Table 3 Eating disorder service model characteristics

Allen, Mountford, Brown, Richards, Grant, Austin, Glennon & Schmidt (2020)

UK

A ‘commitment’ to person-centred care.

Is encouraged.

A group of young people who have benefitted from or want to support FREED has been established, who provide input into new initiatives for the service model and promotion of the service model.

FREED site-based champion is an important part of the service model. No further details of the team reported.

Service model is for people aged between 16-25 years old with an eating disorder with a duration of <3 years.

All referrals receive an engagement phone call within 48 hours of referral. This phone call validates help seeking, screens for eligibility for the service model and provides initial information about early intervention.

Then, a person should receive an assessment within 2 weeks, and commence treatment within 4 weeks of referral.

-

Service model is considered a ‘service within a service’, meaning it sits within a wider eating disorder service system.

Anderson, Desai, Zalaznik, Zielinski & Loeb (2021)

USA

-

-

-

Service model team includes 12 therapists (disciplines not reported), and this team collaborates with healthcare providers in psychiatry, paediatrics, adolescent medicine, gastroenterology, speech therapy and occupational therapy.

Minimum care team is a primary therapist and an external physician.

Team receives group consultations and one-to-one supervision and has access to expert external consultation (for support with complex cases).

Intake process is aligned with the fundamental tenets of treatment, ensuring intake calls are completed within 24 hours (if possible), and people are referred to other services rather than being placed on a waiting list for treatment.

Intake calls are also used to provide psychoeducation.

Service model does address co-occurring psychiatric conditions using treatment models such as DBT and exposure and response prevention.

Service model reported to have established networks with hospitals and medical providers in the area.

Bern, Milliren, Tsang, Mancini, Carmody, Gearhart, Eldredge, Samsel, Crowley & Richmond (2024)

USA

-

Family and carers were involved in step two of the pathway, particularly with meal support. Parents and carers also had access to psychoeducation from the care team and were involved in discharge planning.

-

Included specialists in adolescent/ young adult medicine, gastroenterology, psychology, psychiatry, nutrition, social work and nursing.

Any person admitted with a diagnosis of ARFID. People were eligible if they were between 4 and 21 years old.

It was reported that over half of the participants had a co-occurring condition such as depression and anxiety. No treatment for co-occurring conditions was reported.

-

Brown, McClelland, Boysen, Mountford, Glennon & Schmidt (2016)

UK

Aimed to deliver person-centred care.

Care plans were collaboratively developed.

Actively encouraged family and carers to participate in assessment and treatment.

-

-

Inclusion criteria: age range of 18-25 years old, a primary eating disorder diagnosis and an eating disorder illness duration of <3 years.

Exclusion criteria: the need for immediate inpatient admission and/or a severe learning disability or co-occurring condition requiring treatment.

Referrals were encouraged from primary care and planned to accept self-referral in future.

All referrals received a screening telephone call within 48 hours. If they are deemed eligible for service model, they were booked into an assessment (aiming for <2 weeks from referral date).

Cooccurring conditions that required treatment were exclusion criteria.

Service model is considered a ‘service within a service’, meaning it sits within a wider eating disorder service system.

Bryant-Waugh, Loomes, Munuve & Rhind (2021)

UK

ARFID formulation, goals and treatment plan developed in collaboration with the young person and their family.

Parental involvement is encouraged at all stages and varies between young people.

At a minimum, parents and carers actively support the young person between sessions to engage in therapeutic tasks linked to agreed goals.

-

Multidisciplinary team mentioned - including occupational therapists, speech and language therapists.

Aims to remove any barriers to referral, recognising that referrals may come from a wider range of clinicians and services than other eating disorder diagnoses.

Referrals are screened to determine the urgency of assessment and confirm that the presentation doesn’t fit any other eating disorder diagnosis.

Self and parent referrals are also accepted.

Acknowledgment of common co-occurring conditions (such as Autism) and noted that this is discussed as part of the assessment.

Treatment for co-occurring conditions not reported.

Service model sits within the wider eating disorder service system.

Clinton, Almlof, Lindstrom, Manneberg & Vestin (2014)

Sweden

Drop-in program enables people to attend the service with no appointment, no obligations and no expectations.

