Anne Koomen, MS, ARNP is a psychiatric nurse practitioner on the Olympic Peninsula, an area of Washington that struggles to maintain adequate access to specialty services. Her work in mental health services began in the early 2000’s, and throughout these years she has held a growing concern about the stark and oftentimes unbridgeable divides between systems of care. She became a psychiatric nurse practitioner after working for a non-profit organization serving children in Bangalore, India where she witnessed innumerable children unable to make the strides forward that they would like to because there were too many barriers for effective collaboration between service providers. It became apparent to her that in order to provide a higher quality of care she would need to transition into a role where she could offer a link between primary care and mental health services.

Ms. Koomen started her career as a nurse practitioner in 2012, and since then has worked in community mental health services in Port Angeles, WA. In this position she provided psychiatric evaluation and medication management for patients across the lifespan in tight collaboration with patients’ therapists, case managers, and primary care providers. Ms. Koomen is now entering into a role as a psychiatric consultant in the primary care clinics at Jefferson Healthcare in Port Townsend, WA. This organization is working hard to extend psychiatric access to this rural community with the use of the AIMS Model, and she is excited to be a part of this process.

Through participation in this program, Ms. Koomen hopes to gain more tools for easing collaboration between the various systems that intersect in patients’ lives. She is particularly looking forward to thinking about ways to expand the collaborative care model into both pediatric and perinatal care where there are strong needs for clear communication between systems and improved access to services. Regarding pediatric care, Ms. Koomen hopes that in 5 years we will be able to use the collaborative care model to coordinate in a more streamlined manner with special education services and teachers. She also hopes that we can continue to grow access for women who are planning pregnancy, currently pregnant, or in their first year after birth in order to improve the outcomes for their mental health and the mental health of their children.

Katherine Kirner, ARNP has worked as a primary care provider at a Federally Qualified Health Center in Twisp, WA for the past 12 years. At least an hour from the nearest hospital or referral center, there is a mixture of  primary and emergent/crisis care. Frustrated by the lack of psychiatric resources in the area, she returned to school for certification as a PMHNP a few years ago. Now, she is also working as a psychiatric nurse practitioner at a small private practice. She continues to use her behavioral health expertise within the confines of a traditional primary care appointment.  

By participating in the Community-Based Integrated Care Fellowship Ms. Kirner looks forward to exploring ways to bring those two worlds together. As her organization moves toward integration of behavioral health and primary care, they are challenged by the geographic isolation of each of their clinics and lack of qualified providers. Ms. Kirner hopes to learn about telehealth and other strategies to provide resources for both patients and clinicians, even in the most remote clinics.

In the future, she would like to see behavioral health strategies used for all aspects of health care – from traditional mental health issues to diabetes and IBS. She is encouraged by the efforts of the University of Washington and other organizations to increase accessibility but acknowledges that there is still significant stigma and resistance on the part of patients. She believes that, through integrated care, we can continue to break down those barriers and normalize the experience of seeking help.

Po Karczewski, ARNP is a contract prescriber, Psychiatric ARNP, currently providing medication management, assessment, and motivational interviewing for an inpatient drug and alcohol treatment facility, a child and adolescent clinic which has not offered medication management previously, and a clinic serving HIV positive clients.  He has always been an advocate for the importance of therapy, good nutrition, physical health, healing environments and psychiatric medication being used in conjunction with each other, along with emphasizing the cautious and judicious use of psychiatric medication. 

Mr. Karczewski hopes to develop a better understanding of how to be an effective voice for integrated care in his community in Pierce County, and to be able to work with the other Fellowship graduates in his area. Some efforts in this area in the past have resulted in sub-standard care, and it is important to have an effective model for integration.

He hopes to see Collaborative Care/integrated care be the standard of practice/organization. He thinks that the sharing of information systems with rigorous history and current status charting is likely to be more effective than attempts at partial co-location of services.

Leslie Hite, ARNP, PMHNP-BC is a Psychiatric Mental Health Nurse Practitioner at Mid-Valley Clinic, a rural health clinic in Omak, WA (Okanogan County). She provides mental healthcare services for individuals across the lifespan and works collaboratively with primary care providers, specialty healthcare providers, chronic care managers, and community support services to provide a “team-based” approach to health. Ms. Hite also takes referrals from healthcare providers all over Okanogan County to meet the mental health needs of Okanogan County.   

Ms. Hite is interested in collaborative and integrated healthcare because she believes that a “team-based” approach has always been the best healthcare approach. She enjoys working together with an individual’s primary care provider and including other specialty providers and community resources to provide the best opportunity for health and wellbeing. Through this fellowship, she hopes to gain knowledge, new resources, and new ideas in providing integrated healthcare. 

Ms. Hite chose to pursue this fellowship to develop knowledge and skill in providing integrated healthcare that she plans to share with the healthcare providers and staff that she works together with which will increase the health of individuals across the clinic, community, and county.

In 5 years, she hopes to see that all healthcare providers are practicing collaborative or integrated healthcare everywhere. In Okanogan County, she hopes to see a positive trend in healthcare statistics or community health scores because of practicing integrated healthcare. 

Angela Hamel, ARNP, PMHNP-BC will be starting her 3rd year serving patients of all ages at Kadlec Behavioral Health Clinic. She is also working at Washington State University as an adjunct professor teaching nurse practitioner students specializing in psychiatry. Prior to becoming a nurse practitioner she was an acute care nurse for over five years.

Mrs. Hamel received her Master’s degree at Gonzaga University. She is currently completing her Doctorate in nursing practice at Chatham University. Mrs. Hamel 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.

