Care and treatment of eating disorders - national specification: consultation

Outcome 6: Transitions

Outcome Statement

Clear transition protocols are in place and used routinely to support safe and coherent care.

Rationale

Transitions are points of increased risk for individuals with eating disorders and can adversely affect quality of care and patient safety. Transitions have been highlighted as being a significant problem for individuals with eating disorders (National Review of Eating Disorder Services, 2021). The ethos underpinning transitions should be to remove gaps in care and delays in treatment for the benefit and safety of the patient, rather than protocols based on service needs. Development of all age community eating disorder services in Scotland (as recommended by the National Review of Eating Disorder Services, 2021) will minimise transitions due to age. However, individuals with eating disorders will still experience essential transitions of care e.g., differing levels of intensity of service provision depending on the provider, and/or geographical moves.

Transitions protocols should be in place to support good communication between and within services and providers with clear lines of responsibilities to support safe and coherent care. Careful consideration should be made to reduce repetition and/or unnecessary service barriers (e.g. a transfer of care needing to be assessed by a primary care mental health team prior to specialist eating disorder services).

SIGN Guidelines for Eating Disorders (2022) propose specific recommendations on managing transitions to supplement the existing Royal College of Psychiatrists (2017) Transition Guidelines for Patients with Eating Disorders. This is in addition to existing guidance from Healthcare Improvement Scotland on Transition Planning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (2018).

When a transition of care takes place, the transition should be identified early, prepared, managed, and followed up by clinicians in both services (SIGN, 2022). Where appropriate, services should work collaboratively for six months before the planned transition to ensure seamless care (Royal College of Psychiatrists, 2017). A written transition plan should be drawn up in collaboration with the patient (and representative, where appropriate) and clinician(s). This plan should be readily accessible and shared appropriately, following consent. (SIGN, 2022). Transition plans should include risk assessment and consider medical assessment and monitoring (MEED, 2022) with clear lines of clinical responsibility documented.

Outcome in Action

6.1 Organisations ensure that transition protocols are in place to support effective communication between services. This includes external and internal service transitions with clear lines of responsibilities to support safe and coherent care.

6.2 Organisations ensure that transfers of open and active cases to other eating disorder services, will not be placed on a waiting list again and should be seen immediately without delay.

6.3 Eating disorder services should collaboratively develop a written transition plan with an individual and where appropriate their representative. Where appropriate, services should work collaboratively for six months before the planned transition and written plans should include risk assessment and consider medical monitoring, with clear lines of clinical responsibility documented.

6.4 For patients in, or moving to Higher Education, eating disorder services should work closely with primary care and University/College mental health services to support consistent and integrated care and minimise delays in treatment.

The option to retain treatment with services in an individual’s home board could be considered while an individual attends Higher Education in another locality if this supports consistency in care, with clear risk assessment and medical monitoring responsibilities agreed.

6.5 Eating disorder services should provide the person’s representative with information and advice around the transition where appropriate and with consent.

What does this mean for the person receiving care?

You:

• will experience continuity and consistency in your care
• will develop a joint plan with your clinicians which will support you if you move between services, and
• will not be put back onto a wait list when moving between services in Scotland if you are receiving active eating disorder treatment.

What does this mean for staff?

Staff:

• understand and can access transitions protocols for within and between services, and
• will know who is responsible for medical monitoring and has clinical responsibility for care at all points of the transition.

What does this mean for the organisation?

The organisation:

• has an all-age range specialist eating disorder service
• ensures clear protocols are in place for transitions within and between services
• has transition protocols which are person-centred and reduce repetition and/or unnecessary service barriers e.g. individuals being placed back on a waiting list or needing to be assessed by a primary care mental health team prior to accessing their new specialist eating disorder service)
• ensures transition protocols stipulate clinical responsibility for care and medical monitoring for each point of service transition, and
• performs regular audits of adherence to transition protocols.

Practical examples of evidence of achievement (Note: this list is not exhaustive)

• Clear transition protocols for each level of common transition pathways within and between services.
• Standardised information is available for individuals with eating disorders and their carers or representatives, where appropriate, to explain the transition process and relevant information on the services they are transitioning to.
• Audit to demonstrate regular transition meetings between services that experience frequent transitions with each other to support good working relationships and to resolve any areas of concern or unmet needs.
• Feedback from individuals who have recently experienced service transitions to support learning and continued development of co-produced transition protocols.