针对长期 COVID 康复的联合医疗模式。

IF 6.7 2区 医学 Q1 MEDICINE, GENERAL & INTERNAL
Joanne M Wrench, Leigh R Seidel Marks
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With the emergence of milder acute illness, the model of care for long COVID in Australia has now moved to primary care, with general practitioners seen as the coordinators of ongoing services and interventions.<span><sup>14</sup></span></p><p>The heterogeneous nature of long COVID symptoms, coupled with no diagnostic tool or single treatment, means the functional burden of long COVID may best be addressed by symptom management approaches.<span><sup>15, 16</sup></span> In this regard, Australian and international guidelines recommend multidisciplinary and coordinated allied health care as a practice standard for people with long COVID,<span><sup>17, 18</sup></span> and there is emerging evidence of corresponding functional improvement.<span><sup>19, 20</sup></span> In line with these recommendations, the National Health Service in the United Kingdom encourages a three-tiered approach to care, with multidisciplinary interventions offered to people with the most severe symptoms requiring input from two or more professionals, stepping down to community therapy teams, and then self-management pathways for individuals with milder symptoms.<span><sup>21</sup></span> In Australia, access to publicly funded allied health intervention for long COVID remains challenging with no system-level coordinated care or funding.</p><p>In early 2022, Austin Health in Melbourne commenced ReCOVery: an allied health-led rehabilitation service aimed at providing multidisciplinary management for long COVID symptoms based on international evidence and guidelines translated into the Australian context.<span><sup>17, 18</sup></span> The key principles in the design of the service were (i) a stepped care model, with access to a multidisciplinary team for individuals with the most severe symptoms, and a self-management pathway for those with less severe symptoms; (ii) symptom management, improved function and participation via coordinated goal-driven allied health care, mainly offered via telehealth; (iii) care designed to complement rather than replace existing care pathways, such as pulmonary rehabilitation; and (iv) patients as partners in their care through shared rehabilitation goals. The team consisted of exercise physiology, clinical neuropsychology, occupational therapy, clinical psychology, nutrition and dietetics, speech pathology and rehabilitation medicine, who onward referred to other medical specialists as required. The Austin Health Human Research Ethics Committee (HREC 88943/Austin-2022) provided approval for the service improvement audit presented.</p><p>The service opened to referrals from general practitioners mid-2022 and received on average one referral each day.</p><p>SMS messages were sent to 4480 former patients of Austin Health who had been treated for COVID-19. About 40% of these patients (1708) responded, with 254 (15%) indicating they had ongoing symptoms. We additionally received 147 referrals (Box 2). Overall, we triaged and assessed 285 people, with 163 going on to receive individual therapy in the eight months the service operated.</p><p>Individuals accessing the service were more likely to be women (72%) and were of working age (average age 49 years) (Box 3). Participants reported that the impact of long COVID on their lives was profound. Self-reported measurement of health-related quality of life and physical and mental health on a 0–100 scale found a significant reduction across all measures since their COVID-19 diagnosis (<i>P</i> &lt; 0.001 for all).</p><p>The most common symptoms reported at a moderate to severe level were fatigue, brain fog and psychological impacts (Box 3). Most participants accessing the service were seen by more than one multidisciplinary team member (63%). Exercise physiology was the most in-demand discipline, followed by clinical psychology and occupational therapy (Box 4). We had a low “fail to attend” rate at 7%. Individual discipline therapy was complemented by online self-management resources<span><sup>22</sup></span> and a bespoke virtual group program that was attended by 72 people. Groups consisted of single sessions on living with long COVID, olfactory impairment, brain fog, and managing fatigue.</p><p>The evidence base for long COVID interventions is emerging, and interventions were based on clinical guidelines, such as the National Institute for Health Care and Excellence guidelines,<span><sup>17</sup></span> that are mainly at the expert consensus or low level of evidence currently. As per these guidelines, the clinic interventions included (i) a one-stop, coordinated approach to care; (ii) management of fatigue, brain fog, olfactory impairment, sleep and voice changes; (iii) clinical psychological support and intervention, including for adjustment to persistent symptoms, ongoing COVID-19 and health anxiety, general psychological difficulties and exacerbation of pre-morbid mental health concerns; (iv) investigation, diagnosis and management of postural orthostatic tachycardia syndrome in conjunction with hypertension specialist medical services; and (v) occupational therapy supporting functional improvement to allow people to return to important activities and life roles, such as work and caring responsibilities.</p><p>There are still relatively few Australian public health services to provide the recommended multidisciplinary care to people living with long COVID. Most people are unable to access rehabilitation services that could provide relief from symptoms, improve quality of life and support return to valued life roles. The ReCOVery model of care was developed using international guidelines and provided impactful care to participants. People accessing our service would otherwise most likely have fallen between the cracks of our health system, unable to access traditional post-injury or acute rehabilitation services or aged care services. The ReCOVery model provides a viable blueprint for a stepped care approach to support patients, and provides initial evidence for allied health discipline requirements through our utilisation data. Despite this, funding for services has largely ceased across multiple public long COVID clinics in Victoria. This has compounded inequity in who can access care, with private allied health options being simply unaffordable to most people. Care plans for access to allied health services can be completed by a general practitioner but only provide five sessions, with gap fees being common.