Senior Medical Tourism Development Projects

Senior medical tourism is a vibrant, growing niche market for warm climate, sustainable, new urbanism destinations.

Also referred to as “third-age” in some parts of the world, senior medical tourism is a hot market with projected growth indirect correlation to the number of baby boomer medical tourism patients with the time and means to travel for long-stays at their chosen destination.

The year 2011 was first time Baby Boomers entered the ≥65 age bracket. That was just the beginning!

Senior Emergency Department Initiatives – and beyond

With the focus on Baby Boomers, one concept being pitched to hospital executives in the USA, SE Asia, the Caribbean, and Canada, is special emergency departments (EDs) tailored for the elderly. These efforts often involve a major construction effort that reorganizes floor plans and brings in special equipment such as reclining chairs, padded stretchers, non-skid floors handrails, special lighting and bedside commodes. Will this catch on and expand beyond the emergency (casualty) department to other service lines within the hospital or clinic? The use of such systems is growing in U.S. hospitals. Cost can vary widely, from $3.2 million spent at Newark Beth Israel Hospital to a more conservative $150,000 in Holy Cross Hospital in Silver Spring, MD, including NICHE designation and training.

While it is quite simple to claim an initiative to sequester and equip five ED bays and brand your hospital or clinic as an elder ED, that is only superficial. All the other support structures, such as physicians, nurses, and other clinicians that are trained in gerontology and other elder care issues are necessary to build out the gerontology-specific initiative for seniors.  One challenge encountered by many who advocate this service line expansion is the lack of positive outcomes. While reduced readmissions are expected, published evidence for that has not yet accumulated.

Transitions of Care

Transitions of Care are key points in the episode of care wherein providers have the ability to impact the trajectory of patients and improve quality of care and decrease the cost of care. An ED visit is a sentinel event and marks early functional decline, leading to poor health outcomes, higher health care utilization and higher cost of care.

At Holy Cross Hospital in Silver Spring, Maryland, (USA), the hospital has been recognized as a National Model of Geriatric Emergency Medical Services. The nation’s first Seniors Emergency Center is an innovative approach to care that makes Holy Cross Hospital one of the best hospitals in Maryland for seniors. It boasts the first Emergency Center in the U.S. designed for—and dedicated to—patients age 65+ with non-life threatening emergencies.  They pioneered this innovative approach, which is today a model of geriatric patient care worldwide.

The center’s team—a patient-centered practice—includes physicians, a geriatric nurse practitioner, registered nurses and a social worker, all specially trained in geriatric emergency medicine.  The team delivers compassionate, personalized elder health care—with quick and accurate diagnosis and treatment plans developed with each patient’s special needs in mind.  As a result, the hospital has realized several advantages, including, but not limited to:

• High levels of patient satisfaction
• Polypharmacy detection
• Increased volume of patients
• Low rate of readmission

Every aspect of the Seniors Emergency Center was designed to promote health, safety and comfort in mind—and attention was focused on details that create a calm, gentle and nurturing environment:

• Treatment bays separated by walls, not curtains, for added privacy and quiet
• Thicker mattresses and heated blanket for patients
• Safety features like handrails, softer lighting and non-slip floors
• Special speakers that make it easier to listen to music or watch TV
• Telephones and remote controls with larger buttons
• Space set aside for private family consultations
• A centrally located nursing station so staff can keep a close eye on every patient
• Discharge planners make sure the transition home or to aftercare setting goes smoothly, including calls to be sure that patients have all they need to get back to their activities of daily living.

Holy Cross Hospital is also recognized as a NICHE hospital. NICHE is an acronym for the Nurses Improving Care for Healthsystem Elders (NICHE) program. NICHE is the leading nurse driven program designed to help hospitals and healthcare organizations improve the care of older adults.  The vision of NICHE is for all patients 65 and over to be given culturally-sensitive and exemplary care.

The mission of NICHE is to provide principles and tools to stimulate a change in the culture of healthcare facilities to achieve patient centered care for older adults. NICHE, based at NYU College of Nursing has over 575 hospitals and healthcare facilities in 46 states, Canada, Bermuda, and Singapore. NICHE designation demonstrates a hospital’s organizational commitment and continued progress in improving quality, enhancing the patient and family experience, and supporting the hospital and other healthcare organization’s efforts to serve its communities.

For a hospital or clinic that is keen to focus on senior medical tourism as a business and market strategy, NICHE designation and training is an affordable differentiator. The current cost (subject to change) of the program is just under $11,000 USD. This provides a competitive edge to medical tourism clinics that elect to focus in this domain area of expertise. One special consideration about NICHE is that it harmonizes with Joint Commission standards. A Joint Commission Standards and NICHE Resources Document details how NICHE resources comply with the Joint Commission Standards in terms of care of the older adult hospital patient. While it does not specifically mention Joint Commission International (JCI) harmonization, there are enough similarities in this case that any hospital seeking JCI or another ISQua-accredited program will find this crosswalk document useful.

A Senior Center of Excellence Model for Medical Tourism

Combining NICHE hospital/health center designation with a senior/geriatric health and wellness tourism citadel model is a winning combination for a senior living and medical tourism development projects in warm-weather regions such as the southern United Sates, Southeast Asia, Latin America, the Caribbean, and around the Mediterranean Sea.

