Post-COVID-19 Recovery Care: The Need for the Interprofessional Approach
COVID IN FOCUS: PERSPECTIVES ON THE LITERATURE
This CHEST series highlights specific studies in the COVID-19 literature that may warrant discourse or reading for members of the chest medicine community. Articles are written by members of CHEST Networks. You can read additional articles in this series.
NOTE: The perspectives shared in this article are those of the author(s) and not those of CHEST.
Post-COVID-19 Recovery Care: The Need for the Interprofessional Approach
By: Mary Jo S. Farmer, MD, PhD, FCCP, and Munish Luthra, MD, FCCP
Interprofessional Team Network
Published: April 22, 2021
A multidisciplinary, interprofessional approach to address the long-term pulmonary and nonpulmonary sequelae of patients who survive COVID-19 is being implemented in many post-COVID-19 ambulatory programs. Given that the long-term outcomes for survivors of COVID-19 remain to be determined, outcome predictions are based on emerging data in these survivors, complications in survivors of the 2003 severe acute respiratory syndrome (SARS) and 2012 Middle East respiratory syndrome (MERS) coronavirus outbreaks, and survivors of post-acute respiratory distress syndrome. A recent single-center study of 143 patients recovering from COVID-19 found that 44% of patients reported decreased quality of life and 87% reported persistent symptoms, including dyspnea, chest pain, cough, fatigue, and joint pain.1
Symptoms in Survivors of COVID-19
Post-COVID-19 symptoms cover a broad spectrum of sequelae, including neuropsychiatric (neurocognitive decline, mood changes, sensory and motor deficits, chronic fatigue and sleep disruption), respiratory (persistent dyspnea, chronic cough), cardiovascular (chest pain, palpitations), hematologic/vascular (persistent or recurrent thrombosis), renal (chronic kidney disease), gastrointestinal/hepatobiliary (persistent liver dysfunction), musculoskeletal (muscle wasting, weakness, deconditioning), and dermatologic (hair loss).
The spectrum of persistent respiratory dysfunction in survivors of COVID-19 reported to date includes fibrotic lung disease, airway disease such as chronic bronchitis, bronchiectasis, and extensive microthrombi increasing the risk for chronic thromboembolic pulmonary hypertension. In addition, the impact on functional capacity and health-related quality of life must be considered.
Potential Programs to Support Survivors
Several hospitals have implemented interprofessional care models to help survivors of COVID-19. Table 1 summarizes the key features of three such programs.
The RECOVERY (CompREhensive Post-COVID CentER at Yale) multidisciplinary program employs telehealth visits followed by an in-clinic comprehensive evaluation for COVID-19 survivors. Since most patients describe persistent dyspnea and exercise limitations regardless of disease severity, the standard initial diagnostic evaluation includes comprehensive pulmonary symptom assessment, pulmonary function testing, a 6-minute walk test, functional assessment by a physical therapist, and repeat chest x-ray or high-resolution computed tomography. Cardiology, neurology, psychiatry, hematology, otolaryngology, and sleep medicine specialists are called to collaborate as needed.2
O’Brien et al3 describe a multidisciplinary COVID-19 recovery service for comprehensive follow-up of patients with COVID-19 pneumonia in Ireland. A team consisting of respiratory, critical care, infectious diseases, psychiatry, and psychology services supported a hybrid model of virtual and in-person clinics for patients with significant physical, psychological, and cognitive impairments associated with COVID-19 pneumonia.
The Johns Hopkins Post-Acute COVID-19 Team (JH PACT) is a multidisciplinary collaborative ambulatory framework supporting COVID-19 survivors. Patients with COVID-19 who require 48 hours or more in the ICU could be referred to the JH PACT ICU for evaluation by physical medicine and rehabilitation and pulmonary services. Patients who did not require ICU care for at least 48 hours or patients who remained ambulatory with identified residual symptoms at 4-6 weeks postdiagnosis were referred to JH PACT-Base. This included a homecare remote monitoring program team with telemedicine, ambulatory pulse oximetry monitoring capability, and potential for home nursing, pharmacy, speech-language, and physical therapy/occupational therapy services. JH PACT referred survivors of COVID-19 to key subspecialties as needed to provide appropriate and timely interprofessional care.4
The COVID-19 pandemic presents an unprecedented challenge to the health care community. It is now equally important to develop sustainable programs to provide care to survivors of COVID-19 as it is to manage patients with acute COVID-19 infection and limit transmission. Multipronged, interprofessional, collaborative recovery care programs are urgently required to identify and address the unique needs of survivors and adapt to the shifting logistical landscape of the ongoing pandemic.
