Team-based care in small primary care practices: a scoping review

Abstract

Background

Primary care practices experience challenges to implementing team-based care, and these challenges may be more pronounced in small-to-medium-sized independent primary care practices (SIPs). Our objective is to provide a review of the literature on team-based care implemented within SIPs.

Methods

The literature was identified using keywords related to primary care and team-based care in PubMed/MEDLINE, CINAHL, Cochrane Library, and EMBASE. Studies on team-based care within small-primary care settings were extracted and organized according to the four domains of the Integrated (Health Care) Team Effectiveness Model (ITEM) framework.

Results

Twenty-five studies met our criteria for inclusion and were included in our review. Of those, only nine of the included studies solely focused on SIPs. Studies addressed some component of task design, including the composition of the team (i.e. MA and MD dyads) and the features of the task (i.e. role interdependence). Studies also discussed team processes, such as communication and coordination. Few studies discussed psychosocial traits during implementation, including trust and psychological safety. Lastly, studies described the organizational context of the practices, which includes their structure, resources or training environment. Identified barriers for team-based care implementation included financial constraints when hiring additional staff and issues with the current payment models that reward team-based care.

Conclusions

Studies solely focused on small primary care practices are limited. Of the four key domains, the biggest gap was identified around psychosocial traits and how mutual trust is fostered. Areas of future research include attention to how trust is built as practices implement team-based care and shift their mental model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14125-w.

Introduction

The National Academy of Medicine (NAM) defines team-based care as “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers — to the extent preferred by each patient — to accomplish shared goals within and across settings to achieve coordinated, high-quality care” [1]. A growing body of evidence demonstrates that team-based care is associated with improved patient experience, better quality of care, and higher work satisfaction [2–6]. As a result, team-based care is endorsed by a range of organizations, including the US and global organizations. For example, the World Health Organization includes team-based care as one of the core principles of primary health care. Similarly, team-based care is among the National Academy of Medicine’s six aims for improvement [7–10].

In parallel with the emphasis on team-based care, primary care settings have been engaged in demonstration projects across the United States to transform their practices into patient-centered medical homes (PCMH) [11]. PCMH includes principles that emphasize quality and safety, enhanced access, and coordinated care that reward practices for providing patient-centered care. Such practice transformations rely on a great deal of organizational change [12, 13]. Studies evaluating the organizational change required for implementing team-based care have been conducted within the broader goal of implementing PCMH, and within the context of financial incentives, have found structured processes of care, staff training, and resource utilization to be useful strategies [12, 13]. Yet, despite the large body of literature on PCMH, these studies have not described the specific process of implementing team-based care, and have noted the need to further examine the greater use of team-based care [14].

Team-based care has been evaluated across a range of settings, including large hospital settings, academic learning collaboratives, and a range of small to medium-sized primary care settings. These studies have demonstrated the positive impact of team-based care on patient safety and health outcomes. In addition, team-based care may improve patient self-management support and medication adherence through the implementation of population management systems [15, 16]. However, relatively few studies have focused specifically on evaluating team-based care within small, independent primary care practices. Among the limited studies, the evidence suggests reduced physician and staff burnout is associated with team-based work, likely due to reassigned roles and responsibilities across the care team [16, 17].

Although team-based care has the potential to improve the quality of care and provider satisfaction, it requires profound changes in the culture and organization of care structures and processes, roles, and responsibilities, and the systems used to manage relationships within and across organizational boundaries [18]. As a result, primary care practices experience significant barriers to implementing team-based care processes, including cultural silos within practices that perpetuate beliefs that non-physician staff cannot expand their roles, lack of experience and local expertise in team-based care, insufficient quality improvement (QI) infrastructure to support team-based care approaches, as well as perceived lack of reimbursement for team-based care processes [18–20].

These barriers may be more pronounced in small-to-medium-sized independent primary care practices (SIPs), which are practices with fewer than 10 clinicians [21]. SIPs are significantly less likely than larger practices and those owned by hospital systems to adopt and use critical team-based care related care structures and processes, due in part to a comparative lack of resources and staff expertise in information systems and practice redesign that translates into less capacity for adopting team-based care [21]. In addition, SIPs are often physician-centric, lack meaningful communication among team members, and can be dominated by authoritative leadership. They face hurdles in payment reform that can hinder their ability to rethink their delivery of care [18].

