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Starting January 1st, 2026, the CMS Transforming Episode Accountability Model, or TEAM, goes into effect for certain acute care hospitals. Considering this program is mandatory, having a game plan to manage it is essential!
Care coordination software supports TEAM’s clinical goals, including improving transitions of care, enhancing care coordination, reducing readmissions and complications, and managing chronic conditions.
TEAM emphasizes coordination, data-driven care, and post-acute engagement, which are all strengths of care coordination software like ThoroughCare.
Episode Management & Care Planning
TEAM requires hospitals to manage entire surgical episodes, from pre-op through post-acute care and primary care follow-up. The Transitional Care Management, or TCM, program supports a patient post-discharge through automated workflows and follow-ups.
Care coordination software allows you to create, share, and update care plans tailored to surgical episodes. This includes tracking goals, barriers, interventions, and progress that align with TEAM’s episode timeframe.
Data Integration & Interoperability
TEAM success relies on accurate, real-time patient data, such as medications, labs, and diagnoses, for decision-making. Having data integration and interoperability is a necessity. Care coordination software integrates with electronic health records, health information exchanges, and devices to pull diagnoses, medication lists, allergies, and labs. This creates a centralized patient record for all care team members and helps hospitals meet CMS requirements for informed care decisions.
Care Coordination and Patient Engagement Across Settings
TEAM requires hospitals to coordinate with post-acute providers and primary care. With care coordination software, care plans can be shared across organizations. Transitions of care are tracked to ensure follow-up appointments occur. Educational materials can be provided to help empower patients and teach them about resources for recovery and lifestyle changes. Ongoing support can also be offered through telehealth and messaging.
Quality Measure Tracking
TEAM’s financial rewards are tied to quality performance, such as reducing readmissions and complications. TEAM uses target prices and retrospective reconciliation, so cost overruns can directly impact your margins.
Care coordination software has analytics with quality metric dashboards to help monitor performance in real-time. High-risk patients can be identified early to prevent avoidable readmissions and penalties. Reports can be generated to forecast performance against target benchmarks. This allows for documentation support for CMS to help show compliance.
As you can see, care coordination software can be a big help with the implementation of TEAM. Reach out to to us today to learn how we can help with the transition.
