms, keeping up with the demand, because the cops could have filled all
300 slots in the first month, no problem. They really could – but you know, we have a certain
number of case managers, there are a certain number of hours in the day, and so – at a certain
point in December, we sort of had to turn the spigot down a little bit and say, ‘Hey, look, maybe
five referrals between now and the end of the year.’ Something like – we did something like,
something very artificial, to let the case managers catch up. Because it wasn’t enough for us to
refer them to the case managers… They had to have time to actually provide the services in a
quality way. (Project Management, 3/2/18)
It’s all great when you’re talking about a smaller area. But if you’re talking about rolling this out
county-wide, the amount of support that has to be out there, especially on a – you know, the
amount of service providers – is going to be incredible. And we’ve already seen it, even with our
small area and our small amount of population – the case managers get overwhelmed very fast
because they have a daunting amount of paperwork that they have to do. Plus, they have to track
them, plus they have to try to get their IDs or their birth certificates, and there’s just so much
involved. To do it on a grand scale, like including the whole county, I think is going to be difficult…
And our deputies, you know, just like any officer, they don’t like to lose face. So they’re not going
to go out there and make these promises to people if there isn’t something to back it up.
(Commanding Law Enforcement Officer, 3/12/18)
I think as LEAD expands and grows, and if that – a part of that role which is – I’m under the
impression that part of that role is to provide that outreach with the staff and provide a clinical
support with the higher acuity clients, and even the low acuity clients need mental health, right?
… if we’re going to keep adding clients – I know it’s a one to twenty ratio, but one thing that I
don’t feel like is being taken into consideration is case managers that have higher acuity clients,
might need to have less clients. Because you don’t want to burn out the case managers either.
(Case Management Clinician, 12/12/18)
Paperwork
In more recent interviews, case managers noted an increase in paperwork, which they regarded as
interfering with their ability to work on other tasks. Specifically, case managers explained how changes
in procedures now mean they have to enter data (e.g., case notes) into multiple data management
systems. Some case managers suggested it would be beneficial to have an administrative/clerical
assistant to help alleviate the data entry that comes with the paperwork tasks case managers are
expected to complete.
Well, some of the paperwork is getting intense (Case Manager #3, 11/22/19)
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So it’s a repetitive data entry and three different programs, except some are – like, CHAMP is
more often. Clarity is like once a month. I don’t know about the other one, we haven’t started
using it yet. But what I’ve been feeling is like, no stability. Like, we have staff that come and go.
Since I’ve been here, there’s been three staffs, you know. We never had a full – like you said, we
never had ten, so we short staffed. But then constantly we are having different things issued for
us to do, like different tasks, since always (Case Manager #1, 11/22/19)
That’s the main thing that I feel like. We still have to service our clients as we started when we
first got hired. We still have things – and I think my feeling is we have so much paperwork to
process, but they don’t understand the population we serve. I’m talking from my clients – they’re
all over the place. And then we have to see them monthly – some you have to see more often.
But you still got to go back and process six months of work that came and then you gotta come
up to the day and still do your processing. So it’s a little like, okay, because we do not know what’s
going on, bottom line. I only know we get more paperwork, add this, add that, like she said, it’s
so much duplication (Case Manager #2, 11/22/19).
Case Manager #1: We need an administrative assistant.
Case Manager #2: They looked at me like I was stupid when I said we should hire a data entry
clerk.
Case Manager #1: We need that.
Case Manager: #3: No, we do. We do. (11/22/19)
Frequency of Meetings and Trainings. Case managers noted that the frequency of weekly meetings and
check-ins with case management staff is time consuming. Specifically, they take time away from case
managers to meet with and respond to their clients’ needs. Some case managers regarded these
meetings and trainings as counterproductive, as many never have the time to actually use the new skills
gained. This was a concern from case managers early in implementation and towards the end of the
pilot. (See Table 10-1 in the Technical Appendix for a list of all the LEAD LAC trainings).
Yeah, so right now, when the meetings are all over, I have to do my – I’m going to miss my 48
hours for my referrals, right? And I still have to do my notes and all the paperwork for yesterday
that happened. Now tomorrow is my day where I meet five clients for sure, and because I’m on
the field, I go out and look for my four clients that have been MIA (Missing in Action). So today I
need to catch up on my referrals, on my notes from yesterday, and – … So just for example, like
right now, I have to go into that meeting and I have to backtrack for Monday my two referrals, I
need to backtrack for my case notes from yesterday – tomorrow I have to meet with five clients,
so I’m gonna review – make sure I have all the documents that they asked for because they have
– you know, birth certificate fee waivers and DMV ID fee waivers – oh, but they need homeless
verification, and they need these forms that I need to fill out. (Case Manager #1, 4/11/18)
One of the biggest challenges is just like, you know, and I don’t think that DHS looks at this like we
– we meet a lot…But it’s every Tuesday for like, two hours. You know, and it’s always a – you see
when you come in here and you try to meet with us, there’s so much stuff that we got going on
at one time that it’s hard to kind of set those meetings up. It’s fine for me, but it impresses on my
case managers – like today, they’ve got clients they gotta go see… we have the case management
call. That forever puts them off – we got interim housing placements that we gotta get clients to,
and all of this stuff, and then it’s just, you know, like the expectations sometimes, you know, with
the addition of all of the meetings and trainings it’s sometimes not realistic… And it’s just like, the
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time that they actually have to see their clients they expected to put a case note on every client
once per week is unrealistic… But it’s because most of the time there’s so many different, you
know, required meetings and required conference calls and required trainings in a given week.
And then when you subtract all of that from a 40 hour work week, you know, and then, you know,
they want to – they give us these quality control reports every week, you know, to tell us, you
know, you didn’t do this with a client, you didn’t put this case note in time, there was no case
notes on this client in the last two weeks, you know? So I just think that that’s one of the biggest
challenges right there. (Case Manager #2, 4/11/18)
Case Manager#1: and this is what kills me sometimes – it’s so many meetings and trainings. I
mean, just like, it’s meetings and it’s trainings and it’s like – they’re crazy.
Interviewer: Besides the OW’s, the OWG’s – what other meetings do you have?
Case Manager #2: We have trainings, outside trainings.
Case Manager #3:: Supervisions –
Case Manager #4: So Housing for Health requires them to go to a lot of trainings and then we
have inside of [case management agency] trainings and then whatever trainings they need
because it’s specific to what their needs are to build their skill set. So that’s how you get all these
trainings. The problem is you have requirements from Housing for Health, ODR, and HOPICS. So
they’re getting overwhelmed because they have all these different entities throwing stuff at them.
(11/22/19)
Petty Cash Budgets. Case managers referred to petty cash budgets as a challenge to carrying out their
job responsibilities. Specifically, case managers noted that they have had to use personal funds to help
meet clients’ immediate needs, such as buying clients food, getting clients document ready, paying for
clients housing applications, etc.). This has harmed morale and impacted the lives of the case managers.
Case Manager #1: -- and one of the biggest challenges is – out of pocket expenses. I know the
program has money for it, I don’t know how much money we get a month, for, you know,
expenses, but it’s always out of pocket.
Case Manager #2: We shouldn’t be spending our money. (12/11/18)
We can’t use petty cash for stuff, like if the client says they’re hungry, say, right now, the client
calls me, hey, I’m hungry – oh, I’ll put in for a food box – I’ll take it to you on Monday – that’s not
a solution. So that means that I will have to spend money out of my pocket, right, to get them
food for the weekend. And I don’t think it’s fair to us and it’s definitely not fair to the clients when
we have all this money that is – and it’s supposed to be spent for that, you know what I mean?
(Case manager, 11/22/19)
Case Manager #1: And anytime we go with a client, engage with a client, if the client is hungry,
we have to provide their basic needs. Whether it’s a meal, whether they have income and they
spent it – I can’t tell them, well, I’m not going to feed you today because you don’t have income.
You know, their basic need is they’re hungry, we’re going to fill that need. So it’s always out of
pocket expenses with that.
Interviewer: Do you get reimbursed for that?
Case Manager #1: We get reimbursed --
Case Manager #2: Eventually. Eventually. Not right away.
Case Manager #1: Eventually. It’s not a quick turnaround where it’s even in two weeks, or three
weeks. (12/11/18)
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I picked up a client from the mental health hospital – she had her own place, but she had been
there for like three weeks, so she didn’t have food, and I was like, asked to take her to Dollar Tree
and like, get her stuff to last over the weekend or whatever, and I spent 20 dollars – I didn’t get
that back for three months. That’s just one instance of like, how long it takes. (Case Manager,
11/22/19)
Interviewer: Would you – if you were – if you could estimate how much money – not petty cash,
but just how much money you’ve spent out of pocket.
Case Manager #1: Oh my goodness.
Case Manager #2: I think it’d be better if you had a time frame.
Interviewer: Sure. What about throughout the whole time you’ve been employed at LEAD?
Case Manager #3: I think [name redacted] has spent maybe like 2000 dollars.
Case Manager #4: She don’t even put like her gas mileage, she drives everywhere –
Case Manager #5: Because I don’t want to wait for my money, and I don’t get it. I have these
issues with what they have --
Case Manager #1: I stopped buying food because I have to buy gas. (11/22/19)
I’m fourteen hundred dollars in the hole. I promise you, I got fifteen dollars in my account right
now… I’m telling the whole staff, if you don’t see me in the next three days, it’s because I can’t
get to work. And I’m not understanding why my September money is not here, my October
money is not here, my New Orleans expenses aren’t here, and last month, I gave money for a
client to move into permanent housing who told me I was going to get my hundred dollars back,
and I still don’t got my money back. (Case Manager, 12/11/18)
It does take some of your – I don’t want to say morale, but it does take some of your like, oomph
to help the clients and be like, ‘You know what, you’re hungry? ‘Okay, here, let me go get you
some food.’ I’m not going to say, go get them a crab meal at top of the dollar, but you know.
(Case Manger, 11/22/19)
Law enforcement officers also highlighted the number of times they spent their own money to provide
basic needs, like food for the clients:
I could easily say, I’ve been through receipts – I mean literally -- two to three grand? (Law
Enforcement Officer, 11/22/19)
Clearly, caring for the LEAD LAC Clients has gone beyond linking them to services, and this on-the-ground
level of care has been integral to building rapport and connecting with the clients.
Transportation. Case Managers noted that a shortage of transportation vehicles for case managers to
use and share. Thus, it makes it difficult for case managers to transport their clients to and from places,
such as the court, doctors, housing, etc. The first case management administrator stated in December
of 17 that the LEAD Case Managers need their own transportation vans to move clients: “We definitely
need to have our own vans.” However, one year later in December of 2018 and again in November of
2019, the case managers still struggled with transporting clients.
Case Manager #1: Yeah. And my thing is now that it’s more people, we got a housing navigator
plus three other case managers, so now we have a – the van has to be available on Mondays and
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Tuesdays for referrals, so that’s out. So Wednesday, Thursday, Friday, those three days that the
van is accessible to everybody without.
Case Manager #2: And I got it already Thursday guaranteed because I’m going to Pomona.
Case Manager #1: But wait, because out of those three days out of five, [name redacted] got it
for Thursday because she goes all the way out, right? So we got Wednesday and Friday. Now
Wednesday and Friday, we’re not supposed to be using the van because we’re supposed to be at
OWG in the mornings, and then a Friday huddle in the afternoon, and then Friday afternoon is
supposed to be admin. So we basically have Wednesday afternoon to really use the company
van. So when she needs it for a unit, we understand. So we’re stuck, so now –
Case Manager #3: But I never get it, I’ve been using my car, I’m serious, that –
Case Manager #1: And we try to coordinate services, but it’s just so hard to travel. (12/11/18)
Case Manager #1: We got one van, and we’re supposed to –
Case Manager #2: One van!
Case Manager #3: So sometimes we coordinate with like E6 and like other teams like, ‘Hey, can
we borrow this? It sometimes happens, and sometimes doesn’t – they’re always outreach, so
always out in the field. But when you put in your mileage [when using own car], you don’t get it
back. (11/22/19)
Open Communication
Maintaining open lines of communication emerged as a challenge in three contexts: data management
and sharing, staff expectations, and staff accountability. LEAD LAC staff reported having challenges with
finding a suitable and efficient way to monitor clients. From the beginning of implementation and
throughout, LEAD LAC partners struggled with ways to not only track client information but share
information with one another.
I think there’s some like real challenges around tracking and keeping track of who’s in and where
they’re [clients] at and that’s been consistent from the beginning…It’s been challenging to find a
system that works…. That spreadsheet that you have seen – is ours. Because there was not a way
of getting that information consistently out of them verbally, and we needed to report on it. Like
I was going to keep some kind of tracking that worked for me anyways, so that spreadsheet has
come as – and when the two program managers had their own – or they were both using [name
redacted]’s internal brain tracking system, like it’s really – that’s not a viable thing to put on other
people in a group. And when you know they’re struggling and like scrambling every time you ask
them [case manager] for a bit of information, like, that undermines their credibility and I feel like
that’s something we’ve been working and trying to supplement with like our programs. (Project
Management, 2/11/19)
Challenges with effectively tracking client progress and sharing that information with partners
contributed to partners feeling that there was no accountability, especially for case managers.
So one issue we had was accountability between the case workers and us in terms of confirming
that the full intake assessment happened, and when – because for a while it was just verbal. So
now we have been greenlighting people into LEAD by email. But also requesting a verification of
that – the fact that the intake assessment happened and when it happened… Frankly, the email
thing has helped accountability-wise on that as well because we’re able to better track – you
know, these four people are still floating around out there with no information – what’s going on?
(Legal/Prosecutorial Partner, 1/7/19)
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So sometimes the officers only see that in a – what is it – tunnel vision, and they only see the part
that they play. They don’t see that it’s a lot of internal stuff that the case managers have to do.
It’s not just referrals and it’s not just going out and looking for clients because we need to engage
them, you know, that stuff is all super important, because we need to get them fully enrolled
before 30 days so that they don’t get charged or booked, right? But sometimes I feel like they
don’t see the work that gets done behind the scenes, and there’s kind of a clash between them
and the case managers or them and the program manager. (Case Manager Clinician, 12/12/18)
But I think with the – you know, I think what has happened, unfortunately here, as well, I told
[name redacted] this as well – well, I think there is not enough accountability for officers, right,
like, in the same way that accountability is for like the [case management] team. I feel like if
you’re going to be partners you need accountability on both sides, but because of the law
enforcement piece, I think there is some resistance… which I think is a problem. I think that
contributes to some of the people at HOPICS feeling like well, ‘Why are we always the ones getting
questioned in LEAD on this?’ (Case Manager Clinician, 9/17/18)
Yeah, and I know that’s why law enforcement has all these questions, and they’re kind of – it’s
like they want to verify our work, because they’ve already – you know, they don’t see it as just
you’re not doing it, it’s just somebody didn’t do it, so now I need to make sure that somebody
does do it because it wasn’t done and clients fell through the cracks, or, you know, clients didn’t
get services. So that’s what I think where their part of it is, like, ‘Did you do it? You ain’t doing it.
Did you go?’ …But in that side, with flipping the coin, there’s a lot of clients who just aren’t ready
to go. And it’s hard for anybody to understand – they’re giving you free shelter, they’re giving
you, you know, a bed, not even a cot, they’re giving you this, they’re giving you that – they can
take you – they’re giving you all these things, why not take it? Sometimes people aren’t ready at
that moment. And it’s hard, it’s hard for some – sometimes to understand that. That somebody
would turn that safety down, and all those services down, to be where they’re at. You know, so I
think that – I think those are two things that I think, when it comes down to explaining ourselves.
(Case manager, 12/11/18)
Our partners are our partners when we have specific things, but overall, for me as case manager,
I’m always defining and justifying what I’m doing and why it’s taking so long for this, or why does
that have to happen. And that’s in addition to the case notes and the whole thing. (Case Manager,
4/11/18)
Communication issues could also explain why case managers reported feeling that other LEAD LAC staff
and partners hold unrealistic expectations. Some case managers expressed frustration and
discouragement because they feel that other LEAD LAC staff and partners do not think case managers
are doing their work correctly, adequately, or in a timely manner. On the one hand, law enforcement, in
contrast to the harm reduction model and the voluntary-nature of LEAD, suggested case managers make
deals with clients. And, project management staff reported that perhaps case managers’ understanding
is client-centered/client-driven service delivery within a harm reduction framework is different from
that of the LEAD model.
The thing that – the one thing that frustrates me – and I never want to tell a case manager how
to do their job because I don’t want them to tell me, ‘Hey, you should do this – yes, this is a
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volunteer program.’…So the problem is, I think some of the case managers, they’re so focused on
housing, housing, housing – housing first, housing first – I think sometimes it’s just, ‘Hey, I need
you to do me a favor. Yeah, we need this housing, but I need you to go to one meeting for me.
What’s one meeting – if you can give me an hour, what’s that going to hurt you, right? So if you
give me one meeting – I can use this and take it to [name redacted] or the prosecutor so we can
get your case reduced or whatever.’ Sometimes you gotta do the old okey-doke right? You know,
is it going to get reduced anyways? … So why – because if I can get them to one meeting, it’s not
that bad. Maybe I can get them to two meetings, right? Maybe I go like, ‘Hey dude, I need five
meetings out of you, and I’ll go with you, and then we can go to the prosecutor and I can get this
warrant taken away.’ I wish the case managers would kind of do that a little bit more. But they’re
still just like, ‘Eh, they don’t want to go, they’ve gotta do this.’ Of course if you give them the
option, they’re not going to want to. So you gotta kind of twist their arm – you know. (Law
Enforcement Officer, 11/20/19)
I mean, some of it’s just been real basic, like staying attuned to like, client driven services versus
like -- I think with like any program they can – there’s like this – like LEAD, they like, started out
strong and then they drift sort of towards like their other services as usual, so helping them keep
with like, the harm reduction and the like, truly client driven – like I’ve just had conversations with
them about like if you do a care plan, like how do you make it like, really what they want to work
on and not things that [case management agency] thinks would be good for them. Like, you need
an ID to get into housing, but they may – that may not be what that person wants right now. So
I think there’s a little bit of a constant tension, like, in their organizational culture. Like, we know
they need housing, and to get them housing, they need these things, so it kind of had a more
paternalistic approach to services versus truly harm reduction client driven. So I think that’s kind
of like all in the soup over there and constantly trying to steer them towards, you know, the
direction that we want for LEAD. (Project Management #1, 12/6/19)
Case managers, however, noted that they are pulled in multiple directions and the work they do never
seems like “enough.”
It’s a lot. And the stuff, really a lot of the brunt of the expectations comes from ODR. I wanna
specify that. So these are expectations that are coming from them, and we have to meet them,
and it just seems like no matter what we do, it’s never enough. (Case Manager, 11/22/19)
In particular, case managers reported feeling that a disconnect between law enforcement and case
management expectations of client success. Officers noted feeling frustrated that clients are not quickly
connected to housing and other services. Officers perceive this timeliness as “false promises” to clients.
However, case managers expressed that securing housing for clients is a much more complicated and
time-consuming task than is perceived.
…if you look at the aspects that I’m looking at it from – when you only have what, maybe three
officers, deputies, assigned to this project, and the fact that you know, they’re constantly on –
almost a weekly or bi-weekly basis, they’re told, ‘Hey, you gotta stop because we’re over
capacity.’ And obviously there isn’t enough resources there. It’s not any one person’s fault, it’s
just the resources aren’t there. And then when the deputies go back out and contact people that
are sometimes out there two or three months after they contacted them and made promises to
them and they say, ‘Oh, you know, we haven’t been contacted by anybody that would offer us
services.’ Then it – you know, it wears on them because then their credibility is kind of in jeopardy
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because they made promises to these people and then they can’t fulfill. (Commanding Law
Enforcement Officer, 03/05/19)
So the attention span of our clients is not as limited as people think where I can get all of this –
that is not ready, so you move on to the next thing. What else can we do until we can get this
done? It’s housing. It’s helping harm reduction. And harm reduction is different per individual,
per whatever their behavior is. If your report comes in and says you’re doing meth, and if I can
get you out that environment and I can put you in the Sobering Center for a day or two, I can show
that we assisted you in framing and reducing harm for 24 hours, 48 hours – or if I give you
cigarettes, tobacco, opposed to you doing meth – that’s harm reduction. If I’m giving you a needle
exchange, that’s harm reduction because I’m preventing you possibly contracting – you know,
incurable disease, Hep C and passing it on to someone else. So it’s different forms, and the
measurements of what everybody is using is not the same. So this time around, it’s just like – I
find myself defending a lot of the activities of the intensive case management. (Case Manager,
4/11/18)
Sometimes to go to the OWG, it looks like we’re not doing our job. But that’s up to the visuals –
they don’t hear the 20 people – I mean, they just took my board down. But if you could see my
housing board, when I came in here, probably five people were housed. We have almost 20-
something people housed. And in the last – in August, it was like, we did 12. In July and August.
And then with the housing navigator, we just did another 8. They don’t hear that, right – it’s just,
well, why didn’t you do this person? And I’m going, well, we’re trying – and I have learnt to say, I
got you on this person. Because we were focused on these 20 people. And these 20 people are
in interim housing. A young lady just went into the LEAD house. Her and her daughter. I don’t
know if you heard – oh, can’t say the names. They went into the LEAD house. (Case Management
Administrator, 12/12/18)
Nonetheless, the case managers are doing great work. As early as April 2018, the case managers
explained that despite their workload, they are serving the needs of their clients.
You know, and we engaging them, we’re housing them, you know, we’re moving them, and in the
process of living in those encampments and trying to get them back in the home, and then we
trying to work on their regular ADL’s [Activities of Daily Living], the daily living that they do – just
trying to make sure that they get showers every day, you know, trying to make sure that they
well-groomed every day. And then trying to just, you know, reintegrate them back into the
mainstream of society. You know, like they got kids, that they haven’t been connected with, so
we’re trying to do that whole family reunification thing. We’re trying to make sure that we can
get ‘em grounded, you know, after that, you know, they get housed, to see if they want to get
back in school, to see if they want to you know, try and look for jobs – you know, um – you know,
just all of the stuff that – you know, make them feel good about themselves. Like yesterday [name
redacted] took one of our clients, [name redacted], just to get his teeth – you know what I mean?
Like that smile is going to bring confidence, you know, and he is really high functioning right now,
he’s really doing well right now. (Case Manager #3, 4/11/18)
Summary of Findings
This study used qualitative analysis in the form of thematic and content analyses to conduct the process
evaluation of LEAD in LAC. Data from focus groups and interviews with LEAD LAC implementers, LEAD
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LAC policy and procedures documents, LEAD LAC Quarterly Reports, and surveys with LEAD LAC clients
provide answers to this study’s research questions. For research question #1, whether LEAD LAC’s model
is consistent with past LEAD efforts in Seattle, comparisons of LEAD Seattle and LAC policies and
procedures documents indicate that LEAD LAC is indistinguishable from the LEAD Seattle model.
Interviews/focus groups and LEAD LAC policy and procedural documentation indicate that LEAD LAC was
implemented with fidelity (research question #2). LEAD LAC faced various barriers throughout
implementation (research question #3). Its most significant barrier was staff turnover, solely among case
management. LEAD LAC partners discussed other barriers including open communication and case
management workload. The facilitators to LEAD LAC implementation were the building of relationships
and stakeholder investment, which many accredit to the work of project management. This resulted in
significant client successes, which the LEAD LAC Client Survey substantiated.
Data from the interviews/focus groups and LEAD LAC Quarterly Reports highlight the successes and
challenges LAC faced early on and throughout the implementation of LEAD. Findings indicate that LEAD
LAC had four key successes: relationship building, stakeholder investment, and client successes. LEAD
LAC staff reported that partner relationship building between LEAD partners was not only a success, but
it helped partners connect clients to health and social services. These successes also helped case
managers build rapport with clients. Data from the client survey open-ended questions substantiate
these successes. For the most part, participants reported positive interactions with their case managers
and police officers. In particular, clients noted that case managers played an important role in helping
them getting access to health housing services and giving them a sense of self-worth.
LEAD LAC also faced numerous challenges, the primary being staff turnover among case management
staff and workload of case managers. Los Angeles’ LEAD program struggled to hire and keep case
managers at implementation. They have yet to have a full staff of case managers. This made serving
clients challenging, as caseloads often exceeded the 20-limit, and case managers were required to
attend meetings and trainings, complete paperwork/client notes across multiple databases, and have
limited to no access to a vehicle or petty cash. Their workload is extensive, and without open
communication, the partners were frustrated about the time it took to provide client services.
Nonetheless, the clients who have been referred have experienced significant changes in their lives and
well-being, and the relationships that were created among the agencies have been robust.
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4. Outcome and Costing Evaluation: Los Angeles County
Method
Evaluation design
While randomized controlled trials (RCT) represent the gold-standard in program evaluation design, real
world constraints precluded randomizing individuals into LEAD and control conditions. One of the
primary arguments against an RCT was the damage removing police discretion might have on obtaining
police officer buy-in, especially since prior research suggests officer commitment is the key to LEAD
success (Clifasefi & Collins, 2016). Another primary argument against an RCT was the potential ethical
concern of having identified a person in need (i.e., a person suffering from drug problems or performing
sex work under the control of a procurer [pimp]) and not offering them LEAD. Therefore, this evaluation
represents an equivalent-groups longitudinal quasi-experimental field trial design. This is the same
research design used by the Seattle LEAD evaluators (Collins et al., 2019).
Measures
Sociodemographic and program data were obtained from the treatment provider (Homeless Outreach
Integrated Care System [HOPICS]) and the LA County Department of Health Services (LADHS). Criminal
history data were provided by the Long Beach Police Department (LBPD), Long Beach City Prosecutor’s
Office (LBCP) and the Los Angeles County Sheriff’s Department (LASD). These data include citations,
arrests, and filed cases occurring in the State of California. Criminal history data were then divided into
six time periods – six month pre-LEAD referral or eligible charge date and six month post-LEAD referral
or eligible charge date, 12 month pre and post, and 18 month pre and post. Arrests were collapsed by
day, and categorized into one of the five criminal history outcome variables – citations, misdemeanor
arrests, felony arrests, misdemeanor cases, and felony cases.
The authors have requested data on jail bookings and days spent in jail in Los Angeles County from the
Los Angeles Sheriff’s Department (LASD), but at the time of this report (December 2019), the data were
still not provided. The authors have also requested data on probation system utilization in Los Angeles
County from the Los Angeles County Adult Probation Department (LAAPD), but these data were also not
provided in time to be included in this report. We are expecting these data in January 2020. As there
were no state prison sentences for the pre or post-measures (as per the criminal history data) for either
the comparison or LEAD group, no data were requested from the California Department of Corrections
and Rehabilitation (CDCR).
Costing measures were broken down into two categories – LEAD program costs and criminal justice
system utilization costs. LEAD program costs were provided by LADHS, and include monthly costs for
programmatic and indirect administrative costs. We made a deliberate attempt to use similar criminal
justice utilization measures as the Seattle LEAD costing study (Collins et al. 2019) in order to aid in
comparability and future systematic reviews of LEAD. These measures include prosecutorial and defense
costs for misdemeanor and felony cases and were provided by the LACDA and LA Public Defender’s
Office. Jail and probation costs will be added as soon as data are provided by the relevant departments.
We made one notable addition to the Seattle costing study – police costs of arrest.
AT THE TIME OF THIS REPORT (DECEMBER 2019), ENOUGH DATA WERE NOT PROVIDED BY THE SITE TO
COMPLETE THE OUTCOME AND COST EVALUATION. THIS WILL BE RECTIFIED AS SOON AS POSSIBLE.
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5. LEAD San Francisco
LEAD SF officially launched on October 26, 2017. According to the LEAD SF grant proposal, the LEAD SF
model seeks to reduce low-level drug and alcohol offender recidivism, strengthen city and community
partnership collaboration, and improve the health and housing status of LEAD participants (BSCC, n.d.).
In order to reach these goals, LEAD SF serves to expand the nexus of existing harm reduction, health,
and social services to LEAD participants who might have otherwise been processed through the criminal
justice system. LEAD SF is multi-agency collaboration effort and includes the following partners: SF
Sheriff’s Department; BART (Bay Area Rapid Transit) Police Department; SF District Attorney’s Office; SF
Public Defender’s Office; SF Adult Probation Department; Glide Foundation; Felton Institute; Drug Policy
Alliance; SF Public Health Foundation; Hatchuel Tabernik and Associates (HTA); and Harder + Co. The
LEAD catchment areas for this site are the Tenderloin and Mission Districts in San Francisco, which the
grant proposal regarded as areas with a high number of individuals facing mental health, alcohol, and
substance abuse problems.
Figure 5-1 shows how LEAD client enrollment has fluctuated dramatically over the first 20 months of the
program, trending slightly downward in 2019. By June 2019, there were over 200 active clients in LEAD
SF.
Figure 5-1: LEAD SF enrollment numbers by month (November 2017-June 2019)
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Originally, LEAD SF planned to operate for two years and enroll a minimum of 250 individuals: 200 pre-
booking and 50 social contacts. Figure 5-2 illustrates that while there were monthly fluctuations, social
contact referrals trended upward during the course of the project. By June 2019, 65% of all LEAD SF
clients were social contact referrals.
Figure 5-2: LEAD SF Social contact client enrollments by month (November 2017 – June 2019)
Figure 5-3 shows the ethnicity breakdown of LEAD SF clients. In June 2019, 46% of active LEAD clients
were White, 32% Black/African American, and 9% Hispanic/Latinx. The remaining 11% was a mix of
American Indian or Alaskan native, Asian, Native Hawaiian or Pacific Islander, and other. Figure 5-4
presents the percentage of White clients by month. The percent has been relatively stable since
program inception, at around 50% White.
