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Housing the homeless: the “traditional approach” versus “housing first” for grant writers

We’ve been writing grant proposals for housing and supportive services for people experiencing homelessness (this is the PC phrase, but “homeless” is used in the rest of this post) since 1993, so we’ve been at it for long enough to see changing funder and client preferences around approaches come and go. For many reasons that are beyond the scope of this post, homelessness remains a growing and in some respects an intractable challenge in much of urban and rural America; essentially, homelessness is a housing shortage problem. Until we address housing abundance, we’re not going to be able to solve or substantially ameliorate homelessness as a problem.

Recently, we wrote a post on the emerging trend toward harm reduction instead of traditional SUD/OUD treatment. A similar phenomenon is going on with respect to providing housing and supportive services for homeless folks. This is the concept of “Housing First:”

Housing First is a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues.

At first glance, Housing First looks like a reasonable and compassionate approach. In the 1980s, when homelessness as an issue entered public discourse, the sentiment was that Mary and her two kids live in their car because she got laid off from the Piggly Wiggly and was evicted from her apartment. While there are many people who find themselves in this sort of predicament, the majority of homeless have SUD/OUD and, in many cases, are co-diagnosed with serious and persistent mental illness (SPMI). But homelessness is easier to avoid, even for people with SUD, OUD, and/or SPMI, when rents are low. That’s why “it’s not the case that homelessness is high where vacancy rates are high. Indeed, it’s the opposite — the vacancy rate is lower in places with more homelessness.”

Housing for the homeless initiatives have traditionally focussed on a step-down approach similar to that which we described in the post on OUD/SUD treatment versus harm reduction. In the traditional paradigm, homeless people receive housing and other services along a continuum of care starting with a high level of care, and then they “step down” to lower care levels in increments, leading to eventual independent living. Following engagement, referral, or self-presentation and development of an individual housing assistance plan (“IHTP”), the step-down levels often proceed something like:

  • Detoxification/stabilization (if needed)
  • Shelter bed in an emergency shelter (usually limited to 30 to 60 days). Significantly, most shelters are “dry,” meaning that drinking and drugging aren’t allowed in the facility. Still, after breakfast, most people living in shelters spend their days out of the shelter on the street, with the idea that they’ll look for a job, attend treatment sessions, etc., and return at night to sleep. While this is more or less “two hots and a cot,” treatment and other supportive services are sometimes provided in-house and/or by referral.
  • Placement in a single room occupancy (SRO) hotel, transitional housing, or supportive housing unit with in-house and referral supportive services (e.g. SUD/OUD and SPMI treatment, legal assistance, workforce development, primary/dental care, etc.) usually provided in the latter two. In supportive housing, such services are usually case-managed and these facilities are usually dry. While there is typically no length of residency cap for SRO units, there is usually a 12 to 24 month max for transitional and supportive housing facilities. Unfortunately, SROs are largely illegal under the modern zoning regime, which may forces many precariously housed people on the street.
  • Independent living, usually with a Housing Choice Voucher (formerly called Section 8) or in another subsidized housing development, or with family.

The levels can be broken down further, but the above was the common approach and was formalized in the 1987 passage of the McKinney–Vento Homeless Assistance Act (McKinney-Vento), administered by HUD. The problem is, though, is that even if a person gets clean and sober, if he or she can’t afford rent, that person is likely to end up back on the street—and thus in high-stress, difficult situations that encourages coping via substance abuse. Covering $700/month in rent is much easier for a person with mental illness and substance abuse challenges than $2,000 a month.

Although McKinney-Vento funds 15 programs with a spectrum of services, the most significant ones are Supportive Housing, Shelter Plus Care (provides site-specific HCVs for the housing development and on-site services), SRO, and Emergency Shelter. One of the first large funded grants S + A wrote was a $4M Shelter Plus Care proposal for a nonprofit in Northern California to convert a vacant motel into a supportive housing facility in 1994. Over the years, McKinney-Vento has disappeared from public view, as these programs have been folded into HUD’s very confusing Continuum of Care (CoC) system. McKinney-Vento programs still form the structure for most federal efforts to help the homeless, but applications are made to the local CoC agency, not directly to HUD—which means local politics come into play, along with typical quiet deals cut among local players. Good luck breaking into CoC funding without an “in.” Well-meaning people in a given community often want to find something to do to help with the issue of homelessness, and they try to find sustainable for it, only to run into the local power structure.

