Providing care for specific groups recovering from COVID-19

Providing care for specific groups recovering from COVID-19

People who have had severe COVID-19 requiring hospitalisation

Patients who have had severe illness are likely to have a range of specialty and rehabilitation follow-up plans in place. They might have been discharged to a hospital virtual care service, which might impact a GP’s ability to provide MBS-funded consultations. If you are uncertain about whether you can bill MBS items, liaise with the service or your local primary health network.

Consider an earlier telehealth appointment to:

• address any concerns noted in the hospital discharge plan
• discuss any patient or carer concerns
• gain a baseline understanding of symptom severity
• assess potential rehabilitation needs in terms of:
  • physical needs, eg mobility, diet, safety at home
  • cognitive or mood disturbance
  • psychosocial needs, including cultural needs and language support needs
• check that appropriate medical and rehabilitation service follow-up has been organised following hospital discharge
• ensure an action plan is in place if symptoms worsen, and that it includes the management of all health issues, not just post–COVID-19 conditions
• check the patient has access to prescribed medicines immediately and in the longer term
• plan for an appropriate face-to-face assessment soon after the patient is released from isolation.

Management will be determined by the specific sequelae experienced during the patient’s hospitalisation (refer to Box 1). Management will also be determined by their other health conditions that require continuing care. There might also be symptoms and signs of treatment-related complications, general deconditioning or post-traumatic stress disorder. In frail, elderly patients, sarcopenia is common.

The duration of a patient’s hypercoagulable state post–COVID-19 is currently unknown. Current evidence does not support routine thromboprophylaxis in patients with COVID-19 not requiring hospitalisation, or post-hospital discharge. However, a period of anticoagulant therapy might be appropriate in selected individuals following discharge and should be guided by the hospital team; for example, pregnant or postpartum patients, or those who have had VTE during their admission.^20,21 

Recommendations for patients discharged following severe COVID-19 include the following:^16,22

• Patients should be encouraged to do regular daily activities and low-to-moderate physical exercise (but not high-intensity exercise) in the first 6–8 weeks post-discharge.
• Patients should have a formal assessment of physical and emotional functioning at 6–8 weeks post-discharge, including measurement of respiratory function and exercise capacity, and referral to appropriate services where indicated. These might include:
  • comprehensive rehabilitation service if there are multiple treatable concerns
  • exercise physiology to facilitate a graded increase in activity tolerance if fatigue is preventing completion of pre–COVID-19 activities
  • pulmonary rehabilitation if there is pre-existing or ongoing lung function impairment
  • strengthening exercise and nutritional support programs, if there is loss of strength or muscle mass
  • formal psychological assessment.

It is important to reassess the family/social situation, as carer’s leave and financial stability can become an increasing concern at this time.

It should also be noted that patients who were not hospitalised might also experience debilitating symptoms. These patients should similarly be referred to treatment pathways, as described above. 

Older people

Medical wellbeing

Proactive surveillance might be required to detect loss of appetite, fatigue, deterioration in function or gastrointestinal symptoms. There could be an increased risk of falls, syncope and delirium.

Patients with functional decline and fatigue might be at increased risk of secondary infections; VTE; poor hydration, malnutrition and poor mouth care; and medicine mismanagement.

For older patients, consider:

• proactive surveillance
• early investigation of symptoms, noting that symptoms might be unreliable
• screening for malnutrition and dehydration
• checking oxygen saturation and blood screening for lymphopaenia, rise in inflammatory markers, hyponatraemia, hyperkalaemia and acute kidney injury.

Maintaining independence and support

Consider the following options to increase support for patients in their homes:

• Home delivery of medicines, including the use of blister packs.
• Assistance with food and meals. Patients can contact My Aged Care on 1800 200 422 to assist with setting up food delivery services, such as Meals on Wheels, which is available for up to six weeks without an aged care assessment.
• My Aged Care can also provide a My Aged Care ID number to enable prioritised online grocery ordering.
• The Older Persons COVID-19 Support Line (1800 171 866) is available to older persons, families and carers for support and advice.
• Patients already receiving a home care package through My Aged Care can also access additional volunteer support through the Community Visitors Scheme.

Refer to an Accredited Practising Dietitian for assessment of nutrition support needs when general support is insufficient.

People with disability

There are often challenges in recognising and managing health problems in people with cognitive disabilities, and this is no different during the post–COVID-19 phase.