Figure 5-3: LEAD SF client ethnicity as of June 2019
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Figure 5-4: LEAD SF White client enrollments by month (November 2017 – June 2019)
In the next two sections, we present the findings of the process evaluation (Chapter 6) and outcome and
costing evaluation (Chapter 7) in the City and County of San Francisco.
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6. Process Evaluation: San Francisco
Process evaluations provide detailed information about a program’s underlying theory, model design,
goals, objectives, operations, service delivery, quality of services, and implementation barriers and
facilitators (Krisberg, 1980; Mears, 2010; Miller & Miller, 2015; Scarpitti et al., 1993). This information is
helpful in enhancing other sites’ ability to replicate a program with similar results. Researchers and
program evaluators can avoid committing a Type III error, as they will know if relevant components
were absent or added (i.e., incorrectly concluding that a program’s outcomes are attributable to the
program components when the intervention was not delivered as indicated [Helitzer & Yoon, 2002]).
Process evaluations contextualize impact and outcome findings by describing how and why an
intervention experienced certain results. They are key to understanding program implementation and
program outcomes.
Process evaluations utilize qualitative and quantitative methods to assess program implementation and
identify how and under what conditions programs work or do not work (Mears, 2010; Pawson & Tilly,
1997). Consistent with previous process evaluation research, this process evaluation employed both
qualitative and quantitative methods in the form of semi-structured focus groups/interviews, client
surveys, and content analyses of LEAD SF and Seattle policy documentation (e.g., policies and
procedures, meeting minutes, etc.). Data were analyzed and triangulated to fully examine the
implementation of LEAD SF and identify the conditions under which LEAD implementation is successful.
Semi-structured focus groups and interviews
Semi-structured focus groups and interviews with LEAD SF Project Management, case management
administrators, case managers, legal/courts partners, senior commanding officers, and front-line officers
were conducted. The purpose of these interviews/focus groups was to:
1. Understand LEAD SF roles,
2. Understand LEAD SF procedures,
3. Understand LEAD impact on community relations and LEAD partner relations,
4. Identify obstacles and facilitators to LEAD development,
5. Identify successes and challenges to LEAD implementation, and
6. Identify best practices in LEAD development and implementation.
The focus groups and interviews occurred biannually. The LEAD SF program manager organized the
scheduling of the focus groups with each of the partners. Those interested in participating simply arrived
to the focus group/interview location at that date and time. There, we obtained non-signature consent
to participate and record the interview/focus group. All participants had the option to keep a copy of
the consent form.
Interviews lasted approximately 30-minutes and focus-groups lasted no more than two hours, in which
questions were posed about mechanisms, contexts, challenges, and facilitators of LEAD SF
implementation. The interview/focus groups were audio recorded, and handwritten notes were taken
when participants wanted to speak off the record. Participants had the right to skip or refuse to answer
any questions and to terminate the interview/focus group. Participants also had an opportunity to
request (during or after) the interview/focus group to review and/or delete audio recordings and
transcriptions (although none ever did so).
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To minimize any risks to participants’ privacy, all identifiable data were redacted, and participants were
identified as their title and number (e.g., case manager #1). Within focus groups/interviews, the title and
number correspond to the same person. However, this is not the case between focus groups and
interviews. The title and number of a participant in one focus group/interview is not the same person in
a different focus group/interview. Because no record of who attended was maintained and the audio
files were deleted upon transcription, linking individuals across focus groups/interviews was not
possible. A total of 15 focus groups, ranging in size from 3-10 (See Table 6-1), and four interviews were
conducted over a two-year period July 2017-November 2019 (See Table 6-2).
Table 6-1: LEAD SF focus groups (n=20)
Focus Group Dates Staff Classification Staff Count
1.10.18 Project Management 3
1.10.18 Case Managers 7
1.10.18 Police Officers 10
1.11.18 Legal/Courts Partners 6
1.11.18 Senior Commanding Officers 4
1.11.18 Case Management Administrators 3
6.4.18 Case Managers 6
6.5.18 Case Management Administrators 4
6.5.18 Senior Commanding Officers 5
6.6.18 Police Officers 4
1.28.19 Case Management Administrators 3
1.28.19 Case Managers 4
1.28.19 Senior Commanding Officers 2
1.29.19 Project Management 3
1.29.19 Legal/Courts Partners 5
10.18.19 Project Management 4
10.18.19 Case Managers 5
10.18.19 Legal/Courts Partners 4
10.18.19 Case Management Administrators 3
11.13.19 Police Officers 4
Table 6-2: LEAD SF interviews (n=4)
Interview Dates Staff Classification Staff Count
1.28.19 Senior Commanding Officer 1
1.29.19 Police Officer 1
1.29.19 Police Officer 1
10.18.19 Senior Commanding Officers 1
1.4.19 Project Management (email 1
communication)
LEAD SF document data
We collected various LEAD SF-related documents for this study (See Table 6-3). Data were collected
from the BSCC website, the San Francisco Department of Public Health (DPH) website, and LEAD Project
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Management. Policy-related documents included the LEAD SF grant proposal, memoranda of
understanding (MOUs), LEAD SF core principles and roles documents, Key Stakeholder Policy Committee
(KSPC) meeting minutes and PowerPoints, and Operational Work Group (OW) meeting minutes and
PowerPoints. We also collected LEAD SF staff training data and procedures documents (e.g., referral and
intake protocols).
Relevant document data were also collected from LEAD Seattle to compare the sites and assess LEAD
SF’s fidelity to the original LEAD model (see Table 6-3). Seattle data include LEAD’s core principles and
role documents, MOUs, and referral and diversion protocols. Documents were collected from the LEAD
King County website and the LEAD National Support Bureau website. We were also in communication
with the LEAD National Support Bureau who provided additional documents (e.g., updated processes)
and clarified any confusions about the program.
Table 6-3: Data documents
LEAD Site Document Type Count
LEAD SF KPC Meeting Minutes 9
LEAD SF KPC Meeting PowerPoints 9
LEAD SF OWG Meeting Minutes 10
LEAD SF OWG Meeting PowerPoints 10
LEAD SF LEAD SF Policies 12
LEAD SF Procedures/Protocol 34
LEAD Seattle Policy: Goals and Principles 53
LEAD Seattle Phone Communication: CSULB 1
& LEAD Seattle
LEAD Seattle Procedures 1
LEAD SF client surveys
The process evaluation relied on LEAD-SF client survey data to contextualize qualitative findings. Surveys
were conducted to (a) understand participant perceptions of LEAD and LEAD partners, (b) understand
motivations for accepting LEAD, and (c) assess procedural justice. The survey was conducted on the
phone and posed a series of closed-and open-ended questions, lasting no more than 30 minutes. Given
that physical signature of consent was not feasible as surveys were only conducted via phone, clients
gave verbal consent to participate and were asked if and where they wanted us to send them a copy of
the consent form. They were also asked to provide contact information for follow-up surveys to occur
every three months for one year. If they agreed to provide contact information, they could always
refuse to participate in the survey when later contacted. Participants received a $20 incentive, even if
they skipped a question(s) or stopped answering the survey. They had the option to receive their $20
incentive in one of four ways: (a) Venmo, (b) email gift card, (c) money mailed to a client-specified
address, or (d) pick-up from a LEAD office of their choice. They received $20 each time they completed
the survey.
Note: The data presented here are the first survey the client completed (Time 1).
Sampling
Potential survey participants are those over the age of 18, who police officers referred to the LEAD SF
program, and the LEAD SF program manager then referred to a case manager. The case manager or
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intake clinician informed the participant of the survey via a researcher-provided LEAD SF 5x8 card
containing information in both English and Spanish about the survey (e.g., purpose, incentive, and
contact information). Case managers distributed cards to all LEAD SF clients. Clients interested in
completing the survey called us on a LEAD-specific phone line. Prior to commencing the survey, clients
were informed that their participation was voluntary, they could skip any question, they could stop the
survey at any time, and they would receive a $20 incentive. Surveys were typically conducted at the
time of the call or scheduled at a time best suited for the client. In instances when calls were missed or
dropped, participants were called a maximum of twice a day over a four-day period.
Table 6-4: Client sample demographics (n=75)
Demographic N %
Age (Mean=38; Median=35)
20-29 22 29.3
30-39 19 25.3
40-49 17 22.7
50-59 8 10.7
60-69 4 5.3
Gender Identity
Male 43 57.3
Female 29 38.7
Transgender/Non-binary 3 4
Race
White, not Hispanic 32 42.7
Black 14 18.7
Hispanic 5 6.7
Asian 3 4
Other 21 28
Employment Status
Full Time 4 5.3
Part Time 26 34.7
No Employment 45 60
Education Level
Less than High School 21 28
High School Graduate or Equivalent 28 37.3
Some College 17 22.7
College Graduate 6 8
Trade School/Occupational Training 3 4
Housing Status
Homeless Alone 38 50.6
Homeless with a Partner 10 13.3
Shelter 16 21.3
Sobering Living 1 1.3
Live Alone 2 2.6
With Family 4 5.3
Other 11 14.6
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The Sample
A total of 75 LEAD SF clients participated in the LEAD client survey (See Table 6-4). More men (57%)
than women (38.7%) participated, and only 4% identified as transgender/non-binary, with an average
age of 38 years. The majority identified as White (42.7%) followed by Other (28%) and most were not
employed (60%). Their level of education varied; 28% have a less than high school education, 37.3% are
high school graduates or equivalent, and 22.7% attended some college. 85.2% of the sample are
suffering from homelessness; 50.6% are homeless alone, 13.3% are homeless with a partner, and 21.3%
are in a shelter.
As LEAD SF diverts individuals with drug-related and/or sex work charges, participants were also asked
about their criminal history and drug and alcohol consumption to gain a better understanding of the
LEAD SF client population (see Tables 6-5 & 6-6). Close to half of the participants reported coming into
contact with the police within the last 30 days (47.1%). Half (50%) also reported having been arrested
between one and three times within the last year. 21.3% of the participants reported having one to
three felony convictions, and more than one-third (36%) reported having one to three misdemeanor
convictions. Of this sample, 37.8% percent reported that their longest time spent incarcerated was less
than 3 months, 28.5% reported between 3 months and 2 years (28.5%), and 20.3% reported three or
more years. Collectively, over the lifetime, 86.5% of the sample spent time in prison/incarcerated
anywhere from one month to five or more years. Slightly more than one-quarter (25.3%) of the
participants also reported having traded sex for money, though only 5.4% of that group considered
themselves a sex worker/prostitute. Lastly, 92% of the participants responded that they had used either
illicit drugs, prescription drugs, or alcohol within the last three months. And, most participants prefer to
use heroin/opioids (31.9%), marijuana (24.6%) or crystal meth (23.2%).
Table 6-5: Client self-reported criminal history
Question N %
Instances of Contact with Police Within the Past 30 Days 70
None 25 35.7
1-5 33 47.1
6-9 9 12.9
10 or more 3 4.3
Number of Times Arrested in the Past Year 72
None 26 36.1
1-3 36 50
4-6 5 6.9
7-9 3 4.2
10 or more 2 2.8
Number of Felony Convictions 75
None 44 58.7
1-3 16 21.3
4-6 2 3
7-9 1 1
10 or more 4 5
Unsure 8 11
Number of Misdemeanor Convictions 75
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None 22 29.3
1-3 27 36
4-6 8 10.7
7-9 1 1.4
10 or more 7 9.3
Unsure 10 13.3
Longest Time Spent in Prison/Incarcerated 74
Never Been 10 13.5
Less than 3 months 28 37.8
More than 3mos but less than 6mos 7 9.5
6 months -1 Year 3 4.1
1-2 Years 11 14.90
3-5 Years 5 6.8
5+ Years 10 13.5
Time Spent Behind Bars Over the Lifetime 73
Never Been 10 13.7
Less than 3 months 17 23.3
More than 3mos but less than 6mos 6 8.2
6 months – 1 year 6 8.2
1-2 Years 9 12.3
3-5 Years 7 9.6
5 or more 18 24.7
Traded Sex of Any Kind for Money 75
Yes 19 25.3
No 56 74.78
Consider Himself or Herself a Sex Worker 74
Yes 4 5.4
No 70 94.6
Table 6-6: Client self-reported drug use (n=75)
Question N %
Used illicit drugs, prescription
drugs, or alcohol in the 3
months
Yes 69 92
No 6 8
Drug of Choice
Alcohol 4 5.8
Cocaine 2 2.9
Crystal Meth 16 23.2
Heroin/Opioids 22 31.9
Marijuana 17 24.6
N/A 4 5.8
Other 4 5.8
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Data analysis
Several methods were used to analyze data in this process evaluation.
First, thematic analysis was used to analyze the focus groups/interview data and survey clients’
responses to open-ended questions about the LEAD program. Thematic analysis is a flexible qualitative
method used for “identifying, analyzing, and reporting patterns (themes) within data” (Braun & Clarke,
2006, p. 6). Themes refer to patterns of information within the data in relation to the study’s research
questions (Braun & Clarke, 2006). This type of analysis can use either an inductive approach or deductive
approach. In an inductive approach, the coding is data-driven; it is based on what the data reveal. In a
deductive approach, the researcher uses a pre-existing schema of codes to analyze and interpret
qualitative data (Braun & Clarke, 2006). This study uses an inductive approach; LEAD SF thematic codes
emerged from the data. Thus, all focus group and interview data audio recordings were manually
transcribed and coded based on emergent patterns. We used NVivo, a software that facilitates thematic
coding in the form of organization and mind-mapping.
Second, we performed both a content analysis and .pdf Comparison Report to analyze the LEAD SF
policy and procedural documents. The content analysis tracked Policy Committee and OW
developments and challenges throughout implementation. Then, the thematic analysis findings from the
focus groups/interviews were cross-referenced with the findings from the content analysis to identify
any connections with staff reported implementation barriers and facilitators. The comparison reports
allowed us to track changes among the various iterations of procedural documents. The next sections
discuss the findings.
LEAD Seattle vs. LEAD SF
LEAD SF and LEAD Seattle documents were analyzed to assess whether the SF model adheres to or
deviates from LEAD Seattle’s model, including its goals, core principles, eligibility and exclusionary
criteria, and core processes.
Goals
Figure 6-1 illustrates the goals comparison. The Seattle model is composed of six goals: (1) reorient
traditional responses to crime, public safety, and health-related problems; (2) improve public safety and
health through the use of evidence-based practices; (3) reduce criminal justice system involvement for
low-level drug and prostitution offenders; (4) undo racial disparities resulting from involvement in the
criminal justice system; (5) sustain the program using LEAD cost savings; (6) strengthen and improve
police-community relationships (LEAD National Bureau, n.d.). The goals as identified in the LEAD SF
grant proposal and Policy Committee documentation align with the LEAD Seattle model.
LEAD SF has three goals: (1) reduce low-level drug offender and alcohol offender recidivism; (2)
strengthen partnership collaboration between city and community-based services to meet the needs of
LEAD participants; and (3) improve the health and housing status of LEAD participants (San Francisco
Department of Public Health, 2017). More generally, SF seeks to improve public health, safety, and
order. SF’s goals are based on the prevalence of alcohol and drug offenders in the Mission and
Tenderloin Districts, the racial disparities in the City’s jail systems (San Francisco Department of Public
Health, 2017), and the size of the City’s jail population (Policy Committee Meeting 06/12/17). Using
LEAD SF, the City seeks to expand existing harm reduction-based services to individuals typically
processed through the criminal justice system. Further, the City seeks to improve police-community
relationships by reorienting the way in which law enforcement interacts with individuals who have drug-
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related criminal charges and co-occurring problems with substance use, mental illness, and
homelessness.
Figure 6-1: Goals comparison
LEAD core principles
Data were analyzed to assess whether SF adhered to the core principles of the Seattle model (See Figure
6-2). LEAD is advertised as an adaptable model, though specific core principles are essential. These
include having committed stakeholders, a harm reduction and housing first framework, intensive case
management, and meaningful police relationships (LEAD National Bureau, n.d.). The core principles
identified in LEAD SF documentation are consistent with Seattle and were actually created and branded
for SF by the LEAD National Bureau (San Francisco Department of Public Health, n.d.). Data from the
focus groups indicate that LEAD SF adhered to most of the core principles throughout implementation.
In particular, LEAD SF partners experienced success with collaboration across agencies and providers.
However, LEAD SF struggled with two LEAD core principles—meaningful police relationships and
maintaining a housing first framework. LEAD SF struggled to secure buy-in from officers early on and
throughout implementation. The program also struggled to secure housing resources for LEAD SF
clients. The LEAD SF case managers were well-versed in harm reduction and outreach, and they refer
their clients in need of intensive case management (ICM) to ICM case managers.
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Figure 6-2: LEAD Seattle core principles
LEAD client eligibility and exclusion criteria
In Seattle, LEAD partners originally intended to divert individuals engaging in low level drug offenses
(e.g., possession of controlled substances or narcotics not exceeding three grams) in the Belltown
Neighborhood where illicit drug markets are prevalent (Beckett, 2014). However, partners were
concerned that this eligibility criteria would primarily bring in male clients, and partners expanded the
criteria to include individuals involved in sex work (i.e., low-level prostitution crimes) to bring in female
participants who might also be struggling with drugs and poverty (Beckett, 2014). Since implementation,
LEAD Seattle partners continued to refine pre-booking and social contact criteria (Beckett, 2014). One
notable eligibility change was the increase from three grams to seven grams as the maximum for
possession of controlled substances or narcotics.
LEAD SF partners also initially struggled with establishing eligibility criteria. In the early stages, partners
were concerned that by developing criteria that was both in accordance with their grant proposal and
Senate Bill 243 guidelines would fail to target those overrepresented in the jail systems (Policy
Committee Minutes, 06/12/2017). Initially, LEAD SF carried out the program with criteria as proposed in
their grant, but problems reaching their target population forced partners to expand charges to include
more felonies (See Table 6-7). This criteria expansion, as well as differences between felony and
misdemeanor penal codes between both cities and states, led to some differences between the LEAD SF
and LEAD Seattle model.
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Notable key differences are evident in the exclusion criteria for pre-booking referrals. Seattle’s drug
offense charges are capped at seven grams, while LEAD SF’s are maxed at five grams. The past criminal
conviction criteria that renders a client ineligible is similar in both sites, with two exceptions. Seattle has
10-year limitations on certain convictions (e.g., domestic violence) and automatic ineligibility regardless
of time when convicted for other crimes (e.g., Murder 1). In contrast, LEAD SF has 8-year limitations on
certain criminal convictions but no convictions that warrant automatic ineligibility. Importantly, both
sites grant the LEAD District Attorney’s discretion to waive any of the exclusions, permitting the
individual to enter LEAD.
The unique contextual landscape of San Francisco, especially in comparison to Seattle, caused LEAD SF
to encounter problems diverting individuals for LEAD. Possession charges in CA are misdemeanors and
not routinely prosecuted through the criminal justice system. As a result, LEAD SF deviated from the
typical LEAD model to expand its eligible charges to include specific, non-violent vandalism and theft
charges.
Aside from these key differences, both sites share similar eligibility criteria for pre-booking referrals.
Both sites also share similar eligibility and exclusionary criteria for social contact referrals. In both sites,
social contact individuals must have a history of eligible charges within the past 24 months, and officers
must have reason to believe that an individual has engaged in or is likely to engage in LEAD-eligible
behavior.
Table 6-7: LEAD Seattle and LEAD SF eligibility criteria
LEAD Seattle eligibility criteria (Protocol June LEAD SF eligibility criteria
2015)
Pre-booking Pre-booking
• VUCSA (Violation of the Uniform Misdemeanor Charges
Controlled Substance Act) and • H&S 11350, 11357, 11377 Possession
Prostitution Offenses • H&S 11550 Under influence
• PC 647 (b), 653.22 Prostitution (sex
workers only) (“sex workers only”
specified 09/17/18)
Felony Charges
• H&S 11352, 11360, 11379, 11379.5 Sale
• H&S 11351, 11351.5, 11359, 11378,
11378.5
Possession for Sale
Added 04/03/18:
• PC 594 Vandalism (damages less than
$2000)
• PC 484, 459 2nd, 470, 476, 477, 478, 487,
496, 666 Theft related (loss less than
$2000)
• VC 10852 Tampering with a vehicle
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Social Contact Social Contacts
• Verification by law enforcement that the • Individual has history of prior
individual is involved with narcotics involvement with LEAD eligible behavior
(possession or delivery) or prostitution. within the last 24 months
• Verification by law enforcement means: • The history of LEAD eligible behavior
Police reports, arrests, jail bookings, occurred in the Mission or Tenderloin
criminal charges, or convictions indicating districts
that the individual was engaged in AND one of the following is present
narcotics or prostitution activity; or • Law Enforcement has directly observed
• Law enforcement has directly observed LEAD eligible behavior
the individual's narcotics or prostitution • Law Enforcement has a reliable basis of
activity; or information to believe that the individual
• Law enforcement has a reliable basis of has engaged in LEAD eligible behavior
information to believe that the individual (e.g., first responder report, a
is engaged in narcotics or prostitution, professional, or a credible community
such as information provided by another member)
first responder, a professional, or
credible community members.
• The individual's involvement with
narcotics or prostitution must have
occurred within the LEAD catchment
area.
• The individual's involvement with
narcotics or prostitution must have
occurred within 24 months of the date of
referral.
• No existing case in Drug Diversion Court
or Mental Health Court.
• The individual cannot have an existing no
contact order, temporary restraining
order, or anti-harassment order,
prohibiting contact with a current LEAD
participant.
LEAD referral process
In LEAD Seattle, the referral process operates as follows (LEAD, 2015). First, an officer determines
whether an individual is eligible for diversion into LEAD, based on a set of site-established eligibility and
exclusionary criteria. Second, the LEAD officer utilizes his or her discretion to decide to arrest or refer
the individual to LEAD. Third, once an individual completes the intake assessment within the allotted
period, the LEAD case management group works with the client to develop an individualized
intervention plan (IIP). The LEAD SF referral process is essentially the same, with one significant
difference (See Figure 6-3).
In SF, officers are required to first refer individuals to the Department of Public Health (DPH) before they
can be referred to case management, an additional layer not present in the Seattle model. DPH is
responsible for conducting the initial intake at the Community Assessment and Services Center (CASC), a
drop in center run by the Adult Probation Department, and individuals are then connected with case
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managers at one of the case management agencies, who work with the individual to develop an IIP. This
additional layer emerged in LEAD SF focus groups as having both advantages and disadvantages. Case
managers, case manager administration, and officers described that having clients travel to different
agencies is an unnecessary hurdle to LEAD participation, while DPH (the program managers) describes
the additional layer as facilitating access and providing program knowledge. In particular, the DPH
clinician meets the unique cultural needs of individuals residing in different districts and ensures that
those who have stay away orders are able to participate in LEAD.
I would say that like, I don’t know if it’s the biggest, but one of the ones is the way referrals
happen. So there’s, you know, the officer has a referral in front of them, so they call somebody
else... who then calls us to show up, right, and then if the person does want to participate, we
have to take them someplace else to have somebody else do an assessment... Yeah. So then, DPH
has to do this assessment, and a lot of times that’s like right when the client is like, ‘Uhh, I gotta
do what? We’ll do that some other time.’ (Case Manager #1, 06/04/18)
It’s a hurdle that a lot of clients aren’t prepared to jump over, and I think in the context of a police
situation, where people are intimidated, people are nervous, people are overwhelmed, um – if
there are drugs involved, there may be some kind of like, chemical thing happening with them
that makes it really uncomfortable for them. So, I think that hoop, I think that, you know, in
retrospect I think it would have been easier to build the structure of LEAD more like it was
intended in Seattle, where there were the officers
went straight to the case managers. So, there
wasn’t this other hurdle to jump through. (Case
Manager #2, 06/04/18)
That’s not how it happens in
– that’s not how it happens in other cities, I mean, other cities, I mean, like, the cops
like, the cops have a direct relationship with case
have a direct relationship with
managers who get called to the scene, and that’s
case managers who get called to
how the alliance begins. Instead of this weird
thing where they have the CASC [Community the scene, and that’s how the
Assessment Service Center] and they have the –
alliance begins.
you know, I just want to – I’ve probably said that
before but that’s the basis of – oh yeah, in Seattle,
where LEAD came from, cops call case managers, and case managers show up on the scene, and
the cops release custody of the client to the case manager, and the case manager develops the
relationship. (Case Manager, 10/18/19)
Like, I agree with having a mental health assessment. I don’t understand why that’s being done at
the intake and engagement point rather than the assessment point. Because it just operationally
makes it really difficult that you know – the moment we get to interact with somebody, as LEAD
has been designed in Seattle – is when that process happens. Here we have to stop, take them off
to CASC, have them meet with a mental health professional who then will give them a diagnosis
– and then we get to start with them. And, that makes absolutely no sense to me, especially
because [the Case Management agency] can do that. (Case Management Administrator,
01/11/18)
Case Management Administrator #1: The idea of community partners was that we got that part
[screening and enrollment] – we don’t – why are we not screening?
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Case Management Administrator #2: We hired staff specifically who could do those screenings
Case Management Administrator #1: You know. It’s like, that’s the point, the point was like we’re
the culturally competent facing and to the community, they trust us – taking us out of it and
making us the next step – it’s like walking through a metal detector to get to the DPH to get to us.
Case Management Administrator #3: The CASC was probation already, so it’s still very
institutional, it’s still got a lot of whatever—the barriers and the trauma, lack of trauma…
Case Management Administrator #2: There’s metal detectors at adult probation… (10/18/19)
During the operational work group [meeting], what we did find was that our program was
different than Seattle in that we have that additional layer of DPH, which did cause some concern
about the relationship between the case worker and the individual. And, we didn’t understand
why DPH needs to be in the middle facilitating that whole relationship. Because their clinical
background may not relate to the practical or the street background that some of the case
workers have, and it could cause barriers, which I think initially it has, or did, with some of the
clientele. So that might be one thing that probably needs to be evaluated going forward, like what
does that really look like and is it needed? (Commanding Law Enforcement Officer, 01/28/19)
Having to go through metal detectors and its proximity to the Criminal Court was in fact mentioned by
some of the clients in the LEAD SF client survey as what they liked the least about LEAD SF.
Survey Question: What do you like least about LEAD?
LEAD SF Client #1: The metal detectors when you come to the office.
LEAD SF Client #2: Having to go through metal detectors and security.
LEAD SF Client #3: It’s too close to 850 Bryant [the Criminal Court].
DPH has been very accommodating to meet the clients wherever they are. The DPH intake clinician has
been flexible and conducts many assessments in the field or where the individual is most comfortable
(Policy Committee Slides 04/23/18). One case manager noted that these mobile screenings have been
beneficial:
Right, that’s sort of the fix that we put in place after some of the early kind of complaints about
the situation [DPH client intake] because what happened was that [the intake clinician] was able
to do mobile intakes out in the field, which is great, actually. It doesn’t always work out, but when
it does, it’s really awesome. [The intake clinician] even did a couple, a couple weeks ago, in front
of city hall, on the grass. (Case Manager, 06/04/18)
It is really important to be able to complete assessments and enroll clients on the fly – wherever
clients might be in the moment. The intake clinician has been able to reach folks in parks, in cafes,
in bus shelters, and in jail. (Project Management, 01/04/19)
DPH has also stressed the value of having DPH’s access to resources, on which the case managers have
relied.
The additional DPH layer of intake has been really helpful. It has been great to have that access
and knowledge about navigating the City’s systems. Case managers often call to brainstorm about
programs and strategies. It’s also been really helpful that clients are entered into the Avatar
database, so that we get notified when our clients show up in other programs. We wouldn’t have
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this collaboration available if we weren’t tapped into DPH’s system. (Project Management,
01/04/19)
I want to say that there’s times, like the emergency DPH shelter beds, which I’ve used too – and
the ICM referrals, sometimes that’s cool. (Case Manager, 10/18/19)
Like, if upon assessment, and they’re doing the assessment, it’s like whoa, this person could really
use ICM – and they pull an MHS140 which is also really good. DPH staff are super useful because
they have access to all these databases that we as line staff in our agencies don’t have, right?
(Case Manager, 10/18/19)
DPH to me is like a two-edged sword. Like, I use DPH, like, when I’m calling an agency, I’ll be like,
‘Hey, I’m working with LEAD. It’s a DPH funded program.’ And, I’ll throw their name out, and
there’s some times when like, the currency of that will buy you a little more – because people are
like, ‘Oh, shit, they’re from DPH.’ But that’s about as far as it goes. I mean, I actually – I feel like
that the whole structure of LEAD kind of got screwed from the beginning with DPH—(Case
Manager, 10/18/19)
The partners clearly recognize the benefits of DPH at the table, however they thought that such
assistance could have been provided while serving their clients rather than at intake.
And I think going forward I would not argue to eliminate DPH from the thing. They are an integral
piece that needs to be in there because of all those things that I just mentioned, but I don’t think
that it needs to be like, hardwired in at intake. I think that it’s already difficult to develop
relationships with folks, that you described so well – that have feelings, that have hearts, they’re
not just like rando, homeless, others, that we just want to get off the streets – you know what I
mean? (Case Manager, 10/18/19)
Could DPH serve more as the service connector versus – not interfering, but being that initial point
of contact? I think it would work just as well if the officers are working with the case workers, the
case worker gets the referral sheet and then sends it to DPH, and then DPH does the service
connections with everyone involved and help us to navigate through the bureaucracy of all the
city stuff. I think that might be more effective than them playing that initial role and being that
initial – so that’s one recommendation I would definitely include. And it doesn’t take away from
DPH, I mean, they’re still the service connector. It doesn’t take away from their role in the
program, but it does take away one extra layer. (Commanding Law Enforcement Officer,
01/28/19)
As the case managers, case management administrators, and officer explain, unlike LEAD SF, LEAD
Seattle’s service providing agency (i.e., case management) handles both the intake and individual
assessment plans. The case managers describe how many clients must travel to the intake office and are
hesitant to complete the assessment at that time. Notably, the individuals are not required to complete
the assessment then; they can return to the intake office for assessment or see the DPH intake clinician
P a ge | 72
in the community within 30 days of their referral. They also highlight how this extra layer created
challenges for case managers to build relationships with clients and with law enforcement.
