Hospitals & Health Systems

Extend the Hospital's Reach Across the Entire Care Continuum

Hospitals Without Walls™ helps hospitals and health systems coordinate care beyond the inpatient episode connecting discharge planning, community providers, mobile services, telehealth, remote monitoring, patients, and caregivers.

Our objective is to help hospitals strengthen continuity, improve patient experience, support value based performance, and reduce avoidable gaps after discharge.

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Healthcare coordination for hospitals and health systems

The challenge facing hospitals

Excellent Inpatient Care Can Be Undermined by a Fragmented Transition

Hospitals provide highly complex care during some of the most critical moments in a patient's life.

However, the hospital cannot control everything that happens after discharge. The transition may involve:

Primary care
Specialists
Pharmacies
Home health
Skilled nursing
Rehabilitation
Assisted living
Community organizations
Unpaid family caregivers

If these participants are not effectively connected, the patient may experience medication discrepancies, delayed follow up, duplicated services, worsening symptoms, emergency department visits, or hospital readmission.

Hospitals Without Walls™ is designed to strengthen the connection between the hospital and the patient's next setting of care.

Patients may leave the hospital with:

New diagnoses
Changed medications
Pending test results
Multiple follow up appointments
New equipment
Wound care needs
Dietary restrictions
Reduced mobility
Cognitive impairment
Significant caregiver dependence
Limited transportation
Inadequate understanding of the care plan
Unresolved social or practical barriers

Who we work with

Flexible Contracting for Hospitals and Health Systems

Potential contracting partners may include:

Acute care hospitals
Health systems
Critical access hospitals
Academic medical centers
Community hospitals
Specialty hospitals
Accountable care organizations
Risk bearing provider organizations
Post acute care networks
Home health agencies
Skilled nursing facilities
Rehabilitation providers
Physician groups
Primary care networks
Specialty networks
Behavioral health providers
Palliative care organizations
Commercial health plans
Medicare value based programs
Medicaid managed care arrangements
Employer and commercial partners
Other organizations responsible for defined patient populations

The structure of each relationship depends on the hospital, population, service area, payment structure, existing capabilities, regulatory requirements, and approved contract.

Identifying patients who may need additional support

Matching Program Intensity to Patient Risk

Not every discharged patient requires the same intervention. A hospital partnership may establish criteria to identify patients who may benefit from enhanced support, including those with:

Risk-identification criteria should be transparent, clinically appropriate, nondiscriminatory, and consistent with the program's available services.

Patients with multiple chronic conditions
Patients with heart failure
Patients with chronic obstructive pulmonary disease
Patients with pneumonia
Patients with diabetes with significant complications
Patients with chronic kidney disease
Patients with dementia
Patients with frailty
Patients with functional decline
Patients with recent falls
Patients with complex medication regimens
Patients with chronic or complex wounds
Patients with serious or progressive illness
Patients with multiple recent hospitalizations
Patients with recurrent emergency department use
Patients with prior readmissions
Patients with limited caregiver support
Patients with difficulty accessing follow up
Patients with transportation barriers
Patients with cognitive or health literacy limitations
Patients with unresolved social needs
Patients with high risk surgical recovery
Patients with a need for palliative support

The Hospitals Without Walls™ solution

From Episode Based Care to Connected Continuity

Our hospital partnership model may support:

