Retention

CDC has developed a tip sheet that provides insights and lessons learned about improving participant retention, including how to establish participant buy-in, retention strategies for months 7-12, and how to build the capacity of Lifestyle Coaches to increase retention.

CDC created the Personal Success Tool (PST) to help increase participant retention. It has interactive, web-based modules to encourage participants, reinforce information they have learned in class, and provide tailored support to meet their needs. The PST is based on behavior change theory and audience research, and has been tested by coaches and participants in nine National DPP lifestyle change programs. It includes motivational messages, testimonials, short games, quizzes, and participant pledges.

Who uses the PST?
The PST is designed for Lifestyle Coaches and National DPP lifestyle change program participants. Coaches use the PST to help participants stay engaged by sending related modules after each class. Participants can review the modules on a computer, smartphone, or tablet, and each activity only takes a few minutes to complete.

The PST is designed to follow the order of the PreventT2 curriculum, but can be used with any CDC-recognized National DPP lifestyle change program curriculum.

Lifestyle Coach Perspectives on the PST

• “Using the Personal Success Tool will help you stay motivated when you need extra encouragement.”
• “Completing the modules will reinforce what you learn in class, helping you master new ideas, and continue to be successful in the long term.”
• “…the PST is easy to use and only takes a few minutes to review during class.”

PST Resources for Lifestyle Coaches (Additional marketing resources, including Spanish language versions, are available on CDC’s PST page on the National DPP Customer Service Center)

• Lifestyle Coach’s Guide—an overview of the PST, including when and how to use it
• Quick Reference Guide—a printable worksheet to schedule when to send each module to program participants
• PST Talking Points—ideas on how to introduce the PST to program participants
• PST Participant Overview—a handout for program participants about the PST

Maryland participated in the Medicaid Coverage for the National DPP Demonstration Project funded by CDC and managed by NACDD. A brief on the retention strategies implemented during that project can be found here.

A survey conducted with the participating Medicaid managed care organizations (MCOs) revealed some lessons learned regarding retention, including:

• Recruitment and retention success depended heavily on the participating MCOs’ traditional communication vehicle with its members. For example, 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.

To learn more about how the Medicaid Coverage for the National DPP Demonstration Project was implemented in Maryland and Maryland’s plan for ongoing sustainability of the program, visit the Maryland Medicaid Demonstration Project page of the Coverage Toolkit.

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 childcare 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

To learn more about how the National DPP lifestyle change program has been implemented in Minnesota, see the Minnesota State Story of Medicaid Coverage page of the Coverage Toolkit.

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. For example, volunteers from the Montana Disability and Health Program at the University of Montana and Centers for Independent Living role-played as National DPP lifestyle change program participants, so that the coaches could practice supporting individuals with disabilities.
• 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).

To learn more about how the National DPP lifestyle change program has been implemented in Montana, see the Montana State Story of Medicaid Coverage page of the Coverage Toolkit.

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. A brief on the retention strategies implemented during that project can be found here. Some of the best practices and lessons that Health Share of Oregon learned from its experience were the following:

Lessons Learned:

• 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

Best Practices:

• Barriers, such as childcare or transportation, should be addressed upfront
  • Partnering with an early learning hub is one way to address childcare
  • 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 can be used 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

To learn more about how the Medicaid Coverage for the National DPP Demonstration Project was implemented in Oregon and Oregon’s plan for ongoing sustainability of the program, visit the Oregon Medicaid Demonstration Project page of the Coverage Toolkit.

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)

In 2022, CDC published a research study about the use of incentives in lifestyle modification programs (like the National DPP lifestyle change program and diabetes self-management education and support services) and how they can benefit participants. The manuscript details how individuals in lifestyle modification programs who received an incentive improved their body weight, body mass index, and blood pressure more than participants who did not receive an incentive.

• Learn more about the findings of a systematic review and meta-analysis here.
• View an infographic of the research study findings on incentives here.

One Maryland MCO that participated in the Medicaid Coverage for the National DPP Demonstration Project provided various program supports according to the schedule below.

To learn more about how the Medicaid Coverage for the National DPP Demonstration Project was implemented in Maryland and Maryland’s plan for ongoing sustainability of the program, visit the Maryland Medicaid Demonstration Project page of the Coverage Toolkit.

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 did not 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 are 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—it resulted in people being frustrated or not realizing that the incentive was tied to reaching a goal.

The study of 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.

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.

To learn more about how the National DPP lifestyle change program has been implemented in Montana, see the Montana State Story of Medicaid Coverage page of the Coverage Toolkit.

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 and program supports to promote healthy habits according to the schedule below. Program retention statistics are included in the Statistics on Enrollment and Retention subsection below.

Health Share of Oregon, one of the Coordinated Care Organizations that participated in the Medicaid Coverage for the National DPP Demonstration Project, shared that one of its best practices relating to program supports includes making sure they are 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 is no funding available.

To learn more about how the Medicaid Coverage for the National DPP Demonstration Project was implemented in Oregon and the plan for ongoing sustainability of the program, visit the Oregon Medicaid Demonstration Project page of the Coverage Toolkit.

In 2012, CDC funded six national organizations through a five-year cooperative agreement to scale and sustain multistate networks of CDC-recognized organizations to deliver the National DPP lifestyle change program. A study based on this effort found that most of the CDC-recognized organizations offered the following three types of program supports and incentives to retain participants in the National DPP lifestyle change program. The incentives were program-funded and were not supported by federal funding.

• Non-monetary Program Supports
  • Program supports included gym memberships, pedometers, food-measuring devices, or cookbooks
  • Used by 118 of the reporting CDC-recognized organizations (78.7%)
• Monetary Incentives
  • Incentives included coupons or gift cards (less than $25 value)
  • Used by 32 of the reporting CDC-recognized organizations (21.3%)
• Removal of Barriers of Access
  • Program supports included childcare or transportation passes
  • Used by 29 of the reporting CDC-recognized organizations (19.3%)

Only the non-monetary incentives were found to significantly impact attendance. When non-monetary incentives were used participants attended an average of 1.8 more sessions and participated in the program an average of 27.8 more days.

Another retention tool utilized by the CDC-recognized organizations was cultural adaptation (e.g., using cultural images, and incorporating cultural dietary restrictions and preferences). When cultural adaption was used participants attended an average of 1.4 more sessions and participated in the program an average of 29.5 more days.

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 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.

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.

A 2023 Report by the North Carolina Department of Health and Human Services on the Minority Diabetes Prevention Program is available here.

The YMCA of the USA implemented the National DPP lifestyle change program with Medicare beneficiaries, through support from the Centers for Medicare and Medicaid Innovation’s Health Care Innovation Awards. The YMCA of the USA DPP 2015 Annual Report found at the end of the eleventh quarter (March 2015), that of the 6,874 Medicare beneficiaries who attended at least one session, 82.9% attended four or more sessions (see table below). For additional data reports from this project, see CMS’ Health Care Innovation Awards page.

Table included in the CMMI Y-DPP model test evaluation report; reformatted for this site.