Detailed Information on the
Healthy Homes Assessment

Develop an efficiency measure to allow the tracking of cost-effectiveness and other efficiencies in achieving program goals.

Complete an independent evaluation of the program and update the Healthy Homes program's strategic plan accordingly.

Tie the current and future budget requests to the accomplishment of the program's annual and long-term performance goals.

Measure: The number of housing units with reduced allergen levels through interventions using healthy homes principles.

Explanation:Since FY 2006 the annual performance measure for the program has been the number of housing units in which allergen levels (i.e., asthma triggers) have been reduced. Research has shown that reducing exposure to residential allergens, in conjunction with medical management, often results in improvements in the frequency and severity of asthma symptoms. Reductions in allergen levels can be accomplished in different ways, depending on the results of the initial home assessment (e.g., pest control would be used to address pest allergens, mold growth would be addressed through control of moisture problems). The "allergen reduction" performance measure was adopted for the program because the direct assessment of asthma symptoms is difficult to obtain in a standardized manner.

Measure: Healthy Homes intervention cost per housing unit

Explanation:A baseline value is being established which represents the average cost for conducting an intervention in target (i.e., high risk) housing based on healthy homes principles. The program will strive to achieve efficiencies by conducting these interventions at a lower average cost per housing unit in future years. This will be accomplished by HUD and its program partners gaining additional knowledge regarding the most cost-effective intervention protocols.

Is the program purpose clear?

Explanation: The Healthy Homes Initiative (HHI) was initially funded in Fiscal Year 1999 through Public Law 105-276 (the Department of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act of 1999). The associated report from the Committee on Appropriations of the U.S. House of Representatives directed HUD to work with federal partners to "develop and implement a program of research and demonstration projects that would address multiple housing-related problems affecting the health of children." The Healthy Homes Initiative continues to adopt a comprehensive approach of addressing multiple housing-related hazards that impact the health of residents, particularly children. In 1998, the Department solicited advice from a panel of subject matter experts to produce a strategic plan for the Healthy Homes Initiative that reflects the opinion of the panel (1). The plan, Healthy Homes Initiative: Preliminary Plan, identified four broad principles for program activities, including: controlling excess moisture; controlling dust; improving indoor air quality, and education and outreach. These principles were considered to be critical to create and maintain healthy homes and improve health-related outcomes, including asthma and allergies, injury, and illness associated with hazardous substances such as radon and carbon monoxide. The program has evolved to have as its primary emphasis the priority health endpoints of childhood asthma and injury, both having strong housing-related risk factors.

Evidence: (1) The Healthy Homes Initiative: A Preliminary Plan (Full Report), April, 1999, see: http://www.hud.gov/ offices/lead/reports/HHIFull.pdf

Does the program address a specific and existing problem, interest, or need?

Explanation: The HHI is directed at the identification and remediation of residential health and safety hazards in U.S. housing, with an emphasis on housing-related issues that affect the health of children from low and moderate income families. The program focuses on high priority issues, in particular asthma and childhood injury, which can be caused or exacerbated by factors in the residential environment. Asthma is a major health problem in the U.S., resulting in approximately 2 million emergency room visits and 5,000 deaths per year. It is the most common chronic childhood disease, affecting about 6.3 million children, and is the leading cause of missed school days (14 million in 2000). Asthma disproportionately affects African Americans (1). The incidence of asthma has increased at an alarming rate in recent years, with the number of asthmatics doubling between 1980 and 1996, to 15 million (2). A national survey of U.S. housing, the American Healthy Homes Survey, conducted by HUD (partially funded by the Healthy Homes program) and the National Institute of Environmental Health Sciences (a co-funder of the survey) found higher levels of important asthma triggers (dust mites, cockroach allergen, rodent allergen) and lead-based paint hazards in older, low income housing (3,4,5,6). Research has shown that residential interventions that include a reduction in asthma triggers can reduce asthma severity in children. One important study, funded by the Program, reported a reduction in children's asthma symptoms following the mitigation of mold and moisture problems in their homes (7). Mold and excess moisture in homes, a common mitigation target of HH grantees, has been linked to both asthma and other respiratory conditions (8). The rates of some childhood injuries (e.g., fire injuries and deaths) are also higher in poor, minority families.

Evidence: (1) U.S. Environmental Protection Agency: Asthma and Indoor Environments http://epa.gov/asthma/about.html (2) Centers for Disease Control and Prevention: Potentially Effective Interventions for Asthma, http://www.cdc.gov/asthma/interventions/background.htm (3) R. D. Cohn et al., National Prevalence and Exposure Risk for Cockroach Allergen in US Households, Environmental Health Perspectives 2006; vol. 114, p. 522-526. (doi: 10.1289/ehp.8561, available via http://dx.doi.org/) (4) S. J. Arbes et al., House dust mite allergen in US beds: Results from the first National Survey of Lead and Allergens in Housing, Journal of Allergy and Clinical Immunology 2003; vol. 111, p. 408-414. (5) Cohn et al., National prevalence and exposure risk for mouse allergen in US households, Journal of Allergy and Clinical Immunology 2004; vol. 113, p. 1167-1171. (6) D. E. Jacobs et al., The prevalence of lead-based paint hazards in U.S. housing, Environmental Health Perspectives 2002; vol. 110, p. A599-A606. http://ehp.niehs.nih.gov/members/2002/110pA599-A606jacobs/ jacobs-full.html (7) C. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives 2006; EHP-in-Press, April, 2006 doi: 10.1289/ehp.8742, available via http://dx.doi.org/ (8) Damp Indoor Spaces and Health, Institute of Medicine, May 2004, http://www.iom.edu/CMS/3793/4703/20223.aspx

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: There is no other federal program that is as comprehensive in addressing multiple environmental health and safety hazards, with an emphasis on protecting the health of children in low-income families as the Healthy Homes (HH) program. Because of the significance of the health outcomes associated with these hazards or conditions (e.g., asthma, childhood injury) and the multifaceted approach needed to address them, other federal agencies have programs that address individual hazards; however, the programs differ in important ways. The US Environmental Protection Agency's (EPA) has a program that addresses asthma triggers, but the focus is on education and outreach and not housing-related interventions (1). The National Institute of Environmental Health Sciences (NIEHS) funds research on the effectiveness of reducing asthma triggers (e.g., cleaning dust mite allergen from carpets, reducing cockroach allergen); however, they do not fund research or demonstration projects that include structural interventions in dwellings (e.g., fixing roof or plumbing leaks, improving ventilation, removing old carpets), which is important for the control of allergens such as mold, cockroaches and dust mites (2). The HH program has actually complemented NIEHS funding by providing supplemental funds to a NIEHS research grantee to cover the costs of structural lead- and injury-hazard interventions in an ongoing study (3). The Centers for Disease Control and Prevention conducts surveys on the national prevalence of asthma and some education/outreach on reducing residential exposure to asthma triggers. The U.S. Department of Agriculture's Cooperative State Research, Education, and Extension Service (CREES) network conducts education and outreach activities on HH issues, which is supported by HUD HH funds (4). The HUD HH program created this partnership to take advantage of this extensive network. HUD's HH Initiative is the only federal program that emphasizes all of the following: the development of local capacity to increase the availability of safe housing by providing training on HH principles to housing program staff; targeting low income residences for interventions (including structural interventions) to reduce multiple health and safety hazards; the education of residents in high risk communities on HH self-protective behaviors; community participation in project development/implementation, and research to improve residential hazard assessment and control methods (5). There are no state, local, or private programs that significantly duplicate the HH program.

