page 157

7

Program Sustainability

Deciding What to Sustain

Tools for Sustainability

Funding Strategies

Strategies to Improve Organizational Capacity

Expanding Partnerships

System-level Sustainability—Public Policy 

Final Notes on Sustainability
page 158 Program Sustainability
page 159

P rogram sustainability has traditionally been viewed narrowly as the act of decreasing dependence on one source of funding and 

shifting financial support for program implementation to a new 

funding stream. In reality, program and organizational sustainability 

is a much more complex and dynamic process.

Program sustainability actually means different things 

depending on the developmental stage of your 

program. Newer programs may want to concentrate 

on sustaining their activities or infrastructure once 

initial funding ends. Experienced programs may 

want to enlarge their target population, transfer 

their best practices to other programs, build new 

relationships with other agencies, or promote broader 

policy initiatives. However, in either case—new 

or experienced—programs should work to better 

ensure sustainability by creating more efficient 

mechanisms for funding, such as the repurposing 

of existing resources through improved alignment, 

and coordination of complementary activities and 

resources. 

Planning for sustainability needs to begin long before 

the program faces the end of its initial funding cycle. 

For example, newer programs must focus on the need 

to collect data to demonstrate program effectiveness. 

Concerns about sustainability are important, however, 

because unsustained programs can result in a loss 

of investment. Discontinued programs are likely 

to disillusion stakeholders and result in barriers 

to community engagement for future initiatives.1

Program sustainability must be a fundamental 

component of the initial and ongoing program plans.

Achieving program sustainability requires time 

7

Key Messages

• Include a Sustainability Plan for the 

program in the initial work plan. 

• Sustainability can be supported by data 

that demonstrate program efficiencies 

and effectiveness; community advocacy; 

funding diversification; collaborative 

partnerships that can maximize resources; 

the capture of generated savings; and the 

attraction of new investments. 

• Healthy homes programs can be sustained 

by integrating and coordinating them 

with other health and housing programs 

and services such as code enforcement, 

weatherization, energy efficiency, and lead 

poisoning prevention.

• Policy-level change is key to institutionalizing programs for long-term sustainability 

• Not achieving sustainability may result 

in failure to achieve the “mission critical” 

goals in reducing the number of homes 

with residential health and safety hazards, 

thereby reducing the adverse health effects 

attributable to poor housing conditions.

Program Sustainability
page 160

and commitment. Ultimately, sustainability 

involves learning from experience (ongoing 

evaluation), making decisions about which 

elements of the program to sustain, selecting 

the right strategies, and using the right tools to 

build support for your program. The experience 

of prior healthy homes programs suggest that 

there are at least five general strategies that 

have been used to promote program growth 

and sustainability:

• Evaluation and continual quality improvement;

• Building and strengthening organizational 

capacity;

• Expanding partnerships;

• Identifying new funding streams and 

diversifying sources of funding; and

• Building a case for systems or policy change.

This chapter will illustrate how different programs 

have used these strategies and tools to build a 

climate of ongoing support for their activities.

Deciding What to Sustain

The first step in planning for sustainability is 

to assess whether continuation of a service, 

program or organization is warranted. If you 

want to assure that the program continues when 

grant funding ends, political leadership changes, 

or you experience turnover in human resources, 

you need to plan for it to become a permanent 

part of your organization or community. To do 

this you must institutionalize your initiative by 

purposely planning for its sustainability.2

Tools for Sustainability

The next step is to determine what resources 

are available to build a climate of support 

for your program. The U.S. Environmental 

Protection Agency’s National Asthma Forum has 

produced a document titled A Systems-Based 

Approach for Creating and Sustaining Effective 

Community-Based Asthma Programs—Snapshot 

of High-Performing Asthma Management 

Programs (https://www.epaasthmaforum.com/

Documents/Resources2008/Forum_Snapshot.

pdf).3 This document highlights key factors 

to consider, and provides examples of how 

programs have sustained their systems of high 

quality asthma care in their communities.

Common tools include:

• Strategic planning by program leadership. 

Programs or organizations with leadership 

that has assessed program strengths and 

weaknesses, opportunities, and threats are 

in better position to survive challenges to 

funding and expand program scope. 

• Open communication. Information flow within 

a program, among partners, and with the 

community as a whole is essential. Programs 

that are flexible and communicate regularly 

with their stakeholders are in a better position 

to identify new opportunities for funding or 

new arenas in which to apply best practices.

• Persuasive program data. Qualitative and 

quantitative data must be presented in a way that 

interested parties can understand and embrace 

promotes support. 

• Active support by community advocates. Advocacy 

organizations, especially those having contacts 

with the media and political stakeholders, can often 

make the case for program needs and impact in 

ways that program officials cannot.

• Engagement of elected and appointed 

officials. Program champions in the wider 

political arena are important to promoting 

funding and organizational infrastructure, 

as well as critical to creating broader policy 

Figure 7.1 To Sustain or Not to 

Sustain?

• Does the community need your healthy 

homes program and/or services?

