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360° Win-Win Model

Better Healthcare Works When Everyone Has a Reason to Make It Work

The Hospitals Without Walls™ 360° Win-Win Model is designed to align patients, families, healthcare professionals, hospitals, health plans, facilities, community organizations, government agencies, employers, and other partners around shared clinical and operational goals.

We believe sustainable healthcare improvement requires more than transferring cost or responsibility from one participant to another.

It requires creating measurable value across the entire continuum.

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The 360° view

One patient. Many participants. Shared purpose.

Patient &
Family
Hospitals & Providers
Health Plans
Facilities
Community
Government
Employers

Every participant contributes to and benefits from one coordinated plan.

What does “360° Win” Mean?

Looking at Healthcare From Every Direction

The term “360°” represents a comprehensive examination of how a healthcare program affects all participating stakeholders.

Before designing or recommending a program, we ask:

A genuine win-win relationship cannot be created by ignoring the burdens placed on one of the participants.
The model must be evaluated from every relevant direction.
  1. 01How does this affect the patient?
  2. 02How does it affect the family and caregiver?
  3. 03How does it affect the treating professionals?
  4. 04How does it affect the hospital or facility?
  5. 05How does it affect the health plan or payer?
  6. 06How does it affect the employer or contracting organization?
  7. 07How does it affect community partners?
  8. 08How does it affect public resources?
  9. 09How does it affect access and health equity?
  10. 10How will quality, safety, experience, and cost be measured?
  11. 11Are responsibilities and incentives properly aligned?
  12. 12Can the program remain operationally and financially sustainable?

The Central Principle

One Patient. Shared Purpose. Clearly Defined Responsibilities.

The patient is placed at the center of the model—but patient-centered care requires the coordinated participation of many people and organizations.

Patient and Family
Hospitals and Providers
Health Plans and Payers
Facilities and Community Partners

One coordinated care plan

Quality, Safety, Experience and Value

Hospitals Without Walls™ seeks to establish:

Collaboration does not eliminate individual responsibility. Each participant remains accountable for the services, decisions, representations, and obligations within that participant's role.
  • Shared objectives
  • Clearly defined responsibilities
  • Appropriate information exchange
  • Respect for professional roles
  • Patient and family participation
  • Measurable performance standards
  • Ethical and lawful incentives
  • Transparent financial arrangements
  • Accountability for outcomes
  • Procedures for identifying and resolving problems

Thirteen Wins

Every Direction. Every Stakeholder.

A genuine win-win model must define what each participant contributes—and what each participant receives. Here are the thirteen directions we evaluate.

01

Win 1 — The Patient

More Connected, Understandable, and Responsive Care

The patient should be the principal beneficiary of healthcare improvement.

Potential patient benefits may include:

  • A more coordinated plan of care
  • Improved access to appropriate services
  • Better communication
  • Fewer gaps during transitions
  • Earlier recognition of changing needs
  • Greater participation in decisions
  • Support for physical, emotional, social, and spiritual needs
  • Better understanding of medications and treatment plans
  • Support for remaining safely in the preferred setting when feasible
  • Reduced unnecessary repetition
  • Improved connection with community resources
  • Greater respect for individual values and preferences
A patient “win” does not mean that every requested treatment must be provided or that every outcome can be guaranteed.
It means the patient is treated with dignity, receives accurate information, participates meaningfully in decisions, and has access to services that are clinically appropriate and lawfully available.
02

Win 2 — The Family and Caregiver

Support for the People Carrying the Daily Responsibility

Family members and caregivers often provide essential support between professional healthcare encounters.

Their responsibilities may include:

  • Medication assistance
  • Transportation
  • Meal preparation
  • Mobility support
  • Personal care
  • Symptom observation
  • Appointment coordination
  • Communication with healthcare professionals
  • Financial and practical assistance
  • Emergency decision making

Potential caregiver benefits may include:

  • Clearer care instructions
  • Education about warning signs
  • Better understanding of the patient's condition
  • Defined points of contact
  • Support during transitions
  • Assessment of caregiver capacity and burden
  • Connection with community resources
  • Inclusion in planning when authorized by the patient
  • Reduced confusion among multiple healthcare organizations
  • Emotional and PsychoSpiritual support
The caregiver's health, capacity, consent, and limitations must be respected. Families should not be assigned responsibilities they cannot safely or reasonably perform.
03

Win 3 — Physicians and Healthcare Professionals

Better Information and Stronger Support for Clinical Care

Healthcare professionals may struggle to manage complex patients when essential information is fragmented across multiple settings.

