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H H S Department of Health and Human Services
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HPSA Designations
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Guidelines for Mental Health HPSA Designation

A. Background

Reauthorization of the National Health Service Corps (NHSC) in 1990 brought about a concurrent change in the designation of psychiatric health professional shortage areas (HPSAs) to mental health HPSAs. This legislative change authorized the utilization of clinical psychologists, clinical social workers, marriage and family therapists, and psychiatric nurse specialists to provide mental health services, in addition to psychiatrists. With this legislative change there is the need to designate mental health HPSAs, rather than psychiatric HPSAs.

B. Overview

This guidance will define and describe mental health HPSAs and core mental health providers.

The purpose of the mental health designation is:

1. to assure that mental health services are available and accessible to underserved populations;

2. to assist in the retention and recruitment of mental health providers in designated areas;

3. to assist in the determination of unusually high mental health needs.

II. Program Structure

A. Program Authority

Section 332 of the Public Health Service Act amended by Public Law 101-597 requires the Secretary to establish, by regulation, criteria for the designation of HPSAs. The regulation setting forth these criteria is codified at 42 CFR part 5. Appendix C of this regulation was amended to revise the criteria for designation of HPSAs (formerly Health Manpower Shortage Areas) having shortages of psychiatric manpower, transforming them into criteria for designation of HPSAs having shortages of core mental health professionals. Core mental health professionals include: psychiatrists; clinical psychologists; clinical social workers; psychiatric nurse specialists; and marriage and family therapists.

B. Availability of Federal Funds

There are no federal funds available.

III. Program Requirements and Characteristics

A. Definition and Eligibility of Providers

1. Core mental health professionals or core professionals include those psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists who meet the definitions below

(a) Psychiatrist means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who

(1) 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

(2) practices patient care psychiatry or child psychiatry, and is licensed to do so, if required by the State of practice.

(b) 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).

(c) Clinical social worker means an individual who

(1) 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

(2) is licensed/certified to practice as a social worker, if required by the State of practice.

(d) Psychiatric nurse specialist means a registered nurse (R.N.) who

(1) 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

(2) is licensed to practice as a psychiatric or mental health nurse specialist, if required by the State of practice.

(e) 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 of Marriage and Family Therapy.

B. Identification of Need for Providers

A geographic area will be designated as having a shortage of mental health professionals if the following criteria are met:

1. The area is a rational area for delivery of mental health services

2. One of the following conditions exists within the area:

(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

(b) a population-to-core-professional ratio greater than or equal to 9,000:1, or

(c) a population-to-psychiatrist ratio greater than or equal to 30,000:1;

3. The area has unusually high needs for mental health services, and has:

(a) 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

(b) a population-to-core professional ratio greater than or equal to 6,000:1, or

(c) a population-to-psychiatrist ratio greater than or equal to 20,000:1.

4. 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.

C. Contiguous Area Considerations

1. Mental health professionals in contiguous areas 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.

(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 (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 or programs or facilities providing such professionals.

D. Population Designations

1. Criteria

Population groups within particular rational service areas will be designated as having a mental health professional shortage if the following criteria are met:

(a) access barriers prevent the population group from using those core mental health professionals which are present in the area; and

(b) one of the following conditions prevails:

(1) 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

(2) 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

(3) 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.

2. Determination of degree of shortage

Designation of population groups will be assigned to degree-of-shortage groups according to the following table, depending on the ratio of population to number of FTE core-mental-health-service providers; the ratio of population to number of FTE psychiatrists; and the presence or absence of high needs:

High Needs not indicated:

Group 1 - there are no FTE psychiatrists or core mental health providers

Group 2 - the ratio of population to the number of FTE core mental health providers is greater than or equal to 6,000:1 and there are no FTE psychiatrists

Group 3 - the ratio of population to the number of FTE core mental health providers is greater than or equal to 6,000:1 and the ratio of population to the number of FTE psychiatrists is greater than or equal to 20,000:1

Group 4 -

(a) for psychiatrists only: all other areas with no FTE psychiatrists or the ratio of the population to the number of FTE psychiatrists is greater than or equal to 30,000:1

(b) for other mental health providers: all other areas with the ratio of population to number of FTE core-mental health-service-providers is greater than or equal to 9,000:1.

High Needs indicated:

Group 1 - there are no FTE psychiatrists or core mental health providers

Group 2 - the ratio of population to the number of FTE core mental health providers is greater than or equal to 4,500:1 and there are no FTE psychiatrists

Group 3 - the ratio of population to the number of FTE core mental health providers is greater than or equal to 4,500:1 and the ratio of population to FTE psychiatrists is greater than or equal to 15,000:1

Group 4 -

(a) for psychiatrists only: all other areas with no FTE psychiatrists or the ratio of population to FTE psychiatrists is greater than or equal to 20,000:1

(b) for other mental health providers: all other areas with the ratio of population to number of FTE core-mental health providers greater than or equal to 6,000:1.

3. Determination of size of shortage

Size of shortage will be computed as follows:

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

For areas with unusually high need:

Core professional shortage = number of persons in population group/4500 - number of core professionals

Psychiatrist shortage = number of persons in population group/15,000 - number of FTE psychiatrists

E. Community Mental Health Facilities and Other Public or Nonprofit Private Facilities

A facility will be considered to have insufficient capacity to meet the mental health service needs of the area of population it serves if:

1. there are more than 1,000 patient visits per year per FTE core mental health professional on staff of the facility, or

2. there are more than 3,000 patient visits per year per FTE psychiatrist on staff of the facility, or

3. 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.