For our first 20 years, most of the proposals we wrote for homeless housing and supportive services followed the above model: the emphasis was always on working with the homeless people to get them clean and sober, with SPMI under control, before moving from a shelter to longer term housing. About 10 years ago, we began to work with clients who wanted to use the Housing First approach: in this approach, underlying SUD/OUD and SPMI challenges are addressed, to an extent, but the overall goal is to provide fast housing—hence the term “Housing First.” This paradigm treats housing as the first step for life improvement and enables access to housing without conditions beyond those of a typical renter. Although supportive services are usually offered, participation is not required. This means the formerly homeless can continue to drink and drug and/or not comply with the SPMI treatment protocols. Utah was the first major state proponent of this approach, in part because Utah allows housing to be built relatively easily, but even Utah has run into problems.

This shift to the Housing Fist model has created something of a battle between the traditional homeless services providers like the faith-based “missions” that are found in most major cities, and the new Housing First kids on the block. This battle is being played out on social media and, most importantly, in public hearings and applications for CoC and other grants. Like any local structured grant system, such as CoC, Ryan White grants for people living with HIV/A, or Title 10 family planning, a “mafia” soon emerges. The mafia is composed of the existing agencies being funded, advocacy groups, and local politicians who have an interest in making sure favored nonprofits get funded. The mafia structure makes it harder for new, innovative agencies to secure a spot at the grant feeding trough. We’ve heard from some of our clients that the Housing First crowd has taken over CoC processes to the detriment of traditional providers. Housing First is clearly the church of what’s happening now.

We’re just grant writers, so we don’t have an immediate opinion as to whether the traditional approach or Housing First is more efficacious, though neither is likely to be highly effective without land-use reform that increases the total number of housing units. Without an abundance agenda, we’re merely reallocating slices of the pie, rather than increasing the pie’s size. Extensive homelessness is a symptom of deeper problems, and it can’t be effectively addressed without dealing with the root cause. Most studies on the subject of “traditional” and “Housing First” are somewhat questionable. While I’ve been in many shelters and other homeless housing settings over the years, I’ve never been in a Housing First facility, but I imagine that things might get a bit out of control come Saturday night. I also don’t know how housekeeping is handled. Also, most people with SUD/OUD and/or SPMI will relapse multiple times, which may send them back to the streets, jail, or residential treatment/hospitalization, meaning that their Housing First unit is actually their Housing Last unit.

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How many troubled Head Start programs are out there? Looking at ACF’s re-bid practices

Diligent grants.gov readers will occasionally see a bunch of notices for individual service areas for the Department of Health and Human Services (DHHS) Administration for Children and Families (ACF) Head Start Program. Recently, for example, a dozen Head Start RFPs were issued, for places like “Kent and Sussex Counties, Delaware” or “Bates, Cass, Cedar, Henry, St. Clair and Vernon Counties, Missouri.” I did some research on grantees in those areas and found that many Head Start programs in them had been taken over by something called the “Community Development Institute” (CDI) Head Start, which appears to be an ACF multi-area Head Start grantee whose job is to take over the miscreant Head Start programs and operate them until a new local operator can be found, wrangled, tackled, press-ganged, etc. To understand what’s going on, it’s necessary consider the long history of Head Start and its kin, Early Head Start.

Head Start, one of the original “War on Poverty” programs, has been around since 1965; ACF says over 1 million children are enrolled in Head Start annually, and there are Head Start programs in most parts of inhabited America—urban, suburban and rural. Many Head Start programs are operated by the 1,000 or so Community Action Agencies (CAAs), another 1965 War on Poverty relic, funded through the DHHS Office of Community Services (OCS).

Head Start grantees, like HRSA-funded Federally Qualified Health Centers (FQHCs), aren’t guaranteed funding and must periodically compete in new RFPs processes. But not every area has a competent grantee in it—particularly in sparsely populated rural areas or extremely poor areas, where services are often most needed. We’ve worked on numerous projects for organizations that are working through various permutations of this problem, our favorite being a SAC applicant who forgot to apply for their Section 330 grant when their Service Area Competition (SAC) NOFO was open, causing the applicant’s HRSA program officer to call, after the deadline, to say, “Where is your application?” HRSA allowed a late application, which is unusual, and we were able to write their SAC proposal in less than a week. These aren’t ideal or recommended conditions, however.

