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: About 500,000 clinicians to get PQRS-related penalty

    The CMS said about 500,000 clinicians will get their fee-for-service Medicare payments cut by 2% this year because they did not meet Physician Quality Reporting System requirements in 2015. The report said half of those affected are physicians and for many the impact may be minor. Medscape (free registration) (6/20) Learn More

  • Study: Black surgery patients have higher readmission risk

    A study published in Health Affairs found black surgery patients in fee-for-service Medicare were 33% more likely to have a 30-day hospital readmission than white patients. The study found black patients in Medicare Advantage plans had a 64% greater risk of readmission than white patients. Health Affairs Blog (6/21) Learn More

  • 20% of patients return to hospital after observational stay

    About 20% of Medicare patients who had an observational stay at a hospital ended up returning within 30 days, and 49.7% were admitted for inpatient care, researchers reported in The BMJ. The study analyzed 363,037 initial observation stays from 2006 to 2011 that resulted in discharge. Connecticut Post (Fairfield County-Bridgeport) (6/20) Learn More