In Brief:
The chronically homeless live in a tangle of problems that many civic leaders find impossible to unravel. Nationally, their numbers are increasing at a greater rate than the overall homeless population (see chart), but it’s a different story in Hennepin County, Minn. Hennepin is well on the way toward its goal of ending chronic homelessness.
As defined by the U.S. Department of Housing and Urban Development (HUD), “chronically homeless” persons are those with a documented disability who have lived in a place “not meant for human habitation” for at least 12 months, or a combined 12 months over the past three years.
Simultaneous physical, mental and substance abuse disorders are the norm in this population. Their troubles can exceed the capabilities and resilience of homeless services in a community, if services tailored to persons with such comorbidities are even available.
When Boston University asked mayors in cities with over 75,000 residents about their response to homelessness, fewer than 1 in 5 said they had much control over it. Only 40 percent had an explicit policy goal aimed at reducing or eliminating it. Almost a third of the cities had no staff fully devoted to serving the homeless.
“Homelessness is one of those issues that many people believe is just intractable,” says Beth Sandor, chief program officer at the nonprofit Community Solutions. Since 2021, Hennepin County has reduced its chronically homeless population by 28 percent, with a 97 percent retention rate.
Now it’s working with Community Solutions to be the first large community in the country to get chronic homelessness to “functional zero.” Based on its overall homeless population, this would mean that fewer than three people in the county would be experiencing chronic homelessness at any given time.
“Their aim is to do that by the summer of 2025,” says Sandor. “If anyone can do that, I think Hennepin County can.”
Rare, Brief and Non-Recurring
Community Solutions brings a systems approach to the problem of homelessness, drawing on strategies that have been used to contain public health threats. This starts with maintaining a by-name, real-time count of the homeless population in a community, the foundational data point for dashboards developed in partnership with the data visualization company Tableau.
Data about the experiences of these individuals in a community’s continuum of care goes into the database. This makes it possible to see what help they have received and what they might need on their path to becoming housed.
This virtual ecosystem has a real-world counterpart. Community Solutions brings all the public- and private-sector groups that are working on homelessness together, to act in concert. This “command center” uses its new data tools to monitor progress and find ways to better coordinate the work of these loosely coupled collaborators.
(Hennepin County)
Pandemic funding enabled the county to create a more functional system, she says. One recent innovation is the Hennepin Shelter Hotline, a single point of contact for anyone experiencing homelessness. Before it was implemented, a person in need would first have to work out which of the county’s homeless services matched their situation, and navigate the system for that, says Werder.
The hotline is diverting 40 to 50 people per week, from those who need shelter to the unsheltered who are unwilling to come inside. The latter are attended to by a “street to housing” team.
Known by Name
The county began working with Community Solutions in 2018, starting by building its by-name list. “We use it for all of our work — we’re working in a large system, but we can only do this on a person-by-person basis because everyone’s situation is unique and they have a different pathway out of homelessness,” says Werder.
The county was invited to join a Community Solutions “Large City Last Mile” cohort. This will bring funding that will enable it to hire a planner focused solely on the chronically homeless, who begins work in a month.
“We’re excited to dig into our by-name list and identify solutions that will bring us over the finish line,” says Werder.
Staying Housed
The county’s work with the chronically homeless doesn’t end when they are placed in housing. Being housed can be frightening and uncomfortable for those who have lived outside, unhoused, for a very long time, says Heidi Haskins, who supervises the county's long term/chronic homeless team. Ensuring that the homeless remain housed is one of its biggest challenges.
(Hennepin County)
Housing comes with wraparound services, but even with these, success depends on ongoing follow-ups by case workers and a work culture that recognizes this reality. “I could probably lose half the people I work with but, luckily, Hennepin County is backing me,” says case manager Toni Wenbourne. ”We do assessments with every person that we work with to see what barriers they’re facing, what housing is best for them and what benefits or resources they’re not receiving.”
The by-name tracking system is integral to this work and to ensuring that each chronically homeless person is connected to a case worker. Before it was implemented, help was provided on the basis of referrals, Haskins says, and reliance on referrals didn’t result in truly equitable access to the county’s services.
Haskins is looking forward to having a dedicated planner for the chronically homeless, using by-name data to get an even better grasp on what’s going on with each client. This will be a further safeguard against clients losing housing because their situations get out of control.
The fact that the county has a working model in place has meant that it is one of the few jurisdictions to show real success with HUD’s emergency housing voucher (EHV) program. EHV funds have been a factor in 40 percent of recent placements, Haskins says.
“Our case managers don’t give up,” she says. “I get goosebumps every time I go to a lease signing or an apartment tour, to see the possibility of someone moving in who has been homeless longer than 12 months.”
(Jason Houston / eight16creative)
What’s Working
Sandor sees several things that are foundational to Hennepin County’s success. One is the state’s long-term commitment to addressing homelessness and its strategic decisions around issues from funding to zoning. “They were one of the first states with a Medicaid waiver to pay for services and housing; in their 2024 budget they have approximately $1 billion for housing initiatives,” she says.
The county uses real-time data to target the use of services and resources. This is accompanied to a commitment to continuous improvement, actively looking for bottlenecks and points where people are falling through the cracks.
The character of the team is another factor, she says. Everyone, including the state, is rolling in the same direction, with an “all hands on deck” attitude regarding homelessness.
Community Solutions works with partners in more than 100 communities around the country. This sense of alignment, interconnectedness and shared purpose is a common denominator among those approaching “functional zero” for one or more populations.
The chronically homeless population has the greatest need for services and the most complex path from the street to housing. What Hennepin County is accomplishing sends a message about the possibility of ending overall homelessness, says Sandor.
“If we can do it here, we can do this for anyone in any city.”
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