Addressing Diabetes Disparities

Diabetes outreach and education has been an important initiative at THT for over 5 years. The primary goal is to address major barriers identified with the management of diabetes in Trenton. This includes circumstances such as the lack of coordinated care among health services, the need for peer support and education for diabetes self-management, and lack of access to healthy foods to aid those working their best to control their disease.

This initiative is made up of the following programs:

Care Management and Navigation

The Care Management Team provides access to a full range of services to individuals with complex health and social conditions that are directly referred from community partners. Social Determinants of Health (SDoH) screenings and social, psychological, and health care support are provided in addition to accompaniment to medical appointments and local social service agencies to address needs related to food, clothing, shelter, and finances.

Screening and Outreach

THT conducts community outreach and screenings throughout Trenton. Screenings include HbA1c (blood glucose level), blood pressure, height, weight, and social determinants of health (SDoH). If a screening is not possible, THT still provides health information and handouts at community events. 

Amputation Prevention

The Amputation Prevention Project is a multifaceted intervention to prevent diabetes-related complications, including amputations, among Medicaid members living in the greater Trenton area. Our team has conducted thorough literature reviews to identify best practices for minimizing these complications. Based on our findings, we will implement and test various preventive care strategies, such as endocrinologist visits, HbA1C testing, and foot screenings. Additionally, we are partnering with Johnson & Johnson’s Save Legs, Change Lives campaign to raise awareness about amputation prevention in the community. For more information on this project, please email Bilquis Busari at obusari@trentonhealthteam.org.

Project Dulce

In previous years, our diabetes program has included Project Dulce, an evidence-based 5 to 6-week curriculum to help community members understand the condition of diabetes, as well as healthy food distribution (previously referred to as ProduceRx) in collaboration with Snipes Farm and Education Center. 

Project Dulce Class offerings were versatile and adapted to meet community needs with offerings in English, Spanish, Haitian-Creole. 

Classes covered topics including, but not limited to:

• Blood sugar monitoring
• Recognizing + treating hypoglycemia + hyperglycemia
• Principles of healthy eating + the MyPlate method
• Stress management + physical activity
• Medications
• Risk reduction + complication prevention
• Technology + diabetes
• Preparing for travel

Produce Rx

For the healthy food distribution aspect of our diabetes program, Trenton Health Team partnered with Snipes Farm and Education Center to provide participants with certified organic fresh produce once a week for 8 weeks.

C4T – Diabetes Stakeholder Group

C4T is a Trenton diabetes care stakeholder group of medical professionals with backgrounds in endocrinology, nutrition, pharmacy, primary care, and more. This group provides guidance and leadership on CCDC projects such as the development of an evidence-based diabetes care pathway. This has been a long-standing Community Advisory Board workgroup of Trenton Health Team (THT) which meets quarterly.

Living With Diabetes? Join Our Incentive Program.

We’re offering up to $100 in gift cards for attending your doctor’s appointments, as well as completing diagnostics. If you’re interested in participating, please click the button below!

What are THT’s goals with outreach?

We are focusing on:

• Health Care: Improving health outcomes of Trenton residents with type-2 diabetes

• Social: Increasing patient engagement and self-management of type-2 diabetes

• Environmental: Increasing the availability of healthy foods for the Trenton community

To accomplish these goals, we are working to unify the care delivery process by streamlining systems that impact information, decision support, treatment, and modes of communication for patients and providers.

If you or your organization is interested in getting involved or looking for more information, please reach out to Amanda Mungcal at amungcal@trentonhealthteam.org or Judith Hamilton at jhamilton@trentonhealthteam.org.