Evidence: (1) See for example, the response to question 1.4 in the assessment of EPA's Indoor Air Quality Program, http://www.whitehouse.gov/omb/expectmore/detail.10004374.2005.html (2) The NIEHS extramural research grant portfolio can be searched for key terms at: https://www-apps.niehs.nih.gov/portfolio/ (3) See project titled, Children's Environmental Health Center, Dr. Bruce Lanphear, Principal Investigator,http://www.niehs.nih.gov/translat/children/grantees/home.cfm (4) Information on the CREES Healthy Homes Initiative is available at: http://www.csrees.usda.gov/ProgView.cfm?prnum=5002 (5) See archived summaries of past Notices of Funding Availability for the Healthy Homes Demonstration and Technical Studies Programs at: http://www.hud.gov/library/bookshelf12/supernofa/

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: HUD's Healthy Homes Initiative is non-regulatory and supports activities to improve, develop, demonstrate and evaluate methods for the assessment and mitigation of residential environmental health and safety hazards. The Program pursues its objectives primarily through the competitive award of grants for research (technical studies) and demonstration projects (1), with additional project work conducted through contracts and interagency agreements. Contracts are used to implement targeted support and evaluation activities for the grant program (e.g., summarization of the scientific literature, developing standard environmental assessment protocols), developing education/outreach materials, increasing capacity building, and conference support. Interagency agreements (i.e., the transfer of funds to other federal agencies to fund specific activities) are used to support activities in other federal agencies that are instrumental in helping HUD achieve program objectives. For example, HUD provides funding to the US Department of Agriculture (USDA) Cooperative State Research, Education and Extension Service (CSREES) to support a USDA's Healthy Homes Program. In this way, HUD can leverage the already established infrastructure and extensive network of excellent CSREES coordinators and grantees (2). This fosters collaboration and information sharing between federal partners with a similar mission. Also, because funding can be applied towards addressing multiple hazards in the home, grantees are not restricted to addressing one hazard at a time. For example, recipients of HUD's Lead Hazard Control Program (LHCP) grants can only use funds to address lead-based paint hazards. Such a grantee may encounter a home with other hazards (e.g., no smoke detectors, mold growth, pest infestation) but would not be able to address the hazards with LHCP funds. There is currently no evidence that another approach or mechanism would be more efficient or effective to achieve the goals of the Healthy Homes Initiative.

Evidence: (1) See archived summaries of past Notices of Funding Availability for the Healthy Homes Demonstration and Technical Studies Programs at: http://www.hud.gov/library/bookshelf12/supernofa/ (2) Information on the CREES Healthy Homes Initiative is available at: http://www.csrees.usda.gov/ProgView.cfm?prnum=5002

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The availability of grant funds is announced annually through HUD's Notices of Funding Availability (NOFAs), which describe program objectives and establish requirements for applicants and grant/cooperative agreement recipients (1). The HH Demonstration grant program requires applicants to target areas where low-income families with young children are at considerable risk of, or suffer from, preventable/controllable childhood illnesses or injury (e.g. asthma, elevated blood lead levels, fire-related injury). The application review process considers the applicant's selection of a target area where the need/extent of the problem is a critical component for a successful project. Applicants must provide compelling statistics about demographics, socioeconomics, childhood illnesses, injuries, poverty and housing to score well in this rating factor. In addition, an applicant must demonstrate the experience and capacity to address the target population and ensure that program resources reach the intended beneficiaries. Within their target areas, grantees are required to market their program to those at greatest risk, who are often those least likely to seek out such services (e.g., low income minority families). Grantees must also provide materials in alternative formats for persons with disabilities and provide materials in languages other then English for individuals with limited English proficiency (LEP) (2, 3). In addition to the HH Demonstration program, the HH Technical Studies program emphasizes the development of cost-effective tools and protocols that are intended for adoption by public and private organizations with interests in public health and housing. It has been clearly demonstrated that the demand for HH program grants greatly exceeds the available funding. For the three Fiscal Years, 2003, 2004, and 2005, an annual average of 14.5% of grant applications to the HH program received funding. Since the inception of the Healthy Homes Initiative, a total of 76 grants/cooperative agreements have been awarded for a total of about $60 million. HH program contracts have also directly targeted beneficiaries. For example, through a FY 2006 contract, a training curriculum is being developed on the safe rehabilitation of dwellings damaged by hurricane-induced flooding and winds. This training will be administered to target audiences (e.g., contractors, property managers, workers) in the Gulf coast areas that were severely impacted by Katrina and other hurricanes in 2005. Another contract will support community outreach and education on the same issues (4). The HH program has also successfully targeted beneficiaries through an interagency agreement with the U.S. Department of Agriculture, which leverages its extensive Cooperative State Research, Education, and Extension Service (CSREES) network (5).

Evidence: (1) Healthy Homes Demonstration grant program and Healthy Homes Technical Studies grant program - Notices of Funding Availability (NOFA) for Fiscal Year 2005: http://www.hud.gov/library/bookshelf12/supernofa/nofa05/hhdsec.pdf http://www.hud.gov/library/bookshelf12/supernofa/nofa05/hhtssec.pdf (2) The Grant Agreement requires grantees to comply with both the General Section of the NOFA and program-specific NOFAs. The General Section requires all HUD grantees to comply with Executive Order 13166 "Improving Access to Services by Persons with Limited English Proficiency" by following HUD's Guidance (Federal Register/Vol. 68, No 244/Friday, December 19, 2003/ Notices) http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2003/pdf/03-31267.pdf (3) Healthy Homes Initiative Outreach Materials http://www.hud.gov/offices/lead/hhi/consumer.cfm (4) The Statements of Work for the two FY 2006 contracts are available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (5) Information on the CREES Healthy Homes Initiative is available at: http://www.csrees.usda.gov/ProgView.cfm?prnum=5002

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: Explanation: The Healthy Homes Initiative (HHI) program has a comprehensive residential environmental health and safety focus that is consistent with the original Congressional directive to "develop and implement a program of research and demonstration projects that would address multiple housing-related problems affecting the health of children." (1, 2) The identification of specific long-term performance measures that are appropriate for the program has evolved over time as the program has continued to sponsor residential hazard assessment and control activities. During the start-up period for the HHI, the operational benchmark was awarding of grants, contracts, and interagency agreements to achieve the program's goals and objectives. As a result, in the developmental phase, annual goals reflected the awarding of specific numbers of grants and procurement actions (3). When the process for awarding grants was well established, the performance measure shifted to the delivery of units with interventions using HH principles (i.e., interventions aimed at reducing multiple health and safety hazards) (4). Many HH grantees focus on performing housing interventions to control asthma triggers to achieve a reduction in asthma morbidity in children living in targeted homes. This focus is consistent with the importance and increasing prevalence of this disease and the fact that, if residential asthma triggers are controlled, the frequency and severity of asthma symptoms are reduced (5). As a result of these findings, the program adopted two new long-term performance measures associated with residential interventions to reduce asthma triggers, i.e., the number of homes in which allergen levels (asthma triggers) in dust are reduced and a target number of children with a resulting reduction in asthma symptoms. These performance measures are consistent with HUD's Strategic Goal, C4, address housing conditions that threaten health. (6).

Evidence: (1) Conference Report on Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act of 1999. (2) The Healthy Homes Initiative: A Preliminary Plan (Full Report), April 1999. Available at http://www.hud.gov/utilities/intercept.cfm?/offices/lead/reports/HHIFull.pdf. (3) U.S. Department of Housing and Urban Development Performance and Accountability Reports (Fiscal Years 2002, 2003, 2004) are available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (4) U.S. Department of Housing and Urban Development Performance and Accountability Report (Fiscal Year 2005) and the U.S. Department of Urban Development Fiscal Year 2006 Annual Performance Plan. The reports are available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (5) U.S. Environmental Protection Agency: Asthma and Indoor Environments http://epa.gov/asthma/about.html (6) HUD Strategic Plan (Fiscal Years 2006 - 2011) is available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: Over the long term, the HHI will mitigate residential health and safety hazards that threaten children, including reduction in the levels of allergens in house dust (1). With the reduction in allergen levels and other hazards, there is anticipated to be a corresponding reduction in the incidence, frequency and severity of asthmatic episodes as well as a reduction in home injuries, including carbon monoxide poisoning and falls. Given the limited annual HHI funding level of approximately $10 million that has been available to reduce multiple health and safety hazards, HUD does not expect to make a major impact on the national prevalence of children with active asthma over the next five years, based on the number of housing interventions that are directly supported by the HH program. However, other HH activities (e.g., education that will result in the adoption of self-protective measures) are also expected to result in behavioral outcomes that improve health, but these behavioral outcomes are more difficult to quantify. In HUD's Strategic Plan for Fiscal Years (FY) 2006-2011, the HH program adopted a long-term performance measure of reducing allergen levels in 5,000 homes and, consequently, reducing asthma symptoms in an estimated 3,000 children (2). This performance measure will guide the HH program over the next five years. These targets are ambitious and will require significant increases in annual program production over the FY 2006-2011 period. To achieve these long-term measures, HH grantees will have to increase the number of homes with reduced allergen levels by 78% and the number of children with improvement in asthma symptoms by about 133% by 2011 relative to the estimated FY 2006 baseline. The asthma reduction target is particularly ambitious because it requires thorough assessment of symptoms before, and approximately one year after, an intervention. Grantees have found it especially challenging to retain participants throughout the project period, which can be up to two years long. The impacts of the HHI are also anticipated to be significant relative to the development and evaluation of effective residential assessment and intervention protocols, and coordination of HH training and outreach activities; activities which will foster coordination among state, local, and private-sector stakeholders in the health and housing communities. One example of this is the National Healthy Homes Training Center (3). Individuals, including health practitioners, who regularly visit homes as part of their work are offered HH awareness training in this program. It is anticipated that these trainees will become the "change agents" in their respective organizations and advocate for the adoption of measures targeting residential hazards. HUD funds the National Healthy Homes Training Center through an interagency agreement with the Centers for Disease Control and Prevention (CDC). In addition to training, the Training Center also provides outreach to health and housing program administrators and decision makers about the relationship between housing and health.

