Trenton Health Team’s community-focused work helping residents with diabetes address social determinants of health challenges will be featured during the RISE Summit on Social Determinants of Health this coming March.
The Summit, considered “the place for cross-sectional thought leaders to discuss actionable, tactical, and scalable solutions to social determinants of health (SDoH) challenges and achieve better outcomes for the most vulnerable populations, ” draws community organizations, payers, hospitals and health systems, funders, manufacturers and government agencies.
“We are proud to have THT’s ongoing work recognized and eager to share lessons learned with our colleagues across the country,” said THT Executive Director Gregory Paulson.
Aida Martinez, who leads the Capital City Diabetes Collaborative (CCDC), will be joined by Director of Community Care Cheryl Towns and Director of Population Health Coiel Ricks-Stephen, for a panel discussion about THT’s role in coordinating and supporting community care and education addressing SDoH affecting Trenton residents with diabetes.
Funded through the Merck Foundation’s “Bridging the Gap: Reducing Disparities in Diabetes Care” initiative, the CCDC tackles 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.
After listening to community residents’ recommendations for diabetes education and support, the CCDC launched Project Dulce, an evidence-based, culturally appropriate, community-based diabetes management, education and support program. Peer groups learn together and support healthy lifestyle choices.
To address the lack of coordinated care among health care services, CCDC provides community-based care management to Trenton residents with complex health and social conditions. Services may include social, psychological, and health care support, as well as consistent monitoring and education, through an ongoing relationship to manage chronic conditions and reduce the likelihood of complications.
Through partnership with Snipes Farm and Education Center, the CCDC offers Produce Rx to overcome a lack of access to healthy foods. The COVID-19 pandemic has both increased the need for free food and greatly complicated distribution. To overcome these challenges, THT has partnered with ModivCare, the contracted transportation vendor for New Jersey Medicaid participants, to deliver free nutritious, fresh produce to Trenton residents living with diabetes.
The CCDC also uses tools such as NowPow, a community resource directory and referral platform, to identify local agencies and resources that can best meet clients’ needs, immediately refer the client for assistance, and then follow up on results. Collaboration is also enhanced as both health care organizations and community-based organizations use the Trenton Health Information Exchange to securely share social determinants of health screenings and referrals.
“We look forward to showcasing the good work of our community health and education teams,” said Cheryl Towns, who supervises the Care Management Team.

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