The National Diabetes Prevention Program — Changing Lifestyles to Prevent Type 2 Diabetes

The National Diabetes Prevention Program — Changing Lifestyles to Prevent Type 2 Diabetes

>>Good afternoon, good
evening, or good morning, depending on from when and
where you are joining us. I’m Dr. Phoebe Thorpe and it’s
my pleasure to welcome you to CDC Public Health Grand
Rounds for November 2018. The National Diabetes Prevention
Program: Changing Lifestyles to Prevent Type 2 Diabetes. We have an exciting
session– oops– but first a few housekeeping
slides. Public Health Grand Rounds has
continuing education available for physicians, nurses,
pharmacists, veterinarians, and others. Please check out our
website for more information. The course code is PHG10 and
this is our disclosure slide. Grand Rounds is available
on all your favorite web and social media sites. Please send the questions
to [email protected] and we will try to include your
question in the Q and A today. Want to know more about
prediabetes and preventing it? We have a featured
video segment on YouTube and our website called
Beyond the Data, which is posted after
the session. This month’s segment features my
interview with Dr. Ann Albright. We have also partnered with
the CDC public health library to feature scientific
articles about the topic. The full listing is available
at Here is a preview of our
upcoming Grand Rounds topics. Please join us if you can. In addition to our
outstanding speakers– which I will give a special
thank you to Dr. Pryor who is joining us
from California, he had to evacuate his
home due to wildfires– I’d also like to acknowledge
the important contributions of the individuals listed here. Thank you. And now for a few words from CDC’s Deputy
Director, Dr. Schuchat.>>Today, 30 million
Americans have diabetes and another 84 million Americans or 1 in 3 adults
have prediabetes. You may never have heard of
this, but today you’ll find out why prediabetes matters and
what you can do about it if you or a loved one has it. Prediabetes is characterized
by blood glucose levels that are higher than
normal, but not high enough to be diagnosed with diabetes. People with prediabetes
have an increased risk of developing type 2 diabetes,
heart disease, and stroke. Prediabetes does not mean
an inevitable progression to diabetes. Research shows that people
with prediabetes who take part in a structured lifestyle change
program can cut their risk of developing type 2
diabetes by more than half. People over 60 can cut
their risk by nearly 3/4. The National Diabetes Prevention
Program or DPP is designed to help people make changes in
diet, exercise, and behavior. The program starts with weekly
lessons the first 16 weeks, then monthly for
another 6 months. These can lead to lasting
health improvement. The goals are to lose
5-7% of body weight through healthier eating
and to get 150 minutes of physical activity a week. It doesn’t take a radical weight
loss to make a big impact. The impact of this
program can last for years. Research has found that
even 10 years later people who completed a diabetes
prevention lifestyle change program were 1/3 less likely
to develop type 2 diabetes. Most people who have
prediabetes are not aware of it. Increasing screening is key. The CDC-led National Diabetes
Prevention Program is a partnership working collectively
to prevent or delay onset of type 2 diabetes in
adults through the delivery of an evidence-based
lifestyle change program. Today we will hear about how
partners are delivering this program across the
U.S. and how private and public health care insurance
providers are supporting this effort. The national levels of type 2
diabetes have been increasing along with the obesity
epidemic and make scaling up the DPP an urgent
national priority. Working together, we can
make it easier for people with prediabetes to participate
in evidence-based, affordable, high quality lifestyle change
programs to reduce their risk of type 2 diabetes and
improve their overall health.>>And now for our first
speaker, Dr. Ann Albright.>>Thanks, Phoebe. It’s really a pleasure to
be with all of you today. As you heard, there are
over 30 million people who have diabetes. That’s about 9.4% of
the U.S. population. It’s expensive; 237 billion
in direct costs and 90 billion in reduced productivity
and disability. Prediabetes is a condition
where blood sugar is higher than normal, but not high enough yet to constitute type 2
diabetes, but as was noted, it does put you at
increased risk for other serious
health problems, including heart attack
and stroke. Prediabetes really is a
significant health issue in our nation. So, as we work to improve
the outcomes for those who already have
diabetes, it is imperative that we really do
focus and invest in preventing new cases
of type 2 diabetes. Fortunately, we have
strong evidence that– for the prevention or
delay of type 2 diabetes in those at high risk. We have multiple
randomized controlled trials that have been done in the
U.S. and around the world. The most preeminent one done
in the U.S. is referred to– is known as the Diabetes
Prevention Program Research Study, which was led by NIH with critical support
from CDC and others. The trial was done in
adults and about half of the study participants were
from high-risk ethnic groups. The intervention tested– the interventions tested
were lifestyle program, a structured lifestyle program,
the medication metformin, which has been used– is used to treat type 2 diabetes,
and a placebo. The intensive lifestyle
intervention did consist of this structured
curriculum that addressed diet, physical activity, and
behavior change modification. The intervention did
involve 16 weekly sessions and then 6 monthly sessions
over the course of a year. The goal was 7% weight loss and 150 minutes of
physical activity. So, let’s take a look at the
results from the study briefly. The lifestyle change program
did reduce the incidence of type 2 diabetes, as
you heard earlier, by 58%, 31% for those using medication. The 58% reduction
was seen in those with a 5-7% weight loss and,
as was noted, those over 60, 71% reduction in the
development of type 2 diabetes. Exciting is that this is
a long-lasting impact. Not only have we now been
studying the trial for 10 years, we now have 15-year
data that shows that after 15 years there
still is a 27% reduction in the development
of type 2 diabetes. So, this shows both
prevention and delay. Very importantly, though,
we also have research trials that have been done in the real
world and so that is critical to allow us now to transition
from these research studies into the actual implementation
of the lifestyle intervention. We also, by the way,
have support from very esteemed bodies like the U.S. Preventive
Services Taskforce and the Community Guide who all
recommend this intervention. So, to implement this proven
lifestyle intervention nationwide, CDC did establish
the National Diabetes Prevention Program, officially
called the National DPP. Congress authorized
CDC to establish it and so that’s good
news for all of us. The National DPP is the largest
national effort to mobilize and bring together effective
