Imagine being responsible for the full 30-day post-discharge care of your surgical patients, including costs and outcomes. This isn't a hypothetical scenario; it's the reality of the TEAM initiative, launching in 2026. Time is running out to prepare for this new mandate.
Managing the recovery process after surgery can be daunting, especially for individuals undergoing procedures like ostomy surgery. Post-discharge management plays a pivotal role in measuring patients' successful recovery, reducing avoidable complications, and enhancing long-term quality of life. Recognizing these challenges, the Transforming Episode Accountability Model (TEAM) initiative was developed to improve care coordination and support, specifically targeting episodes of care for Medicare beneficiaries. TEAM aims to minimize fragmented care by ensuring that patients are given the right support throughout their recovery process, reducing unnecessary emergency department (ED) visits and hospital readmissions.
What Is the TEAM Initiative?
The Transforming Episode Accountability Model (TEAM) is a mandatory, episode-based alternative payment model introduced by the Centers for Medicare & Medicaid Services (CMS). Starting January 1, 2026, TEAM will require selected acute care hospitals to assume responsibility for both the cost and quality of care for patients undergoing five specific surgical procedures, including ostomy-related surgeries. The initiative is designed to enhance care transitions and ensure that patients receive consistent, high-quality care after their hospital discharge.
The model will span five years, ending December 31, 2030, and will build on earlier efforts to improve care coordination, such as the Bundled Payments for Care Improvement Advanced and Comprehensive Care for Joint Replacement (CJR) models. The goal is to reduce avoidable readmissions, improve patient outcomes, and encourage hospitals to work more closely with primary care providers to ensure ongoing care and support.
Key Features of the TEAM Model
- Targeted Surgical Procedures: TEAM focuses on improving the care of patients undergoing specific surgical procedures. For new ostomates, the most relevant procedure in the context of post-discharge care is the major bowel procedure, which is part of the initiative. Other included procedures include lower extremity joint replacements, spinal fusion, surgical hip femur fracture treatments, and coronary artery bypass grafts.
- Post-Discharge Accountability: For the first 30 days after discharge, hospitals taking part in the TEAM initiative will be held accountable for the total cost of care associated with the episode, which includes both the hospital stay and post-discharge services. This could involve follow-up visits with primary care providers, skilled nursing facility stays, and any other necessary outpatient services. This comprehensive approach aims to ensure that patients receive the necessary support throughout their recovery, ultimately improving their long-term health outcomes.
- Financial Incentives and Risk Sharing: TEAM participants will receive a target price for each episode of care. This price reflects the expected Medicare costs for the entire episode, including surgery, hospital stays, and all services following discharge. By linking payments to the total cost of care, CMS aims to incentivize hospitals to improve care coordination, reduce waste, and prevent avoidable readmissions and complications.
- Hospitals that manage to provide high-quality care while staying below the target price may receive a financial reward from CMS, while those exceeding the target price may need to repay a portion of the funds. The model will also incorporate quality performance adjustments to ensure that hospitals focus on providing high-quality care, not just cutting costs.
Additional Model Design Features
- Participation Tracks and Financial Risk: To ensure that hospitals of all types can participate, TEAM will feature three participation tracks, each with varying levels of financial risk:
- Track 1: No downside risk for the first year or up to three years for safety-net hospitals. This track offers lower levels of reward.
- Track 2: For safety-net or rural hospitals, with lower risk and reward for years 2 through 5.
- Track 3: Higher levels of risk and reward for hospitals taking part from years 1 through 5.
- These tracks allow hospitals to ease into the financial aspects of the model and participate in a way that aligns with their capabilities and resources.
- Performance Evaluation and Quality Adjustments: Performance in the model will be assessed by comparing actual Medicare costs to the target price and through the evaluation of specific quality measures. Hospitals will be incentivized to provide high-quality care, with adjustments made based on their performance in these areas. High-quality, cost-effective care will result in financial rewards, while deficient performance could result in repayment obligations.
The Role of Education in TEAM
The success of TEAM depends heavily on patient education, especially for those with new ostomies. With the right information and support, ostomates can manage their recovery at home more effectively, reducing complications and the need for additional medical interventions. The TEAM model acknowledges this by promoting enhanced educational resources and communication between patients and providers.
Benefits of TEAM for New Ostomates
The TEAM initiative is poised to significantly help patients, particularly those who are newly managing an ostomy. By ensuring that hospitals are incentivized to coordinate care across all stages of recovery, from surgery through the first 30 days post-discharge, the model aims to:
- Enhance Continuity of Care: Ensuring that patients have consistent follow-up appointments with primary care providers and other specialists as needed.
- Improve Quality of Life: Education and resources aimed at empowering patients with the knowledge and confidence to care for their ostomy at home.
- Reduce Avoidable Readmissions and ED Visits: With more comprehensive post-discharge care, patients are less likely to experience complications that could lead to unnecessary ED visits or readmissions.
