1
Introduction

This chapter addresses the provision of mental health care services under TRICARE, the military’s medical services delivery system. It begins with an overview of the TRICARE program and then provides basic information on TRICARE’s mental health services and the professionals that provide them, with a focus on governing statutes and regulations. The statement of task for the Institute of Medicine (IOM) committee responsible for this report is presented next, followed by the committee’s approach to responding to it. The chapter concludes with brief summaries of related IOM reports and a description of the present report’s organization. Many of the topics touched on in this chapter are addressed in greater detail in later chapters.

TRICARE’S RESPONSIBILITIES AND STRUCTURE1

TRICARE is the US Department of Defense (DOD) health-care benefits program for all seven uniformed services—the Army, the Navy, the Marine Corps, the Air Force, the Coast Guard, the Commissioned Corps of the Public Health Service, and the Commissioned Corps of the

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General information in this section is derived from the TRICARE Beneficiary Handbook (TRICARE, 2009b) and other materials on the TRICARE Web site: http://www.tricare.mil. This chapter contains a brief summary of the information as it existed when the report was written; TRICARE sources should always be consulted for authoritative materials.



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1 Introduction T his chapter addresses the provision of mental health care services under TRICARE, the military’s medical services delivery system. It begins with an overview of the TRICARE program and then provides basic information on TRICARE’s mental health services and the professionals that provide them, with a focus on governing statutes and regulations. The statement of task for the Institute of Medicine (IOM) committee responsible for this report is presented next, followed by the committee’s approach to responding to it. The chapter concludes with brief summaries of related IOM reports and a description of the present report’s organization. Many of the topics touched on in this chapter are addressed in greater detail in later chapters. TRICARE’S RESPONSIBILITIES AND STRuCTuRE1 TRICARE is the US Department of Defense (DOD) health-care benefits program for all seven uniformed services—the Army, the Navy, the Marine Corps, the Air Force, the Coast Guard, the Commissioned Corps of the Public Health Service, and the Commissioned Corps of the General information in this section is derived from the TRICARE Beneficiary Handbook 1 (TRICARE, 2009b) and other materials on the TRICARE Web site: http://www.tricare.mil. This chapter contains a brief summary of the information as it existed when the report was written; TRICARE sources should always be consulted for authoritative materials. 

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE National Oceanic and Atmospheric Administration—and the National Guard and Reserves. It is the contemporary embodiment of a commit- ment to provide care for the country’s defense and fighting force that extends back to 1775 and has evolved to extend services to the larger military family (DOD, 2009). TRICARE had its origins in demon- stration projects and a reform initiative implemented in the 1980s in the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).2 Its integrated system grew out of what had been dispa- rate programs that provided care to active-duty personnel via military health facilities and to their dependents, retirees,3 and other eligible persons via a network of military and civilian providers. The program’s services combine the health-care resources of military treatment facilities (MTFs)—referred to as the direct-care component—with networks of civilian health-care professionals, medical facilities, and suppliers—the purchased-care component. TRICARE operates as a single-payer system and covers most inpatient and outpatient medical care that is deemed necessary by a medical professional, including emergency and urgent care, medi- cal and surgical procedures received on an inpatient basis and an outpatient basis, home health care, hospice care, clinical preventive services, maternity care, pharmacy services, and behavioral health care services (TRICARE, 2009b). The TRICARE program is managed by the TRICARE Management Activity (TMA) under the DOD assistant secretary of defense for health affairs. It is organized into six geographic health-service regions. The three regions in the United States are TRICARE North, TRICARE South, and TRICARE West; and the regions abroad are TRICARE Europe, TRICARE Latin America and Canada, and TRICARE Pacific. Each region is responsible for overseeing the administration and management of TRICARE health services, fund- ing regional initiatives to improve the delivery of health-care services, CHAMPUS is still referred to in some regulatory and policy documents that address 2 TRICARE operations. The US Office of Personnel Management offers the following somewhat circular 3 definition of a military retiree: “any member or former member of the uniformed services who is entitled, under statute, to retired, retirement, or retainer pay on account of service as a member, or who receives military retired or retainer pay” (OPM, 2009). Eligibility for retiree status is usually determined by length of service (typically, 20 years or more), although there are other circumstances in which a service member may qualify. Military retirees are a subset of military veterans.

