Supporting Safer, More Coordinated Transitions Between Care Settings
Hospitals Without Walls™ helps patients, caregivers, clinicians, facilities, and community organizations coordinate care when a patient moves from one healthcare setting to another.
Our transitional care model focuses on timely information exchange, medication safety, follow-up, patient and caregiver understanding, and early identification of unresolved needs.
What Is Transitional Care?
Connecting the Patient's Care Before, During, and After a Transition
Transitional care supports continuity when a patient moves between settings, such as:
- Hospital to home
- Hospital to skilled nursing or rehabilitation
- Skilled nursing or rehabilitation to home
- Emergency department to community based follow up
- Institutional care to assisted living
- Home to a higher level of care
- Palliative or serious illness care across settings
The purpose is to help the patient, authorized caregivers, and participating providers understand the care plan, assigned responsibilities, medications, follow up needs, warning signs, and available support.
Transitional care does not replace the discharge planning responsibilities of a hospital, facility, home health agency, or other regulated provider.
Why Transitions Require Attention
Important Information Can Be Lost Between Settings
During a transition, patients may experience:
- Incomplete or delayed transfer of health information
- Conflicting medication lists
- Unclear treatment instructions
- Delayed appointments or services
- Unresolved laboratory or diagnostic results
- Missing equipment, supplies, transportation, or medications
- Confusion about which provider is responsible
- Changes in function, cognition, symptoms, or caregiver capacity
- Difficulty understanding when and where to seek help
These risks may be greater for people with multiple chronic conditions, complex medication regimens, frailty, functional limitations, cognitive impairment, serious illness, behavioral health needs, or limited caregiver support.
Who May Benefit?
Transitional Support Based on Individual Need
Transitional care services may be appropriate for patients who:
- Have recently left a hospital, rehabilitation facility, or skilled nursing facility
- Have experienced repeated emergency department visits or hospitalizations
- Take multiple medications or have recent medication changes
- Need follow up with several clinicians or organizations
- Have new equipment, wound-care, rehabilitation, or monitoring needs
- Have difficulty understanding or following the discharge plan
- Face transportation, food, housing, financial, or caregiver barriers
- Have experienced a decline in mobility, cognition, or ability to perform daily activities
- Require palliative, behavioral health, or community based support
Eligibility and services depend on clinical need, patient consent, provider availability, payer requirements, program criteria, and applicable law.
Our Transitional-Care Pathway
Defined Actions Across the Transition Period
Before Discharge
When Hospitals Without Walls™ is involved before discharge, coordination may include:
- Reviewing the anticipated transition plan
- Identifying the receiving setting and responsible providers
- Confirming available contact information
- Reviewing medication, equipment, supply, transportation, and service needs
- Identifying functional, cognitive, behavioral, social, and caregiver concerns
- Clarifying followup appointments and pending results
- Helping the patient and caregiver understand the next steps
The discharging organization remains responsible for its required discharge assessment, planning, documentation, instructions, referrals, and transfer of information.
At the Time of Transition
The care team may help verify that authorized information reaches the appropriate receiving providers and that the patient or caregiver has access to:
- Discharge instructions
- A current medication list
- Followup information
- Prescriptions and medication-access instructions
- Equipment and supply arrangements
- Wound-care or treatment instructions
- Rehabilitation or home service referrals
- Warning signs and emergency instructions
- Appropriate contact information
Early Follow-Up
After the transition, authorized personnel may contact the patient or caregiver to review:
- Whether the patient arrived safely
- Changes in symptoms or function
- Access to medications, food, equipment, and supplies
- Understanding of the care plan
- Appointment and referral status
- New barriers or caregiver concerns
- Questions requiring communication with a qualified clinician
The timing and form of follow up depend on clinical need, contractual requirements, payer rules, and program design.
Ongoing Coordination
When additional support is appropriate, the program may provide:
- Mobile or virtual clinical follow up
- Medication review and reconciliation
- Chronic disease and symptom monitoring
- Caregiver education
- Rehabilitation and functional support
- Home safety assessment
- Community resource linkage
- Palliative care coordination
- Communication among authorized providers
- Reassessment and escalation when needs change
Medication Safety
Establishing an Accurate and Understandable Medication Plan
Medication reconciliation may include comparing available medication lists, identifying apparent omissions or duplications, reviewing recent changes, assessing access and adherence barriers, and communicating questions to an authorized prescriber or pharmacist.
Patients and caregivers may receive education about:
- Medication names and purposes
- Doses and schedules
- Recently started, stopped, or changed medications
- Special administration or monitoring instructions
- Potential warning signs identified by the treating clinician
- What to do when a medication cannot be obtained
- Whom to contact with questions
Only legally authorized professionals may prescribe, discontinue, or modify medication orders.
Follow Up and Information Exchange
Closing the Loop Between Providers
Subject to consent and applicable privacy requirements, coordination may address:
- Primary care and specialist appointments
- Home health, rehabilitation, behavioral health, palliative care, or hospice referrals
- Laboratory and diagnostic orders
- Pending test results
- Medical equipment and supply needs
- Pharmacy communication
- Transportation and accessibility
- Community and social service referrals
- Changes in the patient's condition or care plan
A referral does not guarantee acceptance, availability, coverage, payment, or a particular start of care date.
