Prevent What Is Reasonably Preventable. Never Delay Necessary Care.
Hospitals Without Walls™ coordinates clinical, functional, medication-related, behavioral, social, environmental, and caregiver support to address factors that may contribute to avoidable acute-care use.
Our objective is to identify risks early, strengthen care transitions, and help patients receive appropriate care before preventable problems become crises.
The Right Goal
Appropriate Care—not Hospital Avoidance at Any Cost
Some hospitalizations and readmissions may be preventable. Others are medically necessary, appropriate, and potentially lifesaving.
Hospitals Without Walls™ does not seek to keep patients at home, in a facility, or in a lower-acuity setting when hospital evaluation is required.
A responsible prevention program must pursue two goals simultaneously:
- 1Reduce avoidable deterioration and unnecessary acute-care use when possible.
- 2Escalate patients promptly when emergency or hospital care is medically necessary.
Patient welfare must take priority over utilization targets, financial incentives, and performance statistics.
What Is a Hospital Readmission?
A Return to Acute Inpatient Care After Discharge
A readmission generally refers to a new hospital admission following discharge from an earlier hospital stay.
Different programs may use different definitions.
For example, the Medicare Hospital Readmissions Reduction Program uses specified 30 day, risk standardized, unplanned readmission measures. Those measures include certain readmissions to the same or another applicable acute care hospital and exclude some planned readmissions.
A website, organization, or contract should not describe every return to the hospital as:
- Preventable
- Unnecessary
- A failure of care
- A quality defect
- Attributable to one provider
- Included in a particular payer measure
The applicable definition, population, exclusions, time period, and methodology must be identified before performance is evaluated.
Why Patients Return to the Hospital
Readmission Is Usually a Multifactored Event
Potential contributors may include:
- Progression of the underlying illness
- A new medical condition
- Complications
- Medication discrepancies
- Adverse medication effects
- Difficulty obtaining medication
- Incomplete discharge information
- Delayed follow-up
- Missed appointments
- Limited access to primary or specialty care
- Inadequate symptom monitoring
- Functional decline
- Falls
- Poor nutrition or dehydration
- Cognitive impairment
- Behavioral-health needs
- Inadequate caregiver support
- Unsafe living conditions
- Transportation barriers
- Equipment or supply delays
- Poor communication among providers
The presence of one or more risk factors does not prove that a hospitalization was preventable.
Our Prevention Model
Coordinated Action Across the Continuum
Depending on the patient and program, our model may include:
- 1Risk identification
- 2Comprehensive assessment
- 3Medication reconciliation
- 4Individualized care planning
- 5Timely post-discharge contact
- 6Coordination of clinical follow-up
- 7Patient and caregiver education
- 8Condition-specific monitoring
- 9Functional and home-safety support
- 10Referral and service coordination
- 11Defined escalation pathways
- 12Reassessment after meaningful changes
No single intervention prevents every hospitalization. Programs should combine the components appropriate to the population and individual patient.
Identifying Risk
Finding Vulnerability Before the Next Crisis
A prevention assessment may consider:
- Recent hospital or emergency use
- Multiple chronic conditions
- Severity and stability of illness
- Medication burden
- Previous medication discrepancies
- Frailty
- Functional decline
- Falls
- Cognitive impairment
- Behavioral-health needs
- Nutritional concerns
- Missed follow-up
- Limited health literacy
- Social isolation
- Caregiver availability
- Transportation
- Housing and home safety
- Access to food, medication, equipment, and utilities
- Prior difficulty following a care plan
Risk prediction can help direct resources, but no screening tool can determine with certainty whether an individual will be hospitalized.
Professional assessment and patient specific judgment remain necessary.
Before Discharge
Prevention Begins With Preparation
When coordination starts before hospital or facility discharge, the authorized team may help clarify:
- Diagnoses
- Procedures performed
- Current clinical status
- Medication changes
- Pending test results
- Follow up appointments
- Required laboratory or diagnostic testing
- Wound-care needs
- Rehabilitation needs
- Diet and activity instructions
- Medical equipment and supplies
- Home health or community services
- Caregiver responsibilities
- Warning signs
- Emergency instructions
- Responsible clinicians
- The patient's goals and preferred setting
Hospitals and facilities remain responsible for their own discharge-planning duties.
The First Days After Discharge
Confirming That the Plan Works in the Real World
Depending on clinical need and program design, early follow-up may include:
- Confirming that the patient reached the intended setting
- Reviewing discharge instructions
- Reconciling medications
- Confirming access to prescriptions
- Identifying new or worsening symptoms
- Confirming appointments
- Verifying equipment and supplies
- Assessing mobility and safety
- Determining whether caregivers understand their roles
- Identifying barriers
- Communicating concerns to authorized professionals
- Escalating urgent findings
The timing and form of follow-up must be individualized. A uniform contact schedule is not appropriate for every patient.