Evidence: (1) See "Basic Facts About Asthma" on the U.S. Centers for Disease Control and Prevention web cite: http://www.cdc.gov/asthma/faqs.htm (2) HUD's Strategic Plan 2006-2011 http://www.hud.gov/offices/cfo/reports/hud_strat_plan_2006-2011.pdf (3) National Healthy Homes and Training Center http://www.healthyhomestraining.org/

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The Program's annual performance measures have changed over time as the Healthy Homes Initiative (HHI) has evolved. The initial annual measures were output measures that reflected: 1) the initiation of projects by program partners to achieve program goals (i.e., grants and cooperative agreements, contracts, and interagency agreements (referred to collectively as procurement actions)), and, 2) the number of units in which HH interventions were conducted (1). In HUD's Strategic Plan for Fiscal Years (FY) 2006-2011, the Program adopted the long term measures of reducing allergen levels in 5,000 homes, with a corresponding outcome measure of decreasing asthma symptoms in an estimated 3,000 children (2). Annual performance measures that track progress in achieving the new long term measures have been created and will be reported in HUD's Fiscal Year 2007 Annual Performance Plan. The annual performance targets for the two new performance measures will increase annually through FY 2011. The focus on reducing allergen levels in house dust and the subsequent reduction in children's asthma severity is a reflection of the increasing prevalence of this disease and its adverse impact on children's health, the presence of important asthma triggers in the residential environment, and the interest of program partners in addressing housing-related hazards that are associated with illness (3). The program will not focus exclusively on the reduction of asthma triggers alone, but will continue with its strategic goal of comprehensively reducing multiple housing-related hazards, including residential injury hazards, that impact the health of residents, particularly children in low-income families.

Evidence: (1) U.S. Department of Housing and Urban Development Performance and Accountability Reports (Fiscal Years 2002, 2003, 2004, 2005) are available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (2) HUD Strategic Plan (Fiscal Years 2006 - 2011) is available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (3) U.S. Environmental Protection Agency: Asthma and Indoor Environments http://epa.gov/asthma/about.html; Centers for Disease Control and Prevention: Potentially Effective Interventions for Asthma, http://www.cdc.gov/asthma/interventions/background.htm

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The annual measures in the initial years of the HHI focused on getting projects established, including grants and cooperative agreements, contracts, and interagency agreements (identified as procurement actions). The program exceeded its targets for this measure in Fiscal Years (FY) 2002 - 2004 (1). This measure was updated by a performance output, the number of housing units that received HH interventions, to capture grantee performance. The target for this measure was exceeded in FY 2005 (2). The two ambitious new long term targets for HHI performance measures (established in FY 2006), are the number of homes in which allergen levels in dust are reduced and the number of children with reduced asthma symptoms (3). These will by necessity require the adoption of ambitious annual targets, the first of which (interventions resulting in allergen reductions) is being established in FY 2006. This annual measure is ambitious because currently not all HH grantees are measuring the levels of allergens in house dust as part of their assessment protocols and the fact that imprecision in the measurement of dust-allergen levels can interfere with the ability to demonstrate reductions. The program has taken steps to improve allergen sampling and measurement, and thus improve grantees' ability to demonstrate reductions in dust-allergen levels by requiring grantees to adopt a standard sampling protocol and specific quality control measures (4). The annual target values for homes with post-intervention reductions in dust-allergen levels assumes improvements in allergen sampling and analysis and an increase in the number of grantees conducting these interventions. The annual target for the number of children with asthma symptom reductions is ambitious because studies have shown that a multifaceted approach will be needed to achieve such reductions (including optimization of medical care in conjunction with multiple environmental interventions). Grantees will also be challenged to recruit families into their programs and to keep them enrolled for the entire project period (often up to 2 years). This is especially challenging for high-risk (low-income) populations that generally move more frequently than more affluent families. The annual targets for the HH program assume a high level of success in reducing asthma symptoms and a high retention for project participants. Baseline levels of allergens in house dust were established for U.S. homes in the 1999-2000 National Survey of Lead and Allergens in Housing, conducted by HUD and the National Institute of Environmental Health Sciences (5). A new survey being conducted by HUD and the U.S. Environmental Protection Agency is also collecting data on allergen levels in U.S. housing, with results expected in 2007. Annual estimates for the number of children with active asthma are collected through the CDC's National Health Interview Survey (6).

Evidence: (1) U.S. Department of Housing and Urban Development Performance and Accountability Reports (Fiscal Years 2002, 2003, 2004) are available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (2) U.S. Department of Housing and Urban Development Performance and Accountability Report, FY 2005, http://www.hud.gov/offices/cfo/reports/cforept.cfm (3) HUD Strategic Plan (Fiscal Years 2006 - 2011) is available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (4) These requirements are found in section III.C.3.i of the FY 2005 Healthy Homes Demonstration Program NOFA: http://www.hud.gov/library/bookshelf12/supernofa/nofa05/hhdsec.pdf (5) R. D. Cohn et al., National Prevalence and Exposure Risk for Cockroach Allergen in US Households, Environmental Health Perspectives 2006; vol. 114, p. 522-526. (doi: 10.1289/ehp.8561 available via http://dx.doi.org/) S. J. Arbes et al., House dust mite allergen in US beds: Results from the first National Survey of Lead and Allergens in Housing, Journal of Allergy and Clinical Immunology 2003; vol. 111, p. 408-414. R. D. Cohn et al., National prevalence and exposure risk for mouse allergen in US households, Journal of Allergy and Clinical Immunology 2004; vol. 113, p. 1167-1171. (6) Information on the collection of data on the prevalence of asthma in the U.S. using the National Health Interview Survey is available at: http://www.cdc.gov/asthma/NHIS/default.htm

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The majority of Healthy Homes (HH) program funds are awarded annually as grants and cooperative agreements following the evaluation of applications that are submitted in response to annual Notices of Funding Availability (NOFAs) for the HH Demonstration and HH Technical Studies Programs. Both NOFAs describe the overall goals and objectives of the HHI as well as the specific goals and objectives for the individual HH Demonstration and HH Technical Studies grant programs (1). Applicants for grants/cooperative agreements must clearly describe a target area, state the goals and objectives for their proposed projects and identify the major benchmarks and milestones that would be used to track progress. Application requirements include the submission of a logic model that requires the applicant to link the proposed project to HUD's strategic goals and policy priorities and to clearly identify important benchmarks (outputs) and outcome measures (2). These requirements allow reviewers to evaluate applications relative to Departmental and HH program objectives and priorities. Following the award of a grant or a cooperative agreement, grantees are required to submit quarterly progress reports using the Office's web-based Quarterly Progress Reporting System (QPRS). This system requires the reporting of outputs and outcome measures that are important in achieving both project-specific and overall programmatic goals (e.g., the number of homes assessed, the number of interventions completed, the number of people trained) (3). Statements of Work developed for program contracts and interagency agreements (IAAs) are written in accordance with goals of the HHI. The contracts and IAAs are performance-based, and generally awarded on a fixed price basis with reimbursement of services approved by the assigned Government Technical Representative, contingent upon the contractor successfully completing interim project deliverables (4). Contractors must also submit quarterly progress reports, which are used to track progress against the project schedule. Federal partners also provide periodic progress reports, generally on an annual basis, with ongoing monitoring in the interim (5).

