The hybrid space in eating disorder treatment: towards a personalized approach to integrating telehealth and in-person care

Abstract

The combination of in-person and telehealth treatment for individuals with eating disorders is becoming an important clinical and research avenue. Despite this, a framework for describing such care, which is coming to be known as hybrid treatment, is lacking. We propose a definition for “the hybrid space” and a conceptual model that delineates the characteristics of hybrid interventions, using a person-centered approach. These characteristics include sociodemographic characteristics and social determinants of health; factors determining use; clinical characteristics; treatment context, participants, and services provided; treatment modality; and the proportion of in-person to telehealth care. Such a model may be helpful in steering development in this nascent field as it provides a framework that clinicians can flexibly adapt to their specific contexts and that researchers can investigate more rigorously. This model may contribute to the improvement of eating disorder treatment as hybrid interventions have the potential to exploit the best of both in-person and telehealth care while offering the possibility for personalizing and tailoring treatment to individuals. Ultimately, we hope that this framework will be a useful clinical tool which can lead to the development of guidelines for clinical practice.

Introduction

The integration of telehealth into the field of eating disorder (ED) treatment, as in many fields of medicine, has become increasingly ubiquitous since the COVID-19 pandemic. Nonetheless, the appropriateness of telehealth in ED treatment must be evaluated on a case-by-case basis, as some essential elements of medical monitoring [1] may be difficult to translate to virtual formats. Though still in its infancy, the combination of in-person and telehealth treatment—in what is increasingly referred to as hybrid care—can very well address this dilemma and can prove to be a crucial element of ED treatment. Beyond the practicality of this approach, hybrid care creates new avenues for personalized and tailored treatment. Given this potential to improve standard care, a model that defines and describes hybrid interventions is urgently needed. In this article, we will present a definition of the hybrid model of care and some considerations which can be helpful in determining who may benefit most from this care in the context of ED treatment. Such a model, while still exploratory, can be pertinent in view of a future where personalized and hybrid care for EDs is the norm rather than the exception.

Telehealth, associated challenges, and the potential for hybrid care

Though the term telehealth englobes a plethora of modalities, in the context of ED treatment, the ones most often referred to are online self-help, telemedicine (that is, synchronous care provided by videoconferencing), and mobile phone apps. The majority of research in telehealth for EDs to date has focused on various types of online self-help and points to the effectiveness of such tools in reducing ED psychopathology in adults and older adolescents with EDs [2, 3]. A more limited evidence-base, including a small number of randomized clinical trials, similarly suggests that treatment delivered by telemedicine is effective [4, 5]. Furthermore, naturalistic studies carried out during the COVID-19 pandemic even showed an equivalence between multidisciplinary care provided in-person and via telemedicine in both adult [6–8] and adolescent [9] populations. Finally, the investigation of mobile phone apps in the treatment of EDs remains in its infancy and is yet to be conclusive with regards to effectiveness [10] though general trends towards acceptability have been observed [2, 10].

These findings are promising as telehealth can be useful for decreasing barriers to care [11] and increasing its reach, convenience, and access [2, 12–17], which is a key issue and priority in ED treatment [18].

However, despite these findings, there remain challenges with the exclusive use of telehealth in ED treatment. For one, current knowledge is largely based on lower-quality studies [4] that must be replicated in larger samples, with more rigorous methodologies, and outside of the pandemic context, before their real-world effectiveness can be confirmed. Second, it remains unclear which types of telehealth are acceptable and to whom, as only few studies have specifically explored this dimension [4, 19]. Third, engagement in virtual treatment has been noted as a potential concern [3]. Fourth, experience from the pandemic has demonstrated that some components of in-person care, at the very least for medical monitoring and for those with severe illness, continue to be essential [20, 21].

Furthermore, telehealth, when used on its own, may not be the optimal or preferred form of care for many, despite its convenience and accessibility. Studies suggest a trend towards preferences for in-person care during the pandemic amongst individuals of all ages, including children, adolescents, their caregivers, and adults [15, 22–26]. Given this, it is likely that in-person care will continue to be relevant in the foreseeable future.

