Public Hearing in Reference to Certificate of Need Application for a Proposed Women Only Binge Eating Disorder Treatment Center

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1 Public Hearing in Reference to Certificate of Need Application for a Proposed Women Only Binge Eating Disorder Treatment Center Submitted by Attuned Eating and Living Centers, LLC February 26, 2015

2 Green Mountain at Fox Run Overview Located in a facility previously used as a ski lodge, with a capacity of approximately 40 women based on current staffing First program of its kind to promote a philosophy, subsequently backed by years of research, that diets are an ineffective way to manage weight, and in fact dieting can be harmful from a physiological and metabolic perspective Weight management program that provides actionable strategies and tools for improving a woman s complex relationship between food, body and behavior so that she can begin to heal from long- term debilitating physical and psychological dysfunction related to eating behavior Core program components include behavioral education, nutrition education and fitness programs Over its 40+ year history, the program has helped women suffering with serious binge eating issues better understand the emotional, behavioral and metabolic consequences of binge eating; the program helps women develop concrete approaches to better manage these dysfunctional behaviors 2

3 Binge Eating Disorder DSM- V Definition Diagnostic criteria include: A. Recurrent episodes of binge eating, characterized by both: 1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat under similar circumstances 2. Sense of lack of control over eating during the episode B. Binge- eating episodes are associated with three or more of the following: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of feeling embarrassed by how much one is eating 5. Feeling disgusted with oneself, depressed, or very guilty afterward C. Marked distress regarding binge eating D. Binge eating occurs, on average, at least once a week for 3 months E. Binge eating is not associated with inappropriate compensatory behavior as in bulimia, and does not occur exclusively during the course of bulimia or anorexia 3

4 Project Description Binge Eating Disorder Outpatient Treatment Center and Transitional Living Program Separate outpatient treatment center located approximately one mile from Green Mountain at Fox Run in Ludlow, for the psychiatric and psychological treatment of adult women suffering from Binge Eating Disorder Programs will include outpatient therapy, Intensive Outpatient Program, Partial Hospitalization Program Transitional Living Program: overnight accommodations for individuals who wish to stay at the Fox Run facility but not participate in the Fox Run program; supportive services but no clinical services offered Goal to provide clinical treatment for women suffering from BED and related health issues Seamless integration with the non- clinical Fox Run weight management and healthy lifestyle program affording clients of both programs the option of participating in the weight management and healthy lifestyle program, and receive clinical treatment and therapy for a more serious BED diagnosis when a more intensive level of care is clinically indicated First of its kind in the United States to offer evidence based treatment specifically for BED in conjunction with an approach to addressing dysfunctional eating behavior in a non- clinical residential setting for weight management based on Mindful Eating principles, a behavioral approach that has also been shown to be effective in long- term improvement in dysfunctional eating behavior 4

5 BED Treatment Center Outpatient Therapy Services to be Offered Outpatient therapy sessions, including: Individual psychiatric assessment and pharmacological treatment by a psychiatrist; Individual BED assessment conducted by a doctoral or master s level psychotherapist; Individual and group therapy provided by a doctoral or master s level psychotherapist; and Nutritional therapy conducted by a registered dietitian 5

6 BED Treatment Center Intensive Outpatient Program Services to be Offered 6 Three to four hours per day, average of three days per week and, for an average period six weeks. The IOP is designed to stabilize dysfunctional eating behavior related to BED with the goal of returning the patient to normal activities A multidisciplinary clinical team will evaluate each patient and develop an individualized treatment plan. The program includes the following services: a. Individual psychiatric assessment and pharmacological treatment by a psychiatrist; b. Individual BED assessment conducted by a doctoral or master s level psychotherapist; and c. Individual and group therapy provided by a master s or doctoral level psychotherapist, utilizing evidence- based therapeutic techniques such as: Cognitive behavioral therapy (CBT) and Dialectical behavioral therapy (DBT) Mindfulness- based therapy Interpersonal group therapy Meal support therapy Body image therapy Art and music therapies Family therapy Nutritional therapy conducted by a registered dietitian d. Primary care intervention for identified medical complications (provided primarily by local providers)

