Four months after the CMS Transforming Episode Accountability Model (TEAM) officially launched, hospitals and home health agencies in mandatory participation markets are already adapting to a new reality: post-acute performance now carries greater financial and operational consequences than ever before.
For many providers, the shift has been immediate.
Hospitals participating in TEAM are placing greater scrutiny on post-discharge outcomes, referral reliability and operational responsiveness across their home health networks. Agencies, meanwhile, are discovering that long-standing referral relationships alone may no longer be enough to maintain preferred partner status.
Instead, hospitals are increasingly evaluating which organizations can consistently support lower readmission rates, faster initiation of care and stronger recovery outcomes for surgical patients included in a TEAM bundle.
The result is a meaningful evolution in how hospital-home health partnerships function under value-based care.
While bundled payment initiatives are not new, TEAM expands accountability across a broader mandatory footprint and places renewed emphasis on coordination during the critical 30 days following discharge. For home health agencies operating in TEAM markets, the first several months of 2026 have highlighted both the opportunities and operational challenges that come with this new environment.
What Is TEAM - And Why Is It Different?
TEAM, or the Transforming Episode Accountability Model, officially launched on January 1, 2026 as CMS’s newest mandatory bundled payment program for select surgical episodes.
The model applies to Traditional Medicare beneficiaries and includes approximately 800 hospitals across selected geographic markets. TEAM also expands upon prior bundled payment programs such as BPCI-A and CJR by increasing mandatory participation and broadening episode accountability.
Under TEAM, hospitals receive a target payment amount that covers:
- The inpatient surgical stay
- The procedure itself
- All related care during the 30-day post-discharge period
That episode includes:
- Home health services
- Skilled nursing care
- Outpatient therapy
- Physician follow-up
- Durable medical equipment
- Related medications and other post-acute services
The model currently includes five surgical categories:
- Lower extremity joint replacement
- Surgical hip and femur fracture treatment
- Spinal fusion
- Coronary artery bypass grafting (CABG)
- Major bowel procedures
CMS designed TEAM to address a persistent issue in healthcare delivery: fragmented transitions between inpatient and post-acute care that contribute to avoidable complications, rehospitalizations and higher Medicare spending.
What makes TEAM particularly important for home health agencies is that hospitals are now directly accountable for what happens after discharge, not just during the inpatient stay.
That accountability is already changing referral dynamics in TEAM markets.
Hospitals Are Evaluating Home Health Partners Differently
One of the clearest trends emerging since TEAM went live is that hospitals are becoming more deliberate about post-acute partnerships.
Historically, many home health referral relationships were relatively informal and heavily relationship-driven. Referral volume often flowed toward agencies that could accept patients quickly and maintain good communication with discharge teams.
Those factors still matter. But hospitals participating in TEAM are now placing greater emphasis on measurable outcomes and operational reliability.
Across the industry, agencies are reporting that hospitals are asking more detailed questions about:
- Readmission performance
- Speed to start of care
- Surgical recovery competency
- Episode management capabilities
- Clinical staffing models
- Patient engagement workflows
- Performance consistency across patient populations
This reflects a broader shift from transactional referral management toward outcome-based partnership evaluation.
Hospitals now have stronger financial incentives to identify post-acute providers capable of helping reduce avoidable utilization during the 30-day episode window. For many systems, that means narrowing focus toward agencies that can demonstrate consistent operational performance.
In practical terms, hospitals are increasingly asking:
- Can this agency reliably manage high-acuity surgical patients?
- Can they prevent avoidable ED utilization?
- How quickly can they initiate care after discharge?
- Can they support lower total episode costs while maintaining quality?
For agencies accustomed to relationship-based referral patterns, TEAM is introducing a more data-driven evaluation process.
Why Readmissions Are Receiving So Much Attention
Among all the metrics hospitals are monitoring under TEAM, avoidable rehospitalizations remain one of the most important.
When a surgical patient returns to the hospital during the episode window, the financial impact can be significant. Readmissions directly affect both episode cost and quality performance under bundled payment models.
As a result, hospitals are placing heightened attention on home health agencies’ ability to:
- Identify early signs of deterioration
- Escalate issues quickly
- Educate patients effectively
- Coordinate care transitions smoothly
- Prevent avoidable complications
This is especially important for high-risk surgical populations included in TEAM, such as:
- Joint replacement patients
- CABG patients
- Spinal surgery patients
- Hip fracture recovery patients
Many of these patients require close monitoring during recovery and may experience complications related to mobility, medication management, infection risk or chronic condition exacerbation.
For home health providers, this means clinical competency is becoming an increasingly visible differentiator.
Agencies with strong rehospitalization performance - particularly within TEAM-related surgical populations - may be better positioned to strengthen hospital relationships over time.
Speed to Care Is Becoming a Competitive Advantage
Another operational area receiving greater attention under TEAM is timeliness of care initiation.
