The CMS TEAM Model is a coordinated care episode generated by complex patients who demand various specialties. Hospitals can monitor the total cost of episode care, coordinate the transition of post-acute care, and enhance performance by using the integrated flow. The key to success is the implementation of advanced analytics, care coordination networks, integration of primary care, specialty care, and post-acute care, and streamlined communications.
The process of delivering healthcare to complex patients tends to resemble a puzzle with missing parts. Patients who jump between specialists, primary care practitioners, and post-acute facilities are not coordinated well enough. The CMS TEAM Model changes this approach by creating structured episodes of care that align all providers toward common quality and cost goals.
This value-based payment model holds hospitals accountable for 30-day episodes spanning inpatient stays through post-acute care. Rather than paying separately for each service, Medicare sets target prices for entire episodes. Hospitals that coordinate care effectively and stay under target prices share in savings. Those exceeding targets face financial penalties.
This formula works best with complex patients. These patients normally need several specialists, prolonged hospitalization, and a variety of post-acute care. They have a greater readmission rate, redundancy in services, and ineffective care transitions without appropriate coordination. The TEAM Model CMS framework overcame these difficulties by providing well-defined care pathways and effective shared responsibility among all providers.
What is the CMS TEAM Model?
The CMS TEAM Model is an optional value-based reimbursement scheme in which hospitals organize full episodes of care for certain medical conditions. Bundled payments allow hospitals to be released with payments that cover inpatient fees, physicians, and post-acute care over 30-day episodes.
Key Components:
- Episode Definition: 30-day periods starting with inpatient admission
- Bundled Payments: Single payment covering all episode services
- Quality Metrics: Specific performance measures hospitals must meet
- Shared Savings: Hospitals keep a portion of the savings below the target prices
- Risk Sharing: Hospitals pay penalties for episodes exceeding targets
This model includes five clinical episodes: acute myocardial infarction, coronary bypass surgery, hip/knee replacement, congestive heart failure, and chronic obstructive pulmonary disease.
How Does Multi-Disciplinary Care Coordination Work?
The Medicare TEAM Model involves multi-disciplinary coordination, which involves effective communication amongst all providers involved in patient care. All TEAM members share the same objectives in different episodes, but each of them can contribute their particular expertise.
Primary Care Integration
Primary care physicians act as episode coordinators, providing discharge planning and follow-up. They exchange information regarding the treatment plans with specialists and organize specific referrals.
Specialist Collaboration
Treatment approaches by cardiologists, orthopedic surgeons, and other specialists are aligned according to episode targets. They are involved in care planning meetings and scaling protocols as per the episode performance data.
Post-Acute Care Transitions
Skilled nursing care facilities, home health care agencies, and rehabilitation centers are provided with detailed plans of care. Hospitals make post-acute performance efficient and adjust partnerships based on quality outcomes.
Care Coordination Workflow:
- Pre-Admission: Risk assessment and care planning
- Inpatient Stay: Daily multidisciplinary rounds
- Discharge Planning: Comprehensive transition coordination
- Post-Acute Care: Ongoing monitoring and communication
- Episode Closure: Performance review and improvement planning
What Role Does Technology Play in Episode Management?
Through digital health platforms, episode performance at all care settings can be tracked in real-time. Such systems combine clinical data, financial information, and quality metrics in combined dashboards.
Advanced Analytics Features:
| Function | Purpose | Benefits |
| Real-time Dashboards | Monitor KPIs across episodes | Immediate performance visibility |
| Predictive Analytics | Identify high-risk patients | Proactive intervention |
| Cost Tracking | Monitor episode spending | Financial accountability |
| Quality Metrics | Track clinical outcomes | Continuous improvement |
| Care Coordination | Connect all providers | Seamless communication |
Healthcare systems use these platforms to:
- Track post-acute care spending and identify leakage
- Monitor gain/loss per episode against targets
- Generate custom reports for stakeholder review
- Coordinate care transitions between settings
- Capture social determinants affecting outcomes
How Do Hospitals Track Episode Performance?
Hospitals monitor multiple performance indicators throughout each 30-day episode. Success requires balancing cost control with quality improvement across all care settings.
Financial Performance Metrics:
- Episode Cost: Total spending vs. target price
- Post-Acute Spending: SNF, home health, and rehab costs
- Readmission Costs: Unplanned return visits
- Provider Leakage: Services from non-network providers
Quality Performance Indicators:
- Readmission Rates: 30-day hospital returns
- Patient Safety: Hospital-acquired infections
- Functional Outcomes: Mobility and independence measures
- Patient Satisfaction: HCAHPS scores
- Care Transitions: Discharge planning effectiveness
Successful hospitals typically achieve 10-20% reductions in episode costs while maintaining or improving quality scores. They accomplish this through better care coordination rather than service reduction.