Potential professional benefits may include:

  • More complete patient information
  • Timely communication after transitions
  • Support with care coordination
  • Identification of unresolved care gaps
  • Improved medication information
  • Better connection with home and community services
  • Reduced administrative duplication
  • Support for patient and caregiver education
  • Clear escalation pathways
  • Defined roles among participating professionals
  • Better longitudinal visibility
  • Data for quality improvement
Hospitals Without Walls™ does not replace the independent clinical judgment of qualified treating professionals.
Each professional remains responsible for practicing within applicable licensure, credentialing, privileges, scope of practice, ethical standards, and organizational policy.
04

Win 4 — Hospitals and Health Systems

Extending Continuity Beyond the Hospital Discharge

Hospitals are responsible for highly complex episodes of care, but many risks emerge after the patient leaves the facility.

Potential hospital and health-system benefits may include:

  • Stronger post discharge follow up
  • Improved care transitions
  • Better communication with community providers
  • Support for medication reconciliation
  • Earlier identification of post discharge problems
  • Improved patient and caregiver education
  • Coordination of home and community services
  • Support for readmission reduction initiatives
  • Better patient experience
  • Improved visibility into downstream care
  • Support for value based contracts
  • Measurable clinical and utilization reporting
Results depend on the population, intervention, implementation, baseline performance, payment model, and available data.
No program can prevent every readmission or post discharge complication.
05

Win 5 — Health Plans and Payers

Quality, Coordination, and Responsible Use of Resources

Health plans and payers must balance member access, quality, network performance, regulatory requirements, and financial stewardship.

Potential benefits may include:

  • Improved coordination for high-risk members
  • Better chronic disease support
  • Closure of care gaps
  • Improved medication management
  • Stronger transitions
  • Support for appropriate utilization
  • Improved member and caregiver engagement
  • Better connection with network services
  • Reduced fragmentation
  • Earlier identification of unmet needs
  • Improved quality-measure performance
  • More complete program and outcome data
  • Potential reduction of avoidable total cost of care
Financial savings must be measured using valid data and an agreed methodology. They should never be assumed solely because a coordination program has been implemented.
06

Win 6 — Skilled Nursing, Assisted Living, and Post Acute Facilities

Additional Clinical Connectivity and Transitional Support

Facilities care for patients with substantial clinical, functional, behavioral, and social needs.

Potential facility benefits may include:

  • Improved access to professional consultation
  • Better communication with hospitals and medical practices
  • Support for changes in condition
  • Medication review
  • Palliative care coordination
  • Wound care coordination
  • Telehealth access
  • Mobile professional services
  • Support for residents with complex chronic conditions
  • Improved transition planning
  • Caregiver and family communication
  • Quality and utilization monitoring
Programs must be designed to complement—not improperly replace—the facility's required staffing, professional services, emergency procedures, or regulatory responsibilities.
07

Win 7 — Home Health and Community Healthcare Organizations

Stronger Referral Pathways and Better-Connected Services

Community-based healthcare organizations often see the patient's real living environment and provide essential longitudinal support.

Potential benefits may include:

  • Better communication with physicians and hospitals
  • More complete referral information
  • Faster identification of eligible patient needs
  • Clearer care-plan responsibilities
  • Reduced duplication
  • Improved coordination of disciplines
  • Timely escalation of clinical concerns
  • Better transition planning
  • Access to appropriate partnership opportunities
  • Shared quality improvement initiatives
  • More complete outcome measurement
Referrals must be based on patient need, patient choice, eligibility, quality, availability, and lawful contracting practices.
No participant is guaranteed referrals or patient volume.
08

Win 8 — Community Organizations

Connecting Healthcare With Real-Life Support

Medical treatment alone may not resolve barriers involving food, housing, transportation, isolation, personal safety, or caregiver capacity.

