5
Research Regarding the Determinants of High-Quality Mental Health Care

In this chapter, the committee reviews existing standards and expectations for the delivery of high-quality mental health care with special reference to psychosocial services relevant to the most prevalent conditions in the TRICARE beneficiary population. The statement of task that guided the committee’s work requested that it review the scientific literature regarding the quality and effectiveness of care provided by licensed mental health counselors. The committee was also asked to offer recommendations regarding modifications of current TRICARE policy with respect to allowing licensed mental health counselors to practice independently. Because the policy is built around TRICARE’s system of quality management through the specification of educational, licensing, and clinical-experience requirements of practitioners, it is appropriate to identify and examine other components of a modern quality-management system to assess whether and under what circumstances counselors could serve as independent providers. The material in this chapter thus addresses determinants of high-quality mental health care for all mental health professionals at a clinical and systems level.

Several previous Institute of Medicine (IOM) reports on healthcare quality, mental health and substance-abuse care, and treatment of posttraumatic stress disorder (PTSD) were especially influential in the committee’s deliberations. In particular, the aims, rules, and frameworks set forth in Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) provide an approach for this chapter and are



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5 Research Regarding the Determinants of High-Quality Mental Health Care I n this chapter, the committee reviews existing standards and expecta- tions for the delivery of high-quality mental health care with special reference to psychosocial services relevant to the most prevalent con- ditions in the TRICARE beneficiary population. The statement of task that guided the committee’s work requested that it review the scientific literature regarding the quality and effectiveness of care provided by licensed mental health counselors. The committee was also asked to offer recommendations regarding modifications of current TRICARE policy with respect to allowing licensed mental health counselors to practice independently. Because the policy is built around TRICARE’s system of quality management through the specification of educational, licensing, and clinical-experience requirements of practitioners, it is appropri- ate to identify and examine other components of a modern quality- management system to assess whether and under what circumstances counselors could serve as independent providers. The material in this chapter thus addresses determinants of high-quality mental health care for all mental health professionals at a clinical and systems level. Several previous Institute of Medicine (IOM) reports on health- care quality, mental health and substance-abuse care, and treatment of posttraumatic stress disorder (PTSD) were especially influential in the committee’s deliberations. In particular, the aims, rules, and frameworks set forth in Crossing the Quality Chasm: A new Health System for the st Century (IOM, 2001) provide an approach for this chapter and are 

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE summarized in the first section. The chapter then examines quality-of- care issues from clinical and systems perspectives and concludes with an examination of barriers to the implementation of clinical and systems strategies. Appendix C contains the committee’s working definitions of several key terms used in this chapter, including diagnosis, treatment, psycho- therapy, and quality. gENERAL CONCEPTS OF HEALTH-CARE QuALITY AND “EvIDENCE-BASED PRACTICE” Health-Care Quality Avedis Donabedian articulated as early as the 1960s a conceptual model for measuring health-care quality that remains highly relevant today. The model assesses three main components of health-care quality: structure, process, and outcome (Donabedian, 1966). Structure refers to characteristics of the health-care system or provider, such as training or clinic resources adequate for serving the population. Process refers to the care that is delivered—assessments, tests, and treatments. outcome refers to the health status of patients after they receive care. Access to care and patient satisfaction are other important components of health-care quality (Donabedian, 1998). Although it is desirable to know whether the care that is delivered to patients produces good outcomes, many factors that are independent of treatment quality can also affect a person’s health status after treatment, including illness severity and the patient’s ability and desire to adhere to a treatment regimen. Process measures of care, if they have a demon- strated link with outcomes, can therefore be useful tools for measuring treatment quality. In the late 1990s, evidence, largely from research in processes of care, that health-care quality in America had serious and pervasive problems was mounting. Examples were inadequate access to care, unac- ceptable rates of medical errors, and patients receiving care that was not needed or not receiving care that was needed. IOM’s Committee on the Quality of Health Care in America identified several underlying causes of the problems: the growing complexity of science and technology, which made it increasingly difficult for clinicians to stay abreast of new information; the shift from an acute-disease management paradigm to

