The CMS TEAM Model changes how hospitals manage costs for defined Medicare episodes by shifting to bundled payments instead of separate service payments. Bundled payments cover the full patient episode from inpatient admission through the typical 30-day post-discharge period. This shifts financial accountability to hospitals for coordinating care, preventing complications, and limiting avoidable readmissions.
Effective role definition and smooth collaboration of a TEAM are the key components to success. Identical care coordinators should have defined transition tracking workflows. Doctors need real-time cost information when they make decisions. Administrators have to keep track of post-acute spending trends. With the right combination of these factors, the hospitals experience tangible changes: the reduced number of readmissions, the optimization of post-acute placement, and the enhanced financial reconciliation that not only secures the margins but enhances patient outcomes as well.
What is the CMS TEAM Model?
The TEAM Model CMS (Transforming Episode Accountability Model) is a type of value-based payment model in which hospitals receive a monetary payment for full-treatment episodes. Every episode commences with a patient’s inpatient admission and moves through to post-discharge healing, providing a sense of responsibility on the continuum.
CMS sets a target price on each episode depending on the expenditures done historically, costs in the region, and risk factors of patients. Hospitals that are less than target and deliver quality benchmark keep the savings. Fall short of the goal, and you incur losses. This model forces strategic decisions about:
- Resource utilization during hospitalization
- Discharge timing and destination selection
- Post-acute care provider relationships
- Readmission prevention protocols
The Medicare TEAM Model covers specific MS-DRG codes linked to surgical and medical conditions. Each code triggers episode tracking with predefined cost expectations and mandatory quality measures that affect final reconciliation amounts.
Core TEAM Roles and Responsibilities
To construct an efficient episode management, one needs to be clear on who manages what. All the roles have their specific obligations, which directly influence financial and clinical results. This is the way successful organizations form their TEAMs.
Clinical Leadership
Clinical decisions that influence the trajectories of episode costs are set by physicians and specialists at the very first stage. Most of the episode spending goes on their decisions regarding procedures, drugs, length of stay, and discharge plan.
Key responsibilities include:
- Following evidence-based protocols for covered MS-DRGs
- Participating in daily interdisciplinary rounds to identify discharge barriers
- Collaborating with post-acute providers on transition planning
- Reviewing individual performance data against peers
Clinical leaders also analyze practice pattern variation. When one surgeon consistently generates higher costs without better outcomes, that gap needs immediate attention and intervention.
Care Coordinators
Care coordinators oversee the patient journey from admission through post-discharge follow-up. They make sure that crucial activities do not fall through the interdepartmental openings in hospitals and with other providers.
Daily coordination work involves:
- Assessing patients within 24 hours of admission for discharge needs
- Identifying social determinants affecting recovery capacity
- Arranging skilled nursing, home health, or rehabilitation services
- Scheduling follow-up appointments before discharge occurs
- Conducting post-discharge calls to catch early warning signs
Effective coordinators should use a digital health platform that shows real-time patient status, assigned tasks, and episode-level costs across all care settings.
Quality Management TEAM
Quality managers protect revenue by monitoring the performance metrics that determine financial reconciliation. The TEAM Model directly ties payment adjustments to quality scores, making this TEAM essential for financial success.
They concentrate on:
- Tracking readmission rates and complication frequencies
- Ensuring accurate quality measure reporting to CMS
- Analyzing patterns in quality failures across episodes
- Training clinical staff on documentation requirements
Poor quality scores reduce shared savings or amplify losses. A hospital that controls costs but misses quality benchmarks still faces significant financial penalties under reconciliation rules.
Data Analytics Specialists
Analytics TEAMs convert raw episode data into actionable intelligence that guides operational improvements. They identify which episodes lose money, where post-acute spending leaks occur, and which providers deliver optimal value.
Essential analytics functions include:
- Building dashboards showing episode-level financial performance
- Comparing actual spending against target prices by MS-DRG
- Highlighting statistical outliers for clinical review
- Projecting reconciliation amounts before CMS finalizes results
Without robust analytics capabilities, TEAMs operate without visibility into what’s working and what’s failing financially.
Post-Acute Care Partners
Episode success depends heavily on relationships with skilled nursing facilities, home health agencies, and rehabilitation centers. These partners handle the majority of post-discharge care and account for substantial episode costs.
Effective partnerships require:
- Establishing preferred networks based on documented outcomes and cost efficiency
- Creating standardized referral processes with clear clinical criteria
- Sharing patient data electronically through secure connections
- Monitoring readmissions originating from each facility
Costs and outcomes often worsen when patients choose post-acute providers without guidance, compared to hospitals that manage structured preferred networks.
