This document outlines a model of care to guide acute care clinicians in planning for and delivering care to patients with COVID-19 in the post-acute phase.
Operationalisation of this model at the local level will vary depending on location and demographics, leadership, governance, resources and local policies.
Adult patients aged 16 years and older who have tested positive to COVID-19 may be managed in the acute inpatient environment or in the community.
Assessment and planning for post-acute management should commence while a patient is still being treated in the acute environment. It is crucial that management of these patients occurs in the most appropriate environment to support their recovery.
1 This improves patient outcomes and patient experience; ensures appropriate length of stay; and supports patient flow from the acute inpatient environment.
The team responsible for the care of a person with COVID-19 in the acute care environment should be multi-specialty and multidisciplinary. Teams and service models should include medical, nursing and allied health staff, but will vary according to the acuity of the patient, presenting symptoms, local resourcing, geographic location and service models.
The goal is for safe and appropriate discharge of the patient and transition of care to the primary care provider, with specialist follow-up, as required.
[back to top]
The post-acute phase of COVID-19 commences once a patient is:
This should be informed by the clinical judgement of the senior clinician treating the patient. The immediate post-acute phase of COVID-19 continues for approximately three months from diagnosis, but this may vary for patients with a prolonged length of stay in the acute care environment.
COVID-19 is an acute illness with an undefined length of recovery.
2 A patient who continues to have ongoing symptoms after three months is considered to meet the definition of long-COVID.
Long-COVID is defined as signs and symptoms that develop during, or after, an infection consistent with COVID-19; continue for more than 12 weeks; and are not explained by an alternative diagnosis.
The scope of this model of care is limited to the immediate post-acute phase of COVID-19. Further work is planned to provide guidance for the management of patients with long-COVID.
[back to top]
This document outlines a model of care to guide acute clinicians in planning for, and delivering, care to patients in the post-acute period. The aim is to improve patient outcomes and patient flow from the acute environment.
This model of care should be read in conjunction with the following state and national documents addressing clinical care of people with COVID-19 and virtual care:
Use of this guideline and other policy documents will be underpinned by local factors, such as location and demographics; and service factors, such as leadership, governance, resources and policies/procedures.
This model of care is based on current evidence which includes reference to models of post-acute care in other jurisdictions. The evidence check from the NSW Health
COVID-19 Critical Intelligence Unit, Post-acute andsub-acute COVID-19 care, provided the basis for development of this model of care.5
It is supported by expert clinical consensus of a multi- specialty, multidisciplinary group and was developed in consultation with representatives from the COVID-19 Communities of Practice (intensive care, respiratory, rehabilitation, primary care, community health, COVID care in the home and palliative care), allied health representatives and the Ministry of Health Chief Allied Health Officer and Integrated Care team.
The scope of this model of care is to support adult patients with signs and symptoms of post-acute COVID-19, which may be experienced in the first three months (approx.) from diagnosis, regardless of severity of disease.
Note: May also include central nervous system or gastrointestinal thromboembolic disease.
Note: fatigue and sleep disturbance may also indicate the emergence of a mental health condition.
National COVID-19 Clinical Evidence Taskforce. Care of People with Post-Acute COVID-19.6
[back to top]
Providing care for patients with COVID-19 as they move from critical and acute care environments back into the community is complex. A range of models are available to support this care.
The disease burden experienced by patients in the post-acute phase varies. It is considerable in some patients; particularly those who have experienced a prolonged stay in the ICU, and those who acquire complications and/or have underlying chronic illness. Functional status and biological parameters are affected, which requires increased monitoring and close follow-up in the post-acute phase.7
Patients should be managed with an emphasis on holistic support while avoiding over-investigation and over-treatment. Models of care encompass clinical assessment, investigations, managing comorbidities, improvement of functional status, medical- management, self-management, safety-netting and referral; and social, mental health and cultural support.8
The following key elements are recommended as the basis for this model of care.
The patient should receive the following assessments at each transition of care, including in preparation for discharge:
The treating team should assume responsibility for ensuring each of these assessments is completed and documented in the patient's medical record prior to transfer, along with the contact details of the patient's usual GP.
The rehabilitation referral checklist in Appendix 1 may be completed by nursing or allied health staff; provided these clinicians can trigger the appropriate referral to a rehabilitation physician or pulmonary rehabilitation team.
Tools that may be used for the purposes of patient assessment will depend on patient presentation and ongoing symptoms. The assessment tools included in this model of care are not intended to be prescriptive, nor are they an exhaustive list of all tools available.
COVID-19 is an acute illness with a recovery phase.2
For the purposes of this model of care, we refer to the definition of moderate to severe COVID-19 outlined in the
Australian Guidelines for the clinical care of people with COVID-19. Patients who have been treated in ICU and/or those who have required respiratory supports beyond standard oxygen therapy are included in the moderate to severe COVID-19 category.1
Those who have experienced significant functional deterioration due of COVID-19 may also fall into the moderate to severe category.