• Do your evaluation results demonstrate 

that you are making a difference?

• Does the community value the program 

and its services?

• Do you need to sustain the entire program?

• What parts of the program are the most 

effective and needed?

• Can you coordinate funding from multiple 

sources to sustain your program?

Emily Gantz McKay of Mosaica—The Center for 

Non¬profit Development and Pluralism. Nonprofit 

Organization Sustainability. November 2006. 

http://www.mosaica.org/Home.aspx

Program Sustainability
page 161

change.

• Media involvement. While programs may 

want to control their message by limiting 

media contact, the reality is that an invisible 

program is not a viable program. Judicious, 

sustained, and positive media engagement is 

optimal.

How these tools and approaches support 

program sustainability is demonstrated in the 

following examples from the field:

Funding Strategies

Policymakers and practitioners recommend that 

healthy homes programs secure support from 

multiple funding streams. Diversified funding is 

a cornerstone to achieving sustainability. This 

can include grant funding from government 

programs and private sources (e.g., foundations) 

and tax levy funding. Support can also be 

achieved by leveraging resources through 

partnerships, such as sharing costs for services 

with other agencies, assessing fees for services, 

and mainstreaming healthy homes activities with 

existing initiatives.

Governmental grants. Federal grants often 

provide seed money for healthy homes 

programs, but they also require programs to 

demonstrate their ability to sustain activities 

via matching or leveraged funding from public 

or private sources. Appendix 7.1 provides an 

overview of federal funding for healthy homes 

and related categorical programs. The Delta 

Institute’s publication Creative Funding Strategies 

for Remediation of Lead and Other Healthy 

Housing Hazards: A Guide for Increasing PrivateSector Financing is targeted both to lenders—

explaining how they can benefit from financing 

healthy homes programs—and government and 

non-governmental organizations, delineating 

Figure 7.2 Examples from the 

Field: Leveraging Public and Private 

Sector Funding in Philadelphia

Philadelphia Healthy Homes for Child Care 

leveraged HUD Healthy Homes grant funding with 

contributions from the YMCA to furnish relocation 

units, and $150,000 from the Nonprofit Finance 

Fund to cover additional safety-related repairs to 

28 homes that house family child care programs.

Figure 7.3 Example from the Field: 

Annie E. Casey Foundation (AECF) 

and the Coalition to End Childhood 

Lead Poisoning.

The Annie E. Casey Foundation, the nation’s 

largest Foundation focused on children, 

recognized the nexus between its core mission 

of helping build better futures for disadvantaged 

children and the successful work being done by 

the Coalition to End Childhood Lead Poisoning 

in Baltimore’s most distressed neighborhoods. 

The case for investment from Casey’s educational 

outcomes portfolio began around the dramatic 

results the Coalition was achieving in reducing 

lead poisoning and creating critical policies 

and legislation to further advance this work. 

Casey’s investment was sustained through the 

Coalition’s performance in achieving outcomes, 

building capacity, and translating lessons learned 

into effective public policy. Most recently, the 

Foundation provided critical support for the 

Coalition’s development of the national Green 

and Healthy Homes Initiative. In turn, the Coalition 

has been able to leverage Casey’s support as 

match funding to attract federal, state and local 

grants and additional investment from many other 

national, regional and community foundations.

Program Sustainability

how they can provide incentives and reform 

existing subsidy programs. http://deltainstitute.org/sites/default/files/1-DeltaREDI_

CreativeFundingStrategiesForRemediationOfLead.

pdf.

4

Private sector foundation funding. In an era of limited 

funding, many local government agencies have 

received funding from philanthropic organizations to 

advance healthy housing goals. Pursuing foundation 

funding is one way to leverage local funding and 

diversify your funding streams. It should not be 

assumed that private foundations prohibit grants to 

local government agencies. Agencies may be able 

to apply individually or in partnership with local or 

national nonprofit organizations. The Foundation 

Center (http://foundationcenter.org/) maintains 

a searchable listing of foundations and training 

resources, as well as newsletters, webinars, and 

other tools that can help with the identification and 

development of foundation proposals. Additional 

sources of philanthropic support can come from 

family and community foundations, local grantmaking cooperatives (e.g., “Giving Circles”), and 

through other local civic organizations. Other 
page 162

potential funding sources include corporate 

foundations or corporate charitable investment 

committees. In addition, regional, state and local 

funder affinity groups offer helpful fundraising 

resources including grant-writing workshops and 

regular announcements of proposal deadlines.

Here are some simple tips on planning for 

foundation funding:

1. Identify your needs. Develop a clear 

understanding of what you can accomplish 

with funding. Donors want to fund areas of 

programs that will have the most impact in 

fulfilling your mission. It is important to have 

estimated costs and be able to show how the 

request fits your strategic plan.

2.Analyze your audience. A case statement 

reflects and addresses the funder’s giving 

priorities, geographic focus and other 

guidelines. As such, case statements need to 

be fine-tuned for each foundation.

