Greg Hudson, DNP, ARNP works as a PMHNP in the Tacoma area. He is currently practicing at Greater Lakes Mental Healthcare in Lakewood, WA, working with both adults and children in an outpatient community mental health setting. Additionally, he is working with Hope Sparks, a counseling agency for children and families in Tacoma, to establish a collaborative medical practice.

Mr. Hudson was led to the collaborative care fellowship after witnessing the gaps in service and challenges that his clients experience when transferring to primary care. He is especially interested in developing a model of care that provides more collaborative support for primary care providers to care for psychiatric patients. He is looking forward to collaborating and building relationships with the UW faculty and providers throughout the state.

Greater Lakes struggles with the push to transition stable clients out to primary care that is not equipped to handle their needs. A common topic of discussion amongst his coworkers surrounds those in the community who are “recycled” back to Greater Lakes after crisis or hospitalization due to lack of community services. In Pierce County, the opening of a new psychiatric hospital Wellfound (a 120 bed joint-venture between CHI and Multicare) is sure to change the landscape of psychiatric care in the South sound. While more psychiatric beds are welcome, the people that fill those beds will need quality psychiatric care after discharge.

Mr. Hudson is enrolling in the collaborative care fellowship to help prepare for these changes and promote systems of integrated and collaborative care in the community.  

Mr. Hudson hopes that his participation in this program will help him to understand and implement a model of care where psychiatric specialists can provide support and consultation to primary care providers. He hopes that he can be a “leader from the front lines”, working with clients, providers, and the systems that manage them to close existing gaps and best utilize available resources. He hopes that in the future psychiatric care is more accessible and less stigmatizing for those in need and collaborative care is the norm rather than the exception.

Terese Schneider, DNP, ARNP, PMHNP is employed by the VA Puget Sound Health Care System as a psychiatric nurse practitioner at the Bremerton, WA outpatient clinic in primary care mental health integration (PCMHI). Half of her time is dedicated to same day access; the remainder includes referrals from primary care providers for psychiatric medication consultation.  Acute, chronic or complex psychiatric cases are typically referred to specialty psychiatry care.

Dr. Schneider has been an advanced practice psychiatric nurse since 2004 at which time she obtained a Master’s Degree and board certification as a Psychiatric Mental Health Clinical Nurse Specialist. She was board certified as a Psychiatric Mental Health Nurse Practitioner in 2005. From 2004 to 2005 she worked for the Hampton Virginia VAMC  as a psychiatric prescriber, participated in a tobacco cessation research study and conducted group therapy. Dr. Schneider worked for the Philadelphia, PA VAMC from 2005 to 2006 in the outpatient addiction treatment monitoring ambulatory detox and counselling for substance abuse. From 2006 to 2015 Dr. Schneider served as a psychotherapist for the Horsham, PA VA outpatient clinic where she obtained  certification in Cognitive Behavior Therapy for Depression, Cognitive Processing Therapy for PTSD, and Cognitive Behavior Therapy for Insomnia. She also conducted Seeking Safety groups and smoking cessation treatment.

In 2014, Dr. Schneider obtained her Doctor of Nursing Practice degree as a  Psychiatric Nurse Practitioner from a prestigious program at Robert Morris University in PA. Dr. Schneider has been employed by the VA Puget Sound Health Care System since January, 2016 as a psychiatric nurse practitioner, having worked in Primary Care Mental Health Integration and in the Addiction Treatment Unit. Prior to becoming an advanced practice psychiatric nurse, Dr. Schneider had worked as a psychiatric RN BSN in various inpatient and outpatient mental health facilities for 15 years. 

Dr. Schneider hopes to learn more efficient and effective methods for curbside consultation. She also wants to learn the best evidence-based psychopharmacologic interventions for the psychiatric disorders that she treats. The advantages of PCMHI include allowing the Veteran immediate access to professional behavioral health providers in psychopharmacology and psychotherapy on the same day at the same location. PCMHI also provides expert consultation in behavioral health issues to busy primary care providers, who have varying degrees of familiarity dealing with behavioral health concerns of Veterans. 

