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

Integrating behavioral health services greatly improves patient outcomes

CareSouth Carolina reports on how it co-located Licensed Independent Clinical Social Workers with primary care teams—and collected data to track its goal of reaching 0% disparities.

Behavioral Health Integration module

Health coaches can be a patient’s guide through the healthcare experience.

Incorporating health coaches and nurse practitioners into care teams helped High Plains Community Health Center significantly improve patient experience and give physicians more time with patients. Watch this video about the Center’s transformation.

The Medical Assistant module

Establish a practice improvement team to support care transformation.

Designating leaders in your organization dedicated to supporting and improving care teams is essential to practice transformation. Cambridge Health Alliance created a toolkit for developing a practice improvement team based on their own experience of doing so.

The Practice Team module