17 Feb26_V4_SoM_RHTP_Project Narrative.pdf

State of Maine

Rural Health Transformation Program

Project Narrative

1. RURAL HEALTH NEEDS AND TARGET POPULATION

2. RHTP: GOALS AND STRATEGIES

3. PROPOSED INITATIVES AND USE OF FUNDS

4. IMPLMENTATION PLAN AND TIMELINE

5. STAKEHOLDER ENGAGEMENT

6. METRICS AND EVALUATION PLAN

7. SUSTAINABILITY PLAN

EXECUTIVE SUMMARY

Maine stands out as America’s oldest and one of its most rural states, where rural residents face far higher risks of chronic disease than the national average. Adults in Maine’s rural communities are more likely to have heart disease, the leading cause of death in our state. One in eight lives with diabetes, and one in five has lost six or more teeth to decay or disease. These complex health needs, combined with our aging population, drive rising demand for services, while rural geography adds costs, logistical barriers, and workforce shortages. Together, these challenges call for a new approach to delivering rural health care, and Maine’s Rural Health Transformation

Plan (RHTP) proposes a path to achieve that transformation.

Maine’s RHTP strategy envisions a future rural health system in which where one lives no longer dictates health outcomes or access to care; a stronger workforce, mobility innovations, and technologies ensure quality care is available to rural Mainers when they need it, where they need it; and a rural health system that is strong and sustainable for generations of Mainers.

CMS-RHT-26-001

State of Maine RHTP Proposal - 2

This plan is organized around five initiatives. To empower rural Mainers to achieve their own healthy living goals, we will adopt and expand proven population health solutions.

To expand the supply of care, we will grow our rural healthcare workforce and spread technologies that connect every community to advanced care. And, to ensure care will be available and affordable long into Maine’s future, we will pair affordability measures with strategies that advance quality, efficiency, and fiscal durability. By the conclusion of this work, rural Mainers will have a resilient and integrated rural health system that is accessible to all and delivers consistent, high-value care and better health outcomes statewide.

1. RURAL HEALTH NEEDS AND TARGET POPULATION

Maine’s Rural Population: For generations, Maine has carved its resilient character and economic might out of the forests, farms, rivers, and oceans that makeup our rural regions. With a population of approximately 1.36 million people spread across a land area nearly equivalent to all other New England states combined, Maine is one of America’s most rural states. Portland, Maine’s largest city, is home to fewer than 70,000, ranking 558th largest in the country and

Maine's only city in the nation’s largest 1,000. Bangor, the largest community in Maine's northern region, is home to fewer than 33,000, ranking it 1,262 largest.

For the purposes of the RHTP, rural areas and populations of Maine are defined in accordance with the Federal Office of Rural Health Policy (FORHP). Under this classification, over 690,000 Maine residents, equating to 51% of the state’s total population, live in rural areas, as compared to 19% of the U.S. population. Twelve of Maine’s 16 counties are considered “fully rural,” with 100% of their populations in rural areas. The remaining four counties are designated as “partially rural,” with a mix of rural and non-rural populations. Significant portions of the populations of several counties, including Aroostook (99%), Washington (99%), and Knox (78%), State of Maine RHTP Proposal - 3 reside in areas deemed “frontier and remote” (FAR) by the United States Department of

Agriculture. Additionally, Maine’s rural population includes year-round residents of 15 offshore islands, with populations ranging from a few dozen to over a thousand residents. Many have no healthcare facilities while others are served by a single small clinic.

In this proposal, data are aggregated at the county level since many measures are not available at the census-tract level. This analysis provides the foundation for identifying and describing the target populations that will benefit from our RHTP. Detailed Data Tables are provided in the Other Supporting Materials.

Target Population: Our proposal focuses on the 690,000 Mainers living in rural areas and the health care providers who serve them. This includes residents of Maine’s 12 fully rural counties and rural areas within its four partially rural counties. Because providers in both rural and non-rural areas care for these communities, the program is expected to benefit all Mainers. In 2024, for example, nearly 50% of patients receiving inpatient services at Northern Light Eastern Maine

Medical Center, the only tertiary care facility for northern Maine located in Bangor, came from fully rural counties. To address the needs of these rural populations, Maine’s RHTP focuses on high-priority health areas, including primary, specialty, perinatal, behavioral, and oral healthcare, with special attention to older adults and youth with behavioral health needs.

Rural Demographics: Maine is home to hundreds of thousands of rural residents seeking a great place to live, work, and raise a family. We are also America’s oldest state with a median age of

45; fully rural counties are home to an even older population, with an average median age exceeding 50. As our population ages, our healthcare system has experienced a growing demand for services, increase in complex conditions, and shortages of critical healthcare workers. With

State of Maine RHTP Proposal - 4

Maine’s population aged 65 and older projected to increase by 16% from 2025 through 2030, strains on Maine’s rural healthcare system are only expected to intensify.

Economic challenges compound barriers to rural health. In the past 25 years, global forces have battered Maine’s heritage industries of forestry, fishing, and farming, which are the lifeblood of our state’s economy. These changes have taken millions of dollars out of our rural areas. As jobs are lost, communities have been disrupted, contributing to substance use disorders and behavioral health needs. Employment, wages, and education among rural Mainers lag their peers in other parts of the state and country. Median household income in rural Maine is 13% below the national average and one in six children live below the poverty line.

