What is the challenge?

Many primary care practices struggle to provide high-quality care while remaining financially stable. There simply isn’t enough time in the day for busy providers to meet all their patients’ needs. When all aspects of a patient’s care depend upon a single provider it can have a negative impact on both care quality and practice productivity—and can contribute to an inefficient and stressful work environment. Furthermore, provider-dependent practices have difficulty providing the full range of services that improve patient outcomes, such as care coordination or more intensive follow-up of high risk patients. In order to move to a more team-based, efficient, and satisfying model of care, primary care practices will need leadership and a commitment to change the culture from the traditional provider-centered, hierarchical model of practice to a more team-based culture of mutual respect and appreciation for all members of the team.

What needs to change?

Strong evidence indicates that primary care practices should move to a team-based model of care, where care teams explicitly share responsibility for a defined group of patients and have systems to support team-based care. The team can take several forms, but generally includes a core team built around one or a small number of specific providers. The core team collaborates to manage the encounters (visits, e-mail, etc.) generated by patients of their provider(s). In addition to the provider(s), a care team might include one or more medical assistants (MAs), a registered nurse (RN), and one or more administrative staff or other lay-person roles such as health coach or patient advocate. In larger practices, the core teams are supported by an extended team consisting of centralized health professionals and administrative staff. Commonly, professionals include RNs in care management or supervisory roles, pharmacists, and behavioral health specialists. Practices often need to reorganize the work to maximize each team member’s skills and expertise, offload provider tasks, expand the services that can be offered, and use standing orders and predefined workflows that take full advantage of the team structure. 

For many reasons, it is useful to engage patients as members of their care team:

  • To help patients see the core team as an enhancement to their provider’s care and support, and not a dilution of provider involvement in their care
  • To help patients understand the different, complementary skills and roles team members play
  • To give patients more opportunities to get questions answered and needs met by individuals with whom they have a relationship
  • To help the practice improve the quality and relevance of its care and service

High functioning team-based care requires a change in the provider-focused mental model including explicit efforts to build trust, respect, and value for new roles in the primary care workforce, and for thinking of patients as partners in care.

Webinar: Paul Burgess webcast "Third Space Health Care"

Making the Case for Team-Based Care: Lessons from Vibrant Health

What do we gain by making these changes?

Involving additional team members in the delivery of chronic illness and preventive care has been repeatedly shown to improve performance measures. Evidence also suggests that team-based care can help primary care practices increase productivity, enhance efficiency, and create a more satisfying work environment. When clinicians and staff work together, a practice is better able to meet patients’ needs and can often increase its capacity to see more patients.

Webinar: Building Your Primary Care Team to Transform Your Practice

  1. Identify the leadership for teams and start building a team culture

    Even before you begin building your team, it’s important to identify clear leadership for this change and start developing a culture that supports teamwork. It is a culture that empowers and prepares staff to take on new roles and act independently, encourages providers to give up tasks done better or more efficiently by others, and encourages communication. Strategies that LEAP sites have found helpful include:

    • Ensure that formal and informal practice leaders repeatedly voice clear and strong support for team-based care, and act consistently in a way that signals their support for this model.
    • Dedicate resources for team-building exercises to help team members begin developing trust and a coordinated way of working together.
    • Locate core team members in close proximity with each other. Several LEAP sites had team rooms or team spaces where providers and core team staff did their charting and telephoning.
    • Encourage daily huddles and meetings to organize the work and solve problems together.

    Flatten the hierarchy by encouraging all member of the team to have a voice in discussions, explicitly sharing performance information and credit (e.g., performance bonuses) for successes with all members of the team.

  2. Develop a core team structure or structures that you think will meet the needs of your patients and providers, AND TEST IT

    No single core team structure appeared superior to others. Some LEAP sites built their core teams around a single provider (e.g. a teamlet with 1 provider and 1 or 2 MAs) and some built multi-provider teams (e.g., 2-3 providers, 2-3 MAs, 1 RN). Smaller core teams may make it easier for staff to develop relationships with patients. The extended team in most LEAP sites included RN care managers, behavioral health specialists, and pharmacists. These additional professionals could be employees of the clinic or supported by an affiliated organization such as a health plan, community mental health center, or academic institution. Administrative staff could be centralized and/or linked with a core team. 

  3. Develop clear roles and responsibilities for every member of the team

    These should ensure that each team member is working to the top of their skillset and credentials. This most often means expanding the roles of additional staff members to take on tasks previously done by providers or not done at all. For example, preventive care procedures (e.g., immunizations, ordering cancer screening, assessments such as monofilament foot exams) in most LEAP sites were routinely and independently performed by MAs and/or LPNs. Be sure to research state policies regarding licensure and scope of practice rules for various roles. You may also want to explore state liability regulations.  

