page 37

Program Design

Program Design Questions

Mainstreaming Healthy Homes Activities

Healthy Homes Program Components

Program Parameters

Eligibility Requirements

Recruitment

Priorities for Assessment and 

Intervention

Organizational Structure

Staffing

Clarifying Roles and 

Responsibilities

Budget Priorities

Evaluation and Program 

Performance Measures

3
page 38 Program Design
page 39

T he design of your healthy homes program should reflect priorities identified during the community planning process, 

which explored community concerns and reviewed health and 

housing data.

The program plan starts with defining your target population and specifying health and housing outcomes you hope to achieve. Ideally, the 

design process and program plan development 

are collaborative activities, involving community 

partners and stakeholders. Chapter 6 discusses 

logic models for linking your desired outcomes 

to activities and resources. These can be useful 

frameworks in the program planning stage.

Program design calls for decisions on such 

factors as:

• Goals and objectives

• Target population

• Geographic target area

• Eligibility requirements

• Participant recruitment and retention

• Staffing

• Organizational structure

• Home assessment methods

• Intervention protocols 

• Resource availability 

• Partner roles and responsibilities 

• Leveraged resources (including service 

systems)

• Development of service delivery protocols 

Key Messages

• Conduct program planning in 

collaboration with partners, agencies and 

community stakeholders.

• Mainstreaming your healthy homes 

activities and leveraging partnerships can 

allow healthy homes initiatives to expand 

and move forward without dedicated 

funding.

• Multiple strategies are required to 

recruit and retain program participants—

residents, property owners, and 

contractors.

• Staffing and organizational structure of 

healthy homes programs vary based on 

individual program goals, resources, and 

partnerships.

• Program evaluation must be considered 

early in the program planning process.

3

Program Design
page 40

• Compliance with and utilization of existing 

laws and regulations

• Data collection

• Evaluation plan

Program Design Questions

The program design process answers the 

following questions:

• Why: Why is a healthy homes program 

needed? What priority health and housing 

problems exist in the community? What does a 

healthy home mean to the community? What is 

the vision and mission of the program?

• Who: Who is most affected by housing based 

health hazards? Who is most likely to benefit 

from healthy housing activities? Who is the 

target population? Who will refer participants 

to the program? Who will provide leadership for 

administering the program? Who is responsible 

for coordinating the work of program partners 

and stakeholders? What agencies have 

resources, service systems or regulations that 

can be leveraged? Who will provide program 

services? What staff are needed? Who among 

elected officials and local decision makers will 

champion the program?

• What: What are the program’s goals and 

objectives? How will the program assess home 

hazards? What services and interventions are 

needed to make a home healthier and safer? 

What education and support do residents, 

homeowners and the community need?

• When: What is the program timeline for 

achievement of short-, intermediate- and 

long-term goals? What is the schedule for 

target housing and residents from intake to 

case closure? When will data be available that 

demonstrate program outcomes? 

• Where: Where is the high-risk housing located 

in the community? What is the program’s 

geographic target area? What assets exist in 

the target area and community at large?

• How: What resources and partnerships are 

needed to implement the program? What level 

of funding is needed? What sources of funding 

will be targeted? What infrastructure or service 

systems can be leveraged? What systems 

or public policies need to be developed or 

revised? What immediate actions can be 

taken to initiate healthy housing activities? If 

effective, how will the program be sustained?

Mainstreaming Healthy 

Homes Activities

As you begin planning your healthy homes 

program and working with community partners, 

it can be helpful to brainstorm actions that can 

be taken immediately to advance the healthy 

Program Design
page 41

homes movement in your community. Gather 

your partners and stakeholders together to 

explore the question: What can our community 

do without dedicated healthy homes funding to 

accelerate healthy homes activities?

Examples of such activities include:

• Recruiting the fire department to assist with 

fire safety education and provision of smoke 

alarms and carbon monoxide detectors.

• Partnering with code enforcement agencies 

to take advantage of existing enforcement 

systems and resources to make homes 

healthier and safer.

• Cooperating with local childhood lead 

poisoning or lead hazard reduction programs 

to remediate lead-based paint hazards in 

target properties.

• Working with existing housing rehabilitation 

programs to prioritize healthy housing 

assessment and interventions as a part of their 

funding requirements.

• Advocating for funding “set asides” for 

healthy homes within CDBG-funded housing 

rehabilitation programs.

• Working with public housing agencies as they 

implement building upgrades and address 

pest management issues.

• Promoting smoke-free multifamily housing to 

property owners and managers, and residents.

• Cooperating with sustainable and green 

housing initiatives to prioritize housing 

rehabilitation treatments or new construction 

practices that result in health improvements.

• Collaborating with weatherization and energy 

efficiency programs.

• Contacting local law schools or bar 

associations to recruit volunteers to work with 

target populations on legal issues that impact 

public benefits and/or housing habitability.

• Redirecting existing funding where possible.

• Identifying a researcher or evaluation 

specialist interested in healthy homes issues.

• Sponsoring an intern to focus on a healthy 

homes mini-project.

• Exploring health plans and HMO 

reimbursement options for home visits and 

environmental services in homes of children 

with poorly controlled asthma.

• Exploring the donation of cleaning supplies, 

mattress and pillow covers, and vacuum 

cleaners.

“Mainstreaming” your healthy homes activities 

within existing service systems and programs 

promotes sustainability of these efforts. When 

partners and stakeholders work strategically 

to establish a healthy homes program prior 

to dedicated funding, they are laying the 

groundwork for securing resources as well as 

piloting and cost estimating interventions. These 

activities can be used to leverage funding when 

applying for healthy homes grants.

Healthy Homes Program 

Components

A healthy homes program includes some or all of 

the following functions:

• Identification of program participants

• Establishment of referral systems

• Establishment of intake and eligibility criteria

• Resident education, behavior change, and 

interviewing

• Visual assessments 

• Environmental measurement/sampling

• Asthma action or case management plans

• Scope of work development

• Housing interventions

• Community education 

• Environmental follow-up

Each healthy homes program will look different 

depending on your program’s resources, 

strategies and partners. The flow chart in Figure 

3.1 depicts each programmatic stage from 

referrals and intake through family education 

and case management and housing intervention.

Program Design
page 42

Figure 3.1 Flow Chart of Program Stages

Intake and Eligibility

Application and enrollment based on target area, income, and other 

program criteria (e.g., age, health condition)

Resident interview

Quality of Life Survey

Resident education

Provision of cleaning kits and mattress and pillow 

 covers

Resident/Family Services

Visual Assessment

Lead Risk Assessment/Inspection

Home Safety Assessment

Environmental/Measurements/Sampling

Energy Audit

Environmental Assessment

Education on cleaning

Coordination of health services

Health care access/health insurance

Compliance with asthma action plan

Case Management or Asthma Action Plan

Specification of treatments

Information on grants and loan

Permit requirements 

Clarification of roles and responsibilities of property 

 owner and contractors

Scope of Work

Medical services

Social services

Legal advocacy

Employment assistance

Smoking cessation

Weatherization or rehab programs

Care Coordination and Referrals

Moisture control

Mold remediation

Integrated pest management

Housing repair and rehabilitation

Lead hazard control

Air quality—venting, dehumidifier use, dust reduction

Installation of safety devices

Housing Interventions

Post-intervention visual assessment

Post-intervention environmental/allergen sampling

Pest Monitoring

Reinforcement of education Environmental Follow-up

Reinforcement of behavior change

Monitoring and revision of case management or 

 asthma action plan

Follow-up Education and Case Management

Program Design

Recruitment and Referrals

Health care providers, government funded health, housing or social 

service programs, community organizations, canvassing, self-referral
page 43

Program Parameters

Determining program parameters includes:

• Defining eligibility criteria for program 

services;

• Identifying recruitment partners, referral 

systems, and retention strategies; and 

• Determining assessment methods and 

intervention priorities. 