7 BED Treatment Center Partial Hospitalization Program Services to be Offered Highly structured and monitored program for patients requiring a greater degree of monitoring and support in order to return to a level of functioning consistent returning to independent living. Patients participate in the program five days per week, for approximately six hours of intensive therapy per day. A multidisciplinary clinical team will evaluate each patient and develop an individualized treatment plan. Services provided will be similar to those offered by the Intensive Outpatient Program, but the intensity of therapy will be greater and more frequent: a. Individual psychiatric assessment and pharmacological treatment by a psychiatrist b. Individual Binge Eating Disorder assessment conducted by a doctoral or master s level psychotherapist c. Individual and group therapy provided by a master s or doctoral level psychotherapist, utilizing evidence- based therapeutic techniques such as: Cognitive behavioral therapy (CBT) and Dialectical behavioral therapy (DBT) Mindfulness therapy Interpersonal group therapy Meal support therapy Body image therapy Psycho- educational group therapy Art and music therapies Family therapy Nutrition therapy conducted by a registered dietitian d. Primary care based intervention for identified medical complications (provided primarily by local providers) 7

8 Transitional Living Program Services to be Offered 8 Overnight accommodations and activities, for additional cost, to IOP and PHP program participants who do not wish to or may not be able to secure their own accommodations while in treatment. Primary goal is to provide participants additional non- clinical support during non- treatment times. Program will be housed at the existing Fox Run facility, until volumes reach a point requiring additional space elsewhere to house the program. Non- clinical services will be provided by individuals with experience working with behavioral health populations, including: Daily meal support, as needed, for meals not monitored in one of the programs; Weekly collaborative meal preparation; Assistance with planning weekly restaurant outings; Menu planning and grocery shopping; Assistance with resume writing and employment search; Assistance with time management and budgeting; Coordinated external leisure activities; and Assistance with planning shared household chores and other activities of daily living.

9 HRAP Standards Related to the Institute of Health Improvement Triple Aims Improving the individual experience of care Estimated that 30 percent of people who seek weight loss programs suffer from BED Recent analysis of past participants of the Fox Run program identified 27% of clients reported exhibiting at least two eating behaviors on a regular basis that qualify as criteria required for a BED diagnosis. The Fox Run program offers educational sessions designed to teach strategies for helping to deal with the stressors that result in binge eating, but offers no clinical treatment for BED. The management team estimates that approximately 30% of GMFR s existing clients would benefit from clinical treatment. Clinical treatment program specifically designed to provide psychiatric and psychological treatment for women suffering from BED and its associated medical and psychological comorbidities, offered in conjunction with the benefits of the Fox Run program for helping women to improve body image and begin to establish healthy eating patterns, based on a mindful eating philosophy that will carry through the entire continuum of services. The benefits of this uniquely integrated continuum combining two complementary program philosophies, both which have been show to be effective in managing BED symptoms, is anticipated to significantly elevate the efficacy of care for participants of either and both programs. 9

10 HRAP Standards Related to the Institute of Health Improvement Triple Aims Improving the individual experience of care, continued Typical BED treatment model consists of individual psychotherapy, or treatment in a more restrictive setting such as an intensive outpatient program, a partial hospitalization program, or a residential eating disorders treatment center. The challenge with these models is that a more comprehensive care continuum, one capable of addressing the specific needs of BED sufferers, is not well coordinated. The individual psychotherapy setting is typically not capable of managing comorbid physical conditions such as obesity, hypertension, diabetes, and other medical conditions. Therapists who treat women suffering from BED are often therapists who specialize in the treatment of other eating disorders, and the treatment methods used to treat eating disorders such as anorexia nervosa and bulimia nervosa are not consistent with the evidence base for effective treatment of BED. More restrictive settings, including IOP, PHP and residential treatment centers, almost always group women seeking treatment for BED into the same clinical setting as women suffering from other eating disorders. This co- mingling of diagnoses, each with very different indicated methods of treatment can be contra- indicated for women seeking treatment for BED. The proposed Treatment Center, dedicated to the treatment of adult women suffering from BED, coupled with the existing non- clinical Green Mountain at Fox Run short- term weight management and healthy lifestyle retreat, will offer a uniquely integrated care continuum, based on an evidence based treatment model that does not exist elsewhere in Vermont or within the United States. 10

