V. CALCULATING POPULATION TO PROVIDER RATIOS Mental V-1

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

Mental 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

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 > 20,000:1psychiatrists Population to Provider Ratios Needed for Designation (MENTAL) V-4

Population to Provider Ratios Needed for Designation (Continued) V-5 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 ) is greater than 0.6, or c) The elderly ratio (# of persons > 65 to the # of adults ages ) 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

Low-Income Population > 20,000:1 psychiatrists, or > 6,000:1 CMHP including psychiatrists, or > 4,500:1 CMHP including psychiatrists and > 15,000:1 psychiatrists 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: 2007 Claritas Population Estimates V-6

Contiguous Areas Are Overutilized 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 : ____ 

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. STEPS V-10

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

Core Mental Health Providers (CMHP) Includes: 1. Psychiatrists 2. Clinical Psychologists 3. Clinical Social Workers 4. Psychiatric Nurse Specialists 5. Marriage and Family Therapists V-12

1. 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

2. 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

3. 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

4. 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

5. 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 MFT. 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 settings 1 1 Usually defined as < 2 weeks average length of stay. V-18

Include: All psychiatrists or CMHPs (including psychiatrists) who provide patient care in the service area, including those who: 1) Serve in State Scholarship or Loan Repayments 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: V-21 Note: All providers who meet these qualifications should be listed, even if their FTE will be 0.  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

 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 Include in Survey, but Exclude in FTE (continued):

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 COUNT ALL MENTAL HEALTH 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: V-25

Providers Location ofHours of Direct Provider Name SpecialtyPractice/CTPt. Care/Week 1 1) S. Freud, M.D. Psychiatry 5 Oedipal Lane 20 City, CA ) C. Jung, M.D. Psychiatry11 Dream Drive 40 City, CA ) H. Lecter, Ph.D. Clinical6 Can Street 26 PsychologyCity, CA ) M. Houlihan, R.N. Psychiatric1400 Captain Avenue 55 Nursing City, CA ) R. Weisheimer, M.S. Marriage & Fam.69 Shex Street 10 CounselingCity, CA ) L. Schlessinger, M.S.W.Clinical Social1 Radio Road 6 WorkCity, CA Total Psychiatrists: 2 Total Core Mental Health Providers: 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.  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 0.5 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 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: V-28

FTEs Geographic Designation Provider NameSpecialtyLocation of PracticeHours of Direct Pt. Care/Week 1 FTE Based on Hours Total FTE S. Freud, M.D.Psychiatry5 Oedipal Lane City, CA (20/40=.5) 0.5 C. Jung, M.D. 2 Psychiatry11 Dream Drive City, CA (40/40= /.5=.5) 0.5 H. Lecter, Ph.D.Clinical Psychology 6 Can Street City, CA (26/40=.65) 0.65 M. Houlihan, R.N.Psychiatric Nursing 1400 Captain Avenue City, CA (55/40=1.375) 1.0 R. Weisheimer, M.F.T.Marriage/Family Counseling 69 Shex Street City, CA (10/40=.25) 0.25 L. Schlessinger, M.S.W. Clinical Social Work 1 Radio Road City, CA (6/40=.15) 0.15 Total Psychiatrists: 2Total Psychiatrist FTE: 1.0 Total Core Mental Health Providers: 6 Total Core Mental Health FTE: 3.05=3.1 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-29

FTEs Low-Income Designation Provider NameSpecialtyLocation of Practice Hours of Direct Pt. Care/Week FTE Based on Hours % Medi- Cal % SFS % of L-I Total L-I FTE S. Freud, MDPsychiatry5 Oedipal Lane City, CA % 0.0 C. Jung, M.D.Psychiatry11 Dream Drive City, CA %15%45%.225 H. Lecter,Ph.D.Clinical Psychology 6 Can Street City, CA %85%.55 M. Houlihan, R.N.Psychiatric Nursing 1400 Captain Avenue City, CA %10%60%.60 R. Weisheimer,M.S.Marriage/Fam. Counseling 69 Shex Street City, CA %5%30%0.075 L. Schlessinger, M.S.W. Clinical Social Work 1 Radio Road City, CA %10%.015 Total Psychiatrists: 2Total L-I Psychiatrist FTE: 0.225=.2 Total Core Mental Health Providers: 6 Total L-I Core Mental Health FTE: 1.465=1.5 (20/40=.5) (40/40=1=.5) (30%+15%=45%)(.45x.5=.225) (26/40=.65) (.85x.65=.55) (55/40=1.37=1) (50%+10%=60%) (.60x1.0=.60) (10/40=.25)(25%+5%=30%) (.30x.25=.075) (6/40=.15) (.10x.15=.015) V-30

Survey Providers Survey all mental health providers in the service area for the type of designation being sought (psychiatrists only or all CMHPs):  Must include hospital hours (psychiatrist)  Minimum two-thirds response rate required V-31

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-32

STEP 4 Calculate the population to provider ratio. V-33

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-34

Population to Provider Ratio V-35 Geographic Mental HPSA Civilian Population Ratio: Civilian Population = 20,900 Psychiatrist FTE = 1 (20,900 / 1 = 20,900:1) Psychiatrist Ratio: 20,900:1 CMHP FTE = 3.1 (20,900 / 3.1 = 6,742:1) CMHP Ratio: 6,742:1

Population to Provider Ratio Geographic Mental HPSA with High Needs Civilian Population (High Needs) Ratio: Civilian Population = 20,900 Psychiatrist FTE = 1 (20,900 / 1 = 20,900:1) Psychiatrist Ratio: 20,900:1 CMHP FTE = 3.1 (20,900 / 3.1 = 6,742:1) CMHP Ratio: 6,742:1 V-36

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 / 1.5 = 6,758:1) CMHP Ratio: 6,758:1 Population to Provider Ratio V-37

What to Include in the Population Provider Ratio Section of Your Application Population:  Cover letter with summary findings  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-38

Totals and Ratio  Total number of providers  Total FTE  Explanation of any high need indicators  Population to provider ratio V-39 What to Include in the Population Provider Ratio Section of Your Application (continued)

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-40

Contiguous Area Resources V-41

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 V-42

STEPS 1) Identify the boundaries of each contiguous area 2)Evaluate each area to determine availability of resources V-43

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 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-44

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 > 40 minutes away from the population center of the proposed area and are therefore inaccessible due to excessive distance. (30% or more disparity between the service area and the contiguous area) 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.) V-45

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 V-46

Determine If Providers Are Excessively Distant 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) 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: > 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-47

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. V-48

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.  Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio. Population to Provider Ratios: MENTAL: > 20,000:1 psychiatrist or > 3,000:1 CMHP and > 10,000:1 psychiatrist V-49

Example Whole County ASAPS Map Analysis Looking at Whole County Designation for Del Norte County V-50

ASAPS Mapping - we zoom in to county and keep zooming in to get to the MSSA layer V-51

Once we have zoomed into the MSSA layer, then we define the proposed area. The purple area is the proposed area, Del Norte County. 100% and 200% poverty rate V-52

All the contiguous areas touching the proposed County must be analyzed by following the federal criteria. *Note contiguous areas located near CA boarder (Curry & Josephine County) must be analyzed/included in application. V-53

List of all the contiguous areas and a closer look at the contiguous areas. On this map I am showing the Contiguous areas that are HPSA Designated – but always double check on the HRSA website database for designations. V-54

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 V-55

Defining ASAPS Maps If using the public transportation in a 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. When using public transportation, the 100% poverty level must be > 20% V-56

Whole County Summary:Total Pop: 24,115 White Pop: 91.97% Black Pop: 4.99% Hispanic Pop: 17.62% Below 200% Pov: 44.50% Below 100% Pov: 20.03% 65 year or older Pop: 13.28% Elderly Ratio:.18% Youth Ratio:.35% * Based on Total Population (Not Civilian Pop.) Proposed Area: Del Norte County (Crescent City) V-57

Sample HPSA Worksheets V-58 Del Norte County Area

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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, and  Miles and minutes of travel time V-65

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 (Geographic only).  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-66

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-67

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-68

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 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. V-69

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 Alcohol and Drug Substance Abuse V-70

Geographic Mental Physician Survey Entire Del Norte CountyDel Norte V-71

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APPLY FOR DESIGNATION 1 or more contiguous area conditions met No contiguous area conditions met Evaluate Contiguous Area 1 or more High Need Indicators Present NO High-Need Indicators Present Evaluate Service Area for High-Need Indicators STOP: Area Not Qualified For Designation Calculate Population-to- CMHP & Population-to-Psych Ratio Define Rational Service Area Determine Core Mental Health Profession (CMHP) FTEs Determine Service Area Population Evaluate Contiguous Area STOP: Area Not Qualified For Designation APPLY FOR DESIGNATION STOP: Area Not Qualified For Designation 1 or more High Need Indicators Present No contiguous area conditions met 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 CHMP = Core Mental Health Professional Psych = Psychiatrist POP:CMHP > 4500:1 and POP:Psych > =15000:1 POP:CMHP > =6000:1 or POP:Psych > =20000:1 or POP:CMHP > 4500:1 and POP:Psych > =15000:1 POP:CMHP > =9000:1 POP:Psych > =30000:1 or POP:CMHP > 6000:1 and POP:Psych > =20000:1 POP:CMHP > =6000:1 POP:Psych > =20000:1 or V-74