Bringing Appropriate Medical Care to the Patient
Hospitals Without Walls™ coordinates mobile physician services for qualified patients who may benefit from receiving medical evaluation and follow up at home, in a residential community, or in another appropriate nonhospital setting.
Through participating medical practices and qualified professionals, our model connects in person mobile care with telehealth, remote monitoring, care coordination, and community based services.
Medical Care Beyond the Traditional Office
The Patient's Location Should Not Become a Barrier to Appropriate Care
Some patients have substantial difficulty reaching a medical office because of illness, disability, frailty, impaired mobility, cognitive limitations, transportation barriers, or caregiver constraints.
Depending on availability and clinical appropriateness, mobile medical services may support:
- In person medical evaluation
- Chronic disease management
- Post hospital follow up
- Medication review and reconciliation
- Geriatric assessment
- Palliative and serious illness care
- Functional and safety assessment
- Coordination with specialists and other providers
- Caregiver education
- Advance care planning
- Referral for diagnostic, therapeutic, and community services
Mobile medical care does not replace emergency services, hospital care, or specialist evaluation when those services are medically necessary.
Who May Benefit?
Services Based on Clinical Need and Operational Feasibility
Mobile physician services may be considered for patients who:
- Have difficulty leaving home because of illness or functional limitation
- Require follow up after hospitalization or facility discharge
- Have multiple chronic conditions
- Have experienced declining function, frailty, or repeated falls
- Take multiple medications or have recent medication changes
- Live in an assisted living or residential community
- Require palliative or serious-illness support
- Have cognitive impairment or substantial caregiver needs
- Need an in-person assessment that cannot be completed adequately through telehealth
- Face transportation or accessibility barriers
A request does not guarantee acceptance. The participating medical practice must determine whether it can provide the requested service safely and appropriately.
Our Mobile-Care Process
A Defined Path From Referral to Follow-Up
- 1
Referral or Request
A patient, authorized representative, clinician, facility, health plan, or other permitted source may request evaluation.
- 2
Eligibility and Safety Review
The participating organization evaluates the patient's location, clinical needs, urgency, service area, provider availability, payer requirements, and whether the setting is suitable for a mobile visit.
- 3
Consent and Information Exchange
Required consent is obtained, and relevant health information is collected or requested through lawful channels.
- 4
Mobile Clinical Visit
A qualified professional completes an assessment appropriate to the patient's needs, the practitioner's scope of practice, and the capabilities of the setting.
- 5
Care Plan and Orders
The responsible practitioner develops or updates the medical plan, issues authorized orders, provides education, and identifies necessary follow-up.
- 6
Coordination
With appropriate authorization, relevant information may be communicated to the patient's other clinicians, pharmacy, facility, home health agency, laboratory, diagnostic provider, rehabilitation team, or community services.
- 7
Reassessment
Follow-up may occur through another mobile visit, telehealth, remote monitoring, office-based care, or referral to a more appropriate level of service.
The Mobile Medical Assessment
Understanding the Patient Within the Living Environment
Depending on clinical need, a mobile evaluation may address:
- Current symptoms and diagnoses
- Recent hospitalization or emergency care
- Medication use, access, adherence, and potential discrepancies
- Vital signs and other available clinical information
- Mobility, transfers, balance, and fall risk
- Ability to perform daily activities
- Cognition, mood, behavior, and communication
- Nutrition, hydration, and swallowing concerns
- Pain and other symptom burdens
- Skin integrity and wound related concerns
- Medical equipment and supply needs
- Caregiver availability and capacity
- Home safety and accessibility
- Patient goals, preferences, and advance care planning
- Need for laboratory, imaging, specialist, rehabilitation, or community services
The scope of each visit depends on the patient's condition, available equipment, professional judgment, and the limitations of the setting.
