0920-24EV AppxC-C Performance Measure Guidance

Appendix C: Component C: OPPE-NCCDPHP-DDT-Component C Performance Measure Guidance-PS23-0020-new-2024-2026-04-15-2024

Form Approved

OMB Control Number: 0920-1282

Expiration Date: 06/30/2026

DP23-0020: A Strategic Approach to Advancing Health Equity for Priority Populations with or at Risk for Diabetes (2320)

Centers for Disease Control and Prevention

Component C

Performance Measure Definitions Guidance

February 1, 2024

Public reporting burden of this collection of information is estimated to average 8 hours per response per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282).

Table of Contents

Purpose of this Document 4

General Guidance 4

Selection of Performance Measures 4

Strategies and Performance Measures 4

2320 Performance Measure Reporting 5

Reporting Period 5

Baseline Data Collection 5

Performance Measure Targets 5

Questions or Technical Assistance Needs 6

2320 Performance Measure Definitions 6

Strategy C.1 7

Measure C.1.1 7

Strategy C.1 9

Measure C.1.a 9

Strategy C.2 11

Measure C.2.1 11

Strategy C.2 13

Measure C.2.a 13

Strategy C.2 15

Measure C.2.b 15

Measure C.3.1 17

Measure C.3.3 21

Measure C.3.a 23

Measure C.4.1 26

Measure C.4.2 28

Measure C.4.a 30

Measure C.5 33

Glossary 35

Strategy 1 Key Terms 35

Strategy 1 Resources 35

Strategy 2 Key Terms 35

Strategy 2 Resources 37

Strategy 3 Key Terms 37

Strategy 3 Resources 37

Strategy 4 Key Terms 37

Strategy 4 Resources 38

Purpose of this Document

The purpose of this document is to provide guidance on reporting performance measures for the Centers for Disease Control and Prevention (CDC) Notice of Funding Opportunity (NOFO) DP23-0020. Performance measurement is a critical component of CDC’s strategy for monitoring and evaluating both program and recipient performance. The performance measures monitor progress towards short-term, intermediate, and long-term outcomes as a result of recipient efforts to implement evidence-based type 2 diabetes prevention and risk mitigation strategies. All recipients are required to collect and report on performance measures annually to clarify and describe what is occurring as a result of the implementation of NOFO strategies.

General Guidance

Selection of Performance Measures

All DP23-2320 recipients must document progress for all performance measures associated with DP23-2320 strategies in their workplan. Each performance measure profile in this document lists the related strategies. Component C recipients will report on all short-term, intermediate, and long-term performance measures. CDC will monitor and evaluate Component C 5 long-term performance measure. However, recipients may be required to provide contextual information for these performance measures in the progress and measure notes. Recipients should review the performance measure profiles for additional reporting guidance on what to measure, targets, etc.

Strategies and Performance Measures

Some performance measures may have more than one related strategy listed in the profiles. The AMP system will label the performance measure to help you identify which performance measure to choose depending on the strategy. Use the table below to confirm the appropriate performance measures associated with each strategy.

Component C Strategies and Performance Measures

Strategies and Performance Measures		Page #
Strategy 1: Administrative Infrastructure: Serve as the hub for the partner network and manage its administrative infrastructure.
1.1	Number of people specified in the enrollment goal reached through tested marketing strategies supported by the partner network	7
1.a	Number of participants enrolled in CDC-recognized National DPP delivery organizations participating in the network	9
Strategy 2: Participant Referral Process: Work with and fund clinical and community partners with specialized expertise reaching one or more priority populations to institutionalize participant referral processes
2.1	Number of people at risk for type 2 diabetes (total # and # from priority populations) referred to a CDC-recognized organization participating in the network	11
2.a	Number of people referred to a CDC-recognized organization participating in the network who enroll in the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP)	13
2.b	Number of health care organizations implementing the American Medical Association (AMA)-sponsored prediabetes quality measures	15

Strategy 3: Program Delivery & Participant Support: Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support.
3.1	Number of National Diabetes Prevention Program (National DPP) Lifestyle Coaches that received training on working with priority populations, including assessing and addressing social needs	17
3.2	Number of people enrolled in CDC-recognized organizations participating in the network who are assessed for Social Determinants of Health (SDOH)-related needs	19
3.3	Number of people enrolled in CDC-recognized organizations participating in the network who receive services to meet Social Determinants of Health (SDOH)-related needs from organizations participating in the network	21
3.a	Number of participants assessed for SDOH-related needs who are retained* in CDC- recognized organizations	24
Strategy 4: Payment/Coverage: Work with payer and employer partners to implement existing coverage policies and test new coverage policies within the network.
4.1	Number of public or private payers or employers including the National Diabetes Prevention Program (National DPP) Lifestyle Change Program (LCP) as a covered health benefit	26
4.2	Number and types of new coverage, payment, or risk sharing models implemented for the National DPP lifestyle change program (LCP)	28
4.a	Number of participants enrolled in CDC-recognized organizations in the network that are receiving reimbursement from a public or private payer or employer	30
5	Number of program completers in CDC-recognized National Diabetes Prevention Program (National DPP) delivery organizations participating in the network who reduce their risk for type 2 diabetes	33

