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Trenton Health Team Announces Five-Year Program to Improve Access to Diabetes Care for Trenton Residents

Trenton Health Team today launched the Capital City Diabetes Collaborative to improve health outcomes of Trenton residents with diabetes, increase patient engagement and self-management of their disease and improve the availability of healthy foods for Trenton residents. Trenton Health Team is one of eight program grantees supported through the new $16 million, five-year Merck Foundation initiative, Bridging the Gap: Reducing Disparities in Diabetes Care, to help mobilize community-based partners and improve diabetes care for vulnerable and underserved populations in the United States.

Within the six zip codes of Trenton, 31% of adults have hypertension and 16% have diabetes, compared with approximately 9% for Mercer County, NJ and the United States. High rates of diabetes and its related complications, such as heart disease and stroke, are due in large part to a number of barriers to care. These include challenges in obtaining medications, lack of coordinated care across providers, and limited knowledge about diabetes, its complications and the importance of regular screenings and compliance. Within the city, 52% of residents are African-American and 34% are Hispanics.  With nearly 26% of residents living in poverty, additional barriers include: economic, environmental, social and behavioral challenges.

Promoting health equity among people with diabetes requires a comprehensive approach that brings together high-quality health services with resources drawn from outside of the health system. Collaboration across multiple sectors can address the many factors that influence health, such as access to healthy foods, and safe options for physical activity, housing, and education.

“Diabetes is one of the most prevalent chronic conditions among our residents and has been a central focus of many of Trenton Health Team’s efforts,” stated Gregory Paulson, Executive Director, Trenton Health Team. “While we continue to see improved outcomes, we recognize the need to create a unified, comprehensive, multi-disciplinary, evidence-based system that is consistent across city providers and tailored to the needs of individual patients.”

Trenton Health Team is committed to raising the health status of all residents of the city and will use a targeted approach for segmenting and empaneling patients from among the 5,275 Medicaid beneficiaries who have been identified as having diabetes.  The Capital City Diabetes Collaborative will build on coordinated efforts among healthcare providers that have been facilitated by the Trenton Health Team since its founding in 2006.  Partners will work together to identify the best, evidence-based approaches for screening and treatment that will be adopted city-wide. In addition, community-based tactics will be used to help close gaps in health care and mobilize cross-sector collaboration to address barriers to effective diabetes management.  The project will introduce risk stratification to enable patients with the highest level of need to be identified and enrolled in care management, use a care coordination model for complex diabetes patients, and will partner with non-health sector organizations to increase access to healthy foods, safe places for physical activity, and offer peer support and mentoring, both in-person and through a multi-media technology platform called InquisitHealth.

“We need to look beyond the usual health care solutions to address the growing burden of diabetes, especially among vulnerable populations in the United States,” says Julie L. Gerberding, Chief Patient Officer, Merck and Chief Executive Officer, Merck Foundation. “Through Bridging the Gap, we are pleased to bring together these eight diverse organizations, and look forward to leveraging their expertise to help more people effectively manage their diabetes and improve their overall health.”

“Addressing the growing issue of diabetes is a high priority for our city,” says James Brownlee, Director of the Department of Health and Human Services, City of Trenton.  “We recognize the complexity of clinical and social dimensions that must be considered for a successful intervention and are pleased with the comprehensive approach this grant makes possible.”

Trenton Health Team joins selected organizations in communities across the country, as part of Bridging the Gap, working to improve the delivery of diabetes care and address the social and environmental factors that affect health. Additional program grantees include: Alameda County Public Health Department (Oakland, Calif.); Clearwater Valley Hospital and Clinics (Orofino, Idaho); La Clínica del Pueblo (Washington, D.C.); Marshall University (Huntington, W.Va.); Minneapolis Health Department (Minneapolis, Minn.); Providence St. Joseph Health (Renton, Wash.); and Western Maryland Health System (Cumberland, Md.).

“The Bridging the Gap award will expand our capabilities to identify and target groups and individuals that experience the highest levels of diabetes-related disparities and help us improve the overall quality of care for thousands of Trenton residents,” stated Eric Schwartz, MD, MBA, FACP, Executive Director, Capital Health Institute for Urban Care.  Dr. Schwartz will serve as Principal Investigator for the project.  “We feel confident that the combination of proven clinical models of care coupled with social and educational support for improved self-management of this challenging chronic condition will result in positive outcomes for our community.”

The University of Chicago (Chicago, Ill.) will serve as the National Program Office for Bridging the Gap, and in this capacity, will support the program efforts of the grantee organizations and provide leadership in building a national public-private partnership to help reduce disparities in diabetes care. Local project evaluation will be conducted in collaboration with Montclair State University through its Center for Research and Evaluation on Education and Human Services (CREEHS).

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The Trenton Health Team (THT) is a community health improvement collaborative serving the six zip codes of Trenton, NJ.  The collaborative is an innovative partnership among Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the Department of Health and Human Services of the City of Trenton.  The vision of the Trenton Health Team is to make Trenton the healthiest city in the state.  Our mission is to transform healthcare for the city by forming a committed partnership with the community to expand access to high quality, coordinated, cost-effective healthcare. For more information, visit: or follow us @trentonhealth.



The Merck Foundation is a U.S.-based, private charitable foundation. Established in 1957 by Merck, a leading global biopharmaceutical company, the Foundation is funded entirely by the company and is Merck’s chief source of funding support to qualified non-profit charitable organizations. Since its inception, the Merck Foundation has contributed more than $870 million to support important initiatives that address societal needs and are consistent with Merck’s overall mission of inventing for life by bringing forward medicines and vaccines for many of the world’s most challenging diseases. For more information, visit