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rian on the staff of the facility. (Here the umber of FTE primary care physicians is Fomputed as in Part I, Section B, paragraph s above.)

(ii) There is excessive usage of emergency room facilities for routine primary care.

(iii) Waiting time for appointments is more chan 7 days for established patients or more than 14 days for new patients, for routine health services.

(iv) Waiting time at the facility is longer than 1 hour where patients have appointments or 2 hours where patients are treated on a first-come, first-served basis.

3. Determination of Degree of Shortage.

Each designated medical 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 8737, Mar. 2, 1989; 57 FR 2480, Jan. 22, 1992]

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Medium to maximum security Federal and State correctional institutions and youth detention facilities will be designated as having a shortage of dental professional(s) if both 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.

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 dental examinations are routinely performed by dentists 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 intake dental examinations are routinely performed upon entry, then-Number of 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 dental examinations are routinely performed upon entry, then-Number of internees-average number of inmates+x(1+2xALOS)xnumber of new inmates per year where ALOS-average length-of-stay (in fraction of

year).

(The number of FTE dentists 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 ratio (R) of internees to dentists, as follows: Group 1-Institutions with 500 or more inmates and no dentists.

Group 2-Other institutions with no dentists and institutions with R greater than (or equal to) 3,000:1.

Group 3-Institutions with R greater than (or equal to) 1,500:1 but less than 3,000:1. 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 Area for the Delivery of Dental Services.

(a) The following areas will be considered rational areas for the delivery of dental health services:

(1) A county, or a group of several contiguous counties whose population centers are within 40 minutes travel time of each other.

(ii) A portion of a county (or an area made up of portions of more than one county) whose population, because of topography, market or transportation patterns, distinctive population characteristics, or other factors, has limited access to contiguous area resources, as measured generally by a travel time of greater than 40 minutes to such resources.

(iii) Established neighborhoods and communities within metropolitan areas which display a strong self-identity (as indicated by a homogenous socioeconomic or demographic structure and/or a traditional of interaction or intradependency), have limited interaction with contiguous areas, and which, in general, have a minimum population of 20,000.

(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.

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cluded but must be weighted in proportion to the fraction of the year they are present in the area.

(b) Migratory workers and their families may be included in an area's population using the following formula: Effective migrant contribution to population=(fraction of year migrants are present in area)x(average daily number of migrants during portion of year that migrants are present).

3. Counting of Dental Practitioners.

(a) All non-Federal dentists providing patient care will be counted, except in those areas where it is shown that specialists (those dentists not in general practice or pedodontics) are serving a larger area and are not addressing the general dental care needs of the area under consideration.

(b) Full-time equivalent (FTE) figures will be used to reflect productivity differences among dental practices based on the age of the dentists, the number of auxiliaries employed, and the number of hours worked per week. In general, the number of FTE dentists will be computed using weights obtained from the matrix in Table 1, which is based on the productivity of dentists at various ages, with different numbers of auxiliaries, as compared with the average productivity of all dentists. For the purposes of these determinations, an auxiliary is defined as any non-dentist staff employed by the dentist to assist in operation of the practice.

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hours per week). Where appropriate datar available, adjusted equivalency figures: dentists who are semi-retired, who operaz reduced practice due to infirmity or ot limiting conditions, or who are available the population of an area only on a partbasis will be used to reflect the red availability of these dentists. In comput these equivalency figures, every 4 hours 1⁄2 day) spent in the dental practice willy counted as 0.1 FTE except that each deat working more than 40 hours a week vir counted as 1.0. The count obtained for a pa ticular age group of dentists will then y multiplied by the appropriate equivalent weight from table 1 or 2 to obtain a fullequivalent figure for dentists within particular age or age/auxiliary category. 4. Determination of Unusually High Needs Dental Services.

An area will be considered as having usually high needs for dental services if least one of the following criteria is met:

(a) More than 20% of the population (or = all households) has incomes below the po erty level.

(b) The majority of the area's populatio does not have a fluoridated water supply. 5. Determination of Insufficient Capacity a Existing Dental Care Providers.

An area's existing dental care providen will be considered to have insufficient capac ity if at least two of the following criteri are met:

(a) More than 5,000 visits per year per FT dentist serving the area.

(b) Unusually long waits for appointment for routine dental services (i.e., more than i weeks).

(c) A substantial proportion (3% or more) c the area's dentists do not accept new p tients.

6. Contiguous Area Considerations. Dental professional(s) 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 contig

uous area:

(a) Dental professional(s) 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-(FTE) dentist ratios are in excess of 3,000:1, indicating that resources in contiguous areas cannot be expected to help alleviate the shortage situation in the area being considered for designation.

