Team-Based Care: Redesigning Primary Care for the Future

Background

The shift to value-based care is transforming the roles and expectations of primary care practices nationwide. As healthcare shifts from focusing on volume to emphasizing quality, outcomes, care coordination, and cost efficiency, primary care organizations must rethink how they structure their teams and oversee patient populations. Implementing value-based care demands proactive management of chronic diseases, smoother care transitions, improved patient engagement, and the ability to use data to drive decision-making.

To succeed under 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?

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, thereby improving quality, safety, and patient outcomes.

In practice, physicians focus on diagnosis and complex decision-making, while supporting staff, such as nurses and medical assistants, in administering immunizations, updating preventive care measures, managing medication refills, and initiating 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:

  1. 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 (ACP).
  2. 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).
  3. 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.
  4. 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 the 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 provider productivity, expand patient access, and improve financial sustainability by improving staff roles and reducing inefficiencies in care delivery. A 2021 organized review by the U.S. Department of Veterans Affairs Evidence-Based Synthesis Program found that team-based care consistently improved workflow efficiency, increased patient throughput, and improved care coordination across multiple clinic types (Shekelle et al., 2021). Similarly, the National Academy of Medicine (2023) reported that high-functioning teams can reduce provider 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

A growing body of evidence shows that team-based care models can significantly improve both patient and provider experience. In a comprehensive review of team-based primary care interventions, studies that implemented multidisciplinary teams (typically involving more than two providers) reported significantly higher patient satisfaction scores compared with traditional provider-centric care, with 57% of studies demonstrating statistically significant improvements in patient satisfaction under team-based approaches (Will et al., 2019). Patients in these models more often described enhanced communication, greater trust, and improved access to services.

Providers also reported benefits. The Veterans Affairs Evidence-Based Synthesis Program found consistent associations between team-oriented models and improved professional experience, including reduced role strain and enhanced collaboration, which are linked to lower burnout and higher job satisfaction (Shekelle et al., 2021). These improvements in both patient and provider domains suggest that team-based care contributes to a more organized, satisfying clinical environment.

System-Wide Impact

Team-based care is a critical strategy for addressing growing workforce and access challenges across the U.S. healthcare system. Current projections estimate a shortage of up to 86,000 physicians by 2036, driven by population aging, rising care demand, and high rates of physician retirement (Association of American Medical Colleges [AAMC], 2023). In this context, team-based care expands system capacity by redistributing clinical work across interdisciplinary teams and enabling clinicians to practice at the top of their license (American College of Physicians [ACP], 2023; National Academy of Medicine [NAM], 2023).

System-level evidence also indicates that team-based primary care models are associated with reduced use of emergency and inpatient services. A national systematic review found that many team-based care interventions demonstrated lower rates of emergency department visits and preventable hospitalizations, particularly for ambulatory care–sensitive conditions, as a result of improved access, continuity, and proactive chronic disease management (Shekelle et al., 2021). Similarly, a recent scoping review of co-located team-based primary care models reported that these models improved care coordination and access and were frequently associated with decreased reliance on urgent and acute care services (Fereday et al., 2024). Together, these findings support team-based care as a system-level strategy for maintaining access, improving population health, and supporting value-based care models under increasing workforce constraints.

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.

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