CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS  Office of the Chief Medical Officer  Clinical Operations  Outpatient Eating Disorders Treatment  Psychotherapy - 07   Category: Psychotherapy Published Date: July 2022

PARAMETER GOAL To establish guidance and direction on the outpatient treatment of clients with eating disorders or suspected eating disorders.  To define levels of care for clients diagnosed with an eating disorder. Per Department of Health Care Services (DHCS) Behavioral Health Information Notice 22-009, treating clients with eating disorders is a shared responsibility between the Mental Health Plan (MHP) and Medi-Cal Managed Care Plans (MCPs).  MHPs are required to provide and cover all medically necessary Specialty Mental Health Services (SMHS) in accordance with their performance contract with DHCS.  As such, SMHS providers must provide a full array of outpatient mental health services to clients diagnosed with an eating disorder who are appropriate for an outpatient level of care. MCPs are contracted to provide comprehensive medical case management services, including coordination of care, to ensure the provision of all medically necessary physical health and non-SMHS. TERMINOLOGY Eating Disorders: Maladaptive eating patterns that result in clinically significant emotional distress and functional impairment.  The following are specific types of eating disorders: Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other specified feeding/eating disorder MEASURES Eating Disorders Examination Questionnaire – Short Form (EDE-QS) SCOFF Questionnaire TREATMENT STRATEGY Clients with eating disorders have a range of clinical presentations, and treatment planning will vary accordingly.  Clinicians should decide, based on a client's presentation, whether medical monitoring is needed and whether that can be handled by the mental health provider, by primary care, or with medical consultation.  Similarly, treatment teams should decide whether nutrition education/interventions can be addressed by the mental health provider or through medical/primary care expertise. A stepped-care approach to treatment depending upon symptom severity: SMHS with either consultation from primary care or with primary care as part of the treatment team Intensive outpatient program (at a Higher Level of Care Eating Disorder [HLOC ED] facility) Partial hospitalization program (at an HLOC ED facility) Residential treatment (at an HLOC ED facility) Inpatient care Medical/physiological stabilization Psychiatric/psychological stabilization Establishing a team approach to treatment that has access to or specifically includes: Therapist Physician (consider whether a primary care physician is necessary for medical monitoring) Psychiatrist Staff who can provide general education on nutrition/monitoring of diet (dietician consult vs. mental health staff) Enhanced mental health services for clients with eating disorders: Weekly therapy: Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) where emotion regulation associated with Borderline Personality Disorder is present Family therapy for child, adolescent, and adult clients Psychoeducation on nutrition and healthy eating, which could include exposure therapy to food and eating, mindful eating, movement therapy (comfort with one’s body) Consultation with primary care, dieticians, and physician on lab results, vitals, and Body Mass Index (BMI) changes (medical monitoring of lab results, reviewing electrolyte levels) Targeted case management to link clients to adjunctive services and supports, including places to obtain healthy and affordable food Treatment planning/coordination to manage the components of treatment and reduce individual therapist burden relative to caseload responsibilities Factors to consider in determining treatment intensity: BMI can be a useful indicator, with 15 as a lower limit Consider the risks of atypical anorexia where the client falls within a normal weight bracket Consider activity level and other health indicators Recent dramatic weight loss increases health risks Care coordination across levels of care: HLOC ED (i.e., Inpatient, residential, partial hospitalization program [PHP], intensive outpatient program [IOP] facilities) must have a clear understanding of SMHS prior to transitioning a client to lower levels of care Prior to a client's transition from inpatient, residential, PHP, or IOP to outpatient eating disorder treatment, the outpatient provider should have: An authorization from the client/family to share the client’s medical record with an outpatient provider An in-person or virtual case conference with the client (and family where appropriate) and the HLOC ED treatment team to establish continuity of treatment A copy of the meal plan One of the Department of Mental Health (DMH) care coordination teams will facilitate a connection between outpatient SMHS providers and HLOC ED treatment providers  Coordination can include obtaining clinically needed documents from the HLOC ED treatment provider. Contact Information: ED_ECT_Auths@dmh.lacounty.gov EATING DISORDER REFERRAL PROCESS - DMH SYSTEM OF CARE PROVIDERS The mental health provider submits a secure request for HLOC ED treatment to DMH ED_ECT_Auths@dmh.lacounty.gov and submits the DMH Eating Disorder Referral Form that includes and is not limited to clinical information listed in item B below.  