3.Compile story components. Story components can 

include your program’s history, leadership, data 

related to need and impact, areas of excellence and 

innovation, summary of your strategic plan, and 

basic budget information.

4.Write it. State the problem, describe your 

solution(s), explain why you are the best program 

or organization with the best people to implement 

it, and demonstrate why the need is urgent. Simply 

stated, be clear about what you are requesting 

funding for and why the foundation needs to 

support your efforts.

5.Shape it. Remember that your case statement 

will change over time and should be tailored 

for each foundation in relationship to its 

funding goals.5

Recovering Program Costs through Reimbursement.

Some services essential to healthy homes programs, 

such as inspection and case management, are 

eligible for reimbursement. Costs of environmental 

investigations and case management home visits 

to the homes of children with elevated blood lead 

levels have been reimbursed by Medicaid since the 

last decade. Since each state must document and 

negotiate rates of reimbursement, however, rates 

vary widely. Hospitals and health insurance programs 

are also beginning to reimburse for home visiting 

programs or case management for asthma control 

based on the impact of these services in reducing 

medical costs.

Dedicated Revenue Sources. Dedicated 

sources of funding and incentives to comply 

with housing standards can fulfill an important 

role in sustaining healthy homes efforts. 

Some municipalities have secured funding for 

lead hazard control from dedicated taxes on 

paint and gas and dedicated fees from annual 

inspectional and certification requirements. In 

Maine, the Lead Poisoning Prevention Fund was 

established and is funded by a 25 cents-pergallon fee on all paint sold in the state. The fund 

is used for education, outreach, and training to 

identify and reduce lead paint hazards. Other 

approaches are highlighted in Figure 7.5.

Strategies to Improve 

Organizational Capacity

One way to build sustainability is to strengthen 

organizational capacity. Community Wealth Ventures, 

Inc. (http://www.communitywealth.com) pinpoints 

the characteristics important to organizational 

capacity. (See Figure 7.6.) 

In some cases, sustainability occurs when services or 

interventions become routine within an organization, 

such as when a pilot or demonstration project 

becomes part of an agency’s or a department’s 

standard services.6 Pilot and demonstration projects 

should be encouraged so that programs continually 

strive for greater effectiveness and cost efficiency. 

However, these innovations need to be evaluated to 

determine if the activity or intervention is effective 

and identify which elements need to be improved. 

Program Sustainability

Figure 7.4 Example from the 

Field: Children’s Mercy Hospital’s 

Environmental Health Program 

Negotiates Costs through Hospital 

Services

The Environmental Health Program of 

Children’s Mercy Hospital charged fees for home 

assessments of asthma environmental triggers. 

The program tried to obtain Medicaid and health 

insurance reimbursement for the services, but was 

not successful. However, because the program 

was offered through a hospital, it could negotiate 

fees in the interest of supporting the hospital’s 

mission to provide services regardless of the 

ability to pay.
page 163

Figure 7.5 Examples from the 

Field: Rental Property Fees, 

Dedicated Uses of Sales Tax 

Revenues, or Liability Protection in 

New Jersey and Maryland

In 1996, the State of Maryland adopted critical 

legislation to sustain lead safe housing. The 

“Reduction of Lead Risk in Housing” law requires 

owners of rental properties built before 1950 to 

register their units with the State’s Department of 

the Environment, distribute specific educational 

materials, meet specific lead paint risk reduction 

standards, and pass a lead dust clearance test 

prior to sale or lease of older rental units. Owners 

in compliance with this law are eligible for limited 

liability protection. Owners of rental units built 

between 1950 through 1978 may voluntarily opt–

in to receive these protections. The net result 

of these laws has been a 98% reduction in lead 

poisoning cases from 1993 to 2010. http://mde.

maryland.gov/Land/Documents/LeadFactSheets 

LeadfsOwnersRightsResponsibilities.pdf.

In 2004, New Jersey adopted the Lead Hazard 

Control Assistance Act that expanded funding 

available to landlords and property owners to 

support lead hazard control activities. A $20 fee 

was added to all properties covered under the 

State’s Hotel and Multiple Dwelling Law, with 

the revenues forming the basis for Lead Hazard 

Control Assistance Fund administered by the 

Department of Community Affairs. In addition, a 

percentage of the State’s sales tax collected on 

the sale of paint (up to $7,000,000 or 50 cents 

per container) was allocated to the Fund. Finally, 

all multi-unit buildings with three or more units 

inspected by the Department of Community 

Affairs as a part of its five year inspection cycle 

for the Hotel and Multiple Dwelling Law are 

required to be assessed for lead hazards. http://

www.njcitizenaction.org/lead.html.

Figure 7.6 Characteristics of 

Sustainable Organizations 

• Strong Leadership: Solid and visionary 

leadership exists at all levels of the organization 

or program (management, staff and 

community). 

• Community Engagement: Awareness and 

buy-in from the community are present. The 

organization and its partnerships are perceived 

as credible. 

• Relevance: The program or organization meets 

the community’s needs.

• Adaptability & Agility: The program or 

organization has the ability to anticipate and 

respond productively to the changing external 

environment.