Carers should be advised about possible post–COVID-19 symptoms, as outlined in Box 2. These might be difficult to pick up by carers unfamiliar with the patient. In patients with cognitive disabilities, carers might need to look for secondary signs, such as increased fatigue, food refusal with anorexia and a decline in skill levels with deterioration in function.

The person might need extra support with mobility and ADLs. The disruption in their life with change of environment, change of carer and changes in their daytime activity might trigger deterioration in behaviour that will take some time to settle after the acute infection and treatment phase. Behavioural change can be especially challenging for carers and needs specific inquiry.

If food refusal or anorexia are noted, consider malnutrition screening and referral to an Accredited Practising Dietitian.

People from culturally and linguistically diverse communities

Locally and internationally, COVID-19 infection rates were disproportionally higher in CALD communities, in part due to social determinants of health.³

Ensure you are aware of support resources that you can refer them to, which can be shared with their communities. Healthdirect have COVID-19 resources, including on recovering form COVID, in a number of languages. You can share these resources with patients when English is not their first language.

If an interpreter is required for consultations, practices can use the Australian Government’s Translating and Interpreting Service (TIS) Doctors Priority Line. GPs are eligible for a free TIS code. All doctors should be registered. Call 1300 131 450 or visit the TIS website. The RACGP has developed a fact sheet to provide guidance on, and support with, providing telehealth consultations with patients who require an interpreter.

If social worker support is required due to ongoing symptoms, encourage your patient to engage with local services or the Centrelink social work services. If an interpreter is required, they can call the Centrelink multilingual phone service on 131 202 and ask for a social worker.

Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples have disproportionate exposure to social factors associated with risk of severe COVID-19 illness, which in turn is a risk factor for post–COVID-19 conditions.^23,24

You can support the cultural safety of Aboriginal and Torres Strait Islander patients by ensuring the following:

• Your practice is welcoming and inclusive (refer to Step 1: Providing effective, culturally safe healthcare on the National Aboriginal Community Controlled Health Organisation–RACGP resource hub for advice). Many Aboriginal and Torres Strait Islander patients will have had bad experiences in health services, and often attend expecting this to be the case. Knowing this, and taking steps to consciously minimise the risk of another poor experience, allows the patient to receive high-quality care and develop trusting therapeutic relationships.
• Your practice provides an opportunity for patients to identify as Aboriginal and/or Torres Strait Islander and have their response recorded in your clinical information systems. Identifying Aboriginal and Torres Strait Islander patients means that appropriate clinical care can be given, such as recommended immunisations  or other preventive care; appropriate Medicare programs can be used, such as item numbers for health assessments, and the Pharmaceutical Benefits Scheme Closing the Gap co-payment; and local referral networks can be used, such as care coordination and supplementary services, or local Aboriginal and Torres Strait Islander health practitioners.
• All practice staff are encouraged to do cultural awareness training (offered free of charge to RACGP members and for a nominal fee for other practice staff via gplearning).
• An understanding of the particular circumstances of the patient. How many people are at home with them? What are their cultural and family obligations? Have they got money for food and medications? Have they understood the information that has been given them so far? Do they need any help advocating with other services?  

Babies and children

There are limited data on the incidence and severity of post–COVID-19 conditions in babies and children. In a review of 14 studies, the prevalence ranged from 4% to 66%, with a number of limitations identified in these studies.25 The review noted that it is difficult to differentiate post–COVID-19 symptoms from the indirect impacts of the pandemic, such as absence of sports, hobbies, socialising and schooling.²⁵

Severe acute COVID-19 disease is rare in babies and children, so children have a lower risk of post–COVID-19 conditions.²⁶

While very rare, paediatric inflammatory multisystem syndrome (PIMS-TS), which is temporally associated with SARS-CoV-2, must be considered. Common symptoms include fever, abdominal pain, gastrointestinal symptoms (significant vomiting and diarrhoea), neurological symptoms and/or rash.

Parents/guardians/carers should be advised to monitor for these symptoms and other possible post–COVID-19 symptoms, as outlined in Box 2, noting that these might be difficult to pick up in younger children who do not speak yet.

Parents can be reassured that the risk of their child developing PIMS-TS is extremely low.²⁶ They should be reminded that, irrespective of the cause of any severe symptoms, any child who is seriously unwell needs to be treated quickly. There are other conditions that are not related to COVID-19 that a child can develop.

If a child presents with post–COVID-19 symptoms at four weeks post-acute infection, consider referring them for specialist paediatric advice.⁴