V. CALCULATING POPULATION TO PROVIDER RATIOS Mental Health Care V-1

CALCULATING POPULATION TO PROVIDER RATIOS (MENTAL HEALTH CARE) Objective: Participants will understand how to: 1) Identify mental health providers 2) Calculate full-time-equivalency rates, and 3) Determine the population to provider ratios for mental health geographic and population designations V-2

Mental Health Designations 1) Psychiatrists Only, or 2) Core Mental Health Providers (CMHP)1, including Psychiatrists Clinical Psychologists Clinical Social Workers Psychiatric Nurse Specialists Marriage and Family Therapists ¹ - Must include all of these for this type of designation V-3

Population to Provider Ratios Needed for Designation (MENTAL HEALTH CARE) Geographic Area A rational service area - MSSA, combine 1 or more MSSAs, or whole county > 30,000:1 psychiatrists, or > 9,000:1 CMHP including psychiatrists, or > 6,000:1 CMHP including psychiatrists and > 20,000:1 psychiatrists CMPH always includes psychiatrists. Third option – count psychs in both!! V-4

Population to Provider Ratios Needed for Designation (Continued) Geographic Area w/Unusually High Needs A rational service area plus one of the following: a) 20% or more of the population is < 100 % of the poverty level, or b) The youth ratio (# of persons < 18 to the # of adults ages 18 - 64) is greater than 0.6, or c) The elderly ratio (# of persons > 65 to the # of adults ages 18- 64) is greater than 0.25, or d) Alcohol or substance abuse prevalence data showing the area to be in the worst quartile of the nation, state, or region > 20,000:1 psychiatrists, or > 6,000:1 CMHP including psychiatrists, or > 4,500:1 CMHP including psychiatrists and > 15,000:1 psychiatrists V-5

Low-Income Population Number of individuals in the service area that are at or below 200% of the Federal poverty level Must be >30% of the population in the service area Source: 2005 Claritas Population Estimates > 20,000:1 psychiatrists, or > 6,000:1 CMHP including psychiatrists, or > 4,500:1 CMHP including psychiatrists and > 15,000:1 psychiatrists V-6

Contiguous Areas are Over-utilized if > 20,000:1 psychiatrists, or > 3,000:1 CMHP including psychiatrists and > 10,000:1 psychiatrists V-7

POPULATION SIDE OF THE RATIO (SAME AS PRIMARY HEALTH CARE) : ________________ V-8

PROVIDER SIDE OF THE RATIO : ____ V-9

STEPS 1) Identify all mental health providers for the type of designation being sought in the area to be designated 2) Determine the number of hours each provider works in patient care (office and follow-up hospital inpatient care) serving the population to be designated 3) Calculate the FTE for each mental health provider serving the population to be designated 4) Calculate the population to provider ratio V-10

STEP 1 Identify all mental health providers for the type of designation being sought in the area to be designated. V-11

Core Mental Health Providers (CMHP) Includes: I. Psychiatrists II. Clinical Psychologists III. Clinical Social Workers IV. Psychiatric Nurse Specialists V. Marriage and Family Therapists V-12

I. Psychiatrist A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who a) is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, is “board eligible” (i.e. has successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry); and b) practices patient care psychiatry or child psychiatry, and is licensed to do so if required by the State of practice. V-13

II. Clinical Psychologist a) An individual with a doctorate in psychology who is practicing as a clinical or counseling psychologist and is licensed or certified to do so by their State of practice; or b) if licensure or certification is not State required, the individual must have a doctorate in psychology and two years of supervised clinical training or counseling experience (excluding school psychologists). V-14

III. Clinical Social Worker (CSW) a) Is certified as a CSW by the American Board of Examiners in Clinical Social Work; or is listed on the National Association of Social Workers’ Clinical Register, or has a masters degree in social work and two years of supervised clinical experience; and b) is licensed to practice as a social worker if required by the State of practice. V-15