2320 Performance Measure Reporting

Reporting Period

Unless otherwise indicated in the performance measure profile, the reporting period for performance measures is the DP23-0020 performance period. Recipients will report on performance measures 90 days after the close of each budget period.

Baseline Data Collection

Recipients are expected to submit baseline data, Year 2 target values, and Year 5 target values on Monday, April 1, 2024, as part of the Evaluation and Performance Measurement Plan. Baseline data are considered the initial data collected prior to the start of the program. These data serve as a point of reference in which program goals can be measured over the course of the 5-year funding period. Baseline data can be updated up to the Year 2 evaluation reporting period, Monday, September 30, 2024.

Performance Measure Targets

Target values for subsequent years will then be submitted annually as part of the continuation application process. Recipients should work closely with their evaluator and project officer to identify a feasible and achievable target. Recipients are asked to submit their performance measure data 90 days after the end of each performance period in the Annual Performance Report.

Questions or Technical Assistance Needs

Any questions about the guidance included in this document should be directed to the evaluator and project officer assigned to your state/organization. All questions should be submitted through the AMP system. Communicate any challenges with data collection to CDC. CDC understands that collecting some of this data may be challenging and time- consuming. CDC will make an effort to be flexible and accommodate the specific circumstances of the recipient where appropriate.

2320 Performance Measure Definitions

The purpose of the performance measure definitions is to assist recipients with submitting all required components on the Annual Performance Measure Report. The performance measure definitions operationalize each measure as a tool for planning and reporting.

There is a definition for each performance measure that includes a detailed set of required reporting components and additional information and guidance.

The Values to be Reported section comprises the following:

• Progress notes;

• Numerator definition;

• Denominator definition (if applicable);

• Proportion definition (if applicable);

• Measure elements;

• Date data collected;

• Measure notes; and

• Other attachments (if applicable).

Note that recipients will report information for the areas highlighted in BLUE in alignment with the annual reporting template. Review the Additional Information and Guidance section for helpful hints, data source recommendations, unit of analysis, result statement(s), definitions of key terms, and resources associated with each measure.

DP23-0020 Component C Performance Measure Definitions
Strategy C.1	Serve as the hub for the partner network and manage its administrative infrastructure.
Measure C.1.1	Number of people specified in the enrollment goal reached through tested marketing strategies supported by the partner network.
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to assess recipient progress towards increasing the number of people reached through tested marketing strategies supported by the partner network. Note: Please refer to Component C: Strategy 1 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of people specified in the enrollment goal reached through tested marketing strategies supported by the partner network. Number of people from priority populations specified in the enrollment goal reached through tested marketing strategies supported by the partner network. Note: Required to report both values.
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Description of business plans and strategies and how they were used to increase enrollment; Description of partnerships and how they were used to increase enrollment;

	Description of marketing plans and strategies and how they were used to increase enrollment; Description of total population and priority populations reached through tested marketing strategies; Name and description of strategies, channels, and messaging used to increase enrollment; and/or Describe any additional information that provides context for the two values reported. This may include the number of external and internal partners, number of health care systems approached and MOUs signed, number of payers approached and MOUs signed, number of sites and agreements signed, number of community health workers/Promotores, number of members on steering committee/advisory panel, etc.
Progress Notes	The progress notes should include the following for this measure: Summary/description of program and evaluation activities; Description of the progress made during the reporting period; Any facilitators (e.g., partners) to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report the two values for this measure: Select measure C.1.1 and report the total number of people specified in the enrollment goal reached through tested marketing strategies supported by the partner network. Select measure C.1.1 and report the number of people from priority populations specified in the enrollment goal reached through tested marketing strategies supported by the partner network.
Data Source(s)	Organization program records
Unit of Analysis	Individuals
Result Statement(s)	In the US, CDC-funded recipients worked to increase the total number of people reached through tested marketing strategies from # (baseline) to # (reporting year). This change represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of people from the priority populations reached through tested marketing strategies from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.1	Serve as the hub for the partner network and manage its administrative infrastructure.
Measure C.1.a	Number of participants enrolled in CDC-recognized National DPP delivery organizations participating in the network.
Measure Type	Short Term Measure ☒ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to assess the change in enrollment in CDC-recognized National DPP delivery organizations participating in the network. Note: Please refer to Component C: Strategy 1 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of participants enrolled in the CDC-recognized National DPP delivery organizations participating in the network. Number of people from priority populations enrolled in CDC-recognized National DPP delivery organizations participating in the network. Note: Required to report both values.
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Description of total population and priority populations enrolled in National DPP; Name and description of CDC-recognized National DPP delivery organizations participating in the network;