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 InTRoDUCTIon and supporting the operations of MTFs and civilian health-care centers that deliver care to beneficiaries in their regions. In each region, a single provider is responsible for delivering purchased-care services under contract to the program. As of the middle of 2009, Health Net Federal Services managed health-care services for about 3.0 million beneficiaries in the north region, Humana Military Health- care Services for 2.9 million in the south region, and TriWest Healthcare Alliance for 2.7 million in the west region (Stars and Stripes, 2009). In July 2009, it was announced that new contracts had been awarded to Aetna Government Health Plans for the north region, UnitedHealth Military & Veterans Services for the south region, and TriWest for the west region. To access coverage, people must have their eligibility status recorded in the Defense Enrollment Eligibility Reporting System (DEERS) and have valid uniformed-services identification cards that display their eli- gibility. The two main categories of beneficiaries are sponsors and family members. Sponsors—who are active-duty service members, National Guard or Reserve members, or retirees—are automatically registered in DEERS; their dependents are not. Sponsors are responsible for ensur- ing that eligible family members are registered in DEERS for them to receive coverage. Four separate programs under TRICARE provide different options for health-care services, addressing both the diverse needs of the ben- eficiary population and participants’ preferences as to level and form of coverage. Coverage for active-duty service members, their families, and retirees under 65 years old is provided by TRICARE Prime, a managed- care option in which MTFs are the principal source of health care; TRICARE Extra, a preferred-provider option; and TRICARE Standard, a fee-for-service option. TRICARE for Life provides supplementary health-care coverage for TRICARE beneficiaries 65 years old and older who are entitled to Medicare Part A and enrolled in Medicare Part B; it offers full coverage for many services only partially covered by Medicare. All active-duty, National Guard, and Reserve service members are auto- matically enrolled in TRICARE Prime. Military dependents and retirees under 65 years old have the option of choosing from TRICARE Prime, TRICARE Extra, and TRICARE Standard. Table 1.1 lists eligible ben- eficiaries, available coverage options, and restrictions, if any, on benefits under the TRICARE program. TRICARE policies regarding providers, covered persons, and proce- dures are defined by statute as set forth in the United States Code (USC),

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 1.1 Health-Care Coverage Under TRICARE Eligible Beneficiary Coverage Options Active-duty service member TRICARE Prime Active-duty family member (includes spouses, TRICARE Prime unmarried children up to 21 years old or 23 TRICARE Extra years old if enrolled in college full-time) TRICARE Standard Uniformed-services retiree under 65 years old, eligible family members Dependent parent, parent-in-law TRICARE Plusa Active-duty service member who lives and TRICARE Prime Remote works more than 50 miles or 1 hour’s drive from a military treatment facility Family member who resides with an active- TRICARE Prime Remote for duty service member who lives and works more Active Duty Service Members than 50 miles or 1 hour’s drive from a military (TPR ADSM) treatment facility TRICARE Extra TRICARE Standard Active-duty member of the Reserves TRICARE Prime TRICARE Prime Remote Family of a Reserve member activated for more TRICARE Prime than 30 days TPRADSM TRICARE Extra TRICARE Standard Retired National Guard or Reserve member, TRICARE Prime familyb TRICARE Extra TRICARE Standard TRICARE For Life (TFL) if 65 years old or older Medicare-eligible beneficiary under 65 years old TRICARE Prime TRICARE Extra TRICARE Standard Medicare-eligible beneficiary 65 years old or TFL older Congressional Medal of Honor recipient, TRICARE Prime immediate family TRICARE Extra TRICARE Standard Unremarried former spouse of active or retired TFL (if 65 years old or older) military-service member Family of court-martialed sponsor Eligibility determined case by case Family of sponsor missing in action Eligibility determined case by case

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 InTRoDUCTIon TABLE 1.1 Continued Eligible Beneficiary Coverage Options Foreign force member, family Coverage, eligibility depend on c country of origin Survivor Benefits differ depending on survivor status entered in DEERS Victim of abused Eligible for limited medical benefits TRICARE Plus is available only at certain military treatment facilities and allows a beneficiaries who normally are able to get care at a military treatment facility only on a space-available basis to enroll and receive primary-care appointments with the same access standards as beneficiaries enrolled in TRICARE Prime. A sponsor and family members are not eligible for TRICARE health benefits until the b sponsor reaches the age of 60 years and begins to receive retired pay. Must be registered in DEERS and have a valid military ID card. c Care may be provided if the victim’s active-duty spouse has been separated from the d service for an abuse-related offense. The care must be related to an injury or illness caused by the abuse. SOURCE: TRICARE (2009b). Note that several versions of the TRICARE Beneficiary Handbook are extant, addressing different regions and specific programs. An online version of this information is also available: http://www.tricare.mil/mybenefit/. by regulations specified in the Code of Federal Regulations (CFR), and by instructions contained in TMA documents, such as the TRICARE operations, policy, reimbursement, and systems manuals.4 Specific poli- cies regarding behavioral health care are discussed in greater detail in the following section and chapters. MENTAL HEALTH–CARE SERvICES AND PROvIDERS uNDER TRICARE A number of mental health services are covered under TRICARE; most of them are subject to limitations regarding the time, duration, or number of sessions covered per episode, admission, benefit period, or fis- cal year (TRICARE, 2009a). Outpatient services include psychotherapy (individual, group, family, and conjoint therapy and collateral visits), Online versions of the manuals are maintained at http://manuals.tricare.osd.mil/. 4