• Efficiency and Effectiveness: The program 

or organization has demonstrated its ability to 

make an impact and achieve positive outcomes 

in a cost-effective way.

• Robust Infrastructure: There are established 

internal practices (business model) that are 

effective in guiding the organization’s or 

program’s work.

• Financial Health: The program or organization 

has a strategic funding plan that includes 

diversified funding sources, multi-year funding 

and internal revenue generation.

Experimentation implies that not every program or 

intervention is worth continuing. Thus, sustainability is 

based on efficacy.7

An important aspect of organizational capacity 

is to ensure there is a staffing succession or 

continuity plan to address turnover at the staff and 

management level. This can be achieved through 

cross training, mentoring and prioritizing workforce 

development issues. Programs can also be sustained 

by mainstreaming healthy homes practices into other 

programs such as those addressing lead poisoning 

prevention, housing rehabilitation, energy efficiency, 

and property maintenance.

Creating Healthy Housing by Expanding 

Lead Programs. It is common for healthy 

homes programs to refer homes or families 

to local childhood lead poisoning prevention 

or lead hazard control programs, or include 

the identification and remediation of leadbased paint hazards as part of their services. 

The reverse is true: lead programs themselves 

can also transition into more comprehensive 

healthy homes programs by expanding the 

scope of their assessment and interventions. 

While program activities supported by specific 

funding sources must be accounted for, healthy 

homes interventions related to moisture control, 

pest management, and home safety can be 

integrated into lead poisoning prevention 

program services. Transitioning a lead program 

into a broad healthy homes program requires:

Program Sustainability
page 164

• Pilot testing of new program service systems 

and supporting documentation;

• Additional staff training;

• Expanded assessment/inspection protocols;

• Revised case management procedures and 

family education modules; and 

• Additional contractors or contractor training 

to conduct healthy homes interventions.

Creating Healthier Housing through Building 

Codes. Housing codes, when enforced, provide 

the strongest and most direct legal tool for 

preventing and remediating indoor health 

hazards. Historically, housing codes were 

developed to address public health concerns 

of overcrowding, sanitation, and fresh air and 

water. As these measures were successful in 

controlling the spread of disease, the public 

health community became less involved over 

time in the health and safety of housing. The 

resulting separation of public health from 

housing and building codes has resulted 

in a fragmented approach to remediating 

housing-based health hazards. For lead and 

healthy homes programs, housing and building 

codes offer an opportunity to use an existing 

infrastructure—laws, staff, inspection and 

enforcement systems—to improve the health 

and safety of high risk homes.8 Appendix 

7.2 highlights and compares healthy homes 

regulations at the local, state and national level.

Integrating Energy Efficiency and Healthy 

Housing. Energy efficiency efforts can improve 

the health and safety of the living environment 

by reducing contaminants, improving ventilation, 

reducing moisture and condensation, increasing 

safety, and improving thermal comfort.9 The 

U.S. Department of Energy’s weatherization 

assistance programs are natural partners for 

healthy homes initiatives, but careful planning 

is needed to address their priorities and cost 

constraints, which may differ from those of 

health or other housing program partners (see: 

http://www.nchh.org/Policy/National-Safeand-Heatlhy-Housing-Coalition/Policy-Summit.

aspx). It is important for energy retrofit or 

upgrade programs to consider incorporating 

the following health and safety activities and 

interventions:

• Installation of smoke and carbon monoxide 

alarms;

• Repair of interior and exterior water leaks and 

elimination of standing water;

• Assurance of adequate ventilation for vented 

combustion appliances;

• Elimination of un-vented combustion 

appliances;

Program Sustainability

Figure 7.7 Example from the Field: 

Transitioning Lead Programs in 

Baltimore into a Public-Private 

Partnership for Healthy and 

Sustainable Homes.

Recognizing the benefits of strong cross sector 

collaboration, the City of Baltimore has transitioned 

its program from a stand-alone lead poisoning 

prevention program in the health department to a 

public-private partnership on Healthy Homes. The 

City began to implement a health-based housing 

intervention standard for it weatherization, energy 

efficiency, home repair and home rehabilitation 

programs and to align those programs with its 

lead and asthma intervention work. Recognizing 

the cost effectiveness and program efficiencies 

of implementing a comprehensive strategy of 

aligning and coordinating these programs, the 

City created the Green, Healthy and Sustainable 

Housing program in the Department of Housing 

and Community Development. This program works 

closely to align its resources with that of key Healthy 

Homes programs at the Coalition to End Childhood 

Lead Poisoning (through its Green and Healthy 

Homes Initiative) Civic Works, Rebuilding Together 

and the Job Opportunities Task Force, as well as 

local philanthropic partners in order to deliver more 

sustainable healthy homes that reduce asthma 

morbidity, lead poisoning, and trip and fall injuries.