Dr. Schneider is hopeful that as she gains more knowledge and skill in the PMCHI model, she will be able to encourage the providers to utilize the PCMHI services more consistently with its design. She is hoping that primary care providers would eventually adapt to the model and no longer think of the PCMHI team as a separate specialty mental health clinic. Dr. Schneider is also hopeful that the MH and primary care service lines’ leadership would  promote the PCMH model and educate the providers about our model, which has wonderful evidence basis for effectiveness to increase Veterans’ engagement in care and reduce the burden of mental illness on the population. 

Dr. Schneider hopes to see Primary Care Mental Health Integration as a service that people become so familiar with that it would be assumed that “we are on site, effective and utilized to the full extent of our expertise.” The VA Puget Sound HCS is talking about having primary care providers obtain waivers to prescribe buprenorphine for opioid use disorder, and having PCMHI prescribers obtain the waivers to support this practice in the primary care setting. She believes this would provide access to an evidence based pharmacologic agent at the front line of patient care for the opioid epidemic. Dr. Schneider believes that it would reduce the mortality and mortality from opioid use disorder. A recent VA webinar presenter pointed out that primary care clinics do have to provide specialty addiction services to do this.

Amber Kostial, MD, has been running a private adult general psychiatry practice in Bellingham since 2016. She opened her practice after working for a year at the local hospital due to observing the need for increased outpatient psychiatric care in the community. She owns her own practice, but shares office space and participates in an office association with two other psychiatrists and 6 psychotherapists, which allows for a community feeling and ample opportunity for consultation and collaboration.

Dr. Kostial’s interest in collaborative care was sparked by her experience participating in integrated care as a psychiatric consultant for PeaceHealth primary care clinics in Bellingham and via telemedicine with Peace Island Medical Center on San Juan Island. She enjoyed being able to collaborate with primary care providers and behavioral health care managers to help optimize mental healthcare for individuals in a timely and efficient way and to help identify individuals in need of more intensive care with a psychiatric prescriber and/or psychotherapist.

Dr. Kostial gained a basic understanding of integrated care systems through her experience and readings at the time, but through participating in the Integrated Care Fellowship she hopes to gain a breadth and depth of knowledge that will allow her to offer psychiatric consultation services to her community in an optimally informed, effective, and evidence-based way. There is a major shortage of psychiatric prescribers in Whatcom County, with no outpatient psychiatric services offered through the hospital, only a couple community mental health agencies serving individuals with Medicaid, and a handful of private practice psychiatrists/ psychiatric prescribers, with only a couple who take Medicare.

By participating in the Integrated Care Fellowship, Dr. Kostial hopes to help expand the reach of behavioral health care to individuals, including those who may never see a psychiatrist or therapist, in her local community. She hopes to share her experience with other local psychiatrists/psychiatric prescribers to get them interested in participating in integrated care also.

Dr. Kostial hopes that integrated care will be a usual component of primary care within the next 5 years. She also wonders if there might be value in the longer term to extending to some nonprimary care settings (e.g. neurology, dermatology, pain clinics, surgery clinics) to reach patients with frequent specialist contacts and complex comorbidities that may be significantly impacted by/have significant impacts on behavioral health.

Daniel Ferber, MD, does clinical work that includes psychiatric assessment and medication management to patients across the age spectrum. An interdisciplinary approach to patient care is integral to his role as a medical provider working in community mental health.

Dr. Ferber’s interest in participating in the collaborative care fellowship evolved from his role as Medical Director of a Community Mental Health Center currently in the process of implementing a Coordinated Care Behavioral Health Center (CCBHC) grant. He hopes that the knowledge gained from his participation in the fellowship will allow him to be a more effective participant in clinical planning at the agencies where he practices. 

Dr. Ferber believesthe relationships developed from his participation in the fellowship will continue to be an invaluable resource as the application of integrated care evolves and impacts his clinical practice. 

