Engaging Community-Based Organizations

Area Agencies on Aging (AAAs) are public or private nonprofit entities that work to address concerns of older individuals in a designated region. The U.S. population of older adults is expected to grow to 73 million by 2030, and AAAs are working to provide the home and community-based resources needed to support these individuals. AAAs serve an active aging population likely to include beneficiaries eligible for the Medicare Diabetes Prevention Program (MDPP) or the National DPP lifestyle change program, and they can provide location sites to host in-person MDPP or National DPP lifestyle change program sessions. AAAs are required to offer evidence-based programs to the populations they serve, and partnering with an MDPP supplier or CDC-recognized organization gives AAAs access to resources and trained Lifestyle Coaches. Additional information on AAAs can be found in the Shared Learning Resource, Partnership Development to Increase MDPP Referrals and Marketing.

YMCAs are nonprofit organizations that provide health and fitness programs for children and communities. YMCAs aim to improve the lives of the public by “connecting all people to their potential, purpose, and each other” through a variety of programs and activities that promote improving health and well-being. YMCAs have been involved at the state and national level since the inception of the National DPP lifestyle change program. Many YMCAs currently serve as key partners for state diabetes programs and deliver the National DPP lifestyle change program to the community.

Tribal organizations that support American Indian and Alaska Native tribal populations have been engaged in translational research to adapt the National DPP lifestyle change program to suit the unique culture of their populations. CBOs supporting tribal populations could include Tribal Health Consortiums, Tribal Health Councils, and Tribal Associations. For a summary of how tribal organizations are involved in the National DPP lifestyle change program, see CDC’s American Indian and Alaska Native Communities page.

A faith-based organization, such as a church, can be influential partners in raising awareness of and offering programming for diabetes prevention and management. Faith leaders are often trusted source of information and can motivate congregants to make healthy choices. For more information on faith-based organizations, see CDC’s Faith Leaders Toolkit – Diabetes Management and Type 2 Diabetes Prevention.

Charitable foundations with a specific condition or health focus, such as the National Kidney Foundation of Michigan, can offer programming such as the National DPP lifestyle change program to their populations of focus.

A community care hub (CCH) is an emerging model where a hub organization supports a network of CBOs that provide services to address health-related social needs (HRSNs). These hub organizations offer overarching structures that centralize administrative and reimbursement functions and provide a single point of contracting for health care providers and payers. The Western NY Integrated Care Collaborative, Iowa Community HUB, and Oregon Wellness Network are all examples of CCHs that coordinate a network of CBOs.

Umbrella hub arrangements (UHAs) have been created to serve a similar purpose that is specific to the National DPP lifestyle change program. UHAs connect CBOs with health care payment systems to pursue sustainable reimbursement for the National DPP lifestyle change program. Health Promotion Council of Pennsylvania and Trellis are two examples of UHAs. For more information on these and other UHAs, see the Umbrella Hub Arrangement Spotlights page of the Coverage Toolkit.

The November 2023 Department of Health and Human Services (HHS) Strategic Approach to Addressing Social Determinants of Health to Advance Health Equity publication, Community Care Hubs: A Promising Model for Health and Social Care Coordination, highlights the role CBOs can play in addressing social needs and improving health outcomes, including several National DPP lifestyle change program examples.

The September 2022 Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health affirms the importance of increased support for the prevention and management of diabetes, outlines several strategies that support diabetes prevention efforts, and encourages collaboration with CBOs.

CMS’ 2024 Medicare Physician Fee Schedule provides an opportunity for CBOs to receive reimbursement for addressing HRSN. For additional information on Medicare Physician Fee Schedules and the National DPP lifestyle change program, please visit the Medicare section of the Coverage Toolkit.

Granite YMCA is a CDC-recognized organization and MDPP supplier that utilizes partnerships to strengthen their infrastructure and capacity to deliver the National DPP lifestyle change program and MDPP. Granite YMCA has many partnerships including with the Massachusetts College of Pharmacy, New Hampshire Department of Health and Human Services’ chronic disease unit, YMCA’s internal human resources team, and the YMCA board of trustees. Granite YMCA’s partnership with the Massachusetts College of Pharmacy is unique in that it provides pharmacy students with training on diabetes prevention and the lifestyle change program. Like Granite Health, other CBOs can use partnerships to increase engagement in and referrals to the National DPP lifestyle change program. Additional details on Granite YMCA’s partnerships can be found in the MDPP Shared Learning Resource, Partnership Development to Increase MDPP Referrals and Marketing.