Searching local news in many of the counties listed by ACF as needing new Head Start grantees yields articles about whatever is going on at these troubled Head Start grantees, but those local news articles lack detail. Still, the regularity with which ACF issue these service area level RFPs shows the challenges not just of getting a Head Start grant, but of running the program successfully. Overall, Head Start is one of the few federal grant-funded programs that shows up regularly in popular media in heartwarming feature stories about low-income kids learning in a nurturing environment—and that sometimes happens. Head Start has also been the subject of much research, which increases its visibility. The research has generated much debate about Head Start’s efficacy at improving educational outcomes for at-risk kids; given its long history, the grandparents or great grandparents of kids in Head Start today were also very likely were in Head Start. Intergenerational Head Start enrollment doesn’t necessarily argue for the program’s real impact, but we’ll leave discussions of “impact” for another post.

Head Start is as much a jobs program as it is an early childhood education program. Head Start grants fund tens of thousands of jobs for low-income folks to work as non-credentialed or lightly credentialed “teachers.” These jobs have traditionally been filled mostly by single moms, whose kids are usually enrolled in Head Start. Thus, the local Head Start programs meet two critical needs in low-income communities—heavily subsidized early childhood education (or “child care” for the cynics) and reliable, easy-entry jobs with some career-ladder potential. Thus, when a Head Start program goes under, it can be a real crisis in low-income and especially low-income rural areas, which is probably why ACF tries to use the Community Development Institute and similar outfits to plug gaps. If any readers have a good story to tell about recycling of Head Start grants, write a guest post and we’ll post it anonymously.

Need your Head Start, or any other proposal, written? Call us at 800.540.8906 ext. 2, or send an email to seliger@seliger.com.

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More networking, less working: DHHS’s “No Wrong Door Community Infrastructure Grants” RFP

The Administration for Community Living just issued an RFP for what appears to be a new grant program: No Wrong Door Community Infrastructure Grants, which offers grants “to support the development and enhancement of Network Lead Entities (NLEs) which are providing key access functions within a community such as coordination of information and referral, screening, care coordination, care transitions, eligibility and enrollment, and person centered planning.” If your eyes glaze over and you’ve quit reading already, I understand—all those verbs are abstract, and none say something like “construct new housing” or “offer opioid treatment.” They’re all process objectives and no outcome objectives; applicants don’t need to show or pretend to show that 70% of participants held a job six months after the end of project participation.

But if you’re a wily nonprofit executive director, you’re probably stroking your chin and thinking about whether you can round up a herd of partners to apply. No Wrong Door is mostly of interest because it appears to be a “walkin’ around money” program: applicants spend time “networking” and “building networks,” which usually means taking people out to lunch, holding catered meetings, strolling into other organizations with boxes of donuts, hiring new staff people (who can ideally do some direct service delivery as well, but quietly), and so on. At the end of the project, there’ll be a report describing how amazingly successful all that networking has been, and how the network will strengthen the community’s capacity to do all kinds of marvelous and wonderful things in the future, none of which are measurable. When the funding stops, ideally the staff will be trained to do some other useful stuff for the organization that hired it. That’s why this is walkin’ around money for nimble nonprofits that understand the word salad from the RFP quoted in the first paragraph.

A lot of organizations are really sustained with this kind of “glue” funding, which plugs other revenue gaps and allows it to operate more effectively than it would otherwise. Grants like No Wrong Door help pay for services to people whose reimbursements cover 85% of the costs—not 100%. Don’t be fooled by the No Wrong Door description. If you’re a nonprofit, and you can get some letters of support from the usual suspects in your service area, this is the kind of grant that’s easy to overlook but can be surprisingly valuable.

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Deciding on the grant proposal structure: ACF’s recent Early Head Start (EHS) application illustrates the challenge

Many RFPs don’t simply and directly state, “Use the following header pattern in your response to the narrative questions.” Why don’t funders tell applicants which header pattern to use? Bureaucracy, legal requirements, funder indifference, signaling: whatever the reason(s), we’ve run into a bunch of program RFPs recently that don’t explicitly state what headers should be used (like the Small Business Innovation and Research grants (SBIRs) we wrote about last week). In structuring responses to confusing RFPs, there are two main schools of thought: one is to use the general headers found in the RFP, and then reply to all the sub-questions in paragraph form. The other school of thought is to use the general headers and every sub-header found either the narrative instructions (if there are any) or the review instructions (if there are any of those). Neither approach is necessarily “right.”

