PROVISION OF MENTAL HEALTH COUNSELING SERVICES UNDER TRICARE

Committee on the Qualifications of Professionals Providing Mental Health Counseling Services Under TRICARE

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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PROVISION OF MENTAL HEALTH COUNSELING SERVICES U N D E R TRICARE Committee on the Qualifications of Professionals Providing Mental Health Counseling Services Under TRICARE Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by a contract between the National Academy of Sciences and the US Department of Defense via HHS award HHSP23320080006T, TO#24. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14766-8 International Standard Book Number-10: 0-309-14766-2 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: Image © Neville Elder/Corbis. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man- date that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE QuALIFICATIONS OF PROFESSIONALS PROvIDINg MENTAL HEALTH COuNSELINg SERvICES uNDER TRICARE gEORgE J. ISHAM (Chair), Medical Director and Chief Health Officer, Health Partners, Inc., Bloomington, Minnesota KATHRYN K. BASHAM, Professor, Smith College School of Social Work, Northampton, Massachusetts ALISA B. BuSCH, Assistant Professor of Psychiatry and of Health Care Policy, Harvard Medical School and McLean Hospital; Director of Integration of Clinical Measurement and Health Services Research, McLean Hospital, Belmont, Massachusetts N. EMMANuEL g. CASSIMATIS, President and CEO, Educational Commission for Foreign Medical Graduates, Philadelphia, Pennsylvania JOHN H. MOxLEY III, Independent Consultant, Solvang, California HAROLD A. PINCuS, Professor and Vice Chair, Department of Psychiatry and Associate Director, Irving Institute for Clinical and Translational Research, Columbia University; Director of Quality and Outcomes Research, New York Presbyterian Hospital, New York, New York THEODORE P. REMLEY, JR., Professor and Batten Endowed Chair in Counseling, Department of Educational Leadership and Counseling, Old Dominion University, Norfolk, Virginia PHYLLIS W. SHARPS, Professor and Chair, Department of Community Public Health Nursing, Johns Hopkins University School of Nursing, Baltimore, Maryland ROY A. SWIFT, Senior Director, Personnel Credentialing Accreditation Programs, American National Standards Institute, Washington, DC vILIA M. TARvYDAS, Professor, Counseling, Rehabilitation, and Student Development, College of Education, University of Iowa, Iowa City, Iowa Consultant RHONDA J. ROBINSON BEALE, Chief Medical Officer, OptumHealth Behavioral Solutions, Glendale, California v

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Program Staff DAvID A. BuTLER, Senior Program Officer; Study Director JESSICA L. BuONO, Research Associate (until August 2009) SARAH gAILLOT, Christine Mirzayan Science and Technology Policy Fellow ANDREW BRADLEY, Intern TIA S. CARTER, Senior Program Assistant PAMELA RAMEY-McCRAY, Administrative Assistant FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations and Medical Follow-up Agency NORMAN gROSSBLATT, Senior Editor vi

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Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of the independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsive- ness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of the report: Paula g. Allen-Meares, Chancellor, University of Illinois at Chicago Dwight L. Evans, Chairman, Department of Psychiatry, University of Pennsylvania School of Medicine Samuel Templeman (Sam) gladding, Professor and Chair of Counseling, Wake Forest University Sharon M. goldsmith, President, Goldsmith International SP Michael A. Hoge, Professor of Psychology and Director, Yale Behavioral Health, Yale University Kevin C. Kiley, Associate Professor and Chairman of the Department of Obstetrics and Gynecology, Albany Medical College vii

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viii REVIEWERS Janice L. Krupnick, Professor of Psychiatry and Director, Trauma and Loss Program, Georgetown University Richard A. McCormick, Consultant, Clinical Psychologist, and Senior Scholar, Center for Health Care Research and Policy, Case Western Reserve University Robert J. ursano, Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences Myrna M. Weissman, Professor of Epidemiology and Psychiatry, Columbia University College of Physicians and Surgeons, and Chief, Department of Clinical-Genetic Epidemiology, New York State Psychiatric Institute Reg Arthur Williams, Professor of Acute, Critical and Long Term Care Programs, School of Nursing and Professor of Psychiatry, Medical School, University of Michigan Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Dan g. Blazer, J.P. Gibbons Professor of Psychiatry, Duke University Medi- cal Center, and Paul S. Appelbaum, Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, Columbia University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests with the authoring committee and the institution.

