Creating Patient-centered Team-based Primary Care

March 2016
AHRQ Publication No. 16-0002-EF
Prepared For:
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857,

Contract Number: HHSA290200900019I/HHSA29032006T
Prepared By: Mathematica Policy Research Princeton, NJ
Project Director: Deborah Peikes
Principal Investigators: Deborah Peikes and Erin Fries Taylor
Authors: Lisa Schottenfeld, M.P.H., M.S.W.; Dana Petersen, Ph.D., M.P.H., M.A.; Deborah Peikes, Ph.D., M.P.A.; Richard Ricciardi, Ph.D., N.P.; Hannah Burak, B.A.; Robert McNellis, M.P.H., P.A.; Janice Genevro, Ph.D.


The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders.

Suggested Citation

Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, Genevro J. Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16-0002-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2016.


We thank the following people for their helpful perspectives and insights in the preparation of this white paper:

Technical Expert Panel Members

  • Susan Edgman-Levitan, P.A., Executive Director, John D. Stoeckle Center for Primary Care Innovation and Massachusetts General Hospital
  • Amy C. Edmondson, Ph.D., A.M., Professor of Leadership and Management, Harvard Business School
  • Jessie Gruman, Ph.D., President and Founder, Center for Advancing Health 1
  • Jeanne Walker McAllister, M.S., M.H.A., Associate Research Professor of Pediatrics,Indiana University School of Medicine, Indiana Children's Health Services Research
  • Holly Miller, M.D., Medical Director, Taconic IPA
  • Pamela H. Mitchell, Ph.D., M.S., Past President, American Academy of Nursing, and Executive Associate Dean, University of Washington School of Nursing
  • Ron Stock, M.D., M.A., Associate Professor of Family Medicine, The John Kitzhaber, M.D., Fellow in Health Policy, The Foundation for Medical Excellence; and Director of Clinical Innovation, Oregon Health Authority Transformation Center, Oregon Heath & Sciences University
  • Soma Stout, M.D., M.S., Lead Transformation Adviser at Cambridge Health Alliance; Director of Innovation Fellowship at Harvard Medical School Center for Primary Care
  • Jennifer Sweeney, M.A., Vice President, National Partnership for Women & Families

Other Contributors

  • Kathy Hutcheson, M.B.A., M.S., Consumer Engagement Coordinator, Aligning Forces for Quality (AF4Q)—South Central Pennsylvania
  • Phyllis Kaye, M.P.A., PEK Consulting
  • Judith Schaefer, M.P.H., Senior Research Associate at MacColl Center/GroupHealth Research Institute
  • Steve Tierney, M.D., Medical Director; Thomas Mitchell (Nurse Case Manager), Matai Manu (Certified Medical Assistant/Manager), Guil Prickette (Behavioral Health Consultant), Adrienne Tveit (Pharmacist), Brandi Hennard (Registered Dietician), Darius DiMascio (Case Management Support), April Kyle (Customer–Owner), Southcentral Foundation


Of all of the changes envisioned as part of the transformation to improved and more patient-centered primary care, perhaps none is more promising and more challenging than the transition to team-based delivery of care.

Team-based care is defined by the National Academy of Medicine (formerly known as the Institute of Medicine) as "...the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care."1-3

Well-implemented team-based care has the potential to improve the comprehensiveness, coordination, efficiency, effectiveness, and value of care, as well as the satisfaction of patients and providers.2,4-8 To achieve this potential, the transition to team-based primary care requires, for most practices, profound changes in the culture and organization of care, in the nature of interactions among colleagues and with patients, in education and training, and in the ways in which primary care personnel and patients understand their roles and responsibilities.

In addition, although team-based care may implicitly be considered patient-centered from the perspective of the health care system—because it is designed to make primary care more comprehensive and accessible, thereby meeting important needs of patients and families—this perception may not be universal.2,3 From the perspective of some clinicians and patients, team-based care may feel like a departure from patient-centered care because of its perceived potential to (1) disrupt relationships that are highly valued and seen as the foundation of good care, and (2) splinter care delivery across multiple team members.9,10

"Patient-centered primary care is defined by the Agency for Healthcare Research and Quality as care that is relationship-based with an orientation toward the whole person, and that includes partnering with patients and their families to understand and respect each patient's unique needs, culture, values, and preferences. Care that is patient-centered also supports patients in learning to manage, organize, and participate in their own care at the level the patient chooses." 25

Many publications have addressed the challenges and processes of the transition to team-based primary care.3,4,11-14 In addition, the nature and principles of patient-centered primary care have been extensively explored.15-17 That existing body of work represents progress in understanding and conceptualizing patient engagement with the primary care team, but additional information is needed to provide practices (and those who help them transition to new models of care and workforce configurations) with a conceptual framework and actionable strategies to create patient-centered team-based primary care.

This paper: (1) proposes a conceptual framework for the integration of team-based care and patient-centered care in primary care settings; and (2) offers some practical strategies to support the implementation of patient-centered team-based primary care. The conceptual framework emphasizes the importance of relationships as the foundation for high-quality, patient-centered team-based primary care. The strategies and resources are intended to help generate the culture, structure, and processes that support the development and maintenance of good relationships within teams and between teams and patients. They are offered for primary care practices and practice facilitators to consider as they engage in this work.

