EATING DISORDERS

The Eating Disorders Outreach Service: enabling clinicians statewide to treat eating disorders
Elaine Painter, Warren Ward, Peter Gibbon and Brett Emmerson
Objective: The aim of this paper is to describe the Eating Disorders Outreach Service (EDOS), which supports clinicians in the treatment and management of eating disorder patients across Queensland. EDOSs mandate is to facilitate intake to the specialist inpatient and outpatient services at the Royal Brisbane and Womens Hospital (RBWH) and to provide eating disorders education and consultation liaison to clinicians statewide. Method: EDOS provides services in four key areas: intake facilitation, service development, education and training, and consultation liaison. Each area is described in detail. Results: EDOS has grown since its inception to currently comprise a full-time team manager and a number of specialist clinician positions in psychiatry, nursing, dietetics, social work and psychology. The Service has become an integral part of the RBWH Adult Eating Disorders Service, providing statewide assessment and treatment recommendations, consultation liaison services and specialist intervention programs. Conclusions: EDOS has been successful in facilitating patient access to local general medical and psychiatric facilities. EDOS also plays a significant leadership role in the development of effective statewide networking forums for clinicians and key stakeholders, in inservice delivery and in the provision of evidence-based educational opportunities, each of which has contributed to improved access to services for eating disorder patients. Key words: health. clinician support, consumer access, eating disorders, mental

Elaine Painter Statewide Team Manager, Eating Disorders Outreach Service, Windsor, QLD, Australia. Warren Ward Director, Eating Disorders Outreach Service and Senior Lecturer, University of Queensland, Herston, QLD, Australia. Peter Gibbon Senior Psychologist, Research and Evaluation, Mental Health Services, Royal Brisbane and Womens Hospital, Herston, QLD, Australia. Brett Emmerson Executive Director, Metro North Mental Health and Associate Professor, University of Queensland, Herston, QLD, Australia. Correspondence: Dr Peter Gibbon, Mental Health Services, I Floor, Mental Health Centre, Royal Brisbane and Womens Hospital, Herston, QLD 4029, Australia. Email: Peter_Gibbon@health.qld.gov.au

ince its inception in May 2001, the Queensland Eating Disorders Outreach Service (EDOS) has provided an integrated and coordinated approach to the delivery of eating disorder services. Its mandate is to facilitate intake to the specialist inpatient and outpatient services at the Royal Brisbane and Womens Hospital (RBWH) and to build capacity in existing services through the provision of education and statewide consultation liaison to clinicians. During its first 5 years of operation, EDOS comprised two full-time staff who consulted with the specialist inpatient and outpatient teams at RBWH. More recently, staffing has increased to one full-time manager and 3.5 full-time equivalent specialist clinician positions in nursing, dietetics, social work and psychology. The service is an integral part of the RBWH Adult Eating Disorders Service, which comprises five specialist beds on a general adult mental health ward, an outpatient service providing statewide assessment and treatment recommendations,

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doi: 10.3109/10398560903287524 2010 The Royal Australian and New Zealand College of Psychiatrists

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statewide consultation liaison services and a number of specialist intervention programs. To date, EDOS service delivery has focussed on four key areas: intake facilitation, service development, education and training, and consultation liaison. Each of these is described below in further detail.

