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When the Centers for Medicare & Medicaid Services (CMS) launched the Transforming Episode Accountability Model (TEAM) and the AIM for Health Equity and Accountable Care Growth (AHEAD) model, it wasn’t tinkering with policy at the margins — it was redefining what hospitals are accountable for. The new rules make one truth unavoidable: the hospital’s responsibility doesn’t end at discharge. Every missed medication at home, every preventable fall in a skilled nursing facility (SNF), and every readmission triggered by a botched handoff now loops back as a financial penalty. In short, hospitals are paying for what they can’t see. This post-acute problem is a serious blind spot in value-based care today.
For decades, hospitals have treated post-acute care as an external problem, something to be handed off and hoped for. That mindset no longer works. In the world of TEAM and AHEAD, a patient’s journey doesn’t end at the sliding exit doors of the hospital. It continues through the SNF, the home health visit, and every touchpoint in between. The difference now is that CMS is keeping score across that entire journey, and hospitals are on the hook.
Tools to fix it
The tragedy is that the tools to fix this have existed for years. Hospitals could have real-time visibility into what happens after discharge. They could receive updates on therapy progress, vital signs, and medication adherence from SNFs and home health partners. They could intervene early when warning signs appear. They could have lasting integrated provider partnerships. Instead, too many still rely on phone calls, faxes, and hope.