These issues were exacerbated with the introduction of the SF’s Healthy Streets Intervention Programs
([HSIP]), in which Healthy Streets Operation Center (HSOC)-designated law enforcement officers
collaborated with DPH to bring individuals directly to DPH at the CASC to refer them to LEAD via the
social contact referral stream. This significantly impacted the LEAD referral process. In fact, the LEAD
National Support Bureau repeatedly stressed to LEAD SF that this step of the process should change.
Specifically, the LEAD SF Quarterly Report 9 stated “Through feedback from the LEAD National Support
Bureau, …we can make sure that deliberate conversations are happening between officers and clients,
and that warm handoffs are occurring in the community with case managers and law enforcement.”
Figure 6-3: Referral process comparison
LEAD SF successes and challenges
We identified successes and challenges in the LEAD SF implementation process from the focus
group/interview data, LEAD SF policy documents, and LEAD SF Quarterly Reports. The themes that
emerged are collaboration, relationship building, changing perceptions of police, client successes,
stakeholder investment, cultural shifts, training, policy and goal interpretation, procedural ambiguity,
autonomy, LEAD applicability, implementation of the Healthy Streets Operation Center (HSOC), open
communication, and messaging. An additional theme that emerged primarily from client survey data
was after-hours availability.
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Successes
The themes categorized as successes are collaboration, relationship building, changing perceptions of
police, and client successes. These themes are interconnected, as accomplishments in one area led to
success in another (See Figure 6-4). These successes also indicate that LEAD SF is meeting two of their
three goals: strengthen city and community collaboration and improve participants’ health status.
Figure 6-4: LEAD SF successes
Collaboration
The data indicate that the collaboration among LEAD SF agencies progressed and solidified throughout
implementation and that LEAD SF is likely to achieve their second goal: “Strengthen collaboration across
city departments and with community-based organizations to better meet the needs of individuals with
a history of substance abuse and low-level drug offenses by diverting them from the criminal justice
system and into harm reduction-based social services” (LEAD SF Grant Proposal, 2016, p.11). LEAD SF
staff regarded the program’s collaborative nature as positive.
I feel like one of the magic things about LEAD is this like – un-silo-ization of these formerly here’s
an opportunity for us all to come to the same
table and look at the same issues in a
collaborative way and work together in ways
that didn’t – weren’t really happening before
I feel like one of the magic things
compartmentalized and siloed-in –
organizations that didn’t have any connection about LEAD is the…opportunity
to each other, and. So, I think that’s definitely
for us all to come to the same
one of the things that’s working. (Case
table and look at the same issues
Manager, 06/04/18)
in a collaborative way.
P a ge | 74
I wanted to address your question you just asked really quickly, and the other thing that’s helpful
is the collaboration piece, like, having a – someone from the public defender’s office who
represents LEAD clients has been super helpful. Like I would not have known to show up at that
court case that he mentioned unless I got the call from ‘oh, by the way, you know, they’re having–
’ because it wasn’t scheduled. They just decided they were going to have a court case. And I got
the real – like, text from one of the people involved in it in the public defender’s office, and I just
happened to be at the CASC, which is right around the corner from 850 Bryant, and I just showed
up, and bam, he was like, ‘his case is being seen’ and he was like [noise of surprise] like, 'it was so
amazing, so, little collaborations with other agencies that normally would be siloed in their own
– I mean, that cannot be underplayed. That’s one of the beautiful things about LEAD that cannot
be underplayed. (Case Management Administrator, 01/28/19)
Interviewer: Um – so what are the – some of the strengths of LEAD that you’ve seen in action,
now that you’re going to OWs and – part of the –
Commanding Law Enforcement Officer: Oh yeah, I mean just the collaboration, I mean, seeing
[name redacted], sitting next to SFPD, sitting next to Department of Public Health and GLIDE and
harm reduction – and everybody might have their own philosophy – but there’s something for
everybody around that table. (01/28/19)
This collaboration, most importantly, enhanced each partners’ ability to effectively serve the clients.
Interviewer: So, I need to know though what has been really helpful in carrying out your LEAD
duties?
Case Manager#1: …having the public defender has been really helpful.
Case Manager#2: The public defender.
Case Manager#3: Yeah, definitely going to throw that in there as one of the most...
Case Manager#4: I want to say that DPH is – there’s some advantages of having them as one of
the partners. There’s some access to care that – and access to services that if they weren’t
involved, wouldn’t be as easily accessible. (06/04/18)
When case managers struggle to find appropriate resources for their clients, or when particular
intake criteria in programs present challenges, the DPH staff are often able to problem-solve
and/or advocate for clients. (Project Management, 01/04/19)
I work with [name redacted] and [name redacted], with a client that [name redacted] had to leave
OW to engage and try to get him ...I can’t remember exactly which program, but [name redacted]
was really having a hard time getting this client into a detox, I believe. And so I was in the lobby
downstairs working with [name redacted] and [name redacted] and both of them were just
working together and – ‘Well, you know, you can go back and sit with him, and I’ll go make the
calls and I’ll check.’ Which, kind of was my take to begin with, I thought [DPH] would have been
most effective in really helping the case managers, partly with the navigating, partly with the
knowledge of the mental health system and being able to, you know, come in when needed and
collaborate rather than being on the front end on the screening part. I thought that went really,
really well. It was nice to see both of them working together the way that was, and it was great
that [DPH] did have a role in really supporting our case managers that way and not kind of leaving
them in the dark. (Case Management Administrator, 06/05/18)
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Law enforcement officers especially highlighted how being able to engage a potential LEAD participant,
contact a case manager, and then immediately pass the client to a case manager (i.e., the warm
handoff) are unique, meaningful, and valuable components of the LEAD SF program.
Well, I’ll tell you, it’s the handoffs. The social referral is (A) it cuts down on relatively no paperwork.
You just contact [case management agency] and just say, ‘I’ve got a social referral,’ and they – you
fill that out. There you go, ‘all the best,’ off you go. And, then they take them down to the CASC
Center, get them evaluated, and now they’re in their docket. But more so they have [case
management agency] keeping an eye on them... So when we work – shit. So, when we work, we’ll
call [case management agency] and say, ‘Hey, we’re on – who you looking for?’ And they’ll say.
‘Oh, we’re looking for blah, blah, blah, blah, blah, blah’ – and then we’ll walk through – ‘Hey, I just
found— he’s here – we’ll stand by with him until you get here.’ ‘Hey, how’s it going? Boom. Hey,
who are you looking for? Hey, I got him, he’s here – boom.’ It’s warm handoffs. It’s not, ‘Hey,
come back next Monday at three o’clock.’ (Law Enforcement Officer, 01/10/18)
I thought it [LEAD] had potential for the simple fact that it was a warm body handoff. I thought
that was the one thing that a lot of programs were missing, right? And that was great. (Law
Enforcement Officer, 06/06/18)
Collaboration among LEAD SF partners also allowed the identification of implementation challenges and
the determination of solutions to address those challenges. Table 6-8 demonstrates how, according to
the Quarterly Reports, the LEAD SF partners collaborated to problem-solve and ensure fidelity to
program goals and objectives, as stated in the grant proposal. One example from the focus groups
shows how the LEAD team helped to foster law enforcement investment and highlight the applicability
and value of LEAD SF by conducting mini-LEAD trainings during officer roll calls:
We do trainings for the officers, just talking about LEAD, the policy and the purpose, and the
reason for which it’s implemented. We talk about the criteria for LEAD, what type of cases we’re
looking for, and why they should believe in the program. And then we’re recently—when we go
to the roll calls, it’s been very quick. Kind of quick and dirty in a sense because we only get like
maybe ten to fifteen minutes during roll call. And there, we have just talked about the nuts and
bolts of what it looks like procedurally for an officer on the street – what would they do, how
would they fill out the cover sheet, what type of person they’re looking for. We’re very deferential
to the officer because we do recognize that their buy-in is key and important and being able to
speak their language, so that they understand that we understand, you know, their concerns.
Because some officers are very skeptical, and we’ve received that as well, like, you know, ‘What’s
going to happen if they’re rearrested?’ Or, ‘Why should we believe in this program?’ We have so
many programs in San Francisco. And so, getting them to see the value of LEAD. (Legal/Courts
Partner, 01/11/18)
Also reported in the Quarterly Reports, LEAD partners created an important collaboration with the LEAD
National Support Bureau to further identify solutions to policy and procedural barriers and enhance
fidelity to the LEAD program. Between January 2018 and December 2018, LEAD SF participated in
monthly scheduled calls (called LEAD Learning Collaborative Calls) with the LEAD National Bureau to
help “coordinate with law enforcement” (Quarterly Report 3); address “challenges with social contact
vs. pre-booking referrals” (Quarterly Report 3); and “strategize about increasing law enforcement
referrals” (Quarterly Report 4). Case managers and law enforcement also had the opportunity to
participate in separate monthly calls with the LEAD Bureau regarding their specific roles (Quarterly
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Reports 3, 4, 5, 6, & 7). In addition, the LEAD Bureau coordinated another Seattle site visit on April 18-
19, 2018 where various LEAD SF staff were in attendance, and in June 29, 2018, two LEAD National
Support Bureau representatives attended LEAD SF’s OW Meeting and met with law enforcement to
provide feedback and suggestions. LEAD SF’s continuous collaboration is noteworthy because it has
facilitated other successes, such as relationship building, changing perceptions of police, and client
successes.
Table 6-8: Timeline of encountered implementation challenges
Quarterly Period Presented Challenges Suggested Solutions
Oct-Dec 2017 Heavy influx of social contact OW initiated a social contact hold
referrals by law enforcement
Law Enforcement reported that Law Enforcement encouraged to
processing drug cases (e.g., LEAD communicate with District Attorney
eligible charges) is time consuming. (DA) about potential and/or missed
referrals.
Challenging to ensure a warm- N/A
handoff for social clients.
LEAD participants with multiple District Attorney to work with public
arrests defender to address issue
Jan-Mar 2018 Case Manager capacity (i.e., case Ongoing discussion at OW
manager client ratio)
Afterhours Referrals Community Assessment and Services
Center (CASC) seeking to expand work
hours and expand afterhours
communication between case
managers and officers
Tracking clients for follow-up Ongoing discussion at OW
Housing availability for clients N/A
April-June 2018 Case manager client capacity Ongoing discussion at OW
Afterhours referrals CASC seeking to expand work hours
and expand afterhours communication
between case managers and officers
Tracking clients for follow-up N/A
Housing availability for clients Anticipate some LEAD participants may
be eligible for housing at the new
Coordinated Entry Housing Program
July –Sept 2018 Case Manager capacity (i.e., case Ongoing discussion at OW
manager-client ratio)
Afterhours referrals CASC working to expand hours to 7pm
(dates TBD); case managers shared
mobile phone numbers with law
enforcement to encourage
communication
Issues with homeless clients being Working to build good working
relocated by encampment relationships with law enforcement to
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resolution teams, which poses a allow for better communication around
challenge in finding clients for finding clients in different
follow-up and raises concerns that neighborhoods
clients can become destabilized as a
result
Finding suitable and available San Francisco in the process of
housing for the homeless clients launching a new coordinated entry
who are ready for a home housing program that will prioritize
individuals on the street, and anticipate
LEAD clients will qualify
Oct-Dec 2018 Case Manager capacity (i.e., case Ongoing discussion at OW
manager-client ratio)
Afterhours Referrals CASC working to expand hours to 7pm
on Tuesdays starting February 2019;
case managers shared mobile phone
numbers with law enforcement to
encourage communication
Jan –Mar 2019 Case Manager capacity (i.e., case Ongoing discussion at OW
manager-client ratio)
Afterhours Referrals CASC working to expand hours; case
managers shared mobile phone
numbers with law enforcement to
encourage communication
April –June 2019 Case manager capacity (25 active DPH leadership are having
clients per case manager) conversations around the around the
possibility of expanding services
Afterhours Referrals Site has piloted evening operations,
opened in the evenings everyday
Tuesday and extended the CASC hours,
LEAD clinician and case manager
Tracking clients for follow-up Working on building better working
relationships with law enforcement to
facilitate communication regarding
finding clients that have been moved
by encampment resolution teams.
Housing availability for clients Partners have been able to house
several high needs clients through the
SF Coordinated Entry Housing Program;
but most lead clients are not prioritized
for subsidized housing.
LEAD SF program fidelity Partners are working to adjust the
intake process to help build stronger
relationships between law
enforcement and case managers.
July-Sept 2019 Case manager capacity (25 active DPH leadership are having
clients per case manager) conversations around the possibility of
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expanding services, and the future of
the program beyond the grant
Afterhours Referrals Site has piloted evening operations.
Site is anticipating a BSCC grant to help
extend CASC hours to 7pm (and
eventually 10pm) Monday-Friday to
facilitate warm handoffs
Tracking clients for follow-up Working on building better working
relationships with law enforcement to
facilitate communication regarding
finding clients that have been moved
by encampment resolution teams
Housing availability for clients Partners have been able to house
several high needs clients through the
SF Coordinated Entry Housing Program;
but most LEAD clients are not
prioritized for subsidized housing
LEAD SF program fidelity In response to LEAD Bureau feedback,
the SF site has put a halt to the Healthy
Streets Intervention Program and is
focusing on emphasizing officer/case
management relationships and
communications
Relationship building
LEAD SF has helped build positive relationships that have historically been adversarial or non-existent—
between agencies. Even among agencies who collaborate, such as law enforcement and the district
attorney who collaborate on cases, relationship building can be absent. The LEAD SF collaboration
afforded all LEAD partners an opportunity to gain a better understanding of and appreciation for one
another’s roles, especially between law enforcement and other partners. Through that understanding,
they have been able to connect and effectively work together.
Commanding Law Enforcement Officer#1: On the [law enforcement agency’s] side, there’s been
more communication. But we’ve also invited them [DA], you know, to come out, them [DA] and
the public defender, you know, to kind of brainstorm ideas on some of the people that we’re
dealing with in the program. And then maybe – and potentially others that don’t fit this program.
Interviewer: That’s a really interesting approach. So, what kind of prompted that?
Commanding Law Enforcement Officer#2: Well, just the fact that we’ve never had that
relationship with them, you know, so this is kind of an opportunity to build one. (06/05/18)
Yeah, I was just thinking – I know that the case managers have been really active about building
relationships with officers...So, both of the two case management agencies have gone to stations
to talk about the program and have built, you know, direct communication tunnels with law
enforcement in those areas. And it just seems like that, hearing from law enforcement, that’s
been very helpful for them. To have a person that they know, that they can call, and then also to
the case managers’ credit, like, being very responsive. Like, being there right away, being outside
all the time – I’ve heard that that’s been really helpful. (Project Management, 01/10/18)
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For us at [law enforcement agency], we’ve developed a pretty good relationship with the [case
management agency], you know, the [case management agency] program. (Law Enforcement
Officer, 06/05/18)
Just this morning we did a walk-around with some police officers, so that kind of thing, you know,
just sort of building the relationships with them and having them show us what they do. (Project
Management, 01/10/18)
We’re building allies with other clinicians as well as law enforcement and meeting clinicians all
around San Francisco, right. We’re building allies. So, law enforcement will call us, as well as we
might reach out to them as well when we’re on the streets. (Case Management Administrator,
01/10/18)
We actually have a meeting with [law enforcement agency] pretty regularly. Like, we sit down
with the [law enforcement agency] police before the Operational Workgroup and kind of go over
the caseload and say where everyone is at and da, da, da. That’s the kind of relationship that I
would like to see with [other law enforcement agency] at some point... Case Manager, 06/04/18)
Interviewer: so is the process still that law enforcement contacts case managers or is it law
enforcement contacts DPH? Like what is the process now? Has it changed at all?
Commanding Law Enforcement Officer: I think it’s still a combination of both. But more so
procedural-wise, the officers are still sending the pre-booking or the social contact or the referral
form itself to DPH and then DPH will contact the case managers. But I think just in the some of
the operational work groups, I know that the officers and the CBO’s [Community-Based
Organizations] are really building a great relationship to where now the officers are calling the
case workers directly and wanting the case workers to come out. And there’s even been a push
to have the case workers’ numbers on the cover sheets as well, so that the officers can just contact
them directly. (01/28/19)
Well just that all the relationships that we’ve been building across these different organizations
are – now they’re relationships. And you know, they’re really good working relationships.
Whether it’s trying to locate somebody that’s kind of in the wind or getting access to a resource
that we normally wouldn’t have access to because you have access to it. You know what I mean,
that kind of thing. So yeah. (Case Manager, 10/18/2019)
Quarterly Reports indicate that LEAD SF continues to actively
work on furthering collaboration and relationship building
between partners by introducing “a casual LEAD-team hangout
We’re building allies with other
that took place on September 20th [2018] and coffee and
donuts at the Operational Workgroup meetings” (Quarterly clinicians, as well as law
Report 5 & 6). However, case managers, case management
enforcement, and meeting
administrators, and law enforcement stressed that by October
clinicians all around San
of 2019, their collaboration has declined. Law enforcement
officers rarely attend the OW meetings, and thus, they do not Francisco, right. We’re building
meet with case managers prior.
allies.
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Changing Perceptions of Law Enforcement
LEAD SF’s collaborative nature and active working relationships have also facilitated a gradual and
positive shift in perceptions of law enforcement, especially among case managers.
So yeah, definitely, like...just getting to know little shit about officers – excuse my language.
Getting to know little stuff about, you know, these people, and seeing them as people, not just as
a presence on the streets with the gun and the badge. (Case Manager #1, 06/04/18)
So that’s definitely changed my lens and the type of work they have to put in, you know, the type
of work they have to do and the shit they have to see every day. So that’s changed my view of
them a lot. A lot of the law enforcement officers I’ve met -- I can’t even say I’ve met one law
enforcement officer I’m like, ‘god, that guy is a dick.’ You know, I can’t say that. I don’t know if
you guys’ view is any different. (Case Manager #2, 06/04/18)
But I think it’s true, like, it’s having this glimpse of the actual working processes of law
enforcement – as like any of us typically see their human side, in a way that I don’t know that I’ve
ever seen it, and also have a little respect for the challenge. (Case Manager #3, 06/04/18)
We are the experts in the field, the case managers. I also believe that the officers are the experts
in the field in their own way because they’re hands-on as well with the clients. They know exactly
what’s going on out there, whether they do something about it or they can’t do anything about
it; they’re out there 24 hours a day. They know what the hell’s going on out there. They know.
(Case Manager, 10/18/19)
LEAD SF case managers were not the only ones to have this
positive perception of the police; clients did too. Client I also believe that the officers
survey data indicate that a majority of clients reported
are the experts in the field in
positive experiences and perceptions of officers (see Table
their own way because
6-9). In particular, a large number of clients (n=74)
perceived that officers treated them with dignity and they’re hands-on with the
respect and that officers were fair, nonjudgmental, and
clients. They know exactly
polite.
what’s going on out there…
Table 6-9: Officer procedural justice (n-74)
Question Agree-Strongly Agree
# %
Perceived Officer Fairness 69 93.2
Officer Allowed Questions 68 91.9
Officer Answered Questions 66 89.2
Officer Explained LEAD Fully 63 86.3
Perceived Officer Care of Client’s Wellbeing 66 89.2
Officer Did Not Judge the Client 63 85.1
Perceived Officer Helpfulness 68 91.9
Officer Made Sure Client Understood Rights and Responsibilities 66 89.2
Perceived Officer Politeness 68 91.9
Officer Treated Client with Dignity and Respect 67 90.5
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Client successes
LEAD partners explained that connecting clients to services has been positive. According to the LEAD SF
focus groups and Quarterly Reports, LEAD SF is on the right path to achieving its third goal, “Improve
LEAD Participants’ health and housing status.” The Quarterly Reports indicate successes in connecting
clients to medical, health, and housing services; providing legal support to address clients’ warrants; and
relationship building between case managers and their clients. Small successes among the clients are
notable. For clients with substance use problems and/or mental illness, completing ordinary tasks may
be arduous undertakings and significant hurdles to further progress.
But when we see somebody like [name redacted] get a haircut, and that boosts his whole ego
enough to go back home to see his family and daughter that he hasn’t – that he’s been
disenfranchised from, you know, things like that – that shit makes my day. That boosted his whole
confidence. Something that would have been really challenging for him to do himself, you know?
Because he has competing priorities. You know, a simple haircut boosted everything about him.
He’s like a different dude now, you know? So those are the little sparks, and things like this happen
every day. (Case Manager, 01/10/18)
But we did have one legitimate success where – her name was [name redacted], but she went by
a street name of [name redacted]. She was very scared of law enforcement. She was getting a bad
name on the streets. She ended up getting arrested by us...Lost her dog, right, but [name
redacted] and those guys at [case manager agency] got a hold of us. And, together we found her
dog – which kind of gave us a new look in her eye. And, she became an active participant, and
seeing [case manager agency] and all the sort of stuff. (Law Enforcement Officer, 06/06/18)
Oh – there’s so much success with the clients, honestly. The clients that we have, we are doing
great things with. I think my favorite one is someone who’s trained as a psychologist is – we have
a client, and who is still to this day very difficult –
causes some staff splitting between us and DPH, as
we just realize – but this was a woman who has a
serious medical condition that she was unwilling to But we did have one
treat, extensive mental health issues, was not willing
legitimate success where
to even discuss them at all, and through just a really
consistent patience on the part of our case manager, [female, name redacted] was
she is now taking medication for her medical very scared of law
treatment – for her medical needs, taking
enforcement. She was getting
psychotropic medication for the first time, treating
very serious anxiety, and actually went into one of a bad name on the streets.
our acute facilities for 60 days to kind of take a
She ended up getting
breather and really get some care. So that is so
arrested by us...Lost her dog,
exciting to me because she is extremely complex
from a mental health perspective and substance use right, but [name redacted]
perspective. But to see that change in a couple of
and those guys at [case
months – and it’s a lot of hard work, but it’s been –
manager agency] got a hold
that’s so gratifying, and it shows that intensive case
management from a harm reduction – we’re not of us. And, together we found
sitting in an office, we’re there with her wherever
her dog – which kind of gave
she is on a daily basis...We’re able to work with her
us a new look in her eye.
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in a way that deescalates her and can move things forward. (Case Management Administrator,
06/05/18)
One of our greatest successes I’ve been seeing, in a few days now, as a matter of fact is a client
who accessed harm reduction services prior to the rollout of LEAD and was homeless in the
Tenderloin, has some serious health challenges, really chaotic use of methamphetamines, and
when he was referred, he was one of our first referrals, very, uh – angry, hostile, confrontational
young man. And, he was one of our first LEAD referrals, he was a social contact referral… And
since being referred to LEAD, he’s been housed [in a permanent Single Room Occupancy]. His
presentational mental health issues have receded, he presents as more – he just presents better.
He’s physically better. He’s cleaner, he’s present, he’s well spoken, he’s just doing 100 percent
better. And there’s really little evidence – he’s probably still using, but there’s little evidence that
it’s chaotic. Yeah, he’s managing his use well. (Case Management Administrator, 10/18/19)
Project Management #1: I was just taking a phone call for someone, a client who came in
yesterday and was really suicidal because he can’t see his kids and he’s been in housing for like –
temporary housing for like a year and a half, and he’s like, nothing is moving. And for us to be
able to say, his case manager went and saw him and was like, we sent you to go see your family
and your kids like a year and a half ago – let’s do it again. Let’s put you on a bus. We can get you
there. And just to know that we have [flex] funds to do that is really crucial.
Project Management #2: I think that it particularly for a population like this is incredibly important
to be able to offer somebody food or snacks or coffee as a way to engage them.
Project Management #3: Or a month of rent. (10/18/19)
LEAD SF partners’ success with clients echo findings from the client survey. Clients were asked to rate
their experiences with their case manager using a series of closed-ended questions. Results show that a
majority of clients either agreed or strongly agreed that case managers treated them with dignity and
respect, seemed to care about their wellbeing, were knowledgeable about services, and were fair,
polite, and nonjudgmental (See Table 6-10).
Table 6-10: Case manager procedural justice (n=74)
Question Agree-Strongly Agree
# %
Perceived Case Manager Fairness 72 97.3
Case Manager Allowed Questions 74 100
Case Manager Answered Questions 73 98.6
Case Manager Explained LEAD Fully 71 95.9
Perceived Case Manager Care of Client’s Wellbeing 72 97.3
Case Manager Did Not Judge the Client 71 95.9
Perceived Case Manager Helpfulness 74 100
Case Manager Made Sure Client Understood Rights and Responsibilities 71 95.9
Perceived Case Manager Politeness 71 95.9
Case Manager Was Knowledgeable about Services 72 97.3
Case Manager Treated Client with Dignity and Respect 72 97.3
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Clients’ responses to open-ended ended questions about their experience with LEAD also lend support
to partners’ reported client successes. Clients were asked to describe what they like most about LEAD,
and the overarching theme was support. This theme was composed of four sub-themes: nonjudgmental
staff, routinization, humanization, and services and resources (see Table 6-11).
Table 6-11: Client survey themes
Key Theme Sub Themes
Support NonJudgmental Staff
Routinization
Support
Humanization
Services and Resources
Consistent with clients’ procedural justice ratings of case managers, clients reported they appreciate
LEAD staff. Some clients specifically referenced their case managers and noted that they appreciate
their caring and nonjudgmental demeanor. The client responses below highlight this sentiment.
[I] never participated in anything like this before, first time. They seem like they genuinely care
about people. And, when you see someone care about you like that, you don't wanna disappoint
them. You wanna give it your best effort. (LEAD SF Client)
Honestly, the employees. They got the perfect group of people. Basically, I'm satisfied with the
people that I got. That's huge. (LEAD SF Client)
I think the best thing is the case managers. They, for me, treat us the same. They are not judge-y,
and you can tell by the look on their faces and the way they talk, they have some heart in it. I got
sick, and the case managers checked on me and brought me food and water. They've been my
backbone. They got – helped – me everything I needed to get myself together. They got me
housed [navigation center], and now I’m going to college. (LEAD SF Client)
These findings highlight the importance of ensuring that case managers are able to build rapport and
trust with clients.
Relatedly, clients reported that they appreciate LEAD’s humanizing aspect. Clients noted that staff made
them feel more than just a client and gave them a sense of self-worth. Further, clients positively
regarded staff’s willingness to advocate for them.
That someone is there to represent you when, you know, you can't represent yourself. (LEAD SF
Client)
They don't see me as a client, [they] see me as a person, [they are] willing to help me with
whatever it is. (LEAD SF Client)
I feel that they were very nonjudgmental and very friendly. I feel very welcomed and that I can
trust them and keep coming back. (LEAD SF Client)
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First off, they don't judge you. They give you what you need and give you your space. They meet
you where you are at, and that's really important. They give you suggestions to resources and
services, instead of like telling you to do this or do that. They just tell me it's optional. They don't
really force stuff on you. (LEAD SF Client)
Oh boy, um, it is giving me a chance to see myself and be happy again, and to change. (LEAD SF
Client)
They actually care, not just doing their job. They generally care, I can call them for whatever. If I
need someone to talk to, something to eat, or need clothes. They help me. They have been my
family, not just case managers. The whole crew. (LEAD SF Client)
In addition, clients reported liking that staff help them structure their day to day lives (routinization).
Clients reported that staff help them with small and mundane tasks, such as getting to appointments,
getting document-ready (e.g., getting their ID, birth certificate, etc.), and simply being there when
clients feel like they need someone to talk to. The following client quotes highlight this sentiment.
That they [staff] help me have some structure and organization in my daily routine. One of the
hardest thing about living on the streets is having a schedule, a routine. (LEAD SF Client)
They are reliable in all conversation. Helpful getting me to my appointments, decisions with my
life (rehab, drug use); they don't judge me. They help me. (LEAD SF Client)
That my case managers is one of the only case managers is actively doing what he can so that I
can accomplish my goals. My short-term goal is better my well-being, helping me micromanage
my day-to-day. (LEAD SF Client)
I have someone to help me do everything. Like, if I need someone to talk to, there's someone
there. (LEAD SF Client)
My case manager is on top of everything (LEAD SF Client)
The people involved seemed very supportive and willing to go out of their way to help you. They
help you complete things. They make me feel comfortable enough to ask for help and talk. (LEAD
SF Client)
They are really helpful and they seem to be on the ball, they’re nice and are actually trying to help.
(LEAD SF Client)
The persistence of my case manager to stay on top of me and provide the support. What I like
most is transportation, they pick me up and take me where I need to go. (LEAD SF Client)
As the clients explain, living on the streets sometimes poses challenges in having a daily routine and
completing small tasks that may otherwise seem mundane to the average person. These findings are
consistent with case managers’ emphasis on celebrating small successes and suggest that case managers
are engaging clients from a harm reduction standpoint.
