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  • 5 Levels of Care

    According to the American Psychiatric Association’s practice guidelines for eating disorder treatment, there are 5 levels of care for patients. A “level of care” refers to what is the most appropriate form of treatment that provides a setting for recovery in the least restrictive environment. Factors that determine the most appropriate level of care include:

    • Medical stability.
    • Suicidality.
    • Percentage of body weight/BMI.
    • Motivation and cooperation for treatment
    • Co-existing Conditions such as mood disorders and/or substance use.
    • Self-sufficiency or support required for eating and/or weight restoration.
    • Extent of purging behaviors.
    • Extent of compulsive exercising.
    • Environmental stressors and support from others.
    • Geographic availability of treatment programs.

    The 5 Levels of Care

    Level 1: Outpatient

    Outpatient care refers to a patient working on an individual basis (vs. being a part of an organized program). Outpatient care usually involves a combination of a psychotherapist, nutritionist, and medical doctor who monitor the patient’s safety and provides treatment through regularly scheduled office visits.

    Appropriateness:

    Outpatient care usually requires 1 to 3 hours a week and is best suited for patients who are medically stable with no suicidality, are at least 85% of expected body weight, have fair to good motivation, do not have any major mood or substance use issues, are able to eat and maintain a weight restoration plan on own, can manage compulsive exercise urges, are capable of reducing purging behaviors without supervision, have a good support system from others, and live near qualified treatment providers.

    Level 2: Intensive Outpatient

    Intensive Outpatient Programs (IOP) are usually 3-5 days per week, 3-4 hours per day. IOPs can be private, clinical or hospital, may consists of a group of 2-20 patients, and can vary in content and hours (mornings, afternoon, evening programs). IOPs consist of a collaborative group or treatment providers and treatment primarily is in a group context with group therapy and 1-2 supervised group meals daily. Some programs do not allow patients to continue outpatient treatment while in the IOP, while others may allow individual therapy and psychopharmacological with their private team. IOP programs usually require a commitment length of 4 weeks or more.

    Appropriateness:

    Intensive outpatient care requires a commitment to treatment several days a week and is best suited for patients who are medically stable with no suicidality, are at least 80% of expected body weight, have at least fair motivation, do not have any dangerous mood or substance use issues, require some supervision for meals but are able to eat and maintain treatment goals when not in the program, can manage compulsive exercise urges, are capable of reducing and maintaining a reduction in purging behaviors without constant supervision, have at least some support from others, and live near a qualified treatment program.

    Level 3: Partial Hospitalization or Full Day Program

    A partial hospitalization program or a full-day program is usually at least 5 days a week, 8 hours a day. These programs can also be private or hospital based and consist of 3 supervised meals and snacks with group therapy remaining as the main modality of treatment. Partial hospitalization/full-day programs however, are more likely to include individual therapy, individual nutritional therapy and in-house medical supervision and usually require a minimum time commitment of 4 weeks or more.

    Appropriateness:

    A partial hospitalization program or a full-day program is a serious “full-time” requiring daily commitment to treatment and is best suited for patients who are medically stable without extensive medical monitoring, no suicidality is present, at least 80% of expected body weight, have at partial motivation, do not have any dangerous mood or substance use issues, require supervision for meals and weight restoration with ability to adhere to treatment plan when not in the program, has some control to resist urges to compulsively exercise, are capable of reducing and maintaining a reduction in purging behaviors without constant supervision, have at least some limited support from others, and live near a qualified treatment program.

    Level 4: Residential Treatment Facility

    A residential treatment facility can be a private treatment center or an adjunctive center to a hospital where patients received treatment on a 24hour/7day basis, while temporarily living at the facility. Residential facilities have staff on duty 24 hours a day for continuous supervision and treatment. Patients live as a part of a therapeutic community having their snacks and meals provided to them and participating in various group therapies, experiential treatments, individual therapy, nutritional therapy and have in-house medical care provided. Some residential centers have a full-time medical staff and can accept patients who are medically compromised, while others centers may require an incoming patient to have some basic medical stability. Types and styles of residential treatment facilities vary greatly from clinic style management to more “luxurious” programs. Some centers may have larger populations of patients while other offer smaller personalized types of programs. Most residential centers for children and adolescence also provide educational services to avoid any interruption in academics. Residential treatment usually require a minimum time commitment of 30-45 days, however, some centers can provide longer-term care.

    Appropriateness:

    A residential treatment facility is a place where patients live and focus on their recovery. Patients who meet criteria for a residential typically are medically stable to the extent that I.V. fluids, nasogastric tube feedings or daily multiple laboratory tests are not required, no acute suicidality requiring constant individual supervision is required, is less than 85% of expected body weight, have at poor to fair motivation for treatment, requires close/constant supervision and/or more intense treatment for mood and/or substance use issues, require supervision for meals and weight restoration and has difficulty or failed to adhere to treatment plans of levels 1-3, require supervision to resist urges to compulsively exercise, are NOT capable of reducing and maintaining a reduction in purging behaviors without constant supervision, have no support from others or have severe family conflicts, do not live near a qualified treatment program.

    Level 5: Hospitalization

    Hospitalization is required for patients who are medically compromised, suicidal or completely uncooperative for treatment which poses an imminent risk to their health. Today, most hospitalizations are for the acute management of medical/psychiatric risks, nasogastric re-feeding with weight restoration to a minimally acceptable level and safety until a lesser level of care is appropriate and available. A few hospitals may provide medical stabilization in specialized eating disorder units, but most only provide medical/psychiatric/weight stabilization until a discharge plan is in effect.

    Appropriateness:

    Hospitalization is required when there is a significant, potentially life-threatening risk to a patient’s health and well-being. Hospitalization is required for patients who are medically compromised may require I.V. fluids for hemodynamic and electrolyte stabilization, nasogastric tube feedings for weight restoration, cardiac monitoring and daily laboratory tests to monitor body systems. Hospitalization is also required for severe psychiatric conditions and/or suicidality. Other criteria for hospitalization include patients who are less than 85% of expected body weight or acute weight-loss with refusal to eat even if not less than 85% of expected weight, very poor motivation or uncooperative with treatment, require constant supervision for meals and weight restoration, require constant supervision to resist urges to compulsively exercise, requires constant supervision to control purging behaviors, have no support from others or have severe family conflicts, do not live near a qualified treatment program and require a supervised environment until stabilized with an aftercare plan.