Defining Team-Based Care


Defining Team-Based Care

Team-based health care is defined 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. Source: Mitchell et al. 2012. Core principles & values of effective team-based health care

Principles of Team-based Care include:

  • Shared goals
  • Clear roles
  • Mutual trust
  • Effective communication
  • Measurable processes and outcomes

In May 2012 the CDC released the Task Force on Community Preventive Services recommendations for team-based care (TBC) for improving blood pressure control on the basis of strong evidence of effectiveness.

A review of 77 studies of team-based care showed that patients' control of blood pressure improved when their care was provided by a team of health professionals - a primary care provider supported by a pharmacist, nurse, dietitian, social worker, or community health worker - rather than by a single physician.

The collected studies showed that team-based care helped increase the proportion of patients with controlled blood pressure, led to a decrease in both systolic and diastolic blood pressure, and improved outcomes in patients who had diabetes and elevated blood lipids. Team members supplemented the activities of the primary care provider by providing support and sharing responsibility for hypertension and diabetes care, such as medication management, patient follow-up, and helping the patient adhere to their control plan, including monitoring routinely, taking medications as prescribed, reducing sodium in the diet, and increasing physical activity.

To learn more about the Summary of Task Force Recommendations and Findings visit:

The Community Guide


Continuous and Team-Based Healing Relationships Improving Patient Care Through Teams

This Implementation Guide addresses why care teams are important for improving patient care and ways to build an effective care team that meet patients' needs and expectations. This is a product of the Safety Net Medical Home Initiative , which was supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice policy.


Role of Emergency Medical Services Providers:

Emergency Medical Services (EMS) providers are finding themselves in expanded roles. The transformation in health care has prompted the growth of new EMS models such as Community Paramedicine. Community Paramedicine is an emerging field in health care where emergency medical technicians (EMTs) and paramedics operate in expanded roles in an effort to connect underutilized resources to underserved populations. Community Paramedicine is not meant to compete with existing healthcare services, but to complement existing services and to work with them in a team approach. The emerging models often focus on areas such as reducing preventable emergency department visits and decreasing hospital readmissions. However, there are efforts to include EMS in team-based care for improved high blood pressure management.

  • Encourage patients to manage his or her care and treatment.
  • Help patients monitor blood pressures and blood glucose levels. Educate on importance of knowing their numbers.
  • Provide education on medication adherence in compliance with physician recommendations.
  • Work with a healthcare team to support patients in following a care plan and setting/achieving self-management goals.
  • Provide assistance in locating appropriate social service and community supports.

Source: The Feasibility and Role of Community Paramedicine in Nebraska, May 2011

The expanded role of EMS can support population health management and provide EMS providers with valuable knowledge of the communities they serve.


Expanding the Roles of Emergency Medical Services Providers: A Legal Analysis
With support and guidance from the Office of the Assistant Secretary for Preparedness and Response (ASPR), the Association of State and Territorial Health Officials (ASTHO) seeks to identify feasible approaches to increasing the opportunities to engage emergency medical services (EMS) providers for day-to-day activities in communities across the United States.


Role of the Pharmacist:

  • Fills prescriptions per providers orders, after checking for any contraindications
  • Educate patients on how and when to take medicine, advising on potential side effects
  • Advises about general health topics
  • Teaches other healthcare practitioners about proper medication therapies for patients
  • Completes insurance forms
  • Oversees the work of pharmacy technicians and pharmacists in training (interns)

Source -

How to Partner with the Pharmacist:

  • Learn what pharmacists can and cannot do in your state by checking with the Board of Pharmacy
  • Meet with local pharmacists to discuss their role in hypertension control and management such as; performing in-pharmacy blood pressure (BP) checks, advising on home BP self-monitoring, educating patients on hypertension medications, and tracking refill patterns
  • Meet with local pharmacists to discuss their role in diabetes control and management such as; in-pharmacy blood glucose checks, advising on home blood glucose monitoring, educating patients on diabetes medications, and tracking refill patterns
  • Discuss possible models for hypertension and/or diabetes management with engaged pharmacists providing resources and/or examples (i.e. team-based care models)


The CDC has developed a Program Guide for Public Health - Partnering with Pharmacists in the Prevention and Control of Chronic Diseases. This guide provides definitions, in depth description of the role of pharmacists, pharmacist scope of practice policies and strategies for partnering with local pharmacists in your state. The guide also provides examples of evidence-based programs such as the Asheville Project and the Diabetes 10-City Challenge. You can download the complete PDF report here

Another resource is the CDC's Team Up. Pressure Down . a nationwide program in partnership with the Million HeartsĀ® initiative, to lower blood pressure and prevent hypertension through pharmacist-patient engagement.


