Turning post-acute visibility into TEAM success with actionable insights

This article was originally featured in Fierce Healthcare.

Starting January 2026, the Centers for Medicare & Medicaid Services (CMS) will launch the Transforming Episode Accountability Model (TEAM) – a mandatory five-year initiative designed to improve surgical episode outcomes and lower Medicare spending.

For hospitals selected to participate, TEAM introduces a new level of accountability: financial responsibility for the entire recovery episode, not just the surgery. This includes post-acute care (PAC) – where clinical and financial risks are often highest. To succeed, hospitals will need real-time visibility into post-discharge care to enhance coordination, improve outcomes, and manage costs effectively.

TEAM’s impact on hospitals and post-acute collaboration

TEAM focuses on five high-volume, high-cost surgical procedures: lower extremity joint replacement, surgical hip/femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedures. Each episode concludes 30 days post-discharge, with CMS evaluating hospitals based on:

• Quality Measures: Readmissions, safety indicators, and patient-reported outcomes
• Cost Performance: Actual Medicare spending compared to CMS target prices

Hospitals that meet quality benchmarks while staying below target costs will earn incentive payments; those exceeding targets may face financial penalties. Because much of the episode’s cost and risk occurs after discharge, success hinges on strong collaboration with post-acute partners.

Under TEAM, hospitals must move beyond reactive care management. Success will require real-time alignment between acute and post-acute teams – ensuring every post-discharge decision supports both quality outcomes and financial sustainability.

The visibility gap hindering care coordination

Once patients transition to PAC, hospitals often lose visibility into recovery. Traditional data sources – such as claims data and Minimum Data Set (MDS) assessments – arrive weeks or months after care is delivered, making them useful only for retrospective analysis.

This delay creates critical challenges, making it difficult to identify complications early, evaluate post-acute partners’ performance, and coordinate care effectively. Hospitals often remain unaware of issues until a patient is readmitted or visits the emergency department – by then, it’s too late for early intervention.

These gaps not only impact hospital outcomes but also leave post-acute partners without the real-time insight needed to adjust care plans, manage high-risk patients, and demonstrate value in shared accountability models like TEAM.