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The forthcoming TEAM bundled payment model will offer home health providers opportunities to boost utilization and develop stronger referral partnerships – if they understand and succeed in their roles within a 30-day episode of care.
The Transforming Episode Accountability Model (TEAM), set to begin on Jan. 1, 2026, requires providers to “front-load” the episode of care, initiate care quickly and keep lines of communication strong and smooth, industry experts told Home Health Care News. And even home health providers that are not in markets where TEAM will be mandatory in 2026 need to understand and prepare for the TEAM approach to care.
“Of all providers included in TEAM, home health is likely the largest upside opportunity,” Brian Fuller, managing director of ATI Advisory’s value-based care design and delivery practice, told HHCN. “I could foresee settings like skilled nursing facilities or inpatient rehab facilities being anti-mandatory models, because typically what we see in these bundled payment models is … more of a push to home, or to home quicker. But that all benefits home health. In fact, in most bundled payment models and conditions that I’ve seen tested, we actually see home health utilization increase in many cases.”
The model makes hospitals accountable for quality and costs and collapses often-siloed payment systems, Fuller said. For home health providers, payment mechanisms are unchanged, with Medicare paying for care as usual. On the back end, Medicare considers a year’s worth of data and determines target and actual costs of the 30-day episode when reconciling with hospitals.
TEAM bundles payments for five selected procedures and extends to 30 days following the outpatient procedure or 30 days following discharge from the hospital, depending on whether the condition involves an inpatient stay or outpatient procedure. The five selected conditions are: lower extremity joint replacement (LEJR), surgical femur and fracture treatment (SHFFT), spinal fusion, coronary artery bypass graft (CABG) and major bowel procedure.
The first inflection point
For a patient undergoing a SHFFT episode, for example, the TEAM episode of care is triggered upon discharge from the hospital. The payment bundle includes the procedure and hospital care, including physician visits. Patient discharge is the first inflection point for the bundle, with the next setting of care significantly impacting costs.
Inpatient rehab is the most expensive option, Fuller said, followed by skilled nursing and then, the most affordable option, home health.
Decisions regarding patient care pathways depend heavily on the specific patient, their functional needs, medical and physician coverage needs and caregiver availability.
Lower-acuity patients are often good candidates for immediate transfer to home health, but utilization differs geographically. Many factors play into a region’s utilization trends, according to Fuller, but one key determinant is service supply.
“The variation is wild,” Fuller said. “In some parts, we see very high inpatient rehab utilization for SHFFT episodes and in other parts of the country, virtually no inpatient rehab. In some parts very, very high skilled nursing facility [utilization] at very, very high lengths of stay. And in other parts of the country, the default is home health. So it really depends on the part of the country, in addition to the unique patient needs.”
Enter the HHA
The hospital determines the patient’s post-discharge plan, but home health agencies may get involved even before discharge. For home health providers, getting involved early is key, Jordan Holland, senior vice president of value-based care at Compassus, told HHCN.
Compassus is a home-based service provider offering home health, home infusion, palliative and hospice care, among other offerings. The company employs over 7,000 people and operates in 32 states.
For some patients, such as a homebound person with a planned procedure like a joint replacement, Compassus may perform home assessments, install medical equipment, and perform other tasks before a patient’s procedure.
“In those cases, we might actually start the relationship before the actual patient procedure, which can be very beneficial for continued success in the home to reintroduce that patient back in that environment,” Holland said. “Other times, we might get involved more when that patient is in the hospital, but preparing for discharge. Ideally, the more upstream we can collaborate in this patient’s interactions, the more successful we can be in getting that patient in the home.”
HHAs sometimes get involved later, even weeks after the patient is discharged from care. Higher-acuity patients may be discharged first to a skilled nursing facility before being discharged into home-based care. Home health providers can therefore benefit by partnering with inpatient rehab and skilled nursing providers in their markets to allow for efficient referrals, according to Fuller.
While multiple transitions are sometimes necessary, Compassus’s preference is to get involved early.