Key benefits of this transition included:

1. The development of a Learning Network for 

shared data and best practices;

2. Cross training of all home visiting programs 

(code enforcement, visiting nurses, foster care, 

fire safety, non-profit programs) in the use of 

a comprehensive assessment for home based 

environmental health and safety hazards;

3. Realignment of programs under one departmental entity to create a more efficient and 

comprehensive housing intervention program; and 

4. Establishment of an effective post-remediation 

maintenance program.
page 165

Figure 7.8 Example from the 

Field: Using Housing Codes and 

Partnerships in Boston

The Boston Department of Inspectional Services, 

Housing Inspection Division, has trained all of 

their city-funded inspectors to conduct healthy 

homes assessments and enforce housing code 

violations in the homes of children with asthma. 

The ability to use existing human resources and 

routine inspection and enforcement systems 

(e.g., State Sanitary Code for Housing) was the 

result of meaningful community partnerships, 

an internal champion within the Department of 

Inspection Services, collaborative planning and 

piloting, media coverage, and political buy-in. This 

system capitalized and integrated core functions 

of two city agencies—the Boston Public Health 

Commission who is responsible for program 

management, outreach to health care institutions, 

communication efforts and program evaluation, 

and the Boston Inspectional Services Department, 

that is responsible for inspections in response 

to referrals received from clinicians, health 

care providers and insurers, issuing correction 

orders, conducting reinspections and enforcing 

compliance through housing court if needed. The 

result of this collaboration: the Breathe Easy at 

Home program.

• Exhausting kitchen and bath fans and clothes 

dryers to the outside;

• Using lead-safe practices in older homes and 

lead dust cleaning and clearance testing upon 

completion;

• Installing a working air conditioner in at least 

one room of hot climate homes; 

• Conduct radon testing following intervention; 

and,

• Sealing all leaks in ductwork.10

Linking Property Maintenance and Healthy 

Housing. Property owners, managers, and 

residents can promote healthy housing through 

routine property maintenance. Enterprise 

Community Partners (ECP) recently released 

a comprehensive set of educational cards and 

training modules to empower residents to 

maintain their green building. (See http://www.

greencommunitiesonline.org/tools/toolkits/

resident_training.asp.) Property managers 

and resident coordinators can customize 

the Resident Education Cards to provide 

green tips and information specific to their 

development. The Resident “Training in a Box” 

contains educational modules for trainers that 

cover a variety of green and healthy living 

practices. Additionally, ECP continues to offer a 

Sustainability Training Grant to support project 

teams to develop and deliver customized 

educational materials and trainings for residents.

Similarly, Greater Boston’s Local Initiative 

Support Corporation (LISC) is in the process 

of finalizing a document that can be used by 

community development corporations, owners, 

and managers of affordable housing. The 

policies represent a sample of green and healthy 

practices that LISC found to be practical in two 

Boston community development corporations 

and their management companies, as well as 

ways to resolve questions about responsibility 

for implementing the policies. This document 

will be published on the Boston LISC website in 

2011 (http://www.bostonlisc.org/).

Expanding Partnerships

Figure 7.9 Example from the Field: 

Integrating Healthy Housing and 

Energy Efficiency in Bellingham, 

Washington 

The Opportunity Council of Bellingham 

Washington’s Healthy Homes grant focused on:

• Reducing asthma triggers for low-income 

children;

• Leveraging existing technical expertise of the 

weatherization program with Healthy Homes 

funding; and 

• Integrating services within a community action 

agency.

By using the capacity of its weatherization and 

community outreach services, the program 

recorded an average cost of $5,620 per unit 

for a package of services that included a home 

assessment, resident education, pollution 

mitigation, ventilation, floor coverings, supplies 

and evaluation activities. Based on the effort’s 

success, the Opportunity Council partnered with 

policy professionals to develop a Weatherization 

Plus Health curriculum and protocol for use by 

other programs interested in replicating this 

model. See: http://www.afhh.org/dah/dah_wx_

docs/WXPlusHealthDescription.pdf.

Program Sustainability
page 166

Significant evidence documents that coalitions 

and partnerships are an effective means of 

leveraging resources and wielding influence 

in the pursuit of improved community health. 

Based on these findings, the Robert Wood 

Johnson Foundation established the Allies 

Against Asthma initiative (Allies) in 2000 by 

funding seven community-based coalitions 

nationwide to develop, implement, and sustain 

comprehensive asthma management programs 

aimed at effecting long-term community change 

(http://www.asthma.umich.edu). Similarly, 

the U.S. Environmental Protection Agency’s 

Community Action for a Renewed Environment 

(CARE) program is committed to creating 

self-sustaining, community-based partnerships 

that continue to improve the local environment 

after EPA funding ends. The CARE program has 

produced a Sustainability Checklist that can 

be found at http://www.epa.gov/care/library/

CARE_Sustainability_Checklist.pdf.

