CMS TEAM Success Requires Thinking Beyond Physicians: Here Are 7 Ways to Do That

When it comes to succeeding in the CMS Transforming Episode Accountability Model (TEAM), physician engagement is often the first priority and rightfully so. Physicians drive clinical decision-making and shape patient outcomes. However, putting all the weight on individual providers misses a crucial point: TEAM success is only possible when everyone involved in the care journey is aligned.

Nurses, therapists, case managers, social workers, and administrative staff each contribute to the success or failure of an episode. Building a high-performing TEAM strategy requires shifting focus from individual excellence to coordinated execution.

This article explores why care redesign must go beyond physicians and how hospitals can mobilize their entire workforce to improve outcomes and reduce costs.

What TEAM Success Actually Looks Like

The TEAM model is CMS’s latest mandatory bundled payment initiative. It replaces voluntary models models like BPCI-A and CJR with broader scope and and mandatory participation across geographies.Success in TEAM means more than staying under budget. It means:

• Patients receiving timely, appropriate care at every step

• Smooth transitions between care settings

• Fewer readmissions and complications

• Clear documentation and data sharing

• Clinicians and staff understanding their role in the episode

Achieving this requires a team-based approach that aligns clinical, operational, and financial goals across the organization. TEAM holds hospitals, not individual physicians, financially accountable through retrospective reconciliation against target prices, adjusted for quality.

Why CMS TEAM Strategies That Focus Only on Physicians Fall Short

While physicians often lead clinical care, they don’t operate in isolation. Even the best surgeon or specialist cannot succeed in TEAM without the support of others. Consider the following:

• Nurses are the frontline stewards of recovery. They catch early signs of complications, educate patients, and coordinate discharge.

• Therapists determine a patient’s ability to return home or require further rehabilitation.

• Case managers and social workers ensure patients have access to the services, transportation, and follow-up they need to stay out of the hospital.

• Billing and coding staff influence financial reconciliation and compliance.

If these roles are left out of episode planning, gaps in communication, delays, and avoidable costs will follow. Under TEAM, hospitals bear the risk, but physician performance is inseparable from nursing, therapy, care management, and administrative execution.

Strategies for Thinking Beyond Physicians to Achieve Success in TEAM

To succeed in CMS’s TEAM model, hospitals need to move beyond physician-focused strategies and embrace a truly collaborative approach.

Here are

1. Training Everyone on TEAM Episode Goals and Definitions

One of the first steps toward TEAM success is making sure everyone understands what an episode actually is. Many staff may not know when an episode starts, what it includes, or how their actions influence outcomes.

Practical Steps:

• Create clear, accessible training materials that define episode triggers, post-acute periods, quality metrics, and financial implications.

• Hold department-specific training sessions so each role sees how they contribute.

• Incorporate TEAM education into onboarding for new hires.

When staff understand the structure and goals of TEAM episodes, they can make better day-to-day decisions and spot opportunities to improve efficiency. Training should also include details about the model’s 30-day post-discharge accountability window and the quality measures CMS uses in reconciliation, such as readmissions and patient-reported outcomes.

2. Giving Frontline Staff Access to the Right Data

Data should not be limited to physicians or executives. Nurses, case managers, and therapists need access to actionable insights to do their jobs effectively. Unfortunately, many hospitals still rely on siloed systems or generic dashboards that don’t provide episode-specific information.

Utilizing a data platform like Avant-garde Health’s CMS TEAM product, helps address this by providing frontline teams with intuitive, episode-level analytics that are easy to interpret and act on. Their platform delivers clear insights into performance trends, cost drivers, and quality metrics which allows everyone from bedside nurses to care coordinators to contribute meaningfully to episode success.

Examples of how to use this data:

• Use patient-facing scorecards or risk alerts that flag patients in TEAM episodes and indicate risk factors like high readmission likelihood or SNF overuse.

• Share summary data in weekly huddles or shift meetings so everyone sees performance trends and goals.

• Involve frontline teams in performance reviews by giving them visibility into metrics that reflect their work and benchmark against peers.

With access to relevant data, staff are more likely to take ownership of outcomes and spot issues before they escalate.

3. Supporting Transitions and Coordination Across Settings

Transitions of care are among the most vulnerable points in any episode. A poorly coordinated discharge or missed handoff can unravel days of successful treatment and add unnecessary cost.

Rather than relying on a single person to manage transitions, hospitals need systems that promote consistent communication and follow-up.

Strategies for Improving Transitions:

• Standardize discharge planning so all teams use the same criteria and timelines.

• Use digital checklists to confirm that post-discharge appointments, prescriptions, and transportation are in place.