Evidence: (1) Healthy Homes Demonstration grant program and Healthy Homes Technical Studies grant programs - NOFAs, available at: http://www.hud.gov/library/bookshelf12/supernofa/nofa05/hhdsec.pdf, http://www.hud.gov/library/bookshelf12/supernofa/nofa05/hhtssec.pdf (2) Logic models are required to be submitted under Factor 5 in all HUD NOFAs and require the use of the Form HUD-96010. (3) OHHLHC web-based Quarterly Progress Reporting System, http://pluto.ddlinc.com/qprs/qprsr1.nsf/ (4) An example of a HH contract showing a payment schedule based upon the successful completion ofcontract deliverables is available at http://www.hud.gov/offices/lead/hhi/hhiresources.cfm. (5) An example of a progress report from a Federal partner (Centers for Disease Control and Prevention is available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: There are plans to conduct such evaluations but, to date, these have not occurred on a regular basis. In November 2005 the Office issued a contract to conduct a thorough evaluation of the Healthy Homes (HH) program. The evaluation, to be completed in January 2007, will include a review of all final work products (e.g., final reports and scientific manuscripts) for completed grants and cooperative agreements and a review of work plans and quarterly reports for active projects. A telephone questionnaire will then be administered to representatives from each funded project. The evaluation will capture key findings from HH-sponsored projects (grants/ cooperative agreements, contract-based projects interagency agreements). This evaluation will identify and organize "best practices" for residential assessment and hazard control and will identify key research findings (1). The evaluation will also review HHI progress relative to its strategic plan, Healthy Homes Initiative: Preliminary Plan, as developed with the input of outside experts who were convened at the start of the program in 1999 (2). HUD plans to discuss the evaluation findings at another meeting of outside experts to review HHI progress and help to refocus program activities, as necessary. Evaluations of the types of housing interventions being used in HH-funded projects have been conducted by both HH grantees and other researchers and have shown the interventions to be effective in reducing asthma morbidity among children living in treated homes. In addition, all HH grantees are required to conduct formal evaluations of their interventions (3).

Evidence: (1) The Supporting Statement for the Paperwork Reduction Act Submission (submitted to the Office of Management and Budget) for the project titled "Evaluating Outcomes of HUD's Healthy Homes Grants" is available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm. (2) The Healthy Homes Initiative: A Preliminary Plan (Full Report), April, 1999, see: http://www.hud.gov/ offices/lead/reports/HHIFull.pdf (3) The requirements for grantees to formally evaluate the effectiveness of their interventions can be found at: Healthy Homes Demonstration grant program and Healthy Homes Technical Studies grant program - Notices of Funding Availability (NOFA); http://www.hud.gov/library/bookshelf12/supernofa/nofa06/fundsavail.cfm

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Earlier budget requests for the Healthy Homes (HH) Program were not explicitly tied to the annual and long-term performance goals. Rather, budget requests were linked to the expected number of grant monitoring visits (1,2). However, the FY 2008 budget request for the Healthy Homes Initiative is explicitly tied to the annual and long-term performance goals in HUD's Strategic Plan and its Annual Performance Plan. The budget references both goals, and does not request funds for any programs that did not directly contribute to these goals. Specifically, in FY 2008 the Healthy Homes program will reduce allergens in 787 housing units. The program budget included specific information about how the OHHLHC will allocate the funds to achieve this measure through Healthy Homes Demonstration grants, interagency agreements, and a new initiative "Creating Healthy Homes" to develop health-based consensus standards for evaluating and addressing housing-related hazards and disseminate guidance to industry and the public. Ultimately, these efforts should help the HHI improve its score in this area.

Evidence: (1) FY 2007 Budget http://www.hud.gov/about/budget/fy07/fy07budget.pdf (2) FY 2007 Congressional Justification http://www.hud.gov/offices/cfo/reports/2007/cjs/part3/leadhazred.pdf

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: In early 2006, the Office of Healthy Homes and Lead Hazard Control (OHHLHC) undertook an effort to assess the number of units that had been treated using healthy housing principles and update HUD's Strategic Plan, Annual Performance Plan, and Management Plan. Previously, OHHLHC reported goals as cumulative totals; these totals were increased over time, but did not capture efficiencies or adequately reflect actual progress. While the FY 2003-2008 Strategic Plan did not include quantitative performance measures for the HHI, the 2006-2011 Strategic Plan includes ambitious long term targets to complete interventions to reduce dust-allergen levels (i.e., important asthma triggers) in 5000 homes, and consequently decrease asthmatic episodes in at least 3,000 children (1). The FY 2006 Annual Performance Plan currently projects that the HH Program will complete healthy homes interventions in 1200 homes; this annual measure will be amended to "a reduction in allergen levels in 600 homes," to better track the new long term measure . The FY 2007 APP will project interventions that reduce dust-allergen levels in approximately 690 housing units and reduce the frequency of asthma episodes in approximately 380 children. The Program will also use the results of an ongoing evaluation (to be completed in January 2007) to inform strategic planning. A meeting of outside experts, similar to the initial planning meeting that was held in FY 1999, will be organized following completion of the evaluation to review the results of the evaluation and assess program progress in achieving suggested goals and objectives identified in the original HH Initiative plan (2).

Evidence: (1) HUD's Strategic Plan 2006-2011 http://www.hud.gov/offices/cfo/reports/hud_strat_plan_2006-2011.pdf (2) The Healthy Homes Initiative: A Preliminary Plan (Full Report), April, 1999, see: http://www.hud.gov/ offices/lead/reports/HHIFull.pdf

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: Grantees are required to report on the progress of their grant activities on a quarterly basis using a web-based Quarterly Progress Reporting System (QPRS) (1). In 2002 the Lead-Based Paint Hazard Control grant program initiated this web-based system. Because of its success, the Healthy Homes (HH) grant programs adopted QPRS in 2003. The reporting format used by the lead hazard control grant programs was modified to make it applicable to both the HH Demonstration grant program and the HH Technical Studies grant program. QPRS collects information on such key benchmarks as the numbers of: clients contacted, clients enrolled, individuals trained (by work discipline), dwellings assessed for hazards, housing interventions completed, and individuals reached through outreach and education efforts (2). Grantees are also required to develop a separate spreadsheet that identifies targets for key benchmarks and milestones for each calendar quarter. The HUD Government Technical Representative (GTR) sends the grantee a letter that identifies its performance category for the previous quarter. Grantees that are behind ("yellow" status) or significantly behind ("red" status) must take corrective actions to improve their performance, with individually-tailored response plans and frequent GTR monitoring for "red" grantees (3,4). This system has worked well in helping ensure that grantees monitor their own performance relative to schedule and cost disbursements. It also helps GTRs and HUD to target grantees that could benefit from on-site technical assistance or monitoring visits. HH program contracts are awarded on a performance-based, fixed price basis. Contractors have clearly designated schedules for the completion of milestones and deliverables, with incremental payments made upon completion of deliverables. This system has worked well, with no problems in contractor performance to date. The performance of Federal partners is also tracked with respect to the completion of deliverables on a schedule identified in a written interagency agreement that is monitored by a HUD GTR and Government Technical Monitor (GTM). This monitoring system has also worked well to date.

Evidence: (1) The Grant Agreement requires grantees to report on a quarterly basis by following 24 CFR 84.51(b) or 85.40(b)(1) (as applicable to non-governmental and governmental grantees, resepectively), as implemented by OHHLHC Policy Guidance Issuance 2001-03 (http://www.hud.gov/ offices/lead/grantfrm/pgi/2001_03.pdf). (2) OHHLHC web-based Quarterly Progress Reporting System, http://pluto.ddlinc.com/qprs/qprsr1.nsf/ (3) The Office of Healthy Homes and Lead Hazard Control, "A Program Guide for OHHLHC Grantees," Chapter 3, Program Start-up: Getting Off to a Good Start, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (4) The Office of Healthy Homes and Lead Hazard Control, Grants Management Desk Guide, Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: Managers are held accountable through Departmental Performance Accountability and Communication System Summary Ratings. Specific performance rating elements for managers focus on making HUD's programs and people more efficient and accountable and are directly tied to performance and schedule results (1). HH program contracts and interagency agreements (IAAs) are awarded on a fixed price basis with payments tied to specific deliverables or other performance benchmarks identified in the contract or IAA (2). The program has encountered no contract performance problems to date. Grantees are required to report on the progress of their grant activities on a quarterly basis using a web-based Quarterly Progress Reporting System (QPRS) (3, 4; see answer 3.1). Grantee performance is assessed against specific benchmarks for delivering output and outcome measures on a quarterly and annual basis using color-coded performance criteria, e.g., a designation of red indicates that the grant is significantly behind schedule. One grantee is currently under investigation by the HUD Office of the Inspector General because of the GTR's concerns of possible financial mismanagement. The performance of federal partners is tracked against required deliverables by the assigned Government Technical Monitor. HUD's Office of the Chief Financial Officer reported its financial management goals and processes in the FY 2004-2008 "HUD Financial Management Five Year Plan" (5).

