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Team-Based Care in the Primary Care Pediatric Office

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Why Team-​​Based Care?

Several changes in the healthcare environment are driving the move toward team-based medical care—

  • shortages of primary care physicians,
  • influx of new patients with medical insurance,
  • adoption of the medical home, and
  • emerging payment and care delivery models.

Team-based care allows physicians to connect with their patients on key clinical issues and provide comprehensive, continuous, coordinated care by involving more of the practice staff in patient care as appropriate to their training and capabilities. Team-based care can also increase a practice's efficiency and productivity. 

Understanding the Importa​​nce of Team-Based Care

Team-based care engages a greater number of staff in patient care and affords physicians, as the leader of a practice team, additional time to listen, think deeply, and develop relationships with patients and their families.

Team members are aware of the health history, status, and unique needs of the patient and family, and are assigned different responsibilities, which together are designed to result in continuous, comprehensive, coordinated care during and between visits. As a result, all members of the team feel engaged in their key role of caring for the patient.

A successful collaborative team environment includes the following:

  • ​​A culture of trust
  • Clearly defined roles and responsibilities
  • Strong leadership
  • Respectful and empathetic open communication
  • Appreciation of diversity
  • Equal participation among all team members
  • Established common goals
  • Consensus decision making
  • Solution-focused problem solving
  • Ongoing evaluation ​




​​​​​​​​Team-Based Care in the Primar​​y Pediatric Practice – Implementation Strategies


    1. Determine Composition of the Team

    Team members provide integrated, comprehensive care for patients and their families in the primary pediatric ambulatory care setting. 

    The team should be led by the pediatrician and can include pediatric nurse practitioners, physician assistants, nurses, telephone triage nurses, medical assistants, administrative staff (eg, front office, billing, information technology, scribes), mental health professionals, social workers, dietitian/nutritionists, care coordinators, youth/families, and/or others.

    Team composition may vary depending on the needs of the patient population. Children and adolescents with certain acute problems or chronic conditions may require inclusion of pediatric medical and surgical specialists and subspecialists as remote members of the team.

    For instance, medical assistants, schedulers, front office, billing staff and information technology staff may be responsible for referral tracking, fulfilling tasks on the plan of care, appointment recall, and other tasks. Nurses may perform the responsibilities of care coordination such as seeing that medical diagnostic results are received, specialist appointments are kept, and home care is coordinated.    

    Every practice is different. What works in one pediatric practice may not work in another. The model of team-based care should be specific to each practice’s patient needs, community resources, and the individuals on the team. The key is to be dynamic, changing, and evolving when new patient needs arise, community resources change, and team composition requires adaptation. ​​


    • Worksheet on thinking about the practice's team-based care 

    2. Select a leader

    ​Optimal pediatric health care depends on a team-based approach with supervision by a pediatrician leader, per the AAP policy statement on scope of practice. A pediatrician is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all ambulatory primary care practice settings. A pediatrician who leads a health care team also determines when referral to other physicians is warranted. Under the pediatrician leader's guidance a full range of health care services may be managed by other team members—all facilitating comprehensive, coordinated, patient centered care. ​

    3. Develop a team’s mission statement, values, and goals

    Create a mission statement for the practice that speaks to its aims for team-based care. Characteristics of effective mission statements are as follows: value, inspiration, plausibility, and specificity.

    3a. Involve staff in the development of the mission statement as equal participants on the team. Consider involving youth and families in this process.

    3b. Describe the value of team-based care in a way that encourages employees as well as the patients/families in the practice, sounds reasonable and plausible, and is specific and relevant. Use concise sentences.  

    3c. Distribute drafts of the mission statement to every employee (and youth/families if applicable), and ask them what, if anything, should be added or changed. Not only will this result in a better, more comprehensive statement, but employees and the patients/families in the practice will be more invested in it because they helped form it. It should be stated clearly so that it is understood by all.

    3d. Convey the mission statement to others inside and outside the practice. Post it in the office, where practice leaders, employees, patients and their families, and visitors can see it every day.  Place it on practice materials, such as patient brochures, employee training manuals, letterhead, and the practice website.​


    4. Define roles for clinician and non-clinician team members

    ​4a. Outline all responsibilities and tasks that need to be performed to provide high quality, accessible, family centered, continuous, coordinated, and comprehensive care to patients and their families.
    Develop a comprehensive list and obtain review from other members of the practice team to determine whether anything is missing.

    4b. Determine what tools and resources are needed to carry out each task.
    For instance, an office clerk administrative team member may be designated to collect data on a daily or weekly basis, and a practice manager may collate and identify gaps in quality control and assurance. Potential resources might include "protected" time to carry out the expected transformation duties, or templates to automate processes within practice management software and/or electronic health records.