Identification of High-Risk Patients: Transparent, clinically appropriate, nondiscriminatory criteria to identify patients who may benefit from enhanced support.
Pre-Discharge Coordination: Coordination before the patient leaves, including discharge-plan review, caregiver identification, equipment, medications, referrals, and scheduling.
Patient and Caregiver Engagement: Education and preparation so the patient and authorized caregiver understand the plan and can carry it out safely.
Timely Post-Discharge Contact: Structured follow up within the contractually defined timeframe, matched to the patient's risk and clinical circumstances.
Medication Reconciliation Support: Comparison of pre-admission and discharge medications, review of what the patient is actually taking, and communication of discrepancies to the authorized prescriber.
Mobile Clinical Services: Eligible services delivered in the home, residential setting, or another authorized location.
Telehealth Follow-Up: Technology enabled post discharge visits, symptom review, medication follow-up, specialist consultation, and care conferences.
Remote Patient Monitoring: Collection and review of authorized condition specific measurements connected to defined review and escalation procedures.
Primary and Specialty-Care Coordination: Confirmation and coordination of follow up with the responsible physician, practice, or specialist.
Home Health and Post-Acute Coordination: Coordination with home health, skilled nursing, rehabilitation, and other post acute providers.
Palliative-Care Integration: Symptom management, goals of care communication, advance care planning, and continuity between inpatient and community palliative care.
Functional and Frailty Assessment: Evaluation of mobility, fall risk, cognition, nutrition, continence, skin integrity, and functional ability that may affect the discharge plan.
Behavioral and PsychoSpiritual Support: Appropriate behavioral, emotional, and whole-person support provided according to the patient's needs, preferences, consent, and available qualified professionals.
Caregiver Education: Preparation and education so caregivers understand the plan, medications, warning signs, and when to seek help.
Community-Resource Navigation: Assistance connecting patients and caregivers to community services, transportation, food, housing, and other supports.
Escalation of Changes in Condition: Defined clinical escalation protocols and rapid communication when concerning findings emerge.
Quality, Utilization, and Financial Reporting: Reporting designed to evaluate program performance without identifying individual patients where not lawful or authorized.

The specific program is determined by the hospital's population, objectives, existing capabilities, service area, payment structure, regulatory requirements, and approved contract.

The discharge does not end the care journey

Extending Accountability Beyond the Hospital Door

A patient may be clinically ready to leave the hospital while still facing significant risks. Our transition process may begin before discharge and continue into the patient's next care setting.

Pre discharge coordination

Preparing Before the Patient Leaves

When authorized by the hospital and patient, pre discharge activities may include:

Understand the discharge plan
Reach the intended destination safely
Reconcile medications
Confirm follow up appointments
Recognize warning signs
Access mobile, virtual, or monitoring services
Connect with community resources
Communicate with the responsible clinician
Prepare for the next care setting
Participate meaningfully in healthcare decisions

Early coordination allows unresolved needs to be identified while the hospital team is still available.

Post discharge follow up

Timely Contact When Questions and Problems Often Emerge

Depending on the contract and clinical need, follow-up may include:

Strengthening continuity after discharge
Improving patient experience
Supporting value based performance
Reducing avoidable gaps after discharge
Connecting inpatient and community care
Supporting high risk populations
Promoting appropriate use of healthcare resources
Supporting caregivers
Improving communication across settings
Developing more meaningful performance information
Coordinating with existing hospital and community partners

A routine follow up call or virtual visit must never delay emergency evaluation.

Caregiver preparation

The Discharge Plan Must Be Realistic

A care plan may depend on a family member who has not been adequately prepared or who cannot safely perform the expected tasks.

The hospital partnership may evaluate:

Coordinating appointments
Managing medications
Communicating with multiple providers
Arranging transportation
Responding to changes in condition
Supporting daily activities
Navigating insurance and community resources
Preparing for care transitions
Making authorized healthcare decisions
Balancing employment and caregiving responsibilities

Caregivers should not be treated as unlimited or automatically available resources.

Comprehensive geriatric support

Addressing the Risks That Diagnoses Alone May Miss

Older adults may have clinical risks extending beyond the reason for hospitalization.

A geriatric focused hospital program may evaluate:

Frailty
Mobility
Fall risk
Cognition
Delirium risk
Medication burden
Nutrition
Continence
Skin integrity
Sensory limitations
Functional ability
Depression and anxiety
Social isolation
Caregiver capacity
Advance care planning
Home environment

These factors may materially influence whether the discharge plan can be carried out safely.

