SF Streamlined Its Street Teams. Now, Fewer People Are Getting the Help They Need

Five mornings a week in San Francisco, a team of city outreach workers pile into a van. There are medical professionals, behavioral health specialists, social workers, and peer counselors. Their task: drive around their assigned neighborhood, find homeless people on a specified list, and — if they can locate them — help them get the care that they need.

It sounds great on paper. But the Integrated Neighborhood Street Teams — rolled out under Mayor Daniel Lurie’s order in March — are leaving large service gaps in their wake. 

Teams of four to six city employees can spend an entire day looking for one person. Staff have been attacked in the field. Morale is rock-bottom. Nurses are quitting. Perhaps most frustrating of all: skilled outreach workers are driving past people on the street who desperately need their help, because of a strict directive to only find and serve people on their designated list.

“It’s as if they want people to be out of their mind, bleeding all over the street, in order to get on the list,” one worker told me. “We're just driving around waiting for people to crack.” 

Seven current and former members of these neighborhood street teams spoke to me for this story. They all requested anonymity so they could speak candidly without losing their city jobs. In my 10 years reporting on issues of homelessness and public health in San Francisco, this has become an increasingly common request. Official communication about city programs has always been tightly controlled — and it’s getting worse. Press statements are vague. Questions go unanswered. Access to city staff for interviews, particularly those not in high ranks, is limited or impossible. 

But when people on the front lines stay quiet, their stories don’t get told. Sometimes, granting anonymity is the only way to move past bureaucratic barriers, to get a real picture of how our taxpayer dollars are being spent.

And six months into Lurie’s reorganized street medicine program, it’s not looking good. Outreach workers I spoke to describe an expensive, disorganized program that doesn’t have clear objectives.

They’re left with the same question as me: As thousands of people struggle to survive on city streets, why has San Francisco implemented a system where its highly skilled professionals are only permitted to truly help a handful each day?

The Shakeup

Before Lurie stepped in, things didn’t operate this way. Street medicine workers roamed the streets of San Francisco, often carrying backpacks filled with medical supplies. Teams with different specialties — such as behavioral health crises, or post-overdose care — would hand out water, prescribe medications, transport people to clinics, and connect people to shelter. 

It wasn’t a perfect system. There were far too many different outreach teams patrolling the streets. In 2023, a 139-page audit of the city’s 11 street outreach teams by the city’s Budget and Legislative Analyst’s office highlighted siloed efforts that led to duplication and confusion.

Nevertheless, for the city’s estimated 8,000 homeless residents, those teams were, in many instances, literal lifesavers.

In March, two months after Lurie took office, he announced an overhaul of San Francisco’s street medicine teams with a stated goal of streamlining services. Now, around 40 people are assigned to work in five neighborhood units, serving areas that align with police districts and one at-large citywide team.

In an attempt to tighten the teams up, the pendulum has swung too far in the other direction. Workers told me that their teams are so tightly monitored that every possible piece of information is logged. Outreach data is bloated, seemingly intentionally: One person said that every time they hand out a flyer on substance use to someone on the street, it’s logged as a referral — even if there’s no additional attempt made to prescribe them medication, get them on a waitlist for treatment, drive them to a clinic, or connect them with an addiction counselor. Forty flyers means 40 referrals, end of story — on paper. 

The List

Teams are told to apply a laser-like focus to their “shared priority lists” of people in their assigned neighborhoods who have been deemed a nuisance, or need help. These lists cap out at 20 people, but the number is often lower.

So who are these people? Unlike successful models in other cities, with criteria that target  specific populations and establish concrete goals — such as housing homeless veterans in Houston  — there is no singular defining trait uniting those on San Francisco’s lists. Repeated requests for list criteria from the Department of Emergency Management turned up next to nothing. “While the emphasis is on proactive response, intervention, and service offerings, some street team deployments are in response to 311 or non-emergency 911 calls,” a spokesperson said. 

So, if an angry neighbor complains about a person over and over to 311, there’s a chance that person will end up on the street medicine team’s list. That’s the case regardless of that person’s actual medical needs, and regardless of if there’s a person a block away who is quietly, in a way that isn’t causing a nuisance, in need of serious medical treatment. In this way, the lists are established according to politics and visibility, not clinical necessity.