Over the next five years , Dr. Ferber envisions coordinated care/integrated care as contributing greatly to improved health outcomes for our patients. Hopefully, the coordination between physical and mental health providers will not be implemented in such a way that it is perceived as an additional burden on our medical providers. 

Rachael Barry, ARNP  is a psychiatric nurse practitioner for the Multicare Assertive Community Treatment (ACT) team. ACT is a multidisciplinary evidence-based treatment model that provides outreach-based care to clients with severe and persistent mental illness. This work involves seeing clients where they live or where they are at for the moment (shelter, hospital, McDonalds).

Ms. Barry’s interest in this program was sparked by the transdisciplinary nature of the program she works in right now. She sees first-hand how effective it can be when multiple disciplines work together towards the single goal of assisting clients live better lives. Her interest is also spurred on by frustration that she is not more effective in her collaborative efforts with primary care providers.

Ms. Barry’s hope for this program is that she will gain the skills and expertise needed to work more effectively with primary care providers to ensure clients receive the care they need as they become ready to move on from the intensive nature of ACT. She also hopes to gain insight into new and better ways she can leverage her skill set to serve clients.

Ms. Barry believes her participation in this program can positively affect the level of integrated care in her current practice and is excited to find new ways to build on her current practice model and think outside the box for how psychiatric care is delivered.

Ms. Barry hopes that in 5 years collaborative/integrated care will have expanded to the point where clients have meaningful access to psychiatric care before they have reached a crisis point with their symptoms. She also hopes that she will not have to argue for delay of transition to a lower level of care for clients served by her team because there is no one willing to continue prescribing the clients psychiatric medications.

Raghuram B. Bhat, MD, MA, FAPA is a board-certified psychiatrist, with additional board certifications in addiction medicine and geriatric psychiatry, as well as a Fellow of the American Psychiatric Association. He is currently the Medical Director of an addiction treatment center in Southwest Washington. Prior to this, Dr. Bhat held a number of medical leadership roles in WA and NY, including serving as Medical Director of dual diagnosis outpatient clinics, Medical Director of a methadone clinic, and Chief Medical Officer of a community mental health organization. He has taught and mentored medical students, psychiatry residents, and addiction psychiatry fellows, as well as psychiatric nurse practitioners and other psychiatrists. He has been interviewed in both written and television news about his work providing medication-assisted treatment for underserved adults with opioid addiction.

Dr. Bhat believes in providing compassionate, patient-centered, trauma-informed medical and psychological care for clients suffering from addiction, within a team-based approach that utilizes the best available pharmacological and behavioral treatments. He has a special interest in understanding and treating the psychological trauma that often underlies addiction.

Dr. Bhat applied to the Community-Based Integrated Care Fellowship with the hopes of learning how the approach may be applied to help more persons in his community benefit from evidence-based treatments for addiction, perhaps by expanding the team-based approach, successfully used in addiction treatment centers, to a broader team including primary care physicians and other community health providers. In the more distant future, Dr. Bhat is hopeful that such a community-based integrated approach may be further expanded, beyond addiction treatment, to include those for whom psychological trauma may be underlying the course of their general medical conditions.

David Paris, PMHNP-BC received his nurse practitioner degree from the University of Washington. He has worked in inpatient and outpatient psychiatry settings for more than 20 years, and currently works as a Psychiatric Nurse Practitioner for a private nonprofit clinic in Cowlitz County.

Mr. Paris also currently provides telepsychiatry services for crisis patients in Grays Harbor County. His employer is rapidly expanding into other services not robustly available in rural counties, including primary care and substance use disorder treatment. The integration of these services with ongoing mental health services is a primary focus of effort. He has extensive experience implementing and providing remote psychiatry services, including in austere locations. His current interest is the comprehensive management of patients with severe and chronic mental illness.

