III. CALCULATING POPULATION TO PROVIDER RATIOS Primary Care III-1

Calculating Population to Provider Ratios (Primary Care) Objective: Participants will understand how to: 1) Identify all primary care providers 2) Calculate Full-Time-Equivalency (FTE) 3) Determine the population to provider ratios for primary care geographic and population designations III-2

Population to Provider Ratios Needed for Designation (Primary Care) Contiguous Areas are overutilized if: > 2,000:1 1 - See Appendix V for additional information on calculating infant mortality rates 2 - See Appendix V for information on insufficient capacity Geographic Area: ≥ 3,500:1 A rational service area: county or sub-county (MSSA) Geographic Area w/Unusually High Needs: ≥ 3,000:1 A rational service area plus one of the following: a) More than 20% of the population has incomes at or below 100% of the Federal poverty level; or b) More than 100 births per year per 1,000 women ages 15-44; or c) More than 20 infant deaths per 1,000 live births 1 ; or d) Meets insufficient capacity criteria 2 Population Groups: ≥ 3,000:1 A rational service area plus meets the requirements of the specific designation category (e.g. low-income, homeless, etc.) III-3

Population Side of the Ratio A.Geographic Area Designations B. Population Designations : III-4  ________________

A. Geographic Designations Resident Civilian Population = Total permanent population in the service area (non- institutionalized population) Excludes: inmates or individuals in institutions (e.g. nursing homes, prisons, college dormitories, military installations, Native Americans on reservations, etc.) Source: Must use 2007 Claritas Population Estimates, effective Can add: i. Migrant Farmworkers Data from the 2000 Migrant and Seasonal Farmworker Enumeration Profiles Study, or other approved source (must include methodology) ii.Tourists Formula: 0.25 X [fraction of year present] X [average daily number of tourists] (Use local data, which must include methodology and length of stay.) iii.Seasonal Residents Those who maintain a residence in the area, but inhabit it for only 2-8 month year (Use census or local data, which must include methodology.) iv.Homeless Local data (must include methodology) III-5

B. Population Designations 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 Medicaid-Eligible Population Number of individuals in the service area that are eligible for Medicaid  Must have > 30% of the population in the service area with incomes < 200% of the Federal poverty level Source: Department of Health Care Services Homeless Population Number of individuals in the service area that are homeless Source: 2000 census data, or local data (must include methodology) III-6

Migrant Farmworker Population Number of individuals in the service area who are migrant farmworkers adjusted for the fraction of the year they are in the service area. Source: State/local data & 2000 Migrant & Seasonal Farmworker Enumeration Profiles Study Ex:Napa County, California Agricultural Season = 4 months 4/12 =.333 Migrant Farmworker Pop = 5,659 5,659 X.333 = 1,884 Total Migrant Farmworker Population = 1,884 Native American/Native Alaskan Number of individuals in the service area that are Native Americans or Native Alaskans Source: 2000 census data III-7 B. Population Designations (continued)

III-8 MIGRANT AND SEASONAL FARMWORKER ENUMERATION PROFILES STUDY CALIFORNIA FINAL prepared for the Migrant Health Program Bureau of Primary Health Care Health Resources and Services Administration by Alice C. Larson, Ph.D. Larson Assistance Services P.O. Box 801 Vashon Island, WA (voice) (fax) ( ) September, 2000

Use information in highlighted column. TABLE THREE CALIFORNIA ALL AGRICULTURAL WORKERS ESTIMATES FINAL County Adjusted MSFW Farmworker Estimates Migrant Farmworkers Seasonal Farmworkers Non-Farmworkers In Migrant Households Non- Farmworkers In Seasonal Households MSFW Farmworkers And Non- Farmworkers Alameda1, ,043 Alpine Amador ,311 Butte7,2633,3633,9001,2364,42612,925 Calaveras Colusa13,9326,4507,4812,3718,49024,792 Contra Costa2,4701,1441, ,5054,395 Del Norte ,076 El Dorado ,708 Fresno145,91967,56178,35924,82888,917259,665 Glenn3,7471,7352, ,2836,668 Humboldt ,664 Imperial29,31213,57215,7414,98817,86252,162 Inyo Kern92,14242,66249,48015,67856,148163,968 Kings16,5927,6828,9102,82310,11129,526 Lake2,9111,3481, ,7745,181 Lassen Los Angeles14,1806,5667,6152,4138,64125,234 Madera29,67613,74015,9365,04918,08352,809 Marin ,240 Mariposa Mendocino6,1422,8443,2981,0453,74310,930 Merced26,10012,08414,0164,44115,90446,445 Modoc ,515 Monterey86,94140,25346,68714,79352,978154,712 Napa12,2225,6596,5632,0807,44721,748 Nevada Orange11,2845,2256,0601,9206,87620,081 III-9

