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

News And Research

  • Study links 30-day HF mortality rates to long-term survival

    Hospitals with the lowest 30-day risk-standardized mortality rates had a 76.8% long-term survival rate for heart failure patients, compared with a 73.7% rate among hospitals with the highest RSMR rates, according to a study presented at the American College of Cardiology's annual meeting and published in JAMA Cardiology. "Findings from our study suggest that hospital-level 30-day RSMR may be a useful metric for hospital performance and should potentially be weighted more in CMS financial incentive programs," researchers wrote. MedPage Today (free registration) (3/13) Learn More

  • Geriatricians' care model helps keep readmission rates low

    Geriatricians in the Pioneer Accountable Care Organization Model had a lower patient readmission rate for conditions associated with value-based penalties under the Hospital Readmissions Reduction Program, compared with other specialties, a study in the American Journal of Accountable Care showed. Researchers cited the care model used by geriatricians, which included continuity of care across settings and enhanced palliative care. RevCycle Intelligence (3/13) Learn More

  • National Quality Forum releases opioid prescribing guidance

    The National Quality Forum released "The National Quality Partners Playbook: Opioid Stewardship," to help clinicians safely prescribe opioid medications. The playbook was developed by the NQP Opioid Stewardship Action Team that included clinicians, federal agencies, health care organizations, pain management experts and other groups. Becker's Hospital Review (3/9) Learn More