Appendix C to Part 5 - Criteria for Designation of Areas Having Shortages of Mental Health Professionals
42:1.0.1.1.6.0.1.5.3 : Appendix C
Appendix C to Part 5 - Criteria for Designation of Areas Having
Shortages of Mental Health Professionals 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 “broad-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.
C. Determination of degree of shortage. Designated areas
will be assigned to degree-of-shortage groups according to the
following table, depending on the ratio (RC) of population to
number of FTE core-mental-health-service providers (FTEC); the
ratio (RP) of population to number of FTE psychiatrists (FTEP); and
the presence or absence of high needs:
High Needs Not Indicated Group 1 - FTEC = 0 and FTEP = 0 Group 2 -
RC gte * 6,000:1 and FTEP = 0 Group 3 - RC gte 6,000:1 and RP gte
20,000 Group 4(a) - For psychiatrist placements only: All other
areas with FTEP = 0 or RP gte 30,000 Group 4(b) - For other mental
health practitioner placements: All other areas with RC gte
9,000:1.
* Note: “gte” means “greater than or equal to”.
High Needs Indicated Group 1 - FTEC = 0 and FTEP = 0 Group 2 - RC
gte 4,500:1 and FTEP = 0 Group 3 - RC gte 4,500:1 and RP gte 15,000
Group 4(a) - For psychiatrist placements only: All other areas with
FTEP = 0 or RP gte 20,000 Group 4(b) - For other mental health
practitioner placements: All other areas with RC gte 6,000:1.
D. Determination of Size of Shortage. Size of Shortage
(in number of FTE professionals needed) will be computed using the
following formulas:
(1) For areas without unusually high need:
Core professional shortage = area population/6,000−number of FTE
core professionals Psychiatrist shortage = area
population/20,000−number of FTE psychiatrists
(2) For areas with unusually high need:
Core professional shortage = area population/4,500−number of FTE
core professionals Psychiatrist shortage = area
population/15,000−number of FTE psychiatrists 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.
B. Determination of degree of shortage. Designated
population groups will be assigned to the same degree-of-shortage
groups defined in part I.C of this appendix for areas with
unusually high needs for mental health services, using the computed
ratio (RC) of the number of persons in the population group to the
number of FTE core mental health service providers (FTEC) serving
the population group, and the ration (RP) of the number of persons
in the population group to the number of FTE psychiatrists (FTEP)
serving the population group.
C. Determination of size of shortage. Size of shortage
will be computed as follows:
Core professional shortage = number of persons in population
group/4,500−number of FTE core professionals Psychiatrist shortage
= number of persons in population group/15,000−number of FTE
psychiatrists Part III - Facilities A. Federal and State
Correctional Institutions 1. Criteria.
Medium to maximum security Federal and State correctional
institutions and youth detention facilities will be designated as
having a shortage of psychiatric manpower 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
1,000:1.
Here the number of internees is defined as follows:
(i) If the number of new inmates per year and the average
length-of-stay 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 average length-of-stay is specified as one year or
more, and the intake psychiatric examinations are routinely
performed upon entry, then -
Number internees=average number of inmates+number of new inmates
per year
(iii) If the average length-of-stay 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×[1+(2×ALOS)]×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.)
2. Determination of Degree of Shortage.
Designated correctional institutions will be assigned to
degree-of-shortage groups, based on the number of inmates and/or
the ration (R) of internees to FTE psychiatrists, as follows:
Group 1 - Institutions with 500 or more inmates and no
psychiatrist.
Group 2 - Other institutions with no psychiatrists and
institutions with R greater than (or equal to) 3,000:1.
Group 3 - Institutions with R greater than (or equal to) 2,000:1
but less than 3,000:1.
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 ×
(number of inpatient admissions per year) + 0.5 × (number of
admissions to day care and outpatient services per year).
2. Determination of Degree of Shortage.
State or county mental hospitals will be assigned to
degree-of-shortage groups, based on the ratio (R) of workload units
to number of FTE psychiatrists, as follows:
Group 1 - No psychiatrists, or R>1,800.
Group 2 - 1,800>R>1,200.
Group 3 - 1,200>R>600.
Group 4 - 600>R>300.
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) shortage, 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.
3. Determination of Degree-of-Shortage.
Each designated facility will be assigned to the same
degree-of-shortage group as the designated area or population group
which it serves.
[45 FR 76000, Nov. 17, 1980, as amended at 54 FR 8738, Mar. 2,
1989; 57 FR 2477, Jan. 22, 1992]