PART II-POPULATION GROUPS The following population groups will be designated as having a shortage of dental manpower: 1. Those American Indians and Alaska Natives who are members of Indian tribes (as defined in section 4(d) of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976); 2. Other American Indians (as defined in section 4(c) of Pub. L. 94-437), migrant populations, and other population groups within particular geographic areas will be designated if both of the following criteria are met: (a) Access barriers prevent the population group from use of the area's dental providers (such as refusal of practitioners to accept certain types of patients); and (b) The ratio (R) of the number of persons in the population group to the number of FTE dentists serving the population group, and practicing within 40 minutes travel time of the center of the area where the population group resides, is at least 5,000:1 (4,000:1, where unusually high needs for dental services exist in the population group, as determined in accordance with paragraph B.4 of Part I of this Appendix). The population of the group is to be counted in accordance with paragraph B.2 of Part I of this Appendix, except that for migrant populations in high impact areas (as defined in section 319(a)(5) of the Act), the average number of migrants in the area during the period of highest impact will be used. B. Determination of Degree of Shortage The degree of shortage of a given population group, designated as having a shortage of dental manpower, will be determined as follows: 1. The population group will first be assigned to a degree-of-shortage grouping as in paragraph C of Part I of this Appendix, based on the ratio (R) of the group's population to the number of dentists serving it, together with the presence or absence of unusually high needs for dental services among the population group. 2. In comparing any two population groups within a degree-of-shortage grouping, or in comparing a designated population group with a designated area within the same grouping, the area or population group with the larger population will be assumed to have the greater shortage. (In the case of Indian tribes, the population figure used will be that population served by each I.H.S. facility which requires staffing.) PART III-FACILITIES A. Federal and State Correctional 1. Criteria. Medium to maximum security Federal and State correctional institutions will be designated as having a shortage of dental manpower if both of the following criteria are met: (a) The institution has at least 250 inmates. (b) The ratio of the number of internees per year to the number of FTE dentists serving the institution is at least 1,500:1. (The number of internees is the number of inmates present at the beginning of the year plus the number of new inmates entering the institution during the year, including those on short sentences who left before the end of the year.) 2. Determination of Degree of Shortage. The degree of shortage of a given correctional institution, designated as having a shortage of dental manpower, will be determined as follows: (a) Grouping of Correctional Institutions. Correctional institutions will first be grouped as follows, based on number of inmates and/or the ratio (R) of internees to dentists: Group 1-Institutions with 500 or more inmates and no dentists; Group 2-Institutions with 250-499 inmates and no dentists; or with any number of inmates and R<3,000; Group 3-Institutions with 3,000 R<1,500. (b) Relative Shortage within a Group. In comparing any two institutions within a given group, the institution with the larger number of internees will be assumed to have the greater shortage. B. Public or Non-profit Private Facilities 1. Criteria. Public or nonprofit private facilities providing general dental care services will be designated as having a shortage of dental manpower if both of the following criteria are met: (a) The facility is providing general dental care services to an area or population group designated as having a dental manpower shortage; and (b) The facility has insufficient capacity to meet the dental care needs of that area or population group. 2. Methodology. In determining whether public or nonprofit private facilities meet the criteria established by paragraph B.1 of this part, the following methodology will be used: as (a) Provision of Services to a Designated Area or Population Group. A facility will be considered to be providing services to a designated area or population group if either: (1) A majority of the facility's dental care services are being provided to residents of designated dental manpower shortage areas or to population groups designated having a shortage of dental manpower; or (ii) The population within a designated dental shortage area or population group has reasonable access to dental services provided at the facility. Such reasonable access will be assumed if the population lies within 40 minutes travel time of the facility and non-physical barriers (relating to demographic and socioeconomic characteristics of the population) do not prevent the population from receiving care at the facility. Indian Health Service facilities and migrant health centers (as defined in section 319 (a)(1) of the Act) are assumed to be meeting this requirement. (b) Insufficient Capacity to Meet Dental Care Needs. A facility will be considered to have insufficient capacity to meet the dental care needs of a designated area or population group if either of the following conditions exists at the facility: (i) There are more than 5,000 outpatient visits per year per dentist on the staff of the facility. (ii) Waiting time for appointments is more than 6 weeks for routine dental services. Indian Health Service facilities will be considered to have insufficient capacity if the staffing requirements established by the Indian Health Service are not met. 3. Determination of Degree of Shortage. The degree of shortage of a facility designated as having a shortage of dental manpower will be determined as follows: (a) Facilities will be grouped as in paragraph C.1 of Part I of this Appendix, in the same groupings as the designated area or population group which they serve. (b) In comparing a facility with other designated facilities, areas, or population groups within the same grouping, the population figure used for the facility shall equal that proportion of the population of the designated area or population group which the facility serves. The area, population group, or facility with the larger population or service population will then be assumed to have the greater shortage. APPENDIX C-CRITERIA FOR DESIGNATION OF AREAS HAVING SHORTAGES OF PSYCHIATRIC MANPOWER PART 1-GEOGRAPHIC AREAS A. Criteria A geographic area will be designated as having a shortage of psychiatric manpower if the following three criteria are met: 1. The area is a rational area for the delivery of psychiatric services. 