CMS TEAM Model: How To Win In The New Bundled Payment Era

Medicare requires surgical episodes to be paid under the CMS TEAM Model, a mandatory bundled payment initiative starting in 2026 for selected acute care hospitals. It makes hospitals answerable for the quality and expense of care from admission through 30 days post-discharge. To be successful, providers need to promote fairness, coordinate across settings, track episode-level expenses in real-time, and expedite SNF transitions. Workflows for care and analytics powered by AI are crucial. Intelligent digital systems enable hospitals to enhance clinical and financial performance in addition to maintaining compliance.

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Value-based care is becoming a fundamental necessity rather than an option. One prominent example of this shift is the CMS TEAM Model (Transforming Episode Accountability Model), which requires hospitals to assume accountability for the full episode of care, not just for operations. Post-acute transitions and 30-day readmissions are increasingly covered by bundled payments, so providers require real-time knowledge, smooth coordination, and equity-focused tactics.

Platforms that streamline processes, facilitate cross-team collaboration, and provide intelligent automation are essential for hospitals that want to succeed. The key to meeting cost, quality, and compliance goals is selecting the appropriate digital health platform. Failing to adjust could result in missed savings opportunities and financial fines.

Exploring All About CMS TEAM Model 

The CMS TEAM Model represents Medicare’s latest step toward value-based care. This bundled payment framework combines all associated expenditures during a care episode into a single payment rather than paying for each service separately. This covers the surgical procedure, the 30-day post-discharge time frame, and the inpatient stay.

Hospitals must maintain care quality and equitable results while maintaining costs within CMS guidelines. TEAM will be mandatory for selected hospitals based on procedure volume, geography, or other CMS-defined factors, so preparation is non-negotiable.

End-to-End Support for Episodic Models

Hospitals must have infrastructure that supports care outside of their walls in order to be successful under the TEAM Model CMS. This entails using shared insights and optimized workflows to coordinate the activities of inpatient, post-acute, and outpatient physicians. Under this architecture, manual systems and compartmentalized EHRs are unable to offer the flexibility required to satisfy CMS requirements.

TEAM performance depends on smooth coordination throughout the entire continuum of care, not only on financial criteria. Timely handoffs, patient education, SNF supervision, and open communication with every member of the care team are all essential components of episode-based management. Hospitals must be equipped to deliver quality and efficiency throughout the full care cycle.

A comprehensive platform purpose-built for episodic models provides the necessary support for hospitals to meet CMS expectations. Hospitals must move beyond isolated systems and adopt integrated platforms that align financial, clinical, and equity goals.

Full Program and Cost Management

Hospitals need visibility across entire episodes:

• Monitor the total cost of care across care settings
• Identify high-cost areas and control post-acute leakage
• Track outcomes alongside financial performance

Real-Time Performance Tracking

Timely insights are vital to keep care and spending aligned with CMS benchmarks:

• Live dashboards show key performance indicators
• Custom reports track spend versus targets and NPRA positioning
• Alerts help avoid unplanned readmissions and over-utilization

Advanced Analytics for Accurate Insights

Analytics serve as the foundation for accountability under the CMS TEAM Model. Good platforms convert data into insights that can be used to make decisions.

Custom Reporting

Hospitals require access to reports that:

• Break down episode spend per patient
• Compare real-time vs. benchmark performance
• Forecast gain/loss outcomes for CMS reconciliation

Risk Stratification and Insights

AI-driven analytics improve decision-making by:

• Predicting complications and high-cost cases
• Identifying opportunities for earlier interventions
• Supporting personalized care planning

AI-Driven Care Coordination Workflows

The TEAM approach places a strong emphasis on care transitions. To decrease costs and enhance results, primary care, specialists, and post-acute providers must coordinate handoffs.

Collaboration Across Settings

Integrated workflows promote:

• Seamless communication across care teams
• Better discharge planning and therapy alignment
• Reduced duplications and fewer readmissions

Real-Time Clinical Alerts

Care teams receive:

• Immediate alerts for therapy delays or SNF overuse
• Risk flags for readmissions or complications
• Prompts for follow-up and mobility tracking

Promoting Health Equity Across Episodes

Health equity is a formal performance domain under the TEAM Model CMS. Hospitals cannot achieve high-performance scores without proactively addressing disparities in care access, delivery, and outcomes. Meeting equity standards is now just as critical as controlling spending.

Data collection and interpretation must go deeper than clinical vitals. Racial, ethnic, linguistic, socioeconomic, and other social determinants of health must all be supported by a complete digital health platform. With the aid of equity dashboards, underprivileged groups can be guaranteed prompt follow-up, well-coordinated discharges, and focused treatments that enhance long-term results.

Equity is a measurable performance domain under the Medicare TEAM Model. Addressing health disparities is no longer optional. It’s a core performance indicator.

Health Risk Assessments

Hospitals can close equity gaps by capturing:

• Medical history and personal demographics
• Social risk factors impacting recovery

Equity Analytics

With the right platform, hospitals can:

• Track equitable outcomes across population groups
• Adjust care based on social and clinical risk
• Align with CMS health equity benchmarks

Seamless PAC Transitions and Point-of-Care Support

The quality of post-acute care (PAC) influences both costs and outcomes under TEAM. Managing transitions and therapy programs can be the difference between shared savings and financial penalties.

SNF and Therapy Monitoring

Hospitals must track:

• SNF LOS per patient
• Types and frequency of therapy delivered
• Recovery metrics to ensure timely discharge

Point-of-Care Intelligence

Clinicians need:

• Access to up-to-date history and clinical notes
• Tools that guide decisions based on patient milestones
• Systems that surface at-risk patients early

Wrap Up

The CMS TEAM Model redefines how hospitals are evaluated and reimbursed. Effectively managing entire episodes, advancing equity, coordinating care across many settings, and utilizing real-time information are becoming necessary rather than elective.

Hospitals must proactively implement infrastructure that supports CMS’s objectives for equity, cost containment, and quality. As 2026 draws near, prompt planning makes the difference between an organization’s success and failure.

Why CareSpace® is the Right Move Forward

Persivia CareSpace®, an intelligent Digital Health Platform, offers hospitals a powerful combination of analytics, automation, and care coordination to excel under the CMS TEAM Model. With proven results in reducing costs and improving episode outcomes, CareSpace® is the trusted choice for organizations seeking value-based success.