Building the Foundation

Care Teams and Workforce Guide

Version 3 – June 2026

Key Activity 2: Identify gaps in staffing and decide how to address them.

After you have understood your patients’ needs and developed a core team that meets regularly, you’re ready to build your expanded care team. Like the core care team, these expanded care teams are ideally linked to specific patient panels and support defined core care teams, prioritizing the ability to build and maintain relationships over time. It may be that your organization has many of these staff in place, and creating your teams requires retraining and reorganization. For some, it may require a decision to hire additional staff.

1. Prioritize expanded care team functions.

High performing primary care functions that are often covered by expanded care team members are described below. Index staffing for the expanded care team, along with expanded care team member duties and recommended education and licensure, can provide a starting place for considering a full care team array.

Population Health Management

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Core and Expanded Care Team Functions, Team Members and Roles

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Population health management is the “process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.”[1] The Population Health Management Initiative (PHMI) is designed to support all aspects of this work, from defining a group of individuals (empanelment) to financial and care models (patient-centered population-based care for populations of focus).

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Care Team Duties and Recommended Education and Licensure

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For the purposes of care team development, important population health roles on the expanded team assure that patients receive planned services (e.g., routine childhood vaccinations, colorectal cancer screening, HbA1c testing for patients with diabetes). The panel manager and population health specialists roles work together to right-size panels, run care gap reports, and conduct proactive outreach to patients to close gaps in care. Their work can span across multiple panels.

California’s Comprehensive Quality Strategy strives to improve the quality of healthcare and services provided by all Medicaid managed care entities in the state. There are several population management functions anchored by the expanded care team, including:

  • Initial and ongoing assurance that patients are empaneled appropriately and connected to needed services.
  • Outreach for patients who have not yet established care but have been assigned to the practice by a managed care plan, as well as established patients with care gaps for preventive or chronic disease management services.

Access

Creating excellent access to care is an ongoing challenge for busy practices in communities where there are more people who need care than resources and staffing available. Long waits for appointments not only cause potential delays in diagnosis and treatment, but also undermine patient satisfaction and perceptions of the quality of treatment given.[2] Virtual and after-hours care can help expand access to people with transportation challenges and other daytime conflicts. Managing supply and demand through a systematic empanelment process is another way practices can get a handle on access. Finally, having nursing staff on the expanded care team focus on addressing immediate care needs in person or on the phone, where appropriate, and triage when needed to help the core care teams to manage the needs of their patient panels.

Behavioral Health Integration

Integrating behavioral health into primary care is helpful for expanding access to behavioral health services. The goal of integrated care is to equip the primary care team with effective tools for diagnosis and treatment so people can be cared for holistically by those with whom they have established relationships.[3] Using a structured, team-based approach to behavioral health integration can ease the stigma for some seeking behavioral health treatment, and has been shown to improve depression scores and improve patient and physician experience.[4][5] Studies have also demonstrated cost savings from lower rates of emergency department visits.[6]

Yet, many primary care teams would like more support to manage patients’ complex mental health or substance use disorders. Consulting behavioral health providers, including clinical psychologists, psychiatrists and psychiatric mental health nurse practitioners (PMHNP), can support primary care providers in diagnosing and treating mental health and substance use disorders, including pharmacologic management. They may serve as consultants to the primary care provider, who continues to manage care for the patient, or they may provide direct services to patients, depending on their capacity, patient complexity and staffing priorities. These consulting behavioral health providers work closely with the core care team, particularly to support the behavioral health specialists in addressing routine and lower acuity behavioral health needs.

The collaborative care model (CoCM) is an evidence-based approach to treating common mental health conditions in primary care, which incorporates measurement-based care principles, systematic follow-up, and a team-based approach to supporting patients with persistent mental health challenges.[7] Based on the principles of effective chronic illness care, the collaborative care model focuses on defined patient populations tracked in a registry, measurement-based practice, and treatment to target. Trained primary care providers and embedded behavioral health professionals provide medication and psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected.

More than 90 randomized controlled trials and several meta-analyses have shown the CoCM to be more effective than usual care for patients with depression, anxiety and other behavioral health conditions. CoCM is also shown to be highly effective in treating comorbid mental health and physical conditions, such as cancer, diabetes and HIV. There is strong evidence for use of the collaborative care model as an evidence-based approach to management of patients with depression. To learn more about CoCM, visit the AIMS Center Collaborative Care Implementation Guide.

