The University of Virginia Health System quietly launched its “Hospital to Home” program in 2010, and since then the hospital-based post-acute program has become a rip-roaring success, reducing costs and readmissions.

The H2H program is centered around an in-hospital clinic staffed by nurse practitioners, who sit down with heart failure patients within seven days of their discharge from the hospital. The program costs roughly the salary of two nurse practitioners and affords patients and their families a one-hour appointment to review medication and self-management strategies, and ensure that patients have a firm grasp on their condition, which isn’t always the case.

“We’ll often start the conversation with, ‘Tell me what you understand about why you were in the hospital,’ ” says Nita Reigle, R.N., an acute care nurse practitioner who works in the H2H program. “In many cases, it’s been pretty eye-opening to hear their perception of why they were in the hospital and the reality of what’s wrong with their heart.”

Practitioners keep in contact with patients for 30 days after discharge. Before the program, the typical time frame for a follow-up appointment was six weeks, “missing the key window,” says Reigle.

What started as a pilot program has turned into a highly visible program that draws attention from people who aren't enrolled in the H2H program, Reigle says.

Even more impressive are the program’s numbers. Researchers analyzed records of 5,000 patients and found that after 30 days of being discharged from the hospital, patients in the program had a readmission rate 7.3 percent lower than those not enrolled. That reduced the average cost for H2H participants by almost $16,000.

“It was surprising,” says Tim Welch, M.D., lead author of the study, who completed a fellowship in UVA's advanced heart failure and transplant program. “Before, I think it wasn’t widely known how beneficial the clinic was — with actual numbers and the write-up, this says, ‘Yes, it truly is.' ”

Hospitals increasingly are partnering with organizations in the community, such as nursing homes or community pharmacies, to create similarly successful programs. These post-discharge calls and visits are something “we know work, no matter what type of readmission diagnosis the patient has,” says Charisse Coulombe, vice president of clinical quality for the American Hospital Association's Health Research & Educational Trust.

“We know from experience and anecdotal stories from patient advisers that when patients are getting discharged, it’s a little unnerving … . It’s a scary time and something we [hospitals] need to recognize and acknowledge,” she says.