1. Frequently-Asked Questions

2. Additional Resources: FAQ – What is Cities for Life? What is Cities for Life? – Why implement this program in my local community? Why implement this program in my local community? – Why is it important to involve the community in diabetes management? Why is it important to involve the community in diabetes management? – How is Cities for Life different from other chronic disease management programs? How is Cities for Life different from other chronic disease management programs? – Who were the target audiences for Cities for Life? Who were the target audiences for Cities for Life? – How were patients identified for the Cities for Life program? How were patients identified for the Cities for Life program? – How will this model improve my practice? How will this model improve my practice? – What benefits did Cities for Life bring patients? What benefits did Cities for Life bring patients? – How did Cities for Life recruit physicians? How did Cities for Life recruit physicians? – How did Cities for Life engage physicians? How did Cities for Life engage physicians? – What were the benefits for Cities for Life physicians? What were the benefits for Cities for Life physicians? – Who funded this program? Who funded this program? – How do I find funding? How do I find funding? – How much does a program like Cities for Life cost? How much does a program like Cities for Life cost? –What was the role of the patient navigator?What was the role of the patient navigator? –What skills were important for patient navigators?What skills were important for patient navigators? –How do I find patient navigators?How do I find patient navigators? –How did Cities for Life engage community members?How did Cities for Life engage community members? –What resources are beneficial in helping those living with diabetes?What resources are beneficial in helping those living with diabetes? Program Background In Primary Care Practices Funding Patient Navigation In the Community

3. What is Cities for Life? Cities for Life was a community-based diabetes management program in Birmingham, Alabama, led by the American Academy of Family Physicians Foundation with support from Sanofi US. The program helped Birmingham’s community groups and primary care providers create an environment that facilitated and encouraged healthy lifestyles and diabetes prevention and self-management. – Cities for Life had both clinical and community components. The clinical component included local family medicine practices that refer patients living with or at risk for type 2 diabetes to patient navigators. Patient navigators work with the patient to identify the best programs in their local area, encourages program participation and serve as a resource. The community component of Cities for Life was driven by a Community Action Team (CAT) of more than 80 local organizations. Led by a Steering Committee, the CAT helped supplement resources to inform the website, www.mydiabetesconnect.com, a free searchable database that alerts people to the availability of local programs and services. Patient navigators used this database to help patients find programs and services to help them manage their diabetes. www.mydiabetesconnect.com

4. Why implement this program in my local community? Nearly 26 million people in the U.S. have diabetes, including seven million who are undiagnosed. 1 An additional 79 million people in the U.S. have elevated blood glucose levels and are at increased risk of developing type 2 diabetes. 2 If current trends continue, the Centers for Disease Control and Prevention (CDC) estimates one in three people in the U.S. will have diabetes in 2050. 3 Better models of diabetes management are needed. The Cities for Life model helped primary care providers and community organizations develop stronger linkages to provide support for patients living with or at risk for diabetes, allowing them to better self-manage their condition outside of their doctors’ offices. References: 1 Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA: U.S. Department of Health and Human Services; 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 17, 2011. P.1, l.2,7. 2 Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA: U.S. Department of Health and Human Services; 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 17, 2011. P.1, l.16-18. 3 Centers for Disease Control and Prevention. Diabetes Success and Opportunities for Population-based Prevention and Control, At A Glance; 2011. Atlanta, GA: U.S. Department of Health and Human Services; 2011. http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Diabetes-AAG-2011-508.pdf. Accessed August 30, 2011. P.2,l.B7-B8http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Diabetes-AAG-2011-508.pdf

5. Why is it important to involve the community in diabetes management? One of the challenging aspects of managing diabetes is that it is a 24/7 disease. People living with diabetes likely only see their primary care physician three to four times a year for a total of six hours annually, leaving patients with 8,760 hours each year where they are largely “on your own” to manage their disease. During this time, individuals could turn to family members, colleagues and other sources of community “peer support” to help them better manage their diabetes. The individual’s ability to live a healthy life with diabetes–and confidence in that ability–is enhanced by the support provided by the surrounding community. The Cities for Life model helped primary care providers and community organizations develop stronger linkages to provide support for patients living with or at risk for diabetes, allowing them to better self-manage their condition outside of their doctors’ offices.

6. How is Cities for Life different from other chronic disease management programs? Cities for Life incorporated the use of both patient navigators and peer support. Patient navigators worked directly with family medicine practices and helped create sustainable linkages between existing community resources and patients living with or at risk for diabetes. Cities for Life worked closely with key community partners to help develop the patient navigation system and guide patients towards appropriate, accessible resources that facilitate a healthy lifestyle and diabetes management outside the exam room.