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE psychoanalysis, psychological testing, and medication management. Inpatient services incorporate acute care, psychiatric partial hospitaliza- tion, and residential treatment-center care. In addition, a number of substance-use services are covered: inpatient detoxification and reha- bilitation; outpatient care; individual, group, and family therapy; and psychiatric partial hospitalization. Coverage limitations are in many cases defined by statute; specifics are in Title 10 of the USC and Title 32 of the CFR. Authorized providers recognized under TRICARE are defined in 32 CFR Part 199 and, generally, the TRICARE Policy Manual 6010.54-M, Chapter 11, Section 1.1. For mental health services, they comprise psy- chiatrists and other physicians, clinical psychologists, certified psychiatric nurse specialists, clinical social workers, certified marriage and family therapists, pastoral counselors, and mental health counselors (32 CFR § 199.4(c)(3)(ix) and TRICARE Policy Manual 6010.54-M, Chapter 7, FIguRE 1.1 Interactions between TRICARE beneficiaries and mental health service providers. Figure 1-1 uneditable bitmapped image

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 InTRoDUCTIon Section 3.10). Figure 1.1 schematically illustrates the interaction between beneficiaries and those professionals. Table 1.2 outlines the restrictions on their practice under TRICARE. Specific information on the scope of practice and training, experience, and licensing requirements for each type of provider is delineated below. Appendix D contains excerpts from 32 CFR § 199.6 that detail these requirements. Additional detail on the education of mental health professionals is provided in Chapter 3. Psychiatrists and Other Physicians Psychiatrists are certified in the prevention, diagnosis, and treat- ment of mental, addictive, and emotional disorders and are qualified to assess both the physical and mental aspects of mental illness. They are differentiated from other mental health professionals by their medical training and can prescribe medications, perform physical examinations, and order laboratory tests and imaging studies. Training includes education that leads to a medical or osteopathic degree from an accredited university and at least 4 years in a psychiatric residency program (AADPRT, 2009). Authorization under TRICARE requires a medical or osteopathic degree, completion of an approved psychiatric residency program, and licensure by the state in which the person prac- tices (TRICARE Policy Manual 6010.54-M, Chapter 11, Addendum A(2)(B), 2002). Psychiatrists and other physicians may apply for board certification in psychiatry or a subspecialty of their choosing, but it is not required. As noted in the section on primary-care providers (PCPs) below, physicians trained or board-certified in other specialties may also be involved in mental health care and making diagnoses and in some cases may deliver treatment. Title 32 of the CFR requires that “clinicians providing individual, group, and family therapy meet CHAMPUS requirements as qualified mental health providers and operate within the scope of their licenses.” It goes on to state (32 CFR § 199.6(b)(4)(vii)(B)()(i)) that [t]he ultimate authority for planning, development, implementation, and monitoring of all clinical activities is vested in a psychiatrist or doctoral level psychologist. The management of medical care is vested in a physician.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 1.2 Mental Health Professionals Under TRICARE—Disciplines and Associated Restrictions Need Requires Participation Supervision Agreement and Referral by to Practice Able to Supervise Disciplinea Physician Independently Applicable Staff Licensed physician — No Yes (including psychiatrist) Licensed clinical No No Yes psychologist Licensed/certified No No Yes psychiatric nurse specialists Licensed/certified clinical No No Yes social worker Licensed/certified No if Yes Yes if participation marriage and family participation agreement is therapist agreement is signed; signed; no if participation yes if agreement is not participation signed agreement is not signed Licensed/certified pastoral Yes No Yesb counselor Licensed/certified mental Yes No Yes health counselor Licensure/certification must be at full clinical level of practice. a If supervisee is not able to work toward licensure with discipline of supervisor, supervisor b cannot supervise under TRICARE standards; supervisor must also be working within scope of his or her practice/license/certification. SOURCE: NQMC (2005).

