Annual Utilization Report of Primary Care Clinic
Facility Name:EUREKA COMMUNITY HEALTH CENTER
OSHPD ID:306124007Report Status:Revised
License Category:Community ClinicReport Year:2004
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Clinic Services
Section 3 - Patient Demographics
Section 4 - Encounters by Principal Diagnosis
Section 5 - Encounters by Principal Service
Section 6 - Revenue and Utilization by Payer
Section 7 - Income Statement
Section 8 - Capital Projects and Funds
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:EUREKA COMMUNITY HEALTH CENTER
2.OSHPD ID Number:306124007
3.Street Address:2412 BUHNE STREET
4.City:EUREKA
5.Zip:95501
6.Facility Phone No.:(707) 441 - 1624 ext.
7.Administrator Name:Ann Sokoloff
8.Administrator E-mail Address:asokoloff@opendoorhealth.com
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:1/1/2004
11.Operation Open To:12/31/2004
12.Name of Parent Corporation:Open Door Community Health Centers, Inc.
13.Corporate Business Address:785 18th Street
14.City:Arcata
15.State:CA
16.Zip:95501 - 3207
17.Person Completing Report:Marylee Bytheriver
18.Phone No.:707-826-8633
19.Fax No.:707-826-8638
20.E-mail Address:mbytheriver@opendoorhealth.com
30.Submitted by:mbytheriver
31.Submitted Date and Time:6/27/2005 4:34:06 PM
Section 2 - Clinic Services
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health Clinics and Rural Clinics(1)
2.Indicate clinic type, if applicable:FQHC
Rural Health Clinic
Line
No.		Rural Health Clinic(1)
3.Is this a 95-210 Rural Health Clinic?No
Table 2.1 - Community Services
Check one or more boxes for each service provided.
Line
No.		Community Services(1)
Offered
10.Adult Day CareNo
11.Child CareNo
12.Community EducationNo
13.Community NutritionNo
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachYes
19.Social ServicesNo
20.Substance AbuseYes
21.TransportationNo
22.Vocational Training PlacementNo
23.Other (See Survey)No
Table 2.2 - Languages Spoken By
Check the staff box if one or more staff members speaks the listed language. Check the patients box if 100 patients (or more than 1% of your patient population) are best served in a listed language. Estimates are acceptable if exact counts are not available.
Line
No.		Language Spoken By(1)
Staff		(2)
Patients
30.ArabicNoNo
31.ArmenianNoNo
32.CambodianNoNo
33.ChineseNoNo
34.HindustaniNoNo
35.HmongNoYes
36.JapaneseNoNo
37.KoreanNoNo
38.LaotianNoNo
39.PortugeseNoNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishYesYes
44.TagalogNoNo
45.VietnameseNoNo
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):8%
56.Primary non-English language spoken by patients (from list above):Spanish
FTE's and Encounters by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Encounters
60.Physicians3.203.2012,294
61.Physician Assistants1.671.676,342
62.Family Nurse Practitioners1.081.083,845
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.000
66.Registered Dental Hygienists0.000
67.Psychiatrist0.000
68.Clinical Psychologist0.120.12357
69.Licensed Clinical Social Worker (LCSW)1.561.562,486
70.Marriage, Family and Child Counselors (MFCC)0.000
71.Other Profiders billable to Medi-Cal**0.000
74.Other Certified CPSP prividers not listed above***0.000
75.Subtotal7.630.000.007.6325,324
** Other Provider billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists, Acupuncturists and any other professional who is able to be reimbursed through the Medi-Cal program.
*** Comprehensive Perinatal Services Program - List all other professional not listed above that are certified by the CPSP program to render services and can be reimbursed.