National Kidney Foundation of Michigan (NKFM) is one of Michigan Department of Health and Human Services’ (MDHHS) MBEP partners. As a chapter of the National Kidney Foundation, the organization seeks to eliminate preventable kidney disease, accelerate innovation to improve patient experiences, and dismantle structural inequities affecting individuals with kidney disease. NKFM has been a long-standing partner of MDHHS, supporting continued engagement of Medicaid managed care organizations (MCOs) in the state, participating in CDC’s 6|18 diabetes prevention initiative, and providing input into Michigan’s Medicaid benefit covering the National DPP lifestyle change program. NKFM delivers the National DPP lifestyle change program in metropolitan Detroit and offers both in-person and distance learning sessions. Additional information on NKFM’s program can be found here.

New Jersey YMCA State Alliance is one of New Jersey Department of Health’s MBEP partners. The New Jersey YMCA State Alliance delivers the National DPP lifestyle change program in numerous YMCAs throughout the state (both in-person and distance learning) and collaborates with a variety of health care providers and CBOs to increase awareness of and participation in the program. Additional information on its program can be found here.

Since 2012, RIPIN, a coordinating body for CBOs delivering the National DPP lifestyle change program, has partnered with Rhode Island Department of Health to provide the infrastructure needed to operationalize the Community Health Network (CHN). The CHN is a centralized data management and referral system linking individuals to evidence-based health and wellness programs and classes for chronic disease management and prevention, including the National DPP lifestyle change program. Additional information on RIPIN and the CHN can be found here.

The Balm in Gilead is a faith-based organization that delivers the National DPP lifestyle change program in 52 local affiliate sites across seven states: Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, and Virginia. It received funding for its Southeast Diabetes Faith Initiative through CDC’s 1705 grants to address health equity through building out National DPP infrastructure in underserved areas with a focus on priority populations including African Americans and older adult men. As part of this initiative, the Balm in Gilead created an all-male cohort, Healthy Men of Omega, which collectively achieved 7% weight loss. Information detailing recruitment and retention strategies for this unique cohort can be found in the MDPP Supplier Learning Series Scaling the MDPP with Populations of Focus resource. For additional information on the Balm in Gilead’s Southeast Diabetes Faith Initiative, please see the recording and slides from their presentation at the NACDD 1705 Virtual Showcase in June 2023.

The Sight Center of Northwest Pennsylvania is a CDC-recognized organization and MDPP supplier that has utilized several unique methods for promoting the National DPP lifestyle change program and the MDPP. These methods include partnering with AAAs, elected officials, and senior living facilities. The Sight Center has also utilized cable access television and news publications to promote the MDPP to potential participants. Additional information on the Sight Center can be found in the MDPP Shared Learning Resource, Partnership Development to Increase MDPP Referrals and Marketing.

YMCA of Greater Seattle is one of Washington State Health Care Authority’s (WA HCA) MBEP partners. WA HCA began engaging with YMCA of Greater Seattle as part of their partnership with Washington State Alliance of YMCAs. The YMCA of Greater Seattle acts as the fiscal and contractual sponsor of the Washington State Alliance of YMCAs and leads the Alliance in delivering the National DPP lifestyle change program to Medicaid beneficiaries in partnership with other YMCAs in the state. They also connect individuals to other beneficial health programming at their local YMCA facilities by including a 6-month complimentary membership to their local YMCA facility during the first half of their year-long participation in the National DPP lifestyle change program. YMCA of Greater Seattle offers both in-person and distance learning sessions of the National DPP lifestyle change program. Additional information on its program can be found here.

YMCA of Metropolitan Milwaukee (Y-MKE) is one of Wisconsin Department of Health Services’ (WI DHS) MBEP partners. WI DHS chose to collaborate with Y-MKE because of the value it brings as a CBO well-positioned to implement innovative approaches to reach populations most at risk for diabetes. Y-MKE’s impact in Milwaukee is widespread, and they have been able to reach individuals that otherwise may not have participated in National DPP lifestyle change program. Y-MKE’s belief is that lasting personal and social change happens in the places where their members live, work, and play—placing them squarely in communities with populations at greatest risk for diabetes. Y-MKE offers both in-person and distance learning sessions of the National DPP lifestyle change program. Additional information on its program can be found here.