Medical tourism development expert, Maria Todd, of the Mercury Advisory Group in Denver, Colorado (USA) developed the first such citadel in South Florida in the early 1980s. “Back then there was no NICHE designation or JCI accreditation for hospitals or health facilities, so we sought State of Florida accreditation for the healthcare facilities and State of Florida accreditation for senior living accommodation.”

Todd was appointed the project manager over three successive projects to develop three small senior medical tourism citadels, which included leading the project to develop the facility standards for both the housing and healthcare sides of the business. She worked closely with the citadel’s owner/medical director and other internal and external advisers who were Board-certified experts in gerontology and gerontological-certified nurses to covert the 90-room beachfront hotel into a senior living and medical tourism resort. Besides architects, planners and designers, she recruited Registered Physical Therapists and Certified Occupational Therapists who had additional certifications in rehabilitation aquatics, post-stroke care, Alzheimer’s memory care, and cardiac rehabilitation to collaborate on the standards development.

Todd says that today, her strategy would be adjusted to include a full-service poly-clinic staffed by Board-certified gerontologist physicians and certified gerontology nurses. In the 1980s, her maiden project, a 90-room dilapidated beachfront hotel conversion, had a clinic created out of three hotel rooms that were taken off market to create a nurses’ station, minor lab bench, a small pharmacy, a supply room, and two small consultation/exam rooms for physician visits and minor procedures. Another area designated specifically for medical tourism patients took an additional 18 hotel rooms and converted that wing to 14 private rooms, a private, post-operative spa cafe, massage therapy rooms, solarium, and library. The nurses station was co-located in the center between the two senior living and medical tourism respite care areas. The full-service hospital was a 15-minute drive from the resort. Patients were transported back and forth from the hospital by private limousine.

After thirty years of experience, if space and capital were available, she says she would augment the primary care center with visiting specialist consultation rotations in cardiology, neurology, orthopedics, urology, pulmonology, interventional radiologists, dermatology, podiatry, cosmetic surgery, and regenerative medicine, among others. The ideal setting would be no more than 5km from the NICHE-designated hospital or health center, and without transportation obstacles such as drawbridges or railroad crossings en route.

Within such a citadel would be included, an integrated outpatient dialysis center that could provide hemodialysis and peritoneal dialysis, and an ambulatory (outpatient) surgical center (ASC) and a small laboratory setup to perform, among other procedures, the following related services:

• Fistulagrams
• Peripheral Artery Angioplasty
• Peripheral Artery Stenting
• Fistula Maturation Procedures
• Thrombolysis
• Thrombectomy
• Central Venous Access for Temporary Use
• Vessel Mapping
• Ultrasound imaging
• Tunneled Catheter Placement for Hemodialysis
• Treatment of erectile dysfunction
• Angioplasty
• Athrectomy
• Limb salvage microsurgery procedures
• Hyperbaric oxygen chamber (for wound healing)
• Minimally-invasive medical ablation (laser or radiofrequency) procedures for varicose veins that cause pain or for those that are cosmetically unappealing
• Endovenous Ablation Treatment
• Sclerotherapy
• Ambulatory Phlebectomy
• Non-surgical vertebroplasty
• Tarsal tunnel nerve decompression surgery for peripheral neuropathy
• Stem cell and plasma-rich platelet harvesting via liposuction
• Limited blood and urine lab testing, wound cultures, and adipose-derived stem-cell processing

Overall, for-profit providers operate 85% of all U.S. dialysis facilities and treat 89% of dialysis patients, and the charges are often in the range of $4500 USD per session. Payments are highly discounted by Medicare, Medicaid and contracted commercial insurers,  Hospitals operate 9% of dialysis facilities but treat only 7% of patients. But when a senior travels abroad, Medicare, Medicaid and many U.S. commercial insurers do not cover services rendered outside the USA.

2013 research indicates that dialysis centers can be developed abroad for about $50,000 USD per seat with as many as three seat turnovers per work day. Each patient generally requires three treatment sessions per week. Average international dialysis medical tourism revenue is about $400 USD per session.  The fee-for-service revenue potential is tremendous.

But senior medical tourism patients who need dialysis require special needs accommodation, special diets, frequent lab testing, and are often in a weakened state. They would benefit from a relaxing, bucolic resort setting in a warm climate with an integrated golf cart transportation system to get around the citadel community.

