Building the Foundation
The key activities below will guide you through the process:
- Develop and test a core care team structure.
- Identify gaps in staffing and decide how to address them.
- Engage patients.
- Leverage teams to lead continuous improvements.
After working through the key activities above, you will be able to:
- Define and establish a core care team incorporating team-based care principles.
- Assure that care teams know their patient panels (applies only if the practice is also working on empanelment or has it in place).
- Assure that patients know their care team.
- Build expanded care team functions that incorporate team-based care principles.
Key Activity 1: Develop and test a core team structure.
The core team is the heart of a practice, and is designed to meet most of the needs of most patients. This core team is where continuous healing relationships between patients and families occur, and is the primary source of healing and value in health care.
1. Understand your patients’ needs.
Delivering high-quality, comprehensive primary care means that teams should be built to address most of the common needs of their patients, and should “have the capacity to either directly deal with them or have the diagnostic skills to appropriately refer the patient to a specialist.”[1] For most primary care practices that care for a general population, the core care team will include, at a minimum, a primary care provider and medical assistant. However, for many practices that serve people with complex social and behavioral health needs, additional capabilities are needed on the core team day to day. Having clearly defined patient panels is the starting point for understanding patient needs and designing care teams to address them. See the Empanelment Guide for more on how to master empanelment, including the bidirectional process of patients choosing a provider, and providers knowing their patient panel.
If your care team is established to address a specific subpopulation of patients, other care team roles may be required. For example, the maternity care population is a special population that requires time bound, condition-specific services to support a healthy pregnancy, birth and postpartum transition. While not all practices provide the full spectrum of prenatal and postpartum services, some may add perinatal services staff if their focus is on improving perinatal outcomes. Care team roles specific to the maternity care population may include a Comprehensive Perinatal Services Program (CPSP) worker and doulas to provide personal support to pregnant persons and families throughout the pregnancy, childbirth and postpartum experience.
2. Identify a core care team that, together, meets most patient needs.
As you explore your patients’ needs, think about how the medical, social, and behavioral health needs of your patients are being met. For many practices, the prevalence of these needs is such that adding capabilities to address them in the core team feels imperative. The index model for the core team is outlined below.
FIGURE 2: SUMMARY TABLE OF THE CORE CARE TEAM MODEL
Team Member |
Role |
Recommended Full-Time Equivalent (FTE) Per Panel |
|---|---|---|
Primary Care Provider (PCP) |
Provides direct patient care, including diagnoses and treatment. |
1.00 FTE to 1,250 patients |
Medical Assistant (MA) |
Assists the primary care provider with direct patient care, and is responsible for patient flow on the day of a visit, including pre-visit planning and visit and room preparation. |
1.0 FTE per panel |
Social Health Support/Community Health Worker (CHW) |
Helps identify needs and connect patients to social health services. |
0.50 FTE per panel |
Behavioral Health Specialist |
Provides day-to-day support for care team and patients with behavioral health needs in close partnership with behavioral health providers on the expanded care team. |
0.50 FTE per panel |
Together, this core care team is the primary healthcare partner for patients and families. They provide the proactive, planned delivery of in-person and virtual primary care for a defined panel of patients based upon evidence-based clinical judgment, patient needs and preferences, and health equity considerations. Core care teams act as the coordinating hub of healthcare services, including physical, social and mental health care needs. Each individual role is described below.
Primary Care Provider (PCP)
- A primary care provider provides direct patient care, and leads and works collaboratively with the core and expanded care team.
- The PCP can be a medical doctor or osteopathic physician (MD/DO), nurse practitioner (NP) or physician assistant (PA).
- An MD/DO may partner with a nurse practitioner or physician assistant to share a combined panel where the MD/DO manages more of the clinically complex care.
- The index model recommends an average panel size of approximately 1,250 patients for each PCP.
- Panel size may shift up or down based on the specific needs and characteristics of a CHC’s patient population.
Medical Assistant (MA)
- At a minimum, the medical assistant’s role is to facilitate the flow of a patient visit, including vital sign measurements, rooming, discharging and providing after-visit summaries.
- MAs also assist with pre-visit planning, complete overdue health maintenance or open orders, ensure screenings are completed and documented, and facilitate follow-up after the visit.
- MAs can also participate in quality improvement, lead team huddles and conduct outreach to patients. The “teamlet” model emphasizes the role of MAs as health coaches.[2]
- Innovative practices point to enhancing the MA role as a key step in improving team-based care.[3]
Social Health Support/Community Health Worker (CHW)
-
- A community health worker serves as a community resource specialist under the supervision of a licensed provider.
