HPSA Designation Criteria for Mental Health
Also see:
Part I -- Geographic Areas
A. Criteria.
A geographic area will be designated as having a
shortage of mental health professionals if the following
four criteria are met:
1. The area is a rational area for the delivery of
mental health services.
2. One of the following conditions prevails within
the area:
(a) The area has --
(i) A population-to-core-mental-health-professional
ratio greater than or equal to 6,000:1 and a population-to-psychiatrist
ratio greater than or equal to 20,000:1, or
(ii) A population-to-core-professional ratio
greater than or equal to 9,000:1, or
(iii) A population-to-psychiatrist ratio greater
than or equal to 30,000:1;
(b) The area has unusually high needs for mental
health services, and has --
(i) A population-to-core-mental-health-professional
ratio greater than or equal to 4,500:1 and a population-to-psychiatrist
ratio greater than or equal to 15,000:1, or
(ii) A population-to-core-professional ratio
greater than or equal to 6,000:1, or
(iii) A population-to-psychiatrist ratio greater
than or equal to 20,000:1;
3. Mental health professionals in contiguous areas
are overutilized, excessively distant or inaccessible
to residents of the area under consideration.
B. Methodology.
In determining whether an area meets the criteria
established by paragraph A of this part, the following
methodology will be used:
1. Rational Areas for the Delivery of Mental Health
Services.
(a) The following areas will be considered rational
areas for the delivery of mental health services:
(i) An established mental health catchment area,
as designated in the State Mental Health Plan
under the general criteria set forth in section
238 of the Community Mental Health Centers Act.
(ii) A portion of an established mental health
catchment area whose population, because of topography,
market and/or transportation patterns or other
factors, has limited access to mental health resources
in the rest of the catchment area, as measured
generally by a travel time of greater than 40
minutes to these resources.
(iii) A county or metropolitan area which contains
more than one mental health catchment area, where
data are unavailable by individual catchment area.
(b) The following distances will be used as guidelines
in determining distances corresponding to 40 minutes
travel time:
(i) Under normal conditions with primary roads
available: 25 miles.
(ii) In mountainous terrain or in areas with
only secondary roads available: 20 miles.
(iii) In flat terrain or in areas connected by
interstate highways: 30 miles.
Within inner portions of metropolitan areas, information
on the public transportation system will be used
to determine the distance corresponding to 40 minutes
travel time.
2. Population Count.
The population count used will be the total permanent
resident civilian population of the area, excluding
inmates of institutions.
3. Counting of mental health professionals.
(a) All non-Federal core mental health professionals
(as defined below) providing mental health patient
care (direct or other, including consultation and
supervision) in ambulatory or other short-term care
settings to residents of the area will be counted.
Data on each type of core professional should be
presented separately, in terms of the number of
full-time-equivalent (FTE) practitioners of each
type represented.
(b) Definitions:
(i) Core mental health professionals or core
professionals includes those psychiatrists,
clinical psychologists, clinical social workers,
psychiatric nurse specialists, and marriage and
family therapists who meet the definitions below.
(ii) Psychiatrist means 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 Specialities
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.
(iii) Clinical psychologist means an individual
(normally with a doctorate in psychology) who
is practicing as a clinical or counseling psychologist
and is licensed or certified to do so by the State
of practice; or, if licensure or certification
is not required in the State of practice, an individual
with a doctorate in psychology and two years of
supervised clinical or counseling experience.
(School psychologists are not included.)
(iv) Clinical social worker means an individual
who --
(A) Is certified as a clinical social worker
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 master's 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) Psychiatric nurse specialist means
a registered nurse (R.N.) who --
(A) Is certified by the American Nurses Association
as a psychiatric and mental health clinical
nurse specialist, or has a master's degree in
nursing with a specialization in psychiatric/mental
health and two years of supervised clinical
experience; and
(B) Is licensed to practice as a psychiatric
or mental health nurse specialist, if required
by the State of practice.
(vi) Marriage and family therapist means
an individual (normally with a master's or doctoral
degree in marital and family therapy and at least
two years of supervised clinical experience) who
is practicing as a marital and family therapist
and is licensed or certified to do so by the State
of practice; or, if licensure or certification
is not required by the State of practice, is eligible
for clinical membership in the American Association
for Marriage and Family Therapy.