IV. Psychiatric Nurse Specialist A registered nurse who a) Is certified by the American Nurses Association as a psychiatric and mental health clinical nurse specialist, or has a masters degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical training; and b) is licensed to practice as a psychiatric or mental health nurse specialist if required by the State of practice. V-16

V. Marriage and Family Therapist (MFT) a) An individual with a masters or doctoral degree in marriage and family therapy and at least two years of supervised clinical experience who is practicing as a MFT and is licensed to do so if required by the State of practice; or b) if licensure or certification is not State required, is eligible for clinical membership in the American Association for Marriage and Family Therapy. V-17

List all Psychiatrists or CMHPs who: Provide mental health care in the service area Provide direct care or consultation and supervision Practice in ambulatory or other short term care settings2 2 Usually defined as < 2 weeks average length of stay. V-18

Include: All psychiatrists or CMHP (including psychiatrists) who provide patient care in the service area, including those who: 1) Serve in State Scholarship or Loan Repayment Programs 2) Serve at Indian Health Clinics and are not Federal providers 3) Plan on retiring but are still seeing patients V-19

FTE Exclusions from Survey: Mental health providers engaged solely in research, administration, or teaching Mental health hospital staff involved exclusively in inpatient or emergency room care Mental health providers with full-time staff positions in correctional institutions, youth detention facilities, residential treatment centers for children with emotional or developmental disabilities, and inpatient units of State or County mental hospitals Psychiatrists who are suspended under provisions of the Medicaid- Medicare Anti-Fraud and Abuse Act for 18 months or more V-20

Include in Survey, but Exclude in FTE: Mental health providers who serve in the NHSC Scholarship or Loan Repayment Programs (FTEs will include State Loan Repayment Program recipients) Physicians who are graduates of foreign medical school who are not citizens or lawful permanent residents (including those with J-1or H-1B visas) Mental health providers who are Federal providers (e.g. Commissioned Officers at Indian Health Services or Bureau of Prisons) V-21

Include in Survey, but Exclude in FTE: (cont’) Mental health providers who are planning on retiring but are still seeing patients Note: All providers who meet these qualifications should be listed, even if their FTE will be 0. V-22

Sources of Provider Data State Licensure Lists National, State, and Local Professional Association Directories Medicare and Medicaid Practitioner Lists Local Telephone Directory Yellow Pages Commercially Developed Listings V-23

STEP 2 Determine the number of hours each provider works in out-patient care (this includes office visits and follow-up hospital in-patient care) serving the population to be designated. V-24

Designation Types and Whom To Include in the Provider Count Designation Type: Count all psychiatrists or other CMHP (inc. Psychiatrists) who serve all persons: Geographic in the service area Low-Income in the service area that have incomes Population < 200% of the Federal poverty level (Medicaid and Sliding Fee) Medicaid-Eligible in the service area that are Population Medicaid-eligible Migrant Farmworker in the service area that are migrant Population farmworkers Native American/ in the service area that are Native Native Alaskan American or Native Alaskan For each provider, include the number of hours of patient care provided (office and hospital inpatient) in the service area. V-25

Providers Total Psychiatrists: 2 Total Core Mental Health Providers: 6 Location of Hours of Direct Provider Name Specialty Practice/CT Pt. Care/Week3 1) S. Freud, M.D. Psychiatry 5 Oedipal Lane 20 City, CA 90001 2) C. Jung, M.D. Psychiatry 11 Dream Drive 40 City, CA 90001 3) H. Lecter, Ph.D. Clinical 6 Can Street 26 Psychology City, CA 90021 4) M. Houlihan, R.N. Psychiatric 1400 Captain Avenue 55 Nursing City, CA 90003 5) R. Weisheimer, M.S. Marriage & Fam. 69 Shex Street 10 Counseling City, CA. 90009 6) L. Schlessinger, M.S.W. Clinical Social 1 Radio Road 6 Work City, CA 90006 Total Psychiatrists: 2 Total Core Mental Health Providers: 6 3 - Must include hospital hours V-26

