Implementing Interventions to Decrease Readmission Rates in a Behavioral Hospital For People Experiencing Homelessness

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.