DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT STATE-DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA DESIGNATION 6 CCR 1015-6 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Adopted by the Board of Health on November 15, 2023; effective January 14, 2024.

1.1 Purpose

This rule establishes quantitative methods for determining which areas of Colorado have a shortage of health care providers and thus, should receive a state designation as a health professional shortage area. The methodology for behavioral health care services designation is based upon:

1) The estimated demand for behavioral health care services encounters within a population defined by a discrete geographic area;

2) The estimated supply of behavioral health care services encounters for the population within a discrete geographic area;

3) The determination of whether supply meets demand within a discrete geographic area; and 4) The designation of geographic areas as behavioral health care services health professional shortage areas where the resultant supply falls short of estimated demand for minimally adequate substance use disorder treatment.

The methodology for primary care designation is based upon:

1) The estimated demand for primary care service encounters within a population defined by a discrete geographic area;

2) The estimated supply of primary care service encounters for the population within a discrete geographic area;

3) The determination of whether supply meets demand within a discrete geographic area; and 4) The designation of geographic areas as primary care health professional shortage areas where the resultant supply falls short of estimated demand for primary care services.

1.2 Authority

This regulation is adopted pursuant to the authority in Section 25-1.5-404(1)(a), Colorado Revised Statutes.

1.3 Definitions

1) “Behavioral Health Care Provider,” pursuant to Section 25-1.5-502(1.3), C.R.S., means the following providers who provide behavioral health care services within their scope of practice:

a) a licensed addiction counselor (LAC), b) a certified addiction counselor (CAC), c) a licensed professional counselor (LPC), d) a licensed clinical social worker (LCSW), e) a licensed marriage and family therapist (LMFT), f) a licensed psychologist (Ph.D. or Psy.D.), g) a licensed physician assistant (PA) with specific training in substance use disorder, h) an advanced practice nurse (APN) with specific training in substance use disorder, pain management, or psychiatric nursing, or i) a physician with specific board certification or training in addiction medicine, pain management, or psychiatry.

2) “Behavioral Health Care Services,” pursuant to Section 25-1.5-502(1.5), C.R.S., means services for the prevention, diagnosis, and treatment of, and the recovery from, mental health and substance use disorders.

3) “Capacity” means the typical volume of health service encounters a health care professional can produce within the scope of his or her practice and scheduled clinical hours.

4) “Catchment Area” means a discrete geographic area where a preponderance of the civilian noninstitutionalized population within the service area could reasonably expect to access behavioral health services within the service area without excessive travel, when it is adequately resourced.

5) “Census Block Group” means a statistical division of a census tract defined by the U.S. Census Bureau.

6) “Civilian Noninstitutionalized Population” are all people who live and sleep most of the time within the boundaries of a geographic area but are not housed in a group quarter such as a correctional institution, juvenile facility, military installation, or dormitory.

7) “Colorado Health Systems Directory” means the clinician data system administered by the Colorado Department of Public Health and Environment’s Primary Care Office (section 25-1.5- 403, C.R.S.) which provides a comprehensive database of all licensed clinicians and health care sites in Colorado.

8) “Encounter” means an instance of direct provider to patient interaction with the primary purpose of diagnosing, evaluating or treating a patient’s health care concern.

9) “Minimally Adequate Treatment” means the minimum necessary health care service visits for diagnosis, treatment or recovery needed to address a specific or general medical or behavioral health care service need.

10) “Prevalence” means the proportion of a population who has behavioral health care needs at some point within the previous year.

11) “Primary Care Provider” means the following health care professionals as defined in Section 25- 1.5-502(5), C.R.S., who provide primary care services within their scope of practice:

a) an advanced practice nurse (APN) with a focus or specialty in primary care, women’s health, or nurse midwifery;

b) a physician (MD or DO) with specific board certification or training in family medicine, general internal medicine, or general pediatrics; or c) a physician assistant (PA) with a practice focus on primary care services.

12) “Primary Care Services,” means a type of primary health services, as defined in Section 25-1.5- 502(10), C.R.S., that involves comprehensive first contact and continuing care services for the prevention, diagnosis, and treatment of any undiagnosed sign, symptom or health concern not limited by problem origin or diagnosis.

13) “Polygon” means a closed, irregular geometric shape on a map surface that defines equivalent road travel distances from a central point within the shape.

14) “Population Centroid” means the geometric center of a group of population points within a geographic shape (e.g., census block group).

15) “State-Designated Health Professional Shortage Area,” pursuant to Section 25-1.5-402(11) and Section 25-1.5-502(13), C.R.S., means an area of the state designated by the Primary Care Office in accordance with state-specific methodologies established by the State Board by rule pursuant to Section 25-1.5-404 (1)(a), C.R.S., as experiencing a shortage of health care professionals or behavioral health care providers.