STEP 3 Calculate the FTE for each mental health provider serving the population to be designated. V-27

FTE Calculation 40 hours = 1.0 FTE Every 4 hours (½ day) is counted as 0.1 FTE A provider serving more than 40 hours a week is counted as 1.0 FTE A provider whose hospital hours are unknown is counted as a 1.0 (no adjustment factor) Each provider’s FTE is rounded to the nearest tenth of a percent prior to totaling Examples: 0.875= 0.9 0.817= 0.8 0.83 = 0.8 0.85 = 0.9 Psychiatric interns and residents are counted as 0.5 FTE (40 hours = 0.5 FTE) Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and SFS patients. It is not based on whether the provider is accepting new Medicaid patients. V-28

INCLUDE IN THE FTE COUNT All appropriate providers providing mental health services in the service area 40 hours = 1.0 FTE)  Adjust FTE based on number of hours of direct patient care  Hours may be less than full time due to administrative duties, research, teaching, semi-retirement, or infirmity  If less than full time due to provision of services in another location, calculate based on the number of hours of direct care provided in the service area  Providers in facilities or institutions that provide both inpatient and outpatient services will only be counted for the number of hours in outpatient units or other short-term care units.  Psychiatric interns and residents - count as 0.5 FTE (40 hours = 0.5 FTE)  Physicians who are graduates of foreign schools who are citizens or lawful permanent residents but have restricted medical licenses are counted as 0.5 FTE (40 hours = 0.5 FTE) V-29

INCLUDE IN APPLICATION BUT EXCLUDE FROM FTE COUNT: Providers under contract with the NHSC Federal Scholarship or Loan Repayment Programs (This does not apply to providers in State loan repayment or scholarship programs.)  Other Federal providers (e.g. Commissioned Officers at IHS or BOP sites, etc.)  Physicians who are graduates of foreign schools who are not citizens or lawful permanent residents (including those with J-I or H1-B visas.) V-30

DO NOT INCLUDE IN APPLICATION OR FTE COUNT: Providers engaged solely in administration, research, or teaching  Hospital staff physicians involved exclusively in in-patient or emergency room care  Providers with full-time staff positions in correctional institutions, youth detention facilities, residential treatment centers for children with emotional or developmental disabilities, and in-patient units of State or County mental hospitals  Providers who are suspended under provisions of the Medicaid- Medicare-Anti-Fraud and Abuse Act for a period of 18 months or more V-31

FTEs Geographic Designation Provider Name Specialty Location of Practice Hours of Direct Pt. Care/Week1 FTE Based on Hours Total Rounded FTE S. Freud, M.D. Psychiatry 5 Oedipal Lane City, CA 90001 20 0.5 (20/40=.5) C. Jung, M.D.2 11 Dream Drive 40 (40/40=1.0 1.0/.5=.5) H. Lecter, Ph.D. Clinical Psychology 6 Can Street City, CA 90021 26 .65 (26/40=.65) 0.7 M. Houlihan, R.N. Psychiatric Nursing 1400 Captain Avenue City, CA 90003 55 1.375 (55/40=1.375) 1.0 R. Weisheimer, M.F.T. Marriage/Family Counseling 69 Shex Street City, CA 90009 10 .25 (10/40=.25) 0.3 L. Schlessinger, M.S.W. Clinical Social Work 1 Radio Road City, CA 90006 6 0.15 (6/40=.15) 0.2 Total Psychiatrists: 2 Total Psychiatrist FTE: 1.0 Total Core Mental Health Providers: 6 Total Core Mental Health FTE: 3.2 ¹ - Must include hospital hours (for psychiatrist only) ² - Dr. Jung is in his last year of residency and is therefore counted as 0.5 V-32

