The region’s medical providers will standardize best-practices for diabetes care. Trained community members with success managing their own disease will help their neighbors do the same. And healthy foods will be delivered directly to patient’s homes.
Those elements are among the goals of the Capital City Diabetes Collaborative, a project of the Trenton Health Team that will be funded by a five-year, $1.5 million grant from The Merck Foundation, a charitable foundation established 70 years ago by the New Jersey-based pharmaceutical giant Merck & Co. In Trenton, the adult diabetes rate is nearly twice that of Mercer County, or the nation, at large.
The Trenton Health Team was one of eight organizations — and the only Garden State group — selected to share in the $16 million Merck made available for the “Bridging the Gap” competition, which is designed to build sustainable partnerships, spark primary-care transformation, increase access to care for those with diabetes, and improve patient outcomes.
Beyond the usual answers
“We need to look beyond the usual healthcare solutions to address the growing burden of diabetes, especially among vulnerable populations in the United States,” said Julie L. Gerberding, the Merck Foundation CEO. Some 300 organizations initially expressed interest in the funding.
For THT, a nonprofit founded 13 years ago that coordinates with local healthcare providers, city officials, faith groups, and other community organizations to improve care for the city’s most vulnerable residents, the grant opportunity made good sense. “We already have all the players at the table. We already have the structure in place,” said Martha Davidson, the group’s communications and development director.
Community health studies have revealed that while 9 percent of adults have diabetes nationwide, the rate in Trenton is 16 percent, and 21 percent among adult Medicaid patients living there, according to THT. In all, at least 6,200 city residents over age 18 are living with the chronic blood-sugar condition, which can lead to high-blood pressure, nerve damage, and other problems.
To reduce those numbers, THT said the diabetes collaborative will focus on improving clinical services, enhancing social systems to help people manage the disease, and improving environmental factors that make it easier for citizens to lead healthier lifestyles — an essential factor in diabetes care. In many ways, the program enables the nonprofit and its partners to build on the work they are already doing.
“It really lets us take it to the next level,” said THT executive director Gregory Paulson. “We don’t have to spend the time trying to understand the population and trying to find the patients who will benefit from these services,” he said. “So we’re able to hit the ground running on day one.”
The right expertise
The clinical program will enable experts from Trenton’s main medical providers — Capital Health, St. Francis Medical Center, and the Henry J. Austin Health Center — the city’s federally qualified health center — to review their facilities and make sure they have the equipment and specialists needed to best address diabetes. If needed, the providers can share certain staff, or connect via telemedicine, to ensure all patients have access to the right expertise.
“It’s really an amazing collaboration among providers,” said Dr. Eric Schwartz, executive director of the Capital Health Institute for Urban Care.
The clinical team will review its protocol and determine what the best diabetes care looks like and, using national guidelines, ensure these tools are in place at all sites to provide uniform care, Schwartz said. The group will also organize patients into risk groups so they can best target their resources toward those with the greatest needs or the most potential for benefit.
The collaboration also includes a unique social-support element, a peer-mentoring system that will match individuals who have successfully managed their own diabetes with neighbors who are struggling to get a handle on the disease. Mentors will be carefully vetted and trained, Schwartz said, and a specially designed app enables them to communicate directly with patients in need, while the system captures critical medical data on blood sugar and other factors.
“We can tap into those who are doing well and help us help the community,” Schwartz said. “The real work is around patient engagement and diabetes self-management and lifestyle change.”
Much of diabetes care involves regular blood-sugar monitoring and changes in diet and exercise to reduce sugars and carbohydrates and lose weight — challenges for many individuals regardless of social status or community resources. But studies have shown diabetes rates are often higher in low-income communities, which can provide fewer options for affordable healthy food, less safe spots for exercise, and limited medical options.
“Who better to do that than someone who has faced the same challenges,” Paulson added. “They really are the ones who are able to support individuals in achieving the behavioral changes that are so important to managing diabetes.”
The environmental focus of the collaboration also enables THT to expand a number of projects it has launched with longtime community partners, like the YMCA and the Boys and Girls Club, to address obesity and other concerns. Together, these groups have already created urban gardens, a successful farmers market, and healthier options at some corner stores.
Paulson said the next step is to get these healthy options into people’s homes, since not all community members have the time or transportation to get to a farmers market. The Merck funding will enable the group to explore options like a “mobile farmers market” or a home delivery service, like the upstart Blue Apron, which could provide families with fresh, locally grown food and easy instructions right in their own kitchen.
These programs would also provide local jobs and could serve as an economic engine for the community, Paulson said. “Our focus in this grant is making a change that is going to be sustainable.”