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Also consistent with LEAD SF reported successes, clients positively regarded LEAD’s services and
resources, though many were not specific about the particular resources they enjoyed most. However,
two clients reported liking LEAD SF’s legal services. One client, for example, felt positive about the
prospect that LEAD could help him resolve his warrants. The other described how he was charged for an
offense he did not commit, and LEAD was able to help him resolve that problem. Overall, it appears that
LEAD SF has made significant strides towards improving clients’ quality of life.
Challenges
Themes that emerged as challenges at both the initial stage and throughout implementation are
stakeholder investment, cultural shifts, training, policy and goal interpretation, procedural ambiguity,
autonomy, LEAD applicability, open communication, messaging, and the implementation of the Healthy
Streets Operation Center ([HSOC] see Figure 6-5). Specifically, LEAD Administration faced ongoing
challenges in securing law enforcement buy-in and clearly communicating LEAD SF goals, values, roles,
and procedures to LEAD partners. An additional theme that primarily emerged from client survey data is
after-hours availability.
Figure 6-5: LEAD SF challenges
Stakeholder Investment
LEAD SF’s most significant challenge has been securing stakeholder investment, particularly from law
enforcement. Importantly, at each biannually focus group session (January 2018, June 2018, January
2019, and October 2019), LEAD SF partners discussed the importance of securing early officer buy-in and
noted how challenging it has been for LEAD SF to maintain “consistent representation” (Project
Management, 12/17/19) especially from SFPD. And, this struggle continued well into the end of the
pilot.
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…Try and get a police department buy-in at the grant making stage. Because I think here, one of
the struggles has been gaining momentum with the police department, which they weren’t part
of the grant, from what I understand. (Legal/Courts Partner, 04/18/19)
Because they didn’t have specific officers assigned, and there were some messaging issues and
buy-in issues with who was addressing the rest of the staff, I think there’s some work that needs
to be done there. (Legal/Courts Partner, 01/11/18)
I mean, law enforcement, it’s important to get the right people on board. So, I’m not sure we’re
totally there yet… (Project Management, 01/10/18)
But the biggest challenge right now, or one of the biggest challenges, is to get more of a law
enforcement presence. (Project Management, 10/18/19
The partners across the LEAD SF focus groups attribute the challenge to securing and maintaining officer
buy-in to: the significant cultural shift; the challenges providing sufficient law enforcement training both
on procedures and in harm reduction; difficulties associated with providing consistent messaging about
LEAD’s goals, principles, and procedures; and LEAD SF officer perceptions that they neither have open
lines of communication nor an equal voice in LEAD.
Cultural Shift
Law enforcement and other stakeholders identified how practicing and valuing LEAD’s principles of
harm reduction and diversion is crucial, albeit difficult because the partnership required between police
officers and case managers is unique, and LEAD is a significant shift from traditional policing. Most case
managers have not worked closely with law enforcement, and many were hesitant about doing so.
Most of them [case managers] have never worked in this, you know, truly diverse,
multidisciplinary team. You know, working with law enforcement, you have to allow these folks
that are working, you know, for these programs, that live on the streets, that they were addicts
themselves, or they’ve been in jail or had these experiences with law enforcement. So, for them
it’s a growing experience as well. (Commanding Law Enforcement Officer, 6/5/18)
Interviewer: Has your relationships with the police or having the police be this conduit to harm
reduction made you more effective at reaching a population you wouldn’t have otherwise been
reaching?
Case Manager#1: I mean, yeah, it’s helping us reach the police.
Case Manager#2: That’s definitely a population that we’ve not been able to connect with before.
Case Manager#3: The only thing was, I was hesitant when they said working with law enforcement
because of my past history. But the cool thing is we get to educate the officers. (06/04/18)
The police also struggled with certain agency partnerships:
So, it’s a weird relationship to try to be partners with people who like the commander said, calls
a press conference and says, ‘Look at all these dirty cops, look at the sheriffs, look what they do
in their jails. You know, they’re all terrible people. But, let’s be a partner now because you’re
going to help us keep people out of jail. Because we’re true believers.’ (Commanding Law
Enforcement Officers, 06/05/18)
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One of the Legal/Courts Partners explained the significance of the cultural shift, particularly for law
enforcement:
...One thing that has occurred to me is that, you know, it is a huge culture shift to tell police officers
here, ‘this is the way you’ve been arresting people for 20 years; now stop...’ If you work in any
organization [and] there is a culture about it, and for us to all of a sudden switch to a different
culture, I think it would be hard. (06/04/18)
A law enforcement officer emphasized that a cultural shift in policing does not happen overnight:
I’ve been around...cops for almost thirty years, and it’s not going to be like – it’s not going to be
push a button or snap your fingers and everybody is going to go, ‘Okay, we’ll do it different.’
(06/05/18)
The Legal/Courts Partners emphasized the need to explain to law enforcement why such a cultural shift
is necessary (i.e., traditional criminal justice system approaches may be ineffective in addressing the
causes of criminal behavior):
And I think that rather than just sort of talking about the LEAD program, I do think we need to talk
about sort of, you know, from a sort of clinical-behavioral training, like not something coming
from either office, not something coming from internally, but sort of, you know, this idea about,
‘Hey, this is sort of what’s happening to somebody who is, you know, who you keep incarcerating,
and this is, you know.’ Even if it is to—a crime like breaking into a car at which everyone is upset
about. ‘And this is why this system is not going to solve your problem.’ (06/04/19)
Relatedly, one commanding law enforcement officer noted the importance of recruiting officers that are
willing to take a chance on strategies that fall outside traditional policing practice:
LEAD or any type of diversion type of program requires you to take a chance, to think outside of
what your norm or what your everyday norm is because if you take a chance, and it’s the wrong
chance, you’re going to be the one that’s going to have to answer for it. So, I just think that the
individual, what makes a person good for these type of programs is one who can think outside
the box or who’s willing to take a chance and do something different and see if it works or not.
And who’s forgiving in the mistakes that’s going to be made, because if someone like – with this
program, people are always – you know, they fall back, they regress, you don’t see the change
immediately – you have to… ‘Like okay, they made a mistake.’ Like the commander said, ‘Let’s
get them back on the right path.’ And, they just don’t give up on them, and say okay, ‘It’s time to
go to jail and lock them up and stuff like that.’ So, I think those are the type of qualities that you
have to look for in staff. (Commanding Law Enforcement Officers, 01/28/19)
It’s definitely so important to get that like culture shift in the law enforcement sort of treatment
over incarceration. Like, that’s the number one most important thing. But then also giving law
enforcement a tool to do treatment and not incarceration. You can’t just say, ‘Oh yeah, these
people clearly need services, don’t arrest them.’ You need to actually give them the services.
(Project Management, 10/18/19)
Part of the issues the Legal/Courts Partner identified was how the cultural shift could be smoother if law
enforcement was more educated on the consequences and limitations of their approach. Similarly, case
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managers and case management administration identified the need for law enforcement to have more
training in LEAD core principles and harm reduction methods and effectiveness, since that is the
foundation of the LEAD program.
Training on LEAD Procedures and Core Principles
In the grant proposal, LEAD SF indicated that during the startup period, a training plan would be
developed to ensure partners received training in LEAD goals and procedures and harm reduction. The
LEAD National Support Bureau, the Harm Reduction Coalition, and the Drug Policy Alliance (DPA) would
provide trainings. Law enforcement were to receive additional training in the LEAD referral protocol and
implicit bias. Case managers and outreach workers were to receive additional trainings in harm
reduction, effective case management, and LEAD procedures, including service referrals and data entry.
LEAD SF’s Policy Committee meeting minutes and presentations indicate the committee began their
preliminary discussions about a training plan between June and August 2017 with an anticipated start
date of September 2017. According to the Quarterly Reports, 82 trainings occurred between September
22, 2017 and June 17, 2019 (see the Technical Appendix). Training topics included an overview of LEAD
with the LEAD National Support Bureau, harm reduction, motivational interviewing, mental health and
trauma, total reform care, the criminal justice system (e.g., laws and processes), and behavioral huddles.
Trainings reported in LEAD SF’s Quarterly Reports are consistent with staff’s reported trainings.
Harm reduction-specific trainings occurred on five separate occasions, once in September 2017 and
December 2017, twice in January 2018, and once in October 2018, and various LEAD SF staff attended.
The first training on harm reduction occurred on September 22, 2017, and 12 officers were in
attendance. The law enforcement department trainings in October 2017 also contained harm reduction
content. On October 24, 2017 (7 officers attended) and again on November 2, 2017 (8 officers
attended), trainings were held for BART PD. On October 25, 2017, one training was held for SF Sheriffs (7
officers were in attendance) and one training was held for SFPD (14 officers attended). In December,
LEAD Orientation for Law Enforcement trainings were held on the 7th (11 officers attended) and on the
13th in the Mission (17 officers attended) and in the Tenderloin (10 officers attended) district. According
to SF Staff Administration, approximately 50% of these department trainings covered harm reduction.
The harm reduction-specific trainings occurred on January 12 and January 31, 2018. The January 12th
training on harm reduction was solely for DPH staff, and no officers attended the January 31st training.
Additional harm reduction-specific trainings occurred in October 2018 and in June 2019, and only case
managers attended. LEAD-specific law enforcement department trainings occurred on August 14, 2018
(20 officers attended), on September 12, 2018 (60 officers attended), and on May 1, 2019 (45 officers
attended).
Because LEAD SF launched throughout all LEAD SF partnering police departments, it was incredibly
difficult to train all officers. For example, SFPD has about 2,000 officers (San Francisco Police
Department, 2018), and training all officers both in LEAD and in harm reduction are inevitable
challenges. Further, because officers frequently change precincts, it was also possible that those trained
are no longer assigned to the Mission or the Tenderloin.
Nonetheless, the data suggest that law enforcement could have benefited from more harm reduction
trainings that are tailored to police officers. For example, when asked during a focus group of 10 officers
in January 2018 about harm reduction, again in June 2018 with five officers, in January 2019 with three
officers, and in October 2019 with four officers, some of the officers either never heard of it, did not
know what it was, or did not know how it related to LEAD.
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Yeah, I’ve never heard that term, so. (Law Enforcement Officer, 01/10/18)
So what I figured out, on my own, is that the Department of Public Health has what’s called a
harm reduction. Harm reduction is everything. It’s panacea. It’s the golden chalice. As long as
something is a little bit better than when I first talked to this person five minutes ago, like, you
know, giving them a sandwich – I just had a success. (Law Enforcement Officer, 06/06/18)
Interviewer: Have you had like a harm reduction training. That was run by LEAD.
Law Enforcement Officer: Gosh, I don’t know. I’ve been to so many darn trainings…What exactly
is harm reduction? (01/29/19)
Interviewer: Are you familiar with harm reduction? The term harm reduction?
Law Enforcement Officer #1: Yes.
Law Enforcement Officer #2: It’s a model, right, harm reduction –
Interviewer: Are you familiar with how harm reduction operates within LEAD?
Law Enforcement Officer #3: Not within LEAD. I know some other agencies that run with LEAD,
like GLIDE has harm reduction teams – but not within LEADs. (10/18/19)
LEAD case managers who attended the focus groups also iterated this sentiment. They emphasized the
need to train law enforcement in harm reduction principles and commented that the harm reduction
training for law enforcement could have been insufficient:
Teaching them [law enforcement] about harm reduction, that helps a lot. It’s not an easy sell, but
that’s huge. Because as they learn about harm reduction and the way that it is best practiced,
then they start getting a little more comfortable with it. (Case Manager, 06/04/18)
The police did not get front-end training on this. We weren’t training with a bunch of people with
lots of bars and stars and all kinds of stuff, that took ten, fifteen, twenty years to get. But the line
cops, our best stuff is the cops that we talk to on the street that didn’t get any training but learned
about it from us. And well, guess what, a half hour discussion with a couple people on the street
isn’t good enough for any one or two officers who care to learn about LEAD. (Case Manager,
01/10/18)
I know we lost [name redacted], but if someone like [name redacted] or whoever gets that
position sort of says to law enforcement, ‘Hey, you guys need to utilize LEAD.’ You know, it has
to be like a direct command that the captain is here, and the captain needs to get on his street
force and be like, ‘I need to see those referrals.’ And then – it’s very simple to measure, we look
at LEAD-eligible arrests, it’s a published document – and then we look at LEAD-eligible referrals
from those arrests, and right there it’s a goose egg. It’s a bagel, right, and it’s like, why is that?
And it’s because it’s not been authoritatively stated down the chain of command that this is what
the purpose of this program is. And we’re only going to know how successful it is when you
engage in the full apparatus that is this program. (Case Management Administrator, 10/18/19)
As such, LEAD SF administration offered additional trainings that were grounded in harm reduction (e.g.,
syringe access, Narcan, social justice, and medication-assisted treatment). However, few LEAD SF
partners attended the trainings (see Technical Appendix), and only two officers attended a motivational
interviewing training that LEAD SF Project Management describes as “steeped in harm reduction
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principles.” Low law enforcement attendance at these trainings led the LEAD SF Project Management to
discuss harm reduction at “any available moment” during their Operational Workgroup meetings:
Because of the challenges of getting a bunch of law enforcement officers to take time off of the
streets to attend trainings, our team has really made an effort to use any available moment to
talk about how harm reduction works with our clients. In our Operational Workgroup meetings,
when each client is discussed, we try to give examples. And we did get feedback from law
enforcement that they really need to hear about the successes, because they don’t necessarily
see successes – you know, somebody will just disappear. And they need to be reassured that
things are happening, so, we’ll need to figure out ways of communicating that. (Project
Management, 01/10/18)
Like Project Management, other partners noted the importance of communicating small successes to
law enforcement. Under harm reduction, even small wins, like taking a shower, getting a haircut, and
getting an identification card, are celebrated. While these wins may appear insignificant to some, such
small wins can be significant challenges for individuals dealing with drug addiction, mental illness, and
homelessness. For law enforcement, however, success is typically defined as a client being off the
streets, abstinent from drugs, and in secure housing. Because law enforcement frequently see clients
after the referral takes place (meaning they may still be living on the streets and perhaps still using
substances), informing officers that the program is serving as a valuable resource for the clients, no
matter how small, may impact their willingness to buy-in into LEAD.
You might scoff at the small wins that we consider “successes”, but part of the harm reduction
approach allows for helping clients address the small challenges that they are ready to address in
a process that builds relationships and builds confidence needed to address bigger issues in the
future. (Project Management, 01/04/19)
I can tell you that the last Operational Working Group meeting that I went to, we had – we’ve had
different people from the police come from the two stations, right. We try to help kind of get the
word out, which we try to expose them to so that they can go back and talk about it. And there
was one lieutenant who came in to one of the meetings and they had done an operation in the
Mission for prostitution because it’s a huge problem, neighbors are complaining – I think two
years ago we had four homicides related to prostitution – two women who were doing the work
and two pimps and that night they had two women who took LEAD referrals and the lieutenant
was all excited because she was saying, ‘Oh yeah, I saw so and so, you know. She’s doing good;
she’s staying at this hotel – you know.’ So that – so those kind of like, you know, even if it’s a little
success, that was – you know, so to hear a police – so, I think that’s one example of what’s going
well. (Commanding Law Enforcement Officer, 06/05/18)
I would love – we have a client that I would love for you to talk to, the mother and son team…who
live on the street in the Tenderloin, and they have a dog. And the dog was like – someone
complained about the dog, the dog was taken away from them. We had to – we got them back
their dog, the paperwork that gives them permission to have the dog – all of the ancillary
equipment that the dog needs to be muzzled and safe, the licenses, everything, and this took –
took months to get this happen, and they were going to kill the dog. They were just going to
confiscate the dog because it’s two black people living on the street in the Tenderloin, with boxes
and an angry dog. And we’re just going to take that thing and put it down. It was a huge success
for my team. Oh my god, it’s huge. (Case Management Administrator, 06/05/18)
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However, even as LEAD SF nears the end of its pilot implementation, January 2019 and October 2019
focus groups indicate that officers who made referrals are not aware or do not see the change to the
lives of the clients.
I don’t think I’ve had a successful LEAD contact. LEADs has never called me and said hey, we made
contact with this person, and actually got them into a program somewhere, and I see the same
people out there doing the same thing over and over again. (Law Enforcement Officer, 10/18/19)
Incongruous definitions of success also continue to persist and harm reduction buy-in from officers
remains challenging. In a focus group with two officers and an interview with a commanding officer in
January 2019, the officers commented that harm reduction is a tool that may work for some LEAD
clients but not all. And, these officers feel that case managers overemphasize harm reduction as the
only tool that will help clients.
So, if you talk to most people who’ve been in the life – and I’ve never been a drug addict, but
many of my case workers are people who have lived the life – they’re not tremendously, you
know, responsive to the harm reduction. But I’m sure it works for some. Somebody’s gotta –
everybody can’t – the same thing can’t work for them. So, maybe for somebody harm reduction
is perfect. (Commanding Law Enforcement Officer, 01/28/19)
The outreach workers are taught harm reduction, and I believe in harm reduction, I like it – but
they think it’s a panacea. And with the silos and the procedures of the city – the city also has
bought into yes, harm reduction. Harm reduction is it, that’s the key, that’s the answer to
everything. And we’re saying, ‘No, we are flexible, we work with a more broad spectrum and
open mind when we deal with humans. That is just a tool.’ And there’s where we start butting
heads with [name redacted] and [name redacted] and the others because they can’t – I keep
asking people. Is it they don’t want to get it? They can’t get it? They’re not willing to get it? They’re
afraid of losing their jobs because their job is to dictate policy and procedure? – I don’t know…The
case workers are only harm reduction – it’s the only tool they’re allowed. ‘I need to use a Swiss
army knife.’ And they’re told, ‘Sorry, you get the Philips head, and you will use nothing but the
Philips head.’ (Law Enforcement Officer, 01/29/19)
Further, the officers noted that sometimes clients need more intervention if harm reduction is not
working.
They have different definitions. Their idea of success is whatever the person wants. You want a
sandwich, you want clothes, I’m going to say, ‘No, that’s not helping them.’ Putting them in
housing, lately, that’s been the big one. Get them in housing. We have a couple of them that
we’ve got them in three or four times, and they walk out. Some of them – one girl using drugs in
front of the other people in there, and we talked to the LEAD person in charge of the program at
the woman’s place and she said, ‘Look, I can’t have her shooting heroin in front of the other heroin
addicts, so we had to throw her out.’ LEAD’s response: ‘Let’s put her back in.’ They actually fought
and argued with me and left the meeting and said, ‘Well, if you don’t know – just keep her – it’s
like Groundhog Day.’ No. All you’re doing is setting them up for failure because – and another
counselor agreed with me on this – that you’re beating their self-esteem down. They have very
low self-esteem to begin with. And now if she keeps getting kicked out of the same programs
over and over – she’s a mess right now. (Law Enforcement Officer #1, 01/29/19)
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So, like any kind of program, you know, you have to come to grips when is enough and when am
I exhausted – you know, I’ve reached my limits. And we shouldn’t look at it for the sake of a
number or sake of, Hey, it takes a year to build rapport and this and that.’ Law enforcement
doesn’t have a year. And, if they see that they need a little – because it’s repetitive behavior. And
if they’re documenting repetitive behavior, then we need to take advantage of that
documentation and be able to just up the ante on ‘Hey, this person here clearly needs just a little
bit more when it comes to supervision and/or direction, mandated direction.’ So, I think when
we bring up a case like that, it shouldn’t feel like we’re going to throw a grenade in the middle of
the table because we’re saying ‘Hey, you know what, maybe we need to consider AOT [Assisted
Outpatient Treatment]. Maybe we need to consider going the conservative route.’ (Law
Enforcement Officer #2, 01/29/19)
Another issue with training that officers identified is the need for training with LEAD Seattle. They
stressed communication and exposure with the LEAD National Support Bureau should have occurred
prior to the program launch. While four officers went to Seattle prior to launch in October 2017, other
officers stated it would have been beneficial to work with the Seattle team prior to launching the
program. They would have preferred to gain a hands-on perspective about the referral processes and
learn from Seattle officers of challenges officers might expect throughout program implementation:
We should have gone to Seattle first. We should have been able to spend at least three or four
days there, then try and implement it and learn from their mistakes because they’re already going
to be able to show us maybe shortcuts or things that you’re just inevitably going to run into versus
just what we’re trying to fight our way through, right? (Commanding Law Enforcement Officer,
01/10/18)
Moreover, officers noted a thorough and longer training with the Seattle Team (i.e., the LEAD National
Support Bureau) would have been beneficial:
I think a week or at least three days of being on patrol with the officers who are doing it, so you’re
seeing them engaged, and seeing how they are doing it, followed up prior, post, with some
classroom experience, hands on stuff, so then when you come back, you are better able to explain
what’s going on. Have the questions already answered – then when there is that rare question
you aren’t prepared for, you know exactly who to call to get that answer. (Law Enforcement
Officer, 01/10/18)
Prior to the launch of LEAD SF (October 2017), four officers went to Seattle for LEAD training, and 28
police officers were trained in LEAD procedures in SF, with the expectation that those officers would
educate other officers in their department about LEAD. However, for some, that was not the case.
Interviewer: You didn’t get like the policies and procedures about what to do?
Commanding Law Enforcement Officer: Nothing... That when you – you bring over a potential
individual that qualifies for LEADs – so he came to the station, we met, and we discussed it. And
because my officers really had no clue on how to implement LEADs, it was just like, ‘Here. Here’s
LEADs. Go talk about it.’ Even if you’d read it, it didn’t make sense. There was no— you know, a
police officer is smart. They’re like, ‘Whoa’ – they’re like, ‘Okay, you do this, this, this, and that.’
They don’t want you to read through a paragraph and try to figure out what needs to be done.
(01/11/18)
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Both LEAD SF Legal/Courts Partners and LEAD SF Project Management emphasized that, in fact, many
trainings or information sessions were held. From November 2017 through January 2018, these agencies
held LEAD-specific policy and procedure trainings for law enforcement and attended roll calls to inform
line officers about LEAD.
We do trainings for the officers, just talking about LEAD, the policy and the purpose, and the
reason for which it’s implemented. We talk about the criteria for LEAD, what type of cases we’re
looking for, and why they should believe in the program. (Legal/Courts Partner, 01/11/18)
At officer roll calls, they discussed the “nuts and bolts” of LEAD in SF.
We only get like maybe ten to fifteen minutes during roll call. And, there we have just talked about
the nuts and bolts of what it looks like procedurally for an officer on the street – what would they
do, how would they fill out the cover sheet, what type of person they’re looking for. We’re very
deferential to the officer because we do recognize that their buy-in is key and important and being
able to speak their language so that they understand that we understand, you know, their
concerns. (Legal/Courts Partner, 01/11/18)
However, by June 2018, the LEAD SF senior command officers stressed to LEAD SF Administrative Staff
that, “they had had enough training and that the rest would be done internally.” The LEAD SF
Administrative Staff then concluded that “command staff meant there would be no more roll calls.” One
commanding officer explained:
Commanding Law Enforcement Officer: Um, we do it in-house. It was rolled out initially when I
came – I asked the captains, I said ‘Hey, you know, we gotta start talking about this again at lineups
and everything else.” And then like I said earlier, somebody new comes in, that’s another
opportunity to do it. …Seattle has come down here a few times and we’ve done that, but we
haven’t sent anybody up that I recall. Recently.
Interviewer: And then I know that DPH does their own trainings – are those for police too or are
those just DPH trainings or how does that even work?
Commanding Law Enforcement Officer: I know that they’re offered up, or that there’s notice
about it, but some of the stuff I think is – I don’t know that it’s LEAD specific, I guess is the best
way I would put it. (10/18/19)
Still, SF Legal/Courts Partners underscored the need to return to officer roll calls.
One of the things we had talked about that we haven’t operationalized yet is going back to the
police department’s roll calls and kind of regularized meetings and presenting again [on] what we
need – because there are other charges that people are eligible for...so I think that’s something
we need to do to follow up on. (06/04/18)
The pause in roll call trainings could have led to procedural ambiguity in the referral process. Many
officers expressed dissatisfaction about not having a thorough understanding of the process. Some
discussed viewing a PowerPoint presentation, while others only received a “sheet of paper.”
Law Enforcement Officer #1: Yeah, they showed like, a PowerPoint presentation, was it in lineup
Law Enforcement Officer #2: Not here. Nah, I didn’t get a PowerPoint.
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Law Enforcement Officer #1: They didn’t do it? So in Mission it was just like this little – I guess it
was like a train the trainer type of thing, so they told one of our officers, lieutenants or sergeants,
this is how this works, now go teach everybody type of thing. And then whoever had to teach us
made a little PowerPoint.
Law Enforcement Officer #3: Did not see that PowerPoint. Literally got the sheet of paper and
said, ‘follow the instructions on here.’ (11/13/19)
Moreover, an analysis of the evolution of the Law Enforcement Cover Sheet (the sheet of paper to which
officer #3 is referring) shows many additions and deletions within the first five months, including the
addition of eligible felony charges and reordering and clarifying steps to initiate a referral (i.e., who
officers first contact, when they email documents to each recipient, and when they contact case
managers [See Figure 6-6]). Some of the specifications of the referral process were added at the request
of law enforcement. Other changes made to the Law Enforcement Cover Sheet reflect LEAD SF project
management and case management needs, including the referring officer’s contact information and
information on where and when the referred client is typically seen to provide a feedback loop with law
enforcement.
At almost every Operational Workgroup, there were suggestions about how we could improve as
a program, and we tried to implement these suggestions and constantly work towards a smoother
process. We went through a bunch of versions of the referral coversheet because we found that
what made sense before launch was different in practice. I like to think that we are responsive to
feedback – I’m sure we’ll have many more edits to come. (Project Management, 01/04/19)
The changes to the Law Enforcement Cover Sheet demonstrate the commitment to both improving the
protocol and addressing the needs of law enforcement and case managers. These changes show the
responsivity of the SF Project Management and the communication among the partners at the OW.
However, these changes in the process could also explain the officers’ sentiments and lack of
investment in LEAD implementation, especially if the alterations were not effectively communicated to
line officers:
Interviewer: So, you didn’t get any of the lists of the all new offenses?
Law Enforcement Officer #1: I’m not aware of any.
Law Enforcement Officer #2: I don’t think you just have the current LEAD sheet...The current
referral sheet has that.
Law Enforcement Officer #1: When did it come out?
Interviewer: In April [2018].
Law Enforcement Officer #2: Yeah, well, I don’t – a lot of times [name redacted] will hand out
the new LEAD sheets at the meetings. So, if you’re not there at the meetings or –
Law Enforcement Officer #1: I have – yeah. You know, this all began, I don’t know, a few months
ago when they gave us a stack of sheets, and I still have – you know, several, from –
Law Enforcement Officer #2: So, you have the original sheet.
Law Enforcement Officer #1: Whatever they gave us. But no one’s told us since –
Law Enforcement Officer #2: It’s changed three times. Well, I mean, I’m not going to throw LEAD
constantly under the bus because that’s not the point of this. I do know that LEAD has been very
proactive in changing the sheets, [LEAD SF Administration] has been emailing them out, and there
are a lot more [law enforcement] at the meetings now. There’s been a captain, a couple of
sergeants, and also...Yeah, so they have been more active in that. So, I know [law enforcement
agency] has the new LEAD sheets. You guys might not have it, but I know that they’ve been taken...
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Law Enforcement Officer #1: Yeah, I mean, I’m not saying that they’re not, and there may be, but
I mean, we’re like a month – I don’t know.... Yeah. So I mean, it may just not have trickled down
or someone – they’re somewhere and we just haven’t seen them. (06/06/18)
To encourage officer buy-in, develop a further understanding of harm reduction among law
enforcement, connect officers with LEAD Seattle, and better inform officers with the LEAD protocol,
starting in April 2018, officers occasionally participated in the LEAD National Support Bureau monthly
law enforcement calls. Additionally, the Bureau coordinated an SF site visit in April 2018 to “discuss
ways to best coordinate with law enforcement, and challenges with social contact vs. pre-booking
referrals” (Quarterly Report 3). The Bureau visited the LEAD SF site again in June 2018 to discuss “the
values of LEAD and strategies of making it [LEAD] effective in San Francisco” and Seattle officers both
accompanied SFPD and BART officers on walk-alongs and “had one-on-one conversations [with officers]
to encourage referrals” (Quarterly Report 4). Moreover, between August and September 2018, the LEAD
SF Administration reestablished LEAD SF Orientations that some officers attended.
More recently, between April and June 2019, LEAD LAC SF Administration continued to participate in
LEAD Learning Collaborative calls with the Bureau to identify how to better coordinate with case
management teams and law enforcement. Some law enforcement officers also participated in monthly
calls with the Bureau. In addition to this, two members of the Bureau visited the LEAD SF site to observe
the site’s Operational Workgroup as well as to meet with individual LEAD teams. However, in October
2019, Project Management continued to identify this “challenge” in LEAD implementation.
I would say a huge challenge of ours has been training law enforcement and just getting in there.
They’re very much like to train their own staff and it’s hard to get them to agree to outside
trainings. I mean, I’ve heard so many times – like, we don’t need that. We’ve already covered
that. Everybody knows. Everybody knows about that. So that’s a big challenge. (10/18/19)
Figure 6-6: Law enforcement cover sheet evolution
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Messaging
Case managers also identified a lack of information dissemination about the LEAD program to officers.
One case manager explained:
I think if I look at it in a whole nutshell, it’s like I said, there’s a lot of policemen out there that
don’t even know about LEAD. So, you take the ones in the Tenderloin, and you see cops on the
street beat walking right in the middle of that junk we’re talking about. They might not even
understand what LEAD program is because the police department is not actually fully presenting
this to the whole enforcement unit. ...Just like in Mission, I talk to cops, they don’t know what
LEAD’s about – because they just don’t know. But how can you not know when you’re from the
Mission Station and your captain is supposed to be on top of this? (06/04/18)
They further emphasized the need for effective, accurate, and consistent messaging around LEAD.