	Add relevant data for the organizations in your partner networks, including delivery mode (in-person or virtual), number enrolled per organization, etc.; The DPRP organization code; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of program and evaluation activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report the two values for this measure: Select measure C.1.a and report the total number of participants enrolled in CDC-recognized National DPP delivery organizations participating in the network. Select measure C.1.a and report the number of participants from priority populations enrolled in CDC-recognized National DPP delivery organizations participating in the network.
Data Source(s)	Organization program records
Unit of Analysis	Participants
Result Statement(s)	In the US, CDC-funded recipients worked to increase the total number of participants enrolled in CDC-recognized National DPP delivery organizations participating in the network from #(baseline) to #(reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of participants from the priority populations enrolled in CDC-recognized National DPP delivery organizations participating in the network from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.2	Work with and fund clinical community partners with specialized expertise reaching one or more priority populations to institutionalize participant referral processes.
Measure C.2.1	Number of people at risk for type 2 diabetes (total # and # from priority populations) referred to a CDC-recognized organization participating in the network.
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient progress towards increasing the number of people at risk for type 2 diabetes referred to a CDC-recognized organization participating in the network. Note: Please refer to Component C: Strategy 2 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of people at risk for type 2 diabetes referred to a CDC- recognized organization participating in the network. Number of people at risk for type 2 diabetes from priority populations referred to a CDC-recognized organization participating in the network. Note: Required to report both values.
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Description of total population and priority populations referred to a CDC-recognized organization participating in the network; Description and name of CDC-recognized organization;

	Description and name of health care systems; Description and name of Community Based Organizations; Description and name of community health partners; Description of the mode (EHR, fax, telephone, other) of referral used by health care systems, Community Based Organizations, and/or community health partners; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report the two values for this measure: Select C.2.1 and report the total number of people at risk for type 2 diabetes referred to a CDC-recognized organization participating in the network. Select C.2.1 and report the number of people at risk for type 2 diabetes from priority populations referred to a CDC-recognized organization participating in the network. Note: Recipients will need to implement a system to capture data on referrals.
Data Source(s)	Organization program records
Unit of Analysis	People at risk for type 2 diabetes referred. People at risk for type 2 diabetes from priority populations referred.
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of people at risk for type 2 diabetes referred to a CDC-recognized organization participating in the network from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of people at risk for type 2 diabetes from priority populations referred to a CDC-organized participating in the network from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.2	Work with and fund clinical community partners with specialized expertise reaching one or more priority populations to institutionalize participant referral processes.
Measure C.2.a	Number of people referred to a CDC-recognized organization participating in the network who enroll in the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP).
Measure Type	Short Term Measure ☒ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient progress towards increasing the number of people referred to a CDC-recognized organization participating in the network who enroll in the National DPP LCP. Note: Please refer to Component C: Strategy 2 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of people referred to a CDC-recognized organization participating in the network who enroll in the National DPP LCP Number of people from priority populations referred to a CDC- recognized organization participating in the network who enroll in the National DPP LCP Note: Required to report both values.
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Description of total population and priority populations referred to a CDC-recognized organization participating in the network who enroll in the National DPP LCP;

	The CDC-recognized organization name; The DPRP organization code; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of program and evaluation activities; Description of the progress made during the reporting period; Any facilitators (e.g., partners) to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; Any facilitators or barriers specific to the priority populations; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report the two values for this measure: Select C.2.a and report the total number of people referred to a CDC- recognized organization participating in the network who enroll in the National DPP LCP. Select C.2.a and report the number of people from priority populations referred to a CDC-recognized organization participating in the network who enroll in the National DPP LCP.
Data Source(s)	Organization program records
Unit of Analysis	Individuals referred
Result Statement(s)	In the US, CDC-funded recipients worked to increase the total number of people referred to a CDC-recognized organization who enroll in the National DPP LCP from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of people from priority populations referred to a CDC-recognized organization who enroll in the National DPP LCP from # (baseline) to # (reporting year). This change represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.2	Work with and fund clinical community partners with specialized expertise reaching one or more priority populations to institutionalize participant referral processes.
Measure C.2.b	Number of health care organizations implementing the American Medical Association (AMA)-sponsored prediabetes quality measures.
Measure Type	Short Term Measure ☒ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient progress towards increasing number of health care organizations implementing AMA- sponsored prediabetes quality measures. Note: Please refer to Component C: Strategy 2 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Number of health care organizations implementing the AMA-sponsored prediabetes quality measures
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Description and name of health care organization(s); Description of method used to track progress on the quality measures; Description and name of AMA-sponsored prediabetes quality measures; and/or Describe any additional information that provides context for the values reported.

Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made to review EHR specifications for the quality measures; Any facilitators noted during the specification review that will impact implementation in year 2; Any barriers noted during the specification review that will impact implementation in year 2; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.2.b and report the number of health care organizations implementing the AMA-sponsored prediabetes quality measures.
Data Source(s)	Organization program records
Unit of Analysis	Health care organizations
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of health care organizations implementing AMA-sponsored prediabetes quality measures from #(baseline) to #(reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.3	Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support.
Measure C.3.1	Number of National Diabetes Prevention Program (National DPP) Lifestyle Coaches that received training on working with priority populations, including assessing and addressing social needs .
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient efforts to increase the number of National DPP Lifestyle Coaches who have received training on working with priority populations. Note: Please refer to Component C: Strategy 3 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Number of National DPP Lifestyle Coaches that have received training on working with priority populations, including assessing and addressing social needs.
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide last day of data collection for this performance measure.
Measure Notes	The measure notes should include the following for this measure: Description and name of trainings (including which priority populations were addressed);

	Description and name of instruments and/or strategies used to assess and address social needs or priority populations that were included in the trainings (i.e., training on PRAPARE); and/or Describe any additional information that provides context for the values reported (e.g., self-paced training completed on different dates).
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.3.1 and report the number of National DPP Lifestyle Coaches that received training on working with priority populations, including assessing and addressing social needs.
Data Source(s)	Organization records
Unit of Analysis	Lifestyle coaches
Result Statement(s)	In the U.S., CDC- funded recipients worked to increase the number of Lifestyle Coaches that received training on working with priority populations from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.3	Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support.
Measure C.3.2	Number of people enrolled in CDC-recognized organizations participating in the network who are assessed for Social Determinants of Health (SDOH)- related needs.
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor the change in participant enrollment in CDC-recognized organizations participating in the network who are assessed for SDOH-related needs. Note: Please refer to Component C: Strategy 3 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of people enrolled in CDC-recognized organizations participating in the network who are assessed for SDOH-related needs Number of people from priority populations enrolled in CDC-recognized organizations participating in the network who are assessed for SDOH- related needs Note: Required to report both values.
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.

Measure Notes	The measure notes should include the following for this measure: The CDC-recognized organization name; The Diabetes Prevention Recognition Program (DPRP) organization code; Description of priority population enrolled; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.3.2 and report the total number of people enrolled in CDC- recognized organizations participating in the network who are assessed for SDOH-related needs. Select C.3.2 and report the number of people from priority populations enrolled in CDC-recognized organizations participating in the network who are assessed for SDOH-related needs.
Data Source(s)	Organization records
Unit of Analysis	Participants enrolled in CDC-recognized organizations. Participants from priority populations enrolled in CDC-recognized organizations.
Result Statement(s)	In the US, CDC-funded recipients worked to increase the total number of participants enrolled in CDC-recognized organizations who are assessed for SDOH-related needs from # (baseline)) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of participants from priority populations in CDC-recognized organizations who are assessed for SDOH-related needs from #(baseline) to #(reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.3	Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support.
Measure C.3.3	Number of people enrolled in CDC-recognized organizations participating in the network who receive services to meet Social Determinants of Health (SDOH)-related needs from organizations participating in the network.
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor the change in participant enrollment in CDC-recognized organizations, participating in the network, who receive services to meet SDOH-related needs. Note: Please refer to Component C: Strategy 3 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of people enrolled in CDC-recognized organizations who receive SDOH-related services. Number of people from priority populations enrolled in CDC-recognized organizations who receive SDOH-related services. Note: Required to report both values.
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: The CDC-recognized organization name;