(c) Practitioners who provide patient care to the
population of an area only on a part-time basis
(whether because they maintain another office elsewhere,
spend some of their time providing services in a
facility, are semi-retired, or operate a reduced
practice for other reasons), will be counted on
a partial basis through the use of full-time-equivalency
calculations based on a 40-hour week. Every 4 hours
(or 1/2 day) spent providing patient care services
in ambulatory or inpatient settings will be counted
as 0.1 FTE, and each practitioner providing patient
care for 40 or more hours per week as 1.0 FTE. Hours
spent on research, teaching, vocational or educational
counseling, and social services unrelated to mental
health will be excluded; if a practitioner is located
wholly or partially outside the service area, only
those services actually provided within the area
are to be counted.
(d) In some cases, practitioners located within
an area may not be accessible to the general population
of the area under consideration. Practitioners working
in restricted facilities will be included on an
FTE basis based on time spent outside the facility.
Examples of restricted facilities include correctional
institutions, youth detention facilities, residential
treatment centers for emotionally disturbed or mentally
retarded children, school systems, and inpatient
units of State or county mental hospitals.
(e) In cases where there are mental health facilities
or institutions providing both inpatient and outpatient
services, only those FTEs providing mental health
services in outpatient units or other short-term
care units will be counted.
(f) Adjustments for the following factors will
also be made in computing the number of FTE providers:
(i) Practitioners in residency programs will
be counted as 0.5 FTE.
(ii) Graduates of foreign schools who are not
citizens or lawful permanent residents of the
United States will be excluded from counts.
(iii) Those graduates of foreign schools who
are citizens or lawful permanent residents of
the United States, and practice in certain settings,
but do not have unrestricted licenses to practice,
will be counted on a full-time-equivalency basis
up to a maximum of 0.5 FTE.
(g) Practitioners suspended for a period of 18
months or more under provisions of the Medicare-Medicaid
Anti-Fraud and Abuse Act will not be counted.
4. Determination of unusually high needs for mental
health services. An area will be considered to
have unusually high needs for mental health services
if one of the following criteria is met:
(a) 20 percent of the population (or of all households)
in the area have incomes below the poverty level.
(b) The youth ratio, defined as the ratio of the
number of children under 18 to the number of adults
of ages 18 to 64, exceeds 0.6.
(c) The elderly ratio, defined as the ratio of
the number of persons aged 65 and over to the number
of adults of ages 18 to 64, exceeds 0.25.
(d) A high prevalence of alcoholism in the population,
as indicated by prevalence data showing the area's
alcoholism rates to be in the worst quartile of
the nation, region, or State.
(e) A high degree of substance abuse in the area,
as indicated by prevalence data showing the area's
substance abuse to be in the worst quartile of the
nation, region, or State.
5. Contiguous area considerations. Mental
health professionals in areas contiguous to an area
being considered for designation will be considered
excessively distant, overutilized or inaccessible
to the population of the area under consideration
if one of the following conditions prevails in each
contiguous area:
(a) Core mental health professionals in the contiguous
area are more than 40 minutes travel time from the
closest population center of the area being considered
for designation (measured in accordance with paragraph
B.1(b) of this part).
(b) The population-to-core-mental-health-professional
ratio in the contiguous area is in excess of 3,000:1
and the population-to-psychiatrist ratio there is
in excess of 10,000:1, indicating that core mental
health professionals in the contiguous areas are
overutilized and cannot be expected to help alleviate
the shortage situation in the area for which designation
is being considered. (If data on core mental health
professionals other than psychiatrists are not available
for the contiguous area, a population-to-psychiatrist
ratio there in excess of 20,000:1 may be used to
demonstrate overutilization.)
(c) Mental health professionals in contiguous areas
are inaccessible to the population of the requested
area due to geographic, cultural, language or other
barriers or because of residency restrictions of
programs or facilities providing such professionals.
Part II -- Population Groups
A. Criteria. Population groups within particular
rational mental health service areas will be designated
as having a mental health professional shortage if
the following criteria are met:
1. Access barriers prevent the population group from
using those core mental health professionals which
are present in the area; and
2. One of the following conditions prevails:
(a) The ratio of the number of persons in the population
group to the number of FTE core mental health professionals
serving the population group is greater than or
equal to 4,500:1 and the ratio of the number of
persons in the population group to the number of
FTE psychiatrists serving the population group is
greater than or equal to 15,000:1; or,
(b) The ratio of the number of persons in the population
group to the number of FTE core mental health professionals
serving the population group is greater than or
equal to 6,000:1; or,
(c) The ratio of the number of persons in the population
group to the number of FTE psychiatrists serving
the population group is greater than or equal to
20,000:1.
