Tailored, post-procedure digital engagement reduces likelihood of ER visits and readmissions
TEAM: What You Need to Know
The U.S. Centers for Medicare & Medicaid Services (CMS) has set a goal to transition the majority of Medicare enrollees into a value-based care model by the end of 2030. To help this transition move forward, CMS is implementing the Transforming Episode Accountability Model (TEAM) and more than 741 hospitals will be included in this mandatory program.
TEAM kicks off on January 1, 2026, aiming to drive improvements and lower costs in five episodes-of-care categories. These episodes begin with a hospital inpatient stay or hospital outpatient procedure and extend to 30 days after the patient is discharged.
The episodes are: lower extremity joint replacement (LEJR), surgical/hip femur fracture treatment (SHFFT), spinal fusion, coronary artery bypass graft (CABG) and major bowel procedures.
Learn more at CMS
It’s Time to Get Ready: TEAM is Coming
Right now, hospitals picked to participate in TEAM have a window of opportunity to assess their readiness and close gaps—but the countdown has indeed begun to get the proper protocols and pathways in place by the January 1, 2026 kickoff.
Attempting to improve hospital performance under TEAM independently is daunting. However, there are several pieces of good news and possibly even a silver lining:
- Hospitals do not need to go it alone–nor should they.
- The right digital engagement strategy—which can educate and support patients as well as address issues before they escalate—can do much of the heavy lifting for hospitals and care teams.
- For hospitals that are well prepared, they can avoid financial penalties and may even see financial gains.
Staying Vigilant to What’s Happening at Home
It’s common for patients, including Medicare beneficiaries, to have concerns about the recovery process and care following a procedure. For instance:
- They may not understand their discharge instructions.
- They may not have a support system to help them be well cared for at home. (Note: Only 10.4% of traditional Medicare beneficiaries and 8.0% of Medicare Advantage (MA) beneficiaries received home-based medical visits in 2019)1
- They may not have resources to get to their follow-up appointments.
Unaddressed issues and anxiety associated with them can swiftly escalate, leading to poor care plan adherence, such as:
- Taking medications improperly
- Using medical equipment improperly
- Performing wound care incorrectly or inconsistently
- Missing or not scheduling appointments
When one or more of these things happen, it can easily lead to worsening health outcomes that send people to the ER, increasing the cost of care.
Intervention Before Issues Escalate
Monitoring patient recovery post-procedure using two-way digital communication is one of the best ways to identify potential complications early on, allowing for timely interventions and preventing costly readmissions or trips to the ER. It allows patients to easily reach out with questions or concerns, and the 24/7 availability fosters a sense of wraparound support.
Specifically, the right precision platform can deliver personalized educational content on post-operative care, medication management, rehabilitation exercises and more. Timely reminders for follow-up appointments and symptom monitoring also contribute to better outcomes and reduced costs.
To learn more about Get Well and our solutions for federal customers, including Get Well Anywhere – Federal (GWA-F), please visit our website and schedule a demo today.
To ensure the digital engagement strategy you implement is well-suited to support your TEAM objectives, ask:
- Does it cover the surgical episodes of care relevant to my organization?
- Does it educate and engage the patient before their scheduled procedure?
- Does it consistently support them through discharge into the TEAM-mandated, 30-day recovery period?
- Does it consider whole person needs, including regular assessments of both physical and psycho-social issues?
- Does it offer wraparound support, including guidance in removing barriers to care?
- Does it offer the option for the patient to engage with a live navigator (without adding to staff)?
Precision digital engagement supports patients at every step in their care with critical attention to easing transitions from acute care to post-op recovery, wherever it is. The best way to succeed under TEAM is by preparing patients for their procedure and recovery period with bite-sized personalized information and support.
Read More: How to Maximize TEAM Performance? Engage on the Front End to Maximize Results Post-Episode
Schedule a Demo: Get Well offers precision patient engagement solutions that address the entire patient journey from pre-through post-episode care and can be a trusted partner in helping you achieve TEAM objectives.
1 Videon TM, Rosati RJ. Percent of Medicare Enrollees Who Use Home-Based Health Care and Number of Visits Among Respondents to the Medicare Current Beneficiary Survey by Plan Option. Med Care Res Rev. 2025 Jun;82(3):252-259. doi: 10.1177/10775587251318404. Epub 2025 Feb 24. PMID: 39994828.