While SIPs have been declining in recent years, they continue to play a vital role in delivering care across the United States [22]. More than 70% of all healthcare outpatient visits occur in primary care settings, specifically in practices with five or fewer physicians [23]. Yet, studies and tools to implement team-based care have often focused on larger practices or practices associated with hospital systems rather than on SIPs [24, 25]. Furthermore, recent reviews on team-based care have focused on the addition of specialty staff to teams, such as a nurses or pharmacists, a model that may not be feasible in a SIP context [26]. Other reviews have focused on the impact of team-based care on health outcomes such as blood pressure or diabetes management [24, 27, 28]. Importantly, except for one publication, reviews did not highlight the specific structural and contextual factors that affect team-based care processes. The one exception, Cross et al. (2018), was informed by the Integrated (Health Care) Team Effectiveness Model (ITEM) framework. However, this paper did not address the full scope of the ITEM framework in the context of SIPs [29].

To our knowledge, there have been no reviews focused on the structures and processes used for the adoption of team-based care in SIPs. To fill this gap, we conducted a scoping review of the literature on team-based care specifically within SIP settings. We utilized the (ITEM) [30] framework to guide the analysis of the structures, processes, and relationships within primary care teams and to identify the barriers and challenges to implementing teams in SIPs.

New contribution

The benefits of team-based care on patient safety and health outcomes have been widely documented in the literature. In addition, a significant amount of research has been focused on team-based care through the implementation of PCMH and practice transformation in primary care settings. Among these studies, team-based care was recognized as one of the most critical elements of primary care practice transformation. However, there has been less focus on identifying specific facilitators and barriers to implementing team-based care within primary care settings, and no review to date has focused on synthesizing this in the context of SIPs. In our review, we use a comprehensive literature search to identify facilitators and barriers to implementing team-based care within SIPs. Specifically, findings may provide physician leaders and SIP practice owners with new ideas about how to optimize care processes to improve quality, outcomes, and clinician and staff satisfaction. Further, we identify structures and processes that have been implemented to involve all practice staff members as part of the team. Furthermore, our review may be relevant for understanding team building for other healthcare professionals as it focuses on the processes and relationships between team members and specifically, reports on the psychosocial traits integral for team-based care implementation, which have been narrowly documented. Lastly, findings from our review can help policymakers pursue involvement in incentivizing team-based models of care in SIPs.

Conceptual framework

Our review applies Lemieux-Charles and McGuire’s Integrated (Health Care) Team Effectiveness Model (ITEM) framework [30]. We selected the ITEM framework as it aligns conceptually with the core elements of team-based care and offers a comprehensive model for understanding how team structures, processes, and contextual factors interact to influence team effectiveness. Integrating insights from both organizational studies and health care team effectiveness research [30], ITEM captures not only structural and organizational elements of team-based care but also the psychosocial and relational components, such as communication, trust, and shared mental models - elements that are especially salient in SIPs. The framework describes the characteristics of a team by separating their interactions into task design, team process, team psychosocial traits, and organizational context. Organizational context refers to goals/standards, structure/characteristics, rewards/supervision, resources, training environment, and information systems. Task design refers to task type, task features, and team composition. Team processes include communication, collaboration, coordination, conflict, leadership, decision-making, and participation. Team psychosocial traits include cohesion, norms, efficacy, and problem-solving effectiveness [30].

Lemieux-Charles and McGuire’s ITEM framework posits that task design factors are often influenced by the external environment and can shape outcomes through their impact on team processes and traits. Furthermore, processes and traits interact with each other and are considered group-level phenomena as processes include communication and conflict and psychosocial traits include norms and shared mental models. Shared mental models are the shared perspectives of the team and how the team understands their task environment. As such, this framework provides a useful lens for examining facilitators and barriers to implementing team-based care across SIPs.

