One Patient. One Coordinated Plan. One Connected Continuum of Care.
Hospitals Without Walls™ helps organize communication, responsibilities, services, and resources around the needs and goals of each patient.
Our care coordination model connects participating clinicians, hospitals, facilities, health plans, home based providers, community organizations, patients, and authorized caregivers while preserving each participant's independent professional and regulatory responsibilities.
What Is Care Coordination?
Organizing Care and Sharing Information Around the Patient
Care coordination is the deliberate organization of patient-care activities and the appropriate exchange of information among those involved in the patient's care.
Effective coordination seeks to ensure that:
- The patient's needs and preferences are understood
- The right information reaches the right people at the appropriate time
- Responsibilities are clearly assigned
- Services are connected across settings
- Referrals and follow up needs are addressed
- Important changes are communicated
- Patients and caregivers understand the care plan
- Unresolved concerns are identified and escalated
Care coordination supports healthcare delivery. It does not replace the clinical judgment, legal authority, or regulatory obligations of participating professionals and organizations.
Why Coordination Matters
Patients Should Not Become Lost Between Providers and Settings
A patient may receive services from multiple physicians, hospitals, pharmacies, laboratories, rehabilitation providers, home health agencies, facilities, health plans, community organizations, and caregivers.
When these participants do not communicate effectively, patients may experience:
- Conflicting or incomplete care plans
- Medication discrepancies
- Duplicated or delayed services
- Missed appointments
- Unresolved referrals
- Repeated testing
- Incomplete transfer of clinical information
- Uncertainty about who is responsible
- Poorly supported transitions between settings
- Confusion for patients and caregivers
Care coordination creates defined pathways for communication, follow up, and accountability.
Who May Benefit?
Coordination Proportional to the Patient's Needs
Care coordination may be particularly helpful for patients who:
- Have multiple chronic conditions
- Receive care from several professionals or organizations
- Have recently left a hospital or post acute facility
- Have experienced repeated emergency visits or hospitalizations
- Take multiple medications
- Have frailty or functional limitations
- Have cognitive or behavioral health needs
- Require palliative or serious illness support
- Depend on family or other caregivers
- Face transportation, housing, food, financial, or accessibility barriers
- Have difficulty understanding or carrying out the care plan
The intensity and duration of coordination should reflect the patient's clinical, functional, behavioral, social, and environmental needs.
Our Care-Coordination Process
From Assessment to Follow-Through
- 1
Referral and Eligibility Review
The organization reviews the request, patient needs, service area, available resources, consent requirements, payer criteria, and operational capacity.
- 2
Whole-Person Assessment
Depending on the program, the assessment may address:
- Diagnoses and current symptoms
- Medications and treatment plans
- Recent healthcare utilization
- Mobility and ability to perform daily activities
- Cognition, mood, and behavior
- Nutrition and safety
- Living environment
- Caregiver capacity
- Social and practical barriers
- Patient goals and preferences
- 3
Care-Plan Development
The care plan may identify priorities, responsible participants, authorized services, monitoring needs, referrals, follow-up requirements, communication pathways, and escalation instructions.
- 4
Connection of Services
The coordinator helps connect authorized participants and address identified gaps without directing services outside the coordinator's legal or contractual authority.
- 5
Follow-Up
The coordinator tracks assigned actions, referrals, appointments, information requests, and unresolved barriers according to the program's scope.
- 6
Reassessment
The plan may be updated when the patient's condition, goals, living situation, providers, or services change.
- 7
Transition or Completion
Coordination may end or transition when goals are reached, the patient moves to another program, eligibility changes, services are declined, or another organization assumes responsibility.
The Individualized Care Plan
A Shared Roadmap With Defined Responsibilities
Depending on the program, a coordinated care plan may include:
- Patient goals and preferences
- Active diagnoses and priority concerns
- Current medications
- Treating professionals and organizations
- Ordered and authorized services
- Appointments and referrals
- Monitoring requirements
- Functional and safety needs
- Behavioral and PsychoSpiritual health considerations
- Caregiver roles and limitations
- Community resources
- Communication methods
- Escalation and emergency instructions
- Reassessment and transition goals
The care plan should identify who is responsible for each action. A shared plan does not authorize one participant to alter another provider's orders or responsibilities without lawful authority.
Medication Coordination
Creating a Consistent and Understandable Medication Record
Medication coordination may include:
- Comparing available medication lists
- Identifying apparent omissions, duplications, or inconsistencies
- Reviewing recent medication changes
- Assessing access and adherence barriers
- Communicating questions to authorized prescribers or pharmacists
- Educating the patient and caregiver
- Updating records after authorized changes
- Monitoring required follow up
Only an authorized prescriber may initiate, discontinue, or modify a prescription. The coordinator does not independently change medication orders.
Referrals and Closed-Loop Follow-Up
A Referral Is Not Complete Merely Because It Was Sent
Depending on the agreement, referral coordination may include:
- Identifying an appropriate qualified provider
- Confirming patient preference
- Transmitting authorized information
- Verifying receipt
- Supporting scheduling
- Identifying transportation or accessibility barriers
- Tracking whether the service occurred
- Obtaining authorized results or recommendations
- Communicating follow up needs to the responsible professional
- Escalating unresolved concerns
A referral does not guarantee acceptance, appointment availability, insurance authorization, coverage, payment, or completion.
