Background
The transition to value-based care is reshaping the expectations and responsibilities of primary care practices nationwide . As healthcare delivery moves away from volume-driven models toward those that reward quality, outcomes, care coordination, and cost effectiveness, primary care organizations must rethink how they structure their teams and manage patient populations. Value-based care requires proactive management of chronic conditions, better care transitions, improved patient engagement, and the ability to use data to drive decision-making.
To succeed in value-based arrangements, practices are increasingly adopting provider-led, team-based care models that support whole-person, coordinated care. In these models, physicians, nurse practitioners, physician assistants, nurses, and medical assistants work collaboratively at the top of their license to deliver consistent, patient-centered care. Team-based structures enable practices to:
- Improve efficiency and reduce bottlenecks
- Expand access to services
- Enhance chronic disease management
- Increase patient satisfaction and engagement, and
- More effectively meet quality performance measures tied to reimbursement
Value-based care also emphasizes addressing social drivers of health, improving preventive care, managing risk-stratified populations, and closing care gaps—efforts that are difficult for a single provider working independently. By thoughtfully redesigning workflows and distributing responsibilities across a multidisciplinary team, primary care practices can strengthen clinical outcomes, support staff well-being, and improve financial sustainability under value-based payment models.
What is Team-Based Care?
Team-based care changes how clinics work so that everyone can operate at the top of their license. According to the American Medical Association (AMA, 2023), team-based care is a model in which healthcare professionals work collaboratively to coordinate and deliver comprehensive, patient-centered care. At its core, this approach enhances communication, collaboration, and coordination among all members of the healthcare team to improve quality, safety, and patient outcomes.
In practice, physicians focus on diagnosis and complex decision-making, while supporting staff such as nurses and medical assistants to administer immunizations, update preventive care measures, manage medication refills, and initiate discussions about advance care planning.
The model emphasizes proactive, organized care through pre-visit planning, daily team huddles, and shared documentation.
Importantly, effective practice redesign does not necessarily require hiring additional staff; rather, it involves redistributing work within the existing team to ensure every member operates at the top of their license. By engaging staff in workflow, redesigning and empowering them with tools and authority to make real-time decisions, practices can create a more nimble, coordinated, and patient-centered environment.
The 4-Stage Office Visit
At the core of team-based care is a restructured office visit, divided into four stages:
- Data Gathering: Medical assistants or nurses document patient concerns, update medical and social histories, review upcoming preventive care needs, administer vaccines, highlight medication refills, and introduce advance care planning.
- Physical Exam & Data Verification: The provider and medical assistant enter the room together. While the provider performs the exam and verifies information, the assistant serves as a real-time scribe, entering data into the electronic health record (EHR).
- Medical Decision-Making: Provider and patient collaborate to establish diagnoses and treatment plans. The assistant records diagnoses, updates flow sheets, and enters orders requiring provider approval, ensuring seamless documentation.
- Patient Education & Implementation: The provider leaves the room to review and sign documentation while the assistant remains with the patient to reinforce instructions, deliver education, and schedule follow-up visits. This cycle allows the provider to move efficiently to the next patient while maintaining continuity of care.
Practice Redesign and Physical Space
Effective implementation requires changes not only to workflow but also to the physical environment. Teams typically include one Provider with one or two clinical assistants— who are co-located in “flow stations”, enabling immediate communication and shared problem-solving. Requests for prescription refills, referrals, and same-day appointments are handled together, often in real time, creating a more responsive and collaborative practice culture.
Standardized protocols further support consistency, especially in chronic disease management. For example, team members can proactively manage hypertension, diabetes, or preventive screenings between visits, improving long-term patient outcomes.
Benefits of Team-Based Care
Productivity & Financial Sustainability
Recent evidence shows that team-based care models enhance clinical productivity, expand patient access, and improve financial sustainability by optimizing staff roles and reducing inefficiencies in care delivery. A 2021 systematic review by the U.S. Department of Veterans Affairs Evidence-Based Synthesis Program found that team-based primary care consistently improved workflow efficiency, increased patient throughput, and enhanced care coordination across multiple practice types (Shekelle et al., 2021). Similarly, the National Academy of Medicine (2023) reported that high-functioning teams can reduce clinician burnout, improve retention, and decrease operational costs—each contributing to long-term organizational stability. While financial results vary by setting, these findings support team-based care as a sustainable strategy to improve both care quality and practice viability.
Patient & Provider Experience
Patients report greater satisfaction, describing a sense of being cared for by a coordinated team rather than a single Provider. Surveys show increased trust, improved communication, and enhanced access. Providers benefit from reduced administrative burden, stronger collaboration, and restored satisfaction in practice.
System-Wide Impact
Team-based care reduces unnecessary emergency department visits and hospital admissions by offering more accessible, coordinated, and preventive services. This shift supports value-based payment models, where proactive management and prevention are incentivized.
Conclusion
The transition to team-based care represents more than a workflow redesign, it is a cultural transformation. By leveraging the skills of the entire care team, primary care practices can achieve higher productivity, improve clinical outcomes, enhance patient and Provider satisfaction, and build a strong foundation for financial sustainability in a value-based environment.
In short, team-based care is not just a solution to the physician shortage; it is a pathway to delivering better, more sustainable care for the future.
References
- Association of American Medical Colleges (AAMC). (2023). The complexities of physician supply and demand: Projections from 2021–2036. AAMC. https://www.aamc.org/advocacy-policy/addressing-physician-workforce-shortage
- American College of Physicians. (2023). Team-Based Care Toolkit. Retrieved from acponline.org
- Centers for Disease Control and Prevention. (2024). Team-Based Care to Improve Blood Pressure Control. Retrieved from cdc.gov
- BMC Health Services Research. (2024). Fereday, A. et al. Scoping review of co-located, team-based primary care models in Canada. Retrieved from bmchealthservres.biomedcentral.com
- Health Resources and Services Administration (HRSA), Bureau of Health Workforce. (2024). Projecting health workforce supply and demand. U.S. Department of Health and Human Services. https://bhw.hrsa.gov/data-research/projecting-health-workforce-supply-demand
- Shekelle, P. G., Begashaw, M. M., Miake-Lye, I., Beroes, J. M., & Ganz, D. A. (2021). Effects of different team-based primary care models on patient, professional, and system outcomes: A systematic review. U.S. Department of Veterans Affairs, Evidence-Based Synthesis Program (ESP). https://www.hsrd.research.va.gov/publications/esp/teambased-primarycare.pdf
- National Academy of Medicine (NAM). (2023). Implementing optimal team-based care to reduce clinician burnout. https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout
- UBC Centre for Health Services and Policy Research. (2025). Evaluating Team-Based Care: Best Brains Exchange Report. Retrieved from chspr.sites.olt.ubc.ca
- ScienceDirect. (2025). Productive teamwork in primary care improves preventive services and outcomes. Retrieved from sciencedirect.com
