Supporting the People Who Help Support the Patient
Hospitals Without Walls™ recognizes that family members, friends, and other trusted caregivers may play an essential role in helping patients manage illness, medications, appointments, mobility, personal needs, and transitions between care settings.
Our model seeks to include and support authorized caregivers while preserving the patient's dignity, autonomy, privacy, safety, and right to make decisions.
Caregivers Are Part of the Care Continuum
Care Often Continues After the Professional Leaves
Depending on the patient's needs, caregivers may help with:
- Medications and treatment schedules
- Appointments and transportation
- Meals, hydration, and household needs
- Mobility and activities of daily living
- Medical equipment
- Symptom observation
- Communication with healthcare professionals
- Emotional and social support
- Safety within the home
- Transitions between hospitals, facilities, and home
- Advance-care planning and serious-illness decisions
- Coordination of services and community resources
Caregivers should receive information, training, and support proportionate to the responsibilities they are expected and legally permitted to perform.
Who Is a Caregiver?
Family Is Defined by the Patient
A caregiver may be:
- A spouse or partner
- An adult child
- A parent
- A sibling or other relative
- A friend or neighbor
- A legally authorized representative
- A privately hired caregiver
- Another person identified by the patient
A family or informal caregiver is not automatically a licensed healthcare professional, legal representative, surrogate decision maker, or paid personal care worker.
The caregiver's authority depends on the patient's consent, decision making capacity, applicable law, and any valid legal documentation.
Our Caregiver Support Process
Understanding the Patient's and Caregiver's Needs
- 1
Identify the Caregiver
With the patient's permission, the care team identifies the people involved in the patient's daily support and clarifies how the patient wishes them to participate.
- 2
Clarify Roles
The care plan identifies which responsibilities belong to the patient, caregiver, treating professionals, facilities, agencies, and other organizations.
- 3
Assess Preparedness and Capacity
The team may ask whether the caregiver has the knowledge, physical ability, time, resources, emotional readiness, and willingness to perform the expected tasks.
- 4
Provide Education and Training
Qualified personnel may explain the care plan and teach appropriate tasks within their professional authority.
- 5
Connect Resources
The caregiver may be connected with respite, counseling, support groups, social services, personal care, transportation, benefits assistance, or other available resources.
- 6
Reassess
Caregiver capacity and needs may change as the patient's condition, function, treatment, or living situation changes.
Caregiver Assessment
Asking What the Caregiver Can Realistically Provide
Depending on the program, a caregiver assessment may address:
- Understanding of the patient's condition
- Knowledge of the care plan
- Ability to manage medications or equipment
- Physical ability to assist safely
- Availability and scheduling
- Sleep and fatigue
- Emotional distress
- Competing family or employment responsibilities
- Financial strain
- Transportation
- Health conditions affecting the caregiver
- Relationship or communication concerns
- Need for interpretation or accessible instruction
- Availability of backup support
- Willingness to continue in the caregiving role
Caregivers should not be presumed capable, available, or willing merely because they are related to or live with the patient.
Education and Practical Training
Making the Care Plan Understandable and Actionable
Depending on the patient's needs and the caregiver's lawful role, education may address:
- Diagnoses and expected care needs
- Medication schedules
- Nutrition and hydration
- Mobility, transfers, and fall prevention
- Skin and wound observation
- Infection precautions
- Medical equipment
- Appointments and referrals
- Behavioral or cognitive changes
- Pain and symptom observation
- Warning signs
- Emergency procedures
- Available community resources
- Whom to contact with questions
Teaching should use plain language and account for the caregiver's language, health literacy, culture, sensory needs, and learning preferences.
When appropriate, the educator may use teach-back or demonstration to confirm understanding. Education does not authorize an unlicensed caregiver to perform a task restricted by law or requiring licensed clinical judgment.