Methods

This scoping review followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines to identify studies that examined team-based care in small primary care settings. Search queries in PubMed/MEDLINE, CINAHL, Cochrane Library, and EMBASE were used to identify studies published from 2000 onwards because of the introduction of PCMH in 2007 [31] and increased implementation of team-based care within primary care settings [32]. Search terms specified the inclusion of “team-based” or “team-based care” or “shared care” and “primary care” or “small to medium-sized primary care” combined with the Boolean operator “AND”. The complete list of search terms can be found in the Appendix. Studies that (a) were focused on primary care settings; (b) discussed team-based care (described care delivered by multiple team members and some level of coordination, shared responsibility or task distribution); (c) included SIPs; (d) were published after 2000; and (e) included primary or secondary data were included. Because this review focused on team-based care in SIPs, we only included papers that provided information on practice size and discussed team-based care. We defined SIPs as practices with less than 10 health professionals [21]. For studies that broadly addressed team-based care and included practices of varying sizes, we included the study if at least one practice in the study met the SIP definition, based on reported practice size information, allowing us to extract SIP-specific findings (i.e., including a table with the number of clinicians at the clinic or describing the practice size in the methods or results). Including these studies enabled us to compare team-based care processes across settings and identify challenges and facilitators that may be unique to SIPs, while still capturing broader insights from mixed-practice studies. In our analysis, findings specific to SIPs were highlighted when reported. Otherwise, results from mixed-size studies were considered in the broader context but were interpreted with caution to avoid overgeneralizing from larger practices. Studies were excluded if they (a) were conducted in specialty clinics that did not include primary care services; (b) did not include information on practice size; and (c) only included practices with greater than 10 health professionals. Additionally, although PCMH transformation includes team-based care implementation and there is a great deal of literature evaluating PCMH in SIPs, we excluded studies that did not discuss team-based care outcomes and processes (i.e. workflow redesign, communication, care coordination, or team functioning) in their results. Eligible article types included original peer-reviewed research in English such as qualitative, quantitative, and mixed-methods studies that examined the implementation, adaptation, or use of team-based care. Conference abstracts, reviews, and commentaries were excluded.

We utilized Covidence for the screening and review process (see Fig. 1 for the flowchart). The literature search results yielded 3,143 non-duplicate results. Due to the high volume of records identified in the search, the first author reviewed each title and removed clearly irrelevant records, resulting in 86 articles. Two reviewers (DZ and DB) independently screened the abstracts, resulting in 57 articles for full-text review. Four reviewers (DZ, DB, DS, and JC) conducted the full-text review, resulting in twenty-five studies for inclusion. Disagreements about inclusion in the title/abstract screening and full-text review stage were resolved through discussion with the research team. While we did not conduct dual screening of all titles, the combination of an inclusive title-screening strategy, independent dual abstract screening, and team-based full-text review provided multiple opportunities to identify relevant studies and reduced the likelihood that pertinent abstracts were missed. Previous research suggests that a single reviewer process has negligible impact on the findings of reviews [33]. While not all studies explicitly framed their research as implementation studies, all included studies described how team-based care was introduced, adapted or sustained in practice. Our analysis was guided by the ITEM framework to extract information about the structures, processes, and contextual factors that facilitate or hinder the implementation of team-based care.

Fig. 1.

Flowchart of Search Results

Results

Research setting and study design

Our search resulted in 25 studies that met the inclusion criteria. The studies included in our review were published between 2010 and 2020. Twenty-two of the studies were based in U.S primary care clinics. Nine focused solely on small to medium sized primary care settings and the remaining eighteen included a range of small to large practice settings. Seventeen were qualitative studies and five used quantitative data. Although all the studies addressed team-based care, in six studies team-based care was implemented as part of the broader goal of evaluating the implementation of PCMH. Table 1 summarizes the articles included in the review. We analyzed our data around the features of task design, team process, psychosocial traits, and organizational context in the ITEM framework. We extracted and organized quantitative and qualitative results from the studies across the four ITEM domains and assessed whether the study addressed each domain. The presence of each domain is summarized in Table 2.

Table 1.

