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

  • Providers focus on social determinants of health as APMs gain traction

    Medicare, Medicaid and commercial health insurers' embrace of advanced payment models is encouraging accountable care organizations, hospitals and other health care providers to focus more on social determinants of health, particularly in Vermont and other states with CMS innovation waivers. Health care providers are covering the costs of housing, offering boxes of fresh produce and assisting with social support services for high-risk patients. The Washington Post (tiered subscription model) (9/17) Learn More

  • Hospitals seek more integrated care to reduce readmissions

    Hospitals faced with readmission penalties and other Affordable Care Act incentives are looking for ways to better integrate care, such as following up with patients after discharge, said Dr. West Paul, vice president of quality and patient safety at WakeMed Health & Hospitals. Community groups also work with patients to make sure their basic living and health care needs are met, while emergency medical services agencies provide non-emergency care that keeps people out of the hospital. WUNC-FM (Chapel Hill, N.C.) (9/15) Learn More

  • Hospital uses QI initiative to reduce NICU X-rays, costs

    Children's National Health System in Washington, D.C., implemented a quality improvement initiative that reduced the number of chest X-rays done on NICU patients and associated costs, researchers reported at the American Academy of Pediatrics annual meeting. The initiative was part of a larger program to reduce unintended extubations. Becker's Hospital Review (9/18) Learn More