Note: HLOC ED treatment includes inpatient, residential, partial hospitalization, or intensive outpatient levels of care Referral Form Information required but not limited to the following: Demographic and contact information (includes caregiver information for minors) Insurance information (e.g., copy of client’s Medi-Cal card or Medi-Cal number) Current eating disorder symptoms/associated behaviors Frequency (e.g., number of times per day/week/month) Intensity (e.g., mild, moderate, severe) Duration (e.g., 15 minutes or 60 minutes, or some other time period) Current impairment in functioning related to the eating disorder symptoms/associated behaviors as well as impairment in functioning related to any other mental health symptoms currently experienced Indicate if the current level of functioning is different from the past level of functioning and, if so, describe the difference History (including onset) of eating disorder symptoms/associated behaviors Additional current mental health and historical mental health symptoms/associated behaviors History of assaultive behavior History of involvement with the legal system Current diagnosis/diagnoses History of eating disorder treatment (e.g., hospitalizations, other HLOC ED treatment, outpatient) History of other mental health treatment received/currently receiving Level of care for eating disorder treatment (e.g., inpatient, residential, partial hospitalization, or intensive outpatient) recommended by the referring mental health provider/treatment team Medications and purpose for medications (e.g., psychotic symptoms, mood stabilization, etc.) Level of social and family support Any other relevant information that would assist with the decision-making process Current BMI Current labs If items 1-15 are clearly documented with the requested specificity in the full assessment completed by the referring mental health provider, the full assessment document can be submitted. DMH staff will confirm receipt of the request and contact the mental health provider should additional information be needed. DMH psychiatrist will review all submitted documentation to inform the determination of the level of care needed (e.g., inpatient, residential, partial hospitalization, intensive outpatient, or other services). If additional information is needed, a clinical consultation may need to be scheduled with the DMH psychiatrist. DMH staff will contact the mental health provider to inform them of the authorization determination. If HLOC ED treatment is approved, information regarding the specific treatment program authorized will be provided. The HLOC ED treatment provider will contact the client, provide information about their admission process, and coordinate placement. The HLOC ED treatment provider, during the discharge planning process from the HLOC ED treatment program, will coordinate with the mental health provider for the provision of outpatient mental health services upon discharge. STAFF TRAINING In an effort to further support all providers, DMH is providing the following trainings:  Eating Disorders 101 Eating Disorders 102 Monthly Learning Collaboratives to support 101/102 DMH training information can be found on Events Hub or DMH employees may access Events Hub through the DMH Applications page on SharePoint. As with all mental health disorders, providers are encouraged to seek additional training and educational resources on their own. One reputable resource is https://www.eatingrecoverycenter.com/ Washington University School of Medicine in St. Louis: Department of Psychiatry, Center for Health Weight and Wellness: 360 Eating Disorder Training Family Based Treatment for Eating Disorders Eating Disorders Bootcamp for Dietitian and Other Providers Evaluation, treatment, and Medical Management of Eating Disorders You’ve Got This! Early identification of Disordered Eating and How You Can Help Dialectical Behavior Therapy (DBT) for Bulimia Nervosa (BN) and Binge Eating Disorder (BED) Webinar SUPERVISION AND CONSULTATION DMH is developing opportunities for case consultation, including peer-to-peer consultation.  For more information, contact Debbie Innes-Gomberg at DIGomberg@dmh.lacounty.gov Center for Discovery 25 years+ in Eating Disorders Treatment Contract with DMH Address: 8484 Wilshire Blvd., #510, Beverly Hills, CA 90211 Contact Number: 833-410-9607 Services: Separate programs for Adults and Children & Adolescents Residential, Partial Hospitalization, Intensive Outpatient, and Outpatient. Other locations: Woodland Hills, Glendale, Lakewood, La Habra, Thousand Oaks, Torrance, Rancho Palos Verdes Information: (888) 975-0615 Reasons Eating Disorder Center Contract with DMH Address:  4619 Rosemead Blvd, Rosemead, CA 91770 Contact Number: (800) 235-5570 Services:  Adult Inpatient Program, Adult Residential Treatments, Adolescent Inpatient Program, Adult Virtual Outpatient Eating Disorder Care, Adolescent Virtual Partial Hospitalization Program and Intensive Outpatient Program Services Other locations:  Rosemead, Arcadia Pasadena, San Marino  RESOURCES California Department of Health Care Services Behavioral Health Information Notice 22-009 Eating Disorder Hope The Eating Recovery Center LAC DMH QA Bulletin 22-08 Missouri Eating Disordered Advisory Council National Center of Excellence for Eating Disorders National Association of Anorexia Nervosa and Associated Disorders National Eating Disorder Association National Institute of Diabetes and Digestive and Kidney Disorder - Weight Management - Binge Eating Disorder: Binge Eating Disorder - NIDDK (nih.gov) National Institute of Mental Health: Eating Disorders Substance Abuse and Mental Health Services Administration - Eating Disorders UCLA Inpatient and Outpatient Eating Disorder Treatment Programs US Department of Health & Human Services: Office of Women's Health: National Eating Disorders Awareness Week (NEDAW)