Medication Management

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Role of the Pharmacist in the Care Team

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Comprehensive medication management (CMM) is a patient-centered approach to optimizing medication use and improving patient health outcomes. It is delivered by a clinical pharmacist working in collaboration with the patient and their care team. CMM uses a process in which the patient’s medications—including prescription, nonprescription, alternative, traditional, vitamins or nutritional supplements—are individually assessed to determine that each medication has an appropriate indication; is effective for the clinical condition and for achieving defined patient and clinical goals; is safe in the context of the patient’s potential comorbidities; can be taken by the patient as intended; and adheres to the prescribed regimen.[8]

Studies have shown that CMM produces:

  • Improved diabetes outcomes.
  • Improved hypertension control and lowered lipids.
  • Reduced provider workload.[9]
  • Reduced hospital admissions.
  • Improved patient experience.[10]
  • A financial return on investment as high as 12-131[11] with an average of 3-1 to 5-1.[12]

However, under the current prospective payment system (PPS) fee-for-service model, these positions are not billable for health centers. Practices may choose not to include this function at all, identify a different revenue source, or outsource part of this function (e.g., managing refills or other consultations). Alternatively, fulfilling this crucial function could be an opportunity when considering a capitated payment model.

Care Coordination, Health Education and Care Management

Care Coordination: Care coordination involves deliberately organizing patient care activities and sharing information among all the participants concerned with the patient’s care to achieve safer and more effective care.[13] The Institute of Medicine identifies care coordination as a key strategy to improve the effectiveness, safety and efficiency of the healthcare system.[14] Assisting patients with referrals to other care providers or resources in the community, supporting appointment scheduling and follow-up, and ensuring adequate information exchange between primary care providers and specialists supports safe, appropriate and effective care for patients who may otherwise suffer from the fragmentation in the healthcare system. As with other key functions, Care Teams and Workforce Resource 2: Care Team Duties and Recommended Education and Licensure offers examples of roles to fulfill these functions, but the unique staffing needs, priorities and resources differ at each practice, and some more clerical care coordination functions may be outsourced to a third-party organization.

Self-Management Support and Health Education

Self-management support provides patients with the skills and confidence needed to manage their health day to day. Health education is a part of self-management support, as is building confidence and supporting goal setting and action planning. Self-management support can help and inspire people to learn more about their conditions, and to take an active role in their healthcare.[15] There are many ways to approach offering self-management support and health education, from durable tools such as videos or health plan resources to a centralized or third-party group that specializes in this aspect of care.

Care Management

Care management is a team-based, person-centered and comprehensive approach designed to assist high or rising risk patients and their support systems in managing medical, social and behavioral health conditions more effectively. Care managers offer or oversee care coordination and health education activities, and provide higher intensity services to engage patients in goal setting and self-management support to improve their health.

It is important to note that the care manager is not intended to provide care management for patients with complex circumstances. That role would be provided by a complex care manager and is not included in this care team model, however it is covered through the Department of Health Care Services Enhanced Care Management (ECM) benefit.

Instead, care managers can focus on rising risk patients who comprise 20% of an average panel.[16] Rising risk patients are those individuals with poorly controlled chronic physical and behavioral health conditions or complex social needs who are at increasing risk for poor long-term outcomes or acute health events, such as emergency department visits and inpatient hospitalizations. The rising risk patient population can be further stratified by risk, and practices may choose to select a tool, such as the Milliman Advanced Risk Adjusters (MARA) rising risk model, to more precisely and proactively identify patients for early intervention and care management to make appropriate and efficient use of limited resources.[17]

Quality Improvement

Paul Batalden, a physician, writer and quality improvement expert, once said, “In healthcare, everyone has two jobs: to do your work and to improve it.” As important as it is to provide the functions of high-performing primary care described above, so, too, is creating the infrastructure and staff support to continuously improve it. Expanded care teams need clinical quality improvement leads and support for data analysis to monitor performance measures, create reports, track progress and work with teams to improve patient care. More detail is available on how to set this up in Key Activity #4.

Meeting Language Needs

Communicating with patients and families in their preferred language is vital to person-centered and family-centered care, and for creating trusting relationships between care teams and diverse patients, families and caregivers. Language barriers are associated with lower quality of care, poor clinical outcomes, longer hospital stays and higher rates of hospital readmissions.[18] Cultural humility and linguistic proficiency enables the core and expanded care team to help patients, families and caregivers navigate the healthcare system with safe and timely access to needed services.

Language concordance between providers and patients has been shown to improve care through fewer medical errors, increased understanding of illness and the treatment plan, adherence to the treatment plan, and satisfaction with care.[19] More about language concordance is in the Advancing Health Equity section below.

