Interviews with city administrators, officials from other communities involved with the Massachusetts Prevention and Wellness Trust Fund grant and the state Department of Public Health paint a picture of general confusion dogging the administration of grant money intended to try innovative-but-unproven approaches to improving the health of underserved communities.
Mosaic Cultural Complex, a partner in the grant which spurred a city audit, has in the last several months found itself at the center of a web so tangled that City Manager Edward M. Augustus Jr. called Monday, Feb. 1, for state Attorney General Maura T. Healey’s office to intervene.
Karyn Clark, chief of Community Health for the city’s Division of Public Health, said late last week that difficulties surrounding Mosaic and others involved in the grant could be traced to its inception.
“It’s been a challenging grant from the beginning, and I think we all knew it would be. It’s a very complicated grant. These other pieces, obviously, are very concerning,” Clark said.
The city was tapped in January 2014 as coordinating partner for the disbursement of grant funds and selected the 11 partners from the Worcester area, including Mosaic, to provide the services.
“There were eight other cities and towns awarded grants from the trust fund. I don’t think everyone came to the table with everything. I think it was, you come with what your capacity is and then if you don’t have these certain pieces, then we will get people trained on these other components that are required in order to make it move forward,” Clark said.
The grant, which aims to lower the rates of the most common preventable diseases and to address health disparities, awarded Worcester $6 million over four years.
Since then, Mosaic Cultural Complex has received more than $200,000 in reimbursement checks from the city to pay workers for services provided in the community as outlined by the grant proposal.
Augustus put a stop to reimbursement checks to Mosaic in light of the state attorney general’s pending review and Mosaic’s inability to abide by the original contract with the city under the grant’s terms and submit payroll journals to prove it was paying its employees on a three-month cycle.
Augustus admits the city had previously been handling the administration of the grant unlike any other community partnership in the state, requiring documentation from its community partners that its employees were working and being paid for that work before reimbursing its partner organizations.
Much of the recent controversy revolving around Mosaic originates from the question of whether Mosaic is fulfilling its role as community partner in the area of clinical hypertension, specifically self-measured blood pressure monitoring.
Clark said Friday, Feb. 5, she’s not sure if there are any documents that prove Mosaic is holding any chronic disease self-management classes either.
“I don’t know if there’s any backup the city requires when the organization submits records for payment. From what I have seen, I don’t remember seeing them, but that doesn’t mean that it’s not there,” Clark said.
According to the 2014 Prevention and Wellness Trust Fund Legislative Report, Mosaic is the only community partner in the state covering all three clinical areas covered by the grant, including hypertension screening, chronic disease self-management, and self-measured blood pressure monitoring.
Scott Zoback, interim director of communications for the state Department of Public Health, said in an email that each grant partnership is only required to have one community partner for each of the “four priority conditions” the grant covers: hypertension, tobacco, pediatric asthma and fall risk assessment.
“The community partner requirement is by condition, not by intervention. So for hypertension, there must be a community partner – almost always found in the community intervention row of that condition,” Zoback said.
In other words, Mosaic could serve as the community partner for hypertension, but did not have to be responsible for all three areas of hypertension: screening, chronic disease self-management, and self-measured blood pressure monitoring.
If Mosaic was only listed as the community partner for the chronic disease self-management portion of hypertension [as it was when it applied to be part of the grant], that’s all the agency would have been responsible for. It did not need to take on the other components to be eligible to receive funds from the grant, according to the state DPH.
At the time the grant application was submitted by the city, Mosaic noted that the organization was only in position to offer chronic disease self-management programs under the hypertension area of its community-based partner profile.
So what might have gone wrong, and why all the confusion as to what Mosaic was responsible for under the grant?
“Basically, this grant is almost like a clinical trial,” Clark said. “It’s based on evidence-based models that marry the community and clinical piece. Usually, clinical and community don’t speak the same language. I think everyone knew setting [up] processes would be challenging, but that was expected. There’s a lot of things that have to be set up in order to make that happen.”
According to Clark, the state DPH was providing grant recipients training to meet the requirements of certain parts of the grant, but confusion could have set in immediately.
“In order to make the different models work with the conditions that were selected, each condition had to have clinical and community partners. My understanding all along is that for hypertension there has to be both [clinical and community]. And that’s the only component Mosaic is involved with,” Clark said.
Mosaic served as the community partner to clinical hypertension partners Edward M. Kennedy Center and Family Health Center Worcester.
According to Clark, Mosaic was supposed to be accepting referrals from the Kennedy Center and Family Health Center and also recruiting people to join in the intervention.
The clinical partners would identify a hypertension patient and, if the patient met certain criteria, the patient then was referred to Mosaic. Mosaic was responsible for reaching out to the community and finding people to participate, then holding classes on chronic pain self-management.
According to the city’s website, “clinical and community partners will engage patients with uncontrolled hypertension by teaching them to self-monitor the changes in their blood pressure. Patients will also learn about healthy living through [the] Stanford Model Chronic Disease Self-Management Programs (CDSMP) at local community-based organizations led by Mosaic Cultural Complex.”
Representatives from three other community partnerships in the state – Metrowest, New Bedford and Lynn – all told the Sun they were unsure of the relationship between clinical and community partners as spelled out in the 2014 legislative report.
Zoback said, “Under the model of the Prevention and Wellness Trust Fund, all grantees are required to have both community and clinical partners for any condition they are addressing, including hypertension. It is a priority of the trust fund to extend care into the communities in which individuals live, work and play.”
Clark said, “The bottom line is … there are some outcomes to be expected, but no one really knows because this [grant] has never been done before.”
A representative from the state DPH, which oversees the funding of the grant, said the DPH will not be involved with the attorney general’s investigation of payments made to Mosaic.
The grant contract and oversight, according to the state DPH, would be focused on the city and not any of the partner groups under the Worcester-area collaborative.