On a cold January morning in 2026, an 82-year-old woman named Margaret left the hospital after her hip surgery. For Medicare, the “moment of truth” begins not in the operating room, but the second Margaret is discharged. Will her pain medication be filled on time? Will she know when her at-home physical therapy starts? Will someone ensure she has the right walker delivered to her doorstep?

Until now, the answers to these questions have often been left to chance, resulting in fragmented care and costly readmissions. But with the launch of Medicare’s Transforming Episode Accountability Model (TEAM), the rules of the game are changing. Hospitals will no longer simply treat the surgery, they will own the 30 days that follow, both clinically and financially.

This program is an important test case in the accountability of care coordination.

What is the TEAM program?

TEAM is a five-year, mandatory, episode-based payment model beginning in January 2026. It applies to hospitals covered under the Inpatient Prospective Payment System (IPPS) nationwide.

Hospitals will receive target prices for episodes, covering surgery, inpatient stay, and 30 days of downstream services. Success will be measured on both spending relative to those targets and quality performance.

In its initial pilot, 743 hospitals will participate and roughly 500,000 annual discharges will be covered. Five high-cost surgeries are included: lower extremity joint replacement, surgical hip femur fracture, spinal fusion, coronary artery bypass graft, and major bowel procedures.

How can hospitals adapt?

For many hospitals, this type of risk bearing post-surgical care coordination is a net new workflow. There are critical steps to meeting the TEAM targets while upholding quality. The surgeries covered by TEAM are complex in that they often require follow-up in a home or outpatient setting after surgery, equipment, and medication, and are high risk for high-cost follow-ups. Tracking of work and time-sensitive follow ups will be pertinent to success in the 30-day post op window.

The digital command center for patient recovery

Hospitals need a platform to coordinate care, visible to providers, referral partners, care teams, and families. By creating a single pane of glass that unifies real-time care plans for all, it ensures transparency and coordination.

• Referral Management: Automatically routes patients to their primary care providers for follow-up visits, with appointment reminders sent via text or app.
• Equipment Logistics: Uses partnerships with durable medical equipment vendors to ensure same-day delivery of walkers, commodes, or CPAP machines.
• At-Home Therapy Scheduling: Integrates with physical therapy networks to schedule sessions within 48 hours of discharge, using AI-driven matching for availability.
• Medication Adherence: Track compliance, with alerts to caregivers and care managers if doses are missed.
• Assisted Living Transfers: Provides digital intake forms and placement matching tools for families when a patient can’t return safely home.
• Intelligent Assistant: Break down complex medical information into clear, actionable insights, helping patients and their loved ones navigate recovery.

What to look out for

By holding hospitals accountable for the total cost of care, TEAM aims to fix a long-standing gap: the handoff from hospital to home. If it succeeds, it could reduce readmissions, accelerate recovery, and make Margaret’s story of smooth transitions, right equipment, timely therapy, the rule, not the exception.

The mandate for technology is clear. Build the connective tissue. Create the tools that anticipate patient needs, coordinate the actors, and prove that technology can deliver both better outcomes and lower costs.

Because in TEAM’s world, the surgery may end in the hospital, but the business of care is only just beginning.