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 InTRoDUCTIon Psychologists Clinical psychologists perform many of the same functions as psychiatrists in developing treatments and interventions for people with mental health problems. However, they focus mainly on counseling, psychotherapy, rehabilitation, and behavior modification, and they are generally not permitted to prescribe medications (except those licensed and practicing in Louisiana, New Mexico, and Guam).5 They also inter- pret psychological tests, such as intelligence examinations, personality tests, and brain-function assessments. Clinical psychologists must have a doctoral degree (PhD or PsyD) in psychology or a closely related field. Graduate training includes practicum courses that provide clinical experience in counseling and diagnostic testing and an internship that involves working directly with clients under the supervision of a licensed psychologist. Clinical psychologists are able to obtain licensure after completing the required training and passing a state licensing examination (APA, 2009; BLS, 2008-09a). To be certified under TRICARE, clinical psychologists must be licensed or certified in psychology by the state in which they practice and have 2 years of supervised clinical experience in psychological health services, or they must be credentialed by the National Registry of Health Service Providers in Psychology (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.7, 2002). These providers are able to deliver ser- vices under TRICARE without physician supervision. Psychiatric Nurse Specialists Psychiatric nurse specialists provide advanced treatment for mental health disorders or behavioral health problems through psychotherapy and management of medications. They may perform direct inpatient care and couple, family, and group therapy, and they may serve as consultants, evaluators, and resources for staff nurses. Some have pre- scription privileges. Psychiatric nurse specialists are prepared as PCPs in psychiatric settings. The American Nurses Credentialing Center offers certification in adult psychiatric and mental health and in fam- ily psychiatric and mental health to nurse practitioners; clinical nurse In addition, the DOD Psychopharmacology Demonstration Project, which took 5 place in 1991–1997, graduated 10 students from its pharmacotherapy training program and granted them privileges (Ralph and Sammons, 2006).

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE specialists may be certified in adult psychiatric and mental health and in child/adolescent psychiatric and mental health. Under TRICARE, they are able to provide covered care without physician referral and supervision. Authorization requires licensure as a registered nurse (RN) and a master’s degree (MS, MSN, or MN) or doctoral degree (PhD) in nursing with a specialization in psychiatric and mental health nursing. Additional training requirements include 2 years of post–master’s degree experience with an average of 8 hours of direct patient contact per week (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.6, 2002). They must also be certified by the American Nurses Association through the American Nurses Credentialing Cen- ter, which requires a minimum of 500 clinical hours in psychiatric and mental health nursing under faculty supervision during the graduate program; coursework in advanced health assessment, advanced pharma- cology, and advanced pathophysiology; and clinical training in at least two psychotherapeutic treatment modalities . To practice psychotherapy, certification and 800 hours of direct patient contact in advanced clinical practice are required (American Nurses Credentialing Center, 2009). Clinical Social Workers Clinical social workers, also referred to as mental health and substance-abuse social workers, provide diagnosis, biopsychosocial assessment, and treatment for people with mental illness and sub - stance-abuse problems through individual, couple, family, and group therapy and rehabilitation. Practitioners must have a master’s degree (MSW, MSSA, or MSS) from an accredited program that includes coursework in clinical assessment, counseling, psychotherapy, and case- load management. Additional training typically includes a minimum of 900 hours of supervised clinical field experience (BLS, 2008-09b). To be authorized under TRICARE, certification or licensure at the master’s level is required by the state in which the provider practices. Licensing requirements vary by state; however, most require at least 2 years or 3,000 hours of post–master’s degree clinical social-work practice under the supervision of a master’s-level social worker in a clinical set- ting, which satisfies TRICARE requirements (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.5, 2002). Clinical social workers authorized under TRICARE are able to provide covered care within the scope of their licenses without physician referral and supervision.

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 InTRoDUCTIon A note accompanying the requirements directs that “patients’ organic medical problems must receive appropriate concurrent management by a physician.” Marriage and Family Therapists Marriage and family therapy is recognized by the federal govern- ment as a “core” mental health profession, as are psychiatry, psychology, social work, and psychiatric nursing (HHS, 2009). Marriage and family therapists are trained in psychotherapy and family systems. They may assess, diagnose, and treat mental and emotional disorders through brief, solution-focused, family-centered treatment but are not authorized to prescribe medications (American Association for Marriage and Family Therapy, 2009). To become a marriage and family therapist, a person must earn a master’s or doctoral degree in counseling with a focus on marriage and family therapy from a graduate program accredited by the Commission on Accreditation for Marriage and Family Therapy Education. Licensure or certification requires 2 years of post–master’s degree supervised clinical experience. Training requirements include a com- bination of 200 hours of approved supervision and 1,000 hours of supervised clinical experience in the practice of marriage and family counseling, or a combination of 150 hours of approved supervision in the practice of psychotherapy that includes at least 50 hours of approved individual supervision in the practice of marriage and family counsel- ing and 750 hours of supervised clinical experience in the practice of psychotherapy that includes at least 250 hours of clinical practice in marriage and family counseling. A person must pass a state licensing examination or the national examination for marriage and family thera- pists administered by the American Association of Marriage and Family Therapy Regulatory Boards, which is used as a licensure requirement in most states. Authorization under TRICARE requires licensing or certification in the state in which the provider practices. TRICARE policy allows certified marriage and family therapists to provide covered services within their scope of licensure if they enter into a participation agreement (PA) to practice independently. A PA requires a provider to agree that a patient’s physical health problems must receive appropriate concurrent management by a physician. If a PA is not

