Summary

The physical and mental rigors associated with military service take their toll on the men and women who defend the country, the families that support them, and those who have retired from active duty. The responsibility for providing health care to that population rests with TRICARE. TRICARE is an integrated, single-payer health-services provider that combines the health-care resources of military treatment facilities with networks of civilian health-care professionals, medical facilities, and suppliers.

TRICARE’s beneficiary population is large and diverse. As of 2009, it encompassed some 9.5 million people in the United States and abroad. Only about 20% are active-duty members of the armed forces or activated members of the National Guard or Reserves; the remainder are family members of those groups (26%) and retirees and their families (54%). Almost half are female. The population spans a range of ages: 21% are under 18 years old, and 20% are over 64 years old.

The mental health–care needs of that population are equally large and diverse. Warfighters are vulnerable to a variety of complex and sometimes difficult-to-diagnosis conditions, including posttraumatic stress disorder and traumatic brain injury. Stresses resulting from multiple and long deployments put military families at risk for marital conflict, intimate-partner violence, and behavioral disturbances in children. Age-related changes in health and personal circumstances open retirees to depression.



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Summary T he physical and mental rigors associated with military service take their toll on the men and women who defend the country, the families that support them, and those who have retired from active duty. The responsibility for providing health care to that population rests with TRICARE. TRICARE is an integrated, single- payer health-services provider that combines the health-care resources of military treatment facilities with networks of civilian health-care profes- sionals, medical facilities, and suppliers. TRICARE’s beneficiary population is large and diverse. As of 2009, it encompassed some 9.5 million people in the United States and abroad. Only about 20% are active-duty members of the armed forces or activated members of the National Guard or Reserves; the remainder are family members of those groups (26%) and retirees and their families (54%). Almost half are female. The population spans a range of ages: 21% are under 18 years old, and 20% are over 64 years old. The mental health–care needs of that population are equally large and diverse. Warfighters are vulnerable to a variety of complex and sometimes difficult-to-diagnosis conditions, including posttraumatic stress disorder and traumatic brain injury. Stresses resulting from mul- tiple and long deployments put military families at risk for marital con- flict, intimate-partner violence, and behavioral disturbances in children. Age-related changes in health and personal circumstances open retirees to depression. 

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Those needs are met by a set of professionals who have different education, training, and expertise. Among them are mental health coun- selors, who—like clinical social workers, marriage and family therapists, and psychiatric nurse specialists—typically hold master’s degrees and are obligated by state licensure and other requirements to have demon- strated clinical experience in order to practice. They provide services to individuals and groups through psychotherapy,1 behavior modification, and other systematic intervention strategies. Federal code and TRICARE policy require counselors2 to deliver services subject to a physician’s referral and supervision for them to be eligible for reimbursement. That distinguishes counselors from some other providers. INTENT AND gOALS OF THE STuDY In 2008, Congress directed the Department of Defense (DOD) to ask the Institute of Medicine (IOM) to conduct a study of the creden- tials, preparation, and training of people who were practicing as licensed mental health counselors and to make recommendations for permit- ting these counselors to practice independently under the TRICARE program. In response, IOM formed and convened the Committee on the Qualifications of Professionals Providing Mental Health Counseling Services Under TRICARE. In TRICARE, independent practice frees providers from require- ments that state that a beneficiary must be “referred for therapy by a physician” and that the referring physician “must actually see the patient to evaluate and diagnose the condition to be treated prior to referring the beneficiary” and provide “ongoing oversight of the course of referral related treatment throughout the period during which the beneficiary is being treated,” including “ongoing communication between the This report uses the term psychotherapy interchangeably with counseling, following the 1 convention applied by most of the literature. Some sources differentiate between the two, however, and definitions are provided where needed. This report uses the term counselors to identify persons who are more formally referred 2 to as mental health counselors or professional counselors. The education, training, licensing, and certification requirements for counselors are addressed in Chapter 3. This chapter also differentiates the requirements for counselors from those applied to other mental health professionals.