11 HRAP Standards Related to the Institute of Health Improvement Triple Aims Improving the health of populations Estimated 3.5% of women living in the Unites States suffer from BED, and two thirds of these 5.4 million female BED sufferers are categorized overweight or obese. It is therefore estimated that approximately 5.4 million women living in the U.S. could benefit from the combined GMFR and Treatment Center programs, and 3.6 million women could benefit from the Treatment Center programs alone. Depression and anxiety are common co- occurring psychological issues associated with individuals suffering from BED. Typical chronic medical comorbidities can be detrimental to a BED sufferer s physical health, including: Obesity, with its concurrent risk for Type 2 diabetes, high blood pressure, high cholesterol, gallbladder disease, heart disease and certain types of cancer Malnourishment due to a lack of proper nutrition. Bingeing episodes usually include foods that are high in sugar, fat and/or salt, but low in essential nutrients An estimated 16% to 30% of bariatric surgical patients experience binge eating disorder; BED is related to poorer surgical outcomes, and additional interventions are often needed to improve long term outcomes The strong association between obesity, BED, comorbid psychological conditions and chronic medical comorbidities suggests that the proposed integrated continuum of services will significantly enhance health outcomes for women seeking a sustainable approach to healthy weight management and at the same time are in need of substantial clinical and therapeutic intervention for BED and associated co- occurring psychological and chronic medical comorbidities. Source: National Institutes of Health, The National Institutes for Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) 11

12 HRAP Standards Related to the Institute of Health Improvement Triple Aims Reducing the per capita cost of care for populations BED- related obesity in women costs businesses approximately $2.5 billion annually in lost productivity, 12 lost work, restricted and bed days. Early identification and treatment can help reduce these problems in the workplace. (EAP Digest, 2003) Kaiser Permanente Center for Health Research, Wesleyan University and Rutgers University, found that more than 63% of participants in its BED treatment program had stopped bingeing at the end of the program, compared to just 28% of those that did not participate. Binge Eating Disorder is a condition which significantly impairs people s lives and increases their risk of significant medical complications that often require costly ongoing medical intervention. (Wonderlich, 2014) By providing the clinical interventions necessary to address the psychological pathology associated with women suffering from BED, while at the same time addressing associated chronic medical conditions, it is anticipated the long- term medical costs will be reduced based on improvements in overall psychological and physical health. In Vermont, which has a 23.2% obesity prevalence and an estimated 12- month BED incidence of 6,141 adult women ages 18-65, the Treatment Center is anticipated to improve the overall health status of adult Vermont women suffering from BED, thereby reducing the overall cost of care for this patient cohort.

13 CON Standard 1.2: Applicants shall show that services have been shown to improve health. The Treatment Center therapeutic programs will subscribe to the most widely researched treatments for BED, which are based on cognitive- behavioral procedures. Peer reviewed literature suggests that Cognitive Behavioral Therapy (CBT) eliminates bingeing in approximately 50% of participants and reduces it in many others (Wilfley, Wilson, & Agras, 2010). There is an emerging trend of mindfulness based treatment for binge eating, a behavioral approach to overeating and emotional regulation, which shows promise in eliminating binge eating (Baer, R 2005). The Treatment Center will use these methods in its core therapeutic approach. 13

14 CON Standard 1.4: Applicant shall show that it will be able to maintain appropriate volume for the service and will not erode volume at any other VT facility No other known comprehensive treatment program specifically designed to provide a continuum of psychiatric and psychological treatment of BED with concurrent coordination of treatment medical comorbidities programs of this nature exists in Vermont. 14

15 CON Standard 1.3: To the extent neighboring health care facilities provide the services proposed, applicant shall demonstrate a collaborative approach to delivering the service No other known comprehensive treatment program specifically designed to provide a continuum of psychiatric and psychological treatment of BED with concurrent coordination of treatment medical comorbidities programs of this nature are known to exist in Vermont Applicant is currently working collaboratively with clinical and administrative leadership at Brattleboro Retreat, Rutland Regional Medical Center, and Springfield Hospital, and will continue to work with local providers in order to ensure that a community- based approach to care coordination is taken 15