    4c. Match team roles to scope of practice, licensure, training, and capabilities fostering team care.
    List the responsibilities and tasks that need to be performed and which staff should be assigned to each role. Clearly define roles for each staff member based on skills, capabilities, and within scope of practice and licensure established in state laws. (This information can be found within each professions' state licensing authority.) Consideration of staff costs and overhead for a practice is essential in this process. Use this information to craft job descriptions for each team member.

    4d. Create training manual with step-by-step guidance on each task.
    In addition to the job descriptions for each team member, create a training manual for members of the team. It should include step-by-step procedures for each task required to fulfill the responsibilities as noted by their job description. Once staff roles and responsibilities are defined, review this information with staff to obtain input and to identify specific areas where additional training is needed. Revise job descriptions as needed.

    4e. Distribute training manual, including job description roles and responsibilities, among care team members.
    Provide staff with their newly defined job roles and responsibilities once they have been documented in the training manual. These are essential elements for the practice's policy and procedural manual and should be used for orientation, training, and team evaluation.

    4f. Cross-train care team members
    Train a staff member thoroughly on job duties and responsibilities. Then, when skills and knowledge base are at a satisfactory level, have that staff member mentor another employee in the role.

    4g. Evaluate team member performance
    Customize team member performance evaluation tools to include the new responsibilities. Provide fact-based feedback assessing team members' performance compared to job descriptions and tasks. QI reports, patient survey results, team member peer review, team leader evaluations, and self-assessments are documented sources of performance and should be referenced. Provide additional training to address any problem areas. 


    • ​Physician's Guide: Understanding and Working With Integrated Case Managers.

      Kathol, Roger G, Hobs Knutson Katherine, Dehnel, Peter J.
      For purchase from Springer Publishers. 

    5. Adapt work space to facilitate team-based care

    ​Care teams can be more successful if their work space is designed to support direct communication and collaboration and ease a patient's journey through the clinic.

    Work space design should:

    • Promote coordination and communication among team members
    • Be patient-friendly, reduce patient anxiety by being conducive to privacy, comfort, and a clear understanding of the care plan
    • Accommodate day-to-day variations and be flexible enough to accommodate new models for primary care delivery
    • Reduce waste and cost
    • Employ standardization in design and equipment and place needed equipment in exam rooms to promote patient safety and decrease error
    • Integrate necessary technology

    Ways that traditional office space does not facilitate team-based care:

    • When physicians and staff often work in different parts of a medical office communication is hindered because they do not have a consistent line of sight to their fellow team members.
    • Storing necessary supplies and equipment in special rooms separate from the exam room, requires staff to leave the care area to acquire what they need, which is inefficient.
    • Variation among exam rooms in layout and location of supplies causes wasted time as team members must orient themselves to each room.
    • Electronic health records (EHRs), computers, and monitors are set up in exam rooms so that a physician's back is to the patient and family, which hinders communication and make interactions less effective.
    • Clinical staff work areas are often not located near exam rooms.
    • Patient flow paths are often illogical and can confuse patients. Patients move through work areas where protected health information is stored and conversations regarding patient care are occurring. A clear space for "check out" at the completion of a visit is often missing, resulting in patients leaving the office without follow-up appointments, referrals, and post-visit instructions.

    If possible, redesign office space to optimize patient flow and to co-locate team members in work zones for pre- and post-visit work in order to facilitate communication and collaboration. Ideally this space would also be situated so that team members will not be easily observed or overheard by patients and families.


    6. Pre-visit Preparation

    Prepare for upcoming patient visits by reviewing a patient's record (particularly issues occurring since the last visit) and identifying issues that should be addressed either before or during the patient visit. Communication between team members may be electronic messages, e-mails, or notes in a patient record. The following steps are options to help implement communication between team members when preparing for patient visits:

    6a. Convene an internal communications team
    Choose a lead clinician, referral-tracking staff member, clinical nurse, and scheduler to join together as a team to develop a process for internal communication among all team members. The lead clinician may be a physician, mid-level practitioner, nurse, or practice manager. This team will lead the practice in implementing team-based care communications.

    6b. Create policies and procedures for internal communication
    Document a policy and procedure for structured preparation of upcoming patient visits. This should include identifying critical patient needs to be addressed either before or during the visit. In the policy, demonstrate how communication occurs regularly by including samples of meeting minutes, agendas, or memos/e-mails to staff. Team meetings should be held weekly (at a minimum), to discuss scheduled patients and identify whether any pre-visit information or resources will be needed to maximize efficiency during the office visit. For example, the team may need to contact a patient, obtain lab reports, review prior records, review screening reports, or obtain and review diagnostic studies.

