TEAM Success Depends on How Well a Hospital Ensures Medicare Patients Get the 30-Day Episode of Care They Need

The Centers for Medicare & Medicaid Services (CMS) has made it clear that hospitals need to improve post-operative health outcomes for Medicare patients in 2026. Its Transforming Episode Accountability Model (TEAM) policy will reshape how care is coordinated and delivered to support Original Medicare patients from surgery through 30 days post-hospitalization.

CMS is specifically targeting patients undergoing one of five surgical procedures: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft, or major bowel procedures. Hospitals must improve care transitions between providers to ensure care completion, encouraging healthcare organizations to refocus efforts on coordination and scheduling processes, to deliver high-value care across the inpatient and post-acute settings.

This policy is hardly a suggestion. TEAM is mandatory, and it will run for five performance years from January 1, 2026, to December 31, 2030, in selected Core-Based Statistical Areas nationwide, requiring more than 700 hospitals to participate. Essentially, CMS has incentivized care coordination by placing accountability for episodic care costs directly on hospitals, with the goal of minimizing care fragmentation, reducing the risk of avoidable readmissions, and lowering Medicare spending.

Of the hospitals required to participate, it is estimated that up to two-thirds may lose revenue under TEAM, according to a Brandeis University analysis. Hospital leaders already know a single readmission can push an episode over the target; therefore, preventing post-operative complications and ensuring timely follow-up with providers have become core revenue-protection strategies, not optional improvements.

Value-based care forges ahead

At the heart of this policy is value-based care (VBC). For too long, Medicare patients in the hospital or outpatient settings have navigated a maze of disconnected appointments and providers. Poor care coordination, scheduling delays, missed follow-ups, and gaps in communication lead to fragmented care that slows recovery, increases complications, and drives costs through emergency room utilization. These challenges are rooted in the traditional fee-for-service (FFS) payment model, which often leads to duplicated use of resources and nominal health outcomes.

However, TEAM should change the trajectory of post-operative care fragmentation for Medicare patients for the aforementioned surgical procedures. This model requires healthcare leaders to rethink patient journeys from end to end, including post-acute care.

Hospital executives and provider network leaders should investigate and onboard systems that reduce friction between discharge and follow-up care, ensuring care completion between providers and giving clinical teams visibility into referral completion. This longitudinal view also maintains documentation that satisfies continuity of care requirements.

To help eliminate care fragmentation, leaders should also prioritize solutions that drive referral-to-appointment completion for care loop closure, which ensures more patients receive post-surgical care to avoid complications. Scheduling post-discharge appointments in real time for Medicare beneficiaries will not only ensure TEAM compliance but will also bolster patient experience and build confidence as they leave the hospital with follow-up care already in place.

Smart provider matching at the point of care can also retain more referrals by keeping patients in-network. A unified workflow for all referrals, resulting in fewer clicks and less confusion, means provider matching can be conducted based on specialty, location, insurance, and real-time availability, for an easier track to the right provider, not just any provider. Having the ability to quickly book appropriate appointments and maintain complete visibility into patient transitions and care encounter completion is critical for the TEAM 30-day window.

Photo: gustavofrazao, Getty Images

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