As value-based care continues to evolve, ensuring a smooth transition from hospital to post acute care is more important than ever. The CMS TEAM (Transforming Episode Accountability Model) initiative is designed to improve care coordination, reduce hospital readmissions, and create stronger collaboration between hospitals and post acute care providers.
What is CMS TEAM?
CMS TEAM is a mandatory program that helps healthcare providers work together more effectively. It focuses on improving patient transitions from hospitals to post-acute care, making sure patients get the right care at the right time. The goal is to reduce unnecessary hospital stays and improve patient recovery while keeping healthcare costs under control.
To succeed under CMS TEAM, healthcare providers need a strong post-acute care network. Here’s how they can build one:
1. Review Past Post Acute Care Data
The first step is analyzing past patient data to identify problems such as high readmission rates and inefficiencies in care transitions. By understanding these patterns, providers can set goals to reduce unnecessary hospital returns and improve patient recovery times.
2. Choose the Best Post Acute Care Providers
Not all post acute care facilities perform at the same level. Hospitals should work with providers that have low readmission rates, shorter stays, and efficient discharge planning. Since post acute care can make up over half of total episode costs, choosing high-quality providers is essential for both better patient care and financial stability.
3. Build Strong Partnerships for Better Transitions
Working closely with post acute care providers ensures that patients receive seamless, high-quality care after leaving the hospital. Hospitals and post acute care facilities should establish shared savings programs to keep costs down while maintaining excellent care. Regular meetings and open communication help ensure that both sides are aligned on patient needs and CMS TEAM goals.
4. Improve Communication and Data Sharing
One of the biggest challenges in healthcare is miscommunication. Hospitals and post acute care providers should use technology that allows real-time data sharing. This ensures that all caregivers have the latest patient information, reducing errors and improving treatment decisions. Training healthcare teams on best practices for communication can also help prevent misunderstandings and improve patient outcomes.
5. Standardize Care Plans for Consistency
When hospitals and post acute care providers follow the same care pathways, patients receive more consistent, high-quality treatment. Digital tools can help by providing real-time patient updates and ensuring care plans are followed correctly. Involving primary care doctors, specialists, and post acute care teams in creating care plans leads to better long-term results for patients.
The Future of Post Acute Care with CMS TEAM
The CMS TEAM initiative is reshaping post-acute care by prioritizing collaboration, improving efficiency, and reducing costs. By following these five steps, healthcare providers can build a stronger post-acute care network, meet CMS requirements, and ultimately improve patient recovery.
Technology Solutions for Better Care
Integrating advanced technology can make care coordination easier. PointClickCare’s PAC Management tool gives hospitals real-time access to patient data in post-acute care settings, helping them make better decisions and reduce hospital readmissions. These solutions also cut down on administrative work, allowing care teams to focus more on their patients.
By embracing these changes, healthcare organizations can navigate the evolving landscape of post-acute care while ensuring better outcomes for their patients.