EDUCATION AND TRAINING

The initial goal of the education and training strategy was to engage existing services and to address the barriers to service access that had resulted from a general lack of eating disorder management knowledge and skills or from a lack of understanding of the role mental health services play in providing assessment and treatment interventions. This goal was partially achieved through the development and delivery of district-based 1-day assessment and treatment workshops for Queensland Health staff. However, the demand for education and training has grown such that EDOS now delivers education to families and to a broad range of professionals and paraprofessionals, including teachers, personal trainers and gym instructors. The growing demand for specialist eating disorder skills and knowledge has necessitated an increase in EDOSs educational capacity. This has been achieved in part through the formation of the Queensland Eating Disorders Network (QEDN) in collaboration with other organizations and professionals. Over the last 3 years, QEDN has invited high profile national and international speakers including Christopher Fairburn from Oxford University and Janet Treasure from the London Maudsley Institute to present eating disorder workshops to Queensland clinicians. EDOS also hosts three breakfast meetings a year at RBWH on behalf of QEDN to facilitate networking among eating disorder clinicians and these are video linked to rural, regional and remote sites. EDOS hosted the 7th Australian and New Zealand Academy of Eating Disorders Conference in Brisbane in 2009. In 2008, EDOS received funding to develop a series of 2-day workshops entitled Overcoming BN and BED: a skills-based training workshop for professionals utilising a cognitive-behavioural self help manual. The workshops provide education on time-limited interventions that can be implemented by health professionals possessing varying levels of eating disorders expertise. It is anticipated that the training will enable healthcare professionals to better meet the needs of people with eating disorders and to specifically improve responses to the treatable but distressing diagnoses of BN and BED. The workshops provide a mix of skills development, clinical education and practical experience, plus the opportunity for professional networking among clinicians working with eating disorders. To date, more than 150 clinicians have attended the workshops. Workshop participants have included Queensland Health employees, clinicians from the community sector and non-government organizations, university students and student support staff, and private practitioners. They have come from a range of practice settings, including inpatient and community services and from a broad range of professions including psychology, nursing, dietetics, social work, medicine, counselling, exercise physiology, physiotherapy,

INTAKE
Streamlining intake to RBWH specialist services has improved access for both local patients and those not resident in the RBWH Mental Health catchment area, and all access to the adult eating disorders service is now managed by EDOS. Referrers are offered resources and ongoing support via phone or email and processes that support intake such as referral forms and assessment feedback sheets have been designed to educate as well as inform referrers. An unforeseen outcome of EDOSs intake management has been that EDOS has had to assume the role of advocate on behalf of patients wishing to access Queenslands public health services. This role has allowed EDOS to identify the barriers to patients accessing local services.

SERVICE DEVELOPMENT
EDOSs acquired knowledge of the barriers to local service access facilitated an expansion of its operations into the realm of service development, culminating in the development of the Eating Disorder Statewide Reference Group in 2004. This group was later replaced by the Eating Disorders Subgroup (EDS), which links into Queenslands Statewide Mental Health Network. Representation on the EDS covers all Queensland regions and includes representatives of Child and Youth Mental Health Services (CYMHS), District Mental Health Services (DMHS) for adults, non government organizations, consumers and carers, and general practitioners. To date, EDOS has secured funding to:
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survey Queensland Health service delivery and provide input into the eating disorders component of the 2007 Queensland Mental Health Plan; develop a 2-year training project for professionals working with bulimia nervosa (BN) and binge eating disorders (BED) (see below); establish the statewide EDOS team manager position, which plays a key role in the EDS, particularly in terms of service development and education; provide a 6-week carer training program, Skills based training for carers supporting a loved one with an eating disorder. This is currently being delivered in partnership with the Eating Disorders Association.

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relationship education and disability support. Participants have also included a person who has recovered from an eating disorder. Process evaluations monitoring program implementation, reach and quality have identified positive preliminary outcomes and workshop participants report high levels of satisfaction with the complexity, scope and professional relevance of the material presented. The majority of participants also perceive the presentation format and teaching level to be appropriate, report the acquisition of new knowledge and skills, and support the continuation of the workshops. As a consequence of the development of an EDOSmodified Centre for Eating and Dieting Disorders gym training program, EDOS has been approached by the Academy of Eating Disorders to participate in international discussions around its ongoing development and implementation. In addition, a prominent gym chain has requested EDOS training for their state managers to facilitate the development and implementation of eating disorder policies. Education alone, however, has proven to be insufficient to remove access barriers, as evidenced by a continuing reluctance by some services to provide ongoing treatment to eating disorder patients. The greatest breakthrough in increasing skills and knowledge and in changing the culture surrounding the admission and ongoing treatment of eating disorder patients in medical and adult mental health facilities has come from the provision of support delivered directly via consultation liaison.

