Home Health & Community Healthcare Organizations
Connecting Home Based Services Around the Whole Person
Hospitals Without Walls™ works with home health agencies and community healthcare organizations to strengthen coordination across hospitals, physicians, post-acute facilities, homes, and community settings.
Our model helps qualified organizations provide connected, person-centered care while preserving each provider's independent clinical, regulatory, documentation, and billing responsibilities.
Care continues at home
Building a Connected Continuum Around the Patient
Patients returning home may rely on physicians, hospitals, home health agencies, rehabilitation providers, pharmacies, laboratories, behavioral health and palliative care professionals, equipment suppliers, community organizations, health plans, caregivers, and other support services.
Without effective coordination, patients may face incomplete information, medication discrepancies, delayed follow up, duplicated services, unresolved barriers, or uncertainty about whom to contact.
Hospitals Without Walls™ helps participating organizations create defined connections around the patient's needs, goals, and care plan.
Patients may rely on:
- Physicians
- Hospitals
- Home health agencies
- Rehabilitation providers
- Pharmacies
- Laboratories
- Behavioral health and palliative care professionals
- Equipment suppliers
- Community organizations
- Health plans
- Caregivers
- Other support services
Who we work with
Partnerships Across Home and Community Based Care
Potential partners include:
- Medicare certified, Medicaid, and state licensed home health agencies
- Private duty nursing and personal care organizations
- Home and community based service providers
- Community clinics and mobile healthcare organizations
- Rehabilitation and community paramedicine programs
- Behavioral health, palliative care, and hospice organizations
- Aging, adult day health, and community health worker programs
- Social service and faith based organizations
- Other qualified healthcare and support service entities
Partnerships must distinguish among skilled home health, personal care, custodial support, medical services, hospice, and community services.
Our partnership model
Coordinating Services Without Blurring Responsibilities
Depending on the contract and patient's needs, a partnership may support:
Services depend on patient eligibility, clinical need, provider authority, payer requirements, operational capacity, and applicable law.
- Referral, admission, and hospital to home transition workflows
- Whole person assessment and individualized care planning
- Medication reconciliation and physician communication
- Chronic disease, palliative, behavioral-health, and functional support
- Home safety evaluation and caregiver education
- Telehealth and remote patient monitoring
- Mobile healthcare and community resource linkage
- Discharge planning, escalation, and quality measurement
From referral to safe transition
A Coordinated Workflow
- 1
Referral from an authorized source
- 2
Eligibility, capacity, and safety review
- 3
Consent and lawful information exchange
- 4
Required clinical and functional assessment
- 5
Care plan development with assigned responsibilities
- 6
Service delivery by qualified personnel
- 7
Monitoring, communication, and escalation
- 8
Reassessment as needs change
- 9
Discharge or transition planning
The accepting organization determines whether it can safely provide the requested services. A referral does not guarantee admission, coverage, payment, or a start of care date.
Supporting home health agencies
Extending Coordination Around the Certified Plan of Care
Hospitals Without Walls™ may help home health agencies coordinate with certifying and treating practitioners, hospitals, specialists, pharmacies, laboratories, equipment suppliers, rehabilitation providers, palliative care professionals, community resources, patients, and authorized caregivers.
The home health agency remains responsible for its required assessments, plan of care, services, supervision, documentation, billing, quality program, and compliance. Hospitals Without Walls™ does not replace the agency's governing body, administrator, clinical manager, certifying practitioner, or required professional personnel.
Whole person care at home
Understanding the Patient Within the Home Environment
Depending on the program, assessment and coordination may address:
- Medical conditions, symptoms, treatments, and recent hospitalization
- Medications, allergies, adherence barriers, and monitoring needs
- Mobility, transfers, activities of daily living, rehabilitation, and fall risk
- Cognition, mood, behavioral health, and ability to follow instructions
- Living arrangements, caregiver capacity, transportation, food, and social isolation
- Accessibility, utilities, sanitation, equipment, emergency planning, and other safety concerns
- Pain, symptom burden, serious illness goals, quality of life, and advance-care preferences
Care plans may identify:
- Patient goals
- Responsible practitioners
- Authorized services
- Treatment orders
- Monitoring
- Education
- Referrals
- Communication pathways
- Emergency instructions
- Reassessment
- Discharge goals
No organization may independently alter another provider's lawful orders or responsibilities without proper authority and communication.
Priority service areas
Transitions, Safety, and Ongoing Support
Hospital-to-Home Transitions
Coordination may include discharge documentation, medication reconciliation, pending results, follow up appointments, equipment, wound care, referrals, patient education, warning signs, home safety, and escalation of unresolved concerns.
Medication Safety
Partners may compare medication lists, identify apparent discrepancies, communicate with authorized prescribers, involve pharmacists, educate patients and caregivers, and document authorized changes. Only legally authorized professionals may prescribe or alter medication.
Function and Rehabilitation
Qualified professionals may address mobility, strength, balance, transfers, walking, self-care, communication, swallowing, cognition, assistive devices, fall prevention, caregiver training, and maintenance or improvement of function when skilled care is appropriate.
Chronic Disease and Supportive Care
Programs may provide education, symptom review, monitoring, appointment coordination, caregiver support, palliative services, behavioral health referrals, grief support, and communication about goals of care.
Palliative care may be provided alongside disease-directed treatment and is distinct from hospice, which has separate eligibility and coverage requirements.
Home Safety and Community Resources
Coordination may address fall hazards, accessibility, medication and equipment safety, food, transportation, housing, utilities, social isolation, respite, personal care, home modifications, benefits navigation, and other practical barriers.
