Skilled Nursing & Post Acute Facilities
Connecting Post Acute Care With the Complete Healthcare Continuum
Hospitals Without Walls™ works with skilled nursing facilities and post acute organizations to support coordinated transitions, comprehensive assessment, interdisciplinary communication, appropriate healthcare utilization, and continuity after discharge.
Our objective is to help residents receive the right care, from the right qualified professional, in the right setting, at the right time.
Supporting complex patients across care settings
Care Does Not Stop at the Facility Door
Patients entering skilled nursing and post-acute care frequently have complex medical, functional, rehabilitative, medication-related, cognitive, behavioral, social, and caregiver needs.
Their care may involve:
When these participants are not effectively connected, important information, responsibilities, and follow up needs may become fragmented.
Hospitals Without Walls™ helps participating facilities develop a coordinated framework that extends from admission through treatment, discharge, and appropriate follow up in the next care setting.
- Hospitals
- Attending physicians
- Medical directors
- Specialists
- Nursing personnel
- Rehabilitation professionals
- Pharmacies
- Laboratories
- Diagnostic providers
- Health plans
- Home health agencies
- Durable medical equipment providers
- Family members and caregivers
- Community organizations
Who we serve
Partnerships Across Post-Acute and Continuing Care
Potential partners may include:
- Medicare certified skilled nursing facilities
- Short term rehabilitation facilities
- Long term care facilities
- Nursing facilities
- Subacute care organizations
- Transitional care units
- Continuing care organizations
- Post surgical rehabilitation programs
- Complex care facilities
- Specialized nursing programs
- Facility ownership and management organizations
- Post acute networks
- Risk bearing provider organizations
- Other appropriately licensed care facilities
The exact relationship depends on the facility's licensure, certification, services, resident population, payer arrangements, geographic location, and written contract.
Our facility partnership objectives
Better Connections Before, During, and After the Facility Stay
A facility partnership may be designed to support:
These are program objectives and do not guarantee a particular result.
- Organized admission from the hospital or community
- Timely receipt and review of transition information
- Comprehensive resident assessment
- Medication reconciliation and review
- Identification of clinical and functional risks
- Interdisciplinary care planning
- Access to appropriately qualified professionals
- Timely communication of changes in condition
- Prevention and management of avoidable complications
- Appropriate escalation when higher-acuity care is needed
- Resident and family engagement
- Discharge planning
- Coordination with home health and community services
- Follow up after discharge
- Measurement of quality, utilization, and experience
Transition into the facility
Beginning With a Safe and Informed Admission
A successful transition begins with accurate, timely, and clinically relevant information.
Depending on the program and available authorization, the admission process may support review of:
Missing, conflicting, or unclear information should be identified and addressed through an established communication pathway.
- Hospital discharge documentation
- Current diagnoses
- Recent procedures
- Medication lists
- Allergies
- Pending laboratory or diagnostic results
- Treatment orders
- Wound care needs
- Rehabilitation needs
- Dietary requirements
- Cognitive and behavioral concerns
- Infection control considerations
- Required equipment
- Follow up appointments
- Advance directives
- Identified patient goals
- Family and caregiver information
- Known social or environmental barriers
Comprehensive resident assessment
Understanding More Than the Primary Diagnosis
The Hospitals Without Walls™ model supports assessment of the resident as a whole person.
Relevant areas may include:
Medical Condition
- Active diagnoses
- Recent hospitalization
- Symptoms
- Comorbidities
- Clinical stability
- Risk of deterioration
- Preventive and continuing care needs
Medication-Related Needs
- Medication reconciliation
- High risk medications
- Possible duplication
- Potential interactions
- Adherence barriers
- Monitoring requirements
- Need for prescriber or pharmacist review
Medication decisions must be made by appropriately authorized professionals.
Functional Status
- Mobility
- Transfers
- Balance
- Activities of daily living
- Rehabilitation potential
- Assistive device needs
- Fall risk
- Ability to participate in treatment
Cognitive and Behavioral Health
- Memory
- Orientation
- Decision making capacity
- Delirium risk
- Depression or anxiety concerns
- Behavioral symptoms
- Need for qualified evaluation
Nutrition and Hydration
- Nutritional risk
- Weight changes
- Swallowing concerns
- Hydration
- Dietary needs
- Need for specialized assessment
Skin and Wound Risk
- Existing wounds
- Pressure injury risk
- Skin integrity
- Repositioning needs
- Support surface requirements
- Need for qualified wound evaluation
Palliative and Supportive Needs
- Pain
- Symptom burden
- Serious illness concerns
- Quality of life priorities
- Advance care planning preferences
- Family and caregiver needs
Social, Cultural, and Spiritual Needs
- Communication preferences
- Language
- Family relationships
- Cultural values
- Social support
- Spiritual concerns, when desired by the resident
- Transition barriers
Assessment findings must be incorporated into the facility's required care-planning and documentation processes as applicable.
