Our Partners and Projects
Partners Map

Together on Diabetes seeks to draw on the strengths of communities and support traditional and non-traditional public and private-sector partners coming together, collaboratively developing and expanding effective patient self-management programs, and broadly engaging and mobilizing affected communities in the fight against type 2 diabetes.

In partnership with the University of Kansas, a collection of case studies and results from each of the project under the Together on Diabetes initiative may be found online. These publications provide descriptions on focus areas, context, intervention elements, partners, outcomes, learnings, and efforts at sustainability. Click here >>

Together on Diabetes partners and projects:

  • American Academy of Family Physicians Foundation, in partnership with Peers for Progress, National Council of La Raza and the University of North Carolina’s Gillings School of Global Public Health, will receive $5,234,876 over 3 years to incorporate patient self-management education, peer support and community outreach for low-income Hispanics and African Americans into the patient-centered medical home model. Project Leader: Edwin Fisher. (read more >>)
  • American Association of Diabetes Educators will receive $2,251,585 over 4 years to implement and evaluate diabetes self-management support programs that will augment the already existing diabetes self-management education programs at four Federally Qualified Health Centers. Project Leader: Ruth Lipman. (read more >>)
  • American Pharmacists Association Foundation, working with government agencies, professional associations, pharmacy chains and others, will receive $4,384,210 after 4 years to adapt and expand the evidence-based Asheville Project model to patients covered by public and private health insurance in 25 communities heavily affected by diabetes. In this model, patients receive diabetes education and then are teamed with community-based pharmacists who make sure they use their medications correctly. Project Leader: Benjamin Bluml. (read more >>)
  • The Camden (N.J.) Coalition of Healthcare Providers and the Cooper Foundation will receive $3.45 million over five years to strengthen community-based components of its Camden Citywide Diabetes Collaborative care model by focusing on patient self-management, education and support, care coordination, food access and physical activity programs, and behavioral health and community engagement activities in order to bend the curve on the diabetes burden and health care costs in the city. Project Leader: Nadia Ali. (read more >>)
  • Duke University Medical Center and the Durham County (N.C.) Department of Health and Human Services will receive $6.25 million over five years to develop, pilot and implement a series of community-based interventions designed to improve diabetes self-management, health outcomes and quality of life for diagnosed and undiagnosed adults with type 2 diabetes, while also reducing disparities based on race, age, gender, socioeconomic status, or insurance status. Project Leader: Michelle Lyn. (read more >>)
  • Feeding America, in partnership with three member food banks in Texas, Ohio and California, will receive $3.1 million over three years to create and pilot bi-directional food bank-health center partnerships that will provide diabetes screening, care coordination, nutrition and disease education, and healthy foods to adults who are living with type 2 diabetes and food insecure. Project Leader: Kim Prendergast. (read more >>)
  • Harvard Law School Center for Health Law and Policy Innovation will receive $981,862 over four years to develop comprehensive state-level policy recommendations for eliminating barriers to care, improving outcomes and enhancing health care policy for patients with type 2 diabetes as part of the Center’s Providing Access to Healthy Solutions initiative. Project Leader: Robert Greenwald. (read more >>)
  • Johns Hopkins Center for American Indian Health will receive $2.25 million over two years to work intensively with four Southwestern tribal communities to pioneer public health innovations by identifying and filling gaps in diabetes prevention and care, encouraging and supporting healthy behavior changes, helping patients self-manage their disease and navigate care systems, and by building and coordinating medical, non-medical and policy efforts at the community level. American Indians and Alaska natives suffer the highest rates of type 2 diabetes in the nation – as high as one in three in the Navajo and Apache communities this initiative will target. Project Leader: Allison Barlow. (read more >>)
  • Marshall University Center for Rural Health, in partnership with the U.S. Centers for Disease Control and Prevention and the Appalachian Regional Commission, will receive $2.61 million over five years to build the capacity of 10 community diabetes coalitions to implement evidence-based programs that support long-term behavior change and improve the health of people living with type 2 diabetes. Project Leader: Richard Crespo. (read more >>)
  • The Mississippi Public Health Institute, in partnership with the Mississippi Department of Health, University of Mississippi Medical Center, the Mississippi Division of Medicaid, and the University of Mississippi School of Pharmacy, will receive $2,681,958 over 3.5 years to implement a coordinated, evidence-based, community approach to systematically lower the incidence and severity of diabetes in the Delta Region by integrating existing medical and non-medical systems of care, supporting the creation of patient-centered medical homes and developing policies that positively impact environmental and social determinants of health related to type 2 diabetes. Project Leader: Ellen Jones. (read more >>)
  • Morehouse School of Medicine / Bristol-Myers Squibb Foundation Partnership for Health Equity in Diabetes based at the Morehouse School of Medicine’s National Center for Primary Care is a 5 year $2,172,981 collaboration to maximize national impact of Together on Diabetes by achieving replicability, sustainability, and scalability. The National Center for Primary Care will leverage their extensive relationships with the primary care and health equity communities to disseminate and scale successful models and lessons learned from Together on Diabetes projects. (read more >>)
  • National Council on Aging will receive $4.87 million over three years to demonstrate a nationally scalable model for delivering the Stanford DSMP on-line and in community settings in partnership with the national YMCA-USA, OASIS Institute, WellPoint and Stanford University. Project Leader: James Firman. (read more >>)
  • National Network of Public Health Institutes (NNPHI) (NNPHI) will receive $180,144 to develop and host a two-day summit in the first quarter of 2012 and support a the Learning Collaborative for Together on Diabetes® grantees. NNPHI also will leverage its expertise and network to inform the annual summit and learning community activities, provide leadership and professional development opportunities for Together on Diabetes® grantees, and enhance relationships between Together on Diabetes® grantees and the broader public health practice community. Project Leader: Christopher Kinabrew. (read more >>)
  • Public Goods Project The Public Good Projects, in partnership with the Institute of Medicine, has conceived of the country’s most ambitious health information marketing campaign to date – A Healthy America – to create a continuous and enduring supply of innovative media that markets health to all Americans using the most powerful new and traditional media platforms available. This effort represents the coming together of the Institute of Medicine, and the Public Good Projects – a non-profit media organization born of the successful HBO health information campaigns: Addictions, The Alzheimer’s Project, and The Weight of the Nation. A Healthy American will launch to the public between June and December 2015. In preparation, the Bristol-Myers Squibb Foundation has granted $250,000 to the Public Good Projects and the Institute of Medicine for the research and development period of this project. Project Leader: John Hoffman (read more >>)
  • Sixteenth Street Community Health Center in Milwaukee, Wisconsin, will receive $295,615 over three years to help Hispanic patients with type 2 diabetes who have fallen out of a doctor’s care for their diabetes at least twice in a 12-month period to reconnect to care, drawing lessons on linkage to care models used for people living with HIV/AIDS. Project Leader: Wina Zorro. (read more >>)
  • United Hospital Fund will receive $2,845,967 over three years and work with the New York City Department of Health and Mental Hygiene and the Department for the Aging to develop and test an integrated, community-based diabetes control strategy for seniors living in “naturally occurring retirement communities and the surrounding neighborhoods.” Project Leader: Fredda Vladeck. (read more >>)
  • University of Kansas received $2,885,944 over five years to develop and implement an online documentation and support system that will help the Foundation evaluate and understand what is being accomplished by Together on Diabetes™ at the individual project and overall initiative levels, while also helping to improve the individual and collective performance of Together on Diabetes™ grantees and their projects. Project Leader: Jerry Schultz. (read more >>)

