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A Citywide Plan to Address Homelessness, Substance Use, and Mental Health

In 2014, the City of Boston suddenly condemned and shut down the Long Island Bridge, which had connected the mainland of Greater Boston to hundreds of City-run emergency shelter and recovery beds on Long Island. With no prior infrastructure planning and just a three-hour window to evacuate more than a thousand people off the island, most of the emergency shelter beds were hastily relocated to the South End in the area near Boston Medical Center. This section of the city at the intersection of Massachusetts Avenue and Melnea Cass Boulevard has since struggled as a worsening epicenter of substance use, homelessness, and mental illness, while the opiate and homelessness crisis has grown citywide.

The COVID-19 pandemic accelerated these crises, with opioid-related overdose deaths increasing by 20% in 2020 alone as social isolation, mental health challenges, financial precarity and housing instability have deepened. Across Massachusetts, the highest increase in opioid-related deaths has been among Black men, and the crisis has been worsened by the prevalence of fentanyl, a synthetic opioid that’s up to 100 times stronger than morphine. 

So far, our policy response has failed. We’ve seen a concentration of services in the South End and Lower Roxbury area without appropriate support from the City, making it harder for individuals to recover, and eroding the trust between Boston residents and their city government. We’ve seen service providers facing the added risk of infectious disease, without resources sufficient to meet the growing needs of residents living at the intersection of these crises. We’ve seen a misguided police response that creates additional harm to create the appearance of action. And we’ve heard promises about rebuilding the Long Island bridge--a complicated, costly endeavor that would be years away at best--when the urgency for immediate action and resources grows everyday.

These issues are personal for me. I have shared my family’s story of mental illness to help break the stigma and push for action. We’ve lived through the intersectional barriers and complexity of broken systems, and I’m committed to transforming these structures as mayor. Boston residents deserve compassionate care, urgent action, and accountability.

1. Creating a Citywide Plan and Regional Coalition

We must act and plan beyond “Mass & Cass” to address the roots of this crisis. The opioid crisis is a nationwide public health emergency, but it is particularly acute across the Greater Boston region. In Boston, it is compounded by a severe lack of affordable housing, an inadequate mental health infrastructure, and persistent racial disparities. Boston should take direct accountability while leading coalitions for regional action:

  • Centralized, committed leadership: Currently, responsibility for these overlapping crises is split between the Chief of Human Services, the leaders of Boston Public Health Commission, Office of Recovery Services, Boston Police Department, service providers and community organizations. We need to elevate these issues within City Hall to shift from a reactive position to a proactive one. We need direct accountability to the Mayor’s office so that residents, community organizations and government agencies are aligned on a coordinated, citywide strategy and action plan.

  • Transparent community engagement: Over the last few years, efforts to engage the community have fallen short, with the Mass and Cass 2.0 Task Force meeting inconsistently. Community engagement should include ongoing data transparency about how City resources are being used, with what outcomes, including the number of overdoses, reversals, and fatalities; the frequency, size and scope of police response; and the number of individuals who have secured housing and recovery services. 

  • Municipal leaders task force: Boston leadership must proactively collaborate with leaders in our neighboring communities to unite behind a public health and housing-first strategy. The disastrous closure of the Long Island Bridge has shown us the consequences when one city’s decisions are made in a vacuum. Moving forward, Boston must ensure that our City’s public health approach is complemented by our neighbors, including through a multi-city partnership with the MBTA to connect unhoused people with resources and services, like a similar partnership in Los Angeles.

  • Regional recovery infrastructure: We must work as a region to plan for and invest in recovery infrastructure that operates at the regional level, including advocating for a new recovery campus, such as at the Arborway Yards or another publicly-owned parcel. Leveraging Boston’s immense healthcare resources requires proactive and transparent collaboration with regional and state partners to expand access to treatment. 

  • Drug trafficking enforcement: The Suffolk District Attorney’s Office is a key partner in efforts to stop the predation of people with substance use disorder by drug traffickers––including the recent indictments against three people for trafficking fentanyl, heroin, and methamphetamine. The Boston Police Department should work in collaboration to scale up efforts to support regional anti-trafficking enforcement.

  • State and federal policy change: Deeper regional collaboration will allow Boston to accelerate progress towards policy changes at the state and federal level. In the Massachusetts State Legislature, we must push for increased funding for additional detox beds, especially to increase capacity to serve women in recovery, and long-term supportive housing, continued limits on opioid prescriptions, public health education on fentanyl and ways to reverse opioid-related overdoses, and more resources for treatment for methamphetamine addiction. At the federal level, we need to build on short-term changes implemented during the pandemic, including home-delivery of medication for opiates; deregulation of buprenorphine, and more resources for community health centers to scale up their decentralized response.

