Home-care guidelines for patients with COVID-19

Determining the appropriate monitoring protocol

Once a person has been deemed in need of – and appropriate for - home care, to determine the most appropriate home monitoring protocol, including frequency of review:

  • assess – Does the patient have any red flag symptoms? Red flag symptoms and vital signs are suggestive of severe disease, and these patients should be immediately escalated to the jurisdictional hospital-led COVID-19 service for management
  • assess – What are the patient’s medical and social risk factors?
  • determine the patient’s current symptom severity and clinical observations. You will then need to develop and implement a customised management plan.
Box 3. Red flag symptoms5–7,9
Vital signs of concern: Vital symptoms of concern:
  • New or worsening breathlessness
  • Syncope or light-headedness
  • Chest pain or tightness
  • Blue lips or face
  • Cold and clammy, or pale and mottled skin
  • Vomiting, significant abdominal pain, or diarrhoea >4 times a day
  • Poor oral intake with significant drop in urine output
  • New onset confusion or carer concern
  • Haemoptysis
  • Severe headache, particularly in children
*Each state and territory Department of Health might have their own acceptable paediatric observation range.
 
Box 4. Risk factors7-9
Medical risk factors Social risk factors
  • Unvaccinated or only partially (not up-to-date) vaccinated against COVID-19
  • Age <1 month or ≥65 years
  • Pregnant
  • Comorbidities:
    • lung disease, including COPD, asthma or bronchiectasis
    • cardiovascular disease, including hypertension
    • obesity (body mass index >30 kg/m2) (or BMI >95th percentile)
    • immunocompromising conditions*
  • Chronic kidney disease
  • Diabetes (type 1 or 2)
  • Liver disease
  • Significant neurological disorders, such as stroke or dementia
  • Some chronic inflammatory conditions and therapies
  • Significant frailty or disability
  • Severe mental health conditions
  • Low health literacy
  • Low digital literacy or access to technology
  • Social isolation
  • Large household or other members at risk (including carers or children)
  • Homelessness
  • Substance use
  • Risk of violence or neglect
  • Geographical difficulty in accessing rapid medical support
  • Specific communities and groups:
    • people living in aged care facilities
    • people with a disability
    • people from culturally and linguistically diverse communities, or with language barriers
    • Aboriginal and/or Torres Strait Islander people
Immunocompromising conditions*
  • Primary or acquired  immunodeficiency:
    • haematologic neoplasms: leukaemia, lymphoma, myelodysplastic   syndromes
    • post-transplant: solid organ (on immunosuppressive therapy), haematopoietic stem cell transplant (within 24 months)
    • immunocompromised due to primary or acquired (AIDS) immunodeficiency or Down Syndrome
  • Immunosuppressive therapy (current or recent)
    • Chemotherapy, whole body radiotherapy or total lymphoid irradiation
    • High-dose corticosteroids (≥20 mg of prednisone per day, or equivalent) for ≥14 days
    • Selected other potent immunosuppressive therapies (refer to ATAGI advice)
 
*Modified with permission from National COVID-19 Clinical Evidence Taskforce. Pathways to care for adults with COVID-19 (version 4.2). Check for updates in the Taskforce’s Living Guidelines.
 

Refer to boxes 1 and 2 in ‘Home-care suitability assessment’ section.

Box 5. Monitoring protocol7,9
Risk Definition Monitoring protocol
Low
  • Patient aged from 1 month to <65 years who is up-to-date with COVID-19 vaccination, has no medical or social risk factors and is asymptomatic or has mild disease
OR
  • Patient aged from 1 month years to <50 years if Aboriginal and/or Torres Strait Islander who is up-to-date with COVID-19 vaccination, has no other medical or social risk factors and is asymptomatic or has mild disease
 
In most cases, patients deemed to be at low risk will not need support from their GP to manage their symptoms. 
 
