Initiating Team-Based Care

The case study reported by the Agency for Healthcare Research and Quality (AHRQ), titled “Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice”, discusses how primary care practices within Bellin Health in Green Bay Wisconsin are coping with the new team-based changes to deliver care.

Today, professional satisfaction in primary care can be low, time spent on direct patient care is perceived to have declined, and the lack of patient engagement affects patient outcomes. To make improvements, the team approach was initiated to help overcome physician burnout and improve patient outcomes and experience.

Bellin Health added Care Team Coordinators (CTC) to each care team to identify and close care gaps and be the primary point of contact for the patient and family. The Bellin primary care practice piloted the team-based care model consisting of eleven family practice physicians, two nurse practitioners, and one physician assistant.

The Bellin team-based care model has:

  • Implemented previsit planning, previsit labs, and improved access to care
  • Enabled the care team to spend more time with patients and is conducting functional and behavioral health screenings, coaching, and medication reconciliation
  • Involved the core team in the scheduling of appointments, examines different needs for each patient, and ensures that documents, labs, and other records are available and reviewed
  • Conducted care team meetings on a weekly or biweekly basis
  • Removed the documentation burden from the provider
  • Conducted discussions in between visits with patients along with discussions on follow-up visits, test results, triage issues, medication refills, and referrals
  • Conducted consistent messaging to patients to reinforce the team concept


Bellin invested about $250,000 in their staffing model, infrastructure. The investment has proven to be worthwhile, since the practice has seen an increase in reimbursements even in a fee-for-service environment..

Bellin is now investing an additional $40 million in capital funds to expand the team-based care approach, including co-locating to all of their ambulatory practice environments. For more information, email Kathy Kerscher, Team Leader of Operations for Primary Care at Bellin Health at

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