In developing the conceptual framework and identifying practical strategies for implementing and sustaining patient-centered team-based care, we drew on literature and expert input and interviews. Although the strategies may not yet be supported by evidence from clinical trials or other evaluation studies, they provide important insights and key considerations for primary care practices seeking to provide patient-centered team-based care.

We hope this paper will stimulate further discussion about how to integrate the principles of patient-centered care into workforce reconfigurations and other aspects of the transition to new primary care models. In addition, we hope the strategies identified here that others have found useful will serve as a starting point for investigations into the effectiveness of interventions to provide patient-centered team-based primary care.

Background and Literature

At the same time that more primary care practices are beginning to implement or expand team-based care, the emphasis on providing patient-centered care continues. In this section, we briefly summarize the literature on the potential benefits of team-based and patient-centered care and describe why promoting these two qualities simultaneously is important for providing high-quality care.

Team-Based Primary Care. Team-based care offers many potential advantages18,19 including expanded access to care (more hours of coverage, shorter wait times);20 more effective and efficient delivery of additional services that are essential to providing high-quality care, such as patient education, behavioral health, self-management support, and care coordination;5-8,13,21 increased job satisfaction;22 and an environment in which all medical and nonmedical professionals are encouraged to perform work that is matched to their abilities.23 Fundamental to this approach is the belief that, when practices draw on the expertise of a variety of provider team members, patients are more likely to get the care they need.4,8 A larger provider team might also support quality improvement; with effective intra-team communication and problem solving, practices can engage in data-driven, continuous quality improvement.24

Patient-Centered Care. Patient-centered care is considered to be care that is relationship-based and makes the patient feel known, respected, involved, engaged, and knowledgeable.16,25 Providing this type of care is increasingly perceived as “the right thing to do,” and is considered by many to be justified on moral grounds alone.16 Research also links patient-centered care to positive outcomes, including improved physician-patient communication and relationships, higher patient satisfaction, better recall of information and treatment adherence, better recovery, and improved health outcomes.15,26-28

The Issue

Why does the integration of team-based care with patient-centered care warrant attention? Two primary areas of concern and inquiry have emerged in response to the transition to team-based primary care: (1) the structures, processes, knowledge, and supports that are needed in the primary care practice to create and sustain effective teams; and (2) the potential effects of this transition on relationships among team members, and between patients and those who provide care.

As primary care practices adopt a team-based model of care, a significant challenge is identifying and providing them with the structures, processes, and other types of support (such as training) they need to facilitate and sustain effective communication among provider team members and develop and maintain good intra-team relationships. Effective communication is essential in ensuring that care is continuous and patient-centered,16,29,30 as well as coordinated and coherent; it is the pathway through which team members become aware of each patient's needs, culture, values, and preferences, and understand one another's role in delivering care to the patient.

The increasing focus on the use of teams in primary care has also prompted concern among patients and clinicians that this model might compromise clinicians' ability to offer "relational continuity" to patients, resulting in patients no longer feeling like their health care providers truly know them. Relational continuity refers to ongoing, caring relationships in which a patient is known by his or her provider so that past care is linked with current care, usually with an expectation that these relationships will continue in the future.4 A sustained therapeutic relationship extending across care episodes has been identified as a goal of primary care.10,35 Many studies show that relational continuity, the healing relationship, and trust between patients and their primary health care providers are crucial parts of medical care and are key attributes of care that many patients and providers value.16,36-39 Patients accustomed to seeing a single provider over multiple episodes of care may find it disconcerting to shift to a team-based care model in which they are expected to have relationships and intensified involvement with additional clinical and nonclinical provider team members.9,10 Further, some stakeholders have raised concerns that practice transformation efforts aimed at building and using provider teams may focus too heavily on practice infrastructure and processes such as health information technology, changing workflows, and adding new staff, and pay insufficient attention to helping teams develop the skills and capacities to build partnerships with patients and provide patient-centered care.31-34

A Proposed Blueprint for Patient-centered Team-based Care

Based on our review of the literature, expert input, and interviews, we propose a conceptual "blueprint" that shows the ideal of how a primary care practice can provide patient-centered team-based care (Figure 1).

We use "provider team" to refer to a group of primary care practice personnel who identify as members of a team and who work together to provide care for a panel of patients. The provider team can include a range of clinical personnel—such as physicians, nurse practitioners, physician assistants, nurses, care managers, dietitians, pharmacists, and social workers—as well as nonclinical staff, such as receptionists and peer counselors. We use "patient-centered care teams" to refer to the customized teams that form to provide care for, and include, individual patients. These teams may include some or all members of the provider team, depending on the patient’s needs at that time and the constellations of clinicians and staff in different practices, but they always include the patient in the role that he or she prefers. ("Patient" includes any family members and caregivers the patient wishes to be involved.) The composition of teams may vary across practices and among patients at different times in the same practice. 2 Further, a large practice may have multiple teams that provide care to different patient panels.