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE increasing management of chronic conditions; poor organization of the health-care system to meet the demands of the growing complexity and the paradigm shift; and inadequate use of information technology (IOM, 2001). An IOM committee defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 4). Good quality means providing patients with services in a technically competent manner with good commu- nication, shared decision making, and cultural sensitivity. Crossing the Quality Chasm laid the groundwork for a quality-driven approach to health care by adopting six aims governed by 10 rules as universal guid- ance for changes in the system and in provider–patient interactions. These are delineated in Tables 5.1 and 5.2, respectively. Berwick (2002) noted that the report provided an underlying frame- work for the changes needed in American health care at four levels: • Level A: the experience of patients. • Level B: the functioning of small units of care delivery (“micro- systems” such as a cardiac surgical team). • Level C: the functioning of organizations that house or support microsystems (such as clinics and hospitals). • Level D: the environment of policy, payment, regulation, accredita- tion, and other factors that influence the organization at Level C. TABLE 5.1 Aims of the Future Health-Care System 1. Safe—avoiding injuries to patients from the care that is intended to help them. 2. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). 3. Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. 4. Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care. 5. Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy. 6. Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. SOURCE: IOM (2001).

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 5.2 Rules to Guide the Transition to a Health-Care System That Better Meets Patients’ Needs 1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits. 2. Customization based on patient needs and values. The system of care should be designed to meet the most common types of needs but have the capability to respond to individual patient choices and preferences. 3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision making. 4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information. 5. Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction. 8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events. 9. Continuous decrease in waste. The health system should not waste resources or patient time. 10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. SOURCE: IOM (2001), pp. 8-9. It is critical that efforts to establish and improve quality address all levels with a central focus on affecting Level A—the experience of patients. Any committee recommendations regarding modifications of

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE TRICARE’s policy on the practice of licensed mental health counselors should reflect the goals articulated in this framework. Crossing the Quality Chasm called for purchasers, regulators, health professions, educational institutions and the Department of Health and Human Services [to] create an environment that fosters and rewards improvement by 1) creating an infrastructure to support evidence-based practice, 2) facilitating the use of information technology, 3) aligning payment incentives, and 4) preparing the work force to better serve patients in a world of expanding knowledge and rapid change. (IOM, 2001, p. 5) That agenda applies directly to the role of TRICARE, its contrac- tors, and mental health professions and organizations that serve the beneficiary population. Evidence-Based Practice Achieving the changes described above requires a conceptual frame- work that uses both a clinical approach and a systems approach to deliv- ering high-quality health care. In this framework, the practice of health care is designed so that each member of the clinical team has a defined role (e.g., physicians focus on acute-care delivery and patients who have not responded to treatment, and nonphysician clinicians focus on supporting chronic-care management that includes supporting patient self-management and follow-up); patients receive education about their illnesses and how to participate fully in their treatment, including self-monitoring of symptoms and behavioral change; clinicians receive continuing education and, when needed, clinical consultation; and cli- nicians have an information-support system that can provide reminders, monitor patient outcomes, provide feedback, and assist in treatment planning (Wagner et al., 1996). The shift toward a systems approach to a high-quality infrastruc- ture requires attention to more than the delivery of specific treatments. Nonetheless, evidence-based practice is an important part of the con- ceptual framework. The goal of evidence-based practice is to improve health-care quality by bringing to the usual practice the knowledge gained by clinical research (IOM, 2001, 2006; President’s New Freedom Commission on Mental Health, 2002). Evidence-based practice applies the best research evidence combined with clinical expertise according to

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE individual patient values (IOM, 2001). The best research evidence is obtained from clinical research and includes research in epidemiology, diagnosis, and treatment. Clinical expertise is gained from clinicians’ training and experience in working with patients. Experience allows clinicians to be thoughtful, efficient, and accurate in providing patient care. It also enables them to provide compassionate care, which takes patients’ values, preferences, and rights into account (Sackett et al., 1996). High-quality care for mental and substance-use (M/SU)1 conditions has several important components that are independent of the specific diagnosis for which a patient is treated. Clinicians who treat patients with M/SU conditions need to have adequate training. At the outset of treatment, M/SU clinicians need to be able to conduct a thorough clinical evaluation so that they can formulate a diagnosis and develop a treatment plan. Components of the evaluation include reasons for the evaluation; history of the presenting problem; past experiences with M/SU symptoms, behaviors, and treatment; medical history; informa- tion about family relationships and history of M/SU illnesses; devel- opmental history; history of interpersonal functioning (family, friends, and work); legal history; a safety assessment that examines whether the patient or others are at risk of harm; and a mental-status examination to assess the patient’s mood state, cognitive processes, and ability to function. Evaluations should include collateral information when pos- sible, such as information from other clinicians, family members, or significant others and results of diagnostic medical tests and evaluations that might be used to exclude medical conditions that are causing or exacerbating symptoms. Clinicians need to determine, on the basis of the above evaluation, the appropriate treatment setting for the patient, such as inpatient versus outpatient (APA, 2006a). It is also important for clinicians to establish a therapeutic alliance with a patient at the outset of treatment to promote the patient’s engagement and adher- ence, and to educate the patient and his or her family members about the condition for which the patient is being treated and about how to prevent or minimize exacerbations. Continuing tasks for M/SU clini- cians include monitoring of a patient’s response to treatment, assessing This chapter follows the convention of abbreviating “mental and substance-use” as 1 “M/SU” established in IOM’s Improving the Quality of Health Care for Mental and Substance- Use Conditions (2006).