The recent ACF Early Head Start (EHS) RFP, for which we just wrote a proposal, offers a good example of this challenge. Like SBIRs, the EHS RFP has, bafflingly, two sets of narrative instructions: on Adobe page 35, under “Approach” and the other on Adobe page 57, under “Application Review Criteria.” Neither is quite canonical—in other words, the instructions don’t say, in big bold type, “USE THIS HEADER SET.” Instead, ACF offers maddening ambiguity. Perhaps this maddening ambiguity is deliberate, but is more likely due to this fact: the folks who write the RFPs never write the proposals in response and, as bureaucrats, likely they simply don’t care.

Regardless, one has to decide whether it’s better to use just top-level outlines, like “1. Community Need and Objectives, 2. Program Design and Approach,” or sub-header outlines, like “1. Community Need and Objectives, a. the proposed service area and location(s) where services will be delivered.” We chose to mostly follow page 57, while still referencing material on page 35. As with SBIRs, though, there is no 100% right answer, because neither the NIH or ACF give applicants one—but both could reject applications that don’t follow the weakly specified instructions.

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HUD’s Lead Hazard Reduction grant program and the hazards of government autopilot

The NOFA for HUD’s Lead Hazard Reduction (LHR) grant program just came out, and it has $275 million to undertake, as usual, “comprehensive programs to identify and control lead-based paint hazards in eligible privately-owned target housing.” LHR NOFAs are issued every year or two, which is fine, but those of you who are alive and able to read or access the Internet are probably aware that there’s another health hazard out there this year, and it’s a health hazard that’s probably more urgent than lead-based paint—lead-based paint has been illegal in the US since 1980 and HUD’s been funding LHR grants for at least 30 years (we know, because we’ve written so many funded LHR proposals). It’s hard to believe that there’re all that many housing units left in the US with lead-based paint, but HUD soldiers on.

Sure, lead is a health hazard, but COVID-19 is also a health hazard; if I had to bet which one most persons would consider more hazardous right now, I’d bet on COVID-19. $275 million may be a small amount of money by federal standards, but I wonder how much the staff at HUD thought about whether public housing authorities (PHAs) and cities want to work on lead abatement this year, versus how much they’d like and need to work on COVID-19 abatement; $275 million can buy a lot of masks, education, and tests (although tests are still in short supply right now). It’s not really the fault of HUD bureaucrats, since LHR grants have been authorized by Congress for for decades and Congress usually just keeps funding programs like this, no matter what’s going on in the real world. Nonetheless, it would seem to me that a simple, bipartisan vote to amend the underlying legislation would be relatively easy—instead, LHR, at this point, is indicative of the dangers of government autopilot. Autopilot is fine in clear, consistent weather, but it can be disastrous during unpredictable storms—and the world has been hit by a storm in 2020.

I’m not presenting an argument against lead-hazard control: I don’t know enough to say whether lead-hazard control remains, in the absence of a pandemic, a (relatively) good idea or a (relatively—compared to other health-related activities) bad idea. I’ll posit, however, that a lot more people are going to die and suffer from COVID-19 this year, than will die or suffer from lead-based paint, and the failure to change course in the face of new events is evidence of deeper malaise.

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Generalized human and social services: ACF READY4Life and Fatherhood FIRE RFPs

Astute newsletter readers saw two useful Administration for Children and Families (ACF) Office of Family Assistance (OFA) RFPs with lots of money available (albeit with overly long names) in our last edition: Fatherhood – Family-focused, Interconnected, Resilient, and Essential (Fatherhood FIRE) and Relationships, Education, Advancement, and Development for Youth for Life (READY4Life). Both have grants to $1.5 million for family formation and resilience services. A phrase like “family formation and resilience services” should make smart nonprofit Executive Directors sit up and take notice, because we’ve seen fewer overt generalized human services grants over the past few years—the kind of grants that we sometimes call “walkin’ around money.

