Alternative Approaches for Expanding the Air Force's Task Force True North Program

The Air Force aims to maximize airman fitness and minimize threats to individual and unit readiness. Negative outcomes, such as domestic and sexual violence and suicide, and their associated effects on readiness, can be avoided by increasing airman fitness and ensuring that effective prevention and treatment programs reach those in need. It is this premise that drives the Air Force's Task Force True North (TFTN) program, which makes the assumption that the Air Force can prevent these behavioral threats to readiness by increasing access to health services by embedding health care providers directly into units. We did not evaluate this assumption in this project.

The objective of this project was to assist the Air Force in identifying approaches to expanding its TFTN program, including estimating each approach's associated manpower requirements, recruiting requirements, total costs, and implementation timelines. Our goal was not to assess the effectiveness of the embedded program model or of the TFTN program itself, but rather to develop a model to project provider staffing and program costs based on three potential courses of action for program expansion.

TFTN was modeled after U.S. Special Operations Command's (USSOCOM's) Preservation of the Force and Family (POTFF) initiative¹ and the Air Force Comprehensive Airman Fitness (CAF) framework, which is described in Air Force Instruction (AFI) 90-5001.² The CAF “is a holistic, strength-based, and integrated framework that plays a role in sustaining a fit, resilient, and ready force. It includes fitness in the mental, physical, social, and spiritual domains, and incorporates the Wingman concept of Airmen taking care of Airmen. CAF is not a standalone program, but encompasses multiagency programs and activities across the Air Force.”³

Table 1 shows the CAF fitness “domains,” with the analogous POTFF performance areas below them in parentheses. The second column of the table shows the tenets of the Air Force domain. The third column lists the goals of the analogous POTFF performance area.

The Military's Rationale for Embedded Care

The military's rationale for relying on embedded care providers is that stigma associated with seeking mental health care, as well as other perceived barriers to care, can be circumvented by bringing the care directly to the service member. In addition to proximity, embedding providers can increase the continuity of care delivered to service members throughout a deployment cycle. There is also a commonly held belief that providers assigned to units will reduce stigma associated with seeking care by forging relationships with unit members and understanding their experiences and culture, thus establishing more provider “credibility.” Stigma may also be reduced by demonstrating to service members that their command and senior leaders are supportive of behavioral health care. Embedded providers can also benefit commanders by providing a single point of contact for understanding mental fitness–related concerns and an opportunity to build trust with the provider. The embedded providers’ presence alone may raise mental health awareness in commanders and service members. Embedded providers are also well positioned to recognize problems in service members before they become severe enough to require referral to specialty health care. Early recognition and early intervention can prevent threats to unit readiness and tragic outcomes. We did not conduct a systematic or in-depth review of the literature on embedded care to test these assumptions. Rather, we began with the assumption the Air Force makes: that embedding care can improve the health of the force.

Examples of Embedded Provider Programs from the Other Military Services

Each of the other services in the U.S. military has experience with embedded behavioral or physical health programs, though the structure, focus, and results of each vary. While some studies that have been conducted point to advantages of certain embedded program designs, overall, the research is limited, and a systematic literature review of embedded care was beyond the scope of the current study. But it is clear from the interviews with leaders of embedded programs that benefits and drawbacks result from each type of embedded care model. Because of the diversity in program design and implementation across the services, each program offers opportunities to draw lessons learned for the Air Force's expansion of TFTN. In addition, USSOCOM has substantial experience in developing and implementing an embedded health program throughout its units and special operations components in each of the services.

Although not exhaustive, our analysis of the interviews with leaders of the embedded health programs in the Army, Navy, Marine Corps, and USSOCOM shows that each service administers its program in ways substantially different than the others. For example, the degree of standardization among the programs ranges from very little, as is the case with USSOCOM's POTFF initiative, to highly standardized, as in the Army's Embedded Behavioral Health (EBH) program. Further, organizational structure, chain of command, and the personnel included in provider teams also varies widely among the other services and USSOCOM. Each program has its own strengths and trade-offs and can offer critical lessons for the Air Force's efforts.