Renn Polk, ARNP received MSNs from the University of Southern Maine and Norwich University. She completed her psychiatric nurse practitioner residency at the joint Duke University and Durham VA Medical Center program. She is currently in the Doctoral completion program at Gonzaga University. In addition to her academic experience, Ms. Polk is a U.S. Army Veteran and current Army Reservist who will assume command of the 1972nd Combat Operational Stress Control Unit in June 2018.

Ms. Polk chose to pursue the Community-Based Integrated Care Fellowship as she has experienced how the false distinction between medical and mental health care can encumber patient care. She believes that integrated and patient-centered approaches are requisite elements of good health care. As part of her fellowship experience, she hopes to improve her own practice of integrated care and take an active role continuing the adoption of successful integrated care models in the Army and VA health care systems.

Ms. Polk’s clinical interests include moral injury, trauma, and stressor related disorders, and adjustment disorders related to military service and transitions. Her research interests include the identification and treatment of moral injury. She is currently proposing research investigating the intersection of trauma experiences, moral injury, and psychophysiological reactivity.

Howard Welsh, ARNP resides in Forks, WA where he does primary care for local residents, many of whom are loggers, truckers, and fishermen or longtime members of the local tribes engaged in subsistence activities. There is a sizable community of locals working in the forests gathering salal, mushrooms, and recycling cedar for roofing shakes.

There is one grocery store and two hardware stores. There is a Head Start and an elementary and secondary school system. Along Highway 101 there are some restaurants and motels with service workers, cooks, and waitresses. There are a few state and federal employees as well. This makes for a diverse population of patients. 

There are serious alcohol and polysubstance problems and seemingly intractable poverty-driven health problems with every kind of social and mental health problem imaginable. Residents watch the logs being loaded onto trucks and driven to the ports in Port Angeles and Aberdeen-Hoquiam and loaded onto ships headed overseas, where they are milled and processed – work the local residents used to do for decent wages.

In a community like this, Mr. Welsh is expected to do everything, so integration of healthcare is a necessity. According to Mr. Welsh, “The local people just don’t get any mental health care, or any care at all, without the integration of the clinic services wth the local agencies which are bare bones. It is good that an old curmudgeon such as myself is here trying to provide some patient advocacy where it is otherwise lacking.”

Since Mr. Welsh enjoys being a nurse, as well as fishing/ hunting/hiking, he will continue working here until something “forces him into retirement.”

Mr. Welsh appreciates the UW for helping him be a better provider and actually giving him the instruction he needs to keep working effectively in this environment.

Ginny Buccola-Tourney, DNP, ARNP works as a PMHNP, both in a small private practice and in community mental health, both in Pierce County. At the community mental health center where she spends most of her time, she serves as the manager of medical services, providing supervision and administrative support to a team of 5 providers as well as providing direct care to clients. She provides medication management for children, adolescents and adults with a specialty focus in perinatal mental health. She also enjoys providing reflective supervision in infant mental health for our local Nurse Family Partnership nurses and teaching both about perinatal mental health and infant mental health.

Ms. Buccola-Tourney is very interested in a model of care that supports psychiatric specialists serving as consultants to primary care providers. She would like to develop a sustainable model for her clinic to provide consultation to their area primary care providers. She is also hoping to build relationships and learn from other providers throughout the state.

Her clinic has struggled to recruit and retain psychiatric providers, and this will be even more pressing over the next few years as the majority of their provider team is close to retirement. Simultaneously there is a great push to transition more stable clients out of her clinic and back to their primary care providers. This type of transfer is not always successful as there is no current structure for them to provide ongoing consultation or relationship building with our informal community partners. With active collaboration we would be able to expand access for clients to have their psychiatric medications safely and effectively managed.

Ms. Buccola-Tourney has many hopes! She hopes that they have an effective consultation system in place for psychiatric specialists to provide consultation with primary care providers. She hopes that EMR systems are in place to facilitate provider to provider communication. She hopes that psychiatric care is more easily accessible to those who are in need and that they can receive the best quality care quickly and efficiently.