Practice Facilitation Handbook

Module 19. Implementing Care Teams

Table of Contents

Care teams are groups of primary care staff members who collectively take responsibility for a set of patients. Care teams blend multidisciplinary skills, focusing several people’s insights, rather than a single physician’s, on each patient’s problems. Care teams involve the efficient delegation of responsibilities such that no team members perform duties that do not require their skills. A number of practices have demonstrated that many primary care visits, especially for chronic disease, involve relatively simple matters that could be handled by nonphysician team members via protocols or standing orders (Bodenheimer, 2007).

The composition of a care team will depend on the size and resources of the practice and the needs of the patient population (Coleman & Reid, 2010). Teams are generally organized around a primary care provider (e.g., physician, advanced practice nurse, physician assistant). Nurses, pharmacists, nutritionists, social workers, educators, and care coordinators may also be part of the care team. In smaller practices, care teams have fewer members. Such practices may also build virtual teams by linking themselves and their patients to providers and services in their communities.

“A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they are mutually accountable.”

–J.R. Katzenbach in The Wisdom of Teams

Why Change to Care Teams?

Mounting evidence demonstrates that a team of providers with multidimensional skill sets most effectively delivers health care. For example, many care and care-coordination activities are better provided by nonphysician members of a care team (Coleman & Reid, 2010). In fact, a 2006 evidence review of diabetes interventions found that providing team-based care was the single most effective intervention in improving intermediate diabetes outcomes (Shojania, et al., 2006).

Unless supported by a care team, physicians simply do not have the time to provide ideal care for all their patients, and many burn out trying. For example:

  • Most physicians only deliver 55 percent of recommended care and 42 percent report not having enough time with their patients (Bodenheimer, 2008).
  • Providers spend 13 percent of their day on care coordination activities and only half of their time on activities using their medical knowledge (Loudin, et al., 2011).

Figure 19.1 illustrates how the time demands of primary care visits exceed the available hours. Taking care of the top 5 common chronic conditions for 2,500 patients would take a physician working alone 6.7 hours per day (Østbye, et al., 2005). It would take an additional 7.4 hours to provide the panel of patients with the preventive services most strongly recommended by the U.S. Preventive Services Task Force (those with Level A or Level B evidence) (Pollak, et al., 2008). Add to that the 4.6 hours it takes to care for acute problems, and you find that a physician would have to work 18.7 hours a day to care for a panel of 2,500 patients. And that doesn’t count time for phone calls, charting, and other administrative tasks.

Figure 19.1. Time demands in primary care

Picture showing time demands for a panel of 2,500 patients. Chronic care management = 6.7 hours per day, Level A and B recommended preventive care services = 7.4 hours per day, and acute care = 4.6 hours per day, for a total of 18.7 hours per day. And that doesn’t count phone call, charting, and other paperwork or other administrative tasks. Cutting panel size to 1,250 = 9.35 hours per day.

Based on data from: Yarnall KSH, Pollak KI, Østbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003 Apr;93:635-64; and Østbye T, Yarnall KSH, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005 May;3:209-14.

How Do Care Teams Function?

Teams deliver comprehensive, first-contact care and address the needs of patients and families through a broad range of services delivered by multidisciplinary professionals. In the team-based care model, all care team members contribute to the health of the patients by working at the top of their licensure and skill set. For example:

  • Nurses can conduct complex care management,
  • Front desk staff can reach out to patients who need but have not received evidence-based care,
  • Medical assistants (MAs) can provide patient self-management support, and
  • Pharmacists can conduct medication reconciliation and management.

Team-based care decreases costs and increases revenue (Coleman & Reid, 2010).

Team-based care requires all team members to make adjustments. Primary care providers need to learn to delegate tasks that they traditionally performed. MAs in particular take on new and enhanced responsibilities for patient care. They need to learn to work side by side with providers and do more during the rooming process—from reviewing medicines to goal setting to patient education.

Elevating the involvement of and expectations for MAs, and the level of confidence of providers in MAs, is a key element of success. Offering special training to MAs can communicate that leadership supports the elevated role of the MA within the care team. Finally, all team members need to learn how to communicate effectively with each other.

How Can a Practice Facilitator Help a Practice Implement Team-Based Care?

Depending on the level of care provided at the practice, the practice facilitator might help the practice in one or more of the following activities:

  1. Prepare for the transition to team-based care:
    • Help identify a change champion for team-based care who can lead the effort.
    • Increase their knowledge about care teams and how teamwork differs from traditional approaches by providing training and resources.
    • Provide examples of best practices and set up virtual or in-person site visits.
  2. Set up teams:
    • Create new workflows of how teams will deliver care.
      • Assign roles and responsibilities that enable working at level of licensure.
      • Create new ways of communicating that strengthen team approaches to care:
        • Previsit planning.
        • While patient is in the office.
        • Postvisit.
        • Performance and feedback.
  3. Optimize already existing care teams by helping team members clarify roles, tasks, and expectations; redesign workflow based on these things; and improve communication and problem-solving skills.
  4. Set up performance measures to monitor the care team’s effectiveness (see Module 7 on performance measurement).

Activities To Do With Your Practices

The following are exercises that you can conduct with your practice. These two exercises will give your practice a better understanding of spreading workload and shifting job responsibilities, and the benefits to care teams. You can find copies of the exercise sheets that you can take with you to your practices in the Module 19 Appendix.

