Developing a Multidisciplinary Eating Disorder Treatment Team in a University Setting

1. Developing a Multidisciplinary Eating Disorder Treatment Team in a University Setting Aimee Daigle, FNP | Jennifer Gilkes, MD Vanessa Richard, RD, LDN | Rachel Stokes, PsyD

2. Objectives • Define the role, function and value of a multidisciplinary eating disorder treatment team in a university setting. • Discuss “how-to” skills for developing and implementing an eating disorder treatment program within a university setting. • Identify the key components of a multidisciplinary eating disorder treatment team. • Discuss ways to increase treatment effectiveness and measure treatment outcomes.

3. Role, function, and value

4. Role, Function, and Value • Evaluate and Assess • Students are often identified in various departments on campus and referred to the treatment team • Administration • Faculty/Staff • Residential Life • Sorority/Fraternity • Self-referrals

5. Role, Function, and Value • Provide Treatment and Referrals • Provide outpatient treatment services • Provide referrals for community care • Provide support for clients navigating the university and/or healthcare system • Ex. withdrawing from classes, leaving housing, enrollment, disability services, health insurance/reimbursement assistance

6. Role, Function, and Value • Financial Value of Treatment • Estimated Treatment Cost • 1 year of community outpatient treatment • Out of Pocket: $7,000-10,000 • With Insurance: $1,400-2,000 • Assuming 80% coverage • 1 year of LSU Student Health Fees • $390 (Fall, Spring, Summer fees combined)

10. HOW TO Develop a treatment team

11. “How-to” Skills 1. Solicit Administrative Support from Key Departments • Ex. counseling center, medical clinic, health promotion 2. Determine which Treatment Components will be Provided • Individual /Group Therapy • Nutrition Counseling • Medical Treatment • Psychiatric Treatment • Case Management • Exercise Monitoring

12. “How-to” Skills 3. Find and Establish Working Relationships with Providers • Creating a working relationship between core treatment providers is vital in successfully building a treatment team • Within a Student Health Center • Across campus • Community providers/resources • Establish a strong, frequent communication pattern between providers

13. “How-to” Skills 4. Schedule Time for Interdisciplinary Meetings • Treatment Team Meetings • Weekly consultation/review for providers participating in the team • Weekly to biweekly phone /email consultation with community providers • Documentation of review for charting purposes

14. “How-to” Skills 4. Schedule Time for Interdisciplinary Meetings • Client Staffing Meetings • All providers and client in attendance • Held once per semester or as needed • Aids in multifaceted treatment planning • Provides continuity of care • Additional way to track progress • Gives the client a voice in treatment • Opportunity for family and/or partner to attend

15. “How-to” Skills 5. Determine Types of Documentation • Treatment Contract • Evaluation/Assessment Forms • Staffing Reviews/Reports • Treatment Team Meeting Reviews • Assessment Measure • Treatment Plan

16. “How-to” Skills

17. “How-to” Skills

18. “How-to” Skills 6. Create a Policies and Procedures Manual • Purpose: • Establishes the scope of practice of the treatment program/boundaries • Rely on policies/procedures when higher level of care is needed and/or noncompliance issues • Helpful for risk management purposes

19. “How-to” Skills 6. Create a Policy and Procedures Manual • Essential Components • Establish the central goal of the treatment program • Identify core procedures to meet identified goals • Identify type of documentation and where documentation will be stored (EMR vs. paper chart) • Helpful Hints • Consult with peer institutions with established teams • Adapt to meet the needs and constraints of your resources

20. “How-to” Skills 7. Designate Case Management Services • For individuals with complex needs • Can be provided by existing team members or dedicated case manager • Examples: • Client is without health insurance • Referral to community providers or higher level of care • Intensive medical services

21. “How-to” Skills 8. Advertise the Treatment Program • Freshman orientation • Campus-wide outreach • Brochures/literature stands • Student Health Center website 9. Develop Campus Wide Relationships • Communication with campus partners, administrators, faculty and staff

22. “How-to” Skills 10. Create a Referral Base • Self referrals • Parent, partner, family and friend referrals • Administrative referrals (mandated) • Expectations must be clear about ongoing communication with administrative referrals • Ex-residence hall disturbances • Faculty/Staff referrals