FTEs Low-Income Designation Provider Name Specialty Location of Practice Hours of Direct Pt. Care/Week FTE Based on Hours % Medi-Cal SFS % of L-I FTE Total Rounded L-I FTE S. Freud, MD Psychiatry 5 Oedipal Lane City, CA 90001 20 0.5 0% 0.0 C. Jung, M.D. 11 Dream Drive 40 30% 15% 45% .22 0.2 H. Lecter,Ph.D. Clinical Psychology 6 Can Street City, CA 90021 26 .65 85% .55 0.6 M. Houlihan, R.N. Psychiatric Nursing 1400 Captain Avenue City, CA 90003 55 1.0 50% 10% 60% .60 R. Weisheimer,M.S. Marriage/Fam. Counseling 69 Shex Street City, CA 90009 10 .25 25% 5% 0.1 L. Schlessinger, M.S.W. Clinical Social Work 1 Radio Road City, CA 90006 6 0.15 .06 (20/40=.5) (30%+15%=45%) (40/40=1=.5) (.45x.5=.225=0.2) (26/40=.65) (.85x.65=.55=0.6) (50%+10%=60%) (.60x1.0=.60=.6) (55/40=1.37=1) (10/40=.25) (.30x.25=.075=.1) (25%+5%=30%) (6/40=.15) (.10x.15=.015=0.02=0) Total Psychiatrists: 2 Total L-I Psychiatrist FTE: 0.2 Total Core Mental Health Providers: 6 Total L-I Core Mental Health FTE: 1.5 V-33

Survey Providers Survey all mental health providers in the service area for the type of designation being sought (psychiatrists only or all CMHP): Must include hospital hours (psychiatrist) Minimum two-thirds response rate required V-34

Calculate Non-Responders Use survey average (minimum two-thirds response rate required) Example: Sacramento, California - 80 providers 60 - respond to survey 20 - no response after repeated telephone calls (Response rate = 60/80 = 75%) Total FTE for the 60 responders = 28 FTEs 1) Divide FTE of responders (28) by the number of responders (60) for the average FTE of responders (.46) 2) Multiply number of non-responders (20) by the average FTE of responders (.46) for FTE of non-responders (9.3) 3) Add FTE of responders (28) and non-responders (9.3) for total FTE = 38.0 V-35

STEP 4 Calculate the population to provider ratio. V-36

Population to Provider Ratio 2 Possible Ratios: Psychiatrists Core Mental Health Providers Step 1: Determine if area has high need Youth ratio: 5,881/11,483 = .51 (min. > = .6) Elderly ratio: 3,681/11,483 = .32* (min. > = .25) * Indicates High Need V-37

Population to Provider Ratio Geographic Mental HPSA Resident/Civilian Population Ratio: Resident/Civilian Population = 20,900 Psychiatrist FTE = 1 (20,900 / 1 = 20,900:1) Psychiatrist Ratio: 20,900:1 CMHP FTE = 3.2 (20,900 / 3.2 = 6,531:1) CMHP Ratio: 6,531:1 V-38

Population to Provider Ratio Geographic Mental HPSA with High Needs Resident/Civilian Population (High Needs) Ratio: Resident/Civilian Population = 20,900 Psychiatrist FTE = 1 (20,900 / 1 = 20,900:1) Psychiatrist Ratio: 20,900:1 CMHP FTE = 3.2 (20,900 / 3.2 = 6,531:1) CMHP Ratio: 6,531:1 V-39

Population to Provider Ratio Low-Income Mental HPSA Low-Income Population (200% Poverty) Ratio: Low-Income Population = 10,137 (49.47%) Psychiatrist FTE = 0.2 (10,137 / 0.2 = 50,685:1) Psychiatrist Ratio: 50,685:1 CMHP FTE = 1.5 (10,137 / 0.2 = 6,758:1) CMHP Ratio: 6,758:1 V-40

