1. (1) Background

   1. (a) In the early 1990s, the Alabama Department of Mental Health and Mental Retardation developed a psychiatric bed need methodology that provided for an inventory of 37.1 beds per 100,000 population. Originally, the methodology was calculated using regions; however, in 2003 it was changed to reflect a statewide need methodology. Although the statewide need methodology was helpful in the early years to ensure access to care, it resulted in an uneven distribution of psychiatric beds, with higher concentrations of beds in some regions and shortages of psychiatric beds in other regions of the state.
   2. (b) Over time, the number of psychiatric beds, both private beds and state beds, has declined. States have transitioned funding for mental health services from institutional care to community-based services, as state budgets have been cut and as more is known about the benefits of providing care in a non-institutional, community setting. Alabama mirrors these national trends, as it has closed three state facilities and downsized from 4,000 beds in 2009 to approximately 1,600 beds in 2017. In some areas, community-based services include crisis stabilization and access to timely follow-up care. In other areas, community resources may be limited, and those with psychiatric emergencies often present to a general acute care hospital emergency room for care; some of the more severely mentally ill remain for extended periods of time in private psychiatric facilities, waiting on a state bed to become available.

2. (2) Methodology

   1. (a) Discussion.  The Statewide Health Coordinating Council (SHCC) developed a proposal for a new methodology based on the increasing need for psych beds and a better distribution of those beds. Approved by the full SHCC, the purpose of this inpatient psychiatric services need methodology is to identify, by region and by bed type, the number of inpatient psychiatric beds needed to ensure the continued availability, accessibility, and affordability of quality inpatient psychiatric care for residents of Alabama. Only the SHCC, with the Governor's approval, can make changes to this methodology. The State Health Planning and Development Agency (SHPDA) staff shall annually update statistical information to reflect more current utilization through the Hospital Annual Survey.

   2. (b) Bed Need Determined by Region and by Category of Bed.  The new methodology is based upon the regional needs of the state as opposed to a statewide need methodology. It also addresses need based on the category of patients served in the beds being used; the bed categories include: 1. Child/Adolescent; 2. Adult; and 3. Geriatric. Calculation of beds needed will be based on utilization of those beds by category and by region as reported annually in the Hospital Annual Report. The Hospital Annual Report must be amended to accomplish the purposes of this new methodology. This new methodology will become effective after the certification by the Healthcare Information and Data Advisory Council of the first new Hospital Annual Report following the passage of this amendment. All providers will report their licensed beds, operating beds and patient days by inpatient psychiatric category each year via the new Hospital Annual Report. Operating beds may be the same as or fewer than the total number of licensed psychiatric beds. Providers with unrestricted psychiatric beds obtained prior to the effective date of this new methodology shall be allowed to change the categories of their beds during the first two reporting periods. The bed allocation by category reported on the third Hospital Annual Report following the passage of this amendment shall be considered final for operating beds. Thereafter, any permanent change to a different inpatient psychiatric bed category for an existing operating bed or beds will require the approval of a new CON. This requirement will not apply to licensed beds not currently in use; however, once beds are put into use, the provider will have to declare the category(ies) of the beds.

      After this methodology becomes effective, applicants for new inpatient psychiatric beds will be required to select a category (Child/Adolescent, Adult, Geriatric) for which they are seeking inpatient psychiatric beds. Applicants may apply for more than one inpatient psychiatric category if a need is shown. See Section (3)(c), below regarding new beds.

      Note: This new methodology is intended for planning purposes. The declaration of psychiatric beds by category on the Hospital Annual Report is not intended to preclude providers from using their psychiatric beds as necessary to address seasonal needs and surge situations. If a hospital determines that it needs to permanently change its psychiatric bed allocation, a new CON will be required. This new methodology, however, does not apply to pediatric specialty hospital providers, and is not intended: to preclude pediatric specialty hospital providers from using their pediatric specialty beds to provide pediatric psychiatric services, as necessary; to require such providers to report or declare via the SHPDA Hospital Annual Report their pediatric specialty beds used for pediatric psychiatric services as psychiatric beds, with related patient days, by inpatient category; or require such providers to obtain a CON for any new or additional use of their pediatric specialty beds for the provision of any pediatric specialty services, including pediatric psychiatric services.

3. (3) Planning Policies

   1. (a) Planning on a Regional Basis.  Planning will be on a regional basis. Please see attached listing for the counties in each region as designated by the SHCC.

   2. (b) Planning Policies for applicants.

      1. 1. An applicant for an inpatient psychiatric bed must be either: 1) an established and licensed hospital provider that has been operational for at least twelve (12) months; or, 2) a new inpatient psychiatric hospital seeking a minimum of at least twenty (20) inpatient psychiatric beds. (Specialty, Free-Standing Psychiatric Hospitals must have at least twenty (20) inpatient beds pursuant to Rule 420-5-7-.03 Classification of Hospitals, found in Chapter 420-5-7 of the Alabama Department of Public Health Administrative Code.)
      2. 2. An applicant for inpatient psychiatric beds in a particular category must demonstrate the ability to comply with state law.
      3. 3. In Certificate of Need decisions concerning psychiatric services, the extent to which an applicant proposes to serve all patients in an area should be considered. The problem of indigent care should be addressed by Certificate of Need applicants.