Telehealth and remote monitoring
Defined Communication With Defined Responsibilities
When clinically appropriate and legally permitted, telehealth may support professional follow-up, chronic disease management, behavioral health care, palliative support, care conferences, education, and transition follow-up.
Remote monitoring may involve measures such as blood pressure, heart rate, oxygen saturation, weight, blood glucose, or temperature. Programs should define who orders the service, supplies equipment, reviews information, responds to findings, documents actions, and manages escalation.
Telehealth and remote monitoring do not replace required in-person care or emergency services and are not continuous emergency surveillance unless expressly designed and represented as such.
Patient, caregiver, and community engagement
Making the Care Plan Understandable and Actionable
Patients and authorized caregivers may receive education about diagnoses, medications, equipment, nutrition, mobility, wound care, infection precautions, warning signs, appointments, emergency procedures, and available resources.
Education should reflect the patient's language, health literacy, cognition, sensory needs, culture, and preferences.
Community referrals should be based on patient need and preference. Availability, eligibility, cost, and funding vary, and a referral does not guarantee acceptance or payment.
Referral integrity, privacy, and billing
Trustworthy Partnerships With Clear Accountability
Referral decisions should reflect patient need, patient preference, provider qualifications, service availability, geographic coverage, payer requirements, quality information, and applicable law. Hospitals Without Walls™ does not purchase patient referrals or offer unlawful remuneration for federally reimbursable referrals.
Information may be exchanged only through lawful channels, including applicable privacy, confidentiality, authorization, security, and professional requirements. Agreements should define permitted uses, authorized recipients, access controls, security duties, breach procedures, retention, and patient rights.
Each billing provider remains responsible for eligibility, medical necessity, orders and certification, assessments, plan of care and visit documentation, coding, claims, duplicate billing prevention, quality reporting, overpayments, and audits. Documentation must reflect the patient's actual condition and services provided.
Referral decisions should reflect:
- Patient need
- Patient preference
- Provider qualifications
- Service availability
- Geographic coverage
- Payer requirements
- Quality information
- Applicable law
Agreements should define:
- Permitted uses
- Authorized recipients
- Access controls
- Security duties
- Breach procedures
- Retention
- Patient rights
Quality and performance measurement
Evidence Before Claims
Contracts may measure:
Referral response, start of care, completed visits, and follow up
Medication reconciliation, care-plan completion, communication, and referral closure
Functional status, condition-specific outcomes, wound outcomes, symptom burden, and patient goals
Falls, medication-related events, infections, and unplanned acute-care use
Patient, caregiver, and partner experience
Emergency department visits, admissions, readmissions, and cost when reliable data are available
Measures should define:
- The population
- Data source
- Exclusions
- Reporting period
- Analytical method
- Risk adjustment when appropriate
- Limitations
Outcomes and savings should not be attributed to the program without an appropriate evidentiary basis.
Contract development
A Partnership Built Around Defined Needs
- 1
Organizational Consultation
Review the population, services, service area, payers, capacity, and objectives.
- 2
Gap Assessment
Identify coordination needs and complementary services.
- 3
Program Design
Define eligibility, workflows, responsibilities, technology, communication, and escalation.
- 4
Compliance Review
Evaluate professional, home health, privacy, referral, payer, billing, telehealth, and contracting requirements.
- 5
Measurement Plan
Establish baseline information, performance measures, reporting, and limitations.
- 6
Written Agreement
Define services, responsibilities, compensation, data use, quality standards, insurance, governance, and termination rights.
- 7
Implementation and Improvement
Train personnel, test workflows, activate communication pathways, launch the program, and review performance through agreed governance.
Responsibility and accountability
Coordination Does Not Automatically Transfer Regulatory Duties
Unless a lawful written agreement expressly provides otherwise, each participating organization remains responsible for its licenses and certifications, admission and discharge decisions, personnel, assessments, plans of care, supervision, services, documentation, billing, quality reporting, emergency procedures, patient rights, privacy, security, and regulatory compliance.
Hospitals Without Walls™ is an independent healthcare-delivery and collaboration model. It is not a Medicare-certified home health agency, hospice, physician practice, health plan, personal-care agency, or community service organization unless a lawful agreement and applicable authorization establish that role.
Why partner with Hospitals Without Walls™?
One Connected Continuum Around the Patient at Home
Our model may help organizations:
These are intended capabilities, not guaranteed outcomes.
- Strengthen hospital-to-home transitions
- Coordinate with physicians and other providers
- Identify whole person needs
- Connect complementary services
- Improve authorized information exchange
- Support patients and caregivers
- Establish escalation pathways
- Address community-resource barriers
- Measure outcomes transparently
- Participate in broader population health initiatives
Request a home or community-care contract
Let Us Build a Coordinated Partnership
We will evaluate whether an appropriate, compliant, operationally feasible, and measurable partnership can be developed.
Tell us:
- What type of organization you operate
- Which population you serve
- Where you provide services
- Which payers are involved
- Which services you provide
- Which gaps you want to address
- Which outcomes matter to your organization
Important notice
Services vary by program, location, patient eligibility, clinical need, provider availability, payer authorization, and applicable law. Participation does not create eligibility, medical necessity, certification, coverage, or payment, and no improvement in clinical outcomes, function, utilization, reimbursement, cost, or financial performance is guaranteed.
This page provides general organizational information and does not constitute medical, legal, regulatory, billing, coding, or reimbursement advice. If a patient may be experiencing a medical emergency, call 911.