IPCP Roles Competency

What is the Roles Competency?

Roles/Responsibilities: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of the patients and populations served.

Roles/Responsibilities Behavioral Expectations:

  • Communicate one’s roles and responsibilities clearly to patients, families, and other professionals.
  • Recognize one’s limitations in skills, knowledge, and abilities.
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs.
  • Explain the roles and responsibilities of other care providers and how the team works together to provide care.
  • Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention.
  • Forge interdependent relationships with other professions to improve care and advance learning.
  • Engage in continuous professional and interprofessional development to enhance team performance.
  • Use unique and complementary abilities of all members of the team to optimize patient care.

Learning Objectives

To meet these competencies, it is important to understand who are the team members and what they do.  Therefore, this module will address the following objectives.

Upon completion of the online module, you will be able to:

  1. Identify who are the team members.
  2. Describe each team member's perspective of care and what they do.
  3. Discuss how the team works together to care for a patient with complex physical, psychological, social, and spiritual issues.


Team Members

Click on each + below to learn more about each team member.

  • Greet arriving patients.
  • Confirm contact info and benefits/insurance status. 
  • Provide AVS for patient to review med list prior to visit.
  • Answer incoming phone calls. Start phone note for nurse calls and assign priority, high, low, or routine.
  • Sort and distribute incoming faxes.
  • Schedule appointments as needed and return visits.
  • Calls all ‘no-shows’ at the end of the day.
  • Makes outgoing phone calls for population health reminders as delegated.
  • Assists with requests for medical records to and from Loyola.

  • Patient intake (e.g. documenting chief complaint, V/S, height, weight)
  • Review and update EHR as directed
  • Assist providers with management of point-of-care alerts for services due
  • Provide care for patients scheduled on RN schedule (e.g., BP, lab draws, or weigh recheck)
  • Various tests and procedures (e.g., castings) would not see this in our model
  • Assist in setting self-management goals and follow-up on established goals
  • Order clinical supplies
  • Forms completion

Additional MA responsibilities:

  • Medication administration per delegation guidelines or order for oral medications and injections (acetaminophen/Motrin, immunizations, Depo-Provera, Vit B12, PPD)
  • Process prescription renewals as directed by a provider or RN
  • Vaccine inventory management
  • Patient follow-up for normal and low complexity test results as directed  by provider

Additional LPN responsibilities:

  • Telephone management: follow-up on items delegated b the provider or RN (e.g. complete final disposition of triage call, test results)
  • Collect initial data for RN triage
  • Prescription refills per protocol including updating Problem List in EHR
  • Patient follow-up for mildly complex test results
  • Conduct OB first trimester intake (not sure if in our scope0
  • Provide patient instructions per protocols (e.g. diet, preps, respiratory equipment, diabetes foot care, exercise)
  • Medication administration per order for oral, topical, ophthalmic, injections (e.g. testosterone, Depo-Provera, Toradol & antibiotics)
  • Allergy injections for maintenance doses
  • Receive and manage verbal orders from providers with delegation agreement
  • Provide care for patients scheduled on clinical support staff schedule (e.g. suture removal, weight or PB recheck
  • Various tests and procedures (e.g. start IV's, straight cath), infusions (e.g. hydration), monitor blood transfusions, administer Rhogam
  • Chronic pain management. follow-up for prescription refills & other tasks per protocol (e.g. MAPS report, generating drug screening lab requisitions)

  • Clinical decision making and diagnosis based on exam, medical history and EBP guidelines.
  • Initiate and modify treatment for patient’s diagnoses. Medication reconciliation to reflect changes made during office visit.
  • Enter orders to initiate referrals, follow up visits, consults etc
  • Initiate care plan and update after visit
  • Active participant in daily huddles and weekly/BIW care coordination meetings.  
  • May participate in shared medical appointments and non-traditional office visits (phone, skype, home visits).
  • Maintain involvement in population health and stratification
  • Interprets and triages results to determine the appropriate level of follow-up needed and by which team member.  
  • Confirms that patient has received the after visit summary
  • Works with team to ensure paperwork (prior authorization, FMLA, etc) is completed and signed in a timely manner.

