Medical Status
- Diagnoses
- Symptoms
- Disease severity
- Recent acute-care use
- Treatment history
- Preventive-care needs
- Treating professionals
- Unresolved follow-up
Chronic Disease Management
Coordinated, Continuing Care for the Whole Person
Hospitals Without Walls™ supports people living with chronic illness by connecting medical care, monitoring, education, functional support, behavioral health, caregivers, and community resources around an individualized plan.
Our goal is to help patients understand their conditions, follow appropriate treatment, recognize meaningful changes, and receive the right level of care at the right time.
Chronic Conditions Require Continuing Care
Care Between Appointments Matters
A chronic condition generally lasts for an extended period and may require continuing medical attention, affect daily activities, or both. Effective care may depend on more than an occasional office visit.
Patients may need:
- Ongoing clinical follow-up
- Medication management
- Condition-specific monitoring
- Education and self-management support
- Rehabilitation
- Nutritional support
- Behavioral-health care
- Functional assistance
- Caregiver involvement
- Coordination among multiple professionals
- Support during transitions
- Help addressing social or environmental barriers
Hospitals Without Walls™ helps connect these elements across medical offices, hospitals, facilities, homes, and virtual-care settings.
Conditions We May Support
Individualized Care Across Multiple Diagnoses
Depending on the program and participating professionals, coordinated support may be appropriate for people living with:
- Cardiovascular disease
- Heart failure
- Hypertension
- Diabetes
- Chronic pulmonary disease
- Asthma
- Kidney disease
- Neurologic conditions
- Dementia
- Arthritis
- Chronic pain
- Cancer
- Depression or anxiety
- Chronic wounds
- Obesity
- Other continuing or interacting conditions
This list does not establish eligibility, medical necessity, coverage, or the availability of a particular service.
Every condition requires individualized evaluation by appropriately qualified professionals.
Multiple Chronic Conditions
One Patient—not a Collection of Separate Diseases
Many patients live with more than one chronic condition.
Separate disease-specific recommendations may conflict or create:
- Medication burden
- Competing treatment priorities
- Repeated testing
- Multiple appointments
- Dietary conflicts
- Financial strain
- Transportation difficulties
- Confusing instructions
- Caregiver burden
- Increased risk during transitions
Our approach considers how conditions and treatments interact and which outcomes matter most to the patient.
The care plan should balance disease-specific recommendations with function, safety, quality of life, treatment burden, patient preferences, and professional judgment.
Our Chronic Disease Management Model
From Assessment to Continuing Coordination
A coordinated program may include:
- 1Comprehensive assessment
- 2Identification of conditions, risks, strengths, and barriers
- 3Review of patient goals and preferences
- 4Medication reconciliation
- 5Development of an individualized care plan
- 6Assignment of responsibilities
- 7Patient and caregiver education
- 8Appropriate monitoring
- 9Coordination of referrals and services
- 10Communication of meaningful changes
- 11Clinical escalation when necessary
- 12Periodic reassessment and care-plan revision
Services must be based on clinical need, consent, professional authority, payer requirements, operational availability, and applicable law.
Comprehensive Assessment
Understanding the Complete Patient
Depending on the patient and program, an assessment may address:
Medications
- Prescriptions
- Nonprescription products
- Supplements
- Allergies
- Apparent discrepancies
- Adherence barriers
- Access and affordability
- Monitoring requirements
- Need for prescriber or pharmacist review
Function
- Mobility
- Strength
- Balance
- Daily activities
- Ability to manage treatment
- Rehabilitation needs
- Assistive devices
- Fall risk
Cognition and Behavioral Health
- Memory
- Understanding
- Decision-making
- Mood
- Anxiety
- Coping
- Substance-related concerns
- Ability to perform self-care
- Need for additional evaluation
Social and Environmental Needs
- Housing
- Food
- Transportation
- Utilities
- Social support
- Health literacy
- Language
- Home safety
- Technology access
- Financial or practical barriers
Caregiver Needs
- Availability
- Ability
- Understanding
- Willingness
- Stress
- Need for education
- Need for backup support
Patient Goals
- Symptoms the patient most wants addressed
- Activities the patient wants to preserve or regain
- Treatment preferences
- Acceptable burdens and tradeoffs
- Personal definition of quality of life
- Preferred participants in decision-making
Not every patient requires every assessment component.
The Individualized Care Plan
One Plan With Defined Priorities
The coordinated care plan may identify:
- Active conditions
- Patient goals
- Responsible professionals
- Medication-related actions
- Condition-specific monitoring
- Follow-up appointments
- Rehabilitation needs
- Nutrition-related referrals
- Behavioral-health support
- Patient and caregiver education
- Home-safety interventions
- Community resources
- Warning signs
- Escalation procedures
- Reassessment intervals
- Expected outcomes
The plan should be understandable, realistic, and updated when the patient’s condition, circumstances, or preferences change.
Hospitals Without Walls™ does not independently alter another professional’s lawful treatment plan or medical orders.
Medication Management and Safety
Accurate Information. Authorized Decisions.
