Your Care Team
What's a care team?
Traditionally, primary care has been provided by a doctor and a nurse. That way of delivering care worked well for many years. But as health care has become more complex, we have discovered the benefits of including providers with different areas of expertise on our patients' care teams.
The providers you see at an appointment will depend on the needs you have that day. Your team is committed to giving you exactly the care you need.
Who's on a care team?
The most important member of the team is you. You can provide us with the information we need to partner with you to achieve your health and wellness goals.
Providers (physicians, nurse practitioners, physician assistants and residents)
As a team, our provider staff brings care to all of our patients. The provider teams work together to diagnose and treat complex and acute health concerns, create plans of care and support other members of your team in delivering you the very best experience and outcomes.
Our nurse practitioner and physician assistant staff also provide face-to-face care in our Mayo Clinic Express Care clinic sites, as well as online diagnosis and treatment options.
Registered nurses (RN) - care team and care coordination
If your provider has designed a customized plan of care for your chronic condition, you may be connected to a care coordinator. These professionals will provide education about your diagnosis and follow your progress closely to ensure you are maintaining your best possible health.
Care team nurses work closely with each provider's group of patients to provide screening during your visit, blood pressure checks, well-child assessments and other assessments.
Primary Care Connection nurses are available via telephone to help diagnose symptoms, offer treatment options or coordinate an appointment to visit with your provider or care team.
Licensed practical nurses (LPN)
These providers will prepare you for your appointment, coordinate your preventive screenings and give vaccinations.
Desk, Appointment, eHealth and Secretarial Staff
These team members help you schedule appointments and tests either via telephone or during your face-to-face visit, route your Patient Online Services message to the individual who can best respond to your request, assist your provider with completing forms, and other administrative issues.
What specialty programs are associated with care teams?
The Primary Care in Rochester/Kasson Anticoagulation Clinic directly manages the anticoagulation needs of patients who have a primary care provider at one of our sites. There are locations at both Mayo Family Clinic Northeast and Mayo Family Clinic Kasson, which are staffed by a team of LPNs, RNs, pharmacists and a physician medical director.
Care Transitions Program
This program helps patients (age 60 and older) who are leaving the hospital or skilled nursing facility. It provides transition care to improve health outcomes and reduce the chance of being readmitted to the hospital. Patients who need this transition care are identified during their hospital stay and may be enrolled in this program then.
Integrated Behavioral Health (IBH)
Integrated Behavioral Health (IBH) is an innovative health care delivery model that integrates the Department of Psychiatry and Psychology into the Primary Care setting. Behavioral health specialists work alongside internal medicine, family medicine and pediatric primary care teams to meet the psychosocial and mental health needs of empaneled patients. The goal of this model is to provide cost-effective, accessible, evidence-based behavioral health care services to primary care patients across the Mayo Clinic Enterprise. The IBH team, consisting of social workers, psychologists, APRNs, RNs, and psychiatrists, is committee to advancing contemporary models of population-based mental health care.
- Diagnostic assessment
- Short-term psychotropic medication management
- Evidence-based cognitive behavioral therapy for a range of mental health and behavioral problems
- Adult and pediatric psychiatric care coordination based on the collaborative care model
- Connecting with social service resource needs
- Assistance with triage and referrals to the right-step level of behavioral health care within Mayo Clinic and the community
Integrated Community Specialties (ICS)
This practice provides access to specialists in your primary care location. Adult specialties include: Behavioral Health (psychiatry and psychology resources), Cardiology, Endocrinology, Gastroenterology, Gynecology, Neurology, Orthopedics, and Sleep Medicine. Pediatric specialties include: Asthma, Attention Deficit/Hyperactivity Disorder, Dermatology, Developmental Disorders, Ear, Nose and Throat (ENT), and Sports Medicine/Concussion. Referrals are required from your care team.
Medication Therapy Management/Pharmacy Staff
Medication Therapy Management (MTM) is a service that provides individual consultation on all your medications. Our pharmacist team is specially trained to provide personalized, comprehensive review of all your prescription, non-prescription and herbal medications. Your MTM pharmacist will work closely with you and your care team to be sure that your medications are as safe, effective and convenient as possible.
Nursing Home and Subacute Care
Primary Care in Rochester/Kasson also provides extended health care services to local nursing homes and skilled care facilities. Our staff gives on-site care for established Mayo Clinic patients including admission evaluations, acute illness evaluation/treatment, pain evaluation/management, care coordination assistance with other health care professions and more.
Obstetrics / Prenatal Care
Family Medicine obstetrics physicians provide preconception counseling, prenatal care and delivery services. If you are ready to start or grow your family, our obstetrics providers offer the care you need.
Palliative Care Homebound Program
This program is a home-visit service for people who are at least 60 years old, homebound and high-risk, frail individuals with late-stage, life-threatening illnesses. Patients are referred to this program by their primary care team.
This clinic is designed specifically for Primary Care in Rochester/Kasson patients who require minor procedures (e.g. aspirations/injections, skin biopsies, stitches, wart treatments, etc.) and other minor procedures). Patients are referred to this clinic by their primary care team. This clinic is staff by providers from Community Internal Medicine, Geriatrics and Palliative Care and Family Medicine.
Staff in this practice help patients and their families cope with the stressors and challenges caused by illness or life-altering events. They assist with assessment of patient/family needs, coordinate discharge planning, provide community referrals and counseling, and help families with coping and decision making in times of medical crises.
Find a Care Team
We believe it is important for everyone to have a primary care provider and team partnering with them in sickness and in health. Your care team can connect you to resources that can help keep you healthy. They'll remind you when you’re due for preventive exams or immunizations. Best of all, you'll have more people available to answer questions and provide care whenever you have a health concern.