Employment is also lower, with only 37% of working-age adults in fully rural counties employed full-time and year-round, compared to 44% in partially rural counties. Median household income in fully rural counties is $68,000, 13% below the national average, and nearly one in seven individuals and one in six children in these counties live below the poverty line.

Health insurance coverage varies as well: over 10% of non-elderly adults in fully rural counties are uninsured (versus less than 8% in partially rural), and the rate of Medicaid coverage is higher:

nearly one in three individuals in fully rural counties versus 1 in 4 in partially rural counties.

Population Health: Residents of fully rural counties experience higher rates of chronic disease, oral and behavioral health challenges, and adverse maternal and infant outcomes. These communities also have higher shares of residents with complex healthcare needs: over 10% are veterans (compared to 6% nationally), one in seven of whom has a service disability of 70% or more, reflecting complex healthcare needs related to their service. In addition, disability prevalence is higher across Maine than nationally (16% vs. 13%), with more than one in five residents affected in three fully rural counties.

State of Maine RHTP Proposal - 5

Adults in Maine’s fully rural counties have higher rates of chronic conditions than the national average. Heart disease is the leading cause of death, with coronary heart disease affecting

9% of fully rural residents compared to 7% nationally. Diabetes rates are highest in Aroostook

(14%), Piscataquis (13%), Somerset (12%), and Washington (13%) counties. High blood pressure impacts 36% of adults in fully rural counties, compared with 32% nationally, with Aroostook and

Washington counties the highest at 40%. The effect of these elevated chronic condition rates is reflected in mortality outcomes. In 2023, fully rural counties had an age-adjusted mortality rate of 856 per 100,000, compared with 769 in partially rural counties and 751 nationally. Age-adjusted mortality rates for cancer, cardiovascular disease, and chronic lower respiratory disease are substantially higher in fully rural counties than in partially rural counties or nationally, underscoring disparities in access to primary and specialty care and gaps in preventive services among Maine’s rural population.

Behavioral Health: Rural Maine communities also face worse behavioral health outcomes. While

21% of adults in the U.S. reported ever having received a depression diagnosis in 2022, this rate is higher across Maine’s fully rural counties at 25%. Acute behavioral health needs have become especially pronounced among Maine children in recent years Between 2019 and 2021, suicide-related emergency department (ED) visits among children under 19 years of age increased by

59% and have remained elevated since. In 2023, rural Mainers experienced higher rates of alcohol-induced deaths (17 vs. 13 per 100,000 nationally), drug-induced deaths (48 vs. 32), and suicide (21 vs. 14), reflecting both unmet behavioral health needs and limited access to crisis response care in these communities.

Infant and Maternal Health: Infant and maternal health outcomes highlight additional disparities. Statewide, 8% of infants were born with low birth weight from 2022 to 2023, but this

State of Maine RHTP Proposal - 6 exceeded 10% in two fully rural counties (Oxford and Washington). Every single child death is a tragedy, and in five fully rural counties, infant mortality rates exceeded the statewide rate of 6 deaths per 1,000 live births, including Franklin (9), Kennebec (7), and Somerset (7). Moreover, between 2014 and 2025, 11 of the state’s 28 birthing units closed, leaving only 17 remaining. The impact has been greatest in rural areas. During this period, the average driving distance to a birthing unit in fully rural counties increased by 27%. In 2023, women in fully rural counties traveled 27 miles on average to reach a birthing unit. This is 80% farther than the 15 miles traveled by women in partially rural counties. In two northern Maine counties, some women must drive two hours for perinatal and birthing services, and for significant pregnancy complications, the drive can extend to four hours one way, as the state has only one Level 4 Maternal and Newborn

Care Center, located in southern Maine.

Access to Care: Rural residents also face significant challenges in accessing care due to provider shortages and limited hospital capacity. Maine has 32 general acute care hospitals (GACHs) and critical access hospitals (CAHs) in operation (14 and 18, respectively), but eight of 12 fully rural counties have no GACHs, leaving communities heavily reliant on CAHs.

In addition to limited hospital and facility access, rural Maine residents face disparities in access to primary care, dental, and behavioral health providers. Fully rural counties in Maine have

983 residents per primary care physician, 39% higher than partially rural counties. Four fully rural counties exceed 1,400 residents per physician: Oxford (1,526), Piscataquis (1,451), Somerset

(1,419), and Washington (2,096). The gap in dental access is also stark, with 2,331 residents per dentist in fully rural counties compared to 1,518 residents per dentist in partially rural counties, a

54% differential. Two fully rural counties exceed 5,000 residents per dentist.

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Similar disparities exist in access to behavioral health providers. Fully rural counties have

217 residents per mental health provider, 35% higher than the ratio in partially rural counties

(160). In Lincoln and Somerset Counties, the ratio exceeds 1:400 (437 and 424, respectively).