What to Include In the Population Provider Ratio Mental Health Care Section of Your Application Total adjusted population Source of data List of Providers: Include the Following for Each Provider: Name Location: Non-metro areas - name of town Metro areas – complete address with zip code, and CT if available Degree (M.D., MFT, R.N., M.S.W., etc.) Average # of hours/week of patient care in area Verification that hospital hours are included % of practice Medicaid (for low-income and Medicaid-eligible designations) % of practice Sliding Fee Scale (for low-income designations) FTE total for each provider rounded to the nearest tenth of a percent Description of how information was obtained (source, method) V-41

Total number of providers Total FTE What to Include In the Population Provider Ratio Mental Health Care Section of Your Application (continued) Totals and Ratio Total number of providers Total FTE Explanation of any high need indicators Population to provider ratio V-42

What Not To Include In Your Application Information on the weather or climate Information on road conditions, construction, or number of avalanches Personal statements of driving time Average number of funerals History of the early settlers of the area Newspaper articles Pictures of the mayor General information on access issues that is not specific to the area or population Copies of old applications V-43

Contiguous Area Resources V-44

Contiguous Area Resources Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, over-utilized, or inaccessible to the population of the area proposed for designation Purpose of Contiguous Area Analysis: To identify nearby sources of care and determine if they are inaccessible to the population in the proposed service area V-45

1) Identify the boundaries of each contiguous area. STEPS 1) Identify the boundaries of each contiguous area. 2) Evaluate each area to determine availability of resources. V-46

Identify the boundaries of each contiguous area A. Identify on a map the boundaries and population center of the proposed service area B. Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center C. Map the boundaries of each contiguous area in all directions (North, East, South, & West) Boundaries The boundaries of each contiguous area may be based on Travel time (40 minutes) Socio-economic/demographic characteristics Established neighborhoods Physical barriers Designated HPSA The boundaries of contiguous areas are often (not always) based on the same census delineation as the proposed area Proposed service area = whole county Contiguous areas = whole counties Proposed service area = census tracts (MSSA) Contiguous areas = census tracts (MSSA) V-47

PROCESS OF EVALUATING AVAILABILITY OF RESOURCES A) Check the HPSA list to determine if any of the contiguous areas are designated as HPSA and therefore considered inaccessible. If it is not a HPSA, then Determine if there are significant socio-economic/demographic disparities or physical barriers If there are no significant socio-economic/demographic disparities or physical barriers, then C) Determine if the contiguous area’s providers are located > 40 minutes away from the population center of the proposed area and are therefore inaccessible due to excessive distance If they are not excessively distant, then D) Determine if the resources in the contiguous area exceed the population-to-provider ratio and are therefore over-utilized If they are not over-utilized, this area cannot be designated. (Consider a different kind of designation) V-48

A) Check the HPSA status of the contiguous areas and determine if this type of HPSA is inaccessible to the proposed area If the proposed service area is: Then the contiguous area is inaccessible if it is a: Geographic without high needs Geographic HPSA Geographic with high needs (based on 100% poverty indicator) Geographic HPSA, Low-Income HPSA Low-Income HPSA Medicaid Eligible HPSA Geographic, Low-Income, or Medicaid Eligible Poverty Population HPSA Geographic, Low-Income, Medicaid Eligible or Poverty HPSA V-49

B) Determine if Significant Socio-economic/Demographic Disparities or Physical Barriers Exist Significant demographic disparities between the population in the service area and the population in the contiguous area which result in the population being isolated from nearby resources (A 30% or more disparity between the population in the service area and the population in the contiguous area) Significant socio-economic disparities: 100% poverty rate or 200% poverty rate (A 30% or more disparity between the population in the service area and the population in the contiguous area) Significant physical barrier: mountains, large parks, bodies of water, highways, railway yards, industrial areas, etc. which result in the population being isolated from nearby resources V-50

C) Determine If Providers Are Excessively Distant Develop a list of providers in the contiguous area, Map their office locations Determine the travel time from the proposed area’s population center to the contiguous area Providers > 40 minutes from the population center are excessively distant Mental Health Care: > 40 minutes Interstate Roads - 30 miles X 1.33 = 40 minutes Primary Roads - 25 miles X 1.6 = 40 minutes Secondary Roads - 20 miles X 2.0 = 40 minutes V-51

