An Algorithm to Match Patients to Level of Care

A new test instrument includes measures of readiness for patient and family.

The complex course of eating disorders, marked by refusal to accept treatment, premature termination of treatment, and relapse, can lead to significant health care costs. There is also little consensus about specific factors in medically stable patients can point to specific treatment. For example, should the patient be treated as an outpatient, or in day treatment, or in residential care?

The Short Treatment Allocation Tool for Eating Disorders (STATED) is a new evidence-based tool that was developed to help match eating disorders patients to the most appropriate and cost-effective care (Geller et al., 2016). Josie Geller, MD, St. Paul’s Hospital, Vancouver, British Columbia, and colleagues (J Eat Disord. 2018; 6:45), who developed the STATED algorithm, use three patient factors to assign a patient to specific care: (1) medical stability, (2) severity of symptoms/life interference, and (3) readiness/engagement to assign individuals to a specific level of care. The STATED instrument is similar to American Psychiatric Association guidelines, except that the STATED includes a treatment option that focuses on quality of life.

Finding study participants

The authors sought to determine how closely current allocation of patients to a level of care aligns with STATED recommendations. To find participants, letters describing the authors’ study were sent via email to eating disorders listservs. Healthcare professionals who self-identified as providing care for youth and/or adults with eating disorders were eligible to participate.

Most health care professionals who participated in the study were psychologists (n=47), followed by physicians (n=40), nutritionists and registered dietitians (n=27), and therapists (n=23).  Thirty-seven percent of participants reported working in centers with intensive treatment programs, including inpatient or residential programs. More than 30% were allied with outpatient treatment centers that worked with a larger eating disorders team or network; others worked in a practice affiliated with an academic institution.

Correlations were found in many areas

Most practices were in accord or alignment with the STATED. recommendations. Patients with poor medical stability were seen as being more suited for in-hospital medical stabilization treatment than for other less intensive forms of care; those with more severe symptoms were seen as more suited to care in day programs, inpatient, or residential or quality of life-focused treatment options. Patients with higher readiness ratings were seen as more suited to recovery-focused treatment options.

Despite the correlations in many areas, the authors reported high levels of inconsistency, particularly in the readiness dimension (58% for adults and 6% for families). Possible explanations for this included a lack of understanding of the implications of low readiness, the absence of validated measures, and a lack of research on family readiness.  Another possibility was lack of alternatives to action-oriented programs, such as care that focused on quality of life for very ill individuals whose readiness levels were very low.

Improving readiness for care              

A first step, according to Dr. Geller and her associates, would be to help build awareness of the importance of readiness among patients and families. Among clinicians, improving the analysis of readiness by training collaborators and improving readiness would involve providing training to assessors, who could use a collaborative/motivational interview style to accurately assess patient and family readiness.  In addition, it would be helpful to ensure that a menu of treatment options be available, with clear program guidelines for each level of care.

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