Interdisciplinary care planning
One Resident. One Coordinated Direction.
A resident may require the involvement of several professionals and organizations.
The coordinated care plan may identify:
Not every resident requires every service. Care must be individualized according to clinical need, professional judgment, resident preferences, payer authorization, and available resources.
- Resident goals and preferences
- Immediate clinical priorities
- Rehabilitation goals
- Nursing interventions
- Medication related actions
- Dietary or swallowing needs
- Skin and wound care needs
- Behavioral health support
- Palliative care needs
- Monitoring parameters
- Responsible professionals
- Communication procedures
- Escalation instructions
- Family or caregiver involvement
- Anticipated discharge needs
- Follow up requirements
Changes in condition
Early Recognition. Clear Communication. Appropriate Response.
A resident's condition may change rapidly.
Participating facilities should maintain clear procedures for:
- 1Recognizing a material change
- 2Assessing the resident within the responder's authorized scope
- 3Documenting relevant findings
- 4Notifying the appropriate qualified professional
- 5Following lawful clinical orders
- 6Informing the resident or authorized representative as required
- 7Escalating to emergency services when necessary
- 8Monitoring the resident's response
- 9Updating the care plan when appropriate
Technology and remote consultation may support this process, but they do not replace bedside assessment, professional judgment, or emergency services.
Appropriate hospital utilization
Preventing Avoidable Transfers Without Delaying Necessary Care
Some complications and transfers may be preventable through timely recognition, appropriate treatment, effective communication, and coordinated follow-up.
However, not every hospital transfer is avoidable.
A resident should be transferred for emergency or hospital evaluation whenever clinically necessary.
Hospitals Without Walls™ does not define success as keeping every resident inside the facility. Success means responding appropriately to the resident's needs and using the level of care required for safety.
Financial incentives must never cause participating organizations or professionals to:
- Delay emergency evaluation
- Withhold medically necessary treatment
- Conceal a material change in condition
- Pressure a resident or representative to refuse necessary care
- Act outside an authorized scope of practice
- Place cost reduction above resident welfare
Medication safety
Supporting Accuracy Across Transitions
Transitions among hospitals, facilities, medical practices, pharmacies, and homes may create medication discrepancies.
A contracted program may support:
- Collection of the best available medication history
- Comparison of pre-transfer and post transfer medication lists
- Identification of omissions, duplications, and discrepancies
- Review of allergies and adverse reactions
- Clarification of incomplete or conflicting orders
- Communication with authorized prescribers
- Resident and caregiver education
- Monitoring of medications requiring follow-up
- Accurate medication information at discharge
Medication reconciliation does not authorize an individual to prescribe, discontinue, or modify medication unless legally permitted to do so.
Rehabilitation and function
Supporting Recovery and Safe Participation
Post acute care frequently centers on the resident's ability to regain or maintain function.
A coordinated program may address:
- Mobility
- Transfers
- Balance
- Strength
- Endurance
- Self care
- Communication
- Swallowing
- Cognitive function
- Use of adaptive equipment
- Fall risk
- Home access needs
- Caregiver training
- Discharge readiness
Rehabilitation goals should be individualized, measurable, clinically appropriate, and developed by qualified professionals.
Wound and skin support
Coordinating Care for Residents With Complex Skin Needs
Depending on clinical need and the participating providers, a facility partnership may support:
- Skin and wound assessment
- Pressure injury risk identification
- Documentation of wound characteristics
- Coordination with qualified wound care professionals
- Treatment plan communication
- Nutrition-related referral
- Pressure redistribution and repositioning planning
- Equipment coordination
- Monitoring of healing or deterioration
- Escalation when infection or another complication is suspected
- Education for residents, staff, and caregivers
Specific wound treatment must be ordered and performed by appropriately qualified professionals in accordance with applicable law and facility policy.
