Contextual Factors Affecting the Implementation of Team-Based Primary Care: A Scoping Review

  • Dori A. CrossEmail author
Part of the Organizational Behaviour in Health Care book series (OBHC)


Team-based primary care (TBPC) has diffused rapidly in concert with other reform initiatives. However, little is known about the contextual factors that best position practices to leverage team-based strategies for improved healthcare delivery. Sixty-two empirical articles were analysed in a scoping review to explore key factors in the domains of environment, task and technology that influence the success of establishing and maintaining TBPC practices. Key findings address the importance of internal performance management structures and external payment mechanisms that reinforce TBPC. Incremental task delegation, combined with consistent communication and integrated documentation practices, is critical for shared role understanding and sustained TBPC commitment. Finally, electronic health records can provide a collaboration and communication platform to enhance team functioning. This review provides insights to providers and policymakers regarding enabling contextual factors for successful TBPC implementation, and identifies promising areas for future research – specifically technology use and performance measurement as they relate to teams.


Primary care Teams Context Review 


  1. Allan, H. T., Brearley, S., Byng, R., Christian, S., Clayton, J., MacKintosh, M., & Ross, F. (2014). People and teams matter in organizational change: Professionals’ and managers’ experiences of changing governance and incentives in primary care. Health Services Research, 49(1), 93–112.CrossRefGoogle Scholar
  2. Altschuler, J., Margolius, D., Bodenheimer, T., & Grumbach, K. (2012). Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Annals of Family Medicine, 10(5), 396–400.CrossRefGoogle Scholar
  3. Anand, S. G., Adams, W. G., & Zuckerman, B. S. (2010). Specialized care of overweight children in community health centers. Health Affairs, 29(4), 712–717.CrossRefGoogle Scholar
  4. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32.CrossRefGoogle Scholar
  5. Bates, D. W., & Bitton, A. (2010). The future of health information technology in the patient-centered medical home. Health Affairs, 29(4), 614–621.CrossRefGoogle Scholar
  6. Belanger, E., & Rodríguez, C. (2008). More than the sum of its parts? A qualitative research synthesis on multi-disciplinary primary care teams. Journal of Interprofessional Care, 22(6), 587–597.CrossRefGoogle Scholar
  7. Boon, H. S., Mior, S. A., Barnsley, J., Ashbury, F. D., & Haig, R. (2009). The difference between Integration and collaboration in patient care: Results from key informant interviews working in multiprofessional health care teams. Journal of Manipulative and Physiological Therapeutics, 32(9), 715–722.CrossRefGoogle Scholar
  8. Bosch, M., Dijkstra, R., Wensing, M., Van Der Weijden, T., & Grol, R. (2008). Organizational culture, team climate and diabetes care in small office-based practices. BMC Health Services Research, 8(1), 180.CrossRefGoogle Scholar
  9. Bunniss, S., & Kelly, D. R. (2008). ‘The unknown becomes the known’: Collective learning and change in primary care teams. Medical Education, 42(12), 1185–1194.CrossRefGoogle Scholar
  10. Chan, B. C., Perkins, D., Wan, Q., Zwar, N., Daniel, C., Crookes, P., & Harris, M. F. (2010). Finding common ground? Evaluating an intervention to improve teamwork among primary health-care professionals. International Journal for Quality in Health Care, 22(6), 519–524.Google Scholar
  11. Chesluk, B. J., & Holmboe, E. S. (2010). How teams work––Or don’t––In primary care: A field study on internal medicine practices. Health Affairs, 29(5), 874–879.CrossRefGoogle Scholar
  12. Chunchu, K., Mauksch, L., Charles, C., Ross, V., & Pauwels, J. (2012). A patient centered care plan in the EHR: Improving collaboration and engagement. Families, Systems, & Health, 30(3), 199.CrossRefGoogle Scholar
