PITTSBURGH, PA, July 20, 2026 – Ten Ten Ten, a nonprofit organization dedicated to improving U.S. health outcomes and reducing healthcare costs, today announced the release of Care Team Integration: Building and Onboarding the Non-Physician VBC Care Team, a new implementation guide for independent primary care practices.
The 81-page guide helps practices convert a value-based care strategy into everyday clinical operations. It offers ready-to-use, customizable job descriptions, protocols, staffing models, business cases, and 90-day onboarding checklists for four key roles in a high-performing care team: the clinical care manager, clinical pharmacist, medical social worker, and medical assistant or care coordinator.
“A collection of job titles does not create an integrated care team,” said Jenn Block, PhD, Ten Ten Ten’s Chief Architect, Value-Based Care. “Practices need clearly defined responsibilities, reliable handoffs, shared workflows, and a common understanding of who owns each part of the patient journey. This guide provides practice leaders with the practical building blocks to develop that operating model.”
Value-based care encourages practices to keep patients healthier between visits, coordinate care across different settings, close clinical and social care gaps, and intervene before increasing risk leads to avoidable emergency department visits or hospital stays. However, many independent practices lack the time, staffing, and resources needed to develop these functions from the ground up.
Care Team Integration aims to close that gap. It demonstrates to practices how to identify and stratify patients, prepare for visits, manage chronic conditions between appointments, support medication adherence, address social and behavioral barriers, and improve transitions from hospitals and other care settings. It also explains how the four roles collaborate through a shared patient registry, daily huddles, warm handoffs, standing orders, and closed-loop referrals.
“The most consequential breakdowns in primary care often happen in the spaces between visits, medications, referrals, and care settings,” said Bhargav Raman, MD, cofounder and Lead, Clinical Strategy & Analytics at Ten Ten Ten. “This guide helps practices put clear ownership and repeatable processes into those spaces, so a missed follow-up or unresolved barrier does not become a preventable health crisis.”
Recognizing that many practices cannot support four new full-time employees, the guide offers flexible staffing options, including redeploying existing team members, adding part-time or remote staff, using contracted professionals, and sharing specialized roles across multiple practices. It also provides a framework for assessing how AI can reduce administrative work and expand staff capacity while keeping clinicians responsible for clinical judgment.
The guide was developed by lead authors Jenn Block, PhD, and Bhargav Raman, MD, with contributions from Kate Eisenberg, MD, PhD; Mathew Philip, MD; Valerie Choniuk, MPA-HCA, CPXP; Faarina Khan, MD; and Satya Sarma, MD.
Independent practices, medical groups, and healthcare leaders interested in downloading Care Team Integration or seeking implementation guidance can visit https://tententen.org/our-work/value-based-care or email [email protected].
Ten Ten Ten
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Pittsburgh, PA 15215
Media Contact:
T.J. Tedesco
Executive Director, Ten Ten Ten
Email: [email protected]
Tollfree: 1-855-4TENTEN (855-483-6836)
Ten Ten Ten is a nonprofit organization working toward a simple national healthcare goal: Top Ten health outcomes, healthcare spending at Ten Percent of GDP, within Ten Years. Through public education, open-source playbooks and implementation guides, analytics, certification, and partnerships, Ten Ten Ten works to identify and advance healthcare models that improve outcomes, reduce total cost, and expand equity across the population.
