Washington, DC: The National Academies Press, 2014; permission conveyed through Copyright Clearance Center, Inc.190 AUDIT-C indicates Alcohol Use Disorders Identification Test-C; HARK, Humiliation, Afraid, Rape, Kick; NHANES III, National Health and Nutrition Examination Survey III; NHIS, National Health Interview Survey; and PHQ-2, Patient Health Questionnaire-2. 40 Appendix A. Continued Implementation of a System of Care for Patients With HBP SM-7: Use of Team-Based Care to Better Manage HBP Measure Components The CDU relies on various available components of team-based care in clinical settings for patients with HBP, which may include: Pharmacists RNs/APRNs Physician assistants Medical assistants Community health workers Integrated care managers Social workers Behavioral interventionists Trainees Algorithms to support clinicians EHR support (BP recording, actionable prompts for clinicians, population health management) Remote HBPM (EHR integration) Monitoring performance metrics Population health management Telephone-based follow-up Regular team meetings (best practice updates, workflow evaluation) Assigned roles and responsibilities (patient and clinicians, clarity about team member roles) *Optional: SM-4: EHR to diagnose and assess, SM-8: use of telehealth, SM-10: performance measurement Goals of team-based care: Improve clinical workflow Patient education Closer follow-up of BP after initiation Medication titration Laboratory follow-up Improved adherence Lower clinician burn-out193 Checklist Goal: To optimize outpatient hypertension management (to be specifically stated as team s purpose/responsibility). Team Members: Lead clinician (at least 1): APRN or physician Clinical support (at least 1): pharmacist, nurse, physician assistant, medical assistant, community health worker, care manager, or EHR support modules specific to hypertension Administrative support (at least 1): scheduler, receptionist Expert referral (onsite or external): designated referral system for refractory patients: cardiologist, nephrologist, endocrinologist Team meetings: regular meetings on at least a quarterly basis to evaluate delivery of care for patients with hypertension. Performance monitoring: Use of PM 1 5 and QM 1 6 for feedback on performance and quality of care. 