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.

Kristin Bernhart, MD is a consulting Child and Adolescent Psychiatrist at Allegro Pediatrics, a multi-site pediatrics practice on the Seattle Eastside. Her role includes direct patient care of pediatric patients referred by Allegro pediatricians for diagnostic clarification and treatment recommendations. She provides consultation to the pediatricians about the psychiatry and behavioral health care of their patients. She is also involved in the development of Allegro Pediatrics’ behavioral health program, with the goal of building a program that can better support Allegro pediatricians and reach a larger population of patients needing care.

Dr. Bernhart believes integrated care offers an approach that can broaden the impact of psychiatric and behavioral health care for many patients and families who might not otherwise be able to access needed care. The percent of pediatric patients experiencing psychiatry and behavioral health concerns is high, and growing, while the opportunity for treatment from clinicians with the experience, training, and expertise has not kept pace. Primary care pediatricians continue to be first line in identifying and treating many children and adolescents in need of such care. She believes families and their pediatricians can benefit from the added support provided by care managers and psychiatrist consultants in the integrated care model.

Allegro Pediatrics includes close to 100 pediatricians and cares for close to 100,000 pediatric patients in its practice. Dr. Bernhart’s hope is that by participating in the UW Community-Based Integrated Care Fellowship she will be able to help build an integrated behavioral health program at Allegro in order to broaden the reach of psychiatry and behavioral health care for their patients.

Five years from now, Dr. Bernhart hopes that the integrated care model will build traction in pediatrics to support the increasing numbers of children and adolescents in need of psychiatry and behavioral health care in our area.

Keyna Graham-Heine, DNP, ARNP-PMHNP-BC, provides care as a Psychiatric-Mental Health Nurse Practitioner at Valley Cities Behavioral Health in King County, WA. She primarily provides psychiatric evaluations and medication management across the lifespan, working with a team consisting of clinician (counselor or therapist) and care coordinator.

Dr. Graham-Heine worked as a registered nurse for over 10 years in community health settings, including a Federally Qualified Health Center (FQHC), and the perspective on the needs of both primary care and behavioral health practitioners has led to an interest in integrated care. She hopes to learn integrated care frameworks and gain expertise to support primary care providers and improve client outcomes. Telemedicine, perinatal mental health, substance use treatment, and pediatric mental health treatment are all content areas of particular interest. University of Washington’s Community-Based Integrated Care Fellowship will provide additional support in honing interdisciplinary practice skills which Dr. Graham-Heine can apply in her current practice setting, where psychiatric providers consult at a local FQHC.

She previously had an opportunity to participate in UW’s interdisciplinary Leadership Education in Adolescent Health Fellowship, during which her leadership project topic pertained to increasing uptake of the Partnership Access Line in Pierce County to support primary care providers in providing behavioral health care and ultimately improve pediatric behavioral health outcomes. Through this project she found that primary care providers in Pierce County provide a great deal of behavioral health care and want more support and collaboration with their psychiatric colleagues in doing so. She wants to be well-prepared to provide this interdisciplinary support as a psychiatric specialist. As integrated care rolls out in her home community of Pierce County, where there are limited psychiatric resources, these skills will enable her to provide this type of support in her own community in the future.

Dr. Graham-Heine hopes that in 5 years Collaborative Care/integrated care will be an option for services in every community and for every client.

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. 

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.

Eric Pascual, PA-C is a newly graduated physician assistant, working at Columbia Wellness, a mental health clinic in Longview, WA.

Through Collaborative Care/integrated care, he hopes to gain knowledge about tele-psychiatry and other methods to better serve his community and the surrounding areas.

Mr. Pascual would also like to learn how to integrate psychiatric practices with primary care in anticipation of future growth of his company.

Five years from now, he would like to see a fully integrated partnership between primary care and mental health services at his job.

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.

Janet Clingaman, MN, ARNP received her Master of Nursing degree in 1991 at the University of Washington. She has worked as a psychiatric nurse practitioner for the past 24 years in Washington state, mostly in rural community mental health centers.

Ms. Clingaman has worked in mental health settings her entire nursing career, inspired to enter this specialty by a nursing school mentor. Her first experience with integrated care was at her current job at Unity Care Northwest in Bellingham, an FQHC where she has worked for the past 4 years.

Ms. Clingaman’s interest in integrated care stems from a career working largely in isolation from the general medical community, and the challenges she had in advocating for the medical needs of her patients. Her primary patient population has been the chronically mentally ill, a population with a high burden of co-morbid health problems who encounter many barriers getting healthcare.

Her goals for the remainder of her career are to improve the integrated care program at her current job and to serve as a preceptor to future nurse practitioner students.