About the Primary Care Team Guide

For more than 20 years MacColl Center for Healthcare Innovation at Kaiser Permanente Washington Health Research Institute has supported the transformation of health care delivery through innovative research, model development, training and technical assistance.

We are pleased to offer primary care practice staff and practice facilitators strategies, resources and creative ideas for improving team-based care. All of the content and resources are freely accessible for your learning and adaptation. 

The Primary Care Team Guide is the result of more than five years of research and engagement with leading primary care practices across the United States through the Robert Wood Johnson Foundation-funded “The Primary Care Team: Learning From Effective Ambulatory Practices” (PCT-LEAP) project and the Healthy Hearts Northwest intervention.

The Build the Team and Do the Work sections of the website share the best practices gathered during the PCT-LEAP project. More recently we have added the Support the Work section. Modules in this section are designed to assist teams, quality improvement coaches and health system leaders to develop process improvements, plan clinic staffing and explore ways to pay for innovative models of care. Much of this newer content was based on what practice facilitators learned from working with primary care practices during the Health Hearts Northwest intervention. We encourage both primary care practice staff and practice facilitators to use the full range of resources available on the website.


The PCT-LEAP Project (2012–2017)

“The Primary Care Team: Learning From Effective Ambulatory Practices” or LEAP, was designed to identify, study, and engage 30 exemplar primary care practices from across the United States that are using their workforce creatively. The LEAP Program was co-directed by Ed Wagner, MD, MPH, and Margaret Flinter, PhD, APRN.


Healthy Hearts Northwest (2016–2019)

Over the course of three years, our Healthy Hearts Northwest intervention touched over 200 clinics across WA, OR, and Idaho—many of them small, independent, and rural. The Practice Persona content on our site is based on the experience of over a dozen practice facilitators who supported quality improvement efforts in these practices.



Most of the content of this website was produced by the staff of the MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute. Major contributing authors for Build the Team and Do the Work sections include Ed Wagner, Clarissa Hsu and Brian Austin. DeAnn Cromp, Sarah McDonald and Julie Reardon were invaluable in collecting and organizing the resources for the site. Our three co-editors who worked with us in the early stages of this site’s development and contributed not only to the text but also to the organization of the content include:

  • Tom Bodenheimer, MD, MPH Professor, Family & Community Medicine, University of California, San Francisco
  • Lisa Letourneau, MD, MPH, Executive Director, Maine Quality Counts
  • Carolyn Shepherd, MD, former Chief Medical Officer, Clinica Family Health Services

We would like to thank the members of our National Advisory Committee, whose hard work and thoughtful insights made the PCT-LEAP project possible.

  • Tom Bodenheimer, MD, MPH (NAC Chair) - UCSF Department of Family & Community Medicine
  • Marjorie Godfrey, MS, RN - The Dartmouth Institute for Health Policy & Clinical Practice
  • Carlos Jaen, MD, PhD - UT Health Science Center
  • Lisa Letourneau, MD - Maine Quality Counts
  • Nitzali Rivera, LPN - Union Square Family Health Center
  • Marie Schall - Institute for Healthcare Improvement
  • Carolyn Shepherd, MD - Leibig-Shepherd, LLC
  • Elaine Skoch, RN - Health System Redesign Solutions
  • Donna Thompson, MS, RN - Access Community Health Network
  • Jurgen Unutzer, MD - University of Washington

The content contained within the Practice Persona module on this site was created by Health Hearts Northwest staff. We’d like to thank the practice facilitators at Qualis Health and the Oregon Rural Practice-based Research Network for sharing their experience and insights. Major contributing authors include Brian Austin and Claire Allen at MacColl, Caitlin Dickinson at ORPRN, and Tara Kline at Qualis Health.