Bringing Appropriate Healthcare Services to the Patient

WHAT IS MOBILE HEALTH DELIVERY?

Mobile health delivery brings appropriate healthcare services, professionals, equipment, information, and support closer to where patients live and function.

Depending on the program, mobile health delivery may combine:

• In person home and community visits
• Mobile physician and advanced practice services
• Skilled nursing services
• Telehealth and virtual consultations
• Remote patient monitoring
• Diagnostic and laboratory coordination
• Medication review
• Rehabilitation services
• Behavioral and PsychoSpiritual support
• Palliative care coordination
• Transitional care
• Caregiver education
• Community resource navigation
• Communication with hospitals, specialists, health plans, and other providers

Mobile care is not a single service or vehicle. It is a coordinated delivery system designed to connect the patient with the appropriate level of care through the most suitable combination of in-person, virtual, technological, and community-based resources.

Traditional healthcare often assumes that patients can travel reliably to medical offices, laboratories, imaging centers, hospitals, pharmacies, and other facilities.

For many patients, that assumption is not realistic.

Access may be limited by:

• Frailty
• Reduced mobility
• Physical disability
• Cognitive impairment
• Serious chronic illness
• Dependence on oxygen or medical equipment
• Lack of transportation
• Geographic distance
• Caregiver limitations
• Financial barriers
• Language or communication needs
• Homebound status
• Recent hospitalization
• Infection risk
• Social isolation
• Difficulty navigating multiple healthcare organizations

When appropriate services can safely reach the patient, mobile care may help close gaps that would otherwise remain unaddressed.

Mobile health delivery does not replace hospitals, emergency departments, specialists, or other necessary facility-based care. It creates another point of access within a connected continuum.

WHO MAY BENEFIT?

Mobile health services may be appropriate for individuals who:

• Have difficulty leaving the home
• Require substantial assistance to attend appointments
• Live with multiple chronic conditions
• Have recently been discharged from a hospital or facility
• Experience recurrent changes in condition
• Require close follow up
• Need medication reconciliation
• Have wounds or other conditions requiring ongoing assessment
• Are affected by frailty or functional decline
• Have a high risk of falls
• Live with dementia or cognitive impairment
• Require palliative support
• Depend heavily on family or unpaid caregivers
• Face transportation or geographic barriers
• Have missed necessary appointments
• Need coordinated care across multiple providers
• May benefit from telehealth or remote monitoring
• Live in senior communities, assisted living, or post acute settings

A patient’s suitability for any mobile service must be determined individually by appropriately qualified professionals based on clinical condition, safety, environment, service availability, coverage, and applicable program requirements.

The Right Care. The Right Setting. The Right Time.

Hospitals Without Walls™ begins by identifying what the patient needs and which setting can safely and effectively meet that need.

We ask:

• Does the patient require emergency evaluation?
• Does the patient need hospital-level care?
• Can the concern be addressed safely in the home or community?
• Is an in person examination necessary?
• Can part of the encounter be completed through telehealth?
• Is remote monitoring clinically appropriate?
• Are mobile diagnostic or treatment services available?
• Does the home environment support safe care?
• Is a caregiver available when needed?
• Which professionals should be involved?
• Who will review results and follow up?
• How will information be communicated across the care team?
• What should happen if the patient’s condition worsens?

Mobile care is appropriate only when the required service can be delivered safely, lawfully, and within the capabilities of the participating professionals and organizations.

Qualified healthcare professionals may provide authorized services in homes, senior communities, post-acute settings, workplaces, or other approved locations.

Depending on program scope, mobile visits may involve:

• Medical assessment
• Nursing assessment
• Medication reconciliation
• Chronic condition follow up
• Functional evaluation
• Wound evaluation
• Palliative assessment
• Behavioral health support
• Care plan review
• Patient and caregiver education
• Post discharge follow up
• Referral coordination

Virtual care may connect patients and caregivers with qualified professionals through secure video, audio, or other authorized communication technologies.

