Physician Groups & Medical Practices
Extending the Reach of Medical Care Beyond the Office
Hospitals Without Walls™ works with physician groups and medical practices to support coordinated, person-centered care across offices, hospitals, facilities, homes, and virtual environments.
Our model helps connect appropriately qualified professionals, authorized healthcare services, technology, patients, families, and community resources around a unified care plan.
Helping medical practices care for the whole person
The Patient's Needs Continue Between Office Visits
Physicians frequently care for patients whose medical needs are influenced by factors that cannot be fully evaluated or addressed during a conventional office encounter.
These may include:
Hospitals Without Walls™ is designed to help participating practices identify and coordinate appropriate services beyond the office while preserving the treating clinician's professional responsibilities and patient relationship.
- Multiple chronic conditions
- Medication complexity
- Functional decline
- Cognitive impairment
- Limited mobility
- Recent hospitalization
- Difficulty attending appointments
- Home safety concerns
- Behavioral or emotional needs
- Social barriers
- Caregiver limitations
- Palliative care needs
- Poor coordination among multiple providers
Who we work with
Partnerships Across Medical Practice Settings
Potential partners may include:
- Primary care practices
- Family medicine practices
- Internal medicine practices
- Geriatric practices
- Multispecialty medical groups
- Specialty practices
- Independent physician associations
- Accountable care organizations
- Clinically integrated networks
- Management services organizations
- Risk bearing physician organizations
- Community clinics
- Rural practices
- Concierge and direct care practices
- Telehealth practices
- House call practices
- Other appropriately organized medical entities
Each relationship must be structured according to the organization's ownership, licensure, payer contracts, patient population, professional responsibilities, and applicable law.
Our partnership objectives
More Complete Support for Complex Patients
A physician group partnership may be designed to support:
These are potential program components not guaranteed services or outcomes.
- Comprehensive patient assessment
- Care planning
- Care coordination
- Chronic disease support
- Transitional care
- Medication reconciliation
- Mobile healthcare services
- Telehealth
- Remote patient monitoring
- Functional and frailty assessment
- Behavioral health coordination
- Palliative and supportive care
- Caregiver education
- Community resource connection
- Referral tracking
- Communication across care settings
- Quality and utilization measurement
Preserving the physician-patient relationship
Coordination Should Strengthen not Displace Established Care
Hospitals Without Walls™ is designed to complement the patient's established healthcare relationships.
Unless the parties and patient lawfully establish a different arrangement, the participating physician or medical practice retains responsibility for the medical services it provides, including:
Hospitals Without Walls™ does not replace the treating physician's independent clinical judgment.
- Clinical evaluation
- Diagnosis
- Treatment decisions
- Prescribing
- Orders
- Medical necessity determinations
- Follow up within the practice's scope
- Documentation
- Billing and coding
- Professional standards
- Patient communication
- Referral decisions
Comprehensive whole-person assessment
Understanding the Factors That Affect the Care Plan
Depending on the program, appropriately qualified professionals may assess relevant areas such as:
Medical
- Active diagnoses
- Symptoms
- Recent healthcare utilization
- Treatment history
- Clinical risks
- Preventive-care needs
Medication-Related
- Current medications
- Allergies
- Potential discrepancies
- Adherence barriers
- Monitoring requirements
- Need for prescriber or pharmacist review
Functional
- Mobility
- Balance
- Transfers
- Activities of daily living
- Instrumental activities of daily living
- Rehabilitation needs
- Fall risk
Cognitive
- Memory
- Orientation
- Judgment
- Ability to follow instructions
- Decision making concerns
- Need for further evaluation
Behavioral and Emotional
- Mood
- Anxiety
- Coping
- Grief
- Behavioral symptoms
- Risk concerns
- Need for qualified behavioral health services
Social and Environmental
- Living arrangement
- Transportation
- Food access
- Social isolation
- Financial or practical barriers
- Home safety
- Caregiver availability
- Community resource needs
Palliative and Supportive
- Pain
- Symptom burden
- Serious illness needs
- Quality of life priorities
- Advance care planning preferences
- Family and caregiver concerns
Not every patient requires every assessment component. Selection must be individualized and clinically appropriate.
Care coordination
Turning Separate Services Into a Connected Plan
A coordinated program may help:
- 1
Identify the patient's needs and goals
- 2
Clarify which professionals and organizations are involved
- 3
Identify gaps, conflicts, or duplication
- 4
Establish responsible parties
- 5
Facilitate authorized information exchange
- 6
Coordinate referrals and services
- 7
Support the patient and caregiver
- 8
Monitor completion of agreed actions
- 9
Communicate material changes
- 10
Reassess and revise the plan when necessary
Coordination does not transfer a professional's responsibility to another participant unless a lawful written arrangement explicitly does so.
