From TEAM Compliance to TEAM Excellence ReferWell ensures your surgical episodes succeed by combining intelligent routing technology with hands-on care navigation to convert referrals and prevent readmissions.
Up to two-thirds of participating hospitals will lose revenue under TEAM according to Brandeis University analysis.
All costs for 30 days post-discharge are included in episode pricing, including readmissions.
TEAM covers five high-volume surgical procedures requiring coordination.
Hospitals need patients to:
(1) Convert referrals → see high-quality, in-network specialists for post-surgical care, and
(2) Not get readmitted → remain healthy and complete their recovery journey without complications.
Beginning on January 1, 2026, The Centers for Medicare & Medicaid Services (CMS) Transforming Episode Accountability Model (TEAM) policy will reshape how care is delivered and coordinated to support Medicare patients throughout their surgical journey. About 714 acute care hospitals must comply and coordinate care from surgery through 30 days post-hospitalization for Medicare patients undergoing one of five surgical procedures:
ReferWell is the technology partner of choice for hospitals and health systems looking to transform the trajectory of post-operative care fragmentation. To ensure your Medicare patients’ surgical episodes achieve positive outcomes, ReferWell’s intelligent software-as-a-service scheduling platform with empathetic human-led care navigation can convert referrals and prevent readmissions.
Learn how ReferWell’s Readmission Prevention Bundle Can:
The expected impact achieves:
Industry baseline: ~15% readmission rate
With comprehensive care navigation: 10-12%
ReferWell’s platform uses a curated provider database and intelligent provider match search and scheduling technology that filters referral providers by insurance, subspecialty, response time, location, and language.
For TEAM Compliance, This Means:
Direct patients to specialists with lowest readmission rates
57% reduction in patient leakage, keeping costs predictable
Real-time visibility into who showed up, who didn’t, and who needs intervention
ReferWell’s care navigators are trained to cultivate trust and empathy with each patient. Leveraging our intelligent scheduling platform, our care navigators engage patients and schedule appointments turning outreach into completed care.
For TEAM, This Means:
Don’t just schedule—ensure patients actually attend post-operative appointments
Address transportation, mobility, work conflicts, insurance confusion
Contact patients who miss appointments before they deteriorate
Identify warning signs of complications and intervene early
Convert Referrals to Appointments
Target Achievement Rate
80-85%
vs. 50% industry baseline
Decrease 30-Day Readmissions
Target Readmission Rate
<12%
vs. 15%+ industry baseline
Only half of Medicare beneficiaries who were readmitted within 30 days had a follow-up visit with a clinician. Roughly two-thirds of post-discharge adverse events were preventable or could have been mitigated.
Industry standard: 50% of referrals result in visits
With ReferWell: 80-85% visit completion rate, providing real-time insights to providers
Outpatient follow-up visits reduced 30-day all-cause readmissions by 21% in meta-analysis. Care transition programs with nurse coaches reduced readmission rates from 11.9% to 8.3%, saving $500 per case.
Industry baseline: ~15% readmission rate
With comprehensive care navigation: 10-12%
Financial Impact Per Episode
Average surgical episode cost: $30,000-50,000
One prevented readmission: $15,000 saved
One prevented complication: $8,000-25,000 saved
Network retention vs. leakage: $5,000-15,000 margin protection
Annual Impact (1,000 Episodes/Yr)
30 fewer readmissions: $450,000
Better specialist routing: $2-5M
Network retention: $5-15M
Total Potential Impact: $7.5-20M+
What Software Can't Do
What Care Navigators + Technology Can Do
ReferWell tripled patient access to specialists, achieving 69% patient follow-through with referral appointments through their combination of advanced scheduling platform and highly trained care navigators.
“The combination of technology and human touch is what makes the difference between scheduling an appointment and ensuring a patient actually receives the care they need.”
Patients get high-quality, in-network, low-readmission providers
Patients don’t return to the hospital through proactive monitoring