A Multidisciplinary Model for Emergency Psychiatric Care

Oregon health systems team up to integrate care for behavioral health patients
Hospital & Health Networks – November 10, 2017

Chris Farentinos, M.P.H., is vice president of the Unity Center for Behavioral Health in Portland, Ore.

Psychological well-being is essential to overall health. To provide effective health care, we must attend to and treat the whole person. Nationally, the current behavioral health system is in crisis. Nearly 1 in 5 people in the U.S. will suffer from depression, anxiety disorders or another behavioral health ailment at some point in their life, according to the National Alliance on Mental Illness, and about 1 in 25 American adults, or 10 million people, live with a serious behavioral health challenge.

Oregon and southwest Washington are no exception. We see it every day in emergency departments across the Portland, Ore., metropolitan area. Behavioral health patients must often wait for days in emergency departments for a bed in a more appropriate care setting. Is that the best way to treat psychiatric emergencies?

In response to this crisis and its effect on the health of our entire community, Legacy Health took a leadership role in the creation of the Unity Center for Behavioral Health, the locus of a more integrated system of care for behavioral health patients. In an unprecedented collaboration between otherwise competing health systems, Legacy Health, Oregon Health & Science University, Adventist Health and Kaiser Permanente joined forces to create a better way to treat psychiatric emergencies. The vision for Unity Center was to create a medical-psycho-social model of care in which no one will be left untreated; to create a door to recovery in full collaboration with all local behavioral health and addictions residential and outpatient programs; and to do all of that guided by a trauma-informed model of care.

Multidisciplinary approach
Trauma-informed care is an organizational structure and treatment framework that involves understanding, recognizing and responding to the effects of all types of trauma. At Unity Center, our approach to trauma-informed care is to tend to the behavioral health needs of our patients while being mindful of a patient’s past trauma, emphasizing the physical, psychological and emotional safety for patients while helping survivors rebuild a sense of hope and empowerment. We meet people where they are.

In the past, the six EDs owned and operated by Legacy Health in the Portland metro area served as a critical stopgap for patients who could not otherwise access behavioral health services. In 2016, nearly 10,000 patient visits in these EDs were for behavioral health issues. On a daily basis, Legacy Health EDs were boarding 10 to 20 patients who were awaiting beds in behavioral health facilities. The same was true for other major health systems across the Portland tricounty area, including OHSU, Adventist Health and Kaiser Permanente hospitals. The reality of ill-equipped medical EDs trying to meet the needs of patients with behavioral health concerns changed significantly with opening Unity Center for Behavioral Health in February of 2017.

Unity Center Psychiatric Emergency Service provides rapid assessment by a social worker, nurse and psychiatrist and effective interventions for patients in crisis. The PES provides a living room-like milieu with observation recliners that allow patients to be comfortably monitored and treated for up to 23 hours. In this multidisciplinary model, nurses, social workers, peer support specialists and behavioral health therapists are integrated in the therapeutic environment, interacting and monitoring patients continuously. It is this level of staff interaction and engagement that provides for safe and effective treatment.

Peer support staff stationed at the PES, through their lived experience of a behavioral health challenge and their recovery success, help increase patient engagement, hope and resilience. Their common goal for PES programs is stabilization of acute symptoms and avoidance of unnecessary psychiatric hospitalizations. Unity Center discharges 77 percent of the patients who seek care within an average of 20 hours of stabilization, crisis intervention and discharge planning.

Community involvement
Creating a coordinated and friendlier transition of care model at Unity is a personal issue for me. My career in Portland since 1994 has been primarily working in community-based programs. The transition from hospital to outpatient behavioral health and addictions treatment agencies is where so much of health care breaks down. In planning for Unity, we were offered a unique opportunity to bring together many community-based services and create a more intentional model for transitions of care with co-location of community navigators and in-reach workers. Leveraging technologies such as electronic notification systems allows Unity staff to notify primary care, payers and outpatient agencies such as Cascadia, Central City Concern, LifeWorks and others when patients arrive and trigger a more effective handoff.

Another unique aspect of this project has been the collaboration with the Portland Police Bureau, EMS, Multnomah County staff, the city of Portland and other hospitals. We learned from other hospitals around the country that are providing psychiatric ED care that it is critical to get the police “out of the business” of transporting patients in crisis, affording patients the right to be transported by ambulance like any other medical emergency. Unity incorporated this model of ambulance transport for individuals in a behavioral health crisis, changing state rules to provide our community with the same medically oriented treatment. Today when police respond to a 911 call about a person in crisis, there is a communitywide agreement in Portland that the patient will be transported to the hospital via ambulance and not in the back of a police car in handcuffs.

In this environment of shrinking health care dollars, it is imperative that health systems collaborate to accomplish their objectives. Unity Center was built using $43.5 million in donations from the community, led by transformational $20 million donation from Marcia Randall and the Robert D. and Marcia H. Randall Charitable Trust. While the Unity Center is operated by Legacy Health, the hospital structure features a governance committee formed by four health systems. Each health system contributed significant staffing and other resources to the two-year planning process. In addition to Legacy’s donation of the building and renovation costs, the OHSU Department of Psychiatry provides recruitment, medical staffing and residents through its Adult Psychiatry Residency and Child and Adolescent Fellowship programs. All participating health systems share in the profits or losses for Unity.

It’s working
In the eight months since opening, Unity Center has made significant progress in reframing how the community manages its most acute behavioral health patients.

Early results show that Unity Center has reduced the number of hours local EDs are on divert status by 68 percent. Prior to Unity Center, local Legacy Health EDs experienced on average 58.43 hours per month of divert status in 2016 — in large part due to an abundance of behavioral health patients. In 2017, we are seeing that divert status drop to on average 18.84 hours per month. The reduction of divert time for two Legacy partner hospitals has resulted in more efficient use of organizational resources.

In the Unity Psychiatric Emergency Department, we have been serving on average 30 patients per day who arrive by ambulance, police, walk in and transfers from other hospital EDs.

Since opening earlier this year we have received numerous inquiries from hospitals in other parts of the U.S. and around the world, including South Carolina, Washington, New Jersey, Australia, Japan and Canada, all looking for solutions to behavioral health crises in their communities.