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 SUMMARy referring and treating provider” (32 CFR § 199.6). TRICARE recog- nizes psychiatrists and other physicians, clinical psychologists, certified psychiatric nurse specialists, clinical social workers, and certified mar- riage and family therapists working under a participation agreement as independent providers of mental health services. DOD provided the committee with a statement of task that requested assessments of the educational, licensing, and clinical- experience requirements imposed on mental health counselors and the extent to which they are authorized to practice independently under other federal health-care programs. The statement of task also asked for a review of the history of regulations under which mental health–care providers are recognized under TRICARE, data on the percentage of patients under the care of counselors, and a review of studies of the comparative outcomes and effectiveness of care provided by counselors. Finally, it requested that the committee offer conclusions and recom- mendations for permitting counselors to practice independently under TRICARE, including any limitations on that practice. DOD did not ask for an analysis of and the committee did not address issues surrounding access to mental health care. REPORT SYNOPSIS Mental Health Issues in the TRICARE Beneficiary Population The committee’s statement of task identified a set of illnesses for attention in assessing the education, licensure, and clinical experience of and the quality and effectiveness of care provided by counselors: • Major depressive disorder; • Schizophrenia; • Posttraumatic stress disorder; • Bipolar disorder; • Mental disorders due to a general medical condition; • Somatoform disorders; and • Delirium, dementia, amnestic, substance-use, and other dis- orders regularly associated with head trauma. Those illnesses may be caused or exacerbated by physical and psychological exposures related to military service. They present chal-

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE lenges for all health professionals. Their diagnosis may be difficult because of overlapping symptoms between multiple distinct mental health disorders or between mental and general health disorders. Treatment in some cases entails pharmacologic and other medical interventions—which are outside the ambit of counselors, marriage and family therapists, clinical social workers, and, in some circumstances, other nonphysician practitioners—rather than or in addition to psycho- logical care. For such conditions as bipolar disorder or schizophrenia, for example, evidence-based practice recommends that patients receive medication to minimize symptoms or prevent repeated episodes of ill- ness. For other conditions—such as major depression, substance-use disorders, and anxiety disorders—medications can be efficacious, but patients with symptoms or exacerbations may also be adequately treated with psychosocial interventions alone. Often, patients can benefit from a combination of medications and psychosocial treatment. The com- mittee noted that evidence-based psychosocial interventions exist for schizophrenia and for major depressive, acute stress, posttraumatic stress, bipolar, substance-use, generalized anxiety, obsessive-compulsive, and panic disorders. The committee’s research also found other disorders that TRICARE beneficiaries are at special risk for. These psychosocial problems—which include issues related to interpersonal relationships, behavior, and stress—fall more directly in counseling’s primary focus on promoting coping and facilitating growth related to life-cycle transitions. The diversity and the diagnostic and treatment complexity of the mental health illnesses found in the beneficiary population highlight the need for a comprehensive approach to quality management in care delivery in the TRICARE system. Education, Licensing, and Clinical-Experience Requirements The statement of task requested the committee to perform assess- ments of the educational, licensure, and clinical-experience requirements imposed on counselors. Those requirements are essential components of a credentialing system that helps to establish whether a professional is prepared to practice. They are also components of a system of quality management for a care provider. The field of counseling comprises several specialties in educational and career guidance and clinical care. Educational requirements for

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 SUMMARy graduate programs in mental health counseling vary by institution. Admission requirements include a bachelor’s degree and some combi- nation of a minimum grade-point average and standardized test scores, successful completion of relevant preparatory coursework, letters of rec- ommendation, personal interviews, and evidence of interest in the field as demonstrated by volunteer work and the like. Graduation require- ments typically mirror a state’s requirements to apply for entry-level licensure as a mental health counselor. They include successful comple- tion of core curricula and a minimum number of course, practicum, and related training and experience hours. Some graduate programs in mental health counseling are accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP), an independent agency created by the profession. The educational requirements and curricula for mental health coun- selors who graduated from institutions that are CACREP-accredited in mental health counseling or clinical mental health counseling (after July 1, 2009) contain elements relevant to preparing counselors to serve as independent practitioners and to diagnose and treat for disorders that may be found in the TRICARE beneficiary population. These include knowledge—and the skills and practices needed to implement knowledge—of • The etiology, diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders. • The principles of the diagnostic process, including differential diagnosis, and the use of current diagnostic tools, such as the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). • Evidence-based treatments and basic strategies for evaluat- ing counseling outcomes in clinical mental health counseling (CACREP, 2009). Licensure requirements for mental health counselors vary by state. In general, they comprise • A master’s degree or higher degree in mental health counseling or sometimes a related field. • A minimum number of semester hours of coursework—either 48 or 60.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE • Adherence to a state or national organization’s code of ethics or conduct. • A number of hours of supervised and total professional experience. • Passage of one or more examinations of professional competence. Some states require a minimum number of hours of patient contact or continuing education per year for license renewal. There are consider- able differences among the states in the details of the requirements. Typi- cally, only those in higher or the highest licensure level for a state may diagnose and treat patients independently. Codes of ethics or conduct and in some cases state laws require counselors to provide services only within their competencies and scope of practice, to diagnose properly, to educate themselves in and apply scientifically based treatment modali- ties, and to appropriately refer patients who present with problems outside their competencies and scope of practice. Two examinations are commonly used to assess fitness for licensure. The more rigorous, the National Clinical Mental Health Counselor Examination (NCMHCE), comprises clinical simulations that span the diverse characteristics of the TRICARE beneficiary population. The NCMHCE requires experience and competencies that are desirable in persons who serve as independent practitioners and diagnose and treat for mental and substance-use (M/SU) disorders that may be found in the TRICARE beneficiary population. TRICARE’s clinical-experience requirements for licensed counsel- ors comprise “two years of post-masters experience which includes 3000 hours of clinical work and 100 hours of face-to-face supervision” [32 CFR § 199.6(c)(3)(iv)(C)()]. The requirements mirror those specified for a person holding certification as a Certified Clinical Mental Health Counselor, a voluntary credential administered by a professional organi- zation of counselors, and they are similar to those imposed by states for the higher or highest level of licensure as a mental health counselor. The research reviewed by the committee indicates that—although education, licensing, and clinical-experience requirements play roles in a system of quality management—there is no information that would allow one to determine whether a particular education level, licensure, or amount of clinical experience is needed to serve effectively as an inde- pendent practitioner or to establish whether a practitioner is adequately

