TRICARE: certified mental health counselors. Interim final rule

This rule is submitted as an interim final rule (IFR) in order to meet the Congressional requirement set forth in the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2011, Section 724, which required the Department of Defense to prescribe regulations by June 20, 2011, to establish the criteria, as had previously been studied in accordance with Section 717 of the NDAA 2008, that would allow licensed or certified mental health counselors to be able to independently provide care to TRICARE beneficiaries and receive payment for those services. Under current TRICARE requirements, mental health counselors (MHCs) are authorized to practice only with physician referral and supervision. This interim final rule establishes a transition period to phase out the requirement for physician referral and supervision for MHCs and to create a new category of allied health professionals, to be known as certified mental health counselors (CMHCs), who will be authorized to practice independently under TRICARE. During this transition period the MHCs who do not meet the requirements for independent practice as established in this rule, may continue to provide services to TRICARE beneficiaries under the requirements of physician referral and ongoing supervision. This transition period, ending December 31, 2014, will allow time for those MHCs who seek to continue providing services under the TRICARE program to meet the independent practice requirements as outlined in this notice. After December 31, 2014, the Department of Defense will no longer recognize those mental health counselors who do not meet the criteria for a CMHC and will no longer allow them to provide services even upon the referral and supervision of a physician.

Coping versus grieving in a "death-accepting" society: AIDS-bereaved women living with HIV in Indonesia

The aim of this study was to understand how AIDS-bereaved women in Indonesia cope in a society where death is believed to be fated. Data analyses were conducted based on the women’s interview transcripts and journal entries. Each of the women experienced at least three traumatic life events. The most challenging experience was learning that they have contracted a disease they regarded as associated with prostitution. Given the short lapse of time between their husbands’ deaths and learning about their seropositivity, biographical disruption appeared to have acted as an ‘analgesic’, while concerns to protect their children seemed to have triggered biographical reinforcement. This phenomenon may have brought about a positive bereavement outcome. Specific counselling programmes for women affected by HIV/AIDS are needed, but emphasis should first be placed on improving their wellbeing and their perception of stigma.

Elimination of requirement for prior signature consent and pre-and post-test counseling for HIV testing. Final rule

This document adopts, without change, the proposed rule published in the Federal Register on December 29, 2008, updating informed consent requirements related to testing for the Human Immunodeficiency Virus (HIV) for Veterans receiving health care from the Department of Veterans Affairs (VA). This final rule is in accordance with related provisions of the Veteran's Mental Health and Other Care Improvements Act of 2008. The final rule eliminates the regulatory requirement for written informed consent for HIV testing and specific pre- and post-test counseling of Veteran patients. VA will implement this rule through internal policy guidance specifying these requirements and how they apply to HIV testing.

Court compliance as a predictor of postadjudication recidivism for domestic violence offenders

This study evaluated pre- and postadjudication behavior of 220 male defendants convicted of a domestic violence-related offense using court records and police department data. Our goal was the identification of possible predictors for continued criminal behavior that could pose a risk of further harm to victims. Factors identified as significant predictors of defendant recidivism were having two or more court reports of noncompliance with domestic violence treatment, two or more warrants issued by the court for noncompliance, and two or more reports to law enforcement of new criminal activity involving the defendant. Law enforcement reports were the strongest predictor of recidivism, with an odds ratio of 7.7 and confidence interval of 3.0-19.7. These results illustrate the importance of monitoring multiple dimensions of defendant behavior while under court supervision and of communicating information on noncompliance with victims and advocates to assist in safety planning efforts.

Elimination of co-payment for weight management counseling

The Department of Veterans Affairs (VA) published a direct final rule amending our medical regulations to designate weight management counseling (individual and group sessions) as a service that is not subject to VA's co-payment requirements. VA received no significant adverse comments concerning this rule or its companion substantially identical proposed rule published on the same date. This document confirms that the direct final rule became effective on June 16, 2008. In a companion document in this issue of the Federal Register, we are withdrawing as unnecessary that proposed rule.

An analysis of the law of confidentiality with special reference to the counselling of minors

Although professional counsellors would be aware of the need to maintain confidentiality in their work with clients, the basis and scope of this obligation is generally less well understood. This article examines the issue of counsellor-client confidentiality from a legal perspective, and considers the potential bases of legal liability which counsellors may have with respect to the maintenance of client confidentiality as well as the circumstances under which disclosure of this information will be required or may be permitted. It is contended that the general issue of counsellor-client confidentiality presently poses particular difficulties for counsellors who work primarily with children and adolescents, especially when clinical services are provided directly to adolescents. In such instances, counsellors may be confronted by competing and even conflicting interests, and may be required to exercise judgement in relation to the disclosure of confidential information which has been provided by a minor. Although there is no clear law which directly relates to this area, it is argued that counsellors may presently have a primary obligation to respect the wishes which are expressed by a "mature minor" in relation to the provision of counselling services. It is further argued that awareness of general legal principles which are of relevance to areas of professional practice can provide much assistance to practitioners who could be required to make decisions in the course of their work which may later be examined in the context of legal proceedings.