As depicted at the top of the blueprint, a practice that provides patient-centered team-based care takes a patient-centered approach to planning and delivering care. That is, the practice views developing good relationships with patients as a key component of high-quality care, actively seeks and appropriately responds to patients' preferences and values, and works to support patients in achieving their health goals. Reading the figure from left to right, as individual patients seek care at a primary care practice that is committed to a patient-centered team-based approach, they encounter a united provider team with good relationships among its members. Members of this provider team aim to respect, trust, and communicate skillfully with one another. We refer to this as the "coherence" of the provider team. This group of providers is also identifiable as a team; it looks and feels to patients within the practice like a well-functioning unit working collaboratively to meet their health care needs.

Coherent, identifiable teams are able to build relationships with individual patients and form patient-centered care teams with each patient in any role and capacity the patient prefers. (These roles may change over time and as circumstances change.) On the far right of the figure, the patient-centered care teams are shown in different configurations indicating where the patient fits into the team. That is, although an enduring provider team exists independently of the patient, multiple patient-centered care teams (that vary in size and configuration) come into being for some period of time, depending on each patient’s health care needs and preferences. Good relationships among provider team members create the foundation for good relationships with patients. All these relationships are essential to the formation of successful patient-centered care teams.

Figure 1. Conceptual blueprint for the provision of patient-centered team- based careFigure1

Strategies for Providing Patient-centered Team-based Care

In this section, we offer some practical strategies that different types of practices can consider to support the delivery of patient-centered team-based care. The strategies are based on approaches found in the literature and expert input and interviews. First, we describe strategies that might help practices adopt a patient-centered approach to planning and delivering team-based care. Then, we describe strategies that practices might use to develop high-performing provider teams that can build effective relationships with patients to form patient-centered care teams.

Many practices may face challenges in implementing a patient-centered team-based approach, as these efforts may require significantly changing their organizational culture, infrastructure, and processes. Strategies and examples of how practices and health care systems have overcome these hurdles may prove useful to practices and to primary care “change agents,” such as practice facilitators.40-42

A. Adopting a patient-centered approach to planning and delivering team-based care

Creating a practice-wide commitment to patient-centeredness is an important first step in delivering effective patient-centered team-based care. Fundamental to this commitment is: an orientation toward viewing patients as equal and knowledgeable partners in care; efforts to seek patient input to inform the organization and delivery of care, and a "culture of relationship" within the practice, in which providers prioritize building relationships with patients. We offer possible strategies for operationalizing this commitment to patient-centered care both at the organizational level and during each individualized patient-provider interaction.

"A big part of [patient-centered care] is looking at patients and families as an untapped resource who bring unique insights and experiences to the table."

—Jennifer Sweeney, M.A., Vice President, National Partnership for Women and Families

1. Engage patients in setting practice-level procedures and policies.

At the practice level, practices can involve patients in setting direction and visualizing patient-centered team-based care before changing the care-delivery model. This process can help to build a shared understanding of patient-centered team-based care among patients and providers. Among other topics, practices can seek patient input on (1) how all members of the patient-centered care team should function and communicate to best serve patients' needs, (2) what patients need and want to know about patient-centered team-based care (and the best ways to share this information), and (3) ideas for maintaining and strengthening patients' relationships with providers as a practice transitions to team-based care. Ideally, practices can offer multiple opportunities for patients to provide input on planning and delivering team-based care. One expert noted that "you have to have a mindset of giving families 20 different kinds of ways to have their voice be heard." Practices may need to invest time and resources to orient patients and providers to their respective roles in this process. The following strategies may be effective for engaging patients:

  • Enlist a core group of patients to provide ongoing input and contribute to planning processes. Practices can form a patient and family advisory council or build relationships with "patient partners" to involve patients in planning and refining team-based care approaches. This core group of patients can meet regularly to provide input on organizational-level topics that affect patient and family experiences.

  • Offer opportunities for all patients to provide input. In addition to inviting patients to serve on advisory councils or as patient partners, practices can seek other ways to invite input from all patients. For example, practices can place a comments box at the front desk or use patient surveys, such as those in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite (available at, to collect feedback on how the practice is doing.

Potential Aspects of Philosophies of Patient-Centered Team-Based Care
  • Provider teams view patients as whole people with rich lives, varied personal and cultural needs and preferences, and the ability to make important contributions to their care.

  • Provider teams seek to not only earn patients’ trust, but also trust them to make the most appropriate health care decisions for themselves given their personal needs, preferences, and circumstances.

2. Develop, communicate, and use the practice’s philosophy of patient-centered team-based care.

Some primary care practices have developed their own philosophies of patient-centered team-based care, with input from patients, organizational leaders, team members, and other stakeholders. After developing the philosophy, a practice can use it to inform its approach to adopting, delivering, and evaluating team-based care. Methods some practices have used to accomplish this goal include:

  • Achieve buy-in from leadership. Engaging leadership in developing and reinforcing guiding principles can foster the adoption of the principles throughout the organization. For example, one primary care organization's leader emphasizes its philosophy of patient-centered team-based care in his orientation session with new hires.