  4. Encourage and enable staff to work independently.
    • Develop standard work processes for the delivery of common services, and incorporate them into practice workflows and into the Electronic Health Record. Systematizing expanded roles in standard work helps reduce variation and prevent backsliding.
    • Maximize the use of standing orders. Standing orders enable staff to independently perform key clinical tasks without having to involve the provider.
  5. Engage patients as a member of the care team and help them understand what they can expect in a team-based model of care.

    Many patients may not be familiar with the team-based approach and do not know what to expect when receiving care from multiple team members or the benefits of having a team around them. It helps to develop simple scripting that clinicians and staff can use to explain that all team members are working together, communicating regularly, and operating under the direction of the patient’s primary care provider. 

  6. Provide team members with regular, dedicated time to meet about patient care, quality improvement, and to facilitate strong working relationships.

    While it can be financially and logistically challenging to take staff members “off line,” dedicated time is an essential investment to create high functioning teams that deliver high quality, coordinated care to patients. LEAP sites use a variety of approaches to meetings, including huddles, improvement events, and care conferences. 

  7. Provide training so that staff members learn new tasks and how to coordinate with team members.

    LEAP sites support team members with strong internal training programs, having found that current educational programs often do not prepare the workforce for a high functioning team model. Many LEAP sites emphasize cross-training so workflows are not interrupted when short-staffed. 

  8. Develop career ladders for staff members in all roles.

    Many LEAP sites have been able to hire enthusiastic, talented individuals into relatively low paying roles such as Medical Assistant, Administrative staff, or lay roles such as community health worker, health coach or patient navigator. In an effort to reward excellent performance and keep staff, some sites have found explicit career ladders to be useful.


Webinar and power point presentations

  • Webinar and power point presentations

    Webinar: Paul Burgess webcast "Third Space Health Care"

    Dr. Paul Burgess presents initial findings from his Harkness Fellowship project "Third Space Health Care: how innovations pioneered for vulnerable populations are shaping the future of primary care in the United States." He describes efforts in Alaska, Oregon, North Carolina, and Vermont.

  • Webinar and power point presentations

    Webinar: Building Your Primary Care Team to Transform Your Practice

    Learn about building your primary care team in this webinar featuring LEAP sites. This is part of a great series of webinars on Advancing Team-based Care organized by Community Health Center, Inc. Slides are also available at http://weitzmaninstitute.org/NCA

  • Webinar and power point presentations

    Introducing the Primary Care Team Guide, December 9, 2014


  • Video

    Making the Case for Team-Based Care: Lessons from Vibrant Health

    In this video, learn from one LEAP site about their transition to team-based care. Team members at Vibrant Health Family Clinics in Ellsworth, Wisconsin, explain why they went to a team-based model and how they paid for it as a traditional fee-for-service practice.

  • Video

    The Practice Team Video

    Get started understanding why building an integrated practice team is important.

  • Video

    Engaging patients in improving care

    Learn how to engage patients in QI in this video from the UCSF Center for Excellence in Primary Care

ToolkitsImplementation guides and other documents with extensive resources included

  • Toolkits

    Team-Based Care Toolkit

    Learn from one LEAP site about building your care team, in this comprehensive toolkit. (This tool is currently being updated by the LEAP site. The updated tool will be made available as soon as possible.)

  • Toolkits

    Care Team Starter Pack

    Learn from one LEAP site about building your care team by redesigning care team roles, in this "CareTeam starter pack." At West County Health Centers, Inc., the care team includes the medical provider, MA, Nurse Care Manager, Care Team Representative, and Patient Navigator. Read more about these roles and how they interact to provide high quality care for patients.

  • Toolkits

    Practice Improvement Team Toolkit

    At LEAP site Cambridge Health Alliance, each clinic has a practice improvement team, which includes patients. See this toolkit for guidance on how to recruit patients and engage all team members meaningfully in practice improvements.

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Old Town Clinic Primary Care Team Structure

    Learn how one LEAP site has configured its care team structure. This document describes the core and extended team member roles at Old Town Clinic. Each of the 4 teams has a name and identify that reflects features of the local environment in Portland, Oregon, such as the "Burnside Bridges."