lifestyle change program to communities across
the country. It serves to unite all sectors so we can really
achieve national scale. The National DPP has 4
overarching strategic goals; increase the supply of quality
programs across the U.S., increase demand for the National
DPP among people at risk, increase referrals from
healthcare providers, and increase coverage among
public and private payers. All of these critical elements
have to work simultaneously since all are required. Let’s take a look at where we
are on the progress to achieve– where we are in achieving the
goals in each of these areas. So, first let’s take a look at increasing the supply
of quality programs. As you can see, the trajectory
is showing a significant increase in the number
of organizations who are delivering the lifestyle
change since its launch. There are currently close to 1800 organizations offering
the program in all 50 states, in D.C., and in some of
our U.S. territories. Many of these groups have
multiple delivery sites. The program is being
delivered in person, online, and through distance
learning by a whole array of various kinds
of organizations. CDC’s diabetes prevention
recognition program plays a key role in assuring the quality across these many
unique organizations. It’s part of the National DPP. We award recognition in
3 categories; pending, preliminary, and full. The standards are
updated every 3 years. They are really a critical part
of the recognition program. They are the heart of
the recognition program and they are updated every 3
years, both to stay in alignment with the science of type
2 diabetes prevention, but also to respond to the
lessons we have learned through the program delivery and the analysis of
participant data. There are many benefits
of CDC recognition. We have now data that allows
us as a country to look at how we are doing in program
outcomes across the nation. It also is very important
now for those who are providing coverage
for the intervention. Many of these payers now
require CDC recognition. It also allows support to be
given to those organizations who are delivering
the intervention. We can provide assistance,
training, and resources, and also can be very effective
part of marketing your program. So, let’s now take a look
at increasing the demand for the program among
people at risk. The number of participants
enrolled in the National DPP lifestyle
change program has really grown rapidly. This graph represents trends
in cumulative enrollment of almost 1/4 million
people who are currently– for whom we currently have data. There are many more people
enrolled in the program but data is not yet
submitted for them. We do have a system in place to track these numbers
in real time. Since 2016, CDC has
worked with the Ad Council, the American Medical
Association, and the American
Diabetes Association to launch the first national
prediabetes awareness campaign and get people to complete a
brief prediabetes risk test. We’ve used humor to engage
people in the campaign. We’ve used a comedic
doctor talking to patients, cute animal videos– which
we know people watch– and we also– which is showing
us now from what we’ve achieved so far in the campaign about 3
million people know their risk for prediabetes as a
result of this campaign. We’re really excited to be
launching the third phase of this very successful
campaign on November 14th, tomorrow, World Diabetes Day. The new campaign assets will
focus on the message of 1 in 3 adults has prediabetes
and will again use humor to reach people at risk and
encourage them to take action to know where they stand. Please take the test yourself. Share it with everyone
you know and share it in your social media channels. So, now let’s turn
to increase referrals from healthcare providers. CDC works with many different
national partner organizations to help identify and
refer at-risk individuals to CDC-recognized programs
who offer the intervention. Each of these groups is working
with the clinical care community or implementing systems– some involving the
electronic health record– to increase healthcare
provider screening, testing, and referring people
with prediabetes to CDC-recognized organizations
around the country. The role of healthcare
professionals really is critical. And now the last strategic goal
is increasing coverage among public and private payers. Our goal since the inception of the National Diabetes
Prevention Program has been all payer coverage and we have
made significant progress. Many public and private insurers
are offering the National DPP lifestyle change program
as a covered benefit in specific markets
or geographic areas. There are some examples of these
commercial health plans listed on the left of your slide, but
these are just some of them. In addition, another 3.4
million public employees and their dependents in
19 states have coverage and other states are
working towards this goal. We also support work to make the
National DPP lifestyle change program available as a
covered benefit for Medicaid. There is a lot of energy
in this area right now. Currently, there are
9 states who have full or partial coverage through
Medicaid authorities, demonstrations, or pilots. Beginning in April 2018, the National DPP lifestyle
change program became a covered service for eligible
Medicare beneficiaries. It’s called the Medicare
Diabetes Prevention Program or MDPP and is part
of the National DPP. You will hear more about the
MDPP from our next presenter. Together, all of this work
has informed the development of an online toolkit to assist
public and private payers and employers pursuing
coverage for the program. We encourage you to
look at that toolkit. In response to the
program’s tremendous growth, we have recently launched
our newest resource, the National DPP
Customer Service Center. The customer service
center really provides a hub of resources, training,
and technical assistance for CDC-recognized
delivery organizations and other national DPP
stakeholders nationwide. You can access numerous
resources including toolkits, training videos, and very
importantly connect with others in the National DPP community. You can also engage with experts
at CDC and other organizations for technical assistance. The National DPP is
bringing all sectors together to unify efforts and get this
highly effective intervention implemented nationwide. In addition to this very
critical intervention, we also need interventions that
focus on the whole population because we need fewer people
ever developing prediabetes and those with prediabetes
will benefit from this as well, but they are both necessary,
not one or the other. This really is our opportunity
to make a significant impact on type 2 diabetes prevention and the data tells us
we must all succeed. Please join this
effort and stay tuned for even more new
exciting developments that are coming your way. You will now hear from
Nina Brown-Ashford, Deputy Director CMS
Innovation Center Prevention and Population Health Group. [ Applause ]>>Good afternoon
and thank you, Ann, for that overview
and introduction. I will note I also love
cute animal videos, so very, very excited about that. So, I’m going to provide a