Whole-Person Transition Assessment
Looking Beyond the Discharge Diagnosis
Depending on the program, transitional care assessment may consider:
- Current diagnoses, symptoms, and treatment priorities
- Medication and monitoring needs
- Mobility, transfers, self care, and fall risk
- Cognition, mood, communication, and decision making support
- Nutrition, hydration, and swallowing concerns
- Pain, symptom burden, and serious illness goals
- Home safety and accessibility
- Caregiver availability and capacity
- Transportation, housing, utilities, food, and financial barriers
- Patient goals, preferences, language, culture, and health literacy
Identified concerns may lead to education, communication with authorized providers, or referral to qualified services.
Mobile, Virtual, and Remote Support
Extending Follow-Up Beyond the Traditional Office
When clinically appropriate, legally permitted, and operationally available, transitional support may include:
- Mobile clinical visits
- Telehealth appointments
- Telephone followup
- Virtual care conferences
- Remote patient monitoring
- Digital education and communication
- Coordination with home based providers
Remote monitoring may involve measures such as:
- Blood pressure
- Heart rate
- Oxygen saturation
- Weight
- Blood glucose
- Temperature
Programs must define who reviews incoming information, how often it is reviewed, what thresholds require action, and how concerns are escalated. Remote monitoring is not continuous emergency surveillance unless expressly designed and represented as such.
Escalation and Emergency Planning
Helping Patients Know What to Do When Conditions Change
Patients and caregivers should receive understandable instructions describing:
- Expected recovery or treatment needs
- Symptoms or changes to report
- Which provider to contact
- How to obtain after hours assistance
- When urgent evaluation may be necessary
- When to call 911
Hospitals Without Walls™ does not replace emergency medical services. Digital messages, routine monitoring systems, and nonemergency telephone lines should not be used when immediate emergency assistance is required.
Medicare Transitional Care Management
A Defined Billing Service With Separate Requirements
General transitional care support is not automatically the same as Medicare Transitional Care Management, commonly called TCM.
Medicare TCM is a defined professional service subject to eligibility, timing, communication, face to face visit, medical decision making, documentation, coding, and billing requirements. When TCM is offered, the billing practitioner remains responsible for determining whether all current requirements have been satisfied.
Participation in a Hospitals Without Walls™ transitional care program does not establish Medicare eligibility, create medical necessity, or guarantee that TCM or any related service may be billed or reimbursed.
Working With Healthcare Organizations
Transitional Care Programs Designed Around the Population
Hospitals Without Walls™ may develop transitional care arrangements with:
- Hospitals and health systems
- Health plans and insurance companies
- Government and military healthcare programs
- Skilled nursing and rehabilitation facilities
- Assisted living and senior communities
- Physician groups and medical practices
- Home health and community healthcare organizations
- Employers and other qualified contracting organizations
Written agreements should define the eligible population, services, referral process, responsible parties, communication standards, privacy safeguards, escalation pathways, compensation, reporting, and performance measures.
Quality and Performance Measurement
Evaluating the Process and the Results
Depending on the program and available data, measures may include:
- Successful post-transition contact
- Medication reconciliation completion
- Timely clinical follow up
- Referral and appointment completion
- Transfer of required information
- Patient and caregiver understanding
- Resolution of identified barriers
- Patient, caregiver, and partner experience
- Emergency department visits, hospitalizations, or readmissions
- Clinical, functional, utilization, and financial outcomes
Measures should identify:
- The population
- Baseline
- Data source
- Reporting period
- Exclusions
- Analytical method
- Risk adjustment when appropriate
- Known limitations
Transitional care interventions may improve selected outcomes in some populations and settings, but results vary. Not every emergency visit, hospitalization, or readmission is preventable, and no particular outcome or savings level is guaranteed.
Request Transitional Care
Build a More Connected Path Between Care Settings
Patients, caregivers, clinicians, and organizations may contact Hospitals Without Walls™ to discuss available transitional care services.
Organizations seeking a contract should be prepared to describe:
- The population and transition settings
- Current discharge and referral workflows
- Identified coordination gaps
- Available clinical and community resources
- Technology and information exchange capabilities
- Payer and regulatory requirements
- Desired process and outcome measures
Important Notice
Services vary by location, program, patient eligibility, clinical need, provider availability, payer authorization, contractual terms, and applicable law.
Hospitals Without Walls™ does not guarantee admission to any service, appointment availability, insurance coverage, reimbursement, prevention of hospitalization or readmission, or improvement in clinical, functional, utilization, or financial outcomes.
This page provides general information and does not constitute individualized medical, legal, regulatory, billing, coding, or reimbursement advice. Patients should follow the instructions of their treating professionals. If a patient may be experiencing a medical emergency, call 911.
If a patient may be experiencing a medical emergency, call 911.