International patients fall into many major categories, including travellers, working/retired expats and medical tourists. Hospitals may wish to attract one or all of these groups and cater to their specific needs.

Preparation is everything

The basics of expectation management include good communication, building strong relationships, shared decision-making, thorough explanations and careful listening. The range of obstacles faced by international providers is extensive. Eve Jokel, MPH, International Patient Services Director at the Portuguese healthcare group Luz Saúde, told ITIJ: “There are challenges at various points in the care process that can impact the timeliness and effectiveness of care that international clients receive.” The most prominent issue is speaking the client’s language. “It is not simply the physician that matters, but also staff at reception, nurses, technicians and all others involved in the patient journey,” Jokel said. “Finding support at reception delays admission and may require several staff members, especially in hospitals that have not provided guidance about how they should manage these situations. The appearance of a person who does not speak the language is not a daily event.”

As a solution, Jokel suggested that employees are frequently reminded of the support that exists and have easy access to assistance, so they can act quickly and decisively. “When an international client appears, such as an expat living in the country, our team can be called by other services in the hospital to support the language and cultural differences,” she said. "However, we also work towards ensuring that services have solutions available and the ability to manage international patients, without depending on the international team. With regards to those who travel for care, our people will typically be following the entire process, guiding the patient and supporting the services as required.

“Another delay at admission may be caused by staff attempting to work with unknown or infrequent insurers and trying to understand membership cards and guarantees of payment in other languages, in particular for expats and tourists with ambulatory care they may have scheduled themselves,” Jokel said.

“Additional support and internal approvals are often required to confirm acceptance of uncommon insurances presented at reception, as well as to confirm co-payment amounts to collect from the client, and other conditions presented in the insurer’s authorisation. In this case, we have guidance for the more common international insurers, as well as staff available who manage this group and know how to work with them. International clients travelling for care will have these matters settled in the hospital prior to arrival,” she added.

Furthermore, it is essential for medical services that require informed consent or the client to follow care instructions that the documents are available in other languages, or an interpreter is on hand. “The same challenge is also true upon discharge,” Jokel explained, “where the client needs to understand postoperative/discharge instructions. At any point where the client is simply agreeing without understanding the information they receive, the risk to a successful outcome may increase.”

Native speakers

Danny Quaeyhaegens, Head of the International Insurance Department at Bangkok Hospital Pattaya, Thailand, also acknowledged the inherent difficulties. “If the patient doesn’t understand everything to the smallest detail, how can they give informed consent? How can the patient clearly explain their symptoms? How can a doctor make themselves understood when explaining the condition and plan of investigation/treatment?" he asked. The hospital must be able to communicate clearly with the patient, insurer, friends, relatives and healthcare provider to remove uncertainty.

“For such clear communication, the healthcare workers need to master the English language sufficiently and as not all foreigners can speak English, there should also be support in other languages available,” Quaeyhaegens said. “In our hospitals, we employ native speakers for many different languages, whose main task is to facilitate communication between patient and hospital staff.”

If the patient doesn’t understand everything to the smallest detail, how can they give informed consent?

The expectations of international patients are certainly likely to differ from local nationals. An individual may not fully understand the health system of the country they are in. Jokel said: “If a person is not familiar with their surroundings, it causes more doubts and they may continually refer to how things would be managed in their home country.”

This may lead a patient to delay a doctor’s recommendations until they have received confirmation from a physician they know, or even postpone undergoing care until they return home, especially tourists. “International patients require more guidance using the hospital and more time with clinicians to understand and trust in the care they receive,” Jokel confirmed.

Up-to-date notes are essential

Robert Sigal of the French Healthcare Association and CEO of The American Hospital of Paris said that both international and domestic patients will expect a successful outcome. But, expectations may vary about the process of care and information they receive, which should be managed. Differences may also arise regarding the culture, affecting expectations of amenities on offer, such as accommodation standards, food types and practices.

One key factor is incomplete patient information on arrival. Diamela Corrales, Director of International Programs and Guest Services at Jackson Health System International, said the completeness of patient notes can depend on where they’re coming from.

