Eating Disorder Referral Practices


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The Eating Recovery Center discovered a number of trends in eating disorder diagnosis, treatment and referral. This report discusses those trends and provides eating disorder clinicians with recommendations for effectively referring patients when patient situations dictate a need for collaborative treatment.

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Eating Disorder Referral Practices

  1. 1. The Eating Recovery Center’sReport onReferral Practices:Recent Research Reveals Trends in the Processof Referrals for Eating Disordered Patients
  2. 2. The Eating Recovery Center’s Report on Referral Practices: Recent Research Reveals Trends in the Process of Referrals for Eating Disordered Patients Introduction......................................................................1 The Case for Patient Referral.........................................1 Facility Types and Patient Needs...................................2 Table ofContents Factors to Consider When Making a Referral Decision..........................................................2 How to Find a Referral Source.......................................3 Overcoming Obstacles to Referral . ..............................4 Conclusion........................................................................5 Works Cited......................................................................5 For more information, contact: Eating Recovery Center 877-825-8584 To learn more about Eating Recovery Center, please visit
  3. 3. IntroductionIn May 2009, the Eating Recovery Center, one of a few treatment centers in the U.S. to provide a full spectrum oftreatment options for adults with eating disorders, surveyed a number of eating disorder professionals from acrossthe country to gain a better understanding of how eating disorders are diagnosed, treated and referred in facilitiesacross the country.From the survey’s 158 respondents, the Eating Recovery Center discovered a number of trends in eating disorderdiagnosis, treatment and referral. This report discusses those trends and provides eating disorder clinicians withrecommendations for effectively referring patients when patient situations dictate a need for collaborative treatment.The Case for Patient ReferralIn recent years, eating disorder clinicians have gained a stronger understanding of the complex nature of an-orexia, bulimia and related diseases. Treatment must focus not simply on psychotherapy, but should also ac-knowledge and address the multiple etiologies of anorexia and bulimia - including the genetic, psychological,social and emotional/spiritual causes of the disorder - through a comprehensive, integrated treatment regimen.With successful treatment relying on a coordinated interplay among weight restoration, therapy, nutrition educa-tion, disease management and in severe cases, medical stabilization, clinicians are finding it critical to work withother professionals to effectively treat eating disordered patients.The majority (52%) of behavioral health professionals who responded to the Eating Recovery Center’s surveystate that their eating disorder case loads have increased by, on average, 33 percent over the past three years.This growth, along with recent studies that have highlighted the complex nature of these diseases and multipleetiologies that must be addressed in treatment, has demonstrated the critical need for clinicians to work effec-tively with other professionals in a multi-disciplinary approach.While 83 percent of respondents are comfortable diagnosing eating disorders and 81 percent are very com-fortable treating eating disorders, 94 percent responded that they share some portion of that treatment withother professionals. This finding indicates that behavioral health professionals have become more accustomedto referring eating disorder patients when they believe another professional may be better suited to the specificchallenges the patient presents.Overall, the respondents illustrate awareness of eating disorders’ escalation without appropriate treatment.When dealing with the nation’s deadliest mental illness, clinicians seek certainty that they can provide the mostappropriate treatment for every eating disorder patient. Although every patient requires decision making on acase-by-case basis, the following are situations where a referral is often considered.A. Difficulty Diagnosing the Patient. Though the majority of survey respondents are comfortable di- agnosing eating disorders, all respondents identified a number of barriers to effective diagnosis. While a primary diagnosis of anorexia nervosa or bulimia nervosa may be a relatively simple conclusion, clinicians unfamiliar or less familiar with its unique medical issues may have more difficulty diagnosing co-morbidi- ties. In fact, incomplete differential diagnosis is the top barrier (50%) that the surveyed clinicians identify as preventing effective diagnosis of eating disorders. A clinician or treatment center that specializes in diag- nosing and treating specific co-morbidities, whether they are psychological or physiological, may be better suited to treating this patient. Other barriers to diagnosis involve interaction with patients. Nearly half of respondents (46%) find unco- operative or untruthful patients to be a barrier to effective diagnosis and 17 percent of respondents find that insufficient time to meet with patients impacts the effectiveness of their diagnosis. Though most survey respondents felt comfortable diagnosing eating disorders, one-third (33%) felt that lack of training/education in diagnosing eating disorders impacted their ability to effectively diagnose a patient, and 19 percent cited a lack of adequate information about eating disorders as a barrier to effective diagnosis. In these situations, referral to a specialist is necessary.B. Lack of Medical or Clinical Resources. Whether a private practice psychologist, a registered dietitian or a family therapist, nearly every eating disorder specialist has experienced lack of resources at times. In fact, nearly two-thirds (63%) of survey respondents cited a lack of medical resources to treat the medical complications of as the top reason they refer patients. Other reasons cited include lacking other resources to treat patients (49%) or patients have co-morbid psychological illnesses or addictions they do not treat (38%).C. The Patient Requires a Medical Intervention or Higher Level of Care. When asked what diag- nostic criteria they use to determine whether a patient requires a medical intervention, respondents’ answers varied greatly. Many clinicians refer every anorexia nervosa or bulimia nervosa patient to a physician for evalu- ation, others refer based on the patient’s BMI, and still others look to medical labs or behavioral indications. ICopyright ©2009. Eating Recovery Center.All rights reserved.
