I visited another eating disorder hospital unit yesterday. In our conversation about the services and schedule and parent visitation I learned an interesting and important item about insurance in the US. I was chafing at how parents are only allowed visitation for very limited hours (a total of six hours for children and five for adolescents a WEEK). It was pointed out that for insurance to pay for inpatient and partial hospitalization there are a specific set of hours required for each service offered: nutrition, physician, group, individual therapy, family sessions... and that this left few hours for visitation.

I'm curious to hear from parents, and from clinicians, how much insurance rules influence the schedule while in care at different facilities.

It goes without saying, for me, that access to parents and siblings is not only a human right but therapeutic and an opportunity for family education and support. When a child is hospitalized for an injury or non-psychiatric illness they generally - in modern hospitals - have rooming in for parents. Doesn't it strike anyone else as bizarre that psychiatric hospitalization would offer LESS time with family - the very people who most need to understand and support the treatment and the patient?

(A notable exception: Westmead offers rooming in for families on the eating disorder unit. Now this is the model I would like to see everywhere!)


  1. That is an interesting, good point about insurance. However, couldn't parents be present for many if not all of the sessions (e.g, therapy, physician), especially if it is a child patient? This will allow for the hour requirement to be met but still allow family involvement in all aspects of treatment (not only the typical one family session per week and a few visits), just like when kids are hospitalized for any other medical illness.

    As a side note: I am currently an intern in peds psychology. One of the behavioral pediatricians who I work closely with told me that he thinks child mental health should be treated as more "pediatric" and less "psychiatric." He definitely seems on to something ...

  2. I'm often really disheartened by the lack of hours alloted for visitation by family/friends, both for those suffering with eating disorders and individuals suffering from other other mental illnesses. Often only 3-5 hours a week is permitted, but even more frustrating that the limited amount of time is the fact that many facilities restrict the hours to very specific and potentially inconvenient times (such as 4-5 p.m. when family cannot get off work and make it to the hospital before 6 or 7). Facilities really need to take a family-friendly approach and work on incorporating the individuals supports more strategically in treatment.

  3. While this may explain a lot that happened to us while my daughter was inpatient, it is certainly not in the child/adolescent's or family's best interest. At the least, inpatient facilities should explain this to families so they understand that it is 'not them' per se (eg. the dysfunctional family). However, I think if families fully understood this, insurance companies might be in for a real and justified backlash. I think this is terrible and causes such damage.

  4. The challenges of replicating this arrangement in the US are legion and most tediously familiar, so I won't dwell on them at length. The important thing, IMHO, is to establish this as a goal, a clinical best-practice, if you will, and then take each obstacle in turn. I think it could be done, but it would take much concerted effort on the part of parents, providers and payors (and probably legislators). One question raised by the peds psych intern, why can't this be accommodated now? Much of the therapy modalities (at least in our program) are group-based and therefore not amenable to parent participation. But again, program design could take this into account, but I think there probably would (should) always be times when the patient is not in the presence of their parent(s).

  5. I think the service hours provided issue only partly "explains" it, b/c parents might be invited for rounds or, as at our local unit, to do the child-patient's daily menus and meet with the dietitian. But family wouldn't be permitted during groups, b/c it would compromise the privacy of other patients (and there wouldn't be space in the already too-small rooms). Families mostly aren't allowed during the significant downtime that is mostly characterized as "constant observation" after meals and snacks (just sitting with the feeling of food/fullness w/o engaging in self-defeating behaviors).

    Additionally, I mostly think it's a staffing issue. Staff have more duties/oversight in the milieu if there are visitors on the floor (checking them in/out; monitoring interaction, rules compliance; general observation ... all resulting in more to report and note). It's more work to have more people on the unit, and to keep track of what's going on.

    There are also concerns for other patient courtesy ... young siblings might be rowdy or crying or playing in a robust, disruptive way; peers need rest; patients and families may have disagreements or emotional interactions during visiting time, and that can be loud/bothersome for the personal space of other patients.

    There are usually not enough places/rooms to accomodate visitors, and having someone else's family hanging out in your patient room, or sitting at their desk, bed ... is a boundary issue.

    Similar to the regular pediatric floors where family rooming-in is encouraged, family-inclusive eating disorder units probably need to be designed and built to accomodate those goals, including enough room for families to eat meals with their patient. Many hospital-based programs don't have that ... maybe free-standing residential places have more options, but I don't have experience in that setting.

  6. I very much agree that this is not something that can be addressed without a shift in how we see the role of the family during treatment.

    Naturally, a patient would have times separate from family - for practical and therapeutic reasons. The question is whether these policies are in the service of successful treatment, hospital management, convenience, tradition, or a true case of parentectomy? It probably differs between programs, too.

  7. Hmmm.... We have always had unlimited visitation for parents on Kartini Clinic's inpatient service and have not run into problems with insurance. Yet. 12 years later.

  8. Unlimited visitation: wise
    Insurance coverage: smart
    A clinic that offers the first and secures the second? Priceless!


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