Success for a coalition or partnership means, 

in part, establishing the kind of relationships 

that lead to mutual benefits, and produces 

results beyond the level that organizations 

or individuals could realize on their own.11

Partnerships support sustainability through:

• Comprehensive and coordinated efforts;

• Joint funding and larger grants;

• Decreased competition for funding;

• Reduced duplication of effort;

• Efficient fundraising efforts; and

• Increased access to and credibility with 

elected officials and policy makers.12

System-level Sustainability—

Public Policy

Some programs are institutionalized at a higher 

level through legislation requiring standardized 

services. Public policy is an important component 

of organizational sustainability as it affirms and 

institutionalizes specific activities by mandating 

them as a part of a government agency’s core 

mission. In the case of healthy homes, public 

policies generally cover housing or building codes, 

ordinances, or rules on inspection and remediation 

of housing-based health hazards. Some experts 

argue that programs must be supported at the 

policy level for true sustainability to be realized.13

Program Sustainability

Figure 7.10 Examples from the 

Field: Expanding Partnerships in 

Baltimore and South Central Los 

Angeles

Los Angeles’ Esperanza Community Housing Corp. 

collaborated with St. John’s Well Child and Family 

Center and Strategic Actions for a Just Economy 

(SAJE) to develop a coordinated approach to 

referrals, home visiting programs and tenant 

education. Physicians at St. Johns’ seven centers 

completed a “Medical Evidence Form” that noted 

any environmentally-driven conditions in children 

seen at clinical visits (including elevated blood 

lead levels, vermin bites, etc.) The completed form 

triggered a visit from an Esperanza promotoras de 

salud who provided client education on the risks 

of lead poisoning and other environmental health 

threats. Promotoras also conducted lead dust 

sampling, assessed mold and moisture, monitored 

cockroach infestation and provided cleaning kits 

and IPM supplies. The community health worker’s 

report to the physician after the visit then resulted in 

letters from the physician to the landlord about the 

relationship between housing conditions observed 

and the child’s health condition. In order to limit the 

threat of evictions, the physicians sent these letters 

only in cases where there was a positive relationship 

between the tenant and the rental property owner. 

SAJE conducted workshops in the community on 

tenants’ rights and worked with the city attorney 

to ensure owner compliance. Esperanza and SAJE 

were founding members of the Healthy Homes 

Collaborative that is an association of communitybased organizations committed to eliminating 

environmental threats in homes. The Healthy 

Homes Collaborative also provides leadership 

for negotiating with the City of Los Angeles for 

stronger code enforcement. The Collaborative 

sponsored the first South Los Angeles Conference 

on Health and Human Rights in 2009, attended by 

700 individuals.

Creating Healthy Housing through Public 

Policy. State and local building codes that 

address health and safety issues are often the 

only mechanisms to address high-risk housing.14 

Codes, however, do not guarantee safe and 

healthy housing. Because of limited resources, 

many local code enforcement agencies rely on 

complaints to trigger an inspection and tenants 

may be reluctant to file a complaint due to fear 

of retaliation. As a result, mandated systematic 

inspections are recommended for rental housing 

located in areas considered to be high risk.15
page 167

Figure 7.11 Examples from the 

Field: Coordinated Policy Initiatives 

in Oregon and Maryland

The City of Portland provided leadership for 

a city-appointed task force that developed 

recommendations for code enforcement related 

to its healthy homes efforts.

The City of Gresham established a systematic 

inspection program that mandated inspection of 

rental housing units selected through a sampling 

process. The program includes a complaint-driven 

component. Violations found in one unit of multifamily housing triggers inspections of adjacent 

housing units.

Multnomah County, Oregon passed a resolution 

and ordinance related to improving rental housing 

conditions in the unincorporated areas of the 

county. This legislative infrastructure provides 

renters with a mechanism to improve substandard 

housing.

The State of Oregon worked to make health and 

housing a priority through improved property 

maintenance regulations, and passed legislation 

supporting managed care reimbursement for 

services for chronic respiratory disease. 

A City of Baltimore ordinance requires all owneroccupied and rental units with gas appliances 

to have carbon monoxide monitors on all floors. 

Enforcement began March 2010.

Healthy homes programs can create or take 

advantage of existing public policies at the 

local, state, and federal levels that require the 

inspection and remediation of housing hazards 

to advance health outcomes. (See Figure 7.11)

Marketing Healthy Housing in Public and 

Private Housing. Smoke-free housing policies 

illustrate the use of the marketplace to drive 

demand for healthy homes principles.

Building National Coalitions to Support Policy 

Change. Building momentum for long-term 

policy change can require coordinated activity 

among multiple partners. Funders such as the 

Robert Wood Johnson Foundation, California 

Endowment, Blue Cross Blue Shield Foundation 

of Minnesota, and others convene policy forums 

on healthy housing-related issues to promote 

discussion of policy initiatives.

Figure 7.12. Federal, State, Local, 

and Private Examples of Smoke-Free 

Housing Initiatives

In 2009, HUD issued PIH-2009-21 (HA) that 

encouraged public housing authorities to 

implement smoke free policies in public housing 

(see: http://www.hud.gov/offices/pih/publications/

notices/09/pih2009-21.pdf). The federal Americans 

with Disabilities Act also provides for smokefree workplaces and public accommodations for 

individuals with substantial physical impairments 

that limit major life activities, including breathing.

