US Behavioral Health Profiles Implementation Guide
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US Behavioral Health Profiles Implementation Guide, published by . This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-behavioral-health-profiles/ and changes regularly. See the Directory of published versions

Quick Facts

Quick Facts

Patient Information:

- Name: James Wolff (prefers to be called James, legal name Jennifer) 
- Age: 60 
- Gender: Male (assigned female at birth) 
- Race: Non-Hispanic African American 
- Status: Retired, lives alone in Orlando, Florida 
- Insurance: Medicare 

Medical History:

- Type 2 Diabetes: Takes metformin 2000 mg daily 
- Moderate Depression: On antidepressants, recently discontinued due to difficulty scheduling PCP appointments 
- Severe allergies to peanuts and penicillin 
- History of substance use, clean for the past year  

ED Visit (6 months ago):

- Symptoms: Chest pain, sweating, heart racing 
- Vitals: Elevated blood pressure (157/92) and heart rate (111) 
- EKG: Normal sinus rhythm 
- Suspected Panic Attack: Given Ativan 0.5mg orally 
- Declined morphine due to past opioid issues 
- Overnight observation and blood workup (CBC, BMP, HbA1c) 
- Consulted in-house psychiatrist: Evidence of depressive symptoms, low suicide risk 
-     Prescribed: Paroxetine 10mg daily, Ativan 0.5mg every 8 hrs PRN 
- Care navigator assistance: New PCP appointment, bus fare vouchers 

PCP Encounter (following week):

- Discussed feelings of loneliness and lack of motivation 
- Continued Paroxetine 10mg daily 
- Referred to community mental health provider and in-house care manager 
- Requested female counselors 

Initial Behavioral Health Encounter (two weeks later):

- Discussed mental health history, abusive past relationship, and support from late partner 
- Strained relationship with adult daughter, Sarah Wolff. Limited family support 
- Administered depression and suicide risk assessments (PHQ-9 score: 12) 
- Recommended CBT, peer coaching, and grief support group 
- Eligible for SAMHSA grant program 
- Scheduled weekly CBT sessions and provided widower's support group info 

In-House Care Manager Encounter (same day):

- Assessed SDOH using the PRAPARE tool 
- Identified needs: Food, reliable transportation, housing security 
- Connected with community meal service and local supportive housing office 
- Received bus fare vouchers 
- Eligible for reduced-fare MetroCard and reinstated disability benefits 

Follow-Up Behavioral Health Encounter (one month later):

- Reported slight improvement, adherence to medication, and missed CBT sessions due to transportation 
- Found support group unhelpful: connected with community recreation center for social engagement 

Second PCP Encounter (three months later):

- Complained of fatigue, dizziness, nausea, and discontinued antidepressant 
- Experienced a recent fall at home 
- Reported daily beer consumption for relaxation 
- Lab work showed elevated HbA1c (6.9%) 
- Provided alcohol abuse prevention education and harm reduction activities 
- Scheduled endocrinologist appointments and virtual CBT sessions 

Second Follow-Up Behavioral Health Encounter (one month later):

- Reported improved diabetes management and eating habits, reduced alcohol intake 
- Scored 3 on AUDIT and 12 on PHQ-9 
- Started new antidepressant (Bupropion 200mg daily) 
- Referred to a psychiatrist for medication management 
- Connected with community recreation center for Zumba and line-dance classes 
- Scheduled follow-up visit to review progress