Abstract

An estimated 2.3 to 3.5 million individuals are homeless in the United States, many of whom have chronic medical and mental illnesses. Underserved individuals who are homeless experience gaps in services, resulting in poor health care outcomes and readmission to the hospital setting, often presenting in crisis through the emergency department. The financial state of hospitals is negatively impacted by the burden of patients returning to the hospital due to unresolved issues. The current article presents the role of a psychiatric-mental health nurse practitioner as part of a pilot program, Opportunity Village Mobile Health, that provides a comprehensive approach to meet the physical and mental health challenges of homeless individuals who are discharged from inpatient to outpatient services. Continuity of health care services are made available to this unique patient population to reduce hospital readmission rates and provide much needed transitional care.

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