Care Teams

Our most important step in becoming a health home is the creation of multidisciplinary care teams.


At Health Care for the Homeless, we are becoming a health home in order to provide integrated, whole‐person care—of the highest quality possible—to all of our clients. While this transition means improving many areas and aspects of our practice, our most important step in becoming a health home is the creation of multidisciplinary care teams.

Each team represents a mix of the clinical disciplines here at Health Care for the Homeless. And collectively, the members of each team provide all the care and services our clients need to move toward better health and stability. Each team works as a single, cohesive group of diverse providers who share clients and collaborate to develop goals and a care plan for each client.

With high-functioning care teams we will be better positioned to deliver safe, efficient and coordinated health care that addresses the whole person, including the complex barriers to care that our clients face.


Care teams 101 at Health Care for the Homeless

  • Each care team has 6-12 members representing the range of clinical roles needed to meet all clients’ whole-person care needs.
  • Each team is identified by its own color. 
  • Each team has its own panel of clients.
  • All care teams are guided by a set of five principles to ensure their success.
care team member

"Everyone in the huddles is on the same page when it comes to how to approach a client regarding certain issues, and comes together to present things that others may not know. This happens often!"

Five principles

Five principles guide our care teams:

1) Shared Goals. The team—including the client and, where appropriate, family members or other support persons—works to establish client goals that reflect client priorities, that can be clearly articulated and that are understood and supported by all team members.

2) Clear Roles. There are clear expectations for each team member’s functions, responsibilities and overall team role. Together, these maximize overall team efficiency, making it possible for the team to divvy up—and not duplicate—work and do more for clients.

3) Mutual Trust. Team members share trust that results in a team spirit of reciprocity and shared achievement.

4) Effective Communication. The team prioritizes communication and establishes channels and norms for clear, complete, candid communication.

5) Measurable Outcomes. Team members agree on and implement reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team’s goals. These are used to track and improve performance immediately and over time.