6
Findings, Conclusions, and Recommendations

This chapter builds on the foundation laid in Chapters 15 to draw general conclusions and recommendations as requested in the statement of task.

OVERVIEW OF THE COMMITTEE’S WORK AND FINDINGS

The committee’s statement of task called for a series of assessments and reviews of the preparation of counselors for professional practice; the institutions that educate them; the licensure, clinical experience, certification, and regulatory and legal requirements applied to them; and their practice in government and other settings.

The statement of task also asked for conclusions and recommendations regarding the independent practice of licensed mental health counselors under the TRICARE program, including recommendations for modifications of TRICARE policy on and limitations of independent practice. It asked the committee to pay particular attention to the preparedness of licensed mental health counselors to diagnose, treat, and appropriately refer persons with a set of illnesses and disorders that service members could be at special risk for.

A 2006 report to Congress by the Department of Defense (DOD) on the use of counselors in the Military Health System (MHS) yields insight on those requests (DOD, 2006). It notes that there is substan-



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6 Findings, Conclusions, and Recommendations T his chapter builds on the foundation laid in Chapters 1–5 to draw general conclusions and recommendations as requested in the statement of task. OvERvIEW OF THE COMMITTEE’S WORK AND FINDINgS The committee’s statement of task called for a series of assessments and reviews of the preparation of counselors for professional practice; the institutions that educate them; the licensure, clinical experience, certification, and regulatory and legal requirements applied to them; and their practice in government and other settings. The statement of task also asked for conclusions and recommen- dations regarding the independent practice of licensed mental health counselors under the TRICARE program, including recommendations for modifications of TRICARE policy on and limitations of indepen- dent practice. It asked the committee to pay particular attention to the preparedness of licensed mental health counselors to diagnose, treat, and appropriately refer persons with a set of illnesses and disorders that service members could be at special risk for. A 2006 report to Congress by the Department of Defense (DOD) on the use of counselors in the Military Health System (MHS) yields insight on those requests (DOD, 2006). It notes that there is substan- 0

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE tial variability among the states in training programs and requirements for licensure as a counselor, that only some educational programs are accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP), that in most states licensure requires only minimal coursework in diagnosis of and treatment for mental disorders and no specific clinical experience with people who have mental disorders, and that in some states a license can be obtained with a postgraduate degree in a field other than counseling. The report asserts that physician supervision ensures quality of care for TRICARE beneficiaries. The committee found that education, accreditation, licensure, cer- tification, and clinical-experience requirements for mental health profes- sionals are components 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 mental health professionals to diagnose and treat disorders that may be found in the TRICARE beneficiary population. Indeed, research regarding the quality of care for mental or substance-use conditions indicates that there are widespread deficiencies in the training of providers and in the infrastructure that supports their practice (IOM, 2006). A 2007 assessment of mental health–care provision in the MHS found the same deficiencies (DOD Task Force on Mental Health, 2007). Reviews of government programs and government-contracted and private insurers found 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 institu- tional practice. 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. Despite an extensive search, the committee identified no literature bearing directly on the comparative quality and effectiveness of care provided by licensed mental health counselors. A review of research related to more general characteristics of mental health practitioners and the care that they deliver found that assertions of differential effective- ness among types of mental health providers are generally not based on empirical evidence. A 2009 meta-analysis (Spengler et al., 2009) con- cluded that “there are no comprehensive quantitative analyses on . . .

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0 FInDInGS, ConCLUSIonS, AnD RECoMMEnDATIonS whether any form of educational experience is linked to clinical judg- ment accuracy.” In summary, the committee did not identify any evidence that dis- tinguishes 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 experience. Its research instead points to the need for a comprehensive quality-management system that facilitates the proper diagnosis of and treatment for disorders in the TRICARE beneficiary population by all mental health practitioners. RECOMMENDATIONS The committee was tasked to offer: 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 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 supervision1 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 Current TRICARE policies regarding the practice of counselors are detailed in 1 Chapter 1.

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE • 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 National Clinical Mental Health Counseling Examination (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 in which they can be seen, and the interventions and populations (including pediatric, adolescent, and geriatric) that the practitioner has demonstrated competency in. TRICARE currently requires certified clinical social workers to hold “a master’s degree in social work from a graduate school of social work accredited by the Council on Social Work Education” in order to practice independently (32 CFR § 199.6, documented in Appendix D). The committee believes that a parallel requirement for counselors is appropriate.2 CACREP accreditation in clinical mental health counsel- ing requires programs to provide evidence that student learning has occurred in a number of knowledge, skills, and practice categories that are desirable for an independent practitioner in TRICARE, including (CACREP, 2009) • Etiology, the diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders. • Principles of the diagnostic process, including differential diag- nosis, and the use of current diagnostic tools, such as the cur- rent edition of the Diagnostic and Statistical Manual of Mental Disorders. • Accurate multi-axial diagnosis of disorders. This may make CACREP eligible to apply for recognition by the US Department of 2 Education through the National Advisory Committee on Institutional Quality and Integrity, a federal entity that sets and enforces standards for accrediting agencies and associations.

