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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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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

1

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.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

National Oceanic and Atmospheric Administration—and the National Guard and Reserves. It is the contemporary embodiment of a commitment 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 demonstration 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 disparate 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, medical 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, funding regional initiatives to improve the delivery of health-care services,

2

CHAMPUS is still referred to in some regulatory and policy documents that address TRICARE operations.

3

The US Office of Personnel Management offers the following somewhat circular 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.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 Healthcare 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 eligibility. 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 ensuring 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 beneficiary 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 automatically 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 beneficiaries, available coverage options, and restrictions, if any, on benefits under the TRICARE program.

TRICARE policies regarding providers, covered persons, and procedures are defined by statute as set forth in the United States Code (USC),

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 1.1 Health-Care Coverage Under TRICARE

Eligible Beneficiary

Coverage Options

Active-duty service member

TRICARE Prime

Active-duty family member (includes spouses, unmarried children up to 21 years old or 23 years old if enrolled in college full-time)

TRICARE Prime

TRICARE Extra

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 works more than 50 miles or 1 hour’s drive from a military treatment facility

TRICARE Prime Remote

Family member who resides with an active-duty service member who lives and works more than 50 miles or 1 hour’s drive from a military treatment facility

TRICARE Prime Remote for

Active Duty Service Members

(TPR ADSM)

TRICARE Extra

TRICARE Standard

Active-duty member of the Reserves

TRICARE Prime

TRICARE Prime Remote

Family of a Reserve member activated for more than 30 days

TRICARE Prime

TPRADSM

TRICARE Extra

TRICARE Standard

Retired National Guard or Reserve member, familyb

TRICARE Prime

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 older

TFL

Congressional Medal of Honor recipient, immediate family

TRICARE Prime

TRICARE Extra

TRICARE Standard

TFL (if 65 years old or older)

Unremarried former spouse of active or retired military-service member

Family of court-martialed sponsor

Eligibility determined case by case

Family of sponsor missing in action

Eligibility determined case by case

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Eligible Beneficiary

Coverage Options

Foreign force member, familyc

Coverage, eligibility depend on country of origin

Survivor

Benefits differ depending on survivor status entered in DEERS

Victim of abused

Eligible for limited medical benefits

aTRICARE Plus is available only at certain military treatment facilities and allows 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.

bA sponsor and family members are not eligible for TRICARE health benefits until the sponsor reaches the age of 60 years and begins to receive retired pay.

cMust be registered in DEERS and have a valid military ID card.

dCare may be provided if the victim’s active-duty spouse has been separated from the 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 policies 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 fiscal year (TRICARE, 2009a). Outpatient services include psychotherapy (individual, group, family, and conjoint therapy and collateral visits),

4

Online versions of the manuals are maintained at http://manuals.tricare.osd.mil/.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

psychoanalysis, psychological testing, and medication management. Inpatient services incorporate acute care, psychiatric partial hospitalization, and residential treatment-center care. In addition, a number of substance-use services are covered: inpatient detoxification and rehabilitation; 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 psychiatrists 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 Interactions between TRICARE beneficiaries and mental health service providers.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 treatment 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 practices (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)(1)(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.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 1.2 Mental Health Professionals Under TRICARE—Disciplines and Associated Restrictions

Disciplinea

Requires Supervision and Referral by Physician

Need Participation Agreement to Practice Independently

Able to Supervise Applicable Staff

Licensed physician (including psychiatrist)

No

Yes

Licensed clinical psychologist

No

No

Yes

Licensed/certified psychiatric nurse specialists

No

No

Yes

Licensed/certified clinical social worker

No

No

Yes

Licensed/certified marriage and family therapist

No if participation agreement is signed; yes if participation agreement is not signed

Yes

Yes if participation agreement is signed; no if participation agreement is not signed

Licensed/certified pastoral counselor

Yes

No

Yesb

Licensed/certified mental health counselor

Yes

No

Yes

aLicensure/certification must be at full clinical level of practice.

bIf supervisee is not able to work toward licensure with discipline of supervisor, supervisor cannot supervise under TRICARE standards; supervisor must also be working within scope of his or her practice/license/certification.