These provider shortages are reflected in ED utilization: among commercially insured individuals under 65 with a mental health condition, mental-health related ED visits are highest in fully rural counties, reaching 40 per 1,000 insured in Somerset and 33 per 1,000 in Franklin Counties, compared with 22 statewide.

In addition to provider shortages, rural Maine residents face challenges in accessing care both in person and virtually. Nearly 40,000 Maine households lack a vehicle, including nearly one in 10 older households, and our most rural counties have some of the highest share of residents without transportation. Public transportation is very limited as a practical option for Mainers, with only 0.2% of working-age adults using it in Maine’s fully rural counties. Internet access is also more limited across rural Maine, with one in eight households in Maine’s fully rural counties going without an internet subscription, compared to one in 10 nationally. The share of households without an internet connection is highest in Maine’s most remote counties, including Aroostook

(20%), Piscataquis (16%), and Washington (17%). These counties also have notably lower rates of telehealth usage among commercially insured residents with a mental health condition, likely reflecting limited internet access.

Rural Facility Financial Health: Maine’s rural healthcare system includes hospitals, federally qualified health centers (FQHCs), Rural Health Clinics, community mental health centers, Certified Community Behavioral Health Clinics (CCBHCs), and Opioid Treatment Programs

(OTPs). Maine's rural hospitals, which include 18 CAHs and five larger hospitals with Sole

Community Hospital, Medicare-Dependent Hospital, and Rural Community Hospital

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Demonstration designations, face financial pressures. In 2023, 19 of 23 (83%) rural hospitals fell below the S&P Global threshold for adequate days cash on hand, 43% had financially vulnerable operating margins, 57% had financially vulnerable total margins, and 74% did not meet the target for adequate average age of plant. Eight of the 23 rural hospitals failed in all four benchmarks, underscoring widespread financial vulnerability. Operational responses include two hospitals converting from GACH to CAH status to access higher Medicare and MaineCare reimbursements in recent years. In June 2025, Northern Light Inland Hospital, a Medicare-dependent hospital in fully rural Kennebec County, closed due to operating losses.

Financial pressures are compounded by shifts in payor composition. From 2017 to 2023, inpatient days for commercially insured patients declined by 51% across Maine’s rural hospitals, while Medicaid inpatient days increased by 20%. Commercially insured outpatient visits fell 22% across Maine’s rural hospitals during this time, while Medicaid visits rose 46%. Medicaid payments accounted for 16% of net patient revenues across Maine CAHs in recent years, compared with 13% for CAHs nationwide.

Maine’s FQHCs play a critical role in mitigating access gaps, serving over 200,000 patients in 2024, 72% with incomes below 200% of the federal poverty level. Medicaid and

Medicare patients comprised 29% and 27% of FQHC patients in 2024, respectively, and over 8% of patients were uninsured. In the most rural areas, FQHCs serve even higher proportions of

Medicaid and uninsured patients, providing preventive care, dental care, cancer screenings, behavioral health, and chronic condition management. Maine’s FQHCs offer dental care in 13 of

16 counties and are the only dental providers accepting MaineCare in two of these counties.

2. RHTP: GOALS AND STRATEGIES

Maine’s RHTP strategy envisions a future rural health system that:

State of Maine RHTP Proposal - 9

Bridges the Rural Divide: This means that where one lives no longer dictates health outcomes or access to care. All Mainers have the tools to make healthy choices and live healthier lives, and rural communities have the information, choices, and flexibility to create their own local, data-driven solutions.

Provides Seamless Delivery: This means that a stronger rural healthcare workforce, innovations, and technologies ensure convenient, accessible and effective care - available to rural Mainers when they need it, where they need it.

Offers Efficient, Incentive-Aligned Systems: This means communities come together to reduce fragmented service delivery, and value-based payments move us beyond fee-for-service, ensuring dollars go further and rural health systems are strong and sustainable for future generations of Mainers.

Maine will track our progress through four overarching performance objectives:

Objective Baseline Goal Motivation

Living Healthier Lives: Well-controlled blood pressure (BP) among individuals in rural areas with high BP

Baseline rate for all Mainers is not currently available but will be collected beginning in FY 2026 using RHTP funding. For Maine Medicaid populations in 2023, 64% of members with high BP had adequate BP control.

Increase the relative percentage of residents in rural areas with high BP that is well-controlled by 10%.

Heart disease is the leading cause of death across the state's most rural and remote counties. Improving BP control among rural residents will demonstrate effectiveness of healthy lifestyles, preventive interventions, and chronic disease management strategies.

Quality of Healthcare Delivered: 30-day all-cause readmission rate

Baseline rate for all Mainers is not currently available but will be collected beginning in FY 2026 using RHTP funding. Nationally, the 30-day all-cause readmission rate from 2016-2020 was 13.9.

Reduce the relative 30-day all-cause readmission rate among rural patients by 10%.

Rural Maine residents face access barriers due to limited provider availability, a challenge that is expected to grow as the state's population ages substantially in the coming years. Delivering efficient and high-quality care, central to Maine's RHTP strategy, will be paramount to managing patient care and preventing complications during this period.

Getting Care When Mainers Need It: Non-financial barriers to care

In 2022, 26% of Maine adults in rural areas reported delaying medical care for reasons other than costs.

