Recent years have seen homelessness hit record numbers across the country1. Between 2023 and 2024, the United States saw an 18% increase in all people experiencing homelessness. Massachusetts is one of the states hardest hit. Homelessness in the commonwealth has increased 94.1% from 2007 to today, due to persistent housing supply shortages and an affordability crisis2. In Greater Boston, Black renters and homeowners experience higher rates of being housing cost-burdened than White renters and homeowners, as well as higher rates of homelessness3. This pattern repeats for Hispanic/Latine residents. In greater Boston, as in the rest of the United States, structural racism4 drives housing and other inequalities for racialized groups.
While Massachusetts has a robust shelter system, there are gaps in our housing service landscape. Although they make up only a small share of the state’s unhoused population, chronically unsheltered people who use drugs continue to have acute needs that are poorly met by the traditional shelter system. At the intersection of Boston’s Massachusetts Avenue and Melnea Cass Boulevard (Mass and Cass), the housing, opioid, and mental health crises have converged, resulting in an area with open drug use and encampments5.
To better meet the needs of this group, in 2021 the City of Boston initiated planning for Low Threshold Shelter (LTS) programs using a harm reduction and housing first approach. The LTS programs provide transitional shelter and housing while connecting program participants to supportive services. These include medical care, mental health care, housing navigation services, and substance use treatment and harm reduction services. These supportive services aim to help participants address immediate needs while they work to get a permanent housing placement6. In January 2022, six LTS programs were implemented in Boston, with one of the sites (Roundhouse) closing in August 2023. A temporary site, known as 727 MA Ave, was launched by BPHC and was in operation from November 2023 – August 2024.
Given structural racial disparities in housing, the city aimed to understand if the program was equitably connecting its participants to housing. To facilitate the program achieving equitable outcomes, BPHC, through funding from the Office of Minority Health (OMH)*, launched the Boston Pathways initiative. One element of this initiative is a 3-year equitable evaluation, which they hired ICH to conduct.
ICH is using an equitable evaluation framework to design and implement a mixed methods evaluation that includes a race equity analysis of housing data. ICH and BPHC shared some preliminary evaluation results at the American Public Health Association (APHA) 2024 conference. Using competing risk models, with BPHC administrative LTS data from January 2022 to June 2024, we found that Black non-Hispanic guests were 11% more likely to be placed into permanent housing compared to white guests (however, this result was not statistically significant). Conversely, we saw that Hispanic/Latinx guests and female guests were less likely to be placed into permanent housing compared to White and male guests, respectively.
We also conducted 23 qualitative interviews with people living in the LTS during July and August 2023. Nearly all interviewees were unsheltered prior to entering the LTS. They cited a number of structural barriers that prevented them from becoming housed before the LTS, including incarceration, lack of job access, low wages and job instability, and experiences of stigma and discrimination. Many highlighted that LTS services helped address these structural barriers through supportive services such as accessing documentation, benefits, housing vouchers, medical care, mental health care, substance use treatment or services, and sealing criminal records. They also shared that their time living in an LTS program benefited them in a number of ways, with reported improvements in access to housing, sense of safety and ability to rest, social connections and relationships within and outside of the LTS, physical and mental health, substance use behaviors, and quality of life.
We are currently building off of our initial results and exploring former LTS guests’ experiences after they’ve been placed into housing. We are also looking at supplementary datasets from the Homeless Management Information System (HMIS) to understand how factors such as benefits access, income, or disability status impact LTS guests’ housing outcomes.
Our initial evaluation results suggest that the LTS is a promising model that helps address a myriad of individual and structural barriers that prevent some of the most marginalized individuals from getting housed. Yet, further research looking at long-term housing retention is needed to fully understand the impact of this model. Unfortunately, since the launch of the LTS programs, several sites have closed due to lack of funding.
The twin substance use and housing crises, compounded by structural racism, aren’t likely to end any time soon. While Massachusetts has a long way to go to fully address structural racism, in Boston, the LTS has succeeded at connecting those who are disengaged with the traditional shelter system to key services to help them get housed. These program models should receive additional support and expand to other communities to facilitate humane and equitable access to housing for all.
*This project is supported by the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $492,838 with 100 percent funded by OMH/OASH/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by OMH/OASH/HHS, or the U.S. Government. For more information, please visit www.minorityhealth.hhs.gov