Chronic Disease Management
Coordinating Ongoing Care Where the Patient Lives
Mobile medical services may support patients living with conditions such as:
- Cardiovascular disease
- Hypertension
- Diabetes
- Chronic respiratory disease
- Kidney disease
- Neurologic conditions
- Cognitive impairment
- Arthritis and mobility limitations
- Multiple coexisting chronic conditions
- Serious or advanced illness
Care may include symptom assessment, treatment-plan review, medication management, patient education, monitoring, referral, and communication with other authorized professionals.
No particular diagnosis automatically qualifies a patient for mobile services or insurance coverage.
Transitional and Post-Discharge Care
Supporting Continuity After a Change in Care Setting
Following discharge from a hospital, skilled nursing facility, rehabilitation facility, or other setting, mobile care may help address:
- The discharge plan
- Medication reconciliation
- New or worsening symptoms
- Follow up appointments
- Pending tests
- Wound or treatment instructions
- Equipment and supply needs
- Functional changes
- Home safety
- Caregiver questions
- Referrals and unresolved barriers
Mobile follow up does not transfer or eliminate the discharge responsibilities of the hospital or facility, and it does not guarantee that a readmission will be prevented.
Medication Safety
Reviewing the Medication Plan in the Patient's Environment
A mobile visit may allow the qualified professional to compare available medication lists with the medications present in the home or residential setting.
The review may address:
- Duplicate or apparently omitted medications
- Recently started, stopped, or changed medications
- Access and affordability barriers
- Patient understanding
- Administration difficulties
- Adherence concerns
- Potential adverse effects or interactions
- Monitoring requirements
- Pharmacy and prescriber communication
Only legally authorized professionals may prescribe, discontinue, or modify medication orders.
Mobile Care and Telehealth
Combining In Person and Virtual Capabilities
Mobile visits may be supplemented by:
- Telehealth follow up
- Virtual specialist participation
- Remote patient monitoring
- Secure clinical messaging
- Interdisciplinary care conferences
- Electronic information exchange
- Patient and caregiver education
Technology may extend continuity, but it does not replace an in person examination when one is medically necessary.
Diagnostic and Support Services
Connecting the Patient With Additional Resources
When available and appropriate, a mobile care plan may coordinate with qualified organizations providing:
- Laboratory testing
- Diagnostic imaging
- Pharmacy services
- Medical equipment
- Home health services
- Rehabilitation
- Behavioral health care
- Palliative care
- Hospice
- Personal care services
- Transportation
- Nutrition and social services
Each organization independently determines eligibility, acceptance, scheduling, coverage, and service availability. A referral does not guarantee that a service will be provided or paid for.
Mobile Physician Care Is Not Home Health
Distinct Services With Distinct Responsibilities
A physician or other qualified practitioner's mobile medical visit is not the same as Medicare-certified home health care.
Medicare home health is a defined benefit furnished by a Medicare certified home health agency when applicable eligibility, certification, plan of care, and other coverage requirements are satisfied.
A mobile medical practice does not become a home health agency merely because it treats a patient at home. Likewise, a home health agency does not assume the physician's independent responsibility for medical diagnosis, treatment, and authorized orders.
When both services are involved, their responsibilities should be clearly defined and coordinated.
Mobile Medical Care Is Not Hospital-at-Home
Outpatient Care Must Not Be Presented as Inpatient Hospital Care
Routine mobile physician services are distinct from an authorized hospital at home program.
Hospital at home involves inpatient-level care delivered under the responsibility of an eligible participating hospital and is subject to separate federal, state, clinical, operational, and hospital requirements.
Hospitals Without Walls™ does not represent routine mobile visits as hospital-level care. A patient who requires emergency or inpatient services must be directed to an appropriate emergency department or hospital.
Facility and Community Visits
Supporting Patients Across Residential Settings
Subject to applicable requirements and agreements, participating professionals may provide services in:
- Private residences
- Assisted living communities
- Senior residential communities
- Group residential settings
- Skilled nursing or post acute facilities
- Other appropriate community locations
The patient's location does not eliminate requirements concerning professional licensure, facility policies, consent, privacy, credentialing, documentation, prescribing, billing, or coordination with the responsible care team.
