What Skilled Nursing Facilities Need to Learn as the TEAM Model Reshapes Hospital Referral Partnerships

Nursing homes are under growing pressure to prove their value. As CMS holds hospitals and ACOs more accountable for what happens after discharge, including cost, readmissions, length of stay, and outcomes, those same measures are increasingly what determines which SNFs a hospital keeps sending patients to.

Industry specialists covering the shift have been direct about what it means for post-acute providers: hospitals will feel pressure to work with SNFs that can help manage costs after discharge, and they'll look for evidence before choosing partners. For a SNF, that means the days of being a default discharge destination are ending, and facilities that can show measurable performance will keep winning referrals.

The SNF Is Now Part of the Hospital's Accountability Chain

The TEAM model holds hospitals financially responsible for a full episode of surgical care, from the procedure through 30 days after discharge. Traditional Medicare beneficiaries undergoing one of five surgical procedures fall under the model, and about 720 hospitals currently participate. The five covered procedures are:

• Coronary artery bypass graft
• Major bowel procedure
• Lower-extremity joint replacement
• Surgical hip and femur fracture treatment
• Spinal fusion

Before TEAM, a hospital's financial responsibility for a patient largely ended at discharge. Now, whatever happens during a patient's SNF stay inside that 30-day window counts directly toward the hospital's own cost and quality performance. That makes the SNF an extension of the hospital's performance, and it gives hospitals a real financial reason to be selective about who they refer to and to keep choosing partners who consistently deliver.

This is where a facility's coordination infrastructure becomes its referral strategy, not just a clinical nice-to-have. Circle Health's licensed care managers work inside a facility's existing workflow to catch early signs of decline, close care gaps before they cause a transfer, and keep documentation consistent enough to show a hospital exactly how a patient's episode was managed. For a SNF trying to earn a lasting place in a hospital's TEAM referral network, that kind of provable, consistent performance is the real asset.

SNFs Can't Wait to Be Told Which Patients Qualify

Not every hospital will flag a referral as a TEAM patient. A facility that waits to be told loses valuable time it could have used to plan care properly.

The stronger position is for SNFs to recognize the relevant surgical diagnoses themselves, on admission, regardless of whether the hospital confirms TEAM status. That single habit is what separates a facility reacting to a patient's needs days into a stay from one that's already built the care plan around them.

Why Care Coordination Is the Real Differentiator

Everything TEAM rewards comes down to one thing: whether a facility can manage a patient's recovery well enough to avoid an unplanned hospital return. That's a care coordination problem, and it's where SNFs have the most room to stand apart from each other.

A few practices consistently separate facilities that perform well under this kind of scrutiny:

• Discharge planning that starts on day one of admission, not in the final days of a stay
• Proactive identification of care gaps, catching missed medication reconciliation, unaddressed fall risk, or therapy gaps before they become a setback
• Consistent monitoring for early signs of deterioration, so a change in condition is addressed before it becomes a transfer
• A named point of contact per patient, so nothing falls between nursing, therapy, and discharge planning

Technology plays a real role here too, but as a support for judgment, not a replacement for it. AI tools applied to a facility's own EMR data can flag missed opportunities in a resident's trends, surface where reimbursement could be improved, and point to where clinical services may need to expand. SNFs that track length of stay, rehospitalizations, and quality measures consistently, and act on what that data shows, put themselves in a stronger position than those relying on instinct alone. Our guide to care coordination programs in SNFs covers how to build this discipline with existing staff, without adding new leadership roles. For more on how TEAM's financial structure works from the hospital side, and what it expects from post-acute partners, our cms team model guide breaks down the episode mechanics in more detail. 

Three Practical Steps to Get TEAM-Ready

Beyond the general principles, there are concrete steps a facility can take now:

1. Identify which of your referring hospitals are TEAM participants. Reach out directly to the hospital's care coordinator or post-acute care manager, understand what they expect from a SNF partner, and keep that communication open on an ongoing basis.
2. Put your existing technology to work. Most SNFs already have an EMR and reporting tools that can track outcomes; the gap is usually consistent use, not missing tools.
3. Keep the core goal in view. The purpose of all of this is to move patients safely and efficiently to their next level of care, whether that's home or another setting, not just to hit a specific metric.

Two More Models Are Already on the Way

TEAM isn't the last accountability model SNFs will need to prepare for. Two more are already scheduled:

• The LEAD Model launches January 1, 2027, and runs for a full decade. It supports smaller, independent, rural, and high-need practices and includes its own version of the SNF three-day waiver.
• CJR-X, the expanded Comprehensive Care for Joint Replacement model, launches January 1, 2028. It covers hip, knee, and inpatient ankle replacements, and uses a 90-day episode window, three times longer than TEAM's 30 days.