Support for primary care
Extending Longitudinal Care Into the Patient's Daily Environment
A primary-care partnership may support:
- Post-hospital follow-up
- Chronic condition monitoring
- Medication reconciliation
- Identification of functional decline
- Fall risk evaluation
- Home safety observations
- Patient education
- Caregiver engagement
- Referral coordination
- Community resource linkage
- Communication with specialists
- Palliative care assessment
- Advance care planning support
- Follow up on unresolved needs
The primary care professional remains responsible for services and decisions assigned to the practice.
Support for specialists
Connecting Specialty Treatment With the Broader Care Plan
Specialty care may be highly effective within its defined clinical focus while the patient simultaneously receives care from several other professionals.
Hospitals Without Walls™ may help:
- Communicate specialty recommendations
- Coordinate required follow up
- Identify barriers to completing treatment
- Support monitoring ordered by the specialist
- Connect the specialty plan with primary care
- Facilitate authorized services in the home or community
- Educate patients and caregivers
- Communicate material changes
- Coordinate transitions after procedures or hospitalization
The specialist retains responsibility for the specialty services and clinical decisions the specialist provides.
Chronic disease management
Supporting Patients Between Encounters
A physician directed chronic care program may include:
- Patient education
- Care plan reinforcement
- Symptom monitoring
- Medication related communication
- Appointment coordination
- Identification of adherence barriers
- Referral completion
- Caregiver support
- Remote patient monitoring
- Communication of clinically relevant findings
- Escalation under defined protocols
The program must identify which professional reviews information, who may issue orders, expected response times, and what patients should do during an emergency.
Transitional care
Connecting Hospital Discharge With Continuing Medical Care
After hospitalization or another significant transition, a patient may face:
- New diagnoses
- Medication changes
- Pending test results
- Specialist appointments
- Rehabilitation needs
- Medical equipment needs
- Functional limitations
- New caregiver responsibilities
- Unclear instructions
- Changes in the living environment
A physician group partnership may support:
- Receipt and review of discharge information
- Medication reconciliation
- Timely follow-up
- Referral coordination
- Communication with post-acute providers
- Home health coordination
- Patient and caregiver education
- Review of warning signs
- Identification of unresolved needs
- Appropriate clinical escalation
No program can guarantee that every readmission or complication will be prevented.
Mobile healthcare services
Appropriate Care Where the Patient Lives
Depending on location, clinical need, provider availability, payer authorization, and applicable law, mobile services may include:
- Physician or advanced-practice professional visits
- Nursing services
- Rehabilitation
- Behavioral health services
- Palliative care services
- Wound evaluation
- Laboratory specimen collection
- Selected diagnostic services
- Medication review
- Patient and caregiver education
Every service must be performed by an appropriately qualified and authorized professional or organization.
Telehealth and virtual care
Connecting Patients and Professionals Through Technology
Telehealth may support:
- Follow up encounters
- Chronic-condition management
- Medication related communication
- Behavioral health services
- Palliative support
- Family conferences
- Care coordination
- Patient education
- Post discharge assessment
- Interdisciplinary consultation
The program should address:
- Patient consent
- Professional licensure
- Patient location
- Privacy and security
- Documentation
- Prescribing requirements
- Emergency procedures
- Accessibility
- When in person assessment is necessary
Telehealth must be used only when clinically appropriate and legally permitted.
Remote patient monitoring
Selected Health Information Between Visits
When ordered, authorized, clinically appropriate, and available, remote monitoring may involve:
- Blood pressure
- Heart rate
- Oxygen saturation
- Weight
- Blood glucose
- Temperature
- Other appropriate clinical measures
The physician group agreement should define:
- Who orders monitoring
- Who reviews incoming information
- How frequently it is reviewed
- Which findings trigger action
- Who receives alerts
- Required response times
- Documentation responsibilities
- Patient instructions
- Emergency procedures
- Device and connectivity limitations
Remote patient monitoring does not guarantee continuous observation or detection of every clinical change.
Medication coordination
Supporting Accurate Information and Appropriate Follow-Up
Medication related coordination may include:
- Obtaining the best available medication list
- Comparing information across transitions
- Identifying possible discrepancies
- Communicating questions to the prescriber
- Facilitating pharmacist review
- Supporting patient education
- Identifying access or adherence barriers
- Tracking required laboratory monitoring
- Confirming authorized changes
Only a professional with appropriate legal authority may prescribe, discontinue, or modify medication.