Facility based visits must respect the facility's clinical authority and regulatory responsibilities.
Emergency and Urgent Conditions
Mobile Services Do Not Replace Emergency Response
Mobile physician services are generally scheduled and are not a substitute for 911, emergency medical services, or an emergency department.
Patients and caregivers should not wait for a mobile visit when symptoms suggest a possible emergency.
If the patient may be experiencing a medical emergency, call 911.
Professional Standards and Accountability
Care Within Lawful Authority
Each participating healthcare professional remains responsible for:
- Maintaining required licensure
- Practicing within the authorized scope of practice
- Maintaining appropriate credentials and insurance
- Evaluating whether the setting is suitable
- Obtaining required consent
- Protecting patient privacy
- Performing and documenting the clinical service
- Making appropriate referrals
- Communicating significant findings
- Prescribing within lawful authority
- Following applicable emergency and reporting requirements
- Billing accurately for services actually provided
Hospitals Without Walls™ does not direct or override the independent clinical judgment of a licensed treating professional.
Medicare and Insurance Coverage
A Home Visit Does Not Automatically Qualify for Payment
Medicare and other payers may cover qualifying professional services delivered in a residence or other permitted setting when current coverage, enrollment, medical-necessity, documentation, coding, and billing requirements are satisfied.
Coverage may depend on:
- The service performed
- The patient's eligibility
- Medical necessity
- The practitioner's qualifications and enrollment
- The place of service
- The documentation
- Applicable payer policies
- Whether another payment arrangement applies
- Federal and state requirements
Each billing provider is responsible for confirming current requirements and submitting accurate claims. Participation does not guarantee insurance coverage or reimbursement.
Organizational Partnerships
Mobile Programs Designed Around Defined Populations
Hospitals Without Walls™ may develop mobile medical 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
- Employers and other qualified organizations
Written agreements should define the population, services, geographic coverage, professional responsibilities, staffing, scheduling, technology, information exchange, privacy, safety, billing, quality measurement, and governance.
Quality and Performance Measurement
Evaluating Access, Care, and Outcomes Responsibly
Depending on program objectives and reliable data availability, measures may include:
- Referral response and completed visits
- Time to clinical evaluation
- Medication reconciliation
- Care plan and referral completion
- Patient and caregiver experience
- Coordination with other providers
- Changes in condition specific or functional measures
- Urgent and emergency escalations
- Emergency department visits
- Hospital admissions and readmissions
- Program costs and healthcare utilization
Evaluation should define:
- The population
- Baseline
- Data source
- Exclusions
- Reporting period
- Comparison method
- Risk adjustment when appropriate
- Limitations
Studies of home based medical care have reported potential benefits in selected populations, but results vary substantially by program design, patient characteristics, service intensity, and research quality. No clinical, utilization, or financial outcome is guaranteed.
Request Mobile Physician Services
Bring Appropriate Medical Care to the Patient
Patients, caregivers, clinicians, and organizations may contact Hospitals Without Walls™ to discuss available mobile medical services.
Organizations seeking a contract should be prepared to describe:
- The population to be served
- Geographic locations
- Clinical and operational needs
- Existing provider relationships
- Facility or home setting requirements
- Scheduling and response expectations
- Payer and billing arrangements
- Technology and information exchange capabilities
- Desired performance measures
Important Notice
Mobile medical services vary by location, clinical need, professional availability, patient eligibility, setting, payer authorization, contractual terms, and applicable law.
A request does not guarantee acceptance, a same-day visit, a diagnosis, treatment, prescription, referral, coverage, reimbursement, prevention of hospitalization, or improvement in clinical or financial outcomes.
This page provides general information and does not constitute individualized medical, legal, regulatory, billing, coding, licensure, 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.