California’s Smokefree Workplace Act prohibits 

exposure to smoke in common areas of multifamily 

properties. New York City has similar prohibitions. 

Registries of NYC smoke-free properties are 

available at http://www.smokefreehousingny.

rentlinx.com/Map.aspx. Registries in Michigan are 

available at http://www.mismokefreeapartment.

org/listing.html. Maine has at least 13 smokeor tobacco-free public housing authorities. 

MaineHousing also awards a one point incentive 

for smoke-free to developers of affordable housing 

who apply for Low Income Tax credits (see http://

www.smokefreeforme.org).

For a private sector perspective, Enterprise 

Community Partners provides extra points in 

allocation of Low Income Tax Credits. via their 

Green Communities criteria that include smokefree housing. http://www.greencommunitiesonline.

org/tools/criteria/index.asp

Incorporating Healthy Housing as a Principle of 

Sustainability. Many communities have begun to 

establish commissions to link land use, transportation, 

and other public service planning to resource 

conservation and sustainable development. An 

often overlooked issue in sustainability discussions 

is how public health can be affected by issues such 

as urban sprawl, absence of sidewalks, walkable 

communities, and the location of jobs in areas with 

limited access to public transportation. Incorporation 

of healthy housing principles into sustainable 

growth discussions represents an important way to 

raise awareness of and strengthen healthy homes 

efforts. HUD’s Office of Sustainable Housing and 

Communities can serve as a resource for the creation 

of sustainable communities. http://portal.hud.gov/

hudportal/HUD?src=/program_offices/sustainable_

housing_communities.

Program Sustainability
page 168

Final Notes on 

Sustainability16

Planning. Continuation of programs doesn’t 

happen by itself. Sustainability should be 

planned for with intention and, ideally, 

incorporated into the initial program plan.

Funding Diversification. Programs usually begin 

with one funding source and diversify over 

time to enlarge their program or add service 

components. Sustainable organizations are not 

dependent on any single funding source but 

obtain resources from a variety of avenues. 

Funding usually includes both multi- and singleyear grants and contracts that overlap.

Program Qualities. Sustainable programs are 

characterized by their effectiveness, ability 

to demonstrate positive results, inspired and 

committed leadership, strong financial and 

program management policies and procedures, 

and an established constituency of individuals 

and organizations that value their services.

Community Support for Programs. Community 

support can only be authentically harnessed if 

residents and community-based organizations 

are treated as full partners. Programs should not 

postpone reaching out to community groups 

to a time when community support is needed. 

Partnerships with the community should be 

fostered from the beginning; they are central 

to program planning and design. Constituent 

support is a key component of advocacy for 

programs and services, and can be influential in 

securing political will.

Supporting Non-profit Organizations. If a 

public health or housing program wants to 

nurture community involvement in program 

planning, outreach, service delivery, evaluation 

and/or advocacy, it should have a reasonable 

expectation of what nonprofit organizations 

can do with and without funding. It is important 

to support the work of community-based 

organizations that are also challenged by 

sustainability issues.

External Environment. Paying attention to the 

economic, political, and social issues prepares 

programs for emerging challenges. Programs 

and organizations need to be adaptable to 

changing conditions—ready to meet possible 

threats as well as capitalize on opportunities as 

they arise.

Achieving Sustainability. Attaining and 

maintaining sustainability is an ongoing process 

that begins with an active commitment to 

delivering effective programs and sound 

management.

Program Sustainability

Figure 7.13 Example from the 

Field: National Safe and Healthy 

Housing Coalition

The National Safe and Healthy Housing 

Coalition is a broad coalition of organizations 

working to improve housing conditions 

nationwide, especially for low-income families, 

through education and outreach to key national 

stakeholders and federal public decisionmakers. The Coalition is guided by a 15-member 

Steering Committee representing green building 

design, public health, health care financing, 

low-income housing development, realtors, 

building inspectors, and children’s health and 

safety organizations. Priorities include national 

partnership building, federal legislation and 

federal regulations and administrative policies. 

See http://www.nchh.org/Policy/National-Safeand-Healthy-Housing-Coalition.aspx.
page 169

Figure 7.14 Example from the Field: 

Incorporating Healthy Housing 

as a Principle of Sustainability in 

Baltimore

Baltimore’s 2009 Sustainability Plan has been 

incorporated into the city’s comprehensive 

master plan. The Sustainability Plan highlights 

seven priority areas: (1) cleanliness, (2) pollu-

tion prevention, (3) resource conservation, (4) 

“greening” of the city’s physical space and 

food supply, (5) transportation, (6) environ-

mental awareness, and (7) promoting a green 

economy. Each focus area has multiple goals, 

each with a set of strategies for sustainability, 

timelines for implementation, and recommen-

dations that agencies should take in promot-

ing specific priority areas. The priority areas 

and strategies were developed over a twoyear process through multiple meetings with 

governmental and private sector leaders and 

broad-based community engagement of over 

1000 members of the public. 