16 Standard 1.6. Explain how applicant will collect and monitor data relating to health care quality and outcomes Performance and Quality Improvement Plan and associated activities will conform to Joint Commission Behavioral Health Standards Methods of collecting and monitoring date relating to quality and outcomes are outlined in the proposed program s initial Quality and Performance Improvement Plan included in Applicant s September 19, 2014 submission 16

17 Standard 1.7. Applicant will explain how project is consistent with evidence- based practice Studies have shown that mindfulness- based methods for treating BED are likely to enhance effectiveness of Cognitive Behavioral Therapy (CBT) for BED treatment, the following psychological treatment methods that have shown to be effective in producing positive outcomes Dialectical Behavioral Therapy (DBT) although originally developed for the treatment of Borderline Personality Disorder, has been adapted for Bulimia and Binge Eating. ( Linehan 1993, Telch, Agras & Linehan 2001) Mindfulness- based eating awareness training (MB- EAT) and an adaptation of Mindfulness- Based Cognitive Therapy (MBCT) have been developed specifically for BED. (Baer 2006, Kristeller & Hallet 1999) Mindfulness skills are taught to counteract the tendency to use binge eating to avoid or dissociate from emotional awareness. With DBT interventions, a rapid response of binge abstinence has been shown to continue to the end of treatment and at one- year follow- up. (Safer and Joyce 2011). Combination of mindfulness and CBT for binge eating has demonstrated improvements in eating pathology through increased self- awareness (Woolhouse, Knowles & Crafti 2012). Overall, evidence- based treatment of CBT results in significant improvements in eating pathology and general psychopathology that are maintained over one and two year follow- ups (Wilson 2011). Short term CBT treatment for BED has shown long term efficacy in reducing eating symptomatology, eating disorder pathology and co- morbid depressive symptoms by further improving or stabilizing conditions over a course of four years (Fisher et al., 2014). CON application s Appendix A includes a number of peer reviewed journal articles that support the efficacy of using the treatment methods described above 17

18 Standard 1.7. Evidence- based Practice, continued American Psychiatric Association (APA) Practice Guidelines for the treatment of patients with eating disorders strongly recommend specialized multidisciplinary teams who understand specialized eating disorders treatment practices Due to limited access to such teams geographically, programs that offer multidisciplinary intensive outpatient treatment with transitional living options have been valuable for those seeking care. APA recommends a team that collaborates by offering nutritional rehabilitation and counseling with a focus on decreasing binge eating rather than on weight loss, in conjunction with behavioral therapies such as individual and group therapies, including CBT and DBT Motivational dynamics when treating eating disorders require a strong therapeutic alliance, empathy and support that build trust. The level of structure provided (difference between IOP and PHP) depends on what is required to monitor and provide coaching for binge behaviors, psychiatric and behavioral factors influenced by level of depression, body image dissatisfaction and low self esteem. APA also states there is increasing evidence for the need for highly structured 5- day- a- week programs. Behavioral approaches to weight management can be a useful component through a non- diet approach with a focus on self- acceptance, improved body image and better nutrition and health with increased physical movement. 18

19 Cost of the Project is Reasonable Less expensive alternatives to this treatment program do not exist in Vermont; although individual therapists do provide treatment for eating disorders in Vermont, these are all outpatient therapy only, and do not include a higher level of care such as IOP or PHP; the only alternatives in Vermont for individuals demonstrating a higher level of acuity for which outpatient therapy is insufficient, include out- of- state residential or in- state inpatient treatment 19

20 Primary Service Area Projected BED Incidence Rate There is an identifiable, reasonably anticipated need for the proposed project Primary Service Area Projected BED Treatment Episodes 20 Source: Substance Abuse and Mental Health Services Administration, National Association of Eating Disorders

21 Vermont Only Projected BED Incidence Rate Projected Demand for Services in the State of Vermont Vermont Only Projected BED Treatment Episodes Based on the estimates outlined above, within the state of Vermont there appears to be over 6,000 women currently suffering from BED, and an estimated 1,744 of those women would be anticipated to seek treatment within a given year, but with currently no IOP or PHP option available to them. 21 Source: Substance Abuse and Mental Health Services Administration, National Association of Eating Disorders