While some of this planning activity can occur 

as part of the process to secure funding, the 

program “start up” phase requires an additional 

level of detail to prepare policies, protocols, and 

program materials. Most programs can expect an 

additional three to six months to get underway.

Eligibility Requirements 

Eligibility—who is qualified to receive program 

services—involves determination of the 

following:

• Geographic location of target housing;

• Target populations for services: children with 

asthma, older adults, and/or families residing 

in substandard housing;

• Inclusion/exclusion criteria such as income 

levels, property tenure (owner-occupied 

versus rental property), private versus public 

housing, level of housing deterioration; and

• Availability of documentation needed to 

demonstrate eligibility.

• Review of applicable requirements related 

to federal grant funds (i.e., criteria under the 

HUD Lead Hazard Control Grant Program).

Eligibility decisions involve tradeoffs and include 

criteria for families, property owners, and 

properties themselves. A broader definition 

makes it easier for the program to meet its target 

numbers for recruitment in a timely manner, 

but may make it more difficult to demonstrate 

specific health benefits and target services to 

those most in need. For example, criterian such 

as “rental units housing families of children with 

asthma who agree to remain in their residence 

for 12 months after renovation,” may be too 

Figure 3.2 Most Common 

Recruitment Challenges Reported 

by HUD Healthy Homes Grantees 

• Difficulty in reaching the target population 

(related to client transience or fear of 

authorities)

• Overly strict enrollment criteria

• Over-reliance on partners for referrals and 

lack of back-up recruitment strategies

Source: HUD, 2007, pp 36–37.

Program Design

restrictive resulting in the program not reaching 

its benchmarks for enrollment. On the other 

hand, eligibility defined as “families living in 

substandard housing within a specific geographic 

area” may not yield the health outcomes central 

to the goal of healthy homes programs.

An Evaluation of HUD’s Healthy Homes Initiative: 

Current Findings and Outcomes reported that 

the majority of grantees surveyed defined unit 

eligibility by using a combination of specific 

population groups and housing conditions.1

Many of these programs explicitly required 

enrolled families to have a child with physiciandiagnosed asthma.

Based on these experiences, several eligibility 

issues deserve special attention:
page 44

Table 3.1 Recruitment and Eligibility Strategies Used in Model Programs

 Eligibility Criteria

Project Recruitment Illness, Health 

Name Strategy Geography Income Age Housing Condition or

 Other 

 Criteria

Baltimore 

City’s 

Transition 

from Lead to 

Healthy 

Housing

Recruited families 

of EBLL children 

receiving case 

management 

services from the 

Health Department and women 

with high-risk 

pregnancies 

referred by nonprofit programs.

City of 

Baltimore 

only

Lowincome

Children 0–6 

years and 

pregnant 

women

Owneroccupied 

and rental 

housing units 

with a focus 

on rental 

property

EBLL or 

pregnancy

Boston 

Breathe Easy 

Home 

Program

Web-based 

referrals provided 

by doctors, nurses, 

BPHC, other health 

professionals, and 

asthma home visiting programs.

Boston area

neighborhoods 

with highest 

rates of asthma 

and multifamily rental 

housing

LowincomeAdults and 

children

Public 

housing and 

private 

rental 

housing

Have 

physiciandiagnosed 

asthma.

Case 

Western 

Healthy 

Homes and 

Babies

Families recruited 

through Case 

Western pediatric, 

family medicine, 

and geriatric clinics by attending 

medical residents.

City of 

Cleveland and 

first ring suburbs served by 

Case Western 

clinic

LowincomeChildren, 

pregnant 

women, 

and “frail” 

seniors 

Owneroccupied 

and rental 

housing 

units with 

a focus 

on rental 

property

Diagnosis of 

asthma for 

children and 

seniors at risk 

for falls 

Esperanza 

Community 

Housing 

Corporation, 

South Central 

Healthy 

Homes 

Demonstration Project

Referral by St. 

John’s Well Child 

and Family Center 

and door-to-door 

recruitment of 

families in the 

buildings that 

housed referred 

families (some 

resulting from 

tenant-organizing 

activities of Strategic Actions for a 

Just Economy.)

13 Census 

tracks in 

City of Los 

Angeles

Low 

income

Families 

with 

children 

under six 

and at high 

risk for lead 

poisoning

Substandard 

housing

At risk for 

lead 

poisoning; 

diagnosis of 

asthma

Program Design
page 45

 Eligibility Criteria

Project Recruitment Illness, Health 

Name Strategy Geography Income Age Housing Condition or

 Other 

 Criteria

Philadelphia 

Healthy 

Homes for 

Child Care

Recruited through 

word of mouth, 

child care resource, 

and referral agencies, and advocacy 

groups that work 

with children and 

youths.

19 zip codes 

in Philadelphia 

with large 

numbers of 

EBLL children, 

high rates of 

asthma, and 

large numbers 

of home-based 

child care 

providers

Child care 

providers 

must 

meet 

HUD 

income 

guidelines 

for Lead 

Hazard 

Control 

Grants

Licensed 

child care 

providers, 

enrolled in 

Keystone 

Stars quality 

improvement 

program

Licensed 

home-based 

child care 

providers 

(primarily 

owneroccupied)

One or more 

children in 

the providers’ 

care had to 

have an EBLL 

or diagnosis 

of asthma

Opportunity 

Council 

Weatherization Program

Recruited primarily 

from client families 

served by 

Opportunity 

Council’s 

weatherization or 

Head Start 

programs.

Four-county 

area in 

northwest 

Washington 

state

125% of 

federal 

poverty 

level

At least one 

child with 

clinically 

diagnosed 

asthma

Owneroccupied units 

and family 

child care 

homes that 

served 

children from 

these units 

Asthma 

diagnosis 

Units with 

pets or 

cigarette 

smokers were 

excluded

Program Design

Figure 3.3 Criteria for Targeting 

Most Likely to be Used by HUD 

Healthy Homes Demonstration 

Grantees

• Families with children in a specific age range

• Families with children with medicallydiagnosed asthma or at risk for respiratory 

illness

• Housing units located in specific 

geographic and census tracks

Source: HUD, 2007 p.15

• Use of community health workers or 

Promotores de Salud can increase the 

effectiveness of recruitment and retention.

Because they live in the neighborhood being 

served, they are familiar with the community 

and credible to families enrolled in the 

program. (See Seattle/King County and 

Esperanza Community Housing Corporation 

case studies located in Appendix 1.)