Medication-related coordination may include:
- Creating the best available medication list
- Comparing medication information across settings
- Identifying apparent omissions or duplications
- Reviewing allergies and adverse reactions
- Identifying access and adherence barriers
- Communicating questions to authorized prescribers
- Facilitating pharmacist review
- Supporting required laboratory follow-up
- Educating patients and caregivers
- Documenting authorized changes
Only appropriately authorized professionals may prescribe, discontinue, or modify medication.
Patients should not change prescribed treatment solely because of general information presented on this website.
Patient Education and Self-Management
Helping Patients Participate Confidently in Their Care
Self-management support may help patients:
- Understand their conditions
- Understand the purpose of treatment
- Follow medication instructions
- Monitor agreed health indicators
- Recognize warning signs
- Prepare for appointments
- Communicate concerns
- Follow appropriate nutrition or activity recommendations
- Solve practical problems
- Set realistic goals
- Use available community resources
- Know when and how to seek help
Self-management does not mean that the patient manages serious illness alone.
Qualified professionals remain responsible for the services and decisions within their respective roles.
Monitoring and Follow-Up
Responding to Change Before It Becomes a Crisis When Possible
Depending on the condition and care plan, monitoring may include:
- Symptoms
- Blood pressure
- Heart rate
- Oxygen saturation
- Weight
- Blood glucose
- Temperature
- Medication response
- Functional status
- Wound status
- Nutrition
- Mood or behavior
- Other clinically appropriate indicators
Every monitoring program should define:
- What is monitored
- Who reviews the information
- When it is reviewed
- Which findings require action
- Who is contacted
- Expected response times
- Documentation requirements
- Emergency instructions
- Technology limitations
Monitoring cannot guarantee that every deterioration or complication will be detected or prevented.
Telehealth and Mobile Care
Extending Appropriate Care Beyond the Office
When clinically appropriate and legally permitted, services may include:
- Telehealth follow-up
- Mobile professional visits
- Remote patient monitoring
- Virtual care conferences
- Medication-related communication
- Patient and caregiver education
- Behavioral-health support
- Palliative-care support
- Post-discharge follow-up
Technology and mobile services do not replace emergency care, required in-person evaluation, or hands-on services when those are necessary.
Condition-Specific Support
Support Tailored to Each Condition
Heart and Circulatory Conditions
A coordinated plan may address:
- Symptoms
- Blood-pressure monitoring
- Weight monitoring when appropriate
- Medication adherence
- Dietary guidance from qualified professionals
- Activity recommendations
- Follow-up appointments
- Recognition of warning signs
- Communication with treating clinicians
Chest pain, severe breathing difficulty, fainting, stroke symptoms, or another possible emergency requires immediate emergency evaluation.
Diabetes
A coordinated plan may address:
- Glucose monitoring
- Medication use
- Nutrition
- Physical activity
- Foot care
- Vision and kidney follow-up
- Recognition of high or low blood glucose
- Access to supplies
- Patient education
Treatment targets must be individualized by the authorized treating professional.
Chronic Pulmonary Disease
A coordinated plan may address:
- Respiratory symptoms
- Medication and inhaler use
- Oxygen safety
- Activity tolerance
- Infection warning signs
- Rehabilitation
- Smoking cessation support
- Escalation planning
Severe or rapidly worsening breathing difficulty requires emergency evaluation.
Kidney Disease
A coordinated plan may address:
- Medication review
- Blood-pressure and diabetes management
- Laboratory follow-up
- Nutrition and fluid instructions
- Dialysis coordination when applicable
- Access planning
- Symptom monitoring
- Communication among treating professionals
Kidney-disease recommendations must be individualized according to disease stage, treatment, and professional guidance.
Neurologic and Cognitive Conditions
A coordinated plan may address:
- Function
- Mobility
- Memory
- Communication
- Medication safety
- Behavior
- Caregiver support
- Home safety
- Advance-care planning
- Referral for qualified evaluation
Sudden confusion, weakness, speech difficulty, or another acute neurologic change may represent an emergency.
Chronic Wounds
A coordinated plan may address:
- Qualified wound assessment
- Treatment orders
- Infection concerns
- Pressure redistribution
- Nutrition
- Circulation and diabetes management
- Equipment and supplies
- Caregiver education
- Monitoring and escalation
Wound services must be ordered and provided by appropriately qualified professionals.
Chronic Pain
A coordinated plan may consider:
- Underlying causes
- Functional goals
- Medication benefits and risks
- Nonmedication approaches
- Behavioral and emotional factors
- Rehabilitation
- Safety
- Monitoring
- Patient preferences
No single treatment is appropriate for every person with chronic pain.
Behavioral and Psychospiritual Health
Chronic Illness Affects More Than the Body
Long-term illness may affect mood, sleep, identity, relationships, hope, meaning, and the ability to follow treatment.
A coordinated program may support:
- Behavioral-health screening
- Referral to qualified professionals
- Integration of medical and behavioral care
- Grief support
- Caregiver support
- Patient-directed spiritual support
- Crisis escalation
Spiritual support is optional and must never be imposed.
