Over the past decade, the National Association of Chronic Disease Directors (NACDD) has collaborated with the CDC’s Division of Diabetes Translation to increase the capacity of state health departments (SHDs), State Medicaid agencies (SMAs), health care organizations (HCOs), and community-based organizations (CBOs) to expand access to and utilization of the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP). Securing and implementing all payer coverage, including publicly financed insurance such as Medicaid and Medicare, for evidence-based diabetes interventions such as the National DPP LCP is essential to address the diabetes epidemic in the U.S. Diabetes is currently the most expensive chronic condition in the U.S., accounting for 25% of the nation’s total healthcare expenses.
As NACDD initiated and shepherded the Umbrella Hub Demonstration (UHD) Project (2019-2024) to assess a centralized service delivery model through umbrella hub arrangements (UHA) to improve payer engagement, NACDD and CDC identified complementary Community Care Hub (CCH) projects funded by the Administration for Community Living (ACL). Like UHAs, CCHs centralize operations such as recruitment, referrals, compliance, payer contracting, and billing for evidence-based chronic disease services. CCHs also address individual social needs, recognizing their vital impact on health outcomes. To learn more about the UHD project, please visit the Umbrella Hub Arrangements page of NACDD’s Coverage Toolkit.
In 2023, NACDD collaborated with CDC and ACL to engage three leading CCH organizations: the Iowa Community HUB, Oregon Wellness Network (OWN), and the Western New York Integrated Care Collaborative (WNYICC). This initiative examined how these models utilize blended and braided payment arrangements to deliver a range of evidence-based chronic disease prevention and management programs, along with social care services.
Key informant interviews with these three CCHs facilitated NACDD’s understanding of the core business functions of CCHs and the unique advantages they provide. CCHs offer tailored approaches to address both medical and social care needs—such as food insecurity and housing instability—thereby fostering individual engagement in year-long programs like the National DPP LCP and enhancing population-level chronic disease risk reduction. NACDD developed this report about the role SHDs can play in supporting CCH efforts.
While UHAs primarily center around the National DPP LCP, CCHs typically provide a broader array of evidence-based programs, including those targeting arthritis, balance improvement, hypertension management, to name a few. These supplementary services help meet a number of community needs and create additional income streams for CCHs, thereby bolstering their sustainability. Further insights and findings from this initiative can be accessed via NACDD’s Coverage Toolkit.
Today NACDD continues to partner and collaborate with CDC and ACL, focusing on four CCHs: Health Promotion Council (HPC), OWN, Trellis, and WNYICC. This ongoing project seeks to gather business model intelligence and explore how CCHs can enhance participant engagement and retention by connecting National DPP LCP participants with related medical and social services.
Across the nation, NACDD is observing the development of innovative infrastructure strategies that support flexible and sustainable payment models capable of financing interventions across the care continuum and mitigating the risks of chronic disease. Key learnings from the ongoing CCH initiative will be disseminated through the NACDD Coverage Toolkit later this year. If you have any questions or want to connect in relation to this work, please contact Susan Buell at sbuell_ic@chronicdisease.org.