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

    This project was conducted from October 2011 through March 2013 and was funded by grants from AAFP Foundation and Sanofi-aventis U.S. This project is designed to help community groups – including key primary care providers – create an environment facilitating healthy lifestyles and diabetes management. Key elements include the Patient-Centered Medical Home, diabetes self-management education, peer support, community activities and resources, and social marketing. 

    Study Description and Methods

    The Cities for Life (CfL) demonstration project was developed and implemented in Birmingham, AL from August 2011 through December 2013. The key components of the Cities for Life were a practice-based demonstration project, or clinical component, and a community component that included a community engagement campaign and development of the community resources website.

    Specific Aims and Objectives

    The main goal of the Cities for Life (CfL) project was to help community groups and primary care providers create an environment that facilitates and encourages healthy lifestyles and diabetes prevention and self-management.

    Objective 1: To foster community leadership and collaboration among physicians as well as civic, business, and community-based groups to build a model that can demonstrate real-world diabetes prevention and management in the way communities support healthy living.

    Objective 2: To create linkages between primary care practices and existing community resources for improved treatment of obesity and diabetes care by facilitating referrals and patient access to diabetes self-education, wellness resources, and support.

    Objective 3: To identify gaps and barriers in availability and use of community resources centered on diabetes prevention and diabetes care (in patients and primary care practices) by using surveys and interviews.

    Objective 4: To promote and support Cities for Life and energize communities to promote comprehensive diabetes prevention and management using public relations.

    Program Overview

    The clinical component of CfL included local family medicine practices that referred patients living with or at risk for type 2 diabetes to patient navigators. The patient navigators were given training and provided extensive information concerning existing programs and services within the Birmingham community that help patients manage their disease or reduce their risk for developing diabetes. The patient navigators worked with patients to identify the best programs in their local areas, encouraged program participation, and served as a resource for patients in addition to their physicians.

    The community component of the project was driven by a Community Action Team (CAT) of more than 80 organizations drawing from local primary care, health, civic, business, faith, and media organizations with programs and activities that could help those with diabetes. The CAT was formed to supplement these resources by informing the website, mydiabetesconnect.com, a free searchable database that alerts people to the availability of local programs and services. In addition to informing the website, the CAT identified or created educational programs, relevant local events, and community resources for community members. It also worked to address resource gaps as well as identify and facilitate future funding and partnership opportunities to sustain and expand Cities for Life.


    This project was conducted from August 2011 through December 2013.


    This project has been completed.

    Key Findings and Publications

    Patient Navigators Connecting Patients to Community Resources to Improve Diabetes Outcomes.Loskutova NY, Tsai AG, Fisher EB, LaCruz DM, Cherrington AL, Harrington ML, Turner TJ, Pace WD. J Am Board Fam Med. January-February 2016; 29(1): 78-89.


    For others interested in implementing parts of the Cities for Life model, the study team has developed a toolkit of best practices. The toolkit is designed to help other cities and other smaller entities such as health care organizations, community based organizations, and individual providers implement components of the Cities for Life model. The toolkit is available on the upon request by contacting Natalia Loskutova.

    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, ext. 6149

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