Evidence: (1) Managers' Performance Accountability and Communication System (PACS) and (Executive Performance Accountability and Communication System (EPACS)) forms. (2) HUD Handbook 2210.3, "Procurement Policies and Procedures", especially Chapter 12, "Monitoring Contractor Performance." http://www.hudclips.org/sub_nonhud/cgi/hudclips.cgi (Handbooks | Administrative | Search | Document number | 2210.3 | chapter 12) (3) OHHLHC web-based Quarterly Progress Reporting System, http://pluto.ddlinc.com/qprs/qprsr1.nsf/ (4) The Office of Healthy Homes Grantee desk guide "A Program Guide for OHHLHC Grantees", Chapter 7, Reporting and Recordkeeping, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (5) HUD Financial Management Five Year Plan http://www.hud.gov/offices/cfo/5yearplan.pdf

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: An annual procurement plan identifying all program expenditures is created before the start of each fiscal year (1). Grants are awarded, based on the recommendations of an Application Review Panel and the Selecting Official, at the end of the fiscal year and executed in the first quarter of the subsequent fiscal year. For contracts and interagency agreements, there have been small amounts of unobligated funds at years end since the inception of the Healthy Homes Initiative (HHI) and all funds have been obligated by the funds obligation deadline (since 2002, the end of the fiscal year after the appropriation's fiscal year). About 80% of program funds are annually spent on competitively awarded grants and cooperative agreements. The Office's Government Technical Representatives (GTRs) ensure that grantees expending $500,000 or more in Federal funds conform to the requirements of OMB Circular A-133 (2). Grantees must also submit a summary of their expenditures through the online quarterly reporting system, which is monitored by the GTR. GTRs also track grant expenditures and make payments through HUD's electronic Line of Credit Control System (3). GTRs request invoices to support payment requests on a random and targeted basis (4). Vouchers submitted by grantees are approved or rejected by the GTR within 5 days of submission. Contract and interagency agreement awards are made based on HUD's Office of the Chief Procurement Officer's schedule and the OHHLHC's annual procurement plan. The program uses fixed price performance-based contracting, and payments are based on the contractor meeting specific contract milestones or deliverables specified in the contract. Vouchers submitted by contractors are reviewed for approval by the GTR and paid or rejected within 30 days of submission, with most paid within 10 days (5,6,). HUD's Office of the Chief Financial Officer provides oversight of all financial monitoring and systems (7).

Evidence: (1) Healthy Homes Program procurement plan for FY 2006. (2) See, for example, 2006 Healthy Homes Technical Studies Notice of Funding Availability (NOFA), Section VI.A.1: http://www.hud.gov/offices/adm/grants/nofa06/ltssec.pdf and 2006 Healthy Homes Demonstration NOFA, section VI.B.6:http://www.hud.gov/offices/adm/grants/nofa06/hhdsec.pdf (3) HUD Line of Credit Control System http://hudatwork.hud.gov/apps/po/f/loccs/index1.cfm (4) The Office of Healthy Homes and Lead Hazard Control, Grants Management Desk Guide, Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (5) Handbook 2210.17, REV 2 "Discretionary Grant and Cooperative Agreement Policies and Procedures," par. 5-12.a.5. http://www.hudclips.org/sub_nonhud/cgi/hudclips.cgi (Handbooks | Administrative | Search | Document number | 2210.17 | chapter 5) (6) HUD Handbook 2210.3, "Procurement Policies and Procedures," par. 12-6.A.4.b(2) http://www.hudclips.org/sub_nonhud/cgi/hudclips.cgi (Handbooks | Administrative | Search | Document number | 2210.3 | chapter 12) (7) Officer for Chief Financial Officer http://www.hud.gov/offices/cfo/finmgmt.cfm http://www.hud.gov/offices/cfo/finsys.cfm

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: No efficiency measure has yet been developed and implemented for this program. However, HUD will adopt an efficiency measure using cost data provided through an independent evaluation that will be completed in early 2007. This evaluation will establish a baseline level for the average cost per intervention, calculated on a unit basis. The measure will be based on direct housing intervention costs reported by Healthy Homes (HH) grantees to reduce levels of residential allergens (e.g., through integrated pest management, specialized cleaning, moisture control), address injury hazards, and provide education and training to families. The majority of program funds are competitively awarded as grants or cooperative agreements through the annual Notices of Funding Availability (NOFAs) for the Healthy Homes (HH) Demonstration Grant and Technical Studies Grant Programs (1). Over Fiscal Years (FY) 2003 - 2005 an average of 80% of program funds have been awarded through this vehicle. Starting in FY 2005, HUD has required applicants to submit grant applications electronically, which has reduced costs to the applicant (e.g., copying, shipping, storage capacity). The proposed budgets in all HH grant applications are reviewed and scored with respect to reasonableness and the soundness of the accompanying budget justification under Rating Factor 3, "Soundness of Approach". The HH Demonstration Program NOFA emphasizes the use of cost-effective methods to recruit and conduct HH interventions in low income housing units, and applicants are directed to provide a projected "per unit" cost estimate in their applications (2). The HH Technical Studies Program focuses on the development of cost-effective assessment and remediation methods that would be feasible for use in low income housing (3). OMB circulars regarding competitive sourcing/cost comparisons are incorporated into legally binding grant agreements for HH Program grantees (4). Grantees have documented the efficacy of lower cost interventions in reducing the severity of asthma and the number of residential injury hazards. An important study by a HH grantee showed that interventions to reduce mold and moisture hazards in the homes of asthmatic children at an average cost of $3,458/home resulted in a reduction in asthma symptoms and hospital utilization (5). Another HH grantee reported a significant reduction in the number of children with severe asthma following implementation of "integrated pest management" measures at an average cost of $268/home (6). A third grantee reported significant reductions in injury hazards, pest infestation, dust-lead levels, and cockroach allergen levels five months following interventions with a median cost of $865/unit (7). As more results are received, the program will identify the most cost-effective assessment tools and interventions for use by grantees and the general public. The FY 2006 HH Demonstration Program NOFA has initiated the process of directing grant applicants towards residential interventions that have been shown to be effective (8). All HH program contracts are competitively awarded. The HH program uses indefinite quantity support contracts that were competitively awarded to small businesses. Individual task order contracts for specific projects are competed among two or more of the support contractors.

Evidence: (1) Healthy Homes Demonstration grant program and Healthy Homes Technical Studies grant program - Notices of Funding Availability (NOFA) are available at: http://www.hud.gov/library/bookshelf12/supernofa/nofa06/fundsavail.cfm (2) The discussion of program goals and objectives is found in sections I.B. and I.C. of the Demonstration Program NOFA (pages 11859 and 11860). The unit cost requirement is found in Section V.A.2.c(e)(iii) on page 11866 of the Federal Register notice (vol. 71, No. 45, March 8, 2006). (3) The description of the HH Technical Studies Program can be found in the FY 2006 NOFA (see Sections I.A and I.B, pages 11835 and 11836 of the Federal Register notice (vol. 71, No. 45, March 8, 2006. (4) An example of a HH program grant agreement demonstrating the incorporation of OMB circulars is available at: http://www.hud.gov/library/bookshelf12/supernofa/nofa06/fundsavail.cfm. (5) C.M. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives, EHP-in-Press, 2006doi:10.1289/ehp.8742 available via http://dx.doi.org/ (6) M. Sandel et al., 2006. Can integrated pest management impact urban children with asthma? Submitted for publication. (7) S. Klitzman et. Al., 2005. A multihazard, multistrategy approach to home remediation: results of a pilot study. Environmental Research, vol. 99, 294-306. (8) See the "Model for Implementation for Healthy Homes Remediations" for the FY 2006 HH Demonstration NOFA at: http://www.hud.gov/offices/adm/grants/nofa06/implementhhi.doc

Does the program collaborate and coordinate effectively with related programs?

Explanation: There are many examples of coordination between the Healthy Homes (HH) program and related programs in both the public and private sectors. The collaboration started when the OHHLHC convened a meeting of experts from many disciplines in 1999 to develop a strategic plan for the HH initiative. Meeting attendees included representatives from other federal agencies, academia, non-profit organizations, and state and local agencies (1). The program has entered into successful formal collaborations in which HH program funds supported activities in several federal agencies, including the U.S. Department of Agriculture (USDA), the U.S. Centers for Disease Control and Prevention (CDC), and the National Institute of Standards and Technology (NIST). Collaboration with the USDA supported HH activities among its Cooperative State Research, Education, and Extension Service (CSREES) grantees (2). This partnership resulted in the development of a popular consumer publication, Help Yourself to a Healthy Home, which was translated into Spanish and will be translated into Bosnian and Hmang in FY 2007 (3). This partnership also allowed HUD to coordinate with USDA's existing network of knowledgeable CSREES staff throughout the Nation. The CDC collaboration leveraged CDC's public health network and supported the development of a "Healthy Homes Reference Manual" and a National Healthy Homes Training Center to train housing and public health professionals in HH principles (4, 5). The HH program also collaborated with the National Institute of Environmental Health Sciences in a national housing survey which resulted in the first national estimates of the levels of important allergens (e.g. dust mite, cockroach, rodent) in dust from floors and bedding (6). Other federal agencies also receive regular updates on HH program activities through staff participation in quarterly meetings of the Interagency Committee for Indoor Air Quality. Since inception of the program, the agency has also held a tri-agency (HUD/EPA/CDC) grantee conference (Atlanta, GA; December, 2000) that provided a structured forum for HH grantees to exchange ideas and best practices, and a conference for HUD Lead Hazard Control and HH program grantees (Orlando, FL; June, 2004). HUD will partner with CDC to host a joint conference, that will include sessions on HH issues, in December, 2006 (agencies to be represented include USDA, CDC and EPA).

