Huddle for Care provides solutions that build upon providers’ breadth of understanding of operations and patient needs. Themes run the gamut: getting leaders’ buy-in and keeping teams motivated, working on more focused solutions such as providing scales to heart failure patients at discharge, and partnering with public health departments to train community members to be emergency medical services workers.

Huddle collaborators

Currently, 430 individuals from more than 255 different organizations are using the Huddle for Care site. These collaborators represent hospitals, nursing homes, accountable care organizations, home health agencies and community-based organizations. Three health care organizations, highlighted here and all with similar challenges in care coordination, are among those participating in Huddle for Care to connect with others in the field and find the most effective solutions.

Hutchinson Regional Medical Center in Kansas has significantly reduced length of stay, emergency department visits and ambulance calls for patients with pulmonary conditions by implementing a chronic disease management program. Led by a multidisciplinary team, this program focuses on transitioning patients with respiratory diagnoses out of the intensive care unit to a pulmonary unit, as well as providing consistent, comprehensive education to patients and families. Nurses follow up with patients at home, and occupational therapists teach energy conservation techniques to patients in the home setting. After the center began participating in the program, readmissions decreased by 51 percent for patients enrolled in the pulmonary care transitions program.

The Aledade Delaware accountable care organization wanted primary care physicians to have real-time access to admission, discharge and transfer notifications when their patients visit a hospital. The ACO accomplished this by integrating practices’ electronic health record, practice management and scheduling systems with the Delaware Health Information Network via a population health management tool, the Aledade app. Now, patients receive timelier, better-coordinated care. In 2015, 30-day all-cause readmissions per 1,000 discharges decreased by 11.4 percent, and emergency department visits leading to hospitalization decreased by 8.1 percent.

Baylor Scott & White Health in Texas is improving medical management in skilled nursing facilities to reduce hospital readmissions. Its primary intervention was using and maximizing the employed physician model in local SNFs, a project that emerged from a partnership with the TMF Health Quality Institute (the local quality improvement organization) and the SNFs. Within six months, changes in medical management led to a 3 percent reduction in readmission rates for the local SNFs.

Distilling strategies

Huddle for Care was developed to follow up on a nursing care initiative of the Gordon and Betty Moore Foundation that improved care transitions among hospitals in the San Francisco Bay area. The participating hospitals had formed a collaborative to share strategies, solve problems collectively, and ultimately bring to light the great work being done in hospitals and the community.

With the significant progress in research and theory design on improving care transitions and reducing readmissions over the last 10 years, culling and sorting through that information and applying it to everyday practice can be daunting. Huddle for Care aims to distill that information into practical, tangible strategies that a nurse, case manager, discharge planner or other care transition professional can pick up and test in his or her organization — all while connecting and problem-solving within a community of peers from around the country. Huddle for Care website content is currently organized according to 19 of the most common care transition challenges, with nearly half focused on patient interaction — getting patients to follow up appointments, addressing health literacy and so forth.

The Huddle team considers capturing these perspectives and promoting collaboration among care settings critical to improving health care.

For more information and to join this growing community, visit or contact the HRET Huddle for Care team at

Shereen Shojaat is a program manager and Cynthia Hedges Greising is a communications specialist, both with the Health Research & Educational Trust.