National Eating Disorders Association

If your loved one is struggling with outpatient treatment or needs a higher level of care, you will need to consider several different options. Finding a program or physician that has expertise in treating all aspects of eating disorders is crucial.

Determining level of care

Several types of treatment centers and levels of care are available for treating eating disorders. Knowing the terms used to describe these is important because insurance benefits (and the duration of benefits) are tied not only to a patient’s diagnosis, but also to the type of treatment setting and level of care.

Treatment is delivered in hospitals, residential treatment facilities, and private office settings. Levels of care consist of acute short-term inpatient care, partial inpatient care, intensive outpatient care (by day or evening), and outpatient care. Acute inpatient hospitalization is necessary when a patient is medically or psychiatrically unstable. Once a patient is medically stable, he/she is discharged from a hospital, and ongoing care is typically delivered on an outpatient basis or at a subacute residential treatment facility, where the individual lives in a home or dormitory setting. The level of care in such a facility can be fulltime inpatient, partial inpatient, intensive outpatient by day or evening, and outpatient. There are also facilities that operate only as outpatient facilities. Outpatient psychotherapy and medical follow-up may also be delivered in a private office setting.

The level of care your loved one needs will depend on a variety of factors. The most important factor is medical and psychiatric safety, which may require hospitalization before selecting a more specialized program. Hospitalization may be required for complications of the disorder, such as electrolyte imbalances, irregular heart rhythm, dehydration, severe underweight, or acute life-threatening mental breakdown. Partial hospitalization may be required when the patient is medically stable, and not a threat to him/ herself or others, but still needs structure to continue the healing process. Partial hospitalization programs last between 3 and 12 hours per day, depending on the patient’s needs. As the patient improves, they will typically move to less intensive and less structured programs.

Other factors influencing level of care are the goals of treatment. Generally, the following issues are typically treated in this order:

  • medical and psychiatric stabilization
  • stopping destructive behaviors (i.e., restricting foods, binge eating, purging/nonpurging)
  • addressing and resolving any coexisting mental health problems that may be triggering the behavior

Be aware that normalization of eating patterns can take months to establish themselves in the patient’s dayto-day life. It is important to remember that seeking intensive eating disorder treatment is only the first step towards recovery. Recovery from an eating disorder is an active, ongoing process, and they will continue to need lots of support at mealtimes and elsewhere long after discharge. This is why family involvement in treatment is so important: you need to learn how to help manage your loved one’s eating disorder after they are discharged. High levels of support, whether through a step-down program, family involvement, or both, can help stop a revolving door of admissions and discharges.

Selecting an appropriate eating disorder treatment program

First, you will need to find a treatment program that meets your loved one’s needs. Consulting with your family member’s treatment providers and recommendations should give you a good idea of what level of care is most appropriate and what aspects of the eating disorder most need addressing.

Second, determine whether a particular level of care and specific treatment center is covered by your insurance carrier, and whether the treatment facility accepts insurance. If the treatment center is not part of the health insurer’s system (out-of-network), the insurer may pay a percentage of the treatment costs, with the patient responsible for the remainder. It is best to negotiate this percentage with the insurer before starting treatment. If your insurance does not provide any coverage, you need to determine whether you and/or your loved one will be able to pay for treatment without insurance. A small number of treatment centers offer financial assistance; but most do not. However, inquiring whether a facility is able to work with your current financial situation may be worth investigating if the patient does not have financial resources or insurance. If you are having trouble obtaining insurance coverage for your loved one’s eating disorder treatment, see page 45 for more information.

Thirdly, determine the philosophy of the treatment facility and the type of care they provide. Is the center’s view of eating disorders supported by up-to-date research? Does it support ideas of eating disorder causes and recovery that are congruent with your family’s situation? Does it encourage or require a high level of family involvement?

In addition, “evidence-based treatment” is increasingly emphasized, meaning that many eating disorder programs advertise that they use these types of treatments. It’s important to check how frequently these therapies are used, and the qualifications of the therapists providing them. Many facilities have also begun advertising their efficacy via outcome studies. However, residential treatment hasn’t been studied for efficacy in randomized control trials, and long-term outcomes have not been followed. Some treatment centers will only evaluate people who were not discharged prematurely, or they may only assess individuals who returned surveys, which could be biased towards individuals who are doing well. The eating disorder community also does not have a standard definition of what recovery looks like, which can make interpreting these studies even harder. Don’t ignore these data, but interpret them with caution.

Lastly, think about what will happen after discharge. Does the program have a step-down program or is there another one that you intend to use? Discharge plans can be complicated and require much coordination of care among different healthcare providers. That takes time. Effective discharge planning needs to start much earlier than a day or two before the patient is expected to be discharged from a facility.