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE function and safety, maintaining a therapeutic alliance, and monitoring and enhancing adherence. Systematic monitoring of patient response to treatment with established clinical scales and measures can improve M/ SU outcomes, reducing symptoms and possibly avoiding hospitalization (Slade et al., 2006; Trivedi et al., 2006). Many patients who have M/SU conditions have co-occurring medical or other M/SU conditions, and integrating and coordinating treatment provided by multiple clinicians can be critical. Once there is a diagnosis, clinicians must determine the most appropriate treatment for an individual patient on the basis of the clinical literature. Randomized controlled trials are an important part of the evidence base for understanding the efficacy of clinical treatments, but they are not the only evidence considered in evidence-based care. Often, patients enrolled in randomized controlled trials can differ sub- stantially from those seen in usual care settings. For many patients and clinical scenarios, evidence from randomized controlled trials is sparse or nonexistent. Observational, nonrandomized studies can provide useful information about patients not typically seen in clinical trials. However, they may be subject to biases, and evidence-based practice requires an ability to evaluate a study systematically to determine whether it is valid in its conclusions and whether it is applicable to an individual patient (Evidence Based Medicine Working Group, 1992). A barrier to implementing evidence-based practice is that not all clinicians have the appropriate training or adequate time to search the clinical literature independently and repeatedly to obtain the best, most recent evidence and to appraise it critically for validity and appli- cability. A survey of graduate psychotherapy training in psychiatry, psychology, and social work by Weissman and colleagues (2006) found that programs “often did not require the gold standard of didactic and clinical supervision for [evidence-based training].” Mullen et al. (2007), writing about social work professionals, cite several barriers to facilitat- ing evidence-based training of current practitioners, including a non- supportive workplace culture, infrastructure that does not provide the time and resources needed to access up-to-date best practices informa- tion, and limited resources to support the implementation of practices once they are identified. There are resources, however, that can assist clinicians in implement- ing evidence-based care (Guyatt et al., 2000); such resources include reviews and guidelines that systematically review the literature and weigh

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE the strength of evidence. Guidelines and systematic reviews, although useful in implementing evidence-based practices, have their own limita- tions. For example, they are not available for all clinical circumstances, and research evidence continues to evolve after a guideline or review is researched and published. Therefore, such resources should not be seen as a replacement for a practitioner’s independent inquiry and critique of the diagnostic and treatment literature (Guyatt et al., 2000). The RAND study described in Chapter 1 found that in the TRICARE population, the most prevalent diagnoses encountered by mental health and general medical clinicians are mood disorders, anxiety disorders, substance-use disorders, and adjustment disorders (Meredith et al., 2005). Many beneficiaries presented with co-occurring or multiple disorders. Although some TRICARE beneficiaries may need subspecial- ized mental health expertise to be treated for mental health conditions related to deployment and active combat, others can be well served by evidence-based practices available to the general population. Evidence- based guidelines exist to assist practitioners in accurate screening, diag- nosis, and pharmacologic and psychosocial treatments for many of the conditions seen in the beneficiary population. Table 5.3 provides examples of existing evidence-based psychosocial treatments for a sample of M/SU conditions that were either highlighted by TRICARE as conditions of particular interest or found to be among the more prevalent in the RAND study. Chapter 2 provides background information on them, briefly summarizing their signs and symptoms and their incidence rates. If an M/SU clinician is to conduct evidence- based practice, he or she needs to have training and experience in those treatments and have the capacity to learn and adapt as the evidence base on existing and new treatments expands. It is important to note that the table does not encompass all the evidence-based models for the conditions. Following the National Guideline Clearinghouse (2009) criteria for inclusion of clinical practice guidelines (CPGs), the table includes expert guidelines that are no more than 5 years old.2 However, evidence-based practice continually evolves, so even guidelines that have been available for no more than 5 years can be outdated and not reflect the most recent literature. It is important to note that evidence- based medication treatment is available for each of the conditions in the That is, guidelines that were released no earlier than 2004 (the present report was 2 written in 2009).

