New Virtual Care Programme Aims to Transform Severe Obesity Management in Western Sydney
Key Takeaways:
- Nepean Blue Mountains Local Health District (NBMLHD) is building “Living Well Virtual Care”, a 12–18 month virtual programme offering evidence-based, multidisciplinary care to adults living with severe obesity in Western Sydney.
- The programme is modelled on the internationally recognised Family Metabolic Health Service (FMHS) adult model of care and is designed for people who face barriers attending hospital-based services, including long travel distances, physical disabilities or severe anxiety.
- Funded through NSW Health’s Translational Research Grants Scheme and supported by the Agency for Clinical Innovation, Living Well has been designed to be scalable across NSW, including in regional and rural communities.
A new digital pathway for severe obesity care
Nepean Blue Mountains Local Health District (NBMLHD) is building the “Living Well Virtual Care” programme, a new digitally enabled clinical pathway designed to improve access to evidence-based severe obesity management in Western Sydney.
Living Well will run as a 12–18 month virtual programme. It draws its inspiration from the successful and internationally recognised Nepean Blue Mountains Family Metabolic Health Service (FMHS) adult model of care.
The programme supports adults living with severe obesity through a holistic, evidence-based, multidisciplinary approach. This approach addresses not only a person’s physical and mental health, but also the social factors that influence their long-term wellbeing.
Extending the reach of an established service
A central aim of Living Well is to reach people who may currently be missing out on specialist care.
“Living Well will allow us to extend the reach of the Family Metabolic Health Service to people who are waiting long periods of time to see us, or who may otherwise never engage with us,” explains Dr Kathryn Williams, Clinical Lead of the Family Metabolic Health Service and Principal Investigator of the Living Well program.
The programme is particularly suited to people who face barriers attending hospital-based services. These include people who live long distances from clinics, people with physical disabilities and people who experience severe anxiety.
Responding to growing demand across NSW
Demand for public obesity services continues to grow across NSW. Without timely intervention, a person’s health and quality of life can deteriorate, increasing the risk of chronic disease, disability and future hospitalisations.
Living Well has been developed as an affordable, scalable response to this challenge. By offering earlier, virtual access to coordinated care, the programme aims to support better health optimisation and ease pressure on emergency departments and inpatient services. These are outcomes that the in-person Family Metabolic Health Service model of care is already delivering.
“Severe obesity is a complex, chronic condition and it requires sustained, coordinated care,” continues Kathryn.
“Living Well will put the right support in place earlier, improving health outcomes for patients while also delivering better value for the health system.”
For healthcare professionals, this emphasis on obesity as a complex, chronic condition requiring sustained and coordinated care reflects the kind of evidence-based foundation covered in The College of Contemporary Health’s Obesity Essentials course, which supports clinicians to strengthen their understanding of obesity management in practice.
What the programme offers
The Living Well Virtual Care programme brings together a range of digital and supportive elements, including:
- On-demand educational content
- Live webinars and group interventions
- Practical resources to support participants to engage their GP in medical weight management and the management of obesity-related complications
- Links to trusted external online resources relevant to severe obesity
- Opportunities for peer connection and support
Alongside engaging with the online content, participants receive one-to-one health coaching.
Designed to scale across the state
Living Well has been designed to be scalable across NSW, including in regional and rural communities, and is supported by the Agency for Clinical Innovation.
“This program will demonstrate how digital care can be used as an extension of high-quality clinical services,” says Kathryn.
“For many patients it will mean timely access to care, greater confidence in managing their health, and a more positive experience as they journey through the health system.”
Funding and research significance
The Living Well Virtual Care Program is funded through NSW Health’s Translational Research Grants Scheme. It is one of three NBMLHD high-impact research projects with the potential to be translated into policy and practice and to build research capability within NSW Health.
CCH insight
As services like Living Well show, effective care for people living with severe obesity depends on clinicians who understand obesity as a complex, chronic condition and can support people through sustained, coordinated care. The College of Contemporary Health’s Obesity Essentials course is designed to help healthcare professionals build confidence in evidence-based obesity management.
