VOICES: Phyllis Wojtusik, EVP, Value-Based Care, Real Time Medical Systems

This article was originally featured in Skilled Nursing News.

This article is sponsored by Real Time Medical Systems (Real Time). With CMS’s Transforming Episode Accountability Model (TEAM) now in effect as of January 1, 2026, hospitals face increased responsibility for surgical episodes and post-acute care coordination. Under TEAM, hospitals are accountable for outcomes and costs for 30 days post-discharge, elevating the role of SNFs in recovery and in preventing readmissions. In this Voices interview, Phyllis Wojtusik, RN, Executive Vice President of Value-Based Care at Real Time, discusses TEAM’s implications for hospitals and SNFs, how collaboration is evolving across the continuum, and the steps facilities should take now to succeed under TEAM.

Skilled Nursing News: CMS’s TEAM launched January 1, 2026—how does this impact SNFs?

Phyllis Wojtusik: TEAM shifts responsibility to hospitals for ensuring quality surgical recovery during the 30-day post‑discharge period. The model focuses on five surgical diagnoses and approximately 742 hospitals identified by CMS, marking one of the most significant shifts in value-based care (VBC) to date. Because many of these patients transition to SNFs for skilled rehabilitation, hospitals will seek post‑acute partners that can support recovery plans, monitor for early clinical changes, and prevent unnecessary readmissions. SNFs play a critical role in helping hospitals meet quality and cost targets under this new model.

Although SNFs are not financially tied to TEAM incentives, their performance is essential. Facilities that consistently demonstrate timely communication, strong therapy and nursing coordination, and streamlined care transitions will strengthen their reputation with local hospitals. Showing the ability to manage risk and sustain progress after discharge helps SNFs build trust and stand out as reliable care partners.

Why does TEAM matter across the care continuum?

Wojtusik: TEAM isn’t limited to hospitals—it reshapes expectations for every care setting involved in recovery. Hospitals will prioritize SNFs that can maintain momentum after discharge, especially for surgical patients who require structured rehabilitation and vigilant monitoring. Coordinated workflows, clear care plans, and shared visibility into patient status will help hospitals meet benchmarks and keep episodes on track.

This model also reflects CMS’s broader goal: enrolling all Medicare beneficiaries in a VBC program by 2030. TEAM is another step toward that vision, tying the continuum together and requiring acute and post-acute providers to work in true partnership. It represents a transition from episodic care to integrated accountability, where success depends on shared responsibility for outcomes—not just within one setting, but across the entire patient journey.

What changes will TEAM bring to care collaboration?

Wojtusik: Historically, hospitals and SNFs have shared some accountability for readmissions, but penalties alone haven’t driven significant reductions. TEAM changes that dynamic by making hospitals fully responsible for outcomes for 30 days post-discharge. They can no longer say, “Your surgery is complete—now you’re on your own.” Instead, they need care partners who can successfully rehabilitate patients, prevent infections, and manage chronic conditions that could lead to readmission.

To do that, hospitals need visibility into what’s happening in SNFs—whether a patient’s blood pressure is stable, therapy goals are being met, or mobility is improving. Real Time’s TEAM Insights provides that line of sight for hospitals, equipping them with live clinical data across their SNF network to strengthen collaboration, manage length of stay, and facilitate seamless care transitions. By sharing real-time data on patient progress, care providers can identify early warning signs of deterioration and intervene before complications occur.

Why is preparation critical for SNFs?

Wojtusik: Preparation matters because hospitals will begin forming preferred post-acute networks based on performance under TEAM. SNFs that are ready to demonstrate strong rehab outcomes—and explain how those results are achieved—will stand out as reliable partners. It’s not just about reporting numbers; it’s about telling the story behind those results. For example: if a SNF receives 10 patients in a month, they should be able to say: “Nine went home within 20 days, one was readmitted—here’s why, and what we did to ensure a successful discharge after their return.”

Flexibility is also key. Each hospital may prioritize different goals—one might focus on patient education, another on therapy milestones. SNFs need to understand these priorities and align their processes accordingly. Traditionally, SNFs have focused on internal benchmarks like CMS quality measures. Those remain important, but under TEAM, they also need to ask: “How do I support my hospital partner’s goals?”

How can SNFs position themselves for success under TEAM?

Wojtusik: Start by identifying which hospitals in your market are participating in TEAM. Then initiate conversations: “How are you planning to manage these patients? What infrastructure do you have in place? How can we work together?” These discussions help SNFs align with hospital strategies and close communication gaps.

Beyond establishing relationships with acute providers, SNFs must also strengthen their internal capabilities to deliver on those commitments. That starts with meaningful, actionable insights—not just raw EHR data—to track clinical changes, monitor functional progress, and document interventions that prevent decline or readmission. SNFs that combine strong outcomes with proactive engagement and real-time data transparency will thrive in a model where collaboration and shared accountability drive success.

Fill in the blank: In 2026, the skilled nursing landscape will be defined by…

Wojtusik: Its ability to adapt to VBC and evolving regulatory changes—while managing staffing challenges and sustaining strong patient outcomes.

You may view this article on the Skilled Nursing News website, here.