  13. Collinsworth, A., Vulimiri, M., Snead, C., & Walton, J. (2014). Community health workers in primary care practice redesigning health care delivery systems to extend and improve diabetes care in underserved populations. Health Promotion Practice, 15(Suppl. 2), 51S–61S.CrossRefGoogle Scholar
  14. Cross, D. A., Cohen, G. R., Nong, P., Day, A.-V., Vibbert, D., Naraharisetti, R., & Adler-Milstein, J. (2015). Improving EHR capabilities to facilitate stage 3 meaningful use care coordination criteria. AMIA Annual Symposium Proceedings, 5, 448–455.Google Scholar
  15. Cutrona, S. L., Choudhry, N. K., Fischer, M. A., Servi, A., Liberman, J. N., Brennan, T., & Shrank, W. H. (2010). Modes of delivery for interventions to improve cardiovascular medication adherence: Review. American Journal of Managed Care, 16(12), 929.Google Scholar
  16. Denomme, L. B., Terry, A. L., Brown, J. B., Thind, A., & Stewart, M. (2011). Primary health care teams’ experience of electronic medical record use after adoption. Family Medicine, 43(9), 632–642.Google Scholar
  17. Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanselow, N. A. (1996). Primary care: America’s health in a new era. Washington, DC: National Academies Press.Google Scholar
  18. Donnelly, C., Brenchley, C., Crawford, C., & Letts, L. (2013). The integration of occupational therapy into primary care: A multiple case study design. BMC Family Practice, 14(1), 60.CrossRefGoogle Scholar
  19. Drach-Zahavy, A., & Freund, A. (2007). Team effectiveness under stress: A structural contingency approach. Journal of Organizational Behavior, 28(4), 423–450.CrossRefGoogle Scholar
  20. Edwards, S. T., Rubenstein, L. V., Meredith, L. S., Hackbarth, N. S., Stockdale, S. E., Cordasco, K. M., & Yano, E. M. (2015). Who is responsible for what tasks within primary care: Perceived task allocation among primary care providers and interdisciplinary team members. Healthcare, 3(3), 142–149.Google Scholar
  21. Elder, N. C., Jacobson, C. J., Bolon, S. K., Fixler, J., Pallerla, H., Busick, C., … Pugnale, M. (2014). Patterns of relating between physicians and medical assistants in small family medicine offices. The Annals of Family Medicine, 12(2), 150–157.Google Scholar
  22. Ferrer, R. L., Mody-Bailey, P., Jaén, C. R., Gott, S., & Araujo, S. (2009). A medical assistant-based program to promote healthy behaviors in primary care. The Annals of Family Medicine, 7(6), 504–512.CrossRefGoogle Scholar
  23. Finlayson, M. P., & Raymont, A. (2012). Teamwork-general practitioners and practice nurses working together in New Zealand. Journal of Primary Health Care, 4(2), 150–155.Google Scholar
  24. Freund, T., Everett, C., Griffiths, P., Hudon, C., Naccarella, L., & Laurant, M. (2015). Skill mix, roles and remuneration in the primary care workforce: Who are the healthcare professionals in the primary care teams across the world? International Journal of Nursing Studies, 52(3), 727–743.CrossRefGoogle Scholar
  25. Friedberg, M. W., Van Busum, K., Wexler, R., Bowen, M., & Schneider, E. C. (2013). A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Affairs, 32(2), 268–275.CrossRefGoogle Scholar
  26. Friedman, E. L., Chawla, N., Morris, P. T., Castro, K. M., Carrigan, A. C., Das, I. P., & Clauser, S. B. (2014). Assessing the development of multidisciplinary care: Experience of the National Cancer Institute Community Cancer Centers Program. Journal of Oncology Practice, 11(1), 36–43.Google Scholar
  27. Goldman, J., Meuser, J., Lawrie, L., Rogers, J., & Reeves, S. (2010). Interprofessional primary care protocols: A strategy to promote an evidence-based approach to teamwork and the delivery of care. Journal of Interprofessional Care, 24(6), 653–665.CrossRefGoogle Scholar
  28. Grace, S. M., Rich, J., Chin, W., & Rodriguez, H. P. (2014). Flexible implementation and integration of new team members to support patient-centered care. Healthcare, 2(2), 145–151.CrossRefGoogle Scholar