Palliative and supportive care
Relief of Suffering Throughout Serious Illness
Palliative care may be appropriate for residents living with serious illness, whether or not they are receiving curative or disease directed treatment.
A coordinated palliative approach may address:
- Pain
- Shortness of breath
- Nausea
- Fatigue
- Anxiety
- Emotional distress
- Functional decline
- Communication about goals
- Family support
- Spiritual concerns, when desired
- Advance care planning
- Coordination with treating professionals
Palliative care is not automatically hospice care.
Hospice eligibility, election, certification, coverage, and services are governed by separate clinical and regulatory requirements.
Telehealth and virtual support
Extending Access to Appropriate Professionals
When clinically appropriate and legally permitted, telehealth may support:
- Clinical consultation
- Follow up
- Review of selected symptoms
- Medication related communication
- Palliative support
- Behavioral health services
- Resident and family conferences
- Interdisciplinary care conferences
- Post discharge follow-up
- Education
Telehealth is not appropriate for every condition.
Facilities must maintain procedures for determining when an in person assessment, emergency response, or hospital evaluation is required.
Remote patient monitoring
Monitoring Selected Health Information Between Encounters
Where ordered, authorized, available, and appropriate, remote patient monitoring may involve selected information such as:
- Blood pressure
- Heart rate
- Oxygen saturation
- Weight
- Blood glucose
- Temperature
- Other clinically appropriate measures
Every monitoring program should clearly define:
- Who reviews the information
- When it is reviewed
- Which findings require action
- Who receives alerts
- Expected response times
- Escalation procedures
- Documentation requirements
- Device limitations
- What residents and staff should do in an emergency
Remote monitoring does not guarantee detection of every clinical change and does not replace emergency services.
Infection prevention and control
Supporting Facility-Based Safety Systems
Facilities remain responsible for maintaining infection-prevention and control programs required by applicable law and professional standards.
A partnership may support coordination related to:
- Recognition and communication of symptoms
- Standard precautions
- Hand hygiene
- Personal protective equipment
- Environmental cleaning
- Respiratory hygiene
- Vaccination access
- Surveillance information
- Laboratory and diagnostic coordination
- Outbreak communication
- Transfer documentation
- Staff and resident education
All services must be consistent with the facility's infection control authority, policies, and applicable public health guidance.
Discharge to home or community
The Next Transition Begins Before the Resident Leaves
Discharge planning should begin early enough to identify the resident's expected needs after leaving the facility.
A coordinated discharge plan may address:
The resident and authorized caregivers should receive understandable instructions appropriate to their roles.
- The resident's goals and preferred setting
- Clinical readiness
- Functional ability
- Medication reconciliation
- Prescriptions and medication access
- Home health needs
- Rehabilitation needs
- Medical equipment
- Follow-up appointments
- Transportation
- Nutrition
- Wound care needs
- Home safety
- Caregiver capacity
- Community resources
- Warning signs
- Emergency instructions
- Responsible professionals
- Pending results
- Information transfer
Follow-up after facility discharge
Extending Continuity Into the Next Setting
Depending on the contract and patient authorization, post-discharge support may include:
- Confirmation of arrival in the next setting
- Medication review
- Follow up communication
- Appointment coordination
- Home health coordination
- Medical equipment follow-up
- Review of warning signs
- Caregiver education
- Identification of new barriers
- Communication with authorized professionals
- Reassessment after a material change
- Escalation when appropriate
The objective is to reduce avoidable gaps without duplicating services already assigned to another responsible provider.
Resident and family engagement
Care Planning With the Resident
Residents and their legally authorized representatives should receive understandable information about:
- The resident's condition
- The proposed care plan
- Available services
- Material risks and benefits
- Reasonable alternatives
- Medication changes
- Rehabilitation goals
- Discharge expectations
- Warning signs
- How to raise concerns
- How to make complaints or grievances
- The right to participate in decisions
- The right to accept or decline services, subject to applicable law
Residents retain their legal rights, dignity, privacy, and freedom from abuse, neglect, exploitation, discrimination, and inappropriate restraint.
Facility workflow integration
Designed to Support Existing Operations
Hospitals Without Walls™ may coordinate with authorized facility functions such as:
- Administration
- Medical direction
- Nursing
- Rehabilitation
- Social services
- Dietary services
- Pharmacy
- Infection prevention
- Quality assurance
- Utilization management
- Discharge planning
- Health information management
- Compliance
- Resident and family services
The program should identify where Hospitals Without Walls™ adds defined support and where the facility retains responsibility.