Despite variations in program design and implementation, through interviews with program stakeholders, we identified some key commonalities that characterize the other services’ and USSOCOM's programs:

• First and foremost, program design must follow directly from program goals, rather than the inverse. The type of specific program goal of the embedded program—for example, to increase readiness, to provide better medical care for the service member, to strengthen relationships between providers and units—will directly affect how the program should be structured, whether providers should fall within the unit chain of command, and how data on program effectiveness should be collected.
• Second, all embedded providers need to be able to build trust and buy-in with both unit commanders and service members. Interviewees we spoke with emphasized two key elements in forging those relationships: (1) effective training in and/or underlying understanding of specific unit needs and unit and service culture and (2) actual embedding within the units to increase repeat interaction, increase accessibility, and normalize treatment so that stigma is lessened. Further, each interviewee stressed that providers need to understand the unit's responsibilities and unique characteristics in order to be able to correctly determine whether a service member is fit for duty.
• Third, even if programs are not centralized or standardized across all units, data collection should be centralized so that the service can better disseminate lessons learned, have adequate information to effectively advocate for additional resources, and better target efforts to address program goals, whether in specific units or across the service's program.

RAND Framework for Squadron Risk Levels and Personnel Packages

During the course of this study, we developed a framework for analyzing mental, physical, and social squadron risk levels. To identify where squadron manpower needs may be greater, we first sought to identify the squadrons that might be at highest risk, as well as a method for assessing risk that the Air Force could use in the future. Our squadron risk framework and our initial assessment of squadron risk served as a foundation for the Air Force TFTN team's further assessments of risk. The TFTN team was able to access additional data sources suggested by RAND related to sensitive topics, such as sexual assault, suicide, and problematic behaviors, which allowed the Air Force to build an even more robust data set on risk metrics. We recommend that the Air Force continue to build on the risk framework and risk assessment developed by RAND and continue to acquire additional data to inform its evolving risk metrics. The next section describes our risk framework and its risk assessment.

Unit Risk and Protective Factors

Looking at the common risk factors across negative outcomes is useful for developing efficient support services. In a 2017 study, RAND researchers reviewed risk factors for sexual harassment, sexual assault, unlawful discrimination, substance abuse, suicide, and hazing, seeking to identify risk factors that were common across those problematic behaviors. They found substantial empirical evidence that climate is associated with sexual assault, sexual harassment, unlawful discrimination, substance abuse, and suicide (Marquis et al., 2017). Prior engagement in the problematic behavior, attitudes toward it, and access to means all increase the likelihood of these problematic behaviors. In an earlier study, the researchers also reviewed research on prevention strategies and found that education, skills building and social support, bystander support, and changes to attitudes, norms, and culture are viable prevention strategies (Marquis et al., 2017). Embedded providers may be well positioned to offer these prevention services to their units.

Data and Metrics Used for Independent RAND Risk Framework and Assessment

The first step that we took in determining a squadron's risk and its degree of need for assistance in any of the CAF domains was to establish some measures of the current status of each domain. To do so, we made use of data and approaches developed by the Air Force's 711th Human Performance Wing at the Air Force Research Laboratory (AFRL/711th HPW), detailed data from the Air Force's Military Personnel Data System (MilPDS), and analyses from earlier RAND research. These data sources enabled us to develop risk metrics for the physical, mental, and social domains. Because of the lack of available data, we were unable to develop any metrics for the spiritual domain. Table 2 shows how our variables were combined to determine squadron risk levels in the physical, mental, and social domains.

After ranking squadrons in each domain, we categorized them as being at high, medium, or low risk in each domain, as follows:

• High risk: top 5 percent of squadrons by risk
• Medium risk: the next 10 percent of squadrons
• Low risk: the remaining 85 percent of squadrons.

Analysis of Personnel Package Composition

We are not aware of any data on the relative effectiveness of one type of embedded provider versus another. Therefore, we looked to the types of providers that are currently included in other examples of embedded provider programs. We strongly recommend that, as the Air Force expands the TFTN program, it carefully track the effectiveness of the different types of providers included in the packages. In particular, if there is variation across the composition of the personnel packages, it is especially important to capture the difference in outcomes across those personnel packages.

Drawing on examples from other embedded provider programs and after discussions with our sponsor, we developed the personnel packages for low-, medium-, and high-risk squadrons shown in Table 3.

With the composition of personnel packages defined for the different risk levels by CAF domain, the categorization of the risk levels of each squadron allowed us to estimate the costs of providing these packages to squadrons that need them.