Medication Reconciliation and Review
Reducing Confusion Across Care Settings
Medication related risk may arise when:
- A medication is added
- A medication is discontinued
- A dose is changed
- Different records conflict
- The patient resumes an old medication
- The patient cannot obtain a prescription
- Instructions are misunderstood
- Multiple prescribers are involved
- Nonprescription products or supplements are omitted
- Monitoring is incomplete
Coordination may include:
- Creating the best available medication list
- Comparing pre admission and discharge information
- Identifying apparent discrepancies
- Reviewing allergies and adverse reactions
- Communicating questions to prescribers
- Facilitating pharmacist review
- Educating patients and caregivers
- Tracking required follow up
Only appropriately authorized professionals may prescribe, discontinue, or modify medication.
Medication review alone should not be represented as guaranteed to prevent readmission.
Timely Clinical Follow-Up
Connecting the Patient With the Responsible Professional
Follow up may be needed with:
- Primary care professionals
- Medical specialists
- Surgeons
- Advanced practice professionals
- Home health agencies
- Rehabilitation providers
- Pharmacists
- Behavioral health professionals
- Palliative care teams
- Other authorized providers
Coordination may help schedule appointments, transfer necessary information, identify access barriers, and confirm completion.
An appointment date alone is not evidence that the patient received or benefited from the service.
Condition Specific Monitoring
Watching for Meaningful Changes
When ordered and appropriate, monitoring may include:
- Symptoms
- Blood pressure
- Heart rate
- Oxygen saturation
- Weight
- Blood glucose
- Temperature
- Medication response
- Functional status
- Wound status
- Nutrition and hydration
- Cognition or behavior
- Other clinically appropriate findings
Every monitoring program should specify:
- What is monitored
- Who reviews the information
- When it is reviewed
- Which findings trigger action
- Who responds
- Expected response times
- Documentation requirements
- Emergency instructions
- Technology limitations
Monitoring does not guarantee continuous observation or detection of every deterioration.
Patient and Caregiver Education
A Plan Must Be Understood to Be Actionable
Patients and authorized caregivers may need clear information about:
- The patient's condition
- Medication instructions
- Diet and activity recommendations
- Equipment
- Wound care
- Follow-up appointments
- Expected recovery
- Warning signs
- Whom to contact
- When to call 911
- Available community resources
Education should reflect the patient's language, health literacy, cognition, hearing, vision, culture, preferences, and ability to carry out the plan.
Providing written instructions alone does not establish understanding.
Function, Mobility, and Fall Prevention
Medical Stability Is Not the Same as Functional Safety
A patient may leave the hospital medically stable yet have difficulty:
- Walking
- Transferring
- Bathing
- Dressing
- Preparing food
- Managing medication
- Using equipment
- Reaching follow up care
- Responding during an emergency
Coordination may include:
- Functional assessment
- Rehabilitation
- Assistive device evaluation
- Fall risk reduction
- Home safety review
- Caregiver training
- Support service referral
A suspected serious injury or sudden loss of function requires prompt clinical evaluation.
Social and Environmental Barriers
Treatment Cannot Succeed if the Plan Cannot Be Carried Out
Potential barriers may include:
- Inability to obtain medication
- Food insecurity
- Transportation problems
- Unstable housing
- Unsafe living conditions
- Lack of electricity or refrigeration
- Limited telephone or internet access
- Social isolation
- Language barriers
- Financial strain
- Inadequate caregiver support
Hospitals Without Walls™ may help identify these barriers and connect patients with available resources.
Identification or referral does not guarantee that a resource exists, that the patient qualifies, or that the service will be funded.
Palliative and Supportive Care
Addressing Symptoms and Goals During Serious Illness
Patients with serious illness may experience repeated acute care use related to symptoms, uncertainty, limited support, or changing goals.
Palliative care may help address:
- Pain
- Shortness of breath
- Fatigue
- Nausea
- Anxiety
- Emotional distress
- Communication about goals
- Caregiver concerns
- Spiritual needs, when desired
- Advance-care planning
- Coordination among clinicians
Palliative care may be provided alongside disease directed treatment and is not automatically hospice care.
The objective is not to prevent hospitalization when hospital care is consistent with the patient's needs and informed choices.
Advance Care Planning
Preparing for Decisions Before a Crisis
When desired and appropriate, advance-care planning may help patients:
- Identify healthcare goals
- Consider future treatment preferences
- Select an authorized decision-maker
- Discuss acceptable benefits and burdens
- Complete applicable documents
- Communicate preferences to relevant professionals and family members
- Revisit decisions as circumstances change
Advance-care planning must be voluntary.
It must never be used to pressure a patient to decline treatment or reduce costs.
Telehealth and Mobile Care
Extending Appropriate Access Beyond the Facility
When clinically appropriate and legally permitted, services may include:
- Telehealth follow-up
- Mobile professional visits
- Virtual care conferences
- Remote patient monitoring
- Medication related communication
- Behavioral health services
- Palliative support
- Patient and caregiver education
- Care coordination
Telehealth does not replace emergency care, required in-person evaluation, or hands on services when those are necessary.
