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Home / PMH Test/ Team-Based Care & Team-Building

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College of Family Physicians of Canada

Best Advice Guide: Team-Based Care in the Patient’s Medical Home

This guide examines the benefits of team-based care for both practice efficiency and patients’ health outcomes.


The Primary Care Team LEAP, USA

The Primary Care Team Guide

Online modules, tools and videos that help you assess your practice, get started, build a team and change practice and outcomes. Topics include changing workflow, population management, planned care, care management, medication management, referral management, self-management support, mental health, communication and connections with the community.



Optimizing Nursing Care

Registered Nurses’ Association of Ontario and the Registered Practical Nurses Association of Ontario

Primary Care Nurse Toolkit for Employers and Members of Primary Health-Care Teams

This toolkit helps to realize the full scope of practice for primary care RNs and RPNs. Provides a practical approach to full scope of practice utilization including a video case series developed from interviewing primary care teams in six primary care organizations representing the range of models of primary care delivery.


Safety Net Medical Home Initiative

Change Concepts: Organized, Evidence-Based Care. Improving Care for Complex Patients: The Role of the RN Care Manager

This resource sheet defines care management (sometimes called case management) and provides practical recommendations about how to provide care management services to high-risk patients.


The Primary Care Team LEAP, USA

The Registered Nurse (RN)

This learning module covers how to make the best use of RNs by giving them work uniquely suited to their clinical expertise and delegating many typical RN tasks to other members of the team.


Further Resources

Case Management / Conferences


Provincial eConsult Initiative

eConsult is a service that enables faster access to specialist advice for Ontarians. An eConsult enables requesting clinicians, family physicians and nurse practitioners to engage in a secure electronic dialogue with specialists to manage patient care, without the need for a face-to-face visit. eConsults may avoid the need to refer a patient to a specialist for diagnosis and treatment.

Working with both Champlain BASE eConsult and Ontario Telemedicine Network’s eConsult and Teledermatology services, pilots are underway to evaluate services for widespread access and use by Ontario physicians.


Cancer Care Ontario

Guidelines & Advice: Multidisciplinary Cancer Conferences

Multidisciplinary Cancer Conferences (MCCs) are regularly scheduled meetings of healthcare providers from various disciplines. Participants discuss the diagnosis and treatment options of individual cancer patients. MCCs are an integral part of the cancer care system. The documents and tools available here are meant to help hospital staff develop new MCCs, or modify current ones. All the templates can be adapted to suit an individual MCC.



3 minute 25 second Video: Planned Care Huddle

This is a short example of a “morning huddle” involving the physician and medical assistant designed to highlight, communicate and facilitate planned care elements of an office visit.



For Group Practices or Existing Teams

Canadian Alliance of Community Health Centre Associations

Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres

This toolkit is an accessible source of information for team members of all primary healthcare disciplines. The toolkit contains eight learning modules, each presenting an aspect of knowledge, a skill or an attribute that team members need in order to work effectively in primary healthcare teams.


Canadian Foundation for Healthcare Improvement

13 minute 40 second Video: CFHI Quality Improvement Primer: Working Together and Team Effectiveness

Because health care requires both a personal and business focus, various forms of relationships or teams must work together—interprofessional service delivery teams and inter/intra-organizational teams that focus on the business of health care, including quality, cost and innovation. Working with people from across organizations and/or sectors within health care requires paying attention to those working relationships. While many believe that working together is intuitive, it is hard work. This quality improvement primer on working together and team effectiveness aims to guide teams through that process.


Safety Net Medical Home Initiative (SNMHI)

Chance Concepts: Continuous & Team-Based Healing Relationships

This guide provides guidance on how practices can develop and sustain strong care teams. Key changes for continuous and team-based care include the following:

  • Establish and provide organizational support for care delivery teams accountable for the patient population/panel.
  • Link patients to a provider and care team so both patients and provider/care team recognize each other as partners in care.
  • Ensure that patients are able to see their provider or care team whenever possible.
  • Define roles and distribute tasks among care team members to reflect the skills, abilities and credentials of team members.

See examples of one SNMHI participant’s interventions and results for this Change Concept here.


Association of Family Health Teams of Ontario

Interprofessional Communities of Practice – Available to AFHTO only.

For AFHTO members only.

https://www.afhto.ca/members-only/library/member-news/help-your-team-members-get-the-support-they-need-encourage-them-to-join-ihp-communities-of-practice/[RA1] [RA2]