SOURCE: NQMC (2005).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 interpret 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 services 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 prescription 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 family psychiatric and mental health to nurse practitioners; clinical nurse

5

In addition, the DOD Psychopharmacology Demonstration Project, which took place in 1991–1997, graduated 10 students from its pharmacotherapy training program and granted them privileges (Ralph and Sammons, 2006).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 Center, 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 pharmacology, 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 substance-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 setting, 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.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 government 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 combination 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 counseling 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 therapists 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

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

signed, supervision and referral by a physician are required (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.8, 2002).

Pastoral Counselors

Pastoral counselors are trained in psychology and theology and provide counseling, as well as spiritual guidance, to patients. Certification by the American Association of Pastoral Counselors requires that people obtain a 3-year professional degree from a seminary and a specialized master’s or doctoral degree in a mental health or behavioral health discipline. Postgraduate training includes at least 1,375 hours of supervised clinical experience and 250 hours of direct approved supervision (American Association of Pastoral Counselors, 2009).

Authorization under TRICARE requires licensure or certification by the state in which the counselor practices and a combination of 200 hours of approved supervision and 1,000 hours of supervised clinical experience in the practice of pastoral counseling or a combination of 150 hours of approved supervision in the practice of psychotherapy, including at least 50 hours of approved individual supervision in the practice of pastoral counseling, and 750 hours of supervised clinical experience in the practice of psychotherapy, with at least 250 hours of supervised clinical practice in pastoral counseling. As of 2009, six states licensed pastoral counselors: Arkansas, Kentucky, Maine, New Hampshire, North Carolina, and Tennessee. In states that do not offer licensure or certification, a pastoral counselor must be, or must meet all the requirements to become, a fellow or diplomate member in the American Association of Pastoral Counselors.

Pastoral counselors practicing under TRICARE must have a written referral and continuing supervision by a physician for their services to be reimbursable. However, because of the similarities among the requirements for licensure, certification, experience, and education, pastoral counselors may elect to be authorized as certified marriage and family therapists in many states and under TRICARE. That gives those providers the option of entering into a PA to practice independently under TRICARE. Without authorization as a marriage and family therapist and signing of a PA, services are covered only when a physician refers a beneficiary for therapy and continuing supervision by and communication with that physician is maintained throughout the course of treatment. Pastoral counselors cannot provide services under both

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

provider categories (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.9, 2002).

Mental Health Counselors

Licensed mental health counselors (LMHCs) provide assessment and diagnosis of and treatment for mental illnesses, emotional problems, and substance-use issues to individuals and groups through psychotherapy, behavior modification, and counseling (AMHCA, 2009). Throughout the United States, several titles are used to identify people who practice in this discipline, including licensed professional counselor (LPC), licensed professional mental health counselor, licensed clinical professional counselor, licensed professional counselor of mental health, licensed clinical mental health counselor, and licensed mental health practitioner. In this report, the term counselor is used generically to refer to these professionals; specific titles are used in the text when needed to conform to the terminology in specific publications that are being discussed.

Educational requirements include a master’s degree in mental health counseling or an allied mental health discipline from a graduate program in counseling and 2 years of post–master’s degree clinical experience under the supervision of a licensed or certified mental health professional. Most states also require a minimum of 60 hours of graduate study and 3,000 hours of supervised experience to apply for licensure, but these criteria vary by state.