The hours immediately following hospital discharge are often high-risk for surgical patients. Delays in medication reconciliation, mobility support, wound assessment or patient education can contribute to avoidable complications and emergency department utilization.
Because of this, hospitals are increasingly prioritizing agencies that can rapidly initiate services after discharge.
In many TEAM markets, agencies are building new workflows designed specifically around surgical episode management, including:
- Same-day admissions
- Pre-discharge coordination
- Pre-operative outreach
- Introductory patient calls before surgery
- Rapid post-discharge nursing visits
- Immediate safety assessments
Some organizations are also working to identify TEAM-eligible patients before the inpatient stay even occurs, allowing care teams to prepare proactively for discharge transitions.
This type of operational coordination may become increasingly important as hospitals seek tighter episode management and reduced variation in post-acute outcomes.
Agencies Are Discovering Readiness Gaps
One of the more revealing developments during TEAM’s early months has been what agencies are learning about their own operational readiness.
Many organizations entered 2026 believing they had strong outcomes overall. But when examining performance more closely — by diagnosis, geography, clinician or referral source — some are discovering meaningful variation beneath the surface.
For example:
- An agency may perform well overall but struggle specifically with orthopedic recovery populations
- One branch may consistently outperform another on hospitalization prevention
- Certain referral pathways may produce stronger outcomes than others
- Timeliness of care may vary significantly depending on staffing models
This level of operational visibility matters more under TEAM because hospitals are increasingly evaluating agencies through a surgical episode lens rather than relying on broad organizational averages alone.
Readiness under TEAM is not simply about having “good numbers.”
It is about understanding:
- Which patient populations an agency performs best with
- Where operational weaknesses exist
- Whether performance can be replicated consistently
- Which workflows improve outcomes
- How risk can be identified earlier during an episode
Importantly, agencies of every size are facing these challenges.
Larger enterprises may have more sophisticated data infrastructure but also greater operational complexity across multiple markets. Smaller organizations may be more agile operationally but lack formal analytics resources or specialized episode-management workflows.
Size alone does not determine TEAM readiness.
Operational consistency does.
Clinical Competency Matters More Under TEAM
As hospitals place greater scrutiny on post-acute performance, clinical competency with high-acuity surgical patients is becoming increasingly important.
TEAM episodes include patient populations that often require:
- Advanced wound management
- Cardiac recovery oversight
- Fall prevention
- Mobility training
- Medication management
- DVT prevention
- Rapid complication escalation
Hospitals are paying closer attention to whether agencies have clinicians properly trained for these recovery pathways.
This has led some agencies to develop specialized surgical recovery programs or focused TEAM workflows designed around:
- Standardized education
- Risk-based care planning
- Consistent escalation protocols
- Enhanced communication with physicians
- Earlier intervention strategies
The agencies likely to succeed under TEAM are not simply those with referral capacity. They are the organizations that can operationalize high-quality surgical recovery management consistently across episodes.
How Technology Is Supporting TEAM Readiness
As operational expectations increase under TEAM, many home health agencies are reassessing the systems and workflows they use to manage episode performance.
Traditional referral and care management processes may not provide enough visibility for organizations now responsible for supporting bundled payment outcomes.
To adapt, agencies are increasingly looking for ways to:
- Identify TEAM patients earlier
- Monitor hospitalization risk dynamically
- Improve visit planning
- Track referral-specific outcomes
- Standardize episode workflows
- Reduce operational variation
Technology platforms focused on clinical and operational intelligence can help support these efforts.
For example, Mosai’s platform enables agencies to flag TEAM-related patients during referral intake and surface hospitalization risk insights that may help guide more proactive intervention strategies.
Mosai’s visit recommendation tools can also support agencies in evaluating visit frequency patterns intended to reduce hospitalization risk and strengthen episode outcomes.
Importantly, technology alone does not create TEAM success.
But as hospitals place greater emphasis on measurable outcomes and operational reliability, agencies may increasingly need better visibility into:
- Which patients are highest risk
- Which workflows are working
- Which referral relationships perform best
- Where operational gaps exist
Organizations that can turn data into operational action may be better positioned in the evolving TEAM environment.
TEAM Is Still Early — But the Direction Is Clear
Only a few months into implementation, TEAM is already influencing how hospitals and home health agencies approach post-acute collaboration.
Hospitals are becoming more selective about partner performance. Agencies are reevaluating their operational readiness. And referral relationships are increasingly being shaped by measurable outcomes rather than historical patterns alone.
For home health organizations, TEAM represents both a challenge and an opportunity.
Agencies that can demonstrate strong clinical performance, operational responsiveness and data-driven insight may strengthen their role within hospital networks as bundled payment models continue to evolve.
Those that cannot may find it harder to compete in a more accountability-focused referral environment.
What is becoming increasingly clear in 2026 is that TEAM is not simply another CMS pilot program.
It is accelerating a broader shift toward outcome-driven post-acute partnerships — and home health agencies are now firmly part of that equation.