Contracting and implementation

From Hospital Need to Operational Program

1
Step 1
Executive and Clinical Discovery
We meet with hospital leadership and clinical teams to understand:
- The population to be served
- The principal transition challenges
- Existing discharge and care management workflows
- Service area and geography
- Access and equity barriers
- Available data
- Desired outcomes
- Value based responsibilities
- Operational requirements
- Contracting structure
2
Step 2
Population and Utilization Assessment
Where lawful data are available, the parties may evaluate:
- Population characteristics
- Chronic condition burden
- Readmission and emergency department patterns
- Care transition needs
- Post-acute utilization
- Service gaps
- Caregiver needs
- Geographic considerations
- Existing vendor capabilities
Individually identifiable health information should be shared only when lawful, authorized, necessary, and consistent with the applicable program.
3
Step 3
Workflow Review and Program Design
The proposed program defines:
- Eligibility criteria
- Scope of services
- Participating providers
- Referral pathways
- Consent procedures
- Care coordination workflows
- Clinical escalation protocols
- Technology requirements
- Data responsibilities
- Privacy safeguards
- Performance measures
- Reporting procedures
- Implementation timeline
4
Step 4
Financial Modeling and Compliance Review
The parties evaluate the laws, payment models, and requirements applicable to the arrangement. These may include:
- Hospital licensing and regulatory obligations
- Emergency services requirements
- Discharge planning obligations
- Utilization review responsibilities
- Health information privacy and security
- State medical privacy laws
- Professional licensure and credentialing
- Telehealth requirements
- Value based and episode based payment rules
- Business associate agreements
- Marketing and communications
- Fiduciary obligations
The exact legal requirements depend on the program. Each organization should obtain advice from its own qualified legal and compliance professionals.
5
Step 5
Written Contract
The written agreement establishes:
- Contracting parties
- Covered population
- Services
- Responsibilities
- Fees and payment
- Data use
- Privacy and security
- Quality standards
- Insurance requirements
- Indemnification
- Audit rights
- Incident reporting
- Business continuity
- Reporting
- Performance measures
- Governance
- Termination rights
- Transition responsibilities
6
Step 6
Implementation
Implementation may include:
- Workflow development
- Technology configuration
- Personnel training
- Staff education
- Patient and caregiver communications
- Referral activation
- Data testing
- Escalation testing
- Quality review procedures
- Pilot launch
7
Step 7
Measurement and Improvement
Performance is evaluated according to agreed measures, and the program is refined through the established governance process.

Data and technology integration

Information Must Follow the Patient

A hospital partnership may require secure exchange of protected health information through authorized channels.

A hospital partnership may require secure exchange of:

Diagnosis
Medical history
Medication information
Genetic information
Treatment details
Behavioral health information
Disability related information
Individual assessment results
Individually identifiable healthcare utilization
Personal communications with healthcare professionals

Integration may involve

Electronic health record interfaces, secure portals, health information exchanges, APIs, secure messaging, electronic referrals, claims feeds, and population-health platforms.

The parties must define permitted data use, role-based access, minimum-necessary practices, security requirements, retention, incident response, and whether business associate or data-use agreements are required.

Health equity and access

A Discharge Plan Is Not Complete if the Patient Cannot Access It

Barriers may include language, disability, transportation, rural geography, digital access, health literacy, financial limitations, food insecurity, housing instability, pharmacy access, lack of a regular clinician, cultural or religious needs, and caregiver limitations.

Programs may incorporate:

Language access
Disability access
Transportation resources
Rural geography
Digital access
Health literacy
Financial limitations
Food insecurity
Housing instability
Pharmacy access
Cultural or religious needs
Caregiver limitations

Services must be provided without unlawful discrimination.

Quality guardrails

Lower Utilization Must Never Come at the Expense of Patient Safety

Hospital partnerships should monitor for:

Delay emergency evaluation
Deny medically necessary care
Discharge a patient prematurely
Conceal a material clinical finding
Disregard professional standards
Act beyond the clinician's authorized scope
Disclose protected information unlawfully
Modify a medical opinion improperly

A program is not successful if it reduces spending while worsening safety, access, patient experience, or clinical outcomes.

Readmission-reduction support

Addressing Contributing Risks Without Denying Necessary Care

CMS describes the Hospital Readmissions Reduction Program as encouraging hospitals to improve communication, care coordination, and patient and caregiver engagement in discharge planning.

Patients must be transferred or referred for hospital evaluation whenever that level of care is clinically necessary.