  29. Graffy, J., Grant, J., Williams, K., Cohn, S., Macbay, S., Griffin, S., & Kinmonth, A. L. (2010). More than measurement: Practice team experiences of screening for type 2 diabetes. Family Practice, 27(4), 386–394.Google Scholar
  30. Grover, A., & Niecko-Najjum, L. M. (2013). Primary care teams: Are we there yet? Implications for workforce planning. Academic Medicine, 88(12), 1827–1829.Google Scholar
  31. Hann, M., Bower, P., Campbell, S., Marshall, M., & Reeves, D. (2007). The association between culture, climate and quality of care in primary health care teams. Family Practice, 24(4), 323–329.CrossRefGoogle Scholar
  32. Hays, R. (2007). Measuring quality in the new era of team-based primary care. Quality in Primary Care, 15(3), 133–135.Google Scholar
  33. Helfrich, C. D., Dolan, E. D., Simonetti, J., Reid, R. J., Joos, S., Wakefield, B. J. and Nelson, K. (2014). Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. Journal of General Internal Medicine, 29(Suppl. 2), S659–S666.Google Scholar
  34. Hilts, L., Howard, M., Price, D., Risdon, C., Agarwal, G., & Childs, A. (2013). Helping primary care teams emerge through a quality improvement program. Family Practice, 30(2), 204–211.CrossRefGoogle Scholar
  35. Howard, J., Shaw, E. K., Felsen, C. B., & Crabtree, B. F. (2012). Physicians as inclusive leaders: Insights from a participatory quality improvement intervention. Quality Management in Health Care, 21(3), 135–145.CrossRefGoogle Scholar
  36. Hudson, S. V., Ohman-Strickland, P., Cunningham, R., Ferrante, J. M., Hahn, K., & Crabtree, B. F. (2007). The effects of teamwork and system support on colorectal cancer screening in primary care practices. Cancer Detection and Prevention, 31(5), 417–423.CrossRefGoogle Scholar
  37. Hung, D. Y., Rundall, T. G., Crabtree, B. F., Tallia, A. F., Cohen, D. J., & Halpin, H. A. (2006). Influence of primary care practice and provider attributes on preventive service delivery. American Journal of Preventive Medicine, 30(5), 413–422.CrossRefGoogle Scholar
  38. Hysong, S. J., Knox, M. K., & Haidet, P. (2014). Examining clinical performance feedback in patient-aligned care teams. Journal of General Internal Medicine, 29(Suppl. 2), S667–S674.CrossRefGoogle Scholar
  39. Jesmin, S., Thind, A., & Sarma, S. (2012). Does team-based primary health care improve patients’ perception of outcomes? Evidence from the 2007–2008 Canadian survey of experiences with primary health. Health Policy, 105(1), 71–83.CrossRefGoogle Scholar
  40. Johnston, S., Green, M., Thille, P., Savage, C., Roberts, L., Russell, G., & Hogg, W. (2011). Performance feedback: An exploratory study to examine the acceptability and impact for interdisciplinary primary care teams. BMC Family Practice, 12(1), 14.Google Scholar
  41. Kaferle, J. E., & Wimsatt, L. A. (2012). A team-based approach to providing asthma action plans. Journal of the American Board of Family Medicine, 25(2), 247–249.CrossRefGoogle Scholar
  42. Kastner, M., Tricco, A. C., Soobiah, C., Lillie, E., Perrier, L., Horsley, T., … Straus, S. E. (2012). What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review. BMC Medical Research Methodology, 12(1), 114.Google Scholar
  43. Kendall, M., Mason, B., Momen, N., Barclay, S., Munday, D., Lovick, R., … Cormie, P. (2013). Proactive cancer care in primary care: A mixed-methods study. Family Practice, 30(3), 302–312.Google Scholar
  44. Kim, T. W., Saitz, R., Kretsch, N., Cruz, A., Winter, M. R., Shanahan, C. W., & Alford, D. P. (2013). Screening for unhealthy alcohol and other drug use by health educators: Do primary care clinicians document screening results? Journal of Addiction Medicine, 7(3), 204–209.Google Scholar
  45. Kozlowski, S. W., & Ilgen, D. R. (2006). Enhancing the effectiveness of work groups and teams. Psychological Science in the Public Interest, 7(3), 77–124.CrossRefGoogle Scholar