If language concordance is not possible, practices can develop strategies for ensuring the provision of appropriate interpretation services, and allow additional time for visits and other outreach efforts, such as phone calls by members of the care team. Interpretation services may be provided either on-site through trained healthcare interpreters, multilingual staff, or machine translation or via remote interpretation. The use of professional interpreters is associated with improved clinical care, raising the quality of clinical care for patients with limited English proficiency to nearly equal to that for patients without language barriers.[20]

Practices can document patients’ preferred languages and communication approaches in the electronic health record (EHR), which can help staff prepare for upcoming visits and understand at a population level what additional services might be useful.

2. Assess and build on current team strengths.

You may be lucky in that your organization has all of this expertise in place already. If so, your task is to think about opportunities to improve what you have created. Looking at clinical measures or your Population Health Management Capabilities Assessment Tool can provide ideas of where to start.

On the other hand, you may find that your teams are missing key roles, or your organization has known gaps. You can use the table below to conduct an inventory of your organization’s current state with regard to delivering the key functions of primary care.

Download Core and Expanded Care Team Inventory Tool

If you find that there are gaps in the functions that are or could be offered, you must choose where and how to add staff. For the purpose of this work, we recommend beginning with improving population health management and quality improvement capacity. As your organization moves forward in selecting and managing a population of focus, it will be really important that your core care team is strong and your expanded care team has some key roles including:

  • A panel manager or data analyst who can manage panel sizing, open and close panels, and create gap reports. Approximately one FTE across 10 panels. Strong data analysis skills.
  • A population health specialist who conducts proactive outreach to patients, and can work with others to create campaigns for needed preventive screenings. Approximately one FTE across 10 panels. Education and experience comparable to that of a strong medical assistant.

Though critical to population health management, neither of these roles requires specific licensure or certification. You may find that you have staff within your organization who have the relevant skills, expertise and lived experience to be redeployed to these roles. If so, figuring out how best to retrain staff becomes a priority. Upskilling medical assistants and lay health workers is a significant challenge, and one that practices often can’t take on by themselves. Creative partnerships with unions and community colleges have shown some promise.[21] Enterprising groups have stepped into the gap with training programs for specific roles (e.g. National Institute for Medical Assistant Advancement). Two PHMI webinars, Unlocking the Potential of Care Teams: Lessons Learned from PHMI Health Centers and Harnessing the Potential of Your Care Team to Boost Patient Outcomes provide strategies and examples from PHMI team that bolster care team performance, engagement, and retention. Methods discussed include collaboratively designing care team roles and upskilling medical assistants.

3. Use the Business Case Tool to help make decisions on hiring.

If you find that you need to recruit externally for new staff roles on the core or expanded care team, there are multiple avenues to explore. Consider recruiting and hiring, soliciting volunteers, partnering with other organizations through shared services arrangements, or outsourcing clerical or transactional functions (e.g. medication refills) to an external organization. The Business Case Guide provides a structured tool to help teams walk through the financial implications and sustainability implications of bringing on new positions and services.

The tool includes consideration of current expected payments from health plans, value-based payment arrangements, such as APM 2.0, and any other funding streams, such as CalAIM or grant programs. Working through this Excel workbook as an interdisciplinary team can help teams integrate financial, clinical and operational perspectives on the value of adding new care team roles, and encourage new ways of organizing care, such as exploring group visits or flipped visits.

If, after working through the Business Case Tool, you decide to recruit, this is a special opportunity to build a workforce that reflects the diversity of your patients. Hiring new care team members can be an opportunity to:

  • Consider diversity and equity when hiring to reflect the needs of the community and patient populations served. Build in processes to assure equity in hiring, such as widening recruitment by reaching out to job boards, schools, community-based organizations and training programs that are serving diverse communities.
  • Revise recruitment process to emphasize flexibility, effective communication and the desire to work in a team. Consider lived experience or job-related experience working with the community as a job requirement. Hire for these attributes rather than exclusively focusing on specific clinical skills or experience.
  • When possible, let the care teams lead the hiring process for new members to ensure compatibility and promote a sense of shared accountability for the team’s performance. The Advancing Equity section of this guide includes additional tools and resources on inclusive hiring.

4. Consider Partnering with External Organizations to Address Gaps in Care

If it is not feasible to provide a service as an internal function, consider expanding access to care through formal agreements or memorandums of understanding with outside organizations. Leadership should proactively review and seek new partnerships with external service providers to enhance the availability and accessibility of preventive services.