little bit of an overview. As Ann mentioned, we are now
covering the Diabetes Prevention Program as a covered
service under Medicare, which we are very excited about. So, I’ll be talking a little
bit about that coverage as well as addressing some
of the key components of the MDPP outlined here. So, we know that MDPP
works to prevent high rates of type 2 diabetes among older
Americans and so when we look at how type 2 diabetes is
affecting Americans 65 years and older, we know that
about 25% are living with type 2 diabetes and
about 50% of individuals, older Americans 65 or older
actually have prediabetes. We estimate that care
for older Americans with diabetes costs Medicare
about $104 billion annually and this number is
continuing to grow. Seeing that this
was a big issue, the Medicare Diabetes
Prevention Program model test, which was implemented
by the YUSA through a Healthcare
Innovation Award, actually served 7800
Medicare beneficiaries. And what we saw was that it
was wildly effective in terms of reducing weight and
allowing beneficiaries to achieve weight loss as
well as reducing costs. And so we went through
rule-making to expand the Diabetes
Prevention Program as a covered Medicare service
and create a new supplier type so that these individuals who deliver DPP could
actually enroll in Medicare to provide the service. So, we know that DPP,
as Ann highlighted, really does a great job of
promoting healthier behaviors for eligible Medicare
beneficiaries at risk for type 2 diabetes as well as
decrease overall Medicare costs. So, I wanted to highlight some
of the specific criteria as far as which Medicare beneficiaries
are eligible to be able to receive MDPP services. So, it is available for Medicare
part B and C beneficiaries as long as they meet one of the
following eligibility criteria. So, having a BMI or body mass
index of at least 25 or 23 if self-identified
as an Asian American, 1 of 3 blood test requirements,
and they cannot have any of the following diagnoses
or conditions listed below. So, the MDPP covers up
to 2 years of services for eligible beneficiaries. So, in that first year–
which is really that core set of services– we have
months 0 through 6 and these are 16 sessions that
are available to beneficiaries that are offered at least a
week apart and they are able to be attended regardless
of weight loss. In months 7 through
12, we then move on to the core maintenance
sessions and so these are 6 monthly
sessions, again available to beneficiaries regardless of the weight loss
that they achieve. In months 13 through
14, that’s where we move on to the ongoing
maintenance sessions and these are 12 monthly
maintenance sessions and in order for
beneficiaries to be able to attend these sessions, they
must have achieved and maintain at least a 5% weight
loss as well as meet the attendance goals
in order to remain eligible. An important thing to note
is that this was expanded as an additional preventive
service, so there is no copay for beneficiaries to
receive this service. It does leverage the
CDC’s approved curriculum and they can attend
in-person sessions and there are a limited number of virtual make-up
sessions that are allowed. So, what we really try to do
with this service is to make– develop it with a
performance-based payment. So, they are really based
on meaningful outcomes such as beneficiary
attendance and weight loss. So, as you can see here,
within the first 6 months of the program, a supplier could
actually receive a reimbursement of up to $165 if a
beneficiary attends all sessions and if they meet the weight
loss targets they could achieve $325 reimbursement. For the full 12-month
program, if a beneficiary went through the entire program but didn’t achieve
any weight loss goals, they could receive $195 or $445 if they achieve all
of the goals. Sorry about that. I talked faster than I advanced. So, one important criteria is that MDPP suppliers
must actually adhere to the requirements to establish and maintain enrollment
as a supplier. So, CDC recognition is the
crux to their enrollment and this really has
to happen first. So, they have to have CDC
preliminary or full recognition in order to be able and
eligible to enroll in Medicare. They have to obtain a national–
a national provider identifier through the national plan and
provider enumeration system, and then there are a
couple of enrollment options that they can utilize
to enroll in Medicare. So, they could use this– do
this using the online system that we call PECOS or they could
actually submit a paper form. I will just note there is about
a 90-day faster turnaround for them to enroll
using the online system versus the paper form,
but there are those 2 mechanisms available. If you are already
enrolled in Medicare, so you are already providing
services as a Medicare provider, you must actually reenroll
as an MDPP supplier. Because this is a new supplier
type, we had to work really hard to develop enrollment
requirements that would allow us to be able to identify these
types of suppliers and then in order to maintain enrollment
in Medicare you actually have to maintain compliance with the
CDC’s recognition requirements– as I mentioned, that is the
core of the enrollment– as well as the MDPP supplier
standards, which are outlined in the physician fee
schedule final rule in which we expanded a program. So, one thing that
I like to highlight because there is a
little bit of confusion. The MDPP is under the National
Diabetes Prevention Program umbrella and so we do
like to highlight this. This really is a joint
partnership between CMS and the CDC and I always joke
that once the rule was final, CDC and CMS were married in
holy regulatory matrimony. And so we worked very closely
with our colleagues at CDC, they’re a wonderful team, and it’s been a really
great experience, but CMS is really the payment,
enrollment, and oversight arm of the MDPP program and so
the suppliers receive payment from CMS and they have to remain
compliant with those criteria that I outlined earlier. We really view CDC as the
quality assurance arm. So, they– the MDPP
suppliers have to maintain that CDC recognition, follow
the quality standards, which includes the use of
that approved curriculum. We want to make sure that our
beneficiaries are receiving a quality program and benefit. So, what can you do to help? Screen, test, and refer your
at-risk Medicare patients. So, you can screen them using
the CDC’s prediabetes screening test, there is a link here, you
can use 1 of the 3 blood tests that Ann highlighted and
are also listed here, and please do refer your
at-risk Medicare patients with prediabetes to one of
their nearby MDPP suppliers. We do have a supplier map on our
CMS website where you can go in, put your address, and see where
the nearest MDPP supplier is to you so that you can
enroll either yourself or refer your beneficiaries
to enroll. How else can you help? So, we really need to increase
MDPP supplier capacity. This is a new service, we know
that new services take time to roll out and ramp up,
so suppliers were able to begin billing for the
benefit beginning April first of this year. So, we know that there’s going