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE clinical experience requirements prepare licensed mental health counselors to diagnose and treat such illness such [sic] as major depressive disorder, schizophrenia, post-traumatic stress disorder, bipolar disorder, mental disorders due to a general medical con- dition, somatoform disorders and delirium, dementia, amnestic, substance use and other disorders regularly associated with head trauma, and recommendations, if any, for standardization or adjustment of such requirements. Independent practice under other federal programs—The • report shall provide for an assessment of the extent to which licensed mental health counselors are authorized to practice inde- pendently under other Federal programs (such as the Medicare program, the Department of Veterans Affairs, the Indian Health Service, and Head Start), and a review of the relationship, if any, between recognition of mental health professions under the Medicare program and independent practice authority for such profession under the TRICARE program. Independent practice under FEHBP—The report shall provide • for an assessment of the extent to which licensed mental health counselors are authorized to practice independently under the Federal Employee Health Benefits Program and private insurance plans. The assessment shall identify the States having laws requir- ing private insurers to cover, or offer coverage of, the services of members of licensed mental health counselors and shall identify the conditions, if any, that are placed on coverage of practitioners under the profession by insurance plans and how frequently these types of conditions are used by insurers. Historical review of regulations—The report shall provide for a • review of the history of regulations prescribed by the Department of Defense regarding which members of the mental health profes- sion are recognized as providers under the TRICARE program as independent practitioners, whether such regulations and/or other applicable policies were at the direction of Congress, and an examination of the recognition by the Department of third-party certification for members of such profession. Clinical exposure and capabilities studies—The report shall • include a review and synthesis of available data describing the proportion of all patients under the care of licensed mental health counselors with major depressive disorder, schizophrenia, post-traumatic stress disorder, bipolar disorder, mental disorders due to a general medical condition, somatoform disorders and delirium, dementia, amnestic, substance use and other disorders

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 InTRoDUCTIon regularly associated with head trauma. Additionally, the report shall include a review of outcome studies and of the literature regarding the comparative quality and effectiveness of care pro- vided by licensed mental health counselors, particularly with respect to effectiveness of care for persons with major depressive disorder, schizophrenia, post-traumatic stress disorder, bipolar disorder, mental disorders due to a general medical condition, somatoform disorders and delirium, dementia, amnestic, sub- stance use and other disorders regularly associated with head trauma and provide an independent review of the findings. Conclusions and recommendations—The report shall include • conclusions and recommendations for permitting licensed mental health counselors to practice independently under the TRICARE program including recommendation regarding modifications of current policy for the TRICARE program with respect to allow- ing licensed mental health counselors to practice independently in the TRICARE program, paying particular attention to the preparedness of licensed mental health counselors to diagnose, treat and appropriately refer persons with disorders of particular importance to TRICARE beneficiaries including major depres- sive disorder, post-traumatic stress disorder, mental disorders due to a general medical condition, somatoform disorders and delirium, dementia, amnestic, substance use and other disorders regularly associated with head trauma. Limitations to practice—The report shall include any recom- • mendations [regarding] limitations to practice independently with respect to DOD beneficiaries. DOD did not ask for an analysis of issues surrounding access to mental health care. As already noted, that was the central topic of the 2005 RAND monograph Expanding Access to Mental Health Counselors—Evaluation of the TRICARE Demonstration (Meredith et al., 2005). Access to care was also discussed in a 2007 report by the DOD Task Force on Mental Health. That report found that “mental health professionals are not sufficiently accessible to service members” and that children of service members and members of the National Guard and Reserve experience particularly constrained access. The task force recommended that DOD “ensure a full continuum of care to support psychological health is available and accessible to all service members and their eligible family members, regardless of location” and recom- mended changes to TRICARE’s resources, staffing, number of providers, and care obligations to accomplish it.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE COMMITTEE APPROACH TO TASK To answer the questions posed by the sponsor, the committee under- took a wide-ranging evaluation of the scientific literature, relevant laws and regulations, and publications produced by mental health professionals and educational and other organizations affiliated with them. Data sources and keyword searches were selected according to their overall relevance to the topic of interest. Because of the interdisciplinary nature of the topic, a wide array of electronic databases were queried, including PsycINFO and PsycARTICLES. To supplement the computer- ized searches, the reference sections of related and relevant publications were searched manually. General and specialized Internet search engines were used to find references in fields not covered by scholarly databases. The committee also benefited from presentations by the spon- sor, professional organizations, managed-care providers, and experts in various relevant issues during two workshops. Appendix A lists the participants and their topics. Many of the organizations and individuals provided additional information for the committee’s consideration and responded to questions and requests for data. Their efforts greatly aided the committee’s work. OvERvIEW OF RELATED INSTITuTE OF MEDICINE REPORTS IOM has published several reports that address issues relevant to the present subject, in particular the delivery of mental health services to and mental health issues in military populations. They are summarized briefly below. Some reports are revisited in greater detail in the chapters that follow. IOM Studies Addressing the Delivery of Mental Health Services The IOM committee responsible for Managing Managed Care: Quality Improvement in Behavioral Health (IOM, 1997) was charged with developing a framework for performance indicators, accreditation standards, and quality-improvement mechanisms that could be used for managed behavioral health care. The report concluded that multiple players—including local, state, and federal governments; accreditation,

