NOFO: MMHU-2

C.1. Background

In 2013, 1,072 people in Illinois died of an opioid overdose.[1] In 2020, the number of fatal overdoses reached 2,000, and in 2021 and 2022, surpassed 3,000.[2] The opioid overdose epidemic has accelerated nationwide.[3] To hold companies responsible for their roles in the opioid crisis, the Illinois Attorney General has engaged in multiple investigations, lawsuits, and settlements with opioid manufacturers, distributors, and chain pharmacies. The funds from the settlements will support recovery in communities hardest hit by the opioid crisis and throughout the state.

The Illinois Office of Opioid Settlement Administration (OOSA) is the entity responsible for planning, administering, and managing 55 percent of the funds received from opioid settlements according to the Illinois Opioid Allocation Agreement and Executive Order 2022-19. The established processes ensure transparency and consideration of regional needs such as overdose rates, disparities created for specific populations, and resources to address opioid-related harms. OOSA is housed within IDHS/SUPR.

About IDHS/SUPR

The mission of IDHS/SUPR is to provide a recovery-oriented system of care along the continuum of prevention, intervention, treatment, and recovery support where individuals with SUD, those in recovery, and those at risk are valued and treated with dignity and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated. IDHS/SUPR is working to counteract systemic racism and inequity and to prioritize and maximize diversity throughout its service provision process. This work addresses existing institutionalized inequities, aims to create transformation, and operationalizes equity and racial and social justice. It also focuses on creating a culture of inclusivity for all, regardless of race, gender, religion, sexual orientation, or ability.

Funding Source

The Office of the Illinois Attorney General has certified—and the Governor’s Opioid Overdose Prevention and Recovery Steering Committee has approved—the use of up to $15 million from the Illinois Opioid Remediation State Trust Fund (Fund) for MMHU-2 services for priority populations in accordance with the Illinois Opioid Allocation Agreement and the Fund allocation process. In April 2023, IDHS/SUPR awarded Advocates for Human Potential, Inc. (AHP) a grant to serve as the RCCA. The RCCA administers subawards with organizations providing prevention, intervention, treatment, and harm reduction services for people with SUD in accordance with state-approved strategies.

C.2. Need

The funds from the settlements will support prevention efforts in communities hardest hit by the opioid crisis and throughout the state. Fund distributions must be used equitably in service areas disproportionately affected by the opioid crisis as outlined in the Illinois Opioid Allocation Agreement, for example, areas with the following characteristics:

• High opioid fatality rates, including
  • Counties other than Cook County with a crude rate of 1.8 or greater per 100,000 people and
  • Zip codes within Cook County with more than 100 overdoses (fatal and nonfatal) within the most recent year included in the Illinois Opioid Data Dashboard, http://idph.illinois.gov/opioiddatadashboard/

• Concentrated poverty, including
  • Counties other than Cook County with a poverty rate greater than 12 percent and
  • Zip codes within Cook County with a poverty rate greater than 12 percent, per the U.S. Census Bureau, https://www.census.gov/quickfacts/fact/map/IL/

• Concentrated firearm violence, including communities eligible for Reimagine Public Safety Act funding, https://www.dhs.state.il.us/page.aspx?item=144282

• Other conditions that hinder the communities from reaching their full potential for health and well-being, including counties other than Cook with a crude nonfatal overdose rate of 4.0 or greater per 100,000 people, as listed in the Illinois Opioid Data Dashboard, http://idph.illinois.gov/opioiddatadashboard/

Access to health care, including MAR, is challenging to many populations, and these priority populations are often those who are most in need, as described below:

• About one in nine people experiencing homelessness in Illinois has a chronic SUD.[4] Individuals experiencing homelessness are at greater risk for disease and untreated wounds, yet high costs, lack of health insurance, and transportation issues prevent proper medical care. [5,6,7]

• Two-thirds of individuals sentenced to jail have an SUD, and very few participate in any form of drug treatment during incarceration.[8] The first two weeks following release hold significant risk of overdose death.[9] More likely than the  general population to have a chronic condition, such as high blood pressure,[10] individuals who were formerly incarcerated face competing demands of securing housing, employment, and health care, often with little to no fiscal or social support.