  • Role features

    Clinica Care Team Pod Structure

    Learn how one LEAP site developed its care team structure, in "pods." This document describes the team member roles in each pod and ways that this structure is supported. Each pod is identified by a color. Pod members are co-located in the same space. (Note: The document summarizes a 2011 site visit by Tom Bodenheimer, for the California HealthCare Foundation's Building Blocks project)

  • Role features

    "Share the Care" Assessment of Team Roles and Tasks

    This is an example of a planning tool, to assess who is currently doing what tasks in your practice and then who should be doing each task, based on how we learned that LEAP sites define clear roles and responsibilities. Task distribution will vary from practice to practice, but the tool is in the discussion about roles that this worksheet can stimulate. Your practice may be able to redestribute tasks in a way that better fits your workforce and patient needs.

  • Role features

    Team Effectiveness Tool

    A helpful way to gain insight about improvements to teamwork as a result of clarifying and enhancing roles is to measure it. Your practice can develop your own tool to measure team functioning; here is one example, from the Saskatchewan Ministry of Health.

  • Role features

    Roles and Responsibilities Diagram

    See how one LEAP site has developed the core primary care team roles of Patient Advocate, MA, and RN. This diagram reflects the responsibilities of each team member in a way that the practice felt best utilized each team member's skill and training.

Case summariesVignettes, profiles and testimonial videos

  • Case summaries

    Primary Care Team Conceptual Diagram

    Based on the LEAP site visits, we developed a conceptual diagram to help practices think about how to organize a care team around the patient. The core team is collectively responsible for a defined patient panel. The next layer of extended team members are centralized resources available to all teams. An additional outer layer includes affiliated staff who are not employed by the practice but are part of the care team through formal links with outside organizations.

LEAP Learning ModuleOther helpful topics included in this website

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    MA and Nurse level visits

    This algorithm was developed by LEAP site Clinica Family Health Services to decide whether a patient visit is an MA-level or RN-level visit. RN-level visits can be billed 99211, so this tool is helpful for clarifying roles as well as reimbursement for nursing services.

  • Clinical protocol

    MA and Nursing standing orders

    See several examples of standing orders for MAs and nurses, including reading PPD results, administering asthma medications, ordering labs, and more.

  • Clinical protocol

    Lab Cheat Sheets

    See how one LEAP site, Clinica Family Health Services, helps nurses and MAs with lab protocols using visual guidelines for reference in the lab setting. There are 1 page "cheat sheets" for several tests and procedures, to help nursing staff perform a variety of tasks from urine pregnancy tests to ultrasounds.

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Care Team "dance" and roles

    LEAP site West County Health Centers creates time and space for care team members to learn how to work together as a team. West County developed training materials around the concept of the "team dance" to describe how they artfully interact together to provide great care to patients. Materials include a description of each care team role: MA, front office, and RN.

  • Staff training

    Care Team Training

    See the team training used by LEAP site Cambridge Health Alliance–Union Square Family Medicine to orient all members to the team culture and facilitate working relationships.

  • Staff training

    Team Development for Clinicians and MAs

    See the curriculum developed by one LEAP site to develop the critical relationship between provider and MA. Learning how to work together as a team is a skill that benefits from training and support, just like clinical skills. This training helped improve the partnership between providers and MAs through developing an aligned "purpose statement," communicating effectively, giving and receiving feedback, and identifying a decision-making style.

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Lessons Learned about protocol

    Read about lessons learned in developing protocols for nurses, MAs, and pharmacists on the care team, described by Carolyn Shepherd, M.D., who is retired from her position as Executive Vice President of clinical services at Clinica Family Health Services in Colorado.

  • Workflow

    Anatomy of a Huddle

    Learn about one LEAP site's approach to huddles, by looking at their guidelines for running effective team huddles that involve identifying patients for specific services or follow-up and preparing for the day.

  • Workflow

    Extended huddles for complex patients

    Learn how one LEAP site uses extended huddles to discuss complex patients. All care team members are present, from the MAs to front desk staff, to bring insight into new approaches to help patients with complex health issues who are not reaching clinical targets. These huddles are led by the Behavioral Health Consultant.

  • Workflow

    Contraception training for MAs and Nurses

    See an example of training materials from one LEAP site, Clinica Family Health Services. This presentation trained MAs and RNs about contraception protocols, workflows, and their respective roles in providing patients with family planning services.

Patient materialsAction plans, brochures, team cards, welcome letters

  • Patient materials

    Patient Partner Packet

    Learn how one LEAP site uses a team member called the "Patient Partner" to orient new patients to the practice. The Patient Partner gives each new patient this booklet along with an introduction to the PCMH concept, who is on the care team, and what those team members can help the patient with.

  • Patient materials

    Patient Welcome Packet

    See patient materials used by one LEAP site to introduce patients to their care team and engage patients in this model of care.