Study characteristics

Author	Study Design	Country	Year	Study Aims	Practice Size	Results
Balasubramanian et al.	Qualitative research	USA	2010	To examine qualitative data from 25 intervention practices to understand how they engaged in a team-based change management strategy and issues addressed	Small	Primary care practices can successfully engage in facilitated team meetings but leaders must be engaged in the process
Berry et al.	Multi-method	USA	2013	To analyze practice characteristics, prior experiences, and dimensions of PCMH in practices participating in the Primary Care Information Project (PCIP)	Small	Despite considerable potential challenges to achieving PCMH implementation, survey results revealed substantial implementation of key aspects of PCMH
Black et al.	Cluster randomized trial	Australia	2013	Evaluate the impact of a team-based approach with non-GP staff in GP practices	Small to large	Practice team roles were not significantly associated with change in Patient Assessment of Chronic Care Illness Scores
Dai et al.	Quantitative research	USA	2020	Examined team configurations and teamwork in family medicine practices	Small to large	Team configurations vary considerably by practice organization and practice size
Du et al.	Qualitative research	USA	2020	Investigated reasons behind why professionals defined their team in certain ways	Small to large	All participants acknowledged the importance of working in a team but had different perspectives on how the teams were defined
Everett et al.	Mixed methods study	USA	2022	Aimed to describe how primary care providers define team membership boundaries and coordinate tasks	Small	Many PCPs define team-membership based on within-visit task interdependencies
Flinter et al.	Qualitative research	USA	2017	Examined the role of RNs in primary care practices	Small to large	Regardless of practice type or corporate structure, LEAP primary care practices use RNs as a key part of their care team model
Ghorob and Bodenheimer	Qualitative research	USA	2015	To summarize the common elements exhibited by care teams	Small to large	29 practices exhibited 9 common elements
Goldberg et al.	Qualitative research	USA	2013	Describe the details of team composition and functioning of 3 primary care practices with team-based care models	Small	3 different team-based care models were exhibited by practices in this study
Gray et al.	Qualitative research	USA	2019	To understand how patients, family caregivers and physicians in the US describe the ideal patient-and-family-centered care (PFCC)	Small to large	6 themes were identified that defined the role of a medical team quarterback
Gurewich et al.	Qualitative research	USA	2016	To describe how 8 primary care sites operationalized medical home standards and barriers	Small to large	All sites varied in how many components they implemented but faced similar challenges to implementing and sustaining medical home standards
Howard et al.	Qualitative research	USA	2018	Explore the difficult-to-implement elements of PCMH with the aim of identifying successful strategies and implementation challenges	small to medium	Two main themes emerged relating to creating effective teams and funding team-based care
Leach et al.	Qualitative research	USA	2017	To describe current primary care team designs, primary care professionals’ perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care	Small to large	Practices had a variety of team designs being influenced by the social and policy context
Lieberthal et al.	Mixed methods	USA	2017	To quantify the activities required for PCMH transformation and explore barriers and facilitators to transformation	small to medium	Practices had variations in their workforce composition and 11 major themes emerged from the interviews
Lyson et al.	Qualitative research	USA	2019	To examine the implementation of care teams in safety-net clinics in California	Small	3 salient themes emerged in the clinics around physical space, organizational structure and empowerment, and staffing
Medgyesi et al.	Qualitative research	Canada	2020	To examine the perspectives of physicians who have had a long-standing relationship with a co-located pharmacist to identify barriers and facilitators to integrating a clinical pharmacist	small	6 themes were identified that contained barriers or enablers to the integration of a co-located pharmacist
Norful et al.	Qualitative research	USA	2018	To elicit PCP perspectives about the use of RNs in primary care	small to large	3 themes emerged from the qualitative data and suggest PCPs perceive RNs to be an integral part of interprofessional primary care teams
Nutting et al.	Intervention	USA	2010	To explain the effect of facilitation on practice outcomes in a 2-year PCMH National Demonstration Project intervention and describe the practices’ experience in implementing components of PCMH	Small to large	By the end of the 2 years, practices in both facilitated and self-directed groups had at least 70% of the National Demonstration Project components
O’Malley et al.	Qualitative research	USA	2015	To describe how primary care practices have overcome challenges to providing team0based care and implications for care delivery and policy	Small to large	Primary care teams had common characteristics
Park	Cross-sectional and observational study	USA	2015	To examine the number and distribution of PCPs, NPs, and PAs in PCMH and non-PCMH practices within New York State	Small to large	PCMH practices were more likely to have NPs and PAs compared with non-PCMH practices
Scuderi	Intervention	USA	2017	To train 6 primary care practices on team-based care using TeamSTEPPs framework	Small to large	Common challenges in improving team-based care emerged from the practice transformation process
Sinsky et al.	Qualitative research	USA	2013	To identify how practices distribute functions among the team, use technology, improve outcomes, and make the job of primary care feasible	Small to large	The innovations revealed a shift from a physician-centric-model of work distribution to a shared-care model can result in high-functioning teams
Swankoski et al.	Descriptive research	USA	2020	To characterize changed staffing patterns during the 4-year Comprehensive Primary Care (CPC) initiative and compare these patterns with similar non-CPC practices	Small to large	During the initiative, CPC practices added different staff towards a more traditional staffing model
Tsarouha et al.	Qualitative research	Germany	2020	To gain an in-depth understanding of psychosocial demands and resources in the primary care setting	Small	The results identified psychosocial demands and resources along two tasks: issuing medical prescriptions and blood sampling
Wagner et al.	Qualitative research	USA	2017	To describe the configuration and deployment of practice teams based on an in-depth study of 30 primary care practices viewed as innovators in team-based care	Small to large	Practices expanded the roles of existing staff and added new personnel needed to perform tasks and functions expected of PCMH