- Encourage Proactive Care: By holding hospitals accountable for both cost and quality, TEAM encourages the prevention of complications, improving the patient’s experience and long-term health outcomes.
Enhancing Post-Surgical Care with HRS RPM and WoundConnect
The challenges in post-discharge management, particularly for surgical patients like new ostomates, as highlighted by the upcoming TEAM initiative, necessitate innovative solutions to improve recovery and reduce negative outcomes. Remote Patient Monitoring (RPM), offered by Health Recovery Solutions (HRS), plays a crucial role in addressing these challenges by enabling early identification of complications, including infections, and proactively preventing unnecessary rehospitalizations and emergency department (ED) visits.
HRS provides RPM solutions that go beyond basic biometric data collection. Features such as the camera capability for patients to take images of wounds, edema, skin rashes, etc., allow for the remote assessment of surgical sites for early signs of infection like redness, swelling, or purulent drainage. This visual data, combined with the ability to track and trend biometric data such as temperature, blood glucose, pulse ox, etc., can provide clinicians with prompt alerts to potential issues before they escalate.
Furthermore, the integration of HRS with expert standardized wound care through the WoundConnect program provides a comprehensive approach to post-surgical wound management. HRS WoundConnect leverages a partnership with Corstrata, bringing the expertise of their Wound and Ostomy Certified Nurse (WOC) Consultants to your organization.
HRS WoundConnect facilitates direct-to-clinician consultation, utilizing standardized, evidence-based wound recommendations by care setting and wound type. This ensures that any concerns identified through RPM, such as potential infection, are promptly addressed with expert guidance on appropriate interventions, potentially preventing the need for hospital readmission or an ED visit. The presence of WOC nurse-led wound care has been shown to quadruple the probability of healing (80% vs 18%), significantly decrease adverse events and hospital readmissions, and reduce the number of treatment weeks.
The ability to conduct virtual visits through the HRS platform further enhances care coordination, allowing multiple disciplines and providers to collaborate on a patient's care plan remotely. This is particularly beneficial in the post-surgical period, where timely communication and adjustments to the care plan can significantly improve healing, adaptation, and prevent complications. For the ostomate, strategically scheduled video visits provide comprehensive ostomy care education, including pouching system recommendations, troubleshooting ostomy concerns, and fluid and nutrition education with monitoring to address a primary cause of ostomate readmissions of dehydration.
By leveraging RPM for early detection and the expert wound care knowledge embedded in HRS WoundConnect, healthcare organizations can proactively manage post-surgical patients, leading to:
- Earlier identification of infections and other complications, allowing for prompt intervention.
- Reduced risk of hospital readmissions and ED visits through proactive management and expert guidance.
- Improved patient outcomes with evidence-based treatment protocols and enhanced monitoring.
- Better care coordination through virtual visits and seamless data sharing.
As hospitals prepare for initiatives like TEAM, integrating HRS WoundConnect with robust RPM capabilities offers a powerful strategy to enhance post-discharge management, improve patient outcomes, and achieve the goals of reducing readmissions and improving the quality of care. The combination of technology, expert clinical support, and a focus on standardized, evidence-based care provides a comprehensive solution to the growing challenges in post-surgical care and wound and ostomy management.
Ready for 2026? Your Action Plan for TEAM Success
The Transforming Episode Accountability Model (TEAM) represents a significant shift in how hospitals manage post-discharge care, especially for patients who have undergone major surgeries such as ostomy procedures. By ensuring that hospitals are incentivized to coordinate care more effectively and promoting continuity of care, TEAM can potentially improve both clinical outcomes and patient experience. Integrating solutions like HRS WoundConnect with robust RPM capabilities further enhances this potential, providing a comprehensive approach to post-surgical care. As TEAM takes shape and hospitals begin their participation in 2026, it will offer new opportunities for hospitals, patients, and healthcare providers to collaborate more closely to improve the recovery process for ostomates and reduce avoidable complications.
Your Next Step: Preparing for TEAM with HRS RPM and WoundConnect
Our goal is to improve the lives of patients and support the surgeons and organizations that care for them. Reach out today to explore how HRS can help with your TEAM initiatives, position your organization for success, and achieve better outcomes for your patients.
TEAM Resources Available
- Find out if your hospital is included by checking the TEAM Participant List
- Team Overview Webcast: The 50-minute webcast presents information about TEAM, including episode definitions, pricing and payment methodology, and additional resources to support participants. The webcast recording, slides, and transcript are available on TEAM’s webpage.
- Team FAQ's: TEAM Frequently Asked Questions (FAQ) webpage addresses common questions about TEAM. Questions and answers are organized by topic and cover the following aspects of TEAM: General, Eligibility, Point of Contact, Voluntary Opt-in Opportunity, Care Delivery/Quality Strategy, Episodes/Payment, Model Overlap, and Learning System/Technical Assistance.