“In my mind, the way to be the most successful in getting that patient back into the home is much more of that upstream interaction,” Holland said.
Home health providers receive referrals for TEAM patients through existing relationships with hospitals. A discharge planning team, which can include a licensed social worker or case manager, communicates directly with HHAs. The case manager or other member of the team informs the patient about the HHA’s services and, on the day of discharge, coordinates with the HHA to get a clinician into the patient’s home quickly.
Another potential friction point lies in the onset of care. Hospitals have reported issues with home health providers not beginning care for several days or not showing up at all, Fuller said. Front-loading the episode of care, or delivering patient care as soon as possible, is crucial to providing effective care specific to a patient’s condition and to maintaining relationships with hospitals.
Certain pain points can cause breakdowns in communication between hospitals and HHAs. Compassus aims to acquire as much information about a patient as possible in order to develop a holistic care plan, which requires certain technology components to allow for front-end data exchange.
After discharge from the hospital, HHAs still must continue to collaborate with their physician partners, Holland said. This can be complex, because physicians may work on different electronic medical records (EMRs) or prefer a direct phone call.
“We’ve invested a lot in making sure that we’re very, very interoperable with our hospital partners to gather as much information about these patients as possible,” Holland said.
When treatment plans change
Once a TEAM patient is in post-acute care, the “number one focus” is preventing readmissions, Fuller said.
If a readmission occurs during the 30-day episode, the hospital is held financially accountable, Fuller said. Lower readmission rates can aid in forging relationships with TEAM hospitals, allowing HHAs to increase referrals.
“If you’re a home health provider caring for TEAM beneficiaries, you are going to have to be a high performer on readmissions,” Fuller said. “Readmissions are a double whammy under TEAM, meaning that the claim that it generates will count against the hospital participant financially. So it’s another $8,000 to $10,000 to $12,000 hospital claim as a readmission, which will count against them financially. It is also one of the quality measures under the composite quality score, and so it will count against them on their quality performance.”
Lower quality scores can reduce hospitals’ savings under TEAM.
Compassus aims to identify any unexpected health setbacks as proactively as possible, according to Holland, by sending as much data as possible to the company’s directors of clinical services who manage home health patient panels.
Based on that data, directors of clinical services modify a patient’s care plan to match the patient’s evolving needs.
“From there, you still certainly have those unexpected setbacks that then result in re-hospitalization,” Holland said. “The key is really quick coordination with that hospital case management team where that patient might be going, so that you might be able to potentially prevent that hospitalization altogether, if they can get stabilized and back in the home. Or at the very least, minimize what their hospital stay is by ensuring that you have the appropriate plan of care to get them back in the home quickly.”
Day 30 and beyond
The 30-day episode of care does not restart if a patient is readmitted to the hospital, Fuller said. All care delivered after the procedure adds to utilization costs, which continue to count against the bundle at day 30. At that time, the clock stops, and a proration methodology is used to assign costs inside the 30-day episode of care or outside the episode.
Home health for a specific patient may not end when the 30-day TEAM period does. HHAs work in 30-day billing periods but over 60 days of care. Most often, Holland said, providers will continue to have a relationship after the 30-day TEAM episode of care, until a patient can succeed independently.
In the future, TEAM may play an even greater role in HHAs’ operations. CMS has indicated that it will expand the payment concept across various patient conditions and, further down the line, possibly geographies. Even for HHAs not currently impacted by the payment model, “that doesn’t mean just take your eyes off TEAM,” Fuller said.
“This is a little-known statement in the 3,000-page rule that established TEAM; CMS makes it very clear that they intend to add episodes to TEAM,” Fuller continued. “While you may say, ‘We don’t care for that many of these five conditions,’ or ‘These five conditions only represent a small percentage of our volume, or a small percentage of our revenue,’ if, and when, CMS adds other conditions, it could be in conditions that are, in fact, high volume for the home health provider. … This is not the end of the story.”
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