If GP involvement is requested by the patient or their carer, or via a triage service, a management plan may be developed in partnership with the patient and carer and could include the following:
  • Activating supports for people in isolation, including medicines, food, mental health services and financial aid – local councils could be engaged to provide these services
  • Providing information to enable the patient to:
    • monitor symptoms with daily symptom diary
    • confirm that a support person or carer will be checking on them at least twice a day
    • request telehealth review if symptoms worsen or if the patient or their carer is concerned
  • Telehealth consultation frequency will depend on:
    • symptoms
    • patient confidence
    • clinical judgement
  • Consider a brief wellbeing check from the practice every three days if the patient remains and more frequently if symptoms progress. This could be carried out by nursing staff and include questions, such as ‘Are you okay, better or worse? Would you like a check with the doctor?’ – If the patient is feeling worse, or is not improving, a clinical review should be undertaken by the GP
  • Provide education regarding re-exposure, post-COVID-19 symptoms and the importance of ongoing preventative hygiene measures such as hand hygiene/mask use
Medium
  • Patient aged from 1 month to <65 years (or aged <50 years if Aboriginal or Torres Strait Islander), is up-to-date with COVID-19 vaccination, asymptomatic or mild symptoms, but has one medical or social risk factor
  • Patient aged from 1 month to  <50 years, is not up-to-date with COVID-19 vaccination, but has no risk factors and is asymptomatic or has mild symptoms
  • Patient aged >65 years (or aged >50 years if Aboriginal and/or Torres Strait Islander), is up-to-date with COVID-19 vaccination, with no risk factors and is asymptomatic or has mild symptoms
This could be developed in partnership with the patient and carer and could include the following:
  • Activating supports for people in isolation, including medicines, food, mental health services and financial aid – local councils could be engaged to provide these services
  • Consider arranging for patient to have access to a pulse oximeter, and provide education on how to use, and what value to look for, and how and when to report
  • Ensure patient has written instructions for self-monitoring and symptom reporting
  • Advise the patient to:
    • monitor symptoms twice daily using a daily symptom diary and pulse oximeter (if appropriate)
    • have a carer phone to check on them twice daily
    • request telehealth review if self-monitoring suggests deterioration
  • Arrange daily brief wellbeing checks from the practice. This could be carried out by nursing staff and include questions, such as ‘Are you okay, better or worse? Would you like a check with the doctor?’ – If the patient is feeling worse, or is not improving, a clinical review should be undertaken by the GP
  • Arrange telehealth video consultation every 2–3 days or as determined to be clinically necessary
  • Provide education regarding re-exposure, post-COVID-19 symptoms and the importance of ongoing preventative hygiene measures such as hand hygiene/mask use
High
  • If the patient does not meet the criteria for either low or medium risk
  • Escalate to the jurisdictional hospital-led COVID-19 service

If a patient has been assessed as requiring and suitable for home care, a management plan will need to be put in place to ensure the safety of the patient and other household members. This might (but not always) include a formal collaboration between the GP and a hospital-led service,* and should include the following:

  • Establishing the date of symptom onset as day zero (or the date of testing, if asymptomatic)
  • Educating the patient about indicators for disease progression; in particular, discussing the risk of deterioration in the second week after symptom onset
    • The use of a TGA approved pulse oximeter may be considered in patients with risk factors for deterioration and, if utilised, are of most benefit where there is regular clinician check-in with the patient and as part of broader symptom monitoring
  • Educating the patient and other household members about infection prevention and control procedures to stop the spread of COVID-19
  • Determining the frequency of contact and follow up required, as determined by the monitoring protocol and as per changes in symptoms, the stage of the illness, and individual patient characteristics and concerns
  • Providing information on where, when and how to seek emergency medical assistance (refer to ‘Escalating care’) to the patient, their caregivers and/or other household members
  • Establishing who will manage the patient if the treating GP is not available
    • Consider the availability of other GPs/nurses in the practice
    • Provide contact details for after-hours/medical deputising services or other after-hours services formed in collaboration with the local health district/network
  • Provide details of the National Coronavirus Helpline (1800 020 080) or service engaged for additional care of COVID-19 patients in your jurisdiction, and refer to the online healthdirect COVID-19 symptom checker
  • If the patient has low English literacy, they can access in-language assistance by calling the National Coronavirus Helpline on 1800 020 080 and selecting the option for interpreter services.
  • Creating an action plan for the patient and their carers to monitor their symptoms and know when and how to escalate support
  • Discussing the care arrangement for other household members and extended family/community members, if the entire household test positive
  • Determining if the patient has an advance care directive/plan and/or enduring power of attorney in the event the patient becomes unwell and cannot express their care wishes
  • Uploading a shared health summary and sending a medical summary to the hospital- led COVID-19 service (if admitted to such) if the patient has a My Health Record
  • Providing the patient written materials reinforcing matters discussed, including monitoring and managing symptoms, medicine management, infection prevention and control procedures, contact details for the practice and contact details for if the treating GP is not available and how and when to seek emergency assistance. The relevant hospital or commissioned health service might already have appropriate material to provide to patients, or you can use the RACGP’s guide, action plan and symptom diary for patients. This can be emailed or printed and picked up by a support person for delivery to the patient’s home