Smart organizations figure out that these kinds of grants can be used to fill in the cracks of an organization’s budget, because the project concepts that can be funded are broad. Also, in most cases, only a process evaluation (e.g., number of outreach contacts made, number of referrals, etc.) is feasible, since there’s usually no way to tract outcomes. In the ’90s and ’00s we saw more broad, general-purpose RFPs, but we’ve seen fewer since the Great Recession. The feds seem to have lost interest in many kinds of general-purpose grants and have instead been targeting particular services, like primary health care and job training.

Many organizations are already doing things like fatherhood and family development, but without calling their activities “fatherhood and family development.” Federally Qualified Health Centers (FQHCs), for example, often serve low-income patients who are impoverished by single parenthood, usually in a female-headed household. Nimble FQHCs should apply for READY4Life, Fatherhood FIRE, and similarly nebulous grant programs, since they can re-brand their existing Case Managers and Patient Navigators as “Family Support Coordinators” and “Parenting Specialists.” Obviously, the FQHC wouldn’t say as much in the proposal—that would be supplantation—but, in the real world, a lot of organizations keep their lights on and their clients happy using these strategies.

Organizations apart from FQHCs should be doing this too. Job training and homeless services providers, for example, often work with populations that need family reunification training, and the organizations are already often providing wraparound supportive services. Funders love synergistic proposals that say things like, “We’re going to do job training services for ex-offenders, and those ex-offenders will also be eligible for Fatherhood FIRE services in order to ensure that they remain in their children’s lives.”

Increased funding for generalized human services typically follows some kind of seismic societal shock. Seliger + Associates began in 1993, soon after the Rodney King verdict civil unrest, which was soon followed by the onset of mass school shootings with Columbine. Then came the Great Recession: the feds respond to social turmoil with huge new grant programs (21st Century Community Learning Centers was an example) and big budget increases for existing programs (like the 2009 Stimulus Bill). With the COVID-19 crisis, the cycle is repeating. Since March, three giant stimulus bills have been passed, with at least one more likely. The enormous civil unrest and protests unfolding after the recent police killing of George Floyd will likely lead to grant programs too; the feds’s objective is to get grants on the streets quickly to nonprofits, which act as a kind of buffer to politicians.

With growing “defund the police” sentiment in big, left-leaning cities, politicians are engaging in a sort of bidding war with proposed police budget cuts; politicians say some version of, “We want to redirect huge amounts of police budgets to solving the underlying problems that generate crime.” Translated, this means, “We plan to fund local nonprofits to conduct some kind of human services.”

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Foster Family Agencies (FFAs) and why political rhetoric rarely focuses on child abuse

Tyler Cowen asks an interesting question: “Why the low status of opposition to child abuse?” A reader speculates that, on the cultural left, “the highly visible progressive segment that drives wokeness, is culturally powerful, etc.” does not emphasize child abuse, and, “while there’s nothing obviously wrong with their attention to sexual and racial discrimination, the energy put into it is disproportionate to the massive social cost of child abuse.” One possible answer to this query is that, as Cowen posits, “virtually everyone is against child abuse, so opposing it doesn’t make anyone significant look worse.” Another reader lists some reasons the political right could be quiet, and he says that “you can’t even think of a solution [to child abuse] by reasoning from your political views.” I’d venture another component: detecting child abuse is frequently hard because it occurs inside the home and away from most eyes, plus, once it has been unambiguously detected—what then?

What’s the alternative when the family is abusive, or, more readily and frequently, borderline abusive? Many GWC readers already know that the existing foster family system (FFS) can be characterized in a variety of ways, but “harmonious, well-funded, and functional” are rarely among them. Something like “completely f-ed up” is probably more common, in candid conversation if not publicly.* Most foster “family parents” are in effect small businesses in that they receive monthly payments from the contracting foster family agency (FAA),** which are higher for higher-risk kids. With several high-risk kids in the household, monthly payments can rise into the thousands of dollars—the foster kids know this and know they are, in some respects, a commodity. Still, some foster parents are saints (if you are one or know one and you are about to leave a comment, let me say that I’m aware of great and loving foster families) but most are running a very small enterprise on a tight margin. Plus, as much as I hate to say it, some number of foster families are motivated by the the very unattractive, horrific, and illegal impulses that you might imagine motivate them. To counteract bad actors, one needs a whole massive bureaucratic oversight machine, which is itself expensive, invasive, and onerous—and it discourages the well-meaning people who might otherwise participate. Most of us don’t want our homes randomly invaded by snooping, judging strangers.