	The Diabetes Prevention Recognition Program (DPRP) organization code; Description of priority population enrolled; Name and description of services received that addressed SDOH-related needs; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report the two values for this measure: Select C.3.3 and report the total number of people enrolled in CDC- recognized organizations who receive services to meet SDOH- related needs. Select C.3.3 and report the number of people from priority populations enrolled in CDC-recognized organizations who receive services to meet SDOH-related needs.
Data Source(s)	Organization records
Unit of Analysis	Participants enrolled in CDC-recognized organizations. Participants from priority populations enrolled in CDC-recognized organizations.
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of participants enrolled in CDC-recognized organizations who received SDOH-related services from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of participants from priority populations enrolled in CDC-recognized organizations who received SDOH-related services from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.3	Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support.
Measure C.3.a	Number of participants assessed for SDOH-related needs who are retained* in CDC-recognized organizations.
Measure Type	Short Term Measure ☒ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient progress towards increasing the number of participants assessed for SDOH-related needs who are retained* in CDC-recognized organizations. Note: Please refer to Component C: Strategy 3 Guidance document located under AMP resources. *Based on CDC’s Diabetes Prevention Recognition Program (DPRP) Standards, participants who are retained in the National DPP lifestyle intervention (i.e., program completers) are defined as those who attended 8+ sessions in the first six months and whose total time in the program is 9 or more full months.
VALUES TO BE REPORTED
Numerator Definition	Total number of participants assessed for SDOH-related needs who are retained* in CDC-recognized organizations. Number of participants from priority populations assessed for SDOH- related needs who are retained* in CDC-recognized organizations. Note: Required to report both values.
Denominator Definition	Not applicable
Measure Notes	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.

Measure Notes	The measure notes should include the following for this measure: Description and name of participating CDC-recognized organizations; Description and name of instruments and or strategies used to assess SDOH-needs; Description and name of SDOH assistance provider and type of assistance offered; Description of participants and participants from priority populations; and/or Describe any additional information that provides context for the two values reported.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not Applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.3.a and report the total number of participants assessed for SDOH-related needs who are retained* in CDC-recognized organizations Select C.3.a and report the number of participants from priority populations assessed for SDOH-related needs who are retained* in CDC- recognized organizations *Based on CDC’s Diabetes Prevention Recognition Program (DPRP) Standards, participants who are retained in the National DPP lifestyle intervention (i.e., program completers) are defined as those who attended 8+ sessions in the first six months and whose total time in the program is 9 or more full months.
Data Source(s)	Organization records
Unit of Analysis	Participants retained* Participants from priority populations retained*
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of participants assessed for SDOH-related needs who are retained* in CDC- recognized organizations # (baseline) to # (reporting period). This represents an increase of % over the funding period.

In the US, CDC-funded recipients worked to increase the number of participants from priority populations assessed for SDOH-related needs who are retained* in CDC-recognized organizations from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.4	Work with payer and employer partners to implement existing coverage policies and test new coverage policies within the network.
Measure C.4.1	Number of public or private payers or employers including the National Diabetes Prevention Program (National DPP) Lifestyle Change Program (LCP) as a covered health benefit.
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor the change resulting from recipient activities to increase the number of public or private payers or employers who have the National DPP LCP as a covered health benefit. Note: Please refer to Component C: Strategy 4 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Number of public payers including the National DPP LCP as a covered health benefit Number of private payers including the National DPP LCP as a covered health benefit Number of employers including the National DPP LCP as a covered health benefit
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Name, description, and type of public payer; Name, description, and type of private payer;

	Name, description, and type of employer; Relevant benefit details (e.g., if the agreement includes coverage through pilot classes and/or wellness programs); and/or Describe any additional information that provides context for the values reported and underserved areas you are working in.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.4.1 and report the number of public payers including the National DPP LCP as a covered health benefit. Select C.4.1 and report the number of private payers including the National DPP LCP as a covered health benefit. Select C.4.1 and report the number of employers including the National DPP LCP as a covered health benefit.
Data Source(s)	The following data sources may be used to obtain data for this measure: Organization program records Employee benefits and coverage policies Note: Recipients must determine the best way to obtain this information.
Unit of Analysis	Public Payers Private Payers Employers
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of public payers including the National DPP LCP as a covered health benefit from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of private payers including the National DPP LCP as a covered health benefit from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of employers including the National DPP LCP as a covered health benefit from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.4	Work with payer and employer partners to implement existing coverage policies and test new coverage policies within the network.
Measure C.4.2	Number and types of new coverage, payment, or risk sharing models implemented for the National DPP lifestyle change program (LCP).
Measure Type	☒ Short Term Measure ☐ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor recipient progress towards increasing the number and types of new coverage, payment, or risk sharing models implemented for the National DPP lifestyle change program (LCP). Note: Please refer to Component C: Strategy 4 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Number and types of new coverage, payment, or risk sharing models implemented for the National DPP LCP
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.
Measure Notes	The measure notes should include the following for this measure: Name and description of new coverage, payment, or risk sharing models; Report the number of people reached and covered by the new coverage, payment, or risk sharing models; Name and description of payer; Report the number of people covered by the payment model; and/or

