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TRICARE Operations Manual 6010.59-M, April 1, 2015
Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Chapter 18
Section 8
Intensive Outpatient Program (IOP) Pilot To Address Behavioral Health Sequelae of Sexual Trauma
Revision:  C-69, August 28, 2020
The National Defense Authorization Act (NDAA) Fiscal Year (FY) 2019, Section 702, authorizes a pilot to treat psychological sequelae associated with sexual trauma to be accomplished through partnerships with public, private, and non-profit health care organizations and institutions. These partnership institutions must provide health care to Active Duty Service Members (ADSM) who are eligible for care under the TRICARE program. The pilot is focused on treatment of ADSMs suffering from Post-Traumatic Stress Disorder (PTSD) and other psychological health conditions associated with sexual trauma.
IOPs provide an outpatient level of care that includes an organized day or evening program for the treatment of mental health and/or Substance Use Disorders (SUDs). This pilot will provide specialized IOP-level services to ADSMs who are suffering from psychological health conditions associated with sexual trauma. These services will meet the requirements of the TRICARE Policy Manual (TPM), Chapter 7, Section 3.16, and Chapter 11, Section 2.7 but with a specific focus on the sequelae of sexual trauma. In accordance with the NDAA FY 2019, Section 702, the intent of this pilot is to determine the “feasibility and advisability” of using such programs by measuring outcomes and sharing of lessons learned. This pilot does not change requirements for treatment provided through the IOP model. These pilot requirements do not apply to the Designated Providers (DPs) or TRICARE Overseas contractor.
3.1  IOPs that offer a specialized focus on sexual trauma as specified in NDAA FY 2019, Section 702, provide evidence-based or evidence-informed treatment for psychological conditions that are common among ADSMs who have disclosed sexual trauma (for example, including PTSD, substance abuse, depression). Only TRICARE authorized IOPs that meet the TPM, Chapter 11, Section 2.7 IOP requirements and are selected by the Defense Health Agency (DHA) upon recommendation by the contractor are eligible for participation under this program. Under this program, IOPs will provide mental health care, support, and other benefits to ADSMs and their family, and will work with existing case management resources (Market/Military Treatment Facility (MTF) or contractor case managers, as appropriate) to link beneficiaries and their families with community-based support systems. In order to qualify for mental health benefits under this pilot, the patient must be diagnosed by a TRICARE authorized or MTF mental health provider with diagnoses associated with a sexual trauma disclosed by the ADSM.
3.2  IOPs participating in the pilot must use only evidence-based treatment strategies for the treatment of diagnoses associated with a disclosed sexual trauma. Treatment may include, but is not limited to individual and/or group psychotherapy and psychoeducation. Approval of an IOP site by the Government signifies compliance with this paragraph.
3.3  A referral for supplemental health care consistent with Chapter 17, Section 3 is required for an ADSM to participate in the Sexual Trauma IOP Pilot.
3.4  Each contractor shall identify at least two, but not more than five IOPs which meet the criteria in this Section and agree to participate in the pilot.
3.4.1  In addition to meeting the criteria included elsewhere in this section to be eligible for participation, IOPs shall also be within specialty care access standards for drive time of a Market/MTF which has at least 5,000 uniformed service personnel enrolled. IOPs selected for this pilot shall be in-network or agree to join the TRICARE network and shall provide more than 50% of care (based on hours) in-person (as opposed to via telehealth). However, the Government may approver one entirely telehealth IOP per region if they meet all other criteria and will continue to provide care via telehealth for the duration of the pilot. Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) facilities are not eligible for the pilot.
3.4.2  To be eligible to participate, each IOP shall enter into a Participation Agreement, Addendum B, approved by the Director, DHA or designee.
3.4.3  The contractor shall provide a list of proposed IOPs for inclusion in the pilot to the Government after confirming the recommended programs meet all criteria and are willing to participate. The Government will provide a final, approved list to the contractor based on the recommend list provided by the contractor. If the contractor is unable to identify sufficient IOPs that meet these criteria, the contractor shall notify the Government and provide proposed alternate proposed IOP sites that do not meet all of the criteria.
3.5  Psychological Assessment
3.5.1  Patient assessment. Includes the assessment of each ADSM accepted by the facility, and must, at a minimum, consist of a physical examination; psychiatric evaluation (to include medication evaluation); psychological assessment; assessment of physiological, biological and cognitive processes; developmental assessment; family history and assessment; social history and assessment; educational or vocational history and assessment; environmental assessment; screening or assessment and recreational/activities assessment. Screening or assessment of sexual dysfunction shall also be performed. Assessments conducted within seven days prior to admission to an IOP may be used if approved by the facility Medical Director, and deemed adequate to permit treatment planning by the IOP.
3.5.2  The participating IOPs with a focus on sexual trauma will assess the core treatment outcomes at the patient level. These outcomes shall be measured within seven days of treatment baseline, within three days of discharge (i.e., post-treatment), three months post-treatment, six months post-treatment and one year post-treatment. Data collected within 14 days of the scheduled follow-up is within allowance.
3.5.3  The core treatment outcomes measured for every ADSM participating in the pilot shall include:
•  PTSD - PTSD Checklist (PCL)
•  Depression - Patient Health Questionnaire-8 (PHQ-8)
•  Alcohol use - Alcohol Use Disorder Identification Test (AUDIT) or AUDIT-C
•  Functioning/Quality of Life (QOL) - QOL or World Health Organization (WHO) Disability Assessment Schedule or Veterans’ Rand-12
•  Brief narrative of family support/involvement
3.6  Outcome Reporting
3.6.1  Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
3.6.2  A written treatment discharge summary shall be provided by the participating IOP to the referring provider within three business days of discharge or program exit. The treatment summary shall list treatment groups attended, pre- and post-treatment outcome measures as defined above, information regarding patient engagement in treatment, and documentation of any suicidal or homicidal ideation during IOP treatment (along with any interventions delivered targeting suicidal or homicidal ideation).
3.7  Special Processing Code (SPC) BH shall be used for claims under this pilot.
Programs which have not been selected for participation in the pilot are not included. Beneficiaries who do not have a psychological condition associated with sexual trauma are also excluded. The pilot is limited to ADSMs.
Reimbursement for care provided under this pilot is in accordance with the TRICARE Reimbursement Manual (TRM), Chapter 7, Section 2. Facilities included in this pilot are excluded (related to care and services provided as part of the pilot) from calculation of the contractor’s network discount.
The contractor shall require IOPs which participate in the Sexual Trauma IOP pilot to share clinical and community outreach best practices with other organizations and institutions participating in the pilot consistent with NDAA FY 2019, Section 702. Participation is specified as staff representation at minimally 75% of scheduled meetings and/or teleconferences related to the pilot (such meetings will occur no more frequently than monthly), timely responses to requests for information regarding best practices, and actively identifying and providing best practice knowledge generated from the IOP to the other participating partner IOPs.
Effective on September 1, 2020 and terminates August 31, 2021.
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