The Centers for Medicare & Medicaid Services (CMS) is accelerating its commitment to value-based care with the launch of the Transforming Episode Accountability Model (TEAM) — a mandatory bundled payment model for selected hospitals aimed at improving care quality and reducing costs for surgical episodes. TEAM is part of a broader movement toward value-based care models, which incentivize healthcare organizations to improve quality, control costs, and advance equity. As healthcare shifts from volume to value, post-acute care (PAC) organizations are finding themselves at a critical inflection point.
Under TEAM, hospitals are not only financially accountable for patient care during inpatient stays, but also for outcomes up to 30 days post-discharge. CMS aims to transform payment models, improve care quality, and promote health equity through initiatives like TEAM. Hospitals must carefully evaluate which partners can help them meet performance benchmarks under TEAM. PAC organizations that cannot demonstrate data-driven value will increasingly lose referrals to those that can.
Understanding the TEAM Model: A New Standard for Accountability
The TEAM model focuses on five high-volume, high-cost surgical procedures and places responsibility for total episode spending and outcomes squarely on participating hospitals. The selected hospitals are mandated by CMS to participate in the episode based payment model and cannot opt out.
The TEAM model uses participation tracks, each with different levels of financial risk and reward, including upside and downside risk. These participation tracks allow hospitals to choose a track that aligns with their capacity for risk, with some tracks offering upside only risk in the first year and others introducing downside financial risk as hospitals progress.
Unlike previous models, TEAM expands the definition of accountability beyond hospital walls. Financial incentives and value-based programs motivate health care providers and accountable care organizations to improve patient outcomes, reduce costs, and enhance care quality. Hospitals are now incentivized, financially and operationally, to form relationships with high-performing PAC providers who can contribute to lower readmission rates, shorter recovery times, and better patient outcomes across the entire 30-day episode window.
This redefinition of responsibility creates both pressure and opportunity for PAC organizations. Those that can align with TEAM hospitals’ performance goals will be better positioned to grow referral networks, demonstrate value, and improve patient outcomes.
The Strategic Imperative for PAC Providers
The challenge for many PAC organizations lies not in knowing which hospitals are participating in TEAM, but in identifying which of those hospitals represent the most strategic fit for collaboration. PAC providers need more than just basic referral data. They require granular, episode-level insights to guide partnership development, optimize discharge planning, and align care strategies with hospital goals.
Specifically, PACs must be able to:
- Identify hospitals participating in TEAM within their service area
- Understand Diagnosis Related Group (DRG)-specific performance metrics tied to surgical episodes
- Pinpoint patient populations at higher risk of poor outcomes or readmission
- Align with hospitals’ cost and quality goals under the TEAM framework
- Tailor outreach and care coordination efforts to support surgical recovery
- Understand quality measures and hospital inpatient quality reporting requirements to align with hospital performance goals
In this new landscape, data becomes a competitive differentiator. PAC organizations that use episode-level analytics to demonstrate how they reduce avoidable costs and improve recovery outcomes will emerge as preferred partners for TEAM hospitals. Emphasizing patient engagement and tracking patient reported outcomes are also critical for demonstrating value, improving the patient experience, and meeting the quality expectations of TEAM hospitals.
How Data-Driven Insights Unlock Strategic Growth Between Health Systems and PAC Providers
To succeed in the TEAM model, PAC providers must not only deliver high-quality care but also communicate their impact in measurable terms. This requires access to reliable data that highlights how their services contribute to reducing readmissions, minimizing length of stay, and improving recovery outcomes across surgical episodes. Hospitals are evaluated against target prices set by CMS for each episode, and if their total episode spending falls below the target price while maintaining quality standards, they can earn a positive reconciliation payment as a financial incentive.
The ability to present DRG-specific metrics, benchmarked against TEAM performance criteria, allows PAC providers to move beyond general claims of quality and into the realm of quantifiable value. Achieving successful outcomes, improving health outcomes, and supporting long term health outcomes for surgical patients are essential for demonstrating value and aligning with value-based care goals. These insights not only support more effective referral development strategies but also drive stronger alignment with hospital care pathways and discharge planning goals.
Supporting Smarter Partnerships and Care Coordination with TEAM Metrics
For PAC providers seeking to become essential partners in value-based care, data intelligence is no longer optional; it is foundational. This is where Trella Health’s TEAM Metrics provide a critical advantage.
Trella Health offers the ability to:
- Identify which hospitals are participating in the TEAM model through the Trella TEAM Metrics
- Access DRG-specific data tied to surgical episodes, including key indicators like length of stay, readmission rates, and patient volumes
- Evaluate episode-level performance metrics to uncover high-impact partnership opportunities
- Align care delivery strategies with the specific performance goals of TEAM hospitals
- Build data-supported outreach strategies that position the PAC organization as a top-performing, accountable care partner
- Refer patients to primary care services and support longitudinal care management for surgical patients after discharge, ensuring care continuity, reducing readmissions, and enhancing long-term health outcomes
By leveraging these capabilities, PAC providers can confidently approach TEAM hospitals with actionable insights that demonstrate their value and relevance in a competitive, performance-based care environment.
Conclusion
As CMS drives forward with mandatory models like TEAM, the healthcare industry is entering a new phase of performance accountability, one that extends beyond hospital walls into the post-acute care continuum. For PAC providers, this is a decisive moment.
Those who can harness episode-level data, align with hospital goals, and demonstrate quantifiable impact will thrive in the TEAM environment. Those who cannot will face increasing difficulty sustaining referral volume and market relevance.
Trella Health’s TEAM Metrics equips post-acute care organizations with the insights they need to navigate this shift successfully. By turning data into strategy, PAC providers can build smarter partnerships, improve surgical episode outcomes, and secure their place in the future of value-based care.
To learn how TEAM Metrics can help your organization grow through strategic, data-backed partnerships, request a demo of Trella Health today.