	Describe any additional information that provides context for the values reported. For example, this may include alternate methods for risk sharing, increasing rates to cover SDOH-related needs commensurate with improved outcomes, using performance benchmarks other than weight loss, and developing alternatives to traditional claims-based processing for reimbursement.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.4.2 and report the number and types of new coverage, payment, or risk sharing models implemented for the National DPP LCP as a covered health benefit.
Data Source(s)	Organization program records
Unit of Analysis	New coverage models Payment models Risk sharing models
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number and types of new coverage, payment, or risk sharing models implemented for the National DPP LCP from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.4	Work with payer and employer partners to implement existing coverage policies and test new coverage policies within the network.
Measure C.4.a	Number of participants enrolled in CDC-recognized organizations in the network that are receiving reimbursement from a public or private payer or employer.
Measure Type	Short Term Measure ☒ Intermediate Measure ☐ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor the change resulting from recipient activities to increase the number of participants enrolled in CDC-recognized organizations in the network that receiving reimbursement from a public or private payer or employer. Note: Please refer to Component C: Strategy 4 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	Total number of participants enrolled in CDC-recognized organizations in the network that are receiving reimbursement from a public or private payer or employer. Number of participants from priority populations enrolled in CDC- recognized organizations in the network that are receiving reimbursement from a public or private payer or employer. Note: Required to report both values.
Denominator Definition	Not applicable
Proportion Definition	Not applicable
Measure Elements	The following elements will be submitted as part of the measure: Baseline: Enter the initial starting point or average amount related to the measure. Target Numerator: Enter the expected amount to be achieved as specified in the approved work plan. Target Denominator: Not applicable. Actual Numerator: State the actual amount or status achieved by the end of the reporting period. Actual Denominator: Not applicable.
Date Data Collected	Provide the date these data were collected.

Measure Notes	The measure notes should include the following for this measure: Name, description, and data collection of public payer; Name, description, and data collection of private payer; Name, description, and data collection of employer; Relevant payer or employer details; Participant coverage details (e.g., length of coverage); Description of priority population enrolled; and/or Describe any additional information that provides context for the values reported that you are working in.
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	In the “Measure Notes”, describe any additional information that provides context for the values reported. How to report values for this measure: Select C.4.a and report the total number of participants enrolled in CDC- recognized organizations that are receiving reimbursement from a public or private payer or employer. Select C.4.a and report the number of participants from a priority population enrolled in CDC-recognized organizations that are receiving reimbursement from a public or private payer or employer. Note: For this measure, “participants” refers to the number of individuals who have access to any level of coverage for the National DPP LCP from the private payers, public payers, private employers, and public employers reported in C.4.1.
Data Source(s)	The following data sources may be used to obtain data for this measure: Organization program records Employee benefits and coverage policies Note: recipients must determine the best way to obtain this information.
Unit of Analysis	Participants Participants from priority populations
Result Statement(s)	In the US, CDC-funded recipients worked to increase the number of participants enrolled in CDC-recognized or organizations in the network that are receiving reimbursement from a public or private payer or

employer from # (baseline) to # (reporting year). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of participants from priority populations enrolled in CDC-recognized or organizations in the network that are receiving reimbursement from a public or private payer or employer from # (baseline) to # (reporting year). This represents an increase of % over the funding period.

DP23-0020 Component C Performance Measure Definitions
Strategy C.1 Strategy C.2 Strategy C.3 Strategy C.4	Serve as the hub for the partner network and manage its administrative infrastructure. Work with and fund clinical and community partners with specialized expertise reaching one or more priority populations to institutionalize participant referral processes. Work with delivery partners to establish a network of both in-person and virtual CDC-recognized program delivery organizations and standardize procedures for participant support. Work with payer and employer partners to implement existing coverage policies and test new coverage policies within the network.
Measure C.5	Number of program completers* in CDC-recognized National Diabetes Prevention Program (National DPP) delivery organizations participating in the network who reduce their risk for type 2 diabetes.
Measure Type	Short Term Measure ☐ Intermediate Measure ☒ Long Term Measure
AREAS	DESCRIPTIONS
Purpose	The purpose of this performance measure is to monitor the number of program completers* in CDC-recognized National DPP delivery organizations participating in the network who reduce their risk for type 2 diabetes. *Based on CDC’s Diabetes Prevention Recognition Program (DPRP) Standards, participants who are retained in the National DPP lifestyle intervention (i.e., program completers) are defined as those who attended 8+ sessions in the first six months and whose total time in the program is 9 or more full months. Note: Please refer to Component C: Strategies 1,2,3, and 4 Guidance document located under AMP resources.
VALUES TO BE REPORTED
Numerator Definition	None. Recipients are not required to report data for this measure. This measure will be monitored and reported by CDC.
Denominator Definition	Not applicable
Proportion Definition	Not applicable

