1. III. CALCULATING POPULATION TO PROVIDER RATIOS Primary Care III-1

2. Calculating Population to Provider Ratios (Primary Care) Objective: Participants will understand how to: 1) Identify all primary care providers 2) Calculate Full-Time-Equivalency (FTE) 3) Determine the population to provider ratios for primary care geographic and population designations III-2

3. Population to Provider Ratios Needed for Designation (Primary Care) Contiguous Areas are overutilized if: > 2,000:1 1 - See Appendix V for additional information on calculating infant mortality rates 2 - See Appendix V for information on insufficient capacity Geographic Area: ≥ 3,500:1 A rational service area: county or sub-county (MSSA) Geographic Area w/Unusually High Needs: ≥ 3,000:1 A rational service area plus one of the following: a) More than 20% of the population has incomes at or below 100% of the Federal poverty level; or b) More than 100 births per year per 1,000 women ages 15-44; or c) More than 20 infant deaths per 1,000 live births 1 ; or d) Meets insufficient capacity criteria 2 Population Groups: ≥ 3,000:1 A rational service area plus meets the requirements of the specific designation category (e.g. low-income, homeless, etc.) III-3

4. Population Side of the Ratio A.Geographic Area Designations B. Population Designations : III-4 

5. A. Geographic Designations Resident Civilian Population = Total permanent population in the service area (non-institutionalized population) Excludes: inmates or individuals in institutions (e.g. nursing homes, prisons, college dormitories, military installations, Native Americans on reservations, etc.) Source: 2010 U.S. Census and 5-year American Community Survey Population Estimates. Migrant Farmworkers Data from the 2000 Migrant and Seasonal Farmworker Enumeration Profiles Study, or other approved source (must include methodology) Tourists Formula: 0.25 X [fraction of year present] X [average daily number of tourists] (Use local data, which must include methodology and length of stay.) Seasonal Residents Those who maintain a residence in the area, but inhabit it for only 2-8 month year (Use census or local data, which must include methodology.) Homeless Local data (must include methodology) III-5 Note: cannot add any of the above to Mental Health Can add

6. B. Population Designations Low-Income Population Number of individuals in the service area that are at or below 200% of the Federal poverty level  Must be > 30% of the population in the service area Source: 2006-2010 5-year ACS Population Estimates Can add: a) Migrant Farmworkers Data from the 2000 Migrant and Seasonal Farmworker Enumeration Profiles Study, or other approved source (must include methodology) b) Homeless Local data (must include methodology). III-6

7. Migrant Farmworkers 200% Poverty PopMigrant Farm Workers Modoc 982460394 Pop 200%Poverty Total4164 200% population for proposed area 2460 2460 / 4164 =59.07% Migrant Farm Workers 394 394 * 59.07% =233 Percentage of MFW for the year MFW Season in / 12 4.5 / 12 = 37.5% Total MFW for MSSA37.5% * 233 =87 Total 200% population for entire county This number is the 200% population for the proposed area This number is the migrant farm workers in the county of your proposed area This is the number of months per season for your county MFW added to 100% Civilian Population Proposed Area Modoc 98 III-7

8. Migrant Farmworker Population Number of individuals in the service area who are migrant farmworkers adjusted for the fraction of the year they are in the service area. Source: State/local data & 2000 Migrant & Seasonal Farmworker Enumeration Profiles Study Ex:Napa County, California Agricultural Season = 4 months 4/12 =.333 Migrant Farmworker Pop = 5,659 5,659 X.333 = 1,884 Total Migrant Farmworker Population = 1,884 Native American/Native Alaskan Number of individuals in the service area that are Native Americans or Native Alaskans Source: 2000 census data III-8 B. Population Designations (continued)

