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*


Day-to-Day; Organized, Evidence-Based Care

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


Population Health Management

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

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


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

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

Medication Management

Clinical Pharmacist

Medication management and patient/provider medication education.

One FTE shared across approximately 10 panels

Care Coordination, Health Education and Care Management

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

*This ratio assumes approximately 1,250 patients per panel.


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.