Health Plans & Insurance Companies

Coordinated Care Designed Around Quality, Member Experience, and Total Cost

Hospitals Without Walls™ works with health plans and insurance companies to support members whose care is fragmented across hospitals, physicians, facilities, homes, virtual environments, and community organizations.

Our model is designed to identify actionable risks, close care gaps, strengthen transitions, improve member and caregiver support, and promote appropriate use of healthcare resources.

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Healthcare coordination for health plans and insurance companies

The health plan challenge

Data May Identify Risk but Data Alone Cannot Resolve It

Health plans may have broad visibility into claims, utilization, pharmacy activity, quality measures, and provider networks.

However, a claim does not always reveal:

Hospitals Without Walls™ seeks to connect payer data with patient centered assessment, professional services, provider communication, and community resources.

What is happening in the member's home
Whether the member understands the care plan
Which medications the member is actually taking
Whether a caregiver is available
Whether the member can attend appointments
Whether equipment has arrived
Whether functional status is declining
Whether symptoms are worsening
Whether social or behavioral barriers are interfering with care
Whether multiple providers are communicating
Whether the member knows whom to contact
Whether the existing plan is realistic

The Hospitals Without Walls™ payer solution

Turning Population Level Information Into Coordinated Individual Action

Depending on the contract, a health plan program may include:

Population stratification
High risk member identification
Member outreach through approved channels
Comprehensive needs assessment
Care plan development
Chronic disease support
Transitional care
Medication management support
Mobile clinical services
Telehealth
Remote patient monitoring
Comprehensive geriatric care
Frailty and functional assessment
Palliative care coordination
Behavioral and PsychoSpiritual support
Caregiver support
Provider communication
Community resource navigation
Care gap closure
Quality and utilization reporting
Total cost of care evaluation

The final program must align with the health plan's benefit design, regulatory obligations, network, member rights, data capabilities, operational structure, and approved contract.

Who may benefit?

Matching Program Intensity to Member Need

Potential populations may include members with:

Risk status alone should not automatically determine enrollment. The member must have needs that the program can reasonably address.

Multiple chronic conditions
Repeated hospitalizations
Recurrent emergency department utilization
Recent hospital or facility discharge
Heart failure
Chronic obstructive pulmonary disease
Diabetes with complications
Chronic kidney disease
Cardiovascular disease
Dementia
Frailty
Functional decline
Multiple medications
Chronic or complex wounds
Serious or progressive illness
Palliative care needs
High fall risk
Cognitive impairment
Behavioral health needs
Significant caregiver dependence
Difficulty accessing network services
Transportation limitations
Unresolved social needs
Rural or geographic access barriers
Open quality measure gaps
High predicted healthcare spending

Population identification

Finding Actionable Risk not Merely Expensive Members

A payer partnership may use authorized data such as:

Eligibility
Claims
Encounters
Pharmacy utilization
Hospital admissions
Emergency department visits
Readmissions
Diagnostic patterns
Procedure history
Durable medical equipment
Laboratory information
Prior authorization
Risk scores
Quality measure gaps
Provider referrals
Health risk assessments
Member or caregiver requests

Selection criteria should consider:

Clinical risk
Functional risk
Transitional risk
Medication risk
Caregiver burden
Access barriers
Modifiable needs
Likelihood of meaningful engagement
Service availability
Benefit eligibility
Equity implications

Hospitals Without Walls™ does not recommend targeting members solely because they are expensive. The program should focus on needs that can be addressed through appropriate intervention.

Member engagement

Respectful, Authorized, and Understandable Outreach

Member outreach should be:

Authorized by the contracting plan
Consistent with applicable law
Clearly identified
Free from misleading statements
Available in accessible formats
Responsive to language needs
Respectful of member choice
Documented
Limited to the approved purpose

Members should understand:

Who is contacting them
The relationship with their health plan
Why they were selected
What services are offered
Whether participation is voluntary
Whether services affect benefits
What information may be shared
How to ask questions
How to decline or discontinue participation
What to do in an emergency

Enrollment should never be obtained through coercion, fear, or misleading promises of coverage or improved benefits.