And, start that relationship early. And, roll it out together instead of just saying let’s go. Because
the hard part is reinforcing the same message over and over and then trying to clean up poor
messaging, because that’s really – that takes more work because now I have to make sure the
person receives the better message and then I have to educate the person delivering the bad
message. (06/04/18)
The SF Legal/Courts Partners argue that LEAD messaging to law enforcement would best come from
commanders:
Legal/Courts Partner #1: ...getting someone that the police officers can hear and understand and
gain some credibility. Because I think when we go and do these things at the roll call, and by we,
I mean...the DA and public defender and the probation department, I think it’s just kind of like,
‘oh, LEAD. You’re just pushing LEAD on us.’ And so, I think, we need to sort of focus at this point
of like what really can we do.
Legal/Courts Partner #2:...I totally agree with that, because even internally in our department, it’s
who the message is coming from that makes the biggest impact.
Legal/Courts Partner #1: Exactly.
Legal/Courts Partner #3: So, like, I see your vision, but I see like a training with sergeants and
above that are truly learning this information, and them being the ones that stand in front of their
members at roll call and having that sergeant saying, ‘Okay, this is what’s happening.’ Because
you know, if we could get them fully engaged and them completely literate on what’s going on, I
think they will be the key in making, you know, that change, that we need...They still don’t have
marching orders, right, and so we’re just kind of sitting here. It’s like, you know, standing in front
of them telling them what we expect them to do, and they’re looking at us like we’re just a bunch
of, like, graduate social workers, you know. (06/04/18)
One law enforcement officer highlighted the value of identifying the “good” and “respect”-ed
supervisors:
We have a lot of really good supervisors that have a lot of respect from coworkers, subordinates.
And when they ask us to do something, we do it. And it’s not a – ‘I’m not going to do it unless
that guy asked me to do it.’ There’s so many things we’re just asked to do on a daily basis but
when boss X says it, sure, I’ll do it twice, because if that guy asked you to do something he has
such a delivery, he has such respect – and it’s not like an up here respect – he’s actually very
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short… So he’s just a cool dude. So when he says, ‘Hey guys’ – he doesn’t say – he goes – ‘We
need one today [a LEAD referral]. Like, I know you can find one. And if you can’t, like, you’re not
in trouble.’ And, I’ll make my best faith effort to go find one. (Law Enforcement Officer, 01/29/19)
A commanding officer suggested any leader regardless of rank, can facilitate buy-in.
The approach that’s effective is you have to find people – we have leaders who have no rank. We
have leaders who have different ranks. You have to find credible leaders within the station, the
district, the borough, whatever your group is, your team is – and you have to get them on board.
They have to go Seattle. You have to establish that first, right. (Commanding Law Enforcement
Officer, 10/18/19).
And, it is clear that referrals are being made.
There have been some really shining stars that have made a lot of referrals, that have been really
engaged, like the lieutenant that comes – or sergeant, lieutenant – is, you know, very much
engaged, and then there’s been others that have been very engaged. And then they come
through and then they have some trickling of officers that are champions, and they bring some
folks in, and then they go in and – just that consistency. I mean, we’ve experienced it at the OW
too. I mean, we’ve had shifts and luckily everyone that’s come through has been awesome.
(Legal/Court Partner, 10/18/19)
Hey, the officers are doing good work. We have progress, you know – and it’s okay to look at
numbers and say, ‘Well, we had a dip or an incline or whatever it is – but it’s not just about
numbers, because what we’re dealing with are people. Right? We’re dealing with people, which
we’re all after the same thing, we’re trying to help people’ – even if from a law enforcement
perspective it’s about, ‘I’m glad if you get help and stop committing crime because that makes
things better for the community and it makes things better for me.’ So we have a little selfish
interest. But in the end, it’s the people that are getting helped. (Commanding Law Enforcement
Officer, 10/18/19).
LEAD Applicability
The topic of LEAD applicability to San Francisco was a recurring theme in three contexts. First,
California’s Proposition 47 impacted client eligibility. Second, the eligibility and exclusion criteria were
obstacles to enrolling pre-booking clients. Third, the services LEAD provides, such as homeless outreach,
are already present in San Francisco.
A common perception among many officers is that Prop 47 (California Courts, 2018), the reduction from
a felony to a misdemeanor charge for certain crimes, makes meeting the goal of LEAD, to divert low-
level drug and alcohol offenders from the system, more challenging. Specifically, in San Francisco,
officers stated that they seldom arrest individuals for low-level drug offenses and were reluctant to
make an arrest for the sake of a LEAD referral. This poses a challenge for officers who are trying to divert
individuals into LEAD, as they do not have a “hammer”.
Just how the criminal justice system works in San Francisco, and what’s a felony and what’s not a
felony. And these – everything in LEAD are just misdemeanors. So, there’s no consequence. You’re
better off just taking the citation than having to do this program. And that’s one of the feedbacks
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from one of the deputies that was trying to do LEAD. They’d offer it, and the person went, ‘Nah,
I’ll just take the citation.’ Because there’s no jail time associated with it. So, it’s just a misdemeanor
cite and release. (Commanding Law Enforcement Officer, 01/11/18)
The way the laws are here now, and especially so here in San Francisco, there really is no hammer.
So, for these lower offenders, let’s say, it’s like, ‘Why would I want to get bothered with something
like that when it’s not going to do anything for me?’ That’s the way I look at it. I’d rather just go
like, ‘Give me my ticket, I’m on my way, and I’m just continuing the way I’m going.’ (Commanding
Law Enforcement Officer, 06/05/18)
Our department was contacted, I don’t know who did it, but before we actually got the grant,
they said, ‘Hey, [name redacted],’ because I’m very into crisis intervention training and mental
health work. I was at a facility where we had the acute mentally ill, most of whom were violent.
A very small percentage of mentally ill people, who were violent, I had that on my caseload. And
so, I was reading all these initiatives, and this one came across my desk. At the time, it was a
quality of life initiative, and I said, ‘Well, this is silly. We already don’t arrest people for these
crimes in San Francisco. They were giving me the Seattle model.’ And, I read through the list of
charges where they were diverting people and I go, ‘Well, we don’t arrest people for that now. It
had been like a decade since drug offenders were in jail.’ So I said, ‘Who would we be reaching?’
And so, I’m glad to see that they changed some of the criteria. (Commanding Law Enforcement
Officer, 01/28/19)
Interviewer: What – does Prop 47 – how does that play a role in your ability to implement LEAD?
Law Enforcement Officer: It puts all of the – What do we want to call it? Gamble, expectation,
hope – on the other person. I’m just merely offering it. So – which is fine, but there’s – kind of at
a lack for words – uh – real consequence.
Interviewer: Oh, so like, there’s no hammer.
Law Enforcement Officer: And not even in a negative way, but there’s no other reason – so if I’m
walking down the street and all of a sudden it turns into two roads, I can equally take either one
of them, unless something persuades me good or bad – it could be a bunch of potholes on that
one, and it just looks uncomfortable, or that one just goes uphill – there’s just nothing. There’s
just two blank roads, and they can choose either one of them. I can either take services or not.
And if I don't, nothing happens to me. If I do, it depends on if I want to get clean that day, if I have
anything else going on, if I feel like going through the detox, or the dates and appointments and
times and – blah. (01/29/19)
Law Enforcement Officer #1: But I think it definitely probably would have been something – a lot
more effective, you know, pre-Prop 47.
Law Enforcement Office #2: Yeah, I agree with that, because there’s the leverage that you have
with the person. Especially if it was a warm handoff, which I think is key, um – when you have
that leverage it’s like, you’re going to be diverted or you’re going to jail. And there’s no in
between, but right now, there’s no leverage, because you’re either going to go to LEADs and get
diverted or – but we’re going to write you a ticket and there’s no consequence if you don’t do
anything. If you don’t go to court for the ticket or you don’t go to LEADs – there’s no consequence.
Law Enforcement Officer #3: No real consequence. Right. (11/13/19)
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SF Legal/Courts Partners noted the impact of the eligibility and exclusion criteria on the number of pre-
booking referrals. Specifically, SF Legal/Courts Partners raised concerns that the eligibility criteria make
it difficult for officers to bring pre-booking referrals:
It’s been a struggle for law enforcement to make those pre-booking referrals. What we’re hearing
from them is that they’re not arresting folks for drug offenses or the DA’s office doesn’t prosecute
those, and so it’s definitely been a conversation that’s ongoing of how do we get those referrals
and – you know, are those people going to jail instead of being referred? (01/10/18)
Officers echoed this sentiment:
Can’t sell it. And we don’t – we don’t make the type of arrest that LEAD is like. Look, they said
we’re not making those arrests, so we would actually have to like, potentially make arrests that
are like – that fit the mold for a LEAD case. We don’t make those arrests anymore. (01/11/18)
As a result of the eligibility issues, the policy group met to discuss expanding eligible charges to include
certain felonies. One member of the SF Legal/Courts Partners focus group explained:
Yeah, anything that will help to lend itself to widening the net for how many pre-bookings we
could get, you know, definitely to help to offer more services to a wider range of people than
we’re doing. (06/04/18)
However, officers who attended the focus groups objected. They expressed concern that the expansion
to include additional felony charges may face community resistance:
Honestly, that’s what I’m anticipating that we’re going to get. They’re going to basically – they’re
going to go, ‘Oh, no, it’s [LEAD] going to work here.’ So, you will take – they are going to expand
it to more serious crimes. Guaranteed. That’s what all – that’s what all of us, at least at my station,
are anticipating. And – which is really not going over well. Because the community – that’s not
what the community wants. Oh, let’s say, ‘Oh, he broke into a car – put him in jail!’ That’s – in the
Tenderloin, as liberal as it is. You broke into a car, you did violence, and you go to jail. There’s no
– ‘We don’t want you to go to [case management agency].’ [Case management agency’s] there to
provide social services. That’s not what they want down there. (Commanding Law Enforcement
Officer, 01/11/18)
We [this officer and another] discussed policy and what should and shouldn’t be eligible offenses.
And [name redacted] – he’s a lieutenant that works at my station and he – I was on vacation or
something – and he was there, and he said that he objected to all these things. When he came
on, he even said that [name redacted] objected to a lot of these offenses, and they’re one of the
managers in the DA’s office. But then, all of a sudden, those things came out as eligible offenses.
(Commanding Law Enforcement Officer, 06/05/18)
At the Policy Committee meeting, the committee voted to add charges to the list of those eligible in
hopes of bringing in more pre-booking referrals (see Table 6-12). On April 23, 2018, the committee
reached a modified consensus vote (9 full approval and 4 conditional, as per the minutes) to include
felony vandalism and felony theft-related charges with a requirement that those felony charges are
believed to support subsistence living. However, many law enforcement officers were still reluctant to
refer on these charges.
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We want to help people for sure, I mean, that’s why we do this job, but we don’t want – when
someone breaks into a house, imagine the victim, right? Like, imagine coming to your car – drug
addict or gangbanger, someone breaks into your car and steals cameras, phones, memories,
whatever – and then you come back and then you see the cops giving them a certificate of release.
Like, where’s the justice in that? (Law Enforcement Officer, 10/18/19)
Table 6-12: Approved LEAD eligible charges
LEAD Eligible Charges Expansion
Felony Vandalism with damages less than $2000
Felony Theft-related offenses with a loss under $2000:
• PC 484 (including credit card frauds)
• PC 459end (including auto burglary cases)
• PC 470, 476, 477, 478, 496, 666
• VC 10952
Policy and goal interpretation
An early sentiment among police officers who attended the focus groups was that LEAD is not necessary
in San Francisco, and more recent focus groups with officers indicate that this sentiment remains. Some
officers argued that a multitude of diversion and related services already exist. Specifically, officers
noted that LEAD is simply a duplication of services and that LEAD funds would be better utilized to
support existing services:
Commanding Law Enforcement Officer #1: ...Well, we already have all these programs in existence
in San Francisco, and the officers are already using it – so it’s just redundant.
Commanding Law Enforcement Officer #2: Let’s put it this way. We have 160 non-profit providers
in the Tenderloin. We don’t need another one. We don’t. We just don’t need it.
Commanding Law Enforcement Officer #3: If we had 161, I mean, that would be – we just don’t
need another way to – and if that’s the case, if we’re just going to do social contact, then we could
be out of it. (01/11/18)
The HOT [Homeless Outreach Team] has always worked. And you know what, they ran out of
funds years ago -- I got a whole parking lot of homeless people inside because the HOT team had
the funding back then. I was giving SROs [Single Room Occupancy] – SROs away like candy. But
they run short, the case managers, they didn’t have the money for the case managers and stuff –
if you’re going to invest in something, invest it in the HOT team. (Law Enforcement Officer,
06/06/18)
Officers also noted that while LEAD is a valuable tool, individuals can still get connected to services via
other avenues:
… I think there’s a lot of places where if you think someone is a sex worker or being trafficked
there are – like I would – the Center for Young Women’s Development, which is now called the
Young Women’s Freedom Center – I mean, there’s a lot of referrals you could make where they
would get help. I don’t know if you have to – I mean, LEAD is great, it’s a good tool to use, but I
think there’d be other resources that you could use for people who are stuck in that trade. So,
I’m not saying no, I would love to see it work, but I wouldn’t even approach somebody from a law
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enforcement officer who was engaged in prostitution. I might say, ‘Hey, you know what, are you
hungry? Are you tired? Is there a place you need to go? Do you need a case worker? Have you
tried this or that?’ – and I think most of us have interacted with people like that in the sex trade.
(Commanding Law Enforcement Officer, 01/28/19)
I don’t think LEAD is the only pathway to services. The officers have discretion where we – San
Francisco is a service rich city. And, the officers have discretion when there’s different type of
offenses that allow them the discretion to call the HOT team to come out and service individuals.
They might be able to call DPW [Department of Public Works] if there’s a situation where they
see individuals that are shooting up or doing something that’s criminal behavior, but they have
the discretion to use a tool. I don’t think LEAD is the only service pathway that the officers have
to use. Is it an additional one? Yeah. Is it a good one that they have at their disposal? Yeah, I
believe so. But I don’t – I mean, prior to LEAD, they were doing what we have, the Neighborhood
Court Program that the officers were able to refer individuals to, pre-trial diversion also let the
individuals before – you know, they got connected through the booking process. So there are
other like service driven diversion programs that the officers have access to. (Commanding Law
Enforcement Officer, 01/28/19)
LEAD’s an option. You know, and because we do have at our disposal a HOT team, we’re able to
have that option. And at the same time, because we do have rapport with different players that
would be in a pseudo MDFT [Multidisciplinary Forensic Team] that we’ve been running outside of
our head and in some of the cases, is that we’re dealing directly with the DA, more directly with
forensics or more directly with the public defender’s office. And then there are people from DPH
that we work with. So yeah, it’s an option. And I think the numbers reflect, we’ve been kind of
stagnant for a while, that officers become a little more savvy or they’re able to go outside of LEAD.
(Law Enforcement Officer, 01/29/19)
A shortage of training, the inability to train all officers in San Francisco, and ambiguous messaging about
LEAD goals could have led the law enforcement team to interpret LEAD as a typical diversion program or
could have led to a misunderstanding of the program goal. One LEAD SF officer stated that “We kept
arguing, what’s our mission? What’s our goal?” In contrast, those agency officials who were familiar
with and/or effectively trained in LEAD and harm reduction differentiated LEAD from other programs
and services by pointing to LEAD’s pre-booking component, harm reduction philosophy, and its
collaborative nature:
The whole idea of the pre-booking was very important to me and very interesting to me because
having that stop there before you walk into the Hall of Justice is a very important point in this
program, and I think it’s very, very forward thinking. So, when we were talking about LEAD, it was
already kind of a natural progression from all the other types of diversionary type of courts and
programs that we were already implementing. (Case Management Administrator, 01/28/19)
LEAD’s philosophy is centered on harm reduction principles, which distinguish the program from other
services in that it seeks to take a client-centered approach by providing services based on what the
client wants (i.e., medically-assisted treatment; use reduction; a shower). It creates an understanding
that criminal behaviors are, in some instances, driven by factors, such as substance use and mental
health:
We recognize that the majority of auto thefts happen because people need to, you know, avoid
withdrawals. And, they’re long time users. So, we can engage them into a harm reduction type of
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approach. Then, the idea is that we can get them into treatment and services that may or may
not be abstinence-based versus having them get picked up for, you know, those other charges.
(Case Management Administrator, 6/5/18)
Procedural Ambiguity
Partners reported a lack of procedural clarity in three contexts: warrants, the referral process, and out
of county referrals. The first draft of the LEAD SF Procedures was created in July 2017 (three months
prior to launch), and procedural changes are expected throughout the launch. The March 2018
procedures has many additions and deletions that lengthened the document from 4 to 27 pages. While
numerous insertions and replacements were made, the following are considered major revisions:
addition of sex workers; addition of harm reduction principles; revised law enforcement client contact
and transportation processes; adjustments to social contact eligibility and exclusion criteria; updates to
Operational Workgroup responsibilities; updates to DPH initial intake screening and assessment
responsibilities; updates to LEAD SF flexible funds spending policies (including short-term housing); and
addition of policies about taking photos of clients. Other insertions include finalized documents (The
Media Plan, the Law Enforcement Cover sheet, Consent Form, the Operational Workgroup
Confidentiality Agreement, and the Emergency Stabilization SRO Hotel Rules Agreement). The next wave
of changes are reflected in the December 2018 processes document. Changes reflected LEAD SF’s
eligibility criteria expansion, minor procedural changes on how DPH contacts case managers for client
referrals and how DPH communicates with external services agencies, and other minor language
changes. The latest iteration of LEAD SF procedures (May 2019) only contains minor grammar and
formatting changes.
These changes to the policy and procedures highlight LEAD SF’s commitment to improving and clarifying
the LEAD referral, case management, and booking processes. Still, a manual tailored to the officers prior
to launching LEAD SF could have been helpful:
...[if] we created a binder or some kind of internal binder with it before we even rolled out the
program, and we would have had like at least a working draft of like, ‘Okay, well, this is what the
police procedures are going to look like when it goes to the officer,’ and then when we went out
and did some training, we would have been able to answer some of those questions that was left,
you know, on the table. I think that that would have been really important to have some written
for them [the officers]. (Legal/Courts Partner, 06/04/18)
Other LEAD partners highlighted that many policy or procedural questions remain unanswered. LEAD SF
Legal/Courts Partners noted the lack of specific guidelines in how to deal with clients who have criminal
charges and/or warrants in a different county and what qualifies as a social contact versus a pre-booking
referral. With criminal charges or warrants, is it the responsibility of the District Attorney or Public
Defender to contact outside counties?
We’re still working it out as to whether when an individual picks up another line offense here and
want to participate in LEAD, how is that going to affect them in the other county? ...we don’t have
an agreement with outside counties that they won’t necessarily violate... And so, we’re still – we
only have one case where that’s been an issue or a concern – so, we’re still trying to work out.
(Legal/Courts Partner, 06/04/18)
There are some legal issues that the legal team haven’t fully come to agreements about, but they
have been really good about coming together on a case-by-case basis and finding the best solution
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for the moment. In this way, they can be even more client centered and not follow a one size fits
all approach. (Project Management, 01/04/19)
Ambiguities in the criteria that categorizes a referral as a social contact versus a pre-booking could lead
to missed client opportunities:
… I think part of that is still coming from the confusion of, you know, what is a pure social contact,
versus what is a pre-booking and how to fill it [the cover sheet] out… (Legal/Courts Partner #1,
01/29/19)
So in other words, the reason why we had such a big discrepancy in the numbers of missed
opportunities was because their spreadsheet [law enforcement] which was responsive to ours
was saying, ‘Well, this arrest was made by someone from Central station. They weren’t trained
on LEAD, and therefore it doesn’t count as a missed opportunity.’ When in reality, the way we
look at it – the definition is if they’re arrested for a LEAD eligible offense in the LEAD catchment
area, it doesn’t matter which officer makes the arrest, they’re technically eligible, and it’s the
definition of a missed opportunity. If the police department hasn’t trained officers from Central
station who happen to be making arrests in the Tenderloin or whatever, right, Northern station,
they’re making arrests in the Tenderloin – then that is a missed opportunity. And it’d be great if
the police department could train all their officers who are passing through LEAD eligible areas
about LEAD, or if we could have, and/or if we could have sort of a catchall: the booking deputies
who work at the county jail one, doing intake, who knew the criteria, and could say, ‘Oh, wait a
second, you’re from Central station – you may not know that we have this program and this
person’s charges seem to be eligible and is there a reason why they aren’t being referred?’ Not
that they would have an override, but to at least make sure that officers who weren’t trained but
who are arresting LEAD eligible people – because all that information goes into CMS [Centers for
Medicare & Medicaid Services]. (Legal/Courts Partner #2, 01/29/19)
The LEAD SF Project Management also noted they faced challenges in OW Meetings in terms of figuring
out the priority of various discussion topics (e.g., discussing clients versus addressing procedural and
policy questions). Legal/courts partners and case management staff in the focus groups explained that
they sought to address procedural issues, whereas law enforcement and LEAD SF Project Management
sought to discuss LEAD clients.
The LEAD SF grant proposal establishes that the role of OW is to discuss clients. One LEAD SF Project
Management member explained:
I think there’s been, I mean, certainly in the Operational Workgroup, there’s been some back and
forth, I mean, there’s always tension around whether they’re supposed to be strictly reviewing
clients and cases type of meeting versus talking about process, procedure – so I think there’s been
back and forth and I know we – because there are so many things to discuss on top of the folks
that we’re serving. Um – the parking lot sort of meeting was designed for that. (06/05/18)
However, allotted OW meeting time (two hours) is rarely enough to thoroughly discuss client cases in
addition to other issues. Because OW meeting topics should focus on clients and eligibility and exclusion
criteria, staff created “parking lot meetings,” in which they meet on a separate occasion to discuss items
not covered in the OW. LEAD SF Project Management commented that parking lot meetings grew out of
necessity:
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Because there wasn’t enough time in the OWs. So, it was out of necessity that way. Otherwise,
we would get into more of the procedural and policy discussions and there wouldn’t be enough
time to go over it. (Project Management, 06/05/18)
...in the Operations Workgroup where [name redacted] and [name redacted] were present – and
in the parking lot meeting before it – I had said, like, I wanna address how we’re going to manage
out of county referrals. Because there are issues with out of county – like, clients’ access to
services in San Francisco if they’re located – their stuff is in Alameda or CoCo County or San Bruno
– is a huge issue, and we keep getting these out of county referrals and that was a topic I wanted
to discuss. We didn’t have time for it in the parking lot, so I brought it up again in the OW, and a
couple of out of county clients were presented and decisions were like – well, we’re going to do
this in that case and this in that case and that in that case – and what I brought up at the end of
all of that –‘ So, can we come to some conclusion and some decision as to how we’re going to do
out of county referrals?’ I was like – I was told in that meeting, ‘We just discussed that.’ I was like,
‘We didn’t have a decision. Nobody made a decision and said going forward, this is how we’re
going to manage out of county referrals. You talked about individual clients.’ But I was told, ‘Oh,
we just closed that topic.’ So, you know, I find that – to me, that’s gaslighting. You know, I’m just
going to say, it’s frustrating. (Case Management Administrator, 06/05/18)
Well, that is a huge failure actually because we have the OW and it’s client-focused. There are no
meetings to address operations and logistics and there really should be. But again, that’s the
heavy handed authoritarian rule of DPH, is that we will dictate, you will follow. And you know, I
think we could do a great – we could be much better served to have key stakeholder meetings
that are all about operations and logistics where we look at things and go like, ‘okay, that’s not
working, and this is why it’s not working, how can we address that, how can we fix it?’ And employ
some creative visionary analytical thinking rather than just this lockstep like: [robotic voice] you
will comply. Here is your order. And like, rigid adherence to the letter of the original agreement,
it’s like – it failed. Let’s move on and fix, right? (Case Management Administrator, 10/18/19)
Discussing on-the-ground processes and practices with the OW rather than solely with the Policy
Committee is important for the success of implementation. Contrary to other partner’s perceptions,
Project Management stressed:
Most of the procedural issues that have come up have been resolved in the Operational
Workgroup. We have been able to problem-solve and make decisions as a group in that setting.
The only policy decision that has had to go back to the Policy Committee, since launch, has been
the one to expand the eligible charges. (01/04/19)
LEAD SF focus groups, however, identified both a lack of communication and disconnect between the
OW and the Policy Committee. Some partners argued that the Policy Committee is not well informed
about implementation at the ground-level:
I mean, I wonder if there is – I don’t know, I haven’t really parsed this out, but I wonder if there
were some way to create more linkages between the Policy Committee, the larger Policy
Committee, and then the Operational Work Group, because, you know, if - - there is kind of a
divide between those things, it wasn’t necessarily seamless, and so you’re left with a bunch of
folks who have to implement with a lot of questions that another group of folks decided on. So –
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and I don’t know how that necessarily would have happened, but it feels like we could have been
more seamless. (Project Management, 06/05/18)
But the two lenses have to come together at some point because there has to be a funnel where
we’re saying as the boots on the ground, ‘we’re actually directly communicating with the clients,
we’re entrenched in the community on a daily basis. We have information for you that could
inform how you’re implementing policy that you need to have.’ So, for me that’s a huge
disconnect that’s happening, right, it’s like, well, LEAD should look like this and the grant’s written
like that and here’s your box, and you’re trying to get out of the box, and I’m like – because the
box doesn’t fit what’s really happening, so we need to change the shape of the box, but the box
is the box and you can’t slip out of the box. (Case Management Administrator, 06/05/18)
So, my understanding is in the Policy Committee, it’s all department heads... And you know, yeah,
they’re up there for a reason; they’re knowledgeable, but sometimes you just have to bring in the
lineback to get things done, to get the solutions and the procedures, and you know. (Law
Enforcement Officer, 01/11/18)
As described by these statements, some LEAD SF partners note the importance of having LEAD partners
(both at the policy and implementation levels) come together to bridge disconnects between the goals
and procedures. In fact, many LEAD SF partners felt they had limited or silenced voices in the LEAD
implementation process.
Open Communication and Equal Voices
Officers perceived their voices as not being heard. Specifically, officers expressed disappointment that
their efforts are not recognized by other LEAD partners, particularly at the policy level and that during
the OW, their concerns were dismissed:
And [name redacted] ... said, ‘well, we’re all supposed to be equal.’ I said, ‘well, how are we equal
as cops in the back of the room, like little kids, while the adults talk, and they only talk to us when,
– “hey, you guys, you wrote out the form, do you have anything you want to add? Good, okay,
anyway, so– “and then they start in – “so, anyone want to accept who the officers added?” Yeah,
no, I got a problem. I don’t want them in. I said, ‘So, what are we supposed to be doing? What do
I do?’ I talk to somebody out there, when they ask me, ‘What’s LEAD?’ I don’t know what to tell
them. I see them again, ‘So, what’s going on with LEAD?’ ‘I don’t know, sir. I got you in and you’re
supposed to trust me as a cop, but I have nothing to tell you, because they won’t talk to us.’ They
won’t work with us, and they definitely don’t want us running it. (Law Enforcement Officer,
06/06/18)
And what I heard in Seattle was everyone at this table has an equal voice, right? And we talked
about this when we implemented this, you know, we tried to step on the gas and get a little bit
more activity or in the area of referrals, and it’s about the cops have to be heard. Because they’re
the ones doing the work, not [name redacted], not me, none of us. They’re the ones doing the
work. And if they’re not listened to, like they don’t feel like their input is valuable, then, you know,
game over. (Commanding Law Enforcement Officer #1, 06/05/18)
I mean, you know, I hate to sound like a little kid, like, you know, ‘you hurt my feelings,’ but it’s
just like, if you’re going to do this, and you want to be successful, I would say that everybody has
to have an equal voice, and then everybody has to listen, and sometimes you’re going to have to
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agree to disagree, and there can’t be agendas. We don’t have an agenda in this. The police
department doesn’t have an agenda. You know, we’re sitting at the table going, ‘Okay, fine, you
want us to try this, we’ll try this.’ (Commanding Law Enforcement Officer #1, 06/05/18)
Officers also reported feeling frustrated at their perception that their contributions or concerns at
meetings are either dismissed or forced into silence:
I would rather spend the time – no, we need to talk – once again, because DPH is in charge, they
set the agenda instead of us, and they lose their sense of priorities and importance in life, because
they go back to an office, we go back to the street, with these girls – and I got shut down on the
last one. I don’t know if you guys were there. Because I brought up how they’re getting – the girls,
they’re all raped; some of them multiple times. They’re coming to me and telling me this – human
trafficking going on – including the drug dealers are being human trafficked over here. They’re
paying off the debt – the mules, selling the dope. And I can’t even discuss that. And other people
got mad in LEAD saying, ‘You know what, that’s important to the officers. We should have that
discussion.’ I was told that was triggering people, and I had to be aware of other people’s triggers
– which is bullshit – so again, the mindsets between law enforcement, DPH, and social workers
are so different – we can’t even work together as a professional group. It’s completely
unprofessional. And we’re now going on six months, and we can’t even bring up things we want
to discuss because I might trigger somebody in the room. (06/06/18)
The LEAD SF focus groups highlight how maintaining open communication and allowing all an equal
voice has been a challenge for LEAD SF Administration, especially with “the way meetings are
facilitated”:
Case Management Administrator #1: I feel like as – you know, mature professionals, we could be
having the conversation about race and everyone is fucking so afraid if you bring up race in the
OW, everybody just freaks out, and I’m like, ‘We cannot do this if we cannot maturely and
professionally have difficult conversations about sticky uncomfortable topics, right?’
