In this continuing education webinar, Bridging the Gap: How Virtual Supports & Extends Higher Levels of Care, Monte Nido Medical Director of Virtual Programming Tara Brass, MD, CEDS and Monte Nido Vice President of Virtual Programs Tiffany King, MBA, explored the evolving role of virtual treatment, including the regulatory landscape, strategies for improving engagement and retention, harm-reduction approaches, and considerations for determining when clients can safely remain in virtual care or need to transition to a different level of care.

Virtual treatment has expanded the ways individuals with eating disorders and other behavioral health conditions can access structured care. Beyond eliminating geographic barriers, virtual programming can help clients translate recovery skills into their everyday environments, involve loved ones without requiring significant disruptions to daily life, and connect individuals with specialized treatment that may not be available locally.

For providers, the question is no longer simply whether treatment can be delivered virtually. It is how to deliver virtual care safely, effectively, and collaboratively while continually evaluating whether it remains the appropriate level of care.

The evolving landscape of virtual behavioral healthcare

The regulatory environment surrounding telehealth continues to change, but several policies have helped maintain access to behavioral healthcare from home. Medicare permanently covers behavioral health telehealth in a patient's home without geographic restrictions, and audio-only care is permitted. The in-person requirement has also been delayed through December 31, 2027, while certain telehealth prescribing flexibilities for Schedule II-V medications have been extended through December 31, 2026.

Private insurance requirements are less consistent. Many states have laws addressing telehealth coverage or reimbursement, but there is no uniform national standard for private or state-funded payers. Requirements vary considerably by state, and some EPO and HMO plans continue to restrict virtual higher levels of care even when the criteria used to authorize treatment are comparable to those used for in-person care. 

Licensure adds another layer of complexity. Clinicians generally need to be licensed in the state where the patient is located, although interstate compacts are gradually expanding opportunities for cross-state practice. Progress varies by discipline, with established or developing compacts for psychologists, physicians, nurses, counselors, social workers, and dietitians. 

For eating disorder professionals, staying current on these requirements is an important part of maintaining continuity and access as virtual care continues to evolve.

What effective virtual care requires

Virtual care changes the treatment setting, but it does not eliminate the need for the clinical and operational foundations of higher levels of care.

A strong virtual treatment model includes several interconnected components:

• Clinical care: thorough intake assessments designed for virtual treatment, evidence-based interventions adapted for telehealth, and established safety and emergency plans.
• Technology and access: secure, HIPAA-compliant platforms and accessible technology support.
• Privacy and safety: verification of the client's location and encouragement of a private, distraction-free treatment environment.
• Collaboration and continuity: multidisciplinary coordination, thorough documentation, awareness of changing telehealth policies, and early planning for ongoing outpatient care.

For clients in higher levels of care, remote medical monitoring and clear processes for obtaining laboratory testing may also be necessary.

These safeguards help virtual treatment function as coordinated clinical care rather than simply translating an in-person appointment onto a screen.

How Virtual Care Supports Recovery at Home

One of the distinct benefits of virtual treatment is that recovery occurs within the environment where clients ultimately need to use their skills.

Transitioning home after a higher level of care can be challenging. Behaviors that felt manageable within a highly structured treatment environment may become more difficult when clients return to familiar routines, triggers, and responsibilities. Virtual care can provide continued structure during this transition while allowing clients to practice recovery skills in real time. 

This can include:

• Integrating back into the home environment with support from a structured care team
• Applying treatment skills to everyday routines
• Receiving real-time feedback when challenges arise
• Involving family members or loved ones without requiring significant disruption to their schedules

Virtual programming can therefore serve as an important bridge between highly structured treatment and greater independence.

Expanding access to specialized treatment

Geography can limit access to specialized eating disorder care. A local program may provide the appropriate level of care without offering groups or clinicians experienced with a client's specific age, clinical presentation, or treatment needs.

Virtual treatment can expand those options by bringing together clients who might otherwise live too far apart to participate in the same specialized program. It can allow programming to be organized around factors such as age or clinical presentation while providing access to a multidisciplinary team with expertise relevant to the individual's needs. 

This expanded access is particularly important when the alternative is not another equally specialized in-person program, but limited or unavailable treatment.

How virtual outcomes compare with in-person care

Growing research on virtual behavioral healthcare suggests that treatment delivered remotely can produce positive outcomes at higher levels of care.

Attendance is one important consideration. A systematic review of 45 studies found lower no-show rates with virtual care compared with in-person treatment, with mental health among the specialties demonstrating the highest uptake of telehealth. 

