We are the largest provider of intensive case management services in San Francisco. The county leans on us to work with the clients who have been refused by other case management programs for being too acute and too high-risk; to take the most complex and “impossible” cases.

We work with a highly acute population, often experiencing co-occurring crises: chronic homelessness; psychiatric crises; substance abuse; complicated medical issues; intensive justice involvement; systemic racism; ongoing complex trauma; high utilization of hospitals and crisis services—the list goes on. The complexity of the cases we are tasked with demands a high degree of skill and commitment, and at caseload sizes significantly higher than what is considered the standard of care for the ACT model that we use. We are forced to take on even bigger caseloads to compensate for high staff turnover.

We consistently work in stressful and often unsafe conditions in the community. Our jobs expose us to moral injury and vicarious trauma. Furthermore, our social workers have been physically assaulted by clients on numerous occasions, after which we have continued working with those clients as we are an “agency of last resort.” And yet we are paid significantly less than the prevailing wage for comparable positions within UCSF and at DPH.

Many of our clinical staff are forced to take second and sometimes third jobs to manage the high cost of living in the Bay Area. The values of “self-care” and “work-life balance” are often unattainable for clinical staff at UCSF-Citywide, which is reflected in our high turnover rate. Nevertheless, we are still known throughout the system of care to provide excellent, professional and compassionate care, and to go above and beyond for our clients and other stakeholders. We hear this sentiment voiced repeatedly by our community partners.

At Zuckerberg San Francisco General Hospital (ZSFG) Inpatient Psychiatry, the vast majority of our patients have some variation of a severe and persistent mental illness along with a substance use disorder, houselessness, HIV, involvement with the legal system, etc.

In addition to this they are in a state of crisis to the degree that they necessitate a Lanterman-Petris-Short Act hold to involuntarily commit them to our hospital due to being a danger to themselves or others, or being gravely disabled. These are the individuals the San Francisco Department of Public Health (SFDPH) and University of California, San Francisco (UCSF) identify as being the most vulnerable, disenfranchised, and in-need in our community.

When state and local leaders pass new policies, such as those regarding conservatorship, our units are where they are implemented. Clinical Social Workers (CSWs) on our units play an integral role in our patients' care here as we assess, provide psychoeducation to, and facilitate therapeutic groups and 1:1s for them; collaborate with outpatient providers; communicate with and provide psychoeducation for families; and aid in the bed flow of the hospital.

Interestingly enough, as highlighted throughout this letter, the CSWs providing treatment to these communities are paid substantially less than our SFDPH Behavioral Health Clinician (BHC) and UCSF CSW Medical classification counterparts at Langley Porter. The same is true of Inpatient Psychiatry. We even work on the same team with SFDPH BHCs and historically have been expected to help cover their vacancies, yet not vice versa. The CSW position here too has been plagued with high turnover rates as people quit or transfer for higher paying positions doing similar jobs.

There has been a constant vacancy for years on our team, which the CSWs are expected to cover. During COVID-19, we even saw our bed census expand to include an additional unit for those who contracted the virus. We continued to provide direct, in-person care throughout the pandemic and watched as other disciplines consistently received help in the form of travel professionals or per diem staff. This lack of investment in our position not only hurts the employees but also further perpetuates the institutional harm which our patient population already endures, and adversely impacts our community as a whole.

What we, the UCSF CSW Campus Classification, are asking for in this letter aligns with SFDPH and UCSF core values of equity. Both institutions have shown multiple times that they have the ability to provide this. For example, UCSF psychiatrists at ZSFG Inpatient Psychiatry received an equity adjustment to their pay to make them more comparable to their SFDPH counterparts, though the gap has again widened without ongoing adjustments. SFDPH has even created an entirely new Department of Care Coordination with various branches that provide heavily overlapping services compared to those of the UCSF CSW Campus Classification. This led to many of those CSWs transitioning to these new positions. By investing in us, UCSF and SFDPH can rectify this ongoing inequity, retain and attract quality staff, provide better care for our patients, and help fulfill the mission that both hope to carry out for our community.

As social workers, we are part of the healing community. We are one of the few programs that provide prenatal, infant, and early childhood mental health services in the city, and also one of only a few that serves this population at UCSF.

Our clinicians serve clients at ZSFG and are known for home visits and community-based outreach. We serve communities all over San Francisco and often navigate delicate and complex human experiences with clients at family resource centers, homeless shelters, residential treatment programs, and early education centers.

We work with families who have recently immigrated to this country, those who are unhoused, families who are struggling with addiction, and countless families with young children throughout the city. Our trauma-informed trained clinicians support families that include young children experiencing many psychosocial stressors such as homelessness, domestic violence, community violence, systemic racism, and persistent and pervasive complex trauma.

We are on the front lines supporting them, holding their experiences and lifting up the voices of their children, while intervening to prevent or address adverse experiences that put this young population at-risk of potential lifelong mental illness. Many of us provide clinical supervision, support the clinical training program, and recruit and plan for the Master’s practicum program.

Our deep sense of integrity and purpose drives us and keeps us going. Yet it is impossible to ignore the parallel experience we share with our clients, within the University system. We are the ones serving the community on the front lines and we are also paid less than our peers at the Medical Center, who serve a different and more privileged community. Not only are we paid significantly less than our counterparts, but we are expected to drive our personal cars with the increasingly high cost of gas, pay for parking, walk through dangerous neighborhoods, and put ourselves in precarious situations as part of the job.

Despite the risk, we do it because it is an honor to serve the populations that we do. But we deserve to be properly and fairly compensated. We deserve equity.

It is glaringly obvious that the clinicians who provide culturally sensitive services, provide services in languages other than English, and serve marginalized populations are also the clinicians who are underpaid and undervalued by the University. It cannot be overlooked that many of us are clinicians of color, immigrants ourselves, or hold histories of intergenerational immigration, as we make an intentional effort to have clinicians that look like and speak the same language as our clients. We want to be and deserve to be acknowledged in ways that are equitable to others in this healing community.

We approach our work as community mental health providers with pride, diligence, and care. We have continued to work and outreach tirelessly throughout the COVID-19 pandemic, driven by the mission to support our clients who are at highest risk and most vulnerable. However, social workers commonly leave after receiving licensure, as our positions do not provide compensation comparable to similar roles within the City and County, UCSF, or other community mental health providers in the Bay Area. The pay inequity contributes to a common feeling of being unseen and unappreciated, and has contributed to burnout and frequent turnover, which negatively impacts our quality of life and unfairly diminishes the quality of care our clients receive.

Frequent turnover resulting from inadequate compensation means that clients are often left in the lurch–clients have to start with a new clinician who may not be fully trained or may be transitioned to a remaining staff member whose caseload has been increased beyond capacity.