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

  • Most states seek value-based payment programs, report says

    A report from Change Healthcare showed at least 40 states are working to get value-based payment programs and there are 15 multipayer initiatives across the states. States that have gone the farthest in embracing value-based payment model initiatives include Washington, Arkansas, Colorado, Minnesota and Tennessee. Healthcare Informatics online (11/14) Learn More

  • Better patient outcomes, higher provider satisfaction in VBC plans

    Higher percentages of patients enrolled in a Humana value-based care health plan were screened for colorectal and breast cancer, and more achieved blood glucose goals, than those in fee-for-service plans, according to a report from the company. Health care providers in VBC networks had higher overall HEDIS, patient engagement and provider satisfaction scores than providers in FFS plans, according to the report. Health Payer Intelligence (11/15) Learn More

  • Research evaluates efficacy of risk assessment, management program in diabetes

    Chinese researchers followed 53,436 adults for an average of 4.5 years and found that 23.2% of those in the multidisciplinary Risk Assessment and Management Program for Primary Care Patients with Type 2 Diabetes Mellitus group had a cumulative incidence of diabetes-related complications and all-cause mortality, compared with 43.6% in the usual care group. The findings in Diabetes Care revealed that the RAMP-DM group also had a lower risk for all-cause mortality and cardiovascular disease/microvascular complications, as well as lower rates for hospitalizations and specialist and emergency attendance, than the usual care group. Healio (free registration) (11/14) Learn More