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An Act To Save Lives by Establishing a Homeless Opioid Users Service Engagement Program within the Department of Health and Human Services
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  22 MRSA §2354  is enacted to read:
§ 2354. Homeless opioid users service engagement program
There is established within the department a homeless opioid users service engagement program to provide 50 opioid users who are among the most vulnerable and unstable in the State rapid access to low-barrier treatment for substance use disorder and stable housing to support their recovery.
 
1.  Definitions.     For purposes of this section, the following terms have the following meanings.
 
A.  "Individuals who are experiencing homelessness" means adults, unaccompanied youth and families with children who lack a fixed, regular and adequate nighttime residence or who are at risk of imminently losing their primary nighttime residence including those who are sharing another person's dwelling on a temporary basis under which permission to remain is contingent upon the hospitality of the primary leaseholder or owner and can be rescinded at any time without notice. "Individuals who are experiencing homelessness" includes individuals and families who are fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking or another dangerous or life-threatening situation involving violence against the individual or a member of the family. "Individuals who are experiencing homelessness" also includes individuals who are exiting an institution where the individual resided for 90 or fewer days and who resided in an emergency shelter or place not meant for human habitation immediately before entering the institution.
 
B.  "Lead provider" means a social service or health care provider that is selected by the department and that executes a social service contract with the department to implement the program.
 
C.  "Medication-assisted treatment" means the evidence-based, whole-patient approach to the treatment of substance use disorder that combines counseling and behavioral therapies with medications approved by the federal Food and Drug Administration for the treatment of substance use disorder, such as buprenorphine and naloxone combination drugs, methadone or naltrexone.
 
D.  "Partner provider" means a social service or health care provider with expertise in all or a portion of the services provided in the program and that executes a subcontract with a lead provider to provide those services.
 
E.  "Program" means the homeless opioid users service engagement program established in this section.
 
F.  "Recovery" means a process of change through which an individual improves the individual's health and wellness, lives a self-directed life and strives to reach the individual's full potential.
 
2.  Social service contracts.     The department shall issue a request for proposals and implement the program through social service contracts.
 
3.  Service location.     The program must provide services in both an urban area and a rural area of the State where social service and health care providers who can successfully implement the program are located. In selecting the areas of the State, the department shall determine which areas of the State have the greatest need based upon the geographic location of opioid users who are individuals who are experiencing homelessness and the extent of emergency services use by those individuals. The department may select one lead provider to implement the program in both the urban area and the rural area or it may select separate lead providers for the urban area and the rural area.
 
4.  Lead providers.     The lead provider or providers with which the department executes social service contracts are responsible for implementing the program and accounting for program funds. To qualify for selection by the department as a lead provider, a social service or health care provider must demonstrate the ability to implement all aspects of the program successfully. A lead provider may subcontract with partner providers to implement portions of the program services that are within the partner providers' expertise. At a minimum, the lead provider and its partner providers shall demonstrate successful experience in the following activities:
 
A.  Engaging with individuals who are experiencing homelessness and who use opioids in the State;
 
B.  Administering medication-assisted treatment to vulnerable populations; and
 
C.  Providing housing support services to individuals who are experiencing homelessness.
 
5.  Program design and implementation.     To the extent permitted by resources allocated to the program, the program must be designed and implemented as described in this subsection.
 
A.  The program must assist participants in attaining and sustaining recovery, minimize the risk of opiate poisoning among participants and decrease the likelihood of diversion of buprenorphine by increasing participants' access to stable and supportive housing, connecting participants with the recovery community and its resources and providing participants with a safe environment in which the participants can identify individualized short-term and long-term goals and develop new skills to support their recovery.
 
B.  To participate in the program, an individual must be an individual who is experiencing homelessness, have a history of drug overdose and meet the criteria for physiological dependence on opioids in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, published by the American Psychiatric Association. The program must give priority to individuals who are being discharged from incarceration or long-term hospitalization due to complications related to substance use disorder.
 
