Annual Utilization Report of Primary Care Clinic
Facility Name:ST. JOSEPH MOBILE HEALTH CLINIC
OSHPD ID:306494084Report Status:Submitted
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:ST. JOSEPH MOBILE HEALTH CLINIC
2.OSHPD ID Number:306494084
3.Street Address:751 LOMBARDI COURT
4.City:SANTA ROSA
5.Zip:95405
6.Facility Phone No.:(707) 524 - 2477 ext.
7.Administrator Name:Kathy Ficco
8.Administrator E-mail Address:pckf@srm.stjoe.org
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:Santa Rosa Memorial Hospital
13.Corporate Business Address:1165 Montgomery Drive
14.City:Santa Rosa
15.State:CA
16.Zip:95405 -
17.Person Completing Report:Kathy Ficco
18.Phone No.:707-546-5899
19.Fax No.:707-524-2473
20.E-mail Address:pckf@srm.stjoe.org
30.Submitted by:2b443cd8
31.Submitted Date and Time:1/25/2005 4:15:01 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:Neither
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 NutritionYes
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachYes
19.Social ServicesYes
20.Substance AbuseNo
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.HmongNoNo
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):95%
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.Physicians0.200.000.000.2090
61.Physician Assistants0.000
62.Family Nurse Practitioners1.400.000.001.402,088
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.000
66.Registered Dental Hygienists0.000
67.Psychiatrist0.000
68.Clinical Psychologist0.000
69.Licensed Clinical Social Worker (LCSW)0.000
70.Marriage, Family and Child Counselors (MFCC)0.350.35318
71.Other Profiders billable to Medi-Cal**0.000
74.Other Certified CPSP prividers not listed above***0.000
75.Subtotal1.600.350.001.952,496
** 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 Nurses0.100.10130
82.Licensed Vocational Nurses0.000
83.Non-Licensed Patient Education Staff0.400.40589
89.Other Providers not listed above0.000
90.Subtotal0.400.000.100.50719
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)1,091
2.Black2
3.Native American / Alaskan Native2
4.Asian / Pacific Islander0
9.Other / Unknown168
10.Total Patients *1,263
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic1,201
12.Non-Hispanic57
13.Unknown5
15.Total Patients *1,263

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%1,029
21.100 - 200%186
22.Above 200%5
23.Unknown43
24.Total Patients *1,263
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients88
31.Total Encounters88
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year813
41.1 - 4 years117104
42.5 - 12 years153156
43.13 - 14 years3524
44.15 - 19 years5265
45.20 - 34 years59137
46.35 - 44 years25127
47.45 - 64 years32136
48.65 and over416
55.Total Patients *485778
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare0
61.Medicare - Managed Care0
62.Medi-Cal199
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP2
65.Healthy Families53
66.Private Insurance8
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee955
71.Free46
74.All Other Payers0
75.Total Patients *1,263
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP30
81.CHDP305
82.EAPC0
83.Family PACT32
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)367
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments324
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 - 13967
2.Neoplasms140 - 2392
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 279157
4.Blood and Blood Forming Disorders280 - 28936
5.Mental Disorders290 - 31967
6.Nervous System and Sense Organs Diseases320 - 389150
7.Circulatory System Diseases390 - 45952
8.Respiratory System Diseases460 - 519466
9.Digestive System Diseases520 - 579104
10.Genitourinary System Diseases580 - 629132
11.Pregnancy, Childbirth & the Puerperium630 - 6773
12.Skin and Subcutaneous Tissue Diseases680 - 70999
13.Musculoskeletal System and Connective Tissue Diseases710 - 73982
14.Congenital Anomalies740 - 75913
15.Certain Conditions Originating in the Perinatal Period760 - 7790
16.Symptoms, Signs, and Ill-defined Conditions780 - 799208
17.Injury and Poisoning800 - 99927
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V83820
19.Dental Diagnosis0
20.Family Planning S-Codes11
21.Other0
25.Total2,496
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 - 99205509
2.Evaluation and Management (established patient)99211 - 992151,190
3.Hospital Related Services99217 – 99223
99231 - 99239		0
4.Consultations99241 - 992750
5.Other Evaluation and Management Services99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99456
99499		0
6.Nursing Facility Related Services99301 - 993160
7.Case Management Services99361 - 993730