Community partners may include:

  • Aging-service organizations
  • Transportation programs
  • Nutrition services
  • Housing support organizations
  • Faith and spiritual communities
  • Disability service organizations
  • Caregiver support programs
  • Behavioral health resources
  • Legal aid organizations
  • Public health agencies
  • Local nonprofit organizations

Potential community-partner benefits may include:

  • Defined referral pathways
  • Better coordination with healthcare organizations
  • Clearer eligibility information
  • Improved communication
  • Reduced duplication
  • Measurable service connections
  • Opportunities to participate in community health initiatives
  • Greater visibility into unmet population needs
Healthcare organizations should not treat community partners as unlimited sources of uncompensated labor. Roles, capacity, funding, consent, and data-sharing responsibilities should be addressed honestly.
09

Win 9 — Government and Public Programs

Better Stewardship With Measurable Accountability

Government agencies must promote access, quality, safety, civil rights, program integrity, and responsible use of public resources.

Potential public-sector benefits may include:

  • Improved access for vulnerable populations
  • Better coordination of publicly supported services
  • Support for aging in the community
  • Reduced fragmentation
  • Stronger health equity initiatives
  • Improved transitions across public programs
  • Earlier identification of clinical and social risk
  • Transparent outcome measurement
  • Responsible use of taxpayer resources
  • Improved accountability among contracted organizations
Public-sector partnerships must comply with applicable procurement, payment, privacy, civil-rights, accessibility, reporting, and program-integrity requirements.
10

Win 10 — Military Members, Veterans, and Their Families

Coordinated Support Across Complex Systems

Military members, veterans, and their families may receive services through multiple public, private, military, veterans, and community healthcare systems.

Potential benefits may include:

  • Improved navigation
  • Better continuity across organizations
  • Support for chronic and complex conditions
  • Mobile and virtual access
  • Behavioral and PsychoSpiritual support
  • Caregiver and family engagement
  • Palliative care coordination
  • Improved transition planning
  • Connection with qualified community providers
  • Reduced duplication
  • Clearer communication among participating organizations
Any military or veterans program must comply with the requirements of the applicable government agency, contract, benefit program, privacy framework, professional standards, and authorization process.
11

Win 11 — Employers and Commercial Organizations

A Healthier and Better Supported Population

Employers and commercial organizations may face the effects of fragmented healthcare through absenteeism, caregiver responsibilities, delayed treatment, chronic illness, and difficulty navigating benefits.

Potential benefits may include:

  • Improved access to appropriate care
  • Navigation support
  • Mobile and virtual services
  • Chronic disease support
  • Caregiver resource coordination
  • Better use of existing benefits
  • Reduced delays in follow-up
  • Improved employee experience
  • Population-level reporting
  • Potential reduction of avoidable healthcare utilization
Employer programs must protect confidentiality and must not allow an employer inappropriate access to an individual's protected health information.
Participation, data use, eligibility, and reporting must comply with applicable employment, benefits, privacy, nondiscrimination, and healthcare laws.
12

Win 12 — Healthcare Workers

Sustainable Care Requires a Supported Workforce

Healthcare improvement cannot be sustained by placing unlimited demands on physicians, nurses, therapists, social workers, caregivers, and other personnel.

Potential workforce benefits may include:

  • Clearer roles
  • Better communication
  • Reduced unnecessary duplication
  • Access to relevant patient information
  • Defined escalation procedures
  • Improved operational support
  • Appropriate use of technology
  • Better workload visibility
  • Participation in quality improvement
  • Respect for professional judgment
  • Training and education
  • Safer care processes
The National Academies' healthcare improvement framework recognizes workforce well-being as an important part of health-system performance alongside patient experience, population health, cost, and health equity.
A workforce “win” does not mean eliminating accountability. It means establishing the conditions necessary for qualified professionals to perform responsibly and effectively.
13

Win 13 — Hospitals Without Walls™ and Participating Business Partners

Sustainability Makes the Mission Possible

A healthcare model cannot continue serving patients if it is clinically ineffective, operationally disorganized, legally noncompliant, or financially unsustainable.

Hospitals Without Walls™ and participating business partners require:

  • Clearly defined contracts
  • Appropriate compensation for legitimate services
  • Predictable responsibilities
  • Reliable performance standards
  • Protection of confidential information
  • Protection of intellectual property
  • Lawful business-development practices
  • Accurate documentation
  • Timely payment
  • Ethical conduct
  • Quality oversight
  • Measurable results
  • Long term sustainability
A legitimate organizational benefit is not obtained at the patient's expense.
It is earned by creating lawful, measurable value for the patient and the contracting organization.