• Strict limits on geographic location can make 

it harder to recruit, especially if multiple family 

and health factors are required. Thirteen (20 

percent) of the grantees surveyed in HUD’s 

evaluation had to broaden their geographic 

target areas over time.2 The use of multiple 

eligibility criteria related to health and family 

factors may require a broader geographic target 

area to assure recruitment success. 

• Rental units can be challenging to serve, 

especially if major structural interventions 

are needed.

 Most healthy homes programs include rental 

properties because the high-risk geographic 

locations targeted usually have a high 

percentage of rental units with maintenance 

issues that result in health and safety 

hazards. The degree of cooperation between 

the owner and the owner’s relationship with 

the tenant may impact the time to recruit, 

obtain documentation to verify eligibility, 

assess conditions, and complete and finance 

structural interventions.

 Scheduling low-level interventions (e.g., 

cleaning, education, provision of safety 

and cleaning supplies, small-scale repairs) 
page 46

can incentivize the property owner’s 

involvement to more intensive housing 

interventions. Both the Case Western 

Healthy Homes and Babies and the 

Children’s Mercy Hospital Environmental 

Health Program (CMH-EHP) staged 

lower level education and environmental 

interventions before more intensive 

structural interventions (Appendices 1.5 

and 1.9). Many healthy homes programs 

combine their funding with lead hazard 

control grants and/or loans as both 

an incentive and means to conduct 

comprehensive housing interventions.

 Any recruitment strategy that targets 

families from rental units must account for 

resident mobility and more frequent unit 

turnover. This may result in more units and/

or families lost to long-term follow-up.

 Some healthy homes programs require 

rental property owners to share the cost 

of structural remediation. Strategically, this 

makes sense if the program is helping the 

property owner comply with lead hazard 

control or building code requirements. In 

these cases, the benefits of the program 

and the amount of funding to be leveraged 

from the owner needs to be communicated 

clearly at the point of recruitment.

• Multiple sources of funding pose a challenge 

based on disparate eligibility requirements. A 

program that seeks to use both Department 

of Energy (DOE) weatherization program 

and HUD funding must recognize that DOE 

typically uses household income of 125 

percent of the area poverty level as a cutoff, 

whereas HUD Healthy Homes Grants use the 

designation of low income, and HUD Lead 

Hazard Control Grants use a household’s 

percentage of the Area Median Income (AMI).3

 Use an application process that collects and 

evaluates all relevant income data at one 

time. This may include verification of the 

occupants’ age and the income of all adults 

living in the housing unit.

 Establish Memoranda of Understanding 

(MOUs) with partnering programs to ensure 

your income verification process meets 

all requirements and to clarify roles and 

responsibilities.

• Exclusion criteria need to be specific.

 Identify the minimum conditions for units 

enrolled in the program. For example, the 

housing unit is structurally sound; there 

are no outstanding building code violation 

orders; property owners have the required 

insurance and are current on their property 

taxes; and the loan-to-value ratio is 

acceptable if owners are asked to agree to 

forgivable loans.

 Provide a list of resources of other housing 

programs and services for applicants 

deemed ineligible for your healthy homes 

program.

• Give owners and tenants a fixed period 

for completing all program phases. If the 

program establishes a “first come, first 

served” approach, be clear about how long 

an application will remain on the waitlist, 

and what will be needed to reactivate the 

application. Once program interventions 

are initiated, tenants and owners need to be 

compliant with project timeframes to continue 

to receive services. This will serve as extra 

incentive for sustained behavior change, 

property owner contributions, and ultimately 

assure program cooperation.

• Provide application support to tenants 

and property owners to streamline the 

application process.

 If needed, identify a staff person who 

can assist with the application process 

and serve as a contact for follow-up. This 

individual must possess good problemsolving skills, be diligent in providing followProgram Design
page 47

up, and have the ability to work with all 

parties to facilitate enrollment.

 Develop mechanisms to reduce the time 

needed to verify income. This can include 

training outreach workers or program staff 

to function as notary publics and developing 

affidavits of income sources for tenants.

 Prepare all applications and supporting 

materials to serve low-literacy populations.

 Ensure that a bilingual staff person or 

translator accompanies program staff on 

home visits to families who do not speak 

English, and all written materials are 

translated into the predominant languages 

of populations in healthy home program 

target areas.

Recruitment

1. Setting Benchmarks

Program benchmarks, resources, and evaluation 

strategies all affect recruitment methods: 

• Expect attrition when setting benchmarks 

for recruitment. The longer the time between 

recruitment, service provision, completion of 

interventions, and post-intervention follow-up/

evaluation, the more likely applicants will drop 

out. To compensate, programs should use a 

common practice in survey research—recruit 

at least 30 percent more units or families than 

they ultimately expect to serve. Regularly 

monitor progress to determine if program 

changes are needed. 

• Understand how available resources limit 

enrollment. The more costly the set of 

interventions planned, the fewer the number of 

housing units and families that can be served. 

• Determine what factors the program will 

evaluate, and if conducting research, what 

statistical power and precision are needed 

to assess outcomes. Higher-level statistical 

analyses and the number of comparisons 

planned across groups will require more 

participants or units to be enrolled. If a 

program wants to draw confident conclusions, 

there must be a large enough sample size 

of participants for the statistical significance 

needed to determine whether outcomes are 

due to chance or the program.

• Understand the role and self-interest 

of rental property owners. If structural 

remediation will be taking place, the property 

owner’s permission and involvement is 

required even if resident families (tenants) 

have already agreed to participate. If the 

owner is unable or unwilling to participate, 

education, case management, installation of 

safety items, and supplies can still be offered 

to families in need. Some programs provide 

relocation assistance to assure a healthier 

living environment for the family. 

Lessons learned from healthy homes programs 

are highlighted in Figure 3.4 

2. Strategies

There is no single “right way” to recruit. 

Almost half the grantees surveyed for HUD’s 

Evaluation reported delays in meeting program 

benchmarks related to recruitment. Threequarters of the grantees used one-to-three 

Program Design

Figure 3.4 Recruitment—Lessons 

Learned

• Find the right organizations, especially 

community health workers (e.g., 

Promotores de Salud), who live in the target 

neighborhood to conduct recruitment.

 Identify a trusted individual within 

the target community to assist with 

recruitment.

 Ensure that all partners understand and 

value the priorities of the project.

• Be realistic in expectations, especially 

about the time needed to recruit.

• Be prepared to re-evaluate and change 

recruitment strategies.

• Time distribution of incentives to retain 

participants (e.g., offer “big ticket” items 

such as vacuums later in the project cycle).

• Piggyback onto recruitment activities of 

existing programs.

• Demonstrate how this program addresses 

needs of potential clientele by reducing 

home-based health hazards threatening 

the health of family members.
page 48

Figure 3.5 Percentage of HUD Demonstration Grantees Using Various 

Recruitment Methods (n=38)

Source: HUD, 2007, p.A.5–6.

Referrals 

from 

providers 

or agencies

Public 

meetings

Distribution of 

info to schools 

or community 

groups

Phone 

calls

Door-todoorMedia ads Property 

owner 

mailings

Community 

group 

mailings

Recruitment Methods

Percentage of Grantees

100

80

60

40

20

0

87

74

68

34

26 29 26 24

methods of recruitment (see Figure 3.5). 

