Care Team

As primary care shifts from transactional to quality focused, incorporating a care team has become even more beneficial. In order to provide comprehensive, patient-centered care, more than just the clinician must play a role. The care team consists of physicians, nurse practitioners, PAs, nurses, care managers, dieticians, and social workers, among others. Having a large, well-coordinated team allows patients to avoid the confusion when attempting to access primary care services and leads to better connectedness in their care. The care team is totally devoted to ensuring that the patient is at the center of the care process. As the driver of the care team, the patient is especially involved in choosing their course of care. Care teams are essential in coordination, and continuity of care. As clinics develop a care team, it is critical that they include the patient voice, to ensure that they are effectively meeting the patients' needs. If the care team lacks cohesion, it will only further contribute to the current, fragmented system. 


Patient-Centered Primary Care Collaborative | July 2017
Healthcare Informatics | June 2016
This roadmap describes a trend towards population health management and value-based payment models through the patient-centered medical home (PCMH). It details the importance of comprehensive primary care that includes behavioral health, social workers, and community services. This resource acts as a guide to help practices transition to value-based care.
American Academy of Pediatrics | January 2016
The Commonwealth Fund | December 2015
This resource explores how the relationship between community health workers (CHWs) and patients can improve care and lead to better outcomes. Community health workers are uniquely positioned in the context of their patients' lives which gives them valuable insights into how to best help their patients. Integrating community health workers into the care team and creating collaboration between clinicians and CHWs can help improve treatment adherence and health outcomes.
November 2015

Associated Stakeholders: 

Care Delivery & Integration

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