Integrated Care Teams: Roles and Responsibilities, Part 1

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At Southcentral Foundation, primary care is provided through Integrated Care Teams (ICTs). The core members of an ICT are a primary care provider, nurse case manager, certified medical assistant, and case management support.

Integrated Care Teams: Roles and Responsibilities

Following is a brief overview of the roles and responsibilities of each core team member.

Primary Care Provider

The primary care provider is responsible for initial assessment and diagnosis of health issues. The provider handles in-clinic visits and helps to set the focus for the team on priority work areas. The provider also sets plans for follow-up on known diagnoses where treatment is stable, and adjusts treatment plans for known diagnoses where goals are not being met.

Nurse Case Manager

The nurse case manager is responsible for population-based panel management. The nurse case manager is also the chronic disease manager, and the preventive disease manager. Often, the nurse case manager’s work is outside the scope of the physical visit, handling things such as customer-owner education, labs and radiology reports, medication refills, and follow-up visit requests.

Certified Medical Assistant

The certified medical assistant (CMA) handles customer-owner check-ins, screenings, and procedure and room setup. The CMA is also responsible for immunizations, venipuncture, and medication administration. CMAs manage the daily schedule and conduct preventive screenings (depression, tobacco, etc.)

Case Management Support

The case management support (CMS) builds relationships with customer-owners and acts as the main point of contact between customer-owners and their ICT. The CMS schedules customer-owners for appointments, coordinates with the Nurse Case Manager to ensure good panel management, and has various other duties, including attaching documents in the Electronic Health Record.

Workspace and Communication

Team members sit together in an open workspace and communicate constantly to ensure that customer-owners are receiving the care they need. It is common practice at SCF for ICT members to perform at the top of their license, which takes some of the workload off the primary care provider, freeing providers up to focus on the most critical tasks in the provision of care.

All the core members of an ICT work together, in relationship, with customer-owners to help them achieve overall wellness. Other providers and care workers can be added to the care team as they are needed for customer-owner cases; part 2 of this blog entry will discuss some of their roles and responsibilities.

Click here to read Integrated Care Teams: Roles and Responsibilities, Part 2.