Diabetes Outreach and Education

Funded through the Merck Foundation’s “Bridging the Gap: Reducing Disparities in Diabetes Care” initiative, the Capital City Diabetes Collaborative, or CCDC, is addressing major issues identified with treatment of diabetes in Trenton, such as 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.

How does the CCDC help?

Through “Bridging the Gap,” the CCDC brings together many different sectors to promote improvements in diabetes care.  Specifically, we are focusing on goals in three sectors:

  • Health Care: Improve health outcomes of Trenton residents with type-2 diabetes
  • Social: Increase patient engagement and self-management of type-2 diabetes
  • Environmental: Increase 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.

Additionally, we are collaborating across sectors to support self-management programs and patient education, along with a Trenton-based online food delivery system, which will provide healthy food deliveries to diabetes patients living in the city, increasing access to healthy foods and encouraging healthy lifestyle choices that may help with disease self-management. Partners include Snipes Farm & Education Center

Project Dulce

This peer mentor education/support group uses a curriculum called “Diabetes Among Friends” featuring practical advice and real-life examples to train peer educators to share understandable diabetes care and education that still meets American Diabetes Association standards.

Participants receive healthy foods, recipes and cooking demonstrations, along with tips for maintaining a healthy and active lifestyle. Classes are facilitated by trained THT staff. For more info, contact Population Health Program Manager Aida Martinez or Peer Educator Judith Hamilton.

“Our goal is that everyone in Trenton who has diabetes or cares for someone with diabetes has access to a program with mentors, right  in their neighborhood, to provide what they need to effectively manage their disease,” THT Senior Director of Population Health Ernest Morganstern said. “Is there a cure for diabetes? No–but with effective behavior modification and good medical care, you can live longer without complications.”

Project Dulce is supported by The Horizon Foundation.

Click on RESOURCES below for links to download care pathway and other diabetes information


Updated “Diabetes Care Pathway”

Diabetes Medication Algorithm — a guide showing which medications are covered by various Medicaid plans.

NEW! Integrating Technology and Human Capital to Address Social Needs: Lessons to Promote Health Equity in Diabetes Care  Journal of Health Care for the Poor and Underserved May 2021

Diabetes Patient Education Booklet — in English and en español

Diabetes Management and Oral Health Among Older Adults Experiencing Homelessness
Click here to view presentation slides and a recording of the webinar hosted by The National Center for Equitable Care for Elders and The Corporation for Supportive Housing featuring THT Director of Population Health Natalie Terens discussing the CCDC at work.

Download a case study of promising practices for addressing diabetes and oral health in the older adult population. (August 2019)

Complex Endocrinology ECHO Program Information — 20 session series begins Sept 19, 2019 Details & Registration info here

Bridging the Gap: Reducing Disparities in Diabetes Care

Learn about our diabetes outreach efforts to help address needs and improve well-being.


Comparing Trenton or Mercer County data with New Jersey rates: