By Jason Lindsey, DNP, MSN, RN, ACM-RN
When talking with case management leaders, I often tell them “once you have seen one case management program, you have seen only one case management program.” I remember having this exact conversation with a colleague and good friend when she told me “we discharge plan from birth to death,” meaning her team managed the operations of the hospital’s morgue. I couldn’t believe it and thought there was no way a case management department would have responsibility for the things that happened outside of the hospital.
As the healthcare landscape has changed, the needs of case management have changed, requiring the evolution of care management to move from discharge planning to focusing on care progression, anticipating the needs of the patient and family well beyond the discharge date. Now, as we consider the implementation of CMS TEAMs and CJR-X models, one reality is becoming increasingly clear: successful management begins long before discharge – there is opportunity for case managers to influence outcomes before a patient ever arrives for a procedure.
So, what are TEAM and CJR-X? TEAM (Transforming Episode Accountability Model) and CJR-X (Comprehensive Care for Joint Replacement Expanded) are CMS episode-based payment models designed to improve quality, care coordination, and cost efficiency for defined periods across surgical episodes of care. On January 1 this year, TEAM required selected hospitals to assume accountability for the total cost and quality of care for 30 days after discharge for five surgical procedure categories. Beginning January 1, 2028, CJR-X expands episode-based accountability for one surgical procedure category to hospitals not already participating in TEAM and extends the recovery from 30 days to 90 days. Both models consider quality outcomes such as readmissions, surgical complications, utilization of the ED, and care outcomes, while also considering cost, including all care-related costs during the defined episode. While both models only apply to traditional Medicare beneficiaries, the care coordination strategies they promote represent best practices that can improve outcomes for patients across all payer groups.
What is the moral of this story? If your hospital isn’t already, it will be participating in some form of mandated bundled payment program based on care quality, outcomes and costs, which are directly impacted by care management strategies. Now, the question really is what can you do to prepare your organization to not only survive these changes, but thrive in the new models?
One of the most impactful strategies for case management departments to implement is pre-procedure engagement for high-risk patients. Meeting with patients before surgery allows case managers to identify barriers to a successful recovery while there is time to intervene. These conversations should assess the practical issues that often determine post-operative success: Is a caregiver available? Is transportation arranged for follow-up appointments and necessary therapy? Are there financial barriers that could impact medication adherence? Does the patient have the necessary equipment and environment for a safe recovery? And lastly, does the patient and family have realistic expectations related to the surgery, post-operative course, and after-care needs? A structured pre-procedure assessment enables case managers to identify these issues, evaluate caregiver readiness, and begin planning for post-acute needs well before the procedure occurs.
Ultimately, TEAM and CJR-X reinforce a reality that case management professionals have long understood: effective care coordination directly influences both patient outcomes and organizational success. In these new models of care, case managers now have the imperative to expand this influence and support of organizational goals.