Sometimes, solving health care's most vexing problems can be as simple as getting all of the right people in the same room.

OK, maybe not that simple; there's lots of stuff to do after that, but it's usually a good start. That what New York's state-based quality improvement organization, IPRO — which contracts with CMS to monitor care provided to Medicare beneficiaries — learned during a recent project to try to curb readmissions. By holding monthly meetings with hospitals and their various partners, IPRO was able to help organizations reduce costly readmissions within 30 days by almost 21 percent, compared with those not taking part, the group announced last week.

"If you've always worked in a hospital or skilled nursing facility, you don't necessarily understand the challenges that each of those other settings encounter when trying to take care of patients," says Sara Butterfield, R.N., who directs the Care Transitions project in New York state. "These folks have now, through the coalition, really developed partnerships, and if there is an issue with a patient or they have a question or there is an event, they now pick up the phone, call one another and talk that through."

IPRO (which stands for their old name, Island Peer Review Organization), started the intervention back in August 2011, and analyzed data on rehospitalizations from a six-month period ending in March 2013. Compared to the same six months ending March 2011 when no intervention took place, IPRO was able to help providers in three different communities in upstate and middle New York cut readmissions overall by 20.8 percent.

Some of the most common causes for return hospital trips in 30 days concerned poor communication among providers, poor communication between patients and clinicians during care transitions, medication management, education of patients for self-management of their care, and issues related to transferring information between care settings, according to a press release. In addition to the monthly meetings between various providers to identify those causes, IPRO has also helped to analyze some of the drivers of readmissions in communities, along with assisting with the rollout of evidence-based interventions, and subsequent evaluation of those interventions.

All three of the communities ended up employing uniform procedures for reconciling patient medications when they moved between care settings, along with standardizing the information transferred among providers at the time of discharge. IPRO isn't the only quality improvement organization to demonstrate such success in curbing readmissions. A study published earlier this year in the Journal of American Medicine found that that those working with QIOs in communities across the country experience about twice the reduction in readmissions compared to those who didn't.

Vigilance is needed from health care leaders, IPRO points out, as some 20 percent of Medicare beneficiaries end up back in the hospital within 30 days, and some 76 percent of those cases are preventable. If hospital leaders really want to address readmissions, Butterfield says, they must look beyond their hospitals and reach out to their various partners to make sure they're on the same page.

"Care transitions can't be addressed in a silo," she says. "It has to be all providers involved in working together to manage patients. This type of approach brings all of those folks together in the community to focus on a more patient-centered approach."

We've written tons about care coordination recently if you're interested in further reading. Back in May, I explored some of the barriers to integrating with physicians and post-acute providers, and some case studies of hospitals that are doing this right. Rahul Koranne, M.D., executive medical director for Bethesda Hospital in Saint Paul, told me that CEOs who view the post-acute side as a "black hole" that's not their problem simply "don't get it." Also, H&HN contributor Lola Butcher wrote this interesting feature on how hospitals are strengthening bonds with post-acute providers.

As always, please share your thoughts in the comment section below, or ping me through Twitter or email if you'd like to have a more in-depth conversation.  Enjoy the holidays!