Behavioral and PsychoSpiritual health
Connecting Physical, Emotional, Social, and Existential Needs
A patient's physical health may interact with mood, anxiety, trauma, grief, behavior, social circumstances, meaning, and personal beliefs.
A coordinated program may support:
- Appropriate screening
- Referral to qualified behavioral health professionals
- Integration of behavioral and medical care
- Patient defined spiritual support
- Grief and caregiver support
- Crisis escalation
- Communication among authorized professionals
Spiritual support is optional and must never be imposed.
Psychiatric diagnosis and treatment must be provided by appropriately qualified professionals.
Palliative and supportive care
Supporting Quality of Life During Serious Illness
Palliative care may be provided alongside appropriate disease directed treatment.
A physician group partnership may coordinate:
- Symptom assessment
- Pain management
- Communication about goals
- Advance care planning
- Family support
- Behavioral and spiritual support when desired
- Coordination among treating clinicians
- Referral to specialized palliative care
- Hospice evaluation when clinically appropriate and chosen
Palliative care is not synonymous with hospice.
Hospice requires separate eligibility, certification, election, and payer processes.
Caregiver and family support
Supporting the People Who Help Carry Out the Plan
With patient permission or other lawful authority, authorized family members and caregivers may receive:
- Education
- Care plan instructions
- Medication related information
- Warning signs
- Appointment information
- Emergency guidance
- Community resources
- Support during transitions
- Assistance navigating services
- Palliative and advance care planning support
A family relationship does not automatically authorize access to protected health information or healthcare decision making.
Clinical independence
Every Licensed Professional Remains Responsible for Clinical Judgment
No administrative, financial, or organizational objective may require a clinician to:
- Provide medically unnecessary care
- Withhold medically necessary care
- Avoid an appropriate emergency referral
- Alter a diagnosis improperly
- Misrepresent medical necessity
- Document inaccurate information
- Bill for a service not properly provided
- Act outside the professional's authorized scope
- Disclose protected information unlawfully
- Make a referral based on improper remuneration
Hospitals Without Walls™ supports coordination. It does not direct licensed professionals to violate their legal or ethical duties.
Referral integrity and patient choice
Referrals Must Be Based on Legitimate Needs
Referral relationships must comply with applicable federal and state requirements.
Hospitals Without Walls™ does not purchase patient referrals or offer remuneration in exchange for referrals reimbursable by a federal healthcare program.
Compensation must reflect legitimate, documented services and must not be determined unlawfully by the volume or value of referrals or other business generated.
Participating organizations must preserve patient choice where required and should disclose relevant financial relationships as required by law.
No website statement, business preference, or contract term should be interpreted as requiring an unlawful referral.
Privacy and information exchange
Appropriate Information to the Appropriate Participant
Care coordination may require health-information exchange among authorized professionals and organizations.
Information use and disclosure must comply with:
- HIPAA, when applicable
- More protective state laws
- Substance use disorder confidentiality requirements
- Mental health privacy requirements
- Patient authorization requirements
- Professional duties
- Contractual data restrictions
- Security safeguards
HIPAA may permit certain information sharing for treatment, payment, and healthcare operations, but every disclosure must be evaluated according to its purpose and the laws applicable to the information.
Documentation
The Record Must Reflect What Actually Occurred
Participating organizations should maintain accurate documentation of:
- Patient consent
- Assessments
- Findings
- Care plans
- Services
- Orders
- Communications
- Referrals
- Medication reconciliation
- Monitoring
- Changes in condition
- Escalation
- Patient and caregiver education
- Outcomes
- Billing support
Documentation should not be altered, exaggerated, backdated, or created solely to produce reimbursement.
Billing and reimbursement
Payment Must Follow the Service and the Law
Each billing entity remains responsible for:
- Enrollment
- Credentialing
- Coverage requirements
- Medical necessity
- Correct coding
- Documentation
- Claim submission
- Supervision requirements
- Place of service requirements
- Modifier use
- Duplicate-billing prevention
- Refunds and overpayments
- Audit response
- Compliance with payer contracts
Participation in Hospitals Without Walls™ does not create coverage for a service or guarantee payment.
No service should be billed unless the billing entity has a valid basis to do so.