Table 2.

Presence of key domains in reviewed studies

Author	Task Design	Team Process	Psychosocial Traits	Organizational Context
Balasubramanian et al.	+	+	+	+
Berry et al.	+	+	-	+
Black et al.	+	+	-	-
Dai et al.	+	-	+	-
Du et al.	+	+	+	+
Everett et al.	+	+	-	+
Flinter et al.	+	+	-	+
Ghorob and Bodenheimer	+	+	-	+
Goldberg et al.	+	+	+	+
Gray et al.	+	+	-	-
Gurewich et al.	+	+	-	+
Howard et al.	+	+	+	+
Leach et al.	+	+	-	+
Lieberthal et al.	+	+	-	+
Lyson et al.	+	+	+	+
Medgyesi et al.	+	+	-	+
Norful et al.	+	+	-	+
Nutting et al.	+	+	-	+
O’Malley et al.	+	+	+	+
Park	+	-	-	-
Scuderi	+	+	+	+
Sinsky et al.	+	+	+	+
Swankoski et al.	+	-	-	-
Tsarouha et al.	+	+	+	+
Wagner et al.	+	-	-	+

+ Indicates inclusion of the domain in the study

Task design

Task design included the type of team (e.g., project management, care delivery team), task features (e.g., interdependence or degree to which staff rely on each other, staff expertise, and clinician and staff autonomy), and team composition (e.g., size). All 25 studies addressed some component of task design, including the composition of the team. Most studies we reviewed had practices composed of medical assistants (MA), nurse practitioners (NP), or physician assistants (PA). Three out of four studies that included solo practices only included an MA or nurse in addition to the physician as part of their team [34–36]. Ten studies noted that practices redesigning care processes also experienced changes in team composition and task features. Changes in team composition were due to hiring additional staff whereas changes in task features were due to expanding roles [35, 37–42].

Two studies that highlighted changes to task features, discussed role expansion. Uniquely to studies focused on role expansion within SIPs, the focus was on MAs and increasing their responsibilities [43, 44]. Specifically, one study found that MAs were empowered to make workflow decisions and facilitate clinic workflow [44]. In a second study with a range of practice sizes, the authors found increased responsibilities such as MAs reviewing patients’ charts pre-visit to identify any needed preventive and chronic care services [43]. Among the studies that featured role expansions, all identified a need to clarify changes to roles and responsibilities [15, 39, 45–47]. For example, one paper discussed the role of a “medical quarterback”, an individual who coordinates and advocates for the patient for appropriate care with the care team. When introducing these roles, the authors emphasized the need for clearly defining the roles for each team member [45]. Another study on physician-run medical clinics found that a co-located pharmacist resulted in both the addition of some tasks and the reduction of others for MAs and physicians. For example, physicians experienced a decreased workload when they were able to more easily refer their patients to the co-located pharmacist [48].

Task interdependence refers to the degree to which members of the team rely on each other. This concept was most salient in two of the nine studies that focused on SIPs. In the three studies that investigated how practices defined team membership, PCPs generally described team membership as an informal and fluid concept [41, 44, 49], due in part to task interdependence. Specifically, in a study focused on SIPs, PCPs relied on other team members between visits yet they often failed to mention other clinic staff including front desk staff as part of their team [49]. Additionally, SIPs were found to have more informal care teams in place. Berry and colleagues (2013) reported that among SIPs working towards a PCMH model, 57% had informal care teams while only 18% had formal care teams.