Under TRICARE policies, educational experience must include 3,000 hours of clinical work and 100 hours of face-to-face supervision. All counselors must pass a state or national licensure or certification examination to be considered authorized providers. If their state does not offer licensure to mental health counselors, they must be eligible for full clinical membership in the American Mental Health Counselors Association (AMHCA) or be certified as clinical mental health counselors by the Clinical Academy of the National Board of Certified Counselors (TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.10, 2002). Clinical membership in the AMHCA requires at least a master’s degree in counseling from an accredited institution and a state license/certification or certification as a clinical mental health counselor (AMHCA, 2009). Counselors are not authorized to prescribe medication, and services rendered by them require referral and supervision by a physician to be reimbursed under TRICARE.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Referral and supervision requirements for mental health counselors6 are delineated in 32 CFR § 199.6(c)(3)(iii)(K) and TRICARE Policy Manual 6010.54-M, Chapter 11, Section 3.1. They state that the services of these providers “may be provided only if the beneficiary is referred by a physician for the treatment of a medically diagnosed condition and a physician must also provide continuing and ongoing oversight and supervision of the program or episode of treatment” if they are to be considered for benefits on a fee-for-service basis. The terms of referral and supervision mandate that

  • “Physicians must actually see the patient to evaluate and diagnose the condition to be treated prior to referring the beneficiary.”

  • “The referring physician [must provide] ongoing oversight of the course of referral related treatment throughout the period during which the beneficiary is being treated.”

  • “Written contemporaneous documentation of the referring physician’s basis for referral and ongoing communication between the referring and treating provider regarding the oversight of the treatment rendered as a result of the referral must meet all requirements for medical records established by [the regulation].”

They also indicate that the “referring physician supervision does not require physical location on the premises of the treating provider or at the site of treatment.”

Chapter 3 provides more detail on counselor’s education, clinical training, and licensure and on the accreditation of institutions that grant their degrees.

Mental Health Care by Primary-Care and Other Providers (Physicians, Advanced Practice Nurses, and Physician Assistants)

PCPs are physicians—typically general practitioners or family practitioners, internists, and pediatricians for younger patients—or physician assistants, nurse practitioners, or sometimes other health-care providers who are often patients’ first point of contact with the health-

6

These requirement also apply to persons practicing as pastoral counselors under TRICARE.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

care system. Although they are not mental health specialists, they have a major role in differential diagnosis of and treatment for mental disorders, especially depression and anxiety. PCPs also typically play a part in managing patients’ psychiatric symptoms in collaboration with mental health professionals (Kushner et al., 2001). Despite documented deficiencies in the quality of mental health care provided by PCPs, patients may prefer to see them or have few alternatives (Geller, 1999). Eaton and colleagues (2008) reported that military spouses most often received their mental health care from PCPs rather than from specialty mental health professionals.

PCPs may refer patients to counselors for treatment and supervise their work under the current TRICARE system.

Other Specialists Not Recognized as Authorized Mental Health Providers

Substance-use counselors are not recognized in TRICARE as authorized mental health providers. Information on them is provided here because the committee’s statement of task listed substance-use disorders among the health conditions of interest.

Substance-use counselors help people who have drug, alcohol, gambling, and food addictions to identify behaviors and problems related to their addictions. Most often, that counseling is done in a group setting, but it can also be done on an individual basis. The counselors also work with family members of people who have addictions and conduct programs aimed at preventing addiction (BLS, 2008-09c). The minimal educational requirements to qualify as a substance-use counselor are less rigorous than those for a mental health counselor. About half the states require a credential to practice, and more than half of these do not require a college degree. However, substance-use counselors are generally required to have about 1,000 hours more of supervised work experience than are mental health counselors. That is due in part to an apprentice training model adopted by the profession in which most of the knowledge, skills, and training is acquired through supervised experience on the job (Kerwin et al., 2006).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

ORIGIN OF THE STUDY

The issue of the independent practice of counselors has been discussed in Congress for several years. Various versions of several pieces of legislation—including the TRICARE Enhancement Act of 2000 (HR 4418, 106th Congress), the TRICARE Mental Health Services Enhancement Act (HR 2739, 107th Congress), the National Defense Authorization Act (NDAA) of Fiscal Year 2006 (HR 1815, 109th Congress), the NDAA for Fiscal Year 2007 (HR 5122, 109th Congress), and the NDAA for Fiscal Year 2008 (HR 1585, 110th Congress)—have proposed the expansion of counselors’ responsibilities under TRICARE, including practice independent of physician referral and supervision. None of these proposals has been adopted into law.