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE TABLE 5.3 Examples of Evidence-Based Psychosocial Interventions for Selected Disorders Relevant to the TRICARE Beneficiary Population Disorder Guideline-Recommended Treatment Major depressive Cognitive behavioral therapy (APA, 2000; VA/DOD, 2009a) disorder Interpersonal therapy (VA/DOD, 2009a) Dialectical behavioral therapy (VA/DOD, 2009a) Behavioral couple therapy (VA/DOD, 2009a) Problem-solving therapy (APA, 2005b; VA/DOD, 2009a) Schizophrenia Cognitive behavioral therapy (APA, 2004b; NIMH, 2009d) Social-skills training (APA, 2004b) Family intervention (APA, 2004b; NIMH, 2009d) Assertive community treatment (APA, 2004b) Supported employment (APA, 2004b; Lehman et al., 2004; NIMH, 2009d) Acute stress Cognitive behavioral therapy (APA, 2004a, 2009a; NIMH, disorder, 2009c; VA/DOD, 2004) posttraumatic Exposure therapy (APA, 2004a, 2009a; IOM, 2008; NIMH, stress disorder 2009c; VA/DOD, 2004) Eye-movement desensitization and reprocessing (APA, 2004a; VA/DOD, 2004) Bipolar disorder Cognitive behavioral therapy (APA, 2002, 2005a; NIMH, 2009b) Interpersonal therapy (APA, 2002, 2005a; NIMH, 2009b) Family-focused therapy (APA, 2002, 2005a; NIMH, 2009b) Substance-use Cognitive behavioral therapy (APA, 2006b) disorders Motivational interviewing (APA, 2006b; VA/DOD, 2009b) Behavioral couple therapy (APA, 2006b; VA/DOD, 2009b) Cognitive behavioral skills training (VA/DOD, 2009b) Contingency management (APA, 2006b; VA/DOD, 2009b) Community reinforcement approach (APA, 2006b; VA/DOD, 2009b) Generalized Cognitive behavioral therapy (DH, 2001; NIMH, 2009a)a anxiety disorder Obsessive- Exposure-response prevention (APA, 2007; Hill, 2007) compulsive disorder Panic disorder Cognitive behavioral therapy (APA, 2009b) The committee was not able to find American Psychiatric Association, Department of a Veterans Affairs, or Department of Defense practice guidelines for generalized anxiety disorder.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE table. For some conditions, such as bipolar disorder and schizophrenia, evidence-based practice recommends that patients receive medication to minimize symptoms or prevent repeated episodes of illness. For others—such as major depression, substance-use disorders, and anxiety disorders—medications can be efficacious, but patients who have symp- toms or exacerbations may also be adequately treated with psychosocial interventions alone. Many patients can benefit from a combination of medication and psychosocial treatment. EvIDENCE-BASED PRACTICE FOR PSYCHOSOCIAL INTERvENTIONS TO ADDRESS CLINICAL ISSuES OF SPECIAL RELEvANCE TO THE TRICARE POPuLATION As noted above, the diagnoses and combinations of diagnoses for which TRICARE beneficiaries receive mental health care are quite varied. Evidence-based guidelines and systematic reviews do not exist for all of them. Even the guidelines that do exist may not apply fully or directly to people who are seeking care. Patients may manifest varying patterns of comorbidity (such as depression and substance abuse and traumatic brain injury), have pressing psychosocial problems that are not well characterized in a simple diagnostic category (such as traumatic grief and sexual assault), or present with clinical problems related to par- ticular issues encountered in military life, such as combat in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). There- fore, clinicians must be able to monitor the scientific literature to adapt and adopt promising practices to fill gaps in available guidelines. This section describes examples of particular psychosocial interventions that, although not based on extensive evidence or formally recommended in guidelines, have been studied with regard to the particular needs of subsets of TRICARE beneficiaries. Several central points should be considered. First, because most of the evidence-based practice models applicable to these issues are focused on remediation and symptom relief for the individual service member, it is important to be mindful of the synergistic effects of individual mental health issues in the context of the couple and family. This section therefore discusses clinical approaches that focus on individual, couple, and family issues.