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 InTRoDUCTIon managed-care, purchaser, professional, and consumer organizations; and the mass media—are involved in quality assessment, but information for informed purchasing decisions is lacking. It recommended that quality of care be monitored with relevant performance measures, valid accredi- tation processes, evidence-based outcome measures, and clinical practice guidelines. It further recommended that quality be clearly addressed in contracts between purchasers and providers, and it suggested that fed- eral and state governments encourage the development of report cards and include all stakeholders in developing, implementing, and using consumer-protection standards. The goal of Crossing the Quality Chasm: A new Health System for the st Century (IOM, 2001) was to identify strategies to improve the quality of US health care substantially. The report concluded that all health-care organizations, professional groups, and purchasers should strive for health care that is safe, effective, patient-centered, timely, effi- cient, and equitable. A 21st-century health-care delivery system, it said, should have health-care processes that are based on continuous heal- ing relationships, shared information between clinicians and patients, evidence-based decision making, and collaboration among clinicians and institutions. The report recommended restructuring clinical educa- tion and assessing provider credentialing to be consistent with those health-system principles. It also recommended applying work-design principles that are used in other industries, using information technol- ogy to support decision making, and realigning payment policies to improve quality of care. A later report—Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (IOM, 2006a)— examined whether the Quality Chasm approach was relevant to health care for mental and substance-use (M/SU) conditions. It concluded that the framework is applicable to behavioral health care and that improving US health care overall requires attending to M/SU health-care quality issues and delivering care with an understanding of mind–body interac- tions. The report recommended that M/SU clinicians and organizations use process and outcome measures to improve the quality of care. It also recommended the development of national standards for credential- ing and licensure of M/SU providers that are based on specific clinical competencies.

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE IOM Studies Addressing Mental Health Issues in Military Populations As part of a larger research effort on veterans’ health issues, IOM committees have been working on a series of reports on the effects of psychological stress on present and former members of the military. Among them is the 2006 report Posttraumatic Stress Disorder: Diagnosis and Assessment (IOM, 2006b), which provided responses to a series of questions posed by the Department of Veterans Affairs, the report’s sponsor. They included, What constitutes optimal evaluation of a patient for PTSD? and What neuropsychological evaluation or other testing should be included in an optimal evaluation of a patient for PTSD? The report concluded that PTSD is a disorder that has robust core clinical features that are consistent among diverse populations. It strongly recommended that PTSD be diagnosed through a face-to-face clinical interview by a health professional trained in diagnosing psychi- atric disorders. The report did not draw specific conclusions regarding the training of mental health professionals who perform the diagnosis and assessment. A later report in the series—Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (IOM, 2008b)—reviewed and assessed the evidence on the efficacy of pharmacological and psychological treatment for PTSD. It sought not to develop clinical practice recommendations but to reach evidence-based conclusions that would inform policy decisions. The committee responsible for the report concluded that the evidence existing when it completed its work was inadequate to determine the efficacy of any pharmacotherapy in the treatment of PTSD.11 It found that the evidence was sufficient to conclude that exposure therapy, a form of cognitive-behavioral therapy, was effective in the treatment of PTSD. There was insufficient evidence to draw conclusions on other psychotherapy, including eye-movement desensitization and reprocess- ing therapy, cognitive restructuring, coping-skills training, and therapy delivered in group formats. The 2008 report Gulf War and Health, Volume : Physiologic, Psycho- logic, and Psychosocial Effects of Deployment-Related Stress (IOM, 2008a) concluded that there is a consistent, positive association between deploy- ment and specific health effects, such as psychiatric disorders (including The committee did not conclude that pharmacotherapy was ineffective but rather that 11 the evidence base was insufficient.

