Diabetes Outreach and Education

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.

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. 

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. 

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.

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 any of these programs or resources, please reach out to Bilquis Busari at obusari@trentonhealthteam.org for more information.