  • Communicate the philosophy widely. Some practices post their philosophy of patient-centered team-based care throughout their offices (including in patient rooms), to continuously remind staff and patients of the organization's guiding principles.

  • Use the philosophy to guide decisionmaking. When making decisions about changes to care design and delivery, practices can assess how well proposed changes align with their philosophy and patient preferences.

  • Incorporate the philosophy into human resources policies and procedures. Some practices have taken steps to maximize the uptake of the guiding principles by incorporating them into their hiring, training, and performance review processes.

  • Use language that reflects the practice's patient-centered philosophy and values. Several experts discussed the importance of thinking critically about the language provider teams use to describe their work on patient-centered care teams. For example, one practice has replaced the word "patient" with "customer-owner." The practice does so to reinforce a new way of thinking about the relationships between providers and the people they serve.

"[Our health organization has created] our credo and our boundaries. Our credo is the behavior we all aspire to and the boundaries are the behaviors we aspire to [avoid]. Every employee signs the document during orientation and every year as part of their evaluation process. Because it's the framework for our performance evaluation, it really gets hardwired that these are our values and these are the behaviors that we won't tolerate."

—Susan Edgman-Levitan, P.A., Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital

3. Hire team members who match the practice’s philosophy and prioritize patient-centered care.

Hiring team members who fit within a culture of patient-centeredness can be an important part of adopting a patient-centered approach to planning and delivering patient-centered team-based care. Some practices have used the following strategies to meet this objective:

  • Incorporate patient-centeredness into job descriptions. A personal commitment to a patient-centered approach, along with strong relationship-building, communication, and active listening skills, can help providers deliver patient-centered care. These characteristics can be added to job descriptions and considered during the hiring process. For example, one pioneering practice uses behavioral interviewing techniques to identify candidates with strong relationship-building competencies.

  • Hire provider team members who come from and understand the communities served. Although not a prerequisite for building strong patient-provider relationships, team members who come from the same community or share the same cultural background as the patient population may more easily forge relationships with patients and provide culturally appropriate care. In addition, hiring team members who can speak the languages spoken by the patient population can increase a practice's ability to provide linguistically competent care.

4. Prepare provider teams to apply the practice's philosophy of patient-centered team-based care in clinical encounters.

In additional to an organizational commitment to patient-centeredness, a patient-centered approach to team-based care requires provider team members to regard patients as important partners in care, take steps to foster relationships with patients, commit to seeking out each patient's needs and preferences, listen to patients' input, and work closely with patients to ensure that the team is responsive to their expressed needs when delivering care. Viewing patients as partners in decisionmaking and seeking and responding to patient input can be new to some providers who are accustomed to being solely responsible for determining the best course of action for patients (and some patients may still prefer that type of relationship). The following strategies can help prepare provider teams to seek patients' input and provide care tailored to patients' preferences:

"As we go in and out of crises, and things ebb and flow, we may want to take on different roles [on the care team] at different times…that’s something that needs to be invited and checked in and offered."

—Jessie Gruman, Ph.D., President and Founder, Center for Advancing Health

  • Train team members to engage patients as partners in care, build relationships, and invite and respond to the needs and preferences patients express. This approach can include training staff in the following areas:

      • Communication, motivational interviewing, and active listening. Research on patient-provider communication indicates that patients’ and providers' perspectives on the quality of communication often differ; many patients express discontent with patient-provider communication, even when clinicians report that their communication is strong.43-45 Offering staff training on these techniques can help to bridge this gap and increase providers’ ability to have input-seeking conversations, build strong relationships, and provide patient-centered care.46

      • Viewing patients as resourceful partners in care, and engaging in shared decisionmaking. Training staff to view patients as knowledgeable and invaluable partners—and to engage them as decisionmakers—is an important part of patient-centered care. One expert noted that patient expertise may include knowledge of rare conditions, as well as knowledge of their own physical and psychological responses to their specific health and health care circumstances. For example, for pediatric patients, insights from the family about their child’s “baseline” can be invaluable. Further, training staff in shared decisionmaking processes can help ensure that health care decisions are made collaboratively, in a way that takes into account the patient's knowledge, values, and preferences.47

    "Each customer-owner [patient] has a different story and everyone learns differently. All of our customer-owners have different needs. Some [Alaska Native] elders don’t speak English, and need translators. Knowing that everyone has their own story, we are all always gauging how to best interact with that customer-owner."

    —Adrienne Tveit, Pharmacist, Southcentral Foundation

    • Topics that can be covered in input-seeking conversations. Providers can be trained to invite patients to express preferences about which team member they would like to see most regularly, how the team should contact them, the language in which they prefer to communicate, and how they would like to be involved in decisionmaking processes. Providers can also be trained to talk to patients about the role that patients want to play on their team. Some patients may want to play a very active role on their care team and to offer extensive input, whereas others may not feel comfortable in this role (and may even decline to provide input when asked). It is also important to train provider team members to seek this input from patients on an ongoing basis, as patients' preferences may change over time as their health issues change.

