Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Karen Burritt PhD, FNP-BC

Second Advisor

Anne McKay DNP, ANP-BC

Third Advisor

Lori Lynn BSN, RN


Background and Objectives: Care coordination for the homeless population is challenging due to the complexity of healthcare and the uncertain life circumstances of the homeless individual. Objectives were developed to guide care coordination for the homeless by utilization of the free clinic to create PCP referrals, appointments and tracking follow-up care to increase appointment attendance and improve health outcomes for the homeless individual.

Design: A quality improvement project.

Setting: A faith-based non-profit homeless shelter organization in the Midwestern United States.

Participants: Participants include 25 homeless guests, 5 staff members including a clinic coordinator, 3 registered nurses and 1 licensed practical nurse.

Intervention: The Donabedian model was used to guide a process that included: a tool to track follow-up appointments, signage to raise awareness about the free clinic, and education of homeless guests. Electronic database record audits were conducted to collect data on improvement, and feedback provided to prompt improvement.

Measurement and Analysis: Documentation of patient appointment attendance tracking, and PCP referral were examined. Observation of care coordination conversations occurred during appointment setting visits. Data relating to guest perceptions on care coordination knowledge and satisfaction was collected by means of semi-structured interviews. Descriptive statistics was used to analyze the data.

Results: 25 homeless guests were interviewed with a mean age of 42; the sample was 70% people of color and 95% male. Number of PCP/specialty referrals increased from 20 to 45 (51%) during implementation. The number of PCP/specialty appointments attended increased from 15 to 32 (55%) during implementation. Emergency calls to the shelter decreased by 26% during and after implementation. 52% of the guests reported that transportation is the most significant barrier to accessing healthcare services. 32% of the guests reported that lack of insurance or lack of qualifying insurance is a barrier to receiving healthcare services. 88% of the guests reported that the free clinic had a positive impact on their overall health.

Conclusion: Care coordination practices can be improved through use of raising awareness about free clinics and community healthcare services, connecting patients with a PCP and helping patients schedule follow-up appointments after hospitalization. As a result of accurate patient appointment tracking, PCP referrals and appointment attendance increase, and hospital-related emergencies decrease.

Available for download on Monday, May 06, 2024