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

  • CMS drops shared decision-making demo project

    CMS officials decided not to move forward on its Shared Decision Making model after too few accountable care organizations signed up to participate. ACOs in the Medicare Shared Savings Program or Next Generation model would have received incentives to test a four-step clinical decision-making process for certain conditions. Health Exec (11/17) Learn More

  • Policy experts discuss cutting health care waste, ACO success

    Policy experts at an American Enterprise Institute briefing said it is possible to reduce waste in the health care system to lower costs, and talked about why accountable care organizations have been slow to show cost savings. "The United States has spent $3.4 trillion dollars on care delivery, and I'm suggesting that half of that is recoverable waste, potentially," said Brent James, M.D., of the Institute for Healthcare Improvement. MedPage Today (free registration) (11/20) Learn More

  • Post-acute care organizations lack tools for participating in VBC

    Eighty-two percent of long-term and post-acute care organizations responding to a survey said they are struggling to participate in value-based care networks, and only 19% reported that they had at least some EHR capacity by the last quarter of 2017. In addition, 86% of LTC facility administrators said they do not exchange information electronically with referring hospitals and physicians. RevCycle Intelligence (11/14) Learn More