FY 2020–2025 Cost Summary

Table 4 summarizes the costs of our independent analysis of squadron risk and personnel packages from fiscal years (FYs) 2020 to 2025. The phasing assumptions of the costs come from an initial Program Objective Memorandum (POM) estimate completed by the Air Force for TFTN. Costs are shown by risk domain (social, physical, and mental) and military and civilian personnel.

Summary of Alternative Courses of Action and Estimating the Cost of Providing TFTN Personnel Packages

Four alternatives or courses of action (COAs) were developed in collaboration with the Air Force TFTN team:

• Baseline: TFTN POM submission with four-year implementation period
• COA 1: modified POM submission assumptions with five-year implementation period
• COA 2: COA 1 assumptions with ten-year implementation period
• COA 3: five-year implementation with personnel reductions in physical health.

We refer to the first COA simply as the baseline. This COA was the initial Air Force position and is based on the assumptions included in the Air Force–developed FY 2021 POM submission. The personnel packages for each mental health and physical health risk level are summarized in Table 5 and Table 6. There are four risk levels, ranging from “high+” to “low.”⁴ The Air Force evaluated each unit type for a risk level and assigned a personnel package based on the identified risk level.⁵ As shown in the second column, personnel are embedded at either the squadron level or the group level, providing services to multiple squadrons. Generally speaking, the higher risk the unit type, the more resources embedded at the squadron level.

COA 1: Modified POM Submission with Five-Year Implementation

COA 1 includes the first set of adjustments the Air Force made to the baseline POM estimate. The three major changes are the addition of one year to the implementation schedule, changes to several unit type risk characterizations for both mental health and physical health, and changes in year of implementation for several of the unit types.

COA 2: Ten-Year Implementation

COA 2 includes most of the same assumptions from COA 1 but extends the implementation to ten years in an attempt to reduce the five-year Future Years Defense Program (FYDP) cost by slowing the ramp-up.

COA 3: Five-Year Implementation with Reductions in Physical Health Personnel

COA 3 returns to the COA 1 implementation schedule of five years. The major change in this COA is the reduction in physical health personnel. All maintenance and logistics readiness–related squadrons are assumed to receive their respective squadron-level personnel packages at the group level rather than embedded at each individual squadron.

Comparison of COAs

Table 7 compares the annual cost based on the cumulative addition of personnel for each of the four alternatives described above. Unsurprisingly, the least expensive option at year 10 is COA 3, because it is the only COA under which personnel are actually reduced. The other three alternatives are relatively close in cost at year 10. At year 5, which would encompass the initial FYDP or budgetary period, the least expensive option is COA 2. This is because the implementation is much slower over a ten-year period.

Monitoring the Expansion of Task Force True North

Monitoring something as sensitive and significant as service member fitness and readiness requires constant vigilance from Air Force leadership and the institution itself. It is not enough to conduct yearly reviews of personnel policies or collect data or statistics. A monitoring plan must consist of long-term and deliberate methods of measuring progress and must include strategies to measure institutional and cultural change over time.

Establishing and maintaining a monitoring framework is a necessary condition to secure the success of TFTN. Long-term, sustained routine monitoring can identify potential problems quickly as they evolve over time. But the monitoring framework alone is not sufficient for sustained success of TFTN. We recommend that the Air Force also periodically conduct a comprehensive evaluation of the integration process to reevaluate monitoring priorities. A rigorous evaluation that uses valid and reliable research methods can give the Air Force a formal assessment of the process and outcomes of TFTN. We recommend that an initial evaluation be conducted about three years after implementation and then every five years.

Recommendations

The planning phase presents the Air Force with a critical window of opportunity to develop strategies, plans, and policies, as well as to put the necessary data systems in place to monitor the expansion of TFTN over time. Insights from other services’ experiences with embedded provider programs and the literature on organizational change inform the following recommendations:⁶

• Ensure top leadership support and commitment.
• Clarify program goals to enable success.
• Plan up front to facilitate data collection and evaluation.
• Consider issues of chain of command and organizational structure.
• Be prepared to respond to changing needs.
• Monitor progress of implementation over time.

During this planning process, both near-term and long-term issues should be considered, and the mechanisms put into place during the planning process should be flexible enough to accommodate learning and adjustments. Program implementation will likely be a process of continual, iterative improvements. Putting the systems in place to collect the appropriate data throughout the implementation process will help to build the evidence base for those improvements along the way and will facilitate program success.