FTE's and Contacts by Primary Care Provider
Line
No.		Primary Care Provider(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Assistants0.000
81.Registered Nurses1.851.85319
82.Licensed Vocational Nurses0.000
83.Non-Licensed Patient Education Staff0.770.77412
89.Other Providers not listed above0.460.46252
90.Subtotal3.080.000.003.08983
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)3,239
2.Black64
3.Native American / Alaskan Native104
4.Asian / Pacific Islander67
9.Other / Unknown3,348
10.Total Patients *6,822
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic385
12.Non-Hispanic3,089
13.Unknown3,348
15.Total Patients *6,822

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%5,055
21.100 - 200%1,416
22.Above 200%152
23.Unknown199
24.Total Patients *6,822
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients0
31.Total Encounters0
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year5644
41.1 - 4 years6994
42.5 - 12 years161170
43.13 - 14 years6565
44.15 - 19 years167219
45.20 - 34 years8331,002
46.35 - 44 years571679
47.45 - 64 years1,0161,079
48.65 and over205327
55.Total Patients *3,1433,679
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare1,215
61.Medicare - Managed Care0
62.Medi-Cal2,051
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP684
65.Healthy Families57
66.Private Insurance1,016
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee1,799
71.Free0
74.All Other Payers0
75.Total Patients *6,822
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP114
81.CHDP0
82.EAPC1,744
83.Family PACT308
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)2,166
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments269
Section 4 - Encounters By Principal Diagnosis
Encounters by Principal Diagnosis
Report the diagnosis (or symptom, condition, problem or complaint) as the main reason for the encounter. Do not report the secondary diagnosis(es). There should be only one principal diagnosis for each encounter.
Line
No.		Classification of Diseases and/or Injuries
for each Principal Diagnosis		ICD-9-CM Codes(1)
# of Encounters
1.Infectious and Parasitic Diseases001 - 1392,961
2.Neoplasms140 - 239155
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2792,233
4.Blood and Blood Forming Disorders280 - 289119
5.Mental Disorders290 - 3195,003
6.Nervous System and Sense Organs Diseases320 - 389700
7.Circulatory System Diseases390 - 4591,387
8.Respiratory System Diseases460 - 5191,785
9.Digestive System Diseases520 - 579632
10.Genitourinary System Diseases580 - 629648
11.Pregnancy, Childbirth & the Puerperium630 - 6774
12.Skin and Subcutaneous Tissue Diseases680 - 7091,208
13.Musculoskeletal System and Connective Tissue Diseases710 - 7392,488
14.Congenital Anomalies740 - 75923
15.Certain Conditions Originating in the Perinatal Period760 - 779144
16.Symptoms, Signs, and Ill-defined Conditions780 - 7991,457
17.Injury and Poisoning800 - 999717
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V833,062
19.Dental Diagnosis0
20.Family Planning S-Codes598
21.Other0
25.Total25,324
Section 5 - Encounters By Principal Service
Encounters by Principal Service
Classify each encounter by the primary CPT code that was reported on the billing document for this encounter. Do not report secondary procedures. There should be one and only one procedure code reported for each encounter.
Line
No.		Evaluation and Management ServicesCPT Codes - 2004(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 992051,882
2.Evaluation and Management (established patient)99211 - 9921511,926
3.Hospital Related Services99217 – 99223
99231 - 99239		825
4.Consultations99241 - 99275104
5.Other Evaluation and Management Services99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99456
99499		81
6.Nursing Facility Related Services99301 - 9931631
7.Case Management Services99361 - 993735,411
8.Preventive Medicine (infant, child, adolescent)99381 - 99384
99391 - 99394
99431 - 99440		297
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		518
10.Counseling99401 - 994120
All Other Services
11.Anesthesia00100 – 01999
99100
99116
99135
99140		0
12.Integumentary System10021 - 19499309
13.Musculoskeletal System20000 - 2999981
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 4999918
19.Urinary System50010 - 538991
20.Male Genital System54000 - 558997
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 5899950
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649992
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 6999082
28.Radiology70010 - 799990
29.Pathology / Laboratory80048 – 893560
30.Medicine - Special Services90281 – 99091
99141 – 99199		3,692
31.Family Planning "Z" Codes"Z" codes7
32.Dental Encountersall CDT codes0
33.Category III Codes0001T - 0074T0
44.Any other encounters0
45.Total25,324
Selected Procedure Code
Report the number of procedures for each code (or range of codes) regardless of whether it is the primary or subsequent procedure code.
