Enrollment, Incentives, & Retention

Commercial Payers → Delivery → Enrollment, Incentives, & Retention


Retaining plan members who have elected to participate in the National DPP lifestyle change program is an important program objective. The longer an individual stays in the program, the better his or her outcomes. Retention also impacts the ability of a CDC-recognized organization to maintain CDC recognition and receive performance-based payments.

An individual is generally considered enrolled when she or he participates in one or more sessions (not counting session zero). Some entities have defined a person as enrolled when she or he agrees (in writing and/or verbally) to participate in the program.


Better Outcomes from Higher Retention

Research from CDC’s Diabetes Prevention Recognition Program (DPRP) 2017 dataset has shown the longer a person stays in the program, the better their outcomes. For example, CDC has found that there is a significant association between staying in the program past the first 16 weekly sessions and achieving the 5%+ weight loss. Participants that remain in the program for 17+ sessions (the second six months of the program) achieve weight loss at higher rates than those in the program for the first 16 sessions (the first six months of the program).

Additional retention and outcomes statistics from CDC analyses on the DPRP 2017 dataset are indicated below.

  • Analyses on three weight loss distributions (low, medium, and high weight loss) found that individuals in all three groups, regardless of amount of weight loss, exhibited the same trend: those attending 17+ sessions and having an average of 150+ minutes of physical activity per week had increasingly higher percent weight loss among all race/ethnicity groups.
  • For women with gestational diabetes mellitus, significant predictors of achieving 5% weight loss were meeting the 150 minutes of physical activity, attending ≥ 17 sessions, staying in the program for more than 183 days, and age 45–64 years.
  • For every additional session attended and every 30 minutes of activity reported, participants lost 0.3% of body weight (p < 0.0001). See the ADA report here.

Enrollment and Retention Strategies

Retention strategies among entities that have delivered or provided coverage for the program include the following:

  • Offer sessions at various times of day
  • Offer sessions at or close to the worksite
  • Allow individuals to make up missed sessions, including through virtual delivery
  • Offer the program in both in-person and online formats
  • Staff the program with trained coaches
  • Provide support in using a digital device (for those participating in an online National DPP lifestyle change program)
  • Offer non-monetary incentives to participants
  • Establish relationships with primary care physicians
  • Address participant barriers, such as providing free or reduced-price child care or transportation. Sites that used such strategies were more likely to have higher attendance during months 7–12 and higher participation over the duration of the year-long program, compared to sites that did not use such strategies.
  • Assess participant for Readiness with a ‘Readiness Assessment’. In this assessment, learn their individual goals for joining the program. Assess each participant individual desires and confidence scale in adhering to the goals of the program. Have a 1:1 meeting prior to or within the first week or two of the program in order to review these items.
  • Address any potential group dynamic issues, especially for an employer setting.

Session Zero

In some cases, an organization may wish to assess the level of an individual’s commitment and readiness to make lifestyle changes prior to the first formal session. Some strategies to determine the level of commitment include:

  • Holding informational sessions, or “sessions zero,” that provide an opportunity for potential participants to understand the expectations of participation, ask questions, and make the commitment to participate.
  • Administering a formal or informal “readiness to change” assessment. One example of a brief, informal assessment that has been incorporated into programs can be viewed here.

CDC has developed a tip sheet that provides insights and lessons learned in improving participant retention. The tip sheet may be accessed here.


Enrollment and Retention Strategies in Practice

Click through the tabs below to see how groups are putting enrollment and retention strategies into practice.

Commercial Health Plan

One commercial health plan has delivered over 40 classes and has supported over 450 individuals in participating in the National DPP lifestyle change program. It delivers most of its sessions at community wellness centers, several of which are co-located with physician offices. These centers are located in communities with high prevalence of diabetes and obesity and significant disparities in care. The retail centers tend to be highly accessible to individuals in the surrounding area.

The health plan’s National DPP program manager cited the following as success factors in retaining participants in the National DPP lifestyle change program:

  • Staffing the program with individuals who are able to connect to the communities, such as coaches who are reflective of the populations they are serving
  • Having social workers on-location where the classes are held to help with additional needs that affect the individuals’ ability to adhere to the program
  • Upholding a strong relationship with the primary care physicians

Solera Health

Solera Health, a preventive care benefits manager, contracts with employers and health plans that cover the National DPP lifestyle change program. The following practices have been critical to Solera for retention of participants:

  • Allowing participants to easily choose or be matched to the CDC-recognized organization that best meets their needs
  • Personalizing program messaging and delivery
  • Allowing participants to make up missed sessions using online technology
  • Ensuring frequent coach-group interactions
  • Offering a wearable fitness tracker as an incentive for completion of the fourth session.