Comprehensive member assessment

Looking Beyond Diagnoses and Claims

An authorized assessment may examine:

Clinical Needs

Diagnoses
Symptoms
Recent changes in condition
Medication use
Treatment burden
Hospital and emergency utilization
Chronic disease management
Preventive and follow-up needs

Functional Needs

Mobility
Activities of daily living
Falls
Weakness
Assistive devices
Ability to leave the home
Ability to manage medications
Ability to obtain food and attend appointments

Cognitive and Behavioral Needs

Cognition
Memory
Depression
Anxiety
Substance-use concerns
Behavioral symptoms
Coping ability
Health literacy

Social and Practical Needs

Housing
Transportation
Food access
Social isolation
Language
Disability access
Financial barriers
Pharmacy access
Digital connectivity

Caregiver Needs

Availability
Capacity
Knowledge
Physical and emotional burden
Ability to carry out the care plan
Need for additional support

The findings help determine whether the member needs education, professional evaluation, care coordination, community resources, or escalation to a higher level of care.

Care plan coordination

One Member. One Understandable Plan.

A coordinated care plan may identify:

The care plan should supplement and organize care—not conflict with treatment ordered by the member's qualified healthcare professionals.

The member's goals
Active diagnoses
Current medications
Responsible providers
Required follow up
Open care gaps
Symptoms requiring monitoring
Functional needs
Behavioral and social barriers
Caregiver responsibilities
Community services
Escalation instructions
Assigned actions
Follow up dates
Measures of progress

Material clinical concerns must be communicated to the appropriate responsible professional.

Transitional care

Supporting Members After Hospital and Facility Discharge

Transitions between settings can create medication, communication, follow-up, and safety risks.

A payer contracted transitional care program may include:

Timely post discharge contact
Review of discharge instructions
Medication reconciliation
Confirmation of prescriptions
Symptom assessment
Functional assessment
Follow up appointment coordination
Home health and post acute coordination
Equipment and supply review
Patient and caregiver education
Identification of unresolved needs
Communication with responsible providers
Escalation of concerning findings

Not every readmission is preventable. Members must receive hospital or emergency evaluation whenever clinically necessary.

Chronic disease management

Supporting Members Between Traditional Encounters

Potential condition specific programs may address:

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

Services may include:

Symptom monitoring
Medication review
Disease education
Nutrition support
Functional assessment
Appointment coordination
Primary and specialty-care communication
Caregiver education
Remote monitoring
Mobile or virtual follow-up
Escalation of changes in condition

Program design should be based on the member's actual needs rather than a diagnosis alone.

Comprehensive geriatric care

Addressing Risks Commonly Missed by Claims-Based Programs

Older adults may experience interconnected clinical, functional, cognitive, medication, caregiver, and social risks.

A geriatric program may evaluate:

Frailty
Falls
Mobility
Cognition
Polypharmacy
Nutrition
Continence
Sensory impairment
Skin integrity
Functional ability
Depression
Social isolation
Home safety
Caregiver capacity
Advance care planning

Findings may be used to coordinate services through the plan's network and approved community resources.

Palliative care coordination

Supporting Quality of Life During Serious Illness

Palliative care may be appropriate for members living with serious illness at different stages of disease and may accompany disease directed treatment.

A payer partnership may support:

Symptom assessment
Palliative care referral
Goals of care communication
Advance care planning
Caregiver support
Behavioral and spiritual support
Coordination across providers
Home based services
Hospice education when clinically appropriate

Palliative care and hospice are not interchangeable. Hospice eligibility and election are governed by the applicable benefit and regulatory requirements.

Palliative programs should be evaluated first for quality, symptom relief, member experience, and goal concordant care. Financial effects should be measured rather than assumed.

Medication management support

Identifying Risks Across Prescribers and Settings

Potential medication-related concerns include:

Duplicate therapies
Conflicting medication lists
Drug interactions
High risk medications
Incorrect use
Adverse effects
Failure to obtain prescriptions
Cost barriers
Nonadherence
Cognitive limitations
Multiple pharmacies
Multiple prescribers
Changes after hospitalization

Depending on program design, support may include:

Medication reconciliation
Pharmacist review
Member and caregiver education
Pharmacy coordination
Prescriber communication
Adherence barrier assessment
Follow up on identified discrepancies

Medication changes must be made by an appropriately authorized prescriber.