Measure Elements	Not applicable
Date Data Collected	Not applicable
Measure Notes	Not applicable
Progress Notes	The progress notes should include the following for this measure: Summary/description of the activities; Description of the progress made during the reporting period; Any facilitators to achieving progress; Any barriers to achieving progress, including steps to overcome those and effects on timelines; and/or Any additional notes that are applicable to the progress.
Other Attachments	Not applicable
Additional Information and Guidance
Helpful Hints	The DPRP State Evaluation Quarterly Report includes enrollment data stratified by priority population.
Data Source(s)	CDC DPRP State Evaluation Quarterly Report
Unit of Analysis	Program Completers Program Completers from priority populations
Result Statement(s)	In the US, CDC-funded recipients worked to increase the total number of program completers* in CDC-recognized National DPP delivery organizations who reduce their risk for type 2 diabetes from # (baseline) to # (reporting period). This represents an increase of % over the funding period. In the US, CDC-funded recipients worked to increase the number of program completers* from a priority population in CDC-recognized National DPP delivery organizations who reduce their risk for type 2 diabetes from # (baseline) to # (reporting year). This represents an increase of _% over the funding period.

Glossary

Strategy 1 Key Terms

• Collective Impact Framework: Broad, cross sector coordination leading to large scale social change that includes five conditions which together produce true alignment and lead to powerful results: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations (SSIR).

• Hub/ Backbone Organization: The group that brings together a diverse, multisectoral partner network and leads the synchronized effort to achieve the required enrollment goal with a focus on priority populations.

• Key Roles and Responsibilities of the Hub: Serves as project manager, conducts data analytics, facilitates initial and ongoing meetings/communication with partners, sets and tracks accountability for each partner’s contribution to the overall enrollment goal and performance measures, and assists partners in overcoming barriers to achievement of network goals.

Strategy 1 Resources

• Marketing and Recruitment Promotional Materials for Priority Populations: The National Diabetes Prevention Program has developed a catalogue of resources focused on supporting organizations scaling the National Diabetes Prevention Program in underserved areas across the country. The priority populations served by these resources include Medicare beneficiaries, men, African Americans, Asian Americans, Hispanics, American Indians, Alaska Natives, Pacific Islanders, and noninstitutionalized people with visual impairments or physical disabilities.

These resources include campaigns and advertisements, sample newsletter articles, social media posts, postcards, radio scripts, and more. To help narrow your search for these resources, they are organized into seven different focus areas appealing to different audiences and campaign types.

• Centers for Medicare & Medicaid Services Innovation Center: This website provides information on the MDPP expanded model.

• MDPP Implementation Resources - National DPP Coverage Toolkit: This section of the Coverage Toolkit includes webinars and resources developed by the National Association of Chronic Disease Directors as part of technical assistance for MDPP suppliers, with funding and support from CDC.

• Turning Referrals into Enrollment Summary: Developed in follow-up to an informational webinar held on October 4th, 2021, this resource details best practices shared by MDPP suppliers for turning referrals into enrollments as well as possible solutions to enrollment barriers (CDC, 2021).

Strategy 2 Key Terms

• AMA Sponsored Prediabetes Quality Measure Set: Three electronic clinical quality measures (eCQMs) that include 1) Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes, 2) Diabetes Prevention Interventions for

Patients at High-Risk for Developing Diabetes, and 3) Diabetes Prevention among Patients at High-Risk for Developing Diabetes.

• Electronic Health Record (EHR): An electronic version of a patient’s medical history. It is maintained by the provider over time and may include the key administrative and clinical data relevant to care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.

• Electronic Patient Registries: Computerized registries associated with EHR systems that track individuals with a diagnosis of prediabetes and related health factors (e.g., lipid panel data, blood pressure) to facilitate STRE options.

• Health Information Exchange (HIE): Delivers the electronic transmission of health care-related data among health care facilities. HIEs have traditionally facilitated access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care.

• Quality Measures: Tools that help payers measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These quality goals include effective, safe, efficient, patient-centered, equitable, and timely care.

• Screen/Test/Refer/Enroll (STRE): The pathway to identify individual at high risk for type 2 diabetes, make them aware of treatment options, and facilitate enrollment and support for those who choose the National DPP LCP intervention.

• Shared Decision Making: A key component of patient-centered health care in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values.

• Standing Orders/Algorithms/Clinical Workflows: Procedures that allow care teams to ensure that patients receive appropriate laboratory testing, understand their risk factors, diagnosis, and treatment options, receive support in adhering to their treatment plan, and are monitored appropriately through regular patient follow-up.