  46. Ladden, M. D., Bodenheimer, T., Fishman, N. W., Flinter, M., Hsu, C., Parchman, M., & Wagner, E. H. (2013). The emerging primary care workforce: Preliminary observations from the primary care team: Learning from effective ambulatory practices project. Academic Medicine, 88(12), 1830–1834.Google Scholar
  47. Legault, F., Humbert, J., Amos, S., Hogg, W., Ward, N., Dahrouge, S., & Ziebell, L. (2012). Difficulties encountered in collaborative care: Logistics trumps desire. Journal of the American Board of Family Medicine, 25(2), 168–176.Google Scholar
  48. Lemieux-Charles, L., & McGuire, W. L. (2006). What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review, 63(3), 263–300.CrossRefGoogle Scholar
  49. Margolius, D., Wong, J., Goldman, M. L., Rouse-Iniguez, J., & Bodenheimer, T. (2012). Delegating responsibility from clinicians to nonprofessional personnel: The example of hypertension control. Journal of the American Board of Family Medicine, 25(2), 209–215.CrossRefGoogle Scholar
  50. McAllister, J. W., Carl Cooley, W., Van Cleave, J., Boudreau, A. A., & Kuhlthau, K. (2013). Medical home transformation in pediatric primary care-what drives change? Annals of Family Medicine, 11(SUPPL. 1), S90–S98.CrossRefGoogle Scholar
  51. McInnes, S., Peters, K., Bonney, A., & Halcomb, E. (2015). An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. Journal of Advanced Nursing, 71(9), 1973–1985.CrossRefGoogle Scholar
  52. Mechanic, R. E., Santos, P., Landon, B. E., & Chernew, M. E. (2011). Medical group responses to global payment: Early lessons from the ‘alternative quality contract’ in Massachusetts. Health Affairs, 30(9), 1734–1742.CrossRefGoogle Scholar
  53. Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Von Kohorn, I. (2012). Core principles & values of effective team-based health care. Washington, DC: Institute of Medicine.Google Scholar
  54. Mohr, D. C., Benzer, J. K., & Young, G. J. (2013). Provider workload and quality of care in primary care settings: Moderating role of relational climate. Medical Care, 51(1), 108–114.CrossRefGoogle Scholar
  55. Morrissey, J. (2013). Filling the gaps in primary care: New roles strengthen relationships with patients. Trustee: The Journal for Hospital Governing Boards, 66(4), 8–10.Google Scholar
  56. Ngo, V., Hammer, H., & Bodenheimer, T. (2010). Health coaching in the teamlet model: A case study. Journal of General Internal Medicine, 25(12), 1375–1378.CrossRefGoogle Scholar
  57. O’Malley, A. S., Gourevitch, R., Draper, K., Bond, A., & Tirodkar, M. A. (2014). Overcoming challenges to teamwork in patient-centered medical homes: A qualitative study. Journal of General Internal Medicine, 30(2), 183–192.CrossRefGoogle Scholar
  58. O’Malley, A. S., Draper, K., Gourevitch, R., Cross, D. A., & Scholle, S. H. (2015). Electronic health records and support for primary care teamwork. Journal of the American Medical Informatics Association, 22(2), 426–434.CrossRefGoogle Scholar
  59. O’Toole, T. P., Cabral, R., Blumen, J. M., & Blake, D. A. (2011). Building high functioning clinical teams through quality improvement initiatives. Quality in Primary Care, 19(1), 13–22.Google Scholar
  60. Page, N. (2006). Task overlap among primary care team members: An opportunity for system redesign? Journal of Healthcare Management, 51(5), 295.Google Scholar
  61. Pullon, S., McKinlay, E., & Dew, K. (2009). Primary health care in New Zealand: The impact of organisational factors on teamwork. British Journal of General Practice, 59(560), 191–197.CrossRefGoogle Scholar
  62. Roblin, D. W., Howard, D. H., Junling, R., & Becker, E. R. (2011). An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries. Medical Care Research & Review, 68(2), 177–201.CrossRefGoogle Scholar
  63. Rodriguez, H. P., Chen, X., Martinez, A. E., & Friedberg, M. W. (2015a). Availability of primary care team members can improve teamwork and readiness for change. Health Care Management Review, 41(4), 286–295.CrossRefGoogle Scholar
