Virtual eating disorder treatment, including virtual PHP/IOP (partial hospitalization program and intensive outpatient program), has made specialized care available to individuals who face geographic, scheduling, transportation, or other access barriers. However, greater accessibility does not mean virtual treatment is appropriate for every patient.
For referring providers, the primary question shouldn’t be, “Can this patient participate virtually?” The more important question is whether virtual care can provide the level of structure, monitoring, and support the patient currently needs.
Fortunately, virtual care has an emerging evidence base. A 2023 study comparing traditional and virtual PHP found virtual PHP to be feasible and associated with improvements across a range of eating disorder and psychiatric symptoms, while another 2023 study of young adults participating in virtual versus in-person PHP/IOP found comparable improvements between the two treatment formats.¹˒² Together, these findings support virtual intensive treatment as a promising option for appropriately selected patients while reinforcing the importance of individualized level-of-care decisions.
That determination requires looking beyond eating disorder diagnosis alone. Medical stability, symptom severity and current behaviors, the home environment, treatment engagement, and collaboration with local providers can all influence whether virtual PHP/IOP is sufficient for healing.
The Importance of Medical Stability
Before referring a patient to virtual care, providers should consider whether the individual is sufficiently medically stable to spend the majority of treatment outside a continuously monitored setting. Medical risk cannot always be determined by appearance, diagnosis, or body weight alone. In fact, significant medical instability can occur across eating disorder diagnoses and body sizes, making comprehensive assessment essential. Areas to evaluate include:
- Vital-sign stability
- Electrolytes and other relevant laboratory abnormalities
- Cardiac concerns
- Hydration status
- Recent or rapid weight loss
- Degree of malnutrition, if present
- Syncope or other concerning physical symptoms
- Frequency/severity of vomiting, laxative use, or other compensatory behaviors
- Need for enteral feeding or intensive nutritional rehabilitation
- Other medical complications related to the eating disorder
If a patient requires continuous medical monitoring or stabilization, a more intensive in-person level of care may be appropriate before virtual PHP/IOP is considered.
Symptom Severity Matters, Not Just the Diagnosis
A diagnosis alone does not determine whether virtual treatment is appropriate. Two people with the same eating disorder may need very different levels of supervision based on the frequency, severity, and medical consequences of their symptoms and behaviors.
Providers should consider the full clinical picture, including the degree of restriction, frequency of bingeing or purging, compulsive movement or exercise, and other behaviors such as laxative or diuretic misuse, food hiding, water loading, or ritualized eating. Just as importantly, they should assess whether these behaviors are escalating, can be interrupted with support, or require closer monitoring.
Evaluate the Patient’s Home Environment and Ability to Interrupt Behaviors
Unlike in-person PHP or residential treatment, virtual care places more of the recovery work in the patient’s everyday environment. Clinicians have less direct observation of meals, post-meal periods, movement, and other common moments for eating disorder behaviors, making it important to consider whether the patient has enough structure and support to manage those behaviors safely outside of treatment hours.
At the same time, practicing recovery skills at home can be an important part of treatment. Patients are learning to navigate meals, routines, relationships, and triggers in the same environment where their healing will ultimately continue.
Providers should also consider whether the home environment makes consistent participation and recovery work possible. This includes reliable technology and privacy for programming, appropriate access to food, the ability to participate in supported meals when needed, and involvement from a parent, partner, or caregiver when clinically appropriate.
Patients do not need to be able to consistently interrupt eating disorder behaviors before beginning virtual care, nor does the home environment need to be perfect. What matters is whether the patient can safely practice recovery skills at home with the level of support available to them.
Consider Treatment Engagement and Collaboration with Local Providers
Readiness for virtual treatment does not mean a patient needs to be highly motivated or ready for recovery on their own. After all, ambivalence is common in eating disorders.
What matters is whether the patient can participate meaningfully enough for the treatment team to monitor symptoms, provide appropriate interventions, and respond when clinical needs change. This may include consistently participating in programming and supported meals, communicating openly about symptoms, and involving supportive others when clinically appropriate.
Even when treatment takes place virtually, some aspects of eating disorder care still require in-person support. Depending on clinical need, patients may need local weight and vital sign monitoring, laboratory testing, EKGs, physical examinations, or medication monitoring.
At Alsana, virtual PHP/IOP includes nutrition counseling, supported nourishment, therapy, group programming, and nursing support, and virtual PHP also includes psychiatric care. Additionally, collaboration with outpatient providers helps maintain continuity of care. Referral to virtual PHP/IOP does not have to mean handing a patient off entirely. The virtual treatment team and trusted community providers can work together to monitor progress, assess changing needs, and support the patient throughout treatment.
A Practical Checklist for Referring Providers
When considering virtual PHP/IOP for patients, providers should evaluate:
- Medical stability: Is the patient medically stable enough to participate safely in virtual PHP/IOP, with appropriate local medical monitoring available?
- Symptom severity: What is the current frequency, severity, and medical impact of eating disorder behaviors? Go beyond the diagnosis.
- Home environment and support: Does the patient have a safe, reliable environment for treatment and appropriate caregiver, family, partner, or other support when clinically indicated?
- Behavior interruption: Can eating disorder behaviors be managed with the structure and support available through virtual treatment and at home?
- Treatment engagement: Can the patient participate meaningfully enough for the team to assess symptoms, provide interventions, and recognize when needs change?
- Local medical care: Can the patient access necessary in-person monitoring, including vitals, labs, EKGs, physical exams, or medication management when needed?
- Outpatient collaboration: Are local providers able to communicate and collaborate with the virtual treatment team to support continuity of care?
- Changing needs: Is there a clear plan to reassess level of care if symptoms worsen, medical stability changes, or virtual treatment is no longer providing enough support?
Ultimately, the goal isn’t to determine whether a patient is a “perfect” candidate for virtual care, but whether virtual PHP/IOP can provide enough structure, monitoring, and support to meet their current clinical needs safely.
Learn more about virtual care at Alsana. Whether you’re exploring treatment for yourself, a loved one, or a patient, our team can help.
References
- Lewis, S. M., et al. (2023). Traditional versus virtual partial hospital programme for eating disorders: Feasibility and preliminary comparison of effects. European Eating Disorders Review. doi:10.1002/erv.3031.
- Ortiz, A. M. L., Cusack, C. E., Billman, M. G., & Essayli, J. H. (2023). Baseline symptomatology and treatment outcomes of young adults in a virtual versus in-person partial hospitalization and intensive outpatient program for eating disorders. International Journal of Eating Disorders, 56 (8), 1644–1649. doi:10.1002/eat.23968.
