Robert Axelrod, MD has recently been appointed to a new role in his organization in which he shares responsibility for the development of a comprehensive strategy for Behavioral Health throughout PeaceHealth including in inpatient hospitals, psychiatric clinics, and all outpatient settings including primary care and urgent care.

After a fifteen year career as a clinical psychiatrist and Medical Director in Longview, Dr. Axelrod is looking forward to this new challenge, but “it’s obvious that the old way of delivering psychiatric care – hiring a bunch of psychiatrists and therapists and referring everyone from primary care – isn’t going to work. The shortage of psychiatrists isn’t going away and it’s impractical to refer the 1 in 4 primary care patients with an active mental health disorder.” 

Dr. Axelrod believes Collaborative and Integrated Care hold the key to solving the supply/demand imbalance. According to Dr. Axelrod, it’s not obvious how to fund these initiatives though CMS’s support of CoCM is promising. In addition it can be hard to persuade clinicians to adopt this model if they are used to working ‘the old way’ – and yet moving incrementally takes too long to solve today’s urgent patient care needs. 

Dr. Axelrod is hoping to learn from this fellowship program about the different models of Integrated and Collaborative care which exist, what resources are available to help develop and implement a community-specific program, how to anticipate and solve barriers to implementation, and how to sustainably fund these initiatives. He would also like to learn about to measure and demonstrate success or failure with these programs.

Auren O’Connell DNP, ARNP provides care across the lifespan as a Family Psychiatric Mental Health Nurse Practitioner and practices within Kittitas Valley Healthcare (KVH) in Kittitas County, WA. He is one of only two psychiatric providers in the county and works solely within federally qualified rural health clinics in serving a rural underserved population.

Over the last year, Dr. O’Connell has built a co-located behavioral health program within a rural healthcare clinic in offering brief psychotherapeutic interventions such as behavioral activation and problem solving therapy in addition to psychiatric evaluation and treatment. He has been garnering support among primary care providers and nurses over the last year across KVH in working towards integrated collaborative behavioral healthcare in the primary care setting.  

With guidance from the program, Dr. O’Connell plans to champion the transition from fee for service colocated behavioral healthcare, to quality and patient centered integrated collaborative behavioral healthcare within primary care settings across Kittitas County.

Dr. O’Connell looks forward to the day when quality based integrated collaborative behavioral healthcare in the primary care setting is available to residents across rural counties as a standard of care within the great state of Washington.

Naomi Wenzel ARNP, M.Ed. says that her early life experiences of living in orphanages in South America within the Hispanic culture has been pivotal in the work that she has chosen to do as she reaches the mid to latter portion of her working career. 

Twenty two years ago, she was invited by the Sisters of Providence (Providence Health care system in Seattle) to join them in caring for the migrant Hispanic families in Yakima.  After assessing the needs of the community and designing tools to measure outcomes, Ms. Wenzel worked out of a medical van where she traveled to apples fields, community centers  or churches to help families access care.  She says part of the greater challenge was that once they assessed the need (through screening) particularly for mental health, there were no affordable resources available for our families to follow through with treatment.  As a way to meet the need, Ms. Wenzel started to volunteer at the local free clinic. 

Ms. Wenzel currently works with Comprehensive Health Care in the inpatient adolescent E and T facility (she also previously worked with outpatient adults and children), where she assesses and stabilizes youth with suicidal, homicidal ideation or who are gravely impaired.  At the Unit, she treats previously undiagnosed mental illness, current mental illness and help youth learn healthy ways to respond  to distress prior to their discharge home,  if the home is a safe environment.  

Ms. Wenzel’s other work involves consulting with a Chemical Dependency inpatient facility in which many of the clients have not been diagnosed or recently treated for their mental illness, and helping with prescribing medications during the withdrawal phase of their chemical dependency treatment. 

Lastly, Ms. Wenzel volunteers at the Free Clinic as the mental health provider and hold support groups at the clinic or at local churches.

Ms. Wenzel’s main interest in Collaborative Care is to assist the underserved populations in Yakima that work in the agricultural industry who typically are not insured. She has found however, that not having access to additional help in Behavioral Health or in Chemical Dependency is a challenge. She is hoping that going through the Fellowship program will give her the expert panel she needs to formulate her idea into a practical and innovative way of dealing with mental illness/chemical dependency in multiple settings and populations, not just the underserved.

Thanks to today’s technology and how easily it has become to connect with different systems, Ms. Wenzel’s hope is that people feel less isolated, and have less and less of a challenge in collaborating with different specialties and truly begin to have an integrated medical system that can offer comprehensive and cost effective ways of doing wellness, and preventing costly consequences of “no care” or inadequate care.

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. 

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.

Susan Marney, ARNP has been a psychiatric nurse practitioner for over 20 years and currently practices at Catholic Charities in Wenatchee, Washington where she works primarily with children and adolescents. Catholic Charities is in the process of integrating with medicine and she is the first practitioner to spend part of each week in a pediatric setting partnering with Columbia Valley Community Health to help provide integrated care.

Ms. Marney was previously the director of the Behavioral Health Department at Confluence Health and worked closely with administration and medical practitioners to move from a co-location model to an integrated one. She has a strong interest in finding ways to integrate services from a patient-centered perspective where relationships with patients are made stronger. She and her colleagues are at the forefront of designing a medical home for the chronically mentally ill and children who are in fragile circumstances and require intensive outpatient care.

Ms. Marney hopes that five years from now, the barriers between agencies in her community will be gone and patients will be able to easily and effectively get their medical and mental health needs met by practitioners who are skilled and well-connected to their patients and to each other.

Michele Rowsome, ARNP functions as a behavioral consultant within a community based outpatient VA primary care clinic in Mount Vernon. She has worked within the VA system for 13 years.

Because of her role as ‘prescriber’ on a Primary Care Mental Health Integration (PCMHI) team, Ms. Rowsome has a built-in and vested interest in integrated care. She hopes to gain clinical skills that will help improve patient outcomes, and knowledge about how to more fully integrate with and consult with primary care providers.

Ms. Rowsome hopes that her participation in this program improves access to and quality of integrated and collaborative care for the rural veterans that she serves.

In 5 years, Ms. Rowsome sees integrated care as busier and more consultative in nature, because there will be strong buy-in from primary care providers. She also views it as a very efficient and cost-effective way to provide mental health care to people who may not be willing or able to present to a specialty mental health clinic. She feels that telepsychiatry has the potential to be an excellent avenue for connecting with patients who live in a rural setting so that they have appropriate access to the care they need.