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE Second, education in specific skills might be conflated with the ability to deliver high-quality care. Several researchers have warned about the danger of focusing too exclusively on operationalizing goals and interventions while sacrificing clinical skills that involve relational capacities, alliance building, and an ability to hold the complexity of the “client in social context” (Stein and Lambert, 1995). Third, some guiding principles are useful in treating recently returned OIF or OEF service members, including these: establish a facilitative helping context that reduces stigma, facilitate family tran- sitions and reduce conflict, prevent social isolation and withdrawal, support employment productivity, and prevent alcohol and other drug misuse and abuse (Ruzek et al., 2004). The following subsections discuss various clinical intervention methods that have undergone some empirical study for assisting active- duty service members and their families with their mental health and psychosocial issues. The intent of this material is to illustrate the array of therapies available to clinicians for some conditions, not to be com- prehensive. Mention of a particular therapy should not be viewed as an endorsement of its use in the TRICARE beneficiary population. Posttraumatic Stress Disorder Several treatment models that address symptoms, affect regulation, and beliefs related to PTSD are oriented to not only the individual ser- vice member but partners, children, and other family members. Treatment approaches include group, couple, and family therapy. Group therapy may focus on rebuilding connections and dealing with trauma-related rage, anger, guilt, and fear (Kingsley, 2007). Couple therapy and family therapy are often useful in educating family members about posttraumatic stress and PTSD responses, promoting communi- cation, strengthening affect regulation, and facilitating new transitions (Harkness and Kador, 2001). One cognitive-behavioral model specifically focuses on couples in which one partner is an OIF or OEF veteran who has a diagnosis of PTSD. Although the researchers are formally evaluating cognitive- behavioral couple therapy with such couples, they have been using the treatment for some time. The couples appear to benefit, as evidenced by increased relationship satisfaction, but most require more than the expected 15 sessions (Monson et al., 2008). One of the couple-therapy

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE tronic data can be useful in assisting clinicians and policy makers in measuring treatment quality. 3. Variability and lack of specificity of training, accreditation, certi- fication, and licensing procedures that ensure an adequately pre- pared workforce that can provide evidence-based treatments. 4. Lack of adequate information systems to measure and moni- tor the quality of patient care, providers, practices, plans, and purchasers. Government organizations—including the Department of Veterans Affairs and the Department of Health and Human Services Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, NIH, and the Substance Abuse and Mental Health Services Administration—have been pursuing research and initiatives intended to overcome such barriers. QuALITY-OF-CARE INITIATIvES IN TRICARE AND THE MILITARY HEALTH SYSTEM A thorough review of quality-of-care initiatives in TRICARE and the Military Health System (MHS) is beyond the scope of this report. This section briefly summarizes the results of some of the recent reports published on the topic by DOD and by organizations that were asked to perform work for it. Health-care quality is identified as a key mission element of the MHS (TRICARE, 2009). In 2008, the Assistant Secretary of Defense for Health Affairs, testifying on mental health before a subcommittee of the House of Representatives Committee on Armed Services, stated that DOD’s quality-of-care initiative “relies on developing and dissemi- nating clinical guidance and standards, as well as training clinicians in clinical practice guidelines and effective evidence-based methods of care” (Casscells, 2008). DOD established the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in late 2007 to lead the effort. In response to a mandate contained in the National Defense Authori- zation Act for Fiscal Year 2007 (Public Law 109-364), DOD contracted for an independent review of its medical quality-improvement program, including efforts by TRICARE’s purchased-care contractors. The result- ing report (Lumetra, 2008, p. 2) concluded that “MHS quality and