2. One of the following conditions prevails within the area: (a) The area has a population-to-psychiatrist ratio of at least 30,000:1; or (b) The area has a population-to-psychiatrist ratio of less than 30,000:1 but greater than 20,000:1 and has unusually high needs for mental health services. 3. Psychiatric manpower 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 Psychiatric Services. (a) The following areas will be considered rational areas for the delivery of psychiatric services: (i) An established mental health catchment area, as designated by the State Health Planning and Development Agency in consultation with the State's mental health authority, 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 or transportation patterns, distinctive population characteristics, or other factors, has limited access to psychiatric resources in the rest of the catchment area, as measured generally by a travel time of greater than 40 minutes to such 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 to estimate distances corresponding to 40 minutes travel time: (i) Under normal conditions with primary roads available: 30 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: 35 miles. Within inner portions of metropolitan areas, the large variations in the scope of public transportation systems and traffic conditions do not permit standard mileage figures to be specified. In these 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 population of the area, excluding inmates of institutions. 3. Counting of Psychiatrists. (a) All nonfederal psychiatrists providing patient care (direct or other, including consultation and supervision), in ambulatory or other shortterm care settings to residents of the area more than one-half day per week will be counted. Those psychiatrists engaged solely in administration, research, and teaching will be excluded. Adjustments for the following factors will be made: (i) Psychiatric residents will be counted as .5 FTE psychiatrists to reflect the fact that a large portion of their time is training. (ii) Foreign medical graduates (i.e., graduates of medical programs outside the U.S.), in psychiatry who do not have a stable immigration status (i.e., U.S. citizenship or a permanent visa), will be excluded from psychiatrist counts since their future availability to help provide psychiatric care to the area's population is uncertain. (iii) Foreign medical graduates in psychiatry who have a stable immigration status but are not fully licensed to practice medicine will be counted as .5 FTE psychiatrists to reflect their practice limitations and time spent in training. (b) Psychiatrists who are semi-retired, who operate a reduced practice due to infirmity or other limiting conditions, or who are available to the population of an area only on a part-time basis will be discounted through the use of full-time equivalency figures. A 40-hour work week will be used as the standard for determining full-time equivalents in such cases. For practitioners working less than a 40-hour week, every 4 hours (or 1/2 day), spent providing patient care services should be counted as 0.1 FTE, and each psychiatrist providing patient care 40 or more hours a week should be counted as 1.0 FTE psychiatrist. (c) In some cases, psychiatrists located within an area may not be accessible to the general population of the area under consideration. Allowances for psychiatrists working in restricted facilities will be made on a case-by-case basis. Examples of such restricted practices include staff positions in correctional institutions, youth detention facilities, residential treatment centers for emotionally disturbed or mentally retarded children, and inpatient units of State or county mental hospitals. (d) In cases where there are mental health facilities or institutions providing both inpatient and outpatient services, those psychiatrists assigned to outpatient or other shortterm care units will be counted. If the psychiatric staff is not specifically allocated to one service or the other, the number of psychiatrists in short-term care will be estimated on the basis of the relative workload in each type of setting. (e) Other physicians and other types of manpower (such as clinical psychologists, social workers, psychiatric nurses, alcoholism and drug abuse counselors, and other mental health workers), also make important contributions to the supply of alcohol, drug abuse, and mental health services and may reduce the need for psychiatrists. National equivalency value for their contributions are not included here, however, because of variations in their responsibilities across States and because of data inadequacies. Their contributions to the supply of psychiatric services will be taken into account when appropriate data and equivalency values become available. 4. Determination of Unusually High Needs for Psychiatric Services. An area will be determined to have an unusually high need for psychiatric services if two or more of the following criteria are met: (a) 30 percent of the population (or of all households), have income below the poverty level, or the area has been designated as a poverty area in accordance with section 242 of the Community Mental Health Centers Act. (b) A youth dependency ratio (ratio of children under 18 to population 18-64), in excess of 60 percent. (c) An aged dependency ratio (ratio of persons aged 65 and over to population 18-64), in excess of 25 percent. (d) A high prevalence of alcoholism in the population, as indicated by a relative prevalence of alcoholism problems which exceeds that in 75 percent of all catchment areas (or other complete set of areas for which the prevalence index is computed), using the index of relative alcoholism prevalence developed by the National Institute on Alcohol Abuse and Alcoholism for the purposes of allotting funds under 42 U.S.C. 4571. (e) A high prevalence of drug abuse in the population, as indicated by a relative prevalence of drug abuse which exceeds that in 75 percent of all metropolitan areas for which appropriate data are available, using the Heroin Problem Index developed by the National Institute on Drug Abuse. 