Patient Satisfaction Planner: Hands across the hospital: Handling internationals

Language, culture, scheduling pose challenge

In an era of managed care and federal cutbacks in health care reimbursement, international patients — who typically pay full charges for medical services — are understandably a prized part of a hospital’s or health system’s business.

Along with this retail rate, as it is often called, come issues and requirements that go beyond providing medical care. They present a unique set of challenges for any health system and particularly for access personnel.

"There is a need for a variety of ancillary services that are critical to providing access," notes Lesley Macherelli, embassy liaison for the Boston-based Partners Healthcare System’s international program.

Some issues are remarkably the same — patients complain about wait time or question the amount of their bills — and some are decidedly different.

Guiding people through the system means not only accompanying patients to appointments, but assisting them at the airport and with housing arrangements in a city that is foreign to them, she adds.

"You’re assuming a lot if you [believe] someone who doesn’t speak English and has lived most of his or her life in a small town in another country can figure out which Sheraton is which," Macherelli points out.

Following Brigham and Women’s example

At Brigham and Women’s Hospital, one of five Harvard Medical School-affiliated hospitals for which Macherelli helps coordinate international business, the volume has grown in recent years, says Kerin Howard, manager of the hospital’s international program. Residents of the Middle East make up the majority of Brigham and Women’s international patients, she notes, but the business is increasing both in numbers and in countries represented.

Before Brigham and Women’s established a separate office for international patients two years ago, Howard says, she worked with those patients as part of her job in the access services department, which is a 24-hour, seven-day-a-week operation. The international office, she notes, is open from 7 a.m. to 8 p.m. and has someone on call around the clock.

International patients, she says, typically make a deposit in advance of their stay of between 75% and 100% of the estimated amount of their bill.

"We do a lot with embassies, so [in those cases] we get a letter of guarantee," says Howard, who reports to Brigham’s director of admitting and oversees a staff of eight. "Every patient at Brigham and Women’s Hospital gets the same quality of care, but we do try to take into consideration the special needs of the international patient."

Patients can elect to pay for concierge services, she says, which the hospital outsources to a local company. "They assist with hotels, transportation, banking, grocery shopping, changing flights, and any other services that a concierge typically provides."

The Pavilion, a newly refurbished patient floor with private rooms only, was scheduled to open Sept. 4 and will be available to patients — international and domestic — willing to pay a premium for special services and amenities, Howard adds.

When it comes to scheduling the U.S. patient, "we look at length of stay in the hospital, but with the international patient, it’s important to consider length of stay in the country," notes Macherelli. "Every day they’re out of their country, it’s costing them much more than just hospital charges. They’re paying for hotels to bring family members with them, and there’s the out-of-work component."

Paying attention to cultural differences

In addition to closely scheduled appointments for international patients, she explains, close attention must be paid to things that otherwise might be taken for granted.

Ensuring that the patient is there on time and follows preoperative instructions, such as not eating after midnight, is not necessarily a given, Macherelli says. Patients have been known to show up for surgery saying they really hadn’t eaten, had "just had a croissant and a coffee," she adds.

Many of Partners’ international patients, the majority of whom come from Arabic countries, "are not early-morning people," notes Howard. "Cultural ideas about time are not the same as here."

Such eventualities, she says, underscore the importance of "doing some education on our end." Her department uses a variety of handbooks and educational literature for international patients, Howard adds.

The importance of customer service

"One international patient is like having 10 domestic patients," she says. "It’s not just language. It’s cultural issues, and it’s the need to have everything done in an efficient and often expedited manner. When they’re leaving, they need a final bill, all their records, and their medications."

Helping Howard keep the fast pace that’s required are three administrative employees who work in the office and five Arabic-speaking patient coordinators who accompany patients to their appointments and serve as interpreters, she says. Spanish is the next most frequently spoken language among international patients, Howard notes, but that language need is met by the hospital’s interpreter services department or by bilingual admitting staff.

A Partners nurse stationed in the United Arab Emirates helps get patients and their records ready for the trip to Boston, she notes.

Having a good customer service program is a big advantage for any access department dealing with international patients, Howard says. Like their domestic counterparts, these patients can present a variety of scenarios that must be handled with patience and tact.

"Sometimes patients come for [a medical procedure] they think will cost a certain amount and it turns out to be more complicated," she says. "There are some common things, but you never know what to expect. They’re all unusual; there’s nothing straightforward."

In effect, Macherelli points out, working with the international patient sets back the clock to a time when health care providers had more time to dedicate to patients.

"Medicine is so highly specialized, we often don’t have time to look at the totality of a patient’s experience," she adds. "[With international patients], you have to look at the whole experience — the foods they eat, [and] the cultural and familial ramifications."

Providing access services to these patients encompasses two kinds of concerns — infrastructure and cultural — and the two categories overlap, Macherelli notes. "Critical [to the process] are triage and the scheduling of appointments, and to do that, you have to have people who can interpret and translate medical records."

With Muslim patients, there are myriad cultural issues, Macherelli explains. "To have a man come into the room and move a bedridden female patient onto another bed can be horrifying to someone," she says. "It has to happen, but there needs to be some sensitivity as to how it happens. [Providers] must be sensitive to patients’ cultural mores or patients can get so distraught that the delivery of care is compromised."

Traditionally, female Muslims will only see female providers, Howard says, particularly for gynecological problems. When it makes sense clinically, the hospital will accommodate those patients, she adds. If a male physician is the best clinician in a particular field, or the only appropriate person on call during the weekend when an in-vitro fertilization needs to take place, Howard says, "usually, the patient will agree" to the care.

Devil’s in the details

Simply entering the international patient’s demographic data into the system can present an interesting challenge, Macherelli points out. Names are typically hard to spell and hard to pronounce, and "virtually every Arabic name begins with Al-,’" she notes. "If a [registrar] types in Al-,’ hundreds of names come up. You have to take these fields all the way down to the date of birth and home address [to identify the patient]."

The date of birth also can be problematic, Macherelli adds. "I have seen the same person give a different date of birth on each of three visits."

In some cases, she says, the day and month are reversed. "It seems like a small thing, but it can cause constant confusion if the dates of birth don’t match up from one year to the next on blood work. You need a thorough intake questionnaire."

Assorted challenges notwithstanding, working with international patients can be a particularly rewarding and positive experience, Howard says. "It’s about making a difference in people’s lives. We have a patient here from the Middle East who is pregnant with conjoined twins. She wouldn’t have the same outcome if she had stayed in her own country."

[Editor’s note: Kerin Howard can be reached at Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; telephone: (617) 732-5777; e-mail:]