You are not the only one who wants to know what is CMS TEAM Model is. Through the Transforming Episode Accountability Model (TEAM), the Centers for Medicare & Medicaid Services (CMS) is spearheading a significant change in Medicare payment. Beginning on January 1, 2026, and ending on December 31, 2030, this required episode-based payment model modifies hospital payments for medical and surgical episodes. CMS is now making hospitals responsible for the cost and quality of care across a 30-day episode rather than paying for individual services.
A random selection of about 25% of eligible Core Based Statistical Areas (CBSAs) will get participation; hospitals will not have the option to opt in. Therefore, if you work as a supplier in one of those areas, you should start getting ready right away.
The Modifications to the CMS TEAM Model
Understanding how the CMS TEAM Model alters accountability is essential to comprehending it. Under the Inpatient Prospective Payment System (IPPS), acute care hospitals will bear the financial burden of full care episodes. These episodes last for 30 days after release and start with a qualifying hospital stay or surgery.
Procedures in Focus
- Lower Extremity Joint Replacement (LEJR)
- Surgical Hip/Femur Fracture Treatment (SHFFT)
- Spinal Fusion
- Coronary Artery Bypass Graft (CABG)
- Major Bowel Procedures
These are not arbitrary decisions; rather, they represent high-variation, high-cost processes where CMS sees room for improvement.
How TEAM Determines Prices
The TEAM model’s target price incorporates risk adjustments based on a three-year historical baseline:
- Safety net status and hospital bed size
- Age range and number of HCCs
- Medicare and Medicaid dual eligibility
- Clinical features unique to each episode
On these target pricing, hospitals are subject to a set discount: 1.5% for bowel operations and CABG, and 2.0% for spinal fusion, LEJR, and SHFFT. You can receive reconciliation payments if you do well, which translates into greater results at cheaper expenses.
Reimbursement-Driven Metrics
CMS uses a Composite Quality Score (CQS), which comprises the following, to link payments to quality:
- Hybrid All-Cause Readmission
- Patient Safety and Adverse Events, or PSI-90
- Patient-Reported Results for LEJR
- The Adverse Events Associated with Opioids
- Inability to Save: Complications Following Surgery
Strong-scoring hospitals receive rewards, but those that fall short of these quality standards risk losing money.
Prioritizing Equity
TEAM makes health equity a priority for operations. For Health-Related Social Needs (HRSNs), CMS mandates universal screening in the following areas:
- Unstable housing
- Food insecurity
- Access to transportation
- Support for utilities
Hospitals have the option to submit a voluntary Health Equity Plan that outlines quantifiable objectives for minimizing inequities. These plans have the potential to affect CMS scoring and long-term financing, so they are not only for show.
Coordinated care is a need. Following discharge, hospitals must actively manage their patients. TEAM needs:
- Before release, a primary care physician (PCP) referral
- Recording follow-up communications within 14 and 30 days
- Unambiguous transfers to qualified home health, nursing, or rehabilitation services
These actions guarantee consistency, lessen issues, and assist sufferers while they heal.
Taking Complexity and Risk into Account
TEAM employs risk adjustments unique to each patient and facility to level the playing field:
- Age range
- HCC count
- Designation of a safety net
- Size of bed
- Dual eligibility for Medicaid
These contributions ensure that hospitals that treat sicker or more vulnerable patients are not subjected to unjust punishment.
Timeline: When Does It Happen?
CMS anticipates that hospitals will be ready in stages:
- Fall 2024: Examine past data to comprehend patterns in episode quality and expense.
- 2025: Implement data tracking systems, HRSN protocols, provider education, and care redesign.
- 2026: The full-scale deployment of TEAM starts.
Among the preparations are:
- Assembling internal groups devoted to post-acute coordination and discharge planning
- Configuring episode statistics and patient tracking
- Educating employees about the new CMS paperwork and reporting requirements
How Persivia Aids in the Success of Teams
With AI-powered care management, risk classification, and real-time episode tracking, Persivia’s CareSpace® technology assists hospitals in staying ahead of TEAM obligations.
The Benefits of Persivia
A centralized platform for end-to-end episode management is CareSpace® for TEAM.
- Risk analytics: Using clinical and claims data to stratify in real time
- Custom Pathways: Personalized treatment regimens that satisfy TEAM standards
- Post-Acute Integration: Linking the processes of inpatients and outpatients
- Virtual tools and remote monitoring: Increase patient involvement after discharge.
- Performance benchmarking: Monitors results and expenses
Prime Healthcare and other hospitals that use CareSpace® have improved patient outcomes and saved millions of dollars. With Persivia, episode-based care is less dependent on guessing.
What to Do Right Now
Here’s where to start if you are wondering what the CMS TEAM Model is and how to implement it:
- Create baseline reports based on previous performance.
- Organize internal care teams.
- Implement social needs screening
- Select a tech partner who is familiar with episode-based models.
All in all, the Persivia system is made to work with every component of the CMS TEAM model, whether it is for handling referrals, identifying high-risk patients, or automating follow-up procedures. Better results, less blind spots, and increased compensation follow.
Further, you can accomplish more with Persivia than just fulfill CMS requirements. It facilitates leadership.