There are several vulnerable groups who are at high risk of deterioration post-discharge, including:
Patients who have experienced significant functional deterioration and/or any patient in these vulnerable groups should be allocated a post-acute care coordinator, regardless of the severity of disease – this includes those being treated in the community.
The care coordinator role has been established on a time-limited basis to support identified and emerging patient needs, and to assist with managing patient flow.
The care coordinator works across multidisciplinary and multi-specialty areas. They ensure the patient is regularly assessed along the patient journey with appropriate clinical handover of care to the primary care provider.
The care coordinator organises any necessary referrals, as required. The duration required for care coordination will vary between patients.
The clinician(s) allocated to the post-acute care coordinator role will vary between facilities and local health districts (LHDs), depending on local resources, the patient cohort and number of patients who require care coordination at any one time.
Where possible, LHDs should aim to use existing care coordinator type-roles; provided these clinicians have knowledge in the assessment and care of post-acute COVID-19 patients. The clinician should be experienced (i.e. it is suggested a Clinical Nurse Specialist or Allied Health Level 3 or above), depending on local resources.
Capacity of the care coordinator should be monitored to ensure a manageable patient load. Facilities with large numbers of patients will likely need several coordinators.
Virtual care may be appropriate for the purposes of care coordination, particularly in LHDs with small numbers of patients over a large geographic area or in districts with large numbers of patients.
Post-COVID care services have been successfully used in other jurisdictions (outside of NSW) for the purposes of follow-up, referral to specialists and provision of individual treatment plans.10
Prior to discharge, all patients with moderate to severe COVID-19 should be reviewed by the treating team with a full assessment of their clinical and functional status, as outlined in key element 1:
Clinical and functional status of a patient is assessed at each transition of care of a
patient is assessed at each transition of care.
Appropriate referrals should be initiated prior to discharge, as required. Upon discharge from the acute environment, patients are transferred to sub-acute and/or primary care; or to sub-acute care initially, then primary care for ongoing management.
Ideally, patients who have been treated in the ICU and those who have required respiratory supports beyond standard oxygen therapy should receive a follow-up at/after three months from diagnosis to assess ongoing (or new) symptoms. Patients flagged as needing specialist follow-up by their primary care provider or allocated post-acute care coordinator should also receive follow-up after three months.
To manage this locally, it is suggested a post-acute multidisciplinary clinic could be established to provide this service. This clinic could include respiratory, rehabilitation, infectious diseases and allied health clinicians, as locally appropriate. These clinics may be run virtually or via a case conferencing model, depending on local capacity and resources.
In addition to respiratory and rehabilitation assessments, a neurocognitive assessment is recommended as patients can experience post- COVID-19 'brain fog' as a result of critical illness.1
Psychological assessment is also recommended as some patients experience depression, anxiety or post-traumatic stress disorder (PTSD) post- hospitalisation; particularly post-ICU admission.11
At the three-month review, patients may receive the following assessments, including (but not limited to):
Other assessments may be required depending on ongoing symptoms.
There are a number of patients who have been found to have other infectious organisms during their acute admission; for example, tuberculosis, hepatitis B, strongyloides and carbapenamase-producing enterobacterales (CPE). These patients should be followed up by local infectious disease services post-discharge.
Results of the three-month follow-up visit, and any ongoing management plans/recommended referrals, should be immediately communicated to the patient's primary care provider. This may include referral to ambulatory multidisciplinary rehabilitation services and/or pulmonary rehabilitation.
At present, there are a significant number of patients being treated in the acute care environment outside their LHD of residence. The location of treatment for the immediate post-acute phase will depend on the patient's need; rehabilitation bed (where required); patient flow demand; and service and transport availability.
The relevant pathway for a patient will depend on patient-centred need, local capacity and capability. The pathways demonstrated below are not intended to be prescriptive but provide guidance for clinicians in establishing models of care delivery. These include discharge or transfer to:
In some cases, the patient may require management via a
combination of these pathways over the course of their recovery. This may be particularly relevant for those patients being discharged to a residential aged care facility or disability residential facility where access to primary care and allied health support may be limited.
The clinical aspects of the various pathways available to aide in clinician decision-making for transfer and discharge options are outlined in the diagram below.
Sub-acute COVID-19 wards may be established to assist with patient flow by providing suitable patients with a step-down from an acute COVID-19 ward.16
Patients suitable for transfer to a sub-acute COVID-19 ward may include the following:
For hospitals that have small numbers of COVID-19 patients, it may be appropriate for a district-wide sub- acute virtual support service to be established to care for patients from multiple facilities.
Inpatient rehabilitation, led by rehabilitation physicians, offers patients a thorough assessment and an individualised, progressive treatment plan which focuses on function, ability and return to participation in society.17 It is suitable for those recovering from COVID-19 with physical and psychosocial barriers to discharge; and those with multiple comorbidities that require coordination of medical and surgical services, such as neurology and respiratory, vascular and renal medicine.
