Diabetes Outreach and Education

• Care Management
• Screening and Outreach
• Resources

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:

Project Dulce

This peer mentor education/support group uses a curriculum provided by Scripps Health featuring practical advice and real-life examples on diabetes care and education. Our peer educators work closely with participants to develop confidence in self-management and provide a space for people living with diabetes to learn comfortably. It is an evidence-based five session curriculum, lessons include:

• Getting to Know Diabetes

• Healthy Eating

• Healthy Coping & Physical Activity

• Diabetes Medications

• Staying Well with Diabetes

Classes are offered in-person and virtually, and in both English and Spanish. If your community or organization is interested in hosting this course conducted by one of our peer educators, reach out to Bilquis Busari at obusari@trentonhealthteam.org for more information. Any individuals who are interested may also reach out to Bilquis.

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 and CBOs to address needs related to food, clothing, shelter, and finances.

If you or someone you know is seeking additional assistance with navigating the health space or learning about more programs, reach out to Aida Martinez martinez@trentonhealthteam.org to learn more or visit the Care Management website.

Produce Rx

In partnership with Snipes Farm and Education Center, a certified organic, local family-owned farm, we will provide fresh produce boxes and education materials to people with diabetes once a week for eight weeks. Participants must undergo a SDoH screening to determine eligibility. 

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. 

If your community or organization is interested in having THT’s Diabetes Outreach team at your event, reach out to Bilquis Busari at obusari@trentonhealthteam.org for more information.

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.

If you are a healthcare professional with an interest in diabetes and want to get involved, contact Aida Martinez amartinez@trentonhealthteam.org for more information.

DIABETES RESOURCES- FOR PATIENTS

• Diabetes Patient Education Booklet — (English) (Español)
• Gestational Diabetes Booklet – (English) (Español)
  • https://drive.google.com/file/d/1bWeNEsw3ZJFfvNakZojP9u8V39KgAOvK/view?usp=sharing
• Insulin Guides (vial and insulin pen)
• Multilingual diabetes handouts

DIABETES RESOURCES- FOR PROFESSIONALS

• “Diabetes Care Pathway”
• Diabetes Medication Algorithm — a guide showing which medications are covered by various Medicaid plans.
• Community Health Collaborative Facilitates Health System and Community Change to Address Unmet Medical and Social Needs in New Jersey Journal of General Internal Medicine, March 2023
• Bridging the Gap: Stories from the Field videos
  • Judith Hamilton, Peer Educator from Trenton Health Team 
  • Susan Jones, Registered Dietitian and Nutritionist from Henry J. Austin Health Center
• 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 Management and Oral Health among Older Adults Experiencing Homelessness  National Center for Equitable Care for Elders, Harvard University, August 2019

GOALS

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.