C) Determine If Providers Are Excessively Distant (continued) Inner Portions of Metropolitan Areas: Distance is based on time using public transportation during non-rush hour. Bus routes and schedules must be described (provide narrative description and include bus schedule if possible). (Use only if the service area has population greater than 20% @ 100% poverty) V-52

D) Determine if Contiguous Areas Are Overutilized Calculate FTE - use the same method as used for the proposed service area. If needed, survey providers and determine FTE serving the population. Use the same surveying method as used for the proposed service area. Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio Population to Provider Ratios: MENTAL HEALTH CARE: > 20,000:1 psychiatrist or > 3,000:1 CMHP and > 10,000:1 psychiatrist V-53

Example Whole County Map Analysis: 55-63 V-54

Identify on a map the boundaries and population Whole County Identify on a map the boundaries and population center of the proposed service area. V-55

Whole County Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% 65 year or older Pop: 8.02% Elderly Ratio: Youth Ratio: * Based on Total Population (Not Civilian Pop.) V-56

Whole County Area 1 (N) – Modoc County A) Identify the contiguous areas in all directions within 40 minutes from the proposed area’s population center B) Map the boundaries of each contiguous area in all directions (N, E, S, W) Area 1 (N) – Modoc County Area 2 (E) – Washoe County, NV Area 3 (S) – Plumas County Area 4 (S) – Sierra County Area 5 (W) – Shasta County V-57

Whole County Identify the boundaries and population center of the proposed service area. V-58

Whole County (Contiguous Areas) Area 1 (N) – Modoc County (Alturas): (Excessively Distant: 103.7 miles/166 minutes) Summary: Res./Civ. Pop: 8,890 White Pop: 90.74% Black Pop: 0.63% Hispanic Pop: 12.01% Below 200% Pov: 45.64% Below 100% Pov: 21.64% Elderly Ratio: 0.28 Youth Ratio: 0.37 HPSA: No Travel Time: 103.7 miles/166 min.   Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% Elderly Ratio: 0.11 Youth Ratio: 0.27 * Based on Total Population (Not Civilian Pop.) V-59

Whole County (Contiguous Areas) Area 2 (E) – Washoe County, Nevada State: (Reno) (Excessively Distant: 85.9 miles/137 minutes) Summary: Res./Civ. Pop: 382,256 White Pop: 81.06% Black Pop: 2.40% Hispanic Pop: 20.06% Below 200% Pov: 28.42% Below 100% Pov: 7.51% Elderly Ratio: 0.16 Youth Ratio: 0.39 HPSA: No Travel Time: 85.9 miles/137 min.   Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% Elderly Ratio: 0.11 Youth Ratio: 0.27 * Based on Total Population (Not Civilian Pop.) V-60

Whole County (Contiguous Areas) Area 3 (S) – Plumas County (Quincy): (Excessively Distant: 69.2 miles/111 minutes) Summary: Res./Civ. Pop: 20,781 White Pop: 92.81% Black Pop: .68% Hispanic Pop: 6.09% Below 200% Pov: 31.21% Below 100% Pov: 12.98% Elderly Ratio: 0.27 Youth Ratio: 0.31 HPSA: No Travel Time: 69.2 miles/111 min.   Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% Elderly Ratio: 0.11 Youth Ratio: 0.27 * Based on Total Population (Not Civilian Pop.) V-61

Whole County (Contiguous Areas) Area 4 (S) – Sierra County (Loyalton): (Excessively Distant: 79 miles/126 minutes) Summary: Res./Civ. Pop: 3,430 White Pop: 94.99% Black Pop: 0.20% Hispanic Pop: 8.78 Below 200% Pov: 31.02% Below 100% Pov: 11.31% Elderly Ratio: 0.23 Youth Ratio: 0.30 HPSA: No   Travel Time: 79 miles/126 min. Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% Elderly Ratio: 0.11 Youth Ratio: 0.27 * Based on Total Population (Not Civilian Pop.) V-62