Transitions Between Care Settings
Maintaining Continuity When the Patient Moves
During transitions between hospitals, post-acute facilities, homes, medical practices, and community settings, coordination may address:
- Discharge information
- Medication reconciliation
- Follow up appointments
- Pending test results
- Equipment and supply needs
- Home health or rehabilitation referrals
- Functional and safety concerns
- Patient and caregiver education
- Warning signs and escalation instructions
- Transfer of authorized clinical information
Each discharging and receiving organization remains responsible for its own required assessments, decisions, documentation, and services.
Patient and Caregiver Participation
Care Should Be Coordinated With—not Merely Around—the Patient
Patients and authorized caregivers should be invited to participate in care planning according to the patient's preferences, decision making capacity, and applicable law.
Participation may include:
- Identifying goals and priorities
- Reviewing the care plan
- Asking questions
- Selecting among available qualified providers
- Reporting barriers and changes
- Clarifying caregiver responsibilities
- Receiving education in an understandable format
- Participating in care conferences
- Updating preferences as circumstances change
Education and communication should account for language, culture, health literacy, cognition, sensory needs, disability, and access to technology.
Connecting Medical and Community Services
Health Needs Often Extend Beyond the Clinical Encounter
Care coordination may help identify and connect patients with resources addressing:
- Transportation
- Food and nutrition
- Housing and utilities
- Personal care
- Caregiver support and respite
- Mobility and accessibility
- Medical equipment
- Benefits and insurance navigation
- Social isolation
- Behavioral health services
- Palliative and hospice services
- Faith based or community support, when desired by the patient
Resource availability, eligibility, cost, and funding vary. Hospitals Without Walls™ does not guarantee that any community service will accept a referral or provide assistance.
Technology and Information Exchange
Supporting Communication Across the Continuum
Depending on program capabilities and patient authorization, coordination may use:
- Electronic health records
- Health information exchange
- Secure clinical messaging
- Patient portals
- Telehealth
- Remote patient monitoring
- Shared care plans
- Electronic referral systems
- Telephone communication
- Virtual care conferences
Technology should support not replace clear responsibility, professional judgment, patient communication, and appropriate follow up.
Information may be accessed, used, or disclosed only as permitted by applicable privacy, confidentiality, security, consent, and contractual requirements.
Professional and Organizational Accountability
Coordination Does Not Transfer Independent Duties
Unless a lawful written agreement expressly provides otherwise, each participating organization remains responsible for its:
- Licenses, certifications, and credentials
- Admission and discharge decisions
- Professional personnel and supervision
- Clinical assessments and treatment
- Orders and plans of care
- Documentation
- Patient rights
- Privacy and security
- Emergency procedures
- Quality reporting
- Coding, billing, and reimbursement
- Compliance with applicable law
Hospitals Without Walls™ coordinates authorized activities within the scope of the applicable program. It does not automatically become the patient's physician, hospital, health plan, home health agency, hospice, facility, or emergency service.
Care Coordination and Medicare Billing
General Coordination Is Not Automatically a Billable Medicare Service
Medicare recognizes several distinct care-management services, each with its own eligibility, consent, clinical, time, documentation, coding, and billing requirements.
These may include, when applicable:
- Chronic Care Management
- Principal Care Management
- Transitional Care Management
- Behavioral Health Integration
- Advanced Primary Care Management
- Other qualifying care-management services
Participation in a general care-coordination program does not establish eligibility or permit billing under any particular code.
Each billing practitioner or organization is independently responsible for confirming current requirements, avoiding overlapping or duplicate billing, documenting services actually performed, and submitting accurate claims.
Organizational Partnerships
Coordination Designed Around the Population and Contract
Hospitals Without Walls™ may develop care-coordination arrangements 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
- Employers and other qualified organizations
Written agreements should define:
- The eligible population
- Program scope and exclusions
- Referral and enrollment requirements
- Roles and responsibilities
- Staffing and qualifications
- Communication standards
- Information sharing permissions
- Technology
- Escalation procedures
- Compensation and billing
- Quality measures
- Governance and termination
Quality and Performance Measurement
Evidence Before Claims
Depending on program design and reliable data availability, measures may include:
- Assessment and care plan completion
- Medication reconciliation
- Referral closure
- Appointment completion
- Timeliness of communication
- Transition follow up
- Resolution of identified barriers
- Patient and caregiver experience
- Partner experience
- Clinical and functional measures
- Emergency department visits
- Hospital admissions and readmissions
- Total healthcare utilization and cost
Measures should define:
- The population
- Data source
- Baseline
- Exclusions
- Reporting period
- Analytical method
- Comparison group
- Risk adjustment when appropriate
- Limitations
Research indicates that some coordinated and continuity of care interventions improve selected processes or outcomes in specific populations. Results vary by intervention, population, setting, duration, and study quality. No clinical, utilization, or financial outcome is guaranteed.
Request Care Coordination
Build a Connected Care Plan Around the Patient
Patients, caregivers, clinicians, and organizations may contact Hospitals Without Walls™ to discuss available care coordination services.
Organizations seeking a contract should be prepared to describe:
- The population to be served
- Current providers and services
- Identified gaps
- Referral and transition workflows
- Available clinical and community resources
- Information exchange capabilities
- Payer and billing arrangements
- Desired quality and outcome measures
Important Notice
Care coordination services vary by program, location, patient eligibility, clinical need, provider availability, payer authorization, contractual terms, and applicable law.
Coordination does not guarantee access to a particular provider or service, insurance coverage, reimbursement, prevention of hospitalization, or improvement in clinical, functional, utilization, or financial outcomes.
This page provides general information and does not constitute individualized medical, legal, regulatory, billing, coding, privacy, or reimbursement advice. If a patient may be experiencing a medical emergency, call 911.
If a patient may be experiencing a medical emergency, call 911.