Miranda Hennes MN, ARNP, PMHNP-BC will be starting her 5th year serving children and adolescents at Excelsior Wellness Center as a psychiatric mental health nurse practitioner. Prior to this she worked at Washington State University (WSU), College of Nursing for 4 years as an adjunct professor and prior to this a Teaching Assistant. Her undergraduate work includes oncology/med/surg, in-home health and Electroconvulsive therapy for the treatment of severe mental health conditions.

Ms. Hennes received her Master’s degree at WSU. She is a Center of Excellence, meaning she has been trained to diagnose and refer clients with Autistic Spectrum Disorders (ASD) to Applied behavioral analysis (ABA). She has also achieved her Medication Assisted Intervention (MAT) waiver for the purposes of opioid use disorder treatment.

Ms. Hennes is participating in the UW Community Based Integrated Care Fellowship and hopes to gain insight into how best to utilize/collaborate services for children and adolescents with ASD. Sometimes people with ASD have agitation which leads to poor ways of communicating through disruptive behavior. The treatment of choice for this is ABA therapy but the waiting lists are months long. The Spokane area is undeserved for this need. The practice improvement plans she will work toward includes a vision of a Spokane Autism Center similar to the pioneers at Seattle’s Autism Center.

In 5 years, Ms. Hennes hopes to see Collaborative Care as the norm instead of a concept providers have to re-route services through due to reimbursement demands.

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.

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.

Danielle Kizer, MD currently works at PeaceHealth St Joseph Medical Center in Bellingham. Her clinical duties include work on the consult/liaison service, attending on the 20 bed, locked, inpatient psychiatric unit, occasional work in the Emergency Department and ½ day a week in the primary care clinics. In addition, Dr. Kizer also has administrative duties as Medical Director for Behavioral Health. 

Dr. Kizer is interested in Collaborative/Integrated Care as she sees it as a creative and effective solution to the shortage of psychiatric providers in the nation. Dr. Kizer sees Collaborative/Integrated Care as a way to provide care to a large population of patients with limited resources, and as a way to provide support to primary care clinicians.

Dr. Kizer hopes to gain improved knowledge regarding implementation and maintenance of Collaborative/ Integrated Care with the hope of applying that knowledge to the newly initiated program at her institution. 

As above, Dr. Kizer has started a small Collaborative/Integrated Care program in her primary care clinics. She hopes to use her knowledge to improve implementation of the program, ongoing care of patients and support of clinicians. 

In 5 years Dr. Kizer hopes that patients and providers see the value of Collaborative/Integrated Care and that it becomes the norm for most primary care clinics. She hopes it will help break down the silos of “medical” and “psychiatric” care and allow all patients access to services.

Erika Rootvik, ARNP is a board certified PMHNP who works in community mental health in Walla Walla, WA.  She performs psychiatric evaluations and medication management for patients across the lifespan, working with outpatient treatment teams that include a registered nurse and a therapist or case manager.  She is also an active participant in the clinical leadership team at her community mental health center.  

Ms. Rootvik has been interested in Collaborative Care/Integrated Care since working with at-risk youth at a school-based health center and realizing how many people “fall through the cracks” in our current healthcare system, struggling to receive adequate services for both mental and physical ailments.  She hopes that through this program she can learn how to better collaborate with medical providers in her community to ensure easy access to appropriate services and improved continuity of care for individuals in her community.   

Ms. Rootvik is pleased that the state has placed great emphasis on providing equal access to mental healthcare services on a payment-based level.  Also, the organization she works for is a mid-adopter for Washington’s Integrated Managed Care, having just transitioned in January 2019.  Despite these initiatives, Ms. Rootvik recognizes that communication between mental health care providers and primary care providers needs to be improved.  She is hoping to develop a quality improvement program that aids in her organization’s collaboration with primary care providers.

Seeing that the need for mental health services is ever-expanding and the shortage of psychiatric providers does not appear to have an end in sight, Ms. Rootvik hopes that over the next few years this issue can be improved via closer collaboration with primary care providers.  She would like to see lower acuity psychiatric patients more easily transferred to medication management under their primary care providers so that mental health providers can continue to meet the demands of more severe cases that require a higher level of care.