Merck Foundation - Bridging the Gap: Reducing Disparities in Diabetes Care

Total Initiative Funding: $16,000,000 (five-year initiative across eight grantees)

Award Date: October 19, 2017

Grant Duration: 5 years

Program Name

Capital City Diabetes Collaborative

Trenton Health Team is one of eight program grantees supported through the Merck Foundation initiative.

Purpose

Improve health outcomes of Trenton residents with diabetes, increase patient engagement and self-management of their disease, and improve availability of healthy foods for Trenton residents.

Community Context

Health Disparities in Trenton:

• Within six zip codes: 31% of adults have hypertension and 16% have diabetes
• Compared to Mercer County, NJ and US: approximately 9%
• Demographic composition: 52% African-American, 34% Hispanic
• Economic challenge: 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 regular screenings
• Economic, environmental, social, and behavioral barriers

Clinical Approaches

• Risk stratification to identify patients with highest level of need
• Enrollment in care management programs
• Care coordination model for complex diabetes patients
• Identification of best, evidence-based approaches for screening and treatment
• City-wide adoption of consistent screening and treatment protocols

Community-Based Strategies

• Cross-sector collaboration to address barriers to effective diabetes management
• Increased access to healthy foods
• Safe places for physical activity
• Peer support and mentoring (in-person and technology-based)
• InquisitHealth: Multi-media technology platform for patient engagement

Patient Segmentation

• Target approach for segmenting and empaneling patients
• Focus on 5,275 Medicaid beneficiaries identified as having diabetes

Implementation Strategy

Trenton Health Team will:

• Build on coordinated efforts among healthcare providers since organization's founding in 2006
• Partner with community-based organizations
• Link healthcare data with community resources
• Address social determinants of health

Initial Implementation Sites

• Martin Luther King, Jr. Elementary School
• Luis Munoz Rivera Community Middle School
• Plan to scale up to additional Trenton schools

Key Partners

Evaluation Partners:

• University of Chicago: National Program Office for Bridging the Gap
• Montclair State University: Center for Research and Evaluation on Education and Human Services (CREEHS) - Local project evaluation

Other Initiative Grantees (Seven 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.)

Leadership

• Gregory Paulson: Executive Director, Trenton Health Team
• Eric Schwartz, MD, MBA, FACP: Executive Director, Capital Health Institute for Urban Care; Principal Investigator for the project
• James Brownlee: Director of the Department of Health and Human Services, City of Trenton
• Julie L. Gerberding: Chief Patient Officer, Merck and CEO, Merck Foundation

About Merck Foundation

• U.S.-based, private charitable foundation
• Funded entirely by Merck
• Chief source of company's funding to qualified non-profit organizations
• Since inception: contributed more than $870 million to support initiatives addressing societal needs

About Trenton Health Team

Community health improvement collaborative serving six zip codes of Trenton, NJ. Innovative partnership among:

• Capital Health
• St. Francis Medical Center
• Henry J. Austin Health Center
• Department of Health and Human Services, City of Trenton

Vision: Make Trenton the healthiest city in the state

Mission: Transform healthcare by forming committed partnership with community to expand access to high-quality, coordinated, cost-effective healthcare