Case Management Administrator #2: I expect it from the officers, but that’s not necessarily who’s
been having the difficulty making space for the conversations too, so – I mean, the way the
meetings are facilitated...
Case Management Administrator #3: And the work – if you say racial disparity, people freak out.
I’m like, ‘Really?’ Everybody kind of wilts and cringes and is like – I got shut down for using that
term in – when we were meeting... (06/05/18)
A perceived lack of open communication and equal voices around the table hinders stakeholder
investment, collaboration, and agency autonomy.
...say that there are these – there are – this is an issue, and how can we address it, and let’s use
the Operations Workgroups to have some fucking transparent, real, honest conversations about
what the struggles are, what the challenges are, what the resistances are, and how we can
overcome them, instead of being like, ‘Oh, what you see isn’t really what you see;’ ‘Don’t really
look over there because you’re not seeing what you see.’ It’s bullshit. We’re not going to have –
this program is never going to work until we’re all honestly at the table transparently and
collaborating. And butting heads – that’s where the transformation comes from... (Case
Management Administrator, 01/11/18)
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However, according to LEAD SF Project Management, the LEAD National Support Bureau gave them
“feedback to not discuss this at OWs” (12/17/19). LEAD SF Project Management also stressed that
“because these conversations were being pushed by case managers,” “law enforcement stopped
attending [the OWs]” (12/17/19).
Agency Autonomy
Officers were concerned about the general perceived lack of trust in officer discretion and accusations
of biased client selection. For example, officers who attended the focus groups described how one of
the LEAD partners suggested that they document the reasons a person was arrested for a LEAD eligible
offense rather than offered LEAD. While this was rejected, it affected law enforcement:
Like they wanted to have – they wanted to fill out a sheet – they wanted the cops to fill out a
sheet – that was for, you know, I was in on – where the cops explained why they didn’t make a
LEAD referral. Right, it’s kind of like – you can’t – in my opinion you can’t do that to the police
officers. You either trust them or you don’t, right? And we can talk about that here. But you from
the public defender’s office, you from the DA’s office, you from any outside of our own – that is
going to be received as criticism, that’s going to be received as judgment. (06/05/18)
Officers’ concerns are substantiated by recurring Policy Committee meeting discussions about LEAD
clients not reflecting the jail population. The issue of officer discretion and biased client selection also
arose in case manager, case management administration, and Legal/Courts Partner focus groups. Officer
frustration regarding the questioning of their discretionary actions is consistent with their dissatisfaction
of poor communication. To illustrate, the LEAD SF Principles for Policing Role (LEAD SF, n.d.) policy
document clearly states that officers are to document their decisions to offer LEAD or not offer LEAD to
individuals. Since the program relies on officer/sergeant discretion, documenting how that discretion is
used is important for review and re-training.
Still, the perceived lack of trust and the push for oversight highlighted the lack of autonomy the officers
have felt in the implementation process. While the police officers seek to effectively carryout their
responsibilities, they feel that they are frequently criticized and often directed on how to perform their
duties.
So, there it is. You ask me how to fix it and where the problem is – we’re talking about language.
[Name redacted] says it’s speak, communication – we’re not speaking the same language. When
it’s run by DPH, they don’t understand what we do as cops. So, to them it’s just easy to say, ‘Fill
out this form. Fill out that form. Fill out that one.’ We drown in paperwork. If the DA’s office and
the police were running this program...we could say, ‘Oh, no, no, no, no, no – you want pre-
booking? We’re going to have to sit down, and we are going to make it happen.’ (Law
Enforcement Officer, 06/06/18)
And, officers emphasized the need to give officers some level of autonomy since LEAD is law-
enforcement driven:
I think another thing, just for future, like if you’re recommending this program to another agency,
I think what would be key to the success is having – if it’s called a law enforcement assisted
diversion program, that law enforcement really drive the program to a certain extent.
(Commanding Law Enforcement Officer, 01/28/19)
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Line officers, yes. They need to be part of that planning so they can offer suggestions like we are
now and say, ‘Hey, maybe this would work better, sir, if we rolled it out this way.’ (Law
Enforcement Officer, 01/10/18)
First two letters of LEAD are law enforcement. Law enforcement assisted diversion…It’ a diversion
program, driven by law enforcement who know and contact the same people often. (Commanding
Law Enforcement Officer, 10/18/19)
This highlights the need for the LEAD SF’s goal of collaboration and relationship building among city and
community partners. Some partners identified how other agencies interfered with their operations or
violated role boundaries (i.e., attempted to dictate best practices to agencies). Law enforcement
described how case management overstepped their boundaries and how they were able to successfully
resolve it:
We had a run in with – not a run in, but whatever, one of the lieutenants actually was making an
arrest and some LEAD people from [case management agency] said, ‘Wait, that’s our client, we’re
trying to get—‘ and we’re like, ‘No, they have a warrant, and they have to—’ ‘but why does –’ We
knew he’d get away. So, there were two incidents like that. So, we met with [the case
management agency] to work that out and that was resolved. They don’t come and interfere
anymore with our arrests. (Law Enforcement Officer, 06/05/18)
Case management and law enforcement both reported that these concerns were partially addressed by
having officers and case management meet to discuss and reach a point of understanding:
Yeah, we sat down with them over that too because our officers witnessed that and they ended
up venting, you know, about [police officers] to our [case management] guys and then our [case
management] guys told them, ‘You know, you can’t be saying or doing that. They gotta do their
job, you know, and you don’t know what’s going on, and you can’t intervene in that.’ So, we also
had to sit down with those guys about that and – so that kind of made the relationship a little
better because we had a head to head with it – a little discussion, because those things aren’t
understood clearly either, you know, for the clinic and the social worker and the case workers out
on the street. You know, this is new to them too. (Case Manager, 06/05/18)
It has been a learning curve for law enforcement and case managers to work together. And, this
relationship was significantly impacted with the introduction of the inclusion of the Healthy Streets
Operation Center in LEAD.
Healthy Streets Operation Center
In January 2018, the City of San Francisco implemented the Healthy Streets Operation Center (HSOC) to
tackle SF’s homelessness crisis (City & County San Francisco Office of the Controller [SF Controller],
2019). Using coordinated city efforts, HSOC seeks to address issues related to homelessness in SF,
including behavioral health problems, street cleanliness, and public safety (SF Controller, 2019).
Essentially, HSOC is a centralized, or shared responsibility, response to 311 calls (e.g., calls regarding
open drug use on streets, homeless tents, needle waste, etc.) among agencies, including SFPD, the
Department of Public Works (DPW), Homelessness and Supportive Housing (HSH), Department of
Emergency Management (DEM), and Department of Public Health (DPH). Eight months later, in October
2018, the SFPD launched a new initiative called the Healthy Streets Intervention Program (HSIP) to
“intervene and disrupt open air drug use and the quality of life issues associated with it in hot-spot
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areas” (SF Controller, 2019, p. 24). And, HSIP-designated SFPD officers work in partnership with HSOC-
designated officers, where these officers have daily allotted times and specified areas where they
conduct HSIP operations (e.g., connecting homeless individuals to CASC or medical facilities [SF
Controller, 2019]). LEAD SF Project Management explains further:
HSOC is Healthy Streets Operation Center, which is the physical location over at the Department
of Emergency Management where the departments are getting together to delve into
homelessness and come up with solutions in a collaborative way, so it’s the police department
and DPH and that homeless department and DPW who all like, staff this facility and take in calls
and respond with how to deal with individuals. But then there are special projects out of HSOC –
HSIP is one of those… So HSOC sends out or has a team of about 50 SFPD officers who are HSOC
officers. They’re basically homeless outreach officers. And, in these HSIP operations, they send
out those officers and ask them to engage with anybody who’s out on the street and say, ‘You
know, do you want services? Do you want to be linked with case management? Do you want blah,
blah, blah?’ And, whoever they can get to agree with anything they’ll bring into the CASC.
(10/18/19)
Around July 2018, LEAD SF began a collaborative partnership with HSOC (Quarterly Reports 5, 6, & 7). In
fact, between July and December 2018, the LEAD Program Manager trained officers operating out of
HSOC in LEAD SF procedures. Part of this collaboration, according to LEAD SF Project Management, was
in part due to the potential overlap between HSOC/HSIP referred individuals and LEAD clients.
The police department started this, as a time when they would pick a day or several hours in a
day where they would send their officers out on the street and totally focus on connecting people
to services, not thinking about arrests at all, so aiming to serve the population of people that are
out there openly using drugs. So, we said that those sound like our clients, so as part of LEAD,
you know, if you want to refer them to us, do it. And it’s sort of turned out that way. (Project
Management, 01/29/19)
In fact, officers, over time, regarded HSOC as a LEAD social contact referral equivalent without the LEAD
paperwork and referred to HSOC as just another services connection tool whose target population
largely overlaps with LEAD.
So, the HSOC that they talked about, the homeless, you know, program, that’s huge. And LEAD
overlaps in many, many ways… Because the people who are chronically homeless, particularly all
the people who are drug users – they will often be people who are also – that the police are
constantly in contact with for law enforcement assisted diversion. You know, because they’re
committing – breaking into cars and so forth. So, it’s a lot of the same people that you’re dealing
with. And then, even forget HSOC, forget LEAD, it’s just the same people you’re talking to every
day. So, there’s all kind of overlap and most of us have made relationships with like, pre-trial
diversion – you know, there’s so many different agencies operating in San Francisco. If they would
just all talk to each other, it would just be so much easier to provide services. (Commanding Law
Enforcement Officer, 01/28/19)
According to the SF Controller (2019), HSIP builds on lessons learned from LEAD SF. HSIP clients, like
potential LEAD clients, are referred by SFPD and/or Adult Probation Department (APD), are assessed by
DPH clinicians at the CASC, and could then be referred to LEAD, if appropriate.
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The introduction of HSOC/HSIP to LEAD SF marks an important deviation in model fidelity, and it
emerged as a concern for LEAD SF case managers and case administration staff. Specifically, case
managers and case manager administration staff expressed concerns that HSIP/HSOC practices are the
antithesis to harm reduction and that it has begun to impact case mangers’ ability to build relationships
with law enforcement and clients. This was attributed to losing the warm hand-off component that both
makes LEAD unique and facilitates rapport-building between LEAD clients and case managers.
So, there’s 32 full time officers devoted to Healthy Streets Operation Center and also Healthy
Streets Intervention, right. So, the nature of the relationship of the law enforcement has changed.
When it was still – when HSOC was sort of in its early formulation stages and LEAD was rolling, we
had more kind of in the moment direct referrals. They would call us, we would show up in the
street. And then, somehow the narrative shifted, where the CASC and DPH became the kind of
like direction that they sent people to. So that was the absence of what I view as the warm
handoff from police. And I think that the absence of that changed the outcome; so that it’s
basically about relationship building with a really super challenging marginalized population that
– there’s no question that many of them – some more and some less, need some – I don’t know
– are asking for some assistance in the situation that they’re in. In the absence of a warm handoff,
we -- now at the last Operational Work Group, we went into the – I don’t know if it was the last
one or the one before that – but we went into the Operational Work Group with a list of 25 roughly
names of new referrals, which is great, right, a bunch of new referrals for the LEAD program. Four
of them, we have an actual relationship with. All the rest of them were referred to LEAD as a sort
of paper process, and a sort of, you know, to use your [another case manager’s] analogy, like the
velvet glove thing, right? Because we’ve become the garment of righteousness, in a situation that
like, isn’t that, you know? The thing is, is that these relationships that we make with clients are
still strong. When we get an opportunity to work with a client directly, the outcomes are great.
(Case Manager, 01/28/19)
Case Management Administrator: I think it’s [warm handoff] lost to the culture. Um – so one of
the challenges that I see that’s developed in the last six months is the folding in of HSOC into the
LEAD program, right?
Interviewer: So that’s a part of LEAD now? What do you mean by folding in?
Case Management Administrator: It is. Well, HSOC is the main LEAD referrer now, right? And so
for me that’s problematic on a couple of levels, right? The first one is it was done unilaterally
without discussion of the key stakeholders in the Operations Work Group. So, it was a decision
made by DPH. And, at [service agency] we’re struggling with that because of what they do and
what it means. But as a result of that, the referrals are more – HSOC does their sweeps and sends
people to the CASC and then those people, we get a sheet of paper that has a name on it and then
that’s it. And then those people are ghosts. So, they’re sort of meaningless referrals. (01/28/19)
Case Manager #1: HSOC isn’t part of the contract.
Case Manager #2: It’s not part of LEAD, it’s not part of anything that is doing anything positive.
Case Manager #1: It’s overshadowing LEAD.
Case Manager #2: Target people who are living on the streets, and clear that area so that they can
take a picture and post it on Twitter to say look at our street, and what we did. And then 30
minutes later, everybody is back, and there’s no change. And the only thing that happened in
those interactions was people were afraid and maybe lost some of their property because DPW
takes it. And maybe had to move. So harm, harm, harm.
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Case Manager #1: And we’ve noticed too that - this is also not a positive – we’ve noticed too that
the referrals we get from those HSOC interventions are one and dones. Like, the people don’t
stick. It’s situational compliance. They just say oh yeah, yeah, cool. I’ll go do whatever the hell
you want to do that’s not jail. And then they don’t stick around. (10/18/19)
Case Management Administrator #1: A challenge that hasn’t been realized is addressing the over-
incarceration of African-Americans in our county jail system through pre-booking referrals has not
been addressed, right? And when we got on to the LEAD program that was our buy-in, that that
was going to be – it was going to address, you know, the war on drugs, and how that’s over-
incarcerated people of color. And what I think is happening since the involvement of HSOC and
HSIP is that we’re getting more people who are drug involved with behavioral health issues and
mental health issues on the street who are unhoused. And those are the bulk of the referrals. So
LEAD sort of instead of addressing recidivism and the over-incarceration of people of color, it’s
being used to address behavioral health issues on the streets, fundamentally, right?
Case Management Administrator #2: There’s already state departments that are funded for doing
that.
Case Management Administrator #1: Yes, it shouldn’t be a LEAD issue.
Case Management Administrator #2: And so we’re looking at – the point of LEAD is to be involved
in the criminal justice process to prevent arrests.
Case Management Administrator #1: Recidivism, yeah.
Case Management Administrator #2: So what we’re seeing is like – some law enforcement are
looking at LEAD as if it’s SF HOT, which is basically an organization that is paid by the city to go out
and engage homeless people in San Francisco. You know, they’re missing the law enforcement
part. It’s like yeah, we do what they do, but only when you’re about to arrest somebody, and also
we have the case managers to carry people and take on a case load, whereas HOT is really –
doesn’t have case managers anymore, they’re really just a straight up referral, you know, they
may drive you to the appointment… (10/18/19)
However, these concerns were heard by all LEAD partners, including law enforcement. The LEAD
National Support Bureau also stressed that these operations are not LEAD. Thus, these HSOC operations
have ceased (Quarterly Report 9).
Ultimately with the service support from the LEAD National Support Bureau, we decided that we
were moving further and further away from like, the LEAD model of like, having the officers
present LEAD to the clients and say this is what it is, you know, this is what you would get from it,
do you want to participate in this and having the individual out on the street like, make a conscious
decision about it. Instead they’re just like, come on down! Or like, do you want to go to jail or do
you want to come with me? You know, like, one or the other of those, which isn’t really what we
were hoping for. So we had conversations with the police department and they heard that and
understood that and so we’ve stopped – so they’ve stopped doing those operations for now.
(Project Management, 10/18/2019)
After-Hours Availability
An additional challenge that emerged from client survey data is that of staff’s after-hours availability.
When asked what clients disliked most about the LEAD program, client’s referenced access to case
managers post business hours and case manager client capacity. Clients noted that not having access to
the case managers after hours is a program drawback. Clients need to talk to/see someone after
working hours and on weekends. Having someone available during those times would be helpful. Some
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clients suggested having a 24/7 hotline specific for LEAD clients. Further, clients noted that the increased
case manager workloads (i.e., case manager-client ratio) meant less time spent with their case manager.
There's no...Everything happens between 8-5 pm.’ …I wish there was a LEAD after hours, like
needle services, like a hotline for when crisis happens. Like no matter how old you are, not just
adults are addicts. There's times I was using and [name redacted] was there only from 9-5, so I'm
left on the streets with nobody to talk to and have to wait until next morning. (LEAD SF Client)
Well okay, one thing, they're not 24 hours. No after-hours, which may be to their detriment
considering their targeted group. I know a little about targeting because I've been in retail
management. And, when you're in retail and you want to target a specific group, you get a hold
of them when they are most commonly available. It'd be better from lunch or right before lunch
to the evening, for people like myself, the mature/older population, after dinner services. (LEAD
SF Client)
References to afterhours availability is not client-specific as these sentiments were also reflected among
some of the officers who participated in the focus groups (although, it did not emerge as a common
theme across focus groups). Officers noted the lack of staff availability after-hours inevitably leads to
missed opportunities, as officers have no avenue for connecting a client to LEAD. Officers also noted
that with LEAD’s target population, it is more common than not for officers to come into contact with
these individuals during evenings, at night, and on weekends. Additionally, even if officers try to refer
individuals after hours, the likelihood that they can re-engage client during business hours the next day
is diminished.
Law Enforcement Officer #1: So, what happens is DPH – all of our resources, all of our tools, are
only open nine to five Monday through Friday. We’ve been telling them that from day one. And
every time I tell them, somebody in LEAD who’s dying – was – I rescue like one – like that girl
[name redacted.] It’s raining out, she was freezing cold, she couldn’t even talk her pneumonia
was so bad – she probably would have died that weekend. [Name redacted] and I drove her to
Goodwill, bought her clothes with our own money, bought her food, and when I tell them in LEAD
– ‘Why didn’t you call us? You need to call us.’ I’m so mad – I literally just yelled at them because
I’ve been telling them for over a year, ‘I work the weekends. Are you giving me permission to
wake your ass up on a Sunday morning at seven, [name redacted]?’ Because that’s what I’m going
to start – and I started doing that a couple of times. ‘Oh, I’m sorry, I’m off duty.’ ‘Oh yeah, I know
that, but you keep telling me the same god damn thing.’ So, what’s the point of six million dollars
if there’s nobody there when you need them?
Law Enforcement Officer #2: So let me add to that real quick – that would be a huge bonus, you
know, if you could extend it to seven days. And even, you know, if that didn’t happen, extending
it to one day in the weekend and then later hours. (01/29/19)
Law Enforcement Officer #3: They’re not seeing – I mean, we start at 4am in the morning, like,
literally – there’s not a single other person out there besides us and the people –
Law Enforcement Officer # 4: Lying on the sidewalk.
Law Enforcement Officer #3: They have no – they’re all gone by the time they go to work, for the
most part. You know, and so they’re not seeing –
Law Enforcement Officer #5: You see that bottom of the barrel, okay, so you see that, and then
mental illness, mental health – and all the stuff that this particular program – this one’s not a hit
on this program – everything that is offered is Monday through Friday, eight to four, in a nice tidy
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little box. So even if we run into people that are looking for help on the weekend, what am I going
to do? ‘Hey, check with me on Monday and I’ll see if I can –.’ (06/06/18)
Officers concerns about this issue did not go unnoticed. LEAD SF Case Manager Administration staff
were aware of these problems:
Case Management Administrator #1: We don’t have anybody to refer to after five. So, a lot of
those clients that are in the Mission that we don’t see – some of them come after five. Or, some
of them may come on the weekend.
Interviewer: So, this is a consistent issue?
Case Management Administrator #2: Yeah. (01/28/19)
Recognizing this as an issue, focus group data, Policy Committee meeting minutes, and Quarterly
Reports reflect how partners worked together to address the problem. Two solutions were
implemented. First, LEAD SF staff worked actively to get in contact with clients who were referred to
LEAD after hours:
So we encourage officers to only make referrals during business hours because we know that’s
when there can be a warm handoff for a client to come directly to us or the case manager. It’s a
lot harder for them to make it in. But, we have had officers refer in off hours, and so they’ll send
us the cover sheet, and then they’ll talk with the case managers about who this person is, where
they typically are, and then the case managers will work with police to outreach to that person.
We have been successful in finding those folks and getting them in for assessment later. (Project
Management, 01/10/18)
Second, by Quarterly Report 6, CASC extended their hours to 8:00 pm on Wednesdays (previously
Tuesdays) to allow for evening referrals at least once a week, and according to Quarterly Report 8 and
the 10/18/19 focus group with project management, CASC hours are now extended Monday-Friday until
10pm. These new hours are funded through their Proposition 47 grant. Further, Quarterly Reports state
that case managers shared their mobile phone numbers with officers to encourage communication
between both partners, which law enforcement officers in focus groups as late as October 2019 stressed
that they used.
Summary of findings
This study used qualitative analysis in the form of thematic and content analyses to conduct the process
evaluation of LEAD in SF. Data from focus groups and interviews with LEAD SF implementers, LEAD SF
policy and procedures documents, LEAD SF meeting minutes and Quarterly Reports, and surveys with
LEAD SF clients provide answers to this evaluation’s research questions. For research question #1,
whether LEAD SF’s model is consistent with past LEAD efforts in Seattle, comparisons of LEAD Seattle
and SF policies and procedures documents indicate that LEAD SF has two key differences–an extra
intake step and an anomalous referral stream–from LEAD Seattle. Interviews/focus groups and LEAD SF
policy and procedural documentation indicate that LEAD SF was initially implemented with fidelity
(research question #2) but has since deviated from that path and faced various barriers throughout
implementation (research question #3). Its most significant barrier is stakeholder buy-in, primarily from
law enforcement. LEAD SF partners discussed in detail other barriers including communication, as well
as facilitators, such as building relationships (question #3), that they encountered in executing their
specific LEAD roles and LEAD more generally. These interviews and focus groups also identified specific
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LEAD SF successes (e.g., client outcomes) and challenges (e.g., cultural shifts [research question #4]),
which policy and procedure documents and LEAD SF client survey data substantiated.
Data from the interviews/focus groups and LEAD SF policy and procedural documenting highlight the
successes and challenges SF faced early on and throughout the implementation of LEAD. Findings
indicate that LEAD SF had four key successes: collaboration, relationship building, client successes, and
changing perceptions of police. LEAD SF staff reported that collaboration between LEAD partners was
not only a success, but it also facilitated partner relationship building (although, this may be declining),
which granted partners an opportunity to better understand one another’s role and led some case
managers to have positive changes in their perceptions of police officers. Further, the collaboration and
relationship building helped partners connect clients to health and social services. These successes also
helped case managers build rapport with clients. Data from the client survey open-ended questions
substantiate these successes. For the most part, participants reported positive interactions with their
case managers and police officers. In particular, clients noted that case managers played an important
role in helping them structure their day-to-day lives, getting access to health, social, and legal services,
and giving them a sense of self-worth.
LEAD SF also faced numerous challenges, the primary being stakeholder commitment from police
officers. San Francisco’s LEAD program struggled to secure buy-in from police officers early on and
throughout implementation. This low, or lack of, officer buy-in was directly or indirectly associated with
other challenges including cultural shift, LEAD applicability, agency autonomy, training, open
communication, and the broad implementation of the Healthy Streets Operation Center (HSOC). LEAD SF
struggled to secure officer buy-in, which was reported as being crucial to implementation by both
officers and other LEAD partners. This lack of officer buy-in was affected by LEAD SF’s challenges in
maintaining clear and open lines of communication regarding LEAD goals, philosophies, and procedures;
a lack of continuous harm reduction trainings; diminished officer autonomy, and a perceived lack of
equal voices at the table. Other challenges affecting officer buy-in were SF’s existing laws on low-level
drug and sex worker offenses, which officers regarded as diminishing the purpose of and questioning
the applicability of LEAD in SF. Nonetheless, the clients who have been referred have experienced
significant changes in their lives and well-being, and the relationships that were created among the
agencies, particularly law enforcement and case management has been robust.
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7. Outcome and Costing Evaluation: San Francisco
Method
Evaluation design
While randomized controlled trials (RCT) represent the gold-standard in program evaluation design, real
world constraints precluded randomizing individuals into LEAD and control conditions. One of the
primary arguments against an RCT was the damage removing police discretion might have on obtaining
police officer buy-in, especially since prior research suggests officer commitment is the key to LEAD
success (Clifasefi & Collins, 2016). Another primary argument against an RCT was the potential ethical
concern of having identified a person in need (i.e., a person suffering from drug problems or performing
sex work under the control of a procurer [pimp]) and not offering them LEAD. Therefore, this evaluation
represents an equivalent-groups longitudinal quasi-experimental field trial design. This is the same
research design used by the Seattle LEAD evaluators (Collins et al., 2019).
Measures
Sociodemographic and program data were obtained from treatment providers (Felton and Glide) and
the San Francisco Department of Public Health (SFDPH). Criminal history data were provided by the San
Francisco County District Attorney’s office (SFDA). These data include citations, arrests, and filed cases
occurring only in the City and County of San Francisco between January 2011 and August 2019. Criminal
history data were then divided into six time periods – six month pre-LEAD referral or eligible charge date
and six month post-LEAD referral or eligible charge date, 12 month pre and post, and 18 month pre and
post. Arrests were collapsed by day, and categorized into one of the five criminal history outcome
variables – citations, misdemeanor arrests, felony arrests, misdemeanor cases, and felony cases. Future
research will add statewide criminal history data from CADOJ; however, that data were not available
during the writing of this report (December 2019).
The authors have requested data on jail bookings and days spent in jail in San Francisco County from the
San Francisco Sherriff’s Department (SFSD), but at the time of this report (December 2019) the data
were still not provided. The authors have also requested data on probation system utilization in San
Francisco County from the San Francisco Adult Probation Department (SFAPD), but these data were also
not provided in time to be included in this report. We are expecting these data in January 2020. As there
were no state prison sentences for the pre or post-measures (reported in SFDA data) for either the
comparison or LEAD group, no data were requested from the California Department of Corrections and
Rehabilitation (CDCR).
Costing measures were divided into two categories – LEAD program costs and criminal justice system
utilization costs. LEAD program costs were provided by SFDPH, and include monthly costs for the
following positions/services: health program coordinator, behavioral health clinician, SFDA attorney and
paralegal assistant, SFADP deputy probation officer and probation assistant, San Francisco Public
Defender attorney and legal assistant, case management services, and indirect administrative costs. We
made a deliberate attempt to use similar criminal justice utilization measures as the Seattle LEAD
costing study (Collins et al. 2019) in order to aid in comparability and future systematic reviews of LEAD.
These measures include prosecutorial and defense costs for misdemeanor and felony cases and were
provided by the SFDA and SF Public Defender’s Office. Jail and probation costs will be added as soon as
data are provided by the relevant departments. We made one notable addition to the Seattle costing
study – police costs of arrest.
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Participants
This evaluation included 429 adults in San Francisco, CA, suspected of recent drug or sex work offenses
between November 2017 and February 2019.
Group allocation
San Francisco Police Department, BART Police Department and the San Francisco County Sheriff’s
Department officers diverted individuals to LEAD using two separate mechanisms. First, pre-booking
diversion was used if individuals were found committing eligible offenses during the officers’ shift
(N=67). Second, social contact diversion was used when individuals were known drug or sex work
recidivists suspected of recent drug or sex work activity, but not found committing an eligible offense
during the time of referral (N=127). There were no significant differences between social contact and
pre-booking referrals on demographics, and only two on pre-referral criminal history measures
(misdemeanor cases at six months and eighteen months) (see Table 10-7 in the Technical Appendix).
Therefore, there was no need to consider social contacts or pre-booking clients in separate groups for
the outcome and costing analyses. For the rest of the analyses, the groups will be aggregated to one
LEAD (treatment) group (N=194).
For the purposes of this evaluation, a comparison group was drawn from non-referred individuals who
were arrested for LEAD eligible offenses from the same geographical area (N=235).2 Although the
comparison group came from the same two districts of San Francisco, selection effects could bias the
LEAD sample. For example, officers could have selected subjects for the program based on their belief
that the client would benefit from LEAD. We compared LEAD and comparison groups on all available
demographics and criminal history variables, over the three time-periods. In both the 6-month and 12-
month follow up periods, we show statistically significant differences on two demographic items (sex
and race/ethnicity) and three pre-implementation period outcomes (citations, felony arrests, and felony
cases). The 18-month pre-implementation period had significant differences in the same outcomes, but
not demographics (see Table 10-8 in the Technical Appendix).
We used PSM to address the significant differences between the LEAD and comparison groups (Shadish
et al., 2002), thereby minimizing selection bias (Apel & Sweeten, 2010). Essentially, PSM approximates
randomization by comparing individuals that have overlapping values of pre-treatment measures.
We used a logistic regression model to create propensity scores. Treatment assignment (1 = LEAD client;
0 = individual from comparison group) was predicted using sex, race (White, Black, other), age at
referral/eligible offense, and the five pre-treatment outcome measures (citations, misdemeanor arrest,
felony arrest, misdemeanor case, and felony case). Nearest neighbor matching was used to match
treatment and comparison cases at a 1:1 ratio. PSM was conducted separately for each recidivism time-
period (6 month, 12 month, and 18 month). For example, to create the matched comparison group for
the six-month follow-up, all 194 LEAD clients and 235 comparison group individuals were eligible.