• Individuals in geographically hard-to-reach communities encounter barriers unique to their location. In Illinois’ rural counties, distance to emergency services or health care facilities may be too far to render timely treatment for overdose. Moreover, rural hospitals may not be as well prepared as their urban counterparts to handle the opioid crisis.[11]

• Social determinants of health pose barriers to wellness and recovery, predominantly for the Black population, who have the highest rate of poverty and unemployment.[12] The non-Hispanic Black population has the highest overdose fatality rate in all age groups except 25-34.[13]

Mobile health units are an increasingly effective way to overcome barriers to accessing MAR by bringing services to individuals in their community. Models include van-based care stationed outside of correctional facilities in Baltimore and integration of buprenorphine maintenance therapy into preexisting harm reduction programs in Philadelphia and Seattle. In Seattle, many program participants enrolled in the buprenorphine program were retained in treatment and reduced opioid use, despite housing instability and polysubstance use. Successful pilots of MMHU-2s have been conducted in Chicago. These pilots provide all forms of MAR to individuals with OUD, as well as recovery support and harm reduction services.

C.3. Scope of Services

Objectives of MMHU-2 funding are to ensure that (1) patients within the priority populations receive immediate care for acute and chronic conditions, including SUD/OUD, wherever it is sought in the service area and (2) transitions to additional recovery services are managed and supported.

This funding opportunity will prioritize services to be delivered to and within the following IDPH regions: West Chicago, Peoria, Champaign, and Metro East. Services to other regions and communities will be considered.

The tasks required and associated performance measures, standards, and potential metrics to be collected are as follows:

Task 1. Fulfill Award Administration Requirements

The subrecipient must fulfill obligations outlined in H.8. Reporting and Grants Administration Requirements, including

a) Organizational needs assessment,

b) Implementation and sustainability plan development,

c) Equity and racial justice plan development,

d) Performance reporting,

e) Fiscal reporting, and

f) Participating in training and technical assistance (TTA).

Task 2. Conduct Assessment Activities

The subrecipient must assess the needs of individuals seeking MMHU-2 services from within and around the targeted community or location of the sub-population (e.g., homeless community). The assessment should evaluate health disparities and the related social and economic inequities that impact access to and need for services, as well as availability of SUD treatment provider organizations, Recovery-oriented Systems of Care, and recovery homes. Within 60 days of award, the subrecipient must

a) Conduct an environmental scan and analysis of Strengths, Weaknesses, Opportunities, and Threats (SWOT) in the communities where the MMHU-2 will operate that meet the above criteria, and

b) Submit a comprehensive written report detailing the results.

Task 3. Plan MMHU-2 Services

Within 180 days of award, the subrecipient must

a) Develop and submit an implementation plan that includes the timeline and process to accomplish the following activities within the first 12 months of the award:

• • Licensing to enable the MMHU-2 to dispense the three forms of U.S. Food and Drug Administration (FDA)-approved OUD medications (buprenorphine, naltrexone, and methadone). Please note further details on medication dispensation in Task 4; there is no set timeline for methadone. The licensure process should be initiated prior to submission of the plan.
  • Acquisition/lease of the vehicle(s), such as vans or buses customized for providing services.
  • Staffing/personnel to support the MMHU-2.
  • Delivery of services. Describe the services to be provided, location(s) where they are to be provided, and frequency of provision.
  • Collaboration with oversight entities, including but not limited to the U.S. Drug Enforcement Agency (DEA) and SUPR.
  • A budget for the projected medication and services not otherwise funded through health insurance, IDHS/SUPR, other government grants, or correctional institutions/jails.

b) Develop policies and procedures to guide program activities that, at a minimum, adhere to the following IDHS/SUPR and DEA requirements:

• • Adherence to the DEA definition of “motor vehicle’’ as a vehicle propelled under its own motive power and lawfully used on public streets, roads, or highways with more than three wheels in contact with the ground; a motor vehicle does not include a trailer in this context.
  • Possession of valid county/city and state information (e.g., a vehicle information number (VIN) or license plate number) on file at the OTP registered location.
  • Maintenance of narcotic drugs in schedules II–V only from the registered OTP location.
  • Maintenance of a storage area for controlled substances in the Mobile OTP that is not accessible from outside the vehicle.
  • Maintenance of a safe, bolted or cemented to the floor or wall, in such a way that it cannot be readily moved to ensure all controlled substances on the Mobile OTP are securely locked.
  • Maintenance of a safe on the Mobile OTP equipped with an alarm system that transmits a signal directly to a central protection company or a local or State police agency, which has a legal duty to respond, or a 24-hour control station operated by the registrant.
  • Returning the Mobile OTP to the registered program location each day and remove and secure the controlled substances inside the registered location. (If the applicant is unable to meet this requirement, please submit a separate exception request for DEA approval).
  • Identification and use of a secure location to store the MMHU-2 on overnight/weekends.
  • Maintenance of a log with information on dispensed controlled substances (dose dispensed, patient, date and time, etc.). The log must be stored at the registered program location.
  • Maintenance of an electronic log, if applicable, that the DEA has preapproved.
  • Maintenance of a hard copy (printed version of the electronic log) each day with each entry initialed by the physician who dispensed the controlled substance.
  • Maintenance of and adherence to protocols for the controlled substances on the MMHU-2 that are secure and accounted for in the event that the mobile component is disabled for any reason (mechanical failure, accident, fire, etc.).
  • Maintenance of and adherence to protocols in place to return to registered location in the event of an unannounced DEA/State inspection.
  • Maintenance of and adherence to protocols in place to ensure services are uninterrupted (i.e., weather, breakdown of unit).
  • Maintenance of and adherence to protocols that ensure that narcotic drugs are safely returned to the DEA registrant’s program location if there is an unforeseen breakdown of the MMHU-2.
  • Maintenance of and adherence to protocols that, at minimum, ensure that any security breach on the MMHU-2 is immediately reported to the DEA and IDHS/SUPR.
  • Maintenance of and adherence to protocols and logs to track any damaged/lost/stolen medication.
  • Maintenance of and adherence to a diversion prevention protocol approved by IDHS/SUPR.

Task 4. Launch the MMHU-2

Within 365 days of award, the subrecipient must launch the MMHU with capacity to:

a) Prescribe and/or dispense at least two of the three FDA-approved medications.

NOTE: One of those medications must be methadone (dispense) or buprenorphine (dispense or prescribe). Due to the complexities associated with dispensation of methadone, no time frame is required. If prescribing, case management services must be provided to assist patient in obtaining medication, and receipt of medication must be confirmed in outcome measures.

b) (Optional, but preferred) Provide and log other services to support successful patient outcomes, to one or more of the priority populations identified above. Other services include:

• • b1. Harm reduction* (including naloxone and overdose prevention education)
  • b2. Recovery support services*
  • b3. Treatment services*
  • b4. Community education and referral services
  • b5. Primary health services
  • b6. Other (e.g., HIV/AIDS prevention services)

The subrecipient must also:

c) Post and maintain the MMHU-2’s schedule and location/route of services on the IL Opioid Helpline.

*Services identified with an asterisk must adhere to IDHS/SUPR requirements as outlined in Administrative Rule, Part 2060 or be connected with an IDHS/SUPR program (e.g., Drug Overdose Prevention Program). Other services may also be required to adhere to requirements of other state agencies’ administrative rules or federal regulations.

Task 5. Build Community Support

Throughout the planning and implementation of the project, the subrecipient will:

a) Conduct engagement activities to gain buy-in and obtain letters of support for the MMHU-2 from stakeholders who are essential to the delivery of MMHU-2 services and to address any community concerns about the MMHU-2 services located within the community.

C.4. Deliverables and Performance Measures

The following table details (a) the deliverables required according to the scope of services and (b) associated performance measures, standards, and potential metrics (subject to change) to be collected by task. Time periods refer to the days from the beginning of the period of performance. Standards for activities refer to percentages of those described in the project plan.

C.5. Funding Details

This funding can be used to lease vehicles such as vans/buses customized for the provision of services, staff/personnel, medication, and services that are not otherwise funded through health insurance, IDHS/SUPR or other government grants or correctional institutions/jails.

