ED Transitions Module 3: Digging deeper – Preparing for and talking about transitions

    This module is designed to help eating disorders professionals understand how to:

    • Have conversations about transitions
    • Establish a clear transition pathway
    • Carry out person-centred planning
    • Bring a transition to a conclusion

    How to have conversations about transitions

    Most people agree on the cornerstones of person-centred transitions, with RCPsych guidance stating that transitions should be:

    However, details on how to go about this in the context of an eating disorder are less readily available. In the video below, we hear from some young people and carers about what they felt worked well when it came to conversations about transitions:

    We also spoke to experienced ED professionals about their advice about how to have conversations about transitions:

    The key messages

    • Start conversations early where appropriate, and with sensitivity
    • Introduce conversations gradually
    • Keep it on the agenda
    • Include AEDS in conversations
    • Discuss what the transition will look like and what support the young person needs

    Additional resources

    Listen to the clips below to hear from Esther, a Team Manager and CAEDS clinician for more than 20 years discuss how she might talk about transitioning from CAEDS.
    1. Deciding when to have a conversation about transitions with young people

    2. Transitioning in a motivational stance (particularly with newly-referred young people)

    3. Opportunities for young people related to transitioning

    4. Talking about transitions with families and the differences compared to discussions with young people

    5. Coming across young people who want to transition

    Transition pathways and protocols

    RCPsych Guidance states that services should have clear protocols and pathways for patients transitioning between them.

    Based on work from the Worcestershire Health and Care NHS Trust Transitions Group, a joint CAEDS & AEDS transition policy may include:

    • Clear process for arranging & supporting transitions
    • “Issues” log to record e.g. delays to transition, issues contacting the YP
    • Transition review panel (e.g., the transition co-ordinator, lead CAEDS & AEDS clinician) to discuss problematic transitions
    • Outcome evaluation


    Learn more: download the South London and Maudsley NHS Trust best practice protocol

    Monitoring the transition pathway

    As the young person moves through the transition pathway, it is important to keep track of their progress. Some suggestions for how to do this are shown below:

    • Maintaining a tracker

      Maintain a database of useful patient information, including: Trust ID, date of referral, when they turn 18, current treatment status, status of transition, their last CAEDS session & “issues” log

    • Weekly huddles

      Your team can meet weekly in 15 minute huddles to discuss patients under the CAEDS pathway. This ensures team members can delegate responsibilities, provide updates & receive support.  

    • CAEDS & AEDS Transition Coordinator

      The clinician the young person is working with will help them to prepare for their transition & together they will work on a transition care plan.  The co-ordinator will monitor the service user's care until they transition

    Monitoring the transition pathway

    RCPsych guidance also recommends having a well-structured, parient-centred care plan. But what does a patient-centred care plan actually mean?

    We believe that it entails providing care that is tailored to suit the person's illness, situation and needs.

    To this end, the plan should specify the following:

    • The (expected) time of the transition and the rationale for it
    • Work which needs to be completed prior to & post transition
    • Plans for a period of joint working (where, who with, duration, etc)
    • The role of other agencies (e.g. social care) in the person's care
    • The views, concerns and wishes of the patient and carers

    Carrying out person-centred planning

    Models assessing preparedness and readiness to transition have been piloted with young people in physical health settings and, to a far lesser extent, in severe mental illness, but not (to our knowledge) in EDs.

    One example of a model from physical health settings is the ReadySteadyGo transition programme, used by University Hospitals Southampton. This programme uses checklists to guide exploration of young people's confidence and skills in taking charge of their healthcare.

    We can use the ReadySteadyGo transition programme to guide us towards some areas we might wish to explore for EDs:



    • Does the YP arrange their own appointments?
    • Does the YP contact their care team themselves if there is a query regarding their appointment or ED?
    • Does the YP travel to their own appointments?
    • If the YP is prescribed medication:
      • Do they look after the medication at home?
      • How do they make sure they take it as prescribed?
      • How do they keep track of when to order repeat prescriptions?
      • Do they go to the pharmacy themselves to collect it?


    • Does the YP feel confident to be seen on their own?
    • Does the YP understand their right to confidentiality and when it may be necessary to breach confidentiality?
    • Does the YP understand their role in shared decision-making?
    • Does the YP feel confident in letting people know about their ED (e.g. tutors, employers, friends)?

    Transfer to adult care

    • Does the YP understand the meaning of transition and transfer of information?
    • Does the YP know the plan for their care when they enter adult services?
    • Does the YP have all the information they need about the adult service their care is transferring to?
      • Do they know who their transition co-ordinator is?
      • Do they know to contact their transition co-ordinator?
      • Are they aware of when their first appointment will be?
      • Do they know where the service is located?
      • Do they how to get there?

    Daily living

    • Does the YP have any support practically and emotionally with meal preparation and eating?
    • Does the YP shop for and pay for their own food?

    Can you think of any other questions that might need asking?


    RCPsych states that transition support should sensitively involve the family and carers. While many YP are happy for parents to remain involved in some capacity, others may want more autonomy when transitioning into AEDS.

    In a low risk situation, you can discuss (and establish) with the YP their expectations around confidentiality & autonomy. Hover over the cards below to explore some questions and follow-up questions which could help to start conversations about confidentiality:

    Can you imagine a scenario where we [AEDS team] are unable to reach you? E.g. your inbox is full, you’re overwhelmed with work, you’re feeling ambivalent about recovery.

    What would be the benefits & cons of AEDS being able to contact your parents in this instance, so that they would prompt you or check-in on you? 

    Can you imagine a scenario where your parents contact us [AEDS team] directly?

    What would you be happy for AEDS to share, if anything?  E.g., whether you are attending appointments, or anything about symptoms? 

    Now imagine a higher risk situation, where the parents have been involved throughout CAEDS and the YP is ambivalent & only able to maintain therapeutic gains in outpatients because of parents' support.

    In this scenario, you would want to be more ‘pushy’ about having contact with the parents. You might consider more direct lines of discussion:
    "We need to have open channels of communication with your parents, otherwise it will be hard to work with you safely and support you in outpatients."

    Once consent to contact is established, you can then negotiate what you would or would not tell the parents, including giving options.

    Confidentiality is explored in more detail in Module 5 of this learning resource.

    Case studies: CAEDS to AEDS transition with a low & high risk patient

    Click the buttons below to read about the different treatment stages of a CAEDS to AEDS transition for a low and high risk patient, along with reflective commentary.

    Bringing transition to a conclusion

    Research suggests that phasing out CAEDS services may improve the transition process, by allowing the CAEDS team to follow-up with the YP after they have transitioned into AEDS (Nadarajah et al. 2021).

    This should: 

    • alleviate feelings of abrupt withdrawal of CAEDS service 
    • allow the YP to build relationships with AEDS team
    • let the YP discuss these experiences with CAEDS team

    Can you think of additional adjustments to improve the post-transition process…?

    Service user recommendations

    Research by Broad et al (2017) found that young people also suggest a number of contributing factors for a positive post-transition experience:

    • Adaptations to treatments e.g. extended Behavioural Therapy Relapse prevention
    • Sharing of clinical information between CAEDS and AEDS 
    • No repeat assessment (unless necessary)
    • Choice about parental involvement & treatment options
    • Physical care environments geared toward young  adults 
    • AEDS treatments that follow-on from preceding treatment  

    Resource: a self-assessment checklist for transition pathways

    East of England NHS has developed a useful ‘Transition Standards’ guide, to help assess your service’s transition pathway and consider ways to embed these standards in practice. Click here to access a list of recommended transition standards (page 9) and a self-assessment checklist (page 41) to help with benchmarking.


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