Value based care
Aligning Coordination, Quality, and Responsible Utilization
Hospitals Without Walls™ may work with physician organizations participating in:
- Accountable care arrangements
- Shared savings programs
- Capitated models
- Global budget arrangements
- Bundled payment programs
- Pay for performance programs
- Commercial risk contracts
- Other value based models
A program may support objectives related to:
- Care coordination
- Patient experience
- Access
- Quality
- Chronic disease management
- Transitions
- Appropriate utilization
- Total cost of care
Financial incentives must never override patient welfare, medical necessity, professional judgment, or applicable law.
Performance measurement
Defined Metrics and Transparent Methods
A physician-group contract may include measures related to:
Access
- Referral to contact time
- Appointment completion
- Service connection
- Follow up availability
Care Coordination
- Completed care plans
- Medication reconciliation
- Referral closure
- Post discharge follow up
- Information transfer
Clinical and Functional Outcomes
- Condition-specific indicators
- Symptom burden
- Functional status
- Patient defined goals
- Other agreed outcomes
Utilization
- Emergency department visits
- Hospital admissions
- Readmissions
- Post acute utilization
Experience
- Patient experience
- Caregiver experience
- Clinician experience
- Complaint resolution
Financial Performance
- Program cost
- Cost per participant
- Total cost of care
- Shared savings
- Return on investment, when methodologically supportable
Every measure should identify its definition, eligible population, data source, exclusions, reporting period, comparison method, and limitations.
No outcome or saving should be attributed to the program without a reasonable evidentiary basis.
Partnership development
A Model Designed for Your Practice
- 1
Step 1
Practice Consultation
We review the patient population, existing workflows, care gaps, payer relationships, and organizational objectives.
- 2
Step 2
Needs Assessment
We identify patients or services for which additional coordination may be appropriate.
- 3
Step 3
Program Design
We define eligibility, services, clinical responsibilities, workflows, communication, technology, and escalation procedures.
- 4
Step 4
Compliance Review
The parties evaluate applicable professional, privacy, referral, fraud-and-abuse, billing, payer, telehealth, and contracting requirements.
- 5
Step 5
Measurement Plan
The parties establish measures, data sources, reporting methods, and analytical limitations.
- 6
Step 6
Written Agreement
The agreement defines services, responsibilities, compensation, data use, quality standards, insurance, governance, and termination rights.
- 7
Step 7
Implementation
Personnel are trained, workflows are tested, communication pathways are activated, and the approved program begins.
- 8
Step 8
Continuous Improvement
Performance is reviewed and changes are made through the agreed governance process.
Responsibility and accountability
Clearly Defined Roles Protect Patients and Partners
Unless a lawful written agreement specifically provides otherwise, each physician group or medical practice remains responsible for:
- Its professional services
- Its clinicians and personnel
- Medical decisions
- Prescribing
- Orders
- Documentation
- Billing and coding
- Credentialing
- Payer compliance
- Quality oversight
- Privacy and security
- Patient complaints
- Professional liability obligations
Each other participating organization remains responsible for its own personnel, services, decisions, documentation, billing, licensure, credentialing, privacy, security, and conduct.
Why partner with Hospitals Without Walls™?
A Broader Support System for Longitudinal Care
Our model may help physician organizations:
These are intended capabilities not guaranteed results.
- Extend coordination beyond the office
- Support patients with complex needs
- Strengthen care transitions
- Connect mobile and virtual services
- Address functional and social barriers
- Engage authorized caregivers
- Support value based objectives
- Clarify responsibilities
- Track referrals and follow-up
- Measure performance transparently
Request a physician-group contract
Let Us Build a Program Around Your Patients and Practice
We will evaluate whether an appropriate, compliant, operationally feasible, and measurable partnership can be developed.
Tell us:
- What type of practice you operate
- Which population you serve
- Where your patients are located
- Which payers and value based arrangements are involved
- Which gaps you want to address
- Which services already exist
- Which outcomes matter to your organization
Important notice
Hospitals Without Walls™ is an independent healthcare-delivery and collaboration model. A partnership does not create employment, agency, medical-staff membership, clinical supervision, payer participation, joint ownership, or a professional entity relationship unless a lawful written agreement expressly establishes it.
Each treating professional retains responsibility for services and decisions within that professional's role, qualifications, licensure, privileges, and scope of practice.
Services vary by program, location, clinical need, patient eligibility, provider availability, payer authorization, and applicable law.
No improvement in clinical outcomes, patient volume, reimbursement, utilization, shared savings, or financial performance is guaranteed.
This page provides general organizational information and does not constitute medical, legal, compliance, billing, coding, or reimbursement advice.
If a patient may be experiencing a medical emergency, call 911.