Annual Utilization Report of Primary Care Clinic
Facility Name:DEL NORTE COMMUNITY HEALTH CENTER
OSHPD ID:306084005Report Status:Submitted
License Category:Community ClinicReport Year:2011
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:DEL NORTE COMMUNITY HEALTH CENTER
2.OSHPD ID Number:306084005
3.Street Address:550 E. WASHINGTON BLVD.
STE. 100
4.City:CRESCENT CITY
5.Zip:95531
6.Facility Phone No.:(707) 465 - 6925 ext.
7.Administrator Name:Hilda Yepes Contreras
8.Administrator E-mail Address:hcontreras@opendoorhealth.com
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:1/1/2011
11.Operation Open To:12/31/2011
12.Name of Parent Corporation:Open Door Community Health Centers
13.Corporate Business Address:670 Ninth Street
14.City:Arcata
15.State:CA
16.Zip:95521 - 6249
17.Person Completing Report:Christopher Peters
18.Phone No.:707-826-8633x5132
19.Fax No.:707-826-8638
20.E-mail Address:cpeters@opendoorhealth.com
30.Submitted by:cpeters
31.Submitted Date and Time:2/8/2012 12:07:51 PM
Section 2 - Clinic Services
LICENSE CATEGORY (TYPE) (Completed by OSHPD.)
Line
No.		(1)
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health 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 EducationYes
13.Community NutritionNo
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessYes
17.LegalNo
18.OutreachYes
19.Social ServicesYes
20.Substance AbuseYes
21.TransportationNo
22.Vocational Training PlacementNo
23.OtherNo
Table 2.2 - Languages Spoken By Staff and Patients
Check the staff box if one or more of your staff members speak a 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.ChineseNoYes
34.HindustaniNoNo
35.HmongYesYes
36.JapaneseNoNo
37.KoreanNoYes
38.LaotianNoYes
39.PortugeseYesYes
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageYesNo
43.SpanishYesYes
44.TagalogYesYes
45.VietnameseNoYes
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):10%
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.Physicians4.590.010.004.6012,918
61.Physician Assistants2.320.000.002.327,669
62.Family Nurse Practitioners0.300.540.000.843,284
63.Certified Nurse Midwives0.000.000.000.000
64.Visiting Nurses0.000.000.000.000
65.Dentists2.080.000.002.088,582
66.Registered Dental Hygienists (Alternative Practice)0.000.000.000.000
67.Psychiatrists0.000.000.000.000
68.Clinical Psychologists0.930.020.000.95954
69.Licensed Clinical Social Workers (LCSW)0.000.230.000.231,239
70.Other Providers billable to Medi-Cal**0.130.000.000.130
74.Other Certified CPSP providers not listed above***0.000.000.000.000
75.Subtotal10.350.800.0011.1534,646
** Other Providers billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists and any other professionals who are 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 Clinical Support Staff
Line
No.		Clinical Support Staff(1)
Salaried
FTE's		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Hygienists (not Alternative Practice)0.770.000.000.771,120
81.Registered Dental Assistants3.960.000.003.960
82.Dental Assistants - Not licensed5.270.000.005.270
83.Marriage and Family Therapists (MFT)0.000.000.000.000
84.Registered Nurses4.220.000.004.221,439
85.Licensed Vocational Nurses3.470.000.003.470
86.Medical Assistants - Not licensed (1)10.830.000.0010.830
87.Non-Licensed Patient Education Staff0.000.000.000.000
88.Substance Abuse Counselors (2)0.000.000.000.000
89.Billing Staff (3)3.700.000.003.70
90.Other Administrative Staff (4)22.250.000.0022.25
94.Other Providers not listed above0.000.000.000.00
95.Subtotal54.470.000.0054.472,559
(1) Also includes Certified Medical Assistants
(2) Does not include substance abuse counseling performed by providers listed elsewhere
(3) Staff must spend 80% of time on billing
(4) Includes Executive Directors, CFO's, Medical & Dental Records staff, Medical & Dental Receptionists & other management staff
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)8,505
2.Black50
3.Native American / Alaskan Native113
4.Asian / Pacific Islander380
5.More than one race27
9.Other / Unknown214
10.Total Patients *9,289
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic1,195
12.Non-Hispanic8,010
13.Unknown84
15.Total Patients *9,289