We’ve worked for many FFAs over the years, and every FFA has the same publicly stated goal, which is aligned with the mission of county child protective services agencies: to facilitate family reunification, whenever possible. Birth families and/or relatives have to be very bad for the kid(s) to be worse off than they are in foster care, given the well-known shortcomings of the FFS. The honest FFAs will admit as much, again off the record. For family reunification, DHHS even has an RFP on the street, “Quality Improvement Center on Family-Centered Reunification.” It only has one grant available, which means it’s wired, so we’re unlikely to write one of these, though we’ve written other proposals in this genre.

It’s also important to understand that FFAs are themselves thin-margin businesses, which are often organized as nonprofits in only the most nominal of senses. The FFS in most states uses contracts with FFAs that reimburse the FFAs for the actual number and types of kids placed and the length of the placement. It is in effect a reimbursed per-capita arrangement that incentivizes the FFA to keep their census of placements as high as possible to cover fixed costs like staff and endlessly recruiting, training, and monitoring foster families. The many things that can go wrong with this structure are fairly obvious.

I have seen occasional articles like “The Best Thing About Orphanages:”

Duke University researchers issued the first report on their multiyear study of 3,000 orphaned, abandoned and neglected children in developing countries in Africa and East and South Asia. About half were reared in small and large “institutions” (or orphanages) and half in “community” programs (kin and foster care). Contrary to conventional wisdom, the researchers found that children raised in orphanages by nonfamily members were no worse in their health, emotional and cognitive functioning, and physical growth than those cared for in their communities by relatives. More important, the orphanage-reared children performed better than their counterparts cared for by community strangers, which is commonly the case in foster-care programs.

I don’t have a final answer to this issue, but orphanages have such bad PR in the United States that I doubt they’ll ever be seriously tried. Any politician who seriously proposes trying them is going to be compared to a Dickens villain and will likely be courting career suicide (on the other hand, I never thought we’d see legal marijuana, and here we are). The last major politician to make a pitch for orphanages was Newt Gingrich in 1990s, and that went nowhere (“[Gingrich] dared to suggest that some welfare children would be better off in private orphanages. In making his off-the-cuff comments, he ignited a media and policy firestorm, the general tone of which was best captured by First Lady Hillary Rodham Clinton, who dubbed the idea ‘unbelievable and absurd'”). Still, given our work with FFAs, I would favor some experimentation in the direction of orphanages, as long as they were re-branded with some clever moniker (“Growth Homes?”). Having a large number of adults watching each other and the kids is probably at least not worse than the current system, although I don’t see orphanages as a panacea. There is no panacea and some problems lack solutions.

All the problems above around foster care enumerated above are only exacerbated by teenagers, who are technically legally “children” but who often have non-childish impulses, are hard to control, and often run away. Even a 13 or 14 year old boy can be six feet tall and weigh 160 pounds or more. Girls present a different set of challenges.

Ideally, most political stances come with a set of solutions, but orphanages have a bad rap, more money would help the current system without alleviating its most pressing problems, and abused kids and FFAs are not large enough interest groups for their votes to be salient to politicians. There are lots of problems that we as a society prefer to sweep under the rug and not think about—it appears, for example, that “Air Pollution Reduces IQ, a Lot.” We could fix a lot of air pollution by depreciating gasoline-powered cars, but most people would prefer to ignore the issue and the incredible damage we do to kids’s health through cars. Animal meat processing factories are another example: if you kick a dog in public, you might be arrested and charged with a crime, but most of us prefer to ignore the horrific things that happen in meat processing factories. Foster care is yet another area in which we hope for the best and prefer not to know too much about what’s really happening.

