Urgent message: Adding travel health services to an urgent care center can increase a practice’s income and enhance its client base.

LYNNE BUNNELL, RN
Providing pre-travel health services in an urgent care clinic makes good business sense. The setting is natural to patients who want to be seen for care just days before leaving on a trip. It also works well for those who are more flexible in scheduling visits because their trips are planned further in the future. Whether clients plan ahead or delay treatment until right before travel, providing travel health services can help grow an urgent care clinic’s business by addressing an unmet need and contributing to patient satisfaction and loyalty over time.
Where should you begin if you want to add travel health services to your urgent care clinic? This article will introduce you to things you need to consider and provide the resources you need to get started.

Services Provided by Travel Health Care Providers
Among the services provided by travel health care providers are:

  1. Talking to patients about details of their planned trips, including countries to be visited, expected activities, and accommodations;
  2. Gathering travelers’ health and immunization history;
  3. Customizing a risk-reduction plan for each patient that includes vaccines, prescriptions, and consciousness-raising about behavioral risks, drawing on available resources;
  4. Referring travelers to primary care and/or specialists as indicated;
  5. Reviewing Vaccine Information Statements (VIS), giving the first round of immunizations, and planning follow up to complete the series;
  6. Providing prescriptions, if indicated;
  7. Educating travelers about how to stay healthy during travel and what to do if they become ill; and
  8. Charting everything and giving travelers an immunization record and appropriate handouts.

Start With What Your Office Already Has
Urgent care clinics already have office setups and highly visible locations designed to encourage walk-in traffic. They have examination rooms and a waiting room, plus medical and support staff. There is a refrigerator and the capability to store and administer vaccines. Emergency medications and training are part of an urgent care clinic’s scope of current practice. And in today’s health environment, computers are obviously an integral part of the office setup. With a few additions, your clinic can easily accommodate the function of a travel clinic. Here are the steps to take:

  • Evaluate your clinic refrigerator for reliability and invest in thermometers if you don’t already have them. Your refrigerator should have a separate freezer section and maintain consistent temperatures. Identify at least two staff members who will be responsible for receiving and logging in vaccines, plus recording the refrigerator and freezer temperatures twice daily so that the cold chain is maintained in order to ensure that vaccines are properly stored. Many resources on proper vaccine storage and handling and documentation (such as temperature logs) are available for free through the Immunization Action Coalition (IAC) at www.immunize.org.
  • Invest in a wall map of the world and/or a good atlas. This helps staff learn about world geography and facilities discussion with travelers about their destinations.
  • Subscribe to some travel magazines for the waiting room to help set the scene. Put up a sign prompting patients to ask about travel health needs when they plan trips so they know you provide such care.
  • Apply to the local public health department for a Yellow Fever Stamp in order to administer that vaccine. There is a course on the CDC site called: Yellow Fever Vaccine: Information for Health Care Professionals Advising Travelers.
  • Familiarize yourself with the Centers for Disease Control Website at www.cdc.gov/travel. The CDC’s Health Information for International Travel, also known as “The Yellow Book,” is an essential resource because it sets out the U.S. standard of care in the field. On the CDC site, you can look up destination recommendations and requirements for the countries your travelers plan to visit. As your practice grows, you may want to subscribe to a service like TravelCare (www.travelcare.com) or Travax (www.shoreland.com) that provides regularly updated, computerized information about destination countries and vaccine recommendations/education concerns for specific itineraries.
  • Add some new reference books to your clinic library for quick staff reference and also for patients to look at during appointments. The CDC’s Yellow Book is available online, but it’s good to have a current hard copy on hand as well. The indexed pages of Shoreland’s Travel & Routine Immunizations (The Blue Book) provide an easy way to quickly access vaccine information. Becoming familiar with the contents allows you to field patient questions with ease. The CDC Pink Book, Epidemiology and Prevention of Vaccine-Preventable Diseases, is another excellent reference source. As time goes by, other books can be added to your clinic’s travel health library.
  • Develop and adopt policies and procedures related to your practice’s new function. Many examples of such policies and procedures are available online to download and review/change as needed by your clinic. The Immunization Action Coalition (IAC; www.immunize.org) has many standing orders for vaccines. By becoming a member of the American Travel Health Nurses Association you also can gain access to their recommended policies via their Website (www.athna.org). While adverse reactions are rare, it is important to orient all staff to your plan for dealing with anaphylaxis.
  • Obtain history and charting forms online, from your reference books or use an electronic medical record for documentation.
  • Obtain International Certificates of Vaccination or Prophylaxis for travelers (“yellow cards”) from the U.S. Government Printing Office. Consult The Yellow Book for information about how to order them.
  • Obtain VIS forms, which federal law requires that you show to patients before administering vaccines, at www.immunize.org/vis or www.cdc.gov/vaccines/pubs/vis/default.htm.

