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Treatment Transitions: Improving Patient Recovery Through Effective Collaboration

Reprinted from Eating Disorders Review
By Kari B. Wolfe, MS, CPC
September/October 2003 Volume 4, Number 5
©2003 Gürze Books

Treating a person with an eating disorder can take many years and many cycles of care before recovery occurs. Research suggests that the course of illness for anorexia nervosa may be 7 to 10 years1 and possibly less for bulimia nervosa2 . As professionals, we often see patients who have received treatment, but for whom the continuum of care has been broken, leaving us without access to critical information. Between 20% and 30% of eating disorder patients drop out of treatment3 . Due to denial and cognitive impairment secondary to malnutrition, there are significant impediments, including denial of the severity of illness. Thus, patients may not fully understand the issues raised during previous treatments. The same ground is therefore covered and re-covered, unnecessarily prolonging the illness.

Collaboration to Improve Recovery
Collaboration across the continuum of care, improved communication, and synergy of treatment approaches may improve recovery. Collaboration and communication are enhanced when outpatient providers work together frequently as a team, and when inpatient and outpatient providers have established ties to one another. Shared knowledge, trust and common language, and the responsiveness of self-identified colleagues all prove beneficial.

In 2002, our center mailed a treatment transitions survey to 100 randomly selected outpatient eating disorders professionals. Sixty-five percent responded. Their feedback is integrated into the recommendations below.

Team Collaboration
Nearly all our respondents agreed that severe eating disorders, such as low-weight anorexia nervosa, are best treated with a multidisciplinary team, including a primary care physician, a dietitian, a psychiatrist, and a psychotherapist. This approach is believed to be superior for many reasons, such as medical comorbidities that pose serious risks, including death, and eating disorder complexities that require skills in nutrition science and psychopharmacology. Uncomplicated bulimia nervosa is an exception. In our survey, professionals who were not working with a team nevertheless recognized its importance and wanted to develop one.

Team success requires that all members have a general knowledge of the other disciplines and that they communicate regularly. Eating disorder patients often minimize symptoms, failing to talk about essential issues. A team is better able to gain the information necessary to adequately treat patients. Teams’ unified treatment recommendations are more effective with families, insurance providers, and patients.

Developing a treatment team. The first step in developing a team is finding professionals who are knowledgeable about eating disorders or who are willing to learn about them. Here are some suggestions for those willing to learn: (1) Send them a copy of the American Psychiatric Association Practice Guidelines. (2) Suggest they join eating disorders associations, such as the Academy for Eating Disorders. (3) Recommend that they subscribe to relevant journals and attend relevant conferences. (4) Suggest that they host a monthly eating disorder consultation group with other professionals.

Close communication is often difficult, given the busy schedules of many professionals. However, effective communication can be achieved with confidential voice mail and faxes. Letters work as well, and might be more confidential. Teams should determine the information that is relevant to the group. Critical information may include: changes in medical status, including weight changes, problems with follow-up, missing appointments, and changes in meal plans. If higher level of care criteria are met, a conference call is needed to plan for the transition. One team member can act as a point person for the team, the family, and the patient. Appropriate information releases must be secured at the beginning of treatment, so providers can discuss important issues with other members of the team. When patients fail to cooperate, it may be a sign of therapy-interfering behavior. In such cases, the therapist and patient may need to negotiate a workable solution.

Outpatient-to-Inpatient Transitions
Our survey indicated that professionals recognize level of care needs according to the severity of illness.4 Treatment failures, including treating patients unsuccessfully for an extended time, may also indicate the need for a higher level of care in order to handle patient resistance and provider countertransference.

Managing change. Outpatient providers have the major responsibility for coordinating the patient’s care and for assessing their levels of care. To manage changes, outpatient providers must know that patients may need higher levels of care from professionals in their region. Therapeutic rapport can be pivotal when convincing a family or patient that a higher level is necessary. Transitional teleconferencing prior to and after a higher-level admission can ease concerns and build confidence. Outpatient providers have a great deal of influence with insurance companies and recommendations from united teams are difficult to dispute. Experts can also help educate insurance companies about industry standards for appropriate levels of care with eating disorders.