While I was writing the precursors to this post, I also realized something unusual about grant writing: I don’t know exactly how to describe the vantage point we have, but it’s not a common one: we’re in this purgatory that’s not where most people thinking about social science and government policy reside. We’re in an intellectual and observational place halfway between the on-the-ground implementers and the in-the-tower legislators and academics. We’re not called on to dream up new programs, ideas, problems, or data, like academics and legislators, but we’re also much closer to the problem space, while not being completely mired in immediate day-to-day experience. Because we’re at a higher level of abstraction than most implementers, we can see comparisons that on-the-ground people sometimes miss, while still seeing enough of the ground floor to have a better idea what’s going on than some academic/legislator-types do. Almost no one asks us what we’ve seen and what we can see across organization types—for example, at one point, “We imagined foundations would hire us to help improve RFPs/funding guidelines. We were wrong.” That essay was written in 2015 and since then, zero funders have sought feedback. I’m not sure what to do with this observation, apart from noting that we see some things other people miss.


* We learn many interesting things from clients, most of which we can’t say publicly. Silence is one of our virtues.

** You can tell that we’re dealing with government because of the number of acronyms in play.

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You’d think there’s no pandemic going on: The FCC shuts down its COVID-19 Telehealth grant submission portal

One of the bigger and more interesting RFPs on the street right now is the FCC’s “COVID-19 Telehealth Program,” which has $200 million available for obvious purposes—but grants are being accepted, reviewed, and approved on a first-come, first-served basis (federal RFPs usually have a fixed due date).* Lots of FQHCs are also implementing, or trying to implement, telehealth programs on the fly, since COVID-19 has hit them with a structural double whammy: patients with COVID-19 need to be isolated as much as possible from other patients, and other patients are avoiding health clinics for fear of catching COVID-19. This has had the unexpected side effect of lowering patient volumes at FQHCs, which, like other healthcare providers, have reacted by laying off staff. You’d intuitively think that, during a pandemic, the need for healthcare staff would expand, but that’s not happened outside of NYC intensive care units.

So the FCC program is designed to help FQHCs and other providers move relatively quickly to telehealth, which may help FQHCs achieve a higher patient volume. On Saturday we were working to backcheck a client’s online FCC application, since it’s our standard practice to make sure that applications are as complete and technically accurate as possible before client upload. But when we tried to log into the FCC’s application site, we were hit by a message telling us that the FCC had closed its application portal for maintenance. Is shutting a site down for “maintenance” still necessary in 2020? The error message felt very 2003, and, as you probably know, we’re in the midst of a pandemic, when every day counts. I guess FCC didn’t get the pandemic memo.

Eventually the site came back up, but its closure seems like a metaphor for many of the challenges we, as a society, are collectively facing from bureaucrats during these strangest of times.

The FCC COVID-19 Telehealth grant program is also unusual because it specifically says that applicants can only buy Internet-connected telehealth equipment—meaning blood pressure cuffs or pulse oximeters that automatically relay information to healthcare providers. I’ve seen budgets for how much these devices cost, and they’re crazy expensive, as most medical devices are. But: did you know that something as simple as an Apple Watch can function as a pulse oximeter—except that FDA regulations are blocking this use? This is the same FDA whose regulations stopped independent labs from rolling out virus testing in February. We try not to link outrage stories here, but it’s hard to read “The Infuriating Story of How the Government Stalled Coronavirus Testing” without being justifiably outraged.

Today, pointless FDA regulations are blocking people from using a relatively cheap and widely available device from being deployed in a medical context. Apple.com lists “Series 5” Apple Watches at $399 and they’re shipping today (there’s been a pulse ox shortage). Our FQHC clients already know this, but pulse oxes are useful for determining whether a COVID-19 patient needs to be hospitalized, or needs supplemental oxygen. Most COVID-19 patients can recover on their own without medical intervention, but low blood oxygenation is a key danger metric: a normal blood oxygenation level is around 95 – 100. If a patient’s oxygenation level consistently falls below 90, that patient likely needs advanced care. Most households have a thermometer, but relatively few have pulse oxes. Many COVID-19 patients are suffering from what doctors are calling “silent hypoxia,” in which the patient is essentially suffocating but doesn’t realize they’re suffocating, and pulse ox data can tell the patient whether they need to go in to see their doc or to an ER. It would be relatively easy for Apple to allow Apple Watch users to link their health data with a healthcare provider, and for the healthcare provider go get an alert if a patient’s blood oxygenation level drops below 92 or 90. Cheap solutions exist but the FDA keeps us from implementing them.


* Other federal departments have been funding similar telehealth-related grants programs: for example, the USDA has $40 million available via the “Distance Learning and Telemedicine Grants.” Those grants aren’t due until July 13, however.

