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Research Questions

  1. How many service members and dependents are remote from behavioral health care?
  2. How does geographic remoteness affect access to and use of behavioral health care?
  3. What are current gaps in policy and practice for improving access to care among remote service members and dependents, as well as some promising solutions?

With many service members now returning to the United States from the recent conflicts in Iraq and Afghanistan, concern over adequate access to behavioral health care (treatment for mental, behavioral, or addictive disorders) has risen. Yet data remain very sparse regarding how many service members (and their dependents) reside in locations remote from behavioral health providers, as well as the resulting effect on their access to and utilization of care. Little is also known about the effectiveness of existing policies and other efforts to improve access to services among this population. To help fill these gaps, a team of RAND researchers conducted a geospatial analysis using TRICARE and other data, finding that roughly 300,000 military service members and 1 million dependents are geographically distant from behavioral health care, and an analysis of claims data indicated that remoteness is associated with lower use of specialty behavioral health care. A review of existing policies and programs discovered guidelines for access to care, but no systematic monitoring of adherence to those guidelines, limiting their value. RAND researchers recommend implementing a geospatial data portal and monitoring system to track access to care in the military population and mark progress toward improvements in access to care. In addition, the RAND team highlighted two promising pathways for improving access to care among remote military populations: telehealth and collaborative care that integrates primary care with specialty behavioral care.

Key Findings

More Than 1.3 Million Service Members and Dependents Are Geographically Remote for Behavioral Health Care

  • Roughly 1.3 million individuals (some 300,000 service members and an additional 1 million dependents) were at risk of living in an area remote from behavioral health care.
  • Remoteness is not a static property but a risk that any service member or dependent could encounter over time.
  • Active component service members are more likely to be remote if they are older, higher ranking, more educated, and married; this pattern was not found for the National Guard/Reserves.

Remoteness Reduces Use of Behavioral Health Care

  • Remote active component service members made fewer visits to any specialty behavioral care provider and made fewer psychotherapy visits than non-remote service members.
  • There is some evidence of a substitution of non-specialist care for specialist care in the active component.

No Monitoring of Existing Policies and Programs Exists, but Some Promising Solutions Do

  • Department of Defense maintains guidelines for access to care but there is no evidence of monitoring adherence to those guidelines.
  • Two promising pathways for improving access to care among remote military populations are telehealth and collaborative care that integrates primary care with specialty behavioral care.

Recommendations

  • DoD should establish clear policies for enhancing access to behavioral health care among remote service members and their dependents, setting an official standard of a maximum 30-minute drive to behavioral health specialty care, working quickly on closing the gap for active component service members, and setting goals of concerted progress toward increasing access for National Guard/Reserve service members and dependents.
  • The department should monitor implementation of these policies by establishing the computing infrastructure and data visualization capabilities to support an interactive data portal to monitor access to care for service members and dependents; making this monitoring system part of a larger effort to develop, test, and assess alternative methods of delivery for behavioral health care in remote settings; and requiring regional managed-care contractors to share their provider database with DoD and to regularly update this database and provide all required data fields, to the best of their ability.
  • Establish a special focus that strives toward improvement of remote behavioral health care by continuing to innovate and collect systemwide evidence on the effectiveness of telemental health and collaborative care treatment in military populations, removing outdated technical and regulatory barriers to telemental health and collaborative care approaches to behavioral health within the Military Health System, and feeding data and evidence into monitoring systems in order to systematically improve both access to and quality of care.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Scope of the Problem: How Many Service Members and Dependents Are Remote, and Who Are They?

  • Chapter Three

    Effects of Remoteness on Civilian Behavioral Health Care Use

  • Chapter Four

    Effects of Remoteness on Military Behavioral Health Care Use

  • Chapter Five

    Barriers and Gaps in Policy and Practice

  • Chapter Six

    Clinical and System Approaches for Improving Access for Remote Populations

  • Chapter Seven

    Recommendations

  • Appendix A

    Defense Enrollment Eligibility Reporting System Personnel Data

  • Appendix B

    Driving Distance to Military Treatment and Veterans Affairs Facilities

  • Appendix C

    Community Provider Shortage Areas

  • Appendix D

    ZIP Code File for Geospatial Analysis

  • Appendix E

    TRICARE Plans

  • Appendix F

    National Study of Drug Use and Health Utilization Analyses

  • Appendix G

    TRICARE Claims Data

  • Appendix H

    Review of the Effectiveness of Telemental Health

  • Appendix I

    Structures, Processes, and Outcomes Framework

This research was sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute.

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