As the Centers for Medicare & Medicaid Services (CMS) Transforming Episode Accountability Model (TEAM) approaches its second year, one lesson is clear: a 30-day episode doesn’t end when the patient leaves the hospital. In an October webinar, Bamboo Health experts shared insights into how health systems and home health agencies can optimize care transitions.
What Is the CMS TEAM Model?
TEAM is a mandatory, retrospective, episode-based payment model that launched in 2026. Nearly 720 hospitals were selected to participate. Each is accountable for the total cost and quality of an episode: the surgery plus 30 days after discharge, including post-acute care such as skilled nursing and home health.
The model covers five surgical categories: coronary artery bypass grafts, lower-extremity joint replacements, major bowel procedures, surgical hip and femur fracture treatment, and spinal fusions. Joint replacement and spinal fusion count in both inpatient and hospital outpatient settings.
Providers keep billing Medicare fee-for-service. Afterward, CMS compares each hospital’s episode spending to a CMS-established target price that includes a 1.5% to 2% discount. The amount of any reconciliation payment depends on the applicable target price, episode spending, and model rules. Accurate documentation and coding of supported diagnoses can affect risk adjustment and the applicable target price.
The Health System View: Pivotal Moments Across Each Care Event
- Before surgery: Pre-op visits that document clinically supported conditions improve risk adjustment. Site-of-care analytics flag joint and spine cases that could move to the lower-cost outpatient setting.
- In the hospital: Next-site-of-care analytics help step patients down when appropriate, such as from a skilled nursing facility (SNF) to home health. Readmission risk models show who needs extra support.
- After discharge: Real-time notifications help care managers monitor SNF stays, support timely home health starts and help address potentially avoidable emergency department (ED) visits.
- Throughout: Real-time and claims-based reporting track spending against target prices, so teams can identify root causes and adjust quickly.
The Home Health View: Provider Pressure Flows Downstream
TEAM is a hospital-based model, but much of each episode occurs in the home. Home health agencies should expect four shifts:
- Preferred-provider pressure. Hospitals will narrow their networks and steer referrals toward agencies with low readmissions and predictable costs.
- More billing complexity. Home health services furnished during the applicable episode window may contribute to episode spending, so precise dates matter.
- A bigger coordination role. Hospitals will expect partners to be their eyes and ears after discharge.
- Closer audit scrutiny. Episode spending is measured against the applicable target price, making accurate documentation important.
The pressure is real, but so is the opportunity. Agencies that prepare now can become the partners hospitals rely on.
Turning Pressure Into A Referral Advantage With TEAM
As TEAM progresses, hospitals will gain more information about which partners support their episode goals. Agencies are using Bamboo Health’s Pings™ solution to stand out:
- Track patients in real time. Admission, discharge and transfer (ADT) alerts flag an ED visit or readmission as the underlying event information becomes available.
- Prove outcomes. Objective rehospitalization and response-time data speak directly to hospital metrics.
- Close the communication gap. Tell partners when a patient is stable or needs escalation.
- Bring a scorecard. Share outcomes data at quarterly business reviews to show why you’re the partner of choice.
What Leading Agencies Do in Practice
Leading home health clients follow a streamlined workflow:
- A morning Pings review. A clinical manager flags hospitalized patients so the team can tell the hospital case manager which services the patient receives at home. Resumption orders are ready, so care restarts without delay.
- Re-engaging recent patients. Alerts for patients discharged from the agency’s care within 90 days can support follow-up and continuity for patients who already know the team.
- Supporting appropriate follow-up after an ED visit. When a patient presents to the ED for a condition that can be treated at home, the team follows up and helps coordinate appropriate next steps.
- Front-loading visits. After a hospital stay, surgery or fall, the agency adds visits to keep the patient safely at home
This all helps care teams spend less time tracking down services for their patients.
Frequently Asked Questions: Adhering to TEAM Requirements
Q: Does TEAM apply to every hospital?
CMS required nearly 720 hospitals to take part, and a few others joined voluntarily. Even so, home health agencies and other post-acute providers that work with those hospitals are affected because the hospitals are accountable for cost and quality across the full 30 days after surgery.
Q: Does a home health agency need to be in TEAM to be affected by it?
Agencies don’t contract with CMS under TEAM, but their results count toward the hospital’s episode cost. Hospitals will look more closely at readmission rates, how quickly agencies initiate care, and how well they communicate when choosing post-acute partners.
Q: How is home health counted in a TEAM episode?
Home health services furnished during the applicable TEAM episode window may contribute to the hospital’s episode spending. That makes accurate admission and discharge dates important for avoiding disputes with hospital partners.
Q: What should home health agencies do to prepare for Year 2?
As TEAM progresses, hospitals will gain additional information about partner performance. Agencies should be ready to show objective outcomes, such as rehospitalization rates and response times. They should also have a way to quickly notify hospitals when a patient is stable or needs escalation.
Q: How do health systems know which patients are in a TEAM episode?
With our Pings solution, patients who qualify for a TEAM episode are automatically added to the health system’s patient list, with no manual work. They drop off 30 days after the episode ends, allowing care managers to focus on patients in the active window.
Q: Where can health systems have the most impact on episode costs?
Common levers include:
- documenting conditions accurately before surgery so risk adjustment reflects the true patient population
- moving eligible joint and spine procedures to the outpatient setting
- sending patients to the lowest-cost setting that’s right for them after discharge
- watching closely for emergency visits and readmissions during the 30 days
Q: How quickly do TEAM-related alerts arrive?
Alerts are delivered after the underlying admission, discharge or transfer event is received and processed. Care teams can step in before a missed visit or a readmission drives up episode costs.
Q: If I use Pings today, can I see who is in our census?
A Census Status filter on the Patient Roster and Ping Feed will let home health agencies, hospices and SNFs include or exclude statuses such as Admitted, Discharged, Transferred or Resumed Services. Saved filters can trigger email or SMS notifications, and exports include a new Census Status column.
Looking Ahead
TEAM’s 30-day accountability is reshaping referral relationships across the care continuum. Health systems that invest in real-time visibility can better manage cost and quality, and home health agencies that prove their outcomes will become the partners hospitals turn to first.
To learn more about preparing for TEAM requirements, watch the full webinar recording here or contact us.