  64. Rodriguez, H. P., Ivey, S. L., Raffetto, B. J., Vaughn, J., Knox, M., Hanley, H. R., … Shortell, S. M. (2014). As good as it gets? Managing risks of cardiovascular disease in California’s top-performing physician organizations. Joint Commission Journal on Quality and Patient Safety, 40(4), 148–158.Google Scholar
  65. Rodriguez, H. P., Meredith, L. S., Hamilton, A. B., Yano, E. M., & Rubenstein, L. V. (2015b). Huddle up! The adoption and use of structured team communication for VA medical home implementation. Health Care Management Review, 40(4), 286–299.CrossRefGoogle Scholar
  66. Roper, R. (2014). Insights on innovative strategies for harnessing health information technology to help individuals, teams. Journal of Ambulatory Care Management, 37(2), 96–99.CrossRefGoogle Scholar
  67. Saba, G. W., Villela, T. J., Chen, E., Hammer, H., & Bodenheimer, T. (2012). The myth of the lone physician: Toward a collaborative alternative. The Annals of Family Medicine, 10(2), 169–173.CrossRefGoogle Scholar
  68. Sanchez, K., & Adorno, G. (2013). “It’s like being a well-loved child”: Reflections from a collaborative care team. The Primary Care Companion for CNS Disorders, 15(6), PCC.13m01541.
  69. Savarimuthu, S. M., Jensen, A. E., Schoenthaler, A., Dembitzer, A., Tenner, C., Gillespie, C., … Sherman, S. E. (2013). Developing a toolkit for panel management: Improving hypertension and smoking cessation outcomes in primary care at the VA. BMC Family Practice, 14(1), 176.Google Scholar
  70. Shipman, S. A., & Sinsky, C. A. (2013). Expanding primary care capacity by reducing waste and improving the efficiency of care. Health Affairs, 32(11), 1990–1997.CrossRefGoogle Scholar
  71. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457–502.CrossRefGoogle Scholar
  72. Strumpf, E., Levesque, J.-F., Coyle, N., Hutchison, B., Barnes, M., & Wedel, R. J. (2012). Innovative and diverse strategies toward primary health care reform: lessons learned from the Canadian experience. Journal of the American Board of Family Medicine, 25(Suppl 1), S27–S33.CrossRefGoogle Scholar
  73. Thomas, M. H. (2014). Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office. Journal of the American Pharmacists Association, 54(4), 427–434.CrossRefGoogle Scholar
  74. True, G., Stewart, G. L., Lampman, M., Pelak, M., & Solimeo, S. L. (2014). Teamwork and delegation in medical homes: Primary care staff perspectives in the Veterans Health Administration. Journal of General Internal Medicine, 29(Suppl. 2), S632–S639.CrossRefGoogle Scholar
  75. Watts, B., Lawrence, R. H., Singh, S., Wagner, C., Augustine, S., & Singh, M. K. (2014). Implementation of quality improvement skills by primary care teams: Case study of a large academic practice. Journal of Primary Care and Community Health, 5(2), 101–106.CrossRefGoogle Scholar
  76. Wholey, D. R., White, K. M., Adair, R., Christianson, J. B., Lee, S., & Elumba, D. (2013). Care guides: An examination of occupational conflict and role relationships in primary care. Health Care Management Review, 38(4), 272–283.CrossRefGoogle Scholar
  77. Willard-Grace, R., Hessler, D., Rogers, E., Dubé, K., Bodenheimer, T., & Grumbach, K. (2014). Team structure and culture are associated with lower burnout in primary care. Journal of the American Board of Family Medicine, 27(2), 229–238.CrossRefGoogle Scholar
  78. Wise, C. G., Alexander, J. A., Green, L. A., Cohen, G. R., & Koster, C. R. (2011). Journey toward a patient-centered medical home: Readiness for change in primary care practices. Milbank Quarterly, 89(3), 399–424.CrossRefGoogle Scholar
  79. Xyrichis, A., & Lowton, K. (2008). What fosters or prevents interprofessional teamworking in primary and community care? A literature review. International Journal of Nursing Studies, 45(1), 140–153.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2018

Authors and Affiliations

  1. 1.University of Michigan School of Public HealthAnn ArborUSA

Personalised recommendations