The evaluation also highlighted successful 

recruitment methods and factors influencing 

achievement of outcomes: 

• A majority, 58 percent, reported referrals from 

health care providers and other agencies as 

a successful or very successful recruitment 

method.

• Almost half, 48 percent, reported distribution 

of informational materials to schools, 

community organizations, and health care 

providers as successful or very successful.

• A total of 29 percent reported recruitment 

through public meetings or other public 

events as successful or very successful.

• Door-to-door recruitment was used much less 

frequently, but the majority of those who used 

it found it successful.4

Over 80 percent of the Evaluation grantees 

offered incentives for property owner and 

tenant recruitment and retention; 88 percent 

reported the use of incentives as effective. 

Grantees differed in what they considered 

incentives, with some identifying the grant 

funding or other financial assistance for the 

costs of the intervention. Costs of incentives 

ranged from five dollar gift certificates to up to 

$8,000 in grant funding to property owners for 

structural interventions. 

Program Design

3. Key Partners

HUD Demonstration grantees reported using 

partners most frequently as a recruitment 

strategy (80 percent of all respondents). Key 

recruitment partners included health care 

providers, health departments, clinics, hospitals, 

and asthma coalition partner organizations, 

followed by community-based organizations and 

housing programs. 

A. Health Care Providers

The majority of model healthy homes programs 

focusing on asthma trigger management 

reported more success when they partnered 

with health care providers to conduct 

recruitment. This is consistent with findings of 

the EPA’s Asthma Health Outcomes Project 

(AHOP 2007)5, 6 conducted by the Allies Against 

Asthma initiative and EPA’s Communities in 

Action for Asthma-Friendly Environments 

Change Package.7 See Figure 3.6 for highlights 

of AHOP findings.

When anticipating an ongoing relationship with a 

health care partner, a liaison should be assigned 

to the project and kept up to date on program 

progress and involved in problem solving. It 

is important to ensure that medical staff is 

educated about health impacts of housing 

hazards and program services. As partner health 

care organizations gain more understanding 
page 49

Figure 3.6 AHOP Findings on 

Health Care Provider 

Partnerships with health care providers have 

the most tangible effects on asthma health 

outcomes when they have the following:

• Offices in the affected community;

• Time or staff dedicated to asthma 

education; and

• Compensation to local healthy homes 

program for providing extra asthmarelated services since most health care 

insurance policies do not reimburse for 

the additional time devoted to this effort.

EPA’s Asthma Forum suggests that 

high-performing asthma programs are 

characterized by five key factors:

• Committed leaders and champions;

• Integrated health care services;

• Strong community ties; 

• High-performing collaborations; and 

• Tailored environmental interventions.

Source: EPA, 2008, p. 1.

of and commitment to healthy homes issues, 

there may be opportunities to provide technical 

assistance in developing or revising protocols.

Health care providers should be given 

information on healthy homes program services 

that their patients are receiving such as case 

management and housing interventions. This 

will strengthen the relationship and help the 

provider feel like part of the team.

Esperanza Community Housing Corporation, 

South Central Healthy Homes Demonstration 

Project’s partnership with St. John’s Well Child 

and Family Centers, reports a strategy that 

involves recruiting families through door-to-door 

canvassing and then referring and sometimes 

transporting them to the clinic. The clinic then 

prescribes a Promotora home visit and obtains the 

patient’s permission to share medical information.

Conversely, health care funders and health 

clinics can consider providing leadership for 

comprehensive asthma management programs 

by providing home visits as an extra level 

of support. EPA’s guide, Implementing An 

Asthma Home Visit Program: 10 Steps To Help 

Health Plans Get Started, offers step-by-step 

instructions on how to start an asthma home 

visit program with particular emphasis on 

environmental risk factor management.8

B. Community-Based Organizations and 

Community Health Workers

Community-based organizations located in the 

target area can serve as meaningful partners for 

recruitment. Community Action Agencies (CAAs) 

usually house a variety of programs in at-risk 

communities, including weatherization (Figure 

3.7), Head Start, anti-poverty, and a variety of 

other social service programs. Because residents 

are familiar with these offices and program 

staff, they are likely to be trusted sources for 

information and referral.

HUD Healthy Home’s grantees and evidencebased research agree on the effectiveness 

of Community Health Workers (CHWs) for 

recruitment and education related to management 

of asthma triggers and implementation of 

Integrated Pest Management.

9, 10, 11, 12 Krieger et 

al. note that the value of CHW visits is attributed 

to multiple factors. The CHW:

• Shares the clients’ community experience, 

culture, and lifestyle—especially important 

factors for Spanish-speaking and other 

minority communities;

Program Design

Figure 3.7 CBO Partnership 

Example 

The Opportunity Council in Bellingham, 

Washington developed a successful Healthy 

Homes Demonstration program based on 

their ability to supplement services offered 

with their existing weatherization program. 

This organizational structure allowed them 

to recruit through their existing network 

of clients (Head Start and weatherization 

services). The program is now a model known 

as Weatherization Plus Health.
page 50

target families and property owners (Figure 

3.9). Conduct focus groups, key informant or 

stakeholder interviews, and/or community 

meetings to collect these insights. Attend to 

the immediate concerns of residents at the 

same time that program concerns and issues 

are addressed.14 To respond to these concerns, 

establish referrals to appropriate resources for 

issues that are outside the program’s scope. 

Families and property owners may be motivated 

by any or all of the following issues:

• Health concerns. Residents may value 

program services to improve existing 

conditions or to prevent illness or injury from 

occurring.

• Improved housing. Owners may be motivated 

by such factors as cost, compliance with 

regulations, satisfying outstanding code 

violations, liability, unit turnover, and ease of 

maintenance issues involved with improving 

and maintaining properties. 

• Strengthening of the owner-tenant 

relationship. Programs can provide incentives 

such as cleaning supplies, equipment, and 

training that support tenant responsibilities. 

Here, it is important to distinguish between 

tenant and property owner roles and 

responsibilities. Many programs include 

a Statement of Tenant Responsibilities in 

recruitment materials. (See Figure 3.10 for 

guidance in preparing materials.) Identify 

local agencies that mediate conflicts between 

property owners and tenants, especially those 

that focus on preventing eviction.

Figure 3.8 Knowing the Target 

Audience

Baltimore’s transition from a Childhood 

Lead Poisoning Prevention Program into a 

Healthy Homes Program began with community meetings and focus groups to garner 

community feedback on current services and 

discuss expectations of the new approach. 

This input resulted in extensive revisions 

to protocols, assessment tools, and client 

education. The outcome is a client-driven 

approach whereby families identify their 

top health and housing concerns and CHW 

provides a combination of referrals to other 

agencies, education, and low-level interventions tailored to the clients’ stated needs.

Figure 3.9 Motivating Tenant 

Involvement

Environmental Health Watch (Cleveland, 

Ohio) reports that when tenants observed 

the immediate outcome of integrated pest 

management, they were more motivated to 

maintain a clean living environment. Most 

families have had long experience with intractable problems and felt hopeless about 

controlling their environment. An integrated 

approach calls for tenants, property owners 

and contractors to work together to improve 

the health of the home environment.

