The challenges of managing overseas medical care

International medical case management is diverse, challenging and complex. Yet it is these factors that make this role so rewarding and engaging. From the routine to the unexpected, my job involves handling the medical treatment of patients all around the world, writes Nichola Walmsley

Having spent seven years working as a practice nurse, and a further five years at a private travel clinic in the UK, I was ready for a new challenge. Something that would allow me to apply my extensive clinical knowledge but in a different way, while learning other skills at the same time. That’s when I looked to the commercial sector and discovered Healix – a global health, travel and assistance company.

Ten years later, I am now one of the Operations Managers. Not only do I have to understand the various challenges a patient with malaria, for example, might be facing, but I also have to establish what care they can access in different continents and how I can help ensure they receive the necessary treatment.

During my day I could be managing around 20 wide-ranging cases. About 80% of those will usually consist of primary healthcare, giving guidance and coordinating treatment. Patients are always keen to get help and advice and I am able to signpost them to the right resources and to better enable them to manage their health. Recently, I supported a child with newly diagnosed insulin-dependent diabetes, a patient with rheumatoid arthritis who started on biologic medication and ensured an adult suffering from mental health trauma accessed UK NICE guidance approved therapy.

A particular aspect of my role that I enjoy is working with a variety of people from diverse backgrounds and specialisms. In addition to our team of nurses, we also have non-medics who are essential to our logistical planning and the relationship-management of medical providers overseas. Cases are discussed with doctors and others as one multi-disciplinary team, helping everyone to develop their understanding and various skillsets, while providing the patient with the very best advice and most appropriate management.

I’m often asked what a typical day looks like. No two days are the same and the work is quite unlike what I was used to in my previous roles. While I might not physically see patients, I consistently rely on the medical expertise I spent years developing in the field to remotely manage critical, acute or more routine health issues in other countries. I’ve outlined just a handful of examples below…

POST-EXPOSURE RABIES TREATMENT IN THAILAND

A parent in Thailand called our health line because their 4-year-old daughter had been scratched by a cat, breaking the skin on her arm, and there was a concern that the cat had rabies.

We get a relatively high number of these types of calls, and our plan of action is often tailored in line with Public Health England’s latest guidelines. One of the first things I had to do was establish whether the child had had the full course of pre-exposure rabies vaccinations and then, based on that information, put together a plan for post-exposure treatment.

The family was based in a remote area of Thailand. Luckily, there was a local facility that was suitable to provide the therapy and we contacted them directly to check that they had stocks available, so as not to waste time with a needless journey. Should there not have been an appropriate clinic in the vicinity, we would have considered repatriating the child. By working with our logistical coordinators, we were able to arrange her treatment along with a series of follow-up appointments so the child was appropriately protected.

Whilst the patient was my number one priority, I was also dealing with an anxious parent. It was important that I was able to help them stay calm so they could take on board the guidance I was giving. I was conscious that I needed to maintain a sensitive balance between relaying the urgent need for action whilst not wanting to alarm the parent or to cause unnecessary distress. I needed the family to have confidence in my advice and be reassured that we would be there to support them along the way. We deal with individuals at a time when they can be feeling particularly vulnerable and confused about navigating international healthcare systems, so my role requires me to communicate in a clear and patient manner, whilst providing practical solutions and action plans.

NAVIGATING THE COMPLEXITIES OF MENTAL HEALTHCARE IN TURKEY

A gentleman in his 40s who recently expatriated to Turkey with his wife, shared that he felt he was constantly worrying, having trouble sleeping, struggling to eat and wasn’t motivated to socialise.

I arranged for a telephone consultation with the patient to gather as much information as possible, so that I could fully understand his current condition. It was vital that I asked carefully considered and thorough questions, so that I could establish what his symptoms were and understand whether he had accessed care through a GP or Employee Assistance Programme (EAP). Following the telephone consultation, I was able to start developing a care plan for him.

I was able to source an ‘in-country’ English-speaking specialist to help the patient talk through how he was feeling and get the support he needed locally, including medications. I continued to follow up with the patient to ensure that he was feeling better and the treatment plan was going well. This included ensuring his prescription was ordered and shipped to him in a timely manner so that he never ran out of medication and to make sure he was always able to attend his follow up appointments.

We always have to be mindful that, when a patient contacts us requiring mental health support, that accessing appropriate services locally can be a huge challenge. Some countries don’t approach mental health in the same way that we do in the UK, so we have to be especially considerate of varying cultural attitudes, including how someone might be treated in that country if they seek support.

ARRANGING AN AIR AMBULANCE FOR CARDIAC PATIENT IN AFRICA

After being alerted to a cardiac patient in Africa, I needed to familiarise myself with the local area and its resources so I was aware of the challenges the patient would be facing when receiving care.

