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:
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:
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.
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:
How to Partner with the Pharmacist:
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 Hearts® initiative, to lower blood pressure and prevent hypertension through pharmacist-patient engagement.
Case Managers are frequently Registered Nurses (RNs) who:
How to Partner with the Case Manager/Nurse:
Role of the Community Health Worker (CHW):
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):
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.
A generalist physician and/or non-physician practitioners (nurse practitioners and physician assistants)
Role of the Primary Care Provider:
How to Partner with the Primary Care Provider:
Role of the Behavioral Health Specialist:
How to Partner with the Behavioral Health Specialist:
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:
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.