Program Design

• Serves as role models for clients related 

to both project aims and the larger goal of 

economic self-sufficiency;

• Has time to communicate information that is 

often not addressed in health care visits, such 

as individualized asthma trigger management;

• Demonstrates and observes the client’s 

implementation activities, and reinforces 

proper techniques; and

• Addresses the individual’s most pressing 

concerns in the context of the home visit.13

CHW and Promotores de Salud are often less 

costly to hire than nurses or asthma educators. 

However, programs that employed them with 

the greatest success engaged in rigorous 

and continual training (Figure 3.8), handson and accessible supervision, visit quality 

control, and competitive compensation. 

Seattle/King County’s Community Health 

Worker Guidelines can be found at http://

www.kingcounty.gov/healthservices/health/

chronic/asthma/resources/hcp.aspx#chw. The 

Healthy Homes Training Center’s Community 

Health Worker training curriculum (English 

and Spanish) can be found at http://www.

healthyhomestraining.org/chw/

4. Recruitment and Educational Messages

Strategies: Successful recruitment and retention 

start with understanding what motivates 
page 51

• Program Materials: Low literacy and culturally 

appropriate recruitment materials and 

educational messages should be used (Figure 

3.10).

• Existing Materials. Whenever possible, use 

existing program materials. For example, 

the Healthy Homes Partnership, an initiative 

between the United States Department of 

Agriculture (USDA) National Institute on Food 

and Agriculture’s Extension Services and 

HUD, includes a growing network of state 

coordinators who provide information about 

home health hazards. This partnership has 

produced a self-help guide, Help Yourself to 

a Healthy Home, that is available in English, 

Spanish, Hmong, Vietnamese, Arabic and 

Bosnian, and is appropriate for low literacy 

audiences. There is also a Native American 

version of the guide. http://www.csrees.

usda.gov/nea/family/in_focus/housing_if_

healthyhomes.html. Another resource is 

The National Center for Healthy Housing’s 

National Healthy Homes Training Center & 

Network, which brings together public health 

and housing practitioners to promote practical 

and cost-effective methods for making 

homes healthier through the use of the Seven 

Principles of Healthy Housing. It also serves 

Program Design

as a forum for exchanging information on 

new research and best practices. http://www.

healthyhomestraining.org

• Literacy. Materials should be evaluated 

according to standards for health care 

communications, reading level, and “plain 

language.” The HHS’s Office of Disease 

Prevention and Health Promotion, Health 

Communications Activities, Health Literacy 

Improvement website offers links to fact 

sheets and other materials: http://www.health.

gov/communication/literacy/default.htm. 

• Cultural Appropriateness. Materials should 

be screened for cultural appropriateness. 

In addition, it is necessary to educate 

recruitment partners, CHWs, inspectors, and 

contractors about behavior that could be 

considered offensive to target groups. These 

can include attitudes toward roles for men and 

women, dress, body language, and physical/

eye/hand contact. Other cultural factors can 

include differing values concerning traditional 

versus Western medicine, and practices 

related to food and housekeeping.

• Communication methods. Multi-media 

communication methods should be employed 

whenever possible. Appendix 3.1 has 

examples of multi-media campaigns that can 

be adapted for your needs. Healthy homes 

programs are encouraged to develop a formal 

“Distribution Plan” to raise awareness of their 

services.

5. Confidentiality and Ethical Concerns

Since healthy homes programs include 

interactions with individuals and collection 

of private information, it is important that 

programs be knowledgeable about the rights 

of participants and how to protect them from 

harm. For example, all confidential health 

information needs to be protected so that it 

is not disclosed inappropriately. Appendix 6.1 

provides detailed information on informed 

consent, Institutional Review Boards (IRB), and 

HIPAA. It is important to note that a healthy 

homes program is voluntary. Program services 

and interventions need to pose minimal risk to 

participants so that they are not harmed as a 

result of voluntary cooperation. Take time to 

explain to residents/families what their roles, 

responsibilities and rights are if they choose to 

Figure 3.10 Strategies for 

Improving Written Materials

• Identify user’s understanding before, 

during, and after the provision of 

information and services.

• Acknowledge cultural differences and 

practice respect.

• Limit the number of messages. Use plain 

language, and focus on action.

• Supplement instructions with pictures.

• Make written communications look easy to 

read.

• Make sure information placed on the 

Internet is easy to find (minimize searching 

and scrolling needed).

Source: Quick Guide to Health Literacy, Improving 

the Usability of Health Information. http://www.

health.gov/communication/literacy/quickguide/
page 52

Most grantees who participated in the HUD 

Healthy Homes Initiative Evaluation reported 

that well-designed resident interviews and 

visual assessments were sufficient to collect 

the data needed for their programs. This 

was echoed by grantees interviewed for this 

manual. Environmental sampling was more 

likely to be used as part of research and to 

show the housing impact of interventions. 

Long-term environmental sampling and 

any post-intervention follow-up can pose 

challenges because residents may move or 

not permit reentry to collect post-intervention 

samples. Also, clinical measurements in nonclinical settings, such as pulmonary function 

measures, can be difficult to standardize. Repeat 

environmental assessments or clinical measures 

are subject to residents’ schedules and 

commitment to the project; the more precise 

the time intervals required to collect repeat 

samples, the greater the challenge.

During the first few years of HUD Healthy 

Homes Grant funding, more emphasis was 

placed on collecting allergen samples to 

measure their levels in dust and document 

intervention effectiveness. At this point in the 

evolution of healthy homes programs, there is 

reduced focus on environmental sampling.

The Evaluation suggested the following 

practices to improve assessments:

• Gather only the information that you plan to 

use;

• Use established validated tools whenever 

possible; and

• Set clear parameters for pre- and postremediation assessment.15

Healthy homes programs also noted the 

importance of:

• Training (Figure 3.12), rigorous supervision, 

and tight quality control for data collection;

• Following equipment calibration and 

maintenance standards faithfully; 

• Treating CHW, Promotores de Salud, and 

other field staff as respected community 

experts who are a valued part of the team 

and free to suggest revisions to protocols and 

procedures;

Program Design

Figure 3.11 Resources

HHS’s Office of Human Research Protections 

provides a variety of guidance materials on 

application of the Common Rule, including 

decision charts for individual projects: 

http://www.hhs.gov/ohrp/policy/checklists/

decisioncharts.htm

As a matter of good practice, all healthy 

homes project staff should undergo training 

on the protection of human subjects. Free 

training can be found at http://ohrp-ed.

od.nih.gov/CBTs/Assurance/login.asp. 

The Agency for Healthcare Research and 

Quality (AHRQ) has developed a toolkit for 

informed consent in research that poses 

minimum risk: http://www.ahrq.gov/fund/

informedconsent/

participate. Research studies on the outcomes 

of interventions should undergo an IRB review 

before recruitment begins. 

Priorities for Assessment and 

Intervention

As noted in Chapter 1, healthy homes projects 

often have multiple desired outcomes: health 

improvement, resident behavioral change, 

repairs and rehabilitation to housing, community 

capacity building, system change, and policy 

development. Chapters 4 and 5 will address 

assessment and intervention methods in detail. 