Team process

Team process refers to communication, collaboration, coordination, leadership, and decision-making within the team. The ITEM framework highlights how team process is a group-level phenomenon and is influenced by task design. Twenty-one of the 25 studies described how small primary care teams collaborate and coordinate. Within team processes, examples included paying attention to communication mechanisms, sharing patient care responsibilities, and physicians encouraging a nurse to be a leader of the team [39, 50, 51]. These team processes are beneficial to overall team effectiveness and success. The included studies identified ways in which team members may have a more active role. However, there was a lack of discussion in the included studies about who from the team was involved in making decisions about practice processes related to patient care.

With regard to communication mechanisms, nine studies highlighted a preference for the use of huddles as an important communication tool [15, 39–41, 46, 47, 49, 52, 53]. However, the frequency with which teams used huddles and who was involved was not consistently described. One study used huddles to define team membership, highlighting the relationship between task design and team process [54]. Huddles also allowed practices to remove barriers between the front and back-office staff by engaging all practice members in these conversations. This platform for collaboration facilitated a greater understanding of how the front office staff roles impact care delivery [52].

Two studies described the use of informal team-based care and various coordination mechanisms [49, 55] including relational coordination (face-to-face interaction), EHR coordination, physical and visual coordination (door flags and paper orders), and formal meetings. One study highlighted the primary coordination mechanism used depends on whether the coordination was needed within a visit or between a visit. Informal team-based care was associated with a lack of clearly defined care teams or designated case managers [49, 55]. Overall, SIPs specifically were found to use more flexible, less formal, and “spontaneous” communication and coordination strategies [44, 55].

Psychosocial traits

Psychosocial traits refer to norms and shared mental models. According to the ITEM Framework, psychosocial traits are influenced by task design [30]. Ten studies discussed psychosocial traits during team-based care implementation and of those, five were focused solely on SIPs. Most attention was paid to trust and psychological safety. Psychological safety is defined as the ability for individuals to ask questions and voice concerns without fear of backlash from their team [56]. Unique to independently owned practices, power differences and hierarchy may threaten psychological safety [34, 37]. O’Malley et al. found that selecting a designated staff member that other team members can go to for concerns or feedback can improve trust and psychological safety [47]. However, within SIPs, this was noted as a new phenomenon for many staff members as they had limited experience with sharing their opinions in a team setting [37]. Overall, efforts to flatten the hierarchy through open communication within SIPs was consistent across four of the studies discussing psychosocial traits.

Four studies highlighted the importance of trust in relationships among the team and how this impacts their uptake of team-based care [15, 44, 54, 57]. One study noted the provider’s willingness to diffuse responsibility and involve the MAs with additional tasks grew over time and the shift in division of labor allowed MAs to feel more empowered [44]. Furthermore, two studies suggested trust between individuals was important in order to share responsibility for the health of their patients [15, 44]. Lastly, trusting your team members and fitting in with the team culture are perceived to lead to teamwork efficiency and overall physician well-being [34].

Organizational context

Organizational context refers to the characteristics of the practice which include: goals/standards, structure/characteristics, rewards/supervision, resources, training environment, and information system. For primary care settings, team structure is largely influenced by the practice’s organizational context [41]. Authors of the included studies noted in their limitations that small primary care settings may be more sensitive to changes in their external environment due to their lack of resources compared to larger practices [37]. These authors also reported that studies conducted in SIPs must be evaluated with the understanding that these practices have often received assistance from external partners to undergo practice redesign [37, 55]. Nonetheless, several studies indicated that the adoption of EHRs as a technological resource facilitated care coordination and team communication. For example, information systems, such as EHRs, were used to coordinate care for standing orders and clinical protocols [15, 39–42, 47, 49, 52].

Practices in several studies provided training when implementing a new care model. Two studies facilitated training to expand RNs roles in ways that allowed them to practice at the top of their license [15, 51]. Additionally, to allow team members to work at the top of their license, one study suggested how structural reorganization can improve the practice’s issues due to shifting roles [37].

