Models of Care for Postacute COVID-19 Clinics: Experiences and a Practical Framework for Outpatient Physiatry Settings.

ABSTRACT: After surviving infection with the SARS-CoV-2 virus, individuals may have persistent symptoms and prolonged impairments that may last for weeks to months. The frequency and heterogeneity of persistent post-COVID conditions have created challenges in care. Specialty clinics are being established in response to an increasing need to care for patients with postacute sequelae of SARS-CoV-2 or long COVID syndrome. Although many post-COVID conditions can be bettered through a comprehensive rehabilitation plan, various clinical settings may benefit from differing models of coordinated care. We present five models of care in varying degrees of development and compare processes and adaptations to address the unique needs of each center and their unique patient populations. Forging a path to recovery will necessitate a multidisciplinary team with physiatry involvement to meet the distinctive needs of patients with postacute sequelae of SARS-CoV-2. Furthermore, it is imperative that there be equitable access to this care and commitment from healthcare institutions to provide resources for these programs.

Adaptations for rehabilitation services during the COVID-19 pandemic proposed by scientific organizations and rehabilitation professionals.

OBJECTIVE: To describe adaptations in the provision of rehabilitation services proposed by scientific and professional rehabilitation organizations to avoid interruptions to patients rehabilitation process and delays in starting rehabilitation in patients with COVID-19. METHODS: A narrative review approach was used to identify the recommendations of scientific and professional organizations in the area of rehabilitation. A systematic search was performed in the main data-bases in 78 international and regional web portals of rehabilitation organizations. A total of 21 publications from these organizations were identified and selected. RESULTS: The results are presented in 4 categories: adequacy of inpatient services, including acute care services and intensive care unit for patients with and without COVID-19; adequacy of outpatient services, including home-based rehabilitation and tele-rehabilitation; recommendations to prevent the spread of COVID-19; and regulatory standards and positions during the COVID-19 pandemic expressed by organizations for protecting the rights of health workers and patients. CONCLUSION: Health systems around the world are rapidly learning from actions aimed at the reorganization of rehabilitation services for patients who are in the process of recovery from acute or chronic conditions, and the rapid response to the rehabilitation of survivors of COVID-19, as well as from efforts in the prevention of contagion of those providing the services.

Beneficial effects of multi-disciplinary rehabilitation in postacute COVID-19: an observational cohort study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic increases the demand for postacute care in patients after a severe disease course. Various long-term sequelae are expected and rehabilitation medicine is challenged to support physical and cognitive recovery. AIM: We aimed to explore the dysfunctions and outcome of COVID-19 survivors after early postacute rehabilitation. DESIGN: Observational cohort study. METHODS: This study evaluated the postacute sequelae of patients hospitalized for SARS-CoV-2 infection and analyzed rehabilitative outcomes of a subgroup of patients included in the prospective observational multicenter CovILD study. RESULTS: A total of 23 subjects discharged after severe to critical COVID-19 infection underwent an individualized, multiprofessional rehabilitation. At the start of postacute rehabilitation, impairment of pulmonary function (87%), symptoms related to postintensive care syndrome, and neuropsychological dysfunction (85%) were frequently found, whereas cardiac function appeared to be largely unaffected. Of interest, multi-disciplinary rehabilitation resulted in a significant improvement in lung function, as reflected by an increase of forced vital capacity (P=0.007) and forced expiratory volume in one second (P=0.014), total lung capacity (P=0.003), and diffusion capacity for carbon monoxide (P=0.002). Accordingly, physical performance status significantly improved as reflected by a mean increase of six-minute walking distance by 176 (SD±137) meters. Contrarily, a considerable proportion of patients still had limited diffusion capacity (83%) or neurological symptoms including peripheral neuropathy at the end of rehabilitation. CONCLUSIONS: Individuals discharged after a severe course of COVID-19 frequently present with persisting physical and cognitive dysfunctions after hospital discharge. Those patients significantly benefit from multi-disciplinary inpatient rehabilitation. CLINICAL REHABILITATION IMPACT: Our data demonstrated the highly promising effects of early postacute rehabilitation in survivors of severe or critical COVID-19. This findings urge further prospective evaluations and may impact future treatment and rehabilitation strategies.

Distinct phenotypes in COVID-19 may require distinct pulmonary rehabilitation strategies.