9. III-9 MIGRANT AND SEASONAL FARMWORKER ENUMERATION PROFILES STUDY CALIFORNIA FINAL prepared for the Migrant Health Program Bureau of Primary Health Care Health Resources and Services Administration by Alice C. Larson, Ph.D. Larson Assistance Services P.O. Box 801 Vashon Island, WA 98070 206-463-9000 (voice) 206-463-9400 (fax) las@wolfenet.com (e-mail) September, 2000

10. Use information in highlighted column. TABLE THREE CALIFORNIA ALL AGRICULTURAL WORKERS ESTIMATES FINAL County Adjusted MSFW Farmworker Estimates Migrant Farmworkers Seasonal Farmworkers Non-Farmworkers In Migrant Households Non- Farmworkers In Seasonal Households MSFW Farmworkers And Non- Farmworkers Alameda1,1485316161956992,043 Alpine000000 Amador7373413961254491,311 Butte7,2633,3633,9001,2364,42612,925 Calaveras13563732383241 Colusa13,9326,4507,4812,3718,49024,792 Contra Costa2,4701,1441,3264201,5054,395 Del Norte6042803251033681,076 El Dorado9604445151635851,708 Fresno145,91967,56178,35924,82888,917259,665 Glenn3,7471,7352,0126382,2836,668 Humboldt9354335021595701,664 Imperial29,31213,57215,7414,98817,86252,162 Inyo7133381243126 Kern92,14242,66249,48015,67856,148163,968 Kings16,5927,6828,9102,82310,11129,526 Lake2,9111,3481,5634951,7745,181 Lassen54425229293331968 Los Angeles14,1806,5667,6152,4138,64125,234 Madera29,67613,74015,9365,04918,08352,809 Marin6973233741194251,240 Mariposa49232683087 Mendocino6,1422,8443,2981,0453,74310,930 Merced26,10012,08414,0164,44115,90446,445 Modoc8513944571455191,515 Monterey86,94140,25346,68714,79352,978154,712 Napa12,2225,6596,5632,0807,44721,748 Nevada2069511035125366 Orange11,2845,2256,0601,9206,87620,081 III-10

11. III-11 Use information in highlighted column. County Adjusted MSFW Farmworker Estimates Migrant Farmworkers Seasonal Farmworkers Non-Farmworkers In Migrant Households Non-Farmworkers In Seasonal Households MSFW Farmworkers And Non- Farmworkers Placer8023714311374891,428 Plumas7133381243126 Riverside34,99116,20118,7905,95421,32262,267 Sacramento7,8453,6324,2131,3354,78013,960 San Benito7,3003,3803,9201,2424,44812,991 San Bernardino7,0123,2463,7651,1934,27312,477 San Diego19,7199,13010,5893,35512,01635,090 San Francisco34315918458209610 San Joaquin60,18427,86532,31910,24136,674107,099 San Luis Obispo11,8965,5086,3882,0247,24921,168 San Mateo4,0841,8912,1936952,4897,267 Santa Barbara31,38114,53016,8525,34019,12355,844 Santa Clara10,5974,9065,6911,8036,45718,858 Santa Cruz19,2488,91210,3363,27511,72934,252 Shasta5,6672,6243,0439643,45310,084 Sierra211014 Siskiyou3,3981,5731,8255782,0716,047 Solano6,5283,0233,5061,1113,97811,617 Sonoma15,7177,2778,4402,6749,57827,969 Stanislaus36,72017,00119,7196,24822,37665,344 Sutter14,1776,5647,6132,4128,63925,228 Tehama3,8251,7712,0546512,3316,807 Trinity8338451451148 Tulare73,81034,17439,63612,55944,977131,346 Tuolumne23510912640143417 Ventura35,18116,28918,8925,98621,43862,605 Yolo14,7946,8507,9442,5179,01526,326 Yuba5,3492,4772,8729103,2599,519 State Total938,758434,645504,113159,732572,0421,670,532 NOTE: County numbers have been rounded and, therefore, may not add to totals.

