Improving Primary Care Team Guide

Why use this guide

Better care experiences, better population health, lower cost, and happier staff.

Primary care practices are achieving this quadruple aim by creating more effective practice teams and becoming certified as Patient-Centered Medical Homes. The Primary Care Team Guide provides step-by-step direction on how to establish these high-functioning teams and implement new functions essential to team-based care. Numerous tools and resources from 31 exemplary practices nationwide are made available to support you.

Featured Resources and Modules

Physicians share their experience with team-based care.

Creating a culture of trust and shared responsibility is the foundation, say physicians.

The result is grateful patients and staff, and better care. Team-Base Care: The Physician Experience Video

Care coordination reduces care fragmentation in primary care.

Care coordination improves connections to community resources and helps practices track patients across services. Check out the Referral Management module for care coordination strategies and toolkits.

Referral Management module

Engage lay health workers as part of the care team.

Lay health workers, like patient advocates, can take over administrative tasks that weigh down clinical staff and reduce time with patients. Neighborhood Family practice in Ohio used a variety of tools to engage patient advocates effectively.

The Lay Person module

The Primary Care Team Guide

Why practice team-based care?

What does team-based care look like?

Introducing "Support the Team"

Why use this guide

Featured Resources and Modules

Physicians share their experience with team-based care.

Care coordination reduces care fragmentation in primary care.

Engage lay health workers as part of the care team.

Share Your Feedback: How could we improve the Team Guide? Let us know