*In a rural or remote setting, it might be appropriate to collaborate with all local health service providers (with the patient’s consent), including the local hospital, ambulance service and community nurses, in managing COVID-19- positive patients in the community. This ensures all service providers are aware of the patients under surveillance and are part of the support structure.

Additional considerations when providing GP shared care for patients admitted to a hospital-led program

Additional considerations when developing a management plan:

  • The patient should be informed that, as the GP, you are providing care for their pre-existing conditions and mental health – all COVID-19-related issues are managed by the hospital-led program team.
  • The patient should have the contact details of the hospital-led program and know how to contact them, if needed.
  • The patient should be educated that, if their COVID-19 symptoms worsen, they need to contact the hospital-led program (or 000, if necessary).
  • The patient may have access to self-monitoring devices, such as pulse oximeters, through the hospital-led program. The patient should be educated by the program on how to use these devices and demonstrate an understanding of what results should be reported and to who. 

Additional considerations when caring for patients from CALD communities

If the patient has low English literacy, they can access in-language assistance from the National Coronavirus Helpline by calling 1800 020 080 and selecting the option for interpreter services.

Patients, including those from CALD communities, might be fearful of going to hospital (if escalation is required) without the presence of other family members if COVID-19 restrictions are in place. Encourage patients and their families to ask questions about potential outcomes of COVID-19 early in the diagnosis so that they are fully informed prior to making decisions about their care. 

Prescription management

Make sure the patient has access to their regular medicines.

Prescriptions can now be sent directly to patients via SMS or email using electronic prescribing (or uploaded to their Active Script List if they are enrolled). Read more about electronic prescribing and access fact sheets for GPs and patients on the RACGP website. Patients can forward their electronic prescription to their local pharmacy for dispensing and request the medicine is delivered, or forward to a family member or carer to pick up.

Patients can also arrange for a family member or carer to pick up a paper prescription from the practice and have it delivered (ensuring isolation requirements are maintained). 

Mental health support

  • Assess the patient’s mental health and general wellbeing and facilitate additional COVID-19 support if needed:
  • In your language resources to provide support for people from CALD communities have been developed by the Transcultural Mental Health Centre
  • Patients from CALD communities can also access language support through the National Coronavirus Helpline by calling 1800 020 080 and selecting the option for interpreter services.
  • Encourage patients to remain physically active within their homes during isolation (and within the limitations of their symptoms and disease severity).
  • Encourage patients to maintain social contact through phone or video calls. Virtual and phone-based support might be available through local community groups for isolated patients.
  • Provide culturally appropriate care.

Using apps and digital tools to support patient care

A number of apps have been developed to support the care of patients with COVID-19, including remote monitoring.

These apps could be used by hospital-led programs or public health units. Speak with your local public health unit to see if apps are being used to support patients in your area.

If your practice is participating in remote monitoring of patients using digital tools, see the RACGP’s mHealth in general practice resource to ensure effective and secure use of mobile devices.

Tracking spreadsheet for COVID-19 patient cohort

You or your practice might consider using a patient tracking spreadsheet to give visibility over your COVID-19 patient cohort and tracking their progress.
An example template is available here, and can be adapted for your use.

Record-keeping

In addition to all clinical consultations, assessments and investigations, GPs should keep a record of all communications with patients and other parties.
 

Box 6. COVID-19 symptoms1
The most commonly reported symptoms of COVID-19 Other symptoms
  • Cough
  • Dyspnoea
  • Malaise
  • Fatigue
  • Loss of taste and/or smell
  • Sputum/respiratory secretions
  • Headache
  • Sore throat
  • Shortness of breath
  • Myalgia
  • Rhinorrhoea
  • Chills
  • Nausea/vomiting
  • Diarrhoea

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