Reduce the relative percentage of adults in rural areas who report delaying medical care for

Between 2018 and 2022, the percentage of adults in rural areas of Maine who reported delaying medical care for non-cost reasons rose from 14% to 26%, an 86% relative increase. Maine's RHTP plan aims to significantly reduce non-

State of Maine RHTP Proposal - 10 reasons other than costs by 10%.

financial barriers and improve access to care in rural communities, through initiatives that include workforce recruitment, telehealth expansion, and AI-driven provider efficiencies.

Durability of Care Options:

Rural hospitals' financial health

In 2023, 57% of Maine's rural hospitals had operating margins at or above 1%.

Reach at least 75% of Maine's rural hospitals achieving annual operating margins sufficient to make ongoing investments to improve operations and care (at or above 1% operating margin).

Maine's rural hospitals serve as crucial access points for care and economic anchors in their communities, yet a recent hospital closure and two hospital conversions highlight the financial challenges these facilities face. Maine's RHTP initiatives aim to not only prevent closures but to strengthen hospital operations and support investments in quality care improvements.

To fulfill this vision, Maine has organized its RHTP around five major initiatives. While our initiatives particularly highlight the needs and solutions related to rural behavioral health, perinatal care, children and youth, and older adults, all rural residents will benefit from the activities and funding, which are delivered efficiently, effectively, and transparently.

Maine’s overall strategy is designed to tackle the challenges identified during our plan’s development, including unaddressed root causes of disease, workforce shortages, gaps in technology and infrastructure, concerns about losing access to care, and the financial instability of rural hospitals and providers. Each of our solutions (initiatives) directly responds to these priorities and reflects the creativity, insights, and innovative ideas contributed by Maine’s rural residents. These five initiatives translate community-driven insights into concrete actions that will improve health, access, and sustainability for all rural Mainers.

Initiative 1- Population Health: Promoting timely access to high-quality care

The first pillar of our strategy empowers rural Mainers across all stages of life to achieve their own healthy living goals by expanding their access to high-quality preventive, primary, chronic, and specialty care in their own communities. It responds to the growing complexity of rural health needs tied to aging populations, increases in chronic disease and behavioral health conditions, State of Maine RHTP Proposal - 11 and fragmented care delivery infrastructure that together make it harder for rural Mainers to stay healthy or recover from illness. This initiative aligns with the RHTP strategic goal to Make

America Healthy Again by increasing the reach of Evidence-Based Practice (EBP) interventions for chronic disease management and other conditions, and by supporting new access points that promote preventive health and address root causes of disease. This initiative also promotes

Sustainable Access by helping rural providers become long-term access points for care. It does this by expanding mobile and co-located services and by strengthening navigation supports and care delivery alternatives through community-based models. The initiative’s activities include:

Initiative 1 – Activities Alignment with Required Elements

Expand Alternative Sites of Care Improving access; Improving outcomes; Partnerships Deploy Evidence-based Practices Improving outcomes Strengthen Rural Maine’s Nutrition Education Infrastructure

Improving outcomes

Expand Community Paramedicine programs Improving access; Improving outcomes; Partnerships

Expand Community Health Worker and Peer Support Programs

Improving outcomes; Partnerships; Workforce

Support access to mental health and SUD support for special populations

Improving outcomes; Improving access; Partnerships

This strategy will expand School-based Health Clinics (SBHCs) and add new Opioid

Treatment Programs (OTPs) in rural areas, increasing access for students and those struggling with substance use. It will also expand behavioral health services, helping more rural residents receive timely support. Finally, it will establish a Community Paramedicine (CP) program in every county, bringing critical care into local communities. Together, these activities strengthen

Maine’s rural healthcare system, improve outcomes, and ensure all services are closer to home.

Initiative 2- Workforce: Strengthening Maine’s rural health workforce

The second pillar of our strategy grows the local health workforce in rural communities. Despite recent progress, shortages of clinicians and health support workers persist in rural Maine, limiting patient choice, driving up costs, and increasing strain on remaining providers. This initiative

State of Maine RHTP Proposal - 12 aligns with the RHTP’s Workforce Development strategic goal by strengthening cultivation, recruitment, and retention of healthcare workers in rural communities, helping rural providers practice at the top of their license, and developing a broader set of providers to serve the healthcare needs of Maine’s rural communities. The initiative’s activities include:

Initiative 2 - Activities Alignment with Required Elements

Recruit and retain healthcare clinicians Improving access; Workforce

Strengthen local talent pipelines Improving access; Workforce; Partnerships

Develop and deploy a Healthcare Workforce Data Dashboard Data-driven solutions; Workforce

Invest in mobile training labs and simulation centers Workforce; Partnerships

Pilot new models in rural workforce transportation Workforce: Improving access

These activities will build Maine’s rural health workforce by expanding rural school-based career programs, training more nurses and allied health professionals with five-year commitments to serve rural areas, and increasing preceptors mentoring students. This initiative will also attract more physicians, clinicians, and advanced practice providers to rural communities, bringing critical care closer to home for rural Mainers.