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Acknowledgments This report could not have been prepared without the guidance and expertise of numerous persons. Although it is not possible to men- tion by name all those who contributed to the committee’s work, the committee wants to express its gratitude to a number of them for their special contributions. Sincere thanks go to all the participants at the public meetings convened on April 9 and July 7, 2009. The intent of the workshops was to gather information regarding issues related to the practice of mental health counselors in various care setting. The speakers, who are listed in Appendix A, gave generously of their time and expertise to help inform and guide the committee’s work. Many of them also provided additional information in response to the committee’s myriad questions. We are indebted to Rhonda Robinson-Beale, who served as a con- sultant to the committee and who shared her deep knowledge of the provision of mental health–care services in managed-care settings. The committee extends special thanks to the dedicated and hard- working staff of the Institute of Medicine’s Board on the Health of Select Populations, who supported and facilitated its work. Board Director Rick Erdtmann helped to ensure that this report met the highest stan- dards of quality. Finally, the committee members would like to thank the chair, George Isham, for his outstanding work, leadership, and dedication to this project. ix

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Contents SuMMARY 1 1 INTRODuCTION 15 TRICARE’s Responsibilities and Structure, 15 Mental Health–Care Services and Providers Under TRICARE, 19 Origin of the Study, 30 Committee Statement of Task, 35 Committee Approach to Task, 38 Overview of Related Institute of Medicine Reports, 38 Organization of This Report, 41 References, 42 2 TRICARE BENEFICIARIES AND MENTAL HEALTH ISSuES IN MILITARY FAMILIES 47 Demographics of the TRICARE Population, 47 Special Exposures and Risk Factors in the TRICARE Population, 48 Mental Health Conditions Identified for Attention by the TRICARE Management Activity, 54 Psychosocial Issues in US Military Families, 75 Data on Patients Under the Care of Counselors, 80 References, 82 xi

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xii ConTEnTS 3 REQuIREMENTS RELATED TO THE PRACTICE OF COuNSELINg 91 The Profession of Counseling, 91 Accreditation of Counselor Educational Institutions, 103 Means of Professional Recognition, 112 Licensing, 113 Certification by Standards Associations, 127 Recognition of Third-Party Certifications by the Department of Defense, 131 Credentialing and Privileging, 132 References, 144 4 INDEPENDENT AND SuPERvISED PRACTICE OF COuNSELORS IN OTHER HEALTH–CARE SYSTEMS 149 Independent and Supervised Practice Under Other Federal Programs, 149 Independent and Supervised Practice Under the Federal Employee Health Benefits Program, 155 References, 164 5 RESEARCH REgARDINg THE DETERMINANTS OF HIgH-QuALITY MENTAL HEALTH CARE 167 General Concepts of Health–Care Quality and “Evidence- Based Practice,” 168 Evidence-Based Practice for Psychosocial Interventions to Address Clinical Issues of Special Relevance to the TRICARE Population, 176 Empirical Evidence Regarding Distinctions Between the Practice of Counselors and the Practice of Other Mental Health Professionals, 182 Strategies for Monitoring and Improving the Quality of Behavioral Health Care, 183 Barriers to Implementing Clinical and Systems Quality- Improvement Strategies, 193 Quality-of-Care Initiatives in TRICARE and the Military Health System, 194 Observations, 197 References, 197

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xiii ConTEnTS 6 FINDINgS, CONCLuSIONS, AND RECOMMENDATIONS 205 Overview of the Committee’s Work and Findings, 205 Recommendations, 207 References, 212 APPENDIxES A Public Meeting Agendas 217 B Additional Demographic Information on the TRICARE Beneficiary Population 221 C Definition of Terms Used in This Report 227 D Excerpts from 32 CFR § 199.6: Selected Subsections Regarding the Practice of Authorized Mental Healt27 Providers Under TRICARE 231 E Excerpts from Army Regulation 40–68: Selected Subsections Regarding the Scope of Practice and Supervision of Licensed Counselors 239 F Case Summary Illustrating the Complexity of Mental Health Issues in the Military Population 241 G State Laws and Regulations Regarding the Practice of Counselors as of November 2009 251 H Biographic Sketches of Committee Members, Consultant, and Staff 327

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