Allowable Costs

Allowable costs are those that are necessary and reasonable based on the activity contained in the statement of work (SOW), are justified in the Budget Narrative, and are allowable under Subpart E of 2 CFR 200. It is expected that administrative costs, both direct and indirect, will represent a small portion of the overall program budget. Any budget deemed to include inappropriate or excessive administrative costs will not be approved. Program budgets and narratives must detail how all proposed expenditures are necessary for program implementation.

Unallowable Costs

Refer to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Part 200 Subpart E – Cost Principles to determine the appropriateness of costs. In addition, and specific to this grant, the following costs will be unallowable without specific prior written approval:

• Entertainment costs, except where specific costs that might otherwise be considered entertainment have a programmatic purpose and are authorized in the approved budget (2 CFR 200.438)
• Capital expenditures for general purpose equipment, including any vehicle regardless of cost, buildings, and land (2 CFR 200.439)
• Capital expenditures for improvements to land, buildings, or equipment that materially increase their value or useful life (2 CFR 200.439)
• Food and other goods or services for personal use of the grantee’s employees, contractors, or consultants unless authorized as per diem under the Illinois Governor’s Travel Control Board (2 CFR 200.445)
• Deposits for items, services, or space
• Dues to societies, organizations, or federations
• Meetings or conventions, unless directly related to the program and approved in advance by the RCCA
• Alcoholic beverages
• Cash payments to intended recipients of services
• Purchase or repair of vehicles
• Lobbying, political contributions, or compensation of a government body
• Fundraising
• Bad debt, fines, or penalties
• Personal-use items, including expenses related to personal use of vehicles
• Unallowable relocation expenses
• Related-party transactions
• Any other costs not approved in the plan and budget

Please refer to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Part 200 Subpart E – Cost Principles to determine the appropriateness of costs.

Indirect Cost Rate

To charge indirect costs to this grant, the applicant organization must (1) have a federal annually negotiated indirect cost rate agreement (NICRA) or must (2) elect to use the de minimis rate.

Indirect Cost Rate Election

• Federally Negotiated Rate: Organizations that receive direct federal funding may have an indirect cost rate that was negotiated with a federal cognizant agency. The organization must provide a copy of the federal NICRA. Organizations must notify the RCCA of any changes to their previously established NICRA no later than 6 months after the close of the organization’s fiscal year.
• de minimis Rate: An organization may elect a de minimis rate of up to fifteen (15) percent of modified total direct cost (MTDC).** Once established, the de minimis rate may be used indefinitely. If programs elect to use the de minimis rate, it is critical that program budgets accurately calculate the MTDC base. Please see the regulation below and note the exclusions to MTDC.

**2 CFR 200.1, Modified Total Direct Costs, means “all direct salaries and wages, applicable fringe benefits, materials and supplies, services, travel, and up to the first $50,000 of each subaward (regardless of the period of performance of the subawards under the award). MTDC excludes equipment, capital expenditures, charges for patient care, rental costs, tuition remission, scholarships and fellowships, participant support costs, and the portion of each subaward in excess of $50,000. Other items may only be excluded when necessary to avoid a serious inequity in the distribution of indirect costs and with the approval of the cognizant agency for indirect costs.”

“No Rate”

Subrecipients have discretion not to claim payment for indirect costs. Subrecipients that elect not to claim indirect costs cannot be reimbursed for indirect costs. The organization must record an election of “No Indirect Costs” in the budget workbook.

C.6. Authorizing Statutes and Regulations

Subrecipients are required to adhere to the requirements outlined in the following:

• Grant Accountability and Transparency Act (GATA), 30 ILCS 708

• Illinois Administrative Code, Government Contracts, Title 44, Part 7000

• Grantmaking, Procurement, and Property Management, and federal regulations under Grants and Agreements, 2 CFR 200

• The requirements and policies outlined in the Illinois Department of Human Services Division of Substance Use Prevention and Recovery (IDHS/SUPR) Contractual Policy Manual
• Any other federal or state statutes, regulations or policies specified in the subaward agreement or its attachments.