Whole County (Contiguous Areas) Area 5 (W) – Shasta County (Redding): (Excessively Distant: 112 miles/179 minutes) (Inaccessible: Designated Mental HPSA) Summary: Res./Civ. Pop: 175,026 White Pop: 89.82% Black Pop: 0.94% Hispanic Pop: 7.14% Below 200% Pov: 36.60% Below 100% Pov: 15.42% Elderly Ratio: 0.22 Youth Ratio: 0.38 HPSA: Low-Income Mental HPSA Travel Time: 112 miles/179 min.   Proposed Area: Lassen County (Susanville)   Summary: Total Pop: 34,708 White Pop: 81.52% Black Pop: 8.91% Hispanic Pop: 14.80% Below 200% Pov: 25.12% Below 100% Pov: 10.30% Elderly Ratio: 0.11 Youth Ratio: 0.27 * Based on Total Population (Not Civilian Pop.) V-63

Sample HPSA Worksheets Whole County V-64

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Determine the Nearest Source of Non-Designated Care Needed for HPSA score: Cannot be a HPSA (of any type) Cannot have significant socio-economic/demographic differences or physical barriers Can be excessively distant Can be overutilized For all applications: Provide a road map with the proposed service area and contiguous areas outlined On the map, indicate the population center of the proposed service area, the nearest source of care, and the route between these points Provide the name and address of the nearest source of care, route, miles, and minutes For inner portions of metropolitan areas, include: Bus route information from the population center of the proposed area to the nearest source of care Miles and minutes of travel time V-70

Survey providers only if necessary: Time Saving Tips Survey providers only if necessary: In contiguous areas, calculate the population to provider ratio counting each provider as 1.0 FTE. If area meets ratio of > 20,000:1, don’t survey. Collect all possible information in one survey (e.g. Medicaid and sliding fee scale even for an area designation). Work with State licensing department to obtain information on providers. Use claims data for Medicaid FTE (works only in fee-for-service Medicaid). V-71

What To Include In The Contiguous Area Resources Section of Your Application Map with Census Delineations Name and boundaries of proposed service area Name and boundaries of contiguous areas Population center for the proposed service area Helpful: current designation status of each of the contiguous areas Road Map Outline of proposed area boundaries Location of nearest source of non-designated care For automobile transportation - start, end, and route For public transportation - start and end points of route V-72

Population to provider ratios For Contiguous Areas that are not Excluded with Current Designations and Whose Providers are Excessively Distant Travel time to closest provider from population center of service area, including miles, route, and type of road; or public transportation information, including bus routes, start/end points, miles, minutes, and source; include bus schedule if available. For Contiguous Areas that are not Excluded with Current Designations and have Access Barriers Description of any significant socio-economic/demographic disparities (e.g. demographic data on racial/ethnic composition or income levels comparing proposed service area population to population in the contiguous area, and source of data), or Description of any significant physical barrier For Contiguous Areas that are not Excluded with Current Designations and are Overutilized Population to provider ratios Description of how information was obtained V-73

For All Designation Requests: Address of nearest source of non-designated, accessible care, including address, miles and minutes via public transportation if metropolitan area Location of nearest source on road map (see above) For Public Transportation Routes: Travel time, based on non-rush hour bus schedules Start/End point of route Include time waiting for transfers while in route Map showing proposed area boundaries, start and end points of bus route Bus schedules, if available Cite source of information (Public transportation can be used for service areas with a 100% poverty population at or greater than 20% of the civilian population.) V-74

Websites Bay Area Public Transit (San Francisco): http://transit.511.org/index.asp Southern California Public Transit (San Diego): http://www.sdcommute.com/ Los Angeles County Metropolitan Transportation Authority http://www.metro.net/default.asp 2000 CT Locator: http://www.ffiec.gov/Geocode/default.aspx U.S. Census Bureau – American Factfinder http://factfinder.census.gov/home/saff/main.html?_lang=en V-75