Activity 1: Team Visualization Exercisei

The goal of this exercise is to illustrate how the current models in most primary care practices do not function as team-based care. When working with your practice, be sure to get all care team members to participate. Each staff member will be given 60 jelly beans and a short, clear plastic cup. Also have a cup in the middle labeled “No one.”

  • Ask the group which staff member performs each of 10 tasks (listed below).
  • Instruct all staff members to drop a jelly bean into each staff member’s cup who they think currently performs that task.
  • Instruct staff members to drop a jelly bean into the “No one” cup if they don’t think anyone currently performs that task. For example, if a staff member thinks a task is currently performed by two physicians, a nurse practitioner, and a physician’s assistant, that staff member would put a jelly bean in each of the cups of those four providers.

Ask which staff member:

  1. SETS the intervals for blood monitoring for patients on warfarin? 
  2. DECIDES when to call a patient with diabetes to come in for a visit? 
  3. SELECTS the vaccines to be given to an 18-month-old baby? 
  4. DECIDES to arrange a diabetes retinal screening referral? 
  5. ORDERS the mammogram for a 55-year-old woman with severe hypertension and heart disease? 
  6. INITIATES diabetes microfilament foot testing to prevent amputations? 
  7. FINDS patients with severe persistent asthma who are not on controller medications and brings them in for an appointment? 
  8. DECIDES which children with ADHD should come for a visit? 
  9. DECIDES when a patient with major depression (PHQ 17) should come back for a visit? 
  10. ADMINISTERS Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening to patients in your practice?

At the end of the exercise, the group will probably discover that most of the jelly beans end up in the primary care providers’ cups. Facilitate a discussion using the following prompts:

  • What did you observe about this exercise? What did you learn from it?
  • What implications do you think this has for you all as a care team?
  • Why are there jelly beans in the “No one” cup? What can you do about that?
  • What should the distribution of jelly beans look like to be real team-based care?
  • What changes would you need to make to how you are currently practicing to do this?
  • How would this affect your workflow?
  • Are there goals you want to include in your quality improvement (QI) plan based on this exercise?

i Provided by Carolyn Shepherd, M.D.

Activity 2: In a Perfect World - Task Reassignment Exercise

This is a good followup exercise to the Team Visualization Exercise. By the end of this exercise, your practice will learn how responsibility could be reallocated among staff members to become more team oriented and efficient in caring for patients.

  • Begin by completing the first column of the Task Reassignment Table (Table 19.1). You may choose tasks associated with a particular care process (e.g., care of patients with diabetes) or general workflow tasks (e.g., intake, documentation, followup). (See the example in Table 19.2.) You may want to confer with the leader of your practice’s QI team on which tasks to list.
  • Next, convene the practice’s QI team and have them fill out the middle and right columns of the Task Reassignment Table.
  • Remind them that in the perfect world all care team members work at the top of their licensure and skill set.
  • Encourage them to think how others can be trained to perform tasks they don’t currently perform.
  • Let them know that tasks currently performed by one person can be split among care team members as long as there are appropriate handoffs.

What your practice will learn from this exercise is the difference between the status quo and the ideal, and what responsibility shifts it will take to get from one to the other.

Table 19.1. Task reassignment table

Task Who does it now? In a perfect world, who would do it?

Adapted from IHI.

Table 19.2 Task reassignment table example

Task Who does it now? In a perfect world, who would do it?
Book appointments RNs and clerical Clerical support
Take incoming calls Everyone Clerical support
Chart preparations MAs Clerical support
Triage RNs and MDs RNs
Medication refill requests RN, MD, clerical Clerical with MD signature
Check-in Receptionists Receptionists
Suture removal MD RN
Dressing change MD MA
Flu shots RN MA


Agency for Healthcare Research and Quality. Patient Centered Medical Home Resource Center. Defining the PCMH. Available at: Accessed April 10, 2013.

Bodenheimer T. Building teams in primary care: lessons from 15 case studies. Oakland: California HealthCare Foundation; July 2007.

Bodenheimer T. The future of primary care: transforming practice. N Engl J Med 2008;359(20):2086-9.

Coleman K, Reid R. Safety Net Medical Home Initiative. Continuous and team-based healing relationships: improving patient care through teams. Implementation guide. 1st ed. Burton T, ed. Seattle, WA: MacColl Center for Health Care Innovation at the Group Health Institute and Qualis Health; December 2010.

Katzenbach J, Smith, D. The wisdom of teams: creating the high-performance organization. Cambridge, MA: Harvard Business School Press; 1993.

Loudin B, Gainer L, Mayor M, et al. Elevating the role of the medical/clinical assistant: maximizing team-based care in the patient-centered medical home. Seattle, WA: MacColl Center for Health Care Innovation at the Group Health Institute and Qualis Health; August 2011.

Østbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3:209-14.

Pollak KI, Krause KM, Yarnall KS, et al. Estimated time spent on preventive services by primary care physicians. BMC Health Serv Res2008;8:245.

Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006:296(4):427-40.

Page last reviewed May 2013
Page originally created May 2013
Internet Citation: Module 19. Implementing Care Teams. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.
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