Medicaid MCOs → Delivery → Enrollment, Incentives, & Retention
Enrollment, Incentives, & Retention
Retaining Medicaid 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
States have employed multiple strategies to encourage continued participation in the National DPP lifestyle change program among Medicaid enrollees. Some of these retention strategies, often used in combination with one another, include:
- Facilitate additional services to eliminate barriers to participation, such as transportation or child care
- Facilitate access to other community resources, such as food stamps or housing support
- Hold sessions at familiar, accessible locations
- Send reminder letters or phone calls
- Allow individuals to make up missed sessions, including through online programs
- Staff the program with coaches trained on disabilities and community health
- Provide simplified materials in multiple languages
- Provide a healthy snack during the session
- Provide incentives for program completion
- Encourage participants to celebrate both small and large successes
Other factors that could enhance enrollment and retention include ensuring that individuals have access to and support in using a digital device (for online National DPP lifestyle change programs). Vendors that deliver the program through an online or distance learning model may have established programs tailored for Medicaid participants.
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.
In 2016, the Minnesota Department of Health and the Minnesota Department of Human Services cited the following as critical success factors and/or best practices for engaging and retaining Medicaid members in the National DPP lifestyle change program. These factors are based on learnings from program implementation, key informational interviews, and participant focus groups:
- Providing services for participants, including transportation and child care to eliminate barriers to participation
- Providing a healthy snack during the session
- Initiating reminder calls or letters and providing ongoing support to participants
- Building in extra time to support participants through sometimes challenging personal/familial circumstances
- Facilitating participant access to other support programs (e.g., food assistance, health insurance, housing support)
- Training community health workers and/or local community clinic staff to serve as lifestyle coaches (and ensuring that they can bill the hours necessary to deliver the program)
- Showing sensitivity to participants with low literacy (e.g., using photos instead of written text, using hands-on activities rather than reading from a script, etc.)
- Coordinating with the participants’ local primary care clinics
- Identifying, with the help of the clinics, a familiar and accessible meeting location for participants (e.g., not necessarily the YMCA, even if the lifestyle coach is from the YMCA)
- Hiring coaches from cultural backgrounds that match the cultural backgrounds of the participants (community health workers are a good option to fill this cultural need)
- Providing instruction in participants’ primary language (e.g., Somali, Hmong, Spanish)
- Translating some program materials (such as a food tracker) into the participants’ primary languages (this has not been done extensively, but is perceived as being a best practice)
Montana: Individuals with Disabilities
In 2012, Montana Medicaid started offering the National DPP lifestyle change program as a covered benefit to Medicaid enrollees with and without disabilities. Over the first two years, roughly one-third of program participants had a disability. Evaluations on the state’s program have indicated that, although individuals with disabilities tended to start with a higher BMI baseline and were less likely to achieve 5–7% weight loss, they could still successfully participate in the National DPP lifestyle change program. Some program adaptations may be necessary, however, to address their needs and to increase success.
A survey that gathered feedback from lifestyle coaches on the program revealed that some curriculum content was too complex for a subset of beneficiaries and that some participants found food journaling to be challenging. It further indicated that transportation is an obstacle to participation. Based on this and other survey feedback, the following recommendations were made:
- Engage family, case managers, and Medicaid transportation assistance services to help program participants with transportation
- Simplify curriculum content as needed
- Simplify self-monitoring tools as needed
- Provide individual support as needed
A program manager from the Montana Department of Public Health and Human Services also shared the following as valuable practices for implementing the program within the Medicaid population and for individuals with disabilities:
- Train lifestyle coaches on different types of disabilities (both physical and cognitive) and how those disabilities could impact how someone might learn, meet goals, and track eating. The Montana Department of Public Health and Human Services engaged the National Center on Health, Physical Activity and Disability (NCHPAD) to provide this training to lifestyle coaches.
- Train lifestyle coaches about issues and solutions relating to accessing health care and fitness centers (e.g., simple things someone could do to rearrange exercise equipment so that it could be more accessible to someone in a wheelchair).
- Enable lifestyle coaches to practice coaching and secure feedback from individuals that are knowledgeable about disabilities. (Volunteers from the Montana Disability and Health Program at the University of Montana role-played as National DPP lifestyle change program participants, so that the coaches could practice supporting individuals with disabilities. Volunteers could also come from Centers for Independent Living.)
