With pressure mounting from nearly every corner to reduce costly and unnecessary rehospitalizations, leaders at Torrance (Calif.) Memorial Medical Center knew they had to laser in on care coordination.

So, hospital officials have begun hosting lunch meetings every other month at the hospital with the medical center's network of seven skilled nursing facilities, along with weekly meetings at each facility to manage cases. The result: a drop in readmissions from about 23 percent to a little less than 8 percent. They've gained regional recognition, too; the California Association of Health Facilities recently pegged Total Wellness Torrance Post-Acute Network as a "program of excellence."

Josh Luke, vice president of post-acute services at Torrance, says meetings were awkward at first because some of the facilities compete for patients. But leaders got on the same page quickly.

"The post-acute sector is so hungry for hospitals to tell them how to address this issue that there's a frenzy when you start talking about readmission prevention and best practices," Luke says. "The reason our program has done so well is because we simply said, 'Here's the expectation.' The challenge that hospitals have is that they don't know where to start."

For Luke — a former hospital CEO now working on the post-acute side — it starts with looking outside the hospital for inspiration on how to best coordinate care. That's led to a series of low-cost or even no-cost process improvements, including discussing patients' discharge status at weekly meetings, eliminating any confusion about medications, scheduling follow-up appointments, and making sure that patients are able to manage their care at home.

These types of care coordination projects are starting to grow in number, says Lindsay Holland, clinical project manager of care transitions for California's quality improvement organization, Health Services Advisory Group of California Inc. In working with other hospitals in California and attending meetings as part of the Total Wellness Torrance program, she's seen that communication is the key ingredient to curbing readmissions.

"As the focus on coordination of care becomes even greater, these kinds of partnerships are going to be essential," she says. "Those conversations between the post-acute providers and the hospitals about why readmissions are occurring, what the gaps are in communication and how they can work together to understand each others' needs really need to take place."

Ryan Yerby, regional director of business development for Skilled Healthcare LLC, which manages three SNFs that are part of Total Wellness Torrance, says that their other hospital partners are looking to emulate the model. He believes that hospital leaders who fail to collaborate with other facilities after discharge are abandoning their work before it's finished.

"It's in every hospital's best interest to work closely with their post-acute partners because, essentially, we are completing the care that they are providing. It's imperative that the sharing of information and best practices take place," Yerby says.