Introduction
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similar challenges have been described post acute hospitalization (Post-Hospital Syndrome (PHS).
Risks may be higher among COVID-19 survivors.
Given recognized acute pulmonary complications associated with COVID-19, pulmonary sequelae are a prominent concern,
,
,
though COVID-19 has demonstrated an ability to impact multiple organ systems.
Further, emerging scientific data describe a potential for lingering symptoms post-COVID-19 infection even among those who do not require hospitalization.
,
The etiology and physiologic correlates of potential persistent symptoms require sufficient resource infrastructure for comprehensive supportive care and further insight into the natural history of COVID-19.
We provide a description of early need recognition, resource redistribution, operational experience, and refined multidisciplinary clinic structure to support COVID-19 survivors: the Johns Hopkins Post-Acute COVID-19 Team (JH PACT).
Available System Resources
The first COVID-19 admission to the Johns Hopkins Hospital was reported March 2020. Swiftly rising inpatient admissions drew heavily on inpatient resources, and Pulmonary and Critical Care Medicine (PCCM) providers were immersed in frontline care. Infection control efforts reduced availability of post-acute and ambulatory rehabilitation centers; provider resources were reallocated to augment in-hospital rehabilitation programs and support safe discharges. Non-COVID-19 research, outside of select clinical trials, was largely halted, and thus clinical effort was expanded for many faculty who traditionally serve in dual clinical and research roles.
Anticipated Ambulatory Needs
,
,
,
,
data is notably limited. Patients developing acute respiratory distress syndrome (ARDS) were anticipated to be at risk for long-term respiratory complications,
and there were emerging reports of potential complications in multiple organ systems.
Importantly, survivors requiring hospitalization, especially in the ICU, were anticipated to be at risk for markedly impaired strength/physical ability, worsened mood/anxiety/post-traumatic stress disorder symptoms, cognitive impairment, and increased use of healthcare resources.
,
,
,
Importantly, aspects of the COVID-19 pandemic, including visitor restrictions, potential limitations on essential rehabilitation services, higher levels and longer duration of sedation during critical illness, and longer lengths of stay had the potential to further complicate recovery.
Hence, a multidisciplinary approach was needed to address the needs of a rising population of COVID-19 survivors.
,
,
Opportunity
The procurement of a physical location for care delivery, which typically requires substantial justification within a formal business plan, can be a barrier to rapid implementation. Coordination for a multidisciplinary model requires harmonization of multiple providers and services in time and space. Rapid adoption of telemedicine on a broad scale, necessitated by infection control measures, overcame these barriers. Specifically, telemedicine allowed for appointments to be scheduled at the mutual convenience of patients and each of the multidisciplinary providers, circumventing the need for schedule alignment at a time of high clinical demand.
Conception and Design
Figure 1Schematic of Anticipated COVID-19 Survivor Streams
Simplified depiction of anticipated COVID-19 survivor courses captured for care in the JH PACT clinic. (1) Patients recovering from ICU admission for COVID-19. (2) Patient recovering from hospitalization for COVID-19. (3) Patients who remained in an ambulatory care setting but experienced prolonged, non-resolving symptoms post-COVID-19 infection.
Figure 2Johns Hopkins Post-Acute COVID-19 Team (JH PACT) Referral Criteria for COVID-19+ Hospital Discharges
Patients requiring 48 hours or more in the ICU were eligible to referral to the JH PACT-ICU, consisting of evaluation by both PM&R and Pulmonary services. Patients requiring hospitalization but no hospital stay were referred to JH PM&R PACT-Base with additional Homecare referral for home physical therapy/occupational therapy services if necessary. Patient then assessed for ongoing pulmonary needs or qualification for remote patient monitoring, and could receive co-referral or independent referral to JH Pulmonary PACT-Base. Patients could also be individually referred to RPM monitoring without JH PM&R or Pulmonary PACT referral (not pictured). Patients who did not require hospitalization but had ongoing symptoms at 4-6 weeks post diagnosis could qualify for referral to either of the JH PACT-Base teams.
Homecare teams provided nursing and essential therapy services (physical therapy; occupational therapy; speech-language pathology) to homebound patients. Co-management and communication with primary care physicians were prioritized. For patients without primary care, networks were developed with academic and community providers to facilitate establishment of care. Hospital social workers and a community health worker were critical components in light of disproportionate representation among vulnerable populations.
Figure 3Key Services and Staff of the JH PACT Clinic
Patient flow and contributing staff members represented above. Green indicates participation in weekly multi-disciplinary clinic meetings. Primary care is featured prominently as an essential collaboration and line of communication. Psychology consisted of partners in both Neuropsychology and Rehabilitation Psychology. CHW=community health worker; RN=registered nurse
Concerns were initially raised regarding access to telemedicine among vulnerable populations and those at risk of marginalization. To address this, research and administrative support staff were trained and re-deployed in telemedicine support to proactively contact patients, assist with software download prior to clinic, and support connection on the clinic day. Nursing staff introduced new patients to the clinic structure and assisted in navigating follow-up testing, which often required repeat COVID-19 test coordination. Clinic workflows and resources (e.g. subspecialty referral contacts) were stored in a central, secure drive accessible only by healthcare team members.
