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

  • Health care leaders question value of CMS readmission program

    Health care leaders say the Hospital Readmissions Reduction Program has been successful but progress has stalled, suggesting it might be time for the CMS to end the program. The program has been criticized for failing to consider social determinants in assessing readmission penalties, and experts say health care organizations are participating in other value-based initiatives that measure quality. Modern Healthcare (tiered subscription model) (8/12) Learn More

  • Study: Specialist access no higher using state standards

    Specialty access standards used by five state Medicaid agencies did not significantly improve access to specialist physicians, according to a study in JAMA Internal Medicine. By next year, the CMS will require state Medicaid programs to implement time and distance standards for managed care organizations to ensure Medicaid patients have adequate access to specialist physicians. Healio (free registration) (8/15) Learn More

  • US health centers get $105M to improve quality of care

    Almost $105 million was awarded by HHS to 1,333 US health centers to use to improve quality of care, efficiency and effectiveness. Healthcare Informatics online (8/16) Learn More