Summary and Review of Expanding Access to Mental Health Counselors—Evaluation of the TRICARE Demonstration

The 2001 NDAA directed DOD to implement a 1-year demonstration project in which access to qualified LMHCs was expanded by not requiring documentation of referral and supervision by a physician. The NDAA also required an evaluation of the demonstration’s impact on service use, cost, and outcomes. As a result, TMA sponsored a study conducted by the Center for Military Health Policy Research (a joint venture of RAND Health and the RAND National Defense Institute) (Meredith et al., 2005). The demonstration project began on January 1, 2003. Mental health care utilization and outcomes were examined in the demonstration and comparison regions by analyzing data on claims before and after the demonstration and surveying beneficiaries after the demonstration. TMA chose two so-called catchment areas7 in the TRICARE central region—Colorado Springs, Colorado, and Omaha, Nebraska—for the project “because their high volume of LMHCs would ensure ample providers for the demonstration” (Meredith et al., 2005, p. xiii).

7

TRICARE defines a catchment area as follows: “the geographic area surrounding an MTF with inpatient capabilities…. Under TRICARE, a catchment area is also used as a planning tool to identify our eligible population, and define areas where our managed care support contractors must offer the TRICARE Prime benefit” (HA POLICY 97-038, March 5, 1997).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

The RAND investigators hypothesized that the demonstration project might affect TRICARE beneficiaries and providers via

  • Increased access to care delivered by mental health counselors resulting from fewer procedural barriers and less of a stigma from seeking counseling services, in contrast with no increased access to psychotropic medication care due to getting medicines solely from a doctor.

  • Higher utilization of mental health services (especially counseling) as a function of direct access to LMHCs. There may be an increase in beneficiaries receiving both medication and counseling.

  • Decreased total cost of care, again due to more use of mental health counselors (as a lower-cost alternative to other mental health specialists) and elimination of supervision costs.

  • Increased or decreased quality of care among those seeing mental health counselors. Increased quality of care could be due to changes in professional roles, including greater autonomy and responsibility, earlier access to care, and earlier interventions. However, the demonstration could decrease quality of care through lower rates of collaboration with other professionals, especially for psychotropic medication treatment in collaboration with physicians, or through inappropriate visits, or based on some characteristics potentially associated with counselors (such as lower use of evidence-based therapy, lack of clinical skill to detect problems) (Meredith et al. 2005, pp. 9-10; emphasis in original).

The claims-data analyses found that in the overall beneficiary population, there was a small but statistically significant increase in the likelihood of being hospitalized for a psychiatric condition in the demonstration region. However, that the finding was not present in later analyses that controlled for characteristics of beneficiaries who were more likely to see LMHCs suggests that it was unrelated to LMHC care. In the overall beneficiary population, there was a decrease in the likelihood of seeing another mental health provider or non–mental health physician provider. In analyses that controlled for characteristics contributing to the likelihood of seeking services from an LMHC, beneficiaries who saw LMHCs were less likely to see psychiatrists and to receive psychotropic

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

medication.8 However, it is unknown whether those use changes were associated with differences in outcomes.

The survey data revealed that enrollees in the demonstration and comparison regions described no difference in access to mental health services, adherence to treatment, or mental health status. Enrollees in the demonstration region were more likely to report favorable ratings of counseling and treatment and of getting care when needed, although the cross-sectional nature of the survey design precludes determining whether this was a consequence of LMHC independent practice. Because the survey data were collected only after LMHC independent practice was implemented, it is possible that the results are due to regional differences and unrelated to the demonstration.

It is important to note that limitations in the data and study design preclude determining whether the LMHC independent practice resulted in different patient or beneficiary access to care or different outcomes. The demonstration project was conducted at roughly the same time as the initiation of major combat operations in Operation Iraqi Freedom. This mission has resulted in an increase in the demand for mental health care services in the active-duty military and their families, and the conclusions drawn regarding access may therefore not reflect current circumstances. Furthermore, even though the study found no evidence of changes in access to treatment as a result of the demonstration, the results might not be generalizable to regions where mental health providers are scarcer.