(c) Dental professional(s) in the contiguous area are inaccessible to the population of the area under consideration because of specified access barriers, such as:

(i) Significant differences between the demographic (or socioeconomic) characteris

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pics of the area under consideration and hose of the contiguous area, indicating that he population of the area under considertion may be effectively isolated from nearby resources. Such isolation could be indicated, for example, by an unusually high proportion of non-English-speaking persons.

(ii) A lack of economic access to contiguous area resources, particularly where a very high proportion of the population of the area under consideration is poor (i.e., where more than 20 percent of the population or of the households have incomes below the poverty level) and Medicaid-covered or public dental services are not available in the contiguous area.

C. Determination of Degree of Shortage.

The degree of shortage of a given geographic area, designated as having a shortage of dental professional(s), will be determined using the following procedure:

Designated areas will be assigned to degree-of-shortage groups, based on the ratio (R) of population to number of full-timeequivalent dentists and the presence or absence of unusually high needs for dental services, or insufficient capacity of existing dental care providers according to the following table:

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tists practicing in the area and serving the population group is at least 4,000:1.

2. Indians and Alaska Natives will be considered for designation as having shortages of dental professional(s) as follows:

(a) Groups of members of Indian tribes (as defined in section 4(d) of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976) are automatically designated.

(b) Other groups of Indians or Alaska Natives (as defined in section 4(c) of Pub. L. 94437) will be designated if the general criteria in paragraph 1 are met.

B. Determination of Degree of Shortage. Each designated population group will be assigned to a degree-of-shortage group as follows:

Group 1-No dentists or R28,000.
Group 2-8,000>R>6,000.
Group 3-6,000>R>5,000.
Group 4-5,000>R>4,000.

Population groups which have received "automatic" designation will be assigned to degree-of-shortage group 4 unless information on the ratio of the number of persons in the group to the number of FTE dentists serving them is provided.

C. Determination of size of dental shortage. Size of dental shortage will be computed as follows:

Dental shortage=number of persons in population group/4,000-number of FTE dental practitioners

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 dental professional(s) if both 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. (Here 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 who left before the end of the year; the number of FTE dentists 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 follows, based on number of in the ratio (R) of internees to dent Group 1-Institutions

mates and no den Group 2-Other in and institutions Group 3-Instituti

B. Public or Non-Profit Private Dental Facilities.

1. Criteria.

Public or nonprofit private facilties providing general dental care services will be designated as having a shortage of dental professional(s) 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 professional(s) shortage; and

(b) The facility has insufficent 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:

(a) Provision of Services to a Designated Area or Population Group.

A facility will be considered to be providing services to an area or population group if either:

(1) A majority of the facility's dental care services are being provided to residents of designated dental professional(s) shortage areas or to population groups designated as having a shortage of dental professional(s);

or

(ii) The population within a designated dental shortage area or population group has reasonable access to dental services provided at the facility. 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.

Migrant health centers (as defined in section 319(a)(1) of the Act) which are located in areas with designated migrant population groups and Indian Health Service facilities 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 FTE dentist on the staff of the facility. (Here the number of FTE dentists is computed as in part I, section B, paragraph 3 above.)

(ii) Waiting time for appointments is more than 6 weeks for routine dental services.

3. Determination of Degree of Shortage. Each designated dental facility will be assigned to the same degree-of-shortage group

as the designated area or population which it serves.

[45 FR 76000, Nov. 17, 1980, as amended sti FR 8738, Mar. 2, 1989; 57 FR 2480, Jan. 22, E

APPENDIX C TO PART 5-CRITERIA KI DESIGNATION OF AREAS HAVIN SHORTAGES OF MENTAL HEAL PROFESSIONALS

Part 1-Geographic Areas

A. Criteria. A geographic area will be de ignated as having a shortage of mena health professionals if the following four e teria are met:

1. The area is a rational area for the deli ery of mental health services.

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

(a) The area has

(i) A population-to-core-mental-health-pr fessional ratio greater than or equal 6,000:1 and a population-to-psychiatrist rati: greater than or equal to 20,000:1, or

(ii) A population-to-core-professional rati greater than or equal to 9,000:1, or

(iii) A population-to-psychiatrist rati greater than or equal to 30,000:1;

(b) The area has unusually high needs for mental health services, and has

(1) A population-to-core-mental-health-professional ratio greater than or equal t 4,500:1 and

A population-to-psychiatrist ratio greate 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 contig. uous areas are overutilized, excessively distant or inaccessible to residents of the ares 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.

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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 profesEsionals (as defined below) providing mental health patient care (direct or other, includE: ing consultation and supervision) in ambulastory 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.

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(b) Definitions:

(1) 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 parttime 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-timeequivalency calculations based on a 40-hour week. Every 4 hours (or 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 detentio ties, residential treatment cent tionally disturbed or mana dren, school systeme State or county m (e) In cases wh facilities or inst tient and outpa

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