16) “State Designated Substance Use Disorder Health Professional Shortage Area” means a State- Designated Health Professional Shortage Area experiencing a shortage of behavioral health care providers providing behavioral health care services for substance use disorder.

17) “Substance Use Disorder” means mild, moderate, or severe recurrent use of drugs and/or alcohol that causes clinically and functionally significant impairment of individuals. Impairment may include health concerns, disability, risky behavior, social impairment, and failure to perform significant responsibilities at work, school, or with family. The diagnosis may be applied to the abuse of one or more of ten separate classes of drugs including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other substances. The dependent use of tobacco and caffeine are not a primary focus of this rule.

1.4 Behavioral Health Care Health Professional Shortage Area Determination Method 1) Catchment areas are created for analysis of behavioral health care provider capacity by determining standard road travel distances from the population centroid of each census block group in Colorado using a variable two-step floating catchment area method.

2) The population of each catchment area is the civilian noninstitutionalized population according to the most recent available data from U.S. Census Bureau at the time of analysis.

3) The estimated burden of behavioral health care needs within each catchment area is determined by multiplying the civilian noninstitutionalized population in the catchment area (section 1.4(2)) by mental illness and substance use disorder prevalence according to age and sex. Substance use disorder prevalence is determined using the most recent available data from the National Survey on Drug Use and Health administered by the U.S. Department of Health and Human Services, Substance Use and Mental Health Services Administration.

4) The estimated behavioral health services demand for substance use disorder in each catchment area is determined by multiplying the estimated burden of substance use disorder (section 1.4(3)) by the number of minimally adequate treatments as reported in the National Comorbidity Survey – Replication administered by the U.S. Department of Health and Human Services, Substance Use and Mental Health Services Administration.

5) The estimated behavioral health care services supply in each catchment area is determined by evaluating a list of behavioral health care providers with a practice address within the catchment area and the behavioral health care providers’ encounter productivity. The list of behavioral health care providers is derived from the most recent available data reported in the Colorado Health Systems Directory administered by the Colorado Department of Public Health and Environment’s Primary Care Office. Each behavioral health care provider is assigned a behavioral health service 12 month productivity rate. The sum of encounter productivity for all practicing behavioral health care providers in the catchment area is the total estimated substance use disorder services supply in the catchment area.

6) Designation of a census block group as a State Designated Behavioral Health Care Health Professional Shortage Area occurs when the supply of behavioral health service encounters falls below the per capita demand for minimally adequate treatment for those who experience substance use disorder within the catchment area.

7) Current designation status of each region of the state will be posted at least annually on or about July 1 on a publicly accessible website.

1.5 Primary Care Health Professional Shortage Area Determination Method

1) Catchment areas are created for analysis of primary care provider capacity by determining standard road travel distances from the population centroid of each census block group in Colorado using a variable two-step floating catchment area method.

2) The population of each catchment area is the civilian noninstitutionalized population according to the most recent available data from U.S. Census Bureau at the time of analysis.

3) The estimated demand for primary care services within each catchment area is determined by multiplying the civilian noninstitutionalized population in the catchment area (section 1.5(2)) adjusted for rates of demand for primary care services according to age and sex. Rates of demand for primary care services are determined using the most recent available data from the Medical Expenditure Panel Survey administered by the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.

4) The estimated primary care services supply in each catchment area is determined by surveying primary care providers with a practice address within the catchment area. The list of primary care providers is derived from the most recent available data reported in the Colorado Health Systems Directory administered by the Colorado Department of Public Health and Environment’s Primary Care Office. Each primary care provider is assigned a primary care service 12 month productivity rate. The sum of encounter productivity for all practicing primary care providers in the catchment area is the total estimated primary care services supply in the catchment area.

5) Designation of a census block group as a State Designated Primary Care Health Professional Shortage Area occurs when the supply of primary health service encounters falls below the per capita demand for primary care demand within the catchment area.

6) Current designation status of each region of the state will be posted at least annually on or about July 1 on a publicly accessible website.

1.6 Data Sources

1) If current data from the sources cited above are unavailable, the department may rely upon comparable data sources.

2) To the extent available, reliable and practicable, the department will rely upon data collected within one year prior to analysis.

3) Health care providers practice characteristics data may be derived from direct survey methods, claims analysis, peer reviewed and validated workforce research tools, and statistical methods.

1.7 Review

Shortage designation status will be reviewed in 2023 and at least every three years thereafter. More frequent review may be performed where data is available and analytical resources are available. Designation status of each area will remain effective for 36 months from the date of publication or when replaced by a more recent analysis.

_________________________________________________________________________ Editor’s Notes History New rule emer. rule eff. 08/15/2018; expired 12/13/2018. Entire rule eff. 02/14/2019.

Entire rule eff. 07/15/2021.

Entire rule eff. 01/14/2024.