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Capital City Diabetes Collaborative to Launch New Diabetes Care Pathway

The Capital City Diabetes Collaborative, a group of medical experts convened by Trenton Health Team (THT) to address diabetes in Trenton, is launching a new, comprehensive and standardized Diabetes Care Pathway with the support of a broad swath of stakeholders and partners in the Trenton clinical care community. The effort is part of the Merck Foundation initiative, Bridging the Gap: Reducing Disparities in Diabetes Care, a grant program funding eight sites nationwide.

In Trenton, 16% of residents have diabetes, double the rate of other New Jersey towns. In 2017 THT reconfigured its Community-Wide Clinical Care Coordination Team (C4T) and formed the Capital City Diabetes Collaborative to address diabetes. The team includes representatives from every major clinical field for diabetes intervention, including: Primary Care, Endocrinology, Nephrology, Podiatry, Ophthalmology, Clinical Pharmacy, Behavioral Health, Nutrition, and Care Management.

The team has been meeting regularly for a year to compile all of the diabetes care protocols currently in use, and then made decisions around the most effective ways to prevent and manage diabetes in Trenton. The result was Diabetes Care Pathway: Trenton, NJ, a comprehensive document for clinicians detailing the most effective ways to treat diabetes patients in the greater Trenton community.

The pathway describes a three-pronged approach to diabetes prevention and management: patient education, social needs referrals, and self-management support. These three methods of intervention are shown to lead to positive, sustainable lifestyle changes among patients. To achieve the best possible outcomes, the document instructs Trenton healthcare providers to incorporate an individualized treatment model, defined as: timely, collaborative with patients, evidence-based, and individualized to patients’ preferences. Additionally, as a preventative measure, treatment will include a range of tests for issues that correlate with diabetes complications, such as high blood sugar.

This broad agreement across sectors is rare for clinical care pathways, and its widespread adoption in Trenton to treat and manage diabetes is reflective of THT’s core vision, to build innovative multi-sector partnerships dedicated to the health and well-being of the greater Trenton community. In the future, THT anticipates that this unified approach will be used as a model to treat diabetes in other cities, and to tackle a range of other health issues facing Trenton residents.

“Getting buy-in from experts across every sector was key to the success of this project,” said Gregory Paulson, Executive Director of Trenton Health Team. “With every viewpoint represented, we were able to determine the optimal solution for each stage of treatment.”

“The goal is for every diabetes patient in Trenton to receive consistent high-level care, regardless of which healthcare provider they choose,” said Dr. Eric Schwartz, Executive Director of Capital Health’s Institute for Urban Care and Principal Investigator for the Merck-funded project. “Knowing that our diabetes care pathway was vetted by experts from multiple industries makes us confident that we will achieve the best possible results.”

“We are proud to align with Trenton Health Team to address the diabetes crisis in Trenton,” said Susan Jones, Registered Dietitian of Henry J. Austin Health Center and contributing member of the Capital City Diabetes Collaborative. “With so many experts representing such a wide range of experience contributing to this project, I have hope that we will see real progress on this issue moving forward.”

With research completed, THT is poised to move into the project’s implementation phase. Partner organizations, including; Capital Health, Henry J. Austin Health Center, and St. Francis Medical Center, are now working on final approvals, with full adoption of new processes expected to take place in January 2019.