Table 1.

Themes Associated with Implementation of the Medicare Diabetes Implementation Program

Themes	Main Ideas	Supporting quotes
Facilitators and Attributes of MDPP	Well organized, relatable curriculum	“…if people didn’t feel that the curriculum was achievable and relatable, I don’t think they would be coming back.”
	In-person format provided personal relationships; online format worked well during COVID restrictions	“We had older adults that wanted to repeat DPP. They wanted to keep doing it because they liked the interaction… being part of a group.”
		“We had to switch everything to virtual, but it’s been amazing for our participants, not only Medicare, but our Medicaid Participants have so many other barriers, just getting to a class.”
	Successful recruitment strategies	“So, we’ve done churches and schools… in senior centers, libraries. Pretty much any place that was willing to give us a room at no cost.”
		“I just spent $4,000 on print ads. We have a digital ad campaign. We have a text ad campaign. I have collaborated with the Area Office on Aging, the Department of Health, a residential home.”
	Use of electronic systems for referral to the program	From hospital-based supplier: “And we have an EMR, we have EPIC. So, we have all kinds of decision trees made, both on the acute care and the ambulatory side, anybody who triggers positive for DPP eligibility, our referral is sent to the primary care physician. They don’t have to refer, but we’re trying to build that collaboration and ongoing education.”
		From health care provider: “We have a registry of patients with prediabetes that, every Sunday night, spits out a report of everyone with prediabetes who’s coming into the office over the next week for a visit; and then our nurse navigators, the day before the visit, when they were doing chart prep, run the calculator on that patient that day before.”
Barriers to MDPP Implementation	Challenging CMS application process	“So, the biggest challenge for us was getting our board members social security numbers… As well as, you know, their birthdates, their addresses, that kind of information.”
		“Why are they making it so cumbersome? It’s irritating to me, you know. I don’t see why Medicare wouldn’t recognize our diabetes education approved program.
	Upfront funding and reimbursement criteria from CMS	“…the majority of the costs are upfront- session one, four, and nine trigger the biggest payments.”
		“I gotta tell you, I’ve been at this for five years. It is not worth it. It is not going to make one bit of difference on your P & L [profit and loss] for your organization.”
	Inadequate number of MDPPs for face-to face delivery; travel	“I have a strong opinion on the biggest barrier, why a lot of people haven’t started off in the program is the CMS rules— ‘we [CMS] will pay you after the fact, if you prove to us that you make the patient lose weight.’ People are saying, ‘we’re not investing the money in this… there’s no guarantee that the patients are going to perform.’ I think that’s the biggest barrier.”
		“Some barriers that we’ve seen are that they [participants] don’t like to drive at night. So having an evening class can be tough sometimes, but we try and offer daytime… we even have offered morning classes in the past.”
	No systematic referral process across health care providers	“we just do a referral system with the physicians’ offices currently. I have had a few people call in to me that they’ve seen that we are a Medicare supplier in their booklet.”
		“… [I’m] going out to some of these primary cares, I mean, some of them are still on paper medical records, and they’re so resource limited that, it’s really hard.”
Suggestions for Improvement	Refine eligibility and payment criteria from CMS	“I think they need to decrease all those crazy regulations. it’s not like we are giving out opioids here. We are providing health, disease prevention, information. Why make it so difficult?”
		“It’s hard for me to say this in the middle of a pandemic knowing where all our federal resources are going, but you know, the coverage for the program would have to drastically change.”
	Allow for MDPP delivery using both face-to-face and virtual options	“…a lot of seniors don’t want to drive at night, you know. So, meeting them where they are. I know that sounds redundant, but we have to meet the seniors where they are and make it entertaining…”
		“…so if you’re focusing on the senior population, we need to make access so simple that we’re pushing it out where they are—churches, senior centers, their cell phones, if they are more savvy, the tablets, or whatever. It’s probably going to take government funding to make it smoother.
	Develop systematic referral system across all providers and hospital systems	…“listen, we did this at our little pocket of [agency name] in the Eastern suburbs. This is something that needs to be implemented in the [health care system computer system]. This is an effort that we need to do all over Western Pennsylvania, and the [health care system] footprint.”
	Educate patients and providers about MDPP	“My plan before COVID was to pair with the Area Agency on Aging. And to really have them, you know, help us get the word out, which is in the works.”
		“We would go out to physicians’ offices, specialty offices, and provide lunch for them, and then tell them what we have. We offer seven disease prevention or management programs”