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Visit FutureNHSED Transitions Module 2: Supporting Transitions Between Services
This module is part of the Eating Disorders Transitions Learning Series.
The resources on this page are designed to help you understand:
- What a good transition between Child and Adolescent Eating Disorder Services (CAEDS) and Adult Eating Disorder Services (AEDS) should look like
- What preparation needs to occur for good transitions
- How services can develop better ways of co-working
- The practicalities of transition planning
This module summarises the Royal College of Psychiatry (RCPsych) "Managing transitions when the patient has an eating disorder" guidance document, as well as providing additional resources and inspiration.
In a hurry? Click the links below to jump to each of the different sections of this module:
The importance of planning for transitions and tailoring your approach
RCPsych guidance suggests the need for clinicians to be aware of Eating Disorders (ED)-specific characteristics which may make transitions between CAEDS and AEDS more difficult.
Think for a moment about the patients that you see...which of their characteristics may make it hard for them to accept a service transition?
Some of these characteristics could include:
- Shame and avoidance
- Anxiety and intolerance of uncertainty
- Comorbidities (e.g. depression)
- Low levels of cognitive flexibility (e.g. comorbid Autistic Spectrum Disorder diagnosis)
- Ambivalence about treatment
- Impulsivity
In planning for a service transition with your patients, try to hold these characteristics and their different needs in mind. You may also need to consider the individual circumstances of the service user - such as whether they are starting university, their cultural background or changes to their social life. These additional factors are explored in greater depth in Module 4.
Hover over the tiles below to view some options for tailoring your approach to transitions to different patient characteristics:
(a) Normalise - a degree of anxiety is normal in novel situations; (b) Find out what is most anxiety provoking about the transition & take action accordingly; (c) Highlight the positives of transition & provide a clear rationale for it; (d) Address uncertainties by providing good quality, relevant and accessible information
Low levels of cognitive flexibility (e.g. comorbid ASD)
Consider continuation of family work whilst progressing to individual treatment, taking into account the patient’s need for a gradual adoption of transition-related changes.
Impulsivity
Involve the patient in creating a well-structured care plan, for them to refer to. Transition preparation should be goal directed with progress carefully monitored and recorded.
Ambivalence about treatment
(a) Take a proactive motivational stance that is appropriate to age and developmental stage. (b) Give options wherever you can. (c) Discuss negotiables and non-negotiables.
Shame and avoidance
More common for those purging or binge eating. Arrange peer-support during the transition if possible, to help alleviate feelings of shame and avoidance.
Additional resources
Starting conversations about transitions and involving parents and carers
RCPsych guidance states that discussions about transitions between Childhood and Adolescent Eating Disorder Services (CAEDS) and Adult Eating Disorder Services (AEDS) should start at least 6 months before the planned transition.
Transition meetings should be set up at the earliest opportunity involving the young person and their family/carers. Good quality information should be provided to patients and their carers. Addressing expectations around autonomy and confidentiality is particularly important.
Timings for transitions
RCPsych guidance states that decisions about the timing of transitions between Childhood and Adolescent Eating Disorder Services (CAEDS) and Adult Eating Disorder Services (AEDS) should consider the following factors:
- The young person's degree of maturity and independence from family
- The need for ongoing work with family/carers
- Education/employment circumstances
- Links with other medical and social services
- The views of the patient and carers
- Geographical moves (e.g. moving to a new city or town for university)
Transitions should be delayed if there is a crisis. Conversely, there may be an opportunity for an early transition to AEDS if the young person is better suited to AEDS and they feel comfortable doing so.
The content below outlines some practical considerations and possible tactics for managing each of these key factors:
Young person's maturity and independence from family/carers
If maturity is low and dependence on family or carers is high, consider continuation of family work under CAEDS with a co-therapist from AEDS, and/or family-based treatment under AEDS or individual treatment from AEDS that retains family involvement. Frame transition as an opportunity for personal growth.
Need for ongoing work with the family or carers
As above, or consider offering multi-family group given its suitability in older adolescents/emerging adults. If available, give family members the option of attending a carer's support group.
Education/employment issues
Consider delaying transition until after important exams or work deadlines/interviews. May-June tends to be the busiest period of the year for school exams.
Links with other medical and social services
GP and other relevant services to be involved at the planning stage (e.g. in a short meeting), as needed.
Wishes of patients and carers
At the start of the transition process, ask for the views of the patients and carers on what they ideally would want the transition to look like, and what support they will need.
Delaying transition if there is a crisis
Delay the transition until the young person has stabilised.
