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Whitepaper

Winning Under TEAM: A Data-Driven Blueprint for Care Transition Excellence

724 hospitals are now financially accountable for the 30 days after a patient leaves the operating room — 874,000 episodes a year, 11% of all Medicare FFS inpatient volume. Nationally, nearly four in ten inpatient discharges are instructed to enter post-acute care. And the claims data says the difference between beating a target price and missing it isn’t how sick the patient was. It’s how well the handoff was executed.

  • 39.2% Share of Medicare FFS inpatient discharges instructed to enter post-acute care
  • 94.1% U.S. counties where the number of home health agencies serving FFS patients declined or held flat, 2019–2023

 

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The Problem

Under TEAM, execution is the variable — not acuity

TEAM measures total episode cost against a target price, plus quality outcomes including avoidable readmissions and ED utilization, for 30 days after discharge. Analysis of 100% of Medicare FFS claims through 2025 Q2 points to one consistent finding across all five covered episode categories: performance variation is driven by the operational execution of care transitions, not by clinical complexity.

  • Fragmented referral workflows, limited post-acute visibility, and delayed placements are the primary sources of avoidable cost and readmission exposure — the controllable half of TEAM performance.
  • Post-acute adherence correlates inversely with length of stay in every TEAM category — as strong as −0.63 in CABG and −0.47 in lower extremity joint replacement. Hospitals whose patients actually begin post-acute care as planned have shorter inpatient stays.
  • Capacity is contracting while accountability expands. Home health visits per patient day fell 17.3% between 2017 and 2023, and FFS home health admissions declined in 83.3% of U.S. counties. Hospitals can no longer rely on available capacity at the moment of discharge.
A green pamphlet tilted on a surface displays the title “Winning Under TEAM: A Data-Driven Blueprint for Care Transition Excellence” with Triella Health’s logo and additional details in white text.

The whitepaper covers:

What TEAM actually holds you accountable for

The five covered episode categories — LEJR, surgical hip and femur fracture, spinal fusion, CABG, and major bowel procedures — how total episode cost is measured against a target price, the quality measures that ride alongside it, and the 3-day SNF stay waiver most hospitals have not yet put to deliberate use.

Where the leverage sits, episode by episode

National average length of stay and 30-day readmission benchmarks for all five categories, plus correlation analysis identifying the primary transition lever in each — from home health referral timing in LEJR to SNF placement accuracy in CABG to real-time capacity visibility in hip and femur fracture.

The clinical capability gap CMS star ratings don't close

Why facility-level performance data on the post-acute providers in your market matters more than a star rating once you own the episode for 30 days — and how to evaluate partners on the outcomes you’re being measured on.

The TEAM Readiness Framework

Four levels of maturity — visibility, standardization, coordination, and optimization — with the specific capabilities that define each, so leaders can locate where their organization actually sits and what the next level requires.

Where AI-enabled intelligence becomes decisive action.

From market intelligence and CRM to care transition automation, Trella connects intelligence and workflows to improve business and clinical outcomes.

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