Initiative 3- Technology Innovation: Modernizing rural care delivery with digital health technology

Investments in growing Maine’s workforce will be complemented by the third pillar of our strategy: accelerating the connection to and adoption of health-enabling technologies. These technologies will give people better access to their health information, expand care delivery options, and provide local access to world-class specialty expertise. The core of this initiative is modernizing and interconnecting EMR systems among rural providers, recognizing that these platforms often serve as the foundation into which telehealth, Augmented Intelligence (AI) solutions, consumer tools, and other health technologies are built. Our strategy recognizes AI as a promising solution for rural health, with opportunities to develop new innovations that could

State of Maine RHTP Proposal - 13 help to overcome many challenges faced by rural providers. This initiative aligns with the RHTP

Tech Innovation strategic goal, as it fosters the adoption of innovative technologies that promote efficient care delivery, data security, improved connectivity, and access to digital health tools. By expanding and strengthening access to and use of telehealth services, this initiative also supports the RHTP Sustainable Access strategic goal by increasing the availability of primary, specialty, behavioral health, oral, and perinatal care to patients in their own home or community, reducing transportation barriers, allowing for flexible scheduling, and providing cost-effective, competent care. Many technology-based activities will be delivered with the Northeast Telehealth Resource

Center (NETRC), operated by Medical Care Development (MCD). Activities include:

Initiative 3 - Activities Alignment with Required Elements

Expand telehealth services Improving access; Technology use;

Partnerships

Support data integration and the reliable exchange of healthcare data Technology use; Data-driven solutions

Expand the use of consumer-facing health technology tools Technology use; Improving outcomes

Enhance Electronic Medical Records (EMR) systems Technology use; Improving outcomes;

Data-driven solutions

Create a Maine Rural AI Hub to support rural providers in adopting today’s AI technologies and establish a Rural Health AI Innovation Institute to promote development of new AI technologies purpose-built for rural populations

Technology use; Data-driven-solutions

As a result, Maine will increase the percentage of adults who have had a primary care visit delivered via telehealth, the percentage of youth who are accessing behavioral health services via tele-behavioral health (tele-BH), the percentage of practices that gain access to specialty consultations via telehealth, and the percentage in rural practices implementing AI tools.

Initiative 4- Access: Bridging the healthcare affordability gap for rural Mainers

Our strategy's fourth pillar protects the long-term accessibility and affordability of rural healthcare in Maine by ensuring hospitals and other providers remain available as reliable access points, supporting the RHTP goal of Sustainable Access. This initiative will improve access to services via enhanced provider enrollment systems, better use of transportation resources for

State of Maine RHTP Proposal - 14 health and wellness services, the provision of strategic payments to at-risk rural providers, and improved consumer technology tools that empower residents to make their own health coverage choices. Expanded access will strengthen disease prevention, chronic disease management, and behavioral health outcomes. It will also better enable residents to pursue employment and educational opportunities that increase self-sufficiency, open long-term health coverage options, and Make Rural America Healthy Again. The Office of MaineCare Services (OMS) will administer this strategy. Key activities include:

Initiative 4 - Activities Alignment with Required Elements

Issue Provider Payments for Uncompensated Care delivered by FQHCs, hospitals, and CCBHCs

Improving access; Improving outcomes; Financial solvency strategies; Cause identification

Issue Provider Payments for provision of Essential Health Benefits to uninsured population

Improving access; Improving outcomes; Financial solvency strategies; Cause identification

Implement more efficient and user-friendly MaineCare Provider Enrollment technology

Improving access; Technology use

Improve coordination and leveraging of existing transportation infrastructure to assist rural Mainers to meet their health and wellness needs through technology and mobility planning.

Improving access; Improving outcomes; Technology use

Improve consumer-friendly transparency tool on state-based marketplace to improve access to and create competition for more affordable care plan options.

Improving access; Financial solvency strategies; Cause Identification

As a result, Maine will increase the number of MaineCare-enrolled providers. The initiative will also serve to expand access to chronic disease management, substance use disorder treatment, primary care, and preventive services in rural communities.

Initiative 5- Sustainable rural health ecosystems: Addressing financial instability of rural providers

The final pillar of our strategy promotes the long-term resilience of Maine’s rural health ecosystem through systems-level incentives and operational strategies that complement the prior initiative’s focus on patient-facing barriers to care. Nearly 40% of Maine’s rural hospitals are stand-alone facilities facing significant financial headwinds due to an aging and shrinking

State of Maine RHTP Proposal - 15 population, changes in payer composition, and workforce shortage. This puts them at high risk of service reduction or closure. This initiative aligns with the Sustainable Access strategic goal and is designed to stabilize and develop the infrastructure, partnerships, operational structures, and financing models needed to sustain advancements after RHTP funding ends.

Initiative Five begins with the short-term provision of tools and tailored technical assistance to improve the efficiency and financial management of at-risk hospitals serving rural

Maine residents, and to improve the ability of rural health providers to successfully participate in

Alternative Payment Models (APMs) and Value-Based Payment (VBP) contracts. Strategic investments in capital improvements and technology, aligned with these plans, will help these hospitals and other rural providers strengthen their financial stability. Once financial stability is achieved, the strategy moves into a second phase: coordinated regional strategic planning to assess community needs, right-size services, build non-hospital care capacity, and enhance collaboration among rural providers. The strategy also includes two targeted activities to address critical structural needs and improve access to appropriate levels of care for rural residents. The first will coordinate with hospitals to establish a sustainable system for inter-hospital patient transfers. The second will increase inpatient step-down treatment capacity for children with complex behavioral health needs in a psychiatric residential treatment facility (PRTF).

