Date of Submission

Fall 12-2-2022

Document Type


Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Dr. Trinette Radasa



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

Problem: In an acute care psychiatric facility in Northern California, the greatest readmission after inpatient hospitalization occurs at 53.9% in a week and 74.8% in two weeks of discharge. For homeless individuals, substance use disorder complicates personal problems and decreases the likelihood of a long-term exit from homelessness. As a result, hospital readmissions among the homeless population are higher than in the general population. One of the problems faced by this unit is frequent readmissions of the same group of homeless patients two to three times every month (24-36 times per year).

Methods: Implementing a nurse navigator program in the mental health unit is anticipated to improve the transition of care between the inpatient setting and the facility's other mental health outpatient clinics. The goal of this nurse navigator is to ensure that patients are medication compliant immediately after discharge from the inpatient unit and can keep outpatient appointments to support medication compliance.

Conclusion: Evidence from the published literature presented a compelling need to include follow-up care, comprehensive discharge planning, and nurse navigation.

Included in

Nursing Commons