Ensuring good working relationships between CAEDS, AEDS and other services
Transition coordinators
A transition coordinator should be appointed for transitions between CAMHS and AMHS. This may involve the identification of a key worker from each service or a permanent joint post shared between services. The role of the transition coordinator is to guide and support patient and carers through the transition process and function as a point of contact.
Clear protocols and pathways
Services should have clear protocols and pathways for patients transitioning between them. Patients and their carers, as well as clinicians and managers, should be consulted during the development and evolution of such protocols.
Providing good information
From the earliest stage the provision of good-quality information to the patient and their family/carers will be important. This may include facts about the service they may be joining, as well as about the process of transition itself. Aspects of care planning and how that is communicated will be part of this.
Additional resources
- Download an example CAEDS transitions flow chart, developed by South London and the Maudsley NHS Foundation Trust
- Download an example Transitions Protocol, designed by Lincolnshire Partnership NHS Foundation Trust
Attachment issues
Respect for the importance of attachments and therapeutic alliances is crucial in the work towards recovery from an eating disorder. A sensitive and developmentally informed approach to a transition may transform it from a traumatic and disjointed experience into an opportunity for building resilience and healthy maturation.
RCPsych guidance emphasises that good working relationships between CAEDS and AEDS need to be nurtured.
They also say that joint working and training fosters a spirit of mutual respect and reciprocal learning between services. This can also prevent splits developing; these can occur in a variety of situations, for example when clinicians from one team imply that the other provides an inferior service.
This point is important. There is some research evidence suggesting that CAEDS and AEDS clinicians do sometimes hold biased beliefs about each other (Lockertsen et al., 2020).
So, let’s look at the reasons why this might be the case in more detail:
CAEDS and AEDS practitioners are different 'tribes' and may hold unhelpful beliefs about each other
Do any of the thoughts shown below ever go through your mind when you are dealing with colleagues from your partner team? If so what does that say about your team relationships? How might this affect transitions of patients?
- "...they only deal with nice, easy, straightforward cases"
- "...if we had the amount of resources they had, we'd do brilliantly"
- "...they deal only with complex, chronic (hopeless) cases"
- "...they exclude families, are focused on impairment or deficits and are remedial/palliative in approach"
Ideas for strengthening co-working with CAEDS or AEDS colleagues
- Regular joint learning events or training sessions between teams
- Shared posts
- Regular meetings between transition champions in both teams
- Shared projects and initiatives
- Joint public-facing initiatives such as conferences, open days, websites, joint GP liaison, joint training of others e.g. on Medical Emergencies in Eating Disorders (MEED)
- Joint quality improvement/research, e.g. finding out how big the referral gap is between CAEDS and AEDS in your locality
- Joint treatment provision, e.g. multi-family groups
There are many other ways in which teams can find creative ways to co-work. Let your imagination run riot!
Building good relationships between other services
RCPsych guidance states that where there has been significant involvement of paediatric or medical services or social care, these services should be involved in transition planning. It is helpful when general practitioners (GPs) can be involved in planning and facilitating the transition; when they cannot be directly involved, minutes of meetings should be copied to them.
It is also important to note that ideal practice is likely to be very resource intensive, especially during periods where relationships between services are changing or developing. As such it is important to look at efficient working practices and have open conversations about resource challenges or possible areas for efficiency improvements.
The practicalities of good transitions
There are a number of practical steps which can support good transitions at a service level:
The transition care plan
An agreed and well-structured, patient-centred care plan, focused on the individual rather than on organisational considerations, can be the most important single element in the whole transition experience.
The patient must be consulted and involved in discussions about the care plan, taking into account their:
- Stage of recovery
- Level of maturity
- Personality
Dunn found that young people and parents agreed that transition preparation should be asset-focused rather than deficit-focused, i.e. focused designing a plan that plays on the strengths of the young person rather than trying to "fix" perceived weaknesses. Building self-confidence was seen as key, along with resilience, help-seeking, coping strategies, self-esteem, organisation and social skills.
The transition care plan is covered in more depth in Module 3.
Additional resources
Multidisciplinary discharge planning meeting & joint working
Formal handover of care should be structured by at least one specific multidisciplinary discharge planning meeting. More than one meeting may be required, if the transition process lasts over several months.
There should be an overlap period of joint working by both services during the transition, in order to:
- Explore and explain the differences in the ways of working between the two services
- Help the patient to get to know key members of staff from the new service
- Put in place arrangements for the necessary therapeutic interventions