    • Providing culturally competent care. Although hiring staff who match the cultural backgrounds of the patient panel can be helpful, staff who share a cultural background with patients are not automatically experts in providing culturally appropriate care. No culture is monolithic, so it is important not to assume that staff who share the culture of the patient population can speak on behalf of every member of their cultural group. Prioritizing training in cultural competence for all staff can help ensure that care is patient-centered and attentive to individual patients' needs and values, and that no team members feel pressured to serve as "cultural experts."

  • Identify creative ways to solicit input from patients on their preferences and goals for treatment. Just as some patients may not be accustomed to providing input on organizational practices, some may be hesitant to provide input regarding their personal values and preferences for their care. The following strategies can help solicit this type of input:

    • Identify tools to help teams solicit the patients' goals for each visit and their overall health. In one practice, medical assistants help each patient fill out these tools before an appointment with a clinician. There are many resources to help practices identify patients' goals for visits, including those identified on the Self-Management Support page on the Agency for Healthcare Research and Quality (AHRQ) Web site (

    • Match patients with provider team members who have the personal skills, status, and/or training necessary for having input-seeking conversations with patients. It is important to carefully consider how traditional medical hierarchies, patients' preferences, and patients’ current medical status can influence input-seeking conversations. For example, one patient may be more comfortable talking about her situation or preferences for care with a medical assistant, and another may prefer to talk with a physician, nurse practitioner, or physician assistant. When identifying the appropriate team member to solicit input from patients, teams should consider past preferences of longstanding patients and aim to find the team member who may best meet new patients' preferences.

5. Introduce patients to the concept of team-based care, while continually seeking feedback.

"If shifting to team care means that our care [as a patient] will improve, why not explain (again and again) what we should expect from our team and help us understand how to take full advantage of this change."

—Jessie Gruman, Ph.D., President and Founder, Center for Advancing Health

Once a practice has successfully engaged a first round of patients in developing a mutual understanding of the concept of team-based care, it is important to communicate this understanding to all patients in the practice, while remaining receptive to feedback from patients that may alter or expand the concept. When a practice decides to adopt a team-based approach to care, practice leadership, clinicians, and staff can communicate with patients about how this model differs from patients’ past experience, what patients should expect in the future, how the practice expects team-based care to improve the quality of care they provide to patients, and how patients can offer feedback to team members and the practice on this model. The following strategies can introduce patients to team-based care:

  • Prepare providers to talk with individual patients. Providers can have personalized conversations with patients to discuss how team-based care may affect them. Experts agree that the framing of this conversation is critical, and that it should focus on how using teams will improve the patient's care and how patients can have a say in how their teams will function. For example, providers might explain that a patient may now see her nurse practitioner more often than her physician, or can elect to receive callbacks or emails regarding lab results from her medical assistant or registered nurse, and that changing to team-based care will likely make it easier for her to make appointments with a provider she knows and to get test results promptly. Providers can also explain how patients can offer feedback on ways the practice can improve the team-based care it provides. The dynamics depend on the patient; some patients will need to have this conversation only once, whereas others may need to have it many times.

  • Offer orientation sessions for patients. Some practices hold group patient orientation sessions to introduce patients to the concept of team-based care and elicit their perspectives about it. The sessions can focus on existing patients if a practice is newly transitioning to team-based care, or on groups of new patients as they come into the practice. One pioneering primary care practice holds orientation sessions led by long-standing patients. Peer patients leading the orientation sessions give tours of the practice to new patients, explain how team-based care works within the practice, and answer questions.

  • Create videos. A few experts suggested that practices could create short videos that explain the concept of team-based care and how it benefits patients, and could post them on the practice's Web site or on YouTube, or show them in waiting rooms. They report that both professional and self-made videos (including current staff and patients as spokespersons) can be effective.

  • Create brochures, letters, and Web site information. Practices can mail letters, distribute brochures, and add material to their Web sites to explain team-based care, illustrate how teams work, introduce each team's members, and describe the expected benefits of team-based care. However, practices may want to test their initial drafts of such information with a handful of patients to elicit feedback, and revise them accordingly before distributing to all patients. Additionally, practices noted that these more passive options for conveying information often require followup with individual patients to make sure that all points are mutually agreeable and clearly understood.

6. Create the practice-level infrastructure needed to support ongoing learning and improvement of patient-centered team-based care.

"This is one way for teams to hold themselves accountable for their promises: tell us [the patient] your goals and then ask us if you’re meeting them."

—Jessie Gruman, Ph.D., President and Founder, Center for Advancing Health

To ensure that practice-wide efforts to provide patient-centered team-based care are having the desired effect, practices can discuss ways to define and measure success, and then incorporate lessons learned into ongoing care provision. Methods for creating this type of learning organization include:

  • Ensure proactive support from leadership. Organizational leaders can establish the expectation that new ideas should be tested, evaluated, and altered based on feedback and outcomes.