</p><p>We were able to effectively run the ReCOVery service almost exclusively via telehealth. Centrally located telehealth hubs for long COVID would be a viable model to provide therapy to people who need it most. This telehealth model supports care by specialist disciplines that are difficult for most Australians to access, such as clinical neuropsychology. We acknowledge that people from culturally and linguistically diverse backgrounds and from disadvantaged communities may not have ready access to telehealth infrastructure, with centre-based options needed for some. A tiered (stepped) approach to care is the most efficient and cost-effective solution to management of long COVID and has been successfully implemented elsewhere.<span><sup>21</sup></span> However, our triaging process was time consuming and lengthy for patients. Streamlining through general practice assessment and referrals may mitigate this barrier to access.</p><p>General practitioners are now seen as the central specialty in the diagnosis and management of long COVID.<span><sup>16</sup></span> Although they are well equipped to be the primary medical contact for patients, they still require education on, and referral options for, therapeutic interventions via allied health. Multidisciplinary rehabilitation is the most effective solution to improve quality of life for patients with severe ongoing symptoms and reduce the burden on general practitioners. Unfortunately, in Australia, unless we shore up access via our public health services or Medicare rebates, this opportunity will be limited to people with significant financial means.</p><p>Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.</p><p>No relevant disclosures.</p><p>Not commissioned; externally peer reviewed.</p>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":null,"pages":null},"PeriodicalIF":6.7000,"publicationDate":"2024-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52457","citationCount":"0","resultStr":"{\"title\":\"An allied health model of care for long COVID rehabilitation\",\"authors\":\"Joanne M Wrench,&nbsp;Leigh R Seidel Marks\",\"doi\":\"10.5694/mja2.52457\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p>Although the acute disease burden of coronavirus disease 2019 (COVID-19) in Australia has reduced, the longer term impacts are becoming increasingly apparent.<span><sup>1</sup></span> The constellation of persistent symptoms is termed “post-acute COVID-19 condition”, also known as “long COVID”, and includes dyspnoea, fatigue, cognitive impairments, headaches, and psychiatric symptoms.<span><sup>2, 3</sup></span> The health impact at a population level is significant, with between 10% and 20% of people having persistent symptoms after a COVID-19 infection.<span><sup>4, 5</sup></span></p><p>Patient testimonies describe the devastating impact of symptoms left untreated by health services.<span><sup>6, 7</sup></span> The functional sequalae of long COVID include reduced quality of life<span><sup>8, 9</sup></span> and difficulty engaging in normal life roles, including family, work and caring responsibilities.<span><sup>10</sup></span> COVID-19 has also disproportionately affected disadvantaged communities who have less access to health care services and less resources to allow for absences from work.<span><sup>11</sup></span></p><p>As the world has returned to normal, many people living with long COVID continue to report feeling left behind and isolated by persistent symptoms.<span><sup>12</sup></span> Alongside this, many people report feeling ignored or not believed by health care providers, who often struggle to pinpoint physiological impairment and associated treatments.<span><sup>13</sup></span> This can lead to a marked discordance between the lived experience of ongoing debilitation and the expectations of the community and health care sector of what recovery from COVID-19 looks like.</p><p>Initially, Australia's response to long COVID followed a specialist clinic model of care, including individual referrals to respiratory and cardiac specialists. 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The team consisted of exercise physiology, clinical neuropsychology, occupational therapy, clinical psychology, nutrition and dietetics, speech pathology and rehabilitation medicine, who onward referred to other medical specialists as required. The Austin Health Human Research Ethics Committee (HREC 88943/Austin-2022) provided approval for the service improvement audit presented.</p><p>The service opened to referrals from general practitioners mid-2022 and received on average one referral each day.</p><p>SMS messages were sent to 4480 former patients of Austin Health who had been treated for COVID-19. About 40% of these patients (1708) responded, with 254 (15%) indicating they had ongoing symptoms. We additionally received 147 referrals (Box 2). Overall, we triaged and assessed 285 people, with 163 going on to receive individual therapy in the eight months the service operated.</p><p>Individuals accessing the service were more likely to be women (72%) and were of working age (average age 49 years) (Box 3). Participants reported that the impact of long COVID on their lives was profound. Self-reported measurement of health-related quality of life and physical and mental health on a 0–100 scale found a significant reduction across all measures since their COVID-19 diagnosis (<i>P</i> &lt; 0.001 for all).</p><p>The most common symptoms reported at a moderate to severe level were fatigue, brain fog and psychological impacts (Box 3). Most participants accessing the service were seen by more than one multidisciplinary team member (63%). Exercise physiology was the most in-demand discipline, followed by clinical psychology and occupational therapy (Box 4). We had a low “fail to attend” rate at 7%. Individual discipline therapy was complemented by online self-management resources<span><sup>22</sup></span> and a bespoke virtual group program that was attended by 72 people. Groups consisted of single sessions on living with long COVID, olfactory impairment, brain fog, and managing fatigue.</p><p>The evidence base for long COVID interventions is emerging, and interventions were based on clinical guidelines, such as the National Institute for Health Care and Excellence guidelines,<span><sup>17</sup></span> that are mainly at the expert consensus or low level of evidence currently. 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引用次数: 0