Escalation of Care
Clear Decisions When a Patient's Condition Changes
A prevention program should define:
- 1Which findings require routine follow-up
- 2Which findings require same-day professional review
- 3Which findings require urgent evaluation
- 4Which findings require emergency services
- 5Who is responsible for each response
- 6How the action is documented
- 7How the care plan is updated afterward
Patients and caregivers should not delay emergency care while waiting for a routine callback or remote-monitoring review.
When Hospitalization Is Appropriate
Necessary Hospital Care Is Not Program Failure
Hospital evaluation may be appropriate when:
- The patient has a medical emergency
- Required diagnostic or therapeutic resources are unavailable elsewhere
- The current setting cannot provide safe care
- Symptoms cannot be adequately managed
- The patient requires a higher level of monitoring
- Qualified clinical judgment supports hospitalization
- The informed patient chooses hospital care after appropriate discussion
The final decision depends on the patient's condition, available alternatives, professional judgment, informed consent, and applicable emergency requirements.
Defining Program Success
Prevention Must Be Measured Honestly
A prevention program may evaluate:
- Timely post discharge contact
- Medication reconciliation
- Follow up completion
- Referral closure
- Patient and caregiver understanding
- Emergency department visits
- Observation stays
- Hospital admissions
- Unplanned readmissions
- Readmissions within a defined period
- Condition specific readmissions
- Potentially preventable utilization
- Mortality
- Patient experience
- Functional status
- Total cost of care
Measures must identify:
- The population
- Index event
- Measurement period
- Planned and unplanned events
- Inclusion and exclusion criteria
- Data source
- Risk adjustment method
- Comparison group or baseline
- Statistical uncertainty
- Attribution method
- Known limitations
A reduction in utilization should never be presented as successful without evaluating safety, mortality, access, patient experience, and possible unmet need.
Proving Prevention
An Avoided Event Cannot Be Observed Directly
It is difficult to prove that one individual hospitalization "would have occurred" without a particular intervention.
Credible program evaluation generally requires comparison of observed results with an appropriate expectation, such as:
- The same population's validated historical baseline
- A matched comparison group
- A risk adjusted benchmark
- A randomized or controlled design
- Another method appropriate to the program and data
The analysis must account for changes in population, eligibility, follow-up time, coding, death, disenrollment, access, and other factors that could influence results.
Hospitals Without Walls™ will not invent an avoided- hospitalization number or multiply an assumed event by an unsupported hospital cost.
Calculating Financial Impact
Savings Require Reliable Cost and Utilization Data
A financial evaluation should identify:
- Which costs are included
- Whether charges, payments, or allowed amounts are used
- The measurement period
- Program operating costs
- Patient cost sharing
- Utilization changes
- Comparison methodology
- Statistical uncertainty
- Any shared savings formula
- Who bears financial risk
Hospital charges should not automatically be presented as the amount paid or saved.
Gross avoided utilization is not the same as net savings. Net savings should subtract the full cost of operating the intervention and account for other changes in care.
For Hospitals and Health Systems
A Partnership May Support
- Discharge transition workflows
- Post discharge outreach
- Medication reconciliation
- Primary and specialty follow up
- Home health and community coordination
- Patient and caregiver education
- Readmission risk management
- Defined escalation
- Outcomes reporting
Hospitals remain responsible for their discharge-planning, quality-reporting, and regulatory duties.
For Health Plans and Risk-Bearing Organizations
A Partnership May Support
- Population identification
- Risk stratification
- Care management
- Provider coordination
- Member engagement
- Community resource linkage
- Utilization monitoring
- Quality measurement
- Financial evaluation
Coverage, authorization, medical necessity, network, and member rights requirements remain governed by applicable law and the relevant benefit arrangement.
For Facilities and Community Providers
A Partnership May Support
- Recognition of changes in condition
- Communication with treating professionals
- Medication coordination
- Telehealth access
- Mobile services
- Transfer documentation
- Post return follow up
- Resident and caregiver education
- Quality review
Facilities and providers retain their independent clinical and regulatory responsibilities.
Request a Prevention Program
Build a Program That Is Clinically Responsible and Measurable
Tell us:
- Which population you serve
- Which acute-care events concern you
- What baseline data are available
- Which providers and services already participate
- Which care transition gaps exist
- Which outcomes should be measured
- What geographic and payer requirements apply
We will evaluate whether an appropriate, compliant, operationally feasible, and scientifically measurable program can be developed.
Important Notice
Hospitals Without Walls™ provides an organizational framework for coordinated care and risk reduction. It does not guarantee prevention of any emergency department visit, hospitalization, readmission, complication, death, cost, penalty, or other outcome.
Not every hospitalization or readmission is avoidable. Necessary acute care must never be delayed to meet a utilization or financial target.
Services vary by program, patient, location, participating provider, payer authorization, operational capacity, and applicable law.
This page provides general educational and organizational information and does not constitute medical, legal, regulatory, insurance, financial, billing, or reimbursement advice.
If a patient may be experiencing a medical emergency, call 911 immediately.