22 Project will improve the quality of health care in the state and provide greater access for Vermont residents Proposed project is unique in Vermont, treatment methods are evidence based and demonstrated to be effective, as detailed in Applicant s CON application Proposed program will offer sliding fee scale and has a defined budget for discounted and uncompensated care for the underserved, a budget that is anticipated to grow as program revenues grow over time Free transportation will be provided to local transportation hubs Currently working with local Chamber of Commerce to secure low cost lodging for low income patients Willingness to enter into Medicaid Single Case Agreements until such time that program is eligible to become a credentialed Vermont Medicaid provider 22

23 23 Projected Average Cost of the Program, Lodging, Meals

24 Other steps to help ensure the program is accessible and affordable to Vermont residents Ongoing and planned outreach education for behavioral health and primary care providers to help them identify appropriate patients in need of treatment Ongoing efforts to become an in- network provider with Vermont health plans; discussions have been initiated with BCBSVT, which includes coverage for medically necessary behavioral health IOP and PHP treatment Advocacy efforts for behavioral health parity legislation requiring health plans to include eating disorder treatment as a covered benefit (currently 28 states have legislated partial or full parity coverage for the treatment of eating disorders) Advocacy for passage of the Federal Response to Eliminate Eating Disorders Act (HR 2101), a comprehensive bill to ensure comprehensive treatment and funding for research for eating disorders 24 Source: eatingdisorderscoalition.org

25 Project will not have an undue adverse impact on any existing services provided by applicant The two programs, Fox Run and the BED Center, will be complementary, not competitive, in nature Separate clinical and program staff, with some sharing of staff among the two programs (e.g., registered dietitian) Shared administrative staff among the two programs (e.g., marketing, finance) 25

26 Role of Psychiatry Medical Director and Attending Physician Serve as Medical Director for the program, overseeing the activities associated with program accreditation, quality assurance, provider credentialing, and other responsibilities typically falling under an outpatient treatment center medical director Ensure that the client meets the criteria diagnostically for admission, continued stay reviews and discharge Initial psychiatric evaluation, and written orders for participation the appropriate level of treatment If psychotropic medications are prescribed, meet with the client weekly for a medical management session, usually lasting approximately minutes, which is an industry standard for this type outpatient psychiatry visit Weekly formal staffing meetings to review individual patient progress toward meeting treatment plan goals Ongoing treatment collaboration with the treatment team through HIPAA compliant communication systems for information related to behavior observed in the clinically staffed programs. At a projected.25 FTE or 10 hours per week, the psychiatrist will be onsite for 1 2 days per week depending on the client activity 26

27 Role of primary care and medical specialists In outpatient behavioral health care the primary care provider will only be needed if any acute health care needs occur. We have budgeted.05 FTE. Since the admissions criteria involves the client being medically stable and able to manage their own ongoing medical care, such as administration of medication, the use of a primary care provider will be minimal, and will be used primarily as a source of care coordination among the Treatment Center programs and addressing comorbid physical conditions. 27

28 Development of Referral Relationships in Support of Managing Co- Occurring Psychiatric and Medical Conditions Conversations are ongoing with Rutland Regional Medical Center, Brattleboro Retreat and Springfield Medical Care Systems in order to forge referral relationships with psychiatric and medical providers who will be willing to work with Treatment Center patients and program care management staff (referred to in the CON application as utilization management) in order to ensure continuity of care locally Treatment Center care management will work closely with patients regular health providers and health insurers to ensure patients receive medically necessary care and communicate treatment progress toward treatment plan goals (subject to obtaining appropriate release of information authority from patients) 28

29 Projected 3- Year Projected Patient Volume and Average Daily Census Projected Patient Volume Note: Volume represents outpatient visits, IOP treatment days, PHP treatment days, Transitional Living Program overnight stays Projected Average Daily Census 29

30 Projected Staff by Provider Type 30 Clinical staff need is based on volume projections and the split between individual and group therapies; clinical staff will be shared among the three clinical programs (OP, IOP, PHP)

31 Proposed Project Financial Projections 31

32 Thank you for your consideration.

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