Topic 6: Federal Manpower Shortage Areas

Federal Government Health Professional Shortage Areas (HPSA) Guidelines for Mental Health Care Designation

Relevance to Underserved Issue

The Health and Rehabilitative Services (HRSA) professional shortage area guidelines (HPSA) provide the criteria needed to determine locations that are underserved.


Summary of Key Information

  • Purpose of the Guidelines
    To provide criteria for identifying areas that have a deficit of mental health providers.

  • Program Authority
    The Public Health Service Act section 332 amended by public law 101-597 requires the Secretary of Health of HHS to establish, by regulation, criteria for the designation of HPSAs.

  • Program Requirements
    The program requires that the core mental health providers who may offer mental health services consist of psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists and marriage and family therapists.

  • Identified Need for Providers
    HRSA has defined three types of shortage designations consisting of
    1. Geographic area
    2. Population based
    3. Facility based

     
  • Criteria necessary to be designated as a mental health shortage area under these categories

 

  1. Geographic Area Based Manpower Shortage Designations

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

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

      1. The population ratio to core psychiatrists and/or non-physician mental health professionals is disproportionate using HRSA defined ratios as defined in the summary table below.

      2. The area has unusually high needs for mental health services (i.e., poverty, children, elderly, high amount of substance abuse and alcoholism) and the ratio of population to core mental health clinicians is disproportionate to meet this need.

    Contiguous area considerations: Mental health professionals near the areas that are being identified as HPSAs will be considered extremely far away, over-utilized or unavailable to the HPSAs if they meet the following criteria: (1) it is more than 40 minutes from the main population center of the area being considered, (2) if the core mental health professionals in that area are overutilized and con not be expected to fill the void (3) there is a cultural, language or geographical barrier and/or because of residency restrictions.

  2. Population Based Manpower Shortage Designations

    1. Population groups in specific service areas are deemed as shortage areas if access barriers prevent the population group from using mental health services.

    2. The ratio of the number of individuals per population group is disproportionate to the number of full-time equivalent (FTE) mental health professionals or FTE psychiatrists.

  3. Facility Based Manpower Shortage Designations

    Types of facilities that fall under this designation include: federal and state correctional institutions, state and county mental hospitals, community mental health centers and other public or nonprofit private facilities.

    Facilities can be deemed manpower shortage areas based on HRSA defined criteria that take into account variables such as the ratio of mental health professional to the defined population, average length of stay, average daily inpatient census, etc.

 Federal Government Health Professional Shortage Areas (HPSA)

Guidelines for Mental Health Care Designation

Summary Table:

Requirement 1: Must be a Core Mental Health Professional

Psychiatrist, clinical psychologist, clinical social worker, psychiatric nurse specialist, marriage and family therapist

Requirement 2: Identification of Need for Providers

Criteria for Shortage Areas Based on Geographic Area

Geographic areas will be designated as having a mental health professional shortage 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 exist within the areas

1. Population to core professional ratio greater than or equal to 6,000:1 and a population-to- psychiatrist ratio greater than or equal to 20,000:1

2. A population to core professional ratio greater than or equal to 9,000:1

3. 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: 

1. 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

2. A population-to-core professional ratio greater than or equal to 6,000:1 or

3. 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: 

1. 20 percent of the population (or all households) in the area have incomes below the poverty level

2. 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

3. the elderly ratio, defined as the ratio of the number of persons aged 65 an over to the number of adults ages 18 to 65, exceeds 0.25

4. 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

5. A high degree of substances 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.

Requirement 3: Contiguous Area Considerations:  HRSA takes into account services in contiguous areas.  Shortage designations are available if continuous areas are considered excessively distant, over-utilized or inaccessible to the population of the area under consideration if one of the following conditions occurs in each contiguous area: 

1. Core mental health professionals in the contiguous area are more than 40 minutes travel time from the closest population centers or from the area being considered for designation

2. 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 over utilization).

3. 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.

Requirement 4: Criteria for Shortage Areas Based on Populations Designations 

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

1. Access barriers prevent the population groups from using those core mental health professionals which are present in the area; and

2. One of the following prevails:

(a) the ratio of the number of persons in the population groups to the number of FTE core mental health providers servicing 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 servicing the population group is greater than or equal to 20,000:1

(c ) the ratio of the number of persons n the population group to the number of FTE psychiatrists servicing the population group is greater than or equal to 20,000:1


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

 

High Needs Not Indicated by 1 & 2 above

High Needs Indicated by 1 & 2 above

Group 1

There are no FTE psychiatrists or core mental health providers

 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 6000:1

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 not 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

The ratio of populations 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

-for psychiatrists only: all other areas with no FTE psychiatrists or the ratio of the FTE population to the member of FTE psychiatrists is greater than or equal to 30:000:1

-for other mental health providers: all other areas with the ratio of population to number of FTE core-mental health-services providers is greater than or equal to 9.000:1

 

-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

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

Determination of Size Shortage: 

For areas without unusually high needs

For areas with unusually high needs

1. Core professional shortage

1. Core professional shortage

2. Psychiatrist shortage

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

Requirement 5: Criteria for Shortage Areas on Facility Based Designations 

Facility designations are available to: federal and state correctional institutions, state and county mental hospitals, and community mental health centers 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 services if: 

Facility Type

Criteria

Federal and State Correctional Institutions

Population is greater than 250 inmates, and the ratio of internees per year to the number of FTE psychiatrists serving the institution is at least 2000:1.

State and County Mental Hospitals

Average daily inpatient census of at least 100, and the number of workload units per FTE psychiatrists available at the hospital exceeds 300, where workload units are calculated using the formula below.**

Community Mental Health Centers and Other Public Nonprofit Private Facilities

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 the facility is the only one providing (or responsible for providing) mental health services to the designated area or population.

**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). 


Relevant Web Resources:

HPSA Website
www.bhpr.hrsa.gov/shortage/hpsacritmental.htm 

Shortage Designation Maps
http://muafind.hrsa.gov/