However, there are several program design 

issues that apply to decisions about home 

assessments and interventions that must be 

considered in the program design phase.

1. Assessment Considerations 

Home assessment for health and safety hazards 

can be achieved in three ways:

• Resident interviews;

• Visual assessment/comprehensive health and 

safety assessment (e.g., HUD’s Healthy Homes 

Rating System); and

• Environmental measurement and sampling, 

and building performance testing.
page 53

• Piloting all procedures and making revisions 

as needed. Once protocols are established, all 

changes should be carefully documented;

• Establishing a tracking system to ensure 

assessments proceed on schedule. Delays in 

this process impact all other phases of the 

project; and

• Assuring that program participants fully 

understand the importance of the assessment 

in developing specific scopes of work 

(interventions) that meet their health needs 

and needs of the property. This can be 

reinforced by sharing the assessment results 

with both the families served and property 

owner.

2. Intervention Considerations 

If this is your first experience with healthy homes 

work, there is an advantage to starting small. 

Figure 3.13 includes a list of common healthy 

homes interventions. Intervention options 

should be tied directly to hazards found as part 

of the home assessment. Most of HUD’s Healthy 

Homes Demonstration grantees surveyed in the 

Evaluation did not undertake major improvements 

initially. As programs developed and additional 

funding became available, the work evolved into 

higher-level structural interventions, such as 

replacement of ventilation systems. 

Programs are encouraged to capitalize on 

existing health and housing programs to leverage 

their resources and provide more comprehensive 

housing interventions. These programs and 

services include case management/home 

visiting programs, weatherization, lead hazard 

control, and CDBG-funded housing rehabilitation 

programs. There is a lack of research showing 

that individual “low-level interventions” (e.g., 

education, cleaning, mattress enclosure, resident 

pest management), when conducted in isolation 

are effective. Such efforts should be incorporated 

into a multi-faceted strategy that includes 

multiple interventions. 

The Community Guide Branch of the CDC 

recommends home-based, multi-trigger, and 

multi-component environmental interventions to 

control asthma for children and adolescents (see 

http://www.thecommunityguide.org/asthma/

multicomponent.html). The Task Force reviewed 

23 studies for effectiveness and found that 

education combined with minor or moderate 

environmental remediation resulted in more 

symptom-free days, savings in asthma care, and 

improved productivity.

Intervention Challenges. Some of the 

intervention challenges programs face include:

• Lack of property owner compliance. Property 

owners’ cooperation is needed to obtain 

consent to work in rental properties and to 

perform maintenance and repair activities. 

Therefore, the following should be built into 

your program design:

Program Design

Figure 3.12 Training of Research 

Assistants

Tulane University hired neighborhood 

residents as research assistants who 

participated in participant recruitment and 

retention and took responsibility for survey 

administration, collection of blood samples, 

and environmental sampling. To assure 

collection of valid and reliable data, they 

participated in a two-month training program, 

were required to pass an oral and written test, 

were evaluated in the field, and participated in 

refresher training.

Figure 3.13 Common Interventions

• Education

• Provision of Cleaning and Safety Kits and 

Mattress and Pillow Covers

• Promoting Smoke Free Homes

• Integrated Pest Management

• Lead Hazard Control

• Moisture Control

• Mold Remediation

• Home Repair and Rehabilitation

• Dust Reduction

• Ventilation Interventions

• Installation of Safety Devices

• Weatherization
page 54

 Presentations to realtors and property 

owner groups to raise awareness of the 

project and funding availability. Provide 

clear cost data and information on benefits 

expected from the interventions. Discuss 

the benefit of a reduction of liability as 

a result of fewer risks of poisonings and 

injuries.

 Inclusion of property owners in the 

planning process to identify issues that will 

encourage participation. Having a voice in 

selecting intervention needs can reassure 

owners that they are valued participants.

 Perform joint field visits with code 

inspectors or other agencies. Identify 

how your program can link services to 

remediating code violations. Programs 

can offer compliance assistance to help 

owners proactively satisfy an “order” or 

use enforcement procedures to correct 

structural defects. 

 Offer funding from your local lead hazard 

control program for window replacement 

in exchange for the property owner 

conducting maintenance and repair 

activities that are health-oriented.

 Offer incentives to residents and property 

owners such as safety items (smoke 

detectors, carbon dioxide detectors, 

or batteries), cleaning supplies, injury 

prevention devices (cabinet locks, nonslip rug pads, stair gates), and paint, 

paintbrushes, plastic and primer.

 Offer free training in lead-safe work 

practices.

 Perform interventions that do not require 

owner consent, such as installing smoke or 

carbon monoxide detectors and providing 

supplies (Figure 3.14).16

• Resident mobility and lack of compliance.

Until the program builds a trusting relationship 

with the community, residents may perceive 

healthy housing issues as a low priority relative 

to other concerns. Some tenants may fear 

repercussions from owners. Others tenants 

or owners may expect more services than a 

program can provide. Options to consider in 

developing a productive relationship include:

 Partnering with community-based 

organizations to assist and support referral, 

recruitment and retention, and conflict 

resolution or mediation.

 Branding the program through 

development of an image or theme that 

distinguishes the program from other 

governmental initiatives and raises 

awareness of its availability. This may 

reduce residents’ concerns that program 

personnel are really police, protective 

services, or immigration officials.

 Provide a calendar with all scheduled visits 

documented for residents/families. Provide 

incentives for completing appointments as 

scheduled. Get as many contact numbers as 

possible for target families and use multiple 

methods to communicate with them.

 Use centralized scheduling to coordinate 

visits between outreach workers and other 

staff, such as risk assessors to minimize the 

number of home visits and disruption to the 

family. 

 Provide information to tenants about 

their rights and responsibilities under the 

program (Figure 3.15).

 Engage CHW and Promotores de Salud for 

recruitment, retention and education.

• Building a strong base of contractors. Unless 

guaranteed a steady and profitable source of 

work, many contractors will avoid the required 

Program Design

Figure 3.14 Incentives 

The Columbus, Ohio Health Department 

customized the provision of Healthy Homes 

supplies based on a family’s need. In all, the 

supplies cost less than $500 and included 

items such as baby gates, storage bin 

for clothing, cleaning supplies, mattress 

and pillow encasings and window locks. 

Combined with education, this type of 

intervention can be conducted without 

property owner consent and can be used 

as an incentive for physical interventions 

and Integrated Pest Management to be 

conducted at a later time.
page 55

training, insurance, or perceived costs of 

“working healthy.” The quality and timeliness 

of the work must be closely monitored by 

program staff. This is especially true when 

combining HUD Healthy Homes funds with 

Lead Hazard Control Grants and federal 

rehabilitation funding (e.g., CDBG). Moreover, 

small contractors may have difficulty keeping 

a tight production schedule and funding upfront costs. Consider the following remedies:

 The HUD Section 3 program requires 

that recipients of certain HUD financial 

assistance grants, to the greatest extent 

possible, provide job training, employment 

and contract opportunities for low- or 

very low-income residents in connection 

with projects and activities in their 

neighborhoods. http://www.hud.gov/

offices/fheo/section3/section3.cfm

 It may be possible to partner with 

community-based and non-profit 

organizations to develop contracting 

crews comprised of residents from the 

target community. This approach advances 

economic development within high-risk 

communities and increase community 

support.