to be a ramp-up period for folks to get enrolled in Medicare. So, encourage CDC-recognized
delivery organizations to enroll as MDPP suppliers. Encourage organizations to
actually become CDC-recognized so that they can eventually
enroll once they’ve met that preliminary recognition, and then educate CDC-recognized
delivery organizations that MDPP is out here and that
there are a ton of resources on our website available to
help you enroll in Medicare to be able to bill
for this service. Lastly, you know, really
work to promote awareness of prediabetes among
the Medicare population. As I said, about 50% of Medicare
beneficiaries are prediabetic and many of them don’t know it. So, you know, have folks get
screened and learn their status, as well as encourage
providers to screen, test, and refer patients
to MDPP suppliers. So, if you want to know
more, there are a number of resources here both
on our website at CMS as well as CDC’s website. And now I will turn it over to
Dr. David Pryor, who is calling in from California and Phoebe
will advance his slides. Thank you. [ Applause ]>>Well, thank you
very much, Nina. I hope everybody
is able to hear me. Very much pleased to be here
with you today via the phone. As was mentioned earlier, I am
right in Southern California in the midst of all of
the fires and good news is that after being evacuated from
my home for the last 5 days, it looks like I’ll be
able to return today. So, that is the good news, but again I am a regional vice
president medical director with Anthem Blue Cross. And, as many of you know,
Anthem is a national insurer with about 40 million medical
members across the country and I work in our
California division. And I wanted to talk a little
bit about our implementation of the National DPP
lifestyle change program over the last year or 2 and talk
through some lessons learned through that, hopefully. Our journey with the National
DPP program really began in August of 2014 when the U.S.
Preventative Services Taskforce issued a recommendation stating that intense behavioral
counseling intervention could promote cardiovascular
disease prevention. And so we took notice of
that and looked around and were excited to find that the National DPP lifestyle
change program met all the requirements for
this recommendation, so really that’s how
it started for us. And, in August of 2016,
we were able to offer this as a fully-covered benefit for our medical members
in California. And as we go to the
next slide, you know, this really has been
a tremendous offering for our employees– our members. It’s been a win-win situation. Many of our large health plans
always ask us the same question. Well, we appreciate what you
do, you provide insurance for our employees, but how can
we continue to improve health, you know, bring more
and more quality to the healthcare experience,
and at the same time, as a large employer, how can
we save on healthcare costs. And so what we certainly know
through our data is that members with diabetes do cost more
than members without diabetes. Our data tells us that
health plan costs for members with diabetes a little over
$11,000 as opposed to $4400 with those members that
don’t have diabetes. So, certainly it’s
really an easy proposition that if we can keep
people healthy, if we can prevent people
from developing diabetes, we can improve their health,
the quality of their healthcare, and we can save costs. So, that was really again
that win-win situation. So, the next step is,
well, how did we go about implementing the
National DPP program. And so we decided early on that
we were going to use vendors to help us implement the program
and we decided that the best way to reimburse for this was
to run all of these visits through our claims system
that we already had in place. Our claims structure
allowed us to really align with the CDC quality and
fidelity metrics and, as I’ll talk about in the next
few slides, we have 4 milestones which we pay our vendors and
it’s worked out very well. So, the next slide
goes into more detail about these milestones. So, milestone number 1, when
somebody enrolls in the program, that’s milestone number 1
and we make a reimbursement to our vendors at that stage. When they have meaningful
engagement through 4 weeks, that’s milestone number 2. When they continue that
engagement up to 9 weeks, they reach milestone number 3. And then, hopefully, if
everything goes well, when they’re able to reach that
greater than 5% weight loss, you know, sometime
between milestone 3 and end of 19 months, right, between
9 weeks and 12 months, that’s milestone 4 and
that is the last payment that our vendors receive. And so, obviously, you know,
we didn’t want to just kind of pay a fee and if people
aren’t able to continue with the program, you know,
that money is kind of lost. So, we– these milestone
payments really helped us to manage this relationship
with our vendors. The other question on the
next slide is, gosh, well, how do you pick the
right vendors. And what we found very quickly with our clients is we
have very diverse needs. Some of the clients that we
insure and provide insurance for are large municipalities. We have large school districts,
but we also have tech companies. Let’s say in the San Francisco
Bay area, for example, younger employees, very
tech savvy, you know, again, different ethnicities. So, we had a lot of different
needs and we realized that it wasn’t going to
be just one size fit all, not just one provider
that’s going to provide DPP, but that we really
needed to allow choices so that we could
have the best fit. And the next slide here
again talks and amplifies on that just a little bit more. So, we knew that our
vendors needed to have kind of a national network
of organizations. We wanted kind of bricks and
mortar community organizations as well as the digital solutions
as well and you’ll see some of the vendors here even from Weight Watchers
to Lark and Sclera. And so, again, Solera was our
company who has relationships with many of these vendors
and they’re contracted, so they were our first major
DPP vendor in California and then we’ve also
added on Omada, which is a pure digital solution
that really appeals to a lot of our tech savvy customers. And the next slide again
talking about choice. What we’ve learned so far is that choice really does
drive the engagement. So, really finding the right DPP
provider for the members is one of the major determinants
of success. If they’re using a
service or a provider who is not really aligned with
their interests and goals, it’s not going to work. And so this choice has
been very valuable for us as we’ve moved forward. The next slide now really wanted
to emphasize a little more of why choice matters and
what’s the preferred delivery. So, our data so far has
shown us the following. It may not be a big surprise to
many of you, but our younger– our younger members, let’s say
18 to 24, 25 to 34, that range, they often opt for the
digital or virtual solutions. OK? As we see our membership
get older and they age, you’ll see a little more mixed, Weight Watchers becoming more
popular as people get older and other community
organizations. And so, overall, I guess as we