Thus, if we are aiming to permanently integrate virtual interventions in the future, the best way to do so may be by combining them with in-person care. Several studies are already pointing to this as an essential next step [22, 24, 25, 27] and our own experience further indicates that clinicians working in pediatric ED programs across Canada naturally implemented hybrid models when public health measures related to COVID-19 were put into place [21]. This suggests an opportunity for expanding and improving the hybrid treatment model.

What is the hybrid space?

To date, there is no clear definition of hybrid care in medicine, broadly, and in ED treatment, in particular [28–31]. This makes the limited literature on the topic difficult to clearly identify because the term “hybrid” is not yet systematically employed. Furthermore, there is a high degree of heterogeneity in hybrid approaches making study results difficultly generalizable. While it may not be possible nor desirable to reduce this heterogeneity, there is not yet consensus on what elements of a hybrid intervention should be clearly outlined in study protocols or for clinical applications, adding to the complexity of generalizability. Finally, there are currently no clear guidelines for the use of hybrid care, even if recent guidelines for the use of telehealth in treating EDs in adolescents have been published [20]. For these reasons, there is a need for both a definition and framework for the implementation and study of hybrid care. In this context, we propose the concept of the hybrid space.

The hybrid space, as we will use it, refers to the continuum of care integrating any degree of use of a virtual modality (i.e., telephone, videoconference, texting, email, mobile apps, and online self-help) with in-person care in order to provide health services to an individual, family, or group within a range of clinical contexts. This definition is based on previous literature [19, 20] and our team’s experience providing and researching ED care. Beyond a definition, however, we are proposing a model for conceptualizing the various facets of care that could be considered in the decision to use hybrid interventions. Some or all of these elements may already be thought about by clinicians when conducting regular, in-person consultations or follow-ups. Nonetheless, we believe it is important to formalize this model in order to better understand hybrid care and in order to ensure it is provided to patients who would benefit most from this type of care. In conceptualizing our model, we looked at elements of hybrid care that have been previously studied, that have been suggested as the object of future studies, and that were important based on our clinical work and previous research involving telehealth use amongst pediatric ED specialists in Canada [21].

Thus, the model we are suggesting includes six facets of care that we recommend be carefully considered in the decision to provide hybrid interventions to patients with EDs (Fig. 1). These facets of care are: (1) the sociodemographic characteristics of the participant(s) involved in addition to the social determinants of their health; (2) the factors determining the use of a hybrid intervention; (3) the clinical characteristics of the participant(s) involved; (4) the treatment context, the intended participants, and the services provided; (5) the treatment modalities; and (6) the degree to which the intervention occurs in-person and online.

Fig. 1.

A graphical representation of the hybrid space framework

Given that research in this domain is still limited and that these facets of care have not been rigorously studied, it is not possible to conclude the order in which these elements should be considered and if certain elements may take priority over others. Rather, what we propose in our hybrid space model is an overview of key considerations.

Facets of hybrid interventions

With regards to modalities, our definition of the hybrid space remains broad and includes all modalities, that is videoconference, telephone, mobile phone app, and online self-help, even if the effectiveness of all such approaches is not yet clearly demonstrated and may vary based on a number of patient and provider-related factors. We prefer to be inclusive and to allow for experience and research to eventually define clearer boundaries. Given this, we urge those implementing hybrid interventions to do so cautiously and to remain critical of any approaches that are not yet clearly recommended in guidelines.

Concerning treatment contexts, hybrid care may be integrated into a number of settings including inpatient, residential, day program, and outpatient. Participants involved can also vary from the individual affected, to family, group, or even multi-family group settings. Interventions can equally include single (e.g., medical, therapy, nutrition, etc.) or multidisciplinary services. Together, these factors are crucial in specifying the type and intensity of interventions.

Clinical characteristics such as ED diagnosis, illness severity, and medical stability should be explicitly stated and will be key features in upcoming research as it is not yet known for whom hybrid care is most useful. On the one hand, medical stability and illness severity are determining factors in the decision to provide the primary treatment via telehealth [21, 22] and any doubts regarding these elements should signal the necessity for an in-person evaluation [20]. In contrast, the specific ED diagnosis does not yet seem to be crucial in orienting treatment modalities because robust studies showing clear differences across diagnostic categories are lacking [5, 32, 33] and because some approaches are recommended for all individuals with EDs [1]. However, more studies and attention are necessary because certain modalities like internet self-help seem to be more helpful in bulimia nervosa than anorexia nervosa [32] and because in-person treatments can differ based on diagnoses despite some similarities [1].