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 InTRoDUCTIon PTSD, other anxiety disorders, and depressive disorders), alcohol abuse, accidental death or suicide in the early years after deployment, and marital and family conflict. It also concluded there is limited but sug- gestive evidence of an association between deployment and incarceration or drug abuse. Finally, it reported inadequate or insufficient evidence to determine whether there is a relationship between deployment and neurocognitive and neurobehavioral effects, sleep disorders or distur- bance, homelessness, or adverse employment outcomes. The report recommended that DOD conduct predeployment and postdeployment screenings for medical conditions and psychosocial status to identify at-risk personnel, implement interventions, and measure long-term consequences of deployment. Other IOM Studies In 2009, IOM released Redesigning Continuing Education in the Health Professions. This report concluded that there are major flaws in the way continuing education (CE) for medical professionals in the United States is conducted, financed, regulated, and evaluated. It found that CE differs widely among and within health professions in terms of content and delivery or learning methods and that it is largely driven by state requirements and regulatory bodies that often focus on the number of hours spent in CE courses. It concluded that requirements that are based on credit hours rather than outcomes—and that vary by state and profession—are not conducive to teaching and maintaining core competencies aimed at providing quality care. The report suggests a new vision for CE based on an approach called “continuing profes- sional development,” in which learning takes place over a lifetime and stretches beyond the classroom to the point of care. It also recommends that consideration be given to creating a national independent institute that would focus on improving CE regulation, including accreditation, certification, credentialing, and licensure. ORgANIZATION OF THIS REPORT The remainder of this report is organized into five chapters and sup- porting appendixes. Chapter 2 provides background information on the characteristics of the TRICARE beneficiary population and some of the

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE mental health issues that they face. Chapter 3 describes how counselors are trained and practice and contrasts this with training and practice of other mental health professionals; the chapter also delineates edu- cational, licensing, and clinical experience requirements for counselors and examines the accreditation of the educational institutions that train them and the examinations that they must pass to enter professional practice. Chapter 4 addresses how counselors practice in other programs that are under the aegis of the federal government. Research regarding the delivery of high-quality mental health care is reviewed in Chapter 5 with a focus on psychosocial services relevant to conditions found in the TRICARE enrollee population. Chapter 6 compiles the report’s findings and offers overall conclusions and recommendations. Agendas from the public meetings held by the committee are pro- vided in Appendix A. Appendix B provides excerpts from the section of the CFR that delineates the rules governing the practice of autho- rized mental health providers under TRICARE. Working definitions of some key terms used in the report are presented in Appendix C. Appendix D presents excerpts of salient sections of the United States Code that describe the scope of practice and the training, experience, and licensing requirements imposed on mental health professionals who practice in the TRICARE system. Excerpts of the regulation that defines the scope of practice and supervision requirements for licensed counselors in the US Army are presented in Appendix E. Appendix F presents a clinical vignette that is intended to provide insight into the complexities of cases that a TRICARE mental health practitioner may face. A comprehensive list of licensing requirements for counselors in the United States is contained in Appendix G. Appendix H provides biographic information on the committee members, consultants, and staff responsible for this study. REFERENCES AADPRT (American Association of Directors of Psychiatric Residency Training). 2009. What is psychiatry training? http://www.aadprt.org/training/default.aspx. (Accessed November 5, 2009). American Association for Marriage and Family Therapy. 2009. FAQ’s on MFT’s. http://www. aamft.org/faqs/index_nm.asp. (Accessed November 5, 2009). American Association of Pastoral Counselors. 2009. About pastoral counseling. http://www. aapc.org/content/about-pastoral-counseling. (Accessed November 5, 2009).