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE patient safety programs are generally comparable to those found in civil- ian facilities, and the MHS processes to establish criteria and measure quality are of high standard.” The Lumetra study included a review of mental health quality issues. It reported that purchased-care contractors were critical of what they deemed an expensive and redundant federal requirement for dual certification of mental and behavioral health facili - ties but had no other specific comments. Other reviews, however, have provided some details that highlighted quality concerns in the MHS. A directive contained in § 723 of the FY 2006 National Defense Authorization Act (Public Law 109-163) instructed DOD to convene a task force to assess mental health services provided by the MHS and to offer recommendations for improving their efficacy. The task force released its report, titled An Achievable Vision, in June 2007 (DOD Task Force on Mental Health, 2007). It noted (p. 33) that although the department had developed evidence-based CPGs for PTSD, depression, substance abuse, and psychosis,5 these guidelines are not consistently implemented across the DOD and the Task Force was unable to find any mechanism that ensures their widespread use. Furthermore, providers who were interested in utilizing evidence-based approaches complained during site visits that they did not have the time to implement them. It concluded (p. 20) that “DOD’s mental health providers require additional training regarding current and new state-of-the-art practice guidelines.” The task force also found that there was “no consistent system for ongoing quality assessment and continuous improvement that includes substantial measurements of psychological health care outcomes” (p. 33). It concluded that “there are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness” and that “the TRICARE network benefit for psychological health is hindered by fragmented rules and policies, inadequate oversight, and insufficient reimbursement” (p. ES-3). Among the recommendations that were offered in reaction to those findings were two that addressed quality of care: DOD and VA later promulgated an additional CPG for TBI. 5

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE • 5.2.3.3: The Department of Defense should ensure that mental health professionals apply evidence-based clinical practice guidelines. • 5.2.3.4: The Department of Defense should routinely track and analyze patient outcomes to ensure treatment efficacy. In addition, the task force underscored the need for TRICARE providers to be specifically trained to meet the needs of their patient population: • 5.3.4.9: The Department of Defense should improve TRICARE providers’ training in issues related to military experiences by: — Requiring that TRICARE mental health contractors offer mediated training packages to all network mental health providers similar to those available through the National Center for Post-Traumatic Stress Disorder, the Department of Defense Center for Deployment Psychology, and military mental health components. — Requiring that TRICARE mental health contractors offer training packages for specific disorders and problems such as post-traumatic stress disorder and other combat stress syndromes each time a treatment plan is approved. DOD published a response to the Achievable Vision report in Sep- tember 2007, outlining the steps that it would take to implement the recommendations (DOD, 2007). The department pledged to empha- size the use of CPGs through a policy memorandum, to create and implement new CPGs, and to facilitate training in them. It also stated that it would review its outcome measures and policies, develop new evidence-based measures as needed, and issue directives requiring the use of outcome measures. Separately, the DOD Inspector General’s office generated observa- tions and a critique of the task force’s work (DOD Office of Inspector General, 2008). It echoed the conclusions regarding evidence-based treatments and indicated that health-care program managers “need to do more to monitor, oversee, and improve effectiveness.”

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 DETERMInAnTS oF HIGH-QUALITy MEnTAL HEALTH CARE OBSERvATIONS On the basis of the review of the papers, reports, and other informa- tion discussed in this chapter, the committee observes that • The statutes and regulations under which TRICARE operates use educational, licensing, and clinical-experience requirements to determine the circumstances under which mental health professionals practice. That constitutes a system of quality management. • The scientific literature on the delivery of health services— including mental health services—indicates that high-quality care is achieved through a patient-centered system grounded in the delivery of evidence-based clinical practices and the monitor- ing of outcomes. • There are established clinical evidence-based practices endorsed by professional guidelines relevant to mental health care for the TRICARE population. • There is a set of systems practices that are appropriate for moni- toring and improving the quality of mental health care (including outcome measurement) and can be applied in the management of the TRICARE system. • All providers should be prepared to deliver evidence-based prac- tices in their scope of practice and to be trained in following and evaluating the accumulating evidence base with regard to promising treatments for problems that are particularly relevant to members of the military and their families. • TRICARE and its contractors should implement effective systems-level quality-monitoring and quality-improvement practices. REFERENCES ABPN (American Board of Psychiatry and Neurology). 2009. The ABPn Maintenance of Certification (MoC) program (rev. 07/26/09). http://www.abpn.com/downloads/moc/ moc_web_doc.pdf. (Accessed December 10, 2009). APA (American Psychiatric Association). 2000. Practice guideline for the treatment of patients with major depressive disorder, 2nd ed. Arlington, VA: APA.

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