Hospital to Home

The Hospital to Home (H2H) Initiative is a resource for hospitals and cardiovascular care providers committed to improving transitions from hospital to "home" and reduce their risk of federal penalties associated with high readmission rates.


Self-contained improvement projects that include a goal statement, success metrics, a tool kit, an assessment, and 3 webinars (evidence, tools, lessons learned) that provide participants with recommended strategies and tools to achieve small, attainable goals in their organization.

  • See You in 7

    The goal of the H2H SY7 Challenge is for all patients discharged with a diagnosis of HF/AMI to have a follow-up appointment scheduled/cardiac rehab referral made within 7 days of hospital discharge.

  • Mind Your Meds

    The goal of the H2H MM Challenge is for clinicians and patients discharged with a diagnosis of HF/MI to work together and ensure optimal medication management.

  • Signs and Symptoms

    The goal of the H2H S&S Challenge is to activate patients to recognize early warning signs and have a plan to address them.

Getting Started

Kick-start H2H at your hospital by utilizing the ”Getting Started Checklist.
Get Started


Interact with others on a listserv who share best practices and lessons learned.

Find out more

News And Research

  • Study: Fewer readmissions not linked to higher mortality

    A study in the Journal of the American Medical Association found the Affordable Care Act's Hospital Readmissions Reduction Program did not increase post-discharge mortality rates for patients with heart failure, myocardial infarction or pneumonia. "If anything, readmission reductions were associated with concomitant reductions in mortality," said Kumar Dharmarajan of Yale New Haven Health, an author of the study. HealthDay News (7/18) Learn More

  • Communication gaps affect home health care, study finds

    Results of interviews with home health care nurses suggest communication gaps between nurses and primary care physicians, as well as between hospitals and PCPs, can affect patient care and lead to medical errors, researchers reported in the Journal of General Internal Medicine. Communication gaps can cause problems with medication lists, patient care orders and access to needed documents, researchers said. Home Health Care News (7/19) Learn More

  • Access to maternity care declining for rural women

    Rural hospitals are closing maternity wards and ending related services, and 119 rural hospitals have closed since 2005. Inductions and cesarean deliveries are more likely at rural hospitals, and a lack of prenatal care increases risks of complications and premature birth. Reuters (7/18) Learn More