The following is a guest article by Phyllis Wojtusik, RN, Executive Vice President, Value-Based Care at Real Time Medical Systems

Hospitals are about to take on greater responsibility for patient outcomes—extending well beyond discharge. Beginning January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will implement the Transforming Episode Accountability Model (TEAM), requiring hospitals to manage care for Medicare patients undergoing the following surgeries: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedures. Each care episode concludes 30 days after the patient is discharged from the hospital.

This shift significantly raises the stakes for acute care providers. Avoidable readmissions and emergency department (ED) visits—often caused by poor transitions, delayed interventions, or fragmented communication—will now impact both patient outcomes and hospital reimbursement. Under TEAM, hospitals are financially accountable for the entire episode of care, making effective post-acute coordination more critical than ever.

Why TEAM Raises the Stakes

Despite best efforts, many hospitals and post-acute partners still rely on disjointed communication methods—disparate EHR systems that lead to a need for phone calls, faxes, and paper discharge summaries. These workflows often leave care teams without timely insights into a patient’s condition, especially during the critical first 72 hours post-transfer, when readmission risk is highest.

Orders may be missed. Medications delayed. Subtle clinical changes overlooked. And patients return to the ED.

Under TEAM, these breakdowns can result in lost shared savings—or even financial penalties.

TEAM Insights: Real-Time Visibility Across Care Settings

TEAM Insights from Real Time Medical Systems (Real Time) is an AI-driven solution designed to help hospitals succeed under TEAM by enabling efficient collaboration between acute and post-acute care teams. It provides access to live clinical data and actionable insights during post-acute stays, empowering care teams to identify subtle changes in condition and intervene early with high-risk patients.

Unlike hospital stays, where risk escalates gradually, readmission risk peaks within the first 72 hours after transfer to a post-acute facility. TEAM Insights aggregates and standardizes data and documentation from all post-acute EHR systems, surfacing meaningful, timely information that supports proactive care management across the hospital’s post-acute care network.

The platform features Real Time’s proprietary AI-based CARD readmission risk score, which stratifies patients into low-, medium-, and high-risk categories based on key clinical indicators, including:

• Clinical alerts (e.g., rising temperature, dropping blood pressure)
• Admission recency (risk peaks within 72 hours)
• Readmissions or ED visits (last 180 days)
• Diagnosis – Comorbid conditions (e.g., diabetes, hypertension)

These scores are displayed in an intuitive dashboard, with configurable alerts that notify care teams when a patient’s risk score changes or vital signs cross critical thresholds—supporting timely, targeted interventions.

Proven Impact: Better Outcomes, Fewer Readmissions

Hospitals leveraging Real Time’s data-driven platform have seen measurable improvements. A 2024 study published in the American Journal of Managed Care found that facilities using Real Time experienced a 52% reduction in readmissions, along with stronger performance on CMS metrics for clinical, financial, and operational outcomes.

TEAM Insights extends these capabilities by providing standardized, data transparency across post-acute care settings—enabling smoother transitions, better coordination, and more efficient workflows, especially for patients with complex conditions.

It also helps hospitals evaluate post-acute networks, identify high-quality, cost-effective partners, and establish standardized care pathways aligned with TEAM’s value-based goals.

Preparing for TEAM: The Time to Act is Now

With TEAM going into effect in less than three months, hospitals must act quickly to strengthen post-acute partnerships and streamline care coordination. TEAM Insights equips clinical teams with the tools and actionable insights needed to manage risk, intervene early, and improve outcomes across the full episode of care.

Real Time supports TEAM’s goals by enabling hospitals to reduce avoidable readmissions, manage length of stay, and improve recovery pathways for common surgical procedures. But its impacts goes beyond TEAM. By facilitating real-time collaboration and data sharing, Real Time drives improved care transitions, enhanced operational efficiency, and strengthened financial performance for both hospitals and their post-acute care partners.

With TEAM Insights, hospitals gain a strategic advantage—not only in meeting CMS requirements, but in ensuring patients recover in the right setting and achieve the best possible outcomes.