-

-

12 member multidisciplinary team: psychiatric nurses, clinical psychologists, a social worker, a psychiatrist and a physician.

Drop-in sessions aimed to enable earlier intervention.

Two-thirds of people receiving treatment from the service accessed the service via the drop in sessions. Also received referrals from other parts of the health service.

No eligibility criteria, open to any adult who feels a need for the service.

-

Positioned within a wider publicly funded eating disorder service system.

Dror, Kohn, Avichezer, Sapir, Levy, Canetti, Kianski & Zisk-Rony (2015)

Israel

-

Parents were involved in phases of reintegration.

-

Psychiatrists, nurses, psychologists, social workers and nutritionists.

Anyone admitted to the psychiatric inpatient unit with an eating disorder diagnosis.

54% of participants had co-occurring depression. No further information was reported.

-

Eisler, Simic, Fonagy & Bryant-Waugh (2022)

UK

-

Family therapy was a common treatment intervention offered, which assumes family involvement.

A family-oriented philosophy to services was a key aim of the workforce training program.

-

Multidisciplinary team included both medical and non-medical staff with significant eating disorder experience.

Given the national rollout of the service model across England, a comprehensive and coordinated workforce development and training package was offered to all teams within the service models. This included training in treatment models, supporting the development of a positive service culture, setting up supervision structures and fostering a culture of evidence-informed practice by promoting ongoing learning, keeping up to date with evolving evidence and routine monitoring of outcome and feedback data.

Enable direct access through self-referral or from primary care services (bypassing generic community mental health teams).

Urgent referrals are to be responded to within 1 week, and routine referrals are to be responded to in 4 weeks.

The service model was required to provide interventions to treat the most common co-occurring mental health problems such as depression and anxiety. The types of treatment offered and how this was done were not reported.

During the roll out of these new service models, each team was grouped with two other teams located close by geographically to promote learning and sharing between the teams.

Fenner & Kleve (2014)

UK

-

A family focussed treatment approach was used for most people (primary model family based treatment).

-

Clinical psychologists, specialist nurse therapist, psychiatrist and systemic family therapist.

Also had access to an ‘extended team’ of paediatricians, general practitioners and dietitians

Team members met every 6 weeks to review practice, for peer supervision and to keep up to date with emerging research.

Early referral encouraged.

Referrals were assessed within 2 weeks.

-

-

Goldstein, Peters, Baillie, McVeagh, Minshall & Fitzjames (2011)

Australia

-

Two parent only groups offered, and a weekly join psychology group.

Parents were supported in setting and reviewing goals for their child, and taught skills to improve communication.

Siblings were able to attend two sessions that aimed to help them understand the illness and its impact on the family.

-

Included nurses, dietitians, clinical psychology and occupational therapy.

People were primarily referred from outpatient service models (85.7%).

To be able to access the service model, people need to be medically stable. BMI was not considered a factor when determining access.

Major Depressive Disorder was reported as a co-occurring condition for 17.9% of participants. Treatment of co-occurring conditions not reported.

-

Hayes, Tweedy & Chapman (2024)

UK

Personalised treatment plans, considering the individual formulation and treatment progress.

New model had a much stronger family-centered approach.

Parents and carers are offered skill-based meal coaching sessions and online or telephone support. An online four-week psychoeducation group is also available.

-

Multidisciplinary team led by nursing staff and supported by therapeutic care workers and a family therapist.

Team also receives support from family therapists and psychologists in the outpatient service.

Not reported however the service model provides step-up care from the outpatient service and step-down care from the inpatient unit.

-

Service model sits within a wider eating disorder service system and the new model is integrated with the outpatient eating disorders service model.

Herpertz-Dahlmann, Borzikowsky, Altdorf, Heider, Dempfle & Dahmen (2021)

Germany

Individualised treatment plans with the young person and their family.

Families offered psychoeducation focused groups and separate and conjoint family sessions.

Young people and their families were visited at home and weekly family therapy was offered.

The first two months of the service model focused on supporting parental management of food intake and other eating disorder symptoms.

-

Multidisciplinary team included a nurse, nutritional therapist, occupational therapist, psychotherapists, child and adolescent psychiatrist.

All young people were admitted to hospital prior to accessing the service model. A two-step admission process included an initial assessment at admission and a second assessment of final eligibility after 4-8 weeks of inpatient treatment.