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 SUMMARy prepared to diagnose and treat disorders that may be found in the TRICARE beneficiary population. In general, the training of the mental health practitioners varies, and fulfillment of education, licensure, and clinical-experience requirements does not ensure exposure to particular disorders or competence in treating for them. Independent and Supervised Practice of Counselors in Other Health-Care Systems The statement of task asked the committee to assess the extent to which counselors practice independently in other settings and to review the history of the regulation of mental health–care providers by TRICARE. Programs such as Medicare, those administered by the Department of Veterans Affairs, the Indian Health Service, and Head Start, and those provided under the Federal Employee Health Benefits Program and by private insurers exhibit no consistent pattern in their policies regarding the independent practice of counselors. The policies are by and large driven by federal, state, and tribal laws and regulations and by institutional practice. In the case of private insurers, recognition of members of particular professions as independent practitioners for the purpose of billing is sometimes determined by the organization that contracts for coverage. A historical review of the regulations prescribed by DOD regarding the recognition of mental health providers as independent practitioners indicates that policy is driven primarily by congressional mandate. In the one circumstance in which members of a nondoctoral-level mental health profession (clinical social workers) were granted independent- practice authority by both TRICARE and Medicare, the profession was granted authority under TRICARE before Medicare. Congress directed that the authority be granted in both circumstances. No conclusions relevant to the topic of the independent practice of counselors under TRICARE can be drawn from the experience of other federal programs or of private insurers. Clinical Exposure and Capability Studies The committee could not identify any published data regarding the number or proportion of patients who had particular mental health

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE disorders that were under the care of counselors. TRICARE provided some data in response to a request from the committee, which are pre- sented in Table 2.16. As the text accompanying the table notes, the data are of limited usefulness. Generally, the committee believes that such information would not answer the question of whether or under what circumstances counselors should be permitted to provide independent services under TRICARE inasmuch as it does not address the quality of care or the ability of counselors to provide high-quality care. The committee sought to identify outcome studies and literature regarding the comparative quality and effectiveness of care provided by licensed mental health counselors. It found that a number of meta- analyses and reviews had examined psychotherapy and counseling effectiveness, but they do not provide evidence on the comparative effectiveness of treatment by different types of mental health–care pro- viders. Arguments of differential effectiveness by mental health–care provider type are generally not based on empirical evidence but are instead based on anecdotal information or supposition. Research sug- gests that experience may have a favorable effect on diagnostic accuracy, but it has consistently demonstrated that the variance observed in treat- ment outcomes is primarily the result of variance in the effectiveness of individual therapists. Research Regarding Quality of Care Available information indicates that supervision of counselors under TRICARE’s current requirements is “highly varied” and that “compliance with the supervision requirement [is] more of a formality than a valuable exercise” (Meredith et al., 2005). A 2006 DOD report to Congress indicated that physician oversight of counselors’ clinical work “occurs predominantly on paper” and “is difficult to ensure to any great degree” (DOD, 2006). The analyses suggest that supervision requirements neither affect quality of care nor add to the protection of beneficiaries. An earlier IOM report (2006) indicated that there are serious defi- ciencies in the health and behavioral health infrastructure that affect quality of care. It found that the education of all health professionals was lacking. The report specifically noted that “not all M/SU clinicians are educated about evidence-based care or receive training in the use of evidence-based clinical practice guidelines” and “quality improvement