Support During Care Transitions
Preparing the Patient and Caregiver for What Comes Next
When a patient moves from a hospital or facility to home or another care setting, caregiver preparation may include:
- Understanding what daily life may be like after discharge
- Reviewing the medication plan
- Clarifying follow-up appointments
- Explaining equipment and supply arrangements
- Reviewing pending tests and referrals
- Identifying warning signs
- Confirming contact and escalation instructions
- Assessing transportation and home safety
- Clarifying which provider is responsible for each service
- Identifying gaps before the transition occurs
The discharging and receiving organizations remain responsible for their legally required transition, assessment, admission, documentation, and care planning duties.
Medication Support
Clear Information With Clear Boundaries
Caregivers may help patients organize or remember medications when appropriate, authorized, and permitted.
Support may include:
- Maintaining a current medication list
- Understanding names, purposes, doses, and schedules
- Identifying recent changes
- Confirming pharmacy access
- Reporting possible side effects or discrepancies
- Communicating questions to a pharmacist or prescriber
- Supporting prescribed monitoring
- Understanding whom to contact before making changes
Only legally authorized professionals may prescribe, discontinue, or modify medication orders.
Caregivers should not be expected to make independent clinical decisions outside their training or authority.
Safety, Mobility, and the Home Environment
Protecting Both the Patient and the Caregiver
Caregiver education may address:
- Safe transfers and mobility
- Fall hazards
- Appropriate use of assistive devices
- Medical equipment safety
- Infection precautions
- Medication storage
- Fire and emergency planning
- Wandering or elopement risk
- Behavioral escalation
- Accessibility and home modifications
- When professional assistance is required
A caregiver should not perform lifting, transfers, procedures, or other tasks that cannot be completed safely.
Identified concerns may require referral to rehabilitation professionals, home health, personal care, equipment suppliers, emergency services, or another qualified provider.
Emotional and PsychoSpiritual Support
Caring for the Caregiver as a Whole Person
Caregiving may involve love, purpose, and closeness, but it may also involve grief, fear, frustration, exhaustion, isolation, or changes in family roles.
Depending on caregiver preference and available resources, support may include:
- Emotional support
- Behavioral health referral
- Grief and bereavement services
- Support groups
- Peer support
- Stress management education
- Family meetings
- Conflict resolution resources
- Chaplain or spiritual care referral
- Patient directed PsychoSpiritual support
- Nonreligious meaning centered support
PsychoSpiritual or religious support is voluntary and must reflect the caregiver's own beliefs and preferences. It does not replace behavioral health treatment or crisis care.
Respite and Community Resources
Caregivers Also Need Time, Support, and Relief
Respite services may provide temporary relief from caregiving responsibilities. Depending on local availability, respite may be provided:
- In the home
- Through an adult day program
- In a residential or facility setting
- By qualified paid caregivers
- Through eligible community or volunteer programs
- By family members or trusted friends
Other resources may include:
- Caregiver education
- Counseling
- Support groups
- Benefits navigation
- Transportation
- Meal programs
- Personal care services
- Legal and financial planning resources
- Home modification assistance
- Disease specific organizations
- Aging and disability agencies
Availability, eligibility, quality, cost, and funding vary. A referral does not guarantee acceptance or payment.
Patient Autonomy, Consent, and Privacy
Family Involvement Must Respect the Patient's Rights
A competent patient determines who may receive information and participate in care, subject to applicable law.
The care team should clarify:
- Whom the patient identifies as a caregiver
- What information may be shared
- Whether the caregiver may attend visits
- Whether a legal representative or surrogate exists
- Which decisions the patient wishes to make independently
- Whether authorization may be changed or withdrawn
Being a relative or caregiver does not automatically create authority to access medical records or make healthcare decisions.
When the patient lacks decision-making capacity, authorized professionals should follow applicable law and valid legal documents when identifying the appropriate decision maker.
Recognizing Caregiver Strain
Early Support Before the Situation Becomes Unsafe
Possible signs of caregiver strain may include:
- Persistent exhaustion
- Sleep disruption
- Anxiety, depression, or irritability
- Declining physical health
- Difficulty managing essential tasks
- Social isolation
- Financial distress
- Missed medications or appointments
- Unsafe lifting or transfer practices
- Conflict within the household
- Expressions of hopelessness
- Inability or unwillingness to continue providing care
These signs should prompt respectful assessment and connection with appropriate professional or community resources.