2. Tackle Housing as the Root of this Crisis

Service providers and advocates emphasize that getting patients into treatment isn’t enough--everyone needs a safe, healthy, affordable home in order for a foundation of stability to pursue a pathway to a job, education, and a better future. To prevent a recurring cycle of falling into the opiate crisis, we must invest in a housing-first approach for all experiencing homelessness and housing instability:

  • Identify Gaps: Boston can immediately complete an audit of all housing units and supportive services in sober homes, short-term residential housing, long-term residential housing, day programs, permanent supportive housing, and through other service providers in Boston. Single-room occupancy units with supportive services is recognized as a best practice, but this model is underrepresented in Boston’s housing stock. 

  • Build supportive housing through the City’s capital budget: In my first 100 days as mayor, we’ll accelerate a comprehensive audit of all City-owned property to identify opportunities to develop supportive housing through our City’s capital budget. We know that the most expensive option is to do nothing. Chronic homelessness draws on public resources across healthcare, public safety, and city services. Leaning in to invest in desperately needed supportive housing will save the City money in the long run. 

  • Streamline zoning for deeply affordable housing: Through a newly-created public planning department, we’ll reform our zoning code and streamline the permitting process so that new scattered-site supportive housing units can move forward across Boston’s neighborhoods. We also need deeply affordable housing to transition people out of supportive units once they’re ready, including housing in the social housing sector like non-profits, community land trusts, and cooperatives. 

  • Lower barriers to entry to shelter: Last year, Boston’s Office of Recovery Services published guidance for shelters and community organizations offering low-threshold supportive space to better serve the full range of unhoused residents and those affected by substance use disorder. We need more supportive spaces with flexible hours that are available to all genders and family configurations––and we need more transparency around how these guidelines are enforced across City-run and private shelters.

  • Integrate transportation: Boston currently lacks the infrastructure to move people safely to shelters and treatment locations. Service providers frequently spend much of their days calling around, trying to find available beds that residents can actually access. We must invest in our public transit, including moving toward system-wide fare-free transit, to connect people with necessary services. In the meantime, Boston should expand support for transportation services aligned with shelters and service providers. 

  • Coordinate across City agencies and partners:  Boston must hire additional housing case managers so that Street Outreach Teams and healthcare providers can connect those they serve with housing. We need a central coordinated system to connect residents with the services they need, including by merging existing datasets so that shelters and emergency providers can more easily coordinate. And we need a more effective system for triage––service providers can typically divert about 20% cases to family members, alleviating strain on shelters, but Boston can lead greater coordination among public, private and nonprofit providers serving the same clients.

3. Invest in Care Coordination

Boston residents who are unhoused, living with substance use disorder or mental illness may have support networks that span mental and behavioral health, primary or specialist care, social work, day programs, education and job training programs, and networks of friends and family. Some people are able to manage appointments on their own, some have the support of friends and family––who provide an average of 32 hours per week of unpaid care––and some benefit from a professional case coordinator. Many people juggling appointments, seeking to enroll in benefits programs, and navigating ongoing family or job stressors find that working with a care coordinator helps them manage the day-to-day tasks involved in seeking and sustaining care.

  • More funding for existing services: Boston is home to supportive housing, health care facilities, and other service providers that do excellent, evidence-based work, despite severe underfunding, as well as City-run shelters and services like AHOPE. We need to invest in our public health infrastructure by fully funding treatment for substance use disorder, mental and behavioral health services and trauma support, supportive housing, and healthcare. When people feel motivated to seek treatment, there is a short window to get them the services they need––we must ensure resources are available when people need them.

  • Hub and spoke model: It’s clear that the existing concentration of services near Boston Medical Center endangers the safety and well-being of both patients and neighbors. We need a thoughtful approach to site substance use disorder recovery services and supportive housing throughout the city based on a hub and spoke model to avoid placing additional transportation burdens on people in need of multiple services, by expanding scattered-site supportive housing units within close proximity of medical and other supportive services. 

  • Additional case managers and coordinators: Boston utilized a care coordination approach to great effect in their work to support people experiencing chronic homelessness; we should use the same approach to supporting people living in the crosshairs of these overlapping crises. We need to invest in care coordination services so that everyone living with substance use has the support they need to manage care, sustain relationships, and access services, including by prioritizing language and communications accessibility and extending the technology tools needed to access telemedicine services. 