To implement this strategy, Maine DHHS will collaborate with the Office of Affordable

Health Care (OAHC), Maine’s all-payer claims database (Maine Health Data Organization, MHDO), the Maine Hospital Association (MHA), and the behavioral health provider Sweetser.

Key activities within this initiative include:

Initiative 5 - Activities Alignment with Required Elements

Improve hospital financial stability through tailored hospital financial management, planning and targeted investment.

Financial Solvency Strategies; Cause identification

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Conduct rural regional health ecosystems planning and implementation

Financial Solvency Strategies; Cause identification; Partnerships

Develop multi-payer alternative payment models Financial Solvency Strategies; Cause identification

Strengthen Maine’s interfacility non-emergency transport system Improving access

Expand access to high-acuity, non-inpatient hospital care for children with complex behavioral health needs

Improving access

As a result of this initiative, Maine will increase regional rural healthcare provider collaboration, the percentage of MaineCare payments that are made through alternative payment models (APMs), the number of hospitals that develop and implement financial management plans, the percentage of Maine children and youth who receive high-acuity behavioral health services in-state, and access to transportation in rural areas.

RHTP Partnerships

Maine’s network of regional and statewide partnerships will be a critical asset in implementing our initiatives. The state is committed to fostering collaboration to maximize RHTP investments by leveraging existing partnerships both within Maine and across New England.

Maine will also develop new partnerships to promote the regional and statewide collaboration needed to advance and sustain improvements in rural healthcare.

Efforts to transform rural health in Maine began in 2019, when Maine DHHS convened its Rural Health Transformation Team to bring together an external group with cross-sector rural health expertise to advise and shape the state’s improvement efforts. This group will be reconvened as the RHTP Advisory Committee, uniting stakeholders from rural hospitals, FQHCs, CCBHCs, behavioral health organizations, emergency medical services (EMS), community-based organizations (CBOs), Tribal health organizations, employers, and academic institutions to guide Maine’s RHTP initiatives.

To strengthen RHTP efforts across northern New England, Maine will continue its participation in the New England Rural Health Association (NERHA) and will contribute

State of Maine RHTP Proposal - 17 toward the development of NERHA’s proposed New England Rural Health Transformation

Center. This cross-state collaborative will provide technical assistance (TA) for rural health challenges addressed regionally through RHTP activity. This includes policy and regulatory issues, data sharing, and opportunities for shared services.

To support the long-term sustainability of Maine’s rural health advancements, the state will organize and convene Rural Regional Planning Groups in Maine’s most rural communities.

These groups, co-led by state and community leaders, will include local healthcare providers, government representatives, public health leaders, social service entities, and community members. RHTP leadership, together with Maine’s OAHC, will provide a structured, data-driven process to help these groups identify essential health services for their communities.

Maine will continue to collaborate with a range of state and regional partners to advance

RHTP efforts and ensure the activities outlined in this proposal benefit providers and patients in rural areas. Letters of support from partners are included in Other Supporting Materials.

Legislative Action

Maine’s current legislative and regulatory framework supports RHTP objectives by promoting expanded access, high-quality care, and cost-effective services in rural communities. State policies largely align with the scoring factors and provide a strong foundation for advancing rural health transformation. Maine does not currently plan to make additional changes to the State

Policy Actions, which are scored based on the analysis referenced in the NOFO and Maine’s internal review, as no external report or analysis was provided.

RHTP

Category

State Policy Action

Requirement

Maine’s Current

Score Maine’s Current Policy and Future Policy Commitments

B.2. Health and Lifestyle

Re-establishment of the Presidential Fitness Test

0/100

Once the Federal administration releases implementation guidance regarding the Presidential Fitness Test, Maine will review and consider whether to implement the Test in Maine. Until that

State of Maine RHTP Proposal - 18 occurs, Maine cannot commit to requiring that schools implement the Presidential Fitness Test.

B.3. SNAP

Waivers

USDA-approved waiver prohibiting the purchase of non-nutritious SNAP items in SNAP

0/100 Maine does not have a USDA-approved SNAP waiver in place and does not plan to pursue one.

B.4.

Nutrition Continuing Medical Education

Requirement for nutrition to be included in CME for physician licensing is currently in place and enforced

0/100

Maine does not currently require nutrition to be included in continuing medical education and does not consider it feasible to make a requirement. Maine physician licensing CME requirements are established by the two medical Boards (allopathic and osteopathic), which have both been consulted and expressed that their licensees receive adequate nutritional education and would not be well served by adding an additional regulatory requirement that they perceive as burdensome.

C.3.

Certificates of Need

Eliminate or loosen CON laws

50/100

Pursuant to the Cicero Institute report, Maine scores a 65/100 in the Certificate of Need categories, which translates to 50 Points for RHTP scoring. Maine does not plan to change its current requirements pertaining to its Certificate of Need review process.

