Care Team Role |
Expanded Duties |
Recommended Education/Licensure |
Primary Care Provider: Physician (MD/DO), Nurse Practitioner (NP), or Physician Assistant (PA)
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- Serves as Primary Care Provider (PCP) and provides direct patient care, including diagnoses and treatment for preventative, acute, and chronic health needs.
- Leads and works collaboratively with the core and expanded care team to deliver whole preson care.
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As per California state licensure requirements.
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- Assists the PCP with direct patient care.
- Manages patient flow on the day of a visit, including pre-visit and visit/room preparation.
- Review and completes any overdue health maintenance or open orders.
- Ensures any screenings are completed by the patient, documents results, and completes any needed follow-up.
- Prepares for, attends, and participates in daily huddles and other team meetings.
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As per California Certifying Board of Medical Assistants (CCBMA).
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- Is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served.
- Serves as a liaison between health and social services and the community to facilitate access to services and to improve the quality and cultural competence of service delivery.
- Conducts outreach and provides community education, informal counseling, social support, and advocacy for moderate and high-risk patients.
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Bilingual in English and the other languages identified by the community health center (CHC).
High school diploma or equivalency.
Minimum two years work or volunteer experience in human services or healthcare with demonstrated knowledge of or ability to work within the targeted community.
CHW certification required for billing through new CalAIM coverage.
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- Has lived experience with the process of recovery from mental health or substance use concerns, or both, either as a consumer of these services or as the parent or family member of the consumer.
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Behavioral Health Specialists:
Licensed Social Worker (LCSW)
Marriage and Family Therapist (MFT)
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- Provides day-to-day support for the care team and patients with behavioral health needs.
- Works with expanded care team members, including the clinical psychologist and psychiatrist to manage patients with more complex needs.
- Can provide brief interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, and motivational interviewing.
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Panel Manager/Data Analyst
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- Manages the panel size, including right-sizing (opening and closing) of panels.
- Identifies patients across the risk continuum in need of preventive and chronic disease management services.
- Creates gap reports and tracks improvements in population metrics.
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Data analysis skills.
No specific license required.
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Population Health Specialist
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- Conducts proactive outreach to patients using care gap reports created by the panel manager, and schedules needed follow up.
- Can work with the clinic's registered nurse (RN) and leadership to run campaigns on needed preventive screening, such as FIT colon cancer screening and vaccination fairs.
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Education comparable to that of a medical assistant.
No licensure required.
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Triage Nurse and Clinic Oversight (RN)
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- Provides access to comprehensive primary care services based upon patient need and evidence-based clinical judgment.
- Oversees workflows within the clinic to assure equitable access to meet patient needs (e.g., asme-day visit, telehealth) or need for emergency or urgent care.
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As per Board of Registered Nursing for RNs
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Consulting Behavioral Health Providers:
Clinical Psychologist
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- Provides psychological evaluation and conducts more extensive testing than the behavioral health specialists.
- Works closely with the PCP and the other behavioral health consultants but cannot prescribe medications.
- Provides treatment ranging from cognitive behavioral therapy, family therapy, group therapy, and hypnotherapy.
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Psychiatrist or Psychiatric Mental Health Nurse Practitioner (PMHNP)
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- Provides direct mental health and substance use diagnosis and treatment, including prescribing medications.
- Works closely with the PCP and the care team, including the behavioral health specialists.
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MD with specialty training in psychiatry.
NP with specialty training in psychiatry.
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- Reviews medical records and assesses progress towards goals to improve patient health.
- Makes suggestions and collaborates with providers on medication management.
- Completes patient visits for medication review and management.
- Makes recommendations for medication adjustments, dosage titration, initiation, and discontinuation, and monitors laboratory values in collaboration with providers and patients.
- Educates patients about the use of their medications.
- Attends team meetings for chronic disease management and participates in the development of patient care plans.
Note: See Care Teams Resource 1 for additional information.
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Doctor of Pharmacy degree.
Many have completed post-graduate training.
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Care Coordinator/Referral Manager
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- Coordinates the care of the patient, including completion of any needed paperwork.
- Facilitates patient access to appropriate medical and specialty providers, as well as other care coordination team support specialists.
- Ensures closed loop referral management.
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Certified medical assistant, LVN, BSW; associate degree in behavioral health; or training as a community health worker/patient navigator.
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Care Manager/Program Oversight
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- Works with care coordinators and health educators to oversee and provide support for rising risk patients with chronic conditions through patient education, goal setting, self-management teaching, and coaching.
- Monitors specific patient activities, interventions, and chronic care protocols that make up the patient's care plan.
Note: Complex care management for high-risk patients is NOT included in this model.
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RN, LCSW, or medical social worker (MSW).
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Self-Management Support and Health Educator
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- Assesses the health needs of individuals and communities.
- Develops programs and provides materials to teach patients and their families about health topics to manage their health conditions.
- Can facilitate and participate in group visits or community events for patients living with chronic disease conditions, such as diabetes and hypertension.
- Provides expert consultation and supports the work of the care team and overall health of the patient.
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Certified health education specialist (CHES).
Helpful to have motivational interviewing training.
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Quality Improvement (QI) Lead
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- Leads the QI team and works with the care teams to improve the quality of care provided to the patient populations.
- Acts as a QI champion and actively supports the teams.
- Pulls together the interdisciplinary oversight group, such as a quality council, to keep momentum going.
- Provides guidance and resources to the teams, and cultivates a quality improvement culture supported by training that encourages all staff to continuously improve the quality of services.
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Minimum requirement is a bachelor's degree or higher.
Quality improvement science training (PDSAs, etc.)
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- Monitors performance metrics, creates reports, and tracks improvements.
- Identifies gaps or barriers in data mapping processes to enhance opportuities for continuous quality measurement and improvement.
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Data analysis skills.
No specific license required.
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