kind of distill all of our data, we found that more people
tend to opt and start with the digital virtual
provider, if you will, but that we’ve actually
had more success in some of those achieving
those weight loss goals with the Weight Watchers
or community organizations, the kind of brick and mortar. You go in, you check
in, you, you know, deal with somebody in person. For us, so far, we’ve had
a little bit better overall results in the weight loss, but
I think that continues to evolve and we kind of really
push to make sure that our digital providers
are engaging in the right way, but those are some things
to certainly consider. I wanted now to go over
just a few case examples of how we’ve implemented this. You know, I work in
our commercial division and we have different segments. We have individual
insurer– individual accounts, we have small group accounts, and we have these very large
group accounts with, you know, hundreds of thousands
of employees and so we had different
strategies for each segment. So, this slide here talks about our small group
case study in California. Again, small group is
typically those small businesses with 100 employees or less. So, in this program, we actually
started and directed individuals in these small groups to take
the CDC prediabetes risk test to determine their
type 2 diabetes risk. We actually ran 4 campaigns
between 2016 and 2018 and more than 60,000 received a series
of emails referring them to take this risk test and
find out what their status was. Here are some of the results. So, as of August of this
year, we had 1811 members who actually committed
to the program. They took the test, they
committed to the program. Of those members, 65% remained
actively engaged and 24% of those members had achieved
the 5-7% weight loss goal. What we found is that
incentives were important. We actually gave Fitbits after the completion
of the fourth week. That helped keep some
of the momentum going. We also learned that
those employers who were very engaged– so it was the vendor
engaging the employee, but also the employer, right, at
the same time working engaging, reminding the employees to
take advantage of this benefit. That seemed to work the best. Also, our vendor
Solera in this case kind of used very sophisticated
and slick emails to outreach and to get the employees
excited. So, they had a lot of work with
implementing these programs and learned that you can’t just
necessarily send a standard email out, you have to
sometimes use some animation and some other little tricks
to get people excited. And so next steps, we’re
going to be the end of this last quarter sending
out a fifth campaign focusing on our small group members. The next slide is a
little case example from our large group business. These are often large
employer groups with over 10,000
employees and wanted to give you some
highlights there. The same thing, we
directed the members to the CDC prediabetes
risk test. We had different mechanisms, this was actually a
large school district that had early retirees,
over 38,000, that we– they received a newsletter
article linking them giving them information about this program
and this covered benefit. We also had another track
for those district employees who were active employees,
over 60,000, where they received a series of
emails sent out by the district in this case encouraging them,
telling them about this benefit, saying, hey, why don’t you
just go and take the risk test and see where you’re at
because we have something that may be helpful to you. And now let’s talk a
little bit about the results from this large school district. As of April 2018, a little over 5200 district employees
have taken the risk screener, 934 district members were
committed to the program, and of that 934, 64%
remained actively engaged and 18% actually achieved
the 5-7% weight loss. Again, with this group we
provided some incentives, a $10 gift card just for
completing the 1-minute, you know, assessment
test and quiz, and again we gave
them the Fitbits after they completed
week 4 of the program. And so, again, it’s– all these
programs when you’re talking about health, wellness,
it’s engagement. How do you engage people? How do you get them started? And then, certainly,
how do you, you know, get them to maintain
that commitment? Just, again, some of our lessons
learned working with employers to implement the National
DPP lifestyle program. That we’ve had our–
obviously, the best success with employers who
are very engaged. When we tell them about the
value proposition, your ability to improve your employees’
health, also the ability to save healthcare dollars,
save healthcare costs, right, that’s really what employers
always want, they want both of those together, then it
seems to be an easier sell. And then employers are engaged and they’re working
with our vendor. Certainly, it’s raising the
awareness of type 2 diabetes, the risk and the costs, and another key is
having this accessible and available provider network. Right? Having choice and
many different providers that can provide the service
certainly was important. And what we’ve found is this
need to kind of have initial and persistent engagement
and so that’s something that we’ve worked hard on,
it’s an ongoing effort, and– but we’ve had some success
so far and, like you said, some of the earlier
presentations, the more creative you can
get as to engage people, provide the incentives,
it seems to really help. Some additional considerations
as you move forward, especially in the payer space,
it’s all about, you know, how do you continue to
drive program completion and weight loss. We certainly feel that–
remember those milestones, if you complete 4 weeks,
you complete 9 weeks– I think there are certainly
benefits anywhere along the pathway. Obviously, the goal
is to get people to complete all 4 milestones and
achieve that 5-7% weight loss. We know that really makes
a significant difference at decreasing that risk
of developing diabetes. So, we’re constantly
looking at ways trying to address dropout
and reengagement. We do have with these vendors
in the contract a pathway back. So, if somebody starts
the program, you know, midway through they
just disengage and they just don’t follow up
anymore, they are allowed a way to come back and
restart the program. So, that was part of our
contract with the vendors and so that is something
certainly I would recommend. And I think the other
part of it is, you know, culturally appropriate
material– and we certainly do offer many
of these programs in, you know, Spanish language,
which is important. And out here and certainly
in California we need to even expand that more to
other languages, but, you know, all those things– digital, in
person, culturally appropriate– all certainly very important. With that being said, I’d
like to turn the presentation over to Arlene Guindon from
the National Kidney Foundation of Michigan. [ Applause ]>>Great. Thank you, David. I really appreciate it and
I’m happy to hear you’re going to be able to go back
to your home soon. So, my goal today is to
provide you with some insight on what it’s like to
deliver the National DPP and eventually the MDPP