Counseling about firearms: proposed legislation is a threat to physicians and their patients

In early 2006, 2 separate but virtually identical bills were introduced in the Virginia and West Virginia legislatures that would have profoundly affected the relationship between a physician and his or her patients. Each bill would have prohibited a physician from asking a patient if he or she owned firearms for the purpose of counseling that patient about ways to reduce risks associated with firearms. Penalties for violation of the bills included revocation of a physician's license to practice. The Virginia bill was initially approved by its state House of Delegates by a vote of 88 to 11. It was ultimately defeated in a Virginia Senate committee. The West Virginia bill did not receive a vote during the 2006 legislative session. Although neither bill became law this year, this type of bill is likely to reappear in future legislative sessions. The Virginia and West Virginia bills were contrary to the best-practices recommendations of medical societies, including the American Academy of Pediatrics. Anticipatory guidance regarding firearms can indeed reduce risks to patients. Yet, the bills would have preferred the judgment of legislators over physicians regarding this aspect of the practice of medicine. In addition, the 2 bills raise legal issues regarding both medical malpractice and the First Amendment protection of the freedom of speech. The Virginia and West Virginia bills would have treated risks associated with firearms differently from other hazards and interfered with a physician's ability to protect his or her patients. The Virginia bill was defeated, in part, through the efforts of physicians to educate legislators. However, physicians must remain prepared to respond to similar state legislative initiatives in the future.

Controlled trial of prescribed heroin in the treatment of opioid addiction

AIM

This study aimed to assess the efficacy of the prescription of intravenous diacetylmorphine (DAM) versus oral methadone with medical and psychosocial support, with a view of improving physical and mental health as well as social integration among socially excluded, opioid-dependent individuals for whom standard treatments have failed.

DESIGN

This study used an open, randomized controlled trial.

SETTING

This study took place in Granada, Spain.

PARTICIPANTS

Sixty-two opioid-dependent participants were randomized, 31 in each treatment group, and 50 of them were analyzed. The participants were recruited directly from the streets, through peer outreach, in well-known meeting places for drug-addicted individuals.

INTERVENTIONS

Participants in the experimental group received injected DAM, twice a day, plus oral methadone, once a day, for 9 months. The control group received only oral methadone, once a day. The two groups received an equivalent opioid dosage. The average DAM dosage was 274.5 mg/day (range: 15-600 mg), and an average methadone dosage was 42.6 mg/day (range: 18-124 mg). The daily methadone dosage in the control group was 105 mg/day (range: 40-180 mg). Comprehensive clinical, psychological, social, and legal support was given to both groups.

MEASUREMENTS

The following were measured in this study: general health, quality of life, drug-addiction-related problems, nonmedical use of heroin, risk behavior for HIV and HCV, and psychological, family, and social status.

FINDINGS

Both groups improved with respect to the total domain assessed. Those in the experimental group showed greater improvement in terms of physical health (the improvement was 2.5 times higher; p = .034) and risk behavior for HIV infection (the improvement was 1.6 times higher; p = .012). In addition, this group decreased its street heroin use from 25 days/month to 8 days/month as seen on the Addiction Severity Index (p = .020), as well as the number of days free from drug-related problems (the improvement was 2.1 times higher; p = .004) or involvement in crime (from 11 days/month to <1 day/month; p = .096 between groups).

CONCLUSIONS

These findings support the hypothesis that, under the same conditions, DAM could be safely delivered, in our context. Also, in physical health, HIV risk behavior, street heroin use, and days involved in crime, DAM plus methadone was more efficacious than methadone alone. This implies that this treatment could provide an effective alternative for the treatment of socially excluded, opioid-dependent patients with severe physical and mental health problems because of drug addiction, when all available previous treatments have failed.

When doing the right thing means breaking the law--what is the role of the health lawyer?

What happens when being a good doctor requires being a bad citizen? What should a doctor do when living up to the requirements of a professional code of ethics or staying true to deeply held personal values requires breaking the law? What should a health care professional do when the appropriate conduct in a particular case is inconsistent with a more generalized principle that has been incorporated into law? Further, what is the role of the ethical health lawyer who advises a health care provider facing such a dilemma?

As health care lawyers advising individuals and institutions, is it our job to advise our clients of all the options available to them, and all the potential legal consequences, or is our role simply to keep our clients acting within the law? Are we information providers, policy counselors, risk managers, or some combination of these?