2013: Special Focus: Diabetes, Depression & Distress

According to the American Diabetes Association, people living with diabetes are at greater risk for depression than people without diabetes. The shock of a diabetes diagnosis and the daily challenge of managing diabetes can take a toll on an individual’s mental well-being and cause distress. Both depression and distress can negatively impact the patient’s ability to engage in self management education and behaviors and to follow the medical treatment established by their health team. To address the important connection between diabetes, depression and distress and the impact on self management, the Foundation awarded 4 three-year, $450,000 grants for the following projects:

  • Health Choice Network of Florida, a Federally Qualified Health Center serving Miami, Florida will integrate behavioral services and care navigation into the diabetes care of high-risk patients diagnosed with diabetes and depression. Project leader: Terisa James. (read more >>)
  • The University of Michigan will evaluate and compare the effectiveness of diabetes self-management and psychosocial support offered at African American churches in Detroit through either a parish peer leader or a parish nurse, and compare those approaches to diabetes self- management education alone. Project leader: Gretchen Piatt. (read more >>)
  • University of Colorado will develop and implement a program to enhance the ability of Federally Qualified Health Centers and primary care practices in the Denver area to provide coordinated, patient-centered care for patients with diabetes and additional mental and behavioral health needs through both clinic- and community-based services. Project leaders: Ross Glasgow / Bethany Kwan. (read more >>)
  • East Carolina University will design and evaluate a unique collaborative, stepped care and “treat to target” intervention for patients in rural eastern North Carolina who have both uncontrolled type 2 diabetes and co-morbid distress and/or depression. Project leader: Skip Cummings. (read more >>)

2011: Special Focus: African American Women (Completed 2013)

African American women represent one of the highest-risk groups of type 2 diabetes in terms of prevalence and disease burden. In November 2010, Together on Diabetes issued a special request for proposals to encourage, identify and promote new and evidence-based approaches to empowering African American women to control their diabetes while taking into account the opportunity they have to impact the health of their families and communities. Each of the following organizations received two-year $300,000 grants:

  • Black Women's Health Imperative worked with clinical and faith-based partners, received a grant to implement a comprehensive self-management, social support and empowerment program for African American women age 40 and older and their families living in three wards in the District of Columbia. Project Leader: Valerie Rochester. (read more >>)
  • East Carolina University implemented a behaviorally centered "small changes" approach and care navigation delivered by lay health worker teams in four rural communities in eastern North Carolina. Project Leader: Doyle Cummings. (read more >>)
  • United Neighborhood Health Services implemented a comprehensive diabetes self-management program including a robust physical activity component which spans the clinical team to the development of community resources in Nashville, Tennessee. Project Leader: Nancy Mason. (read more >>)
  • University of Virginia undertook a comparative study to evaluate the effectiveness of the Call to Health model which includes supportive text messaging, “buddies,” group visits in clinic and community-based settings and community resource referral and mobilization in partnership with the Charlottesville-Albemarle Community Obesity Task Force. Project Leader: Mohan Nadkarni. (read more >>)
  • Whittier Street Health Center working with the Boston Housing Authority and Boston YMCA, connected African-American women living in public housing with comprehensive diabetes management, including health education and support by a certified diabetes educator and peer supporter, nutritional counseling by a dietitian, social service navigation, and a tailored program for physical activity in Roxbury. Project Leader: Patrick Healy. (read more >>)