Starting January 2026, the Centers for Medicare & Medicaid Services (CMS) will launch the Transforming Episode Accountability Model (TEAM) – a mandatory five-year initiative designed to improve surgical episode outcomes and lower Medicare spending.
For hospitals selected to participate, TEAM introduces a new level of accountability: financial responsibility for the entire recovery episode, not just the surgery. This includes post-acute care (PAC) – where clinical and financial risks are often highest. To succeed, hospitals will need real-time visibility into post-discharge care to enhance coordination, improve outcomes, and manage costs effectively.
TEAM’s impact on hospitals and post-acute collaboration
TEAM focuses on five high-volume, high-cost surgical procedures: lower extremity joint replacement, surgical hip/femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedures. Each episode concludes 30 days post-discharge, with CMS evaluating hospitals based on:
- Quality Measures: Readmissions, safety indicators, and patient-reported outcomes
- Cost Performance: Actual Medicare spending compared to CMS target prices
Hospitals that meet quality benchmarks while staying below target costs will earn incentive payments; those exceeding targets may face financial penalties. Because much of the episode’s cost and risk occurs after discharge, success hinges on strong collaboration with post-acute partners.
Under TEAM, hospitals must move beyond reactive care management. Success will require real-time alignment between acute and post-acute teams – ensuring every post-discharge decision supports both quality outcomes and financial sustainability.
The visibility gap hindering care coordination
Once patients transition to PAC, hospitals often lose visibility into recovery. Traditional data sources – such as claims data and Minimum Data Set (MDS) assessments – arrive weeks or months after care is delivered, making them useful only for retrospective analysis.
This delay creates critical challenges, making it difficult to identify complications early, evaluate post-acute partners’ performance, and coordinate care effectively. Hospitals often remain unaware of issues until a patient is readmitted or visits the emergency department – by then, it’s too late for early intervention.
These gaps not only impact hospital outcomes but also leave post-acute partners without the real-time insight needed to adjust care plans, manage high-risk patients, and demonstrate value in shared accountability models like TEAM.
TEAM Insights: actionable data driving better care outcomes
TEAM Insights, developed by Real Time Medical Systems (Real Time), addresses these challenges by equipping hospitals and care teams with live clinical data from post-acute electronic health records (EHRs). Using interventional analytics, TEAM Insights continuously monitors structured and unstructured data, detecting subtle clinical changes – such as shifts in vital signs, mobility decline, medication issues, or early signs of infection – and alerts care teams for immediate action.
Real Time’s proprietary AI-based CARD readmission risk score stratifies patient populations and evaluates post-acute network performance, helping to identify high-performing partners and those needing additional support. By providing real-time insights and clinical alerts with suggested interventions, TEAM Insights enables hospitals to act early – before adverse events or hospital readmissions occur.
Post-acute facilities using Real Time's solution have achieved:
- 50% reduction in hospital readmissions (avg.)
- 40% reduction in length of stay (avg.)
With average Medicare readmissions costing $15,200 and inpatient days averaging $3,025, these reductions translate into significant savings per episode of care.
As hospitals and post-acute partners prepare for TEAM, the ability to see beyond discharge is no longer optional – it’s vital. TEAM Insights helps turn accountability into a proactive strategy, aligning care teams around shared visibility to drive better patient outcomes.
For more information, visit www.realtimemed.com.