摘要

最常见的中重度症状是疲劳、脑雾和心理影响(方框 3)。大多数接受服务的参与者都接受过不止一名多学科团队成员的诊治(63%)。运动生理学是需求量最大的学科,其次是临床心理学和职业疗法(方框 4)。我们的 "失访 "率很低,仅为 7%。个人学科治疗辅以在线自我管理资源22 和定制的虚拟小组项目,共有 72 人参加。长期慢性阻塞性肺气肿干预措施的证据基础正在形成,干预措施以临床指南为基础,如美国国家卫生保健与卓越研究所指南17,这些指南目前主要处于专家共识或低证据水平。根据这些指南,门诊干预措施包括:(i) 一站式协调护理方法;(ii) 对疲劳、脑雾、嗅觉障碍、睡眠和声音变化进行管理;(iii) 临床心理支持和干预,包括对持续症状的适应、持续的 COVID-19 和健康焦虑、一般心理障碍以及病前心理健康问题的加重;(iv) 与高血压专科医疗服务机构合作,对体位性正位性心动过速综合征进行调查、诊断和管理;以及 (v) 职业治疗支持功能改善,使患者能够重新参与重要的活动和生活角色,如工作和照顾他人的责任。澳大利亚为长期慢性心力衰竭患者提供建议的多学科护理的公共卫生服务仍然相对较少。大多数人都无法获得康复服务,而这些服务可以缓解症状、改善生活质量并帮助他们重新扮演有价值的生活角色。ReCOVery 护理模式是根据国际指南开发的,为参与者提供了有影响力的护理。否则,接受我们服务的人很有可能会被我们的医疗系统拒之门外,无法获得传统的伤后或急性康复服务或老年护理服务。ReCOVery 模式为支持患者的阶梯式护理方法提供了可行的蓝图,并通过我们的使用数据为联合医疗学科的需求提供了初步证据。尽管如此,维多利亚州多家公立长期 COVID 诊所的服务资金已基本停止。这加剧了谁能获得医疗服务的不公平,大多数人根本无法负担私人专职医疗服务。获得联合医疗服务的护理计划可由全科医师完成,但只能提供五次治疗,缺口费也很常见。我们几乎只能通过远程医疗来有效运行 ReCOVery 服务。长 COVID 中心远程医疗中心是一种可行的模式,可为最需要的人提供治疗。这种远程医疗模式支持大多数澳大利亚人难以获得的专科治疗,如临床神经心理学。我们认识到,来自不同文化和语言背景以及弱势社区的人可能无法随时使用远程医疗基础设施,因此有些人需要选择以中心为基础的服务。分层(阶梯)治疗是管理长期 COVID 最有效、最具成本效益的方法,已在其他地方成功实施。通过全科医生的评估和转诊来简化流程可能会缓解这一就医障碍。16 尽管全科医生完全有能力成为患者的主要医疗联系人,但他们仍需要通过专职医疗人员进行治疗干预方面的教育和转诊选择。多学科康复治疗是改善有严重持续症状的患者的生活质量、减轻全科医生负担的最有效解决方案。不幸的是,在澳大利亚,除非我们通过公共卫生服务或医疗保险回扣来增加获取机会,否则这种机会将仅限于经济条件较好的人。墨尔本大学通过澳大利亚大学图书馆员理事会达成了 Wiley - 墨尔本大学协议,该协议的一部分就是墨尔本大学提供的开放获取出版服务。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

