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

  • Group analyzes MIPS performance of ACOs

    All of the more than 400 accountable care organizations in Track 1 are likely to get high performance scores in the Merit Based Incentive Payment's Quality Payment Program, according to an analysis by the National Association of ACOs. Findings also showed that most MIPS payment adjustments may range from 0.4% to 2.6% of the Part B expenditures of qualified providers. Healthcare Informatics online (10/12) Learn More

  • CMS unveils 2018 star ratings for MA, Part D plans

    The CMS announced that 44% of Medicare Advantage plans that include prescription drug coverage received at least a four-star rating for 2018, more than half of Part D plans received four or more stars, and average premiums for Part D and MA plans are down. Nearly three-quarters of enrollees in Medicare Advantage plans with prescription drug coverage will be covered by plans with at least a four-star rating, as will 47% of Part D enrollees. Modern Healthcare (tiered subscription model) (10/11) Learn More

  • Communication technique improves patient satisfaction scores

    A study in the journal Family Medicine found the psychosocial BATHE intervention, which stands for background, affect, trouble, handling and empathy, increases hospital inpatient satisfaction scores. The technique lets patients share psychological or life problems with clinicians, and data showed patients who participated gave their physicians an average score of 4.77, compared with a 4.0 score given by patients receiving standard care. HealthLeaders Media (10/16) Learn More