What you'll get from the Primary Care Team Guide

Nationwide, primary care practices are finding that creating more effective practice teams is the key to becoming a patient-centered medical home, improving patients’ health, and increasing productivity. The Primary Care Team Guide presents practical advice, case studies, and tools from 31 practices across the country that have markedly improved care, efficiency, and job satisfaction by transforming to a team-based approach.

These high-performing practices were selected and studied and the Guide developed by a national program of the Robert Wood Johnson Foundation called "The Primary Care Team: Learning from Effective Ambulatory Practices" — or "LEAP."

This guide will show your practice how to build care teams and redesign the work of patient care on your way to becoming a more effective and productive practice. Team-based care requires many specific changes in how practices deploy and use clinicians and staff. Build the Team learning modules illustrate the increasingly important roles that primary care staff play when they are members of an effective team. Do the Work learning modules describe the essential functions of a high-performing primary care practice and how they use all members of the care team to meet patients’ needs. Each module begins with a brief assessment, and includes a short overview of the recommended changes followed by specific action steps and helpful resources you can download, view, or access online anytime. From protocols and job descriptions, to video testimonials and case studies, you should find the tools you need to succeed with team-based care.

Getting Started with LEAP

Who the guide is for?

Achieving team-based care is one essential step toward transforming primary care to meet the quadruple aim: better care experiences, better population health, lower cost, and happier staff. But not every practice is ready for this step. Key ingredients practices must have to make team-based care feasible include:

  • Engaged leadership who are committed to primary care transformation and willing to commit the resources needed to support it.
  • A data-driven quality improvement process.
  • A stable electronic health record (EHR).
  • Providers who support and encourage staff involvement in patient care.

View our resources page to learn more about team-based care and its essential role in enabling practices to become true patient-centered medical homes (PCMH).

Where to start?

If you already understand the basics of team-based care, or if you are ready to implement focused changes:

  • Start by taking a brief  practice assessment  to highlight specific areas where your practice has room to improve. 
  • You can also jump straight to a module of particular interest.

 If you're new to team-based care or skeptical about it:

  • Start with the introductory modules in both sections so you understand the rationale for team-based care and how to get started.
  • Next, explore the Role Modules to learn how to develop and make the most of your primary care team. You’ll find information and actionable steps to help you redesign the roles that medical assistants, registered nurses, lay people, pharmacists, and behavioral health professionals can play in primary care.
  • Then check out the Function Modules to learn how teams work together to share responsibility for a defined population of patients. These modules illustrate how using a team-based approach allows practices to perform new and enhanced functions that improve care, including referral management, care management, self-management support, enhancing access, and others.
  • Each module also includes assessment questions that you can access anytime to help you gauge how well your practice is doing on a specific component of team-based care.




  • Video

    Getting Started with LEAP

    Get started understanding why this work is important.