group and individual therapy. Systems that rely on residential and inpatient care require more intensive staffing ratios than those that emphasize ambulatory care. Integration with primary care and behavioral health services requires different ratios than freestanding care. Treatment systems that build automated tools and information technology infrastructure require fewer staff. Population needs and the prevalence of SUDs also affect staffing needs. Finally, continuing care and peer support services require different staffing patterns from those for acute care services.

To determine appropriate staffing ratios, the committee reviewed DoD’s PHRAMS, which forecasts psychological health staffing requirements to meet the estimated annual need for care. The committee suggests that the PHRAMS program provides a reasonable starting point for determining the quantitative relationship between need and staffing levels. However, PHRAMS underestimates the need for SUD treatment practitioners because the Military Health System Data Repository (MDR) database used by PHRAMS excludes many SUD encounters and appears to exclude encounters in specialty SUD treatment programs. Despite being careful and logical, PHRAMS estimates are far below the number of existing SUD counselors in DoD. The committee’s findings led to the following recommendation with regard to estimating staffing ratios:

Recommendation 12: DoD should incorporate complete data on SUD encounters into the MDR database and recalculate the PHRAMS estimates for SUD counselors.


IOM (Institute of Medicine). 2006. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Academies Press.

VA (Department of Veterans Affairs) and DoD (Department of Defense). 2009. VA/DoD clinical practice guideline for management of substance use disorders. Washington, DC: VA and DoD.

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