12. Provider Side of the Ratio : III-12 

13. STEPS 1)Identify all primary care physicians in the area to be designated. 2)Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. 3)Calculate the FTE for each primary care physician serving the population to be designated. 4)Calculate the population to provider ratio. III-13

14. STEP 1 Identify all primary care physicians in the area to be designated. III-14

15. List all primary care Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) who: 1) Provide direct patient care in the service area, and 2) Practice principally in one of the six primary care specialties:  General Practice  Family Practice  General Internal Medicine  Pediatrics  Gerontology  Obstetrics and Gynecology  Physicians engaged solely in administration, research, or teaching  Hospital staff physicians involved exclusively in inpatient or emergency room care  Locum tenens serving less than 1 year (on contract)  Physicians who are suspended under provisions of the Medicaid-Medicare Anti- Fraud and Abuse Act for a period of 18 months or more  Mid-levels Include in survey, but reduce the following provider’s FTE to 0.0 III-15

16.  Physicians who serve in the NHSC Scholarship or Loan Repayment Programs.  Physicians who serve under a J-1 or H-1B waiver  Physicians who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau of Prisons)  Include physicians who are planning on retiring within six months, but are still seeing patients Include in Survey but reduce FTE to zero III-16

17. Include the following provider’s FTE: All primary care M.D.s and D.O.s who provide direct patient care in the service area, including those who:  Serve in State Scholarship or Loan Repayment Programs  Serve at Indian Health Clinics and are not Federal providers  Plan on retiring but are still seeing patients III-17

18.  State Licensure Lists: http://www2.dca.ca.gov/pls/wllpub/w llquery$.startup http://www2.dca.ca.gov/pls/wllpub/w llquery$.startup  National, State, and Local Medical Association Directories  Local Hospital Admitting Physician Listings  American Osteopathic Association (AOA) Physician Listing  Medicare and Medicaid Practitioner Lists  Local Telephone Directory/ Yellow Pages  www.vitals.com www.vitals.com  http://www.healthgrades.com/ http://www.healthgrades.com/ Sources of Provider Data Use several of these sources to assure a complete listing of physicians is being used. III-18  https://www.breeze.ca.gov/https://www.breeze.ca.gov/

19. STEP 2 Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated. III-19

20. Designation Types and Whom to Include in the Provider Count COUNT ALL PRIMARY CARE PROVIDERS WHO SERVE ALL PERSONS: Geographicin the service area Low-Income Populationin the service area that have incomes < 200% of the Federal poverty level (Medicaid and Posted Sliding Fee) DESIGNATION TYPE: III-20

21. Providers Physician NameSpecialtyLocation of Practice/CT Hours of Direct Pt. Care/Week Hosp. Hours 1) L. McCoy, D.O.Gen.Prac. 19 Main Street City, CA 90001 CT 531 48Included 2) D. Scully, MDPediatrics 11 Park Place City, CA 90001 CT 540 30Included 3) B Spock, M.D.Int. Med. 6 Muldar Ave City CA 90002 CT 538 15Included 4) M. Welby, M.D.Ob-Gyn 3306 Russia Blvd City, CA 90002 CT 543 25Not Included 5) Y. Zhivago, D.O.Fam. Prac. 99 Bones Drive City, CA 90003 CT 539 0 Full Time Administration Total Physicians: 5 III-21

22. STEP 3 Calculate the FTE for each primary care physician serving the population to be designated. III-22

23. FTE Calculation  40 hours = 1.0 FTE  Every 4 hours (½ day) is counted as 0.1 FTE  A provider serving more than 40 hours a week is counted as 1.0 FTE  Only the Total (or Total Low-Income) FTE is rounded to the nearest tenth of a percent: Examples:0.875= 0.9 0.817= 0.8 0.83 = 0.8 0.85 = 0.9  Interns and residents are counted as 0.1 FTE (40 hours = 0.1 FTE) Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and Sliding Fee Scale (SFS) patients. It is not based on whether the provider is accepting new Medicaid patients. For each physician, include the number of hours of direct patient care provided (office and hospital inpatient) in the service area: III-23