By formalizing partnerships with outside specialists, health centers can increase access to essential services such as screenings, preventive counseling, and critical procedures like colonoscopies which are essential for early detection. This approach not only improves patient outcomes by facilitating earlier intervention but also demonstrates a commitment to reducing health disparities and promoting equity in preventive care.

Endnotes

  1. American Medical Association Center for Health Innovation. Population Health Management. Chicago: AMA; [September 11, 2023]. Available from: https://www.aha. org/center/population-health-management. 
  2. Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L, Jones R. Wait times, patient satisfaction scores, and the perception of care. Am J Manag Care. 2014;20(5):393-400. 
  3. Chung H, Rostanski N, Glassberg H, Pincus HA. New Framework to Help Providers Integrate Behavioral Health into Primary Care Practices. New York: United Hosptial Fund; June 7, 2016 [September 11, 2023]. Available from: https://uhfnyc.org/ publications/publication/advancing-integration-of-behavioral-health-into-primarycare-a-continuum-based-framework/. 
  4. Bridges AJ, Andrews AR, 3rd, Villalobos BT, Pastrana FA, Cavell TA, Gomez D. Does Integrated Behavioral Health Care Reduce Mental Health Disparities for Latinos? Initial Findings. J Lat Psychol. 2014;2(1):37-53. 
  5. Balasubramanian BA, Cohen DJ, Jetelina KK, Dickinson LM, Davis M, Gunn R, et al. Outcomes of Integrated Behavioral Health with Primary Care. J Am Board Fam Med. 2017;30(2):130-9. 
  6. Ross KM, Klein B, Ferro K, McQueeney DA, Gernon R, Miller BF. The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case-Control Program Evaluation. J Clin Psychol Med Settings. 2019;26(1):59-67. 
  7. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525. 
  8. McFarland MS, Finks SW, Smith L, Buck ML, Ourth H, Brummel A, et al. Medication Optimization: Integration of Comprehensive Medication Management into Practice. Am Health Drug Benefits. 2021;14(3):111-4. 
  9. Haag JD, Yost KJ, Kosloski Tarpenning KA, Umbreit AJ, McGill SA, Rantala AL, et al. Effect of an Integrated Clinical Pharmacist on the Drivers of Provider Burnout in the Primary Care Setting. J Am Board Fam Med. 2021;34(3):553-60. 
  10. McFarland MS, Finks SW, Smith L, Buck ML, Ourth H, Brummel A, et al. Medication Optimization: Integration of Comprehensive Medication Management into Practice. Am Health Drug Benefits. 2021;14(3):111-4. 
  11. Isetts BJ, Schondelmeyer SW, Artz MB, Lenarz LA, Heaton AH, Wadd WB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc (2003). 2008;48(2):203-14. 
  12. Strand LM, Cipolle RJ, Morley PC, Frakes MJ. The impact of pharmaceutical care practice on the practitioner and the patient in the ambulatory practice setting: twenty-five years of experience. Curr Pharm Des. 2004;10(31):3987-4001. 
  13. Agency for Healthcare Research and Quality National Center for Excellence in Primary Care Research. Care Coordination. Rockville, MD: AHRQ; [September 11, 2023]. Available from: https://www.ahrq.gov/ncepcr/care/coordination.html. 
  14. Institute of Medicine Committee on Quality of Health Care in A. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US) Copyright 2001 by the National Academy of Sciences. All rights reserved.; 2001. 
  15. Agency for Healthcare Research and Quality Center for Excellence in Primary Care Research. Self-Management Support. Rockville, MD: AHRQ; [September 11, 2023]. Available from: https://www.ahrq.gov/ncepcr/tools/self-mgmt/home.html. 
  16. Whittal K, Caldwell A. Rising risk: Maximizing the odds for care management. Seattle: Milliman; March 2018 [September 11, 2023]. Available from: https://www. milliman.com/-/media/products/mara/pdfs/rising-risk_maximizing-odds-caremanagement-dli-edit.ashx. 
  17. Ibid. 
  18. Espinoza J, Derrington S. How Should Clinicians Respond to Language Barriers That Exacerbate Health Inequity? AMA J Ethics. 2021;23(2):E109-16. 
  19. Green AR, Nze C. Language-Based Inequity in Health Care: Who Is the “Poor Historian”? AMA J Ethics. 2017;19(3):263-71. 
  20. 0 Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-54. 
  21. Figueroa Gray M, Coleman K, Walsh-Bailey C, Girard S, Lozano P. An Expanded Role for the Medical Assistant in Primary Care: Evaluating a Training Pilot. Perm J. 2021;25.