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.

Projects

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

Collaborate

Interact with others on a listserv who share best practices and lessons learned.

Find out more

News And Research

  • NCQA to add telehealth to updated HEDIS scores for 2018

    Telehealth will be included as a treatment option for alcohol and other drug abuse or dependence problems, as well as for behavioral health measures, in the National Committee for Quality Assurance's updated Healthcare Effectiveness Data and Information Set scores for next year. The updated HEDIS scores will also address issues related to opioid addiction, including the rate of adult health plan members receiving opioids from multiple providers and pharmacies, and the use of opioids at high dosage for adults on long-term treatment. Healthcare Finance News (7/5) Learn More

  • Forum tackles patient-centered outcomes research integration into CDS

    Participants in a recent Patient-Centered Clinical Decision Support Learning Network forum discussed how their projects advance the integration of federally funded patient-centered outcomes research into point-of-care clinical decision support systems. For instance, the Agency for Healthcare Research and Quality's CDS Connect is getting ready to pilot a repository of computable CDS artifacts involving guidelines-based cholesterol management and statin use, while a Geisinger Health System study aims to improve diagnosis communication using a combination of a patient-facing genomic test interpretation report and a provider-facing report accessible via EHR and patient portal. Healthcare Informatics online (6/30) Learn More

  • Study: Ambulance diversion raises death risk for black heart-attack patients

    A study in Health Affairs found black patients who had a heart attack were more likely to die within a year than white patients when ambulances were being diverted from the nearest hospital for more than six hours on the day of the patient's attack. Dr. Joaquin Cigarroa, clinical chief of the Knight Cardiovascular Institute at Oregon Health and Science University, said people who think they are having a heart attack should ask to be taken to the nearest hospital with a heart catheterization laboratory, ask before being discharged for a referral to a cardiac-rehabilitation program, and follow up with a cardiologist. Reuters (7/4) Learn More

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