TEAM: Understanding the role of SNFs
Beginning in January 2026, the Centers for Medicare and Medicaid Services (CMS) will introduce a new payment model intended to support better long-term health outcomes. CMS defines the new program, Transforming Episode Accountability Model (TEAM), as a mandatory, episode-based, alternative payment model (APM) in which selected acute care hospitals in 43 states will coordinate care for people with traditional Medicare who are undergoing one of five surgical procedures included in the model.
The participating hospitals assume responsibility for cost and quality of care through the first 30 days after the patient leaves the hospital. The goal behind extending the hospital’s responsibility for cost and quality beyond the patient’s stay in the hospital is to improve care coordination and care transitions into post-acute settings, supporting lower costs and better outcomes not only during the acute stay but also after discharge.
5 episodes CMS is initially including in TEAMS
- Lower extremity joint replacement (LEJR)
- Surgical hip/femur fracture treatment (SHFFT)
- Spinal fusion (SF)
- Coronary artery bypass graft (CABG)
- Major bowel procedures (MBP)
Implications for post-acute providers
More than 40% of the total spend for certain procedures CMS has identified for the TEAM model is incurred during the 30 days post discharge from the acute stay. For lower extremity joint replacement and surgical hip/femur fracture procedures, as much as 40% to 60% of the costs occur in the post-acute time frame. This means there are many opportunities for SNFs and other post-acute providers to develop partnerships with hospitals to focus on more efficient care transitions and care delivery models that can benefit their organizations while also improving outcomes.
One key difference between TEAM and earlier models CMS has proposed is that acute care providers don’t get to choose whether they participate. CMS has determined who will be included, and these providers will be looking for post-acute providers who can help them manage total cost of care and support the quality measures CMS will monitor for these populations. Participating hospitals will be looking for post-acute organizations that have systems in place to monitor key metrics, such as length of stay, patient safety events and rehospitalizations.
TEAM also focuses heavily on health equity. CMS will offer payment adjustments for underserved individuals by monitoring which populations are served, patients’ social determinants of health and whether there was equitable care delivery throughout the care episode. The goal is to ensure that all patients can achieve optimal health with better access to high quality care.
In addition to being identified as a preferred provider, if post-acute providers can help hospitals reduce overall costs for the episodes included in the new model while maintaining or improving care quality, there may be an opportunity to share cost savings with hospitals.
How to prepare
There are steps you can take to set your organization up to be a TEAM collaborator when you’re contacted by a local hospital. Start by working to manage your total cost of care. For example, carefully monitoring length of stay in your facility helps you understand the right amount of time to keep a patient—long enough to make sure they have a great outcome, while not adding unneeded days to their stay “just to be sure.”
You can also focus on minimizing rehospitalizations. Make sure patients discharging from your facility are stable and have the support, equipment and additional quality services they need to be safe and to make progress after they leave your facility to help reduce emergency room utilization and rehospitalization. While in your facility, leverage technology to proactively identify patients at risk so you can quickly intervene and help prevent incidents like falls or rehospitalizations. You should also pay close attention to basic healthcare standards related to infection control, identification and treatment, which can be key to these efforts.
It’s also important to make sure you’re gathering data on the populations you’re serving so you can share clear metrics and outcomes data with potential acute partners. Have up-to-date information available about the volume of patients associated with those episodes and your average length of stay, your rehospitalization rate, or other applicable quality measures. This kind of data can demonstrate the ways you can help hospitals achieve their TEAM goals and make you stand out from others.
More insights to come
This blog is intended to provide a just brief background on what is a complex, detailed new payment model from CMS. We’ll be exploring various angles in more detail on this blog in the coming months. For now, it’s important to understand that CMS wants to encourage hospitals to work with post-acute care providers on value-based care opportunities. Now is the time for post-acute providers to begin establishing connections and implementing strategies with acute care providers to help everyone succeed under this new payment model.
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Allison Rainey
As our Head of Nursing and Clinical Informatics, Allison Rainey oversees the deployment of clinical technologies. As a Registered Nurse and License Family Practitioner, Allison drives a caregiver-first approach in our products, collaborating closely with product leaders to ensures our products and services prioritize the needs and challenges faced by healthcare providers. By aligning workflows, designs, and overall product strategy, Allison strives to offer the most user-friendly, clinically superior, and efficient suite of comprehensive solutions in the industry. Allison brings extensive post-acute care experience from her 20-year tenure at NHC, one the largest publicly traded Senior Care providers in the U.S. She is a seasoned leader in population health management strategy, clinical reporting and analytics development, and inpatient hospital care. In her most recent role as AVP of Clinical Information Technology, she oversaw the deployment and utilization of various clinical technologies, including the MatrixCare EHR, across the extensive NHC network. Allison holds a Bachelor’s and a Master’s in Nursing from the University of Tennessee.
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