SustainabilityHealth Equity and the National DPP → Connecting to State and National Initiatives


Connecting the National DPP Lifestyle Change Program to State and National Health Equity Initiatives

While the National Diabetes Prevention Program (National DPP) lifestyle change program focuses on skills that help to address health-related social needs (HRSN), the program can also be connected to larger initiatives that are centered on health equity. It can work in tandem with larger state or national goals, initiatives, or objectives related to addressing health equity, such as reducing the rates of chronic disease in populations of focus, addressing disparities in accessing preventive services, or working to increase access to healthy foods across populations.

For example, state Medicaid agencies, public health, managed care organizations (MCOs), and CDC-recognized organizations may be aware of initiatives across the state and in specific communities that address HRSN and could consider initiating partnerships that increase participants’ access to these services. For example, many states and communities have programs related to healthy food procurement. Strategies to improve access to healthy food among people with higher risk for chronic disease range from implementing healthy food prescription programs at farmers’ markets; stocking healthy foods at certain grocery stores, gas stations, and corner stores; and issuing permits for mobile produce vendors. These types of initiatives may offer opportunities for CDC-recognized organizations to support Medicaid beneficiaries in accessing healthy foods to support the lifestyle changes they are learning about in the program.

This page will describe opportunities to connect the National DPP lifestyle change program to state or national initiatives, and is divided into the following two sections:

  1. Addressing HRSN Through Cross-Sector Partnerships
  2. HRSN Screening Tools

Addressing HRSN Through Cross-Sector Partnerships

Coordinating and collaborating with partners across sectors, including state Medicaid agencies, Medicaid MCOs, health care providers, and community partners can improve efficiencies in addressing HRSN by engaging in strategic planning across teams and departments.

Partners can work together to identify the social risks and assets of populations of focus. For example, emphasizing screening for and collecting data on social needs in MCO contracts, implementing MCO incentive programs to test HRSN interventions, and encouraging the use of standardized documentation and data collection, including ICD-10 Z codes (social determinants of health (SDOH codes) codes) are all ways that Medicaid agencies can work with MCOs to identify the social risks and needs of specific populations. MCOs can work with providers in their network to create standardized social needs screening processes, or support provider education on HRSN. Additionally, community partners can conduct community needs assessments to learn more about the HRSN of the populations they are serving, and share this information with other organizations, including health care delivery organizations.

Below is a table that provides an overview of the ways that providers, payers, government agencies, and CDC-recognized organizations can work together to advance equity and address SDOH. Please reference the following definitions for what is color coded in the table as foundational, collaborative, and enabling activities.

  • Foundational: Describes some activities and policies that are essential first steps to undertaking work to advance health equity.
  • Collaborative: Activities that are specifically and intentionally implemented to address HRSN and improve health equity. These activities are most successfully implemented through partnerships across and within organizations.
  • Enabling: Activities and policies that grow out of a foundational commitment to health equity and which facilitate collaborative work to improve health equity. The absence of these activities and policies makes it difficult to achieve progress in increasing health equity.


Because the National DPP lifestyle change program is offered by community-based organizations (CBOs) that are often already doing work with certain populations of focus, there are opportunities to establish multiple touchpoints and partnerships across different CBOs that are addressing HRSN. Over the course of the year-long program, Lifestyle Coaches can get to know participants well and understand their needs and barriers to health. The community-centric structure of the program lends well to Lifestyle Coaches and CDC-recognized organizations making connections with other programs, resources, and activities that help to support National DPP lifestyle change program participants. Below are some examples of these cross-sector partnerships.

National DPP lifestyle change program adaptations in FQHCs

Federally Qualified Health Centers (FQHCs) in Hawai’i have incorporated some adaptations of the National DPP Lifestyle Change program that involved partnerships with outside organizations. In one case, a Lifestyle Coach became aware that many of their participants did not cook for themselves, and so arranged for a local supermarket to give participants a tour to learn about the healthy prepared food options available to them. Another FQHC aligned their schedule with a local early education program that was at the same location as the National DPP lifestyle change program sessions so that parents could drop their children off while attending the program. Other clinics partnered with exercise programs to help participants engage in accessible, culturally relevant physical activity, such as hula.

Linkages to Community Resources and Health Systems

National DPP lifestyle change programs can consider implementing systems to facilitate referrals between health systems and community resources, such as 2-1-1 referral systems or 800 numbers.

HRSN Screening Tools

HRSN screening tools used at the state and national level can be instrumental in identifying populations and individuals that need additional support. Recent research supports use of universal screening approaches to identify HRSN. Research continues to be conducted to examine use of EHR data, community-level data, and machine learning to prioritize screening or predict HRSN among patients. Within the National DPP lifestyle change program, screening can be used as the first step in addressing barriers to participation. This section will discuss several specific screening tools that can be used to address HRSN and further health equity. For specific examples of how states are screening for HRSN, please see the examples for Rhode Island and Virginia on the Coverage Toolkit page titled, The Connection Between the National DPP Lifestyle Change Program and Addressing HRSN.


The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is designed to equip health care providers and community partners with the knowledge needed to better understand and act on individuals’ HRSN. PRAPARE covers the following domains: personal characteristics, family and home life, money and resources, and social and emotional health. PRAPARE also has a corresponding Implementation and Action Toolkit that compiles resources, best practices, and lessons learned on how to implement a HRSN data collection initiative. This toolkit can assist users in leveraging HRSN data to improve health equity from the individual level to the systems level.

AHC HRSN Screening Tool

The Accountable Health Communities Health Related Social Needs Screening Tool (AHC HRSN Screening Tool) was designed by the CMS Center for Medicare and Medicaid Innovation (CMMI) to evaluate if systematically screening for HRSN of Medicare and Medicaid members influences their total health care costs and health outcomes. The tool includes ten items categorized into five domains: housing stability, food security, transportation, utility needs, and interpersonal safety. The AHC HRSN Screening Tool can be viewed here.

HealthBegins Upstream Risks Screening Tool

The HealthBegins Upstream Risks Screening Tool was developed for health care providers to incorporate SDOH data to inform higher quality patient care and health outcomes. The domains included in this screening tool include education, employment, social connection and isolation, physical activity, immigration, financial strain, housing security, food security, dietary pattern, transportation, exposure to violence, stress, and civic engagement. The HealthBegins Upstream Risks Screening Tool identifies the minimum frequency that health care providers should be evaluating patient HRSN by domain. The tool can be viewed here.

Content Updated: October 30, 2022