Telehealth may support:

• Follow up visits
• Symptom review
• Medication review
• Patient education
• Caregiver guidance
• Behavioral health services
• Specialist consultation
• Care plan conferences
• Post discharge contact
• Review of remote monitoring information

Telehealth is not appropriate for every condition. An in-person examination, diagnostic test, urgent evaluation, or emergency response may still be required.

When clinically appropriate and properly authorized, connected devices may collect and transmit health information such as:

• Blood pressure
• Heart rate
• Oxygen saturation
• Weight
• Temperature
• Blood glucose
• Other condition specific measurements

Remote monitoring does not operate independently. A responsible program requires clear rules for reviewing information, identifying concerning findings, communicating with the patient, documenting actions, and escalating care.

Subject to availability and contractual scope, coordinated mobile services may include:

• Laboratory specimen collection
• Diagnostic testing
• Imaging coordination
• Medication delivery
• Durable medical equipment
• Infusion or injection services
• Wound-care supplies
• Rehabilitation services
• Pharmacy consultation
• Nutrition support
• Social-work services

Each service must be performed by an appropriately licensed, certified, qualified, or authorized professional or organization.

Some patients need direct clinical evaluation but face substantial barriers to office based care.

Mobile physician, nurse practitioner, or physician assistant services may support:

• Comprehensive evaluation
• Follow up after hospitalization
• Review of acute changes
• Chronic disease management
• Medication assessment
• Functional and cognitive evaluation
• Palliative care planning
• Coordination with specialists
• Review of diagnostic findings
• Development or revision of the care plan
• Determination of whether a higher level of care is necessary

The availability and scope of these services depend on state law, professional licensure, payer rules, credentialing, clinical appropriateness, and the participating organization’s capabilities.

The period after hospital or facility discharge can involve medication changes, new symptoms, incomplete information, delayed follow-up, equipment needs, and confusion about who is responsible for the next step.

A mobile transitional-care program may help:

• Confirm that the patient has arrived safely
• Review discharge instructions
• Reconcile medications
• Identify missing prescriptions or equipment
• Assess symptoms and functional status
• Review warning signs
• Coordinate timely follow-up
• Communicate with primary and specialty care
• Arrange eligible home health or community services
• Educate the patient and caregiver
• Clarify whom to contact with questions
• Escalate concerning changes

Mobile transitional care does not guarantee that readmission will be avoided. Its purpose is to identify and address transition-related risks through timely, coordinated follow-up.

Patients with chronic illness may experience important changes between scheduled medical appointments.

Depending on the patient’s needs and the applicable program, mobile care may support people living with:

• Heart failure
• Hypertension
• Diabetes
• Chronic obstructive pulmonary disease
• Chronic kidney disease
• Cardiovascular disease
• Neurologic disease
• Dementia
• Multiple chronic conditions
• Frailty
• Chronic wounds
• Functional impairment

The care plan may incorporate symptom assessment, medication review, monitoring, education, nutrition guidance, caregiver support, functional evaluation, and coordination with the patient’s established clinicians.

Mobile programs should supplement—not fragment—the patient’s existing care.

Patients living with serious illness may have difficulty traveling to multiple appointments while also managing pain, shortness of breath, fatigue, weakness, anxiety, or caregiver burden.

Mobile and virtual palliative support may help address:

• Pain and symptom burden
• Functional decline
• Medication concerns
• Goals-of-care discussions
• Advance-care planning
• Patient and family education
• Emotional and spiritual needs
• Caregiver strain
• Coordination among multiple professionals
• Preparation for changes in condition
• Appropriate transitions to hospice when elected and clinically indicated

Palliative care may be provided alongside disease directed treatment and is not automatically the same as hospice care.

The home can offer comfort, familiarity, and direct insight into how the patient actually lives. It can also present safety and operational challenges that may not be visible during an office visit.

