US Behavioral Health Profiles Implementation Guide
0.1.0 - CI Build
US Behavioral Health Profiles Implementation Guide
0.1.0 - CI Build
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
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