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 InTRoDUCTIon American Nurses Credentialing Center. 2009. Clinical nurse specialist in adult psychiatric & mental health certification eligibility criteria. http://www.nursecredentialing. org/Eligibility/AdultPsychMentalHealthCNSEligibility.aspx. (Accessed November 5, 2009). AMHCA (American Mental Health Counselors Association). 2009. American Mental Health Counselors Association. http://www.amhca.org/. (Accessed November 5, 2009). APA (American Psychological Association). 2009. About clinical psychology. http://www.apa. org/divisions/div12/aboutcp.html. (Accessed November 5, 2009). BLS (Bureau of Labor Statistics). 2008-09a. Psychologists. In occupational outlook handbook, 2008-09 ed. http://www.bls.gov/oco/ocos056.htm. (Accessed November 5, 2009). BLS. 2008-09b. Social workers. In occupational outlook handbook, 2008-09 ed. http://www. bls.gov/oco/ocos060.htm. (Accessed November 5, 2009). BLS. 2008-09c. Counselors. In occupational outlook handbook, 2008-09 ed. http://www.bls. gov/oco/ocos067.htm. (Accessed November 5, 2009). 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. 2009. Who we are & our history. In TRICARE fundamentals course, Section 14, Participant guide. http://www.tricare.mil/tricareu/docs/200906/14_Who_We_Are_ June_09.doc. (Accessed September 18, 2009). Eaton KM, Hoge CW, Messer SC, Whitt AA, Cabrera OA, McGurk D, Cox A, Castro CA. 2008. Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Military Medicine 173(11):1051-1056. Geller JM. 1999. Rural primary care providers’ perceptions of their roles in the provision of mental health services: Voices from the plains. Journal of Rural Health 15(3):326-334. HHS (Department of Health and Human Services). 2009. Guidelines for mental health HPSA designation. Health Resources and Services Administration. http://bhpr.hrsa. gov/shortage/hpsaguidement.htm. (Accessed November 13, 2009). IOM (Institute of Medicine). 1997. Managing managed care: Quality improvement in behav- ioral health. Washington DC: National Academy Press. IOM. 2001. Crossing the quality chasm: A new health system for the st century. Washington, DC: National Academy Press. IOM. 2006a. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Academies Press. IOM. 2006b. Posttraumatic stress disorder: Diagnosis and assessment. Washington, DC: The National Academies Press. IOM. 2008a. Gulf War and health, Volume : Physiologic, psychologic, and psychosocial effects of deployment-related stress. Washington, DC: The National Academies Press. IOM. 2008b. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washing- ton, DC: The National Academies Press.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE IOM. 2009. Redesigning continuing education in the health professions. Washington, DC: The National Academies Press. Kerwin ME, Walker-Smith K, Kirby KC. 2006. Comparative analysis of state requirements for the training of substance abuse and mental health counselors. Journal of Substance Abuse Treatment 30(3):173-181. Kushner K, Diamond R, Beasley JW, Mundt M, Plane MB, Robbins K. 2001. Primary care physicians’ experience with mental health consultation. Psychiatric Services 52(6):838-840. 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. NQMC (National Quality Measures Clearinghouse). 2005. Guidance on TRICARE standards/ regulations: Qualified mental health professionals scope of practice & supervision. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. http://www.maximus.com/nqmc/downloads/Qualified_Mental_Health_Professional. doc. (Accessed October 25, 2009). OPM (U.S. Office of Personnel Management). 2009. Creditable service for leave accrual. In The guide to processing personnel actions. http://www.opm.gov/Feddata/gppa/Gppa06. pdf. (Accessed October 29, 2009). Ralph JA, Sammons MT. 2006. Future directions in miltary psychology. In Military psychol- ogy: Clinical and operational applications, edited by Kennedy CH and Zillmer EA. New York: Guilford. Pp. 371-386. Stars and Stripes. 2009. Six million beneficiaries to get new TRICARE contractors. Pacific edi- tion, July 18. http://www.stripes.com/article.asp?section=140&article=63754. (Accessed October 10, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Addendum A(2)(B). 2002. Participa- tion agreement for partial hospitalization program services. http://www.tricare.mil/tp02/ C11ADA.PDF. (Accessed November 13, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.5. 2002. Certified clinical social worker. http://www.tricare.mil/TP02/C11S3_5.PDF. (Accessed November 13, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.6. 2002. Certified psychiatric nurse specialist. http://www.tricare.mil/TP02/C11S3_6.PDF. (Accessed November 13, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.7. 2002. Clinical psychologist. http://www.tricare.mil/TP02/C11S3_7.PDF. (Accessed November 13, 2009). . TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.8. 2002. Certified marriage and family therapist. http://www.tricare.mil/TP02/C11S3_8.PDF. (Accessed November 13, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.9. 2002. Pastoral counselor. http://www.tricare.mil/TP02/C11S3_9.PDF. (Accessed November 13, 2009). TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.10. 2002. Mental health coun- selor. http://www.tricare.mil/TP02/C11S3_10.PDF. (Accessed November 13, 2009). TRICARE. 2009a. TRICARE Behavioral health care services. Brochure, July. http://www. tricare.mil/mybenefit/Download/Forms/BHC_Flyer_09_L.pdf. (Accessed October 10, 2009).

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 InTRoDUCTIon TRICARE. 2009b. TRICARE beneficiary handbook. http://www.tricare.mil/tricaresmartfiles/ Prod_125/BW_HB_LO_RES.pdf. (Accessed October 10, 2009). Note that several ver- sions of this handbook are extant, addressing different regions and specific programs. An online version of this information is also available: http://www.tricare.mil/mybenefit/. US Congress, House of Representatives. 2005. Report 0-0. national Defense Autho- rization Act for Fiscal year 00. Conference report to accompany H.R. . 0th Congress, st Session, December 18. http://frwebgate.access.gpo.gov/cgi-bin/getdoc. cgi?dbname=109_cong_reports&docid=f:hr360.109.pdf. (Accessed October 5, 2009).

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