Inclusion criteria were a diagnosis of AN or AAN, aged between 12-18 years old, living with at least one carer and within a 60-minute commute of the treatment centre.

Exclusion criteria were organic brain disease or severe psychiatric disorders, substance misuse, self-injurious behaviour, low intelligence, severe comorbid somatic disorders, insufficient knowledge of the German language, planned residential treatment, persistent severe eating disorder behaviour (including nasal gastric tube feeding or daily purging), serous somatic or psychiatric comorbidity or insufficient weight gain.

Many participants had a co-occurring psychiatric condition (n=18, 81.8%), however, it was not reported if these were treated at all.

Severe co-occurring psychiatric conditions were an exclusion criteria for the service

Service model was closely linked to the hospital inpatient unit.

Johnson, Cook, Cadman, Anderson, Williamson & Wade (2022)

Australia

-

-

-

Multidisciplinary team made up of general practitioners or primary care clinicians, private mental health clinician (psychologist or social worker) and optional dietitian.

2 weeks between identification and commencing treatment.

A care coordinator role supported system navigation and ongoing coordination of the care team.

Eligibility criteria included a DSM-5 eating disorder diagnosis.

-

Integration between primary care providers and treatment providers.

Kaplan, Hutchinson, Hooper, Gwee, Khaw, Valent & Willcox (2024)

Australia

Mentions person-centred care.

-

-

Multidisciplinary team included dietitians, nurses and psychiatrist.

All staff received 3 or 4 training modules in eating disorders, covering different aspects of eating disorder care and support.

All admissions screened using the SCOFF questionnaire. If a positive result, person would receive further assessment.

If disordered eating behaviours or an eating disorder detected, the person was placed on pathway.

Eligible with AN, BN or OSFED diagnosis.

All participants had a primary mental health condition, and co-occurring ED or disordered eating behaviour.

Integrated with existing general mental health inpatient units.

Milton, Hambledon, Dowling, Roberts, Davenport & Hickie (2021)

Australia

Online service model that provided a personalised experiences to people seeking support.

Family and carers can independently contact the service model for family-oriented support.

Participatory design workshops embraced co-design principles, ensuring people with lived experience were able to contribute to the design and development of the online/telehealth service model.

Service model staffed by professionally trained and experienced counsellors.

Freely accessible to anyone.

People can contact the service model via phone or online.

Available 7 days per week during operating hours and a person should receive immediate support.

Service offered immediate web based assessment (using a self-report questionnaire), with a dashboard of results provided.

-

Functions to connect people with external service models that can provide assessment and treatment for eating disorders.

Can also be used as a platform where the care team can collaborate and share information between themselves (including the person with an eating disorder).

Moron-Nozaleda, Yanez, Camarneiro, Gutierrez-Priego, Munoz-Domenjo, Garcia-Lopez, Garcia, Garcia, Trujillo, Faya & Graell (2023)

Spain

Individualised treatment plan devised with young person and their family.

Aim to support person in least restrictive environment.

Had a family focus, with parents and carers being active treatment partners.

Family were provided with psychoeducation, support (in person and via phone calls).

-

Consisted of psychiatrist, clinical psychologist, nursing team and paediatricians.

Team met twice daily to coordinate cases and participated in weekly case discussion for more complex situations or presentations.

Most people were assessed within 48 hours of referral.

Eligibility criteria included a child or adolescent with a severe eating disorder diagnosis (requiring hospitalisation), commitment from the young person to participate in treatment, 24/7 availability of at least one carer, a commute of 30 minutes or less from the hospital and parent or guardian agreement to participate in the treatment.

Exclusion criteria were being medically unstable, extreme compensatory or purging behaviours, refusal to eat, severe suicide risk, severe risk of aggression and/or families with limited availability for home care.

-

Links with an eating disorder inpatient unit and outpatient treatment team/s mentioned.

Munro, Thomson, Corr, Randell, Davies, Gittoes, Honeyman & Freeman (2014)

UK

Emphasis on open, transparent assessments and collaborative treatment planning at all stages.

-

-

Consultant psychiatrist, consultant clinical psychologist, clinical psychologists, clinical associate in applied psychology, dietitians, nurse, assistance psychologists and an administrator.