 For small interventions, hiring a 

“handyman” that your program will train 

and fund may be preferable. 

 Make expansion of the contractor base 

a project benchmark, supported by free 

training and problem-solving discussions 

as needed. Provide training delivered at 

convenient times, such as evenings and 

weekends. 

 Pre-qualify a select group of contractors 

and develop an equitable method to rotate 

work. 

 Provide ongoing technical assistance. Make 

frequent visits to project sites at different 

phases of work in progress.

 Consider issuing a Request for Proposal 

asking for a fixed unit price contract for 

specific interventions. This helps manage 

program costs and can also guarantee 

steady work for the contractors selected. 

 Consult other housing rehabilitation and 

weatherization programs to determine 

whether their contractors could be trained 

to perform interventions during “down 

time,” thus keeping contractors fully 

employed.

 Encourage contractors to diversify services 

through training and certification to 

conduct multiple interventions.

 Work with workforce development 

programs to train and apprentice staff to 

perform interventions. Many high school 

and college vocational education programs 

offer a construction track. Partner with 

Youthbuild, or other youth development 

programs. 

 Assure timely payment at job completion. 

Smaller contractors may require partial or 

progress payments.

 Set a standard of performance for 

contractors. If a contractor fails to meet the 

timelines or quality of work expected, take 

steps toward performance improvement 

or initiate action to drop the firm from the 

approved contractor list. 

 Ensure that contractors have necessary 

training and qualifications. For example, 

lead hazard control activities must be 

conducted by persons qualified according 

Program Design

Figure 3.15 Sensitivity to Tenants’ 

Rights

In order to protect the tenancy of renters, 

Esperanza Community Housing Corporation 

and project partners in the South Central 

Healthy Homes Demonstration Project 

coupled home-based environmental risk 

management education, including cleaning 

and pest control products, with education 

on tenants’ rights. Units were also referred 

to code enforcement after home visits, but 

only if there was an established relationship 

between the tenants and a tenants-rights 

organization to assure protection from 

landlord retaliation should enforcement 

action result from the referral.
page 56

to 24 CFR Part 35, subparts B-R (possessing 

certification as abatement contractors, risk 

assessors, inspectors, abatement workers, 

or sampling technicians; or others having 

been trained in a HUD-approved course 

in lead-safe work practices), and firms and 

persons certified in accordance with the 

EPA’s Renovation, Repair, and Painting (RRP) 

Rule (see 40 CFR 745 and http://www.epa.

gov/lead/pubs/renovation.htm). Programs 

often assist small contractors by covering 

the cost of required training.

• Cost Overruns and Funding Limitations. New 

services and interventions require practice to 

achieve optimal efficiency and effectiveness. 

Field staff, contractors, and community 

partners will likely need to pilot and refine 

services and interventions at the beginning 

stages of the project or intervention. Recognize 

early experiences as a training ground for the 

entire project and expect the process to move 

more efficiently after the first 10–15 units.17

 Accompany field staff on initial home visits 

and assessments and visit contractors at the 

job site early and often to provide technical 

assistance. Keep records on the cost of 

supplies, job specifications, intervention 

protocols, and lessons learned to identify 

savings or cost overruns and support future 

planning. Managers, supervisors, and 

coordinators should countinue to make field 

visits after the pilot or beginning stage of 

programs to assure quality. 

 Recognize that some grant sources may 

set maximum amounts for intervention 

costs and others require documentation 

of a minimum percentage of grant funds 

devoted to administrative costs.

 Leverage other sources of funding by 

partnering with other health, housing and 

social service programs to increase the 

comprehensiveness of your interventions 

and support program sustainability.

Program Design
page 57

Organizational Structure

Organizational structure—how a program 

operates, how managers and staff relate to each 

other and how program decisions are made—

reflects the culture and size of the primary 

agency, clarifies roles and responsibilities, 

and can affect a program’s effectiveness and 

efficiency. Simply put, organizational structure 

defines the “chain of command” and specifies 

the span of control of participating staff and 

agencies. Government health and housing 

departments are often influenced by bureaucratic 

structures that can be hierarchical in nature. 

This can be a challenge to healthy homes 

programs that need to be multi-disciplinary 

and implemented by a team of professionals in 

cooperation with community partners. Decisions 

related to organizational structure flow from 

answering the following questions:

• Will healthy homes program staff be located 

in the same organization, department and 

division or separated by function (health, 

housing, or environmental)?

• How will decisions be made—top down or in a 

team environment?

• How much authority will be granted to 

managers, coordinators, and field staff?

• What formal role will partner agencies and 

community agencies fulfill?

• What commitments have been secured for 

intra- and interagency coordination?

Staffing 

Healthy homes programs have different 

organizational structures and staffing. However, 

they usually involve some or all of the following 

functions that can be reflected in job titles.

• Program Direction. The Program Director is 

often responsible for multiple health/housing 

initiatives. This individual provides highlevel oversight to assure that the program is 

funded, implemented within its timeframes 

and budget, adheres to all requirements, and 

advocates for the program internally and with 

program partners.

• Program Coordination and Supervision. This 

individual, often referred to as the Program 

Manager, is usually dedicated to the program 

full-time and responsible for day-to-day 

activities, partnership coordination related to 

service systems, and staff supervision.

• Intake Coordination. This individual is 

responsible for receiving applications from 

residents/families or property owners. She 

or he can be an administrative assistant 

or a program coordinator. Responsibilities 

include screening applications for eligibility 

and ensuring all required documentation is 

obtained and in the case file.

• Community and Family Education. Educating 

the community at large and residents 

that live in target housing is essential to 

the success of healthy housing programs. 

Community education can be conducted 

by health educators, nurses, social workers, 

outreach workers and/or CHWs. Similarly, 

these disciplines can provide one-on-one 

education and support behavior change as a 

part of home visits. Health behavior change 

for occupants in housing units served by 

healthy homes programs is important. For 

more information see Chapter 5, page 115, for 

interventions aimed at resident knowledge 

and education.

• Case Management. Case manager(s) can 

be nurses, social workers, public health 

educators or sanitarians. Some programs 

use CHW or Promotoras de Salud that are 

supervised by nurses or social workers as 

they represent and are trusted by the target 

population. Case management includes the 

assessment of health and social service needs, 

development of an action plan, and ongoing 

referral and support. Case managers provide 

a coordination role to assure that a family’s 

multiple needs are met.

• Environmental Assessment. Visual 

assessment, administering a standard 

questionnaire to residents, and environmental 

sampling are conducted by properly trained 

persons qualified to do the work. Sometimes 

these positions are referred to as sanitarians, 

environmental health technicians, or 

environmental hygienists.

Program Design
page 58

• Laboratory analysis. If a program is collecting 

samples for laboratory analysis, it needs the 

services of an analytical laboratory with all the 

appropriate certifications.

• Data Management. Data management staff 

can be administrative assistants, information 

system specialists or epidemiologists, 

depending on their role and responsibilities. 

Administrative assistants can enter program 

data into health or housing data bases. 