Links to online resources on travel health are listed in Table 1.
Understandably, this article cannot cover everything you need to consider when expanding your clinic to include travel medicine. Details about setting up a travel clinic are available from various sources, including those listed in Table 2.

Table 1. Resources on Travel Health*

CDC Travelers’ Health Homepage: http://www.cdc.gov/travel.
Includes current travel health notices, disease- and destination-specific health recommendations, and guidance on a variety of topics in travel medicine.

  • CDC Travelers’ Health Yellow Book Homepage: http://www.cdc.gov/yellowbook.

Includes a searchable version and a list of any updates occurring between print editions.

  • U.S. Department of State country-specific information, travel warnings, and travel alerts: http://travel.state.gov/travel/cis_pa_tw/cis/cis_4965.html
  • The Practice of Travel Medicine: Guidelines by the Infectious Diseases Society of America: http://www.journals.uchicago.edu/doi/pdf/10.1086/508782
  • U.S. Advisory Committee on Immunization Practices: Recommendations on individual vaccines http://cdc.gov/vaccines/pubs/ACIP-list.htm
  • CDC vaccine information statements for patients: http://www.immunize.org/vis
  • CDC Pink Book: Epidemiology and Prevention of Vaccine-Preventable Disease: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm
*Source: CDC Yellow Book 2012, Table B-01

 

Table 2. Resources for Setting Up a Travel Clinic

  • Travel Clinics of America offers membership and assistance in setting up a travel clinic, travel medicine course, marketing, accounting, corporate referrals, a vaccine buying group and a listing on their website at http://www.TravelClinicsofAmerica.com.
  • The International Society of Travel Medicine’s (http://www.ISTM.org) monograph, How to Begin and Operate a Travel Clinic, is available to members.
  • Shoreland’s Clinic Guide, which can be found at http://www.shoreland.com, is available for free.
  • VaxServe, a subsidiary of Sanofi Pasteur, has a program to help people start providing travel health care. Contact Robert Hettes at [email protected]

 
Determining What To Charge for Travel Health Care Services
Decide upon a consultation fee for travel health services that is in line with the fees your clinic charges for other longer consultations. Consider reduced fees for couples or groups of travelers who visit the clinic together. A small administration charge can be added to each vaccine charge. Most travel clinics require that patients pay on the day they receive the services in cash or with a credit card, and patients then submit claims to their health insurance companies.

Travel clinic billing should be kept separate from billing for urgent care services. If your urgent care clinic has contracts with medical insurers, you will need to set up the travel clinic as a separate business with its own tax ID#. Otherwise, you will have to accept insurance discounts for the vaccinations. As an alternative, Travel Clinics of America membership eliminates the need for setting up a separate business and accounting system for the travel health function (see reference in Table 2).

Seeking Training For Providers
The body of knowledge in the travel medicine filed is large and encompasses vaccines and prescriptions, geographical risks for diseases, consultation with and management of travelers of various ages and in different states of health, special risks associated with travel activities and destinations, and how to deal with illness and accidents abroad. These wide-ranging clinical responsibilities and information are reviewed very well in the clinical article, “The Traveling Patient,” by Francine Olmstead, MD, FACP, in the February 2010 issue of JUCM – The Journal of Urgent Care Medicine.

The challenge (and fun) of providing travel health care is in the details. Each traveler presents a new profile of history and itinerary needs and it can be satisfying to sort out the risk-specific recommendations for vaccines, prescriptions, and health education. Providers who want to serve international travelers must first commit to learning the basics, and continue to study as new scenarios arise and as vaccine and destination information changes. Providers must also cultivate an awareness of what it going on in the world from a political, climatologically, and disease-outbreak point of view and keep abreast of current medical literature pertinent to the field.

Reading the CDC Yellow Book from cover to cover is a great start, but daunting. It is easier to take a course about pre-travel care and then familiarize yourself with the rich CDC resources. The ISTM website (www.istm.org) has a listing of available courses, of carious lengths – courses to travel to and attend at a particular place and time, and others that can be taken online at your convenience. At the outset, taking a shorter course probably makes the most sense so that you are not overwhelmed by the quantity of information to be learned. The www.TravelHealth101.com online course is a thorough introduction in a format that is especially accessible to beginners in the field because the material can be viewed multiple times over several months. ISTM offers more specialized online courses related to specific areas of travel health care.

