Christiana Care's Medical Home Without Walls



Christiana Care's Medical Home Without Walls connects high-need patients with a multidisciplinary care team that coordinates their medical care, as well as psychological and social needs such as food, housing and transportation. Care team members visit patients in their homes or shelters, and accompany them to medical appointments. Other services include helping patients establish health goals, schedule appointments, adhere to medication regimens, find ways to pay for healthcare, fill out forms and access community services.

Partner Organizations

  • Christiana Care Health System                             

Target Population

Complex patients with multiple chronic conditions or social needs

Care Team

Physician, nurse, social worker, health coach


2012 - present

Results/ Studies



Health system


Program website

Medical Home Without Walls Gets Patients Back on Their Feet (2013)

Medical Home Without Walls Provides Care to the Homeless, Disenfranchised (2012)