Other factors to consider when selecting a treatment center include religious affiliation (if any), multidisciplinary approach to care, distance from home, staff/patient ratio, professional qualifications of staff, their experience in treating eating disorders, and adjunct therapies offered. Some treatment centers provide therapies in addition to psychiatric counseling and pharmacotherapy, like equine therapy, massage, dance, or art therapy. These therapies may be appealing, although there is no evidence for these being essential to treatment response, and they may not be covered by your health insurance.

Determining Quality of Care

Determining the quality of care offered by a center is difficult at this time. No organization yet exists to specifically accredit treatment centers for the quality and standard of eating disorder-specific care. Leaders within the national eating disorders community organized in mid-2006 to develop care standards and a process for accrediting eating disorder centers. That effort is ongoing. One national organization, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), provides generic accreditation for healthcare facilities, and some eating disorder centers advertise “JCAHO accreditation.” JCAHO accreditation does not link directly to quality of care for treatment of eating disorders; it assesses safety and credentials of staff. Another issue regarding quality of care is that much care is delivered on an outpatient basis. For individual psychotherapists in private practice, no special credentialing or specialty certification exists regarding treatment of eating disorders. Thus, any mental healthcare professional can offer to treat an eating disorder whether or not he/she has experience or training in this specific area. Therefore, it is important to ask a prospective therapist about his/her knowledge about eating disorders and years of experience treating them.

Professionals in a Multi-disciplinary Care Team

  • Primary care physician (i.e., family doctor, internal medicine doctor, pediatrician, gynecologist)
  • Psychiatrist
  • Nutritionist
  • Clinical psychologist
  • Social worker
  • Claims advocate for reimbursement
  • Other professionals who administer supplemental services such as massage, yoga, exercise programs, and art therapy

Questions to Ask When Seeking a Treatment Center

  • Does the center accept the patient’s insurance? If so, how much will it cover?
  • Does the center offer help in obtaining reimbursement from the insurer?
  • Does the center offer financial assistance?
  • How long has the center been in business?
  • What is its treatment philosophy?
  • Does the center have any religious affiliations and what role do they play in treatment philosophy?
  • Does the center provide multidisciplinary care?
  • Who will be coordinating my loved one’s treatment?
  • Is the location convenient for the patient and his/her support people who will be involved through recovery?
  • If family cannot participate in treatment in-person, what alternatives are there?
  • What security does the facility have in place to protect my loved one?
  • How quickly will you complete a full assessment of my child?
  • Prior to traveling to the treatment center: what are your specific medical criteria for admission and will you talk with my insurance company before we arrive to determine eligibility for benefits?
  • What is expected of the family during the person’s stay?
  • Anorexic-specific: Please describe your strategy for accomplishing refeeding and weight gain, and please include anticipated time frame.
  • How are target weights determined?
  • How do you handle food refusal?
  • What steps do you take to prevent purging? Compulsive exercise?
  • What happens if my child needs a higher level of care? How do you make that decision?
  • If my child does not start to make progress, what will happen?
  • Who is the best person to whom I should fax my loved one’s treatment history and medical records?
  • What are the visiting guidelines for family or friends?
  • What levels of care does the center provide? Please define criteria for each level mentioned.
  • What types of professionals participate on the care team and what is each person’s role?
  • What are the credentials and experience of the staff?
  • How many hours of treatment are provided to a patient each day and week?
  • Which professional serves as team leader?
  • What types of therapy does the center consider essential? Optional?
  • What is the patient-staff ratio?
  • What is the rate of turnover (staff resigning) for clinical staff?
  • How is that handled with patients?
  • Who will the patient have the most contact with on a daily basis?
  • What is the mealtime support philosophy?
  • Who will update key family or friends? How often?
  • How is care coordinated for the patient inside the center and outside if needed?
  • How does the center communicate with the patient’s family doctors and other doctors who may routinely provide care?
  • What are your criteria for determining whether a patient needs to be partially or fully hospitalized?
  • What happens in counseling sessions? Will there be individual and group sessions?
  • Will there be family sessions?
  • How will family be prepared for the patient’s discharge?
  • How does the care team measure success for the patient?
  • How do you decide when a patient is ready to leave?
  • How is that transition managed with the patient and family?
  • What after-care plans do you have in place and at what point do you begin planning for discharge?
  • What follow-up care after discharge is needed and who should deliver it?
  • Does the patient have a follow-up appointment in hand before being discharged? Is the follow-up appointment within 7 days of the discharge date?
  • When is payment due?

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