Mental-health diagnosis and treatment must be provided by professionals authorized to provide those services.
Palliative and Supportive Care
Relief of Symptoms Alongside Appropriate Treatment
Palliative care may be appropriate for people living with serious chronic illness, whether or not they continue disease-directed treatment.
Palliative support may address:
- Pain
- Shortness of breath
- Fatigue
- Nausea
- Anxiety
- Emotional distress
- Functional decline
- Communication about goals
- Caregiver concerns
- Spiritual needs, when desired
- Advance-care planning
Palliative care is not automatically hospice care.
Hospice requires separate eligibility, certification, election, and coverage processes.
Care Transitions
Protecting Continuity When Care Settings Change
Transitions among hospitals, rehabilitation facilities, skilled nursing facilities, physician practices, home health agencies, and homes may create risks involving:
- Medication discrepancies
- Incomplete information
- Pending test results
- Missed appointments
- Equipment delays
- Conflicting instructions
- Functional decline
- Caregiver uncertainty
A coordinated transition may include:
- Review of discharge or transfer information
- Medication reconciliation
- Follow-up coordination
- Equipment and service confirmation
- Patient and caregiver education
- Review of warning signs
- Communication with authorized professionals
- Reassessment of the care plan
No transition program can guarantee prevention of every complication or readmission.
Caregiver and Family Support
Supporting the People Who Help Carry Out the Plan
With patient permission or other lawful authority, authorized caregivers may participate in:
- Care planning
- Medication education
- Symptom observation
- Appointment coordination
- Mobility and safety support
- Nutrition
- Healthcare transitions
- Emergency planning
- Advance-care planning
- Community-resource navigation
A care plan should account for the caregiver’s actual availability, ability, understanding, and willingness.
Family relationships do not automatically create authority to access protected information or make healthcare decisions.
Coordination Across Providers
The Right Information to the Right Authorized Participant
Depending on the patient’s needs, care may involve:
- Primary-care professionals
- Specialists
- Hospitals
- Home health agencies
- Rehabilitation providers
- Pharmacies
- Laboratories
- Behavioral-health professionals
- Palliative-care providers
- Health plans
- Community organizations
Hospitals Without Walls™ supports lawful communication and clearly assigned responsibilities without replacing each provider’s independent obligations.
Medicare Chronic Care Management
A Separate Covered Service With Specific Requirements
Medicare Chronic Care Management is a defined professional service for eligible patients with multiple qualifying chronic conditions.
It has specific requirements concerning:
- Patient eligibility
- Consent
- Comprehensive care planning
- Access and continuity
- Care coordination
- Time or service documentation
- Billing
- Cost sharing
- Interaction with other care-management services
Use of the general term “chronic disease management” on this page does not mean that every Hospitals Without Walls™ activity qualifies as Medicare Chronic Care Management or may be billed under a Medicare care-management code.
Each billing practitioner or organization must independently verify and satisfy the requirements applicable to the service and billing period.
Quality and Performance Measurement
Outcomes Must Be Defined and Verified
A chronic disease program may measure:
- Access to care
- Care-plan completion
- Medication reconciliation
- Follow-up completion
- Referral closure
- Condition-specific clinical indicators
- Functional status
- Symptom burden
- Patient-defined goals
- Patient and caregiver experience
- Emergency department visits
- Hospital admissions
- Readmissions
- Program cost
- Total cost of care when reliable data are available
Every measure should define its population, data source, exclusions, baseline, reporting period, analytical method, risk adjustment when appropriate, and limitations.
No improvement or saving should be attributed to the program without an appropriate evidentiary basis.
Our Care Commitment
Appropriate Care Comes Before Cost Reduction
Hospitals Without Walls™ seeks to identify preventable risks and support appropriate use of healthcare resources. We do not seek to avoid hospital or emergency care when it is medically necessary.
No participant should:
- Delay emergency evaluation
- Withhold necessary treatment
- Alter documentation improperly
- Misrepresent a diagnosis
- Manipulate an outcome measure
- Place financial targets above patient safety
- Act outside an authorized professional scope
The right level of care must be determined by the patient’s condition and qualified clinical judgment.
Request Chronic Disease Support
Let Us Build a Coordinated Plan
Tell us:
- Which conditions are present
- What concerns have developed
- Where the patient lives
- Which professionals are involved
- Whether a recent transition occurred
- Which barriers affect care
- What matters most to the patient
- What coverage or authorization may apply
We will evaluate whether an appropriate, available, and lawful service pathway can be identified.
Important Notice
Hospitals Without Walls™ provides a framework for coordinated chronic disease support. It does not guarantee the availability of every service, control of any condition, prevention of deterioration, avoidance of hospitalization, improvement in function, reduction in cost, or eligibility for reimbursement.
Clinical services must be provided by appropriately licensed or authorized professionals. Treatment, medication, monitoring, and escalation decisions must be individualized.
This page provides general educational and organizational information and does not constitute medical advice, diagnosis, treatment, insurance authorization, or a professional-patient relationship.
Do not delay emergency care while attempting to contact a routine care-management service. If a patient may be experiencing a medical emergency, call 911.