Weight based criteria for access (BMI 13 or less, OR BMI 15 or less and losing > 1kg per week),

Person also had to be safe for community management.

-

The service model was one component of a service system in the region consisting of Tier one services that included guided self-help and internet based interventions, Tier 2 which was community based outpatient treatment, Tier 3 which was the current service and Tier 4 which was hospital inpatient unit.

Newell (2023)

UK

Mentioned delivery of personalised care. Treatment is not limited by biological age. The all-age model enables continuity of care.

Family-oriented approaches and treatment models are part of the service model.

Consultation took place with people who had accessed the service (and their families) and undergone transition between child and youth and adult teams for ongoing treatment.

Multidisciplinary team initially consisted of a consultant psychiatrist, family/systemic therapist, nurses, dietitians, occupational therapist and psychological therapist.

Team expanded as service model has evolved but disciplines within the expanded team were not reported.

-

-

Aimed to integrate adult and child and youth eating disorder community teams.

Newton, Bosanac, Mancusa & Castle (2013)

Australia

A jointly developed and shared conceptualisation of the person's predicament was completed that included goals of treatment.

Aimed to engage both the person and their family to work collaboratively.

Feedback from the eating disorder inpatient unit consumer and carer advisory group and Eating Disorders Victoria (a lead non-government organisation providing support, information, and advocacy) supported the development of the service model.

Consumer and carers were consulted as part of the development of the service model.

A total of 4.2 full time equivalent clinical staff were employed across medical, nursing, dietetic, psychology, social work and occupational therapy.

Designed to facilitate easy access and was available to all people over the age of 16 years old.

There were geographical limitations as to who could access the service model.

Any person who contacted the service was provided with advice on next steps. If a person had a medical referral and met inclusion criteria, an assessment was completed over four sessions.

Co-occurring conditions were identified, but it was not reported if these were treated within the service model.

Most common co-occurring conditions included depressive episode (n=99, 50.3%), recurrent depressive disorder (n=26, 13.2%) and dysthymia (n=34, 17.3%).

Aimed to develop, maintain and maximise partnerships with private and public care providers to deliver a continuum of care for eating disorders.

Painter, Ward, Gibbon & Emmerson (2010)

Australia

-

A 6-week carer program was delivered in partnership with another organisation.

-

One full time manager and 3.5 full time equivalent specialist clinicians (nursing, dietetics, social work and psychology).

Key area of the service model was streamlining intake to existing eating disorder service models (such as the eating disorder inpatient unit). Intake service also provided resources and ongoing support to referrers and advocacy for people accessing public health services for an eating disorder.

-

Enabled integration and improved processes between the system of care for eating disorders, particularly the metropolitan based inpatient and community eating disorder services.

Penfold (2015)

UK

-

-

-

Nurse led service model, with psychological and psychiatry input. External dietitian provides regular groups and sessions.

Timeframe between referral and commencing treatment is not reported.

Day program was accessible to adults aged 16 years or older, with a diagnosis of anorexia nervosa.

-

Day program sits within the wider eating disorder service system, and was established to reduce hospital admissions and provide more intensive community support (including outreach).

Established referral paths from primary care, with most referrals being received from general practitioners. Mental health services can also refer.

Simic, Stewart, Eisler, Baudinet, Hunt, O’Brien & McDermott (2018)

UK

-

Families were included in treatment to mobilise family resources

-

Multidisciplinary team included psychiatrists, a paediatrician, psychologists, nurses, family therapists, an art therapist and a dietitian.

Adolescents (aged 11-18 years old) could access the service model if they had experienced rapid weight loss for longer than 4 weeks, or remained static below 80% of their expected BMI for more than 4 weeks.

The service model also helped people step down from inpatient units.

Treatment of co-occurring conditions was not reported, but the results reported improvements in ratings of mood, and ability to regulate emotions.

Embedded into a comprehensive eating disorder service system.

Strand, Gustafsson, Bulik & Hausswolff-Juhlin (2015)

Sweden

Self-admission is based on the premise that a person can make a choice as to when they are admitted, without needing to explain or justify their need.

-

-

-

People eligible for the service model could access admission immediately, if a bed was available.