III-10 Use information in highlighted column. County Adjusted MSFW Farmworker Estimates Migrant Farmworkers Seasonal Farmworkers Non-Farmworkers In Migrant Households Non-Farmworkers In Seasonal Households MSFW Farmworkers And Non- Farmworkers Placer ,428 Plumas Riverside34,99116,20118,7905,95421,32262,267 Sacramento7,8453,6324,2131,3354,78013,960 San Benito7,3003,3803,9201,2424,44812,991 San Bernardino7,0123,2463,7651,1934,27312,477 San Diego19,7199,13010,5893,35512,01635,090 San Francisco San Joaquin60,18427,86532,31910,24136,674107,099 San Luis Obispo11,8965,5086,3882,0247,24921,168 San Mateo4,0841,8912, ,4897,267 Santa Barbara31,38114,53016,8525,34019,12355,844 Santa Clara10,5974,9065,6911,8036,45718,858 Santa Cruz19,2488,91210,3363,27511,72934,252 Shasta5,6672,6243, ,45310,084 Sierra Siskiyou3,3981,5731, ,0716,047 Solano6,5283,0233,5061,1113,97811,617 Sonoma15,7177,2778,4402,6749,57827,969 Stanislaus36,72017,00119,7196,24822,37665,344 Sutter14,1776,5647,6132,4128,63925,228 Tehama3,8251,7712, ,3316,807 Trinity Tulare73,81034,17439,63612,55944,977131,346 Tuolumne Ventura35,18116,28918,8925,98621,43862,605 Yolo14,7946,8507,9442,5179,01526,326 Yuba5,3492,4772, ,2599,519 State Total938,758434,645504,113159,732572,0421,670,532 NOTE: County numbers have been rounded and, therefore, may not add to totals.

2007 Claritas Population Estimates (Dashboard) III-11 Source: HWDD - Access Database For Geographic HPSAs and MUAs, always use Civilian Population not Total Population.

Provider Side of the Ratio : ____ III-12 

STEPS 1)Identify all primary care physicians in the area to be designated. 2)Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. 3)Calculate the FTE for each primary care physician serving the population to be designated. 4)Calculate the population to provider ratio. III-13

STEP 1 Identify all primary care physicians in the area to be designated. III-14

List all primary care Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) who: 1) Provide direct patient care in the service area, and 2) Practice principally in one of the six primary care specialties:  General Practice  Family Practice  General Internal Medicine  Pediatrics  Gerontology  Obstetrics and Gynecology  Physicians engaged solely in administration, research, or teaching  Hospital staff physicians involved exclusively in inpatient or emergency room care  Locum tenens serving less than 1 year (on contract)  Physicians who are suspended under provisions of the Medicaid-Medicare Anti- Fraud and Abuse Act for a period of 18 months or more  Mid-levels, Physician Assistants, & Family Nurse Practitioners Include in survey, but reduce the following provider’s FTE to 0.0 III-15

 Physicians who serve in the NHSC Scholarship or Loan Repayment Programs, including if it is a “Federal” or “State” program.  Physicians who serve under a J-1 or H-1B waiver  Physicians who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau of Prisons)  Include physicians who are planning on retiring but are still seeing patients Note: Survey located in “Step-by-Step Guidelines” outlines recommended questions. Gather More Information About Each Provider III-16