    6c. Team huddles
    Short team meetings or "team huddles" should be conducted once or twice a day; ideally prior to the start of the morning session and afternoon session in the practice. When bringing the team together, select a place that is convenient and suitable for open discussion of patient information.  

    The purpose of the team huddle is to review the patient schedule for the next segment of the day and prepare for potential challenges, such as patients with complex health needs who require additional time or staff support. In general, team huddles should be brief (ie, less than 10 minutes in duration), and focused on planning tasks related to the next set of patients. In general, the team should discuss patients with complex conditions, patients who have been recently seen in the Emergency Department or hospitalized, patients who are often late or have high service needs, patients who are missing recommended preventive care services, or patients who will require additional time or attention from staff.

    The team huddle could also be used to briefly review the previous day, and to discuss hospitalized patients or other patients who require specific follow-up. The team should decide who will provide any necessary follow-up and the timeframe the follow-up should take place. Team huddles should be led and monitored by the lead clinician for frequency and compliance among staff members.


    6d. Post-visit communication with patients
    Have systems in place to identify patients telephoning with concerns that problems treated within the past 48 hours have persisted or worsened. Identify return visits and Emergency Department visits for the recently treated problem. Establish policies to verify that this information is shared with clinicians and addressed rapidly.

    7. Collaborate with the patient and family

    Post-visit medical summaries are developed together by the practice's care team and the patient and/or family to address the patient's health needs and goals. Once goals have been established they should be reviewed and modified, as necessary, at each relevant visit.

    ​7a. Provide each patient with a post-visit medical summary during the relevant visit
    The practice will provide a written or electronic summary developed in partnership with the patient and family.   

    ​7b. Assess and address barriers when the patient does not meet goals
    A physician or care team assesses or talks with the patient or family to determine reasons for limited progress towards goals, and to help the patient and their family address barriers. Some examples of barriers may include patient's lack for understanding, insurance or monetary issues, or medication side effects. Based on these conversations, the physician or care team may need to discuss modification of goals with the patient and/or family, and come to a mutually agreeable plan that patients and families believe they can follow.​

    7c. Identify patients and families who might benefit from additional care management support
    Assess, and when appropriate, refer patients to clinical specialists or community resources for additional care management support, such as disease management or case management programs.

    8. Establish a clear, realistic, and specific follow up process for patients

    ​Establish and implement a policy and procedure to follow up and recall patients who have not kept appointments for preventive care, chronic disease management, re-evaluations for acute illness, and post-hospital admission/discharge follow-up.​

    9. Assess and evaluate the care team for opportunities to improve care team processes

    9a. Measure and evaluate the quality of the practice's medical records against the practice's medical record review sheet
    Monitor communication among team members as documented in the medical record. Evaluate random samples of patient charts over a one-month period to verify that documentation of communication in the medical record is accurate, complete, clear, and concise. This may be done by comparing individual medical records against a medical record review sheet, which identifies important elements to be documented in pediatric medical records. Review and assess the effectiveness of communication within the care team and with outside providers.


    9b. Measure and evaluate the practice's team-based care.
    Tools exist to measure whether a practice is working together as a high-functioning team to deliver team-based care. These tools include specific measures to understand specific areas where improvement is needed.


    Use the Model for Improvement tools to create action plans for the areas in which improvement needs to take place as identified by a record review
    Based on the evaluation of communication between staff, develop a quality improvement process to address identified gaps and flaws in how communication is exchanged. Allow staff to work as a group to help develop action plans that will be implemented to improve communication processes in the practice. Having the entire care team involved will also help create a practice culture that values continual quality improvement. See the Quality Improvement module for additional information. 

    ​9d. Share results and discuss (and document) action plans
    Once data are analyzed and team members have created action plans, hold a care team meeting to share results. The practice will want to develop minutes from these quality improvement and staff meetings to document discussions and action items. At the start of each meeting, review the minutes of the prior meeting. This allows staff to be updated, recognize prior efforts, and establish a starting point for the meeting's discussion.

    9e. Update communication policies and procedures to address identified quality improvement actions. Provide additional staff training on changes in policies and procedures resulting from QI
    Team meetings should include suggestions for change or improvements in communication process. Implement the action plans that have been created to improve patient care coordination, provide tailored services to practice-specific population, and improve patient satisfaction.


​​We need your help to keep our practice transformation strategies up-to-date amid today's unprecedented changes in health care. Please share your "best practices," innovations, implementation tools, and resources to help other AAP members keep pace as the health care environment rapidly evolves. Simply complete and submit the form below. Thank you for keeping pediatric practice strong. ​​​​​​​​​​


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