Care Teams and Workforce Guide Resource 1:
Core and Expanded Care Teams Functions, Team Members and Roles
©️ 2024 Kaiser Foundation Health Plan, Inc.
This resource is part of the Care Teams and Workforce Guide, which offers a practical, tested approach to building and supporting team-based care, starting with the intentional identification of a core team of people who together can provide care for most patient needs on their panel. It is the third in the “Building the Foundation” series of implementation guides.
This tool provides an overview of the functions that high-performing primary care practices deliver reliably1 and proposes a potential array and FTE of team members to do so. Different teams will adjust these roles and FTE to fit their context.
Collaborating Care Team Member |
Primary Responsibilities |
Recommended Ratio* |
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CORE CARE TEAM |
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Day-to-Day; Organized, Evidence-Based Care |
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Primary Care Provider (PCP) |
Provides direct patient care, including diagnoses and treatment. |
One FTE per panel |
||
Medical Assistant (MA) |
Assists the PCP with direct patient care and is responsible for patient flow on the day of a visit, including pre-visit planning and visit/room preparation. |
One FTE per panel |
||
Social Health Support/Community Health Worker (CW) |
Helps identify and connect patients to social health services. |
0.5 FTE per panel |
||
Behavioral Health Specialist |
Provides day-to-day support for care team and patients with behavioral health needs. |
0.5 FTE per panel |
||
EXPANDED CARE TEAM |
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Population Health Management |
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Panel Manager/Data Analyst |
Management of panels including panel sizing, opening/closing of panels, and creating gap reports. |
One FTE shared across approximately 10 panels |
||
Population Health Specialist |
Uses care gap reports to conduct proactive outreach to patients and schedule for needed follow-up. |
One FTE shared across approximately 10 panels |
||
Quality Improvement |
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Quality Improvement Lead |
Monitors performance measures and works with the care team to improve the quality of patient care. |
0.3 FTE shared across approximately 10 panels |
||
Quality Data Analyst |
Creates reports and tracks quality improvements. |
One FTE shared across approximately 10 panels |
||
Access |
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Triage Nurse/Clinic Oversight |
Provides access to primary care services based upon patient need and oversees clinical workflows. |
One FTE shared across approximately six panels |
||
Behavioral Health Integration |
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Behavioral Health Consultants |
Clinical psychologist and psychiatrist provide additional behavioral health services through psychological evaluation, substance use disorder diagnosis and treatment, and prescribing medications. |
One FTE shared across approximately 10 panels |
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Medication Management |
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Clinical Pharmacist |
Medication management and patient/provider medication education. |
One FTE shared across approximately 10 panels |
||
Care Coordination, Health Education and Care Management |
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Care Coordinator/Referral Manager |
Organizes the care of the patient, including scheduling and follow-up of specialty appointments. |
One FTE shared across approximately 10 panels |
||
Self-Management/Health Educator |
Develops programs and provides materials to teach patients and their families about health topics to manage their health conditions. |
One FTE shared across approximately 10 panels |
||
Care Manager |
Aims to improve care of patients with chronic conditions through patient education, goal setting, self-management teaching, and coaching. |
One FTE across approximately three panels |
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*This ratio assumes approximately 1,250 patients per panel.
Endnotes
1 Meyers D, LeRoy L, Bailit M, Schaefer J, Wagner E, Zhan C. Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices. J Gen Intern Med. 2018 Oct; 33(10):1774-1779. doi: 10.1007/s11606-018-4530-7. Epub 2018 Jul 3. PMID: 29971635; PMCID: PMC6153217.