AADE

The American Association of Diabetes Educators (AADE) has been scaling a model where the National DPP lifestyle change program is delivered by accredited or recognized diabetes self-management education and support (DSMES) programs with funding from the CDC 1212 cooperative agreement (see the National Diabetes Prevention Program Overview).

The AADE encourages its DSMES sites to encourage participant retention by holding a “session zero,” an informational session prior to the first formal session, to assess participants’ readiness and eligibility. A session zero is a forum for educating potential participants about program goals and expectations; discover potential participants’ readiness to change and motivation to engage in the program; discuss logistics and methods of tracking; secure a commitment from interested individuals to participate in the year-long program; and set expectations about attendance.

AADE-sponsored program delivery sites further encourage adherence by recommending that lifestyle coaches check in with participants prior to each person’s fourth session to ensure that they are still committed to the program. This is important because only outcomes and attendance data for participants that attend at least four sessions is included in the CDC analysis for recognition purposes.

YMCA

A senior director of evidence-based health interventions at the YMCA of the USA indicated that the following factors contributed to retaining participants:

  • Ensuring that lifestyle coaches had strong facilitation skills, empathy, and can support an effective group dynamic
  • Educating participants about the requirements of the program prior to the first session (including the program duration and likely challenges of achieving behavior change)

Enrollment, Incentives, & Retention Practices in Rural Areas

Various studies on diabetes education and prevention programs in rural areas have indicated the following factors as contributing to successful implementation:

  • Providing participant transportation to classes when needed
  • Hosting the program in a common, well-known location
  • Developing positive relationships with and engaging providers, social workers, and other community stakeholders
  • Considering cultural sensitivities and differences between counties when recruiting and engaging participants
  • Establishing support from community leaders
  • Educating communities on the underlying social determinants of health
  • Helping communities better understand their capacity, assets, and resources
  • Gaining an understanding of local politics
  • Offering the program via telehealth to increase access

For additional information on establishing diabetes and prevention programs in rural areas, see the following links: Appalachia, Kentuckiana, Montana, Montana telehealth, Federal Office of Rural Health Policy (FORHP)

In addition, the National Association of Chronic Disease Directors (NACDD) collected the following information from state and local health department representatives from Montana, Colorado, North Dakota, and Ohio regarding challenges and opportunities to mitigate the challenges of working with rural populations:

Access

Challenge

  • Lack of lifestyle coaches or CDC- recognized organizations
  • Limited broadband internet access in some rural areas
Opportunity

  • Online delivery options, where internet is available
  • Program delivery in-person and via telehealth technology to remote sites
  • Encouraging the following to deliver the program: Cooperative Extension System through land grant universities; places where people already gather such as community and senior centers, churches, and libraries; and hospital systems that have identified obesity as a priority through community health assessments

Travel Time

Challenge

  • Travel distances—both for coaches and participants—can be further in rural areas
Opportunity

  • Encouraging carpooling, which also enhances opportunities for support
  • Use buy one, get one free registration deals to engage spouses or friends
  • Providing gas cards as incentives
  • Have several lifestyle coaches trained in each organization to share the travel burden

Participants Moving

Challenge

  • Participants may move to a different location throughout the year
Opportunity

  • Allow participants to join a class at other locations so they can complete the yearlong program

Participation

Challenge

  • A less populous area can make it difficult to enroll a sufficient group of participants
Opportunity

  • Word of mouth is very powerful in rural areas
  • Use buy one, get one free registration deals to engage spouses or friends
  • Delivery organizations developing a collaborative service delivery model to increase class options for participants and increase enrollment for all sites

Marketing

Challenge

  • Finding a marketing strategy for the rural population
Opportunity

  • Local radio
  • Local free newspapers available in grocery stores

Lifestyle Coach Support

Challenge

  • Since lifestyle coaches may be spread out, it may be difficult to support them
Opportunity

  • Monthly support calls and annual face-to-face meetings to offer refresher training, support, resources, and best practices

Screening, Testing, & Referral

Challenge

  • Because of the diffused population, it may be difficult to identify potential participants
Opportunity

  • Support from rural health/hospital systems is critical as it may be the only medical care in the area
  • Screening and testing through employers is also key
  • Having a neutral party organize referrals (e.g., the Cooperative Extension) allows providers to have one number for referrals to programs
  • Gaining buy-in from local health care providers and hospitals

Incentive Efforts

Some CDC-recognized organizations and their partners have used incentives to enhance participant enrollment and retention. In general, programs have shown to have higher attendance rates when they include incentives.

