US Behavioral Health Profiles Implementation Guide
0.1.0 - CI Build

US Behavioral Health Profiles Implementation Guide - Downloaded Version 0.1.0 See the Directory of published versions

## Quick Facts

Patient Information:

    - Name: James Wolff
    - Age: 60
    - Gender: Male
    - 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 wife
    - 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