8

Of note, unadjusted analyses indicated that a higher percentage of patients seen by LMHCs received psychotropic medication, compared to patients seeing other mental health counselors. However, that difference was observed in both the demonstration and the comparison regions (particularly before the demonstration, when all LMHCs were required to have supervision and referral by a physician). The difference probably reflects preceding referral or supervision requirements rather than being evidence of prescribing patterns of LMHCs versus other mental health providers if supervision or referral requirements were similar. Furthermore, the observation that, in unadjusted analyses, psychotropic-medication use among patients seeing LMHCs declined by nearly 11% in the demonstration area and 3% in the comparison area suggests that the unadjusted results are consistent with the adjusted (i.e., patients seeing LMHCs have a lower likelihood of receiving psychotropic medication than those seeing other mental health providers).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Department of Defense Response to Congressional Inquiries Regarding the Use of Counselors in the Military Health System

DOD submitted the RAND study to Congress on May 10, 2005. About 6 months later, a House conference report that accompanied the FY 2006 National Defense Authorization Act (US Congress, House of Representatives, 2005) directed DOD to produce a report that included a review of the quality of care provided by LMHCs in the Military Health System (MHS) (DOD, 2006).

The resulting report—Aspects of the Use of Licensed Professional Counselors in the Military Health System. Report to Congress (DOD, 2006)—was delivered in June 2006. It offers insights into DOD’s concerns regarding the independent practice of counselors (referred to as LPCs in the text), which were summarized in the text (pp. 9-10) as follows:

There remains significant variability among the states in training programs and requirements for licensure as a mental health counselor…. Some counselors attend training programs accredited by the CACREP,9 a nationally recognized accrediting agency, while many do not. In most states a qualifying education requires only minimal coursework in diagnosis and treatment of mental disorders and no specific clinical experience with individuals with mental disorders. In some states licensure as a professional counselor can be obtained with a Masters-level postgraduate degree in fields only “related” to counseling. While there is evidence that the extent of training variability has decreased over time, it remains a reality that professional counselors licensed to practice have an unevenness of exposure to classroom education and supervised clinical experiences in the assessment and treatment of persons with mental disorders.

The report states (p. 10) that the purpose of the current policy of supervision of counselors is to “ensure that the quality of care provided to our beneficiaries is not compromised by differences in scope of training and experience from other currently authorized groups of providers.” However, it stipulates that physician oversight of counselors’ clinical

9

The Council on Accreditation of Counseling and Related Educational Programs (CACREP) accredits graduate-level counselor-education programs. CACREP’s function and requirements are addressed extensively in Chapter 4.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

work “occurs predominantly on paper” and is “difficult to ensure to any great degree” (p. 9).

The report notes that “quality of care for mental health … in the MHS is determined largely by the credentialing process and application for TRICARE provider status.” It gives as an example the Navy’s use of counselors in its Fleet and Family Support Programs (FFSPs)10 in states in which counselors are authorized to practice independently. In these circumstances, providers are granted practice privileges on a case-by-case basis , using a standard that specifies education, training, and experience requirements (SECNAVINST 1754.7A; the standard is discussed in greater detail in Chapter 3). The report indicates (p. 8) that

when using the strict criteria … to privilege LPC providers, Navy FFSPs have not noted any consistent differences in the quality of care provided by LPCs when compared to other Master’s-level practitioners. Similarly, no qualitative differences in care are noted by health care administrators operating in the TRICARE managed care system.

It concludes that “referral to LPCs has been strengthened through the use of primary care physicians as the referral source” but that

given the practical obstacles to physician supervision of LPCs and the perceived impediment to accessing services caused by the physician referral requirement, it would be prudent to explore issues of supervision, referral, provider credentialing, and scope of practice to develop options that would preserve quality of care, safeguard the health and well-being of Service members and maximize access to mental health care for all beneficiaries.