Mutual Responsibility

Every Win Requires a Contribution

The 360° Win Model does not promise benefits without responsibilities.

Stakeholder

Potential Benefit

Core Responsibility

Patients

Coordinated, respectful care

Provide accurate information and participate as able

Families and caregivers

Education and support

Communicate limitations and follow safe instructions

Healthcare professionals

Better coordination and information

Practice within scope and communicate important findings

Hospitals

Stronger transitions

Provide accurate and timely discharge information

Health plans

Better quality and utilization management

Support appropriate access and provide necessary data

Facilities

Greater clinical connectivity

Maintain required staffing, safety, and regulatory compliance

Community organizations

Coordinated referrals

Represent capabilities and eligibility accurately

Government agencies

Accountability and public value

Establish clear requirements and lawful oversight

Employers

Better navigation and workforce support

Protect employee privacy and voluntary participation

Hospitals Without Walls™

Sustainable partnership

Deliver contracted services ethically and accountably

The exact responsibilities of each participant must be defined through applicable contracts, policies, care plans, authorizations, and professional standards.

Ethical and Legal Safeguards

A Win Model Must Also Be Lawful

The 360° Win Model does not authorize:

✕Payment for patient referrals
✕Improper inducements
✕Patient steering contrary to patient choice
✕Unnecessary services
✕Upcoding or false claims
✕Inappropriate sharing of protected information
✕Misrepresentation of outcomes
✕Unlicensed clinical practice
✕Undisclosed conflicts of interest
✕Discrimination
✕Retaliation
✕Denial of medically necessary care solely to reduce cost
✕Exclusive arrangements that violate applicable law
✕Exploitation of patients, caregivers, workers, or community organizations
Financial arrangements must reflect legitimate services, fair contractual terms, applicable market considerations, and governing law.
All participants are expected to follow applicable fraud-and-abuse, privacy, security, billing, licensure, civil rights, employment, procurement, and professional requirements.

Patient Choice Remains Central

Partnership Does Not Mean Control Over the Patient

Patients retain applicable rights to:

✓Participate in care decisions
✓Receive understandable information
✓Ask questions
✓Accept or refuse services
✓Choose among available qualified providers, subject to applicable benefit and network rules
✓Designate authorized representatives
✓Request reasonable communication assistance
✓Express grievances
✓Receive emergency care
✓Be free from coercion and discrimination
A contractual relationship among healthcare organizations must not improperly interfere with patient rights or informed choice.

Information-Sharing With Purpose

Connect the Care Without Compromising Privacy

The model depends on appropriate communication, but information should be shared only as permitted and necessary.

Participating organizations should establish:

Better coordination does not require unrestricted access to every piece of patient information.
  • Authorized uses and disclosures
  • Patient consent procedures when required
  • Minimum necessary practices
  • Secure communication methods
  • Role based access
  • Data quality responsibilities
  • Procedures for correcting inaccurate information
  • Breach and incident response
  • Retention and disposal requirements
  • Business associate agreements when applicable
  • Restrictions on secondary use
  • Rules for population level reporting

Measuring the 360° Win

Every Stakeholder Benefit Must Be Demonstrated

Depending on the program, evaluation may include:

Patient Measures

  • Access
  • Safety
  • Symptoms
  • Function
  • Experience
  • Goal concordant care
  • Care plan understanding

Caregiver Measures

  • Preparedness
  • Burden
  • Experience
  • Access to support
  • Understanding of escalation procedures

Clinical Measures

  • Care gap closure
  • Medication reconciliation
  • Timely follow up
  • Chronic condition indicators
  • Safety events
  • Functional outcomes

Utilization Measures

  • Emergency department visits
  • Hospitalizations
  • Readmissions
  • Post acute utilization
  • Transitions between settings

Financial Measures

  • Total cost of care
  • Program operating cost
  • Net financial impact
  • Appropriate service substitution
  • Avoided duplication

Workforce Measures

  • Workload
  • Role clarity
  • Safety
  • Retention
  • Professional experience

Equity Measures

  • Access across populations
  • Language access
  • Disability access
  • Geographic access
  • Differences in outcomes
  • Unresolved social barriers
No single measure establishes a complete 360° win.
The model should be evaluated through a balanced set of clinical, experiential, operational, equity, workforce, and financial measures.

