8.201 Acute Inpatient Eating Disorder (Adult and Adolescent)

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1 8.20 INPATIENT SERVICES Acute Inpatient Eating Disorder (Adult and Adolescent) Description of Services: Acute inpatient eating disorder treatment represents the most intensive level of psychiatric care for the treatment of eating disorders. Multidisciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed and psychiatrically supervised treatment environment. Twenty-four hour skilled psychiatric nursing care, daily medical evaluation and management, and a structured treatment milieu that is specifically tailored to the treatment of eating disorders are required. This can be accomplished on a specialized unit or a unit with a specific, specialized tract/program that relies on evidence based approaches to the treatment of these complex disorders. Inpatient service settings must provide an initial visit with an attending physician within 24 hours of admission for evaluation and treatment planning, and a documented daily visit with an attending licensed prescribing provider. Clinically based facility exceptions to the daily prescribing provider visit requirement may be approved by a Beacon Health Options Medical Director based on founded requests (geographic considerations, provider access/availability, etc.). Granted exceptions must nevertheless provide a documented visit with an attending licensed prescriber a minimum of 5 days per week, no less than every 48 hours, and no less than within 24 hours of discharge. The goal of acute inpatient care is to stabilize individuals who display an acute need for 24 hour care to avoid eating disordered behaviors such as food restricting, purging, over-exercising, use of laxatives/diet pills/diuretics, to avoid imminent serious harm due to medical consequences or co-morbid medical or psychiatric complications such as complications of refeeding syndrome. Special treatment may include enteral tube or parenteral feeding techniques. Active family/significant other involvement is important unless contraindicated. Nutritional counseling is required. Estimated length of stay is based on individual needs which must be documented in the treatment plan. Licensure and credentialing requirements specific to facilities and individual practitioners do apply and are found in our provider manual/credentialing information. Important: While level of care determinations are considered in the context of an individual's treatment history; Beacon Health Options never requires the attempt of a less intensive treatment as a criterion to authorize any service. Reviewed: 7/15/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15 Page 1 of 5

2 Admission Criteria Criteria The following criteria are necessary for admission: 1. Individual has been evaluated by a licensed clinician and demonstrates symptomatology consistent with an Eating Disorder diagnosis as listed in the most recent version of the DSM which requires and can reasonably be expected to respond to therapeutic intervention at the acute level of care. 2. Facility demonstrates ability to safely treat Eating Disorder individuals with specific, individualized, evidence based care. The acute unit must be in Beacon Health Options network or be accredited by one of the organizations listed in Beacon Health Options policy N206 Credentialing Criteria for Facility/Organizational Providers. 3. Individual requires 24 hour monitoring including monitoring during and after all meals as well as in the evening hours to avoid behaviors such as restricting, overexercising/purging, and/or use of laxatives/diuretics/diet pills. There is evidence of actual or potential danger to self or others or severe psychosocial dysfunction related to the eating disorder diagnosis as evidenced by at least one of the following (4-7): 4. Objective signs of medical instability such as: a. Pulse < 40 bpm b. Blood Pressure < 90/60 mmhg or significant orthostatic changes > 20 mmhg c. Blood glucose < 60mg/dL d. Potassium < 3 meq/l or other electrolyte imbalance (magnesium, phosphate, sodium) e. Temperature < 97.0 degrees F f. Severe dehydration g. Renal, cardiovascular or other organ damage h. Poorly controlled Diabetes Mellitus i. Although weight alone should not be the sole criterion for admission or discharge at this level of care, the individually calculated ideal body weight is generally <85% (or BMI of 15 or less) at this level, combined with other objective evidence of medical complications that require 24 hour care. j. Requires enteral tube feeding or parenteral feeding in a structured inpatient acute setting and is unable to utilize these mechanisms safely at a less restrictive level of care. k. pregnancy with potential risk to mother s or fetus health l. refeeding syndrome 5. Significant risk to self or other demonstrated by something such as the following: a suicide attempt that is serious by degree of lethality and intentionality or suicide ideation with a plan and means; assaultive threats or behavior with a clear risk of escalation or future repetition (e.g. has plan and means); a recent history immediately prior to admission of non-chronic Reviewed: 7/15/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15 Page 2 of 5