Source: MIPCD Final Evaluation Report – Figure E-2

The sessions during the last six months of the program emphasize maintaining a healthy lifestyle that was learned in the first six months of classes. Participation in these classes provide continued support and motivation to the program individuals seeking to retain a healthy lifestyle. When developing incentives, steps should be taken to develop a model that encourages participants to maintain participation throughout the second six months of the program, in addition to the first six months.

There are many characteristics of a good incentive program that are important to consider. It will be important to determine:

  • Who will receive the incentive
  • What type of incentive will be given (e.g., cash, vouchers, gifts, etc.)
  • What target or goals will need to be achieved to receive the incentive
  • When participants will receive the incentive (e.g., immediately following achievement of the target or goal, on a fixed schedule, etc.)
  • What the value of the incentive will be
  • Whether the incentive is guaranteed (e.g., when using a lottery method, the incentive is not guaranteed)
  • Whether the incentive employs a positive (carrot) approach for engaging in a healthy behavior or a negative (stick) approach where a loss is achieved for not engaging in a healthy behavior or achieving an outcome.
  • Whether the incentive is aligned with program goals and provides additional support for individuals to achieve the desired outcomes


Incentives in Practice

Click through the tabs below to learn how various organizations have approached offering incentives in their National DPP lifestyle change programs.

Commercial Health Plan

One commercial health plan, for instance, observes that participation and retention is stronger among groups that offer incentives, so has encouraged employers to provide incentives based on 16-week completion. The health plan’s initial incentive plan offered “points” for completing the 4th, 9th, and 16th classes, which could then be used to “purchase” non-monetary incentive items. However, after evaluating the incentives and participation, and finding that many participants would discontinue after the 9th class, the incentive program was changed to favor completion of the 16th class. As a result of the change, retention through the 16th class increased. The health plan also found that non-monetary items, such as awarding wearable fitness trackers after program completion, also proves successful.

State Employee Plans

One state employee plan offered the National DPP lifestyle change program as part of a wellness benefit. It would offer participants points after completing each class, which accumulated throughout the program. The plan had a wellness platform through which participants could use their points to “purchase” health- and fitness-related items.

Another state employee plan found that when outreach mentioned the incorporation of incentives, enrollment was roughly 10 times greater than when outreach did not mention incentives.

Maryland

One Maryland MCO that was involved in a Medicaid demonstration sponsored various incentives according to the schedule below. Information on how retention was improved with the following incentives is pending as this was implemented as part of the ongoing Medicaid Demonstration.


Minority Diabetes Prevention Program

North Carolina received state funds through their Office of Minority Health and Health Disparities to establish North Carolina’s Minority Diabetes Prevention Program, which focuses on increasing minority access to and participation in National DPP lifestyle change programs. It provided grant funding to partners across the state to market and administer the program. Some of the partners used incentives to promote healthy habits according to the schedule below.

Multi-organization study

Preliminary results from a study on incentives show that most of the affiliate sites from six national organizations offered some kind of incentive to recruit or retain participants. Common incentives reported by the sites include the following, from the most common to the least common:

  • Calorie King or other types of diet tracking books;
  • MyPlates or other food measuring devices;
  • YMCA memberships;
  • pedometers;
  • certificates, plaques, or trophies;
  • athletic gear or clothing;
  • gift cards;
  • cookbooks; and
  • free or reduced-price child care.

The study found that sites offering non-financial incentives were 27.5% more effective in retaining participants for at least four sessions and were associated with a 1.4% increase in weight loss when compared with sites not offering non-financial incentives.

In addition, sites that reported using strategies to address participant barriers, such as providing free or reduced-price child care or transportation, were more likely to have higher participant attendance during months 7–12 and higher participation over the duration of the year-long program, compared with sites that did not use such strategies.


Statistics on Enrollment and Retention

The table below shows retention statistics from various health insurance plans, employers, and CDC-recognized organizations who have implemented the National DPP lifestyle change program. More detailed summaries on a few of these programs can be accessed here: Florida Blue case study; CMMI Y-DPP model test report, American Association of Diabetes Educators (AADE) infographic.