The program must include intensive outreach using a collaborative team case review approach to identify and recruit participants. An individual selected for the program who chooses to participate in the program shall sign a written agreement that explains the requirements for program participation and authorizes initiation of case management and treatment services as well as a release authorizing members of the program team to share information regularly regarding the participant's progress in recovery and in attaining individual goals. Participants shall also complete initial assessments regarding substance use disorder, physical health and psychosocial and psychiatric needs as soon as possible.
 
C.  Although a lead provider may adapt the structure of the program to meet the needs of the rural area or urban area it serves, the program must include medication-assisted treatment, intensive case management and immediate access to stable housing as described in this paragraph.
 
(1) The program must provide participants with medication-assisted treatment in accordance with this subparagraph that is initiated within 48 hours of each participant's enrollment in the program. The program must seek reimbursement from the MaineCare program for medication-assisted treatment services whenever possible. The lead provider or partner provider shall employ a medical professional authorized to prescribe for each participant a medication approved by the federal Food and Drug Administration for the treatment of substance use disorder that, in the professional's opinion, is most appropriate given the participant's current medications, substance use and medical history. The authorized prescriber shall take primary responsibility for managing and refilling the prescription.
 
The lead provider or partner provider shall establish a collaborative, interagency staffing model of medication-assisted treatment that includes, to the extent resources permit, the authorized prescriber, a nurse care manager, a licensed clinical social worker or licensed alcohol and drug counselor, a certified psychiatric mental health nurse practitioner and a peer support specialist who meet regularly to plan participant services, review participant progress and implement reenrollment strategies when necessary. The lead provider or partner provider shall use a shared medical appointment model for medication-assisted treatment that supports participants in decreasing the use of illegal drugs and drugs that are not prescribed to the participant by delivering the following:
 
(a) Office-based, daily observed medication administration to participants;
 
(b) The opportunity to participate in individual and group psychotherapy, pharmacotherapy and support groups;
 
(c) Random drug testing of participants;
 
(d) Ongoing evaluations of participants to optimize treatment, including assessments of psychosocial needs and referrals for psychiatric assessments or treatment as necessary; and
 
(e) Treatment of participants' concomitant psychiatric disorders that either complicate the participants' substance use disorder or act as triggers for relapse.
 
(2) The program must provide participants with intensive case management designed to provide an intensive, comprehensive range of community-based services to address the physical and behavioral health needs of participants and support their compliance with medication-assisted treatment and other services necessary to recovery.
 
The lead provider or partner provider shall establish an intensive case management team that includes, to the extent resources permit, an intensive case management team supervisor, case managers, a housing liaison, a transition liaison and peer support specialists. The intensive case management team shall provide intensive outreach, assessment, care coordination, advocacy, support, planning and facilitation of services to meet each participant's comprehensive mental health, medical and dental health needs while reducing redundant services and supporting participants in achieving the following goals:
 
(a) Acquiring medical care and material resources, including, but not limited to, food, shelter and clothing;
 
(b) Improving psychosocial functioning and developing greater autonomy;
 
(c) Developing coping and problem-solving skills;
 
(d) Developing a community support system to help participants meet the demands of community life; and
 
(e) Accessing benefits and services for which participants may qualify, including, but not limited to, housing, medical, behavioral health, employment, education, supplemental income, transportation, utility and community and family integration services.
 
The peer support specialist shall serve as a role model and shall provide one-on-one peer support services to assist participants in reducing harmful behaviors, to identify participants' strengths and skills that can help reduce illegal substance use and to develop participants' recovery goals. The peer support specialist shall also coordinate and facilitate peer recovery groups.
 
The transition liaison shall assist participants who are transitioning out of incarceration or hospitalization. The transition liaison shall recruit individuals who are incarcerated or hospitalized and who expect to be discharged soon for participation in the program and assist those individuals with the enrollment process. The transition liaison also shall coordinate with staff from the correctional or medical facility to facilitate participants' smooth transition from the facility. To the extent practicable, the transition liaison shall ensure that participants have access to housing immediately upon discharge from a correctional or medical facility.
 
