DANBURY — For most of the past 30 years, John R. was one of the troubled homeless men living on the streets of Danbury, staying warm at the library, sneaking along the railroad tracks and drinking in downtown alleyways.

When he wasn’t on the street, he was usually in jail for a theft or assault charge — often the former for trying to score some liquor and regularly the latter after he’d finished it all.

This year, for the first time in his life, John R. has an apartment of his own and is approaching six months of sobriety thanks to the help of a little-known network of agencies and nonprofit providers called the Danbury Community Care Team.

Now the 48-year-old Danbury native, who asked that his full name not be used, is being hailed as a role model by homeless advocates who spent years trying to get him the help he needed.

“We’ve found that we need a role so that it’s so seamless there are no cracks for these folks to fall through,” said Kevin McVeigh, who facilitates that team through Danbury Hospital. “Their most vulnerable times are in between treatments, so we do whatever it takes to be there for them. Because we know if we can keep them engaged with us, we can keep them off the street and get them back on their feet.”

The team connects dozens of local doctors, rehab centers, emergency shelters, police officers, city officials, food kitchens, religious nonprofits and mental health professionals to directly coordinate their services and ensure “wrap around” care for every individual who is, has been or could be teetering on homelessness across the Danbury area.

The group has housed more than 80 longtime homeless individuals over the past three years and provides services to more than 230 others across all three of those categories, McVeigh said. But the work happens largely out of the public eye, shrouded in patient privacy laws and buried under the stigma that still surrounds homelessness.

The success of John R. illustrates how the system is designed to work for every individual case and encourage any person, no matter their addiction or mental health needs, to pursue their own change.

“I have an opportunity to live life today,” John R. said. “I have an opportunity to face all the things in my life and work them out and get through them. I’m quite surprised at myself. I’ve always known I had the ability to make it and I’m doing it.”

‘Cat and mouse’

Sitting in his new favorite armchair in the living room of his own Locust Avenue apartment, John R. recalled that he was not always homeless or drunk or high on opioids.

In the mid-1990s, he forced himself to stay sober after a stint in jail and fell in love. He got married in 1997 and pursued his plumbing career while caring for his wife’s children in their New Haven home.

“I got to a point where I said, ‘Look at everything I’ve achieved in my life. I’ve got a beautiful wife, I’m taking care of children, I’ve got cars, I’ve got a great bank account, I could probably use again,’” he said. “I could probably shoot a bag of dope and it won’t affect me like before. That was maybe 2004 and I haven’t put it down since. I lost everything in a couple of months.”

John R. has been in and out jail eight times since then, including stints for burlary, theft and several assault charges.

He first met McVeigh, who was then working as a counselor at the MCCA rehabilitation center, about 12 years ago. The two hit it off and would work together here and there over years — between jail, back and forth with other residential treatments and through numerous emergency room visits.

When McVeigh was tapped to start the community care team almost five years ago, he worked John R. into the new coordinated access system where all of the providers who worked with him could share their information about his case. They were able to help each other track John R. down when he would seemingly vanish and he’s now been through 10 episodes of treatment in just the past three years, McVeigh said.

After two rounds of treatment in August and September, John R. was given an opportunity: Stay sober and the community care team will be able to provide a housing voucher within a matter of weeks. He almost couldn’t believe it, but he stuck with it and on Dec. 15 he was able to move in to his new place on Locust.

“It’s the first Christmas in a long time that I was able to stay sober and have some place to go and stay warm. It’s a blessing,” he said. “I still look around and think, ‘Okay, when are they coming to throw me out of here?’ But wait a second, if I keep doing the right thing, this might be possible.”

‘Who’s driving?’

The topsy-turvy path John R. took out of homelessness is representative of most peoples’ journey from the streets, through addiction and back into a home.

It also represents the new way of thinking about homelessness called “housing first,” through which a person is treated and then quickly put into a stable housing situation where the rest of their issues can be addressed over time.

The fragility of that process is exactly what the community care team is designed to cushion, by giving every provider that helps that person the best view of every pothole on their road ahead, said Michele Conderino, who oversees homeless services for the Catholic Charities of Fairfield County.

A team of about 30 people meets for at least an hour every week.

“You don’t have a meeting every week and have that kind of attendance unless it’s working,” Conderino said.

At each meeting, the group looks over a list of dozens of names and provides updates, one-by-one, on the most urgent cases or with people who have appointments or court dates the upcoming week.

More than 75 names were on the group’s list at a recent meeting. After discussing the case of a Danbury man who had been awarded a housing voucher in Torrington but could not get there on his own, McVeigh asked, “So who’s driving?”

One provider picked the man up a few hours later.

In other cases, the team checks in on people already housed simply because they haven’t heard an update from that person for some time.

The seemingly mundane tasks underscore how comprehensive the team wants to be with every individual they help to not only get them into homes but to keep them there, Conderino said.

Those efforts have helped reduce the long-term, chronically homeless population in Danbury over the past four years and it should decline again this year, said Conderino, who organizes the Danbury-area annual homeless count.

“We’ve really moved so many of our long, longterm homeless people into housing and they’ve stayed there,” Conderino said. “Now we’re looking at a group of people who have been in the shelters for a year or less. We’re redesigning the system to meet their needs.”

No perfect system

Sometimes the community care team is not able to help an individual in time or break through to someone who simply refuses services.

David Mullen had been homeless, camping behind buildings downtown, for only a few weeks when police found his body partially submerged in the icy Still River the morning of Dec. 1. He had been working with the community care team and his family has said he was due to receive housing benefits just after the new year.

Other familiar faces around downtown have rebuffed years of attempts from providers to seek shelter or enter treatment, but they cannot necessarily be compelled against their will to receive help, officials have said.

Today there are fewer than a dozen such individuals downtown who fit that profile.

“There isn’t one great solution,” Mayor Mark Boughton said. “If there was, everybody would be doing it. The system’s not perfect, but I think we have the emergency space available we need. It’s more the longterm housing stock issue that we need to address.”

This spring the city will begin a study of how to create a single campus that could include office space for community care providers and shelter beds to keep all of those services together, but the plan is still in its infancy, Boughton said.

Each group secures grants and funding for its own programs, but combining many of those services in a single city-owned location could help further boosts the team’s results, the mayor suggested.

With time, though, McVeigh and advocates believe they can break through to people to put in the work that John R. has.

“He should be dead. Most people would be dead,” McVeigh said. “There is no sidestepping the work that goes in. The bottom line is there’s only one person who can do the work on that recovery, and that’s the person.”

John R. shrugged off the suggestion that he is a role model, but he does want to try to help others as he adjusts to his new home life.

“I long for having good friends in my life; good, caring, compassionate people to help you out,” he continued. “I also want to do the same for them. I want to be able to give back. I feel I’ll be able to grow more when I give back, instead of just sitting here in my apartment.”

zach.murdock@hearstmediact.com