PHMI is focused on improving quality of care and equitable health outcomes for five high-priority populations, in alignment with the population health goals set by the California Department of Health Care Services. Each Community Health Center (CHC) participating in PHMI has selected one or more population of focus and metrics that are most meaningful for the care they deliver and the people they serve. Focus areas are:
- Children
- Pregnant People
- Adults with Preventive Care Needs
- Adults Living with Chronic Conditions
- People with Behavioral Health Conditions
The measures associated with these Populations of Focus (PoF) are directly aligned with APM 2.0 to help organizations align payment structure with equity-based population health.
Saban Community Clinic in Los Angeles is one of the 32 CHCs participating in PHMI and selected People with Chronic Conditions for their PoF, with specific focus on patients with diabetes.
Claire Richardson, PHMI coach for Saban said, “In the most classic sense, they are using an extended care team and those on it to the top of their license and in ways that are meaningful to patient outcomes… In my humble opinion, they are the epitome of how managing medication therapies should work!”
Below is an interview with Friedman about Saban’s innovative approach to diabetes care.
How would you describe your clinic and the populations you serve?
We're a community-focused Federally Qualified Health Center (FQHC) serving primarily medical patients in Central LA, with a focus on the Hollywood area. We serve about 25,000 patients a year with a range of services—primarily primary care, but also dental and behavioral health, as well as specialty care like ophthalmology, pulmonology, and cardiology. We also focus on the LGBT and homeless communities, with specific homelessness programs serving about 2,000 to 3,000 patients a year.
We provide services in various capacities, including case management. Our infectious disease team also overlaps with the LGBT community, focusing on HIV, other sexual health diseases, and gender-affirming care.
Tell us about your Clinical Pharmacist-Managed Diabetes and Hypertension Clinic?
We have an integrated pharmacy in our organization, where we have clinical pharmacists trained in various clinical pharmacy activities. They specifically help patients manage their diabetes and hypertension through medication, patient engagement, follow-up, and more. Licensed clinical pharmacists either receive patient referrals or conduct outreach to enroll patients in the program.
Patients meet with the clinical pharmacist to review their medications, conduct medication reconciliation, and focus on managing diabetes. For patients with diabetes, the program includes ensuring they understand their disease, the consequences, and their prescribed medications. The pharmacist also covers dietary concerns within their scope and establishes care plans for regular follow-ups. They ensure patients have access to diabetes-related tools like Continuous Glucose Monitors, and we schedule regular follow-up appointments [every six weeks]. We also track A1C levels and other key indicators over time.
How long has the clinic existed and what spurred its creation?
It started around 2019. Diabetes has always been a growing issue for us, as it is across the country. As we expanded our pharmacy, we identified various opportunities. One of these opportunities was to leverage our licensed clinical pharmacists, who have the expertise to work independently with patients. This allows them to provide targeted care to patients without overburdening the providers. It's really a way to focus on this population and provide them with the services we already have in scope to help on a population level.
How many pharmacists do this work?
We have two at the moment.
What barriers or challenges have you had to overcome with the program, and what advice would you give to other CHCs who might be interested in implementing something like this?
The biggest barrier is payment, because we have individuals who aren't typically reimbursable. In theory, if we move to value-based care, that could change. We had to restructure our billing process so visits are overseen by providers, even though they aren’t conducting the visits. This created another challenge where providers have to sign off on visits they weren't present for, which isn't unprecedented. We see this in other contexts, like annual wellness visits or some nursing visits.
However, as we have tried to increase the volume to address the patient population, it adds more tasks for providers. They have to review the visits and various clinical points, which is challenging, especially with an increased focus on productivity.
Another challenge, which isn’t unique to this program, is patient fidelity. We do regular, repeated outreach, but some patients still fall off—though many stay because they see real improvements.
Could you say more about how patients get enrolled in the program?
We started with provider-led referrals, where providers would refer patients to the program, and the pharmacy team would then reach out to establish care. While we still encourage providers to refer patients, we've also begun targeted outreach to patients with various A1C levels, particularly those with poor control. We try to enroll these patients in the program if they haven't been enrolled already.
When patients are physically with us, we try to capture them during their visit, even if it's just a regular primary care visit. Otherwise, we conduct phone outreach. More recently, as we've expanded care management and coordination, we've leveraged those staff members to connect patients with the clinic during their outreach efforts, including field outreach. For example, in Enhanced Care Management (ECM), where we're doing field outreach to unhoused individuals, we also try to target patients in the field. However, it's a relatively small group that we've targeted with ECM.
This outreach includes shelters, homes, and less well-known addresses, but it's a very small percentage of the population that’s quite acute. We're not doing this for everyone.
What results have you seen from the program?
We created reports to track A1C levels of patients who initially reported within a specific period or were initially out of control, with levels of 9 or above. These reports compare those enrolled in the clinic versus those who were not. We observed a significant reduction of nearly a full point in A1C levels among those in the clinic, which is a substantial drop. For example, patients with an A1C of 9 dropped to around 8, moving them into the “slightly uncontrolled” range.
How do you see the program benefiting your goals within PHMI? What would you want other CHCs to know?
The program fits incredibly well within the PHMI framework and supports a multidisciplinary care team approach. By leveraging the skills of clinical pharmacists and integrating them with our providers and care coordinators, we can effectively manage complex patients who need regular monitoring, such as retesting A1C levels. This approach allows us to provide targeted, evidence-based care without placing the full burden on providers.
It’s a great use of our pharmacy expertise, which is cost-effective compared to medical providers, but still billable since providers oversee the visits. This creates a win-win situation. Although it adds to the volume of provider visits, it effectively utilizes additional skills and has led to noticeable improvements in A1C levels. We are observing meaningful progress of half a point to a full point, which is significant in managing diabetes.
Patients report feeling healthier and better able to manage their condition, and we have data to support these improvements. Overall, this multidisciplinary approach has proven advantageous and aligns well with the goals of the program.
Having clinical pharmacists dedicated to this work on a more frequent basis is especially valuable. Providers, by the nature of their role, must become experts in nearly everything, which is challenging given their broad responsibilities.
Clinical pharmacists, while still handling general pharmacy duties, can focus specifically on diabetes care due to their specialized role. This focus allows them to provide targeted expertise and effectively manage diabetes, which helps divert some of the workload from providers. Overall, this approach has proven beneficial for both patients and providers.