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Case Study 6: Clinica Family Health Services: Enhanced Team Functioning

Carolyn Shepherd, M.D.


The Clinica Family Health Services community health center provides care to a largely uninsured Hispanic population of about 40,000 patients at four sites near Denver, Colorado. The health center was one of the first to participate in the Health Disparities Collaborative of the federal Bureau of Primary Health Care and has worked to improve primary care practice since 1999. The center has made major organizational and cultural changes in the process of forming its high-functioning teams.

Team members

Primary care teams are called “pods.” There are four pods at one site, two at another, and three pods at each of the two other sites. Each pod is color coded to help patients identify with their care team and to improve continuity of care--the walls and the primary care provider business cards and appointment cards are differently colored.

Each pod has three full-time equivalent primary care clinicians: physicians, NPs or PAs, and certified nurse midwives. Medical assistants usually work with a single clinician, contributing to continuity of care. Pods also have a nurse team manager, who is either a registered nurse (RN) or a licensed practical nurse (LPN). Pods share a referral case manager, social worker, office manager, and financial screener. The organization has a registered dietitian who is a CDE. The dietitian helps train RNs and LPNs, supports group visits for people with diabetes with their primary care provider, and counsels individual patients with diabetes. All clinicians and staff who care for patients are required to be bilingual Spanish speakers.


To improve continuity of care, each of the 60 or more primary care clinicians has his or her own panel of 1,000 to 1,200 patients. This panel size maximizes the goal that patients see the same clinician whenever possible at each visit and has improved access to care. The primary care clinicians assess and manage current medical problems and comorbid conditions. For chronic diseases such as diabetes, computer-generated registries, reminders of checks for diabetes management, and status of complications help clinicians provide timely care.

The referral case managers, often high school graduates trained by the center, relieve clinicians of the time-consuming efforts to arrange appointments and negotiate payment for services. Pod case managers help patients set self-management goals, do brief screenings for depression, counsel patients with mild to moderate depression, and help with tobacco cessation follow-up and referrals.

Medical assistants take vital signs, document history of present illness, screen for tobacco use, room patients, draw blood, and do depression screens. Working with pod receptionists, they manage the chronic disease registries and order overdue tests. Up-to-date registry data are pulled directly from the electronic health record database and displayed, using crystal reports and business intelligence tools.

RNs and LPNs play a central role. They coordinate team activities, oversee the medical assistants, and provide health education. They activate diabetes patients to manage their illness by providing diabetes education and seeking patients’ input for goal setting during each visit. Patients choose their own self-care goals as part of their self-management plans. Lessons learned in self-management are then applied by the patient toward other health care goals such as walking or stopping tobacco use. Under a primary care provider’s supervision, RNs and LPNs screen for and treat simple infections, obtain urine cultures, and contact patients.


Clinical sites are organized so that pod teams work in the same open room at the pod’s center, from which they can see all the patient rooms. This enables team members to easily and quickly communicate with one another. Incoming calls are routed to a centralized call center. Calls with clinical content go to the pod receptionist, who also contacts patients with normal lab results, checks patients in and out of their visits, and helps manage chronic disease registries. Outgoing calls are generally made by the case manager, LPN, or medical assistant, using clinical protocols or specific instructions from the clinician to inform patients of abnormal lab results, schedule periodic care, schedule patients in group visits with their primary care provider, and refill prescriptions. Since most of the patients do not have health insurance, the clinic uses a digital retinal camera to screen patients and determine who needs to be referred for specialty eye care.

Insurance coverage

More than half of Clinica Family Health Services patients do not have any health insurance coverage. The cost of care to these patients is supported by a 330 Federally Qualified Health Center grant. Services to patients with diabetes are billed to state Medicaid and Medicare when the patient has this coverage. Less than 8 percent of patients have private insurance.


Continuity of care with the patient’s primary care clinician is 80 percent for well care, 70 percent for diabetes care, and 60 percent for acute care such as asthma visits. Access to care is three days or fewer for established patients compared to three weeks to three months prior to the formation of patient panels, and patients’ no-show rate has dropped from 35 percent to 8 percent.

A summary of Clinica Family Health Services’s self-reported data showed that the average A1C level of its population (now 1,916 patients) with diabetes dropped from 10.5 percent in October 1998 to 7.9 percent in November 2009. The percentage of patients with diabetes with at least two A1C tests within a year rose from 11 percent in October 1998 to 92 percent in November 2009. The percentage of patients with diabetes self-management goals rose from 3 percent in February 1999 to 50 percent in November 2009. The percentage of those having foot examinations rose from 15 percent to 62 percent in the same period. Since 2007, these data have been pulled from the EMR database and now include 100 percent of the diabetes population for every measure.

Related references

Shepherd C. Clinica Family Health Services: Using space and financial incentives to enhance team functioning. In: Bodenheimer T, ed. Building Teams in Primary Care: 15 Case Studies. Oakland, CA.: California HealthCare Foundation. 2007; 9-11. chronic illness. JAMA 2002; 288(14):1775-9.

February 2013​​​