Thanks to a generous, anonymous gift, the Rutgers HOPE Clinic is beginning an in-house diabetes and nutrition education program to address a gap in patient care needs.

When the clinic opened its doors in Plainfield, it had a dual purpose: meeting the health care needs of a community of largely uninsured adults while giving Rutgers physician assistant students real-world experience in community health.

Serving a population with unmet health care means much of the work is managing chronic diseases such as diabetes, high blood pressure, and high cholesterol. But when Frank Giannelli, assistant professor in physician assistant studies and HOPE clinic director, looked at patient needs, he noticed a gap in services.

“Nutrition-related conditions are a huge component of our work due to the social determinants of health in the community, with inadequate access to healthy food,” said Giannelli. “In looking at our programs, we were really missing in-house diabetes education, nutrition education, insulin counseling.”

When patients presented with diabetes or a similar condition, they were referred to other providers and faced many of the same barriers as before visiting the HOPE clinic. Cost, transportation, the availability of language services, and familiarity with the providers could all prevent patients from receiving care.

A solution took shape this year, when the clinic partnered with the Rutgers School of Health Professions’ (SHP’s) Department of Clinical and Preventive Nutrition Sciences to bring diabetes education directly into the clinic. Working together to design and submit a proposal to the philanthropic founder were Giannelli, Patrice Paolella, a certified diabetes educator, Elizabeth Di Prospero, HOPE clinic medical director, Jane Ziegler, chair of clinical nutrition, and Laura Byham-Gray, vice chair of clinical nutrition.

The result? The partnership secured $100,000 over two years to launch HOPE Clinic’s first in-house diabetes education and nutrition counseling program.

“This is the first clinical partnership we’ve had with another SHP department,” Giannelli said. “It’s an important interprofessional moment for us.”

The nutrition department brought the subject matter expertise, and the clinic’s familiarity with their patients and community helped tie the project together. The pilot is focusing first on the clinic’s most medically vulnerable diabetic patients: those whose HbA1c levels, a key measure of blood sugar control, place them in the top 30% of highest-risk individuals at the clinic.

“These are our sickest patients,” Giannelli said. “We want to start with the people who need the most help and who are established primary care patients with us.”

Patients will receive personalized, one-on-one education sessions with Paolella who provides eight hours of office visits a month. Participants engage in individualized sessions designed to build the essential skills needed to manage a complex chronic disease like diabetes.

Once the program is fully established, students will begin to have access to the sessions, observing appointments, reviewing notes, and coordinating follow-up care. It will serve as a real-world model of interprofessional teamwork.

“This is the next step in the natural evolution of HOPE’s growth,” Giannelli said. “We have so many unique professions and when you see someone else in their element doing the work, that builds upon the interprofessional care principles taught in the classroom.”