LOS ANGELES – For most of Northeast Valley Health Corporation’s 70,000 annual patients, the Federally Qualified Health Center’s standard availability of services, including primary, dental, and mental health care, is sufficient to meet their health-related needs.

But for others, especially those dealing with more serious chronic conditions like hypertension and diabetes, more frequent visits have resulted in significantly better outcomes.

“A lot of diabetes care is behavior changes. Seeing patients more frequently adds a level of accountability. It helps us motivate them better to take better care of themselves,” said Nader Tossoun, an ambulatory care pharmacist at NEVHC.

Tossoun said that having more regular contact with patients also helps him to better adjust patients’ medication, based on how their condition is progressing as well as other medications they have been prescribed since the last visit.

In recent months, BD, together with Direct Relief, provided a $150,000 grant to Northeast Valley Health Corporation as a winner of the Helping Build Healthy Communities initiative. NEVHC has been able to offer more monthly visits, as opposed to only quarterly visits, to patients at the highest risk of suffering complications from their chronic conditions.

The grant has also enabled the health care center to hire a bilingual staff member, Jessica Gonzalez, who helps patients receive holistic care, both at NEVHC and beyond.

“I’m able to tackle barriers patients have that affect diabetes, like having healthy food, Gonzalez said, mentioning several local resources, like a drive-through fresh produce event, that patients might not be aware of. Based on a social vulnerability survey conducted by NEVHC, many patients are food insecure, and are also in need of household staples like clothing and diapers. Gonzalez is able to help address these needs by connecting patients with local nonprofits that offer these goods at reduced or no cost.

In some cases, her multifaceted role entails helping patients make appointments at the clinic, reminding them of upcoming appointments, and helping find transportation to the appointment. While sometimes the barrier is language – Gonzalez also works as an interpreter for patients during visits when needed – other times patients struggle to understand byzantine regulations and benefits offered by insurance companies, which she also assists with.

In addition, she helps patients with matters such as applying for state assistance program and following up with blood test results and prescription medication refills.

Gonzalez has also taken her responsibilities beyond logistics and planning. Being in touch with patients and responding to their needs, she stays aware of developments that patients might not be able to identify themselves or requests they might be reticent to ask for directly.

“If a patient says they’re really stressed, I can refer them to a behavioral therapist,” Gonzalez said.

Tossoun, citing a recent, specific example, said that Gonzalez’s work is crucial in helping his patients achieve optimal outcomes.

“I just had a patient who’s homeless. They wanted to eat better, but what’s given to them is not the healthiest option. [Gonzalez] linked them with Project Angel,” he said, of an L.A.-based organization that delivers healthy meals to vulnerable people living with severe illnesses.

“There is a clinical portion of what we need, obviously you need to know which medications are best for the patient, but they don’t live in a bubble. If they’re stressed about rent, they’re not worried about eating a salad for lunch,” he said.

“I try to speak with them and understand, and let them know I’m here for anything they need. I want them to feel confident to call me,” Gonzalez said.

NEVHC’s holistic approach has borne results. The A1C test is a blood test that reflects a person’s average blood sugar level and measures red blood cells that have sugar-coated hemoglobin. The CDC says a healthy level is below 5.7%. Prediabetes is defined as 5.7% to 6.4% and Diabetes is at 6.5% or above. NEVHC’s average diabetes patient comes in initially with an A1C level of 11%.

Tossoun said that he and his colleagues have been able to consistently get patients under 8% in 3-6 months. He said they’re able to reduce A1C by .7% per month.

“A lot of these patients are showing much greater health outcomes because of this,” he said, referring to the increased number of visits and holistic care approach.

Hoping to build off this progress, NEVHC is in the process of hiring another ambulatory care pharmacist, who will have, as one of their responsibilities, a focus on medication refill requests. The pain point this is addressing encompasses situations when a prescription set number of refills expires. At that time, a pharmacist would have to contact the prescribing physician to refill it.

“It’s hard for doctors to keep up with those,” Tossoun said. “We’re hiring to help run a refill program.”

Until then, Tosssoun, Gonzalez, and their colleagues are continuing to work from both a clinical and non-clinical standpoint to their patients achieve healthier outcomes—something that has become even more critical during the pandemic.

“A lot of what we’re doing is reminding patients that they have diabetes and if they get Covid, they are at a higher risk,” Tossoun said.

Still, as much as he tries to motivates and care for patients, ultimately, the impetus for change has to come from them.

“All I do is talk, I tell them, ‘You’re the one playing the game every single day.  You’re the one injecting and taking care of yourself.’ I ask them, ‘Why do you want to take care of yourself?’  It’s not to have nice blood sugar, it’s to be at your grandchild’s wedding and have a long happy life, which we can do if we change these habits.”

But since making major lifestyle changes is difficult, Tossoun said he tries to focus on achieving incremental victories, which can, and often do, lead to substantially healthier results.

“It’s about starting small. So instead of having five tortillas for lunch, let’s cut it down to two. It instills hope that blood sugar doesn’t have to be high even if it always has been.”

“Once they believe in themselves, they make the changes,” he said.