An allied health model of care for long COVID rehabilitation

An allied health model of care for long COVID rehabilitation

Although the acute disease burden of coronavirus disease 2019 (COVID-19) in Australia has reduced, the longer term impacts are becoming increasingly apparent.1 The constellation of persistent symptoms is termed “post-acute COVID-19 condition”, also known as “long COVID”, and includes dyspnoea, fatigue, cognitive impairments, headaches, and psychiatric symptoms.2, 3 The health impact at a population level is significant, with between 10% and 20% of people having persistent symptoms after a COVID-19 infection.4, 5

Patient testimonies describe the devastating impact of symptoms left untreated by health services.6, 7 The functional sequalae of long COVID include reduced quality of life8, 9 and difficulty engaging in normal life roles, including family, work and caring responsibilities.10 COVID-19 has also disproportionately affected disadvantaged communities who have less access to health care services and less resources to allow for absences from work.11

As the world has returned to normal, many people living with long COVID continue to report feeling left behind and isolated by persistent symptoms.12 Alongside this, many people report feeling ignored or not believed by health care providers, who often struggle to pinpoint physiological impairment and associated treatments.13 This can lead to a marked discordance between the lived experience of ongoing debilitation and the expectations of the community and health care sector of what recovery from COVID-19 looks like.

Initially, Australia's response to long COVID followed a specialist clinic model of care, including individual referrals to respiratory and cardiac specialists. With the emergence of milder acute illness, the model of care for long COVID in Australia has now moved to primary care, with general practitioners seen as the coordinators of ongoing services and interventions.14

The heterogeneous nature of long COVID symptoms, coupled with no diagnostic tool or single treatment, means the functional burden of long COVID may best be addressed by symptom management approaches.15, 16 In this regard, Australian and international guidelines recommend multidisciplinary and coordinated allied health care as a practice standard for people with long COVID,17, 18 and there is emerging evidence of corresponding functional improvement.19, 20 In line with these recommendations, the National Health Service in the United Kingdom encourages a three-tiered approach to care, with multidisciplinary interventions offered to people with the most severe symptoms requiring input from two or more professionals, stepping down to community therapy teams, and then self-management pathways for individuals with milder symptoms.21 In Australia, access to publicly funded allied health intervention for long COVID remains challenging with no system-level coordinated care or funding.

In early 2022, Austin Health in Melbourne commenced ReCOVery: an allied health-led rehabilitation service aimed at providing multidisciplinary management for long COVID symptoms based on international evidence and guidelines translated into the Australian context.17, 18 The key principles in the design of the service were (i) a stepped care model, with access to a multidisciplinary team for individuals with the most severe symptoms, and a self-management pathway for those with less severe symptoms; (ii) symptom management, improved function and participation via coordinated goal-driven allied health care, mainly offered via telehealth; (iii) care designed to complement rather than replace existing care pathways, such as pulmonary rehabilitation; and (iv) patients as partners in their care through shared rehabilitation goals. The team consisted of exercise physiology, clinical neuropsychology, occupational therapy, clinical psychology, nutrition and dietetics, speech pathology and rehabilitation medicine, who onward referred to other medical specialists as required. The Austin Health Human Research Ethics Committee (HREC 88943/Austin-2022) provided approval for the service improvement audit presented.

The service opened to referrals from general practitioners mid-2022 and received on average one referral each day.

SMS messages were sent to 4480 former patients of Austin Health who had been treated for COVID-19. About 40% of these patients (1708) responded, with 254 (15%) indicating they had ongoing symptoms. We additionally received 147 referrals (Box 2). Overall, we triaged and assessed 285 people, with 163 going on to receive individual therapy in the eight months the service operated.

