Primary care delivered in the context of a team whose members form a cohesive unit can improve health care outcomes (49). However, the composition of the optimal health care team for coordination of care has yet to be defined. In current generalist practice in the United States, the composition of teams varies greatly among settings. Generalist physicians, practice nurses, and nurses' aides are usually included, but few practices include other personnel (such as generalist office staff, clinical pharmacists, hospitalists, community nurses, and social workers), even though it might improve care coordination (2). A major challenge for generalist practice is to assemble core teams from a long list of “potential players” that are relevant to the patients and communities being served and that are sustainable within the local health care system. Table 2 describes potential team members who may contribute to the process of care coordination. The core team in almost all cases will include the patient, the primary care physician, 1 or more staff members, and subspecialists; others should be added as needs become more complex. For example, in a general internal medicine practice that serves a generally elderly, low-income Hispanic population, the core team might include a family advocate from the community, general internist, geriatric nurse practitioner, geriatric specialist physician, social worker, and medical interpreter. As many persons on the team as possible will be bilingual. The internist would provide overall team leadership, whereas the social worker would be in charge of most care coordination activities.