within the community and why the National
Kidney Foundation of Michigan is interested
in doing so. So, really the National
Kidney Foundation of Michigan is interested
in doing so because prevention
aligns very, very well with our mission. And our mission is to
prevent kidney disease and improve the quality of
live of those living with it. For those for chronic kidney
disease, approximately 70% of chronic kidney disease, the
risk factors that are attributed to it are diabetes and
hypertension align so well that if we can offer
evidence-based programs within the community
and be successful at individuals adopting
healthy behaviors and sustaining those behaviors, we feel like we can really make
an impact within the community. The next slide actually
shows what it looks like and what our results
are to date. We actually owe a new file
and updated results this month to the Centers for
Disease Control, but thus far we’ve served
over 1500 individuals that have completed our
program, the National DPP. The average weight loss for
those individuals is 6%. The recognition factor,
as probably all of you know here, is 5%. And the average physical
activity minutes for those completing the
program is 187 minutes per week. Now, there’s no recognition
factor on it, although the program goal
is 150 minutes per week and it’s critical really
that both the healthy eating and the physical
activity go hand in hand. You really– although you
could do one with the other, you can’t sustain a healthier
lifestyle without doing both. One of the things that we also
measure are not only employee engagement, but are participants
really engaging in the program and are they confident when
they complete those 12 months that they’re able to sustain
those healthy behaviors once they leave the program or once
they graduate from the program. If they’re not, then we
really haven’t done our job as well as we could. If they are, then we feel
like we’ve really armed them with the right tools to
move forward and create that healthy lifestyle. So, as you see from
the fourth bullet, 90% of participants are very
confident in their ability to eat healthier and be active for 150 minutes per
more– or more per week. That’s a critical
success factor for us. And as I go through
the presentation, we’ll talk about how
do we collect that and how do we take checkpoints of those participants
throughout the program. So, one of the things in
launching the National DPP and the MDPP within the
community is there are several factors we need to look at,
several dots we need to connect. And on this slide you see 6 of
those dots; community of focus, finding a host site,
recruit participants, how will the program be
paid for, who will the– who will pay and
reimburse participants for their participation
in the program, and then what are the
available resources and is it culturally
appropriate for the community in which we are launching
the National DPP. I’m going to go through each
one of these and provide you with an example of what I
mean specifically in each one. Each area. So, the community of focus
is our starting point. Where are we going to deliver
the National DPP and MDPP? What communities? We have offices in southeastern
Michigan in Detroit, in Flint, in Ann Harbor, and Grand Rapids and those communities are
very, very, very different. And some of the ways in which
we select where we’re going to start in all honesty
is funding. So, if we have a grant and the
grant focuses on Wayne County and Detroit, that’s where
we’re going to start our focus and launch and get the other
dots and connect those. If we have a demonstration
project, like we might have with Michigan Medicine, and they
want to add in maybe a different but parallel slightly
off the National DPP– maybe a low-carb to see
which one is more successful, we’ll work with them
and we’ll offer it at a Michigan Medicine location. If we have a food bank
that really wants to– where there’s a food desert in
the community, but they want to really engage underserved
areas to participate in the National DPP, then
we’ll have our food– their food truck come
and provide resources to individuals once
they complete a session. So, we can begin to really
communicate with the community and draw them in, but where
we start really is based on a variety of factors,
funding not which being the least of them. So, once we find a community,
who’s going to host the event? So, as easy as this
may seem, it’s not, because we’re asking
organizations in the different communities
to at least give us their space for 12 months minimum,
continuously, or 24 months potentially
with the Medicare DPP. So, that’s not easy to do
that from a space perspective, but some locations
in some communities like clinics we have
relationships with. It tends to be for
different clinics we work with whether it’s a
federally-qualified health center or a large
university system, we can use their
facilities but after hours. And so that brings up
other special challenges of getting people in and out and
making sure that site’s secure. We sometimes look at
recreation centers. Other times, many of our DPP
workshops are offered in houses of worship, temples, churches. We really– the focus of
where we operate is where– what’s available,
what’s easily accessible, and will participants
feel safe and secure when they come to that site. That’s our goal no matter
what the community is. We also offer worksite
wellness, so we’ll offer this in the corporate setting and usually the corporation
will provide that space for us to use. Regardless of who the site is, all sites we develop what we
call a memo of understanding and basically it
manages expectations. What can that site expect from
us when we come in every week and then in monthly
sessions every other week, and what can we expect of
them as far as creating a safe and healthy facility and place
to hold the National DPP. So, once we have the community, we have the host site,
we need participants. Just because we have
those things in place doesn’t mean
participants will come and this is one of the
most challenging aspects is to recruit participants. To recruit them not only to come
to the information session– so we have the information
session before session 1 and it’s to really
tell individuals about what the program is, to answer any questions they
might have about funding and reimbursement,
but also for us to let them know what our
expectations are from them, because we hope that
they’ll be highly engaged, and then what they
can expect from us, the support that they can expect
from us throughout the program. Sometimes we have host sites
that really engage in marketing and recruiting with us. Sometimes we need to do it on
our own through social media, and other times when
we work with clinics or federally-qualified health
centers, we have an e-referral in which they can send
us referrals for patients who qualify for the National DPP through a compliance
secured line. They can go ahead and refer
and then we’ll let them know that we received the referral. It’s most successful
when we receive referrals from clinicians if they
talk to their patient first. I know that sounds basic, but I can tell you how many
