Date of Award

Spring 6-14-2021

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Dr. Lorie Wild and Dr. Lyndsay MacKay

Faculty Reader

Carrie Fry

Executive Summary

A Functional Needs Checklist for a Hospital to Housing Program by Utilizing Structured Approach

Faith Sairez

Executive Summary

Background and Significance
Hospital to Housing (H2H) programs aim to offer alternative discharge destinations for homeless veterans discharging from the hospital (U.S. Department of Veterans Affairs [VA], 2019). H2H programs allow homeless veterans time to find permanent and stable housing and can keep them from living on the streets (VA, 2019). Requirements for referral to transitional housing programs in Washington State include chronic homelessness, existing substance abuse or mental illness, and independent functional abilities (VA, 2019).

Problem and Purpose Statement
Lack of standardized assessment tools have resulted in improper assessments and placements of individuals who do not meet the independent criteria of the H2H program, creating life threatening incidents, and financial losses for the homeless individuals and the organizations involved. The purpose of this project was to create, implement, and evaluate a H2H functional needs checklist to aid non-medical case managers in assessing the functional abilities of homeless veterans.

The IHI Model for Improvement and Kurt Lewin’s change theory was utilized for implementation. The overall aim of this quality improvement project was for the housing program’s case managers to have 8/10 confidence in using a referral checklist by August 2020. A Plan-Do-Study-Act cycle of a referral checklist was implemented during phase one of the H2H program’s referral process. Data was collected using online surveys and small group interviews.

Overall, eight case managers participated. Results of the quality improvement project showed case managers’ perceived accuracy of the checklist and confidence in using the checklist reached the goal of 8/10 by July 2020. Usage of the referral checklist reached 100% by August 2020. Furthermore, there were no major discrepancies between the number of individuals being admitted to the program versus being declined from the program. At the conclusion of the project, the case managers reported satisfaction with the checklist, and an enhanced referral process. There were no requests for changes regarding the checklist after the first PDSA cycle.

The official checklist used at the completion of the project was provided to the case managers and the organization in electronic copy. The next step is to require 100% usage and implement the checklist as standard for all referrals into the program. Compliance from the VA hospital and individual candidates have also been obtained 100% since implementing the checklist. A follow-up DNP project would also ensure sustainability of this project.

Implications for Practice
By implementing an official standardized referral process using an evidence-based tool, this program is setting new best practice for other existing and future H2H programs. This new evidence-based tool creates several opportunities for multiple disciplines to apply the tool into their practices. Providing proper housing for homeless veterans keeps them from living in the streets, avoiding violence and decreasing mortality rates

U.S. Department of Veterans Affairs (VA). (2019). Homeless veterans. U.S. Department of Veterans Affairs. Retrieved from:

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