• Designate care navigators or transition coordinators who ensure smooth handoffs from hospital to post-acute providers.

When teams are aligned and systems are reliable, patients move through the episode more safely and efficiently.

4. Empowering Staff to Speak Up and Solve Problems

Frontline staff often see issues long before they appear in the data. A nurse might notice a trend in delayed discharges. A therapist might find that patients are being sent to facilities with low success rates. A case manager might hear about patients struggling to afford medications.

If staff don’t feel empowered to raise concerns, these problems continue unchecked.

How to Foster Engagement:

• Encourage idea sharing in daily huddles or monthly reviews.
• Create feedback loops that close the loop on staff suggestions.
• Recognize and reward improvement efforts, not just outcomes.

When staff feel heard and supported, they become active participants in the hospital’s success.

5. Aligning Incentives Across Roles

Although CMS reconciliation payments flow to hospitals, internal incentive structures should cascade to all staff involved in the episode. In many hospitals, incentives are physician-focused, with little recognition for the work of nurses, therapists, or case managers. TEAM creates an opportunity to change that.

Consider tying performance bonuses or recognition programs to episode-level outcomes that reflect true team performance such as readmission rates, functional improvements, or patient satisfaction.

Incentive Ideas:

• Group bonuses for high-performing units on TEAM metrics.

• Spot awards for individuals who improve care coordination.

• Shared goals across departments that reward collaboration over volume.

When everyone has skin in the game, it drives more consistent engagement across roles.

6. Leveraging Technology to Bridge the Gaps

Technology can either create more complexity or simplify teamwork. The key is choosing tools that support integrated care delivery without overwhelming staff.

Helpful Tools:

• Care coordination platforms like Avant-garde CMS TEAM that bring together data from EMRs, post-acute partners, and claims systems.

• Real-time communication tools for cross-team messaging and alerts.

• Analytics dashboards that highlight episode performance in real time.

These tools work best when paired with proper training and support, ensuring they enhance rather than distract from patient care.

7. Building Culture Around Shared Accountability

Perhaps the most important shift required for TEAM success is cultural. Hospitals must move from siloed work toward shared accountability. This doesn’t mean every person does everything, but rather everyone owns a piece of the outcome.

Leaders play a key role in building this culture. It starts by reinforcing that:

• Everyone’s contribution matters

• Results are shared, not isolated

• Communication and collaboration are expected, not optional

This mindset leads to fewer handoff errors, more proactive problem solving, and stronger overall performance.

Leadership Matters for Success but It Can’t Just Be From the Top Down

Leadership is essential, but not limited to top executives. Hospitals must foster distributed leadership so nurses, therapists, and case managers can drive micro-innovations that influence outcomes

True progress in TEAM comes when leadership is distributed.

• A nurse can lead improvements in discharge planning.

• A therapist can introduce new functional assessments that speed up home discharges.

• A case manager can drive better connections with community partners.

Hospital and health system leaders should create space for this kind of grassroots innovation while removing roadblocks and aligning resources.

Common Pitfalls to Avoid

Even well-intentioned hospitals can stumble if they don’t build a strong TEAM foundation. Watch out for:

• Only training physicians on episode definitions and expectations
• Underinvesting in care coordination roles
• Failing to include therapy or nursing in care redesign
• Keeping data locked behind dashboards that frontline staff can’t access
• Assuming technology will fix broken communication without cultural change

Avoiding these pitfalls means stepping back and asking: who else needs to be at the table?

A Checklist for TEAM Readiness Beyond Physicians

To wrap things up, here’s a quick checklist to assess whether your organization is truly thinking beyond individual clinicians:

• Have you trained all departments on TEAM episode definitions and goals?
• Do frontline staff have access to relevant performance data?
• Are transitions of care supported by standard processes and dedicated roles?
• Are incentives aligned across clinical and non-clinical staff?
• Is there a culture of shared accountability and open communication?
• Are care redesign decisions made with input from multiple disciplines?

If the answer to any of these is no, there’s an opportunity to strengthen your TEAM approach before risk-based reimbursement goes live.

For more on how to prepare for TEAM, check out our recent article Preparing for CMS TEAM - Challenges & Tools for Success.

Final Thoughts

TEAM is not just about managing costs or checking CMS boxes. It’s about rethinking how care is delivered, from the hospital floor to the patient’s front door. And that requires everyone working together.

When hospitals expand their focus beyond physicians and invest in team-wide engagement, they’re better equipped to deliver quality, coordinated care. And in the end, that’s what TEAM is really all about.

To learn more strategies for success in TEAM, join 160+ individuals and more than 40 of the top hospitals and health systems in the interactive CMS TEAM Collaborative.

Apply to join for FREE today!