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 SUMMARy strategies have received little attention in M/SU education.” It identified a need for an infrastructure to collect and disseminate the new knowl- edge and clinical information required to deliver high-quality patient care and to facilitate quality-measurement and quality-improvement activities. DOD’s Mental Health Task Force also identified problems in the military’s system of care, finding that “the TRICARE network benefit for psychological health is hindered by fragmented rules and policies” and that “there are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effective- ness” (DOD, 2007). Care providers, including the Military Health System (MHS), use delineated scopes of practice and privileging of individual practitioners to ensure that all health professionals deliver the services that they have demonstrated competence in. Previous IOM reports in the Quality Chasm series indicate that the best way for health-care providers like TRICARE to achieve the delivery of high-quality care to their benefi- ciaries is through appropriate standards of education and training for providers, promotion of evidence-based care standards, and monitoring of results (IOM, 2001, 2006). Overall Conclusions and Recommendations Education, accreditation, licensure, certification, and clinical- experience requirements for mental health professionals are com - ponents of a quality-management system. However, they have little specificity with regard to knowledge of and experience with particular health problems or evidence-based practices. That generally limits the confidence that can be placed in the preparation of any of these professionals to diagnose and treat disorders that may be found in the TRICARE beneficiary population. Research regarding the quality of care for M/SU conditions indicates that there are widespread deficien- cies in the training of providers and in the infrastructure that supports their practice. The committee did not identify any evidence that distinguishes mental health counselors from other classes of practitioners in ability to serve in an independent professional capacity or to provide high- quality care consistent with education, licensure, and clinical expe- rience. Its research instead points to the need for a comprehensive

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE quality-management system that facilitates the proper diagnosis of and treatment for disorders in the TRICARE beneficiary population by all mental health practitioners. The committee was tasked to offer conclusions and recommendations for permitting licensed mental health counselors to practice independently under the TRICARE program, including recommendations regarding modifications of current policy for the TRICARE program with respect to allowing licensed mental health counselors to practice independently in the TRICARE program, paying particular attention to the prepared- ness of licensed mental health counselors to diagnose, treat, and appropriately refer persons with disorders of particular importance to TRICARE beneficiaries. In light of the information that it gathered and reviewed, it recom- mends that TRICARE replace its current quality management system for oversight of the practice of counselors through physician referral and supervision with a mental health quality monitoring and management system that incorporates the following two primary elements: [1] Independent practice of mental health counselors in TRICARE in the circumstances in which their education, licensure, and clini- cal experience have helped to prepare them to diagnose and, where appropriate, treat conditions in the beneficiary population. Those circumstances comprise • A master’s or higher-level degree in counseling from a program in mental health counseling or clinical mental health counseling that is accredited by CACREP. • A state license in mental health counseling at the “clinical” or the higher or highest level available in states that have tiered licensing schemes. • Passage of the NCMHCE. • A well-defined scope of practice for practitioners. The scope of practice should be based on a systematic assessment of the professional and cultural competencies necessary to address the mental and behavioral health needs of the TRICARE beneficiary population and should include the types of patients that can be seen, the settings