Process Model for Mental Health Professional Shortage Area Designation To Use: Follow arrows. Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes Define Rational Service Area 1 CHMP = Core Mental Health Professional Psych = Psychiatrist Determine Service Area Population 2 POP:CMHP > 4500:1 and POP:Psych > =15000:1 Determine Core Mental Health Profession (CMHP) FTEs POP:CMHP > 6000:1 and POP:Psych > =20000:1 or or 3 Evaluate Service Area for High-Need Indicators POP:CMHP > =6000:1 POP:CMHP > =9000:1 Evaluate Contiguous Area 6 or 5 Calculate Population-to- CMHP & Population-to-Psych Ratio or POP:Psych > =20000:1 4 POP:Psych > =30000:1 1 or more High Need Indicators Present NO High-Need Indicators Present POP:CMHP > 4500:1 and POP:Psych > =15000:1 or 1 or more High Need Indicators Present No contiguous area conditions met POP:CMHP > =6000:1 Evaluate Contiguous Area or 5 POP:Psych > =20000:1 1 or more contiguous area conditions met No contiguous area conditions met STOP: Area Not Qualified For Designation APPLY FOR DESIGNATION STOP: Area Not Qualified For Designation 7 8 8 STOP: Area Not Qualified For Designation APPLY FOR DESIGNATION 7 8 V-76

HPSA and MUA/MUP Application Process Shortage Designation Program (SDP) Initial Contact Applicant contacts SDP for technical assistance (TA) and information. SDP provides: TA on appropriate designation Maps Population and demographic data Survey samples Application worksheets 1st Step – Application Received (Lal) Log application on tracking database Assign case number Mail acknowledgment letter 2nd Step – 30-day Comment Notice to: (Oakes) County Health Officer/ Department/Medical Society Primary Care, Dental, or Mental Health Association HRSA/SDB copied Case assigned to SDP staff (Chung) 3rd Step – Application Analysis (complete within 90 days, depending on caseload) or Dental & Mental HPSA (Manual Process): Define rational service area (MSSA) Verify population, poverty, & demographic data Geo-code and verify provider data Calculate population to provider ratio Verify contiguous area resources Develop proposed and contiguous area maps Determine data is accurate, current, and consistent with all HPSA criteria If application is “incomplete,” request additional data and allow applicant 15 days for re- submission. Prepare recommendation packet to Federal Shortage Designation Branch (SDB) Submit packet for peer review Submit packet for Manager review and approval (Chung) Mail recommendation packet to SDB and copies to applicant & others (Oakes) Update tracking database (Lal) 4th Step - HRSA Review (SDB) Hold all recommendations for 30-day waiting period Perform primary and secondary reviews Upon approval or denial, post designation on HRSA on-line database Send designation letter to SDP and applicant Primary Care HPSA and MUA/MUP (ASAPS Process) Validate application information before entering data into ASAPS (use on-line tools: maps, data tables, MSSA data) Verify provider data Calculate population to provider ratio Conduct contiguous area analysis in mapping interface (does not apply to MUA/MUP) If application is “incomplete,” request additional data and allow applicant 15 days for resubmission. Verify and enter all additional data needed Prepare notification letter to applicant Prepare ASAPS packet for Manager’s review and approval (Chung) Upon completion, Manager submits recommendation via ASAPS Mail ASAPS packet to applicant and others (Oakes) Update tracking database (Lal) 5th Step – SDP Tracking Update Update SDP tracking database (Lal) File designation letter in program file (Lal) Create monthly dynamic maps (Dixon/Pham) NOTE: HPSA designations are valid for 4 years. To maintain the HPSA status, designees must reapply every 4 years. MUA/MUP designations are permanent, unless there is a change in the MSSA boundary then designees must be reapply for the updated boundary. V-77