A mobile care assessment may consider:

• Fall hazards
• Lighting and accessibility
• Stairs and entry barriers
• Medication storage
• Food availability
• Utilities and temperature control
• Clean water and sanitation
• Infection control concerns
• Fire and oxygen safety
• Medical equipment placement
• Electrical and connectivity requirements
• Emergency access
• Pets or environmental hazards
• Caregiver availability
• Risk of neglect, abuse, or exploitation
• Staff safety

Identified concerns should be documented, communicated, and addressed through an appropriate care, referral, or escalation plan.

A home should not be used as a care setting when the patient’s needs exceed what can be safely provided there.

Technology can improve mobile care only when it is integrated into a defined clinical and operational process.

Technology may support:

• Secure telehealth visits
• Remote physiologic monitoring
• Electronic clinical documentation
• Medication lists
• Appointment coordination
• Patient and caregiver communication
• Clinical alerts
• Care-plan sharing
• Referral tracking
• Outcome measurement
• Population-level risk identification

Technology should not be treated as a substitute for clinical judgment, physical examination, emergency response, or meaningful human communication.

Patients should receive reasonable assistance when digital literacy, disability, language, internet access, or technology availability creates a barrier.

Mobile services are most effective when connected to the broader healthcare system.

Depending on the patient and program, coordination may involve:

• Hospitals
• Emergency departments
• Primary care practices
• Medical specialists
• Health plans
• Pharmacies
• Laboratories
• Imaging providers
• Home health agencies
• Hospice organizations
• Skilled nursing facilities
• Assisted living communities
• Rehabilitation providers
• Behavioral health professionals
• Community organizations
• Family and authorized caregivers

Hospitals Without Walls™ seeks to establish clear communication pathways, define responsibilities, reduce duplication, and help ensure that important findings reach the professional responsible for acting on them.

A successful mobile encounter requires more than reaching the patient.

The process may include:

Information-sharing must comply with applicable privacy, security, consent, and healthcare regulations.

Every mobilecare program should establish clear escalation procedures.

Changes that may require urgent or emergency evaluation include but are not limited to:

• Severe difficulty breathing
• Chest pain
• Signs of stroke
• Uncontrolled bleeding
• Loss of consciousness
• New severe confusion
• Serious injury
• Severe allergic reaction
• Suicidal or violent behavior
• Rapid clinical deterioration
• Any condition that appears life-threatening

Mobile appointments, website messages, remote-monitoring devices, and routine telehealth services must never delay emergency care.

Emergency Notice: If a patient may be experiencing a medical emergency, call 911 or the appropriate local emergency number immediately.

Hospitals Without Walls™ is not an emergency response service unless a specific, lawfully authorized program expressly states otherwise.

Mobile health delivery is a broad model that may include home visits, telehealth, remote monitoring, transitional care, chronic disease support, or coordination of community services.

It should not automatically be described as hospital level care.

“Hospital at Home” or the Centers for Medicare & Medicaid Services Acute Hospital Care at Home initiative involves hospital level acute care delivered by an approved hospital under specific regulatory, clinical, operational, patient-selection, monitoring, and emergency-response requirements.

Hospitals Without Walls™ will describe a program as acute hospital care at home only when it is provided through an appropriately authorized hospital and satisfies all applicable requirements.

The Hospitals Without Walls™ name does not, by itself, mean that every service constitutes licensed hospital care.

Before receiving mobile services, patients or their authorized representatives should receive understandable information about:

• The nature of the proposed service
• Who will provide it
• Whether the encounter is in person or virtual
• Reasonably available alternatives
• Technology requirements
• Privacy considerations
• Potential limitations
• Costs or coverage responsibilities, when known
• How to ask questions or withdraw from voluntary services
• What to do in an emergency

Participation in mobile care should be voluntary unless otherwise authorized by law, and declining a mobile option should not result in inappropriate abandonment or discrimination.

Delivering services outside a traditional facility does not remove the responsibility to protect quality and safety.

Depending on the service, oversight may include:

• Verification of professional licensure and credentials
• Defined scope of practice
• Patient identification procedures
• Infection prevention practices
• Medication safety
• Equipment maintenance
• Environmental safety assessment
• Emergency and escalation protocols
• Documentation standards
• Privacy and data-security safeguards
• Communication and handoff procedures
• Incident reporting
• Patient grievance processes
• Clinical review
• Performance monitoring
• Corrective-action procedures

Participating professionals and organizations remain responsible for meeting the laws, standards, and contractual requirements applicable to the services they provide.

