Imagine being responsible for the full 30-day post-discharge care of your surgical patients, including costs and outcomes. This isn't a hypothetical scenario; it's the reality of the TEAM initiative, launching in 2026. Time is running out to prepare for this new mandate.
Managing the recovery process after surgery can be daunting, especially for individuals undergoing procedures like ostomy surgery. Post-discharge management plays a pivotal role in measuring patients' successful recovery, reducing avoidable complications, and enhancing long-term quality of life. Recognizing these challenges, the Transforming Episode Accountability Model (TEAM) initiative was developed to improve care coordination and support, specifically targeting episodes of care for Medicare beneficiaries. TEAM aims to minimize fragmented care by ensuring that patients are given the right support throughout their recovery process, reducing unnecessary emergency department (ED) visits and hospital readmissions.
The Transforming Episode Accountability Model (TEAM) is a mandatory, episode-based alternative payment model introduced by the Centers for Medicare & Medicaid Services (CMS). Starting January 1, 2026, TEAM will require selected acute care hospitals to assume responsibility for both the cost and quality of care for patients undergoing five specific surgical procedures, including ostomy-related surgeries. The initiative is designed to enhance care transitions and ensure that patients receive consistent, high-quality care after their hospital discharge.
The model will span five years, ending December 31, 2030, and will build on earlier efforts to improve care coordination, such as the Bundled Payments for Care Improvement Advanced and Comprehensive Care for Joint Replacement (CJR) models. The goal is to reduce avoidable readmissions, improve patient outcomes, and encourage hospitals to work more closely with primary care providers to ensure ongoing care and support.
The success of TEAM depends heavily on patient education, especially for those with new ostomies. With the right information and support, ostomates can manage their recovery at home more effectively, reducing complications and the need for additional medical interventions. The TEAM model acknowledges this by promoting enhanced educational resources and communication between patients and providers.
The TEAM initiative is poised to significantly help patients, particularly those who are newly managing an ostomy. By ensuring that hospitals are incentivized to coordinate care across all stages of recovery, from surgery through the first 30 days post-discharge, the model aims to:
The challenges in post-discharge management, particularly for surgical patients like new ostomates, as highlighted by the upcoming TEAM initiative, necessitate innovative solutions to improve recovery and reduce negative outcomes. Remote Patient Monitoring (RPM), offered by Health Recovery Solutions (HRS), plays a crucial role in addressing these challenges by enabling early identification of complications, including infections, and proactively preventing unnecessary rehospitalizations and emergency department (ED) visits.
HRS provides RPM solutions that go beyond basic biometric data collection. Features such as the camera capability for patients to take images of wounds, edema, skin rashes, etc., allow for the remote assessment of surgical sites for early signs of infection like redness, swelling, or purulent drainage. This visual data, combined with the ability to track and trend biometric data such as temperature, blood glucose, pulse ox, etc., can provide clinicians with prompt alerts to potential issues before they escalate.
Furthermore, the integration of HRS with expert standardized wound care through the WoundConnect program provides a comprehensive approach to post-surgical wound management. HRS WoundConnect leverages a partnership with Corstrata, bringing the expertise of their Wound and Ostomy Certified Nurse (WOC) Consultants to your organization.
HRS WoundConnect facilitates direct-to-clinician consultation, utilizing standardized, evidence-based wound recommendations by care setting and wound type. This ensures that any concerns identified through RPM, such as potential infection, are promptly addressed with expert guidance on appropriate interventions, potentially preventing the need for hospital readmission or an ED visit. The presence of WOC nurse-led wound care has been shown to quadruple the probability of healing (80% vs 18%), significantly decrease adverse events and hospital readmissions, and reduce the number of treatment weeks.
The ability to conduct virtual visits through the HRS platform further enhances care coordination, allowing multiple disciplines and providers to collaborate on a patient's care plan remotely. This is particularly beneficial in the post-surgical period, where timely communication and adjustments to the care plan can significantly improve healing, adaptation, and prevent complications. For the ostomate, strategically scheduled video visits provide comprehensive ostomy care education, including pouching system recommendations, troubleshooting ostomy concerns, and fluid and nutrition education with monitoring to address a primary cause of ostomate readmissions of dehydration.
By leveraging RPM for early detection and the expert wound care knowledge embedded in HRS WoundConnect, healthcare organizations can proactively manage post-surgical patients, leading to:
As hospitals prepare for initiatives like TEAM, integrating HRS WoundConnect with robust RPM capabilities offers a powerful strategy to enhance post-discharge management, improve patient outcomes, and achieve the goals of reducing readmissions and improving the quality of care. The combination of technology, expert clinical support, and a focus on standardized, evidence-based care provides a comprehensive solution to the growing challenges in post-surgical care and wound and ostomy management.
The Transforming Episode Accountability Model (TEAM) represents a significant shift in how hospitals manage post-discharge care, especially for patients who have undergone major surgeries such as ostomy procedures. By ensuring that hospitals are incentivized to coordinate care more effectively and promoting continuity of care, TEAM can potentially improve both clinical outcomes and patient experience. Integrating solutions like HRS WoundConnect with robust RPM capabilities further enhances this potential, providing a comprehensive approach to post-surgical care. As TEAM takes shape and hospitals begin their participation in 2026, it will offer new opportunities for hospitals, patients, and healthcare providers to collaborate more closely to improve the recovery process for ostomates and reduce avoidable complications.
Our goal is to improve the lives of patients and support the surgeons and organizations that care for them. Reach out today to explore how HRS can help with your TEAM initiatives, position your organization for success, and achieve better outcomes for your patients.