Team-Based Care

Team-Based Care

An effective primary care workforce is essential to better health and health care for all

Many primary care practices struggle to provide high-quality care to their patients. 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 on a single provider, it can have a negative impact on both care quality and practice productivity — and can also 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 for high-risk patients.

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 a team-based approach. Developing effective care teams means expanding roles, providing training, developing trust and teamwork, and using standing orders so staff can act independently. When clinicians and staff work together, a practice is better able to meet patients’ needs, can often increase its capacity to see more patients and can maintain a more satisfied workforce. Building on decades of experience observing and developing high-performing teams in the MacColl Center for Health Care Innovation, the ACT Center continues our work to better understand and inform the state of the art in high-functioning primary care teams.  

Learn more about our work to advance team-based care

Featured publications

Parchman ML, Stefanik-Guizlo K, Penfold RB, Holden E, Shah AC. Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs. Perm J. 2023 Dec 20:1-6. doi: 10.7812/TPP/23.106. Online ahead of print. Full text

Parchman ML, Stefanik-Guizlo K, Shah AC, Glaseroff A, Holden E, Bertko J, Zúñiga R. How to Identify and Support Emerging Risk Medi-Cal Members with Complex Social and Behavioral Needs: A Diabetes Case Study. California Health Care Foundation. December 2023. Full text

Coleman K, Wagner EH, Ladden MD, Flinter M, Cromp D, Hsu C, Crabtree BF, McDonald S. Developing Emerging Leaders to Support Team-Based Primary Care. J Ambul Care Manage. 2019 Oct/Dec;42(4):270-283. doi: 10.1097/JAC.0000000000000277. PubMed

Wagner EH, LeRoy L, Schaefer J, Bailit M, Coleman K, Zhan C, Meyers D. How Do Innovative Primary Care Practices Achieve the Quadruple Aim? J Ambul Care Manage. 2018 Oct/Dec;41(4):288-297. doi: 10.1097/JAC.0000000000000249. PubMed

Wagner EH, Flinter M, Hsu C, Cromp D, Austin BT, Etz R, Crabtree BF, Ladden MD. Effective team-based primary care: observations from innovative practices. BMC Fam Pract. 2017 Feb 2;18(1):13. doi: 10.1186/s12875-017-0590-8. Full Text

Ladden MD, Bodenheimer T, Fishman NW, Flinter M, Hsu C, Parchman M, Wagner EH. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective ambulatory practices project. Acad Med. 2013 Dec;88(12):1830-4. doi: 10.1097/ACM.0000000000000027. PubMed

Featured resource

The Primary Care Team Guide provides step-by-step direction on how to establish high-functioning teams.

Featured news

11 features of effective leadership at primary care practices in the LEAP project.