Far from Care

Perhaps more than ever, service members and their families need access to behavioral health care. But studies show that people are less likely to seek care the longer they have to travel to receive care.

How many service members and families are remote from behavioral health care? Can access to care be improved?

The conflicts in Iraq and Afghanistan have taken a tremendous toll on the emotional and mental well-being of many service members and their families. The "invisible wounds" of war — depression, anxiety, traumatic brain injury, and drug and alcohol problems — are proving prevalent among today's returning warriors. Many spouses and children of deployed service members also have high rates of anxiety and depression, which can ultimately affect their performance at work and school.

There are many avenues by which service members and their families can obtain help. Professionals, including counselors, psychiatrists, and psychologists, make their services widely available through military treatment facilities, community human service agencies, and private offices. But while many service members and their families do receive behavioral health care, the Department of Defense is concerned that many may live too far from the support needed to help them cope and reintegrate into civilian life.

RAND researchers conducted the first comprehensive study of geographically remote service members' and families' access to behavioral health care and put forward a set of recommendations based on quantitative and qualitative analysis.

Living More Than 30 Minutes from Care Hinders Access

Among civilian populations geographical remoteness usually correlates with rural settings in the United States — sparsely populated areas like Appalachia, the Ozarks, and the Intermountain West. Among military populations we also found many individuals in nonrural settings to be distant from behavioral health care. Individuals living in remote areas, including service members and their families, face several distance-related challenges when it comes to seeking and receiving behavioral health care.

Care providers are few.

Approximately 80 percent of U.S. rural areas are classified as medically underserved — that is, areas that are lacking physicians, dentists, registered nurses, and other health professionals. Medically underserved areas often also have a shortage of psychiatrists, psychologists, and therapists. While military treatment facilities are sometimes located in remote areas, they do not reach all remote service members and their families.

Increased drive time reduces care-seeking.

Studies concerning civilian and veteran behavioral health care have demonstrated that time is of the essence in care-seeking. For some behavioral health issues, even the increase of one additional mile in distance can mean the difference between receiving care and not being treated.

Transportation options are limited.

Rural areas in the United States are notoriously short on public transportation alternatives. And some returning service members may need such options due to physical disability.

Who Are the Distance-Challenged?

The pie charts above show the percentage of full-time active component service members, by service, who are remote from behavioral health care. Note that the Coast Guard has the most active-component service members living 30 minutes or more from behavioral health care professionals (9,781), which represents a dramatically higher percentage (25 percent) of its total service members than the other services, which are between 1 and 3 percent. This is due to the Coast Guard placing many duty stations far from military treatment facilities and in areas that are designated as health professional shortage areas.

The pie charts above show the percentage of National Guard/Reserve members who are remote from behavioral health care. Each of the Armed Forces has a part-time reserve component. It is to be noted that the Army reserve in this case has the vast majority of component personnel living 30 minutes or more from behavioral health care professionals (197,620), which represents a higher percentage (36 percent) in terms of its total component personnel than the other services.

RAND researchers conducted a geospatial analysis using service member and dependent residential location and applied the 30-minute drive time rule to assess the remoteness of military members.

Despite the fact that more part-time service members live 30 minutes or more from care, they are less likely to be affected by distance; that is, they are more likely to receive behavioral health care (after being diagnosed) than their remote full-time active component peers. This might be because reservists have more insurance options because they are typically employed full time outside of the military.

Each dot=25 people

1.3M live 30 minutes or more from a behavioral health care facility or in a low provider density area

• 35,599 Active component
• 256,831 National Guard and Reserve
• 1,098,839 Dependents

RAND identified that roughly 1.3 million military service members and their dependents are geographically remote from behavioral health care. More specifically, approximately 1 million dependents (children and spouses) and 300,000 service members live far from needed care.

Video technology programs involve real-time, synchronous interaction with a clinician from great distances.

Photo by Chrystal Smith/IMCOM

3 Steps to Improved Access

1. Set goals for improvement.

   • Establish 30 minutes as the official maximum drive time to care.
   • Target near-100 percent access to behavioral health care for remote full-time active-component service members within the United States.
   • Set goals for increasing access for National Guard and Reserve service members and all military dependents.
2. Monitor the effectiveness of implementation.

   • Design and implement an interactive data portal to monitor service members' and dependents' care access.
   • Develop, test, and assess alternative methods of remote behavioral health care delivery utilizing this monitoring system to measure effectiveness.
   • Support better oversight by requiring regional managed-care contractors to share their provider database with the Department of Defense.
3. Explore program alternatives.

   • Continue pushing the integration of behavioral health care treatment with primary care and exploring new ways to do this.
   • Improve employment of telemental health (or TMH), a program that leverages telecommunications and video technology to overcome distance challenges enabling real-time, synchronous interaction between clinicians and their patients. Ongoing measurement of the effectiveness of, and removing outdated technical and regulatory barriers to, telemental health and collaborative care approaches within the military health system will be crucial to success.

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Topics

• Health Information Technology
• Mental Health and Illness
• Military Families
• Military Health and Health Care
• Substance Use Disorders