When Interests Conflict

Win-Win Does Not Mean Disagreement Never Occurs

Stakeholders may have different priorities.

Examples include:

  • A patient's preference versus a caregiver's preference
  • Clinical judgment versus financial pressure
  • Immediate program cost versus possible long term benefit
  • Provider workload versus service demand
  • Information sharing versus privacy
  • Standardization versus individualized care
  • Network management versus patient choice

The model addresses conflict through:

  • Patient rights
  • Clinical necessity
  • Informed consent
  • Applicable law
  • Professional ethics
  • Transparent contracts
  • Defined decision authority
  • Escalation procedures
  • Conflict of interest disclosure
  • Quality review
  • Grievance and appeal processes
A fair resolution may not give every participant everything requested. It should protect the patient, follow the law, respect legitimate interests, and document the reasons for the decision.

The 360° Win Development Process

From Shared Goals to Measurable Results

A partnership may be developed through the following process:

  1. 01

    Identify the population and problem

  2. 02

    Define participating stakeholders

  3. 03

    Understand current workflows

  4. 04

    Identify gaps, burdens, risks, and duplication

  5. 05

    Define the proposed benefit for each stakeholder

  6. 06

    Assign responsibilities

  7. 07

    Establish clinical and operational safeguards

  8. 08

    Define legal and compliance requirements

  9. 09

    Select quality, utilization, experience, equity, and financial measures

  10. 10

    Establish data sources and reporting methods

  11. 11

    Implement the approved program

  12. 12

    Monitor performance and unintended consequences

  13. 13

    Correct identified problems

  14. 14

    Evaluate whether value was created for all relevant stakeholders

  15. 15

    Expand, revise, or discontinue the program based on evidence

How This Model Supports Value-Based Care

Aligning Quality, Outcomes, Experience, and Resources

The Centers for Medicare & Medicaid Services describes value-based care as care focused on quality, provider performance, and patient experience.

The 360°Win Model supports this direction by emphasizing:

However, the model may also be used within fee-for-service or other payment arrangements when the applicable contract supports legitimate coordination and quality improvement activities.
  • Person centered care
  • Accountability
  • Coordination across providers
  • Patient and family engagement
  • Quality measurement
  • Appropriate utilization
  • Health equity
  • Workforce sustainability
  • Responsible resource use
  • Continuous improvement

Our Commitment

No One Wins by Making the Patient Lose

Hospitals Without Walls™ is committed to partnerships in which:

✓The patient receives appropriate and respectful care
✓The family receives education and support
✓Professionals receive better coordination
✓Hospitals receive stronger continuity
✓Health plans receive measurable accountability
✓Facilities receive appropriate clinical connectivity
✓Community organizations receive meaningful partnership
✓Government receives responsible stewardship
✓Employers receive lawful population support
✓Healthcare workers receive sustainable operating conditions
✓Business partners receive fair compensation for legitimate value
✓The healthcare system uses resources more intelligently

That is the meaning of a 360° Win Model.

Let us design the win from every direction

Hospitals Without Walls™ works with organizations seeking a patient centered partnership that aligns clinical quality, operational performance, stakeholder responsibility, and responsible financial outcomes.

Request a 360° Partnership AssessmentRequest a Contract

Important information

The 360° Win Model is an organizational framework and does not guarantee that every participant will obtain a particular clinical, operational, or financial result.

Specific benefits, responsibilities, performance standards, financial terms, data rights, and legal obligations must be defined through the applicable contract and program documents.

Nothing on this page authorizes payment for referrals, improper inducements, unnecessary services, false claims, inappropriate information sharing, or any other unlawful conduct.

Evidence and authoritative sources

The principles supporting this model are consistent with authoritative guidance concerning person centered care, value based care, patient and family engagement, workforce well being, health equity, and coordination between healthcare and community organizations.

  • CMS — Value Based Care
  • CMS — Basics of Value Based Care
  • CMS — Accountable Care and Accountable Care Organizations
  • AHRQ — Guide to Patient and Family Engagement
  • AHRQ — Patient and Family Engagement in Primary Care
  • National Academies — National Plan for Health Workforce Well Being
  • HHS — Addressing Health Related Social Needs
  • HHS — Community Care Hubs