Designing Effective Teams

Team-based primary care is one of Ontario’s most powerful tools for improving access, quality, equity, and sustainability. We’re leading the movement to help teams in Ontario grow coherently, and grow together.

Your Voice. Your Impact.

Every person connected to Ontario’s primary care system has the power to create change. Whether you are part of primary care team, an individual clinician, a partner organization, or a member of the public, there is a role for you in strengthening team-based care primary across Ontario.

Evidence-Based Interprofessional Collaboration

High-functioning, evidence-based teams are the foundation of high-quality primary care. Decades of research and practice experience show that when care is delivered through well-designed, interprofessional teams, patients experience better access, better outcomes, and more coordinated, continuous care.

Models such as the Patient’s Medical Home, emerging Health Home approaches, and Ontario’s Team Primary Care all point to the same conclusion: no single provider can meet the full range of patient needs alone. Effective teams improve preventive care, chronic disease management, and patient experience, while also supporting provider well-being and system sustainability.

What distinguishes effective teams isn’t simply who is on them — it’s how they are designed and supported. Evidence consistently highlights the importance of:

A Trusted Home for Team-Based Primary Care in Ontario

We act as an integrator across professions to strengthen how teams collaborate.

AFHTO is your trusted home for team-based primary care. We’re on a mission to build a shared understanding of how team-based primary care actually works: who is part of a team, how roles function together in practice, and how teams can be designed to deliver high-quality, high-impact care, in partnership with professional associations.

AFHTO aims to bring tangible, practical and real world information, tools, and networks together to support implementation and ongoing improvement…..something something….. in other words, not an academic exercise….

Understanding Roles Across the Team

Team-based primary care works best when roles are designed to complement, and not compete, with one another. This illustration is a helpful tool to show how different professionals collaborate around patients, with some roles providing continuous care and others offering specialized expertise as needs arise:

Click on each professional to learn more!

Building a Future-Focused System

Team-based primary care is not just a staffing decision. It’s an intentional choice to build a system that not only meets the needs of current patients, but anticipates and responsibly manages future demands on the healthcare system.

Through team-based care, we’re bypassing fragmentation and creating a unified and thoughtful approach to care, where professionals practice at their full potential and patients receive the coordinated, high quality care they deserve.

Family Physician

Ontario College of Family Physicians

Overview of Role in Team-Based Primary Care

Provides comprehensive medical care across the lifespan and works with the care team to coordinate diagnosis, treatment, and ongoing care

Scope of Practice

Comprehensive medical assessment and diagnosis; prescribing; chronic disease management; preventive care; coordination of care across settings

Examples of High-Impact Use in Primary Care Settings

Longitudinal care for complex patients; shared-care models with NPs and other providers; leadership in quality improvement and clinical governance within teams

Chiropodist

Ontario Society of Chiropodists (OSC)

Overview of Role in Team-Based Primary Care

Provides specialized assessment and treatment of foot and lower limb conditions, supports mobility, helps prevent complications, chronic disease management

Scope of Practice

Assessment, diagnosis, and treatment of foot conditions; nail and skin care; management of biomechanical issues; wound care

Examples of High-Impact Use in Primary Care Settings

Diabetic foot care and ulcer prevention; mobility preservation for seniors; early intervention to reduce ER visits and amputations

Chiropractor

Ontario Chiropractic Association (OCA)

Overview of Role in Team-Based Primary Care

Supports musculoskeletal health and pain management, helps patients maintain function and remain active

Scope of Practice

Assessment and treatment of neuromusculoskeletal conditions; manual therapy; patient education and prevention strategies

Examples of High-Impact Use in Primary Care Settings

Management of back and neck pain; reducing unnecessary imaging and specialist referrals; supporting return-to-work care plans

Kinesiologist

Ontario Kinesiology Association (OKA)

Overview of Role in Team-Based Primary Care

Focuses on movement, physical activity, and functional rehabilitation, supports prevention and chronic disease management

Scope of Practice

Assessment of human movement and function; exercise prescription; functional rehabilitation; health promotion

Examples of High-Impact Use in Primary Care Settings

Physical activity interventions for diabetes, cardiovascular disease, and frailty; supporting functional independence and self-management

Nurse Practitioner

Nurse Practitioners’ Association of Ontario (NPAO)

Overview of Role in Team-Based Primary Care

Provides comprehensive primary care, often as a most-responsible provider, within interprofessional teams

Scope of Practice

Diagnosis, ordering and interpreting tests, prescribing medications, managing acute and chronic conditions, health promotion

Examples of High-Impact Use in Primary Care Settings

Attachment of additional patients; improving access in underserviced areas; chronic disease management and continuity of care

Occupational Therapist

Ontario Society of Occupational Therapists (OSOT)

Overview of Role in Team-Based Primary Care

Supports patients’ ability to participate in daily activities through functional assessment and intervention