To be eligible, people must have been admitted in the past 3 years and be receiving ongoing treatment for an eating disorder with the wider service system.

Exclusion criteria were active suicidal or self-injurious behaviour, active substance use. No BMI criteria was applied.

-

Service model sat within the existing inpatient unit, and within the wider eating disorder service system.

Suetani, Yui & Batterham (2015)

Australia.

-

Clinical team held meeting with family within 48 hours of their child’s admission.

-

Multidisciplinary team noted, but not further described.

Children (<18 years old) admitted to the unit with an eating disorder diagnosis.

-

Eating disorder service model overlaid onto the general paediatric hospital ward (as a result of increasing eating disorder admissions over a number of years).

Links with child and adolescent mental health services for psychological support while on ward and in preparation for ongoing treatment after discharge.

Tantillo, Starr & Kreipe (2020)

USA

-

-

Included people with lived experience (parent peer mentor and young person peer mentor) who contributed to the delivery of education, consultation and support.

Eating disorder experts (n=11) formed the team.

Professionals included nursing, adolescent medicine, psychiatry, art therapy, dietetics, psychology, care management, parent peer mentor and young adult peer mentor.

Clinicians wanting to access the service model had regular weekly opportunities to meet via telehealth.

-

Aimed to support already established health services, particularly those who do not have expertise in eating disorders.

Tchanturia, Smith, Glennon & Burhouse (2020)

UK

-

This was recognised as an area where ongoing work is needed.

Many aspects of the service model were co-designed with people with lived experience.

Pathway were developed using co-design principles and ongoing input.

Multidisciplinary team not explicitly discussed, several training and professional development activities (with a focus on AN and autism) for the wider eating disorder service system workforce mentioned.

All people with AN who access the wider service system were screened for autism, and a positive result would trigger a more in-depth assessment to ascertain diagnosis and eligibility.

Service model not available to other eating disorder diagnoses or child and youth.

The service model offered treatment for AN and Autism as cooccurring conditions.

Service model sits within the wider eating disorder specialist service system.

Wallis, Alford, Hanson, Titterton, Madden & Kohn (2013)

Australia

A comprehensive family assessment informed the development of treatment that was specifically tailored to each family.

Families were essential and the whole family was admitted and part of the treatment.

Service model was developed following suggestions received from families.

Multidisciplinary team consisted of a child and adolescent psychiatrist, paediatrician, clinical nurse consultant, nursing staff and family therapists. The team had support from dietetics, physiotherapy and the hospital school.

Targeted families such as those from regional and remote areas, families with children under the age of 12, families with limited support and families with complex relational or illness dynamics.

Admission criteria were: child or adolescent were under 18 years old, primary diagnosis of an eating disorder, young person had been medically stable for at least 72 hours prior to admission and the young person is eating.

-

The service model was part of a wider service system offering hospital and outpatient eating disorders treatment.

Weber & Davis (2012)

Australia

-

Consultations were offered to family and carers.

-

One part time social worker.

People could self-refer, plus referrals came from primary care providers, local universities and schools.

People were eligible if they were aged over 14 years old.

-

Assessment and referral service model aimed to connect people (following diagnosis of an eating disorder) to treatment providers.

Williams, Dobney & Geller (2010)

Canada

Is person-centred and allows people to set their own goals (rather than the clinical team).

There is capacity for outreach and focus on quality of life rather than recovery.

Pace of treatment is determined by the person.

-

A first step to developing the service model was focus groups were held with people with longstanding eating disorders to explore what they thought would be beneficial.

Multidisciplinary team includes staff from a hospital-based eating disorder team and a community-based mental health rehabilitation team.

Specific disciplines of the team included outreach counsellors, case managers, family therapists, medical internist, nurse, psychiatrist, dietitian.

-

-

-

Williams, O’Reilly & Coelho (2020)

Canada

-

Family involvement offered, and family and carers were viewed as integral to the support of people in the program.

Ultimately, people attending the program could decide if they wanted the involvement of family or carers.

-

Team includes medical, psychiatric, nursing and allied health professionals

Referrals are made by community specialised eating disorder services or mental health teams, or from a primary care provider.

Eligibility criteria included aged between 16-24, and being medically and psychiatrically stable.

-

Service model is part of an integrated provincial network (service system) for people with eating disorders.