7. Who were the target audiences for Cities for Life? Target audiences include: – Those living with diabetes – Those at risk for diabetes – Community health and business organizations – Local primary care practices – The community at large

8. How were patients identified for the Cities for Life program? Physicians from the Cities for Life primary care practices referred patients living with or at risk for type 2 diabetes to a patient navigator. Patients were referred to navigators based on: – Age over 19 years, – Diagnosed with type 2 diabetes, – Have prediabetes or abnormal glucose, or – At risk for type 2 diabetes (two or more of the following): Overweight or obese Not exercising regularly Have a parent or sibling with diabetes Age 45 or over Have high blood pressure Non-white race low HDL cholesterol, high LDL cholesterol, or high triglycerides Women who had gestational diabetes or a baby that weighed 9 pounds or more at birth

9. How will this model improve my practice? Cities for Life provided an opportunity to enhance patient care without increasing physician workload. The program helped physicians provide diabetes patients with the resources they needed to take care of their diabetes 24/7. The program helped link people from primary care to community support by creating partnerships with community organizations which could benefit people living with and at risk for diabetes.

10. What benefits did Cities for Life bring patients? Cities for Life patient navigators helped patients find services in their local community to help reduce their risk of diabetes or better manage their condition. Cities for Life developed mydiabetesconnect.com, a free, searchable database of local programs and services. The goal of the site was to help promote healthy lifestyles, reduce the risk of diabetes and encourage diabetes management in the greater Birmingham area. The website lists a variety of local programs and services for categories, including: – Healthy Eating – Physical Activity – Healthy Families – Support and Education – Healthcare – Research Opportunities

11. How did Cities for Life recruit physicians? A local coordinating center, housed in the medical school of a local university, recruited physicians The coordinating center operated a practice-based research network, so they already had a relationship with physicians in their community. Physicians who were recruited were willing to: – Engage in a collaborative process with community agencies and other primary care providers to identify ways to enhance the links between clinical care and community/education resources. – Dedicate staff time to participate in necessary calls and planning sessions to implement plans with colleagues, etc. – Complete necessary paperwork, as needed. – Use a registry from which data could be abstracted for later study (e.g., clinical status, dates of care, characteristics of visits (scheduled vs. unscheduled), etc.).

12. How did Cities for Life engage physicians? Cities for Life physicians were engaged through on-going communication, including: – Local events – E-mail communications – E-newsletter distribution

13. What were the benefits for Cities for Life physicians? Cities for Life provided an opportunity to enhance patient care without increasing physician workload. The program helped physicians provide diabetes patients with the resources they need to take care of their diabetes 24/7.

14. Who funded this program? Cities for Life was led by the American Academy of Family Physicians Foundation with support from Sanofi US.

15. How do I find funding? Funding options are available from a variety of sources – At the national level, potential funding sources include: Opportunities listed on Grants.gov Federal agencies, such as: – Centers for Medicare and Medicaid Services (e.g. Innovation Center) – Centers for Disease Control and Prevention – US Department of Health and Human Services (e.g. HHS Forecasts) – At the state level, potential sources of funding include: State agencies, such as health departments National Registry of Recognized Diabetes Prevention Programs The Grantsmanship Center – At the local level, potential sources of funding include: Universities, especially medical schools Hospitals Prominent local businesses County health departments Local community health grants (e.g. Walgreens and CVS)

16. How much does a program like Cities for Life cost? The cost of a program like Cities for Life depends on your own program model and your community’s needs. Funding options are available from a variety of sources at the local, state and federal levels. Examples of areas that may require funding include: – Patient navigator salaries if they aren’t already employed in your community, – Data collection for evaluating the project, – Printing promotional literature, – Developing and maintaining websites, and – Salary and office space for personnel to coordinate the effort.

17. What was the role of the patient navigator? Patient navigators were a critical link between the primary care practice, the patient and community-based organizations. They had special training and extensive knowledge of existing programs and services within the local community, so they could work with patients to identify the best programs in their local areas to help them manage their diabetes. The patient navigators checked in on patients, encouraged program participation and served as a resource for patients in addition to their physicians.

18. What skills were important for patient navigators? Patient navigators had special training and extensive knowledge of the existing programs and services within the Birmingham community that could help patients manage their diabetes. Key attributes of a patient navigator include: – Extensive knowledge of existing programs within patient’s community, as listed above. – Understanding of what is best for the patient as it pertains to individuals needs, budget and desires. – Ability to understand the inner workings of primary care practices and successfully coordinate between practices and patients.

19. How do I find patient navigators? Patient navigators may already be working in your community, employed by groups such as public health organizations, the health department, clinics, hospitals, and organizations such as the American Cancer Society or the American Diabetes Association. Patient navigators may have different titles such as patient advocate, patient coordinator, community health worker, community outreach worker, patient advocate, or screening outreach worker. If you need to hire new personnel as patient navigators, you may find willing people through the community organizations you are working with.

20. How did Cities for Life engage community members? The community component of Cities for Life was driven by a Community Action Team (CAT) of more than 80 organizations drawn from local primary care practices, other healthcare organizations, civic organizations, businesses, faith-based organizations and media. The CAT members all have programs, activities or an interest in helping those with diabetes. Cities for Life engaged these community members through on-going communication efforts including: – Monthly newsletters – E-mail – Phone calls – Events – Social media

21. What resources are beneficial in helping those living with diabetes? Beneficial resources may include: – Healthy eating and grocery shopping options – Walking trails, gyms and fitness classes – Diabetes education events and classes – Weight-loss programs – Diabetes support groups