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

Establish a practice improvement team to support care transformation.

Designating leaders in your organization dedicated to supporting and improving care teams is essential to practice transformation. Cambridge Health Alliance created a toolkit for developing a practice improvement team based on their own experience of doing so.

The Practice Team module