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 SUMMARy in which they can be seen, and the interventions and populations (including pediatric, adolescent, and geriatric) that the practitioner has demonstrated competency in. The committee believes that it is important to maintain continu- ity of care for TRICARE beneficiaries who are receiving services from counselors under the current system. It therefore recommends that TRICARE institute a strategy that allows for the continuing service of practitioners who did not graduate from CACREP-accredited pro- grams,3 have not attained “clinical” or similar licensure, or have not successfully completed the NCMHCE. TRICARE may, for example, wish to conduct supervision of such professionals by using a model pat- terned after Army Regulation 40–68, Sections 7–6c and d (Appendix E), which provides for successively greater levels of independent practice as experience and demonstrated competence increase. [2] A comprehensive quality-management system for all mental health professionals. This system should include • Well-defined scopes of practice and clinical privileging of all mental health–care providers in the direct and purchased-care systems that are consistent with professional education, training, and experience, where these scopes are not already present. • Promotion of evidence-based practices for treatment of condi- tions and monitoring of results. • Focused training in the particular mental and related general medical conditions that are present in the TRICARE beneficiary population and in military cultural competence. • A systematic process for continued professional education and training to ensure continuing improvement in the clinical evi- dence base and accommodation of the changing needs of the TRICARE population. • Development and application of quality measures to assess the performance of providers. Some current counselors may have graduated from programs accredited by the Council 3 on Rehabilitation Education, later gained clinical experience and earned licensure in mental health counseling, and be practicing as counselors. The committee does not intend to exclude such persons from practicing in the TRICARE system.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE • Systematic monitoring of the process and outcomes of care at all levels of the health-care system and application of effective quality-improvement strategies. The committee notes that the recommendations regarding evidence-based practices, training and education, quality measures, and monitoring echo the observations offered by the DOD Task Force on Mental Health (DOD, 2007). DOD publications and public pronouncements (Casscells, 2008; DOD, 2008) indicate that MHS is already pursuing these recommendations as part of its efforts to implement best practices in quality management. For example, the DOD Center for Deployment Psychology (CDP) is currently offer- ing courses on military cultural competence to TRICARE personnel and other MHS practitioners (CDP, 2009). In April 2010, CDP will initiate a military and veteran behavioral health post-master’s certifi- cate program that will “teach best clinical practices to mental health professionals who are addressing the behavioral health needs of military personnel, veterans and their families” and include training in military culture, combat trauma, suicidal risk, and blast-related traumatic brain injury (TBI) (CDP, 2010). The committee believes that the framework necessary to support the independent practice of counselors under the circumstances delineated above is thus already being put into place, that TRICARE should be able to implement the recommended policy changes in a timely manner, and that it should do so because of the critical mental health needs in its beneficiary population. As a step toward achieving the comprehensive system recommended here, the TRICARE Management Activity should consider requiring that orga- nizations demonstrate that they have mechanisms in place to promote the delivery of evidence-based care, to apply quality measures to assess the performance of providers, to monitor outcomes, and to implement improvement strategies as a condition of their provider contracts. The committee observes that the barriers to establishing a robust quality infrastructure for mental health care are common to all provid- ers and suggests that TRICARE may benefit from working with other government organizations—such as the Department of Veterans Affairs and the Department of Health and Human Services’ Agency for Health- care Research and Quality, Centers for Medicare and Medicaid Services, National Institutes of Health, and Substance Abuse and Mental Health

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 SUMMARy Services Administration—to conduct or support research to overcome the barriers. REFERENCES CACREP (Council for Accreditation of Counseling and Related Educational Programs). 2009. CACREP accreditation manual. 00 standards. Alexandria, VA: Council for Accreditation of Counseling and Related Educational Programs. Casscells SW. 2008. Statement on mental health by the Honorable S. Ward Casscells, MD. Assis- tant Secretary of Defense for Health Affairs, before the Subcommittee on Military Personnel of the Armed Services Committee, U.S. House of Representatives, March 14. http://www. dod.mil/dodgc/olc/docs/testCasscells080314.pdf. (Accessed October 9, 2009). CDP (Center for Deployment Psychology, Department of Defense). 2009. Welcome to the Center for Deployment Psychology. http://www.deploymentpsych.org/. (Accessed 22 December 2009). CDP. 2010. Military and veteran behavioral health post-master’s certificate program. http:// postgraduatecenter.org/MVBH%20Certificate.html. (Accessed January 15, 2010). DOD (Department of Defense). 2006. Aspects of the use of licensed professional counselors in the Military Health System. Report to Congress. Transmittal letter, August 28. http://www. tricare.mil/planning/congress/downloads/2006/new/Licensed-Mental.pdf. (Accessed October 20, 2009). DOD. 2007. An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board. www.health.mil/dhb/mhtf/ MHTF-Report-Final.pdf. (Accessed October 27, 2009). DOD. 2008. The Military Health System strategic plan. A roadmap for medical transformation. http://www.health.mil/StrategicPlan/2008%20Strat%20Plan%20Final%20-lowres. pdf. (Accessed October 27, 2009). IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the st century. Washington, DC: National Academy Press. IOM. 2006. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Academies Press. Meredith LS, Tanielian T, Greenberg MD, Suarez A, Eiseman E. 2005. Expanding access to mental health counselors: Evaluation of the TRICARE demonstration. Santa Monica, CA: RAND Corporation.

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