  4. 4. In general, if a patient requires medical stabilization, a referral to an inpatient or residential treatment center that offers ongoing medical and nursing support may be necessary. If a patient is not advancing in treat- ment, continues to engage in eating disordered behaviors or fails to restore weight, he or she may require a higher level of care. While referral to a higher level of care may be the most appropriate solution in the short run, patients can often return to their outpatient therapist, dietitian or other care provider after their referral to support and aid their ongoing recovery from the eating disorder. Facility Types and Patient Needs Data show that when referring an eating disordered patient, 73.7 percent of professionals refer to an eating disorder-specific inpatient treatment center, 72.9 percent refer to an eating disorder-specific residential treat- ment center, 57 percent refer to an eating disorder-specific behavioral hospital and 44.7 percent refer patients to a registered dietitian. As the results show, eating disorder professionals are comfortable referring patients to a number of different types of facilities. A vast majority (92%) refer to a facility with which they have an existing professional relationship. One facility type may not fit all. Though a large residential treatment facility may be appropriate for one patient, a patient with co-morbid conditions who needs to weight restore may require a smaller setting with close access to intensive medical care. The key is understanding the factors that come into play in each individual referral decision. Factors to Consider When Making a Referral Decision A. Clinical Strength and Reputation. When rating factors that impact their referral decision, the majority (86%) of respondents identified clinical strength as the most important factor. Reputation was rated as the second most important factor. Though clinical strength and reputation are the most commonly considered factors in a referral decision, these two factors are frequently confused. While many clinicians may seek to base their referral decision on clinical strength, often their understanding of clinical strength is gleaned from reputation, without consideration of the specific capabilities of the center and its treatment philosophy. The following two considerations play greatly into determinations of clinical strength. 1. The Level of Medical Expertise. When a patient’s disease has escalated to a degree where medically supervised weight restoration is necessary or their behaviors have caused significant damage to inter- nal organs, medical supervision is a necessary consideration in a referral decision. Elements that can be considered when weighing medical expertise include onsite employment of internists or nursing staff, the center’s capacity for alternative means of feeding or proximity to a hospital intensive care unit, should the patient require stabilization. A handful of facilities across the country specialize in treatment of the medical needs of seriously medically compromised eating disorder patients. 2. The Level of Psychiatric Expertise. Every facility is different and the needs of each individual patient should be considered prior to any referral. One consideration may include access to a full-time on-site board certified psychiatrist. Though many facilities employ full-time psychiatrists, many utilize the ser- vices of visiting clinicians. Another consideration could be access to family therapy. Though some facili- ties incorporate the family into the patients’ individual therapy sessions, a number of facilities employ family therapists who work with patients and their families outside of individual patient therapy; creating a sense of neutrality for all participants. B. Cost. Cost was considered the third most important factor impacting a referral decision. Please refer to “Overcoming Obstacles to Referral” for more information on cost as a barrier in referral. C. Location. Location falls next in the ratings as a consideration when making a referral. More than half (55%) of behavioral healthcare professionals typically refer patients to a treatment center in the same city. Nearly 40 percent have referred a patient to a facility in the same state and 36 percent have referred a patient to an out-of-state facility. Sending a patient to a facility in close proximity to their home is the optimal choice if the facility is able to provide the appropriate resources the patient requires. Should the patient require a higher level of care or an alternatively structured program, he or she will have a more significant chance at a sustainable recovery if sent to a treatment center in a different location that is better suited to their specific treatment needs. D. Aftercare Availability. The least important consideration was aftercare availability. Several respondents commented that treatment centers “almost never” provide aftercare.2