Evidence: (1) The Healthy Homes Initiative: A Preliminary Plan (Full Report), April, 1999, see: http://www.hud.gov/ offices/lead/reports/HHIFull.pdf (2) Information on the CREES Healthy Homes Initiative is available at: http://www.csrees.usda.gov/ProgView.cfm?prnum=5002 (3) The consumer publication, Help Yourself to a Healthy Home is available at: http://www.uwex.edu/healthyhome/resources.html (4) The Healthy Housing Reference Manual is available at: http://www.cdc.gov/nceh/publications/books/housing/housing.htm (5) Information on the Healthy Homes Training Center can be found at: http://www.healthyhomestraining.org/ (6) Results on residential allergen levels from the National Survey of Lead and Allergens in Housing have been published at: R. D. Cohn et al., National Prevalence and Exposure Risk for Cockroach Allergen in US Households, Environmental Health Perspectives, vol. 114, p. 522-526, April 2006. (doi:10.1289/ehp.8561 available via http://dx.doi.org/) S. J. Arbes et al., House dust mite allergen in US beds: Results from the first National Survey of Lead and Allergens in Housing, Journal of Allergy and Clinical Immunology, vol. 111, p. 408-414, 2003. R. D. Cohn et al., National prevalence and exposure risk for mouse allergen in US households, Journal of Allergy and Clinical Immunology, vol. 113, p. 1167-1171, 2004.

Does the program use strong financial management practices?

Explanation: The HH program establishes an annual procurement plan for each fiscal year that is consistent with the program's strategic goals and ties in with HUD's Strategic Plans (FY 2003-FY 2008 and FY 2006-FY 2011) and Annual Performance Plans. Managers and staff with fiduciary responsibility are required to complete appropriate training. The Office of Healthy Homes and Lead Hazard Control is committed to training, and where appropriate certifying, all staff responsible for committing funds and paying invoices. As part of grant negotiations, the Office reviews an applicant's most recent audit (or other adequate cost or pricing data) before the award is made (1). During grant implementation, a grantee's request for payment is submitted on a signed voucher (HUD-27053) and must be accompanied by supporting documentation, which is reviewed by the assigned Government Technical Representative (GTR) (2). If a grantee does not provide evidence that it is making significant progress in meeting its grant requirements, the GTR can withhold payment until such evidence is provided. Grantees also provide signed financial statements (HUD-269) on a quarterly basis and must provide a summary of expenditures by budget category in their web-based quarterly reports (3). The Office requested a review of one HH grantee by HUD's Office of Inspector General (OIG) for Audit to determine if this grantee administered its Healthy Homes grant in accordance with HUD requirements. The OIG conducted the audit and the Office accepted and is implementing the recommendations of the audit report. All financial management systems meet statutory requirements and are accurate and timely.

Evidence: (1) Handbook 2210.17, REV 2 "Discretionary Grant and Cooperative Agreement Policies and Procedures," par. 4-10 http://www.hudclips.org/sub_nonhud/cgi/hudclips.cgi (Handbooks | Administrative | Search | Document number | 2210.17 | chapter 4). (2) The Office of Healthy Homes and Lead Hazard Control, "Grants Management Desk Guide," Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (3) OHHLHC web-based Quarterly Progress Reporting System: http://pluto.ddlinc.com/qprs/qprsr1.nsf/

Has the program taken meaningful steps to address its management deficiencies?

Explanation: On an annual basis, the Office develops and implements a Management Plan that is reviewed and approved by HUD's Office of Departmental Operations and Coordination. No major deficiencies have been identified in program management; however, steps have been taken to address deficiencies when they are identified. Grant management was strengthened through the adoption of a web-based quarterly reporting system (QPRS) that was initially developed to manage HUD's larger Lead Hazard Control program grants (1). This has improved grant management through its emphasis on the identification and tracking of project benchmarks and milestones and the expenditure of grant funds. It has also provided a means for identifying any problems earlier in the life of a project so that corrective actions can be taken (2). The HUD Office of Inspector General (OIG) conducted a review of the Office's procedures for processing, scoring, and awarding grant applications in Fiscal Year 2004 (the only year in which grant application review was conducted by an outside contractor) (3). The Office adopted the OIG's grant review process recommendations resulting in process improvements such as the implementation of new quality control procedures (4).

Evidence: (1) OHHLHC web-based Quarterly Progress Reporting System http://www.hud.gov/offices/lead (2) The Office of Healthy Homes and Lead Hazard Control, Grants Management Desk Guide, Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (3) HUD Office of Inspector General. Final audit report.PH-2006-0001, "HUD Did Not Properly Award Fiscal Year 2004 Healthy Homes and Lead Hazard Control Grants" (4) Quality Assurance Protocol for the Office of Healthy Homes and Lead Hazard Control's Grant Application Reviews under its FY 2006 Notices of Funding Availability. This protocol will be updated as needed. The FY 2006 protocol is available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: Since its inception in FY 1999, the Healthy Homes Initiative (HHI) has awarded all of its grants and cooperative agreements through competitions. The competitions for the HH Demonstration and HH Technical Studies Grant Programs are announced annually as part of HUD's Super Notice of Funding Availability (SuperNOFA). The rating factors are clearly described in the two HHI NOFAs and are designed to ensure that funds are awarded to the strongest applicants based on merit criteria, such as qualifications of the applicant organization and personnel proposed to work on the grant, the organization's past experience, need/extent of the problem addressed in the application, soundness of approach of the proposed project, resource leveraging, and evaluation of project performance (1). Applications are reviewed by qualified and trained members of an Application Review Panel, using detailed scoring forms. Starting in FY 2005, additional quality assurance measures were added to the review process to ensure sufficient documentation of reviewers' scoring decisions and accuracy in the calculation of the individual scores (2). HH grant funds are available to a wide range of organizations, with state and local governments, Indian tribes, not-for-profit and for-profit organizations and academic institutions eligible for award. NOFA outreach includes annual internal and external satellite broadcasts that can be viewed over the Internet. Information on the grant programs is also distributed at conferences such as the annual conferences of the American Public Health Association and the American Industrial Hygiene Association.

Evidence: (1) The rating factors are described in section V.A of both FY 2006 Healthy Homes NOFAs. The FY 2006 NOFAs are available at: http://www.hud.gov/library/bookshelf12/supernofa/nofa06/fundsavail.cfm (2) To improve and standardize quality assurance procedures associated with the review and scoring of grant applications, the Office of Healthy Homes and Lead Hazard Control developed a quality assurance protocol to be followed by all programs within the Office. A description of the quality assurance protocol followed in FY 2006 is available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: All grantees are required to report on the progress of their grant activities on a quarterly basis using the Office of Healthy Homes and Lead Hazard Control's web-based Quarterly Progress Reporting System (QPRS) (1, 2). As mentioned in response to question 3.1, QPRS collects information on key benchmarks such as a summary of expenditures and number of: clients contacted, clients enrolled, individuals trained (by work discipline), dwellings assessed for hazards, housing interventions completed, and individuals reached through outreach and education efforts (2). Grantees are also required to develop a separate spreadsheet that identifies targets for key benchmarks and milestones for each calendar quarter. The HUD Government Technical Representative (GTR) evaluates each grantee's quarterly report against its benchmarks and provides the grantee a letter that identifies its color-coded performance category (green, yellow, red). Grantees that are on schedule are designated "green," those that are behind ("yellow" status) or significantly behind ("red" status) must take corrective actions to improve their performance, with individually tailored response plans and frequent GTR monitoring. GTRs also track grant expenditures and make payments through HUD's electronic Line of Credit Control System (LOCCS) (3, 4). GTRs review and approve grantees request for payment and may ask for copies of original invoices and records to support payment requests on a random and targeted basis (4). GTRs also perform an annual risk analysis of each grantee. The risk analysis provides a comprehensive performance profile that takes into consideration the grantee's performance as well as other risk factors such as the age of the grant, whether or not the grantee previously received on-site monitoring, total amount of funding expended, etc. The annual risk analysis determines a grantee's risk designation: low, medium or high risk. Only one of the 47 active HHI grants received a high risk designation in the Fiscal Year 2005 risk analysis process. The conclusion of the risk analysis process is the development of the Office's annual monitoring plan, with higher risk grantees being assigned a higher priority for on-site or remote monitoring. During on-site monitoring, the GTR and/or a HUD Government Technical Monitor travels to the grantee's location to review files, interview staff, and observe homes that have received interventions. In remote monitoring, the GTR conducts a thorough desk review of documentation provided by the grantees (3).