Part III -- Facilities
A. Federal and State Correctional Institutions
1. Criteria.
Medium to maximum security Federal and State correctional
institutions for adults or youth, and youth detention
facilities, will be designated as having a shortage
of psychiatric professional(s) if both of the following
criteria are met:
(a) The institution has more than 250 inmates,
and
(b) The ratio of the number of internees per year
to the number of FTE psychiatrists serving the institution
is at least 2,000:1.
Here the number of internees is defined as follows:
(i) If the number of new inmates per year and
the average length-of-stay (ALOS) are not specified,
or if the information provided does not indicate
that intake psychiatric examinations are routinely
performed upon entry, then -- Number of internees
= average number of inmates.
(ii) If the ALOS is specified as one year or
more, and intake psychiatric examinations are
routinely performed upon entry, then -- Number
of internees = average number of inmates + number
of new inmates per year.
(iii) If the ALOS is specified as less than one
year, and intake psychiatric examinations are
routinely performed upon entry, then -- Number
of internees = average number of inmates + 1/3
x (1 + (2 x ALOS)) x number of new inmates per
year where ALOS = average length-of-stay (in fraction
of year). (The number of FTE psychiatrists is
computed as in Part I, Section B, paragraph 3
above.)
B. State and County Mental Hospitals.
1. Criteria.
A State or county hospital will be designated as
having a shortage of psychiatric professional(s) if
both of the following criteria are met:
(a) The mental hospital has an average daily inpatient
census of at least 100; and
(b) The number of workload units per FTE psychiatrists
available at the hospital exceeds 300, where workload
units are calculated using the following formula:
Total workload units = average daily inpatient
census + 2 x (number of inpatient admissions per
year) + 0.5 x (number of admissions to day care
and outpatient services per year).
C. Community Mental Health Centers and Other Public
or Nonprofit Private Facilities.
1. Criteria.
A community mental health center (CMHC), authorized
by Pub. L. 94 - 63, or other public or nonprofit private
facility providing mental health services to an area
or population group, may be designated as having a
shortage of psychiatric professional(s) if the facility
is providing (or is responsible for providing) mental
health services to an area or population group designated
as having a mental health professional(s), and the
facility has insufficient capacity to meet the psychiatric
needs of the area or population group.
2. Methodology.
In determining whether CMHCs or other public or nonprofit
private facilities meet the criteria established in
paragraph C.1 of this Part, the following methodology
will be used.
(a) Provision of Services to a Designated Area
or Population Group.
The facility will be considered to be providing
services to a designated area or population group
if either:
(i) A majority of the facility's mental health
services are being provided to residents of designated
mental health professional(s) shortage areas or
to population groups designated as having a shortage
of mental health professional(s); or
(ii) The population within a designated psychiatric
shortage area or population group has reasonable
access to mental health services provided at the
facility. Such reasonable access will be assumed
if the population lies within 40 minutes travel
time of the facility and nonphysical barriers
(relating to demographic and socioeconomic characteristics
of the population) do not prevent the population
from receiving care at the facility.
(b) Responsibility for Provision of Services.
This condition will be considered to be met if
the facility, by Federal or State statute, administrative
action, or contractual agreement, has been given
responsibility for providing and/or coordinating
mental health services for the area or population
group, consistent with applicable State plans.
(c) Insufficient capacity to meet mental health
service needs. A facility will be considered
to have insufficient capacity to meet the mental
health service needs of the area or population it
serves if:
(i) There are more than 1,000 patient visits
per year per FTE core mental health professional
on staff of the facility, or
(ii) There are more than 3,000 patient visits
per year per FTE psychiatrist on staff of the
facility, or
(iii) No psychiatrists are on the staff and this
facility is the only facility providing (or responsible
for providing) mental health services to the designated
area or population.
RELEVANT EXCERPTS FROM 42 CODE OF FEDERAL REGULATIONS (CFR), CHAPTER 1, PART 5, Appendix C (October 1, 1993, pp. 34-48)
Criteria for Designation of Areas Having Shortages of Mental Health Professionals
[45 FR 76000, Nov. 17, 1980, as amended at 54
FR 8738, Mar. 2, 1989; 57 FR 2477, Jan. 22, 1992]
|