(3) The program shall provide participants with immediate and continued access to stable housing that promotes recovery, independence and harm reduction. The intensive case management team shall identify appropriate housing placements for participants, which may include, but are not limited to, housing first developments, which are developments prioritizing providing permanent housing to individuals experiencing homelessness, recovery residences, private nonmedical institutions and private apartments. The intensive case management team shall collaborate with local housing authorities, affordable housing developers, municipal general assistance offices and housing voucher administrators to provide program participants with priority in accessing these placements.
 
The lead provider or a partner provider shall administer a housing assistance fund to provide participants with immediate access to stable housing. The housing assistance fund must contain sufficient capital to provide all program participants with 5 months of rent at fair market value based on the location of the housing. The lead provider or partner provider may provide a participant with more or less than 5 months of financial assistance from the housing assistance fund, depending on the participant's individual need for financial assistance to achieve housing stability.
 
While participants receive financial assistance from the housing assistance fund, the intensive case management team shall assist participants in securing an alternative financial resource or resources for housing, including but not limited to employment, general assistance, the Bridging Rental Assistance Program established in Title 34-B, section 3011, the federal shelter plus care program authorized by the federal McKinney-Vento Homeless Assistance Act, Public Law 100-77, as amended by the federal Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009, Public Law 111-22, Division B (2009) and housing choice vouchers under Section 8 of the United States Housing Act of 1937, Public Law 75-412, 50 Stat. 888, as amended.
 
D.  A participant may withdraw from the program at any time. The lead provider or a partner provider shall reevaluate each participant's enrollment in the program every month. A participant may receive services from the program for the length of time necessary for the participant to successfully complete the program or to transition to a less intensive model of treatment when considered clinically appropriate. In determining whether a participant has successfully completed the program or may transition to a less intensive model of treatment, the lead provider or partner provider shall consider the participant's sustained abstinence from illegal substance and alcohol use, employment or involvement in other meaningful community activities, psychosocial supports and willingness to participate in further treatment to maintain recovery.
 
Alternatively, a participant may be discharged from the program if the lead provider or a partner provider determines that the program is unable to provide appropriate services due to the participant's physical or mental health or continued illegal substance use.
 
6.  Program evaluation.     Annually the lead provider shall contract with an independent entity to conduct a rigorous evaluation of the program implemented by that lead provider, including a cost-benefit analysis, in order to inform future interventions and provide a model that can be replicated throughout the State. The independent entity shall consider, at a minimum, the following information in conducting the evaluation:
 
A.  The extent of participant engagement in medication-assisted treatment, maintenance of stable housing, achievement of employment or engagement in community volunteer positions and reconnection with family;
 
B.  The number of overdose incidents, the level of involvement with the criminal justice system and law enforcement and the extent of use of emergency medical services including emergency medical response, crisis intervention services, emergency shelter or food resources and inpatient hospital stays for participants during the evaluation period as compared to the year before the evaluation period began; and
 
C.  The number of participants who withdrew from the program voluntarily, who were discharged after successful completion of the program and who were discharged because the program could no longer provide appropriate services.
 
7.  Report.     The department shall report to the joint standing committee of the Legislature having jurisdiction over health and human services matters regarding the program by March 15, 2020 and each year thereafter. The joint standing committee may submit legislation regarding the program, including legislation to continue or expand the program.
Sec. 2. Authority to submit legislation. The joint standing committee of the Legislature having jurisdiction over health and human services matters may submit legislation regarding the homeless opioid users service engagement program established in the Maine Revised Statutes, Title 22, section 2354 to the Second Regular Session of the 129th Legislature.
 
SUMMARY
This bill establishes within the Department of Health and Human Services a program to provide rapid access to low-barrier treatment for substance use disorders and stable housing to support recovery and create stability for 50 opioid users who are among the most vulnerable and unstable in the State. The bill details the program objectives, eligibility criteria for program participants and services that must be provided to those participants, including medication-assisted treatment, intensive case management services and financial and case management assistance to ensure immediate and continued access to stable housing. The bill requires an independent evaluation of the program and directs the department to submit a report to the joint standing committee of the Legislature having jurisdiction over health and human services matters regarding the program by March 15, 2020 and annually thereafter. The joint standing committee is authorized to submit legislation regarding the program.