D.2.

Licensure Compacts

Become a full member of physician, nursing, EMS, Psychology, and PA interstate compacts

80/100

Maine is a member of all Licensure Compacts referenced except for the EMS REPLICA Compact. Maine believes that the current landscape of laws and regulations regarding EMS professionals is best aligned to promote the recruitment and retention of EMS staff in rural areas of the state. Additional potentially burdensome regulation is not needed.

D.3. Scope of Practice

Ensure the most expansive scope of practice for PAs, NPs, Pharmacists, and Dental Hygienists

68.75/100

Maine gets full points for Nurse Practitioner and Dental Hygienist categories and 75% of allocated points for the Physician Assistant category. Pursuant to the Cicero Institute Report, Maine receives 0 points for the Pharmacist category. Maine believes that its current practice permissions for pharmacists merit a higher score than the Cicero Institute’s review. Maine's rules and regulations governing pharmacists’ scope of practice are frequently reviewed and have been expanded several times over the past 15 years. These policies currently allow pharmacists to have prescriptive authority for contraceptives, naloxone dispensing, vaccine administration, HIV prevention, and emergency insulin refills. In addition, Collaborative Drug Therapy Management remains the most impactful mechanism for broader prescribing authority. Maine will continue to review and determine whether additional prescriptive authority for pharmacists is necessary.

E.3. Short- Term, Limited- Duration Insurance

STLDI plans are not restricted in the State beyond the latest federal guidance.

0/100 STLDI plans are available for purchase in the state and are not prohibited or banned. Maine does have some additional requirements for STLDI plans.

F.1.

Remote Care Services

Medicaid reimbursement for different forms of telehealth and licensing/registr

80/100

Maine allows for Medicaid payments for at least one form of live video, store and forward, and remote patient monitoring. As determined by the Center for Connected Health Policy (CCHP), Maine meets requirements for a telehealth license/registration process. Although CCHP did not determine that Maine has an in- State licensing requirement exception, Maine’s current law, State of Maine RHTP Proposal - 19 ation processes for telehealth.

regulations, and procedures expedite the process for out-of-state telehealth-based providers.

Lack of a specific licensure exception has not shown to be a barrier to the practice of telehealth into Maine, as numerous out-of-state providers are now licensed to provide telehealth services to patients in Maine.

Other Required Information

For Factor A.2: Maine is home to six CCBHC entities as of September 1, 2025. A list of every active site of care associated with each CCBHC entity and the address of every active site of care is provided in the Other Supporting Materials.

For Factor A.7: Two hospitals, Riverview Psychiatric Center and Dorothea Dix Psychiatric

Center, received a Medicaid Disproportionate Share Hospital (DSH) payment, consistent with

42 U.S.C. 1396a(a)(13)(A)(iv), from Maine for the most recent Maine plan rate year (SPRY) as defined at 42 CFR 455.301.

3. PROPOSED INITATIVES AND USE OF FUNDS

Maine’s suite of initiatives will be implemented statewide, with clear focus on the needs of the state’s most rural communities. The sections that follow describe each initiative in detail, including all proposed activities and how RHTP funds will be used to enact them. (FIPS codes:

23001, -3, -5, -7, -9, -11, -13, -15, -17, -19, -21, -23, -25, -27, -29, -31.)

Initiative 1- Population Health: Promoting timely access to high-quality care

This initiative targets the complex health challenges facing rural Mainers. It focuses on an aging population, rising chronic and behavioral health conditions, and fragmented care. Activities include improving access by expanding mobile and co-located care, including SBHCs, broadening the reach of evidence-based interventions, increasing access to substance use disorder (SUD) services, and developing alternative community-based care delivery models.

INITATIVE 1 – POPULATION HEALTH: Summary of Activities

State of Maine RHTP Proposal - 20

Main Strategic Goal Main: Make Rural America Healthy Again Secondary: Sustainable Access, Innovative Care, Workforce Development

Use of Funds A, G, H, K, I Technical Score Factors B.1, B.2, C.1, C.2, F.1

Key Stakeholders

Schools, MDOE, FQHCs, healthcare providers, families, CHWs, Peer Supports, Veteran’s Administration (current mobile vans), local Planning Boards, EMS agencies, home health providers, Wabanaki Public Health & Wellness, the Houlton Band of Maliseet Indians, the Mi’kmaq Nation, the Passamaquoddy Tribes at Indian Township and Pleasant Point, and the Penobscot Nation.

Estimated Funding $182,033,832 over five years

Outcomes

To assess initiative impact, Maine will track and report the number of SBHCs, EBP trainings, OTP rural access points, primary and behavioral health connections, as well as the reach of Community Paramedicine, as detailed in Section 6. Metrics and Evaluation Plan.

Activity 1.1: Alternative Sites of Care: Making Care Available Where People Are

Mobile Units: Maine has at least 10 mobile units in operation, serving diverse populations and healthcare needs (e.g., a mobile OTP, perinatal services, mammography, oral health). These units currently all work independently with no central coordination of need assessments or service delivery. While mobile units have gained positive support and Maine’s regulatory and reimbursement frameworks support the work, there is currently limited ability to evaluate their reach, impact, need, or leverage peer experiences across these services.

