Karen Houston, R.N., was skeptical at first: a couple dozen leaders from competing hospitals and facilities scattered across mid and upstate New York, all trying to figure out how to coordinate care better. But the results have been remarkable thus far. Just by meeting monthly to discuss outcomes and explore solutions to their problems, a group of hospitals, physician practices, nursing homes and home health agencies made a dramatic impact in smoothing transitions. Working with IPRO — the Medicare quality improvement organization for New York state — the facilities reduced readmissions by nearly 21 percent.

"What's surprised me is [that] these facilities would be competing for the same patient in our facility," says Houston, quality and continuum of care director for Albany Medical Center. "I wasn't sure they'd all want to sit together and talk about what's working for them, what isn't and how we can improve it. But once we started talking, the goal was to improve transitions for the patient, and the competition thing went away."

Comparing a six-month period ending March 2013 with the same six months ending March 2011, before the program began, providers in three communities in New York had 30-day readmission rates that fell to 25.8 percent from 32.5 percent in 2011.

Reasons for the readmissions were fairly common — poor communication between clinicians or with the patient during transitions, errors in medication management or inadequate education of the health care user about his or her treatment plan.

Ann Myrka, a pharmacist with IPRO, says just meeting with a hospital's community partners monthly can make a measurable difference. "Seeing that other person's face from another facility across the table from you monthly creates a different sort of boots-on-the-ground dynamic that I don't think you can get from a conference call," she says.