24. Adjustment of FTE if hospital inpatient hours not available:  Use for physicians whose office hours are < 40 and information on hours spent in inpatient care is not available  Multiply office hours X appropriate factor  Cannot exceed 1.0 FTE Primary Care SpecialtyAdjustment Factor General/Family Practice1.4 Gerontology1.4 Pediatrics1.4 General Internal Medicine1.8 Obstetrics/Gynecology1.9  If specialty information is not known then use the default which is 1.6 III-24

25. FTEs - Geographic Designation Physician NameSpecialtyLocation of Practice/CT Hours of Direct Patient Care/Week Hosp. Hours FTE 1) L. McCoy, D.O.Gen.Prac. 19 Main Street City, CA 90001 CT 531 48Included1.0 (48/40=1.2=1.0) 2) D. Scully, MD 1 Pediatrics 11 Park Place City, CA 90001 CT 540 30Included0.8 (30/40=.75=.8) 3) B Spock, M.D. 2 Int. Med. 6 Muldar Ave City, CA 90002 CT 538 15Included0.4 (15/40=.375=.4) 4) M. Welby, M.D. 3 Ob-Gyn 3306 Russia Blvd City, CA 90002 CT 543 25Not Included 1.0 (25 x 1.9 = 47.5/40=1.2=1.0) 5) Y. Zhivago, D.O. 4 Fam. Prac. 99 Bones Drive City, CA 90003 CT 539 0---0.0 (0/40=.0) Total Physicians: 5 Total FTE: 3.125=3.1 1 – Dr. Scully spends 10 hours/week doing research. 2 – Dr. Spock chooses to work only 15 hours/week. 3 – Dr. Welby has an unknown number of hospital inpatient hours so the adjustment factor is used 4 – Dr. Zhivago spends full-time in administration. III-25

26. FTEs - Low-Income Designation Total Physicians: 5 Total Low-Inc FTE: 1.615=1.6 1 – Dr. Scully spends 10 hours/week doing research. 2 – Dr. Spock chooses to work only 15 hours/week. 3 – Dr. Welby has an unknown number of hospital inpatient hours so the adjustment factor is used 4 – Dr. Zhivago spends full-time in administration. III-26 Physician NameHours of Direct Pt. Care/Week Hosp. Hours FTE % Medi - Cal % SFS % of Low- Income Total Low- Inc FTE 1) L. McCoy, D.O. 48Included1.064%15%79% (64%+15%=79%) 0.79 (.79 x 1.0 =.79 ) 2) D. Scully, MD 1 30Included0.7535%8%43% (35%+8%=43%) 0.32 (.43 x.75 =.32) 3) B Spock, M.D. 2 15Included0.37560%40%100% (60%+40%=100%).375 (1 x.375 =.375) 4) M. Welby, M.D. 3 25Not Included (25x1.9= 47.5/40= 1.2) 1.013%0%13%0.13 (.13 x 1=.13) 5) Y. Zhivago, D.O. 4 0Included0.00% 0.00

27. Survey Physicians to Determine Their FTE  Survey all primary care physicians in service area  Must attempt to contact physician at least 3 times  Minimum two-thirds response rate required Calculation of Non-Responders Ex: Elk Grove, California - 20 providers 15 - respond to survey 5 - no response after repeated telephone calls Response rate 15/20 = 75% Total FTE for the 15 responders= 9.5 Left off 1) Divide FTE of responders (9.5) by the number of responders (15) for the average FTE of responders (.63) 2) Multiply number of non-responders (5) by the average FTE of responders (.63) for FTE of non-responders (3.16=3.2) 3) Add FTE of responders (9.5) and non-responders (3.2) for total FTE = 12.7  Average response rate applied to non-responders III-27

