city response

City of Cincinnati Board of Health Health Department

William McHugh, D.M., Division Chief, Division of Prevention Ohio Department of Health 35 E. Chestnut St., 6th Floor Columbus, Ohio 43215

3101 Burnet Avenue Cincinnati, Ohio 45229-3098 Phone (513) 357-7280 NOBLE MASERU, Ph.D., MPH Health

Commissioner

November 10, 2011

RE: Review of the Cincinnati Health Department STD and HIV Competitive Grant Applications

Dear Dr. McHugh: This correspondence is a response to the conduct and decision rendered at yesterday's meeting regarding your office's review of our STD and HIV competitive grant applications, which were scored below the eligible numeric required for funding.

Needless to say, we were mortified that a decision to defund an STD program that has existed since 1981 would occur without the customary due process. And moreover that such a decision would be conveyed via a phone call. We were initially encouraged by your invitation to meet with us about the grant application on November 9th. Regrettably our expectation for due process was quickly erased.

The tone of the meeting was immediately established during the review of the Project Narrative: Formatting Section of the STD Prevention Program Application Review Form. When it was brought to the attention of the attendees and unanimously agreed, that some points were incorrectly scored, you emphatically stated that " ... scores will not be adjusted".

Furthermore, you stated that even with an acceptable score, our STD-HIV program does not merit funding because of past performance.

The principal concerns we have are in the following areas: A. Refusal to correct scores and computations that were determined incorrect.

B. Decision to defund a program that is not currently deficient or underperforming

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C. Reviewer inconsistency in scoring D. Operations impact of defunding the CHD STD-HIV Programs E. Public Health Impact ofthe Loss ofSTD and HIV Grants on our citizenry A. Refusal to correct scores and computations that were determined incorrect •

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We have detected an addition error in compilation of a final score, which worked to our detriment. The STD grant's final score was stated to be 69%; but sum of the total scores on the STD Application Review Form work sheets actually adds up to 71%. We were astounded when you exclaimed that ODH would not correct demonstrated errors.

We have provided in the attached documentation evidence of scoring errors and review irregularities, which, if they had been corrected, would have pushed our STD grant score into the acceptable funding range.

We have provided evidence that a misinterpretation ofthe requirements for Appendix I was the result of our losing 20 points, which if we had received those points would have put us very close to the acceptable funding range for the HIV grant. Given that there was no other applicant in Hamilton County, there would not be harm to any applicant if we were simply allowed to submit the information that deemed missing in Appendix I.

B. Decision to defund a program that is not currently deficient or underperforming compared to other regions •

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While we were subject to a corrective action plan and special conditions related to budget revisions and changes in our personnel and staffmg, our plans were submitted and accepted. We received no further adjustment or comments from the project officer with respect to the performance improvement plan.

We have provided documentation that the annual performance measures for 2010 for all of the regions show that CHD was a mid-level performer, higher than at least five other regions that received 2012 funding (see attachment). Ifprior performance was used as part ofthe review, we met 29% of the performance measures in January - June 2010 and 38% ofthe performance measures in JulyDecember 2010. This information about 2010 comparative performance was evidently not considered in the review.

All special conditions that related to budgetary reporting and clinic staffmg issues were resolved as of August 2011, and there were no special conditions that remained to be addressed at the time of the grant submission.

C. Reviewer inconsistency in scoring There was inconsistency in some of the scores assigned by the reviewer "JK" to CHD compared to other applicants. For example, we were given a score of2 for each of the five SMART objectives, with a comment "SMART objectives need to be revised" despite the fact that our format mirrored exactly the sample SMART objective format provided as an example in the RFP. However, Summit County for whom "JK" wrote

that "the objectives needed to be rewritten as SMART objectives", received scores of 3-5 points per objective.

D. Operations impact of defunding the CHD STD-HIV Programs Logistically, if the decision to not fund our program is effective December 31, 2011 but the successful applicant will not be identified until the first week of December, a transition that is started and completed within 3 weeks during the holiday season is guaranteed to cause disruption in provision of services to this high needs community.

This disruption can be expected to last for at least 3-4 months, and may last 6 months or longer, due to the following considerations: • It will be very difficult for any public agency to develop, advertise, compete, and implement contracts within 3 weeks during the holiday season, much less someone corning from an entirely different health district with no knowledge of the agencies, community organizations, neighborhoods and populations in this area.

• There will need to be training of any staffthat will be hired as DIS officers.

While we would hope that a contract could be developed to use our staff, it is a fact that our staff are City employees who may not choose to leave city employment to act as DIS officers if no contract is available.

• Patient follow-up and care will have to be determined for all patients identified between now and December 31, to avoid having any patient that falls between the cracks. Issues include: o Tracking and receipt ofpending Laboratory results o Case reviews for pending cases o Partner notification o Organizational tree for follow ups o Relations with other providers in the community, for example providers treating prenatal patients for congenital syphilis •

CHD provides a total of$1.2 million dollars in funding for STD Control and Prevention above and beyond the ODH STD-HIV grant. This funding covers the following: Staffing 1 physician 3 nurses 3 support staff 1 health counselor Occupancy costs Testing Costs at CHD 5 Health Centers 28,000 STI tests at $12.00 per test (annual cost of$336,000)

E. Public Health Impact of the loss of STD and HIV Grants to the Cincinnati Health Department and our citizenry The STD Clinic at the Cincinnati Health Department has worked cooperatively with the University Hospital STD/HIV Disease Investigation Unit to provide rapid evaluation, treatment, and case management of patients with Syphilis in the Southwest Region of Ohio. The Cincinnati Health Department has also been able to set up effective community partnerships to provide HIV counseling and testing throughout the region.

The Cincinnati Health Department has been the recipient of the STD and HIV Grants for the Southwest Region ofthe state of Ohio for several years. Hamilton County has high numbers of cases ofSTDs, with 6380 cases of Chlamydia and 2510 cases of Gonorrhea reported in 2010. Hamilton County has also been in an outbreak of Syphilis cases, similar to two other counties, with 176 cases in 2009 and 257 cases in 2010. Thus far, in 2011, the number of cases has started to trend downwards, with 178 cases in the first nine months (annualizing to 237 cases in 2011). A change in the STD Grantee can lead to a loss of this momentum for controlling the syphilis outbreak.

In summary, given the irregularities in review scoring, the refusal to correct errors in calculation, in addition to reviewer inconsistency that we have documented above, we believe that as a currently funded program since 1981 that had 2010 annual performance measures that were better than half of the programs to be funded in 2012, that our STDHIV program should not be defunded.

It is our sincere hope that this delineation of the concerns will aid in your understanding of why we are requesting that the STD-HIV program not be defunded, or at least that this program can be funded on a probational basis under contract for 1 year.

ResPAfullrub~'tted'

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Noble Maseru, P .D., Commissioner Cc:

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Mr. Steven R. Wermuth Dr. Ted E. Wymyslo Ms. Melissa Bacon Dr. Wael Safi Mr. Howard Bond Ms. Joyce Tate

Attachments 1. Disease Performance Measures 2. Performance Measures- Page 2 3. 2012 Cincinnati HIV Score Sheet 4. 2012 Cincinnati STD Score Sheet 5. A Representative Illustration of a Scoring Error