• Team-based Care: A collaborative system in which team members share responsibilities to achieve high quality patient care. In this model, physicians, nurses, nurse practitioners, physician assistants, and/or medical assistants coordinate responsibilities, such as pre-visit planning, expanded intake activities, medication reconciliation, updating patient information, and scribing, to provide better patient care. A health team’s composition can vary across health systems and health conditions. For example, in addition to a primary care physician, a chronic care team for a patient with diabetes could comprise the following:

  • CHWs/Patient Navigators

  • Certified Diabetes Care and Education Specialists

  • Registered Dietitians

  • Pharmacists

  • Dentists

  • Ophthalmologists/Optometrists

  • Podiatrists

  • Rehabilitation Specialists

Strategy 2 Resources

• Medicare Diabetes Prevention Program (MDPP) Implementation Resources - National DPP Coverage Toolkit

• Implementation Guide for Engaging Health Care Providers (HCPs) in Referrals to MDPP

• AMA Team Based Care Toolkit

• Bi-Directional Referrals: Considerations for Health Care Providers Webinar

• Implementing Bi-directional Referrals Webinar and Strategy Guide

• Bi-Directional Referrals: Considerations for National DPP Providers Webinar

• Partnering with Patients to Prevent Diabetes

• Preventing Diabetes in Your Medicare Population

• Optimize your EHR to prevent type 2 diabetes

• CMS Quality Measures

• AMA Prediabetes Quality Measures

• The AMA can help you prevent type 2 diabetes

• Screening, Testing, and Referral

• Pre-Diabetes Services: Referring Patients to the MDPP

• Prediabetes identification and management protocols

• Bi-directional feedback loop

Strategy 3 Key Terms

• Please refer to strategy guidance documents for Components A and B: Strategies 5 and 13 for a list of relevant key terms and definitions.

Strategy 3 Resources

• Please refer to strategy guidance documents for Components A and B: Strategies 5 and 13 for appropriate technical assistance and training resources.

Strategy 4 Key Terms

• Benefit Uptake Rate: A measurement of the percentage of people who claim benefits they are entitled to.

• Employee Value Proposition: The promise employers make to their employees

about what is “in it for them” to enroll in and complete a lifestyle change program.

• Medicaid In Lieu of Services (ILOS): An innovative option states may consider employing in Medicaid managed care programs to reduce health disparities and address unmet HRSN, such as housing instability and nutrition insecurity, through the use of a service or setting that is provided to an enrollee in lieu of a service or setting covered under the state plan.

• Performance benchmarks: A common component across value-based payment models that includes the use of a set of standardized measures and benchmarks. For some pay-for-performance programs, providers earn points based on performance against specified benchmarks, and the points govern the amount of payment received or withheld.

• Risk sharing: A risk management strategy that involves a health care payer transferring some risk to a program/service delivery organization.

• Value-based payment: A payment method that ties the amount health care providers (CDC-recognized organizations) earn for their services (providing the LCP) to the results they deliver for their patients (participants), such as the quality, equity, and cost of care. Through financial incentives and other methods, value- based care programs aim to hold providers more accountable for improving participant outcomes while also giving them greater flexibility to deliver the right care at the right time (i.e., including screening for HRSN).

Strategy 4 Resources

• Establishing a Comprehensive Worksite Wellness Program: This CDC resource includes credible tools, guides, case studies, and other resources to design, develop, implement, evaluate, and sustain workplace health promotion programs.

• Improving Employee Participation in Well-Being Programs: This article from the Harvard Business Review discusses approaches for improving employee participation in well-being programs.

• Healm Homepage: Healm provides comprehensive guidance for employers on offering the National DPP LCP as a covered benefit. Registering employers with Healm is a required action in Activity 4b.

• Advancing Partnerships to Align Health Care and Human Services: This resource from the Administration for Community Living (ACL) summarizes a variety of approaches, case studies, and success stories related to strengthening CBO network capacity.

• Medicaid Guidance on Use of In Lieu of Services and Settings: This Medicaid resource provides policies and guidance on employing Medicaid managed care programs to reduce health disparities.

• Benchmarking Medicaid Value-Based Payment Programs: This resource provides guidance from the Medicaid Innovation Accelerator Program on determining performance benchmarks for a Medicaid value-based program.

• Value-based Payment Roadmap to 2030: This article provides a roadmap of how value-based payments could develop over the next several years. The article includes a variety of metrics and statistics regarding Medicaid and Medicare beneficiaries.

• Value-Based Care: What It Is, and Why It’s Needed: This article by the Commonwealth Fund provides an introductory overview of the benefits of value- based care.

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