  • Define and track measurable and specific goals related to providing patient-centered team-based care. Some experts referenced the importance and the challenge of meaningfully measuring the provision of patient-centered team-based care.48 To help meet this need, AHRQ has published an inventory of measures of team-based primary care (available at Some of these measures can be used to regularly gauge staff perceptions of team processes and the quality of relationships among team members. In addition to these resources, practices can use a range of tools to gather patients’ feedback on their experiences with team-based care; for example, practices can ask patients for feedback on their interactions with the provider team in a short verbal conversation or brief written questionnaire at the end of visits, or conduct "walkthroughs" of the practice to see and document care through a patient's eyes.

  • Provide teams with incentives for meeting goals, and evaluate staff according to their progress. Once practices have set goals for providing patient-centered team-based care and have begun tracking their outcomes, they can take steps to make these goals meaningful for staff. Practices can incorporate progress toward goals into evaluations of staff performance, and/or provide incentives to staff who show progress. In addition, any financial incentives previously awarded to physicians, nurse practitioners, and physician assistants (such as shared savings) can be awarded to entire teams of clinical and nonclinical staff. Linking these incentives to team performance can be a powerful way to build team cohesion.

B. Creating Teams That Can Deliver Patient-Centered Care

Coherence and Identifiability

A commonly referenced definition in organizational literature defines a team as being made of members "...who see themselves and who are seen by others as an intact social entity." 51

Having described a host of possible strategies to help practices develop a patient-centered approach to the planning and delivery of team-based care, we now turn to strategies to create teams that can effectively provide this care. As depicted in the conceptual blueprint, teams of clinicians and staff function as provider teams independently of individual patients over time. We propose that, for care to be planned and delivered in a continuous manner over time and in a way that meets the needs, preferences, and priorities of each patient and family, these provider teams need to function as coherent units. That is, members of provider teams will aim to communicate well with one another and act like a single, coordinated entity. We refer to this as the "coherence" of a provider team. Effective provider teams are also seen and experienced by patients as entities that work together as a well-functioning unit to meet patient care needs and help them achieve their health goals—that is, the provider team is easily identifiable as a team. Creating a coherent, identifiable team is essential to the provision of patient-centered team-based care: if the team does not communicate and function well, and the patient does not see the provider team as an entity, it will be extremely difficult for the patient to build a relationship with the team as a whole. These relationships are essential to the formation of patient-centered care teams. We offer strategies below that practices can use to develop coherent, identifiable teams.

The following resources are available to help primary care practices build high-functioning teams:

1. Build coherence among provider team members.

"If there are chinks in the team, patients will pick up on it. If no one has any idea how to be on a team, patients pick up on it."

—Jennifer Sweeney, M.A., Vice President, National Partnership for Women and Families

Building coherence (that is, the ability to communicate well and function collaboratively) in relationships among team members is critical to providing patient-centered team-based care. If team members cannot communicate well with one another, or see themselves as individual, independent providers, care may seem fragmented and disjointed to the patient, and patients may have difficulty developing a relationship with the team. One expert noted that, "As an organization, we have realized that you have to build cohesion on the team first, before you can build a cohesive relationship with the patient." Some practices have used the following strategies to build team coherence:

    • Promote a sense of egalitarianism, unity, and collective responsibility among team members. Within this type of provider team:

        • Members are willing to acknowledge and examine power structures that may prevent them from developing respectful, collaborative relationships with one another, and seek to build teams that encourage partnership and more egalitarian approaches to decisionmaking within the practice and in the provision of care.

        • Members view one another as whole people, and each provider’s full range of skills and personality traits are valued and employed to best meet the needs of the provider team and patients.

        • Members trust other team members to do their jobs well, provide high-quality care, and foster individual relationships with patients.

        • The team as a whole, including the patient, is responsible for meeting patients’ needs.

      "There is a tendency for people to be siloed—this is my job, and this is what I'm doing. But if you’re a nurse, and you notice that someone hasn’t had their blood pressure checked in a while, then you need to bring that up... If something does get overlooked, someone else can jump in."

      —Kathy Hutcheson, M.B.A., M.S., Consumer Engagement Coordinator, Aligning Forces for Quality—South Central Pennsylvania

      • Every team member has a voice in the decisionmaking process and is empowered to meet the patient's needs whenever possible.

      • One team member might serve as the "lead" for a patient to ensure smooth communication among the team; however, this person is not the sole decisionmaker, and may or may not be a physician, nurse practitioner, or physician assistant.

    • Regular team meetings that include all team members (not only physicians, nurse practitioners, and physician assistants) can offer protected time to review patient care, discuss practice operations and processes, and conduct quality improvement activities; they can also be a way to build relationships between team members and promote a collective, non-hierarchical team identity. Bringing in a skilled outside facilitator, such as a practice facilitator, to help establish the expectations listed above during these discussions can be helpful, particularly in practices where more traditional medical hierarchies have existed in the past.

      Some experts note that promoting a strong sense of team unity and collective responsibility for patient care can be transformative for team members, particularly front-desk staff. These staff can come to regard themselves as important members of a provider team with a crucial role to play in promoting patient health during their interactions with patients.

"[One patient] had a situation when her primary care doctor was away. The doctor on call took care of her immediate need and filled in the rest of the staff. The patient said it taught her that she can trust the entire staff, even if it wasn’t the same person every time, because they communicated (with each other)."

