The H2H Program supports patients transitioning from hospital to the community who require enhanced, short-term clinical support, proactive care coordination, and navigation following discharge. H2H provides close follow-up after discharge to identify changes early, coordinate care, and quickly escalate clinical or community care needs.

A referral to the H2H program can be made by completing the H2H Referral Form. Patients can be referred when they are medically stable and ready or near-ready for discharge. Patients referred to H2H will be considered under one of three pathways: Standard H2H Pathway, Congestive Heart Failure (CHF) Pathway and the Chronic Obstructive Pulmonary Disease (COPD) Pathway.

When a referral is received, the H2H team will assess the patient and collaborate with the discharging team to facilitate a safe transition home. The Patient Flow Coordinator will provide short-term follow-up, care coordination, and navigation, while the Nurse Practitioner can provide clinical assessment and follow-up when required. The H2H team will work with existing hospital and community services to address identified needs and escalate concerns when necessary.

The goal of H2H is not to duplicate existing community services, but to bridge gaps between hospital and home, strengthen transitions in care, and identify and address concerns early before they result in avoidable hospital utilization.

For questions, concerns, or to arrange an in-service about the H2H program, please contact Brody Blackwood, H2H Coordinator at brody.blackwood@tbh.net or extension 7871.