Evidence: (1) The Grant Agreement requires grantees to report on a quarterly basis by following 24 CFR 84.51(b) or 85.40(b)(1) (as applicable to non-governmental and governmental grantees, respectively), as implemented by OHHLHC Policy Guidance Issuance 2001-03 (http://www.hud.gov/ offices/lead/grantfrm/pgi/2001_03.pdf). (2) OHHLHC web-based Quarterly Progress Reporting System: http://pluto.ddlinc.com/qprs/qprsr1.nsf/ (3) The Office of Healthy Homes and Lead Hazard Control, "Grants Management Desk Guide," Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (4) HUD Line of Credit Control System: http://hudatwork.hud.gov/apps/po/f/loccs/index1.cfm

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: All grantees are required to report on the progress of their grant activities on a quarterly basis using a web-based Quarterly Progress Reporting System (QPRS) (1, 2). As mentioned in response to question 3.CO2, QPRS collects information on key benchmarks such as: summary of expenditures, number of clients contacted, clients enrolled, individuals trained, dwellings assessed for hazards, housing interventions completed, and the number of individuals reached through outreach and education efforts (2). The Office analyzes grantee performance data at the end of the fiscal year and the results are the major component of grantees' annual performance risk analyses (3). In Fiscal Year (FY) 2003, a summary progress report of all the Office's grantees was posted on its web site; the report indicated each grantee's progress status with respect to its original work plan. In FY 2004, the performance report was redesigned and made available on the Office's web site. The Office is now posting the results of quarterly progress reviews of all grantees on its web site (4).

Evidence: (1) The Grant Agreement requires grantees to report on a quarterly basis in accordance with 24 CFR 84.51(b) or 85.40(b)(1) (as applicable to non-governmental and governmental grantees, respectively), as implemented by OHHLHC Policy Guidance Issuance 2001-03 (http://www.hud.gov/ offices/lead/grantfrm/pgi/2001_03.pdf). (2) OHHLHC web-based Quarterly Progress Reporting System: http://pluto.ddlinc.com/qprs/qprsr1.nsf/ (3) The Office of Healthy Homes and Lead Hazard Control, Grants Management Desk Guide, Chapter 2, Grant Administration - Project Oversight, available at: http://www.hud.gov/offices/lead/hhi/hhiresources.cfm (4) The quarterly progress summary of Office of Healthy Homes and Lead Hazard Control grantees is reported on the Office's web site: www.hud.gov/offices/lead

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program has established long-term performance measures and has done some preliminary tracking of measures that are consistent with strategic goals for the Healthy Homes Initiative (HHI). For example, an estimated 1,759 units have received interventions for allergens (respiratory hazards) in FY 2006. In its early years, the performance measures for the HHI were annual output measures. Because the HHI was in its developmental stage, the initial performance measures focused on making the program operational by establishing projects through grants, contracts, and interagency agreements. In FY 2005 performance measures were changed to annual targets for the number of homes receiving interventions using HH principles (1). In each of these years through 2005, the HHI met its performance goals. In 2006, HUD issued its 2006-2011 Strategic Plan, which includes two long-term outcome performance measures for the HHI. These performance measures focus on childhood asthma; an illness that has increased at epidemic rates over the past several decades, has a strong housing link, and disproportionately affects poor, African American children (2). By 2011 HUD will reduce allergens in 5000 homes and consequently decrease asthmatic episodes in at least 3000 children (3). These new goals are ambitious, however, the Office is confident that they will be met. For example, results of a preliminary survey of HH grantees indicated that 66% of respondents were capturing environmental outputs and health outcomes consistent with the 2011 Strategic Goals There is a strong demand for HHI grant funding, with the number of applications received for the HH Technical Studies and the HH Demonstration grant programs greatly exceeding the available funds; with an average of only 15% of the applications receiving funding over the last three fiscal years (FY 2003 to FY 2005). With this strong demand and the Program's emphasis on cost effectiveness, the Office is expecting to see an increase in program efficiencies as grantees compete to develop more comprehensive and cost-effective ways to make homes safer and healthier. The Office's Lead Based Paint Hazard Control Grant Program has observed increasing efficiencies in the per unit costs of lead hazard control treatments, and starting in FY 2006 is requiring that applicants (except in high-cost areas) keep their average per unit costs to $8000 or less; the HHI is expected to evolve in a similar manner, and is expected to achieve lower per unit costs for hazard assessment and mitigation (4). Grantees have already reported that relatively low cost interventions (ranging from an average cost of $268/home - $3,458/home for various types of interventions) have been successful in significantly reducing dust-allergen concentrations, asthma morbidity in children, and the number of residential injury hazards (5).

Evidence: (1) See U.S. Department of Housing and Urban Development Performance and Accountability Reports for Fiscal Years 2002, 2003, 2004, and 2005 available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (2) Information on asthma epidemiology and the importance of environmental asthma triggers is available from the following locations: U.S. Environmental Protection Agency: Asthma and Indoor Environments http://epa.gov/asthma/about.html Centers for Disease Control and Prevention: Potentially Effective Interventions for Asthma, http://www.cdc.gov/asthma/interventions/background.htm (3) HUD Strategic Plan (Fiscal Years 2006 - 2011) is available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (4) The requirement on the average per unit cost of the lead hazard control treatments can be found in section V.A.3 of the FY 2006 Notice of Funding Availability for the Lead-Based Paint Hazard Control Grant Program, which is available at: http://www.hud.gov/library/bookshelf12/supernofa/nofa06/fundsavail.cfm (5) Average costs for successful HH interventions have been reported in the following peer-reviewed papers, two of which have been published: C.M. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives, EHP-in-Press, 2006doi: 10.1289/ehp.8742 available via http://dx.doi.org/ M. Sandel et al., Can integrated pest management impact urban children with asthma? 2006; Submitted for publication. S. Klitzman et al., A multihazard, multistrategy approach to home remediation: results of a pilot study. Environmental Research 2005; vol. 99, 294-306.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The program began tracking progress toward long- and short-term goals during FY 2006. While initial performance is promising, it is too early to give full credit for performance. The HHI has achieved its annual performance goals. As mentioned in response to question 4.1, during the program's start-up period, the annual goals (FY 2002, FY 2003, and FY 2004) were the awarding of specific number of grants, contracts and interagency agreements (cited here generally as procurement actions) to achieve the program's goals and objectives. By FY 2002, the HHI surpassed its cumulative goal of executing 21 procurement actions by having awarded a cumulative total of 35 actions. By FY 2003, the cumulative goal of 26 actions was exceeded by 15, and by FY 2004 the cumulative goal of 48 actions was exceeded by 4 (1). As the program matured, the performance measure was changed to the completion of interventions in a target number of homes using HH principles. In FY 2005, the annual measure for the HHI was changed to be housing-related, namely, the cumulative number of housing interventions completed using HH principles. By that year, a cumulative total of 4,476 unit-interventions had been completed using HH principles; 79% more than the goal of 2,500 unit-interventions using HH principles (2). The FY 2006 annual performance goal for the HHI was modified to track progress against the program's new long-term measures of reducing allergen levels in 5,000 homes. (3). The annual performance goal for FY 2006 is to achieve allergen reductions in 600 homes. The program has exceeded this goal, with allergen levels being reduced in an estimated 1,759 homes in FY 2006, based on data from the program's Quarterly Progress Reporting System. The estimated value of 1,759 units is based on quarterly reports from HH program grantees of the number of housing units that have received interventions for respiratory hazards for the first three quarters of 2006. This might slightly overestimate the number of units in which allergen levels have been reduced. A more specific reporting field for capturing this information is under development.