For older patients, referral to specific inpatient geriatric 'slow-stream' rehabilitation may be appropriate.
Those with PICS and extra-pulmonary complications (such as significant deconditioning, mobility issues, cognitive impairment, pain and critical illness neuropathy) will likely require inpatient rehabilitation.18
Primary care plays a critical role in the ongoing management of post-acute COVID-19 patients. General practitioners (GPs) and their teams are in a unique position to collaborate closely with the patient to develop an individualised management plan to support their recovery.20
GPs can provide intervention and referral to specialists (if required) for patients experiencing post- acute COVID-19 symptoms. Several HealthPathways
have been developed by NSW primary health networks to support GP assessment and decision-making.
Depending on the region, these may include HealthPathways to assist with symptom management, rehabilitation referral, social and community supports and mental health referral and supports.
Ideally, the GP will be included in any community care arrangements to ensure the smooth transition of care once the need for other specialty teams has ceased.
Note: Those patients with ongoing respiratory symptoms, including those discharged on home oxygen, should be referred to respiratory medicine earlier than the three- month follow-up clinic, if required.
As listed above for 'Inpatient rehabilitation', ambulatory multidisciplinary rehabilitation can provide post-acute COVID-19 patient assessment, management and interventions designed to improve function and quality of life.
Ambulatory multidisciplinary rehabilitation, provided either face-to-face or via virtual care, may be appropriate for those who do not require high level nursing care; particularly those able to mobilise short distances independently; or for those who have a carer to assist them in the home.
Pulmonary rehabilitation (PR) for people recovering from COVID-19 provides supervised exercise training, breathlessness management, advice on pacing activities and managing fatigue, and support. Programs of six weeks have been shown to improve exercise capacity, health- related quality of life and cognition.21
PR may be delivered face-to-face or
virtually, depending on local resources.
Patients suitable for referral to pulmonary rehabilitation include:
Note: Some patients may require initial optimisation with general rehabilitation before progressing to pulmonary rehabilitation.
Multidisciplinary community care includes services and models to support the provision of care in the community to meet the clinical and social care needs of post-acute COVID patients once they are discharged from the acute care environment.
In partnership with GPs, allied health, specialist services, aged care providers, non-government organisations and social care providers, provide and support:
Integrated care involves the provision of seamless, effective and efficient care that reflects the whole of a person's health needs. This includes utilisation of involvement from the primary care provider as well as specialty/hospital-based teams.
Patients with chronic disease (e.g. chronic heart failure) may be known to their local integrated care service.
Patients who experience an exacerbation of their chronic disease due to their COVID-19 infection should continue to be managed by their usual service, with additional input sought from other medical specialties and allied health, as required.
Patients who are readmitted to hospital following discharge from their acute COVID-19 admission may benefit from referral to the local integrated care service.
There are small numbers of patients who have pre-existing non-reversible or progressive disease, either as a result or worsened by COVID-19 infection. Recovery may be uncertain with a high risk of deterioration towards death in the near future.
Examples include patients with advanced progressive metastatic cancer (despite treatment), or elderly patients with end-stage kidney or heart disease. In some instances, this may not be evident until three months post-discharge.22
Patients with advanced pre-existing conditions (e.g. the frail older person with multiple comorbidities) may become increasingly deconditioned as a result of COVID-19 infection. Advance care planning and clarifying goals of care is essential.
Patients may require:
There may also be people receiving acute care who reach limits of care and require optimisation of comfort and dignity. Referral to a palliative care service, based on the patient and family/carers needs, may be appropriate.
Patients who are recovering from COVID-19 should be referred for multidisciplinary rehabilitation assessment and management as early as possible; preferably in the ICU or acute ward environment. Early rehabilitation intervention has been shown to decrease patient length of stay and improve patient outcomes.23
Under this post-acute model of care, an assessment of patient clinical and functional status (including requirement for rehabilitation) should take place at every care transition.
The following checklist may be used for the purposes of assessing the need for rehabilitation medicine referral. This checklist can be completed by nursing or allied health staff; provided they can initiate referral to the appropriate team.
Depending on ongoing symptoms, some patients may require reconditioning and optimisation via general multidisciplinary rehabilitation prior to commencing pulmonary rehabilitation. Other patients may be suitable for direct referral to pulmonary rehabilitation.
* Where a patient has respiratory-only indicators present, ongoing management by the respiratory team should be maintained and the patient referred to pulmonary rehabilitation, where appropriate. Referral for general rehabilitation assessment and management may be sought by the team if indicated.
A patient should be referred to rehabilitation medicine for assessment and management if they have:
[back to top]
The Respiratory and Rehabilitation Communities of Practice
Collaboration: A subject matter expert group, comprised of the following individuals and COPs providedinput in the development of this document.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
Clinicians working with adults with COVID-19 transitioning from the acute care environment to the community
Feedback on this document can be provided to