What Are the Main Challenges in Complex Patient Care?
Complex patients impose special coordination issues that cannot be effectively resolved in a traditional fee-for-service model. These patients tend to come with numerous comorbidities that need the expert knowledge of different providers.
Common Coordination Barriers:
- Communication Gaps: Poor information sharing between providers
- Fragmented Systems: Separate IT platforms that don’t communicate
- Discharge Delays: Extended stays due to placement issues
- Readmission Risks: Inadequate transition planning
- Cost Overruns: Uncontrolled post-acute care spending
Patient Complexity Factors:
Episode outcomes are greatly affected by social determinants. Patients are also at increased risk of readmission when they have housing instability, poor transportation, and family support. To meet these challenges, hospitals do the following:
- Health risk assessments capturing social factors
- Care navigators addressing non-medical barriers
- Community partnerships providing support services
- Transportation assistance for follow-up visits
- Home-based care options reducing facility dependence
How Do Successful Hospitals Achieve Better Outcomes?
The best-performing hospitals integrate multifaceted care-coordination strategies that consider both functional and clinical elements of episode management.
Proven Success Strategies:
- Dedicated Care TEAMs: Assign specific TEAMs to episode patients
- Daily Huddles: Regular communication between all providers
- Standardized Pathways: Evidence-based care protocols
- Performance Monitoring: Real-time tracking of episode metrics
- Continuous Improvement: Regular review and protocol updates
Prime Healthcare Case Example: One major health system achieved remarkable results through systematic care coordination:
- $17 million saved across approximately 200 episodes
- 15% reduction in hospital readmissions
- 7% decrease in skilled nursing facility length of stay
- Enhanced reporting capabilities for data analysis
- Improved care quality through better coordination
These results demonstrate the financial and clinical benefits of effective episode management under the TEAM Model CMS framework.
What Technologies Support Episode Success?
Modern care coordination requires integrated technology platforms that connect all episode participants. These systems provide the analytics and workflow capabilities necessary for effective episode management.
Essential Technology Components:
- Integration Capabilities: Connect hospital, physician, and post-acute systems
- Real-Time Analytics: Monitor performance as episodes progress
- Care Coordination Tools: Facilitate communication between providers
- Quality Reporting: Track clinical outcomes and safety metrics
- Financial Tracking: Monitor costs against episode targets
AI-Driven Features:
Artificial intelligence helps advanced platforms to detect patients at risk of complications or readmission. Such systems perform clinical data analysis, social factors, and historical patterns to provide interventions.
Successful hospitals report that integrated platforms improve their ability to:
- Identify financial and clinical opportunities early in episodes
- Coordinate seamless transitions to post-acute care
- Generate custom reports for performance tracking
- Manage the total cost of care across all settings
- Promote health equity through comprehensive risk assessment
How Can Hospitals Prepare for TEAM Model Success?
Hospital preparation requires systematic changes to clinical workflows, technology infrastructure, and provider relationships. Success depends on creating coordinated care delivery across all episode participants.
Preparation Checklist:
- Technology Implementation: Deploy integrated care coordination platforms
- Staff Training: Educate TEAMs on episode-based care delivery
- Provider Partnerships: Establish relationships with quality post-acute providers
- Process Standardization: Create consistent care pathways
- Performance Monitoring: Implement real-time tracking systems
Partnership Development:
Hospitals must carefully select post-acute care partners based on quality performance rather than just cost. The best partnerships involve:
- Shared quality metrics and improvement goals
- Regular communication about patient progress
- Joint training on best practices
- Data sharing for performance improvement
- Aligned financial incentives
Final Thoughts
The CMS TEAM Model reflects an essential transition to coordinated, accountable practice of complex patients. To be successful, hospitals need to go beyond departmental silos that have traditionally been used and instead establish truly integrated care TEAMs.
Efficient episode management is a mix of state-of-the-art analytics, care coordination, and provider relationships. Hospitals that excel in these components save money considerably and, at the same time, enhance care outcomes of The model’s emphasis on 30-day episodes creates clear accountability for complete care delivery rather than individual services.
The coordinated care delivery structure established through the TEAM Model CMS offers an evidence-based system of value-based healthcare as it is currently being developed. Hospitals that spend resources on proper preparation, technology, and partnering become not only financially successful but also produce better patient care.
About Persivia
Persivia provides end-to-end support to the hospitals involved in the CMS TEAM model via our AI-powered CareSpace® platform.
Our unified digital health exchange provides the powerful analytics and care orchestration functionalities that top health systems deploy to deliver results. CareSpace helps hospitals monitor performance, manage costs, and improve quality on the whole episode with real-time dashboards, predictive analytics, and coordination workflows across care.