Line
No.		Evaluation and Management ServicesCPT Codes - 2004(1)
# of
Procedures
50.Mammogram76082 – 76083
76090 - 76092		0
51.HIV Testing86689
86701 - 86703
87390 - 87391		292
52.Pap Smear88141 - 88155
88164 - 88167
88174 - 88175		522
53.Contraceptive Management11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611		0
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90700 – 90701
90718		262
61.Hemophilus Influenza B (Hib)90645 - 9064823
62.Hepatitis A90632 – 90634
90636		265
63.Hepatitis B90740 - 90747272
64.HepB and Hib9074840
65.Influenza Virus Vaccine90655 – 90658
90660		323
66.Measles, Mumps and Rubella (MMR)9070772
67.Pneumococcal90669165
68.Poliovirus90712 - 9071386
69.Varicella9071651
Section 6 - Revenue and Utilization by Payer
Line
No.		(1)
Medicare		(2)
Medicare
Managed		(3)
Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Healthy
Families
1.Encounters6,48207,38902,317109
2.Gross Revenue
(Charges at 100% Rate)		$579,116$681,109$217,833$12,176
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments-$49,255-$242,337-$80,704$4,477
6.Bad Debts
7.Grants
enter positive numbers		( )( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		-$49,255$0-$242,337$0-$80,704$4,477
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$628,371$0$923,446$0$298,537$7,699
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters2,5394,126011401,761
2.Gross Revenue
(Charges at 100% Rate)		$165,120$291,531$14,732$169,100
3.Sliding Fee Scale
Write-offs		$150,450$93,687
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$62,009$6,920$21,132
6.Bad Debts$11,069
7.Grants
enter positive numbers		( )( )( )( )( $125,912 )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$62,009$161,519$0$6,920$0-$11,093
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$103,111$130,012$0$7,812$0$180,193
*  These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program
Line
No.		(13)
Family
PACT		(14)
San Diego
Med Plan		(15)
LA - PPP		(16)
Alameda
Alliance		(17)
Other
County		(18)
All Other
Payers
1.Encounters48700000
2.Gross Revenue
(Charges at 100% Rate)		$56,722
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$37,877
6.Bad Debts
7.Grants
enter positive numbers		( )( )( )( )( )( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$37,877$0$0$0$0$0
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$18,845$0$0$0$0$0
Line
No.		(19)
Grand Totals
1.Encounters25,324
2.Gross Revenue
(Charges at 100% Rate)		$2,187,439
3.Sliding Fee Scale Write-offs$244,137
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments-$239,881
6.Bad Debts$11,069
7.Grants, enter positive numbers( $125,912 )
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		-$110,587
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$2,298,026
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$2,187,439
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)-$110,587
3.Net Patient Revenue (from Sec 6, line 15, column 19)$2,298,026
Other Operating Revenue
4.Federal Funds$463,271
5.State Funds$30,343
6.County Funds
7.Local (City or District) Funds$26,819
8.Private$83,875
9.Donations/Contributions$41
19.Other$50,695
20.Total Other Operating Revenue (Sum Lines 4 through 19)$655,044
25.Total Operating Revenue (Line 3 + Line 20)$2,953,070

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits$2,207,248
31.Contract Services - Professional$6,054
32.Supplies - Medical and Dental$142,899
33.Supplies - Office$44,298
34.Outside Patient Care Services
35.Rent / Depreciation / Mortgage Interest$104,480
36.Utilities$62,874
37.Professional Liability Insurance$14,524
38.Other Insurance$10,030
39.Continuing Education$25,901
44.All Other Expenses$230,117
45.Total Operating Expenses (Sum Lines 30 through 44)$2,848,425
50.Net from Operations (Line 25 - Line 45)$104,645
Section 8 - Major Capital Expenditures
Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."
Diagnostic and Therapeutic Equipment Acquired During The Report Period
1.Did your clinic acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000?
(If 'Yes', fill out lines 2 through 11, as necessary, below.)		No
Diagnostic and Therapeutic Equipment Detail
Line
No.		(1)
Description of Equipment		(2)
Value		(3)
Date of Aquisition
MM/DD/YYYY		(4)
Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Building Projects Commenced During Report Period Costing Over $1,000,000
Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."
25.Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000?
(If 'Yes', fill out lines 26 through 30, as necessary, below.)		No
Detail of Capital Expenditures
Line
No.		(1)
Description of Project		(2)
Projected Total Capital Expenditure		(3)
OSHPD Project No. (if applicable)
26.
27.
28.
29.
30.
Capital Fund
Line
No.		Capital Fund(1)
40.Beginning Fund Balance
41.Current Year Contribution
42.Current Year Interest Earnings
43.Current Year Expenditures
44.Ending Fund Balance
(Line 40 + Line 41 + Line 42 - Line 43)		$0
General Comments:
Errors and Warnings