Research examining clinical outcomes has also found:

• Virtual IOP and PHP treatment can produce improvements in eating disorder symptoms and depression comparable to in-person treatment.
• A meta-analysis of 103 studies found comparable symptom improvement between video and in-person psychotherapy, with particularly strong findings for anxiety, depression, and PTSD treated with CBT.
• A DBT-based dual-diagnosis IOP found reductions in depression, anxiety, and stress through telehealth that were as strong as in-person treatment, with slightly stronger reductions in depression among the virtual group.

These findings reinforce the importance of evaluating virtual treatment based on clinical appropriateness and outcomes rather than assuming that the physical treatment setting determines quality.

Engagement starts on day one

Access to treatment is only meaningful when clients can remain engaged long enough to benefit from it. Three areas can be particularly important for engagement and retention in virtual higher levels of care: a unified treatment team, early involvement of family or loved ones, and a strong therapeutic relationship.

Build one unified care team

Therapy, nutrition, nursing, medical providers, leadership, and outpatient clinicians should work from a shared treatment plan from the beginning. Integrated multidisciplinary care is associated with improved treatment retention. 

This coordination becomes especially important in a virtual environment, where providers and support systems may be physically separated but still need to communicate consistently.

Involve family and loved ones early

Family and loved-one involvement can provide an additional layer of support outside treatment hours. In a telehealth IOP study, participation in family therapy was associated with lower dropout and a greater likelihood of program completion. 

When appropriate, bringing the client and their support system together within the first weeks of treatment can help establish expectations and strengthen continuity between treatment and home.

Prioritize the therapeutic relationship

Therapeutic alliance is associated with both symptom reduction and treatment completion in eating disorder care. Establishing trust early also creates a stronger foundation for revisiting treatment goals when progress changes or challenges emerge. 

In virtual care, connection is not secondary to the clinical work. It is part of the clinical work.

Using harm reduction to guide level-of-care decisions

Virtual treatment requires ongoing assessment of whether a client can continue to participate safely and effectively at their current level of care.

A harm-reduction framework approaches these decisions as dynamic rather than pass or fail. Instead of treating a setback as automatic evidence that virtual treatment has failed, clinicians can consider liability, legality, clinical risk, readiness, and the available safety supports together. 

This approach may include reassessing every one to two weeks and monitoring indicators such as:

• Weight trends
• Eating disorder behaviors
• EDE-Q measures
• Other relevant mental health indicators
• Overall progress toward treatment goals

When progress stalls, the response may involve revisiting the treatment plan, engaging family or other supports, coordinating with the outpatient team, bringing the case to clinical consultation, and determining whether barriers can be addressed safely within virtual care. 

When those supports are no longer sufficient, transitioning to in-person treatment or a higher level of care may be recommended. The goal is not to keep every client virtual. It is to avoid treating a single setback as failure while also recognizing when a different setting is necessary for safety and progress. 

Creating safety beyond the screen

Remote treatment requires clinicians to plan for risks that may not be immediately visible on camera.

A comprehensive remote safety approach begins with a full risk assessment by a licensed clinician on the first day of treatment. Caregivers can also help identify early signs of distress or concerning behaviors that providers may not be able to observe remotely.

Teams should know in advance:

• The client's current location
• Appropriate local crisis resources
• Procedures for conducting a wellness check
• Who should be contacted in an emergency
• How caregivers or other support people will be involved

Behavioral Treatment Agreements (BTAs) can provide another layer of structure. Rather than functioning as a traditional safety contract, a BTA identifies specific skills the client will use to work toward realistic, achievable goals. These agreements are co-created with the client and revised as symptoms, risk, or readiness change. 

The treatment team and appropriate support people should also understand the agreement so that everyone is working toward the same goals.

Bridging access, safety, and continuity with virtual treatment

Virtual treatment can do more than recreate in-person care through a screen. When thoughtfully implemented, it can extend the support of higher levels of care into clients' homes, increase access to specialized programming, involve families more directly, and provide a structured environment for practicing recovery skills in everyday life. 

At the same time, effective virtual care depends on strong clinical infrastructure. Multidisciplinary collaboration, therapeutic alliance, remote safety planning, frequent reassessment, and clear criteria for stepping up or transitioning care remain essential. 

The goal is not to position virtual and in-person treatment as competing models. Instead, each can play a role within a broader continuum of care. By matching the treatment setting to each client's clinical needs, safety, readiness, and available supports, providers can use virtual care to help bridge gaps in access while maintaining the structure and accountability necessary for eating disorder recovery.

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