  • Support for community health centers: Boston’s existing community health centers constitute a decentralized network with deep expertise in providing linguistically accessible, culturally competent care. There are currently 30 sites across Boston run by either community health centers or Boston Healthcare for the Homeless where residents can access medication assisted treatment. The City should provide financial resources, technical assistance and training to community health center staff to maximize the potential of medication assisted treatment across Boston.

4. Respond with Dignity, Not Criminalization

Criminalization has failed as a response to public health crises. Today, people living at the intersection of homelessness, substance use disorder, and mental illness may have access to comfort stations during the day, but are frequently pushed out of the area by the Boston Police Department by night. This police response is ineffective for the long-term health and well-being of our communities, and it can exacerbate trauma and destabilize treatment. Our approach to these overlapping public health crises must recognize the dignity of every single Boston resident, saving public safety resources to concentrate on violent offenders and predatory traffickers, and scaling up basic City services that keep our communities safe, clean, and whole. 

  • Lead with public health, not criminalization: Communities around the country have developed successful crisis response programs to lead with a public-health lens with proven results. And federal proposals currently on the table would provide funding to municipalities like Boston to develop community-based mobile crisis services. We’ll build a crisis response team with community involvement from the beginning to ensure buy-in across all neighborhoods, adequate staffing and training for service providers. 

  • Meet basic needs and dignity: As the pandemic shuttered local businesses, we have been reminded of the central civic role played by public restrooms and washing facilities. Boston has the resources to invest in restrooms, showers, and laundry facilities that people need to take care of themselves, in turn protecting the safety, hygiene, and security of their surrounding neighborhoods.

  • Expand access to social services: We must connect people with medical care, housing resources, legal aid, and other essential support services, serving as a first touchpoint that can accelerate an individual’s progress toward recovery. Outreach should include hours and resources, ensuring that staff are present to attend to emergencies and have diverse representation across race and ethnicity, language, sexual orientation and gender identity. We must also respond to the evolving needs of Boston residents by focusing trauma-informed resources for recovery from sexual assault and domestic violence, as well as legal services to help people navigate through the CORI system.

  • Deliver food justice: Food is among the most basic of human needs, and the pandemic has revealed the tenuousness of Boston residents’ consistent access to nutritious, affordable, and culturally appropriate food. This access is all the more important for Boston residents living at the intersection of homelessness, substance use disorder, and mental illness––and nutritious food can provide the foundation for individual health and well-being. The City should scale up partnerships with Community Servings, Pine Street Inn’s culinary programs, and other food justice organizations, and launch new partnerships with neighborhood restaurants to enhance residents’ food security and well-being.

5. Scale Up Whole-Community Support

The overlapping crises of substance use disorder, homelessness and mental illness affects children and families, workers and businesses, and residents in neighborhoods all across Boston. Just as our public health response needs additional resources to address these crises with urgency, our basic city services need a similar surge in investment. As Mayor, I’ll work to strengthen collaboration between all City departments, ensuring dedicated resources for impacted families, and targeted support for businesses, neighbors, and community members.

  • Scale up neighborhood and city services: Trash pick-up is an essential service that sets the foundation for the type of community we want to live in. Boston’s Public Works department needs adequate staffing and resources to meet all neighborhoods’ needs. I’ll instruct the department to engage community members in supervised, City-run programs to surge trash clean-up services to hotspot neighborhoods. 

  • Expand access to needle disposal and exchange: We need a decentralized network of permanent syringe disposal kiosks in addition to mobile services, so that people know where to go to safely dispose of needles. We need more than the current number of outdoor syringe disposal kiosks, and we should incorporate metrics other than 311 calls to appropriately allocate kiosks across the City to account for disparities in residents’ comfort level accessing 311 services. We should also launch a multilingual, multichannel outreach campaign to ensure all residents know where their closest kiosk is. 

  • Support residents and families: To protect residents, city departments can do more to hold management companies accountable for security and upkeep of properties in hotspot neighborhoods. No resident should ever fear leaving their home due to threat of violence, and Boston’s public health approach must be coupled with targeted support for residents in neighborhoods affected by these overlapping public health crises. The City should invest in dedicated trauma supports in the Orchard Gardens K-8 School and across Boston Public Schools, and public art, public parks, and other ways to build healthier, more connected communities.

  • Support workers and businesses: It’s unjust to expect workers with low pay and inadequate protections to serve as first responders to overlapping public health crises. As mayor, I’ll create an Office of Worker Empowerment with oversight and resources to advance working Bostonians in both the private and public sectors, and direct resources for one-on-one outreach to workers at businesses in hotspot neighborhoods to ensure all workers know their rights, can access legal assistance for necessary redress, and have access to wraparound supports that account for the effects of these overlapping public health crises on their workplace.