  • Diagnosing, treating, evaluating and managing acute and chronic illness and disease
  • Obtaining medical histories and conducting physical examinations
  • Ordering, performing, and interpreting diagnostic studies (e.g., routine lab tests, bone x-rays, EKGs)
  • Prescribing pharmacologic treatments and therapies for acute and chronic illness [extent of prescriptive authority varies by state regulations]

(APN for patients with complex needs, RN for patients with chronic stable needs)

  • Provide comprehensive and individualized access to physical health, behavioral health, and supportive community and social service, such as Catholic Charities, Proviso, Pillars Community Services, Etc., ensuring patients receive the right care in the right setting at the right time.
  • Coordinates the plan of care.  Ensure accountability for coordinating, providing, and monitoring a patient’s/Family’s needs, including prevention, wellness, medical and behavioral health treatment, care transitions, and access to social and community services through the creation of an appropriate individual plan of care that meets the needs of the patient and the family.
  • Utilize population-based tools to support and monitor wellness and care goals for each patient, aimed at preventing illness and improving individual well-being, clinical outcomes and quality of life while managing multiple chronic illness conditions.
  • Empower patients and their families/caregivers to be active participants in their care, through patient-friendly education and informed shared decision-making that is based on cooperation, trust, and respect for each individual’s health care knowledge and health literacy, values, beliefs, and cultural background.  Encourage patient self-management.
  • Case manages enrollees with complex, chronic medical and psychosocial issues.  Performs utilization management strategies for those cases managed using the lightest and most accurate resource to achieve clinical and financial outcomes outlined by the ACE.  Collaborates with members of the health care team to achieve the clinical and financial outcomes  Uses evidence based practice to build the plan of care.  Partners with enrollee to ensure outcome achievement.
  • Interfaces with providers across the continuum of care via face-to-face interaction, phone conversations, email, fax, and text messaging.
  • Assists with management of statistical data and performance improvement projects
  • Professional development: demonstrates leadership behaviors that enhance and support team functions.  Mentors and coaches staff.  Maintains competencies and participates in continuing education for self an development of colleagues and students.  Participates in delivering professional programs, courses and in-services and community events.  Seeks opportunities to promote self-education, certification, clinical ladder, and awards programs.  Maintains national certification and membership in professional organizations.  Creates opportunities to advocate for the role of the professional nurse as a key member of the multidisciplinary team. 
  • Work with case management staff to insure smooth transition from hospital to home
  • Direct relationship with Community Health Worker and interprofessional care team.

  • Interview patients to obtain nutrition assessment data regarding dietary patterns, lifestyle, food purchasing, practices, resources, and ability to understand and comply with a therapeutic diet
  • Incorporate evidence-based standards when interpreting patient related data
  • Organize patient health and disease information in order to identify nutrition-related problems
  • Perform nutrition diagnosis after identifying the problem and clarifying the cause of the problem
  • Develop and implement an individualized plan for nutrition intervention.  Assist patient with developing self-mgmt, behavior-based goals
  • Assess barriers to diet adherence including food resources, economics, and complexity of diet plan, culture and food beliefs
  • Recognize the varied needs of age-specific populations, as well as cultural, religious and ethnic concerns
  • Measure effectiveness of nutrition interventions in reaching desired outcomes
  • Maintain ongoing communication with the patient's referring physician and other health care providers to ensure continuity of care
  • Provide personal or phone contact and follow-up with patients and physicians as needed
  • Participate in program development and implementation (e.g. support and education groups)

  • Collaborate with the  interprofessional clinic team to develop, plan, implement, and coordinate biopsychosocialspiritual care plans, with a focus on high risk and transitioning patients 
  • Coordinate applications for financial , transportation, medical and  other resources to support patients and families in the community
  • Conduct biopsychosocialspiritual assessments in order to provide short-term evidenced-based counseling for patients, families, and groups related to emotional/mental health needs.
  • Assist with multidimensional assessment of pain and the provision of non-pharmacological interventions for pain management (e.g., guided imagery,  relaxation, cognitive restructuring)
  • Collaborate with the interprofessional team for complex care management  and facilitate appropriate patient referrals for health/mental health problems beyond the scope of services of the Family Medicine Clinic
  • Participate in patient/family care conferences with interprofessional team and in group health care visits as appropriate to facilitate continuity of patient care.
  • Participate with team members in the development, implementation and evaluation of support and education groups for health promotion and disease management
  • Conduct home visits as appropriate to support patient care in the community
  • Adhere to the NASW Code of Ethics including on-gong professional education to provide state of the art biopsychosocialspiritual care.
  • Work with social work students as a Field Instructor in conjunction with Loyola University Chicago and the University Liaison.
  • Meet the Department of Social work management accountabilities of attendance at social work staff meetings, completion of medical record chart notes and statistical reports, and completion of LUMC mandatory education classes and regulatory compliance.

What is a clinical psychologist?

  • A PhD prepared and licensed professional in psychology
  • Training in three areas:
    • Clinical work—Training in psychotherapy
    • Mental health and cognitive assessments
    • Research
  • In primary care, the role focuses on clinical work


  • Order/maintain equipment
  • Staff scheduling (both clinical and administrative support staff)
  • Liaison between clinical and support staff
  • Conflict management
  • The Joint Commission readiness
  • Monitor compliance with clinical competencies for staff

Let’s put it all together in a care situation:

Here is a case study applying roles to a patient scenario: