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V. CALCULATING POPULATION TO PROVIDER RATIOS

V. CALCULATING POPULATION TO PROVIDER RATIOS. --------------------------------------------------. Mental. V-1. CALCULATING POPULATION TO PROVIDER RATIOS. (MENTAL). --------------------------------------------------. Objective : Participants will understand how to:

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V. CALCULATING POPULATION TO PROVIDER RATIOS

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

  2. CALCULATING POPULATION TO PROVIDER RATIOS (MENTAL) -------------------------------------------------- • 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 V-2

  3. 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

  4. Population to Provider Ratios Needed for Designation(MENTAL) -------------------------------------------------- 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 V-4

  5. 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

  6. 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: 2007 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

  7. Contiguous Areas Are Overutilized if: -------------------------------------------------- > 20,000:1 psychiatrists, or > 3,000:1 CMHP including psychiatrists and> 10,000:1 psychiatrists V-7

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

  9. PROVIDER SIDE OF THE RATIO -------------------------------------------------- : ____ V-9

  10. 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 inpatient care (office and follow-up hospital inpatientcare) serving the population to be designated. • 3) Calculate the FTE for each mental health providerserving the population to be designated. • 4) Calculate the population to provider ratio. V-10

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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. -------------------------------------------------- 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 5. Marriage and Family Therapist (MFT) b) if licensure or certification is not State required, is eligible for clinical membership in the American Association for MFT. V-17

  18. 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 settings1 • 1Usually defined as < 2 weeks average length of stay. V-18

  19. 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

  20. 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

  21. 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 schoolwho are not citizens or lawful permanent residents(including those with J-1or H-1B visas) • Mental health providers who are Federal providers Note:All providers who meet these qualifications should be listed, even if their FTE will be 0. V-21

  22. Include in Survey, but Exclude in FTE (continued): -------------------------------------------------- • 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

  23. Sources of Provider Data -------------------------------------------------- • State Licensure Lists:http://www2.dca.ca.gov/pls/wllpub/wllquery$.startup • National, State, and Local Professional Association Directories • Medicare and Medicaid Practitioner Lists • Local Telephone Directory Yellow Pages • Commercially Developed Listings • www.vitals.com V-23

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

  25. Designation Types and Whom to Include in the Provider Count -------------------------------------------------- DESIGNATION TYPE: V-25

  26. Providers -------------------------------------------------- Location ofHours of Direct Provider NameSpecialtyPractice/CT Pt. Care/Week1 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 1 - Must include hospital hours V-26

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

  28. FTE Calculation -------------------------------------------------- For each physician, include the number of hours of direct patient care provided (office and hospital inpatient) in the service area: • 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 0.817= 0.8 • 0.83 = 0.8 0.85 = 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. V-28

  29. FTEs Geographic Designation -------------------------------------------------- • Total Psychiatrists: 2 Total 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

  30. FTEs Low-Income Designation -------------------------------------------------- (20/40=.5) (40/40=1=.5) (30%+15%=45%) (.45x.5=.225) (.85x.65=.55) (26/40=.65) (50%+10%=60%) (.60x1.0=.60) (55/40=1.37=1) (10/40=.25) (25%+5%=30%) (.30x.25=.075) (6/40=.15) (.10x.15=.015) • Total Psychiatrists: 2 Total L-I Psychiatrist FTE: 0.225=.2 • Total Core Mental Health Providers: 6 Total L-I Core Mental Health FTE: 1.465=1.5 V-30

  31. 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

  32. 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

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

  34. 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

  35. Population to Provider Ratio -------------------------------------------------- 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 V-35

  36. 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

  37. 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 / 1.5 = 6,758:1) CMHP Ratio: 6,758:1 V-37

  38. 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

  39. What to Include in the Population Provider Ratio 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-39

  40. 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

  41. Contiguous Area Resources -------------------------------------------------- V-41

  42. Contiguous Area Resources -------------------------------------------------- Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources areexcessively 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

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

  44. 1) Identify the Boundaries of Each Contiguous Area -------------------------------------------------- • Identify on a map the boundaries and population center of theproposed service area. • Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center. • 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

  45. 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 inaccessibledue 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

  46. 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: V-46

  47. 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

  48. 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

  49. 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

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

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