Source: Nepean Blue Mountains Local Health District
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Virtual Care Could Reduce Hospital Admissions in Severe Eating Disorders, Study Finds
Key Takeaways:
- A fully virtual, multidisciplinary treatment programme demonstrated strong engagement and positive clinical outcomes for adults living with severe eating disorders
- Structured online support during high-risk transition periods may help reduce hospital admissions and sustain recovery following discharge
- The model highlights the potential for digitally delivered, evidence-based care to bridge gaps between inpatient and community services
Evaluating a new approach to severe eating disorder care
An evaluation conducted by Oxford Health NHS Foundation Trust has examined whether intensive, fully virtual treatment can effectively support people living with severe eating disorders. The study, published in the Journal of Eating Disorders, focused on a service known as Step Care, developed through the HOPE Provider Collaborative.
Researchers describe this as the first prospective study to investigate a completely virtual, intensive treatment model using multidisciplinary enhanced cognitive behavioural therapy (CBT-E). The programme is designed to support individuals as they transition between inpatient treatment and community-based care.
This period of transition is widely recognised as a critical phase in recovery. People living with severe eating disorders face a particularly high risk of relapse shortly after discharge from hospital, especially within the first two months. The study therefore explored whether structured virtual support during this vulnerable period could help maintain recovery and reduce the likelihood of readmission.
Addressing gaps in existing services
Step Care was developed in response to well-documented challenges within eating disorder services. These include fragmented transitions between inpatient and community care, repeated hospital admissions, and limited access to intensive day treatment.
The service is delivered entirely online and brings together a multidisciplinary team, including professionals from psychology, nursing, dietetics, and art therapy. This integrated approach aims to provide consistent and coordinated care across different stages of recovery.
Step Care operates through three distinct pathways:
- Starting Well – for individuals at risk of requiring hospital admission, with a focus on prevention
- Staying Well – for those recently discharged from inpatient care, supporting early recovery
- Working towards Recovery – for individuals who have begun restoring weight and are focusing on longer-term recovery
Lucy Gardner, professional lead dietitian within the Step Care service, highlighted the importance of integrating nutritional support within a broader therapeutic framework:
“Nutrition plays a crucial role in mental health, yet access to the right level of dietetic support is often inconsistent,” she said. “Our model offers a clear, evidence-informed way to tailor dietetic input to individual need, delivering CBT-E virtually as part of a multidisciplinary team.”
Positive outcomes across key measures
The evaluation reported high levels of engagement and programme completion, including among individuals who had been living with eating disorders for an extended period.
Participants within the Starting Well pathway experienced significant improvements across several clinical and psychological measures, including:
- Body mass index (BMI)
- Eating disorder symptoms
- Psychosocial impairment
- Mood
Importantly, most individuals in this group were able to avoid hospital admission during the course of the programme.
For those in the Staying Well pathway, outcomes were also encouraging. Participants maintained their weight and experienced a reduction in the overall impact of their illness during a period typically associated with high relapse risk. Unplanned hospital admissions were reported to be rare, and many individuals were successfully supported in transitioning to community-based care.
Sharon Ryan, nurse lead within the Step Care service, emphasised the importance of this post-discharge phase:
“The weeks after leaving hospital are often the most fragile,” she said. “Step Care provides consistent multi-disciplinary support at that point, helping people maintain their recovery with support to feel safe and confident out of hospital.”
Implications for future care models
The findings suggest that intensive, evidence-based treatment for severe eating disorders can be delivered effectively in a virtual format. This approach may offer a valuable additional option for supporting individuals at home, particularly during critical transition periods.
Agnes Ayton, clinical lead for the HOPE Provider Collaborative, explained the underlying aim of the service:
“Step Care was designed to bridge the gap between inpatient and community services,” she said. “The findings show that intensive, evidence-based treatment can be delivered safely online, providing continuity of care at a time when people are most vulnerable.”
She also noted that both engagement and clinical outcomes were encouraging, including among individuals who had experienced long-term illness.
A complement to existing services
The authors conclude that virtual programmes such as Step Care may serve as an important complement to traditional inpatient and community services. By providing structured, multidisciplinary support during high-risk periods, these models have the potential to enhance continuity of care and support sustained recovery for people living with severe eating disorders.
As healthcare systems continue to explore digital and hybrid models of care, this study adds to a growing body of evidence suggesting that virtual interventions can play a meaningful role in complex, long-term conditions.
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