Depending on the contract and available data, performance measures may include:

• Time from referral to initial contact
• Time from referral to completed service
• Successful completion of post-discharge follow-up
• Medication reconciliation
• Resolution of identified care gaps
• Patient and caregiver experience
• Symptom and functional outcomes
• Adherence to the care plan
• Completion of ordered follow-up
• Emergency department utilization
• Hospital admissions and readmissions
• Avoidable delays in care
• Escalation response times
• Remote monitoring engagement
• Safety events
• Caregiver burden
• Access across geographic or demographic groups
• Total cost of care, when methodologically and contractually appropriate

Results should be interpreted in light of patient complexity, baseline risk, program design, comparison methods, enrollment criteria, and data completeness.

Hospitals Without Walls™ does not claim that mobile care will prevent every hospitalization, emergency visit, complication, or adverse outcome.

Hospitals Without Walls™ seeks to collaborate with:

• Hospitals and health systems
• Health plans and insurance companies
• Physician groups
• Accountable care organizations
• Government agencies
• Military and veterans healthcare programs
• Skilled nursing and post acute facilities
• Assisted living and senior communities
• Home health organizations
• Community healthcare organizations
• Employers and commercial organizations

Potential partnership models may include:

• Post discharge mobile follow up
• High risk patient outreach
• Chronic disease support
• Comprehensive geriatric assessment
• Palliative care coordination
• Mobile physician services
• Telehealth programs
• Remote patient monitoring
• Medication management initiatives
• Facility based mobile clinics
• Rural or underserved-area access programs
• Caregiver support
• Transitional care programs
• Population health initiatives
• Mobile diagnostic coordination

Each program is developed according to the contracting organization’s population, objectives, service area, resources, regulatory requirements, data capabilities, and mutually approved scope of work.

Hospitals Without Walls™ believes that a patient’s location should not automatically become a barrier to appropriate healthcare.

Our mobile health delivery model is intended to:

• Bring appropriate services closer to the patient
• Improve continuity across settings
• Support patients with mobility and transportation barriers
• Identify unmet needs in the patient’s actual environment
• Strengthen communication among providers
• Support patients and caregivers after discharge
• Combine human care with appropriate technology
• Escalate patients when a higher level of care is required
• Measure safety, access, experience, and outcomes
• Preserve patient dignity, choice, and participation

The purpose is not to move every service into the home.

The purpose is to determine which services can safely reach the patient and to connect the patient promptly with facility based or emergency care when they cannot.

Hospitals Without Walls™ works with healthcare organizations seeking to develop coordinated mobile, virtual, home-based, and community based care programs.

Hospitals Without Walls™ is a healthcare coordination and partnership model. Specific services vary according to the participating organization, geographic availability, clinical need, professional licensure, credentialing, contractual scope, payer authorization, patient eligibility, and applicable law.

Mobile healthcare is not appropriate for every patient or condition. Some patients require in person office, facility, emergency department, or hospital care.

Information on this website is educational and does not constitute individualized medical advice, diagnosis, treatment, confirmation of insurance coverage, or a guarantee of clinical or financial outcomes.

The principles on this page are informed by authoritative guidance and published evidence concerning home based care, transitional safety, telehealth, remote monitoring, and acute care delivered in the home.

• AHRQ Patient Safety Network Safety in Home Based Post Acute and Transitional Care
• AHRQ Home-Based Primary Care Interventions
• CMS Acute Hospital Care at Home
• CMS Report on the Acute Hospital Care at Home Initiative
• CMS Home Health Quality Measures
• AHRQ Patient Safety Network Telehealth and Primary Care Access
• PubMed Systematic Review of Home Based Primary Care for Homebound Older Adults
• PubMed Home Based Primary Care: Systematic Review of the Literature