28. STEP 4 Calculate the population to provider ratio. III-28

29. Population to Provider Ratios Civilian Population Ratio: Civilian Population = 20,900 Primary Care Physician FTE = 3.8 (20,900 / 3.8 = 5,500:1) Civilian Population (High Needs) Ratio: Civilian Population = 20,900 Primary Care Physician FTE = 6.9 (20,900 / 6.9 = 3,029:1) (100% Federal poverty level at 21.1%) Low Income Population (200% Poverty) Ratio: Low Income Population = 10,137 (49.47%) PC Physician Serving that Population = 1.6 (10,137 / 1.6 = 6,336:1) III-29

30. What to Include in the Population to Provider Ratio Primary Care Section of your Application Population  Cover letter with summary findings  Total adjusted population  Source of data and methodology if using source other than Claritas List of Providers Include the Following for Each Provider:  Name  Location: Non-metro areas - name of town Metro areas – complete address with zip code, and CT if available  Degree (M.D. or D.O.)  Specialty (GP, FP, OB-GYN, IM, PEDS, Gerontology)  Average number of hours per week in direct patient care in the area  Inpatient care hours or adjustment to total hours  Percentage of practice that is Medicaid (for low-income and Medicaid-eligible designations)  Percentage of practice that is Sliding Fee Scale (for low-income designations)  FTE total for each provider rounded to the nearest tenth of a percent  Description of how information was obtained (sources, methods of gathering data) Totals and Ratio  Total number of providers  Total FTE  Population to provider ratio  Explanation of any high need indicators III-30

31. Contiguous Area Resources III-31

32. Contiguous Area Resources Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, overutilized, or inaccessible to the population of the area proposed for designation. Purpose of Contiguous Area Analysis: To identify nearby sources of care and determine if they are inaccessible to the population in the proposed service area III-32

33. STEPS 1) Identify the boundaries of each contiguous area. 2)Evaluate each area to determine availability of resources. III-33

34. 1) Identify the Boundaries of Each Contiguous Area A.Identify on a map the boundaries and population center of the proposed service area. B.Determine the contiguous areas in all directions within 30 minutes from the proposed area’s population center. C.Map the boundaries of each contiguous area in all directions (North, East, South, & West). The boundaries of contiguous areas are often (not always) based on the same census delineation as the proposed area: Proposed service area = whole county Contiguous areas = whole counties Proposed service area = census tracts (MSSA) Contiguous areas = census tracts (MSSA) III-34

35. 2) Determine Availability of Resources A.Check the HPSA list to determine if any of the contiguous areas are designated as HPSA and therefore considered inaccessible. If it is not inaccessible HPSA, then B.Determine if there are significant socio-economic/demographic disparities or physical barriers. If there are not significant socio-economic/demographic disparities or physical barriers, then C.Determine if the contiguous area’s providers are located > 30 minutes away from the population center of the proposed area and are therefore inaccessible due to excessive distance. If they are not excessively distant, then D.Determine if the resources in the contiguous area exceed the population-to- provider ratio and are therefore overutilized. If they are not overutilized, this area cannot be designated. (Consider a different kind of designation.) III-35

36. A. Check the HPSA Status of Each Contiguous Area and Determine if This Type of HPSA Is Inaccessible to the Proposed Area If the proposed service Then the contiguous area area is: is inaccessible if it is a: Geographic without high needsGeographic HPSA Geographic with high needsGeographic HPSA, Low-Income HPSA (based on 100% poverty indicator > 20%) Low-Income HPSAGeographic HPSA, Low-Income HPSA III-36