- In accordance with the Plan of Care, CHWs link patients to both community-based organizations and other local services to address health-related social needs, like transportation, housing and food insecurity.
- CHWs can systematically identify social needs through routine screening during visits via questionnaires or empathic conversations.
- CHWs can also advance health equity by understanding and responding to root causes of poor health, and supporting teams to develop culturally responsive practices.[4]
- There is increasing interest in this role due to its inclusion in Cal-AIM.
Behavioral Health Specialist
- Up to 75% of primary care visits include mental or behavioral health components,[5] including behavioral factors related to chronic disease management, mental health issues, substance use, smoking or other tobacco use, and the impact of stress, diet and exercise on health.
- This role is usually filled by a licensed clinical social worker (LCSW) or marriage and family therapist (MFT).
- The LCSW or MFT offers brief interventions for common behavioral health challenges using evidence-based techniques, such as behavioral activation, problem-solving and motivational interviewing. This role supports and coordinates behavioral, mental and substance use treatment with the care team, including behavioral health consultants (psychologist, psychiatrist or psychiatric mental health nurse practitioner).
- Performs patient screening, assessment and testing, and diagnoses and treats mental, emotional and behavioral disorders.
Ideally, people are connected to both community health workers and behavioral health specialists by a warm handoff from another member of the care team with whom the patient has a relationship. During the warm handoff, the patient (and family, if present) are introduced, and some basic information about the patient’s goals and concerns may be shared. Using warm handoffs may decrease stigma and increase utilization of both behavioral and social health services.[6]
Though we suggest licensure and degrees for some of the roles above, a changing reimbursement and certification landscape means there may be many other kinds of skills and training that practices use to address patients’ needs. In particular, peers and certified peer support specialists can play an important role in both social and behavioral health support. Certified peer support specialists are individuals with lived experience with the process of recovery from mental illness, substance use disorder or both, either as a consumer of these services or as the parent or family member of the consumer. California approved a Medi-Cal Peer Support Specialist Certification Program through California Mental Health Services Authority (CalMHSA).
3. Establish a meeting cadence.
Once you’ve understood the needs of the patient panel and assembled a core care team, it is time to create a meeting cadence to begin the hard work of building relationships, problem-solving and managing care together. Like it or not, work gets done through meetings and it is extremely difficult to support team-based care without an opportunity to connect together. High performing teams often have a cadence of daily, weekly and monthly meetings, each with different purposes. Below is a sample of how a team might approach meeting cadence.
FIGURE 3: EXAMPLE CARE TEAM MEETING CADENCE
Meeting |
Cadence/Duration |
Attendees |
Purpose |
|---|---|---|---|
Team Huddle |
Daily, five minutes Daily, 10 minutes |
All clinic Core care teams |
Identify issues for the day and big picture. Review patient list and scrub for care gaps or other opportunities to address patient needs while in clinic. |
All Team |
Weekly, 30 minutes |
Core and expanded care team |
Ice breaker. Review weekly huddle tracker. Identify follow-up opportunities and chances to proactively problem solve. |
Quality Improvement |
Monthly, one hour |
Designated core and expanded care team members with quality improvement support |
Review monthly clinical and operational performance measures on patient panel. Identify small tests of change to close gaps and improve patient care or experience. |
To make the best use of meeting time together, it is worth investing in building meeting skills, including identifying a meeting facilitator (this role can rotate), setting agendas, starting and ending on time, facilitating engagement from all participants, and leaving with an action plan.
As you begin working together as a team, you’ll start to see opportunities for ways to shift work and improve information and workflows. The Supporting Change section below has more ideas and tools to help.
Endnotes
- Jimenez G, Matchar D, Koh GCH, Tyagi S, van der Kleij R, Chavannes NH, et al. Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities. Prim Health Care Res Dev. 2021;22:e68.
- Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457-61.
- Wagner EH, Flinter M, Hsu C, Cromp D, Austin BT, Etz R, et al. Effective team-based primary care: observations from innovative practices. BMC Fam Pract. 2017;18(1):13.
- Ruff E, Fishman E, Gomez R, Sanchez D. Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations. Washington, DC: Families USA; November 5, 2019 [September 11, 2023]. Available from: https://www.familiesusa.org/resources/advancinghealth-equity-through-community-health-workers-and-peer-providers-mountingevidence-and-policy-recommendations/.
- Schrager SB. Integrating Behavioral Health Into Primary Care. Fam Pract Manag. 2021;28(3):3-4.
- Mitchell D, Olson A, Randolph N. The impact of warm handoffs on patient engagement with behavioral health services in primary care. Journal of Rural Mental Health. 2022;46(2):82.