to adult medical and mental health inpatient beds and to increase the effectiveness of inpatient admissions across the state. The toolkit is unique in that it offers an easy to use and accessible one page admission and ongoing management checklist based on recommended guidelines for managing medical and re-feeding risks. It also offers specific management tools, including weight charts, pre-set meal plans and meal completion forms, each supplemented with written guidelines. The toolkit also offers assistance in writing individual patient recovery plans, which are supported by EDOS clinician and dietitian attendance at weekly team reviews and via regular 1-day in-service sessions. The toolkit and supporting processes were trialled extensively over an 18-month period (November 2006 April 2008), with positive results. During the trial period, all but one patient achieved their goal BMI prior to discharge, patients gaining on average between 0.5 and 1.5 kg a week. A number of patients with BMIs ranging from a low of 11 to a high of 20 were admitted to local hospitals, representing a significant improvement on previous admission rates. Since the end of the trial, patients with BMIs as low as 9.8 have been admitted to local hospitals and all 10 of the adult mental health inpatient units in South East Queensland now offer safe and effective admissions to patients with eating disorders. Between November 2006 and January 2009, a total of 56 patients were referred to EDOS for inpatient support, an average of two per month. The average length of stay was 7.6 weeks and, allowing for repeat admissions, this equates to EDOS having provided support to mental health services and medical facilities for up to 10 patients a month in Southeast Queensland and beyond. In more recent months, new referrals have averaged between two and four per week for assessment and inpatient management while the rate of medical admissions has significantly increased.

CONSULTATION LIAISON
Accessing adult mental health beds in Queensland has historically been difficult for people with eating disorders. In the past, many hospitals have refused admission on the basis of arbitrary rules that define acute and chronic presentations or that categorize body mass index as being too low or too high for admission. In the past, EDOSs statewide consultation liaison service provided clinical support in the form of assessment and weekly visits, but access to beds remained problematic. Those patients who did obtain an inpatient bed were often discharged quickly and/or placed on the RBWH Adult Eating Disorders Service waiting list for one of Queenslands five specialist eating disorder beds. The current aim of the EDOS consultation liaison service is therefore to assist health professionals to develop the competence and confidence to work with eating disorder patients, with the ultimate aim of improving treatment access and patient outcomes.

CONCLUSIONS
EDOS is playing an increasingly significant leadership role in the development of statewide clinician and stakeholder networks and in the provision of inservice evidence-based educational opportunities, each of which contributes to improved service access for eating disorder patients. Education sessions coordinated by EDOS, alone or in conjunction with QEDN, have been well attended some international speakers attracting up to 100 participants. The invitation extended to EDOS by the ANZAED to host the 2009 Eating Disorders Conference is testimony to the awareness of EDOSs achievements in providing well-organized education and training workshops. Implementation of the EDOS inpatient toolkit has allowed EDOS to lead standards of care across Queensland through the replication of a safe and effective inpatient treatment model in outreach format. In addition, the

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INPATIENT MANAGEMENT TOOLKIT

In November 2006, EDOS developed an inpatient management toolkit based on RBWH adult inpatient management protocols. The goal was to improve access

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toolkit and the consultation liaison service have dramatically reduced the RBWH waiting list, as local district of residence treating teams become increasingly skilled and confident in managing patients with eating disorders. At the time of writing, EDOS is supporting 12 patients in Southeast Queensland via the consultation liaison package, which all 10 of the mental health

inpatient units in general hospitals are successfully employing.

ACKNOWLEDGEMENT
The authors would like to thank Dr Aaron Groves, Senior Director, Mental Health Branch, Queensland Health, for his strong support of the EDOS model.

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