times we received referrals and we’re the first contact–
the National Kidney Foundation of Michigan is the first contact
of calling the patient saying, hey, we see that you’re
interested in the National DPP and they’re like who are you
and how did you get my name. So, it’s really critical that the healthcare provider
have that first dialogue. As I briefly mentioned,
funding methods are critical. We know that grant funding
is– it ebbs and flows. In many situations
where grant funding is, we know that we can
support individuals within those workshops. CMS has come onboard with
the Medicare benefit. That’s going to help us with that proportion
of the population. We’re doing some demonstration
pilots with a few Medicaid plans in Michigan, so we know
that they’re underwriting it and they can support
that population, so those individuals
don’t have to worry about the funding perspective. We have some commercial insurers
that we work with that fund at a different rate the
individuals participating in the program as
long as they qualify. And then some corporations
also will open the doors wider, so beyond those who qualify,
and let all employees attend– even those with diabetes. So, it’s very tricky
for us and we work with our coaches very diligently
to offer the best program that we can for that population. Where those mechanisms
aren’t in place, we offer individuals the
opportunity to self-pay. We– they can pay in a lump
sum or over a period of time. And if individuals
can’t afford it, none of these funding mechanisms
align with where they’re at, we have scholarships
that are available and it’s really based on need. So, we also look at what
are the available resources in the community because we’re
there for a year or 2 years, depending on the population
we service, and once we leave, we want to make sure that
those community resources and those participants can
sustain that healthy behavior. So, one good example of aligning
available resources is one of the clinics that we work with near the Ann Arbor area
actually has a fitness center– the clinic doesn’t own
the fitness center, but a local community college
owns a state-of-the-art wellness center and they’ve allowed
us, the community college, for anybody that participates
in the National DPP, as long as they attend,
they get a pass to go ahead and use the fitness
facility free. It’s really a low-cost one and
in fact we hold session 5– I also am a lifestyle coach, so
I know by the session number– it’s like jumpstart
your physical activity– we hold it there at
the wellness center. And first I thought, you know,
it’s more than a gimmick, it’s really a lot of people
are intimidated by going into a wellness center
or gym on their own. We heard that when we held
the first session there. I wouldn’t have come
unless I was with a group and group support. Now I see it’s approachable
and I’ll continue to attend. And that was great and that
relationship is fantastic and even when we leave
and that program ends, those 2 organizations
are still there. So, that’s our ultimate goal
is to really show individuals who might not be familiar
with those resources that they’re truly
available for them to use throughout
their lifetime. And absolutely we
want to make sure that the programs are
culturally appropriate. On the west side of the state
in our Grand Rapids office, they do a fabulous job
of working with Latino and Hispanic communities and they have some very
passionate coaches there that not only make sure the
food models are appropriate but the trackers are
appropriate and that the way that we dialogue with
individuals in those locations, they can– is appropriate
and we’re there and it’s a safe environment
in which they can come. It’s just amazing what that
group is doing these days. So, I mentioned just really
briefly engaging participants, but participants
are at the crux. We could have all those
6 factors on paper, it looks great, we got started,
we have 12 to 15 participants at a minimum starting
the workshop, but we need to engage
participants from the beginning. We need to engage them at
the information session. We have them take
a readiness test. If they’re not ready
at the info session, they might not be a
candidate at least this time around to continue that program. And we actually ask them– the coach thoroughly
engages them throughout, not only during the sessions,
but we take checkpoints and we do a baseline survey,
we do an 8-week survey, we do a 16-week, and we do
a 9-month, because we want to take checkpoints to make
sure are we missing anything. Are the individuals engaged? Is there a good relationship
and strong with their coach? It’s really important
that we do it throughout. Once you get them in the doors, it’s not done, it’s
just beginning. What you see here on this slide
are some really sound bites of individuals and some of– I mentioned the 4
surveys that we provide. What amazing things
did they learn and how would you
change the program? We take a lot of their feedback on how would you
change the program and incorporate it
into our workshops. One good example
is healthy recipes. We do a recipe rehab in one
of the sessions and it’s great because participants
bring in their own recipes and they’re more
engaged other than– aside from us giving
a script, you know, here’s what you must take. It’s like, no, here’s
what I go home and cook, how can we make it healthier. Because they’re likely to
continue in that situation than if we didn’t do that. So, how do we sustain
the momentum? We’ve been successful to date. We’ve had CDC full
recognition for 4 years, we hope to have it much longer. It’s been challenging. It’s exciting. What’s made us successful to date are our high engagement
rates, the support that we have in the communities, our
different funding partners. Even though those are
some of the same factors that will help us be
successful down the road, the environment’s
totally changed. Different funding
sources are there. We’re looking at doing a blended
model with online and in person to account for what
you heard David and others talk about,
the virtual DPP. There’s more competition. More organizations are
getting into the marketplace. And there’s growing pains
and we have to get coaches to keep continually being
engaged in the program as well. It’s not easy. It’s ongoing. We’re hoping that we can
stop and take checkpoints and continue to sustain
the momentum that we built for much longer down the road. So, the key takeaways. We need to engage participants. We need to collaborate
with partners. We need to address challenges. And even when we do all
that, we need to keep– we need to keep the main purpose
in mind and the main purpose to me is, for individuals
that participate, we need to make sure that we
can help them create sustainable healthy lifestyles. If we forget that, then we
won’t have a program at all. So, thank you for your time
and I’m going to turn it over to Ann for Q and A. [ Applause ]>>I’d like to turn it
over to Susan to see if we have any questions
coming in online.>>Thank you, Dr. Albright. We do. I first want to
remind our online viewers to submit your questions to [email protected]
or via Facebook. Our first question from
