The Centers for Medicare & Medicaid Services’ (CMS) Transforming Episode Accountability Model (TEAM) marks a shift in surgical care reimbursement. Beginning January 1, 2026, TEAM will mandate participation for selected hospitals, making them accountable for the entire surgical episode, including the 30-day post-discharge period, for certain types of surgeries, such as hip and knee replacements or surgical hip and femur fracture treatment. Even small breakdowns in care, such as missed follow-ups, delayed physical therapy, or poor communication, can derail a patient’s recovery and drive up costs. That’s why it’s critical hospitals have the right partners in place to thrive under TEAM.
Consider a 72-year-old patient recovering from a knee replacement. Her success depends on every handoff, from hospital to home health nurse to physical therapist, happening smoothly. One missed follow-up or delayed therapy session could send her back to the emergency department. Hospitals that prepare now can turn their participation in TEAM into a competitive advantage, improving outcomes and financial performance, delivering higher quality care, and attracting more patients who want to be part of a longitudinal care program.
Key challenges
Hospitals face challenges in taking full episode accountability. Data often exists in silos across systems, teams are stretched thin, and workflows can be inconsistent across care settings. Under TEAM, hospitals must identify and close these gaps early. Addressing these issues starts with supporting teams and aligning clinical workflows so patients don’t fall through the cracks.
Data fragmentation remains a central challenge, with information residing across hospitals, post-acute providers, and outpatient clinics, delaying insights and limiting proactive intervention. Workforce pressures compound the problem, as teams are tasked with monitoring patients after discharge, coordinating across providers, and managing regulatory requirements—all while keeping daily operations running. Differences in how care teams handle follow-ups, documentation, and patient communication create friction and slow response times. Legacy technology, such as older EHRs or disconnected systems, limit visibility and make it harder to act quickly and prevent complications.
Hospitals that address these barriers early can turn challenges into opportunities and deliver seamless, high-quality care under TEAM.
Strategies to succeed under TEAM
Success under TEAM will depend on strategic collaboration. Hospitals must prepare by building and managing high-performing post-acute care (PAC) networks that can deliver consistent, high-quality care beyond discharge. This includes proactively identifying TEAM patients, aligning them with top-performing PAC partners, and ensuring seamless transitions through real-time alerts, bi-directional communication, and sharing of care plans. Engaging patients and families is equally crucial to keep recovery on track and reduce avoidable readmissions.
By closely monitoring patient progress and coordinating care with post-acute partners, hospitals can identify delays or gaps in care and intervene quickly with follow-ups and proactive care. Strong PAC partnerships improve clinical outcomes and financial performance under TEAM.
To thrive under TEAM, hospitals must:
- Leverage real-time data and predictive insights across acute and PAC networks to identify at-risk patients early and prevent complications.
- Use prehabilitation assessments to plan for a patient’s post-operative care, increasing the likelihood of a safe return home after surgery.
- Identify and document chronic conditions before surgery to guide safer, more effective care and support accurate target prices.
- Build strong PAC partnerships with top-performing rehab facilities, home health agencies, and skilled nursing facilities to ensure smooth transitions and consistent care.
- Optimize workflows by standardizing discharge processes, clarifying team responsibilities, and streamlining administrative tasks.
Technology works best when it supports the people who care for patients. By giving care teams real-time visibility, actionable insights, and the ability to coordinate across settings, hospitals can address risks before they become complications. WellSky solutions combine predictive analytics, real-time insights, and clinical support to help hospitals manage TEAM patients from the time the surgery is scheduled until the end of the episode.
Leading through TEAM
TEAM is more than a payment model; it’s a blueprint for delivering higher-value, patient-centered surgical care. For our 72-year-old patient, this means every handoff is seamless, her recovery stays on track, and risk of readmission is minimized, giving her the best chance to recover in the comfort of her own home. Success in this new era depends on equipping care teams, especially case managers, with the right tools, real-time data, and workflows to guide effective care transitions and to act quickly when risks arise. Hospitals that achieve this level of coordination not only meet CMS expectations—they set the standard for the future of surgical care.
