The Primary Care Team Guide

Engage the best of every care team member to create a patient-centered experience.

Why practice team-based care?

What does team-based care look like?

Introducing "Support the Team"

Learn what can be done “behind the scenes” to help a practice achieve, and pay for, high-quality team-based care.

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

Integrating behavioral health services greatly improves patient outcomes

CareSouth Carolina reports on how it co-located Licensed Independent Clinical Social Workers with primary care teams—and collected data to track its goal of reaching 0% disparities.

Behavioral Health Integration module

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

Share Your Feedback: How could we improve the Team Guide? Let us know

Primary care is changing. All across the U.S., practices are trying to transform themselves to improve the quality of their care, become patient-centered medical homes, and qualify for new payment opportunities. The Primary Care Team Guide, developed by staff at the MacColl Center for Health Care Innovation, offers practical advice, resources, and models to help leaders and staff engaged in or considering practice transformation build more effective care teams and deploy them to optimize patient care.