At Kartini Clinic our evolution to the current levels of care we offer has been a long one. In the first days of the clinic we offered only inpatient (hospital rounds for medical stabilization) and outpatient care. In 2000 we developed the day treatment (partial hospital) level of care. This was a big step forward and allowed us to “gently land” patients, who required brief medical stabilization in hospital, to a lower level of care. In day treatment, such patients could get a lot more psychological support, and we could do more parent teaching/involvement. More recently we’ve developed an “intensive” outpatient (IOP) level of care, to facilitate the transition back to school for kids who have graduated from the day treatment level. It, too, seems to have had a positive impact on outcome.
So what are some of the factors that help us decide whether a patient enters or graduates from a particular level of care?
Below are some of our decision points, although please remember this is clinical decision making on the part of our pediatricians (who are medically responsible) in consultation with our director of mental health services and our staff of expert, licensed therapists. As clinical decisions, these are not recipes, not one-size-fits-all circumstances, but rather guidelines for the doctors, therapists and families as they move forward together.Inpatient
This is perhaps the easiest decision to make as it conforms 99% of the time to American Academy of Pediatric guidelines for medical stabilization of children, adolescents and young adults with an eating disorder. According to the APP, you belong in the hospital to begin your re-feeding if:-
your heart rate is below 50 BPM regardless of athletic status
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your pulse differential – lying to standing – is above 34 BPM
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your systolic blood pressure drops more than 9 mmHg from lying to standing
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you have been unable to eat or drink for days
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your electrolytes are deranged
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your weight is less than 76% of where the doctor thinks it should be or less than 76% of where you started, regardless of where you should be
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you have had episodes of fainting
Day Treatment (DTU)
This level of care requires that a patient be able to eat the basic Kartini meal plan with little or no Boost supplement for non-completion of meals. A patient must be medically stable enough to be safely at this level. In other words, they cannot have the problems outlined above that mandate inpatient care. The focus of Kartini Cinic’s Day Treatment Unit level of care goes beyond simple weight restoration (although, believe me, we always work for complete weight restoration – and our results speak for themselves). The DTU is where our kids learn to do a great number of things:-
eat in a social setting
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not hide food
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not engage in eating disordered table behaviors (e.g. smearing, cutting up food into tiny amounts, etc)
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not binge (if they did before)
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not purge (if they did before)
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eat in a reasonable amount of time
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not melt down at the table when asked to eat
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identify their eating disordered thoughts as such
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learn coping skills to deal with their eating disorder anxiety and practice using them further:
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parents are coached (by the family therapist) to assist with #8 and # 9
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patients discuss the challenges around returning to their school and are able to make arrangements to deal with school issues relating to their eating disorder
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parents are able to make all meals, eat them with their child and supervise meals closely
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patients are trained in (respectful) assertive communication
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siblings are brought on board (in family session)
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patients are taught relaxation techniques
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they work in a personal relapse prevention plan
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if this is a repeat admission to this level of care for the patient, they are able to de-construct what went wrong and make a plan to change it
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their eating disorder distress cannot be so disabling that they could not function at a lower level of care.
This is, of course, not an exhaustive list of what must be done at the DTU/partial hospital level of care, just some of the high points. Prior to being discharged, patients must demonstrate an ability to do all of the above in their home setting (for example, over the weekend), not just within the confines of the DTU.
Intensive Outpatient (IOP)
This is the appropriate level of care for patients whom our team feels need a “soft landing” from day treatment in order ease the transition back at school and to reduce the likelihood of readmission to a higher level of care. It is not designed to be an entry level of care, since patients who have not been through the DTU will not have mastered the 18 points (minimum) outlined above. IOP takes place after school and is for only a few hours, four days a week. The kids “get their wings” in the DTU and practice using them in a more sheltered environment, where they have nearly daily de-briefing with and support of their therapists.The team member who assumes responsibility for medical safety (at Kartini Clinic this is the pediatrician) makes the final decision about level of care, with the input of our team and of parents. We do also strongly advocate for our decision based on the best interest of the child with each child’s insurance company, but in case the insurance company disagrees or refuses to listen, there are some (non-Kartini) resources families might want to know about.