The National Defense Authorization Act for Fiscal Year 2008 Directive

The NDAA for Fiscal Year 2008 (Public Law 110-181) directed DOD to enter into a contract with IOM “for the purpose of (1) conducting an independent study of the credentials, preparation, and training of individuals practicing as licensed mental health counselors;

10

FFSPs provide a variety of support services to Navy personnel and their families, including employment, financial, relocation, transition, and counseling assistance; they are not medical-care facilities.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

and (2) making recommendations for permitting licensed mental health counselors to practice independently under the TRICARE program.” In response to that mandate and to fulfill the resulting contract, IOM formed the Committee on the Qualifications of Professionals Providing Mental Health Counseling Services Under TRICARE in early 2009.

COMMITTEE STATEMENT OF TASK

DOD specified several elements for the committee to address:

  • Educational requirements—The report shall provide for an assessment of the educational requirements and curricula relevant to mental health practice for licensed mental health counselors, including types of degrees recognized, certification standards for graduate programs for such profession, and recognition of undergraduate coursework for completion of graduate degree requirements and the extent to which such educational requirements prepare licensed mental health counselors to diagnose and treat such illness such as 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 regularly associated with head trauma.

  • Licensing requirements—The report shall provide for an assessment of State licensing requirements for licensed mental health counselors, including for each level of licensure if a State issues more than one type of license for the profession. The assessment shall examine requirements in the areas of education, training, examination, continuing education, and ethical standards, and shall include an evaluation of the extent to which States authorize members of the licensed mental health counselor profession to diagnose and treat mental illnesses, including illness such as 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 regularly associated with head trauma.

  • Clinical experience requirements—The report shall provide for an analysis of the requirements for clinical experience for a licensed mental health counselor to be recognized under regulations for the TRICARE program, and the extent to which such

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 condition, 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 independently 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 requiring 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 profession 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

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 provided 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, substance 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 allowing 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 depressive 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 recommendations [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 recommended changes to TRICARE’s resources, staffing, number of providers, and care obligations to accomplish it.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

COMMITTEE APPROACH TO TASK

To answer the questions posed by the sponsor, the committee undertook 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 computerized 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 sponsor, 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,

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 accreditation 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 federal 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 21st 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, efficient, and equitable. A 21st-century health-care delivery system, it said, should have health-care processes that are based on continuous healing relationships, shared information between clinicians and patients, evidence-based decision making, and collaboration among clinicians and institutions. The report recommended restructuring clinical education 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 technology 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 interactions. 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 credentialing and licensure of M/SU providers that are based on specific clinical competencies.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 psychiatric 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 reprocessing therapy, cognitive restructuring, coping-skills training, and therapy delivered in group formats.

The 2008 report Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress (IOM, 2008a) concluded that there is a consistent, positive association between deployment and specific health effects, such as psychiatric disorders (including

11

The committee did not conclude that pharmacotherapy was ineffective but rather that the evidence base was insufficient.

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 suggestive 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 disturbance, 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 professional 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 supporting appendixes. Chapter 2 provides background information on the characteristics of the TRICARE beneficiary population and some of the

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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 educational, 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 provided in Appendix A. Appendix B provides excerpts from the section of the CFR that delineates the rules governing the practice of authorized 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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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 behavioral health. Washington DC: National Academy Press.

IOM. 2001. Crossing the quality chasm: A new health system for the 21st 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 6: 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. Washington, DC: The National Academies Press.

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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 psychology: 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 edition, 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. Participation 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 counselor. 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).

Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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TRICARE. 2009b. TRICARE beneficiary handbook. http://www.tricare.mil/tricaresmartfiles/Prod_125/BW_HB_LO_RES.pdf. (Accessed October 10, 2009). Note that several versions 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 109-360. National Defense Authorization Act for Fiscal Year 2006. Conference report to accompany H.R. 1815. 109th Congress, 1st 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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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Suggested Citation:"1 Introduction." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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In this book, the IOM makes recommendations for permitting independent practice for mental health counselors treating patients within TRICARE--the DOD's health care benefits program. This would change current policy, which requires all counselors to practice under a physician's supervision without regard to their education, training, licensure or experience.

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