How Hospitals Can Prepare for CMS TEAM: 6 Essential Steps for TEAM Readiness

The CMS Transforming Episode Accountability Model (TEAM) arrives soon, and hospitals in the first cohort are working against a tight calendar. With January 1 approaching, many organizations realize they cannot build a full episode management program in such a short window. The good news is that early success does not depend on having every pathway redesigned or every analytic tool in place. What matters most is choosing a handful of moves that help teams get organized, understand their current patterns, and begin improving with confidence.

This guide outlines six practical steps that set a strong foundation for TEAM participation. The goal is to help hospitals begin learning quickly, reduce unnecessary variation, and position clinical and operational teams for success in the first year. Each step can be completed with existing resources, even if your organization does not have a mature bundled payment program yet.

Why Hospitals Need a Focused Start

TEAM will require hospitals to manage cost and quality across the inpatient stay and the 30-day post-acute window. Most organizations already have elements of this work in place through ERAS, care management, utilization review, and value-based care initiatives. The challenge is bringing these functions together and creating a structure that supports continuous improvement.

A narrow focus helps hospitals avoid feeling overwhelmed. Instead of trying to redesign entire care pathways or build complex analytics platforms immediately, organizations can concentrate on the areas that have shown consistent impact in other bundled payment models. Hospitals that participated in BPCI, CJR, BPCI-A, or commercial bundles have left behind a trail of proven approaches. The first TEAM year is the ideal time to borrow from those experiences.

The following six steps come directly from those lessons.

Step 1: Clarify Governance and Create a TEAM Steering Group

One of the most common missteps we've seen in bundled payment programs is unclear ownership. TEAM touches nearly every part of the organization. Without a structure that defines who decides what, hospitals experience slow progress, missed opportunities, and uneven communication.

A multidisciplinary steering group provides the coordination needed to manage episode-based work. It brings together leadership, physicians, care management, finance, quality, and IT. More importantly, it clarifies decision rights so that questions do not get stuck in endless review cycles.

What Strong Governance Looks Like

A durable structure typically includes:

A clear executive sponsor: Usually a COO, CMO, CNO, or VP of population health. This person removes barriers and ensures alignment between TEAM work and broader system priorities.

Physician leadership: Surgeon and medical specialty leaders help translate clinical realities into actionable decisions. Their involvement is essential for adoption and credibility, especially in orthopedics, cardiology, and other high-volume TEAM procedures.

Operational leads: Care management, quality, and nursing leaders help integrate TEAM expectations into daily workflows.

Finance and analytics partners: These team members verify data accuracy, review target price implications, and help the steering group understand early trends.

Why Governance Matters Early for Bundled Payments

Hospitals entering TEAM do not need fully built pathways on day one. What they need is consistent direction. Governance serves as the operating system for decisions such as:

• How care variation will be addressed
• What data will be reviewed weekly or monthly
• Which post-acute strategies will be standardized
• How physician partners will be engaged

With this structure in place, decision making becomes faster and more predictable, which is especially helpful during the first year when most hospitals are still learning TEAM's impact.

Step 2: Map Current Patient Journeys from Admission Through 30 Days

TEAM requires hospitals to understand the full episode of care, not just the inpatient stay. Many organizations believe they already know their typical patient flow. However, when they map each step they often discover significant variation in discharge patterns, care management handoffs, and post-acute follow-up.

Why Mapping Matters in Bundled Payments

Mapping exposes the true flow of patients, not the idealized version that lives in a protocol. It helps hospitals:

• Understand where delays occur
• Identify which patients are most likely to enter skilled nursing facilities
• Reveal gaps in communication between inpatient and post-acute teams
• Capture opportunities to increase home discharge
• See where costs accumulate that were previously hidden

Even simple mapping exercises bring clarity. Oftentimes, it will cause hospitals to realize they underestimate their SNF utilization or overestimate the consistency of outpatient rehab referrals. Then, these early insights become the basis for targeted improvements.

Practical Approach to Mapping for CMS TEAM

Hospitals do not need a full process redesign team to begin. Start with:

• A single procedure type
• A small group of frontline clinicians
• A review of current discharge data
• A basic whiteboard or flow diagram

Document each touchpoint from admission to 30 days post discharge. Mark high-variation steps, places where decisions differ by provider, and spots where communication commonly breaks down. This initial map becomes the reference point for all post-acute work.

Step 3: Tighten Documentation and Coding of Comorbidities and Social Risk

TEAM target prices rely heavily on accurate patient characteristics. If documentation does not fully reflect illness severity or social risk factors, the model may assign an unrealistically low expected spend. That puts the hospital at a disadvantage before the first patient even enters the episode window.

Why Documentation is a High-Value Early Step

Improved documentation raises no compliance concerns when done correctly. It simply ensures that what is clinically present is captured in the medical record. Most hospitals already have CDI programs in place but may not always focus on the procedures included in TEAM.