5. Contiguous Area Considerations. Psychiatric manpower 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) Mental health manpower in the contiguous area are more than 40 minutes travel time from the center of the area being considered for designation (measured in accordance with paragraph B.1(b) of this part). (b) Contiguous area population-to-psychiatrist ratios are in excess of 20,000:1, indicating that mental health manpower in contiguous areas cannot be expected to help alleviate the shortage situation in the area for which designation is being considered. (c) Psychiatric manpower in contiguous areas are inaccessible to the population of the requested area because of geographic, cultural, language, or other barriers, or because of residency restrictions of programs or facilities providing such manpower. C. Determination of Degree of Shortage The degree of shortage of a given geographic area, designated as having a shortage of psychiatric manpower, will be determined using the following procedure: 1. Grouping of Areas. Designated areas will first be assigned to groups, based on the ratio (R) of population to number of FTE psychiatrists and the presence or absence of unusually high needs for mental health services, according to the following table: travel time of the center of the area where the population group resides, is at least 30,000:1 (20,000:1 where unusually high needs for psychiatric services are indicated). B. Determination of Degree of Shortage The degree of shortage of a given population group, designated as having a shortage of psychiatric manpower, will be determined as follows: 1. The population group will first be assigned to groupings as in paragraph C.1 of Part I of this Appendix, based on the ratio (R) of the group's population to the number of FTE psychiatrists serving it, together with the presence or absence of unusually high needs for psychiatric services among the population group. 2. In comparing any two population groups within a degree-of-shortage grouping, or in comparing a designated population group with a designated area within the same grouping, the area or population group with the larger population will be assumed to have the greater shortage. PART III-FACILITIES A. Federal and State Correctional Institutions and Youth Detention Facilities 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 manpower if both of the following criteria are met: (a) The institution has at least 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. (The number of internees is the number of inmates or residents present at the beginning of the year, plus the number of new inmates or residents entering the institution during the year, including those who left before the end of the year.) 2. Determination of Degree of Shortage. The degree of shortage of a given correctional institution or youth detention facility, designated as having a shortage of psychiatric manpower, will be determined as follows: (a) Grouping of Facilities. Correctional facilities and youth detention facilities will first be assigned to groups, based on the number of inmates and/or the ratio (R) of internees to FTE psychiatrists, as follows: Group 1-Facilities with 500 or more inmates or residents and no psychiatrist. Group 2-Other facilities with no psychiatrist; and facilities with 500 or more inmates or residents and R<3,000. Group 3-All other facilities. (b) Determination of Degree of Shortage. In comparing any two facilities within a group as defined above, the facility with the larger number of inmates or residents will be assumed to have the greater shortage. B. State and County Mental Hospitals 1. Criteria. A State or county hospital will be designated as having a shortage of psychiatric manpower 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 psychiatrist available at the hospital exceeds 600, 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. The degree of shortage of a given State or county mental hospital, designated having a shortage of psychiatric manpower, will be determined as follows: as (a) Grouping of Facilities. State or county mental hospitals will first be assigned to groups based on the ratio (R) of workload units to number of FTE psychiatrists, as follows: Group 1-No psychiatrists, or R≤1,800. (b) Relative Shortage Within a Group. In comparing any two facilities within a group as defined above, the facility with the larger number of workload units will be assumed to have the greater shortage. C. Community Mental Health Centers and Other Public or Nonprofit Private Facilities 1. Criteria. A community mental health center (CMHC), authorized by Pub. L. 9463, or other public or nonprofit private facility providing alcohol, drug abuse, or mental health services to an area or population group, will be designated as having a shortage of psychiatric manpower if the facility is providing or is responsible for providing psychiatric services to an area or population group designated as having a psychiatric manpower shortage. 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 psychiatric services are being provided to residents of designated psychiatric manpower shortage areas or to population groups designated as having a shortage of psychiatric manpower; or (ii) The population within a designated psychiatric shortage area or population group has reasonable access to psychiatric 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 socio-economic 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 beer given responsibility for providing and coordinating a wide range of alcohol, drug abuse and/or mental health services for the area or population group, consistent with applicable State plans. 3. Determination of Degree of Shortage. The degree of shortage of a CMHC or other public or nonprofit private facility designated as having a shortage of psychiatric manpower shall be determined using the following procedure: (a) Facilities will be grouped as in paragraph C.1 of Part I of this Appendix, in the same groupings as the designated area or population group which they serve. (b) In comparing a facility with other designated facilities, areas, or population groups within the same grouping, the population figure used for the facility shall equal that proportion of the population of the designated area or population group which the facility serves. The area, population group, or facility with the larger population or service population will then be assumed to have the greater shortage. APPENDIX D-CRITERIA FOR DESIGNATION OF AREAS HAVING SHORTAGES OF VISION CARE MANPOWER PART I-GEOGRAPHIC AREAS A. Criteria A geographic area will be designated as having a shortage of vision care manpower if the following three criteria are met: 1. It is a rational area for the delivery of vision care services. 2. The estimated number of optometric visits supplied by vision care manpower in the area is less than the estimated requirements of the area's population for such visits, and the amount of this difference, that is, the computed optometric visit shortage, is at least 1,500 visits. 3. Optometric manpower in contiguous areas are excessively distant, overutilized, or inacces |