Your Patient Was Discharged. They're Back in 18 Days.
The readmission wasn't medical. It was transportation. They couldn't get to the pharmacy. They couldn't get to follow-up. You didn't know until they returned.
TEAM Model accountability raises the cost of weak care transitions. Reduce 30-day readmissions through stronger SDOH documentation and clearer discharge follow-through.
Request Demo5 procedures covered: CABG, LEJR, Spinal Fusion, SHFFT, Major Bowel
How It Works
5-Minute Discharge Summaries
Complete documentation with SDOH screening and post-acute coordination.
30-Day Episode Tracking
Follow patients through surgery and post-discharge with Progressive HPI.
SDOH Intervention Triggers
Identify transportation, housing, and medication barriers before discharge.
Evidence-Linking for Audits
60-second audit package generation with claim-level audio timestamps.
Impact
Readmission reduction
Annual penalty avoidance
Audit package generation
Common Questions
What is the TEAM Model? ▼
CMS's Transforming Episode Accountability Model holds hospitals financially responsible for 30-day surgical episodes and post-discharge outcomes.
How does SDOH documentation reduce readmissions? ▼
50% of readmissions are caused by social factors like transportation, housing, and medication access. Capturing these barriers enables intervention before discharge.
How long does implementation take? ▼
Most teams launch in phased waves over a few months, starting with highest-volume surgical episodes first.
Ready for TEAM Model compliance?
See how OrbDoc can help reduce readmissions and strengthen TEAM Model readiness.
Request Demo