- Ensure that lifestyle coaches share budget-friendly food planning and physical activity information (e.g., talking about exercises that are free or highlighting that frozen fruits and vegetables may be cheaper than fresh produce).
Maryland participated in the Medicaid Coverage for the National DPP Demonstration Project funded by CDC and managed by NACDD. A survey conducted with the participating Medicaid managed care organizations (MCOs) revealed some lessons learned regarding recruitment, including:
- Recruitment and retention success depended heavily on the participating MCOs’ traditional communication vehicle with its members. (e.g., while text messages worked well with one MCO that frequently communicated via text, texts from another MCO that did not traditionally communicate via text resulted in many confused members and lacked success)
- Class reminders from the MCO or CDC-recognized organization via phone and/or email both prior to the first class and before every class were helpful in recruiting and retaining participants.
Health Share of Oregon was one of the Coordinated Care Organizations that participated in the Medicaid Coverage for the National DPP Demonstration Project funded by CDC and managed by NACDD. Some best practices and lessons learned from Health Share of Oregon’s experience include:
- It is more difficult to motivate participants to continue to attend sessions when there are long gaps between them (i.e., monthly classes can be challenging to retain attendance)
- Incentives can be unsustainable if funded with grant money
- It is important to find the communication style that works best for the participants, whether it is text, phone call, or email
- Barriers, such as child care or transportation, should be addressed up-front
- Partnering with an early learning hub is one way to address child care
- An accessible location, especially by public transit, is important
- Allowing family members or caretakers to also participate in the program promotes retention
- Resources should be modified for language and cultural relevance
- A mini-evaluation at the end of each class ensures that methods and/or items promote success
- Communication should be retained to keep participants engaged during the off-weeks
- Bringing in outside resources with additional information and tools can keep participants engaged
- Incentives, raffles, or challenges can provide additional motivation to participants
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’s duration and the 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
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:
- Lack of lifestyle coaches or CDC- recognized organizations
- Limited broadband internet access in some rural areas
- 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 distances—both for coaches and participants—can be further in rural areas
- 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 may move to a different location throughout the year
- Allow participants to join a class at other locations so they can complete the yearlong program
- A less populous area can make it difficult to enroll a sufficient group of participants
- 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
- Finding a marketing strategy for the rural population
- Local radio
- Local free newspapers available in grocery stores
Lifestyle Coach Support
- Since lifestyle coaches may be spread out, it may be difficult to support them
- Monthly support calls and annual face-to-face meetings to offer refresher training, support, resources, and best practices
Screening, Testing, & Referral
- Because of the diffused population, it may be difficult to identify potential participants
- 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
Some CDC-recognized organizations and their partners use 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
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
Note: When covering the National DPP in Medicaid, consideration will need to be given to the type of incentives and program supports that can be offered. Generally, federal Medicaid funds cannot be used to pay for program incentives (unless the state has received approval through an 1115 or other waiver). As such, state or grant funds may be needed to pay for program incentives. Medicaid MCOs could also pay for program incentives out of their administrative funds.
Incentives in Practice
Click through the tabs below to learn how various organizations have approached offering incentives in their National DPP lifestyle change programs.
One Maryland MCO that participated in the Medicaid Coverage for the National DPP Demonstration Project provided various program incentives according to the schedule below.
Health Share of Oregon shared that one of its best practices relating to incentives includes making sure the incentive is related to the material and that it promotes healthy living. It also suggested, as a consideration, to partner with other organizations to provide deals, prizes, or other incentives when there isn’t funding available.
North Carolina: 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. Program retention statistics are included in the Statistics on Enrollment and Retention subsection below.
Montana conducted a study testing the effectiveness of using financial incentives for participation in its Medicaid National DPP lifestyle change program. Participants in the incentive cohort were given incremental financial incentives, up to a maximum of $320, for attendance, behavior change, and weight loss goal achievement. The median incentive amount earned was $110 per participant during the 3-year study.