HPC is a nonprofit organization dedicated to promoting health and preventing chronic disease among populations experiencing health-related disparities. As part of the Umbrella Hub Demonstration, HPC began serving as an umbrella hub organization (UHO) supporting CBOs, also known as subsidiary organizations, delivering the National DPP lifestyle change program. HPC’s subsidiary organizations include health care providers, government agencies, local nonprofit organizations, pharmacies, and private employers. HPC supports these subsidiary organizations by taking on the following roles:

• Recruiting payers and subsidiary organizations
• Reviewing subsidiary organizations’ data for accuracy and quality
• Coaching subsidiary organizations on quality improvement measures
• Contracting with payers, subsidiary organizations, and a billing vendor
• Maintaining Diabetes Prevention Recognition Program (DPRP) status
• Maintaining Medicaid and Medicare provider status

Through the administrative support HPC provides to subsidiary organizations, those organizations can focus primarily on the delivery of the National DPP lifestyle change program. Additional information on HPC and its subsidiary organizations can be found in the HPC Spotlight.

Trellis, a nonprofit and AAA, serves as a UHO supporting organizations delivering the National DPP lifestyle change program. Trellis does this in the context of its mission to assist individuals to age well and develop the capacity of communities to care for an aging population. Trellis had eight subsidiary organizations delivering the National DPP lifestyle change program, including several CBOs. Trellis supports subsidiary organizations through offering the following technical assistance:

• Holding monthly check-ins to provide updated resources and solutions to potential barriers
• Training staff on data and claims submission platforms
• Educating staff on National DPP lifestyle change program eligibility criteria, Diabetes Prevention Recognition Program (DPRP), and Medicare Diabetes Prevention Program (MDPP) requirements and ensuring all are met
• Providing information on available tools, resources, and best practices related to the National DPP lifestyle change program
• Assisting with marketing the National DPP lifestyle change program to priority populations
• Training Lifestyle Coaches on how to assess readiness to change

The technical assistance provided by Trellis allows subsidiary organizations to focus on the delivery of the National DPP lifestyle change program itself, rather than administrative requirements. Additional information on Trellis and its subsidiary organizations can be found in the Trellis Spotlight.

Western NY Integrated Care Collaborative (WNYICC) is a CCH made up of local CBOs providing social care programs and services including the National DPP lifestyle change program. WNYICC centralizes operations of participating CBOs to address HRSN, close gaps in care, and improve patient compliance with health care provider recommendations. Its partners include more than 65 CBOs, eight AAAs, and a Center for Independent Living. A full list of WNYICC network members can be viewed here. For more information, see the WNYICC Spotlight.

Iowa Community HUB is a CCH focused on preventing and managing chronic disease in Iowa by ensuring access to community health promotion programs such as the National DPP lifestyle change program. Iowa Community HUB provides administrative and capacity-building support to over 75 community partners that include health systems, employers, and a variety of CBOs. A full list of Iowa Community HUB’s chronic disease prevention partners can be viewed here. For more information, see the Iowa Community Hub Spotlight.

Oregon Wellness Network (OWN) is a division of the Oregon Association of Area Agencies on Aging and Disabilities (O4AD) that serves as a CCH for 16 AAAs and 18 other CBOs. A full list of OWN’s partners can be viewed here. OWN leads the network in delivering evidence-based health education programs and interventions, including the National DPP lifestyle change program and the MDPP. OWN’s website provides resources for those interested in the National DPP lifestyle change program, including frequently asked questions and a risk assessment quiz. OWN’s vision is to help communities across Oregon create a culture of health and wellbeing, where prevention and wellness are the norm. Their mission is accomplished through leveraging partnerships that have been created across the state of Oregon to help provide services to older adults and individuals living with disabilities. OWN has operated as a CCH since 2017, contracting with different payers and vendors to provide marketing, referral assistance, web development, and revenue cycle management to its partners. They are currently working on becoming a CDC-recognized UHO. Additional information on OWN can be found in the MDPP Shared Learning Resource, Spotlight on the Oregon Wellness Network: Partnership Development.