Barriers and benefits to implementing team-based care

Studies examining the implementation of team-based care reveal both challenges and benefits. Nineteen studies described the barriers and benefits when implementing team-based care. Eight of the nineteen studies focused specifically on SIPs. Among these studies, two identified improved communication as a result of team-based care [37, 44] and one highlighted how this transition allowed clinics to become in tune with what real healthcare needs are [44]. Three studies highlighted increased job satisfaction and decreased burnout [15, 42, 46]. Specifically, satisfaction improved due to staff feeling confident they are doing what is right [42]. This was highlighted by Howard and colleagues as practices were able to provide more comprehensive services and felt working in these teams brought greater joy [46]. Additionally, shifting the division of labor, has allowed clinicians to feel the benefit of a decreased workload [44, 48]. Leach and colleagues highlighted the benefit of freedom that independent practices have when adopting innovations [41]. Results from the study emphasize that independent practices can consider how new innovation may impact all staff members’ workflows. Additional benefits described in the remaining eleven studies were increased perceived efficiency, expanded roles for MAs and RNs, decreased burnout, and rewarding practice environments [34, 38, 39, 43, 57].

The most frequently described barriers to implementing team-based care among the eight studies on SIPs were the cost of hiring additional staff, financial constraints related to hiring and payment models that do not consistently reward team-based care, and having a physician centric model [15, 37, 42, 46, 48, 49]. For example, in one study, practices tested a care coordination model to integrate a team-based care approach. However, they were unable to sustain a care coordinator role due to a lack of reimbursement from payers for population management activities and care coordination [15]. Additional cited barriers were lack of support or superficial support for change, inability to use staff to the top of their skill-level, staffing, and not having a clear defined team [37, 44, 49, 55]. In the other eleven studies, one study suggested that a lack of financial resources also impacts small practices capacity to provide training when attempting to redesign care processes, including roles and responsibilities [47]. Lastly, four studies highlighted staff and clinician turnover as a challenge, as well as having part time staff, which created barriers to integrating them into a team-based care approach. Both structural issues were linked by authors to barriers to achieving care continuity [40, 41, 52, 53].

Discussion

This study provides insights into how elements of team-based care are integrated into small primary care practices and the potential challenges these sites may experience in trying to adopt this approach. The ITEM framework was useful in guiding the analysis of the processes and outcomes of implementing team-based care in primary care. Although many implementation science frameworks such as the Consolidated Framework for Implementation Research and RE-AIM focus on contextual determinants of implementation, we selected the ITEM framework because it links team-level task design, processes, psychosocial traits, and outcomes which can inform implementation. This focus was well-suited for SIPs, where team dynamics and staff interdependencies play a role in adopting team-based care. The studies included in our review suggest that practices that were able to implement team-based care shifted from a physician-centric model, a commonly cited barrier specifically in SIPs, where the physician “does it all” to a more distributed model of health care delivery. This requires an agile organizational structure and leadership that trusts staff by allowing MAs to take a more active role with patient communication, care and sharing responsibility [44]. The idea that “doctors should be doing doctor things” [52] begins to be challenged in settings as more responsibility is delegated to other members of the team. Compared to larger practices with less perceived autonomy [58], for practices that are small and independent, our findings suggest that ensuring psychological safety and sharing the responsibility for care are key components to successful adoption of team-based care.

SIPs may find that shifting away from a physician-centric model is more difficult than in larger practices as they function similarly to small businesses where the lead physicians may be the practice owners [59]. As a result, the PCP is the financial stakeholder in addition to the “revenue engine” of the practice [18]. This model is less common in larger settings that are owned by a larger entity (e.g. hospital, FQHC) [21]. Moreover, compared to larger clinics and health systems with more resources, small practices are constrained by fewer staff available to adopt new roles and responsibilities. The studies included in our review suggest SIPs can be reluctant to add staff due to financial constraints [39, 46]. Payment systems that do not reimburse for patient care delivered by non-physician staff may contribute to the challenges that SIPs face in securing the resources needed to hire the staff they need [39]. When practices do hire additional staff, small practices typically add MAs rather than nurses due to the lower MA salaries [47, 50]. However, despite hiring additional staff, teams may struggle with utilizing their MAs to their full capacity due to having a physician-centric model and the associated power differences [37].