Even modest improvements in capturing:

• Heart failure
• Chronic kidney disease
• Diabetes with complications
• Frailty indicators
• Substance use disorders
• Financial or social barriers

can help ensure that the target price reflects true patient acuity.

Practical Actions for Bundled Payment Success

• Review documentation patterns for each TEAM procedure
• Identify common diagnoses that are present but not captured
• Provide targeted reminders to clinicians
• Ensure coding teams understand which conditions influence target price risk

This step does not require new software or workflows. It requires only a focused review and clear communication with clinicians.

Step 4: Prioritize Post-Acute Care Redesign and Optimization

Post-acute care often drives the largest portion of episode spend. It is also where the greatest variation exists. Early redesign and optimization efforts help hospitals reduce unnecessary skilled nursing use, support safe home discharge, and increase appropriate outpatient rehab referrals.

Why Post-Acute Work Cannot Wait

Many hospitals underestimate how much post-acute pathways influence TEAM performance. Even small changes in SNF utilization, length of stay, or home health frequency can shift total episode cost considerably. Since the episode window is only 30 days, hospitals can influence results quickly by improving coordination and setting clear expectations.

Where to Focus First

Reduce unnecessary SNF use: Identify which patients can be safely discharged home with home health or outpatient therapy. Use simple risk screens, PT and OT assessments, and early discharge planning.

Strengthen home health partnerships: Create clear communication expectations, share care plans, and monitor home health utilization patterns.

Expand outpatient rehab pathways: Many patients can begin outpatient therapy within the first week after discharge. Early scheduling prevents delays and helps maintain functional momentum.

Improve follow-up touchpoints: Early post-discharge phone calls reduce readmissions and help identify patients who need additional support.

Hospitals do not need to build brand-new post-acute networks in the first TEAM year. They only need to strengthen existing processes and reduce variation that adds cost without improving outcomes.

Step 5: Build a Simple TEAM Performance Dashboard or Utilize an Analytics Partner

Hospitals often assume they must develop a complex analytics environment to start TEAM. In reality, a basic early dashboard is enough to support learning and help leaders focus on the right patients.

What a Simple Dashboard Should Include

A lightweight dashboard can be created using standard EHR tools, internal reporting solutions, but we recommend utilizing an analytics partner such as Avant-garde Health to ensure accuracy and timeliness of data. It only needs to include a few indicators such as:

• Expected episode spend
• Home discharge rate
• Skilled nursing utilization
• Readmission rate
• Outpatient rehab use

These metrics represent the early signals that influence both cost and outcomes. Tracking them consistently helps hospitals identify trends without waiting months for full financial settlement data.

Some additional benefits to a platform like Avant-garde include features like:

• Surface key insights from large, complex claims and EHR datasets in seconds
• Predict episode cost risk at the time of scheduling or admission
• Flag patients at high risk for complications or readmission
• Give non-analysts a natural language way to explore performance questions

Learn more or request a demo of Avant-garde's Bundled Payment Solution

Why Early Dashboards Accelerate Learning

Hospitals in earlier bundled payment programs often discovered, sometimes too late, that their internal perception of performance did not match their actual results. A dashboard helps:

• Reveal patterns within the first few weeks of TEAM
• Provide feedback loops for care teams
• Support physician conversations with objective data
• Keep the steering group focused on high-value opportunities

As the program matures, the dashboard can grow. For now, simplicity supports consistency.

Step 6: Learn from Peers Instead of Starting from Zero

One of the most frequent recommendations from hospitals with experience in bundled payments is simple: do not reinvent everything. Organizations that participated in CJR, BPCI-A, and commercial bundles have already navigated the early challenges facing TEAM hospitals today. Their lessons can be used immediately.

What Peers Can Teach

Peer hospitals can help with:

• Early pathway design
• Post-acute care standards
• Physician engagement strategies
• Gainsharing frameworks
• Readmission reduction methods
• Data transparency practices

Many of these approaches have been refined over several years. Borrowing their structure saves time and prevents slow, incremental trial and error.

How to Connect with Experienced Hospitals

Hospitals can:

• Join collaborative learning groups
• Attend webinars with experienced bundled payment participants
• Review case studies from organizations with strong outcomes
• Ask vendor partners for introductions to mature programs
• Include physicians in peer-to-peer conversations

These connections create shortcuts. They help first-year TEAM hospitals align around approaches that have already been tested and improve their readiness for financial reconciliation.

Join the Avant-garde Health learning collaborative with 200+ professionals from over 60 leading hospitals and health systems.

Final Thoughts

Preparing for CMS TEAM does not require a fully developed bundled payment program on day one. Instead, it requires clarity, structure, and a willingness to learn quickly. Hospitals that take these early steps gain visibility into their episode patterns, build essential partnerships, and create a foundation for manageable improvement throughout the year.

Most importantly, these steps help organizations deliver care that is more consistent, safer, and better coordinated. As hospitals move deeper into TEAM, the early investments in governance, mapping, documentation, post-acute redesign, dashboards, and peer learning will continue to pay dividends.

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