 State Licensure Lists: llquery$.startup llquery$.startup  National, State, and Local Medical Association Directories  Local Hospital Admitting Physician Listings  American Osteopathic Association (AOA) Physician Listing  Medicare and Medicaid Practitioner Lists  Local Telephone Directory/ Yellow Pages  Commercially Developed Listings (CD-ROM)  Sources of Provider Data Use several of these sources to assure a complete listing of physicians is being used. III-17 

STEP 2 Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. III-18

Designation Types and Whom to Include in the Provider Count COUNT ALL PRIMARY CARE PROVIDERS WHO SERVE ALL PERSONS: Geographicin the service area Low-Income Populationin the service area that have incomes < 200% of the Federal poverty level (Medicaid and Posted Sliding Fee) Medicaid-Eligible Populationin the service area that are Medicaid- enrolled Homeless Populationin the service area that are homeless Migrant Farmworker Populationin the service area that are migrant farmworkers Native American/ Native Alaskan in the service area that are Native American or Native Alaskan DESIGNATION TYPE: III-19

Providers Physician NameSpecialtyLocation of Practice/CT Hours of Direct Pt. Care/Week Hosp. Hours 1) L. McCoy, D.O.Gen.Prac. 19 Main Street City, CA CT Included 2) D. Scully, MDPediatrics 11 Park Place City, CA CT Included 3) B Spock, M.D.Int. Med. 6 Muldar Ave City CA CT Included 4) M. Welby, M.D.Ob-Gyn 3306 Russia Blvd City, CA CT Not Included 5) Y. Zhivago, D.O.Fam. Prac. 99 Bones Drive City, CA CT Full Time Administration Total Physicians: 5 III-20

STEP 3 Calculate the FTE for each primary care physician serving the population to be designated. III-21

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  Only the Total (or Low-Income) FTE is rounded to the nearest tenth of a percent: Examples:0.875= = = = 0.9  Interns and residents are counted as 0.1 FTE (40 hours = 0.1 FTE) Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and Sliding Fee Scale (SFS) patients. It is not based on whether the provider is accepting new Medicaid patients. For each physician, include the number of hours of direct patient care provided (office and hospital inpatient) in the service area: III-22

Adjustment of FTE if hospital inpatient hours not available:  Use for physicians whose office hours are < 40 and information on hours spent in inpatient care is not available  Multiply office hours X appropriate factor  Cannot exceed 1.0 FTE Primary Care SpecialtyAdjustment Factor General/Family Practice1.4 Gerontology1.4 Pediatrics1.4 General Internal Medicine1.8 Obstetrics/Gynecology1.9  If specialty information is not known then use the default which is 1.6 III-23

 Physicians under contract with the NHSC Federal Scholarship or Loan Repayment Programs (this does not apply to physicians in the State Loan Repayment Program)  Other Federal providers (e.g., Commissioned Officers at Indian Health Service or Bureau of Prison sites, etc.)  Physicians who are graduates of foreign medical school who are not citizens or lawful permanent residents (including those with J-1 or H-1B visas) Note: List these physicians in the application but adjust their FTE to 0.0 Include in survey, but reduce the following provider’s FTE to 0.0: III-24

Do NOT reduce the following provider’s FTE: All primary care M.D.s and D.O.s who provide direct patient care in the service area, including those who:  Serve in State Scholarship or Loan Repayment Programs  Serve at Indian Health Clinics and are not Federal providers  Plan on retiring but are still seeing patients III-25

FTEs - Geographic Designation Physician NameSpecialtyLocation of Practice/CT Hours of Direct Patient Care/Week Hosp. Hours FTE 1) L. McCoy, D.O.Gen.Prac. 19 Main Street City, CA CT Included1.0 (48/40=1.2=1.0) 2) D. Scully, MD 1 Pediatrics 11 Park Place City, CA CT Included0.8 (30/40=.75=.8) 3) B Spock, M.D. 2 Int. Med. 6 Muldar Ave City, CA CT Included0.4 (15/40=.375=.4) 4) M. Welby, M.D. 3 Ob-Gyn 3306 Russia Blvd City, CA CT Not Included 1.0 (25 x 1.9 = 47.5/40=1.2=1.0) 5) Y. Zhivago, D.O. 4 Fam. Prac. 99 Bones Drive City, CA CT (0/40=.0) Total Physicians: 5 Total FTE: 3.125=3.1 1 – Dr. Scully spends 10 hours/week doing research. 2 – Dr. Spock chooses to work only 15 hours/week. 3 – Dr. Welby has an unknown number of hospital inpatient hours so the adjustment factor is used 4 – Dr. Zhivago spends full-time in administration. III-26

FTEs - Low-Income Designation Total Physicians: 5 Total Low-Inc FTE: 1.615=1.6 1 – Dr. Scully spends 10 hours/week doing research. 2 – Dr. Spock chooses to work only 15 hours/week. 3 – Dr. Welby has an unknown number of hospital inpatient hours so the adjustment factor is used 4 – Dr. Zhivago spends full-time in administration. III-27 Physician NameHours of Direct Pt. Care/Week Hosp. Hours FTE % Medi - Cal % SFS % of Low- Income Total Low- Inc FTE 1) L. McCoy, D.O. 48Included1.064%15%79% (64%+15%=79%) 0.79 (.79 x 1.0 =.79 ) 2) D. Scully, MD 1 30Included0.7535%8%43% (35%+8%=43%) 0.32 (.43 x.75 =.32) 3) B Spock, M.D. 2 15Included %40%100% (60%+40%=100%).375 (1 x.375 =.375) 4) M. Welby, M.D. 3 25Not Included (25x1.9= 47.5/40= 1.2) 1.013%0%13%0.13 (.13 x 1=.13) 5) Y. Zhivago, D.O. 4 0Included0.00% 0.00

Survey Physicians to Determine Their FTE  Survey all primary care physicians in service area  Must attempt to contact physician at least 3 times  Minimum two-thirds response rate required Calculation of Non-Responders Ex: Elk Grove, California - 20 providers 15 - respond to survey 5 - no response after repeated telephone calls Response rate 15/20 = 75% Total FTE for the 15 responders= 9.5 1) Divide FTE of responders (9.5) by the number of responders (15) for the average FTE of responders (.63) 2) Multiply number of non-responders (5) by the average FTE of responders (.63) for FTE of non-responders (3.16=3.2) 3) Add FTE of responders (9.5) and non-responders (3.2) for total FTE = 12.7  Average response rate applied to non-responders III-28

Estimate Medi-Cal FTE Using Claims Data (Low-Income Designations) Include all primary care physicians accepting Medi-Cal, even if they are not accepting new patients. 5,000 Claims (fee-for-service) = 1 FTE For Medi-Cal Managed Care counties, a survey is required to determine each provider’s percent of current caseload of managed care patients. Source: Dept. of Health Care Services – Health Care Statistical Section III-29

STEP 4 Calculate the population to provider ratio. III-30

Population to Provider Ratios Civilian Population Ratio: Civilian Population = 20,900 Primary Care Physician FTE = 3.8 (20,900 / 3.8 = 5,500:1) Civilian Population (High Needs) Ratio: Civilian Population = 20,900 Primary Care Physician FTE = 6.9 (20,900 / 6.9 = 3,029:1) (100% Federal poverty level at 21.1%) Low Income Population (200% Poverty) Ratio: Low Income Population = 10,137 (49.47%) PC Physician Serving that Population = 1.6 (10,137 / 1.6 = 6,336:1) III-31

What to Include in the Population to Provider Ratio Primary Care Section of your Application Population  Cover letter with summary findings  Total adjusted population  Source of data and methodology if using source other than Claritas 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. or D.O.)  Specialty (GP, FP, OB-GYN, IM, PEDS, Gerontology)  Average number of hours per week in direct patient care in the area  Inpatient care hours or adjustment to total hours  Percentage of practice that is Medicaid (for low-income and Medicaid-eligible designations)  Percentage of practice that is 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 (sources, methods of gathering data) Totals and Ratio  Total number of providers  Total FTE  Population to provider ratio  Explanation of any high need indicators III-32

