This level of coordination represents a significant change for many hospitals. Currently, responsibility often ends at discharge, with limited visibility into post-acute care. Under the TEAM Model CMS, hospitals must develop systems for maintaining continuity throughout the 30-day episode.
The transformation requires both technological and cultural changes. Electronic systems must support information sharing while care teams adapt to expanded responsibilities. Organizations that successfully implement these changes will see benefits beyond the specific procedures included in TEAM – the infrastructure developed will support better care coordination across all conditions.

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