Dissemination
A referral form (Appendix A) was disseminated via a collated Department of Medicine protocol for COVID-19+ discharges. Hospital and ambulatory referrals were accepted via a centralized email monitored by a referral coordinator and supported by nursing and physician review for appropriate placement in JH PACT-ICU or PACT-Base. PCCM colleagues were engaged to refer patients at the time of ICU downgrade, and clinic information was disseminated among hospitalist staff and medicine residents. Johns Hopkins Health System partners across the state were engaged in providing care under variably adopted portions of the framework, including RPM, offering an enhanced structure for post-COVID-19 care at participating hospitals.
The first JH PACT patient was seen on April 7th, 2020, representing one of the earliest dedicated COVID-19 survivorship clinics in the nation. As of November 11th, 2020, 265 unique patients have been seen in 530 visits by the JH PM&R and/or Pulmonary PACT. New patient JH Pulmonary PACT visits have generated an average of one (range zero to three) additional subspecialty referral per patient over the preceding month.
Ongoing Mission
(improvelto.com); Society of Critical Care Medicine Consensus Statement;
and COVID-19-specific recommendations by the European Respiratory Society (ERS)/American Thoracic Society (ATS).
Symptoms are assessed via validated questionnaires pre-clinic by telemedicine coordinators or via secure messaging and patient self-completion with incorporation into the medical record (Table 1). This approach allows for standardization of care, collation of clinical experiences, and description of the natural history of COVID-19 in the JH PACT population. Laboratory, pulmonary function testing, and imaging follow-up are obtained based on individual indications, though most consistent with British Thoracic Society recommendations., Research partnerships have proven synergistic in provision of clinical resources; we are pursuing additional funding to comprehensively characterize outcomes within this population. Further, trainees routinely rotate through the clinic, providing opportunities for clinical education and research. Importantly, trainees voice appreciation for the ability to see the post-discharge trajectory of patients they cared for in the hospital.
Table 1Standardized Functional and Symptomatic Assessments
Insturments are assessed at new and follow-up visits.
Conclusions
,
, , We have described a successful multidisciplinary approach grounded in a PICS/PHS framework.
,
The rapid adoption of telemedicine, including ambulatory pulse oximetry monitoring, provided a unique opportunity to overcome traditional barriers, and address disparities in care provision. While the ATS and ERS retain equipoise in recommendations for follow-up in a dedicated multidisciplinary clinic for post-COVID-19 care,
the present and future benefits to patients, the health system, and knowledge advancements through the JH PACT clinic are tangible. The comprehensive approach described here has proved successful in providing an enduring support network for COVID-19 survivors locally, alongside the provision of data that will inform our understanding of the natural history of COVID-19 in those requiring hospital-level care or with persistent symptoms in the ambulatory setting.
Conflict of Interest Statement/Funding
Authors receive funding from the National Heart, Lung, and Blood Institute [K23HL138206 (AP); F32HL143864 (JO); K12HL143957 (SR)] the National Institute of Environemntal Health Sciences [K23ES029105 (EB)], the National Institute of Allergy and Infectious Diseases [P30A1094189 (SR)], and the Joint Artifical Intelligence Center [DoD (AK)]. BH serves on the Board of Directors for local Maryland Medicare Advantage insurance plan, Hopkins Health Advantage (d/b/a AdvantageMD), holds a minor equity interest in a private digital compary (TRUE-See Systems, LLC), and within the last year served on an Academic Advisory Committee for a virtual visit research study, receiving a stipend from a Kaiser Permanente affiliate, Mid-Atlantic Permanente Research Institute. The clinic receives financial support via the Maryland State Health Services Cost Review Commission.
Acknowledgements
Administrative support: Laurie Neisser, MBA; Samuel Boadu, MPH; Andrew Byrd, BFin; Stephen Sisson, MD; Joyce Maygers, DNP, RN
Advisory Board: Christian Merlo, MD, MPH; Dale Needham, MD, PhD; Megan Hosey, PhD; Peiting Lien, DPT, NCS; Jyotsna Supnekar, OTR, CHT, CLT; Amanda Gallagher, MA CCC-SLP; Kelly Daley, PT, MBA; Preeti Raghavan, MD
Clinical Support: Arun Venkatesan, MD, PhD; Esther Oh, MD, PhD; Ashraf Fawzy, MD MPH; Alba Azola, MD; Jennifer Zanni, PT, DScPT, CCS; Laurie Fitz, PT; Norma Wright, RN; Denise Wagner, DT, PT; Jessica Engle, DO; Martin Bishop, PharmD, MS, BCACP; Jenna Blunt, PharmD, BCPS; Caitlin Down-Green, PharmD, BCPS, BCACP; Traci Grucz, PharmD; Erin VanMeter, PharmD, BCACP; Badia Faddoul, MS, RN
Hospital System MD Partners: Carmen Salvaterra, MD; David Holden, MD; Steven Kariya, MD
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All listed authors meet ICJME criteria for co-authorship of the manuscript.
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