37. B. Determine if Significant Socio-Economic/Demographic Disparities or Physical Barriers Exist Significant demographic disparities between the population in the service area and the population in the contiguous area result in the population being isolated from nearby resources (A 2 * N or plus 15% for percentages below 15 to determine disparity between the population in the service area and the population in the contiguous area) Significant socio-economic disparities: 100% poverty rate or 200% poverty rate (A 2 * N or plus 15% for percentages below 15 to determine disparity between the poverty in the service area and the poverty in the contiguous area) Significant physical barrier: mountains, large parks, bodies of water, highways, railway yards, industrial areas, etc. result in the population being isolated from nearby resources III-37

38. B. Determine if Significant Socio-Economic/Demographic Disparities or Physical Barriers Exist (continued) Rule of Thumb: 2 * N with poverty or plus 15% for percentages below 15. Examples: Note: Using the lower number between proposed areas and contiguous areas for calculating disparity is suggested. III-38 Proposed Area: MSSA 78.2b – Pico-Union in Los Angeles County Summary: Civilian Pop: 146,918 Below 200% Pov: 68.95% Below 100% Pov: 33.76% White Pop: 33.21% Black Pop: 6.23% Hispanic Pop: 70.11% MSSA 78.2v – Carson/Compton West/Rancho Dominguez: 2* 29.40= 58.8%, is there a disparity here? Summary: Civilian Pop: 106,413 Below 200% Pov: 29.40% Below 100% Pov: 9.75% White Pop: 24.24% Black Pop: 21.80% Hispanic Pop: 40.19% HPSA: No If looking at the 100% pov., 9.75+15=24.75%, is there a disparity there?

39. C. Determine if Providers are Excessively Distant 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) Contiguous area will be measured from the same starting point (which is the population center of the proposed area) Providers > 30 minutes from the population center are excessively distant Primary Health Care: > 30 minutes Interstate Roads - 25 miles X 1.2 = 30 minutes Primary Roads - 20 miles X 1.5 = 30 minutes Secondary Roads - 15 miles X 2.0 = 30 minutes III-39

40. Service Area Travel Calculation Primary Health Care Interstate Roads: 25 miles X 1.2 = 30 minutes Primary Roads (include surface streets): 20 miles X 1.5 = 30 minutes Secondary Roads (mountainous terrain or unpaved road): 15 miles X 2.0 = 30 minutes Dental and Mental Health Care Interstate Roads: 30 miles X 1.33 = 40 minutes Primary Roads (include surface streets): 25 miles X 1.6 = 40 minutes Secondary Roads (mountainous terrain or unpaved road) 20 miles X 2.0 = 40 minutes III-40

41. Determine if Providers are Excessively Distant (continued) Inner Portions of Metropolitan Areas: Distance is based on time using public transportation * during non- rush hour. Bus routes and schedules must be described (provide narrative description and include bus schedule if possible). Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate. If the MSSA doesn’t meet this requirement the next step is to show that there is a 30% or greater public transportation ridership use in the MSSA and Provide documentation to back up the claim. III-41

42. D. Determine if Contiguous Areas are Overutilized  Calculate FTE - use same method as used for the proposed service area.  If needed, survey providers and determine FTE serving the population. Use same surveying method as used for the proposed service area. If applying for low-income designation, gather Medi-Cal and sliding fee scale percentages to calculate low-income FTE.  Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio.  In contiguous areas, calculate the population to provider ratio counting each provider as 1.0 FTE. If area meets ratio of > 2,000:1, do not survey (Geographic only). Population to Provider Ratio: PRIMARY HEALTH CARE: > 2,000:1 primary care physician III-42

43. Determine the Nearest Source of Non-Designated Care Needed for HPSA score:  Geographic Designation: Can be in a Low-Income HPSA  Population Designation: Cannot be a HPSA (of any type)  Cannot have significant socio-economic/demographic differences or physical barriers  Can be excessively distant  Can be overutilized For all applications:  Provide a road map with the proposed service area and contiguous areas outlined.  On the map, indicate the population center of the proposed service area, the nearest source of care, and the route between these points.  Provide the name, phone number, specialty, and address of the nearest source of care, route, miles, and minutes. For inner portions of metropolitan areas, include:  Bus route information from the population center of the proposed area to the nearest source of care including miles and minutes of travel time. For population center info: http://oshpd.ca.gov/HWDD/MSSA/index.htmlhttp://oshpd.ca.gov/HWDD/MSSA/index.html III-43