Scope of Practice

Functional assessment; cognitive and environmental interventions; adaptive strategies; return-to-work planning

Examples of High-Impact Use in Primary Care Settings

Mental health care; aging-in-place supports; functional assessments that reduce hospital admissions and long-term care placement

Pharmacist

Ontario Pharmacists Association (OPA)

Overview of Role in Team-Based Primary Care

Optimizes medication therapy and supports safe, effective medication use within the care team

Scope of Practice

Medication reviews; prescribing and adapting medications within scope; patient education; chronic disease support

Examples of High-Impact Use in Primary Care Settings

Pharmacy management; deprescribing; chronic disease monitoring; reducing adverse drug events

Physician Assistant

Canadian Association of Physician Assistants (CAPA)

Overview of Role in Team-Based Primary Care

Extends physician capacity, provides clinical care under medical directives within interprofessional teams

Scope of Practice

Medical assessment, diagnosis, treatment, and procedures under supervision; care coordinationort

Examples of High-Impact Use in Primary Care Settings

Improving access and continuity; reducing physician workload; enhancing team efficiency in high-demand practices

Physiotherapist

Ontario Physiotherapy Association (OPA)

Overview of Role in Team-Based Primary Care

Supports mobility, injury recovery, and functional rehabilitation across the lifespan

Scope of Practice

Assessment and treatment of movement disorders; rehabilitation; pain management; patient education

Examples of High-Impact Use in Primary Care Settings

Early intervention for musculoskeletal conditions; fall prevention; post-acute rehabilitation within community settings

Psychologistst

Ontario Psychological Association (OPA)

Overview of Role in Team-Based Primary Care

Provides assessment and treatment of mental health conditions using evidence-based therapies

Scope of Practice

Psychological assessment; psychotherapy; diagnosis of mental disorders; consultation

Examples of High-Impact Use in Primary Care Settings

Integrated mental health care; reducing wait times for therapy; supporting complex patients with comorbid conditions

Dietitian

Dietitians of Canada – Ontario

Overview of Role in Team-Based Primary Care

Provides nutrition assessment and counselling, supports prevention and management of chronic disease

Scope of Practice

Nutrition assessment; individualized care planning; counselling; population health interventions

Examples of High-Impact Use in Primary Care Settings

Diabetes and cardiovascular disease management; prenatal and pediatric nutrition; addressing food insecurity

Registered Nurse

Registered Nurses’ Association of Ontario (RNAO)

Overview of Role in Team-Based Primary Care

Provides clinical care, coordination, education, and system navigation within interprofessional teams

Scope of Practice

Assessment, care planning, health promotion, chronic disease management, care coordination

Examples of High-Impact Use in Primary Care Settings

Preventive care delivery; chronic disease monitoring; patient education and navigation

Registered Practical Nurse

Registered Practical Nurses Association of Ontario (RPNAO)

Overview of Role in Team-Based Primary Care

Supports direct patient care and team functioning through clinical and supportive roles

Scope of Practice

Clinical assessments within scope; patient care delivery; collaboration with team members

Examples of High-Impact Use in Primary Care Settings

Increasing team capacity; improving access to timely care; supporting chronic disease follow-up

Respiratory Therapist

Canadian Society of Respiratory Therapists (CSRT)

Overview of Role in Team-Based Primary Care

Supports assessment and management of respiratory conditions across multiple settings

Scope of Practice

Pulmonary assessment; therapeutic interventions; patient education; chronic respiratory disease support

Examples of High-Impact Use in Primary Care Settings

COPD and asthma management; reducing hospital admissions; smoking cessation support

Social Worker

Ontario Association of Social Workers (OASW)

Overview of Role in Team-Based Primary Care

Addresses psychosocial determinants of health, supports patients navigating complex systems

Scope of Practice

Psychosocial assessment; counselling; advocacy; system navigation

Examples of High-Impact Use in Primary Care Settings

Mental health and addictions care; addressing social determinants of health; crisis intervention

Speech-Language Pathologist

Ontario Association of Speech-Language Pathologists and Audiologists (OSLA)

Overview of Role in Team-Based Primary Care

Supports communication and swallowing across the lifespan, improving quality of life and care outcome

Scope of Practice

Assessment and treatment of speech, language, voice, and swallowing disorders

Examples of High-Impact Use in Primary Care Settings

Early childhood development; stroke recovery; supporting aging populations and dementia care

Traditional Healer

Community - and Nation - based organizations (varies)

Overview of Role in Team-Based Primary Care

Provides culturally grounded healing practices that support holistic health and wellness

Scope of Practice

Traditional healing practices as defined by community; spiritual, emotional, and cultural care

Examples of High-Impact Use in Primary Care Settings

Indigenous-led primary care models; culturally safe care; improved trust, engagement, and outcomes for Indigenous patients