The covid-19 pandemic has turned the way we run hospitals upside down, facilitating the expansion of intensive care and revolutionising the way we manage acutely ill patients. The use of virtual services to enhance communication and reduce transmission of covid-19 has been transformational for general practice as well as for hospital outpatient services. It is now essential that we take the opportunity to develop parallel subacute services, facilities, and workforce in the community not only for patients who are ill with covid-19, but also for frail patients who require on going treatment and rehabilitation.
Domiciliary services have been desperately neglected despite sensible legislation and guidelines recommending greater integrated care. Social care has been blamed for causing bed blocking and delays in discharge from acute hospitals. New approaches to care cannot be funded by words alone, but must be accompanied by investment and workforce development.
There has been a gross underestimate of the functional, physical, and emotional consequences of covid-19 as current NHS rehabilitation services are not set up for the recovery phase of this pandemic. The NHS Discharge to Assess plans estimate 45% will need some form of low level medical or social input for recovery, and a predicted 5% of patients will require more focused, ongoing intense rehabilitation. A failure to address these significant rehabilitation needs will result in reduced acute care capacity, poor long-term patient outcomes, and higher associated healthcare utilisation.
We know that covid-19 is a multisystem disease and there has been increasing understanding about the needs of recovering patients. Post-ITU survivors can experience significant respiratory, renal and cardiac problems, as well as muscle wasting, psychological/psychiatric problems and post-traumatic stress disorder. [1,2] It is thought that some survivors may take up to a year to go back to work. These patients require intensive support and rehabilitation in the community to allow them to regain their function, independence, and autonomy.
Frail patients waiting in hospitals, often labelled as social problems, may be left and treated in bed. This makes them more likely to suffer from a wide range of problems: contractures, skeletal muscle loss, constipation, incontinence, altered ventilation/perfusion of the lungs, postural hypotension, poor cardiac function, compression neuropathies, mental health problems and delirium. It is not surprising some fail to cope when discharged back home.
Pressure to discharge from hospital means many patients fail to receive rehabilitation, comprehensive assessments and an opportunity to regain their autonomy and independence. Failure to cope at home may result in placement in a care home. The recent publication of deaths in care homes during the covid-19 pandemic has shown how inadequate NHS input is into care homes and how such placement may not be in the patient’s best interest.
Post-acute care is often focused on discrete specialties, working in siloes, dis-integrated, and historically, under funded. Lack of investment in community services, primary care networks and rehabilitation/reablement services has hampered their development. The NHS Long Term plan and NICE guidelines for integrated care have been very supportive, but have also been patchily implemented. The NHS plan sets out aims for more nursing care to be delivered in the community and in people’s homes. The significant dwindling of district nursing numbers, over the last 10-20 years, was confirmed by the RCN and Queens Nursing institute. The number of district nurses working in the NHS in England has dropped by almost 43% in the last 10 years. Not only have nursing numbers dwindled, but GP numbers have also dropped, not keeping pace with their increased workload. More recently during the covid-19 pandemic, community staff have been deployed to work in the acute sector rather than continuing to work as therapists in the community.
We suggest that a new rehabilitation strategy or national framework for covid-19 patients of all ages requiring rehabilitation is required. [3,4] Rehabilitation should underpin both the inpatient and post-acute care of covid-19 patients, responding to patients’ medical needs and those of their carers and or family. The novelty of this virus and lack of data on long-term outcomes, suggests that unless we build in a rehabilitation plan now, there is potential for under-diagnosis of disability across all age groups, not just in the older population, and to under-estimate the scale of patient rehabilitation required.
Early stratification of covid-19 survivors according to their rehabilitation needs would allow better understanding of their ongoing management across primary care, domiciliary care, and acute settings. Building on covid-19 hospital discharge service requirements, rapid community response teams will prevent prolonged hospital stays and facilitate speedy discharge and continuity of care. Rapid assessment followed by tracking of patients benefits those with complex disease.
Primary and secondary care need to be supported by integrated rehabilitation services with case managers, district nurses, pharmacists and social workers. The introduction of enhanced care, including rehabilitation, to care homes will go a long way to remedy the current difficulties faced by care home covid-19 patients. The essential components of a truly integrated service are thought to be multidisciplinary case management, effective leadership, and a focus on rehabilitation. This cannot be only for people with covid-19, but for others forgotten during the pandemic. The infrastructure already exists. Some areas of the country, such as East Lancashire Trust, have an established integrated assessment and rehabilitation team spanning acute and community services. These exemplars have been able to rapidly mobilise teams to meet demand. The recent introduction of first waiting time standards for community care—of two-hours for older people in crisis and two days to receive reablement support is to be welcomed.
Workforce development (The NHS People Plan) for the delivery of an ambitious rehabilitation plan to support those working in the NHS and covid-19 survivors, is essential. Medical specialists should be seen to be leaders of multidisciplinary teams, despite this seeming unfashionable, alongside a broad skill mix of appropriate therapists (across physiotherapy, nutrition, speech and language and mental health and social care workers). Support from allied health professional students, trainees, as well as volunteers in the private sector, including rehab-focused personal trainers and gym staff could be part of this extended workforce. Volunteers from the community and charitable sector could coordinate patient needs. Recruiting and retraining individuals from industries affected by the economic downturn, such as in travel and hospitality, may provide welcome support.
An operating model should include three overlapping care provisions: intermediate care facilities, alongside domiciliary care and virtual and remote services. Nightingale rehab “Centres of Excellence” could be established to ensure co-located multidisciplinary working and concentration of expertise for larger volumes of patients. The scale of the requirement should not be under-estimated. Mass rehabilitation could be delivered in unused and re-purposed space. These “intermediate care” facilities are essential for improving the outcomes and recovery of survivors of covid. They will enhance the quality of care at the interface of hospital and home and relieve additional burden from care homes.
Data on the natural history and multi-system consequences of covid-19 should be measured and collected, tracking outcomes that matter to patients. Comprehensive geriatric assessment has been found to be effective in older people and thought needs to be given on how to develop and evaluate similar approaches in younger people. The current Community Services Dataset could be expanded and extended to accommodate outcome measurements for covid-19 survivors.
The need for enhanced and expanded post-acute care for covid-19 patients is gaining attention. [3,5] This pandemic gives us the opportunity to develop more innovative, appropriate rehab-responsive services, for all age groups, in the UK. Attention has been appropriately focused on emergent cases, but we should also use this time to drive workforce development, and evolve the NHS into a truly functionally oriented and socially modelled care programme focusing on rehabilitation as a core concept of health and wellbeing.
Competing interests: AM none. JM is a Trustee of Nightingale Hammerson.
- Pandharipande PP, Girard TD, Jackson JC, et al. Long-Term Cognitive Impairment after Critical Illness. New England Journal of Medicine. 2013;369(14):1306-1316.
- Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39(2):371-379.
- Vishal S. Arora JEF. How Will We Care For Coronavirus Patients After They Leave The Hospital? By Building Postacute Care Surge Capacity. In. Health Affairs2020.
- Wade D. Rehabilitation–a new approach. Overview and Part One: the problems. Clin Rehabil. 2015;29(11):1041-1050.
- Grabowski DC, Joynt Maddox KE. Postacute Care Preparedness for COVID-19: Thinking Ahead. Jama. 2020.