Samantha on Facebook. She talks about her last
pregnancy being diagnosed with gestational diabetes
being a real eye-opener. Is there anything
we can do to see that restaurants can provide
reasonably-priced options for people with diabetes?>>Well, I’ll start
that conversation. There are efforts going on throughout the public
health community working with restaurants and other
foodservice organizations. So, there are efforts. They really start with the
consumers in the community. If people demand things or
are interested and they speak to these restaurants
and these locations, then they are often
interested and willing and listening to
their customers. So, it should be the customers
who put that out there. One strategy that people can
often use too is when you go into a restaurant order your
meal and take half of it home. Put it immediately in a
to-go container, half of it, and take the rest of it home. So, you can also
ask the restaurant, but you can also do
some things yourself.>>OK. We’ll go with another
question from online viewers from Sensig. Can you talk briefly– this
is for the whole panel– about the– they’re calling
it metabolic surgery, I believe they’re talking
about gastric bypass– and the impact on
diabetes overall?>>I’ll start or I’ll answer. There are a few tools in our
armamentarium for preventing or delaying type 2 diabetes. You’ve heard about primarily
today the evidence-based lifestyle change program
that is really critical. You also mentioned briefly
the medication metformin and there are a couple of others that are also potential
candidates. There is the opportunity and another third tool
would be bariatric or our various versions
of bariatric surgery. Again, a tool in
our armamentarium. This is a conversation
that people should have with their clinician
to determine which of the tools is
most appropriate for them. I would underscore, however, that lifestyle is common
to every single one. Regardless of whether you
have surgery or you’re on a medication, lifestyle
always wins the day. So, it’s imperative that
you engage in lifestyle and whatever other additional
therapies your clinician thinks are most appropriate for you, but definitely talk
to your clinician. Any– let me just pause
for a moment and see if there are any questions in the room before we
continue with any online. And I know sometimes it
takes– oh, good job, Steve. [ Laughter ]>>So, this is Steve Redd. I have a question
about the challenges in scaling the program. The number of people with prediabetes is pretty large
compared to the number of people that you’ve been able to enroll. And I know that you’re
working hard to make the program available
to more people, but I wonder where the– where are the points where you especially
need to make progress?>>Yeah, there’s probably
a lot to say, but I’ll try to be as succinct as I can. Yes, there are an estimated 84
million people with prediabetes. Part of the issue
we have faced is that people have been
completely unaware of this condition, for starters. So, we really do have to generate increased
public awareness. We must have a national
conversation about this, just as we are about opioids
and we have about HIV/AIDS. We must have that
conversation as a nation. So, that’s first and foremost. People have to be aware. They have to know. And then it really is
about engaging people in the interventions that
have been proven to prevent or delay type 2 diabetes. There’s a lot of
noise out there. There are a lot of things–
people trying various programs, people trying all
sorts of array of diets that they go on and off. This is definitely an area
that is crowded with things that people are attempting
to do. So, I think part of it
then is also focusing on the evidence-based
interventions. Third, I would say that also as
a nation we have to get serious about scaling lifestyle. We can distribute
medications well, people can get surgical
procedures, they know about them,
they know how to get them. We have not treated
lifestyle in the same way. So, I would say that
those things are critical. We have to talk more about this. People have to know
where they stand. We have to treat lifestyle
seriously in the country and be very committed. Look at anything in history,
whether it was sending somebody to the moon, whether it was the
Wright brothers launching the first plane, whether it’s
been any of our conflicts. If people give up, then we will
never get where we need to go. So, you cannot be
faint of heart. We must press on. So, having said that, around really getting
lifestyle implemented and for the first time in our
history taking it seriously and not growing faint of
heart, we also, as I mentioned in my remarks, must also
change the environment in which we live, work,
play, and worship. These are not mutually
exclusive. In fact, they are–
must be done together. So, it requires both that
we are full throttle going after this intervention
and getting it scaled and we are changing the
environment and looking at all those potential
options and looking at the evidence behind
those as well. So, it’s a dual approach and
they are really complementary and must be done together
and taken seriously together.>>From the Medicare
perspective, I would agree wholeheartedly
with everything Ann just said. I think it’s pretty
simple though, as I shared in my remarks,
beneficiaries need to know that they’re at risk,
so they need to know that they’re prediabetic, so
screening by their physician, primary care provider, even
a health fair, you know, start the conversation there. We need suppliers that
can deliver this service to beneficiaries. So, folks that are
already CDC-recognized, having them enroll, get
the necessary support and services they need to be
able to do that, but then folks who could be enrolled in
Medicare but aren’t yet, you know, CDC-recognized,
getting them started on that process because we
know it takes about a year to get preliminary recognition, and then to refer your
Medicare beneficiaries to suppliers near them.>>I’ll add just one more thing because sustainability won’t
happen without funding and I’m, you know, I’m glad that
Medicare is going to fund for Medicare beneficiaries,
but the rate at which we fund is going to
be challenging for individuals, whether you’re online or in
person, to sustain the program. So, let’s not forget
about the funding.>>Well, I know we’re at
the top of the hour and any of the questions
that we did not get to from online we
will actually– we will absolutely answer all
of those questions for you, so no worries, and if any of you
in the audience have questions that we did not get to,
the speakers will be here for a bit longer and you can
also give us your question and we’ll be sure to
get an answer to you. Thank you so much
for your interest and participation in
this Grand Rounds. [ Applause ]>>We’ll see you next month. Public Health Grand Rounds.

3 Replies to “The National Diabetes Prevention Program — Changing Lifestyles to Prevent Type 2 Diabetes”

  1. Excellent learning video, but how do we prevent diabetes in early stages?
    Is there any good that can prevent diabetes?

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