What Hospitals Should Look for
in Post-Discharge Care Partners
Under the CMS TEAM Initiative

On January 1, 2026, CMS launches the Transforming Episode Accountability Model (TEAM)—and hospitals will be at the center of patient risk like never before. With mandatory participation, regional benchmarks, and a tight 30-day post-discharge window, success will hinge on choosing the right post-discharge care partners.

This guide outlines what to look for in a partner—and how the right collaboration can help your hospital deliver better outcomes and thrive under TEAM’s value-based care model.

1. Look for True Care-Coordination Powerhouses

Reducing readmissions starts with seamless coordination. A strong partner should offer:

  • Community Health Workers (CHWs): Address social needs (transportation, housing, food insecurity), guide patients through post-discharge care, and deliver culturally competent support.

  • Providers (APPs & Physicians): Provide in-home or telehealth follow-ups, manage chronic conditions, and support recovery.

  • Clinical Coordinators & Case Managers: Keep care plans on track, ensure follow-ups happen, and maintain clear communication between hospital, patient, and external providers.

  • Pharmacists: Reconcile medications, educate patients on adherence and side effects, and work with care teams to optimize therapy.

  • Senior Solutions Advisors: Help patients and families understand long-term care options, coverage, and services that align with their goals.

2. Prioritize Partners Who Prevent Readmissions

Proactive care keeps patients out of the hospital. Look for partners that provide:

  • Visiting Nurses for in-home assessments, vital-sign checks, and education.

  • Remote Patient Monitoring (RPM) to track blood pressure, weight, glucose, and send real-time alerts for early intervention.

  • Telehealth Access for quick virtual check-ins to catch issues before they escalate.

  • Medication Expertise to identify high-risk drugs, simplify regimens, and prevent complications.

3. Demand Seamless Technology & Data Sharing

Real-time data drives smarter care. The ideal partner offers:

  • Interoperability: Smooth, secure sharing of patient data between hospital and care team.

  • Digital Tools: Use analytics to flag high-risk patients, coordinate post-acute services, and personalize discharge plans.

4. Make SDOH Support Non-Negotiable

Social determinants of health (SDOH) profoundly impact recovery. Partners should help patients overcome barriers by connecting them with food, housing, transportation, emotional support, and insurance navigation. Social workers, CHWs, and senior advisors are critical for building trust and reducing caregiver burden.

5. Ensure Expertise in Chronic Disease Management

Post-discharge care isn’t just short-term. The best post-discharge partners have partners who can manage ongoing conditions like diabetes, heart disease, and COPD.

These partners have clinicians who can adjust treatment plans and medications as needed. Virtual consultations and telehealth check-ins should also be part of the offering so patients get timely support and intervention without having to return to the hospital.

6. Align on Value-Based Care & Cost Efficiency

TEAM makes cost control and outcome alignment essential. Look for partners who deliver predictable, cost-effective care, use transparent pricing, and understand shared-risk agreements.

The right partner will also guide patients and providers through financially sound care decisions so everyone benefits from improved outcomes at lower overall cost. 

The Payoff of Choosing a Value-Based Partner

Hospitals that partner with experienced, value-based care providers can expect fewer readmissions, stronger patient recovery, and better financial performance under TEAM.

Key Focus Area

Your Health Benefits

Comprehensive Care Coordination

Improved patient outcomes through seamless follow-up and continuity of care.

Reducing Readmissions

Reduced hospital readmission rates through proactive care, including in-home visits and remote monitoring.

Technology Integration

Real-time health data sharing, early intervention through RPM kits, and telehealth to ensure continuous care.

Addressing Social Determinants of Health (SDOH)

Greater access to community resources, improved recovery outcomes through support with social needs.

Chronic Disease Management

Effective management of chronic conditions to prevent deterioration, reduce complications, and improve long-term health.

Cost Efficiency & Value-Based Care

Reduced healthcare costs through value-based care principles, risk-sharing contracts, and cost-effective solutions.

Your Path Forward

When TEAM takes effect in 2026, hospitals need partners who excel at care coordination, technology integration, chronic disease management, and SDOH support.

Your Health brings all these elements together—remote patient monitoring, telehealth, and a full multidisciplinary team of physicians, nurse practitioners, pharmacists, CHWs, case managers, clinical coordinators, social workers, and senior solutions advisors—to help hospitals reduce readmissions, improve outcomes, and thrive under the CMS TEAM initiative.