Mobile health delivery

Reaching Members Who Face Access Barriers

Mobile services may help members affected by:

Frailty
Disability
Transportation barriers
Geographic distance
Homebound status
Recent hospitalization
Caregiver limitations
Dependence on medical equipment
Difficulty attending office appointments

Depending on the contract and benefit structure, mobile services may include:

Medical evaluation
Nursing assessment
Functional assessment
Medication review
Palliative assessment
Wound care coordination
Patient and caregiver education
Transitional follow up

Mobile care must operate within applicable licensure, credentialing, network, coverage, and scope of practice requirements.

Telehealth and remote patient monitoring

Technology Connected to Clinical Action

Telehealth may support:

Follow up visits
Symptom review
Chronic condition support
Medication review
Behavioral health
Palliative care
Caregiver education
Care conferences
Specialist consultation

Remote monitoring may collect authorized information such as:

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

A remote-monitoring program must define:

Who reviews the information
How frequently it is reviewed
Which findings generate alerts
Who contacts the member
Who communicates with providers
When urgent or emergency escalation occurs
How actions are documented
What happens when data are missing

A monitoring device is not an emergency-response system unless the program expressly provides that capability.

Care gap closure

From Measure Identification to Completed Care

A health plan may identify an open measure or recommended service, but the member may still face barriers to completion.

Hospitals Without Walls™ may help:

Explain the recommended service
Confirm the responsible provider
Identify an appropriate network provider
Coordinate scheduling
Address transportation or communication barriers
Support mobile or virtual alternatives when authorized
Follow up after the appointment
Obtain confirmation through approved data channels
Communicate unresolved barriers

All services must remain clinically appropriate and consistent with applicable measure specifications, benefit rules, and member choice.

No service should be provided solely to generate a quality code or improve a rating.

Member and caregiver experience

Quality Includes Whether the System Works for the Person

A technically complete care process may still fail if the member:

Does not understand the plan
Cannot obtain an appointment
Cannot access prescribed medication
Receives conflicting instructions
Does not know whom to call
Feels excluded from decisions
Cannot use the required technology
Does not receive language or disability accommodations
Lacks sufficient caregiver support

A payer partnership may measure:

Getting needed care
Timeliness
Communication
Care coordination
Understanding of the care plan
Respect for member preferences
Caregiver preparedness
Complaint resolution
Continued engagement

CMS uses quality rating systems to help consumers compare Medicare Advantage, Part D, and Marketplace plans. Applicable measures and technical specifications change over time and must be verified for each reporting period.

Network coordination

Supporting the Network Not Creating a Parallel System

Hospitals Without Walls™ may coordinate with:

The objective is to strengthen existing network relationships and close gaps—not unnecessarily duplicate services or displace the member's established clinicians.

Primary care practices
Medical specialists
Hospitals
Urgent care centers
Pharmacies
Laboratories
Imaging providers
Home health agencies
Skilled nursing facilities
Rehabilitation providers
Behavioral health organizations
Hospice and palliative care providers
Community based organizations

Network participation, referrals, authorizations, and provider selection remain subject to the applicable plan requirements and member rights.

Health equity

Measuring Whether All Members Can Reach the Program

A payer program should evaluate differences in access and outcomes associated with:

Race and ethnicity
Language
Disability
Age
Sex
Geographic location
Rural residence
Income related barriers
Housing instability
Digital access
Caregiver availability
Other relevant population characteristics

Appropriate program responses may include:

Interpreter services
Accessible communication
Alternative outreach methods
Mobile services
Digital assistance
Transportation resources
Community partnerships
Culturally responsive education
Geographic expansion

Health-equity data must be collected, used, and protected in accordance with applicable law and approved program purposes.

Value based care

Aligning Compensation With Quality and Accountable Performance

CMS describes value based care as care designed around quality, provider performance, and patient experience.

Potential payer contract structures may include:

Fee for service
Per member per month payment
Case rate
Episode based payment
Bundled payment
Performance incentives
Shared savings
Shared risk
Hybrid arrangements

A value based contract should define:

Eligible population
Attribution
Baseline period
Performance period
Included services
Quality measures
Utilization measures
Financial measures
Risk adjustment
Data sources
Program costs
Performance thresholds
Reconciliation
Appeals and corrections
Quality guardrails
Termination and transition procedures

Financial incentives must not encourage denial or delay of medically necessary care.

