Date of Doctor of Nursing Practice Project Completion
Summer 8-14-2025
Faculty Advisor
Dr. Angela Nash
Abstract
PURPOSE This quality improvement (QI) initiative aimed to reduce 30-day psychiatric readmission rates among adults experiencing homelessness by 10% over a 3-month period. Secondary goals included a 15% improvement in medication adherence and completion of follow-up visits.
BACKGROUND Individuals experiencing homelessness and mental illness face higher risks of psychiatric decompensation and hospital readmission. At Houston Behavioral Hospital, 13.34% of psychiatric readmissions involved unhoused individuals, highlighting limitations in standard discharge planning.
METHODOLOGY A pre-post intervention model was used to implement a discharge protocol based on the Transitional Care Model (TCM). The intervention included staff training, the use of a resource guide at discharge, and enhanced coordination with community agencies. Discharge planning was individualized using structured interviews to identify post-discharge barriers and connect patients to housing, food, and transportation resources. Data on housing status, readmission rates,
and patient feedback from 30-day follow-up calls were analyzed.
RESULTS A 1.12% reduction in 30-day readmissions was achieved. Patients discharged on weekdays had better outcomes, likely due to greater access to community services. However, improvement in medication adherence and follow-up visits was limited to 0.8%, primarily due to persistent barriers related to housing and transportation.
IMPLICATIONS Individualized discharge planning and stronger community partnerships are feasible, low-cost strategies to reduce psychiatric readmissions among homeless populations. This model holds potential for broader adoption by healthcare systems seeking to improve continuity of care for socially vulnerable individuals.
Keywords
Homelessness, Psychiatric, Readmission, Mental Health
Recommended Citation
Stacy M. Alvarez, "Implementing Interventions to Decrease Readmission Rates in a Behavioral Hospital For People Experiencing Homelessness" (2025). Doctor of Nursing Practice Final Project Abstract. 125.
https://digitalcommons.library.tmc.edu/dnp_abstract/125