8.Preventive Medicine (infant, child, adolescent)99381 - 99384
99391 - 99394
99431 - 99440		324
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		100
10.Counseling99401 - 99412108
All Other Services
11.Anesthesia00100 – 01999
99100
99116
99135
99140		0
12.Integumentary System10021 - 194991
13.Musculoskeletal System20000 - 299990
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 - 538990
20.Male Genital System54000 - 558990
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589990
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699908
28.Radiology70010 - 799990
29.Pathology / Laboratory80048 – 89356210
30.Medicine - Special Services90281 – 99091
99141 – 99199		37
31.Family Planning "Z" Codes"Z" codes9
32.Dental Encountersall CDT codes0
33.Category III Codes0001T - 0074T0
44.Any other encounters0
45.Total2,496
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		0
52.Pap Smear88141 - 88155
88164 - 88167
88174 - 88175		50
53.Contraceptive Management11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611		0
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90700 – 90701
90718		157
61.Hemophilus Influenza B (Hib)90645 - 9064834
62.Hepatitis A90632 – 90634
90636		202
63.Hepatitis B90740 - 9074713
64.HepB and Hib90748149
65.Influenza Virus Vaccine90655 – 90658
90660		65
66.Measles, Mumps and Rubella (MMR)90707106
67.Pneumococcal9066937
68.Poliovirus90712 - 90713108
69.Varicella9071645
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.Encounters0039303105
2.Gross Revenue
(Charges at 100% Rate)		$0$0$42,837$0$327$11,445
3.Sliding Fee Scale
Write-offs		$0$0$0$0$0$0
4.Free/Complimentary
Write-offs		$0$0$0$0$0$0
5.Contractual Adjustments$0$0$31,604$0$175$7,417
6.Bad Debts$0$0$0$0$0$0
7.Grants
enter positive numbers		( $0 )( $0 )
8.Other Adjustments$0$0$0$0$0$0
9.Reconciliation$0$0$0$0$0$0
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$0$31,604$0$175$7,417
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$0$0$11,233$0$152$4,028
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters161,53358303240
2.Gross Revenue
(Charges at 100% Rate)		$1,744$167,097$6,322$3,270$35,316$0
3.Sliding Fee Scale
Write-offs		$0$159,935$0$0$0
4.Free/Complimentary
Write-offs		$0$0$6,322$0$0$0
5.Contractual Adjustments$1,130$0$2,412$9,907$0
6.Bad Debts$0$0$0$0$0
7.Grants
enter positive numbers		( $0 )( $0 )( $0 )( $0 )( $0 )
8.Other Adjustments$0$0$0$0$0
9.Reconciliation$0$0$0$0$0
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$1,130$159,935$6,322$2,412$9,907$0
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$614$7,162$0$858$25,409$0
*  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.Encounters3400000
2.Gross Revenue
(Charges at 100% Rate)		$3,706$0$0$0$0$0
3.Sliding Fee Scale
Write-offs		$0$0$0$0$0$0
4.Free/Complimentary
Write-offs		$0$0$0$0$0$0
5.Contractual Adjustments$2,734$0$0$0$0$0
6.Bad Debts$0$0$0$0$0$0
7.Grants
enter positive numbers		( $0 )( $0 )( $0 )( $0 )( $0 )( $0 )
8.Other Adjustments$0$0$0$0$0$0
9.Reconciliation$0$0$0$0$0$0
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$2,734$0$0$0$0$0
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$972$0$0$0$0$0
Line
No.		(19)
Grand Totals
1.Encounters2,496
2.Gross Revenue
(Charges at 100% Rate)		$272,064
3.Sliding Fee Scale Write-offs$159,935
4.Free/Complimentary Write-offs$6,322
5.Contractual Adjustments$55,379
6.Bad Debts$0
7.Grants, enter positive numbers( $0 )
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$221,636
15.Net Patient Revenue (collected)
(line 2 – Line 10)		$50,428
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$272,064
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$221,636
3.Net Patient Revenue (from Sec 6, line 15, column 19)$50,428
Other Operating Revenue
4.Federal Funds$0
5.State Funds$0
6.County Funds$0
7.Local (City or District) Funds$0
8.Private$70,010
9.Donations/Contributions$25,485
19.Other$213,852
20.Total Other Operating Revenue (Sum Lines 4 through 19)$309,347
25.Total Operating Revenue (Line 3 + Line 20)$359,775

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits$286,154
31.Contract Services - Professional$11,517
32.Supplies - Medical and Dental$34,199
33.Supplies - Office$4,042
34.Outside Patient Care Services$0
35.Rent / Depreciation / Mortgage Interest$1,800
36.Utilities$0
37.Professional Liability Insurance$0
38.Other Insurance$0
39.Continuing Education$1,413
44.All Other Expenses$20,651
45.Total Operating Expenses (Sum Lines 30 through 44)$359,776
50.Net from Operations (Line 25 - Line 45)-$1
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$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