  5. 5. E. Additional Considerations. In their comments, clinicians also identified the following factors as impact- ing their decision: 1. Specialization in the Treatment of Co-morbidities. Co-morbid addictions such as alcohol or drug dependence and psychological conditions such as depression, obsessive-compulsive disorder or anxiety are frequently seen in eating disorder patients. Should a patient require addiction counseling or medical assistance with withdrawal, choosing a treatment center that specializes in these areas of treatment is most appropriate. 2. Treatment Philosophy. A variety of philosophies, techniques and treatment modalities exist in the field of eating disorder treatment. The approaches each treatment center takes can differ significantly. Ele- ments of treatment philosophy may include: • Religion: Many treatment centers offer a religion-based treatment. Others have religious coun- selors on staff. • Program Curriculum: Curriculum, which may include classes, process groups, individual and group therapy and alternative therapies will vary greatly from one treatment center to the next. When seeking an appropriate option, consider the interests and needs of the patient as well as the structure of the curriculum – whether it is standard or tailored to each individual’s needs. • Approach: Therapeutic focus, integration of program areas, measurement of success, levels of care and structure of patient movement through programming are all elements that should be con- sidered when seeking an appropriate facility for a patient. • Length of Stay: Philosophies on length of stay vary greatly. While some centers employ a mini- mum length of stay, others have set program lengths (eg. 90-day set programs), and yet others treat to the patients’ individual needs – with a treatment stay based on the patient’s tailored program.How to Find a Referral SourceThe comments gathered via the research indicated that clinicians are seeking insight as to how to appropriatelybuild a referral network.Where behavioral healthcare professionals turn when making a referral decisionWhen seeking a referral source, the vast majority (92%) of behavioral health professionals look to an organizationwith which they have an existing professional relationship. Of the respondents, 48 percent consult other profes-sionals, 36 percent rely on a referral from the patient’s insurance company and 23 percent seek referral sourcesusing the Internet.For organizations looking to improve their methodologies for selecting referral sources, the National Eating Disor-ders Association and Eating Disorders Today offer the following recommendations for seeking a referral source.When seeking sources for referral, the best possible scenario is to visit the treatment center and take a tour of itsfacilities. Most treatment centers will schedule a tour and meeting with the treatment team.When onsite visits are not an option, scheduling a time to visit with representatives of the treatment center viaphone is the next best thing.Questions to Guide Your Inquiry:• Ask about the benefits of outpatient therapy versus treatment in a hospital or day program.• Inquire about the facility’s treatment style or philosophy.• What size is the facility; how much individualized treatment will the patient receive?• Does this facility recognize medical issues that may be serious and require immediate attention or hospitalization?• Does the facility have minimum body weight requirements? Many facilities require patients to be at a minimum body weight or BMI to be accepted. Patients with a significantly low body weights or BMI may require an alternate solution.• What medical capabilities do they have onsite (eg. ongoing nursing supervision, alternative feeding mechanisms, proximity to an emergency room or ICU)?• Does this facility collaborate with skilled professionals as part of a treatment team? Does their treatment team include dietitians and internists?• Do you get the impression that you can count on this facility for cooperation and 3Copyright ©2009. Eating Recovery Center.All rights reserved.
  6. 6. guidance and continue to work collaboratively with them in the aftercare process? • Does this facility work with insurance companies? Do they offer pointers about how to secure optimized insurance coverage and are willing to intervene on the patient’s behalf with insurance companies? Does this facility offer a sliding pay scale if needed? • What is their experience and how long have their clinicians been treating eating disorders? • How is the facility licensed? What are their training credentials? Do they belong to the Academy for Eating Disorders (AED)? • Does the facility have a quality improvement program in place or regularly assess the outcome of the treatment provided? • Is this facility familiar with either the APA Guidelines or Britain’s NICE Criteria for the treatment of eating disorders? • What kind of evaluation process will be used in recommending a treatment plan? When will we know it’s time to stop treatment? • Ask the facility to send information brochures, treatment plans, treatment prices, etc. The more information the facility is able to send in writing, the better informed you will be. Overcoming Obstacles to Referral Though referral may be the right decision to make, this choice is not without obstacles. Behavioral healthcare professionals cited the following obstacles, from most prevalent to least prevalent, as impacting both their and their patients’ referral decisions. A. Out-of-Pocket Cost. Often patient financial situations can present a barrier to treatment at an eating dis- orders facility. Manage patients’ fear of cost by speaking with the intake coordinator at the treatment center you are considering. Determine which insurance providers they work with, whether or not they are willing to consider single-user agreements, how they manage patient payment (upfront vs. payment plans) and the degree of their flexibility and willingness to work with the financial resources the patient has available to find a creative solution. Every treatment center differs, and many are willing to develop individualized financial plans to help patients find a way to get help. B. Distance from Home. Fear of leaving family, school or a job can play