Kelly Bridges and his longtime partner Breeanna have been homeless and living sporadically in a van for a few years. Whether it's been lack of work and rental history, or past issues with the criminal justice system, landlords repeatedly have denied the couple a stable place to live.

Other factors have made life even more complicated. Breeanna was the only witness to a 2018 homicide in north Minneapolis and said she's begged police to protect her from threats. The couple also are trying to regain custody of their two young daughters.

Last week, they were making plans for a long winter outside in the van. But a determined case worker from Hennepin County's Homeless to Home program found the couple their first permanent apartment in St. Paul.

The aggressive and coordinated initiative, which has a 30-member team that works one-on-one with people experiencing homelessness, has placed 331 people into permanent housing in the past year. Officials say it's the most impactful single effort in county history.

"The program gave us a chance when nobody else would," Bridges said.

Homeless to Homes morphed from the county's efforts to move 464 homeless, senior citizens and others most vulnerable to COVID-19 into motels and hotels over two years. As the pandemic subsided and people got vaccinated, the county decided to become "housing-focused" with the homeless instead of letting them shuffle through emergency stays in the shelter system.

"There is a disconnect with people in shelters," said Danielle Werder, area manager of the county's Office to End Homelessness. "So we shifted with a laser focus to find permanent housing for the homeless and how to break down barriers to do it."

Not only is the program finding affordable housing, the new residents are staying put. A full 97% of those placed in permanent housing remain there.

Overall, the program has offered services to 868 people. The team, with a total budget from the county of $10.5 million over four years, consists of social and case workers, case aides and managers. Each person experiencing homelessness is assigned a caseworker, who continues to help with additional resources long after an individual is housed.

Team member specialties include people coming out of the criminal justice system and the growing population of senior citizens without homes. The county recently added a member who focuses on substance-use disorders and another who deals with homeless youth.

"The team knocks down barriers one by one," said Lynn Shafer, the program's manager. "It's a well-trained and cohesive team that shares resources with each other and the community."

Case workers meet with their clients every week. She recalled one man who was placed in a hotel during the pandemic, moved to a motel and then was forced back to a shelter. Last week, his case worker found him permanent housing.

"What's impressive about this program is that we are placing people in existing housing," Shafter said. "The county doesn't own the housing. This program may stick out as innovative, but we're really just going back to the basics."

Team workers use a variety of options to find housing that includes vouchers, market rate rentals, properties with designated units for low-income people and potential income from the client themselves.

Once housing is obtained, workers make sure the client has something to sleep on, a place to sit, and a table to eat meals, Werder said. They supply cooking utensils and other household items and help with how to pay rent, get visitation with children and receive mail.

'We want them to move in with dignity," Werder said. "Moving into an empty apartment is terrible."

People who've struggled to maintain a permanent residence face myriad challenges with potential landlords, from past evictions to criminal records. Werder said they do a lot of work expunging warrants and getting clients connected with probation officers.

Case managers will help clients obtain vital documents like a driver's license or a Social Security card, she said. If warranted, they will appeal a landlord's denial of housing.

"If a client has a personal issue, they don't have to work out it before moving into a place," she said. "We have no preconditions and no hoops to get through."

Bridges, 42, said their case worker never gave up on them. She helped the couple out on her own time, brought them food and drove the pair to their new apartment in St. Paul.

Bridges has a record of armed robbery and assault earlier in his life. He said he committed the crimes to help pay bills for relatives. He now earns a disability check, and Breeanna is looking for work. They have been together for 12 years.

He became part of Homeless to Home when he was placed in the county's mental health court in 2020. At that point, he said, his life was spiraling out of control. They had just lost custody of their 4- and 6-year-old daughters.

"The Homeless to Home program really saved us," Bridges said. "I was ready to give up. You just get used to being homeless after awhile."