To reduce inefficiency and coordinate access points that bring care closer to rural communities, Maine proposes contracting with an organization that will provide statewide coordination and mobile unit deployment. This contractor will develop toolkits to support unit implementation and assist organizations in building trusting community relationships critical to success. In coordination with rural planning efforts, the contractor will develop a framework for local communities and potential providers to evaluate whether a mobile unit is a good fit. The contractor will manage RHTP funding to purchase and outfit new mobile units as those needs are justified. Finally, this effort will ensure mobile units contribute to a coordinated and efficient care delivery, including having public health nurses and community health workers (CHWs) on mobile units to support longer-term community connections.

State of Maine RHTP Proposal - 21

Certified Community Behavioral Health Clinics (CCBHC): CCBHCs are behavioral health organizations that provide broad services and meet state and federal requirements for access and standards of care. Maine’s CCBHC Model launched in March 2025. While CCBHCs serve all people with behavioral health needs, the model places special focus on service members and veterans as well as individuals with co-occurring intellectual and developmental disabilities.

Maine CCBHCs serve over 8,500 MaineCare members a month at 21 sites, with additional certified sites expected in 2026. The state will use RHTP funds to initiate weekly primary care co-location hours within CCBHC sites, following the successes of other national CCBHC models.

Co-location of primary care within CCBHCs will improve a person’s ability to get coordinated care in one location and get more coordinated, comprehensive treatment. RHTP funding will be used to cover interprofessional care team meetings and administrative support, develop workflows, and make minor clinic space modifications to accommodate privacy needs for clients.

Funding will also support MaineCare rate setting work to sustain these efforts.

School-Based Health Centers (SBHCs): Located within school buildings, SBHCs provide comprehensive healthcare services and are operated through partnerships between schools, communities, and healthcare providers. While SBHCs increase access to essential healthcare services and reduce caregiver work absence and barriers to care such as transportation, fewer than

10% of Maine public schools have SBHCs. Utilizing RHTP funds, Maine CDC will establish new

SBHCs in rural schools and expand existing services, including extending services to additional grade levels, adding mental health and dental care, and enhancing preventive health services.

Activity 1.2: Spreading Effectiveness and Implementation of Evidence-Based Practices

As Maine deploys new care models and onboards healthcare staff, it is important that the state leverages Evidence-Based Practices (EBPs) to ensure consistent and efficient approaches.

State of Maine RHTP Proposal - 22

Spreading EBPs has been a focus of the State in recent years, but funding has been siloed, and there has been a lack of coordination to make programming more accessible and ensure lasting implementation. Through this activity, Maine DHHS will launch new EBP training and implementation efforts by contracting with a vendor to deliver trainings, provide implementation funding, and generate a more accessible list of resources for busy providers and community partners to access. The RHTP Advisory Committee will prioritize training areas to align with

Maine's RHTP goals and span age ranges and health areas.

Activity 1.3: Nutrition Education Infrastructure

Integrating nutrition education into the clinical health infrastructure is an evidence-based approach to address population health needs and focus on upstream interventions to mitigate or prevent disease. Maine proposes to fund nutrition education to support community-level transformation and create the foundation for future innovative clinical health interventions such as “Food-Is-Medicine.” Community education regarding the impact of lifestyle choices on health is essential to complement clinical interventions. Maine’s nutrition education model for RHTP will focus on supporting information technology, staffing infrastructure, referral pathways, and tracking to create a sustainable system for nutrition education.

Activity 1.4: Transforming Care Capacity through Community Paramedicine

Community Paramedicine (CP) programs can fill critical gaps in the traditional healthcare system by reaching patients where they are - increasing access to preventive care, extending medical services, and reducing EMS usage. Maine is uniquely positioned to become a national leader in the CP model due to its formal EMS licensure rules, which establish education standards, licensing levels, and a clear CP scope of practice. While at least 40 states have some type of CP program, only 23 have enacted CP-based laws, established pilots, or authorized EMS personnel

State of Maine RHTP Proposal - 23 to provide nonemergency care. CP programs have consistently shown reduced emergency department visits, improved chronic disease management, and high patient satisfaction. Despite these successes, expansion, especially in Maine’s most rural areas, has been limited by education system constraints, short-term siloed funding, and the lack of national standardization.

Led by Maine EMS, RHTP funds will support the expansion of CP programs across the state, providing the time and resources needed to implement CP reimbursement models, establish sustainable career pathways for rural EMS providers, and strengthen partnerships.

These efforts aim to deliver measurable improvements within five years. Under a joint workforce structure, CPs will enhance continuity of care and create a scalable framework that complements Maine’s other EMS-related RHTP initiatives.

Activity 1.5: Expand Community Health Worker and Peer Support Programs

Community Health Worker (CHW) Program: Maine has a long-standing and well-organized

CHW workforce, with an estimated 200 individuals, a forthcoming certification process, and integration into several team-based APMs. Despite this foundation, there remains significant opportunity to further support CHWs in statewide health improvement efforts.

This activity will provide a focused…