Case Manager/Nurse:
Case Managers are frequently Registered Nurses (RNs) who:

  • Develop, implement, and evaluate individualized care plans for patients
  • Advocate for the safety of patients
  • Act as a liaison between healthcare providers, families of patients and the patients themselves
  • Educate their patients and their families on how to follow their care plans

How to Partner with the Case Manager/Nurse:

  • Share tools and resources on how to identify and track patients with a diagnosis of diabetes and/or hypertension
  • Educate Case Managers on available community resources to assist the patient in chronic disease management
  • Share information regarding state and national programs
  • Convene like healthcare providers to share resources and effective patient management techniques


Role of the Community Health Worker (CHW):

  • Typically, lay person from the community
  • Provides general health education
  • Serve as role models and community advocates
  • Increase access to healthcare resources
  • Collect data for research/quality improvement purposes

For more information, see Community Health Worker in the
Health Care Models button on the home page

How to Partner with the Community Health Worker (CHW):

  • Advocate and promote the implementation of CHW role descriptions and policies within healthcare systems/provider practices
  • Share information regarding available community resources to assist patients with chronic disease
  • Promote health prevention and chronic disease self-management by supporting a multi-disciplinary team approach



Patients and where appropriate families and caregivers must be included as an integral part of the health care team. Ensuring that patients are active members of the health care team will support self-management, shared decision making, goal setting and improvements in care. In fact, patient centered care is at the core of most health care transformation including the patient-centered medical home model, advanced primary care practices, community care teams and care coordination.

These emerging models also engage patients in ongoing quality improvement efforts in a variety of ways, including soliciting regular feedback through surveys, gathering additional information on patient perspectives through the formation of patient/family advisory councils, and inviting individual patients and consumer and patient organizations to contribute to QI activities.

Source: Peikes D, Genevro J, Scholle SH, Torda P. The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care . AHRQ Publication No. 11-0029. Rockville, MD: Agency for Healthcare Research and Quality. February 2011.


You can learn more about these patient centered models under the Healthcare and Payer Models section of this website.

CMS's Partnership for Patients initiative is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans.

Robert Wood Johnson Foundation Aligning Forces for Quality - Consumer Engagement


A generalist physician and/or non-physician practitioners (nurse practitioners and physician assistants)

Role of the Primary Care Provider:

  • Serves as the entry point for the patient's health care needs
  • Takes continuing responsibility for providing the patient's care
  • Serves as an advocate for the patient, coordinating the entire health care system to benefit the patient

How to Partner with the Primary Care Provider:

  • Identify which providers in your state are reporting to a national quality program such as NCQA (see Basic Component Button on home page)
  • Share available community resources to assist their patients (i.e. blood pressure screenings/smoking cessation/ etc...)
  • Discuss current patient tracking for patients with hypertension and/or diabetes
  • Share resources with PCP and office to assist with blood pressure and diabetes management (i.e. algorithms)
  • Convene healthcare team to explore how all can work to their highest level

Source -


Role of the Behavioral Health Specialist:

  • Assist primary health care providers in recognizing and treating mental disorders and psychosocial problems
  • Assist in preventing relapse or morbidity in conditions that tend to recur over time
  • Evaluate patient care plans with primary care team
  • Teach patients, families and staff about care, prevention and treatment enhancement techniques

How to Partner with the Behavioral Health Specialist:

  • Convene healthcare teams including PCP/staff and Behavioral Health Specialist to promote improved communication resulting in team-based, patient-centered care
  • Advocate for improved awareness and coverage of mental health /behavioral disorders
  • Share resources for patient tracking (i.e. hypertension and/or diabetes)
  • Share information regarding community resources for patients with mental health/behavioral disorders


Role of the Medical Assistant:

Medical assistants (MAs) are often trained in both clinical and administrative work. This multidimensional skill set of medical assistants is ideal for supporting team-based care.

MAs can perform tasks such as optimizing patient flow, panel management, health coaching, and other team duties. Tasks directly related to supporting high blood pressure management may include:

  • Taking blood pressure accurately and involving the patient in accurate blood pressure measurement.
  • Provide patient education, including supporting patient self-measured blood pressure monitoring. Patients can bring in their home BP monitors and practice with the MAs in the clinical setting. MAs may also educate patients on use of a blood pressure log to track self-measured blood pressures.
  • MAs can support patient goal setting and work with the patients and other team members to connect to community supports.
  • MAs can be actively involved in the quality improvement and clinical practice transformation process and support peer-to-peer learning.


Continuous and Team-Based Healing Relationships
Elevating the Role of the Medical/Clinical Assistant: Maximizing Team-Based Care in the Patient-Centered Medical Home
This is a product of the Safety Net Medical Home Initiative , which was supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice policy.