Key Responsibilities Across the Care Continuum
Episode management is a process that involves various stages, which involve certain activities that have an impact on the ultimate results. Achieving success requires a coordinated effort at all levels, such as pre-admission through post-discharge follow-up.
Pre-Admission Planning
Episode optimization starts before the patient arrives for elective procedures. This phase offers opportunities to address barriers and set realistic expectations.
Pre-admission TEAMs handle:
- Medical optimization screening for chronic conditions
- Necessary pre-operative testing coordination
- Patient education about recovery timelines and requirements
- Early identification of probable discharge destinations
Patients who receive clear preoperative education tend to adhere better to recovery plans and experience smoother post-surgical transitions.
Inpatient Care Coordination
The hospital stay establishes the financial foundation for each episode. Length of stay, complication rates, and discharge planning quality all directly impact final costs.
Daily Care Rounds
- Review progress toward discharge criteria
- Address barriers like pending consultations or test results
- Update families on the expected timeline
Resource Utilization
- Select appropriate imaging and laboratory work
- Avoid unnecessary specialty consultations
- Apply evidence-based treatment protocols consistently
Discharge Planning
- Begin conversations on admission day
- Assess home safety and available caregiver support
- Arrange medical equipment delivery before discharge
Delaying discharge planning until late in the hospital stay adds unnecessary costs and increases complication risks.
Post-Acute Transition Management
The highest-risk period occurs in the first week following discharge. Medication errors, missed instructions, and deteriorating symptoms drive preventable readmissions that destroy episode economics.
Critical transition protocols include:
- Complete medication reconciliation before hospital departure
- Written discharge instructions in patient-friendly language
- Scheduled follow-up appointments within seven days
- Direct phone numbers for urgent clinical questions
Post-Discharge Monitoring
Active monitoring is maintained within the entire episode window of 30 days. At-risk patients should be monitored with systems that help detect early issues and prevent unnecessary emergency visits.
Monitoring activities include:
- Structured phone calls at 48 hours and seven days post-discharge
- Real-time review of emergency department visits
- Coordination with post-acute providers on patient status updates
- Rapid intervention when clinical red flags appear
A patient reporting worsening pain or shortness of breath should receive timely clinical evaluation rather than being asked to wait for a routine appointment.
Best Practices for TEAM Model Success
Successful episode management requires deliberate operational practices that reduce variation, improve coordination, and create accountability. Organizations achieving strong results consistently apply these approaches.
Establish Structured Care Pathways
Clinical variation destroys profitability under bundled payments. Standardized pathways ensure consistent, evidence-based care while allowing appropriate clinical judgment.
Effective pathways specify:
- The expected length of stay varies by diagnosis
- Required assessments and interventions with timing
- Discharge criteria that must be documented
- Preferred post-acute settings based on patient complexity
Pathways guide consistency while allowing clinical judgment, helping reduce costly practice variation that doesn’t improve outcomes.
Build Integrated Technology Infrastructure
Disconnected information systems lead to errors, delays, and duplicated work. Hospital records, post-acute data, and quality measures are linked together in integrated platforms to be displayed together in unified dashboards.
Critical technology requirements include:
- Real-time episode cost tracking across all care settings
- Automated quality measure calculation and reporting
- Bidirectional data exchange with post-acute partners
- Predictive analytics identifying readmission risk factors
Teams lose time searching for missing data when systems aren’t connected, which limits timely clinical decision-making.
Develop Post-Acute Networks Strategically
Not all skilled nursing facilities deliver equal value. Some generate high readmission rates. Others charge premium prices without demonstrating superior outcomes for similar patients.
Strategic network development follows these steps:
Performance Analysis
- Track readmission rates by individual facility
- Compare costs for patients with similar acuity levels
- Review CMS quality ratings and patient satisfaction scores
Relationship Building
- Share performance data on mutual patients
- Establish communication protocols for urgent issues
- Create joint initiatives targeting specific improvements
Patient Matching
- Direct medically complex patients to high-capability facilities
- Use lower-cost options for straightforward recoveries
- Consider patient preferences within acceptable quality parameters
Strategic steering improves outcomes while controlling 40-60% of episode costs typically consumed by post-acute services.
Implement Proactive Care Coordination
Reactive coordination that responds after problems emerge costs more and achieves worse results. Proactive approaches anticipate needs and prevent complications before they occur.
Key proactive elements include:
- Risk stratification on admission using validated tools
- Enhanced coordination resources for high-risk patients
- Early primary care physician involvement in discharge planning
- Pre-arranged post-acute placements before discharge day
A patient with diabetes, heart failure, and limited family support requires intensive coordination from admission, not after their first readmission occurs.
