Care Teams and Workforce Guide

About the Guide

This guide 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 of the patient needs on their panel. Centering the cultivation of continuous healing relationships between patients, families and their care teams, the guide then shows how to build out the expanded care team to assure the functions of high performing primary care are in place. Finally, the guide offers a map for how different care team roles can help to support those functions, including licensure and full-time equivalent (FTE) considerations.

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Care Teams and Workforce Resources

Resource 1: Core and Expanded Care Team Functions, Team Members and Roles

This tool provides an overview of the functions that high-performing primary care practices deliver reliably 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.

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Resource 2: Care Team Duties and Recommended Education and Licensure

This tool is a companion to Resource 1 and offers more detail about the activities each care team member performs, along with recommended education and licensure.

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Resource 3: Role of the Pharmacist in the Care Team

This resource offers a deeper dive into the role of the clinical pharmacist and how they contribute to delivering high-quality primary care.

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Resource 4: Daily Huddles Overview and Process

This guide for organizing daily huddles supports one of the ways teams can work together to communicate and manage care.

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Resource 5: CalAIM Guidance for New Covered Services

These documents from the state outline the new community health worker and doula requirements from CalAIM.

View guidelines for community health workers.
View guidelines for doulas.

Resource 6: Workflow Examples

This document provides common workflows for pre-visit planning, proactive outreach and engagement, among other activities to jumpstart your thinking.

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Suggested Citation and Acknowledgements

Recommended citation: Population Health Management Initiative. Jeanene Smith, Catherine Knox, Katie Coleman, and Elise Pomerance. Care Teams Implementation Guide. In: Coleman K and Singer A, editors. Building the Foundation Implementation Guide Series. 1st ed. Oakland, CA: Kaiser Permanente, Health Management Associates, and Pyramid Communications; 2023.

Acknowledgments: This document was created by the Population Health Management Initiative (PHMI), a California partnership of the Department of Health Care Services, Kaiser Permanente and Community Health Centers. We gratefully acknowledge the contributions of these partners and the Regional Associations of California along with the many other academic, health plan and consulting partners who shared their expertise and insights freely as we co-designed the initiative and created these guides.

Individual reviewers and content contributors to the first edition of the Building the Foundation Implementation Guide Series: Jennifer Sayles and Elise Pomerance (KP PHMI); Palav Barbaria, Yoshi Laing, David Tian, Jeff Norris and Karen Mark (DHCS); Allie Budenz and Cindy Keltner (CPCA); Jeanene Smith, Catherine Knox, Nancy Kamp, Ethan Norris, Leslie Brooks and MaryEllen Mathis (Health Management Associates); Anne Tillery, Sarah Starr, Karis Cady, Candace Jackson, Josh Daniel and Denise Rhiner (Pyramid Communications); and Veenu Aulakh.

With additional contributions from: Pyramid Design Team and Kaiser Permanente PHMI team.

 

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