Starting January 1, 2026, the Transforming Episode Accountability Model (TEAM) will put hospitals at the center of patient risk, because participation is mandatory and financial penalties are tied to post-discharge outcomes. Hospitals and their partners will be under more pressure than ever to deliver high-quality, cost-effective care — even after patients leave the building. This means many of us will need to evolve how we work.
How TEAM Will Impact Staff
Case Managers & Social Workers
Managing non-clinical needs has always been complex. Under TEAM, it’s even more critical.
Upfront documentation matters. Social needs must be identified and documented at least six months before an episode. Hospitals need to partner with primary care teams that track social determinants of health (SDOH) to ensure patients have the right supports in place.
Execution over referral. Under TEAM, simply documenting a barrier isn’t enough. Instead of just scheduling appointments, staff must ensure they actually happen. Rather than noting a transportation issue, they need to secure a ride. And instead of merely recording food insecurity, they should arrange for grocery delivery.
Pre-episode planning is the foundation and post-episode execution is where the stakes rise. A single readmission within the 30-day accountability window can swing a hospital from savings to loss. Coordinated discharge planning with trusted partners is now mission-critical.
Clinical Staff
Clinical teams must have clear post-episode protocols or work hand-in-hand with trusted partners. Documentation is key so every provider understands both the medical risks and the social barriers that can cause preventable complications.
Transitioning a patient home — and keeping them there — is about more than protocols:
Medication adherence drives up to 10–20% of readmissions.
Patient anxiety can derail recovery. Early, frequent follow-ups keep patients calm and engaged.
Patient Access & Navigation Teams
TEAM extends responsibility well beyond discharge. Some hospitals will need to create or expand roles they’ve never formally had — or redefine existing ones — to stay connected with patients for weeks after they leave.
Examples of TEAM-critical roles:
Telephonic RN Navigators – Call patients within 24–72 hours post-discharge to confirm meds, review warning signs, and secure follow-ups.
Social Work Navigators – Stay engaged after discharge to help with food, utilities, caregiving, and housing.
Access & Scheduling Coordinators – Lock in all follow-up services before discharge.
Field-Based Coordinators or CNAs – Conduct brief home visits for high-risk patients to check safety, equipment, and meds.
Post-Acute Liaisons – Communicate daily with SNFs, home health, and other partners to prevent delays and escalate issues early.
These aren’t new ideas — but TEAM means hospitals must operationalize and coordinate them like never before.
How Your Health Can Help
Your Health has already built many of the functions TEAM requires — from transitional and chronic care management for seniors to total in-home care designed to keep patients out of the hospital.
Written By: Eddie Caldwell | Vice President of Talent and Workforce Strategy
A New Model, A New Way of Working
To explore how Your Health can support your TEAM readiness, contact us here: