Bridging the Gap: Reducing Disparities in Diabetes Care (Merck Foundation)

Bridging the Gap: Reducing Disparities in Diabetes Care

Total Initiative Amount: $16,000,000

Award Period: 5 years

Award Date: October 19, 2017

Geographic Scope: United States (8 program grantees in different communities)

Primary Recipient: Trenton Health Team (Capital City Diabetes Collaborative)

Purpose

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. Mobilize community-based partners and improve diabetes care for vulnerable and underserved populations.

Focus Areas

• Improving diabetes health outcomes
• Patient engagement and self-management
• Access to healthy foods
• Addressing social determinants of health
• Risk stratification and care coordination
• Evidence-based screening and treatment

Community Context - Trenton, NJ

Diabetes Prevalence:

• Within six zip codes: 16% of adults have diabetes (compared to ~9% in Mercer County, NJ and US)
• 31% of adults have hypertension

Demographics:

• 52% of residents are African-American
• 34% are Hispanics
• Nearly 26% of residents living in poverty

Barriers to Care:

• Challenges in obtaining medications
• Lack of coordinated care across providers
• Limited knowledge about diabetes, complications, and importance of screenings
• Economic, environmental, social, and behavioral challenges

Program Components

• Risk Stratification: Identify patients with highest level of need for targeted enrollment in care management
• Care Coordination Model: For complex diabetes patients
• Multi-Sector Collaboration: Partner with non-health sector organizations to:
  • Increase access to healthy foods
  • Provide safe places for physical activity
  • Offer peer support and mentoring (in-person and through InquisitHealth technology platform)
  • Address housing and education needs

Implementation Details

• Target 5,275 Medicaid beneficiaries with identified diabetes
• Segmentation and empaneling of patients
• City-wide adoption of evidence-based approaches
• Community-based tactics for gap closure

Partner Organizations

Local Partners:

• Capital Health
• St. Francis Medical Center
• Henry J. Austin Health Center
• Department of Health and Human Services, City of Trenton
• Isles, Inc. (community partner)
• Montclair State University (Center for Research and Evaluation on Education and Human Services - CREEHS) for local evaluation

National Program Office: University of Chicago

Other Program Grantees (7 additional organizations):

• 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.)
• Western Maryland Health System (Cumberland, Md.)

About Merck Foundation

Funded entirely by the company and is Merck's chief source of funding support to qualified non-profit charitable organizations. Since inception, has contributed more than $870 million to support initiatives addressing societal needs.