Team-Based Care Pathway Stage 1

Where to Start with
Team-Based Care

In this stage, you may be contemplating a team-based approach to your practice, and may be wondering where to start. If you are an established practice, you may be considering how to recruit team members, based on your patient needs. This stage is also for newly forming teams who want to explore how to work together.

Who are the patients you are serving?

Understanding patient needs is an essential step in formulating your team goals. Knowing who you are serving can help shape team complement, and determine shared roles and responsibilities.

Who will make up the team?

Team complement will be determined by a number of factors, including patient/population needs, clinic size, space, and overall goals. Designing a team should include an understanding of roles and skills to optimize patient and provider satisfaction.

Team Readiness  – Are the practice and team members ready to work as a team? 

Assessing team readiness includes determining whether the team has what it needs to move forward together. This can include logistics like space and time, and other factors like a joint commitment, a shift in culture and a collaborative model of care delivery.

What are the team members’ roles and how will they work together?

Role clarity and understanding is an important element of team-based care. Knowing your own role in relation to others, and how you may work together, are important for teams to discuss. The best way to understand another’s roles is by observing and spending time with each other.

  • Review team members’ role descriptions and make sure you set up time for team members to discuss and learn about others’ roles and scope.
  • This toolkit on Navigating the Team-Based Care Journey from the Family Practice Services Committee reviews elements like sharing time and space, building collaborative teams and the benefits of a team approach.
  • Set up shadow shifts with other providers. Find time to connect with team members around the same patient.

How will we communicate as a team?

Communication is the foundation of any relationship and this includes the clinical team! In early stages, it is important to discuss how, when and even where your team will communicate.

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!