However, for the twelve-month follow-up, LEAD clients needed to have at least 12 months between
2 This list was compiled by the SFDA’s Office, the SF Public Defender’s office, and the SFPD. Because of staff
turnover and access to different data at each office, this list may not be exhaustive of everyone eligible for the
LEAD program in the Mission and Tenderloin districts. However, the researchers maintain that this list was more
valid than developing a list through the local criminal history database, as individuals were filtered for exclusion
criteria.
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referral date and the date their criminal history was pulled (N=115), likewise for individuals in the
comparison group (N=147). In order to achieve adequate balance, some LEAD clients were removed
from the analysis (less than 15% per time-period). For more detail on the PSM process refer to the
Technical Appendix.
We compared predictor variables between the LEAD and comparison groups after PSM to assess
balance. PSM improved the balance of the pre-treatment covariates between the LEAD and comparison
groups. There were no statistically significant differences between the LEAD and PSM comparison
individuals in all but one variable – citations (see Table 10-9 in the Technical Appendix). The 12 and 18-
month pre-treatment indicator for citations remained significant. While it is relatively common to have
problems balancing covariates in applied criminal justice settings (Groff et al. 2019), it is still important
to keep this in mind when interpreting citation outcomes for LEAD San Francisco.
Primary analyses
We used generalized estimating equations (GEEs) to model the effect of LEAD on the five criminal justice
utilization measures for each time period (6 month, 12 month, 18 month). The model for each outcome
included a treatment indicator (LEAD vs. comparison) and a covariate measuring the pre-treatment
outcome levels. For example, the model for 6-month post-treatment felony arrests included a measure
of 6-month pre-treatment felony arrests as a covariate. Because each of the outcome measures were
overdispersed counts (Long & Freese, 2014), negative binomial regression models were deemed most
appropriate. To aid interpretation, we exponentiated the effect sizes to produce odds ratios (ORs).
Alphas were set to p = .05, indicating statistically significant results. Confidence intervals were set to
95%. All models were estimated using GEE commands in SPSS 25. The Technical Appendix includes the
syntax and outputs for each model.
Results
LEAD effects on criminal justice and legal system utilization
Table 7-1 displays the negative binomial regression results, and Table 7-2 shows the odds ratios for the
significant results. Below, we discuss each follow-up period separately.
Table 7-1: LEAD SF criminal justice outcomes by group
Variable 6 Month Post 12 Month Post 18 Month Post
LEAD Comp Sig. LEAD Comp Sig. LEAD Comp Sig.
N 171 171 98 98 40 40
Citations [M(sd)] .18 .05 Wald .22 .14 Wald .43 .33 Wald
(.51) (.24) X2=7.93* (63) (.54) X2=.46 (.81) (.76) X2=.02
Felony Arrests .19 .17 Wald .14 .39 Wald .25 .25 Wald
[M(sd)] (.54) (.49) X2=.34 (.50) (.74) X2=6.12* (.59) (.54) X2=.00
Misdemeanor .09 .26 Wald .08 .46 Wald .18 .53 Wald
Arrests [M(sd)] (.41) (1.04) X2=6.20* (.34) (1.43) X2=10.55* (.59) (.91) X2=3.67
Felony Cases .12 .13 Wald .08 .29 Wald .10 .23 Wald
[M(sd)] (.43) (.43) X2=.08 (.37) (.64) X2=5.87* (.30) (.53) X2=1.91
Misdemeanor .04 .07 Wald .02 .13 Wald .03 .13 Wald
Cases [M(sd)] (.24) (.28) X2=1.45 (.20) (.40) X2=3.21 (.16) (.33) X2=2.24
*Group difference p<.05
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Table 7-2: LEAD SF odds ratios for significant criminal justice outcomes
Significant Outcome Odds Ratio 95% Confidence Interval
Citations at 6 months 0.28 .09 – .25
Misdemeanor arrests at 6 months 3.02 1.26 – 7.19
Felony arrests at 12 months 2.57 1.22 – 5.44
Misdemeanor arrests at 12 months 6.23 2.06 – 18.77
Felony cases at 12 months 3.60 1.27 – 9.44
6-month. Two outcomes in the six-month follow-up were significantly related to LEAD participation.
First, citations were about 72% higher for LEAD clients than individuals in the comparison group, taking
into account pre-treatment levels. Second, misdemeanor arrests were three times higher (302%) for the
comparison group, also taking into account pre-treatment levels. There were no significant differences
for felony arrests, or either felony or misdemeanor cases.
12-month. Three outcomes in the 12-month follow-up were significantly related to LEAD participation
(see Figure 7-1). First, felony arrests were about two and a half times higher (257%) for individuals in the
comparison group, considering pre-treatment levels. Second, misdemeanor arrests were over six times
higher (623%) for the comparison group, also taking into account pre-treatment levels. Third, felony
cases were three and a half times higher (360%) for the comparison group, considering pre-treatment
levels. The result for misdemeanor cases was approaching significance (p=.07) in the same direction as
the results above. Also, while the result for citations is insignificant, the PSM did not balance citations at
the 12-month time period. Therefore, it is likely that despite the absolute difference between groups
(LEAD = 0.22 citations; Comparison = 0.14 citations), the difference was insignificant due to
pretreatment levels of citations.
Figure 7-1: LEAD SF 12-month criminal history outcomes by group post-treatment
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18-month. No outcomes in the 18-month follow-up were significantly related to LEAD participation.
However, for the case of misdemeanor arrests, felony cases, and misdemeanor cases, this is likely due to
the small sample size (only 40 per group). Also, while the result for citations is insignificant, the PSM did
not balance citations at the 18-month time period. Therefore, it is likely that despite the absolute
difference between groups (LEAD = 0.43 citations; Comparison = 0.33 citations), the difference was
insignificant due to pretreatment levels of citations.
LEAD effects on criminal justice system costs
LEAD program costs. We detail average monthly LEAD program costs in Table 7-3. Program costs
reduced as more clients became active in the program (see month-by-month cost breakdown in Table
10-10 of the Technical Appendix). The average cost per LEAD client in San Francisco was $1911. As in the
Seattle evaluation, we reduced costs to just case management and legal services per client, which
equaled $1301 per month in San Francisco compared to $899 in Seattle (Collins et al. 2019). The annual
cost of LEAD case management and legal services in San Francisco is $15,612 per client.
Table 7-3: LEAD San Francisco program costs
Cost Average per month
(Nov 2017-June 2019)
Health Program Coordinator $9,845
Behavioral Health Clinician $9,732
SFDA Attorney $10,332
SFDA Paralegal Assistant $7,196
Probation Assistant $6,903
Deputy Probation Officer $7,895
SF Public Defender Legal Assistant $8,708
SF Public Defender Attorney $14,627
Family Service Agency $26,547
SF Public Health Foundation $3,125
Glide $32,268
Indirect 10% $13,276
Total cost $146,031
Total cost per client $1,911
Case management and legal cost per client $1,301
Criminal justice system costs. We endeavored to calculate criminal justice system costs using four
measures: 1) police costs by arrest, 2) legal costs by filed case; 3) jail costs; 4) probations costs.
Unfortunately, data for jail and probation were not provided at the time of this report and are not
included in cost estimates. We anticipate being able to add these costs in early 2020.
Police costs by arrest type (felony vs. misdemeanor) was determined using a method developed by
Hunt, Saunders and Kilmer (2018). We chose the difference between felony and misdemeanor theft to
be a proxy for all felony and misdemeanor arrests. To get a low/high expenditure on responding to
crime in California, we take the overall amount of money spent in California for Part 1 UCR crimes and
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multiply that by the proportion of general officer time spent on crime. We then multiply that number by
the time spent on felony and misdemeanor thefts to separate expenditures responding to felony theft
vs misdemeanor theft. We now divide by the number of felony theft arrests to get cost per felony theft
arrest. We do the same for misdemeanor theft arrest. Therefore, misdemeanor arrests were assigned a
policing cost of $1877, and felonies were assigned a policing cost of $7528.
To maintain comparability with the Seattle LEAD evaluation, legal costs were average, monthly
estimated costs associated with felony and misdemeanor cases (i.e., prosecution and public defense).
Seattle evaluators estimated costs for misdemeanor and felony cases to be 1/400 and 1/100 prosecution
and public defense salary per year (attorney and support services), respectively (Collins et al., 2019).
Using the monthly salary for a SFDA attorney and paralegal assistant (see Table 7-3), the annual salary
for prosecution is $210,336. Using the same calculation for a SF Public Defender Attorney and legal
assistant, the annual salary for defense is $280,020. Therefore, misdemeanors were assigned a cost of
$1226, and felonies were assigned a cost of $4903.
Figure 7-2 shows that post-treatment costs went down significantly for LEAD clients, from $4252 to
$1653, compared to individuals in the comparison group, which went up from $4757 to $5344 (see
Table 10-11 in the Technical Appendix for model statistics).
Figure 7-2: LEAD SF pre and post treatment criminal justice system utilization costs by group
Discussion
At the 6-month follow-up, clients in San Francisco’s LEAD pilot program have more citations, but
significantly less misdemeanor arrests than the system-as-usual comparison group. This finding could be
due to a true reduction in the severity of crimes committed by LEAD clients, or it could be police officer’s
reluctance to arrest LEAD clients. However, because no LEAD flag on is the client’s record, SF officers
had low buy-in in LEAD, and the majority of officers would not know if an individual is in LEAD, this
finding is not likely due to police reluctance to arrest.
At the 12-month follow-up period, LEAD clients had significantly lower rates of misdemeanor and felony
arrests, and felony cases. Notably, the significant increase in citations for LEAD clients seen at the 6-
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month follow-up was not present after a year in the program. These positive findings are likely due to
the harm-reduction nature of LEAD. LEAD participants’ case managers also coordinated with San
Francisco public defenders to assist with active cases as to not compromise LEAD intervention plans
(Collins et al. 2019).
The lower recidivism for LEAD clients translate into a one-year criminal justice system utilization cost
savings of $3691 over system-as-usual comparison individuals. However, due to data availability, these
costs do not include jail or probation costs, so the criminal justice savings are likely underestimations. In
addition, other system cost savings were not included in this analysis (medical and mental health
system, in particular).
As in the Seattle evaluation, we reduced costs to just case management and legal services per client,
which equaled $1301 per month in San Francisco compared to $899 in Seattle (Collins et al. 2019). The
annual cost of LEAD case management and legal services in San Francisco is $15,612 per client.
LEAD SF case management and legal costs ($15,264 per year) were significantly more than Seattle LEAD
program costs ($10,788 per year). However, since Seattle LEAD saw reductions in program expenses
over time, there is reason to believe that LEAD SF will also see reductions in operating expenses as the
program becomes more efficient and client participation increases.
Limitations
The LEAD San Francisco outcome and cost evaluation had four key limitations. First, given real-world
implementation realities, we employed an equivalent-groups longitudinal quasi-experimental field trial
design in lieu of an RCT. We used methodological and statistical techniques, similar to the Seattle LEAD
evaluation, to increase the similarity of the LEAD vs. system-as-usual comparison group (Collins et al.
2019). For example, the list of individuals eligible but not referred to LEAD were reviewed by members
of the Policy Committee in the SFDA, SFPD, and San Francisco Public Defender’s Offices. If a reviewer
deemed the individual not appropriate for LEAD, the individual was removed from the list. We also
reduced the influence of selection bias by using propensity score weighting. While these techniques are
not foolproof, they are commonly used in the social sciences to increase confidence in field evaluations.
Second, some significant baseline differences between LEAD and comparison groups exist. Specifically,
the LEAD group has more female and White participants, and the comparison condition has a higher
proportion of Blacks/African-Americans. Fortunately, these factors were successfully balanced by
propensity score matching.
Third, data available at the time of writing this report were limited to local criminal history with a
relatively short recidivism follow-up. Although the SFDA local criminal history dataset is large, it provides
coverage only of arrests by the San Francisco Police Department (SFPD), San Francisco Sheriff’s
Department (SFSD), and the BART police. Arrests occurring in other California jurisdictions do not appear
in these data. Since the pre and post-treatment time periods were relatively short, this is limitation is
minimized, but still significant. To develop a more complete picture of criminal activity, criminal histories
will be supplemented with statewide data from CADOJ in the coming months.
Fourth, criminal justice system cost utilizations are incomplete due to missing jail and probation data.
This will also be rectified over the coming months when these data are received.
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8. Conclusion
Findings from both Los Angeles County and the City and County of San Francisco process evaluations
demonstrate that stakeholder investment particularly from law enforcement, effective case
management rooted in harm reduction, and robust relationships among the partners are critical to
successful LEAD implementation and LEAD client successes. Ensuring that all partners have an equal
voice at the table and are able to have open communication can greatly facilitate LEAD implementation
and partner collaboration, which can allow the LEAD team to overcome challenges to implementation.
Relying on the LEAD National Support Bureau for guidance throughout implementation can further
address obstacles that arise.
Findings from the City and County of San Francisco outcome and cost evaluations indicate LEAD reduced
average yearly criminal justice system utilization and associated costs over system-as-usual
comparisons. While this evaluation suffered from several limitations, we used methodological and
statistical approaches to increase our confidence that the effects were due to LEAD and not because of
confounding factors. Taken together, this evaluation adds to the evidence supporting LEAD as a
promising alternative to the criminal justice system as usual.
Future research will add criminal justice system utilization outcomes and costs as the data become
available.
Summary of advice for future LEAD sites from LEAD LAC and LEAD SF
Committed stakeholders are key to successful program implementation. This involves the careful
selection of partners that are not only bought-in to the program but are also open-minded, flexible,
willing, and proactive participants in the implementation of LEAD. Sites should ensure they have
dedicated law enforcement partners. Based on the size and the number of law enforcement
departments at the new LEAD site, securing buy-in from a curated selection of officers, primarily officers
who are respected in their departments, can be more feasible than department-wide implementation.
In addition to committed officers, dedicated case managers are also key. In particular, sites should seek
case managers who have both field and lived experience and are well-versed in harm reduction.
Once dedicated partners are at the table, thorough and ongoing training on LEAD procedures and harm
reduction philosophies, especially for law enforcement, is necessary to securing buy-in and improving
program implementation. Additionally, it is recommended that both law enforcement and case
managers are able to spend time training with the LEAD Seattle Bureau, especially prior to
implementation but throughout to see how the program works in practice.
Strong leadership and effective program management is necessary. Program management should
ensure that all partners have an equal voice/role in the implementation of LEAD. Specifically, law
enforcement should have some level of program ownership, as they are key drivers of the program.
Case managers also must be heard, as they can be easily overworked by the sheer number of cases and
the amount of paperwork; burnout can happen quickly.
Program managers should work to ensure staff are and feel supported (i.e., feel heard, have the
resources to fulfil their roles). Program management shall ensure open lines of communication, as this
is essential to developing good working relationships among LEAD partners. This includes clear and
transparent communication (e.g., paper trail) of clients’ progress, as this facilitates accountability,
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credibility, and trust among partners. Moreover, open communication about LEAD’s goals and
objectives is key to ensuring partners have a clear understanding and to facilitate reaching common
ground.
Program management must also be responsive to ongoing challenges. Maintaining open and working
relationships with the LEAD Seattle National Support Bureau can help address implementation
challenges.
Finally, sites seeking to implement LEAD should ensure that they have the necessary resources in place
(e.g., housing, harm reduction services) in place prior to launching the program. Sites should work to
utilize existing community resources, where applicable, to expand the nexus of services available to
LEAD clients. Both sites explained that more services than what is expected will surely be needed.
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10. Technical Appendix
Process Evaluation (Los Angeles County)
Table 10-1: LEAD LAC training
Training Name of Purpose of Training Attendees: Role & Count
Date Training
5.25.17, BSCC LEAD To introduce BSCC processes to Case Manager: 1 (HOPICS)
5.26.17 Grantee program managers, share Project Managers: 3 (HFH, ODR x2)
Orientation information between two BSCC District Attorneys / Prosecutors: 4
LEAD grantees, provide access to (Long Beach & LA County)
LEAD National Bureau staff Sheriff / Police: 5 (LBPD & LASD)
trainers and technical assistance CBOs: 1 (HOPICS)
providers. Other Treatment Providers: 1
(HOPICS)Other Service Providers: 1
(HOPICS)
Key Stakeholders: 3 (LBPD, ODR, &
LASD Representatives)
Operational Workgroup Members:
11
7.17.17 - Seattle LEAD The purpose of the trip is training Case Manager: 2 (HOPICS)
7.20.17 Visit and capacity building for the LA Project Managers: 2 (Housing for
County LEAD pilot program (LEAD Health & ODR)
LAC) operational and planning District Attorneys / Prosecutors: 5
partners. (Long Beach City Prosecutor's
Office, LA County)
Sheriff / Police: 5 (LAPD & LASD)
CBOs: 2 (HOPICS)
Key Stakeholders: 4 (Director, ODR;
LASD Captain; HOPICS/SSG DHS
Programs Director)
Operational Workgroup Members:
15
9.15.17 CHAMP: Develop skills around data Project Managers: 2 (HOPICS)
LEAD collection for case management CBOs: 2 (HOPICS)
Database & tracking for LEAD Participants. Other Treatment Providers: 2
Evaluation (HOPICS)
Training Other Service Providers: 2 (HOPICS)
Key Stakeholders: 1 (HOPICS)
Operational Workgroup Members:
2
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Septembe Harm Provide on-site observation of and Case Manager: 2 (HOPICS)
r 2017 (x Reduction experience with delivery of Project Managers: 1 (HOPICS)
4) Service syringe exchange and overdose CBOs: 3 (HOPICS)
Provision prevention services Other Treatment Providers: 3
(HOPICS)
Key Stakeholders: 1 (HOPICS/SSG
DHS Program Director)
Operational Workgroup Members:
3
10.25.17 LEAD NSB: Introduce the LEAD program to Project Managers: 1 (ODR)
LEAD Law various law enforcement District Attorneys/Prosecutors: 3
Enforcement audiences - the LEAD officers and (LAC DA & LB CP)
Training officers from stations in/near the Sheriff/Police: 31 (LASD & LBPD)
catchment area
10.26.17 LEAD NSB: To develop law enforcement District Attorneys/Prosecutors: 2
LEAD Law training curriculum to be delivered (LAC DA & LB CP)
Enforcement by local LEAD law enforcement Sheriff/Police: 12 (LASD & LBPD)
Train the
Trainer
10.25.17 LEAD NSB: Technical assistance with Case Manager: 3 (HOPICS)
Case implementing harm reduction, Project Managers: 1 (ODR)
Management case management and direct CBOs: 2 (Harm Reduction Providers
Training services - LA Community Health)
Other: 1 (HFH)
10.27.17 LEAD NSB: To give an overview of Harm Case Manager: 3 (HOPICS)
LEAD Policy Reduction and the LEAD model Project Managers: 2 (ODR & HFH)
Committee District Attorneys/Prosecutors: 2
Harm (LAC DA & LB CP)
Reduction Sheriff/Police: 4 (LASD & LBPD)
Training CBOs: 3 (LAARP, LACHP, NWOL)
Probation: 2
Other Treatment Providers: 3
(HOPICS)
Other Service Providers: 5 (LACHP,
LAARP, HOPICS)
Key Stakeholders: 17
Operational Workgroup Members:
3 (HOPICS, LBPD, ODR)
Other: 2 (ODR & HFH staff)
10.12.17, Needle All case managers spent time Case Manager: 4 (HOPICS)
10.29.17, Exchange & working side by side with harm
12.11.17 Harm reduction providers at needle
Reduction exchange
Practice
11.21.17 LEAD CHAMP Learn the CHAMP database Case Manager: 4 (HOPICS)
Training housing and case management Project Managers: 1 (ODR)
tracking system
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1.17.18, Case The purpose of the training was to Case Manager: 5 (3 Case Mgrs, CM
1.18.18, Management enhance case management skills Program Manager, CM)
1.19.18 Training with in depth, LEAD specific on- Project Managers: 1 (ODR LEAD
site training. LNSB trainers PM)
observed the Operational Work CBOs: 5 (HOPICS)
Group meeting, met with LEAD Other Treatment Providers: 5 (CM
Program Management and Case Agency)
Management Provider agency to Other Service Providers: 5 (CM
develop a training and support Agency)
curriculum. They observed the Key Stakeholders: 2 (ODR LEAD PM,
case management in their work CM Agency Associate Director)
with officers and with LEAD Operational Workgroup Members:
participants. They delivered 3 6
group training sessions and
conducted 1:1 training with each
case manager. Topics covered
included best practices in harm
reduction case management,
motivational interviewing,
working with law enforcement,
case management documentation,
trauma informed care, self-care,
negotiating partnerships with
operational partners.
3.2.18 Case The purpose of this training was to Case Manager: 6 (3 Case Mgrs, CM
Management further develop LEAD case Program Director, CM)
Training 2 management skills. LNSB trainer, CBOs: 6 (HOPICS)
Najja Morris, followed up with the Other Treatment Providers: 6
case management team on (HOPICS)
January training and meet new Other Service Providers: 6 (HOPICS)
staff, review case management Operational Workgroup Members:
supervision structure, discuss new 5
staffing patterns, trouble shoot
complicated cases, and review
strategies for self-care.
3.13.18 Housing for This training is a 5 hour lecture Case Manager: 3 (HOPICS)
Health: LA style and interactive training Project Managers: 2 (HFH)
County designed for Housing for Health Sheriff/Police: 3 (LBPD, LASD x 2)
Homeless providers and partners to and to CBOs: 3 (HOPICS)
Services learn and understand programs Other Treatment Providers: 3
"Whatever it available under HFH and the (HOPICS)
Takes" "Whatever it Takes" approach. Other Service Providers: 3 (HOPICS)
This is the primary vehicle by Operational Workgroup Members:
which LEAD participants access 7
housing and all other physical and
behavioral health services
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1.31.18, Case Develop Intensive Case Case Manager: 3 (HOPICS CM Staff)
2.28.18, Management Management Services skill set
3.28.18 Institute with a harm reduction focus
Training
3.23.18, ODR Case Develop clinical skills to be used Case Manager: 5 (HOPICS Case
3.30.18 Management by non-clinician case managers in Managers, program manager)
Support their work with LEAD participants
4.17.18 ODR/LEAD To provide LEAD law enforcement Project Managers: 1 (ODR)
Trauma officers basic training on trauma Sheriff/Police: 3 (LASD & LBPD)
Training as it affects LEAD participants. Operational Workgroup Members:
This training focused on women 4
and sex workers, recognizing
behavior patterns developed in
response to trauma, strategies for
engaging participants with a
trauma informed framework
6.27.18 LEAD Seattle law enforcement officers Sheriff/Police: 4 (LBPD & LASD)
Practical shadowed LEAD LAC officers in the Operational Workgroup Members:
Training from field to share information and 4 (LBPD & LASD)
Seattle Police lessons learned
Department
4.27.18 Motivational To provide case management staff Case Manager: 4 (Case
Interviewing with skills and techniques that Management Providers)
focus on goal-focused, client- CBOs: 4 (HOPICS)
centered counseling style for Other Treatment Providers: 4
stimulating behavior change by (HOPICS)
helping clients to explore and Other Service Providers: 4 (HOPICS)
resolve ambivalence Operational Workgroup Members:
4 (Case Management Providers)
5.4.18 Interim To provide overview of interim Case Manager: 7 (HOPICS)
Housing housing options, processes, Project Managers: 1 (ODR)
Training collecting and submitting interim CBOs: 25 (HOPICS)
housing applications Other Treatment Providers: 25
Other Service Providers: 25
(HOPICS)
Operational Workgroup Members:
8 (HOPICS & ODR)
5.11.18 HOPICS To provide staff with knowledge Case Managers: 7 (HOPICS)
Comprehensi on all of the available in-house Other Treatment Providers: 20
ve Training services provided/offered by (HOPICS)
HOPICS to clients/participants Other Service Providers: 33
(HOPICS)
Operational Workgroup Members:
7 (HOPICS)
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5.25.18 Cultural To increase staff's understanding Case Manager: 5 (HOPICS)
Diversity of cultural awareness of inclusion, Other Treatment Providers: 30
Training knowledge, and communication Other Service Providers: 30
for promoting client-centered case Operational Workgroup Members:
management 5
7.17.18 Infectious To provide staff with skills and Case Manager: 1 (HOPICS)
Disease & techniques that focus on goal- Project Managers: 1 (HOPICS)
Other Health focused, client-centered Other Service Providers: 5 (HOPICS)
Challenges counseling style for stimulating
behavior change by helping clients
to explore and resolve
ambivalence
7.26.18 Interim To provide training with Case Manager: 2 (HOPICS)
Housing processing and submitting interim Project Managers: 1 (HOPICS)
Training housing applications Other Service Providers: 8 (HOPICS
& other HFH staff)
Operational Workgroup Members:
3
7.2.18 Housing for To provide staff with knowledge Case Manager: 7 (HOPICS)
Health/Brillia on all the available housing and Other Service Providers: 6 (Other
nt Corners supportive services that can be HOPICS staff)
provided/offered by HOPICS to Operational Workgroup Members:
clients/participants. 7
9.12.18 Medication To increase staff's knowledge of Case Manager: 5(HOPICS)
Assisted medication assisted treatment for Project Managers: 1 (HOPICS)
Treatment people with opioid use disorder. Other Service Providers: 59 (Other
for Homeless non-LEAD HOPICS staff)
Individuals Operational Workgroup Members:
6
9.11.18 Office Safety To educate staff on what to do in Case Manager: 4 (HOPICS)
Training safety emergencies in the office Project Managers: 1 (HOPICS)
building including a possible active Operational Workgroup Members:
shooting incident. 5 (HOPICS)
7.20.18, Intensive To provide staff with training for Case Manager: 2 (HOPICS)
8.20.18 Case client-centered approaches to Operational Workgroup Members:
Management case management, case 2 (HOPICS)
Skills Training coordination, and effective
Court methods on services to people
experiencing homelessness while
providing ICMS.
10.1.18 Intensive To provide staff with training for Case Manager: 7 (HOPICS ICMS
Case client-centered approaches to Team)
Management case management, case Operational Workgroup Members:
Skills Training coordination, and effective 7 (HOPICS ICMS Team)
Cohort methods on services to people
experiencing homelessness while
providing ICMS
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Oct-Dec Carelinq Provide staff with in-depth Case Manager: 11 (HOPICS)
2018 training on how to navigate and Other Service Providers: 168 (Other
access resources for clients non-LEAD HOPICS staff & other)
throughout LA County Operational Workgroup Members:
11 (HOPICS)
10.1.18 Emergency Provide safety training and Case Manager: 11 (HOPICS)
Evacuation education staff on evacuation Operational Workgroup Members:
exits as instructed by emergency 11 (HOPICS)
personnel
11.6.18 Working with To provide staff with skills and Sheriff/Police: 3 (LASD & LBPD)
Stimulant techniques that focus on Operational Workgroup Members:
Dependent engagement with stimulant 3 (LASD & LBPD)
Individuals dependent individuals
11.15.18 Active Health & Safety – to enhance Case Manager: 11 (HOPICS)
Shooter preparedness throughout the Operational Workgroup Members:
workplace by providing education 11 (HOPICS)
to help prepare individuals for and
respond to an active shooter
incident
12.5.18 Trauma- Provide staff at dedicated LEAD Case Managers: 1
Informed interim housing site with skills and Project Managers: 1
Care and De- techniques to de-escalate Other Service Providers: 8
Escalation residents in a trauma-informed Operational Workgroup Members:
manner 2
1.2.19 HMIS/CLARIT To provide staff with training for Case Manager: 3
Y: Housing client-centered approaches to Operational Workgroup Members:
Application case management, case 3
and Tracking coordination, and effective
Training methods on services to people
experiences homelessness while
providing ICMS.
Jan- Carelinq: A To provide staff with in-depth Case Manager: 4
March tool for training on how to navigate and Operational Workgroup Members:
(ongoing) coordinating access resources for clients 4
and throughout Los Angeles County.
navigating
county
resource
1.14.19 Addiction Provide addiction medicine Case Manager: 1
Medicine consultation to LEAD law District Attorneys/Prosecutors: 3
Specialist enforcement Operational Workgroup Members:
Ride Along 4
with Law
Enforcement
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1.14.19 Addiction Provide addiction medicine Case Managers: 8
Medicine consultation to LEAD case Project Managers: 2
Specialist management team Other Service Providers: 1
Training for Operational Workgroup Members:
Case 10
Managers
2.4.19 Risk and to provide safety training and Case Managers: 10
Liability education staff on evacuation Other Treatment Providers: 40
Training exits as instructed by emergency Operational Workgroup Members:
personnel 10
2.7.19 De-escalation Provide staff at LEAD House Project Manager: 1
and Problem (interim housing site for female Other Treatment Providers: 10
Solving LEAD participants) training on de-
Training escalation and problem solving
4.24.19 LEAD LNSB met with Law enforcement Project Manager: 1 (ODR)
National and prosecutors to reflect on District Attorneys/Prosecutors: 2
Support program and discuss practices (LAC DA, LB City Prosecutor)
Bureau Sheriff/Police: 4 (LASD, LBPD)
Technical Operational Workgroup Members:
Assistance 7
5.9.19 Trauma Train case managers on trauma Case Managers: 2 (HOPICS LEAD
Recovery informed care and resources Case Managers)
Empowerme Other Treatment Providers: 23
nt Model Operational Workgroup Members:
(TREM) 2 (HOPICS LEADS Case Managers)
6.6.19 Individual Train case managers in Case Managers: 7 (HOPICS LEAD
Service development of ISPs for LEAD Case Managers)
Plan/Note participants and writing case Operational Workgroups Members:
Writing notes 7 (HOPICS LEAD Case Managers)
6.7.19 Motivational Provide overview of basic Case Manager: 7 (HOPICS LEAD
Interviewing motivational interviewing skills Case Managers)
Refresher Operational Workgroup Members:
7 (HOPICS LEAD Case Managers)
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Outcome and Cost Evaluation (Los Angeles County)
TO BE FILLED IN ONCE DATA ARE AVAILABLE
Table 10-2: LEAD LA baseline comparisons by referral mechanism
Pre-booking (N=) Social contact Significance
(N=) statistic
Age [M(sd)] t=
% Male t=
% White
% Black/African American X2=
% Hispanic/Latinx
% Other
Felony Arrests 6 month [M(sd)] t=
Felony Arrests 12 month [M(sd)] t=
Misdemeanor Arrests 6 month [M(sd)] t=
Misdemeanor Arrests 12 month [M(sd)] t=
Felony Cases 6 month [M(sd)] t=
Felony Cases 12 month [M(sd)] t=
Misdemeanor Cases 6 month [M(sd)] t=
Misdemeanor Cases 12 month [M(sd)] t=
*Group difference p<.05
Table 10-3: LEAD LA baseline comparisons by group
Variable 6 Month Pre 12 Month Pre
LEAD Comp Sig. LEAD Comp Sig.