Dialysis, Ambulatory Surgery and more

To complement the senior medical tourism living accommodations, a mixed-use, sustainable, smart-city, or new urbanism development that includes boutique retail shopping, juice, mineral water, and refreshment stands, coffee bars, small convenience grocery, pet care and boarding services, pharmacy, hair and nail salon and barbershop, spa, and thermalism treatments. A gymnasium equipped with cardiovascular, neurological and respiratory therapy rehabilitation equipment can serve as a recreational and therapeutic rehabilitation center. A warm-water therapy pool could be used for both recreational swimming as well as aquatic therapy activities. A great room with mirrored walls can double as an exercise classroom, a yoga room, and gait and balance training center. A game room with free-flowing coffee and tea with areas to play cards, billiards, ping pong, backgammon and other board games. A community garden with irrigation and a potting shed can be developed on a small space on the grounds, to grow fruits, vegetables and flowers. Throughout the senior medical tourism citadel community, small parks would accommodate park benches, picnic areas, a small playground for visiting grandchildren, dog walking and relief areas, bicycle trails, shallow depth water features, rock gardens and waterfalls. A centrally-located great hall could include banquet/meeting rooms, small rooms that convert to large room with dance floor, catering kitchen, a small conference room, and a reception hall. An amphitheater and bocci park could also be integrated at a very low cost.

A Master Development Mixed-Use, Senior Medical Tourism Citdel

Investors for each of these concessions can be approached to do the vertical development while a master developer provides the real-estate project and vendor management. Selling or long-term lease arrangements will both work. A hybrid senior healthcare management and housing or hotel management background is beneficial at managerial levels and project management levels. A management services entity would be required to manage all maintenance of roadway lights, street sweeping, common area landscaping, street trees and turf, alleys, public parks and trails, and aquatic weed control. It would also oversee maintenance of any manmade water features, ponds, lakes, stormwater retention areas and drainage system in the citadel and some coordinate with local services for things such as mosquito control. A second management unit might assume responsibility for commercial and mixed land uses and water distribution services.

Target Market Options

To attract value conscious senior medical tourism guests who wish to live there seasonally, Todd says she would rent serviced apartment accommodations within the citadel with all-inclusive packages available, depending on the medical needs of the client and length of stay. The basic package would include access to all general services and amenities, such as:

• Transportation to and from the airport
• Serviced-apartment (1-, 2-bedroom and studio options)
• Basic weekly housekeeping services
• Maintenance and utilities, except telephone
• Weekly flat linen service
• Laundry facilities
• Expanded basic cable television
• Library and computer area
• Internet service accessible throughout the community
• 4G cellular service towers on site, with local rechargeable SIM card for use with guests’ unlocked cell phone
• Access to all outdoor courtyards, parks and public recreation areas
• Ambulance service to the nearest hospital or medical evacuation airport
• Roving security and maintenance services
• An initial checkup and medical records review by a physician on arrival
• Periodic primary care physician office visits, electrocardiograms, and basic laboratory testing (monthly)
• Nurse visits and blood pressure checks at no cost
• Grocery and pharmacy delivery service
• Access to the pools, thermal waters, exercise classes, gymnasium
• Golf cart transport circuit around the resort
• A monthly food and beverage allowance for coffee shop and refreshment stand expenses and 2 group meals per day in the citadel dining hall
• Free use of bicycles
• Educational Seminars & Classes
• 24-Hour Emergency Paramedic and Security Services
• General Apartment Maintenance
• Scheduled Transportation
• Social Services
• Support Groups
• Trash Pick-Up
• 24-hour Public Safety Patrol
• Wellness Programs
• Worship & Chaplain Services
• Chapel & Prayer Room
• Year-Round Landscaping & Groundskeeping
• Arts/Crafts Studio
• Beauty Salons
• Billiards Rooms
• Bocci court
• Clubhouses
• Community Garden
• Computer Center/Classes
• Private Fishing Lake
• General Store, Gift Shops
• Guest Rooms for visiting family overnight guests
• Physician’s Clinic* ( a separate charge applies for most services)
• Lending Library
• Meeting & Banquet Rooms
• Nature Trails & Park
• Executive 9-hole Golf Course
• Shuffleboard Courts
• State-of-the-Art Fitness Center
• Sweete Shoppe Ice Cream Counter
• Swimming Pools & Whirlpool
• Restaurants
• Entertainment Pavilion
• Woodworking Shop

Todd adds that “Senior medical tourism guests with medical conditions requiring dialysis would benefit from add-on packages that include dialysis services, routine laboratory testing, medication management, and insurance authorization, billing and all claims-related paperwork handling, as applicable.”

“All other medical and retail services would be available on an a la carte basis, as required.  The insurance processing services would require specialized training for specialists to be competent to manage this process for all healthcare revenue cycle services dependent on third-party reimbursement,” Todd continued.

While an article such as this can only cover the tip of the iceberg in potential medical tourism development options, significant planning, place making and citadel development is possible if the land and any existing hotel accommodation is present. For a hospital development project, a senior medical tourism hospital project might include

• A three- to five-story, 200,000 square-foot building that can house 70 private patient rooms and an intensive care unit (ICU) that could include 10-14 intensive care private rooms. Rooms could be designed to accommodate patient companions, or patient companions could be housed nearby at the citadel community.
• Space for diagnostic, surgical and rehabilitation services departments
• Teaching space to train future health care professionals and managers in gerontological specialties with an auditorium and education and conference rooms.

Depending on the proximity to the Citadel, if the auditorium, education and conference facilities are included present at the Citadel, this redundancy could be eliminated. These courses, seminars and workshops could provide ancillary revenue to the project, and also serve as inservice training residencies and experiential learning labs for students of senior health tourism management courses offered through a nearby university or extension program.