Mrs. Hamel has been collaborating with primary care providers in her current organization by making recommendations for patients with mild to moderate symptoms of mental illness. She is hoping to improve this program by participating in the UW Community-Based Integrated Care Fellowship. She is particularly interested in utilizing collaborative care to reach more individuals with mental illness and learn how to incorporate telepsychiatry into her practice to help patients in underserved areas.

Paul Grekin, MD attended University of Michigan School of Medicine and completed psychiatry residency and community psychiatry fellowship at the University of Washington. He began work at Evergreen Treatment Services, an opioid treatment program that now has clinics in Seattle, Renton and Olympia, providing psychiatric care to patients with opioid use disorder who were unable to obtain that care elsewhere. He was subsequently promoted to medical director, overseeing the opioid treatment provided by a team of advanced practice nurses and physician assistants, as well as supervising the managers of each clinic’s dispensaries. During his career he has also served as medical director at Seattle Counseling Service for Sexual Minorities and provided psychiatric care and consultation at Pike Market Medical Clinic.

Patients with opioid use disorder have a high incidence of co-morbid psychiatric and medical problems for which they often have difficulty receiving adequate care due to stigma, distrust, poor organization and lack of resources. They are high users of acute medical systems, including emergency departments and hospitals. Providing primary medical and psychiatric services on site at the opioid treatment program, where the patients are already attending and feel a level of trust, should improve the patient utilization of needed care. However, experience suggests that even co-locating services does not overcome the barriers for many patients. Dr. Grekin envisions using the collaborative care model to facilitate the provision of integrated care by providers with whom the patients already have a trusting relationship. Dr. Grekin is participating in the fellowship to develop the knowledge and skills to implement integrated care using the Collaborative Care model at Evergreen Treatment Services and sees this as a potential model for other opioid treatment programs to pursue.

Laura Katers, PA-C, MCHS, MS began her medical career in 2013 as a primary care provider in community medicine where the lack of mental health care access was so glaring she earned additional training and CME to better screen, diagnose and treat anxiety and depression disorders during the influx of new patients at the start of the Affordable Care Act. Nearly 50% of her patients hadn’t seen a medical provider in over 5 years. At the time, she also developed an interest in pain management as pain medicine is such a complex, nuanced and misunderstood phenomenon, and so many patients were suffering and forgoing care because of stigma or fear. Or, on the flipside, were mired in addiction.

In 2016 Ms. Katers began work as part of an interdisciplinary complex pain team at the University of Washington Medical Center and teaches courses in behavioral medicine with UW MEDEX Northwest. 

Ms. Katers’s interest in integrated care stems back to before PA school, when she worked as an addiction counselor and detox supervisor in Denver, CO. It was here that she saw the true failings of society, the people who fell through the cracks due to untreated mental illness, poverty, addiction, and for some, just plain bad luck. She was trained in substance abuse treatment and counseling and by way of a collaborative approach to care (at the time between local ERs, law enforcement, social workers, mental health, and primary care) she recognized a medical degree would allow her to become a stronger patient advocate. The drive to optimistically increase access to mental health care, patient by patient, is at the underbelly of her clinical interests and goes back to witnessing very dire situations rooted in trauma and addiction, but from which people did blossom with the right support and follow up.

Ms. Katers is interested in finding new solutions to integrating mental health care access not only in the community but also in the hospital, where for some this is the one point of contact to offer aid or intervene. Given that co-occurring psychiatric and substance use disorders can often be linked with pain, she hopes to build networks and collaborations with other community members to increase follow up for patients once they are discharged and to decrease the burden on primary care providers (who may have no mental health training).

Additionally, her team is in the process of establishing a perioperative pain clinic at UWMC where she hopes to share the trainings of the fellowship not only with other providers and staff, but also with patients. She is personally interested in pain psychology, telemedicine, and non-pharmacological approaches to pain management and in developing grants to bring these tools to the community.

Lastly, as an educator, she is interested in opportunity to develop mental health training for frontline providers, including creating affordable CME in primary care, and/or curriculum development with increased focus on behavioral medicine during student training. 

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.  

Kate Cousineau, PA  works in private family practice where she is part of a behavioral health team providing comprehensive behavioral health services to internal clinic patients.  Patients are self identified or identified by their primary care providers as needing more intense psychiatric services than they can provide. Ms. Cousineau works with therapists and social workers, as well as local community resources, to provide integrated care to a rural community in the Gorge.

Ms. Cousineau’s interest in collaborative care started when she was a child welfare social worker.  It was apparent to her that the behavioral health system, primary care system, and drug and alcohol system were separate spokes trying to accomplish similar goals; however, due to their lack of communication and disjointed relationship, patients’ care suffered. 

Patients went to jail or became acutely ill because there was no comprehensive clinic for patients to receive care, and they were often lost to follow-up in the confusion.  Patients also had a hard time developing relationships with so many providers and became frustrated with frequent appointments and differing opinions.  She sadly saw patients die on waiting lists for Medication Assisted Treatment when they were active patients at a local behavioral health or primary care clinic.  This led her to believe in the power of good primary care, and to want to create a model that was supportive to primary care providers and sustainable for patients.

Participation in this program will help Ms. Cousineau solidify a model of care within her clinic and community that will be helpful for her primary care colleagues, financially sustainable, and easy for patients to access.  She hopes that patients isolated by the mountains in the Gorge will have access to a level of quality that they could enjoy in a progressive urban area. 

Ms. Cousineau hopes that integrative care will be the standard of care in 5 years, practiced by all primary care for the benefit of all patients.  Her goal is for all patients to be able to access care in a timely manner, and for no patient to ever die on a waiting list again.