23. “How-to” Skills 11. Define the Community Referral Process • Partial treatment by community provider • Referral for higher level of care or alternative treatment • Outpatient Treatment Providers • Intensive Outpatient Program • Partial Hospitalization Program • Residential Treatment Program • Medical Stabilization/Inpatient Hospitalization

24. Key COMPONENTS OF A TREATMENT TEAM

25. Key Components of a Treatment Team • Psychological Evaluation and Treatment • Nutritional Evaluation and Treatment • Medical Evaluation and Treatment • Psychiatric Evaluation and Treatment

26. Psychological Evaluation and Treatment • Evaluation • Severity of symptoms (outpatient vs. residential treatment) • Emotional functioning and comorbidity • Empirically Supported Treatment Approaches • Cognitive Behavioral Therapy • Interpersonal Therapy • Dialectical Behavior Therapy • Short-term Psychodynamic Therapy • Integrative Approaches

27. Psychological Evaluation and Treatment • Beginning Stage: Building trust, providing psychoeducation, and establishing treatment parameters • Weekly /biweekly therapy • Building a positive therapeutic relationship • Assessing key features of the eating disorder and individual needs • Providing education about the effects of disordered eating patterns • Enhancing motivation for change

28. Psychological Evaluation and Treatment • Mid Stage: Changing beliefs related to food/weight/body and broadening the scope of therapy • Identifying dysfunctional thoughts, schemes, and thinking patterns and developing cognitive restructuring skills • Developing a sense of self without the ED • Focus on interpersonal relationship patterns • Reframing relapses

29. Psychological Evaluation and Treatment • Ending Stage: Preventing relapse and preparing for termination • Summarizing progress • Summarizing areas of continued vulnerability • Clarifying when to return to treatment

30. Nutritional Evaluation and Treatment • Role of the Registered Dietitian • Provide nutrition education and counseling • Bridges therapeutic and medical components • Addresses the “surface” issues • Eating and exercise behaviors, symptom usage • Expertise in disordered eating is preferred • Strong counseling skills • Often met with resistance

31. Nutritional Evaluation and Treatment • Appointment Frequency • Weekly to biweekly follow up • less frequent over time • Primary Goals • Weight stabilization • Nutrition restoration • Reducing symptom usage • Improvement in relationship with food and body

32. Nutritional Evaluation and Treatment

33. Medical Evaluation and Treatment • Role of Medical Clinician • Assess and treat any medical complications that result from eating disorder • May or may not be first point of contact • Educate medical staff on early recognition of/screening for EDs • Liaison between medical clinic, treatment team and involved outside providers (if indicated) • Educate the patient/client

34. Medical Evaluation and Treatment • Initial History and Physical • Schedule adequate time—trust, rapport building • Establish documentation/templates— to assure comprehensive exam, “queue questions” for essential information • Rule out other physical causes for symptoms • GI disorders, infectious/autoimmune disease, primary endocrine disorders, neurological disorder/disease • Determine physical impact/severity of disorder to date • Determine necessitation for immediate medical intervention/hospitalization for medical stabilization • Establish if specialty referrals are indicated • Develop medical goals, treatment plan, follow-up schedule • Educate patient regarding medical needs/complications

35. Medical Evaluation and Treatment • Eating Disorder History • Age of onset, longevity of ED • Weight history --loss/change/amount • “Typical day”—eating habits, hydration, exercise, caffeine use, supplements, alcohol/tobacco use, sleep, bowel habits/patterns • Compensatory behavior history--such as restriction, binge, purge, laxatives, diet pills, supplements, substance use/abuse, exercise • Family history and psychosocial history—FMH EDs, substance abuse, support systems • Medical /surgical /psychiatric history—medications, hospitalizations/dates • Known medical co morbidities

36. Medical Evaluation and Treatment

37. Medical Evaluation and Treatment

38. Medical Evaluation and Treatment

39. Medical Evaluation and Treatment • Medically Unstable/Requiring Immediate Hospitalization • Establish guidelines/criteria for your institution • Key indications • Cardiac problems/compromise • Unstable/abnormal symptomatic vitals signs • CP, HR < 40, abnormal EKG/arrhythmias of concern • Symptomatic/marked electrolyte imbalances/lab abnormalities • Hypokalemia, hypophosphatemia, marked hypoglycemia • GI bleed, obstruction, other GI concerns • Renal/hepatic compromise • EKG abnormalities • Dehydration • Severe malnutrition • Altered mental status • Suicidality • < 70% IBW, low BMI • Use good clinical judgment (safety/do parents need to be contacted?)

