In this episode of The Surgical Journey, Lisa Miller is joined by Dr. Mallika L. Mendu and Dr. Kathryn M. Corelli of Mass General Brigham for a practical discussion on what it takes to manage the full surgical episode under value-based care and the CMS TEAM model. Dr. Mendu is Chief Population Health Officer at Mass General Brigham, Vice President of Clinical Operations and Care Continuum at Brigham and Women's Hospital, and Associate Professor at Harvard Medical School. Dr. Corelli is Associate Medical Director of Strategy and New Program Development within MGB Population Health and an Instructor in Medicine at Harvard Medical School. The conversation moves beyond policy and into the operational work required to support patients across preoperative optimization, the hospital stay, post-acute care, and recovery at home. Dr. Mendu explains why patient-centeredness is central to value-based care, and why episode accountability requires a more connected infrastructure across surgeons, primary care, specialists, home health, post-acute partners, pharmacists, social workers, and care navigators. Dr. Corelli shares how Mass General Brigham is building these programs in practice, including stakeholder interviews, data-driven opportunity analysis, caregiver coaching, physical therapy navigation, post-acute collaboratives, and risk stratification. The discussion also covers what moves the needle in the post-discharge window, why readmission prevention depends on both human touchpoints and scalable technology, and how Healthcare at Home and Home Hospital models may shape the future of surgical recovery. For health system leaders preparing for mandatory episode-based payment, this episode offers a grounded look at the infrastructure needed to support safer recoveries, better patient experiences, and more coordinated care after surgery. Timestamps / Contents 00:00 Welcome to The Surgical Journey 00:54 Introducing Dr. Mallika Mendu and Dr. Kathryn Corelli 01:49 How the CMS TEAM model changes surgical accountability 02:17 Why MGB sees TEAM as an opportunity to improve care delivery 03:45 The challenge of building new workflows for episode-based care 04:16 Dr. Corelli's framework: preoperative optimization, hospitalization, and recovery 05:24 Using stakeholder interviews and data to design better workflows 06:15 Why caregiver coaching matters after surgery 07:42 Patient-centered value-based care across surgery, primary care, and post-acute care 10:04 Surgeon engagement and shared ownership of outcomes 11:02 Physical therapy, case management, and preparing patients for home recovery 13:17 The practical details that make recovery at home safer 13:53 Designing programs that align primary care, surgeons, and post-acute partners 14:22 SNF and home health collaboratives, shared learning, and quality standards 15:10 Using benchmark data to identify post-acute utilization opportunities 15:56 Readmissions and the critical 30-day post-discharge window 17:04 Navigation, medication reconciliation, home services, and care team coordination 18:52 MGB's post-discharge follow-up work and readmission reduction 19:51 Where technology fits into scaling navigation 20:15 Risk scores, frailty measures, FLEX score, and predictive modeling 21:22 Healthcare at Home and Home Hospital in surgical recovery 22:10 Why home-based care aligns with patient-centeredness 23:03 Building workflows for appropriate surgical patients at home 23:40 Neuro spine pilots, SNF at Home, and future care models 24:23 Advice for health systems building TEAM infrastructure 25:01 The need for real-time data and actionable risk identification 25:35 Benchmarking, culture change, patient feedback, and frontline insights 26:20 Why TEAM is a signal for where care delivery is headed 27:21 Closing remarks