a. Please provide an introduction to your agency, service context and modality and your role. If the student is not currently placed in a field internship, the student should review the roles and responsibilities of an IBH provider that may be working with the client/patient described in the case example provided by the instructor.
b. Introduce the client/patient as if you were presenting the person to members of your integrated health care team and/or were writing the first entry about the person in an electronic health record (EHR). Include a brief health history of the client/patient, including information such as chronic health conditions, demographics, and the presenting problem. As relevant, discuss the patient’s family members, work/school history, and living situation. Identify at least one screening tool that you can use to further assess the presenting problem or other potential issues for which you might wish to screen or evaluate. Briefly justify your choice of screening tool and include references.
c. Discuss the ways in which the client’s/patient’s experience at this clinic might be affected by factors such as age, culture, race, ethnicity, religion/spirituality, gender identity, or sexual orientation. Describe what you, as an integrated behavioral health care provider, can do to ensure health care equity for this and other clients/patients at this clinic. Cite a minimum of two references to support your writing.
d. Write a minimum of six functional assessment questions that you will incorporate into your initial assessment. Be sure the questions address the client/patient’s presenting problem. At least one of the questions should be a scaling question.
e. Conduct a literature search and select one evidenced-informed intervention that has been used in the IBH setting and may be appropriate for this client/patient. Explain your rationale for selecting the intervention for this particular client/patient (must include references). What barriers to treatment might you anticipate? How might you prepare for such barriers? How, if, or when will you engage any family members in this client/patient’s treatment? Are there any other factors you might consider, given the demographic and clinical characteristics of the client/patient? List three treatment goals specific to the client/patient.
f. Describe any ethical issues or special considerations you have considered in your approach to working with this client/patient.
g. Write a SOAP note (SOAP is an acronym for subjective, objective, assessment, and plan) that would be entered into the EHR that concisely describes your meeting with the client/patient, including your assessment, brief treatment intervention, referrals, and follow-up plan.
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