Effective Long COVID Assessment and Rehabilitation Pathway

Long COVID-19 Assessment & Rehabilitation Pathway July 2021 Dr Harsha Master GP Lead Covid Rehab

Introduction A significant number of patients started to present with complications post COVID-19, which were observed whether they had been admitted to hospital or remained in the community with a milder illness This lead to the development of a new COVID-19 rehabilitation pathway with an integrated approach A COVID rehabilitation register was developed to identify and map these patients, in order to track patient numbers and outcomes across HCT A task and finish group was started in order to start discussions on how we wanted our pathway to work and to start the co-design

The Team The core team includes Occupational Therapists, Physiotherapists, Speech & Language Therapists, Dietitians, Pulmonary Rehab, Chronic Fatigue, Mental health, Clinical Psychology and a GP We also work closely with colleagues in the acute hospitals, social care, IAPT and the voluntary sector The aim was to provide coordinated, holistic care involving both medical assessment and rehabilitation

Initial Pathway Community Offer Our pathway is lead jointly lead by AHP and GP in partnership. All referrals are triaged by a COVID-19 Rehab Coordinator, who organises onwards referrals of patients across the system Using Yorkshire Screening questionnaire (C19-YRS) for all patients and this must be completed by the patient before triage Patients must have been seen by their own GP had an assessment and appropriate investigations if warranted and acute pathology ruled out

The developed offer Long COVID chronic symptoms (12 weeks+) Complex prolonged stay hospital discharges + community referrals Real MDT approach and specialised in house team allowing coordinated integrated care Group therapy sessions by CFS and PR We have commissioned a clinical psychologist to help support post ITU or admitted patients with trauma/PTDS, who support patients who require OOH rehab through Dh2A and ESD therapy pathways We have access to a specialist OT resource to support cognition and memory difficulties post COVID-19 , plus return to work

The service offer The COVID-19 GP can refer on for further investigations, including for urgent CTPA and to secondary care if needed Integrated care with Respiratory COVID Recovery Clinic and Critical Care Recovery Clinic Development of improved communication and pathways with colleagues in Secondary Care in order to discuss complex patients, share care and facilitate timely access to specialised review. Research GP fellow involvement

Covid Rehab Pathway Criteria for referral: Adults aged over 18 Registered with an East and North Herts GP Confirmed Covid or symptoms highly suggestive of Covid NOTE - A negative swab or antibody test does not exclude Covid

MDT Weekly team meetings, virtual patient centred approach All community teams represented - including Occupational Therapists, Physiotherapists, Pulmonary Rehab, Chronic Fatigue, Speech and Language Therapists, Dietitians, Mental health, Clinical Psychologist, Covid Rehab GP & Rehab Coordinator Complex cases with multiple overlapping symptoms Clinical decision making, learning experience and reflective practice with reflective quality improvement approach Discuss service improvement and patient care

Hertfordshire COVID-19 Rehabilitation Pathway: Findings/Data to date Data from Feb 2021

Referrals Received for COVID-19 Rehab Co-ordination Service 140 120 111 120 85.1% 90 100 White 81 81 80 58 54 BAME 46 46 46 60 41 40 Not specified 6 20 0 10.0% 4.9% Ethnicity Referral Source General Practitioner 90.8% HCT Community Service 3.8% Gender Acute Hospital Inpatients 3.3% Male 34% Female 66% Acute Hospital Outpatients 1.0% Self-referral 0.7% Early Intervention Vehicle 0.3% Mental Health 0.2%

What is Long Covid? Covid-19 is possibly an endothelial disease of blood vessels and seems to be associated with a hypercoagulable state Multi system disorder affects lungs, heart, brain Thought to be due to an exaggerated immune response and autonomic dysregulation caused by acute infection

Key caseload facts Non-hospital attenders suffering more with Long Haul symptoms No significant past medical problems previously & high level fitness Many NHS and frontline workers affected more severely Presentation with multiple complex symptoms Relapsing and remitting pattern and symptoms tend to echo initial illness Poor sleep, mild stress or over- exertion can trigger relapse Main symptoms Shortness of breath, fatigue, chest tightness/ tachycardia, cognitive problems, anxiety and headaches Since second wave more GI issues, dysphonia, & hoarseness as well as persisting altered taste and smell

Key findings Oxygen desaturation on exertion. PE exclusion needed Medical work up vital. Rule out red flags & other causes Dysfunctional breathing Autonomic dysfunction tachycardia/POTS/temps Post Viral Fatigue most common reason people not been able to return to work. Linked to a brain fog presentation where patients are describing a fatigue related cognitive impairment ENT/SALT Hoarseness of voice/dysphonia/sore throat Mast Cell Activation Syndrome- new onset rashes, food intolerances, gut disturbance, allergies Unclear how Long Covid presents in the older population

Treatment options being tried in Long Covid Clinics but not evidence based Focus management on treatable symptoms Suspected MCAS - antihistamines Myocarditis/Pericarditis- Colchicine Tachycardia- Beta Blockers/Ivabradine Poor sleep- Amitriptyline / Magnesium 500-1000mg / Melatonin SR 2-4mg at night Gut health probiotics- Symprove/ PPI Pain- analgesia/steroids

Management Combination of medical assessment & rehab working best Lifestyle advice REST, sleep hygiene, healthy diet Slow stream rehab approach Breathing techniques and re-training Pulmonary Rehab SLOW approach to exercise Meditation, yoga, mindfulness, acupuncture Pacing (avoid relapses/boom-bust cycle) Chronic fatigue Service

Chronic Fatigue Team Treatment Group delivery planned early 2021 ACTIVITY BEHAVIO URS Flare Ups Pacing, Activity Management & SENSITIVI TY CHANGES Understanding Persistent Pain / CFS Sleep Advice SLEEP SELF- CHRONIC PAIN Tool Box Management Slow exercise & Posture / Body Mechanics PHYSICAL DECONDIT IONING Addressing unhelpful thoughts and feelings STRESS/ EMOTION Stress RELATION SHIPS / SOCIAL Management/ THOUGHT S Mindfulness Meditation/ Relaxation Communication

Management Supporting psychological wellbeing-signposting & referring to IAPT Taste & smell training Vocational rehab return to work consultancy and advice Employment support Consider signposting to: - www.yourcovidrecovery.nhs.uk - www.hct.nhs.uk

Work in progress Streamlining patients into tiers as per NHSE guidance Secondary care MDT and the development of a face to face and one stop MDT clinic to allow more integrated care between primary, secondary and community care Ongoing networking with other services e.g. Children's services as needs identified PCN/GP engagement and pathway guidance review Social prescriber to join MDT Screening/triage tool and Outcome measures Research Collecting the community data Your COVID Recovery Stage 2 and digital technology development virtual therapy and website platform Vocational rehab & return to work Discharges and waiting lists Working with Voluntary Sector