Both models mean hospitals and physician groups will keep comparing SNF outcomes against local competitors. A facility that prepares only for TEAM will be playing catch-up again within a year or two.

The Three-Day Waiver Cuts Both Ways

TEAM's three-day SNF waiver lets qualifying facilities accept certain patients who wouldn't otherwise meet the traditional three-day inpatient stay requirement, but qualifying isn't automatic. A facility needs a CMS star rating of three or higher for at least seven of the past twelve months, and CMS refreshes the list of qualifying facilities every quarter. Because CMS looks back over 12 months, a facility that drops below three stars can lose waiver eligibility months later, and needs months at three stars or higher to earn it back. The rating is something to protect early, not repair late.

Even for facilities that qualify, the referral picture isn't uniformly positive. As more joint replacements and spinal procedures move to outpatient settings, some patients may skip inpatient hospitalization altogether and go straight to home health or outpatient therapy, bypassing the SNF pathway entirely. The net effect on referral volume will depend on a facility's market and which procedures it typically sees.

Where Circle Health Fits Into This Shift

Meeting TEAM's expectations mostly comes down to four things: catching the right patients early, acting on that information quickly, tracking what happened, and being able to show it to the hospital afterward. Circle Health's care managers work alongside a facility's existing staff to support exactly that, without replacing how the SNF already operates. In practice, that looks like:

• Early identification of decline, so a change in condition is caught before it turns into a transfer
• Consistent documentation, so a facility can show a hospital how a patient's episode was actually managed
• Support across programs, not just TEAM. The same coordination work also applies to a facility's Medicare ACO program relationships and its care management services support value based care obligations, so a facility isn't running a separate process for each one

Remote patient monitoring reduces readmissions, improving quality star ratings, which matters under TEAM specifically, since every avoided transfer helps both the hospital's episode numbers and the facility's referral standing. Star ratings carry extra weight here too, given the three-day waiver's own threshold, so keeping pace with rising CMS five star quality thresholds is now tied to referral eligibility, not just reputation.

For physician groups, ACOs, and health systems managing SNF populations, the practical point is straightforward: a facility doesn't have to build this coordination capability from scratch for every value-based model it's part of.

Conclusion

TEAM is an early signal of where post-acute accountability is headed, not an isolated policy update. Hospitals are now financially tied to what happens during a patient's SNF stay, which means referrals increasingly go to facilities that can prove they manage risk well, not just those with a spare bed or a long-standing relationship. 

With LEAD and CJR-X following close behind, hospitals and physician groups will only get more rigorous about comparing SNF outcomes against the competition, and the three-day waiver's star-rating requirement ties quality performance directly to which patients a facility can even accept. The facilities that grow their skilled census won't be the ones with the flashiest technology. They'll be the ones that catch patient risk early, coordinate care consistently, protect their star rating, and can prove what they achieved. That combination is what turns a SNF from a default discharge destination into a partner a hospital actively wants to keep working with.

Frequently Asked Questions

What is the TEAM model, and why does it matter to SNFs?

TEAM makes hospitals financially accountable for a patient's full surgical episode, including the 30 days after discharge. Since much of that period is often spent in a SNF, the facility's performance directly affects the hospital's financial result. That gives hospitals a strong incentive to choose SNF partners carefully and keep referring to the ones that perform well.

Does a hospital always tell a SNF when a patient falls under a TEAM episode?

Not necessarily. Many hospitals won't confirm TEAM status on referral, so SNFs need to recognize the five qualifying surgical diagnoses themselves at admission and plan care accordingly from day one.

What does a SNF need to qualify for the three-day waiver?

A facility needs a CMS star rating of three or higher for at least seven of the previous twelve months. CMS updates the list of qualifying SNFs quarterly, so a facility's star rating needs ongoing attention, not just a one-time fix.

What are the LEAD Model and CJR-X, and how are they different from TEAM?

The LEAD Model launches January 1, 2027, runs for ten years, and includes its own SNF three-day waiver to support smaller and rural practices. CJR-X launches January 1, 2028, covers hip, knee, and inpatient ankle replacements, and uses a 90-day episode window, compared with TEAM's 30 days.

Could TEAM actually reduce referrals to some SNFs?

Yes, in some cases. As more joint replacement and spinal procedures shift to outpatient settings, some patients may go directly to home health or outpatient therapy instead of a SNF. The effect varies by market and by which procedures a facility typically receives.

How can a SNF work with a partner like Circle Health to prepare for TEAM?

Circle Health's care managers work alongside existing facility staff to monitor patients, catch early signs of decline, and document outcomes consistently. That helps protect the star rating tied to waiver eligibility and gives a facility the coordination infrastructure to prove its performance to hospital and ACO partners.