Future research should acknowledge and emphasize the role of non-clinical staff as members of the team in small practices as a first step towards leveraging these staff to support clinicians to deliver care more efficiently and effectively. Studies in this review have highlighted the interdependencies in small settings and how the entire staff is involved in patient care [49]. However, other studies also highlighted that clinicians in smaller settings may consider a staff person as a team member only if they are directly involved in providing care, despite the work non-clinical staff does outside of a visit. For example, Nutting et al. describe how support staff’s main purpose in the eye of PCPs may be to maintain patient flow and ease the burden off the physician by relieving them of less complex tasks [18]. This highlights a need to engage all staff, particularly in small practices where staff numbers are limited and establish clear roles to achieve an effective team-based care approach.

There is a large gap in studies that focus on psychosocial traits in small settings. Few of the papers included in our review found that psychological safety either facilitated or hindered building trust within the team when implementing team-based care. Mutual trust is a key component of team-based care and helps establish norms of collaboration which may lead to greater team cohesion. A few studies highlighted how the sense of psychological safety can allow members of the team to feel that they can rely on one another and easily hand off tasks, hence facilitating team-based care. This highlights the bidirectional relationship between team processes and team psychosocial traits. Findings from our review suggest ensuring psychological safety within teams is a key mechanism to increased job satisfaction and reducing burnout [16] This may help address the staff turnover challenges faced by small primary care practices, which have hindered their ability to adopt a team-based care approach [41, 44, 52].

Studies in this review found that practices that expanded roles, increased responsibilities, incorporated huddles to engage the entire practice team and defined the team’s task interdependence were able to increase psychological safety. These findings highlight the interaction between task design, team processes, and team psychological traits as indicated in the ITEM framework. The changes practices made to task design spilled over to team processes and/or team psychosocial traits which can improve overall team functioning and willingness to adopt a new model of care such as team-based care. Further research is needed to understand how team psychosocial traits can lead to reducing power differences found in SIPs to allow for greater adoption of team-based care.

Limitations and strengths

It is plausible there were some studies omitted during this review despite our comprehensive search strategy. Only studies that had identified practice sites with less than 10 clinicians were included which may have excluded studies if they did not specify practice size. Some included studies reported findings across a range of practice sizes. While we focused on SIP-specific data when available, in some cases it was not possible to disaggregate results by practice size, which may limit the specificity of our findings to SIPs, and therefore generalizability remains a concern. Team-based care remains an active area of practice research therefore the review may not capture the complete literature on this topic. Because this review was focused specifically on team-based care models, we may have excluded studies that examined team functioning or collaboration in primary care more broadly, even though such studies could provide relevant insights into team processes and dynamics. Lastly, we did not assess the quality of the included articles. Strengths of this study include the 22-year timeframe which likely captured the full range of models for team-based care, the use of the ITEM framework for analysis, and the specific focus on small independent practices.

Practice implications

Given the flexible and interdependent nature of staff and clinicians in small primary care settings, more attention should be paid to how small practices implement team-based care. This may involve focusing on the organizational context such as the structure and available resources within these settings that can build greater trust and optimize collaboration. This review highlights that there is no one-size-fits-all approach for these settings and future interventions should capitalize on the opportunity to examine the full range of strategies that SIPs apply to enhance team-based care. The ITEM framework highlights the features that future research should pay attention to when creating interventions to implement team-based care. Specifically, future research should focus on elements of psychosocial traits that are unique to SIPs. More than highlighting quality improvement efforts, this review highlights the importance of practice culture and structure in successfully implementing and sustaining meaningful change [37]. It is important to create solutions that empower smaller settings to overcome the barriers faced in their internal environment.

An additional lens that may help understand and guide these efforts is relational coordination theory, which posits that cross-cutting organizational structures such as, shared protocols, team training, joint meetings, and integrated information systems support relationships that are characterized by shared goals, shared knowledge, mutual respect, and high-quality communication among interdependent professionals. These structures support relationships and may drive key performance outcomes including quality, efficiency, worker well-being and the ability to innovate and learn [60]. Further research may benefit from applying this framework as it could provide a useful perspective for identifying further strategies that may enhance trust, collaboration, and team performance in SIPs, ultimately supporting better quality and efficiency.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Conception or design of the work (DZ, JC, DS), studies search and selection (DZ, DB, JC, DS), data synthesis (DZ), manuscript preparation and writing (DZ), revising and finalizing manuscript by providing critical feedback to drafts (DZ, DB, JC, DS). All authors have reviewed and approved the final manuscript.

Funding

Not applicable.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.