Total cost of care management

Better Allocation of Resources Not Simply Fewer Services

Potential financial value may arise through:

Earlier identification of deterioration
Reduced fragmentation
Improved transitions
Medication risk reduction
Avoidance of unnecessary duplication
Appropriate use of mobile and virtual care
Better chronic disease support
Reduced potentially avoidable utilization
Improved access to primary and specialty care
Support for patients and caregivers at home

However, a program may also increase appropriate spending by identifying previously unmet needs.

For example, members may require additional primary care, medications, rehabilitation, home health, equipment, behavioral health, or palliative services.

The correct measure is net financial impact combined with quality, safety, access, and member experience outcomes.

Financial measurement

Savings Must Be Demonstrated With Valid Data

A financial evaluation may examine:

Allowed claims
Paid claims
Inpatient spending
Emergency department spending
Outpatient spending
Professional spending
Pharmacy spending
Post acute spending
Home health spending
Durable medical equipment
Program operating costs
Total cost of care

The methodology should account for:

Baseline risk
Population changes
Member months
Enrollment and disenrollment
Mortality
Regression to the mean
Seasonal patterns
Benefit changes
Network changes
Concurrent interventions
Outlier treatment
Claims runout
Statistical uncertainty

Hospitals Without Walls™ will distinguish projected opportunity, gross avoided spending, and validated net savings.

Quality guardrails

Utilization Reduction Is Not Sufficient

A payer program should monitor for:

Delayed emergency care
Inappropriate denial of services
Worsening mortality
Adverse events
Missed clinical deterioration
Reduced access
Member grievances
Caregiver overload
Medication errors
Unequal outcomes
Network disruption
Improper steering
Unnecessary services
Loss of continuity

A reduction in cost is not acceptable if it is achieved through reduced access, inappropriate denials, inadequate care, or patient harm.

Data exchange

Turning Information Into Coordinated Care

Potential data inputs may include:

Member eligibility
Claims
Encounters
Pharmacy data
Prior authorization
Quality gaps
Risk scores
Provider attribution
Admission, discharge, and transfer notifications
Care management history
Provider directories
Benefit and network information

Potential program outputs may include:

Outreach status
Consent status
Assessment findings
Care plan actions
Provider communication
Referrals
Service completion
Escalations
Quality outcomes
Utilization outcomes
Financial reporting

The parties must establish:

Permitted uses
Minimum necessary access
Data format
Transmission method
Data quality
Security controls
Record retention
Incident response
Member rights
Business associate obligations
Subcontractor requirements
Data return or destruction

Proposed payer workflow

From Population Identification to Measurable Outcome

1
The plan and Hospitals Without Walls™ define the target population.
2
Authorized data are transferred through an approved process.
3
Members are stratified according to approved criteria.
4
Outreach occurs through plan authorized methods.
5
Member identity, eligibility, and consent are verified.
6
A comprehensive assessment is completed.
7
Needs, risks, and care gaps are identified.
8
A coordinated action plan is developed.
9
Network providers and plan personnel are engaged as appropriate.
10
Mobile, virtual, home based, facility, or community services are coordinated.
11
Changes in condition are escalated.
12
Progress and service completion are documented.
13
Quality, utilization, experience, and financial outcomes are measured.
14
Performance is reviewed with the plan.
15
Corrective actions and program improvements are implemented.

Payer program options

Select the Model That Fits the Population

High Risk Member Program: For members with complex clinical, functional, medication, caregiver, or utilization risks.
Post Discharge Program: For members transitioning from hospitals, skilled nursing facilities, rehabilitation, or other settings.
Comprehensive Geriatric Program: For older adults affected by frailty, falls, cognitive impairment, polypharmacy, and functional decline.
Chronic Disease Program: For members living with heart failure, COPD, diabetes, kidney disease, or multiple chronic conditions.
Serious Illness and Palliative Program: For members requiring symptom, communication, caregiver, and goals of care support.
Care Gap Closure Program: For defined quality measures and clinically appropriate preventive or chronic-care needs.
Mobile and Virtual Access Program: For members affected by transportation, mobility, geographic, or other access barriers.
Total Cost of Care Program: For a defined population under a contract with quality and financial accountability.
Custom Health Plan Program: For plans requiring a solution built around their benefit structure, geography, member population, network, data, and regulatory obligations.