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First SAMHSA COVID-19 FOA out,”Emergency COVID-19,” but the deadline is April 10

With the recent passage of the $2 trillion CARES Act to provide COVID-19 relief, we’ve been closely monitoring the issuance of RFPs. On April 2, SAMHSA issued its first FOA (SAMHSA-speak for RFP) under the Act, “Emergency Grants to Address Mental and Substance Use Disorders During COVID-19.” But the submission due date is April 10, which is just 8 days from the posting. This is a model for what other federal coronavirus-related RFPs will likely look like. Although the RFP length is long, most of the content is SAMHSA boilerplate, and the narrative only needs to be 10 pages. Projects are expected to start by May 31. A May 31 start date may seem slow in this time of war, but it’s incredibly fast by the standards of federal agencies.

Only states, territories, and Indian Tribes are eligible applicants. We’re pointing this program out because RFPs for which nonprofit and public agencies are eligible will likely follow in the coming days, issued from a variety of federal agencies. If you’re a nonprofit, you need to be ready to act fast. Some nonprofits aren’t poised to act. We got a query email, for example, from a nonprofit back on March 3. I sent a fee-quote letter and follow-up email that day. The nonprofit disappeared, then, on March 25, sent an email asking for a further call two to three weeks later. Six or more weeks to make a decision to apply may work in normal times, but a culture of inactivity during a crisis is a real liability.

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Don’t split target areas, but some programs, like HRSA’s Rural Health Network Development (RHND) Program, encourage cherry picking

In developing a grant proposal, one of the first issues is choosing the target area (or area of focus); the needs assessment is a key component of most grant proposals—but you can’t write the needs assessment without defining the target area. Without a target area, it’s not possible to craft data into the logic argument at is at the center of all needs assessments.

To make the needs assessment as tight and compelling as possible, we recommend that the target area be contiguous, if at all possible. Still, there are times when it is a good idea to split target areas—or it’s even required by the RFP.

Some federal programs, like YouthBuild, have highly structured, specific data requirements for such items as poverty level, high school graduation rate, youth unemployment rates, etc., with minimum thresholds for getting a certain number of points. Programs like YouthBuild mean that cherry picking zip codes or Census tracts can lead to a higher threshold score.

Many federal grant programs are aimed at “rural” target areas, although different federal agencies may use different definitions of what constitutes “rural”—or they provide little guidance as to what “rural” means. For example, HRSA just issued the FY ’20 NOFOs (Notice of Funding Opportunities—HRSA-speak for RFP) for the Rural Health Network Development Planning Program and the Rural Health Network Development Program.

Applicants for RHNDP and RHND must be a “Rural Health Network Development Program.” But, “If the applicant organization’s headquarters are located in a metropolitan or urban county, that also serves or has branches in a non-metropolitan or rural county, the applicant organization is not eligible solely because of the rural areas they serve, and must meet all other eligibility requirements.” Say what? And, applicants must also use the HRSA Tool to determine rural eligibility, based on “county or street address.” This being a HRSA tool, what HRSA thinks is rural may not match what anybody living there thinks. Residents of what has historically been a farm-trade small town might be surprised to learn that HRSA thinks they’re city folks, because the county seat population is slightly above a certain threshold, or expanding ex-urban development has been close enough to skew datasets from rural to nominally suburban or even urban.

Thus, while a contiguous target area is preferred, for NHNDP and RHND, you may find yourself in the data orchard picking cherries.

In most other cases, always try to avoid describing a target composed of the Towering Oaks neighborhood on the west side of Owatonna and the Scrubby Pines neighborhood on the east side, separated by the newly gentrified downtown in between. If you have a split target area, the needs assessment is going to be unnecessarily complex and may confuse the grant reviewers. You’ll find yourself writing something like, “the 2017 flood devastated the west side, which is very low-income community of color, while the Twinkie factory has brought new jobs to the east side, which is a white, working class neighborhood.” The data tables will be hard to structure and even harder to summarize in a way that makes it seem like the end of the world (always the goal in writing needs assessments).

Try to choose target area boundaries that conform to Census designations (e.g., Census tracts, Zip Codes, cities, etc.). Avoid target area boundaries like a school district enrollment area or a health district, which generally don’t conform to Census and other common data sets.