4 Ways to Improve Your Post-Acute Care Strategy for CMS TEAM

The CMS TEAM program is reshaping how hospitals think about care after discharge. While much of the attention often lands on surgical optimization, OR efficiency, or hospital length of stay, many organizations are quickly realizing that post-acute care may be the single biggest variable affecting both financial performance and patient outcomes.

Small variations in readmissions, skilled nursing facility (SNF) length of stay, and home health utilization can accumulate into significant cost differences over the 30-day episode. For some hospitals, these differences can determine whether they finish the year in the positive or face penalties.

The good news: improving your post-acute care approach is highly achievable. It does not require major capital investments or sweeping organizational restructuring. Instead, it requires a structured framework built on better data, stronger alignment, and thoughtful case management support.

This guide outlines four practical steps that hospitals and physician groups can take to strengthen their post-acute performance for CMS TEAM.

Why Post-Acute Care Matters in CMS TEAM

Post-acute care is where TEAM is often won or lost. Even when inpatient care runs smoothly, avoidable variation after discharge can quickly erode the progress made upstream. Several common referral habits contribute to hidden risk:

• Many hospitals send nearly every patient from the same service line to a single SNF or home health agency, regardless of diagnosis or patient complexity.
• Quality, length of stay, and readmission rates vary widely between facilities.
• A destination that performs well for joint replacement may perform poorly for heart failure, CABG, or spine.
• Small differences in return-to-hospital rates compound into large financial impacts.

Moving from habit-based practice to performance-based referrals is one of the most effective strategies hospitals can use to improve TEAM results. The following four steps outline how to do it.

1. Use Historical Data to Understand Post-Acute Variation

Many organizations make discharge decisions based on long-standing patterns: "Patients from this unit always go to this SNF," or "This home health agency is our default option." These patterns feel efficient, but they mask significant performance variation.

A stronger approach starts by analyzing historical outcomes for each post-acute provider across each major diagnosis and procedure type. Several questions help reveal opportunities:

Which SNFs have shorter stays for each diagnosis?

A single SNF may perform well for total knee arthroplasty but extend stays for heart failure patients. Another may excel with complex medical needs but struggle with orthopedic protocols.

Understanding these differences lets teams match patients with the right setting.

Which providers have consistently lower readmissions?

Even a few percentage points matter. Readmissions are costly clinically and financially in TEAM, and variation between facilities is often larger than expected. Evaluating patterns over time helps identify both high-performing partners and facilities that may require additional support or monitoring.

How does performance vary for specific surgeons or service lines?

A facility that manages Dr. A's patients efficiently may not have the same results with Dr. B's patients. Combining provider-level and facility-level data gives administrators a more complete picture.

Try to use at least two to three years of historical cost, readmission, SNF LOS, and home health data. Break results down by diagnosis, procedure type, and service line. The goal is to move toward a referral strategy guided by insights rather than tradition.

2. Build a Preferred Post-Acute Network Based on Performance

Once variation is understood, the next step is to refine your post-acute network. Many hospitals focus heavily on geography, simply identifying the nearest SNFs or home health agencies. Geography still matters, but clinical performance should matter more when preparing for TEAM.

A high-value preferred network includes:

High-performing SNFs and home health agencies for each diagnosis

Rather than assigning one go-to SNF for all service lines, hospitals can create a set of preferred partners organized by clinical strength. For example:

• SNF A may be the preferred destination for orthopedic cases.
• SNF B may be the strongest partner for complex medical patients.
• Home health Agency C may excel with joint replacement.
• SNF D may perform best for cardiac or pulmonary care.

This structure promotes both quality and accountability.

Transparent criteria for partner selection

Criteria should include:

• Historical SNF length of stay for each diagnosis or procedure
• Readmission rates
• Use of evidence-based pathways
• Communication practices with hospital care teams
• Ability to manage higher-acuity or complex patients
• Patient satisfaction measures
• Responsiveness to collaboration efforts

Using transparent criteria helps avoid the perception of steering and supports patient choice.

Regular communication with post-acute partners

Creating the network is only the beginning. Ongoing collaboration is crucial. Successful teams schedule standing meetings with their SNF and home health partners to:

• Review current performance
• Align on escalation pathways
• Share clinical pathways and expected recovery timelines
• Troubleshoot challenges earlier in the episode
• Identify opportunities to reduce variation

This active communication helps maintain consistency throughout the TEAM period.

