Across the United States, communities are grappling with a difficult question: how do we effectively address homelessness when it is driven by substance use disorder (SUD) and serious mental illness?
For years, the national conversation has centered on a model known as Housing First—the idea that people experiencing homelessness should receive rapid access to housing without requiring sobriety or treatment first. Research shows the approach can improve stability and quality of life for many individuals.
But in practice, the debate around Housing First has become increasingly polarized. Some critics argue the model fails when people with untreated addiction or severe mental illness struggle to maintain housing. Supporters counter that housing is a fundamental human need and a critical foundation for recovery.
Both perspectives contain truth—but neither tells the full story.
The real issue is not whether housing matters. It is whether housing alone can carry the weight of complex behavioral health needs.
A growing body of research shows that homelessness is frequently intertwined with behavioral health challenges. More than three-quarters of people experiencing homelessness live with a current mental health disorder, and roughly one-third meet the criteria for a substance use disorder.
These individuals often face overlapping medical, psychiatric, and addiction-related conditions. Without stabilization and clinical support, even the best housing programs can struggle to sustain long-term outcomes.
Housing providers are not designed to manage withdrawal symptoms, psychiatric crises, or chronic medical conditions. When individuals enter housing while still navigating severe clinical instability, evictions, emergency responses, and repeated system cycling can follow.
This mismatch highlights an important lesson: housing is essential—but for many people experiencing homelessness, it is not sufficient on its own.
The Missing Piece: Behavioral Health Triage
A more effective approach begins with triage-based behavioral health assessment.
In healthcare settings, triage determines the level of care someone needs before treatment begins. The same logic can be applied to homelessness systems.
Before housing placement, individuals can be evaluated for behavioral health needs, withdrawal risk, psychiatric symptoms, and medical complexity. Based on this assessment, they are routed into the most appropriate combination of housing and clinical care.
This approach does not delay housing. Instead, it aligns support with risk from the start—protecting both the individual and the housing environment.
At Ascension Recovery Services, we believe the future of homelessness response lies in a hybrid model that preserves the strengths of Housing First while adding clinical stabilization pathways for higher-acuity individuals.
In this model:
- Individuals with lower-acuity needs move directly into housing with voluntary support services.
- Individuals experiencing active addiction, withdrawal, or severe mental illness receive short-term stabilization through medical and behavioral health programs before transitioning into housing designed to support their recovery.
This creates a flexible system that meets people where they are rather than forcing everyone into a single pathway.
Lessons from Boston’s COVID Response
A powerful example of this model emerged during the COVID-19 pandemic in Boston. Public health agencies, hospitals, homelessness providers, and community partners collaborated to create a triage-based housing response for people living in crowded shelters.
Individuals were moved into hotels and dormitories, where clinicians assessed them for infection risk, withdrawal symptoms, psychiatric conditions, and medical fragility. Patients were then placed in housing environments matched to their level of need, with on-site clinical care and telehealth support.
The results were significant: reduced viral spread, fewer hospitalizations, and improved stability for vulnerable populations.
The lesson was clear—when housing and healthcare systems work together, outcomes improve dramatically.
Building the Next Generation of Recovery Infrastructure
Across the country, communities are recognizing that homelessness driven by addiction and serious mental illness requires the same level of operational planning we expect in healthcare systems.
Housing alone cannot solve the problem. Treatment alone cannot solve it either.
What’s needed is integrated infrastructure—a system that connects stabilization services, recovery programs, supportive housing, and long-term care coordination.
Ascension Recovery Services works with cities, healthcare systems, and community partners to design and develop these recovery ecosystems. By combining behavioral health triage, stabilization programs, and housing pathways, communities can create environments where individuals have a genuine opportunity to recover and rebuild their lives.
The path forward is not Housing First or Treatment First.
It is Housing First—supported by the clinical infrastructure necessary to make recovery sustainable.
If communities want lasting solutions to homelessness and addiction, they must invest in the systems that bring housing, healthcare, and recovery together.