Table 1: Comparison of Post-COVID-19 Interprofessional Care Models
| |
RECOVERY: Comprehensive Post-COVID Center at Yale2 |
RCSI COVID Recovery Service3 |
Johns Hopkins Post-Acute COVID-19 clinic4 |
| Trigger for referral |
Inpatient predischarge (ambulatory oximetry, PT & OT evaluation, arrange home services)
Outpatient
(self, any provider, COVID hotline) |
COVID-19 pneumonia – treated in hospital or community |
ICU care for at least 48 hours → JH PACT ICU
Hospitalization but no hospital stay → JH PM&R PACT-Base |
| Initial assessment |
Visit 1 – Telehealth: Pulmonary consult, symptom assessment, extrapulmonary complications assessment |
Virtual 8-12 weeks after discharge |
JH PACT ICU: Offer PM&R and pulmonary consult
JH PM&R PACT-Base with home PT/OT, if needed |
| Personnel |
Multidisciplinary team (MDT) discussion of active cases |
PA with physician support
MDT support |
MDT: Physician and nonphysician providers, case managers, RNs, and community health workers |
| Recovered, no clinical concerns |
Transition to primary care |
Integrated care in community (primary care, psychology, physiotherapy) |
Primary care |
| Clinical concern |
Visit 2 – Face-to-face: Pulmonary care, neurocognitive screening, mental health screening, subspecialty involvement, if needed |
In-person clinic 12 weeks after discharge |
PM&R PACT-Base referral and homecare, if indicated |
| Significant functional impairment |
- MD visits planned at 3, 6, & 12 months or as needed
- PT/OT outpatient care
- Pulmonary rehab
- PFT, V/Q, or CTA chest
- Cardiac event monitoring, echo, functional cardiac imaging
- Neurocognitive testing
|
COVID survivorship clinic at 6 & 12 weeks
(multidisciplinary providers)
Multidisciplinary post-COVID mental health service |
|
| Abnormal CXR or physiology (PFT) |
- Nonspecific: Continue with RECOVERY
- Specific phenotype: Appropriate advanced lung disease program (eg, airways, ILD, PVD)
|
Respiratory specialty clinic |
Pulmonary PACT-Base referral and RPM (homecare; RNs), if needed |
RCSI = Royal College of Surgeons in Ireland; PM&R = Physical Medicine & Rehabilitation; PT = Physical Therapy; OT = Occupational Therapy; PA = Physician Assistant; RN = Registered Nurse; PFT = Pulmonary Function Test; V/Q scan = Ventilation/Perfusion scan; RPM = Remote Patient Monitoring; ILD = Interstitial Lung Disease; PVD = Pulmonary Vascular Disease
References
- Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-605.
- Lutchmansingh DD, Knauert MP, Antin-Ozerkis DE, et al. A clinic blueprint for post-coronavirus disease 2019 RECOVERY: Learning from the past, looking to the future. Chest. 2021;159(3):949-958.
- O'Brien H, Tracey MJ, Ottewill C, et al. An integrated multidisciplinary model of COVID-19 recovery care. Ir J Med Sci. 2021;190:461-468.
- Brigham E, O'Toole J, Kim SY, et al. The Johns Hopkins Post-Acute COVID-19 Team (PACT): A multidisciplinary, collaborative, ambulatory framework supporting COVID-19 survivors. Am J Med. 2021;134(4):P462-P467.E1.
Mary Jo S. Farmer, MD, PhD, FCCP
Mary Jo S. Farmer, MD, PhD, FCCP, practices pulmonary, critical care, and sleep medicine at Baystate Medical Center in Springfield, MA, where she serves as the Director of Pulmonary Hypertension Services. Her other clinical interests include bronchoscopy and endobronchial ultrasound. Dr. Farmer is involved in medical student, resident, and fellow education, as well as noninvasive ventilation interprofessional education and research, and serves as Assistant Professor of Medicine, University of Massachusetts Medical School - Baystate. She is a steering committee member of the CHEST Interprofessional Team Network and Clinical Pulmonary Medicine Network and serves on the editorial board of CHEST Physician®.
Munish Luthra, MD, FCCP
Munish Luthra, MD, FCCP, serves as Assistant Professor of Medicine and practices pulmonary and critical care medicine at Emory University School of Medicine in Atlanta. His clinical interests include managing patients with complications of lung cancer and immunocompromised critically ill patients in the MICU. He runs a Cancer Complications Clinic at Emory. He is also a passionate medical educator, and his areas of interest include simulation-based teaching and interprofessional education. He currently serves as Vice Chair of the CHEST Interprofessional Team Network, steering committee member of the Clinical Pulmonary Medicine Network, and member of the Thoracic Oncology Pilot Key Opinion Leader Workgroup and Educator Development Subcommittee.
Read more COVID in Focus: Perspectives on the Literature:
Aerosolization Risks of Noninvasive Ventilation in the Era of COVID-19
Aerosol Generation Risk of Chest Physiotherapy and Airway Clearance Techniques in Patients With COVID-19
Asthma and COVID-19
Timing of Intubation in Patients With COVID-19