This bill seems like a Federal support system for PATH programs and has 2 Michigan co-sponsors…
Mental Illness Chronic Care Improvement Act of 2009 - Directs the Secretary of Health and Human Services to enter into chronic care improvement program operator agreements with applicant states to provide for the development, testing, evaluation, and implementation of severe mental illness chronic care improvement demonstration programs……
From the Bill:
care management plan for a targeted beneficiary shall be developed with the beneficiary using person-centered planning principles and shall, to the extent appropriate, include the following:
(A) Explicit general health care goals, measured on a regular basis, such as--
(i) improved access to primary care services;
(ii) improved prevention;
(iii) early identification and intervention to avoid serious health issues; and
(iv) better management of chronic diseases, including but not limited to hypertension, diabetes, obesity, and cardiovascular disease.
(B) A designated point of contact responsible for communications with the beneficiary and for facilitating communications with other health care and related community providers under the plan.
(C) Coordination and communication with family members who are actively engaged in supporting the targeted beneficiary’s participation in the program.
(D) Self-care education for the beneficiary in recognizing and managing symptoms of threshold conditions, educating parents and family members, and educating physicians and medical specialists as appropriate.
(E) Education for physicians and other community providers on required collaboration to enhance communication of relevant clinical information.
(F) Active coordination of supportive community services, including peer support, transportation, day care, personal assistance, housing, primary care (including accompanying targeted beneficiaries to medical appointments), mental health care, and other required services.
(G) The use of monitoring technologies that enable patient guidance through the exchange of pertinent clinical information.