Care Team Roles

This affinity group includes @La_Clinica @LA_LGBT @Native_American @Santa_Barbara @Communicare. Please feel free to share your group’s progress and updates below!

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Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare) ,

It was great to talk with you all today! The notes from our meeting today are attached, and the next steps I captured are as follows:

  • Team agreed to start off by meeting every other month. Next Step: Juliane to send a Doodle Poll to schedule our next call.
  • By popular demand, our next topic will be Getting to Know You: The Care Team. Next Step: Each organization will be prepared to speak about the way their care teams look currently, and any planned changes for the future. Of interest are org structures, roles and definitions, how teams are supporting team members to work at the top of their licenses, and anything else you’d like to share.
  • Teams will post any resources they would like to share / review ahead of the call.
  • Some great resources are already on the “offering block” so I am hoping @tbrownLaClinica can share La Clinica’s Panel Manager job description as well as the list of Panel Manager Activities, and @evanp can share CommuniCare’s Patient Care Coordinator job description.

Thank you everyone! Let’s start leveraging this forum with any questions or insights you’d like to share!

PHLN Affinity Group_Care Teams Kickoff_04.30.19.docx (73.1 KB)

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Here is CCHC’s job description for the Preventive Care Coordinator (there is one position per site). Thanks Preventive Care Coordinator_Salud Clinic.docx (52.2 KB)


Hi all,

Our friends at Clinica Family Health in Denver, CO are offering a two day workshop to learn about team based care and how to develop nurse roles to improve patient experience, quality, and access. Through funding through HRSA, the two day training only costs $100/person. The next training is September 16-17.

Here’s the link with more information:

Let me know if you have any questions!


Hi folks, sorry for the delay. I’m attaching the panel management job description - the one I could locate is actually for a senior care PM (I believe it is still a grant funded position.) but I think the description is the same as that we use for those who track our chronic disease registries.

Also, I’m pasting here the list of Panel Management activities mentioned on the call.

PMA - Senior Care job description.pdf (134.0 KB)

Panel management Assistant (PMA) Activities around HTN and DM

  1. PMA with protected time
  2. Provider Champ (PC) identified
  3. PMA & PC Meeting monthly
  4. PMA @ 100% of dedicated time
  5. PMA & PC Meeting w/ Population Health Manager Monthly
  6. Posting Site Results Monthly
  7. Disseminating & discussing provider level results
  8. Discussing Results at Morning Huddles
  9. Discussing Results at Monthly Staff Meeting
  10. PHASE Algorithm Posted
  11. PHASE Algorithm discussed & distributed at site provider meeting
  12. PMA Visits
  13. PDSA Training Received
  14. PDSA Cycle Implemented

Hi Everyone,

Please find attached our Care Team Structure Flowchart.


Clinic Care Team Flowchart S Licenses 6-14-19.xlsx (22.3 KB)

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Creating QuickNotes Job Aid - April 2018 (1).pdf (227.6 KB)

Attached is the Quick Note Job Aid for NextGen.
Note that while MyPhrase follows the user, QuickNotes follow the provider. So anyone who is logged in can change the provider at the top of the screen and have access to those QuickNotes. In the case of nurses they all use the same “provider” we call it “UDS Nurse”


Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare) ,

Thanks for another wonderful call! We had representation from 4 of our 5 teams, and the conversation was rich. You can find the agenda and our notes attached (forgive anything I captured erroneously). Per request, out next steps are as follows:

  • We will use a GoogleDoc to take notes next time so we can all contribute.
  • Juliane to record our next meeting so those who missed out can listen in!
  • The group agreed that our next topics should include a deep dive on one role on the care team (role definition, scope, reimbursement potential, other financing considerations). For our next meeting, we will start with the difference between RNs and LVNs.
  • Juliane to sent out a Doodle Poll to schedule our next meeting for the end of Aug / early Sept. Please Complete Here!

Documents to share:

  • Thank you @tbrownLaClinica for sharing the QuickNotes Job Aid.
  • Thank you in advance @nancy.tillie for sharing the information you have around reimbursement for RN case management.

All the Best,

PHLN Affinity Group_Care Teams Meeting_06.25.19.docx (71.6 KB)

Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare, @Venice),

Thanks for another great call! Notes can be found in our Google Doc, and I am attaching the document Nancy shared which gives more information about billing for RN Case Management (for Medicare patients).

For our next call, we had a lot of ideas as to where we might take the conversation. My proposal is to prioritize in this order and try to put 2 more calls on the books before the end of the year:

  • Continued discussion on RN role (including standardizing RN role, sharing standard orders, supervision structures, ratios - RN to provider, how RN roles are split up)
  • Deeper dive into roles: Case Manager and MAs, and how onboarding occurs (particularly of MAs)

I will send a Doodle Poll for scheduling. (Also, please forgive my oversight in recording (rather, NOT recording) this call. And feel free to correct any of my notes in the Google Doc!)


ChronicCareManagement Services.pdf (1.6 MB)

Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare, @Venice),

We have our next call on Nov 22 @ 12pm-1pm PST, and I wanted to check with folks about your desired topic. We talked about the following:

  • Struggle in standardizing RN role? Sharing standard orders, etc.
  • Supervision structures
  • Case manager role (pat navigators? Wellness navigator - different from referral coord)
  • Ratios - providers to RNs, and how are RN roles split up? Same people doing nurse visits vs. triage; also struggling with training new team members (MAs in particular - RNs, but then they don’t have time for their role)

Please weigh in: Which topic is feeling particularly juicy to you?


• Case manager role (pat navigators? Wellness navigator - different from referral coord)

Looks good to me, thanks!

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Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare, @Venice),

It was wonderful seeing you all in person last week! I am looking forward to continuing our great conversation at our next Affinity Group Call (Thurs, 19 Dec @ 4pm). Based on your expressed interest, I’d like to propose that we delve in to how your organizations manage training. Please come prepared to share, specifically in the following areas:

  • How do you onboard and train (all roles, but focused on MAs)?
  • Who oversees and manages training for medical staff?
  • How do you ensure staff are maintaining skills and competencies?
  1. Thank you to those of you who offered resources - please feel free to upload here!
    @tbrownLaClinica: Peer coaching & how to give feedback
    @Native_American: Nuances of specialty consults; MA Training Handbook

  2. You all agreed that having one more call in January would be helpful. Please complete this Doodle Poll by EOD on Monday 12/16.

Thanks Everyone!

Sorry for the delay! Here are some of our materials that we use for training around giving feedback - we use the terms “glows and grows”. Also a handout for a previous version of the training that involved teamlets talking about how they like to receive feedback.

Let me know if you have any questions!

GLOWS GROWS and SIA L Feedback Model_ one pager.pdf (286.0 KB) Favorite Forms of Feedback Teamlet Agreements Worksheet.pdf (99.2 KB)

Dear Care Team Affinity Group (@La_Clinica, @LA_LGBT, @Native_American, @Santa_Barbara, @Communicare, @Venice),Care Teams Affinity Group_Jan 2020.xlsx (11.0 KB) Project Aims - Care Teams Affinity Group.pdf (53.8 KB)

We had a great final call today, focusing on the role of Nurses. We touched on recruitment and retention , leveraging nurse to the top of their license , and how overnight triage is handled. You can find the notes here.

It has been such a pleasure spending these past few months with all of you, and I do hope you are able to continue leveraging one another and the relationships you have built. To support you in doing that, please find attached (1) a Roster for the participants in this group as well as (2) a Summary of your Aims outlined in your recent storyboards, so you can remember who is working on what.

Please let me know if you have any questions at all – and I look forward to our paths crossing again!