While the study found that the incentive cohort attended significantly more sessions, reported greater physical activity, and self-monitored fat more frequently compared to the non-incentive cohort, there was no significant difference between the two cohorts in attaining greater than 5% or 7% weight loss.
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 in the National DPP lifestyle change program. 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
- MyPlate or other food measuring devices
- YMCA memberships
- certificates, plaques, or trophies
- athletic gear or clothing
- gift cards
- 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.
MIPCD Grant States
Ten states received Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD) grants. Four of the ten states—Minnesota, Montana, Nevada, and New York—used a subset of the grant dollars to fund incentives specifically for the National DPP lifestyle change program. A summary of key findings from the evaluations is provided below.
The study found that participants receiving incentives had significantly higher attendance (attended 1‒2 more National DPP lifestyle change classes) than control groups without incentives. However, beneficiaries indicated that while incentives served as a hook to get them enrolled, they were not the driver behind continued participation. Reaching goals, starting to feel better, and establishing a relationship with a coach who cares about them and acknowledges their successes were what kept them engaged.
The study also found that the type of incentive used is very important and that consideration must be given to its value and appropriateness. For example, while incentives increased attendance, they didn’t necessarily increase usage of other services evaluated through the grant, such as meetings with a health coach or doctor or gym visits. In the preliminary evaluation, several programs indicated that they had provided program participants with gym memberships, but later found that the participants weren’t using them because some people did not know how to use a gym, were overweight and uncomfortable wearing exercise clothes in the gym or were from a culture that did not approve of co-ed gyms.
The timing and delivery of incentives is also crucial. Incentives should be given as soon as a person meets their goal—the clearer the relationship is between the incentive and the goal, the better the results. In states where this relationship was delayed—where a person had to wait until the next time they came into the class to receive the incentive or wait until it arrived in the mail—resulted in people being frustrated or not realizing that the incentive was tied to reaching a goal.
Study on the incentive design proved inconclusive. When states tested different approaches to offering incentives—such as tying the incentive to activities, outcomes, or both—there was no clear pattern to suggest that one incentive design was more successful than another in improving health or reducing claims-based expenditures and utilization.
The MIPCD final evaluation report can be accessed here.
Statistics on Enrollment and Retention
The following examples illustrate state and partner experiences with enrollment and retention numbers in their implementation of the National DPP lifestyle change program.
Denver Health, a Colorado-based safety net health system, attempted to recruit 4,495 individuals that it identified as being eligible for the National DPP lifestyle change program using medical record data. A total of 782 of these individuals, or 17.4%, attended at least one session. Further, approximately 1 in 10 at-risk individuals would enroll (i.e., verbally commit to participating in a session) when contacted by a lifestyle coach, whereas nearly 1 in 2 individuals would enroll if referred by their provider.
Of the 617 participants who completed the yearlong program, 238 (38.6%) attended nine or more sessions. Approximately 50% of the participants were Medicaid beneficiaries and 80% were low income.
Denver Health: Latinos
Denver Health conducted a study to determine how results differ between Latino and non-Hispanic white participants enrolled in the National DPP lifestyle change program. It found that Latinos were approximately half as likely to attend the sessions and were also less likely to achieve 5% weight loss when compared to the non-Hispanic white participants. Discovering and resolving barriers to participation among Latinos may be a key step in improving attendance and reducing their risk reduction outcomes. The study can be found here.
An analysis on the YMCA of the USA DPP model test, supported by the Centers for Medicare and Medicaid Innovation’s Health Care Innovation Awards (CMMI Y-DPP model test), reported that the reach—the ratio of participants who participated in four or more sessions to the number of participants who participated in at least one session—under the CMMI Y-DPP model test implementation (involving Medicare beneficiaries) was 82.9% at the end of the eleventh quarter (March 2015). The table below shows the number of sessions attended by the Medicare beneficiaries (participants who attended at least one session). See the full CMMI Y-DPP model test report here.
Table included in the CMMI Y-DPP model test evaluation report; reformatted for this site.
North Carolina: Minority Diabetes Prevention Program
Of the individuals who enrolled in North Carolina’s Minority Diabetes Prevention Program, 50% of participants completed at least 4 classes, 33% completed at least 8 classes, and 25% completed at least 9 classes.The statistics may be useful in designing a program for similar populations.