—Kathy Hutcheson, M.B.A., M.S., Consumer Engagement Coordinator, Aligning Forces for Quality (AF4Q)—South Central Pennsylvania

  • Define individual roles and standard work procedures, while encouraging flexibility. Within a team, it is important for each member to clearly understand his or her role on the team as well as his or her role in caring for the patient. To help team members achieve this understanding, practices can clearly delineate each team member’s responsibilities and create standard work procedures (for example, for completing referrals to specialists), so that each team member understands the roles of others. It is equally important, however, to train team members to cover more than one role and to be flexible to make sure that all of the patient’s needs are met. Cross-training team members in standard work procedures and asking them to be flexible can help them understand the interdependencies of their roles and ensure that teams can act in a coherent, fluid way to provide high-quality patient-centered care.

  • Develop structures to support information sharing among provider team members. Patient-centered care needs to be coherently organized and planned, with today's care decisions taking into account yesterday's care experiences, both over time and across multiple providers.4 Experts noted that care organization and planning are particularly important in team-based care to ensure that care provided by multiple team members over time is streamlined and coordinated. To achieve this coordination, team members must share information effectively, either in writing or verbally. Effective intra-team communication also ensures that the patient does not have to convey information about past care or repeat critical pieces of information to various team members. The following strategies can promote strong communication among team members:

    "We don't have providers sitting in one area, case managers in another, etc. Teams sit together in an open area, which promotes communication. It's crucial for the team in building connections, but also for the customer-owners [patients]. They know that when they tell me something I’m not going to send the doctor an email about it—I'm going to have a conversation with him about it, because I sit right next to him."

    —Guil Prickette, Behavioral Health Consultant, Southcentral Foundation

    • Written information sharing. Written information sharing can include documentation of patients' medical conditions and history as well as their preferences, values, and context. This knowledge sharing is important to "bridge separate care events and ensure that services are responsive to needs."49 Written information-sharing methods can include the following:

      • Establishing record systems (in electronic or other format) in which team members can record, update, and easily share patient information.

      • Creating shared care plans that are co-developed by team members and the patient and that team members can use to share information. Such plans can include the patient’s goals, needs, and preferences, and track past challenges and future goals for treatment and well-being.

      • Using real-time forms of written communication, such as secure text messaging, so that team members can quickly share information while the patient is in the office for a visit. For example, a nurse practitioner might see a patient, determine that the patient would like a referral to the team’s dietician, and send a message to the dietician to see whether he or she can talk to the patient immediately.

    • Verbal information sharing. Creating structures to help provider team members share information verbally can not only facilitate the flow of information, but also help build and strengthen team dynamics. Strategies to achieve effective verbal information sharing can include:

      "We've realized that if you can get teams to have clear roles, get them to huddle, get them scheduled to work together, get them to sit together, etc.,...even if all the interpersonal relationships aren't perfect, people perceive that their experience of teamwork is better, and their job satisfaction is higher."

      —Soma Stout, M.D., M.S., Lead Transformation Adviser at Cambridge Health Alliance; Director, Innovation Fellowship at Harvard Medical School Center for Primary Care

      • Co-locating staff to enable team members to talk informally and frequently. When team members can interact spontaneously, they develop rapport and can share insights in real time.4,50 Some practices refer to such arrangements as “flow stations” or “common workrooms” in which clinicians and other staff (such as medical assistants, case managers, schedulers, and so on) sit together. It is important to ensure that discussions either take place in a private space or otherwise protect the confidentiality of patients, so that other patients do not overhear sensitive personal information.

      • Scheduling staff on a team to work at the same time or at least overlap schedules.

      • Holding daily team huddles can provide time for teams to discuss patients scheduled for the day, and any patients whose care has been particularly complex.

      • Providing protected non-care time for team meetings can create the opportunity to review processes of care, fine-tune roles and functions, manage the health of the full panel, and undertake quality improvement projects.

2. Promote the team—as an identifiable and well—functioning entity—to patients.

"Just say, 'We're the blue team.' This helps patients, and the team itself, experience their identity."

—Amy Edmondson, Ph.D., A.M., Professor of Leadership and Management, Harvard Business School

Within high functioning, patient-centered team-based care models, patients have a multifaceted relationship with the team as a whole. In this model, patients feel known and cared for by the whole team over time. Developing the identity of the provider team, so that the team looks and feels like a coherent entity to patients, is an important stepping stone for building smooth and continuous team relationships with patients.

"No matter where I'd go to receive care, they would mention who my doctor was, which linked me over and over to a primary care team that I knew was mine. There was this sense that 'we know you are here and whose team you belong to'—that I'm supported and cared about as a whole person by every member of the team."

—Judith Schaefer (speaking as a patient), M.P.H., Senior Research Associate, MacColl Center/Group Health Research Institute

The following strategies may help make provider teams identifiable to patients, and thus help teams build relationships with patients and include them in patient-centered care teams:

    • Invite patients in larger practices to pick their team. One larger practice gives all new patients information on their various provider teams and the option to select their own team.