40. Medical Evaluation and Treatment • Key Reminders • Eating disorders affect every system in the body • Weight is NOT the only clinical marker of an ED • An ED can occur with NO obvious physical signs or symptoms • Underweight, normal, and overweight patients can still have nutritional deficiencies • Labs are generally normal, don’t be fooled—however, abnormal labs can assist with residential admission criteria • Medical consequences of EDs can go unrecognized even by experienced clinicians • Medications should be targeted on treatment of comorbid conditions • Medications should NOT be used as a substitute for nutritional/behavioral recovery • Keep medical visits to the minimum required to reduce blame of symptoms on a physical cause if ruled out

41. Medical Evaluation and Treatment • Useful Links for Medical Providers • Diagnosis of Eating Disorders in Primary Care http://www.aafp.org/afp/2003/0115/p297.html • Clinical Report—Identification and management of Eating Disorders in Children and Adolescents—American Academy of Pediatrics http://pediatrics.aappublications.org/content/126/6/1240.full.pdf+html • Critical Points for Early Recognition and Medical Risk management in the Care of Individuals with Eating Disorders http://www.aedweb.org/AM/Template.cfm?Section=Medical_Care_Standards&Template=/CM/ContentDisplay.cfm&ContentID=2413

42. Psychiatry and College EDTT • First Evaluation • Establish therapeutic alliance • Diagnose and treat co-occurring illness • Make predictions about illness • Psycho-education • Determine best treatment setting • Subsequent Appointments • Monitor response to medication • Monitor eating disorder symptoms and behaviors • Collaborate with other providers • Assess/monitor psychiatric status and safety

43. Therapeutic Alliance for Eating Disorders • Reduces drop out risk • The clinician should: • Be curious • Welcome the client • Give assurance/support • Praise/validate (hard work and courage)

44. Determine Appropriate Treatment Setting • Anorexia • Outpatient • Intensive outpatient (part-day outpatient care) • Partial hospitalization (full-day outpatient care) • Residential treatment center • Inpatient hospitalization (either on a medical unit for acute stability of physical concerns or on a psychiatric ward) • Bulimia, Binge Eating and EDNOS • Outpatient treatment services

45. Co-occurring Illnesses in Eating Disorders • Diagnose and treat co-occurring illness • Many with bulimia or anorexia suffer from clinical depression, anxiety, obsessive-compulsive disorder, substance abuse, and other psychiatric illnesses • Bulimia is associated with Diabetes I • Binge eating disorder is associated with Diabetes II

46. Psychiatric Evaluation and Treatment • Make predictions about illness • Poor Outcomes: Anorexia • Very low BMI • Family conflict or dysfunction • Long duration of illness • Comorbid psychiatric or personality disorders • Vomiting or laxative abuse • Good Outcomes: Anorexia • Absence of severe weight loss • Absence of serious medical complications • Good social support • Absence of drug abuse

47. Psychotropic Medication • SSRI’s • Fluoxetine • Serotonin-norepinephrine re-uptake inhibitors • Venlafaxine • Desvenlafaxine • Duloxetine • Bupropion (FDA black box warning for use in ED due to increased risks of seizures) • TCA’s and MAOI’s (generally avoided) • Mood Stabilizers • Anti-seizure meds • Second Generation Antipsychotics • Lithium (generally avoided in bulimia) • Benzodiazepines (generally avoided)

48. FDA Approved Medications for Anorexia • There are NONE! • Use medication with caution for comorbid conditions such as depressive or obsessive–compulsive features • Depression, anxiety and obsessions may resolve with weight gain alone • Students with anorexia may be more sensitive to side effects

49. Psychiatric Evaluation and Treatment • Why medications may not work with this population • Anorexia as a self perpetuating illness: • Severe weight loss • Leads to loss of white and grey matter of the brain • Decreased neurotransmitters and proteins • Decreased metabolic rate • Abnormalities in cognitive dysfunction • GI abnormalities that lead to early fullness, decreased gastric motility, constipation, and abdominal distention

50. Psychiatric Evaluation and Treatment • FDA approved medications for Bulimia, Binge Eating and EDNOS • Fluoxetine (60mg) is FDA approved for Bulimia Nervosa • No medications are FDA approved for Binge Eating Disorder or EDNOS