Provision of Mental Health Counseling Services Under TRICARE (2010) / Chapter Skim
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Warfighters are vulnerable to a variety of complex and sometimes difficult-to-diagnosis conditions, including posttraumatic stress disorder and traumatic brain injury. Stresses resulting from multiple and long deployments put military families at risk for marital conflict, intimate-partner violence, and behavioral disturbances in children.
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In response, IOM formed and convened the Committee on the Qualifications of Professionals Providing Mental Health Counseling Services Under TRICARE. In TRICARE, independent practice frees providers from requirements that state that a beneficiary must be "referred for therapy by a physician" and that the referring physician "must actually see the patient to evaluate and diagnose the condition to be treated prior to referring the beneficiary" and provide "ongoing oversight of the course of referral related treatment throughout the period during which the beneficiary is being treated," including "ongoing communication between the This report uses the term psychotherapy interchangeably with counseling, following the 1 convention applied by most of the literature.
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REPORT SYNOPSIS Mental Health Issues in the TRICARE Beneficiary Population The committee's statement of task identified a set of illnesses for attention in assessing the education, licensure, and clinical experience of and the quality and effectiveness of care provided by counselors: • Major depressive disorder; • Schizophrenia; • Posttraumatic stress disorder; • Bipolar disorder; • Mental disorders due to a general medical condition; • Somatoform disorders; and • Delirium, dementia, amnestic, substance-use, and other dis orders regularly associated with head trauma. Those illnesses may be caused or exacerbated by physical and psychological exposures related to military service.
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These psychosocial problems -- which include issues related to interpersonal relationships, behavior, and stress -- fall more directly in counseling's primary focus on promoting coping and facilitating growth related to life-cycle transitions. The diversity and the diagnostic and treatment complexity of the mental health illnesses found in the beneficiary population highlight the need for a comprehensive approach to quality management in care delivery in the TRICARE system.
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The educational requirements and curricula for mental health counselors who graduated from institutions that are CACREP-accredited in mental health counseling or clinical mental health counseling (after July 1, 2009) contain elements relevant to preparing counselors to serve as independent practitioners and to diagnose and treat for disorders that may be found in the TRICARE beneficiary population.
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The research reviewed by the committee indicates that -- although education, licensing, and clinical-experience requirements play roles in a system of quality management -- there is no information that would allow one to determine whether a particular education level, licensure, or amount of clinical experience is needed to serve effectively as an independent practitioner or to establish whether a practitioner is adequately
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Independent and Supervised Practice of Counselors in Other Health-Care Systems The statement of task asked the committee to assess the extent to which counselors practice independently in other settings and to review the history of the regulation of mental health–care providers by TRICARE. Programs such as Medicare, those administered by the Department of Veterans Affairs, the Indian Health Service, and Head Start, and those provided under the Federal Employee Health Benefits Program and by private insurers exhibit no consistent pattern in their policies regarding the independent practice of counselors.
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The committee sought to identify outcome studies and literature regarding the comparative quality and effectiveness of care provided by licensed mental health counselors. It found that a number of metaanalyses and reviews had examined psychotherapy and counseling effectiveness, but they do not provide evidence on the comparative effectiveness of treatment by different types of mental health–care providers.
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, use delineated scopes of practice and privileging of individual practitioners to ensure that all health professionals deliver the services that they have demonstrated competence in. Previous IOM reports in the Quality Chasm series indicate that the best way for health-care providers like TRICARE to achieve the delivery of high-quality care to their beneficiaries is through appropriate standards of education and training for providers, promotion of evidence-based care standards, and monitoring of results (IOM, 2001, 2006)
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In light of the information that it gathered and reviewed, it recommends that TRICARE replace its current quality management system for oversight of the practice of counselors through physician referral and supervision with a mental health quality monitoring and management system that incorporates the following two primary elements: [1] Independent practice of mental health counselors in TRICARE in the circumstances in which their education, licensure, and clinical experience have helped to prepare them to diagnose and, where appropriate, treat conditions in the beneficiary population.
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• 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.
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. 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 military personnel, veterans and their families" and include training in military culture, combat trauma, suicidal risk, and blast-related traumatic brain injury (TBI)
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2005. Expanding access to mental health counselors: Evaluation of the TRICARE demonstration.
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