44. Time Saving Tips Survey providers only if necessary:  In contiguous areas, calculate the population to provider ratio counting each provider as 1.0 FTE. If area meets ratio of > 2,000:1, do not survey (Geographic only).  Collect all possible information in one survey (e.g. Medi-Cal and sliding fee scale even for an area designation).  Work with State licensing department to obtain information on providers. III-44

45. What to Include in the Contiguous Area Resources Section of Your Application Map with Census Delineations  Name and boundaries of proposed service area  Name and boundaries of contiguous areas  Population center for the proposed service area  Helpful: current designation status of each of the contiguous areas Road Map  Outline of proposed area boundaries  Location of nearest source of non-designated care  For automobile transportation – a copy of Google map with route details  For public transportation – start and end points of route III-45

46. For Contiguous Areas that are not Excluded with Current Designations and Whose Providers are Excessively Distant  Travel time to closest provider from population center of service area, including miles, route, and type of road; or public transportation information, including bus routes, start/end points, miles, minutes, and source. For Contiguous Areas that are not Excluded with Current Designations and have Access Barriers  Description of any significant socio-economic/demographic disparities (e.g., demographic data on racial/ethnic composition or income levels comparing proposed service area population to population in the contiguous area, and source of data), or  Description of any significant physical barrier For Contiguous Areas that are not Excluded with Current Designations and are Overutilized  Population to provider ratios, and  Description of how information was obtained What to Include in the Contiguous Area Resources Section of Your Application (continued) III-46

47. For All Designation Requests: For Public Transportation Routes:  Travel time, based on non-rush hour bus schedules (i.e. 10:00 am)  Start/End point of route  Include time waiting for transfers while in route  Map showing proposed area boundaries, start and end points of bus route  Provide source of information (Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate.)  Address of nearest source of non-designated, accessible care, including address, miles and minutes via public transportation if metropolitan area  Location of nearest source on road map (see above) What To Include In The Contiguous Area Resources Section of Your Application (continued) III-47

48. Websites California Public Transit Information and Maps: http://maps.google.com 2000 CT Locator: http://www.ffiec.gov/Geocode/default.aspx U.S. Census Bureau – American Factfinder http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml MSSA Data: http://oshpd.ca.gov/HWDD/MSSA/index.html III-48

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55. Geographic PC PHYSICIAN SURVEY SAMPLE III-55

56. LOW-INCOME PC PHYSICIAN SURVEY SAMPLE III-56

57. APPLY FOR DESIGNATION No Contiguous Area Conditions Met 1or more Contiguous Area Conditions Met for EACH Contiguous Area Evaluate Contiguous Area STOP: Area Not Qualified For Designation Calculate Population-to- Physician Ratio Define Rational Service Area Determine Physician FTEs Determine Service Area Population Evaluate Service Area for High- Need Indicators STOP: Area Not Qualified For Designation STOP: Area Not Qualified For Designation No High Need Indicators Present 1 or more High- Need Indicators Present Process Model for Geographic Primary Care Health Professional Shortage Area Designation To Use: Follow arrows. Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes 2 3 46 9 1 5 98 Ratio < 3000 9 Ratio 3000-3499 Evaluate Contiguous Area 5 1 or fewer Insufficient Capacity Indicators Present 2 or more Insufficient Capacity Indicators Present 1 or more Contiguous Area Conditions Met for EACH Contiguous Area No Contiguous Area Conditions Met STOP: Area Not Qualified For Designation 9 APPLY FOR DESIGNATION 8 Ratio >3500 Evaluate for Insufficient Capacity 7 III-57