While the patient was stabilised at a local medical centre, it was soon evident that the facility was not equipped to provide the higher levels of acute care the patient was going to now need. Now familiar with the local area and its resources, I knew there were no other viable local options, so our focus turned to deciding whether we could transfer the patient out of the country. Moving patients can be high-risk so we have to balance this risk with the necessity for treatment. The patient was relying on us to take charge of the situation and so we had to formulate a plan quickly.

Working alongside our logistical coordinators, we determined that the most efficient route would be to drive the patient to an airport and arrange for an air ambulance to fly him to a centre of excellence. While the ground move consisted of a four-hour drive, this was still going to be the quickest and safest method of transport for the patient.

I consulted with a local air ambulance provider who received the patient at the airport and boarded him with a specialist medical crew. The patient arrived safely into the care of the accepting hospital’s cardiology team, who were able to manage his condition over the next few weeks until he was ready to be discharged.

Medical repatriations often involve multiple members of the team to manage the transfer as there are many obstacles to navigate such as securing a hospital admission, gaining entry and exiting permits, obtaining visas and checking passports. As with many travellers, sometimes patients can find themselves in very remote and potentially unstable areas where there are added security factors to negotiate. In this case, we also had to consider that there were some particularly sensitive political obstacles to navigate. I worked closely with our team of coordinators who were able to plan the logistics of his safe transfer. It was hugely important to ensure all those involved were kept up-to-date, especially as the condition of the patient could have changed rapidly.

Once the patient had recovered and was ready to return to his posting in Africa, I reviewed his travel plans, taking account of the medical treatment he had received and any long-term treatment and medication he would now require. I needed to see and consider the discharge summary and clinic letters so I could put a plan in place for managing his ongoing care. In this instance, I needed to ensure he had enough supplies of his medication, and that he understood what to do when it was time for a repeat prescription. I also helped the patient set up a plan for ensuring he would be able to travel to his next outpatient review with the NHS.

While we were planning all of the practical elements of this repatriation, I was also liaising directly with the patient to keep him informed of developments. It is important that the patient trusts they are in safe hands and feels confident in our ability to expertly handle their situation.

THE CHALLENGES OF MANAGING MEDICAL CARE REMOTELY

Each case is unique, and there are a variety of outside factors that could affect the outcome for the patient beyond their immediate health concerns. These situations can be quite different from those I had experienced previously. In this role I’ve developed an awareness of language barriers, time zone differences, access to resources, varying healthcare standards, unstable political landscapes and cultural nuances, and learnt how to navigate these and manage a care plan accordingly. While these issues have potential to make treatment very complicated, they challenge me to think outside of the box and give me the opportunity to problem solve.

In my previous nursing roles, my patients were always in front of me. Seeing a patient face-to-face meant I was able to build trust by using eye-contact and physically showing empathy. I could pick up on their body language and interpret non-verbal cues to better understand how they were feeling. When I first started remotely managing cases, I had to learn to adapt my communication style to help me build that same rapport over the phone.

Developing clinical triaging and investigative questioning skills is also essential. The approach we take is a bit like a funnel – you start with broad questions which then become narrow and specific. It is vital that you have clear answers in order for you to be able to make the right decisions. We are making and receiving calls, as well as answering emails, so you quickly learn to adapt in a way that finely hones your written and telephone communication skills.

Although each nurse has a set of cases to manage, you are never working alone. Our strong and supportive department helps deliver the highest standards of service. Anything complex would be discussed as part of a multi-disciplinary team to determine the best course of action for the patient. We all rely on each other and so are always willing to help, support and encourage one another. We are fortunate to have a team in New Zealand who take the night shifts and progress the cases that need immediate attention. I work four days a week in nine hour shifts, and this affords me time to balance my job and home life.

I find my role to be highly rewarding and I like the fact that my knowledge is being constantly challenged, while all the time I’m developing skills that I didn’t have before. I have to remain in control, think ahead, constantly assess my patient’s requirements and be prepared to pivot treatment plans when something changes. I may not meet our patients face to face, but I know that I am dealing with incidents involving real people and having a positive impact on their lives.

WHO ARE HEALIX?

Since Healix was founded in 1992, it’s been our mission to change the face of health, travel and assistance for the better.

Around the clock, we support an impressive range of clients, living and working in every country of the world, across corporate, insurance, government and not-for-profit sectors. And their health and wellbeing is at the heart of everything we do, with a dedicated medical team of fully qualified doctors and nurses making for the highest ratio of clinically trained staff in the managed health services industry.

From medical screening, second opinions and emergency evacuations, to infectious disease and pandemic support services, we help mitigate, manage and respond to a myriad of medical risks to ensure travellers and members receive the most appropriate care, wherever they are, 24/7 all year round.