Date of Graduation

Fall 12-18-2015

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions



First Advisor

Dr. Jo Loomis

Second Advisor

Dr. Alexa Curtis

Third Advisor

Dr. Travis Svensson


An estimated 2.3 to 3.5 million people are homeless in the U.S., often living with chronic medical and mental illnesses. The underserved population, such as the homeless, continues to experience gaps in services, resulting in poor healthcare outcomes and readmission to the hospital setting. They often present in crisis through the emergency room, contributing to an already overburdened healthcare system. Increased spending and overutilization of healthcare services continues to rise in the United States (U.S.). Due in part to advancements in technology and expanded health insurance coverage, American healthcare continues be one of the most expensive commodities in the U.S. The financial state of hospitals are negatively impacted by the burden of patients returning to the hospital setting due to unresolved issues. The average per hospital stay associated with a patient readmission averages between $18,732 and $26,760 (Pfuntner, Wier, & Steiner, 2013). Cost containment measures are imperative to the survival of organizations and must be achieved without compromising quality patient care. Opportunity Village Mobile Health (OVMH) in conjunction with Marin County services is a pilot program that aims to provide comprehensive care to the homeless population transitioning from the inpatient setting to the outpatient setting in an effort to reduce rehospitalizations, improve quality of care, and decrease financial burden associated with readmission to the hospital setting. As a member of the OVMH team, a psychiatric mental health nurse practitioner (PMHNP) was assigned as part of the team to provide a comprehensive treatment approach to meet the mental health challenges of the homeless population. The role of the PMHNP was to identify mental and behavioral health service gaps associated with the transitional care process and collaborate with community partners to meet the individualized needs of patients in the program. Through this collaborative effort, continuity of health care services were made available to these patients, and a reduction in readmission rates was expected. Participants in this program were expected to experience better health care outcomes and report feeling valued as members of their communities.