N
Age [M(sd)] t= t=
% Male t= t=
% White
% Black X2= X2=
% Other
Felony Arrests [M(sd)] t= t=
Misdemeanor Arrests t= t=
[M(sd)]
Felony Cases [M(sd)] t= t=
Misdemeanor Cases t= t=
[M(sd)]
*Group difference p<.05
P a ge | 134
Table 10-4: LEAD LA after-matching comparisons by group
Variable 6 Month Pre 12 Month Pre
LEAD Comp Sig. LEAD Comp Sig.
N
Age [M(sd)] t= t=
% Male t= t=
% White
% Black X2= X2=
% Other
Felony Arrests [M(sd)] t= t=
Misdemeanor Arrests t= t=
[M(sd)]
Felony Cases [M(sd)] t= t=
Misdemeanor Cases t= t=
[M(sd)]
*Group difference p<.05
Table 10-5: LEAD LA costs by month
Variable 12 Month Post
LEAD Comp Sig.
N
Cost of criminal justice services pre-treatment [M(sd)]
Cost of criminal justice services post-treatment [M(sd)] Wald X2=
Table 10-6: LEAD LA pre and post-treatment cost of criminal justice services
Variable 12 Month Post
LEAD Comp Sig.
N
Cost of criminal justice services pre-treatment [M(sd)]
Cost of criminal justice services post-treatment [M(sd)] Wald X2=
*Group difference p<.05
P a ge | 135
Process Evaluation (San Francisco)
Table 10-7: LEAD SF training
Training Date Training Name Description/Purpose Attendees: Role and
Count
09.22.17 Harm Reduction Harm reduction principles and Case Manager: 5
practices Project Manager :1
District
Attorney/Prosecutors : 2
Sheriff/Police: 12
CBOs: 1
Other Service Providers:4
Other: 1
10.2.17 - Seattle LEAD Seattle LEAD Program Overview; Case Manager: 3
10.4.17 Visit Discuss LEAD SF Pilot Project Manager:1
District
Attorney/Prosecutors: 1
Sheriff/Police: 4
CBOs: 3
Probation : 1
Other Treatment
Providers: 1
Other Service Providers: 2
Operational Workgroup
Members: 1 (Public
Defender)
10.12.17 - Drug Policy To provide/improve an Case Manager: 4
10.14.17 Alliance understanding of harm reduction CBOs: 1
Conference skill and drug policy and reform Other Treatment
2017 Providers: 1 (Behavioral
Health Clinician)
Operational Workgroup
Members: 1 (Public
Defender)
10.19.17 Behavioral Provide Background of system of Case Manager: 1
Health 101 case & symptom clusters Other Treatment
Providers: 1 (Behavioral
Health Clinician)
Other Service Providers: 2
(Outreach Providers)
10.24.17 BART Police LEAD Program and Referral Project Managers: 1
LEAD Training Procedures District
Attorneys/Prosecutors: 1
Sheriff/Police: 7
Other Treatment
Providers: 1 (Behavioral
P a ge | 136
Health Clinician)
Operational Workgroup
Members: 1 (Public
Defender)
10.25.17 SF Sheriff's LEAD Program and Procedures Project Managers: 1
Dept. LEAD District
Training Attorneys/Prosecutors: 1
Sheriff/Police: 7
Operational Workgroup
Members: 1 (Public
Defender)
10.25.17 SFPD LEAD LEAD Referral Procedures Case Manager: 1
Training - Project Manager: 1
Mission Station District
Attorney/Prosecutors: 2
Sheriff/Police: 14
CBOs : 1
Probation: 1
Other Treatment
Providers: 1 (Behavioral
Health Clinician)
Operational Workgroup
Members: 1 (Public
Defender)
10.31.17 Transforming Trauma informed practices Case Manager: 3
Stress and CBOs: 2
Trauma Other Service Providers: 2
Key Stakeholders: 5
11.2.17 BART Police LEAD Orientation Case Manager: 5
Training - Swing LEAD Project Manager: 1
Shift DAs/Prosecutors: 1
Sheriff/Police: 8
CBOs: 2
Other Treatment
Providers: 1 (Behavioral
Health Clinician)
OW Members: 1 (Public
Defender)
11.7.17 Breaking the Integrate perspectives and share OW Members: 2 (Public
Cycle regional lessons regarding Defender)
frequent users
of government services
P a ge | 137
11.14.17 Transforming Trauma informed practices Case Manager: 2
Stress and LEAD Project Manager: 1
Trauma DAs/Prosecutors: 1
Sheriff/Police: 8
CBOs: 2
Key Stakeholders: 1
OW Members: 1 (Public
Defender)
11.15.17 LEAD Law LEAD Orientation Case Manager: 4
Enforcement LEAD Project Manager: 1
Orientation Sheriff/Police: 8
11.20.17 Motivational Provide LEAD team with a basic Case Manager: 2
Interviewing foundation of how to utilize MI LEAD Project Manager: 1
communication techniques to Other Treatment
more effectively work with clients. Providers: 3 (Drug Court,
SFDPH LEAD Staff)
OW Members: 1 (Public
Defender)
11.29.17 Case Case management training Case Manager: 6
Management
101
12.7.17 LEAD Law LEAD Orientation Case Manager: 2
Enforcement LEAD Project Manager: 1
Orientation DAs/Prosecutors: 1
Sheriff/Police: 11
Probation: 1
Other Service Providers: 1
12.12.17 Harm Reduction Ensure LEAD key stakeholders are Case Manager: 2
Training trained in a harm-reduction Other Service Providers: 1
approach
and best practices
12.13.17 LEAD Law LEAD Orientation Case Manager: 3
Enforcement LEAD Project Manager: 1
Orientation - DAs/Prosecutors: 1
Mission Sheriff/Police: 17
CBOs: 1
OW Members: 1 (Public
Defender)
12.13.17 LEAD Law LEAD Orientation Case Manager: 4
Enforcement LEAD Project Manager: 1
Orientation - Sheriff/Police: 10
Tenderloin Other Service Providers: 1
OW Members: 1 (Public
Defender)
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12.21.17 Motivational Provide LEAD team with a basic Case Manager: 5
Interviewing foundation of how to utilize MI Sheriff/Police: 6
communication techniques to Other Treatment
more effectively work with clients. Providers: 2 (Drug Court)
Key Stakeholders: 5 (DA's
Office Analyst, Citywide,
HTA)
Training Compliance, Compliancy and privacy policies at Case Manager: 3
Provided Upon Privacy and Felton Institute including HIPPA
Hire Data Collection regulations and the CIRCE case
Training management system for data
collection
Oct, Nov, & Trauma A 3-part training that on Case Manager: 4
Dec. 2017 Informed understanding systemic privilege,
Gender overview of
Sensitivity the spectrum of bias, and positive
Training communication skills and
strategies.
N/A Narcan Training Overdose Prevention with Narcan Case Manager: 1
1.4.18 Motivational communication techniques to Other Service Providers: 1
Interviewing more effectively work with clients. (LEAD Behavioral Health
Clinician)
1.9.18 LEAD Program LEAD Program Overview for SF Other: 15
Overview Judges
1.9.18 Tour of SF Dept. Learn about available resources Case Manager: 5
of Project Manager :1
Homelessness & District
Supportive Attorney/Prosecutors : 1
Housing Probation: 1
Navigation Other Service Provider: 1
Center Other: 1 (Public Defender)
1.9.18 Medicine with Care Collaboration Case Manager: 7
Street Medicine Project Manager: 1
Team CBOs: 1
Other Treatment Provider:
1 (LEAD Behavioral Health
Clinician)
Other Service Providers:
18
1.12.18 Harm Reduction Ensure LEAD staff are trained in Other Treatment
Training harm-reduction approach & best Providers: 11
practices Other Service Providers:
LEAD Behavioral Health
Clinician
Operational Workgroup
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Members: 1 (Director-
Forensic/Justice Involved
Behavioral)
1.16.18-1.17.18 Seattle LEAD Understanding Seattle's LEAD District
Visit Program Attorneys/Prosecutors: 15
1.19.18 Legal Training Enhance understanding of criminal Case Manager: 6
Part 1 justice system LEAD Project Manager: 1
CBOs: 1
Other Service Providers: 1
Key Stakeholders: 1
Other: 1
1.19.18 A Woman's New program orientation Case Manager: 7
Place LEAD Project Manager: 1
Probation: 2
Other Service Providers: 1
Other: 1 (Public Defender)
1.19.18 Ethics Training Required legal education on Other: 1 (Public Defender)
professional responsibility rules
1.24.18 Substance Required for CLE (Continuing Legal Other: 1 (Public Defender)
Abuse Training Education Program)
1.25.18 Syringe Access Learn about available resources Case Manager: 6
LEAD Project Manager: 1
CBOs: 1
Other Service Providers: 1
1.26.18 New Laws Review of new laws that Other: 1 (Public Defender)
potentially affect LEAD clients
1.30.18 Mission Police Inform public about LEAD Case Manager: 1
Station LEAD Project Manager: 1
Community DAs/Prosecutors: 1
Meeting Sheriff/Police: 4
Community Members: 38
1.30.18 Harbor Lights Learn about available resources Case Manager: 6
Info Session and LEAD Project Manager: 1
Tour DAs/Prosecutors: 1
Other Treatment
Providers: 3
Other Service Providers: 1
Other: 1 (Public Defender)
1.31.18 Boundaries and Discuss boundary and self- Case Manager: 2
Disclosure in disclosure issues in working with Other Treatment
Harm Reduction this population Providers: 1
with Drug Users Other Service Providers:
22
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2.2.18 Legal Training Enhance understanding of criminal Case Manager: 6
Part 2 justice system LEAD Project Manager: 1
CBOs: 1
Other Service Providers: 1
Key Stakeholders: 1
Other: 1
2.6.18 Tour of Dore Familiarize LEAD staff with Case Manager: 7
Urgent Care services available to LEAD clients LEAD Project Manager: 1
Mental Health DAs/Prosecutors: 1
Facility Probation: 1
Other Service Providers: 2
OW Members: 1
Other: 1 (Public Defender)
2.8.18 Medication Familiarize LEAD staff with Case Manager: 2
Assisted services available to LEAD clients Other: 1 (Public Defender)
Treatment for
Substance Use
Disorders
2.27.18 Community Educate community about LEAD Case Manager: 2
Meeting - LEAD Project Manager: 1
Tenderloin Sheriff/Police: 3
Police Station Other Treatment Provider:
1
Community Members: 43
3.5.18 HIV Services Learn about available resources Case Manager: 4
LEAD Project Manager: 1
Probation: 1
Other Treatment
Providers: 3
3.9.18 Trauma Consider ways to more deeply Case Manager: 2
Informed Care, integrate these ideas into service Other Treatment
Social Justice provision Providers: 1 (LEAD
and Healing Behavioral Health
Clinician)
3.14.18 Complex Case Manager: 2
Trauma Other Treatment
Providers: 17
OW Members: 1
3.28.18 Motivational Provide LEAD Team with basic Case Manager: 4
Interviewing II foundation of MI communication (Glide/Felton)
techniques to work effectively CBOs: 2 (BART Police)
with clients Other Service Providers: 2
(DPH)
3.30.18 Racial Justice Other: 1 (Public Defender)
and Immigration
P a ge | 141
7.27.2018 Forced Labor in Education/Awareness Case Manager: 1
the Drug Community Members: 79
Industry
8.14.18 LEAD SF Orient Law Enforcement to LEAD Project Managers: 1
Orientation SF District
Attorney/Prosecutors: 1
Sheriff/Police: 20
8.28.18-8.31.18 Safer Inside Demonstration of Safe Injection Case Manager: 4 (2 were
Site presenters)
Project Managers: 1 (1
was presenter)
Community Members:
551
9.12.2018 LEAD SF Orient Law Enforcement to LEAD Project Manager: 1
Orientation SF District
Attorney/Prosecutors: 1
Sheriff/Police: 60
CBOs: 1
Probation: 1
9.17.2018 5th Annual Panel discussions and resource fair Probation: 15
Reentry for current and formerly justice Community Members:
Conference and individuals 235
Resource Fair
10.2.2018 Motivational Training placed emphasis on Case Manager: 2
Interviewing reflection
Training
10.2.2018 "Part n Play: Understand the intersection of sex Case Manager: 2
Crystal Meth, and drug use Other Treatment
Sex, and Harm Providers: 28
Reduction"
10.4.2018 Motivational Training placed emphasis on Case Manager: 2
Interviewing reflection and elicit-provide-elicit
Training
10.16.2018 Racial Equity Talk about racial equity LEAD Project Manager: 1
Symposium for Other Service Providers:
TIS Leaders 89
10.18.2018- Disaster Mental Preparing to provide services LEAD Project Manager: 1
10.19.2018 Health Other Treatment
Providers: 49
10.18.2018- Harm Reduction Receive education and participate Case Manager: 7
10.21.2018 Conference in in nation-wide dialogue on harm
New Orleans reduction
11.13.2018 Motivational Role playing using MI techniques Case Manager: 2
Interviewing
Coaching
11.15.2018 Naloxone Overdose prevention and Case Manager: 4
Training response training
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12.10.2018- Pre-Arrest Explore different diversion LEAD Project Manager: 1
12.18.2018 Diversion and programs District
Deflection Attorneys/Prosecutors: 1
Training Sheriff/Police: 2
CBOs: 2
Probation: 1
12.11.2018 Motivational Training placed emphasis on Case Manager: 2
Interviewing reflection and elicit-provide-elicit
Coaching
12.11.2018- Wellness Learning about harm reduction Case Manager: 3
12.18.2018 Recovery Action tools for clients Other Service Providers: 6
Plan
12.20.18 Motivational Role playing using MI techniques Case Manager: 2
Interviewing
Coaching
1.29.19 Mission Police Provide info on LEAD LEAD Project Manager: 1
Station District
Community Attorneys/Prosecutors: 1
Meeting Community Members: 48
1.10.19; 24 Plus for Leadership Support Other Service Providers:
1.17.19; Managers 19
1.24.19; and
1.31.19
1.25.19 Neuroscience of N/A Case Manager: 6
Trust, Other Treatment
Collaboration, Providers: 1
and Other Service Providers:
Engagement 53
2.1.19 Dismantling Further understanding Case Manager: 3
Drug-Related Other Treatment
Stigma Providers: 47
2.7.19-2.8.19 Disaster Mental Preparedness and understanding Other Service Providers:
Health 39
OW Members: 1
2.25.19 Adult First Certification Case Manager: 4
Aid/CPR/AED LEAD Project Manager: 1
3.4.19 Motivational To help case managers better Case Manager: 5
Interviewing understand the stages of change
theory
3.11.19 Tanagra's Team Boundaries and disclosure at work Case Manager: 4
Training and effective team LEAD Project Manager: 1
communication
3.13.19 Clinical and N/A Case Manager: 1
Contemporary Other Treatment
Implications of Providers: 49
Working with
LGBTW
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4.11.19 Verbal De- Learning tactics that develop non- Case Manager: 1
escalation physical skills used to prevent a Other Treatment
potentially dangerous situation Providers: 58
from escalating into a physical OW Members: 1
confrontation or injury
4.16.19 Documentation Learning the proper Case Manager: 4
Training documentation for
Assessments/Behavioral Health
and Treatment Plans
5.1.19 LEAD Training Provide info on LEAD LEAD Project Manager: 1
DAs/Prosecutors: 1
Probation: 63
Other Treatment
Providers: 4
Other (including Public
Defender): 1
5.1.19 Legal Issues in N/A Case Manager: 1
Collaborative DAs/Prosecutors: 5
Court Other Treatment
Providers: 50
Other (including Public
Defender): 4
5.1.19 LEAD Officer Train officers to refer to LEAD Case Manager: 1
Training DAs/Prosecutors: 1
Sheriff/Police: 45
Probation: 1
Other Service Providers: 1
Other (including Public
Defender): 1
5.2.19 Alternative Overview of PD and PA roles in DAs/Prosecutors: 1
Court Training alternative courts Other Treatment
Providers: Unknown
Other Service Providers:
Unknown
Other (including Public
Defender)
5.10.19 Navigating the To give case managers a better Case Manager: 4
Jail System understand of what services are
currently
available in jail, and how to access
those services; learn the process
for resolving unmet health care
needs of those in jail; provide an
overview of demographics and
chronic disease in the jail health
population; get updates in
national chronic pain
P a ge | 144
management guidelines and this
affects patient care.
5.14.19; 6.12.19 Motivational Refreshment training in using
Interviewing good practices that involve
reflective listening; Conversation
Skills (O.A.R.S.) and Elicit-Provide-
Elicit (EPE)
6.3.19 Motivational MI training for Glide staff Case Manager: 4
Interviewing LEAD Project Manager: 1
(MI)
6.17.19 Harm Reduction Learning to develop a set of Case Manager: 4
and De- practical strategies that reduce
escalation the negative
consequences of drug use via
incorporating a spectrum of
strategies from safer use, to
managed use,
to abstinence. Learning tactics
that develop non-physical skills
used to prevent a potentially
dangerous situation from
escalating into a physical
confrontation or injury
7.2.19 Motivational Learn to express empathy through Case Manager: 2
Interviewing reflective listening and to develop LEAD Project Manager: 1
Coaching discrepancy between client’s goals
and values and their current
behavior
P a ge | 145
7.15.19 Motivational Learn reflective listening to Case Manager: 2
Interviewing develop a guiding style of helping LEAD Project Manager: 1
the client. To learn typical
strategies and how to identify
where the client is.
8.5.19-8.7.19 WRAP Wellness Recovery Action Plan Case Manager: 1
Other Treatment
Providers: 1
Other (including Public
Defender): 13
8.12.19 Sexual To help meet the compliance Case Manager: 2
Harassment mandates, and to explore sexual LEAD Project Manager: 1
Video Training orientation, gender identity,
accommodations and hostility.
8.20.19 American Teach probation officers about Case Manager: 1
Probation and how LEAD works; LEAD Team DAs/Prosecutors: 2
Parole presented at national conference Sheriff/Police: 1
Association Probation: 1
National Other Service Providers: 1
Conference OW Members: 5
Other (including Public
Defender): 1 (Public
Defenders)
9.1.19 SFDPH Compliance awareness LEAD Project Manager: 1
Compliance
Training
P a ge | 146
9.10.19 LEAD Seattle TA Problem solving issues in LEAD LEAD Project Manager: 1
Sheriff/Police: 5
OW Members: 2
Other (including Public
Defender): 2
9.20.19 Law and Ethics N/A Other Treatment
and Mental Providers: 1
Health Other(including Public
Defender): 14
9.30.19 One System One System training LEAD Project Manager: 1
P a ge | 147
Outcome and Costing Evaluation (San Francisco)
Table 10-7: LEAD SF baseline comparisons by referral mechanism
Pre-booking Social contact Significance
(N=67) (N=127) statistic
Age [M(sd)] 36 (11.42) 38 (11.70) t=-.98
% Male 72% 65% t=.89
% White 46% 47%
% Black/African American 34% 28% X2=2.19
% Hispanic/Latinx 10% 9%
% Other 9% 16%
Citations 6 month[M(sd)] .33 (.67) .33 (.64) t=-.02
Citations 12 month [M(sd)] .52 (.99) .57 (.95) t=-.36
Citations 18 month [M(sd)] .72 (1.24) .80 (1.16) t=-.49
Felony Arrests 6 month [M(sd)] .13 (.34) .20 (.48) t=-1.43
Felony Arrests 12 month [M(sd)] .30 (.60) .36 (.76) t=-.47
Felony Arrests 18 month [M(sd)] .39 (.67) .46 (.97) t=-.12
Misdemeanor Arrests 6 month [M(sd)] .19 (.80) .28 (.79) t=-.75
Misdemeanor Arrests 12 month [M(sd)] .33 (.89) .39 (.88) t=-.49
Misdemeanor Arrests 18 month [M(sd)] .40 (.94) .52 (.98) t=-.80
Felony Cases 6 month [M(sd)] .04 (.21) .10 (.35) t=-.75
Felony Cases 12 month [M(sd)] .16 (.54) .20 (.60) t=-.47
Felony Cases 18 month [M(sd)] .21 (.62) .22 (.62) t=-.12
Misdemeanor Cases 6 month [M(sd)] .00 (.00) .08 (.30) t=-2.98*
Misdemeanor Cases 12 month [M(sd)] .06 (.24) .13 (.40) t=-1.45
Misdemeanor Cases 18 month [M(sd)] .09 (.29) .21 (.54) t=-2.06*
*Group difference p<.05
Table 10-8: LEAD SF baseline comparisons by group
Variable 6 Month Pre 12 Month Pre 18 Month Pre
LEAD Comp Sig. LEAD Comp Sig. LEAD Comp Sig.
N 194 235 115 147 40 49
Age [M(sd)] 37 35 t=1.70 36 36 t=-.33 36 38 t=-.55
(11.6) (11.9) (10.4) (11.9) (11.9) (13.5)
% Male 68% 81% t=-3.31* 66% 87% t=-4.01* 65% 80% t=-1.52
% White 47% 29% 46% 28% 48% 31%
% Black 30% 35% X2=15.5* 30% 35% X2=10.3* 23% 35% X2=2.9
% Other 23% 36% 24% 37% 30% 35%
Citations .33 .14 t=3.76* .64 .29 t=3.23* 1.10 .24 t=3.84*
[M(sd)] (.65) (.38) (1.0) (.65) (1.2) (.63)
Felony Arrests .18 .54 t=-5.56* .32 1.0 t=-2.88* .33 .98 t=-2.51*
[M(sd)] (.44) (.87) (.70) (1.40) (1.0) (1.5)
Misdemeanor .25 .19 t=.96 .23 .23 t=.05 .45 .45 t=.01
Arrests [M(sd)] (.79) (.53) (.71) (.56) (.82) (1.1)
Felony Cases .08 .21 t=-3.18* .16 .37 t=-3.64* .05 .27 t=-2.56*
[M(sd)] (.31) (.48) (.52) (.66) (.22) (.53)
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Misdemeanor .05 .07 t=-.79 .10 .12 t=-.44 .10 .14 t=-.55
Cases [M(sd)] (.24) (.29) (.32) (.40) (.30) (.41)
*Group difference p<.05
Table 10-9: LEAD SF after-matching comparisons by group
Variable 6 Month Pre 12 Month Pre 18 Month Pre
LEAD Comp Sig. LEAD Comp Sig. LEAD Comp Sig.
N 171 171 98 98 40 40
Age [M(sd)] 37 37 t=.38 36 37 t=-.41 36 38 t=-.70
(11.6) (11.7) (10.2) (12.1) (11.9) (14.2)
% Male 69% 75% t=-1.20 70% 81% t=-1.66 65% 75% t=-.97
% White 44% 34% 41% 33% 48% 30%
% Black 31% 37% X2=3.6 32% 34% X2=1.55 23% 38% X2=3.1
% Other 25% 29% 28% 34% 30% 33%
Citations .25 .15 t=1.91 .54 .31 t=2.06* 1.10 .30 t=3.44*
[M(sd)] (.54) (.41) (.90) (.68) (1.2) (.69)
Felony Arrests .20 .28 t=-1.36 .36 .45 t=-.29 .33 .75 t=-1.52
[M(sd)] (.46) (.64) (.72) (.80) (1.0) (1.5)
Misdemeanor .19 .11 t=1.50 .21 .11 t=1.26 .45 .45 t=.00
Arrests [M(sd)] (.62) (.34) (.72) (.35) (.82) (1.2)
Felony Cases .09 .12 t=-.76 .16 .18 t=-1.04 .05 .13 t=-1.03
[M(sd)] (.32) (.39) (.53) (.44) (.22) (.40)
Misdemeanor .04 .04 t=.26 .09 .06 t=.75 .10 .13 t=-.31
Cases [M(sd)] (.20) (.21) (.32) (.24) (.30) (.40)
*Group difference p<.05
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Table 10-10: LEAD SF costs by month
Nov- Dec- Jan-18 Feb- Mar- Apr- May- Jun-18 Jul-18 Aug- Sep- Oct- Nov- Dec- Jan-19 Feb- Mar- Apr- May- Jun-19
17 17 18 18 18 18 18 18 18 18 18 19 19 19 19
Active 27 27 47 47 47 69 69 69 102 102 102 130 130 130 163 163 163 178 178 178
Clients
Coordinator 11918 11918 8225 8225 8225 10717 10717 10717 9680 9680 9680 11918 11918 11918 10294 10294 10294 6854 6854 6854
Beh. Health 11154 11154 6335 6335 6335 9848 9848 9848 9156 9156 9156 11154 11154 11154 9671 9671 9671 11278 11278 11278
Clinician
SFDA 9621 9621 4752 4752 4752 12938 12938 12938 18482 18482 18482 9621 9621 9621 7020 7020 7020 9650 9650 9650
Attorney
SFDA 6010 6010 6010 6010 6010 7065 7065 7065 9303 9303 9303
Paralegal
Assistant
Probation 7430 7430 6275 6275 6275 7318 7318 7318 6435 6435 6435 7430 7430 7430 6267 6267 6267 7343 7343 7343
Assistant
Deputy 8223 8223 5626 5626 5626 7048 7048 7048 8223 8223 8223 7045 7045 7045 11316 11316 11316
Probation
Officer
SFPD Legal 9557 9557 8175 8175 8175 7982 7982 7982 8195 8195 8195 9557 9557 9557 8191 8191 8191 9583 9583 9583
Assistant
SFPD 12527 12527 21322 21322 21322 10987 10987 10987 11323 11323 11323 12527 12527 12527 14480 14480 14480 18526 18526 18526
Attorney
Family 23926 23926 22574 22574 22574 22574 22574 22574 22574 31769 31769 31769 31769 31769 23926 23926 23926 31481 31481 31481
Service
Agency
SF Public 3367 3367 1213 1213 1213 2149 2149 2149 2149 3367 3367 3367 3367 3367 4183 4183 4183 4715 4715 4715
Health
Foundation
Glide 25659 34194 34194 34194 34194 34194 34194 34194 34194 34194 34194 34194 34194 34194 25659 25659 25659 32731 32731 32731
Indirect 10% 12939 13793 11306 11306 11306 12433 12433 12433 12923 13964 13964 14577 14577 14577 12380 12380 12380 15278 15278 15278
Total costs 142331 151720 124372 124372 124372 136766 136766 136766 142160 153614 153614 160347 160347 160347 136181 136181 136181 168058 168058 168058
Total costs 5271 5619 2646 2646 2646 1982 1982 1982 1393 1506 1506 1233 1233 1233 835 835 835 944 944 944
per client
Case mngmt 3,358 3,674 1,962 1,962 1,962 1,316 1,316 1,316 950 1,052 1,052 823 823 823 555 555 555 651 651 651
/ legal per
client
P a ge | 150
Table 10-11: LEAD SF pre and post-treatment cost of criminal justice services
Variable 12 Month Post
LEAD Comp Sig.
N 98 98
Cost of criminal justice services pre-treatment [M(sd)] $4252 $4757
($8131) (8376)
Cost of criminal justice services post-treatment [M(sd)] $1653 $5344 Wald X2=6.79*
($5302) ($10061)
*Group difference p<.05
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11. List of Acronyms
APD Adult Probation Department
BART Bay Area Rapid Transit
BSCC Board of State and Community Corrections
CASC Community Assessment and Services Center
DEM Department of Emergency Management
DHS Department of Health Services
DPH Department of Public Health
DPW Department of Public Works
GEE Generalized Estimating Equation
HOPICS Homeless Outreach Integrated Care System
HSH Homelessness and Supportive Housing
HSIP Health Streets Intervention Program
HSOC Healthy Streets Operation Center
HTA Hatchuel Tabernik and Associates
ICM Intensive Case Management
IIP Individualized Intervention Plan
KSPC Key Stakeholder Policy Committee
LAAPD Los Angeles County Adult Probation Department
LAC Los Angeles County
LACDHS Los Angeles County Department of Health Services
LASD Los Angeles County Sheriff's Department
LBPD Long Beach Police Department
LEAD Law Enforcement Assisted Diversion
MOU Memoranda of Understanding
ODR Office of Diversion and Reentry
OR Odds Ratio
OW Operational Workgroup
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OWG Operational Workgroup
PSM Propensity Score Matching
RCT Randomized Controlled Trial
SF San Francisco
SFDA San Francisco District Attorney's Office
SFPD San Francisco Police Department
SFSD San Francisco Sheriff's Department
SRO Single Room Occupancy
VUCSA Violation of the Uniform Controlled Substance Act