A key part of your learning process will be identifying mentors in the filed who are willing to help you as you start out, and who can later help you find solutions to difficult cases. Even the most seasoned travel health care providers find it helpful to compare patient scenarios with colleagues.

The payoff for providers is the enjoyment derived from talking to travelers. Listen closely to the stories your travelers tell you about what they look forward to doing on their trips to identify the type of travelers you are dealing with – such as conservatives, risk-takers, high-end vacationers, and backpackers. The challenge is to provide quality care for all travelers based on the current CDC guidelines, taking into account the facts and risks unique to each individual.

Educate Travelers
Vaccines and prescriptions are important because of the diseases and illnesses for which they afford protection. But accidents pose the greatest risk to travelers and can be life-threatening. intestinal problems also can contribute to loss of productive vacation days. Educating travelers is essential because knowledge about behaviors that reduce the risks of getting ill or injured during travel can mean the different between a wonderful trip and a stressful one. The teaching process should also include information about travel health insurance and how to access health care during a trip.

While taking a client’s history and listening to stories about his or her previous travel, a provider can learn about a patient’s specific concerns, which in turn help identify what to teach. Patients often listen best when being taught about ways to avoid a repeat problem.

Some providers give patients handouts that review the important points about issues such as precautions against insects and concerns about food and water. If a particular patient is going to a high altitude or will be doing riskier travel activities, such as deep sea diving or a bicycle tour, extra time for teaching may be indicated.
To save time, you may want to show travelers the video at www.travelhealth101.com (offered by subscription), which reviews essential pre-travel health information that every traveler should know. Clients can view it during the pre-travel visit, while you are writing chart notes and filling out the traveler’s immunization record, and they can also be signed up to view the video again later at home to enhance their learning, which they will see as an added service provided by your clinic.

During the pre-travel visit, don’t forget to chart everything, including the patient’s medical and immunization history, destination information, details about the vaccines and VIS forms given, educational topics covered in the session, and your plans for follow up. You may want to have travelers sign a vaccine consent form, although it is not required. Give each patient a handout with a reminder about the need for follow up and have him or her address a “reminder” postcard. A follow-up email reminder also can be sent to travelers.

Finally, provide travelers with a record of all immunizations on a World Health Organization Certificate of Vaccination, or update the certificate that a patient brought to his or her appointment. Encourage travelers to make copies of this document so the data are not lost.

Networking and Advertising Your Clinic’s New Service
There are many ways to get your urgent care clinic’s name out there as a resource for travelers. For example, you can write a press release to let people in your community know that you are available to see travelers or have a grand opening.

Another idea for expanding your market is offering to discuss travel needs with groups of travelers, such as mission groups, students, seniors, and clubs like Rotary International. Talking to a group will help educate them all at once, after which the travelers can come to the clinic for one-on-one appointments to get their vaccines and prescriptions. You can also write articles for your local newspaper.

To promote your services to business travelers, research corporations in your area and identify those that are likely have employees traveling aboard on business. Make an appointment to meet with the human resources or corporate medical officer of each company to offer your clinic’s services.

To increase your exposure among the medical community, present and interesting case at a hospital grand rounds. Or call specialists such as infectious disease providers to whom you can refer complex cases or patients with post-travel illness. Tell primary care physicians about the travel services you provide and invite them to refer their patients to you. Many primary car providers don’t have time to spend with travelers, or an interest in doing so. After you see a traveler who was referred to you, write a thank you note to the referring clinician to reinforce the referral relationship.

Remember to Listen
Listen carefully as you see urgent care patients, because you may identify travelers who have come into the clinic to check a health need before a trip but were not aware that they needed special pre-travel care. For such last-minute travelers, you may only be able to provide fairly basic information, and perhaps administer a tetanus booster or hepatitis A immunization. Nevertheless, you can use this visit to agree on scheduling a follow-up appointment after the trip to complete the immunization series and plan ahead for future travel. As you get to know your travelers, subsequent visits will be easier because you will build on the previous encounters. Remember that you won’t have time to do everything for every traveler; the goal and challenge is to do the best that you can.
 
 
 

Enhancing Profits with Travel Health Care
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