CMS TEAM Mandate: 5 Steps to Building a High-Performing Post-Acute Care Network

As value-based care continues to shape healthcare delivery, the transition from hospital to post-acute care is critical for a patient’s recovery. The CMS TEAM (Transforming Episode Accountability Model) initiative aims to enhance care coordination and reduce readmissions for five common standard procedures by fostering stronger collaboration between acute and post-acute care providers.

Understanding CMS TEAM

The CMS TEAM initiative is a mandatory value-based care model that seeks to transform healthcare provider collaboration. Specifically, it aims to bridge the gap between acute and post-acute care, ensuring quality transitions to help improve patient recovery and cost control. The initiative focuses on care coordination and reducing readmissions for five standard procedures by fostering stronger collaboration between acute and post-acute care providers. Having a high-performing post-acute network is an essential component for meeting these TEAM requirements and achieving financial and clinical success.

Here are five key steps to help get you there:

Step 1: Analyze Historical Post-Acute Utilization and Outcomes
A strong post-acute network begins with analyzing historical patient utilization data to identify trends in readmissions, care inefficiencies, and cost variations. High-risk patient groups with frequent readmissions should be targeted for improved care strategies, while inefficiencies in transitions should be addressed to reduce extended stays and unnecessary spending.

Setting measurable goals based on this data ensures continuous improvement. If readmission rates are high, targeted interventions should be implemented to reduce them. If post-acute stays are prolonged, refining discharge processes will enhance efficiency. Aligning these strategies with CMS TEAM objectives helps providers comply with regulatory standards while improving patient care and financial outcomes.

Step 2: Identify High-Performing Providers Based On Key Indicators
Evaluating performance of post-acute partners based on readmission rates, length of stay, and total episode costs ensures partnerships with providers that consistently deliver high-quality, cost-effective care. Lower readmissions indicate effective recovery management, and shorter stays suggest streamlined discharge planning.

With post-acute spending accounting for up to 55% of total episode costs, selecting high-performing providers is critical. Partnering with efficient facilities helps hospitals improve patient outcomes while mitigating financial risk under TEAM. Building a high-performing post-acute care network requires a proactive, data-driven approach. Ensuring collaboration with providers meeting these key metrics strengthens care coordination and overall efficiency.

Step 3: Establish Strategic Partnerships for Seamless Transitions
Now is the time to partner with post-acute providers who share a commitment to improving patient outcomes, ensuring smooth transitions, and minimizing complications and unnecessary hospital returns. Collaboration is not only beneficial but critical for acute care providers. Failure to do so can result in excess readmissions, making it difficult to hit target pricing goals.

Shared savings programs incentivize both acute and post-acute teams to focus on cost-effective care while maintaining quality outcomes. Frequent performance reviews and open communication enable organizations to track progress and make necessary improvements. This transparency not only builds trust it keeps everyone informed and working together. Strengthening these partnerships ensures healthcare organizations meet CMS TEAM requirements while enhancing overall patient care.

Step 4: Establish Clear Communication Protocols and Data Sharing
Seamless communication between acute and post-acute providers is essential for preventing care gaps. Interoperable technology platforms should be implemented to enable real-time data sharing, ensuring all care teams have access to up-to-date patient information. Standardizing care hand-off protocols reduces miscommunication and enhances continuity.

Ongoing training on communication tools and best practices helps providers maintain high standards of care. Training should cover technical aspects and best practices for effective communication and collaboration. For example, simulating everyday care transition problems allows team members to practice safely, ensuring they are well-prepared for real-world scenarios. Strengthening these communication processes ensures proactive patient management, fewer readmissions, and alignment with TEAM’s value-based care goals.

Step 5: Standardize Care Pathways Across the Care Continuum
Standardized care pathways are the backbone of a cohesive and efficient care system, ensuring patients receive consistent, high-quality care across all settings.Technology and digital tools are indispensable in creating and maintaining these standardized care pathways. For instance, post-acute care coordination tools can be configured to share critical patient data seamlessly, from initial hospitalization through discharge from post-acute care. This real-time data exchange is crucial for making informed decisions and ensuring that care plans are consistently followed and updated as needed.

Engaging all stakeholders, including primary care physicians, specialists, and post-acute providers, ensures that care plans are comprehensive and tailored to each patient. Clear documentation and communication protocols are vital to avoid misunderstandings and ensure smooth, efficient transitions.

Conclusion

The CMS TEAM initiative is transforming post-acute care by prioritizing care coordination and cost efficiency. By implementing these five key steps—healthcare organizations can build a high-performing post-acute network to help meet regulatory requirements, significantly improve patient outcomes, and reduce costs, ultimately transforming the healthcare landscape.

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