Hospitals and physicians participating in new Fee-For-Value programs rely on high-quality care delivery for the transition from the hospital back to health. ACOs and hospitals depend on skilled nursing facilities, rehabilitation facilities, and home health agencies to manage patients back to health. However, lack of shared plans and direct communication during these transitions are a major source of readmission risk and gaps in care plan adherence. By integrating with TEAM of Care, post-acute partners can offer a substantial differentiation and value proposition that will make them a preferred partner. Shared care plans and real-time exchange of clinical and operational performance information will institutionalize the relationship between primary care providers, hospitals, and their post-acute service providers. With TEAM of Care’s ACO Performance Management Software post-acute providers can: