Date of Graduation

Summer 8-18-2023

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Psychiatric Mental Health Nurse Practitioner

First Advisor

Dr. Trinette Radasa PMHNP-BC, FNP-BC

Second Advisor

Dr. Susan Mortell, DNP, RN, CNL



Background: Psychiatric inpatient readmission of mentally ill homeless men with substance use disorder is greater than that of the non-use population. Substance use disorder co-occurs with high prevalence among patients diagnosed with mental illness. For mentally ill homeless individuals discharged after inpatient treatment, substance use disorder negatively impacts health, behavior, and medication non-compliance, resulting in hospital readmission.

Problem: In acute psychiatric facilities in Northern California, the greatest readmission after inpatient hospitalization occurs at 53% in a week and 74.8% within two weeks of discharge. For homeless individuals, substance use disorder exacerbates personal problems and decreases the likelihood of long-term exit from homelessness. As a result, hospital readmission among the homeless population is higher than in the general population. One of the problems faced by the mental health unit in Northern California is frequent readmissions of homeless patients, two to three times every month (24-36 times per year).

Methods: Implementing a 14-step homeless discharge checklist aims to ensure that patients are medication compliant immediately after discharge from the inpatient unit and to improve the transition of care between the inpatient setting and other outpatient behavioral clinics within the county. This intervention aims to ensure medication compliance after discharge from the inpatient unit and to keep outpatient appointments to support medication compliance.

Conclusion: Evidence from the published literature presented a compelling need to include follow-up care and housing arrangements in homeless discharge planning by following a discharge checklist.

Keywords: discharge planning, homelessness, hospital readmission, nurse navigator, substance use disorder.