A lower readmission rate is not an acceptable outcome if it results from delayed hospitalization or inadequate access to appropriate care.

Hospitals Without Walls™ may support readmission-reduction initiatives through:

What the program provides
Who operates it
What information will be collected
Why the information is collected
How the information may be used
Who may receive it
How it will be protected
Whether participation affects benefits
Whether incentives apply
How to decline or withdraw
Whom to contact with questions or complaints

Quality and performance measurement

Measuring More Than Completed Contacts

Depending on the contract, measures may include:

Process Measures

Time from referral to contact
Time from discharge to follow up
Medication reconciliation
Completion of scheduled visits
Primary care follow up
Specialist follow up
Care plan communication
Closure of identified care gaps

Clinical and Functional Measures

Symptom status
Functional status
Fall events
Wound outcomes
Chronic condition indicators
Medication related problems
Safety events

Utilization Measures

Emergency department visits
Observation stays
Hospital admissions
Unplanned readmissions
Post-acute utilization
Potentially preventable utilization

Experience Measures

Patient experience
Caregiver experience
Understanding of the discharge plan
Access to assistance
Grievances and complaints

Financial Measures

Program operating cost
Total cost of care
Episode spending
Net financial impact
Avoided duplication
Contract specific savings

Results must be risk adjusted and interpreted according to the agreed population, baseline, comparison method, exclusions, data completeness, and statistical uncertainty.

Association does not prove that the program caused an observed result. Claims of savings or return on investment should be made only when supported by an appropriate comparison and reliable data.

Financial models

Contract Structures Designed for the Engagement

Depending on the program, possible financial structures may include:

Fixed administrative fees
Per participant fees
Per member per month fees
Fee for service arrangements
Episode based fees
Shared savings arrangements
Performance based components
Bundled payment support
Implementation fees
Technology fees
Hybrid models

No financial arrangement should reward the denial of medically necessary care, unlawful patient steering, inappropriate restriction of choice, or manipulation of reported outcomes.

Participation in any specific payment model requires program-specific compliance and does not guarantee financial savings.

Integration with existing systems

Designed to Coordinate not Unnecessarily Duplicate

Hospitals Without Walls™ may coordinate with authorized existing resources, such as:

Electronic health records
Health information exchanges
Secure portals
Application programming interfaces
Secure messaging
Electronic referral systems
Claims and encounter-data feeds
Population health platforms
Primary care networks
Specialty networks
Home health agencies
Skilled nursing facilities
Rehabilitation providers
Community resources

The objective is to identify responsibilities, close appropriate gaps, and avoid unnecessary duplication.

Integration depends on authorization, technical capability, contractual cooperation, and applicable privacy requirements.

Why Hospitals Without Walls™

A Coordination Model Built Around the Patient's Entire Journey

Our approach combines:

We do not approach the patient as a diagnosis, discharge, or isolated episode.

We organize the program around the whole person and the complete continuum of care.

Whole person assessment
Person centered care planning
Clinical and nonclinical coordination
Mobile and virtual delivery options
Support across care transitions
Caregiver and family engagement
Defined responsibilities
Privacy conscious reporting
Contract specific quality measures
Continuous program improvement

Extend your health system beyond its traditional walls

Let Us Evaluate Your Population and Transition Challenges

Let us evaluate your patient population, transition challenges, service gaps, value based responsibilities, and opportunities for measurable improvement.

Tell us:

Whom you want to serve
Where the population is located
Which transition challenges you want to address
What services already exist
What outcomes matter
What value based responsibilities apply
What implementation timeline you are considering

Important information

Hospitals Without Walls™ does not replace the hospital's governing body, medical staff, discharge planning obligations, emergency services, utilization review responsibilities, or regulatory accountability.

Specific services remain subject to contract scope, patient eligibility, informed participation, professional licensure, credentialing, hospital privileges where applicable, payer authorization, geographic availability, and governing law.

Hospitals Without Walls™ does not guarantee reductions in readmissions, emergency department visits, length of stay, total cost of care, or other outcomes. Results must be measured for the defined population using an agreed methodology.

If you believe you are experiencing a medical emergency, call 911.