Care coordination among patients with severe mental healtillnessesss has been a long-standing challenge. Patients seen in mental health clinics oftentimes have inadequate control of diabetes, hypertension, and dyslipidemia. In addition, more than 60% of this population also suffers from co-occurring substance use disorders. Without addressing these chronic medical problems, patients with poorly managed medical conditions often were lost to follow-up. The goal of my CHIP is to utilize clinical pharmacists, who have been providing psychiatric medication therapy and treatment of co-occurring substance use disorders, to identify patients who need primary care services. For this pilot, the focus is to connect patients with high HgbA1c to primary care services offered at one of our DHS/DMH co-location clinics in LA County and conduct collaboration case conferences to co-manage this group of high-risk patients. Patients were identified through laboratory results and referrals were made electronically by clinical pharmacists to DHS patient access center. Registration of patients into DHS requires managed care to change primary care provider empanelment, but the process was streamlined by leveraging registration information collected by a clinical pharmacist and made available through electronic referral to DHS patient access center staff. Three metrics are being measured: 1) percentage of patients referred to primary care services 2) percentage of patients successfully made appointments with primary care services 3) percentage of Hgb A1C reduction after 6 months.