Information systems specialists can provide 

oversight for the entire data collection system 

from service delivery to the production of 

process and outcome evaluation reports. 

Epidemiologists or biostatisticians usually take 

responsibility for data analysis.

• Evaluation. Evaluation can be conducted by 

a third party—often an academic partner—or 

in-house by a team that commonly includes 

individuals with training in epidemiology or 

biostatistics.

All staff should understand how their productivity 

and responsibilities affect the overall project. 

Regular staff meetings are important to assure 

that small delays or implementation issues do 

not become large. Case reviews are an especially 

effective tool to identify program strengths 

and weaknesses and refine program protocols. 

Healthy homes programs require innovative staff 

with good problem-solving skills. All staff need 

opportunities for skills training and continuing 

education. Since the program staff are often the 

most effective ambassadors for the initiative, 

it is important to build in opportunities for 

attendance and presentations at professional 

conferences. 

Clarifying Roles and Responsibilities 

Healthy homes programs are characterized by 

many moving parts. Whether your program 

remains small or expands to include other 

organizations and activities, failure to clarify 

roles among staff and partner organizations 

leads to inefficiencies, confusion, and frustration. 

The optimum way to do this is through regular 

team and partner meetings and project-wide 

use of a Policies and Procedures Manual 

(Figure 3.16). Memoranda of Understanding 

and/or subcontracts should be executed with 

partner organizations as a means of ensuring 

accountability and timely performance. Secure 

data-sharing agreements early in the process 

and be sure that your IT systems are compatible 

for data transfer. The policy and procedures 

manual should cover:

• The project work plan including goals and 

objectives;

• Recruitment and enrollment procedures 

and materials, including guidelines for 

documentation to determine when eligibility 

criteria are met;

• Assessment forms with annotations about how 

to record observations;

• Chain-of-custody forms when environmental 

or biological sampling are part of the project;

• Relocation policies, if needed;

• Sample contracts, scopes of work, and 

occupant protection plans for contractor use;

• A master schedule of activities for each 

housing unit and the project as a whole;

• Job descriptions and work flow charts that 

clearly define which staff are responsible for 

project activities;

• Procedures for collecting and submitting 

environmental or clinical samples for analysis;

• Procedures for submitting and approving 

vouchers;

• Data collection and analysis plans;

Program Design

Figure 3.16 Tulane Policy and 

Procedures Manual 

Tulane University developed a Manual of 

Operation that detailed its Healthy Homes 

Technical Study Grant project’s internal 

policies and procedures. All study personnel 

received the Manual and brought it to the 

weekly staff meeting. If any changes were 

made in policies and procedures as a result 

of problem solving and project discussion, 

changes were immediately and carefully 

documented in the Manual. 
page 59

• Consider low-cost interventions in the context 

of resident behavior. One grantee found that 

cheaper fans installed in the bathroom or 

kitchen area were not effective because they 

were so noisy that many families chose not to 

use them. Families receiving quieter fans were 

much more likely to use them.

• Explore funding (leveraging) from partner 

resources such as nursing case management 

through health insurance/HMO reimbursement. 

Other sources include weatherization funds, 

lead hazard control grants and loans, CDBGhousing rehabilitation programs and Prevention 

and Maternal and Child Health Block Grants.

• Dedicate staff and/or a portion of the project 

budget to develop and maintain partnerships 

and coalitions. 

Program managers should be aware that under 

many of HUD’s grant programs, grantees must 

expend a certain portion of grant funds on direct 

remediation activities and have an administrative 

cost cap of 10 percent of the grant.

Evaluation and Program 

Performance Measures

Plans for evaluation must be built into the 

earliest phases of project design and used as 

a management and process improvement tool 

(Figure 3.17). While Chapter 6 addresses program 

evaluation in detail, it is important that decisions 

about health and housing outcomes and what to 

assess and monitor be an ongoing part of your 

• Quality control procedures; and

• Field safety.

Budget Priorities

Programs planners often underestimate the 

administrative time and costs necessary to 

implement their programs. Programs also need 

to scrutinize their own payment mechanisms for 

vendors, subcontractors, and housing contractors. 

Because contractors usually cannot afford to 

wait long periods for reimbursement, programs 

should consider partial or progress payments. The 

HUD Evaluation suggests new programs should 

consider the following budget strategies:

• Identify a cap for total housing unit and 

specific intervention costs at the start of the 

project. Track these costs carefully for future 

planning purposes.

• Weigh the costs and the quality of work when 

selecting contractors. If possible, establish a 

bidding procedure that allows the program to 

factor in contractors’ past performance both in 

terms of timeliness and quality. 

Program Design

Figure 3.17 Benefits of Working 

with an Academic Institution

One grantee identified the benefits of 

working with an academic institution as 

responding, in part, to their self-interest 

in publishing study results. This kind of 

partnership lends itself to healthy homes 

programs’ producing peer-reviewed 

scientifically valid outcomes. The grantee 

reported that this level of evaluation rigor 

sharpened their critical thinking skills as 

they institutionalized project results and 

piloted and expanded their healthy homes 

interventions. 
page 60

program plan. Two kinds of evaluation—process 

and outcome—should be included: 

• Process evaluation focuses on the 

programmatic actions and services needed to 

achieve a particular outcome.

• Outcome evaluation focuses on whether the 

program achieved the desired health and 

housing outcomes.

Decisions about project evaluation should take 

place early in the planning process. Programs 

must decide: 

• Whether to perform the evaluation in-house or 

to use an outside (third-party) evaluator. Costs 

may be lower in-house but outside evaluators 

may bring credibility to controversial decisions 

and a higher level of skills.

• How much weight to place on qualitative 

versus quantitative data. Qualitative data gives 

richness to the understanding of the process; 

quantitative data helps put performance into 

perspective and is necessary for cost/benefit 

calculations.

• What outputs (activities) and health and 

housing outcomes will be used for program 

evaluation?

• How long a time frame should be established 

for program evaluation? For instance, should 

results be examined over a six- or twelvemonth period post intervention, or over a 

longer period?

• Who will the program target for dissemination 

of progress and findings and how will this 

information be provided? It is important for 

programs to demonstrate accountability and 

value to funders, policymakers, health care 

providers, and beneficiaries of services.

Program Design
Program Design page 61

Chapter 3 References*

1

 U.S. Department of Housing and Urban 

Development. 2007. An Evaluation of HUD’s 

Healthy Homes Initiative: Current Findings and 

Outcomes. 

2

 U.S. Department of Housing and Urban 

Development. 2007. An Evaluation of HUD’s 

Healthy Homes Initiative: Current Findings and 

Outcomes. p.36.

3

 See Opportunity Council case study in 

Appendix 1.

4

 U.S. Department of Housing and Urban 

Development. 2007. An Evaluation of HUD’s 

Healthy Homes Initiative: Current Findings and 

Outcomes. p.A–3.

5

 Center for Managing Chronic Disease. 2007. 

Asthma Programs with an Environmental 

Component: A Review of the Field and Lessons 

for Success. Asthma Health Outcomes Project. 

Available: http://cmcd.sph.umich.edu/assets/

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*Websites were verified during the drafting of this document but may have changed.
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Notes
page 64 Program Design