into a patient’s willingness to travel for treatment. As mentioned earlier, proximity to home is ideal if the facility is able to provide the appropriate resources the patient requires. If the patient requires resources that are only available at a distance, the out- of-town choice is the better choice. A patient will have a significantly better chance at a long-term recovery if they receive the appropriate treatment from the start. This may require some time away from home, but will certainly decrease the likelihood of relapse. C. Difficulty Working with Insurance Companies. The varying processes among insurance providers can be a hurdle. Thanks to parity laws in some states, insurance companies must provide the same insur- ance coverage for mental health treatment as they offer for medical and surgical conditions. According to Pauline Powers, MD, in an article from Eating Disorders Review, when working with an insurance provider, it is helpful to know the following: 1. The eating disorder diagnosis 2. Any other co-existing psychiatric disorders 3. Physiologic complications of the eating disorder 4. Level of care recommended: outpatient, inpatient, partial hospitalization, intensive outpatient 5. Anticipated duration of recommended treatment 6. Professionals needed and their required expertise The National Eating Disorders Association also offers advice for working with insurance providers ( D. Patient preference. From location, to program curriculum to length of stay and other amenities, patient preference is often an obstacle for referring physicians to overcome. Patient education is key to overcoming this obstacle. Providing the patient with a realistic picture of the reason they require a certain level of care, as well as information about the unique benefits of the center you recommend will help to assuage patient concerns and fears.4
  7. 7. E. Family Enmeshment. Whether the patient is a child, a teen or an adult, families can become over-involved in their care and ignore boundaries. Remember, an educated family is one that will be a positive influence on the referral process. Provide the family with as much information as possible, not only about eating disorders in general, but also about the benefits of the referral treatment center. Help them understand the value of a higher level of treatment, as well as the dangers their loved one may face if they don’t receive the higher level of care. Engage them in the decision-making process so that they feel ownership in the decision.F. Unfamiliarity with Treatment Facilities. Though the majority of respondents work with facilities with whom they are familiar, many voiced a lack of knowledge about treatment options available. A number of resources are available online and in print to help professionals become more familiar with treatment facilities. and provide listings of treatment providers, as well as resources for referring professionals. Gurze Books prints an annual resource catalogue, which can be ordered for free at referrals occur because clinicians lack appropriate resources, or because patients need a higher levelof care, the practice of shared treatment is growing in the field of eating disorders. Clinicians have found that thecomplex nature of eating disorders requires a multi-faceted, multi-disciplinary approach to treatment.This approach can differ in every treatment center, as well as treatment philosophies, curriculum approaches, pa-tient capacities and medical capabilities. Effective referral requires a thorough knowledge of the needs of a patient,a grasp of the appropriate time to refer and an informed, thoughtful decision about a suitable referral location.This survey was completed by 158 clinicians from across the U.S. who are engaged in eating disorder treatment.Psychologists represented 39 percent of all survey respondents, with psychiatrists, therapists, licensed social workers,registered dietitians and other clinical professionals representing the remaining respondents. Nearly half of the surveyrespondents (47%) treat patients in an individual private practice.Eating Recovery Center was founded in October 2008 by Drs. Emmett R. Bishop and Kenneth L. Weiner, psychiatristswith more than 50 years of combined experience treating eating disorders. As a treatment center that offers a fullrange of treatment options for adults with eating disorders – from intensive inpatient to outpatient programs, EatingRecovery Center works collaboratively with eating disorder clinicians and others to both refer and intake referralpatients when treatment or other circumstances dictate the need.Eating Recovery Center in Denver is one of few treatment centers in the nation to be able to provide a full range oftreatment options for adults with eating disorders – from outpatient to the most medically compromised inpatient.Eating Recovery Center employs a number of experts with decades of experience treating eating disorders at everylevel of care.Works CitedAssociation, N. E. (n.d.). Questions to Ask When Considering Treatment Options. Retrieved June 22, 2009, fromNational Eating Disorders Association: MD, P. (n.d.). Getting Coverage for Eating Disorders Treatment. Retrieved June 22, 2009, from EatingDisorders Review:, M. P. (2007, Spring). Finding the Needle in the Haystack of Eating Disorders Care-Providers. Eat-ing Disorders Today 5Copyright ©2009. Eating Recovery Center.All rights reserved.
  8. 8. For more information, contact: Eating Recover y Center 877-825-8584 To learn more about Eating Recovery Center, please visit Copyright ©2009. Eating Recovery Center. All rights reserved.