Team-Based Care Pathway Stage 3

Team Development

In this stage, your team will have been working together for a while and may want to explore areas for potential quality improvement such as assessing patient experience or developing processes for shared leadership and shared decision-making.

How can we improve workflow and relational continuity among our patients and the broader team?

Team-Based Care can be a new concept for both team members and patients. It is important to understand how the patient receives messaging around team-based care, and how the team is introduced to the patient. When team members trust each other and work as a cohesive unit, patients will also build trust with the team.

How will we manage conflict and support healthy communication with patients and within our team?

In any team, conflict can arise. Learn how to manage conflict and support healthy communication with patients and teams.

How do we consider community assets and the social determinants of health?

Consider the social determinants of health that may be impacting your patients. High-functioning teams may start to look at improvement efforts in terms of building equity and community connections in a patient population. Supporting patients with access to supports outside of the primary care setting can improve patient experience, enhance self-management and sustain behavioural health goals. The community is and can be part of a high-functioning team!

  • PACC Mapping is an engagement and planning approach that helps communities collectively explore how they could address local primary care needs such as attachment and other specific service gaps. The Health Data Coalition can also support your assessment of local needs and assets.
  • Consider Patient Journey Mapping as a way to identify team actions to improve the patient experience.
  • Did you know that 30% of primary care visits are for non-medical (social) reasons? Consider how social prescribing might support your team’s practice. Connecting patients to non-medical resources has been shown to increase patient self-management and reduce medical visits.
  • See CASCH’s Conceptualizing and Implementing Social Prescribing Programs for a comprehensive planning and implementation guide.

For additional supports for your TBC journey see:

As always, if you know of a great resource or tool that should be added to this pathway or the website, please contact us at

Even for well-established teams, it can be useful to revisit things like vision and purpose, and consider elements like team complement and efficient space design. Communication is an essential element to effective, high-quality team-based care, so finding time to work on this is key! Investing in time to huddle, connect and communicate will pay off in the long run for your patients, and your practice. Finally, the most important aspect of team-based care is the patient. Remember to place the patient at the centre of the team, and ensure that cultural safety and humility are guiding your practice. We wish you all the best in your TBC journey!