From Plague to Peace

“Presumptive eligibility” may sound like a medieval plague, but it is a powerful new tool in Maple City Health Care Center’s arsenal of programs to foster health in our community.

It was 5:00 in the afternoon – closing time at Maple City Health Care Center. Typically, patient care teams and front office staff finish up with the last patients of the day, complete paper work, and turn off computers with the hope of being able to leave for home by 6:00 or 6:30.

Just before shutting off the phones for the day, Susana answered a call from the distraught mother of a teenage boy. The mother told Susana that the boy had just tried to commit suicide.

At Maple City Health Care Center, a nurse coordinator on each of our patient care teams is the person responsible for triage – deciding which staff person is best able to help in a particular situation.

While the mother stayed on the phone line, Susana called Nery, the nurse coordinator for one of the patient care teams. Nery is a native Spanish speaker and was able to understand the language and cultural overtones of the mother’s plea for help.

Because the members of the patient care team work in the same space, Nery could quickly confer with both James, the physician on the care team and with Elisabeth, the behavioral health specialist on the team. Within minutes, the team decided that the best alternative for the boy was to enter the system through the Emergency Department at Goshen Hospital. The physician at the ED could make an immediate referral to the Oaklawn Psychiatric Center’s hospital care unit.

Nery, expecting that the mother would be relieved, got back on the phone to explain the strategy for obtaining psychiatric hospitalization for the son.

But the mother, far from feeling relieved, felt even more anxiety. She had no way to pay for an expensive ED visit or for care from a psychiatric hospital.

Nery went upstairs to speak with Casandra, one of Maple City Health Care Center’s health insurance navigators. Using Spanish, Casandra picked up the phone to collect information from the mother.

With the information Casandra collected and because Maple City Health Care Center has been approved by Centers for Medicare and Medicaid to dispense “presumptive eligibility”, Casandra could issue the family temporary Medicaid.

At 5:20, the mother found Javier, one of our front office staff, waiting for her at the front door of Maple City Health Care Center. Javier handed the mother documentation of her presumptive eligibility for Medicaid – coverage that would make the Emergency Department and the psychiatric hospital affordable.

By 5:30, the mother and her son were inside the ED at the hospital – well on their way to receiving the care that the son needed.