Diabetes care in California’s Lost Hills

Project IMPACT: Diabetes improves care for farm workers


A tough commute isn’t enough to discourage Joan Werblun, RN.

“It takes me 3 and a half hours or so, over 500 miles round trip,” Werblun, Community Champion for the California Health Collaborative in the APhA Foundation’s Project IMPACT: Diabetes, says of her drive from her home near Sacramento to Lost Hills, a sparsely populated, predominantly agricultural region in California’s Central Valley, near Bakersfield.

“Lost Hills is very aptly described,” Werblun told Pharmacy Today. “You just drive west, and you drive, and you drive. All of a sudden, in the middle of this flatland, you see what looks like an industrial complex.”

This industrial complex, owned by Paramount Farms, houses storage buildings bigger than 12 football fields, 33,000 acres of pistachio trees and nearly as many of almonds, and more than 100 metal silos that hold 1.5 million pounds of pistachios—each. It’s also where Werblun helps coordinate a novel patient outreach program aimed at the migrant workers in Paramount’s fields and processing plants.

Right place, right time

Werblun joined up with Paramount Farms, the world’s largest pistachio grower and processor, because of a happy coincidence: at the same time the California Health Collaborative, of which she serves on the Board of Directors, was looking to leverage a Project IMPACT: Diabetes grant from the APhA Foundation to provide diabetes care to rural farm workers, Paramount was trying to work out a way to expand its free onsite health coverage to include exactly those services.

“Like a lot of other rural communities across the United States, we have a lot of problems with health conditions like diabetes,” explained Roxanne Wolfe, Paramount’s Health Benefits Administrator. “We wanted to develop a program internally that would not only help the folks with diabetes, but also the prediabetes population.” Recognizing that Paramount couldn’t do that on its own, Wolfe and her colleagues started looking to maximize the relationship with local partners to create a successful diabetes initative.

In addition to the California Health Collaborative and Paramount, the team includes Komoto Pharmacy, National Health Services, Avenal Community Health Center, and MedCor. The close working relationship among these disparate groups is key to the success of the project, Werblun said, noting, “We’re all in this together.”

Overcoming barriers

Once Werblun and Wolfe had assembled their team and were ready to begin the project, the first step was to educate supervisors and corporate leadership about the program, market it to employees, and provide diabetes screenings to Paramount’s hundreds of workers. This was no small task, Werblun explained, considering that those employees regularly work 12-hour shifts ending at staggered times and have to drive long distances to get home.

“We spent days and nights screening people, to get all shifts,” Werblun said. “We advertised throughout the plant, we sent e-mails, we put the word out everywhere that there was a project for diabetes and to come and be screened.” All told, they were able to screen more than 400 people out of more than 1,000 employees.

Another challenge in working with Paramount employees were the language and cultural barriers, as many workers are originally from Mexico and speak only Spanish. Jessica Alvarado, a recent graduate of the University of California, Riverside, with a dual degree in social work and Spanish, was hired by the California Health Collaborative as the project’s promotora—a community liaison specializing in health care who encourages participation by building relationships and trust with patients.

After screening as many employees as they could, Werblun and her team identified 72 patients who were eligible for the program under the Project IMPACT: Diabetes guidelines, which include being at least 18 years of age, not being pregnant, and having a glycosylated hemoglobin (A1C) level of at least 7%.

Assessments and interventions

With the patient list finalized, the Lost Hills team has moved on to the next step—patient assessments. The team is utilizing the APhA Foundation’s diabetes knowledge assessment tool, part of the Patient Self-Management Credentialing Program. Pharmacists will interview all Paramount employees participating in the program to determine their next steps, said Brian Komoto, PharmD, President and CEO of Komoto Pharmacy.

“We’re right in the middle of the management of the patient with diabetes,” Komoto told Today. “Many [patients] do not have a good understanding of diabetes and how they can control it, so part of our job is patient empowerment. At the beginning, it’s really to help them understand the disease and that they can affect and control it.”

Based on the results of the initial visit, Komoto’s team will create a customized care plan for each patient, including educational classes on subjects such as diet and exercise, as well as one-on-one pharmacist counseling sessions. Komoto said that the individual visits should take place quarterly—perhaps more often if necessary. During these sessions, pharmacists will go over the patients’ medications and their use of such devices as blood glucose meters and ensure that patients are maintaining control of their diabetes.

Komoto noted that one benefit of the Project IMPACT program is that each patient’s record lists his or her primary care provider. “We know [whom] we need to contact” to recommend changes to therapy, he said—something that can be particularly challenging when some patients use a private physician, some use rural clinics, and some use Paramount’s onsite clinic. Komoto recalled one patient he was treating who had an A1C level of 12%; thanks to Project IMPACT, he was able to contact the physician to get the patient on a more appropriate regimen.

Classes are a bit trickier to schedule than the individual visits, Werblun said, because of patients’ work schedules and the need to maintain productivity in the plant. She said that classes will likely take place onsite, with three classes on 2 days each week. Classes will be held during lunch, which the program will provide.

The basic Project IMPACT criteria weren’t enough for Werblun and her partners, though. They also identified another 130 patients with prediabetes to work with separately from the APhA Foundation’s research. “We’re hoping that in the end, we can say that … by doing [interventions] in patients with prediabetes, we can prevent these people from moving on to developing diabetes by getting them on a diet, by getting them into an exercise program, by changing some of their health habits,” she explained.

‘They said it couldn’t be done’

Providing a free diabetes care program to the employees of a massive pistachio-growing operation in a remote area of California, overcoming cultural and linguistic barriers along the way, may sound nearly impossible. Werblun, Wolfe, Komoto, and their colleagues are not short on confidence in their ability to improve the health of this underserved patient population, however.

“We don’t need to make supermodels out of people,” Wolfe said. “We want to get people to understand what diabetes is and what the ramifications of prediabetes are. … If I have someone with diabetes, [I want to] give them the tools, the equipment, the medication, and the best care plan that meets their needs so they can self-manage and bring their condition under control.”

One goal the Lost Hills team has in mind is to create a system that isn’t just a temporary fix. “These bridges that we’re building, we’re building them not just for the project,” Werblun said. “They’re something that we can leave behind, that the company will be able to use.”

Even sustainability isn’t enough, she added, mentioning expanding the program to Paramount’s associated companies and even starting community-based classes about other chronic diseases for children as well as adults.

“They said it couldn’t be done, but we’re doing it,” Werblun added. “We’re going to make this work!”

APhA Foundation making an IMPACT

Project IMPACT (Improving America’s Communities Together): Diabetes is a national initiative of the APhA Foundation that aims to improve care for patients with diabetes through community-based interdisciplinary teams that include pharmacists.

This project scales previous Foundation initiatives such as the Asheville Project, Patient Self-Management Program: Diabetes, and the Diabetes Ten City Challenge in 25 communities across the United States. As part of the program, the Foundation will provide communities with tools, resources, guidance, and support to facilitate their success.

Pharmacy Today will profile these Project IMPACT communities over the coming months, bringing you stories of innovative and unique diabetes care programs from coast to coast. Look for a profile of the Eau Claire (SC) Cooperative Health Centers in next month’s issue of Today.

For more information about Project IMPACT: Diabetes, visit the APhA Foundation’s website at www.aphafoundation.org.