Supporting Continuity of Care in Medical Travel

In a previous article (Pre-screening Traveling Patients: 4 Things You Must Know) we discussed important factors to consider when assessing whether or not a patient is a good candidate for medical travel. In this article we will look at the other end of the spectrum to understand what healthcare providers can do to support continuity of care for medical travelers during and after the discharge process.

Because of the nature of medical travel, continuity of care can be a challenge. In some cases, patients may not have a primary care practitioner to return home to for follow-up care. If a medical complication occurs, there is a real concern that a local physician may not want to treat a patient who has undergone surgery or treatment in another country. Additionally, medical travelers may face challenges during discharge due to language, culture and logistical barriers. Careful planning, therefore, is essential to supporting continuity of care after discharge.

Discharge planning

Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community or domestic environments.[1] When a patient’s transition from the hospital to [a hotel] or home is not carefully planned, there can be serious consequences including hospital readmission, adverse medical events, and even mortality. [2]

Discharge planning can be defined as: “the activities that facilitate a patient's movement from one health care setting to another, or to home. It is a multidisciplinary process involving physicians, nurses, social workers, and possibly other health professionals; its goal is to enhance continuity of care. It begins on admission.”[3]

In the context of medical travel, discharge planning should include early identification and assessment of the patient’s needs. For example:

• Communicating with the patient’s primary care practitioner during the pre-screening process (if possible) to schedule appropriate follow-up care or advising the patient to do so.
• Arranging for language interpretation and translation needs that may be required during discharge. For example, anticipating that an interpreter or multilingual nurse will need to be present during discharge and that discharge instructions and medication information may need to be translated into the patient’s language of choice.
• Recommending or arranging transportation and accommodation options appropriate to the patient’s condition and needs. This will require developing criteria for medical traveler accommodations and transportation and vetting these providers.
• Providing the name and contact information of a point-person from the hospital who the patient can contact in case of any needs or an emergency.

Aligning discharge instructions with the needs of medical travelers

Additionally, an important part of discharge planning are the instructions provided to the patient upon leaving the hospital or clinic. The Encyclopedia of Surgery[4] includes a list of recommended instructions that should be provided to patients at discharge. These have been augmented below with information relevant for medical travelers (italicized).

Before leaving the hospital, the patient should receive discharge instructions that include:

• An explanation of the care the patient received in the hospital or clinic. Ensure the explanation is provided in the patient’s language of choice (via a staff member or interpreter) and that consideration is given to the patient’s culture or religious sensibilities.
• A list of medications the patient will be taking (the dosage, times, and frequency). Additionally, the healthcare provider should verify that all medications are legally allowed into the patient’s home country and are available. If not available, the healthcare provider should provide enough medications for the duration of the treatment or the name of an appropriate substitute. It is also important for patients to be aware that medications should be stowed in their carry-on luggage, so they have easy access to them.
• A list of potential side effects of any newly prescribed medications (in the patient’s language of choice).
• A prescription for any newly prescribed medications (in the patient’s language of choice).
• When to see the primary care physician for a follow-up appointment. As noted earlier in this article, this should be scheduled in advance of the patient traveling back home if possible. Note that the patient may also be discharged to a hotel or other accommodation and may require a final appointment with the destination surgeon before authorization (fit-to-fly) is given to travel home.
• Home careinstructions such as activity level, diet, restrictions on bathing, wound care, as well as when the patient can return to work or school, or resume driving. If the medical traveler is discharged to a hotel or other accommodation prior to returning home, the healthcare provider should ask (if pertinent) if the patient is planning to engage in any tours or sightseeing and provide appropriate guidance. The hotel and transportation may also need to be aware of the patient’s condition and specific needs (e.g. wheelchair lift, handicap accessible room, special diet, etc…).
• Signs of infection or worsening condition, such as pain, fever, bleeding, difficulty breathing, or vomiting (in the patient’s language of choice).
• An explanation of any services the patient will now be receiving, such as for a visiting nurse, and to include contact information (in the patient’s language of choice).
• The patient’s medical records.

Raising awareness about the importance of continuity of care in medical travel

The American Medical Association (AMA) recently adopted ethical guidelines[5] on medical travel which address continuity of care. These guidelines recommend that physicians:

• Advise patients who consult them in advance whether the physician is willing to provide follow up care.
• Respond compassionately to requests for follow-up care from returning patients who had not consulted the physician before seeking care abroad, and carefully consider the implications before declining to provide nonemergent follow-up care.

The guidelines also encourage coordinated follow-up care and a transfer of medical records that adhere to HIPAA (U.S. Health Insurance Portability and Accountability Act) requirements.

In Europe, the EU Cross Border Directive states that “patients who have received care in another state are entitled to a written or electronic medical record of such treatment [Article 4(f)]. In addition, when a patient has received cross-border health care and medical follow-up proves necessary, the same medical follow-up is available as would have been if that health care had been provided on the patient’s territory [Article 5(c)].”[6]

Initiatives such as these are raising awareness and addressing some of the challenges of continuity of care in medical travel. However, more needs to be done to ensure patients have a safe and quality care experience after they leave the hospital. Through its standards in areas such as Care Management, Communication and Education, Cultural Competency, Patient Advocacy, and Travel and Tourism, GHA systematically addresses the vulnerabilities faced by medical travelers across the Medical Travel Care Continuum, ensuring healthcare providers are equipped to facilitate the transition of care from the hospital to the patient’s home country or region.

[1] Marshall, W. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. https://www.ncbi.nlm.nih.gov/books/NBK259995/

[2] Laugaland K, Aase K, Barach P. Interventions to improve patient safety in transitional care – a review of the evidence. https://content.iospress.com/download/work/wor0544?id=work%2Fwor0544

[3] https://medical-dictionary.thefreedictionary.com/discharge+planning

[4] https://www.surgeryencyclopedia.com/Ce-Fi/Discharge-from-the-Hospital.html

[5] AMA Adopts Ethical Guidance on Medical Tourism. 2018. https://www.ama-assn.org/press-center/press-releases/ama-adopts-ethical-guidance-medical-tourism

[6] Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches. https://www.ncbi.nlm.nih.gov/books/NBK263154/

*Medical travel is also commonly known as medical tourism or health tourism.

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