Why use this guide

Better care experiences, better population health, lower cost, and happier staff.

Primary care practices are achieving this quadruple aim by creating more effective practice teams and becoming certified as Patient-Centered Medical Homes. The Primary Care Team Guide provides step-by-step direction on how to establish these high-functioning teams and implement new functions essential to team-based care. Numerous tools and resources from 31 exemplary practices nationwide are made available to support you.

Featured Resources and Modules

Physicians share their experience with team-based care.

Creating a culture of trust and shared responsibility is the foundation, say physicians.

The result is grateful patients and staff, and better care. Team-Base Care: The Physician Experience Video

Care coordination reduces care fragmentation in primary care.

Care coordination improves connections to community resources and helps practices track patients across services. Check out the Referral Management module for care coordination strategies and toolkits.

Referral Management module

MAs can play an important role in providing culturally competent care.

In diverse communities, patient-centered care may mean capitalizing on the skills of practice staff to expand healthcare access to a unique set of patients. Asian Health Services engaged MAs as bilingual health coaches for a multi-ethnic patient base.

Clinic-Community Connections module