For team members, the list feels random. Why are these few chosen for intensive care, while the team is driving past others who are clearly in desperate need? Four people I spoke with said their efforts to get individuals on the list have failed; one team member described multiple attempts to add people who had been homeless for more than 10 years, used drugs, were experiencing psychosis, and had severe mental health issues. In every instance, their requests were denied. 

Of the seven people I spoke to, many of whom have worked for the city for years, only one told me they’d successfully added someone to the list.

Ongoing Violence

The speedy rollout of this new system has come with bumps — of course. Nothing as complicated as addressing the behavioral health needs of people living outdoors can be solved in a day with just reorganization. But dangerous conflicts have arisen as the teams are sent into the streets in marked vans to work with people who may have never encountered them before. 

Team members I spoke with shared incidents of weapons being pulled on staff, and a health worker being beaten on the street. Someone threw a coffee through a van window. A few weeks ago, a group of workers were attacked by a man who stabbed straight through their van’s hood several times — and the vehicle did not have doors that locked. 

Challenges in keeping mobile health workers safe are not new, but they have yet to be taken seriously. In a January presentation on safety for employees in the field, Basil Price, the health department’s director of security, highlighted a lack of training on violence prevention, no standardized procedures to protect workers, and no process for responding to incidents. 

With no meaningful action taken, workers are worried the city doesn’t have their back. In April, SEIU 1021 filed a grievance with the Department of Public Health on behalf of street medicine team workers, calling for a written safety plan, staff training, and ongoing risk assessment.  

Progress has been slow. “The problem that we face is that there’s been a wholesale unwillingness by DPH to engage us in a transparent and honest conversation about the reality out there,” Carey Dall, a SEIU 1021 union representative, told me.

Cost of Care Has Skyrocketed

Is it cost-efficient to have highly-paid professionals riding around in a van all day looking for a few people? Team members with significant city salaries said absolutely not, expressing frustration that their client load has been reduced. 

One told me that they used to be able to average seven to 10 clients a day. Now, everyone I spoke with iterated, it’s not uncommon for an entire team to only be able to track down and help just one or two people in a day. That cost of care per person is significant when you have a peer outreach worker, a social worker, a psychiatrist, a nurse practitioner or a doctor on board.  

Plus, not everyone needs that level of intensive care: if a person is a repeat subject of 311 complaints for something like a messy tent or using the bathroom outside, that doesn’t necessarily mean they need to be seen by a doctor or nurse practitioner. A peer outreach worker could singlehandedly field that case and help them get indoors. In those instances, there’s little for specialized team members — who’ve spent an entire day driving around looking for this person — to do. 

The upside here is that a smaller case load does lead to more focused care. For a couple of the people I talked to, it is a relief to do intensive work with a manageable number of people in a system where those on the list can be expedited through bureaucracy. In a city with thousands sleeping outdoors each night, the scope of the crisis can be overwhelming for those on the front lines. 

Previous experiments with more targeted outreach have yielded some success stories: In 2023, dedicated case workers in the Castro focused their efforts on helping 34 longtime unhoused people. The downside: It took six months and more than a dozen teams and city agencies to move a mere 19 people indoors. That’s expensive. 

Meanwhile, those who were served by the pre-Lurie, pre-consolidation approach to street medicine have been abandoned. One health worker expressed concern for the dozen or so homeless clients they used to see each day, who they would provide with prescriptions for high blood pressure, colostomy bags, or insulin for diabetes. “Where are those people getting their medicine now?” they asked.

Fed up with the disorganization, their hands tied to serve people they know need help, skilled staff on the teams are quitting, heading to nonprofits, or asking to be reassigned. “Every health worker is trying to get out of there,” one person told me. In a moment when the city is struggling to fill vacant positions for nurses and behavioral health staff, this is a big loss. 

This new outreach structure continues a worrying pattern for San Francisco: by prioritizing downstream solutions, and only providing care if someone has reached an extreme state of crisis, the city is missing the opportunity to intervene earlier. It's much cheaper — not to mention logical and humane — to help an unhoused person with diabetes access the medicine they need early on, before their condition deteriorates to the point where they need emergency room care.

Unfortunately, unless that person catches the attention of police, politicians, or neighbors with 311 on speed dial, chances are they’re out of luck.