Monitor Financial Performance Continuously
Waiting for quarterly CMS reconciliation reports means discovering problems too late for corrective action. Real-time financial tracking enables mid-course adjustments when they still matter.
Effective financial monitoring displays:
- Current spending versus target price for active episodes
- Post-acute care costs broken down by provider
- Projected gain or loss for each MS-DRG category
- Year-to-date reconciliation estimates with quality adjustments
Monthly performance reviews identify emerging trends before they become financial crises requiring major operational changes.
Common Challenges and Solutions
High Post-Acute Care Costs
Post-acute services often represent the largest single category of episode spending, making them a primary target for cost management.
Solutions:
- Create tiered facility networks matching capability to patient needs
- Use predictive models for optimal post-acute setting selection
- Monitor the length of stay at each facility and intervene on outliers
- Develop robust home health protocols as lower-cost alternatives
Readmissions Within 30 Days
Every readmission adds direct costs while triggering quality penalties that reduce or eliminate shared savings.
Solutions:
- Identify high-risk patients using validated screening instruments
- Ensure medication reconciliation happens before discharge
- Schedule primary care follow-up within one week, maximum
- Conduct structured outreach calls, assessing symptoms and adherence
- Provide patients with direct contact numbers for clinical concerns
Data Integration Gaps
Hospitals, post-acute providers, and primary care physicians often operate incompatible electronic systems, creating information silos.
Solutions:
- Implement platforms aggregating data across all care settings
- Establish health information exchange connections
- Create standardized data sharing agreements with key partners
- Deploy care coordination software with mobile access for field TEAMs
Measuring Success in the TEAM Model
Financial Metrics
Track these critical financial indicators:
- Net Payment Reconciliation Amount: Final gain or loss after quality adjustments
- Spending Per Episode: Actual costs compared to target price by MS-DRG
- Post-Acute Spending Rate: Percentage of episode costs going to post-acute care
- Episode Volume: Number of triggered episodes in each category
Financial success requires consistently spending below target prices across multiple episode types while maintaining quality performance.
Quality Metrics
Quality scores directly multiply financial results, making them as important as cost management.
Monitor these measures:
- Readmission rates within 30 days of discharge
- Complication rates for covered surgical procedures
- Patient experience scores from post-discharge surveys
- Risk-adjusted mortality for included medical conditions
Lowering costs without meeting quality benchmarks results in financial penalties that can outweigh any savings.
Operational Metrics
Operational performance drives both financial and quality outcomes simultaneously.
Key operational indicators include:
- Length of stay compared to expected duration by diagnosis
- Discharge disposition mix across post-acute care settings
- Time to first post-discharge follow-up appointment
- Care coordination touchpoints completed per patient protocol
These metrics reveal exactly where workflows need strengthening to improve overall episode management effectiveness.
The Path Ahead
The CMS TEAM Model mandates coordinated performance in the domains of clinical care, care coordination, quality management, and post-acute collaboration. It requires organized pathways, combined technology, strategic post-acute networks, and proactive coordination to succeed. Having explicit roles, systematic processes, and data-driven knowledge, hospitals can transform episode accountability into a competitive advantage that enhances patient outcomes and financial robustness.
Persivia CareSpace®has built-in analytics, workflows of care coordination, and post-acute collaboration solutions that allow real-time monitoring and risk management through artificial intelligence.The TEAM Model participation can be transformed into quantifiable financial and clinical outcomes with CareTrak integration, which lowers readmissions, minimizes post-acute expenses, and maximizes reconciliation, making TEAM Model integration a viable approach to financial and clinical success.
FAQs
Q1: What is the main goal of the CMS TEAM Model?
The CMS TEAM Model aims to reduce total episode costs while maintaining or improving quality outcomes. Hospitals receive bundled payments and share savings if spending stays below target prices while meeting quality benchmarks.
Q2: How long does a typical TEAM Model episode last?
Most episodes span approximately 30 days from initial hospital admission. Specific timelines may vary depending on the MS-DRG code associated with the episode.
Q3: Can hospitals succeed in TEAM without advanced technology platforms?
No, manual tracking does not provide the real-time visibility and coordination needed for success. Integrated platforms are essential for monitoring costs, managing transitions, and coordinating care across settings.
Q4: What happens if hospital costs exceed the target price?
Hospitals absorb financial losses when episode costs exceed the target. The loss amount depends on how far spending surpasses the target and whether quality requirements are met.
Q5: Do post-acute care providers need to formally participate in TEAM?
No, formal participation isn’t required, but effective partnerships are critical. Coordinated care planning and data sharing with post-acute providers directly impact episode costs and patient outcomes.