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 III-33

Contiguous Area Resources III-34

Contiguous Area Resources Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, overutilized, 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 III-35

STEPS 1) Identify the boundaries of each contiguous area. 2)Evaluate each area to determine availability of resources. III-36

1) 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 30 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 (30 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) III-37

2) Determine 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 inaccessible HPSA, then B.Determine if there are significant socio-economic/demographic disparities or physical barriers. If there are not significant socio-economic/demographic disparities or physical barriers, then C.Determine if the contiguous area’s providers are located > 30 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 overutilized. If they are not overutilized, this area cannot be designated. (Consider a different kind of designation.) III-38

Check the HPSA Status of Each Contiguous Area and Determine if This Type of HPSA Is Inaccessible to the Proposed Area If the proposed service Then the contiguous area area is: is inaccessible if it is a: Geographic without high needsGeographic HPSA Geographic with high needsGeographic HPSA, Low-Income HPSA (based on 100% poverty indicator) Low-Income HPSAGeographic HPSA, Low-Income HPSA Medicaid Eligible HPSAGeographic, Low-Income, or Medicaid Eligible Poverty Population HPSAGeographic, Low-Income, Medicaid Eligible or Poverty HPSA III-39

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 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 poverty in the service area and the poverty in the contiguous area) Significant physical barrier: mountains, large parks, bodies of water, highways, railway yards, industrial areas, etc. result in the population being isolated from nearby resources III-40

Determine if Providers are Excessively Distant 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) Contiguous area will be measured from the same starting point (which is the population center of the proposed area) Providers > 30 minutes from the population center are excessively distant Primary Health Care: > 30 minutes Interstate Roads - 25 miles X 1.2 = 30 minutes Primary Roads - 20 miles X 1.5 = 30 minutes Secondary Roads - 15 miles X 2.0 = 30 minutes III-41

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). Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate. III-42

Determine if Contiguous Areas are Overutilized  Calculate FTE - use same method as used for the proposed service area.  If needed, survey providers and determine FTE serving the population. Use same surveying method as used for the proposed service area. If applying for low-income designation, gather Medi-Cal and sliding fee scale percentages to calculate low-income FTE.  Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio. Population to Provider Ratios: PRIMARY HEALTH CARE: > 2,000:1 primary care physician III-43

Example Inner Portions of Metropolitan Areas ASAPS Map Analysis Looking at a Geographic Designation for MSSA 78.2aaa III-44

ASAPS Mapping - we zoom in to the county and keep zooming in to get to the MSSA layer. III-45

Once we have zoomed into the MSSA layer, then we define the proposed area. The purple area is our proposed RSA (MSSA 78.2aaa – Watts in LA County). Yellow triangle is the most populated, CT The black polygon is the 5 mile travel distance radius - PC 100% and 200% poverty rate We have to use ASAPS Population and Poverty level – ASAPS has the most recent 2009 Claritas population data. III-46

This is still the same MSSA 78.2aaa in Los Angeles County On this map we are showing the 5 mile travel distance (black line) and the 30 minute travel distance polygon (green line) III-47

Since 100% poverty rate is over 20% and this MSSA is in the Inner Portions of Metropolitan Area, we can use public transportation, so everything within and touching the black 5 mile polygon has to be analyzed and is considered a contiguous area. Over 20% applies to Geo designation and for LI designation Inner Portions Metropolitan Area 100% poverty does not have to be over 20% III-48

Census Tract in MSSA 78.2aaa is the most populated CT. See yellow triangle. III-49

All the contiguous areas in the black polygon and touching the black polygon must be analyzed to be consistent with the Federal criteria. III-50

List of all the contiguous areas and a closer look at the contiguous areas III-51

On this map I am showing the Contiguous areas that are HPSA Designated – but always double check on the HRSA website database for designations III-52

Inner Portions of Metropolitan Area (Primary Care HPSA) Proposed Area:MSSA 78.2aaa – Watts in Los Angeles County: Summary:Civilian Pop:86,197 Below 200% Pov: 69.57% *Below 100% Pov: 39.28% White Pop:19.11% Black Pop:32.27% Hispanic Pop:54.40% 65 year or older Pop: 5.30% Infant Mortality Rate: 6.80 *High Need Indicator: 100% of Poverty Rate > 20% III-53

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Inner Portions of Metropolitan Areas (Contiguous Areas) Proposed Area: MSSA 78.2aaa – Watts in Los Angeles County Summary: Civilian Pop: 86,197 Below 200% Pov: 69.91% Below 100% Pov: 38.48% White Pop: 19.11% Black Pop: 32.27% Hispanic Pop: 66.81% 65 year or older Pop: 5.30% Infant Mortality Rate: 6.80 Area 3 (E) – MSSA 78.2v – Carson/Compton West/Rancho Dominguez: There is 30% Socio-Economic disparity Summary: Civilian Pop: 111,759 Below 200% Pov: 31.25% Below 100% Pov: 11.48% White Pop: 24.54% Black Pop: 23.89% Hispanic Pop: 33.84% 65 year or older Pop: 10.64% Infant Mortality Rate: 6.31 HPSA: No 78.2v Also can be ruled out as excessively distant III-56

Defining ASAPS Maps Black Polygon around the proposed area is a 5 miles radius for Primary Care and 7 miles radius is for Dental and Mental Health Green Polygon around the proposed area is a 30 minutes and 40 minutes is for Dental & Mental Health Purple dots you see on the ASAPS map is the provider locations Lines going diagonally means that the MSSA is a designated HPSA (\\\\ this means LI) (////// means Geo) On some of the Frontier area maps you will see the black Polygon only, which mean the proposed area doesn’t have any contiguous areas III-57

Defining ASAPS Maps If using the public transportation in an inner Metro area for your HPSA designation, you only analyze the areas that are in the black Polygon (5 mile or 7 mile radius ) – this rule applies to Los Angeles, San Francisco, and parts of Fresno, etc. Inner Metro area is defined through ASAPS when creating maps for a particular MSSA. Please call SDP staff when beginning your application process. In order to use public transportation, the 100% poverty level must be > 20%.for Geo designation, however for LI designation 100% poverty it does not have to be over 20% III-58

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, and  Miles and minutes of travel time III-59

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 > 2,000:1, do not survey (Geographic only).  Collect all possible information in one survey (e.g. Medi-Cal 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). III-60

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 – a copy of Rand McNally map with route details  For public transportation – start and end points of route III-61

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, and  Description of how information was obtained What to Include in the Contiguous Area Resources Section of Your Application (continued) III-62

For All Designation Requests: 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 only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate.)  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) What To Include In The Contiguous Area Resources Section of Your Application (continued) III-63

Examples Worksheets III-64

Sample HPSA Worksheets Inner Portions of a Metropolitan Area III-65

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78.2bbb III-71

Websites Bay Area Public Transit (San Francisco): Southern California Public Transit (San Diego): Los Angeles County Metropolitan Transportation Authority: CT Locator: U.S. Census Bureau – American Factfinder: III-72

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Geographic PC PHYSICIAN SURVEY SAMPLE III-79

LOW-INCOME PC PHYSICIAN SURVEY SAMPLE III-80

APPLY FOR DESIGNATION No Contiguous Area Conditions Met 1or more Contiguous Area Conditions Met for EACH Contiguous Area Evaluate Contiguous Area STOP: Area Not Qualified For Designation Calculate Population-to- Physician Ratio Define Rational Service Area Determine Physician FTEs Determine Service Area Population Evaluate Service Area for High- Need Indicators STOP: Area Not Qualified For Designation STOP: Area Not Qualified For Designation No High Need Indicators Present 1 or more High- Need Indicators Present Process Model for Geographic Primary Care 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 Ratio < Ratio Evaluate Contiguous Area 5 1 or fewer Insufficient Capacity Indicators Present 2 or more Insufficient Capacity Indicators Present 1 or more Contiguous Area Conditions Met for EACH Contiguous Area No Contiguous Area Conditions Met STOP: Area Not Qualified For Designation 9 APPLY FOR DESIGNATION 8 Ratio >3500 Evaluate for Insufficient Capacity 7 III-81