TREATMENT SETTINGS AND LEVELS OF CARE

P.Santucci, MD. FAED, FAPA | March 2018

Eating disorder treatment can be delivered in a variety of settings.  Based on a variety of criteria recommended in the Guidelines for Eating Disorders published by the American Psychiatric Association, your therapist will recommend a specific setting  that is best for you.

It is important to understand these treatment settings represent different levels  of care and are based on your symptoms. In general, treatment should be conducted in the LEAST restrictive setting possible that provides safety for you. Basically, the more stable you are, emotionally and physically,  the lower the level of care. Outpatient is the lowest level of care, the least restrictive, and usually the first one to be tried. The highest level of care is inpatient hospitalization.  

Because of the severity of the nature of eating disorders and the complexity of care, it is important that the best possible decision be made to help you overcome your eating disorder and get on the road to recovery as quickly as possible. Recovery from an eating disorder generally takes a long time. Duration of treatment can vary from 3 months to several years, depending on the severity of the illness and diagnosis. It is also important to understand that relapse rates are high and often expected during the recovery process, and that there may be various times when another level of care is needed.

Be sure you discuss  your treatment options with your therapist. Learn all you can about your eating disorder and the clinical guidelines. Contact your  insurance company to discuss your policy’s benefits. Obtaining authorization for treatment at the appropriate level of care can be frustrating but support is available to help you through this process.  

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Most individuals are treated on an outpatient basis. Ideally, patients are treated by a multidisciplinary team, consisting minimally of a psychotherapist, nutritionist and physician. All team members should be trained specifically in the treatment of eating disorders and work together to coordinate a treatment plan. Not all individuals will receive this multidisciplinary approach but the treating clinician should have access to all of these resources.

Typically, an individual struggling with an eating disorder will see their therapist/nutritionist one to two times a week. In addition, appointments with the physician/psychiatrist may be needed to monitor status.

Recovery from an eating disorder generally takes a long time. Duration of treatment can vary from 3 months to several years, depending on the severity of the illness and diagnosis.

May meet 2-3 days a week for 3-5 hours a day. Services generally include counseling, nutritional therapy, group therapy and a structured meal. Patients are medically stable and do not need daily medical monitoring. They also are psychiatrically stable and have sufficient control in normal social, educational or vocational situations and are expected to continue to make progress toward recovery.

The program offers numerous benefits, including counseling, nutritional therapy, group therapy, and structured meals. Patients are medically and psychiatrically stable, allowing them to focus on their recovery without daily medical monitoring. With a comprehensive approach, the program supports individuals in regaining control over their eating disorder and making progress towards recovery.

A more intense program, meeting 5-7 days a week for 6-10 hours a day. This is sometimes referred to as “day hospital”. Patients can live at home when they are not in treatment so they can continue to work or attend school. Many partial hospitalization programs have supportive housing options for individual who do not live near the clinic.    

Structured eating sessions are provided along with various types of group therapy. Individuals will meet with their nutritionist, therapist and psychiatrist and medical monitoring will be available. These individuals are considered unable to function in normal situations without engaging in pathological weight control behaviors such as fasting, limited food intake, or daily bingeing and purging.

Sometimes these programs are used as alternatives to inpatient hospitalization. For instance, a patient who has not done well in outpatient, may try an intensive outpatient or partial hospital program before considering inpatient hospitalization. Patients who are being discharged from an inpatient hospital program may need the extra support and time and  may decide to transition (step down) to a partial hospital program.

Medical Unit

Patients who are medically unstable or severely compromised may need hospitalization on a medical unit, a med-psych unit or an eating disorder medical unit. In cases of significant weight loss and malnourishment, an inpatient setting with physicians experienced in the refeeding syndrome would be indicated.

These individuals are at risk for serious or life threatening events. Symptoms that would indicate the need for inpatient treated might be related to significant/rapid weight loss, altered vital signs, abnormal laboratory findings such as electrolyte or EKG changes or co-existing problems such as diabetes.

In situations where patients are medically unstable or severely compromised, it is crucial to seek immediate medical care. Hospitalization on a medical unit, med-psych unit, or an eating disorder medical unit may be necessary. In cases of substantial weight loss and malnourishment, an inpatient setting with physicians experienced in handling the refeeding syndrome becomes essential.

Psychiatric/Eating Disorder Unit

Eating disorder patients can be treated on a general psychiatric unit. However, it is usually recommended that the individual selects an inpatient program which has a specific eating disorder program or separate specialized unit devoted to the care of individuals with an eating disorder.  

Patients who meet the criteria for inpatient admission are psychiatrically unstable, may show rapid worsening of  their eating disorder symptoms and may be suicidal and unable to contract for safety. Inpatient treatment provides a structured environment where 24 hour clinical care is available.

Eating disorder programs are best suited to monitor those undergoing weight restorations and address the medical/nutritional concerns of eating disorder patients while providing assistance in helping them normalize their eating patterns. In addition to providing structure and monitoring of eating patterns, various forms of psychotherapy are provided.

The usual length of stay is less than 3-4 weeks. Once the individual is considered medically stable, they are usually transferred to a lower level of care program.  This can be a partial hospitalization, intensive outpatient, outpatient program or a residential treatment center.

Residential care programs provide a longer term treatment option for patients who are medically stable but have not been able to reach a significant degree of psychological stability or control of their eating disorder behaviors.

This level of care may be recommended if intensive outpatient or partial hospital programs have been ineffective. Residential treatment may also be recommended after inpatient hospitalization to provide additional time for recovery in a structure setting.

The length of stay may vary, but averages 30-90 days.

These settings are live-in facilities that provide 24 hr. care 7 days a week. There is constant medical supervision and monitoring of health conditions but the patient is expected to be medically stable and require no intensive medical intervention.

At this level of care, some psychiatric impairment is expected and  structured programs are provided throughout the day that offer physical and psychological healing. Usually there are a wide variety of groups that include psychoeducation, various types of psychotherapy, coping skills, nutrition and body image. Additional adjunctive therapies such as art, dance and movement, music and equine may also be available.

The facility is usually staffed by skilled multidisciplinary team composed of psychiatrists, psychologists, nutritionist, physicians, nurses, social workers and other professionals.

Most programs offer a holistic approach, but some may have a particular approach, such as 12 step. Some programs will focus on a particular population- for instance, children, adult women and adolescent girls over the age of 12, athletes, Christian-based population or individuals with co-occurring addiction or mood/psychiatric disorders.

To find eating disorder treatment providers in your area, visit the ANAD Treatment Directory.


Outpatient

Multidisciplinary team, weekly sessions, duration varies (3 months to several years).


Inpatient Hospitalization

Medical unit for unstable patients, psychiatric unit for severe cases, specialized care, structured environment, shorter stays.


Intensive Outpatient / Partial Hospitalization

These programs are used when it is determined that individuals need more support than can be offered by outpatient treatment.


Residential Care

Longer-term treatment for medically stable patients struggling with eating disorders, focusing on psychological stability and behavior control.