Table IV:

Components of Collaborative Care Intervention with Stepped-Care Approach

Components of Practice-Based Collaborative Care Model
Collaborative Care Team Member	Collaborative Care Team Responsibilities	Description of Issues Addressed
Primary Care Physician or Advance practice clinician*	Development of Diagnosis and Treatment Plan	Diagnose and evaluate hypertension for secondary causes, additional risk factors, target organ damage
	Medication Management	Modify medications; titrate and adjust dosages; address adherence issues
Care manager	Care Management and Coordination	Conduct initial behavioral/psychosocial assessment that covers NCQA domains. Educate, activate, and counsel; provide ongoing case management
	Medication Management	Recommend medication titration; address adherence issues and/or refer to PharmD/Pharmacist
	Patient Education and S elf-Management Support	Counsel about diet and weight loss strategies; promote medication adherence and/or refer to dietitian, health educator, or health coach
	Psychosocial/Behavioral/Mental Health Services	Provide counseling to address smoking, depression and other psychosocial stressors; assist patients in addressing health insurance, housing, employment, education, and other social or financial issues through referrals and advocacy and/or refer to Licensed clinical social worker, Psychologist, Psychiatrist, or Mental Health RN
Components of Stepped Care Elements
Stepped Elements	Type of Clinician/Service Provider	Description of Issues Addressed
Subspecialist Consultation Services	Subspecialty trained physicians	Engage specialists in the areas of hypertension, diabetes, psychiatry, preventive cardiology, and smoking cessation to assist primary care team in providing consultation on patients with complex management issues.
Community-based Contextualization	Community health workers	Support patients in reaching self-management goals; help patients address social and environmental barriers through outreach and navigation services; engage, activate, and empower patients to participate in the care process

^*Nurse practitioners, physician assistants