    • Introduce patients to all team members and explain their roles. As one expert panel member shared, "Patients need to understand the different roles on a team so that they know who to go to for what, and so they have the right expectations." One practice gives patients a "bio sheet" that provides a picture, profile, and contact information for each team member. All team members—from the receptionist to the medical assistant to the physician—can also take time to explain their roles in providing care to the patient as part of the patient-centered care team. Role explanations can take place during initial introductions and on an ongoing basis as a patient seeks different types of care over time.

"[The team] should be modeling among themselves the same behavior they would be modeling with patients and families. The practice displays dignity and respect for the patients, [and] they have to do the same with each other."

—Jennifer Sweeney, M.A., Vice President, National Partnership for Women and Families

    • Create visual cues. As with a sports team that wears matching uniforms, practices with multiple teams can reinforce team identities with visual cues. For example, the office as a whole can be color-coded. Larger practices can set up color-coded check-in stations for each provider team, each with its own receptionist. The lobby can display color-coded photos of staff denoting their team membership, and staff of the same team can all wear similar color-coded badges.

    • Reiterate "teamness." Team members can continuously reiterate to the patient that they are working together as a coherent unit. As part of this effort, it is helpful if all team members use consistent terminology and language to refer to the team, its members, and how it works.4 For example, one expert suggested that every time a team member sees a patient, she could say, "I know you are on Dr. Brown's team. I am also a member of that team, and I'm going to do X for you today." Reminding patients repeatedly about who is on their team can create an experience in which they feel the team as a whole knows and cares for them.

"The onus is on the provider to share with the patient that they've done their background research: to say 'I've looked at your chart, I understand your history, I've talked to other members of your care team, I can tell you the highlights from my perspectives, but tell me what your thoughts are from your perspective."

—Jennifer Sweeney, M.A., Vice President, National Partnership for Women and Families

    • Demonstrate respect among the team members. Patients are more likely to see team members as an intact social entity if they see members treating each other collegially. When asked about strategies to build the visibility of teams, one expert shared, "I think it is important for team members to know that their reactions to one another are observed by patients. It's important for patients to see you behaving respectfully toward each other."

    • Demonstrate information sharing. It is important to reassure patients that team members are communicating information and to explain to them how that is happening. At each visit, team members can explain to the patient what they have learned from other team members, such as past medical history or treatment preferences. As one expert explained, "When team members communicate information about patients with each other, and each provider tells the patient that they heard and know X/Y/Z from a different provider, the patient learns that the team is a functioning unit that they can trust."

"If [my pediatrician] wants me to talk with another person on the team about something, he will introduce me to that person and explain why that person is a good person for me to talk with."

—April Kyle, customer-owner [patient] at Southcentral Foundation

  • Use "warm handoffs" among the team. Warm handoffs—in which a team member introduces another team member to the patient—are a critical way of building a sense of cohesion, identity, and trust among the team and with patients. A warm handoff occurs when one team member who has a relationship with the patient introduces the idea of the patient working with another team member, clearly explains why the other team member could better address a specific issue with the patient, emphasizes the other team member's competence, asks for the patient’s acceptance of the plan, and then "hands off" that patient to the other provider, either personally or via referral. When the original team member describes the other team member positively and tells the patient how the other staff member will help meet the patient's needs, the colleague is not only transferring trust to the other provider, but also helping the patient to see the team as a coherent, identifiable group.


With the increasing emphasis on using teams to deliver high-quality primary care, abundant and exciting opportunities exist for primary care practices and patients to work together to ensure that such care is patient-centered.

Good relationships provide the foundation for the development of high-functioning teams and for high-quality patient-centered care; therefore, good relationships are critical to the provision of patient-centered team-based care. As depicted in the conceptual blueprint, we propose that for practices to provide patient-centered team-based care effectively, they will first adopt a patient-centered approach. This approach means that the practice will seek patient input while designing and delivering team-based care, prioritize relationships with patients, and prepare provider teams to provide this model of care. Practices will also invest resources to develop and sustain coherent provider teams with strong relationships among team members. Patients will be able to identify these teams, and recognize them as cohesive, well-functioning units with a commitment to providing care that responds to patients' needs and preferences and helps patients achieve their health goals.

Experts and literature consulted for this paper suggested that the strategies outlined here can be among those that can help create the conditions needed for teams to build strong intra-team relationships and continuous relationships with patients, thus creating patient-centered care teams in which providers and patients partner with each other to build health. We encourage practices, researchers, and policymakers to adapt and test these strategies in different settings to investigate their effectiveness in promoting patient-centered team-based primary care. We also hope that this paper will encourage the next generation of new strategies, as well as broader discussion of best practices in implementing principles of patient-centeredness in new models of primary care.


  1. Deceased, July 2014.Go back (1)
  2. The patient's "expanded" care team might also include members from other settings of care (such as schools, specialty practices, hospitals, skilled nursing facilities, community service providers, etc.), based on the patient’s preferences and needs. Understanding how provider teams function in relationship to the medical neighborhood—in general and on a patient-specific basis—should be an important aspect of future work on patient-centered team-based care.Go back (2)


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