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%6,670
21.100 - 200%2,011
22.Above 200%492
23.Unknown116
24.Total Patients *9,289
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
Number
30.Total Patients76
31.Total Encounters290
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year7274
41.1 - 4 years361360
42.5 - 12 years644569
43.13 - 14 years129135
44.15 - 19 years337449
45.20 - 34 years7361,096
46.35 - 44 years459554
47.45 - 64 years1,1021,380
48.65 and over332500
55.Total Patients *4,1725,117
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare1,359
61.Medicare - Managed Care0
62.Medi-Cal3,909
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP194
65.Healthy Families213
66.Private Insurance1,074
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.PACE Program0
70.Self-Pay / Sliding Fee2,540
71.Free0
74.All Other Payers0
75.Total Patients *9,289
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP108
81.CHDP29
82.EAPC
83.Family PACT419
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)556
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments978
* Totals for these tables must agree.
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 - 139916
2.Neoplasms140 - 239243
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2792,262
4.Blood and Blood Forming Disorders280 - 289166
5.Mental Disorders290 - 3194,910
6.Nervous System and Sense Organs Diseases320 - 3891,205
7.Circulatory System Diseases390 - 4591,500
8.Respiratory System Diseases460 - 5192,120
9.Digestive System Diseases, excluding dental diagnosis530 - 579576
10.Genitourinary System Diseases580 - 629716
11.Pregnancy, Childbirth & the Puerperium630 - 6797
12.Skin and Subcutaneous Tissue Diseases680 - 709816
13.Musculoskeletal System and Connective Tissue Diseases710 - 7392,779
14.Congenital Anomalies740 - 75951
15.Certain Conditions Originating in the Perinatal Period760 - 779138
16.Symptoms, Signs, and Ill-defined Conditions780 - 7992,364
17.Injury and Poisoning800 - 999755
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V915,657
19.Dental Diagnosis520-5296,501
20.Family Planning S-Codes964
21.OtherAll other codes not in lines 1-200
25.Total34,646
Section 5 - Encounters By Principal Service
Encounters by Principal Service
Classify each encounter by the principal 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.		Principal ServicesCPT Codes - 2011(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 99205932
2.Evaluation and Management (established patient)99211 - 9921519,530
3.Hospital Related Services99217 – 99226,
99231 - 99239,
99477		147
4.Consultations99241 - 99245,
99441 - 99444		2
5.Other Evaluation and Management Services99291 - 99292,
99354 - 99360,
99450, 99455 - 99456, 99499		2
6.Nursing Facility Related Services99304 - 9931837
7.Case Management Services99363 - 99364,
99366 - 99368		0
8.Preventive Medicine (infant, child, adolescent)99381 - 99384,
99391 - 99394,
99461		1,164
9.Preventive Medicine (adult)99385 - 99387,
99395 - 99397		93
10.Counseling99401 - 99404,
99406 - 99409
99411 - 99412
99420 - 99429
99605 - 99607		0
All Other Services
11.Anesthesia00100 – 01999,
99100,
99116,
99135,
99140,
99143 - 99150		0
12.Integumentary System10021 - 1949914
13.Musculoskeletal System20005 - 299996
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 499990
19.Urinary System50010 - 538991
20.Male Genital System54000 - 559202
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589999
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699791
28.Radiology70010 - 799990
29.Pathology / Laboratory80047 – 89356, 89398433
30.Medicine - Special Services90281 – 99091,
99170 – 99199		2,227
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09999,013
33.CPT Category III Codes0001T - 9999T7
44.OtherAll other codes not in lines 1-331,026
45.Total34,646
Selected Procedure Code
Report the number of procedures for each code (or range of codes) regardless of whether it is the principal or secondary procedure code.
Line
No.		Evaluation and Management ServicesCPT Codes - 2011(1)
# of
Procedures
50.Mammogram77051 – 770590
51.HIV Testing86689,
86701 - 86703,
87390 - 87391		351
52.Pap Smear88141 - 88155,
88164 - 88167,
88174 - 88175		666
53.Contraceptive Management11975 - 11977, 55250,
55300, 55400, 55450, 57170,
58300 - 58301, 58600
58605, 58611, 58670 - 58671		2,081
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90389, 90696, 90698,
90700 – 90703, 90714, 90715,
90718 - 90721, 90723		745
61.Hemophilus Influenza B (Hib)90371, 90645 - 9064826
62.Hepatitis A90632 – 90634,
90636		245
63.Hepatitis B90740, 90743 - 90744, 90746, 90747200
64.HepB and Hib907480
65.Influenza Virus Vaccine90654 – 90658,
90660 - 90668		906
66.Measles, Mumps and Rubella (MMR) and Varicella (MMRV)90704 - 90708, 90710227
67.Pneumococcal90669, 90670, 90732626
68.Poliovirus90712 - 90713134
69.Varicella90396, 90716265
Section 6 - Revenue and Utilization by Payer
Revenue and Utilization by Payment Source
(Do not put any "$" signs, commas or decimals, round up to whole dollar)
Line
No.
(1)

Medicare		(2)
Medicare
Managed
(3)

Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Healthy
Families
1.Encounters4,962015,89602,449348
2.Gross Revenue
(Charges at 100% Rate)		$647,349$0$2,545,655$0$411,447$65,444
3.Sliding Fee Scale
Write-offs		$1,233$0$705
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$58,885$0-$132,738$0$18,795$27,304
6.Bad Debts$0$0$0
7.Grants (see Section 7)
8.Other Adjustments$0$0$3,798$0$5,699$0
9.Reconciliation$8,165$0$153,901$0$0
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$68,283$0$24,961$0$24,494$28,009
15.Net Patient Revenue (collected)
(line 2 – line 10)		$579,066$0$2,520,694$0$386,953$37,435
Line
No.
(7)

Private
Insurance		(8)
Self-Pay/
Sliding Fee
(9)


Free
(10)

Breast
Cancer*
(11)


CHDP
(12)


EAPC
1.Encounters4,2894,7340153846
2.Gross Revenue
(Charges at 100% Rate)		$708,145$798,299$0$22,306$189,686
3.Sliding Fee Scale
Write-offs		$20,614$230,361
4.Free/Complimentary
Write-offs		$0
5.Contractual Adjustments$153,322$9,931$23,316
6.Bad Debts$5$0
7.Grants (see Section 7)
8.Other Adjustments$0$27,805$18$82
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$173,941$258,166$0$9,949$23,398
15.Net Patient Revenue (collected)
(line 2 – line 10)		$534,204$540,133$0$12,357$166,288
*  These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program
Line
No.
(13)

Family
PACT		(14)
PACE
Program**
(15)


LA - PPP
(16)

Alameda
Alliance
(17)

Other
County
(18)

All Other
Payers
1.Encounters96900000
2.Gross Revenue
(Charges at 100% Rate)		$174,553$0$0$0$0$0
3.Sliding Fee Scale
Write-offs		$0$0$0
4.Free/Complimentary
Write-offs		$0
5.Contractual Adjustments$46,643$0$0$0
6.Bad Debts$0$0$0
7.Grants (see Section 7)
8.Other Adjustments$0$0$0$0$0
9.Reconciliation$0$0$0$0
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$46,643$0$0$0$0$0
15.Net Patient Revenue (collected)
(line 2 – line 10)		$127,910$0$0$0$0$0
**  Report number of patients on Line 1 for the PACE Program
Line
No.		(19)
Grand Totals
1.Encounters34,646
2.Gross Revenue
(Charges at 100% Rate)		$5,562,884
3.Sliding Fee Scale Write-offs$252,913
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments$205,458
6.Bad Debts$5
7.Grants (see Section 7)
8.Other Adjustments$37,402
9.Reconciliation$162,066
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$657,844
15.Net Patient Revenue (collected)
(line 2 – line 10)		$4,905,040
Section 7 - Income Statement
Income Statement
(Do not input any "$" signs, commas or decimals, round up to whole dollar.)
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$5,562,884
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$657,844
3.Net Patient Revenue (from Sec 6, line 15, column 19)$4,905,040
Other Operating Revenue
4.Federal Funds - Grants - all others (e.g. 330 funds)$39,309
400.Federal Stimulus Grants - American Recovery and Reinvestment Act (ARRA)
401.Federal Funds - New Access Point (NAP)$0
402.Federal Funds - Increased Demand for Services (IDS)$0
403.Federal Funds - Capital Improvement Project (CIP)
5.State Funds - EAPC
6.State Funds - Other$23,706
7.County Funds - LA County Public Private Partnership$0
10.County Funds - Other County Grant Programs$2,810
11.Local (City or District) Funds$0
12.Private$559,435
13.Donations/Contributions$936
19.Other$24,161
20.Total Other Operating Revenue (Sum lines 4 through 19)$650,357
25.Total Operating Revenue (line 3 + line 20)$5,555,397
Operating Expenses
30.Salaries, Wages, and Emplyee Benefits$3,922,886
31.Contract Services - Professional$196,663
32.Supplies - Medical and Dental$387,741
33.Supplies - Office$56,724
34.Outside Patient Care Services$0
35.Rent / Depreciation / Mortgage Interest$365,921
36.Utilities$83,283
37.Professional Liability Insurance$17,346
38.Other Insurance$0
39.Continuing Education$10,628
40.Information Technology (including EHR)$159,190
44.All Other Expenses$304,470
45.Total Operating Expenses (Sum lines 30 through 44)$5,504,852
50.Net from Operations (line 25 - line 45)$50,545
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
Line
No.		(1)
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)."
Line
No.		(1)
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$0
41.Current Year Contribution$0
42.Current Year Interest Earnings$0
43.Current Year Expenditures$0
44.Ending Fund Balance
(line 40 + line 41 + line 42 - line 43)		$0
General Comments:
Errors and Warnings