兰德-Access-to-Behavioral-Health-Care-for-Geographically-Remote-Service-Members-and-Dependents-in-the-US_173页_2mb

Summary of Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.

Core Content

This report examines the challenges faced by U.S. military service members and their dependents in accessing behavioral health care due to geographic remoteness. It is based on a comprehensive geospatial and longitudinal analysis of data from multiple sources, including the Defense Enrollment Eligibility Reporting System (DEERS), TRICARE claims, and the National Survey on Drug Use and Health (NSDUH). The study aims to understand the scale of the problem, the impact of remoteness on care access and utilization, and the gaps in current policy and practice, while also proposing solutions.

Main Findings

Aim 1: How Many Service Members and Dependents Are Remote from Behavioral Health Care?

• Approximately 1.3 million individuals (including 300,000 service members and 1 million dependents) are at risk of living in areas remote from behavioral health care.
• Geographic remoteness is defined as being more than 30 minutes from a behavioral health provider or in a low provider density area.
• Army service members and National Guard/Reserve (NG/R) personnel contribute significantly to the remote population.
• 10% of active component and 50% of NG/R service members spent at least some time in a remote area over a five-year period.
• Remoteness is not static, and service members may move in and out of remote areas due to deployment, duty stations, or other factors.

Aim 2: How Does Remoteness Affect Access to and Use of Behavioral Health Care?

• Remote service members made fewer visits to specialty behavioral care providers and fewer psychotherapy visits compared to non-remote individuals.
• In the civilian population, remoteness is associated with lower access to care and increased use of non-specialist settings.
• For active component service members, there is evidence of substitution of non-specialist care for specialist care, which warrants further investigation.
• No significant differences in care use were found among active duty or inactive Guard/Reserve service members, suggesting that remoteness may not impact them as strongly.
• Data limitations prevent an assessment of the quality of care or unmet need, as the study could not evaluate these aspects due to insufficient information.

Aim 3: Gaps in Policy and Practice and Promising Solutions

• Current DoD policies lack systematic monitoring of adherence to access guidelines.
• Two promising solutions are:
  • Telehealth (telemental health): A potential tool for improving access, especially for remote populations.
  • Collaborative care models: Integrating primary care with specialty behavioral health care to enhance accessibility and outcomes.
• There is a need for systemwide assessments of the impact of these models, removal of technical and regulatory barriers, and evidence-based improvements to ensure effective implementation.

Key Recommendations

1. Establish a monitoring infrastructure for behavioral health care access:
   • Define a maximum 30-minute drive time to behavioral health specialty care as an official standard.
   • Set goals for increasing access for NG/R and dependents.
2. Develop a data portal with computing and visualization capabilities to monitor access and utilization.
3. Require managed-care contractors to share and regularly update provider databases with the DoD.
4. Continue innovation and evaluation of telehealth and collaborative care models.
5. Remove outdated barriers to the widespread use of telehealth and integrated care approaches.
6. Feed collected evidence back into monitoring systems to improve both access and quality of care.

Key Data and Methodology

• Geospatial analysis was used to identify remote populations.
• TRICARE claims data and NSDUH data were analyzed to assess behavioral health care use.
• A working definition of remoteness was developed using data on provider locations, service member locations, and insurance regulations.
• Demographic and health status of remote populations were also explored.

Conclusion

The study highlights the significant challenges that remote service members and dependents face in accessing behavioral health care. It underscores the need for improved monitoring, policy development, and the adoption of innovative care delivery models such as telehealth and collaborative care to address these gaps effectively. The findings are intended to inform Department of Defense policymakers, command and line leadership, planners, managers, and care providers to enhance the accessibility and quality of behavioral health services for this vulnerable population.