“Some areas in Latin America, Central America and the Caribbean donʼt always have the technology to apply for testing, such as MRI scans, as they have limited medical equipment,” she said. “So, there can be incomplete information on arrival about a patient’s condition.” A ‘peer to peer’ method is used at Jackson International, in which the patientʼs physician speaks directly to their attending physician, which is more reliable than the information being passed via several staff members who may not themselves be doctors.

Sigal also highlighted the pre-consultation concerns. “The quality of information provided to the doctors varies,” he said. “If it is good, it helps physicians prepare accurately. If it comes from a professional – a doctor or insurer – then it tends to be higher quality and more precise.

One key factor is incomplete patient information on arrival

“If vague, however, then the patient will be asked by the French Healthcare Associationʼs international team to request more information from their doctor, including a diagnosis and referral for specific treatment, if possible. Some preliminary financial terms are also needed, such as a quotation for the cost of the expected duration of treatment, so the hospital can frame predicted finances.”

Time is of the essence

Another challenge is the distance the patient is travelling. Corrales explained that her organisation has some arriving from Central America and South America. “The ambulance flight can take so long, the patient deteriorates during the journey,” she said. “The hospital can be updated with vital signs en route by physicians or nurses on the air ambulance team.

“Some families have the benefit of being insured for air ambulances, but some do not, so the hospital needs to find that out before the patient is moved,” she said. “If necessary, visas are processed by the air ambulance crew, who are familiar with the process.”

Jackson International don’t have their own air ambulances, but work with the major groups, approaching them when a particular case requires transport to them. Corrales added that Jackson International has state-of-the-art rehab equipment, ‘but it can be hard to transfer the patient back to their home country, where there may not be the best facilities’.

Sigal explained that, in his experience, transport to the hospital is usually organised by the insurer. “Professional medical air transportation companies are used if the patient is in a critical condition and cannot manage on a domestic flight,” he said.

To pay, or not to pay

Different expectations also arise around the source of funding, whether the patient is insured or self-paying. “Insured patients may have an easier stay as the financial side is clear up front, so they have peace of mind. With self-pay, costs can change, so the patient could be more anxious,” Corrales explained.

Although self-pay and insured patients are both looking for good care above all, it may be the case that self-pay clients take a closer look at the costs and risks for unexpected or additional costs, suggested Sigal. Nevertheless, ‘the patient is paying one way or another, either directly or through their insurance premiums’, he said.

To manage the range of expectations effectively, providers often have a concierge service that looks after overseas patients specifically. For example, Jackson International offers a designated concierge hospitality service, acting as a point of contact for patients, as well as insurance and assistance companies seeking advice on complex cases. Alongside translators, its concierge service includes help with arranging accommodation, including discounts at nearby hotels. Patients are each assigned a hospitality coordinator, who work in shifts, covering 24 hours a day.

In addition, Corrales said: “Some patients have no one living locally to the hospital, so we have implemented the best 24/7 concierge service to take care of the family who come with the patient, and those staying behind, so everyone is updated and understands the plan of care.”

Mark of quality

Sigal has helped develop a new voluntary accreditation label for healthcare providers in France. This focuses on international patients and is the first of its kind. It rates international hospitals on factors including whether they offer English and other major languages, a formal structure to exchange patient records between insurer or other hospitals, and if they have a formal patient complaint process.

Eligibility for this quality label is assessed by a certified, professional independent surveying body, ensuring criteria are fulfilled. Once the label is achieved, ‘insurance companies know that they can trust this hospital’, Sigal explained.

Technology can also be used to help meet international patient expectations. Jokel said: “The pace of tech development everywhere, but particularly in our hospitals, is accelerating rapidly. So, it is necessary for the IT team to incorporate solutions into the software that also supports international clients.

“For example, we offer our full website in English; full English functionality on the ‘My Luz’ app; urgent care telephone triage with English-fluent nurses (Luz24); video consultations with English-speaking physicians; online general training about international clients and patient services in the group; and continual intranet reminders of the support that exists.”

A great international patient experience does not only depend on accreditation, technology and strong safety and outcomes. These factors must be complemented by wider considerations, encompassing non-clinical needs and expectations throughout the process. The choice of approach is wide and growing by the year.