Cities for Life: Community Health Promotion for the Management of Diabetes in the Patient-Centered Medical Home

Program Launch!

The AAFP Foundation, in partnership with AAFP NRN, Sanofi US, and the City of Birmingham, launched the “Cities for Life” Program on April 24, 2012. Elizabeth Stewart and Natalia Loskutova attended the event in Birmingham and had a chance to introduce the program to the city and its officials.

Study Description and Methods

The AAFP National Research Network, working closely with community health, University of Alabama - Birmingham, and Peers for Progress researchers at the University of North Carolina, will work with family medicine and community partners to create an environment facilitating healthy lifestyles and diabetes management, anchored in the patient-centered medical home.

With input from the NRN, UNC, and the AAFP-F, local primary care leaders will link to health, civic, and business leaders to design and implement a program that will help adults with diabetes do the things they need to do, 365 days a year, to manage their disease and get the high-quality, patient-centered primary care they need. Burson-Marsteller, a leading public relations and communications firm, will help energize the program with social marketing efforts.

Specific Aims and Objectives

Key elements of the program will include:

Patient-Centered Medical Home – With electronic health records, state-of-the-art care guidelines, team-based care, including patient navigation, and ties to community resources, patients will be able to obtain state-of-the-art care for their diabetes that is personalized to their needs and their general health.

The program will help collaborating primary care providers to achieve these levels of care.

Diabetes Self Management Education – Through primary care provider organizations, other health groups, or community agencies, adults with diabetes will get the education they need to manage their disease on a daily basis.

The program will work with local providers of diabetes self management education to enable its reach to as many of those with diabetes as possible.

Peer Support for Diabetes Management – Those with diabetes will be able to gain help in figuring out how to implement their management plans in their daily lives and help in staying motivated through peer support provided by trained nonprofessionals.

The program will work with local community groups to develop a peer support program for those with diabetes or to adapt existing peer support programs to the needs of those with diabetes.

Community Activities and Resources – There is no point in learning how to cook healthy meals if there is no place to buy fresh vegetables, no point in learning how to stretch before exercise if there are no safe, attractive placse to go for a walk. The program will work with local groups including civic, business, and governmental groups to enhance community resources and promote activities – walking clubs, farmers markets, etc. – for healthy lives.

Community Leadership – Communities are not transformed by experts, but by the people who live and work in them. Advisory and action committees from all sectors – health, government, business, civic – and just plain citizens will guide the program development and growth. These committees will work with project staff to take all the other plans listed here and tailor them to the needs and strengths of their community.

Social Marketing – To energize broad programs such as this, people need to understand the need, learn about what everybody else is doing, and get the information they need to take full advantage and improve their health. Social marketing campaigns will help people see why the program is important for their own health and for the health of the whole community and tie together all the program elements.


Evaluation will take several forms:

  • Ongoing monitoring, focus groups or surveys will help guide the program to emphasize what is working and fix what isn’t.
  • Surveys of citizens will evaluate the extent to which the message that diabetes is important, preventable, and treatable has been received, the extent to which all citizens understand the needs of those with diabetes and other chronic diseases, and the extent to which they understand why and how to get appropriate clinical care if they have such diseases.
  • Monitoring of community changes – New walking or bicycle paths, expanded clinical or patient education services, improved linkages of primary and specialty care, etc.
  • Clinical and quality-of-life changes in representative panels of adults with diabetes, followed through collaborating primary care providers.


This project is being conducted from August 2011 through December 2013.


This study is currently collecting data.

Contact Information

For additional information about this study, please contact:

Natalia Loskutova, MD, PhD
Director of Evaluation
AAFP National Research Network
1-800-274-2237 x3186

Sharon Hunt, MA
Qualitative Analyst
AAFP National Research Network
1-800-274-2237, x3181

Key Findings and Publications

This project is currently collecting data. Please check back at a later date for results and key findings.

This project was supported by an unrestricted grant from Sanofi-aventis, U.S.