   3. (c) Applying for Additional beds.  Applicants may apply for new psychiatric beds using one of the following occupancy need determinations:

      1. 1. Regional occupancy calculation.

         1. (i) (Total patient days/days in Reporting Period)/.70

            = total beds needed for the region to have a 70 percent (70%) occupancy rate.

         2. (ii) To calculate additional beds needed for the region:

            Total beds needed to reach 70 percent (70%) occupancy rate minus current beds in operation.

            The total patient days and the beds in operation used for the calculations shall come from the information reported to SHPDA through the most recent Hospital Annual Report.

            The following is an example of how the regional methodology would be calculated if a single region had 25,000 adult patient days and 90 adult beds:

            To calculate the regional occupancy:

            25,000 adult days/(90 beds operating x days in Reporting Period) = 76% regional occupancy

            To calculate beds needed to have a 70%t occupancy:

            (25,000 adult days/days in Reporting Period)/.70 = 98 total beds needed for that occupancy level

            Beds needed (98) minus current beds (90) = 8 additional adult beds needed for the region.

         Any region that shows an occupancy rate of 75 percent (75%) or greater in any one of the three (3) bed categories shall be eligible for additional beds in that category. The number of additional beds needed shall be calculated by dividing the average daily census for the region by the desired occupancy rate of 70 percent (70%) and then subtracting from this number the current beds in operation. Information for this calculation shall be obtained from the most recent Hospital Annual Report as compiled by SHPDA. Beds granted under the regional methodology shall be deemed part of the official regional bed inventory at time of issuance. See formula below:

         To calculate regional occupancy:

         Total patient days/(Beds operating x days in Reporting Period)

         To calculate beds needed to get the region to 70 percent (70%) occupancy:

      2. 2. Individual Provider Occupancy Calculation.

         If the average occupancy rate for a single facility within a region is 80 percent (80%) or greater for a continuous period of twelve (12) months in any of the three (3) bed categories, as calculated by the SHPDA using data reported on the most recent Hospital Annual Report, that facility may apply for up to 10 percent (10%) of its current bed capacity or six (6) beds, whichever is greater. An individual facility may demonstrate a need based on occupancy irrespective of the total occupancy for the region in that bed category. Information for this calculation shall be obtained from the most recent Hospital Annual Report as compiled by SHPDA.

         Any beds obtained through the Individual Provider Occupancy Calculation shall not be included in the regional bed calculation for a period of three years after the beds are brought into service. After this three-year period the beds shall be included in the regional count. Any provider obtaining beds through this provision shall not be eligible to use the 10 percent rule for 24 months from the date the CON is granted.

4. (4) Plan Adjustments.  The psychiatric bed need for each region as determined by the methodology is subject to adjustments by the SHCC. The psychiatric bed need may be adjusted by the SHCC if an applicant can prove that the identified needs of a target population are not being met by the current bed need methodology.

   For a listing of Hospitals providing inpatient psychiatric services or the most current statistical need projections in Alabama contact the Data Division as follows:

   MAILING ADDRESS                    STREET ADDRESS
   (U. S. Postal Service)             (Commercial Carrier)
   PO BOX 303025                      100 N. UNION STREET SUITE 870
   MONTGOMERY, AL 36130-3025          MONTGOMERY, AL 36104

   TELEPHONE:                         FAX:
   (334) 242-4103                     (334) 242-4113

   EMAIL:                             WEBSITE:
   data.submit@shpda.alabama.gov      http://www.shpda.alabama.gov

   Appendix APsychiatric Care Regions

   North Central Region                       North Region
   Blount                                     Colbert
   Calhoun                                    Cullman
   Cherokee                                   Franklin
   Chilton                                    Jackson
   Clay                                       Lauderdale
   Cleburne                                   Lawrence
   Coosa                                      Limestone
   DeKalb                                     Madison
   Etowah                                     Marshall
   Jefferson                                  Morgan
   Randolph
   Shelby
   St. Clair                                  Southwest Region
   Talladega                                  Baldwin
   Tallapoosa                                 Clarke
   Walker                                     Conecuh
   Escambia
   Mobile
   Southeast Region                           Monroe
   Autauga                                    Washington
   Barbour
   Bullock
   Butler                                     West Region
   Chambers                                   Bibb
   Coffee                                     Choctaw
   Covington                                  Fayette
   Crenshaw                                   Greene
   Dale                                       Hale
   Dallas                                     Lamar
   Elmore                                     Marengo
   Geneva                                     Marion
   Henry                                      Perry
   Houston                                    Pickens
   Lee                                        Sumter
   Lowndes                                    Tuscaloosa
   Macon                                      Winston
   Montgomery
   Pike
   Russell
   Wilcox

Author: Statewide Health Coordinating Council (SHCC)

Statutory Authority: Code of Ala. 1975, §§22-21-260(13), (15).

History: Effective April 23, 1991. Amended: Filed June 19, 1996; effective July 25, 1996. Repealed and New Rule: Filed October 18, 2004; effective November 22, 2004. Amended (SHP Year Only): Filed December 2, 2014; effective January 6, 2015. Amended: Filed June 21, 2018; effective August 5, 2018. Repealed and New Rule: Published March 31, 2020; effective May 15, 2020. Repealed and New Rule: Published April 30, 2024; effective June 14, 2024.