3 Psychosocial, Occupational, and Cultural and Linguistic Factors significant self-injurious behavior or significant risk-taking or loss of impulse control; recent history immediately prior to admission prompting evaluation or intake of violence resulting from a DSM diagnosis (e.g. Borderline PD); command hallucinations to harm self or other; disordered or bizarre behavior that interferes with activities of daily living to such a degree that the individual cannot function at a lower level of care. NOTE: if this is the main presenting problem, and Eating DO is not the primary presenting problem, consider using the Beacon Health Options Mental Health medical necessity criteria instead. It is expected that the following takes place: 6. The multi-disciplinary discharge planning process starts from the assessment and tentative plan upon admission, and includes the patient and family/significant other as appropriate, unless contraindicated secondary to risk of harm to patient or family/support. A bio-psycho-social outpatient team should be collaborated with or created if not already in place (including physical health practitioner, behavioral health therapist, psychiatrist, nutritional expert). Firm aftercare appointments should be in place. 7. The treatment plan needs to clearly state the benefits individual will receive in program, and the goals of treatment cannot be based solely on need for structure and lack of supports. These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care decisions. Exclusion Criteria Continued Stay Criteria Any of the following criteria is sufficient for exclusion from this level of care: 1. The individual can be safely maintained and effectively treated at a less intensive level of care. 2. Symptoms result from a medical condition which warrants a medical/surgical setting for treatment. 3. The individual exhibits serious and persistent mental illness and is not in an acute exacerbation of the illness. 4. The primary problem is social, economic (e.g., housing, family conflict, etc.), or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration. 5. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service or a primary mental health setting is required. All of the following criteria are necessary for continuing treatment at this level of care: 1. The individual s condition continues to meet admission criteria for inpatient Reviewed: 7/15/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15 Page 3 of 5

4 care, acute treatment interventions (including psychopharmacological) have not been exhausted, and no other less intensive level of care would be adequate. 2. The multi-disciplinary discharge planning process starts from the assessment and tentative plan upon admission, and includes the patient and family/significant other as appropriate unless contraindicated secondary to risk of harm to patient or family/support. A bio-psycho-social outpatient team should be collaborated with or created if not already in place (including physical health practitioner, behavioral health therapist, psychiatrist, nutritional expert). Firm aftercare appointments should be in place. 3. Treatment planning is individualized and appropriate to the individual s changing condition with realistic and specific goals and objectives stated. Treatment plan should be structured to gain weight at an appropriate rate (typically 1-2 lbs/week at this level of care if low body weight was a contributing factor). This also includes appropriate lab work. Lab tests should be ordered upon admission (e.g. electrolytes, chemistry, CBC, and thyroid) and ECG. Follow up tests should be ordered as needed. 4. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement unless contraindicated. Family sessions need to occur in a timely manner unless contraindicated. Education on healthy skills should be included (e.g. CBT or DBT skills, healthy exercise protocols, healthy meal selection etc.). Treatment planning goals should be realistic and attainable. Expected benefits from all relevant modalities, including family and group treatment are documented. 5. All services and treatment are carefully structured to achieve optimum results in the most time-efficient manner possible consistent with sound clinical practice. 6. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress and/or psychiatric/medical complications are evident. 7. Care is rendered in a clinically appropriate manner and focused on the individual s behavioral and functional outcomes as described in the discharge plan. 8. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated and consistent with prescribing guidelines. Treatment plan will be updated to address non-compliance issues. 9. Patient is actively participating in plan of care and treatment to the extent possible consistent with his/her condition. Reviewed: 7/15/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15 Page 4 of 5

5 Discharge Criteria Any of the following criteria are sufficient for discharge from this level of care: 1. Treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged and deployed at a lower level of care. Follow-up aftercare appointment is arranged for a timeframe consistent with the individual s condition and applicable standards. 2. The individual no longer meets admission criteria or meets criteria for a less intensive level of care. 3. The individual, family, legal guardian and/or custodian are competent but non- participatory in treatment or in following program rules and regulations. 4. The non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non- participation issues. 5. Either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment 6. Consent for treatment is withdrawn and, either it has been determined that involuntary inpatient treatment is inappropriate, or the court has denied involuntary inpatient treatment. 7. Support systems that allow the patient to be maintained in a less restrictive treatment environment have been thoroughly explored and/or secured. 8. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care due to exhibiting baseline behavior/symptoms of a chronic condition. 9. The individual's physical condition necessitates transfer to a medical facility. Reviewed: 7/15/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15 Page 5 of 5