With the 2026 launch of the mandatory TEAM model on the horizon, hundreds of U.S. hospitals are facing a seismic shift in financial accountability. This new policy from CMS holds them responsible for the entire 30-day post-operative journey for Medicare patients undergoing major surgeries, from joint replacements to cardiac procedures. To unpack the immense operational and technological changes required to succeed, we are speaking with Faisal Zain, a healthcare expert who specializes in medical technology and its application in modern care delivery. This interview explores the practical steps hospitals must take to navigate this new era of value-based care, focusing on how to replace care fragmentation with seamless coordination, protect revenue by preventing readmissions, and leverage smart technology to ensure every patient gets the follow-up care they need, precisely when they need it.
The TEAM model targets care fragmentation that often occurs under traditional payment systems. Can you share a specific example of how this fragmentation impacts a patient’s 30-day recovery and what key metrics hospitals should now track to measure improvement under this new accountability model?
Absolutely. Imagine a patient, let’s call her Mary, who just had a major lower extremity joint replacement. Under the old fee-for-service model, she might be discharged with a stack of papers and a list of instructions: “Follow up with your surgeon in two weeks, see your primary care physician, and start physical therapy.” It sounds simple, but for a patient recovering from surgery, it’s a maze of phone calls, insurance checks, and scheduling delays. She might put off making the calls, or the first available appointment isn’t for three weeks. This gap is where fragmentation happens. A minor issue that could have been caught in a timely follow-up—like early signs of an infection or improper wound care—can escalate, leading to a costly and traumatic emergency room visit or readmission.
To succeed under TEAM, hospitals must move beyond just tracking the 30-day readmission rate. That’s a lagging indicator. The new core metrics must measure the process itself. We need to be tracking “referral-to-appointment completion” to see if that physical therapy referral actually turned into a attended visit. We need to measure “time-to-follow-up” to ensure it happens within the clinically recommended window. And another critical one is “in-network retention,” which confirms we are guiding patients to trusted partners in care, maintaining that crucial continuity. These metrics give us a real-time pulse on care coordination, allowing us to intervene before a problem becomes a penalty.
With estimates suggesting many hospitals could lose revenue under TEAM, and a single readmission can erase margins, what are the first two or three operational changes a hospital CEO must prioritize to protect revenue? Please provide a step-by-step approach for implementing these changes.
The financial stakes are incredibly high; with up to two-thirds of the 700+ mandated hospitals projected to lose revenue, inaction is not an option. The first priority for any CEO must be to fundamentally redesign the patient discharge process, shifting it from a passive handover to an active, scheduled transition. Step one is to invest in and implement a unified technology platform for scheduling and referrals. This isn’t just an IT upgrade; it’s a core revenue-protection strategy that gives your teams visibility into the entire 30-day episode, from the moment a referral is made to the moment the patient completes their appointment.
Step two is to re-engineer the workflow at the point of care. The new standard must be that no Medicare patient leaves the hospital after one of these five major surgeries without their first follow-up appointment already booked. This means empowering discharge planners or case managers with the tools to schedule that appointment in real-time, right at the bedside. Finally, the third and most crucial step is training and cultural adoption. The CEO must champion this change, ensuring that every clinical team member understands that scheduling this follow-up care is now as critical as the surgery itself. It’s a shift from “we advised the patient” to “we ensured the patient is connected to their next step in care.”
How can hospitals practically implement real-time, point-of-care appointment scheduling for post-discharge follow-ups? Walk us through that workflow and describe how “smart provider matching” ensures patients are connected to the right in-network provider, not just any available one.
The workflow becomes much more patient-centric and efficient. Imagine a case manager with a tablet sitting with the patient before discharge. Instead of just handing them a list of names, they open a single, unified scheduling application. They select the required specialty—say, “spinal fusion follow-up”—and the system instantly presents a list of available, in-network specialists. This is where “smart provider matching” becomes so powerful. It’s not just a directory; it’s an intelligent filter. The system automatically considers the patient’s specific Medicare plan, their geographic location, the provider’s real-time availability, and their specialty.
With a few clicks, the case manager can see Dr. Smith has an opening next Tuesday at 10 a.m. and is just five miles from the patient’s home. They book it right there, and the confirmation is sent to the patient and the receiving provider simultaneously. There’s no more patient confusion, no risk of them accidentally choosing an out-of-network provider, and no administrative black hole where referrals get lost. This process transforms scheduling from a patient’s burden into a seamless part of the hospital’s service, ensuring the patient is connected not just to any provider, but to the right one for their specific needs.
Beyond avoiding financial penalties, how does achieving “care loop closure” enhance the patient experience during the critical 30-day post-operative window? Could you share an anecdote illustrating how complete visibility into a referral’s completion prevents a common complication for a post-surgical patient?
The impact on the patient experience is profound. It’s about replacing anxiety with confidence. When a patient leaves the hospital with their follow-up appointment already confirmed, it sends a powerful message: “We are still with you on this journey.” That peace of mind is invaluable during a vulnerable recovery period. Closing the care loop means the hospital’s clinical team has a longitudinal view of the patient’s progress. They aren’t just hoping the patient followed instructions; they have documented confirmation.
Think of a patient who underwent a major bowel procedure. A common risk is dehydration or nutritional imbalance post-surgery, which can lead to a serious complication and readmission. In a fragmented system, the hospital might not know if the patient ever connected with the recommended nutritionist. With complete visibility, the system flags that the referral was made, but the appointment hasn’t been completed. This triggers an automated or personal outreach from a care concierge or nurse to check on the patient, help them overcome any barriers to scheduling, and reinforce the importance of the visit. That simple intervention, prompted by visibility into the referral’s status, can prevent a dangerous complication, saving the patient from a traumatic return to the hospital and securing a better, safer recovery at home.
What is your forecast for how mandatory models like TEAM will shape the broader adoption of value-based care across other specialties and procedures beyond 2030?
My forecast is that TEAM is not an endpoint but a catalyst. CMS is using these mandatory models as a powerful lever to hardwire care coordination into our healthcare infrastructure. By 2030, the lessons learned and the technologies adopted by these 700+ hospitals will become the new industry standard. The success stories—hospitals that not only avoided penalties but also improved patient outcomes and built stronger provider networks—will create a compelling blueprint for others. I fully expect to see this model expanded to other surgical episodes, such as oncology, cardiology, and other complex procedures where post-acute care is critical. The era of paying for volume without accountability is definitively closing. The future is a system where technology and reimbursement are fully aligned to deliver coordinated, high-value care from start to finish, and models like TEAM are paving that road, one episode at a time.