Caregiver strain should not automatically be interpreted as neglect. However, suspected abuse, neglect, exploitation, abandonment, or immediate danger must be handled according to applicable reporting and emergency requirements.
Crisis and Emergency Support
Immediate Help When Safety Is at Risk
Hospitals Without Walls™ is not an emergency or crisis-response service unless a specific program expressly establishes that function.
In the United States:
- Call 911 for immediate danger or a medical emergency
- Call or text 988 for suicide, mental-health, or substance use crisis support
- Contact the appropriate Adult Protective Services, Child Protective Services, law enforcement, or emergency resource when abuse, neglect, exploitation, or violence is suspected
Patients and caregivers should not wait for a routine appointment, portal message, email, or callback when immediate safety is at risk.
Paid Caregivers, Personal Care, and Home Health
Different Services Carry Different Responsibilities
Family caregiving, paid personal care, and skilled home health are not interchangeable.
- Family or informal caregivers generally provide unpaid assistance based on personal relationships.
- Personal care workers may assist with designated nonclinical activities according to applicable licensing, employment, and program requirements.
- Home health professionals provide authorized skilled services through qualified organizations when applicable requirements are satisfied.
- Physicians and other qualified practitioners diagnose, prescribe, and manage treatment within their professional authority.
Hospitals Without Walls™ does not represent an informal caregiver as a licensed professional or a personal care service as skilled home health care.
Organizational Partnerships
Building Caregiver Support Into the Care Model
Hospitals Without Walls™ may develop caregiver-support programs with:
- Hospitals and health systems
- Health plans and insurance companies
- Government and military healthcare programs
- Physician groups and medical practices
- Skilled nursing and post acute facilities
- Assisted living and senior communities
- Home health and community healthcare organizations
- Palliative and hospice organizations
- Aging and disability organizations
- Other qualified community partners
Written agreements should define the population, services, caregiver-assessment process, professional responsibilities, education, privacy, referrals, crisis escalation, billing, quality measures, and governance.
Quality and Performance Measurement
Evaluating Support Responsibly
Depending on program design and reliable data availability, measures may include:
- Identification of the patient's caregiver
- Caregiver participation authorized by the patient
- Assessment of caregiver preparedness and needs
- Completion of education or training
- Caregiver understanding
- Connection with respite and community resources
- Patient and caregiver experience
- Caregiver strain measured with an appropriate tool
- Transition and follow up completion
- Safety events
- Emergency department visits and hospitalizations
- Sustainability of the caregiving arrangement
Measures should define:
- The population
- Assessment method
- Data source
- Baseline
- Exclusions
- Reporting period
- Analytical method
- Limitations
Caregiver interventions may improve selected outcomes in some populations, but results differ by intervention, patient condition, caregiver needs, service availability, and study quality. No particular caregiver, clinical, utilization, or financial outcome is guaranteed.
Request Caregiver and Family Support
Build a Sustainable Circle of Support Around the Patient
Patients, caregivers, clinicians, and organizations may contact Hospitals Without Walls™ to discuss available caregiver and family support services.
Organizations seeking a contract should be prepared to describe:
- The patient population
- Common caregiver responsibilities
- Identified education and support gaps
- Current transition and discharge processes
- Available respite and community resources
- Privacy and information-sharing requirements
- Crisis and protective-service procedures
- Payer and funding arrangements
- Desired quality and outcome measures
Important Notice
Caregiver and family-support services vary by location, patient and caregiver needs, consent, service availability, eligibility, funding, payer authorization, contractual terms, and applicable law.
Hospitals Without Walls™ does not guarantee the availability, quality, coverage, or payment of any caregiver, respite, personal-care, home health, community, or professional service.
This page provides general information and does not constitute individualized medical, behavioral-health, legal, financial, caregiving, billing, or reimbursement advice. If there is immediate danger or a medical emergency, call 911.
If there is immediate danger or a medical emergency, call 911.