Evidence: (1) U.S. Department of Housing and Urban Development Performance and Accountability Reports for Fiscal Years 2002, 2003, and 2004 report on the Program's performance relative to the performance measure of cumulative number of procurement actions are available at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (2) U.S. Department of Housing and Urban Development Performance and Accountability Report for Fiscal Year 2005 reports the Program's performance relative to the performance measure of cumulative number of dwelling unit interventions completed using HH principles and is at: http://www.hud.gov/offices/cfo/reports/cforept.cfm (3) The long term performance measures for the HHI can be found in "HUD Strategic Plan (Fiscal Years 2006 - 2011),", which is available at: http://www.hud.gov/offices/cfo/reports/hud_strat_plan_2006-2011.pdf

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The program lacks an efficiency measure to show progress in achieving this goal. As noted in response to question 3.4, HUD will adopt an efficiency measure using cost data provided through an independent evaluation that will be completed in early 2007. The efficiency measure will represent an inflation-adjusted average intervention cost per dwelling that future grantees will be required to meet or improve upon. The program will be assessed annually against this efficiency measure. The Healthy Homes Initiative (HHI) focuses on the development and use of cost-effective methods for the assessment and control of housing-related health hazards. HH grant applications are reviewed and scored with respect to reasonableness and soundness of approach and the efficiency of the budget. The HH Demonstration Program emphasizes the use of cost-effective methods to recruit and conduct HH interventions in low income housing units and the HH Technical Studies Program focuses on the development of cost-effective assessment and remediation methods that would be feasible for use in low income housing (1). Grantees have documented the efficacy of lower cost interventions in achieving significant reductions in the severity of asthma, dust-allergen levels, and the number of residential injury hazards, with average costs ranging from $268/home to $3,458/home for various types of intervention (2). Over time, the Healthy Homes Initiative and its partners will improve and standardize how homes are assessed and treated for health and safety hazards using cost-effective protocols. The FY 2006 HH Demonstration Program NOFA has already initiated this process by directing grant applicants towards residential interventions that have been shown to be effective.

Evidence: (1) The discussion of program goals and objectives is found in sections I.B. and I.C. of the FY 2006 Healthy Homes Demonstration Program NOFA (71 FR 11859 and 11860, March 8, 2006). The requirement to provide estimates of per unit intervention costs is found in Section V.A.2.c(e)(iii) on page 11866. The description of the HH Technical Studies Program can be found in the FY 2006 NOFA (see Sections I.A and I.B, pages 11835 and 11836. The NOFAs are available at: HH Demonstration NOFA: http://www.hud.gov/offices/adm/grants/nofa06/hhdsec.pdf; and HH Technical Studies NOFA: http://www.hud.gov/offices/adm/grants/nofa06/ltssec.pdf (2) Average costs for successful HH interventions have been reported in the peer-reviewed papers, two of which have been published: C.M. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives, EHP-in-Press, 2006doi: 10.1289/ehp.8742 available via http://dx.doi.org/ M. Sandel et al., Can integrated pest management impact urban children with asthma? 2006; Submitted for publication. S. Klitzman et. Al., A multihazard, multistrategy approach to home remediation: results of a pilot study. Environmental Research 2005; vol. 99, 294-306.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: The program lacks a controlled study that proves the program is cost-effective or cost-beneficial in comparison to other approaches. There are reasons, however, to believe the program makes a unique contribution to health. Related federal programs focus on single issues (e.g., asthma, injury prevention, lead poisoning prevention) and generally take a considerably narrower approach, such as research or public education. The Centers for Disease Control and Prevention (CDC) is in the process of developing a Healthy Homes Program as a component of its broader "Designing and Building Healthy Places" initiative; however, this program has not yet been implemented (1). There are currently no state, local, or private programs that significantly duplicate the HHI program. Notably, scientific evaluations conducted by several HHI program grantees have demonstrated that interventions have significantly reduced asthma morbidity in children and/or reduced concentrations of allergens in house dust and the number of residential injury hazards (2).

Evidence: (1) Information on CDC's "Healthy Places" initiative is available at: http://www.cdc.gov/healthyplaces/. In February, 2006 the CDC held a workshop with representatives from public and private sector organizations to help establish goals for its Healthy Homes Program. HUD's HHI had a representative in attendance. The summary of this workshop is reported in: Centers for Disease Control and Prevention Coordinating Center for Environmental Health and Injury Prevention, Healthy Homes Goal Workshop, February 14-15, Executive Summary. (2) The effectiveness of pest management interventions was reported in the following paper: M. Sandel et al., 2006. Can integrated pest management impact urban children with asthma? Submitted for publication. Other research demonstrating the effectiveness of low cost interventions in reducing asthma morbidity include the following: C. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives, EHP-in-Press, April 2006; 2006doi: 10.1289/ehp.8742 available via http://dx.doi.org/ W.J. Morgan et al., Results of a home-based environmental intervention among urban children with asthma. New England Journal of Medicine 2004; 351: 1068-80. Reductions in allergen levels and the frequency of injury hazards was demonstrated in the following study: S. Klitzman et al., A multihazard, multistrategy approach to home remediation: results of a pilot study. Environmental Research 2005; vol. 99, 294-306.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: The program has not performed an independent evaluation. An ongoing independent evaluation, however, of the Healthy Homes Initiative (HHI) will be completed in January 2007. It is important to note, however, that high quality evaluations of some individual HHI-sponsored projects have been conducted, and have shown promising results. For example, two grantees that conducted research on the efficacy of low cost residential interventions in reducing asthma morbidity following intervention reported significant reductions in frequency and/or severity of the illness (1). The strongest of these studies was a randomized control trial that assessed the effectiveness of residential interventions focusing on mold and moisture problems, conditions that are commonly addressed by HH program partners. Other researchers have also reported significant improvements in the health of asthmatic children following low cost interventions to reduce exposures to allergens (e.g., cockroach, dust mite) and other asthma triggers (e.g., environmental tobacco smoke), and educate caregivers (2). These are similar to the low cost interventions being implemented by HHI grantees. HHI-funded researchers also reported significant reduction in dust-allergen levels, dust-lead levels, and injury hazards at five months following intervention (3). Other HH-sponsored research has resulted in important research findings with respect to national distributions of allergens in house dust, variability in the laboratory analysis of allergens in house dust, assessment of mold levels in housing with and without water damage, and recent trends in child and adolescent deaths due to residential injuries (4).

Evidence: (1) The effectiveness of mold and moisture interventions in reducing asthma morbidity is reported in the following peer-reviewed paper: C.M. Kercsmar et al., Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives, EHP-in-Press, 2006doi:10.1289/ehp.8742 available via http://dx.doi.org/. The effectiveness of pest management interventions was reported in the following paper: M. Sandel et al., Can integrated pest management impact urban children with asthma? 2006; Submitted for publication. (2) Other research demonstrating the effectiveness of low cost interventions in reducing asthma morbidity include the following: W.J. Morgan et al., Results of a home-based environmental intervention among urban children with asthma. The New England Journal of Medicine 2004; 351:1068-1080; J.W. Krieger et al., The Seattle-King County healthy homes project: A randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. American Journal of Public Health 2005; 95(4):652-9. (3) The effectiveness of HH interventions in reducing multiple environmental hazards is reported in the following peer-reviewed paper: S. Klitzman et al., 2005. A multihazard, multistrategy approach to home remediation: results of a pilot study. Environmental Research, vol. 99, 294-306. (4) Documentation of the national distribution of common residential allergens is reported in the following papers: R. D. Cohn et al., National Prevalence and Exposure Risk for Cockroach Allergen in US Households, Environmental Health Perspectives, vol. 114, p. 522-526, April 2006. (doi:10.1289/ehp.8561 available via http://dx.doi.org/) S. J. Arbes et al., 2003, House dust mite allergen in US beds: Results from the first National Survey of Lead and Allergens in Housing, Journal of Allergy and Clinical Immunology, vol. 111, p. 408-414. R. D. Cohn et al., 2004, National prevalence and exposure risk for mouse allergen in US households, Journal of Allergy and Clinical Immunology, vol. 113, p. 1167-1171. The HHI sponsored study of variability in the laboratory analysis of dust-allergen concentrations was reported in the following paper: A.D. Pate et al., 2005, Proficiency testing of allergen measurements in residential dust. J. of Allergy and Clinical Immunology, vol. 116(4): 844-50. HHI sponsored studies of mold assessment is reported in the following papers: E.W. Horner et al., 2004, Air- and dust-borne mycoflora in houses free of water damage and fungal growth. Applied and Environmental Microbiology, Vol. 70, p. 6394-6400. R.T. Niemeier et al., 2006, Assessment of fungal contamination in moldy homes; comparison of different methods, Journal of Occupational and Environmental Hygiene, vol. 3, p. 262-273. A HHI sponsored study of existing data (death certificate files) to assess trends in child and adolescent deaths from residential injury was published in the following paper: J. Nagaraja et al., 2005, Deaths from residential injuries in US children and adolescents, 1985-1997, Pediatrics, Vol. 116, p. 454-461.