Performance dashboard

Contract-Specific Accountability

Depending on the program, reporting may include:

Domain	Illustrative Measures
Enrollment	Eligible members Outreach Consent Active participation
Access	Time to contact Appointment completion Service availability
Clinical	Symptoms Chronic-condition indicators Medication risks
Functional	Falls Mobility Activities of daily living
Transitional	Post-discharge contact Medication reconciliation Follow-up
Quality	Care-gap closure Applicable contract measures
Utilization	Emergency visits Admissions Readmissions Post-acute use
Experience	Member and caregiver feedback Complaints Grievances
Equity	Access and outcomes across relevant populations
Financial	Program cost Total cost of care Validated net impact

Final measures must use agreed specifications, denominators, exclusions, data sources, and reporting periods.

Responsibility Matrix

Function	Health Plan	Hospitals Without Walls™	Network and Participating Providers
Define eligible population	Approves criteria	Supports program design	Provides relevant clinical input
Provide authorized data	Supplies agreed data	Protects and uses data as permitted	Submits required documentation
Member outreach	Authorizes approach	Conducts assigned outreach	Reinforces participation when appropriate
Benefit determination	Plan responsibility	Does not independently guarantee coverage	Verifies authorization as required
Care coordination	Provides plan resources	Performs contracted coordination	Communicates and completes assigned care
Clinical decisions	Through authorized professionals	Within contracted professional scope	Responsible within individual scope
Quality reporting	Provides specifications and data	Reports contracted measures	Supports accurate documentation
Claims payment	Plan responsibility	Submits required information	Bills according to applicable rules
Compliance	Responsible for plan obligations	Responsible for contracted obligations	Responsible for provider obligations

The executed agreement must establish the final division of responsibility.

Contracting and implementation

Building a Program That Can Operate Reliably

Implementation may include:

1Executive discovery
2Population and claims analysis
3Program design
4Network review
5Financial modeling
6Legal and compliance review
7Data security assessment
8Contract negotiation
9Credentialing and delegation review
10Technology integration
11Member material approval
12Staff training
13Pilot launch
14Performance monitoring
15Corrective action review
16Expansion or redesign

Potential contract subjects include:

Scope of services
Delegated and nondelegated responsibilities
Service levels
Member eligibility
Network requirements
Credentialing
Prior authorization
Claims and payment
Quality measures
Data exchange
Privacy and security
Member communications
Grievances and appeals
Compliance reporting
Fraud, waste, and abuse
Audit rights
Insurance
Indemnification
Performance guarantees
Termination
Continuity and transition obligations

Why Hospitals Without Walls™

A Whole Person Coordination Model

Hospitals Without Walls™ offers health plans a framework designed to:

We do not approach the member merely as a risk score or claim.

We organize services around the whole person.

Reach members across care settings
Combine claims insight with real-world assessment
Identify clinical, functional, cognitive, behavioral, social, and caregiver needs
Coordinate existing network resources
Integrate mobile and virtual care
Strengthen transitions
Support serious and chronic illness
Promote member and caregiver engagement
Measure quality and financial performance
Protect access and patient choice
Adapt to Medicare, Medicaid, commercial, employer, and other payer populations

Let Us Evaluate Your Population and Care Delivery Opportunity

Hospitals Without Walls™ works with health plans seeking measurable improvements in coordination, access, quality, member experience, utilization, and total cost of care.

Request a Health Plan Contract Schedule a Payer Strategy Consultation

Important information

Hospitals Without Walls™ does not make independent benefit determinations or guarantee insurance coverage unless expressly authorized and contractually assigned to perform a particular administrative function.

Specific services remain subject to member eligibility, benefits, network requirements, prior authorization, medical necessity, professional licensure, credentialing, geographic availability, contract scope, and applicable law.

Hospitals Without Walls™ does not guarantee improvements in quality ratings, utilization, total cost of care, shared savings, member retention, or other clinical or financial outcomes.

Evidence and authoritative sources

The principles presented on this page are informed by authoritative federal guidance concerning value based care, care coordination, managed care quality, member experience, and patient safety during transitions.

CMS — Value Based Care
CMS — Basics of Value Based Care
CMS — Care Coordination
CMS — Accountable Care and Accountable Care Organizations
CMS — Medicare Advantage and Part D Star Ratings
CMS — Marketplace Quality Rating System
Medicaid.gov — Medicaid and CHIP Managed-Care Quality
AHRQ — Care Coordination
AHRQ — Care Management and Medical Practice
AHRQ Patient Safety Network Communication During Transitions of Care