A multitude of factors may determine whether or not hybrid care will be provided including but not limited to patient and clinician preference, geographic location, appointment type, and public health regulations (e.g., in the context of a pandemic). These factors are important to consider as they may impact patients’ willingness to participate in and engage with treatment, which can ultimately affect the intervention in addition to outcomes and effectiveness [34].

Sociodemographic characteristics such as age, sex, gender, and socioeconomic status also remain understudied [4] and it is unclear how they may impact hybrid treatment feasibility, acceptability, and effectiveness. Furthermore, while hybrid interventions may be intended to improve access, social inequities may interfere with such a process. Thus, documenting such facets of care as hybrid interventions are implemented will lead to important developments that can ultimately help to keep treatment accessible to all.

Finally, all of these facets of care exist along a continuum which varies between completely in-person to completely online care. Thus, for any given hybrid intervention, the degree to which it occurs in-person and online should be defined. This can be done quantitatively or qualitatively, as is most relevant to the intervention in question. Such delineation may eventually contribute to a better understanding of optimal proportions of in-person to online care.

How, when, and why should hybrid interventions be used?

Considering the multiple, intersecting facets of hybrid care, it remains unclear which factors should be prioritized in the decision to use hybrid interventions. In the interim, referring to conventions for telehealth use can be helpful. In this context, it has been suggested that there is no one size fits all option [35, 36].

With this in mind, specialized care for individuals with EDs should, above all, be flexible and adaptable such that dynamic changes in treatment models can be made in accordance with patients’ current and ongoing treatment needs [36], whether this be a change in modality, in the ratio of in-person to online elements, or in any other facet of care. This flexible approach is at the heart of hybrid interventions. It is also in line with current recommendations and trends in ED treatment which favor stepped care [37] and pragmatic trials [38]. Ultimately, such care aims to increase the array of options available to patients and allows for personalization of treatment, which may be necessary given research pointing to persistently poor responses to manualized treatment in those with EDs [39].

Conclusions

Given the numerous opportunities and the flexibility provided by the hybrid space, it is undeniable that it will be an important part of ED treatment moving forward. Nonetheless, questions about how, when, why, and with whom it should be used are only beginning to be answered. In this context, the hybrid space framework introduced here may be helpful in steering clinicians and researchers as this field develops. Equally important in this process will be the engagement with individuals with lived experience, as they can provide critical insights into what makes interventions both useful and acceptable.

On the one hand, clinical implementation of the hybrid space clearly calls for flexibility and adaptability in order to increase the reach of and engagement with care. Thus, the facets of care laid out here may be used as guides rather than strict constraints. Such use of the hybrid space would be fertile grounds for naturalistic and pragmatic studies examining real word use in transdiagnostic populations. Results from this type of study can lead to hypotheses about specific elements of the hybrid space that could eventually be investigated more rigorously.

On the other hand, the embryonic nature of research in the ED hybrid space necessitates a systematic approach that can lead to the development of evidence-based guidelines. Priorities should be placed on randomized controlled trials that study (1) single telehealth modalities in isolation, (2) with varying ratios of in-person to online care, (3) in specific ED diagnoses. As a first step, such an approach could create a simplified understanding of the significantly more complex, multidimensional hybrid space.

It is our hope that the framework presented here will be useful in clinical settings and helpful in advancing research. Furthermore, we hope this ultimately leads to the generation of guidelines for clinical practice, that are both evidence-based and tailored to individual needs.

Abbreviations

ED

Eating disorder

Author contributions

KN and NC collaborated in conceptualizing the manuscript. KN drafted the original manuscript. NC provided supervision and reviewed the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

NC is funded by a Fonds de Recherche du Québec– Santé Clinician Research Scholar Award (Junior 1) and received a project grant from the Pediatric Research Foundation.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

NC and KN have no competing interests to disclose. Sponsors, including the Fonds de Recherche du Québec – Santé and the Pediatric Research Foundation, were not involved in the conception, review, or approval of the manuscript.