Types of treatment settings and levels of care

Several types of treatment centers and levels of care are used for treating bulimia nervosa. 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. In addition to physical settings for care, in recent years, some aspects of care are being delivered using telehealth. These options may include texting, e-mail, and Skype. Telehealth options are intended to expand and improve access to ongoing care.

Treatment in physical settings is delivered in hospitals, residential treatment facilities, and private practice therapy settings. Levels of care consist of acute short-term inpatient care, residential treatment, partial hospitalization (day treatment) 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 at a subacute care residential treatment facility. The level of care in such a facility can be full-time 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 treatment setting and level of care should complement the general goals of treatment for bulimia nervosa. Generally, goals are as follows:

  • Medically stabilize the patient.
  • Help the patient to stop binge eating and purging/nonpurging behaviors
  • Help the patient to learn coping skills to prevent relapse.
  • Address and resolve any coexisting mental health problems that may be triggering the behavior.

Patients with severe symptoms often begin treatment as inpatients and move to less intensive programs as symptoms subside. Hospitalization may be required for complications of the disorder, such as electrolyte imbalances, irregular heart rhythm, dehydration, severe underweight (although most people with bulimia nervosa are not 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.

Psychotherapy and drug therapy are available in all the care settings. Many settings provide additional care options that can be included as part of a tailored treatment plan. Support groups may help a patient maintain good mental health and may prevent relapse after discharge from a more intensive program.

The intensity and duration of treatment depends on:

  • Insurance coverage limits and ability to pay for treatment
  • Severity and duration of the disorder
  • Mental health status
  • Coexisting medical or psychological disorders

A health professional on the treatment team will make treatment recommendations after examining and consulting with the patient.

Criteria for Treatment Setting and Levels of Care

Insurance companies and the care team use certain criteria to describe the care setting and level of care deemed to be medically necessary to treat each patient appropriately. General, typical descriptions of these settings are provided below. The care setting also is tied to the health insurance coverage level, reimbursement amounts, patient copays, and the duration of care provided in each setting.

Inpatient Care

Patient is medically unstable as determined by:

  • Unstable or depressed vital signs
  • Laboratory findings presenting acute health risk
  • Complications due to coexisting medical problems such as diabetes

Patient is psychiatrically unstable as determined by:

  • Rapidly worsening symptoms
  • Suicidal and unable to contract for safety

Residential Care

Patient is medically stable and requires no intensive medical intervention.

Patient is psychiatrically impaired and unable to respond to partial hospital or outpatient treatment.

Partial Hospital Care

Patient is medically stable but:

  • Eating disorder impairs functioning, but without immediate risk
  • Needs daily assessment of physiologic and mental status

Patient is psychiatrically stable but:

  • Unable to function in normal social, educational, or vocational situations
  • Engages in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques

Intensive Outpatient/Outpatient Care

Patient is medically stable and no longer needs daily medical monitoring

Patient is psychiatrically stable and has symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and continues to make progress in recovery.