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

  • Report: Emergency departments deliver 47.7% of US medical care

    Data showed an average of 47.7% of US medical care was provided through hospital emergency departments from 1996 to 2010, and ED visits increased 44% over that period, according to a study in the International Journal of Health Services. African-Americans had a higher ED use rate than other racial groups and people who were uninsured or on Medicare or Medicaid were more likely to have an ED visit than patients with commercial health insurance. United Press International (10/17) Learn More

  • Education program cut inappropriate catheterization referrals

    Primary care physicians at a rural tertiary medical center stopped making inappropriate referrals for cardiac catheterization after a training and screening program was implemented. Appropriate use guidelines were disseminated to physicians and specialists and posted in catheterization labs, advanced practitioners reviewed scheduled cases for appropriateness, and appropriateness was reconfirmed on the day of the procedure. MedPage Today (free registration) (10/17) Learn More

  • Study analyzes advanced cancer patient hospitalizations

    A study of data from the California Cancer Registry found 71% of advanced cancer patients were hospitalized in the year following their diagnosis and 16% had at least three hospital visits. Researchers wrote in the Journal of Clinical Oncology that initiatives to reduce hospitalization could target high-risk patients and include policies that increase access to outpatient palliative care. Healio (free registration) (10/12) Learn More