Because eating disorder patients are often reticent, a telephone call to gather information about the patient is essential for the inpatient providers before a treatment plan can be formulated. An agreement should be made between inpatient and outpatient providers regarding communication during the inpatient stay.

During longer lengths of stay, it is standard practice for outpatient therapists to disengage from therapy with their patients so that patients may switch to a new treatment setting and develop trust with the new treatment team. However, it is optimal for inpatient and outpatient providers to communicate at least twice during the patient’s stay, to keep outpatient providers abreast of patient progress and to help with interventions if the patient begins to talk about leaving inpatient treatment prematurely. For shorter lengths of stay, good judgment will be needed to help both groups decide the outpatient provider’s degree of disengagement.

Inpatients may say that the outpatient providers were not helpful to them. This may simply mean that such patients are displeased with the recommendation for a higher care level and the outpatient provider(s) who made it.

Inpatient-to-Outpatient Transitions
A teleconference prior to discharge is essential. This conference should include the patient. Treatment progress and issues to address in the lower level of care should be discussed and agreed upon. There may also be times when the inpatient team may need to communicate information to the outpatient treatment team that would not be said in the same way with the patient present. For patients with more severe illness or those who have been inpatients for a longer time, transitional care or “step-down” programs may be indicated for one to three months. These patients benefit from the structure of such programs, which enable them to practice new skills and to gain confidence while facing typical stressors of everyday life. Once patients are ready to return to outpatient care, inpatient/transitional providers should coordinate this hands-off with their outpatient colleagues by scheduling appointments for the patient during the first week following discharge. All pertinent medical records should be forwarded to the appropriate outpatient providers, preferably prior to the first appointment with that provider. Inpatient treatment centers have a wealth of information available to the outpatient providers, often including psychological testing results and family therapy notes that are sometimes difficult to gather on an outpatient basis. According to those surveyed, most outpatient providers want clear and specific treatment recommendations from inpatient providers. They also believe that the discharge plan should contain specific criteria for readmission, such as body weight or other indicators of relapse.

Outpatient providers want to know the specific interventions and program content of the inpatient facility in order to continue with similar language, tools, and skill building. This helps the patient to internalize the inpatient experience. Inpatient and outpatient treatment goals should be discussed and aligned as much as possible. This also sends a congruent message to patients, and less time will be wasted on therapy-interfering behaviors such as splitting between providers. A patient’s own manual. During inpatient discharge planning, it’s helpful for the patient to create a “User’s Manual” to share with the follow-up treatment providers. In the manual, the patient writes down behaviors, events, and perceptions that might cause trouble in the future. These are often called Red Flag Warning Signs5 . Involved families can also be alerted by the patient to these warning signs of relapse.

In our survey, one outpatient professional wrote, “…follow-up communication prior to discharge is the most essential piece.” Patients should be aware that collaboration exists and that outpatient providers expect their return on a specific date.

Getting Patients Back Into Treatment
Although most providers agree that communication and complementary approaches to care are essential, it is unfortunate that when patients fail to follow through with outpatient appointments, many healthcare professionals, inpatient and outpatient, do not try to bring patients back into treatment. Patients may need help with their motivation to change. We cannot assume that patients who reach a particular level of motivation at one point in treatment will maintain this level of motivation6 . Changes in environment or relationships, along with fear, can affect patients, even those with the best intentions.

We urge providers to make a commitment to improve the recovery process for eating disorder patients and to try to go the extra mile when patients don’t follow through. Preventing relapse and keeping patients in treatment can save lives.

References
1. Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord 1997; 22:339.
2. Richards, PS, Baldwin, BM, Frost, HA, et al. What works for treating eating disorders? Conclusions of 28 outcome reviews. Eating Disorders,2000; 8:189.
3. Kahn, C, Pike KM. In search of predictors of dropout from inpatient treatment for anorexia nervosa. Intl J Eat Disord 2001; 30:237.
4. American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry(suppl) 2001; 157:1-39.
5. Gorski TT, Miller M. Counseling for relapse prevention. Independence, MO: Herald House, 1982.
6. Prochaska JO,DiClemente CC. The transtheoretical approach: Crossing traditional boundaries of change. Homewood, IL: Dorsey Press, 1984.

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