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0 FInDInGS, ConCLUSIonS, AnD RECoMMEnDATIonS • [Understanding of ] basic classifications, indications, and contra- indications of commonly prescribed psychopharmacological medications so that appropriate referrals can be made for medica- tion evaluations and so that the side effects of such medications can be identified. • Evidence-based treatments and basic strategies for evaluating counseling outcomes in clinical mental health counseling. • [Development of ] measurable outcomes for clinical mental health counseling programs, interventions, and treatments. • [Critical evaluation of ] research relevant to the practice of clinical mental health counseling. A student must also demonstrate “the ability to recognize his or her own limitations as a clinical mental health counselor and to seek supervision or refer clients when appropriate.” As the committee’s research has documented, there is considerable variability in the examination requirements and numbers of hours of supervised clinical experience needed for state licensure as a mental health counselor. Federal regulation and TRICARE policy already require counselors to have “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) for them to practice in the system, and the committee recommends that this requirement be retained. A requirement for licensure at the higher or the highest level offered by a state would help to ensure that practitioners have the training and expe- rience needed to serve in an independent capacity. Some states—such as Illinois, Kansas, and Nebraska—already follow that strategy, grant- ing authority for independent practice only to persons who hold their highest-level license. The NCMHCE is designed specifically for counselors who work in mental health, in contrast with the National Counselor Examination (NCE), which is a generic counseling examination. It tests the ability to provide services in a clinical capacity, including performing a differential diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the International Classification of Diseases, ninth Revision, Clinical Modification. The NCMHCE’s clinical simula- tions span the range of ages—adolescents, young adults, middle-aged adults, and older adults—and address the primary and secondary clinical features seen in the TRICARE population. The committee concludes

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE that although the NCMHCE has limitations,3 it is a more relevant test than the NCE of the ability of counselors to serve as independent pro- viders of mental health care. State licensure boards apparently also have that view, with some using the NCMHCE as the examination applied to the higher or highest or clinical level of licensure. Scopes of practice—which are called scopes of care in some military health publications—are routinely used in clinical settings to define the circumstances under which practitioners provide services and the ser- vices for which they have demonstrated expertise. A well-defined scope of practice is an essential component of clinical privileging, which, as the committee indicates below, is part of the comprehensive quality- management system that TRICARE should maintain for all health professionals. The committee believes that the requirements listed above, in concert with a comprehensive quality-management system, address the concerns expressed by DOD regarding the independent practice of mental health counselors and would help to ensure that TRICARE beneficiaries who seek counselors’ services would receive high-quality care, including, as appropriate, referral to other professionals. 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,4 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. The NCMHCE is not currently being reviewed by a third-party accrediting body for 3 fairness, validity and reliability. The credibility of the examination would be enhanced if it were to obtain recognition through such a body. Some current counselors may have graduated from programs accredited by the Council 4 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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 FInDInGS, ConCLUSIonS, AnD RECoMMEnDATIonS [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. • Systematic monitoring of the process and outcomes of care at all levels of the health-care system and application of effective quality-improvement strategies. Chapter 5, which summarizes the conclusions of previous Institute of Medicine studies of the determinants of high-quality health care (IOM, 2001, 2006), documents the importance of those steps and pro- vides the foundation of the committee’s recommendation here. The committee notes that the recommendations regarding evidence- based practices, training and education, quality measures, and moni- toring echo the observations offered by the mental health task force convened by DOD (DOD Task Force on Mental Health, 2007). DOD publications and public pronouncements (Casscells, 2008; DOD, 2008) indicate that the 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 offering 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 certificate program that will “teach best clinical practices to mental health professionals who are addressing the behavioral health needs of

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE military personnel, veterans and their families” and include training in military culture, combat trauma, suicide risk, and blast-related traumatic brain injury (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 criti- cal 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 organizations dem- onstrate 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 providers and suggests that TRICARE may benefit by working with other govern- ment organizations—such as 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, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration—to conduct or support research to overcome the barriers. REFERENCES CACREP (Council on Accreditation of Counseling and Related Educational Programs). 2009. CACREP accreditation manual: 00 standards. Alexandria, VA: CACREP. 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, US House of Representatives, March 14. http://www. dod.mil/dodgc/olc/docs/testCasscells080314.pdf. (Accessed October 9, 2009). CDP (Center for Deployment Psychology, DOD). 2009. Welcome to the Center for Deploy- ment Psychology. http://www.deploymentpsych.org/. (Accessed December 22, 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).

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 FInDInGS, ConCLUSIonS, AnD RECoMMEnDATIonS 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. DOD Task Force on Mental Health. 2007. An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board. http:// www.health.mil/dhb/mhtf/MHTF-Report-Final.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. Spengler PM, White MJ, Ægisdóttir S, Maugherman AS, Anderson LA, Cook RS, Nichols CN, Lampropoulos GK, Walker BS, Cohen GR, Rush JD. 2009. The meta-analysis of clinical judgment project: Effects of experience on judgment accuracy. The Counseling Psychologist 37(3):350-399.

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