The novel coronavirus (SARS-CoV-2) has distinct clinical manifestations that can vary from an asymptomatic condition to severe acute respiratory failure. Phenotypes are attributable to different pathophysiological mechanisms and require different treatment strategies. The assessment and identification of different phenotypes can guide therapy configurations such as oxygen therapy, non-invasive ventilation, airway management, and tracheal intubation. Further studies are essential to provide information on the influence of phenotypes in the decision of rehabilitation strategies. The sequelae left in the respiratory system of COVID-19 survivors and its limitations will be a challenge for rehabilitation services worldwide. Lung injuries are directly related to the phenotypes presented, and depending on the degree of these injuries, rehabilitation strategies can be targeted. We believe that differentiating patients, according to their respective phenotypes, can improve decision-making in treatment and individualized rehabilitation.

Effect of the COVID-19 Pandemic on Postacute Care Decision Making.

The response to the coronavirus disease 2019 (COVID-19) pandemic in the United States has resulted in rapid modifications in the delivery of health care. Key among them has been surge preparation to increase both acute care hospital availability and staffing while using state and federal waivers to provide appropriate and efficient delivery of care. As a large health system in New York City, the epicenter of the pandemic in the United States, we were faced with these challenges early on, including the need to rapidly transition patients from acute care beds to provide bed capacity for the acute care hospitals. Rehabilitation medicine has always played an essential role in the continuum of care, establishing functional goals while identifying patients for postacute care planning. During this crisis, this expertise and the overwhelming need to adapt and facilitate patient transitions resulted in a collaborative process to efficiently assess patients for postacute care needs. We worked closely with our skilled nursing facility, home care partners, and an acute inpatient rehabilitation hospital to adapt their admissions processes to the patient population with COVID-19, all the while grappling with varying access to vital supplies, testing, and manpower. As the patient criteria were established, rapid pathways were created to postacute care, and we were able to create much needed bed capacity in our acute care hospitals.

Telemedicine for pediatric physiatry: How social distancing can bring physicians and families closer together.

The coronavirus (COVID-19) pandemic triggered wide scale implementation of telemedicine in the United States. The government response, Coronavirus Aid, Relief, and Economic Security (CARES) Act, permitted loosening of existing restrictions on telemedicine enabling its rapid incorporation into the delivery of medical care for children and adults. Prior to COVID-19, few pediatric physiatrists had opportunities to access high fidelity telemedicine platforms to provide health care for patients with special needs, mobility impairments, developmental delays, neuromuscular disorders or other complex medical conditions. This literature review will explore how telemedicine can optimize health care delivery options for pediatric physiatrists in various inpatient and outpatient settings such as consultations, acute inpatient units, outpatient clinics and long-term care facilities. Detailed analysis of the current research in telemedicine applications as well as a critical review of the limitations and barriers for its use offers a plethora of opportunities for enhancement of continuity and coordination of care. Telemedicine may decrease healthcare disparities and increase access of care for children with special needs. Additional research is needed to assess the efficacy of telemedicine when addressing complex medical conditions in children.

Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19.

This analysis extrapolates information from previous studies and experiences to bring physical medicine and rehabilitation perspective and intervention to the multidisciplinary treatment of COVID-19. The purpose of pulmonary rehabilitation in COVID-19 patients is to improve symptoms of dyspnea, relieve anxiety, reduce complications, minimize disability, preserve function, and improve quality of life. Pulmonary rehabilitation during the acute management of COVID-19 should be considered when possible and safe and may include nutrition, airway, posture, clearance technique, oxygen supplementation, breathing exercises, stretching, manual therapy, and physical activity. Given the possibility of long-term disability, outpatient posthospitalization pulmonary rehabilitation may be considered in all patients hospitalized with COVID-19.

African American Patient Disparities in COVID-19 Outcomes: A Call to Action for Physiatrists to Provide Rehabilitation Care to Black Survivors.

SARS-CoV-2 is a novel and highly contagious coronavirus that has been a major threat to the public's health. As the pandemic has spread across the United States, it has become abundantly clear that vulnerable populations include not only the elderly and individuals with disabilities but also those who are homeless or incarcerated, Latinx Americans, African Americans, and Native Americans. This report is focused on the experience of Black patients, inclusive of African Americans, and recognizes the higher morbidity and mortality in this population. Physiatrists can provide care for the sequelae faced by survivors and prioritize rehabilitation services. Programs must be administered in a way that is geographically accessible to Black communities and demonstrate cultural competence. Future research should focus on the social determinants of health to better understand at-risk populations and improve outcomes.

Role of Rehabilitation Department for Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of Milan.

The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 (COVID-19). The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients' needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.