Individuals accessing the service were more likely to be women (72%) and were of working age (average age 49 years) (Box 3). Participants reported that the impact of long COVID on their lives was profound. Self-reported measurement of health-related quality of life and physical and mental health on a 0–100 scale found a significant reduction across all measures since their COVID-19 diagnosis (P < 0.001 for all).

The most common symptoms reported at a moderate to severe level were fatigue, brain fog and psychological impacts (Box 3). Most participants accessing the service were seen by more than one multidisciplinary team member (63%). Exercise physiology was the most in-demand discipline, followed by clinical psychology and occupational therapy (Box 4). We had a low “fail to attend” rate at 7%. Individual discipline therapy was complemented by online self-management resources22 and a bespoke virtual group program that was attended by 72 people. Groups consisted of single sessions on living with long COVID, olfactory impairment, brain fog, and managing fatigue.

The evidence base for long COVID interventions is emerging, and interventions were based on clinical guidelines, such as the National Institute for Health Care and Excellence guidelines,17 that are mainly at the expert consensus or low level of evidence currently. As per these guidelines, the clinic interventions included (i) a one-stop, coordinated approach to care; (ii) management of fatigue, brain fog, olfactory impairment, sleep and voice changes; (iii) clinical psychological support and intervention, including for adjustment to persistent symptoms, ongoing COVID-19 and health anxiety, general psychological difficulties and exacerbation of pre-morbid mental health concerns; (iv) investigation, diagnosis and management of postural orthostatic tachycardia syndrome in conjunction with hypertension specialist medical services; and (v) occupational therapy supporting functional improvement to allow people to return to important activities and life roles, such as work and caring responsibilities.

There are still relatively few Australian public health services to provide the recommended multidisciplinary care to people living with long COVID. Most people are unable to access rehabilitation services that could provide relief from symptoms, improve quality of life and support return to valued life roles. The ReCOVery model of care was developed using international guidelines and provided impactful care to participants. People accessing our service would otherwise most likely have fallen between the cracks of our health system, unable to access traditional post-injury or acute rehabilitation services or aged care services. The ReCOVery model provides a viable blueprint for a stepped care approach to support patients, and provides initial evidence for allied health discipline requirements through our utilisation data. Despite this, funding for services has largely ceased across multiple public long COVID clinics in Victoria. This has compounded inequity in who can access care, with private allied health options being simply unaffordable to most people. Care plans for access to allied health services can be completed by a general practitioner but only provide five sessions, with gap fees being common.

We were able to effectively run the ReCOVery service almost exclusively via telehealth. Centrally located telehealth hubs for long COVID would be a viable model to provide therapy to people who need it most. This telehealth model supports care by specialist disciplines that are difficult for most Australians to access, such as clinical neuropsychology. We acknowledge that people from culturally and linguistically diverse backgrounds and from disadvantaged communities may not have ready access to telehealth infrastructure, with centre-based options needed for some. A tiered (stepped) approach to care is the most efficient and cost-effective solution to management of long COVID and has been successfully implemented elsewhere.21 However, our triaging process was time consuming and lengthy for patients. Streamlining through general practice assessment and referrals may mitigate this barrier to access.

General practitioners are now seen as the central specialty in the diagnosis and management of long COVID.16 Although they are well equipped to be the primary medical contact for patients, they still require education on, and referral options for, therapeutic interventions via allied health. Multidisciplinary rehabilitation is the most effective solution to improve quality of life for patients with severe ongoing symptoms and reduce the burden on general practitioners. Unfortunately, in Australia, unless we shore up access via our public health services or Medicare rebates, this opportunity will be limited to people with significant financial means.

Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.

No relevant disclosures.

Not commissioned; externally peer reviewed.

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来源期刊
Medical Journal of Australia
Medical Journal of Australia 医学-医学:内科
CiteScore
9.40
自引率
5.30%
发文量
410
审稿时长
3-8 weeks
期刊介绍: The Medical Journal of Australia (MJA) stands as Australia's foremost general medical journal, leading the dissemination of high-quality research and commentary to shape health policy and influence medical practices within the country. Under the leadership of Professor Virginia Barbour, the expert editorial team at MJA is dedicated to providing authors with a constructive and collaborative peer-review and publication process. Established in 1914, the MJA has evolved into a modern journal that upholds its founding values, maintaining a commitment to supporting the medical profession by delivering high-quality and pertinent information essential to medical practice.
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