3. Equip Case Management with Better Tools and Patient-Friendly Materials

Case management plays a central role in the discharge process. They are often the bridge between inpatient teams, post-acute providers, and patients, yet they frequently lack the materials or data needed to support informed decision-making.

Improving post-acute performance for TEAM requires giving case managers tools that promote both transparency and patient choice.

Provide clear, patient-friendly comparison materials

Many organizations give patients a printed list of SNFs or home health agencies with little context. A more effective approach includes materials that:

• Compare providers based on historical performance
• Present key metrics in easy-to-understand language
• Highlight clinical strengths (e.g., orthopedic recovery, cardiac management)
• Respect patient autonomy while giving meaningful guidance

These materials help patients make informed decisions and reduce the risk of defaulting to a lower-performing option.

Train case managers on new pathways and referral logic

When case management understands why certain facilities perform better for specific conditions, they can communicate more effectively with patients and clinicians. Training should include:

• Why specific SNFs or home health agencies are preferred for each diagnosis
• How TEAM financial risk is affected by post-acute variation
• What to say when patients ask about differences between facilities
• How to identify patients who could safely go home rather than to SNF

Investing in case management education leads to more consistent discharge planning across the organization.

Ensure teams have real-time visibility into availability

Even when the right post-acute options are identified, capacity constraints can disrupt the plan. Case management systems should integrate:

• Daily SNF bed availability
• Home health coverage
• Weekend and holiday capacity expectations
• Escalation contacts for urgent placements

Better visibility reduces delays in discharge and maintains continuity.

4. Reduce Unnecessary SNF Utilization and Expand Home-Based Care

One of the most impactful improvements hospitals can make is reducing avoidable SNF use. Many patients are sent to SNFs out of caution, habit, or convenience rather than clinical necessity. This can add thousands of dollars to each episode and increase readmission risk if the facility is a poor fit.

Hospitals can expand their use of home-based care by evaluating three key opportunities:

Identify diagnoses where SNF use is higher than expected

Some conditions truly require SNF-level support. Others do not. Hospitals should review:

• The percentage of patients discharged to SNF by diagnosis
• Regional benchmarks for similar organizations
• Home health and outpatient therapy outcomes
• Patterns among individual physicians

If SNF use is significantly higher than comparable hospitals, there may be room to shift more patients home.

Strengthen home health partnerships

High-performing home health agencies can safely support patients who previously would have gone to SNF, especially if:

• The patient has strong family or caregiver support
• The procedure is predictable (e.g., primary joint replacement)
• The patient has limited comorbidities
• The agency has strong clinical pathways and communication methods

For many TEAM conditions, home health is both appropriate and more cost-effective.

Expand outpatient therapy utilization where clinically appropriate

Outpatient physical therapy can be a suitable destination for select orthopedic, spine, or general surgical patients. Hospitals can incorporate outpatient therapy into discharge plans when:

• Transportation is available
• The patient has adequate mobility
• The patient's home is safe and accessible

With proper screening, outpatient therapy can reduce costs without compromising recovery.

Bringing It All Together

Improving post-acute care for CMS TEAM is not a single project. It is an ongoing process of understanding variation, strengthening partnerships, and aligning teams around shared goals. Hospitals that succeed typically do three things well:

• Use data consistently to guide decision-making rather than relying on habit.
• Support case management with tools that balance transparency and patient choice.
• Adopt a flexible care model that encourages home-based recovery where clinically appropriate.

These strategies help reduce unnecessary variation and improve both clinical and financial outcomes.

Final Thoughts

As hospitals prepare for CMS TEAM, optimizing post-acute care may be one of the highest-leverage opportunities available. While inpatient improvements matter, post-acute decisions often shape the final 30-day outcome.

By analyzing historical results, building a performance-based preferred network, supporting case management, and reducing avoidable SNF use, organizations can significantly strengthen their performance under TEAM.

The path to improvement is practical, measurable, and achievable. Hospitals that adopt these strategies early will be better positioned for success, improved patient outcomes, and increased alignment with physicians and post-acute partners.

To learn more about how Avant-garde Health can support your readiness for TEAM, contact us today!