Performance monitoring: Use of PM 1 5 and QM 1 6 for feedback on performance and quality of care. Program elements (at least 2): 1. Patient educational materials or sessions on hypertension. Availability of BP-specific follow-up in 1 mo (telephone based, with HBPM, telehealth, or clinical support or clinician follow-up). Ability of patients to contact team-based care team in a timely fashion about hypertension concerns (telephone, secure EHR messaging, email, urgent appointments). 4. Algorithm for medication titration led by clinical support team member and lead clinician supervision. 5. Timely follow-up and monitoring of laboratory results, with titration of relevant drug classes. 6. Monitoring adherence by using pharmacy fill data. 7. Provider-specific performance reports with hypertension metrics. (Continued) 41 Rationale RCTs and meta-analyses of RCTs of team-based hypertension care involving nurse or pharmacist intervention demonstrated reductions in SBP and DBP and/or greater achievement of BP goals when compared with usual care.194 197 Similarly, systematic reviews of team-based care for patients with primary hypertension, including a review of studies that included community health workers, showed reductions in SBP and DBP and improvements in BP control, appointment keeping, and hypertension medication adherence as compared with usual care.198,199 Team-based care can be defined by numerous structures that are functional and improve care in various settings and patient populations. Inherently, they try to provide a division of labor and improved workflows so that the delivery of quality care is maximized/optimized. Disease-management-specific programs and protocols help identify areas to improve workflow and patient-centered care. AHRQ summary statement of team-based care: the primary goal of medical teamwork is to optimize the timely and effective use of information, skills, and resources by teams of health care professionals for the purpose of enhancing the quality and safety of patient care. 