Quality and performance measurement
Measuring What Matters
A facility contract may include measures such as:
Transitions
- Completeness of admission information
- Timeliness of post discharge follow up
- Medication reconciliation
- Transfer document completion
- Closed loop referral completion
Clinical and Safety
- Falls with injury
- Pressure injuries
- Medication related events
- Infection related indicators
- Changes in condition appropriately escalated
- Other defined adverse events
Function and Discharge
- Functional progress
- Discharge function
- Successful discharge to the community
- Follow up care completion
Utilization
- Emergency department transfers
- Hospital admissions
- Hospital readmissions
- Length of stay
- Other agreed utilization measures
Experience
- Resident experience
- Family or caregiver experience
- Facility satisfaction
- Complaint and grievance resolution
Operations
- Response time
- Documentation completion
- Staff participation
- Referral acceptance
- Service completion
Every measure must identify its definition, population, data source, exclusions, risk adjustment when appropriate, reporting period, and limitations.
Observed changes should not be attributed to the program without a reasonable analytical basis.
Contract development
A Program Designed for Your Facility
Our contracting process may include:
- 1
Facility Consultation
Review the resident population, existing services, operational challenges, and objectives.
- 2
Needs and Gap Assessment
Identify areas where additional coordination, access, or support may be appropriate.
- 3
Program Design
Define eligibility, services, staffing, workflows, responsibilities, technology, and escalation procedures.
- 4
Compliance Review
Evaluate applicable facility, professional, payer, privacy, billing, referral, and contracting requirements.
- 5
Measurement Plan
Establish baseline information, performance measures, reporting responsibilities, and limitations.
- 6
Written Agreement
Document services, responsibilities, financial terms, quality standards, data use, insurance requirements, governance, and termination rights.
- 7
Implementation
Train personnel, test workflows, establish communication pathways, and activate the approved program.
- 8
Continuous Improvement
Review performance and make approved adjustments through the established governance process.
Responsibility and accountability
Collaboration Does Not Eliminate Legal Duties
Unless a written agreement lawfully provides otherwise, the participating facility remains responsible for:
- Facility licensure and certification
- Resident admission and discharge
- Required assessments
- Resident care plans
- Staffing
- Nursing services
- Medical director requirements
- Pharmacy services
- Infection prevention and control
- Resident rights
- Emergency procedures
- Required documentation
- Billing and coding
- Quality assurance and performance improvement
- Regulatory compliance
Each independent professional or organization remains responsible for its own personnel, services, decisions, documentation, licensing, credentialing, billing, privacy, security, and conduct.
Why partner with Hospitals Without Walls™?
Connecting the Entire Post-Acute Journey
Our model can help participating facilities develop:
These are intended capabilities not promises of guaranteed outcomes or reimbursement.
- More organized care transitions
- Whole person assessment
- Clearly defined responsibilities
- Improved communication pathways
- Access to authorized mobile and virtual services
- Structured medication coordination
- Resident and caregiver engagement
- Post discharge continuity
- Transparent quality measurement
- Responsible use of healthcare resources
Request a facility contract
Let Us Build the Right Partnership for Your Residents
We will evaluate whether an appropriate, lawful, operationally feasible, and measurable program can be developed.
Tell us about:
- Your facility
- Your resident population
- Your current services
- Your most important care-transition challenges
- Your clinical and operational priorities
- Your geographic location
- Your payer relationships
- The outcomes you want to measure
Important notice
Hospitals Without Walls™ is an independent healthcare-delivery and collaboration model. It does not own, operate, license, certify, manage, or control a skilled nursing facility or post acute facility unless a written agreement expressly establishes such a relationship.
A contract with Hospitals Without Walls™ does not transfer a facility's regulatory duties or a healthcare professional's clinical responsibilities unless a lawful written agreement specifically provides otherwise.
Services vary by location, contract, resident need, provider availability, payer authorization, and applicable law.
No reduction in hospital transfers, readmissions, length of stay, complications, costs, survey deficiencies, or penalties is guaranteed.
This page provides general organizational information and does not constitute medical, legal, regulatory, billing, or reimbursement advice.
If a resident may be experiencing a medical emergency, activate the facility's emergency procedures and call 911 when indicated.