Healthy homes strategies incorporated into 

the plan include: • Improving enforcement of the current 

sanitation code;

• Improving the energy efficiency of existing 

homes and buildings;

• Mandating efficiency upgrades to homes at 

the point of sale;

• Using green cleaning products in schools, 

government offices, and businesses;

• Improving the health of indoor environments; • Exploring the feasibility of making all 

Baltimore multi-family dwellings smoke-free;

• Increasing and coordinating all healthy 

housing efforts;

• Ensuring coordination among weatherization, 

lead remediation, and healthy homes 

activities;

• Adopting a policy and plan for elimination of 

pesticide use and other toxic chemicals; and

• Creating green jobs and preparing city 

residents for these jobs.

See http://www.baltimoresustainability.org/

uploads/files/Sustainability_Plan.pdf

Program Sustainability
page 170

Chapter 7 References*

1

 Pluye, P., Potvin, L., and Denis, J.L. 2004. 

Making public health programs last: 

Conceptualizing sustainability. Evaluation and 

Program Planning. (27):121–133.

2

 University of Kansas Work Group for 

Community Health and Development. [no date] 

Chapter 46, Section 1: Strategies for the LongTerm Institutionalization of an Initiative: An 

Overview. In Community Tool Box. Lawrence, 

KS: University of Kansas. Available: http://ctb.

ku.edu/en/tablecontents/chapter_1046.htm.

3

 U.S. Environmental Protection Agency 

National Asthma Forum. 2008. A SystemsBased Approach for Creating and Sustaining 

Effective Community-Based Asthma Programs: 

Snapshot of High-Performing Asthma 

Management Programs. Available: https://

www.epaasthmaforum.com/Documents/

Resources2008/Forum_Snapshot.

4

 Delta Institute. 2010. Creative Funding 

Strategies for Remediation of Lead and Other 

Healthy Housing Hazards: A Guide for Increasing 

Private-Sector Financing. Available: http://deltainstitute.org/sites/default/files/1-DeltaREDI_

CreativeFundingStrategiesForRemediationOf

Lead.pdf.

5

 Briscoe, M. 2010. The fundraising case 

statement: Writing your story. In Brakeley 

Briscoe, Considering Philanthropy, Spring 2010. 

http://www.brakeleybriscoe.com/images/

uploads/2010%20Spring%20Considering%20

Philanthropy%20Newsletter_1.pdf.

6

 Yin, R.K., Quick., S.S., Bateman, P.M., and 

Marks, E.L. 1979. Changing Urban Bureaucracies: 

How New Practices Become Routinized. Lanham, 

MD: Lexington Books.

7

 Altman, D.G. 1995. Sustaining interventions 

in community systems: On the relationship 

between researchers and communities. Healthy 

Psychology. 14(6):526–536.

8

 MacRoy, P. and Farquhar, D. 2009. Creating 

healthier housing through building codes. May 

2009 National Healthy Housing Policy Summit. 

Available: http://www.nchh.org/Policy/NationalSafe-and-Healthy-Housing-Coalition/PolicySummit.aspx.

9

 Fisk, W.J. 2000. Health and productivity gains 

from better indoor environments and their 

relationship with building energy efficiency. Annual 

Review of Energy and the Environment. 25:537–66.

10 Wilson, J. and Katz, A. 2009. Integrating Energy 

Efficiency and Healthy Housing. May 2009 

National Healthy Housing Policy Summit. Available: 

http://www.nchh.org/Policy/National-Safe-andHealthy-Housing-Coalition/Policy-Summit.aspx.

11 Butterfoss, F.D., Goodman, R.M., and 

Wanderman, A. 1993. Community coalitions 

for prevention and health promotion. Health 

Education Research. 8(3):315–330.

12 Gantz McKay, E. 2003. Sustaining Success 

(Power Point Presentation). January 2003 Allies 

Against Asthma Third Annual Meeting.

13 Thompson, B., Lichentenstein, E., Corbett, K., 

Nettekoven, L., and Feng, Z. 2000. Durability 

of tobacco control efforts in 22 Community 

Intervention Trial for Smoking Cessation (COMMIT) 

communities 2 years after the end of interventions. 

Health Education Research. 15(3):353–366.

14 National Center for Healthy Housing. 2009. 

National Healthy Housing Policy Summit 

Meeting Report, May 7, 2009. Available: http://

www.nchh.org/LinkClick.aspx?fileticket=TPQsbl

Pj8fQ=&tabid=340.

15 MacRoy, P. and Farquhar, D. 2009. Creating 

healthier housing through building codes. May 

2009 National Healthy Housing Policy Summit. 

Available: http://www.nchh.org/Policy/NationalSafe-and-Healthy-Housing-Coalition/PolicySummit.

16 Mosaica—The Center for Nonprofit 

Development and Pluralism. November 2006. 

Nonprofit Organization Sustainability. Available: 

http://www.mosaica.org/.

*Websites were verified during the drafting of this document but may have changed.
page 171

Notes
page 172 Program Sustainability