Delivering Care in Communities: Everett’s Mobile Response to the Opioid Crisis
Lead Author: Cassie Franklin, MayorCategory: Health / Access to Care
The Challenge
Faced with a rising crisis of fentanyl and methamphetamine use, Everett’s mayor convened a Drug Crisis Task Force to identify community-rooted solutions. One of the Task Force’s 15 actionable recommendations was a mobile street-medicine initiative designed to meet individuals where they are—especially those who are unhoused or disengaged from traditional office-based care.The Solution
EMOTE is a low-barrier, street-level treatment program that delivers essential medical services—medication assisted treatment (MOUD), counseling, peer support—directly into the environment of individuals struggling with substance use disorder.Key elements:
- A mobile unit (van) operated by a team comprised of peer counselors with lived experience, substance use / mental-health professionals, and support from clinic-based prescribers.
- Outreach to residents who cannot or choose not to engage with traditional clinics—in short, “meeting people on their terms.”
- A partnership model involving the city government, community providers (such as Conquer Clinics), peer support networks and harm-reduction services.
Why It Matters
Bridging Gaps in Access: Traditional treatment pathways often erect structural and emotional barriers for vulnerable populations (unhoused individuals, people with co-occurring disorders). EMOTE removes many of those barriers by delivering care in the community.- Reducing Pressure on Acute Settings: By engaging individuals earlier, in situ, EMOTE helps reduce avoidable emergency-department visits and hospitalizations—aligning with broader goals of population health management and value-based care.
- Peer-Driven Trust Building: Incorporating staff with lived experience builds credibility and adherence among clients, which is especially important in behavioral-health and substance-use settings.
- Scalable Model: Although currently operating in Everett, the design is adaptable for replication in other municipalities seeking to respond to the overdose crisis as a combined public‐health and human‐services challenge.
Impact & Measurement
Since launch in July 2024, EMOTE has engaged in more than 1,000 meaningful contacts with Everett residents. The program tracks a variety of metrics including:- Client demographics
- Number of detox placements and inpatient rehab referrals
- Peer-support services and outreach engagement
- Referrals to outpatient services
- Transportation assistance
- Narcan (naloxone) distribution
- Substance Use Disorder assessments completed
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Community Health Hubs
Lead Author: Lee Harris, County Mayor – Shelby County, TNCategory: Improving Quality of Life
The Challenge
Many communities face high rates of chronic conditions like obesity, diabetes and hypertension, which contribute to cardiovascular disease (CVD)—a leading cause of death. Low-income and medically underserved neighborhoods often have limited access to preventive care, resulting in higher emergency-care use and disproportionate CVD impact on residents of color.The Solution
ShelbyCares is a partnership between the county government and the University of Tennessee Health Science Center (UTHSC) adopting their Neighborhood Health Hub (NHH) model. The approach offers free, neighborhood-based health services directly in high-need communities.Key program features include:
- Health screenings for chronic diseases and CVD risk factors.
- Culturally relevant health coaching and education.
- Nutrition and fitness programs, tobacco cessation support, and referrals to primary care.
- Hubs staffed by trained, community-based health coaches, located strategically in high-need ZIP codes.
Why It Matters
By embedding health services directly in underserved neighborhoods instead of relying solely on traditional clinics, the model reduces access barriers, engages residents in culturally relevant ways, and supports earlier intervention. This place-based, person-centered strategy holds promise for improving both health quality and longevity in communities disproportionately burdened by chronic disease.Impact & Measurement
In two NHH sites between January 2022 and February 2025:- 13,199 total visits were recorded.
- 2,030 unique clients served.
- 1,432 clients received screenings for obesity, diabetes and hypertension.
- 1,579 clients participated in individual or group health coaching (78% engagement rate).
- Health improvements included an 18% drop in blood glucose, a 10% reduction in systolic blood pressure and a 6% reduction in diastolic blood pressure.
- Participant demographics: 94% Black, 67% over age 50, 60% female.
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Health Equity Resource Communities (HERC)
Lead Author: Antonio Hayes, Senator – Baltimore City, MDCategory: Improving Quality of Life
The Challenge
Where someone lives often determines how well — and how long — they live. Many neighborhoods in Maryland suffer from high rates of chronic disease, behavioral-health needs, housing insecurity and systemic disinvestment, making them among the poorest in health outcomes statewide. The HERC initiative responds to this deep-rooted issue by focusing state resources into the communities that need them most.The Solution
HERC is a statewide, community-based strategy established under the Maryland Health Equity Resource Act. It invests state funds into local coalitions that deliver health and social services in historically underserved neighborhoods.One key example: the “RICH 2.0” initiative in West Baltimore, led by the University of Maryland School of Nursing and backed by a $5 million grant. It deploys nurse-led clinics, mobile health units, behavioral-health supports and social-service linkages.
The model also emphasizes cultural competency and community-ambassador training, embedding services in schools, recreation centers and churches.
Why It Matters
By aligning state resources with trusted local partners in underserved areas, HERC shifts from traditional health-delivery models toward ones rooted in neighborhoods and community expertise. The initiative offers a scalable framework for reducing health disparities and strengthening civic-and-social infrastructure in communities that historically have been excluded.Impact & Measurement
Key metrics being tracked include:- Number of residents reached and services delivered.
- Reductions in chronic disease rates, preventable hospitalizations and emergency-room use.
- Improvements in access to primary care, behavioral health, housing and social services.
- Engagement through trained community ambassadors and local partnerships.
