Portland Business Journal – August 1, 2018

Critics of the Unity Center’s open floor plan say mixing in patients who present voluntarily with those who are there involuntarily can create a volatile and over-stimulating environment.

When Portland’s first and only psychiatric emergency department opened in late January last year, hopes ran high that the Unity Center for Behavioral Health would solve a problem plaguing mental health care for decades.

The new facility, operated by Legacy Health in collaboration with Adventist Health, Kaiser Permanente and Oregon Health & Science University, would give patients experiencing a psychiatric crisis a dedicated place to go for care. Unity would help end the practice of boarding these patients for days or weeks at a time in area emergency rooms, which aren’t designed to treat mental illness.

A year and a half later, the experiment has hit some major bumps. Two registered nurses sued Legacy earlier this year, alleging the center’s care model created a dangerous environment and that they were fired after reporting safety concerns (one of the plaintiffs voluntarily dismissed his suit in late June).

The state Occupational Safety and Health Division fined the center in connection with assaults by patients on employees, which the agency found were not adequately logged and evaluated. More than 500 assaults and incidents occurred in the facility’s first seven months. Then the Oregon Health Authority launched an investigation. Finally, last week, Unity temporarily stopped accepting new patients, except for walk ins, in order to implement new safety protocols, raising the prospect of patients remaining in ERs.

All of this raises questions as to whether Unity officials need to make minor adjustments or if they need to address deeper, structural problems.

“Staff and patient safety must always be the No. 1 priority for any health care facility,” said Multnomah County Commissioner Dr. Sharon Meieran, who has spent her career as an Emergency Room doctor. “The reports, the temporary closure cause me deep concern, but I also truly believe in the model, and I see a deep need for this type of service in our community, and so given that desperate need and the potential benefit that can be achieved by Unity, I hope the concerns are addressed head on by the leadership.”

Unity began as an attempt to consolidate acute psychiatric services, ironically at a time when the trend in psychiatric care was away from larger facilities to community-based care. Unity bills itself “a truly original paradigm,” but it was modeled after facilities in Oakland, California, and Arizona.

Along with 107 beds for short-term inpatient care, Unity features a Psychiatric Emergency Service with an open floor plan, including recliners scattered around the room. Unity also offers patients a smaller space called “the living room” and private “calming rooms.” The PES gets an average of 26 patients a day, who can stay for up to 23 hours.

“The idea that when someone presents in a mental health crisis, they are immediately attended to as soon as they walk in door, with someone with expertise in mental health care, so they’re not languishing,” Meieran said.

Nurses, social workers, therapists and peer support staff circulate. The idea is to reduce isolation, which can intensify feelings of fear and anxiety.

Some say the problem is that patients who present voluntarily are mixed in with those who are there involuntarily, which can create a volatile and over-stimulating environment.

“The floor plan is something that should get more scrutiny,” said Bob Nikkel, a board member of the Excellence in Mental Health Foundation and Oregon’s commissioner for mental health and addictions from 2003 to 2008. “If I were in acute emotional distress, I’m not sure I’d want to be in a room with 25 other people.”

Jason Renaud, a volunteer with the Mental Health Association of Portland, said of those he knows who have had a bad experience at Unity, a general theme stood out: Confusion “as to why everyone is put in one large room. Often, that room was crowded. If there’s a fragile, anxious person, it’s not a good match if you have someone screaming next to someone who is terrified and humiliated,” Renaud said.

Said another longtime psychiatric professional who asked not to be named: “It’s really hard to operate a secure, locked unit and follow a living room model because you don’t know who you’re getting.”

Unity officials declined to comment for this story. In a July 20 statement, Legacy Health Chief Operating Officer Everett Newcomb III said the recent investigations have given the center “an opportunity to look deeper into areas of patient safety, including the physical environment at the hospital, and make immediate improvements.”

He said the need for mental health services was so great that the center opened “as quickly as possible.”

“In retrospect, we should have had stronger policies and procedures in place, along with a robust training program for all staff,” Newcomb said.

Another core principle guiding Unity is to provide “trauma-informed” care, an approach not everyone agrees with, Newcomb acknowledged.

“Our goal remains to overcome an ingrained institutional culture that sought to restrain patients, rather than working with them, that sought to medicate patients, rather than seeking to understand their mental health challenges and past traumas,” Newcomb wrote.

But two Unity Center staffers complained to OHA Ombudsperson Ellen Pinney that “numerous employees have been beaten and assaulted by patients,” according to Pinney’s notes, shared by OHA.

“They are so wedded to trauma-informed model … that they do not intervene in cases like this. If you get two or three manic sociopaths, they start running unit. All is conciliatory,” Pinney wrote. “Patients are chronically under-medicated. … They discharge a lot of folks that are no better than when they came in. Or maybe only slightly better.”

Meieran said there’s an important distinction to be made.

“I absolutely continue to believe that model is an effective way to improve the quality and effectiveness of care for patients experiencing mental health crises,” she said. “The model is just that — a model. It needs to be implemented correctly to be effective.”