Provincial Post-Covid Rehabilitation Taskforce Final Report

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 1

FINAL REPORT

PROVINCIAL POST-COVID

REHABILITATION TASKFORCE

Sponsors: Francois Belanger

Vice President

Quality & Chief Medical Officer

Sean Chilton

Vice President

Health Professions and Practice and Information Technology

Kathryn Todd

Vice President

Provincial Clinical Excellence

Co-Chairs: Petra O’Connell

Senior Provincial Director

Neurosciences, Rehabilitation & Vision Strategic Clinical Network

Catherine Hill

Acting Senior Operating Officer

Glenrose Rehabilitation Hospital

Elaine Finseth

Associate Chief Allied Health Officer, AHPPE

Health Professions Strategy & Practice

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September, 2020 v 5.0 2

TABLE OF CONTENTS

EXECUTIVE SUMMARY .................................................................................................................................. 5

INTRODUCTION & ACKNOWLEDGEMENTS ................................................................................................... 6

APPROACH .................................................................................................................................................... 7

Aims .......................................................................................................................................................... 7

Governance ............................................................................................................................................... 7

Activities & Approach ............................................................................................................................... 8

RECOMMENDATIONS ................................................................................................................................... 9

Screening ................................................................................................................................................. 11

Rehabilitation .......................................................................................................................................... 13

Discharge/Transition Planning ................................................................................................................ 14

Longitudinal Follow-up ........................................................................................................................... 16

IMPLEMENTATION CONSIDERATIONS ........................................................................................................ 17

Opportunities & Resources ..................................................................................................................... 18

Challenges & Potential Mitigation Strategies ......................................................................................... 19

Budget & Resource Implications ................................................................................................................. 21

CONCLUSIONS ............................................................................................................................................. 22

REFERENCES ................................................................................................................................................ 23

Appendix 1: Working Group Objectives ...................................................................................................... 29

Appendix 2: Membership............................................................................................................................ 30

Overall Taskforce .................................................................................................................................... 30

Working Group #1 - Screening ................................................................................................................ 32

Working Group #2 – Rehabilitation Strategies ....................................................................................... 33

Working Group #3 - Discharge & Transition Planning ............................................................................ 34

Working Group #4 - Longitudinal Monitoring & Tracking ...................................................................... 35

Appendix 3: Details on Background for WG1, WG3 & WG4 ....................................................................... 36

WG1: Screening....................................................................................................................................... 36

WG3: Discharge & Transition Planning ................................................................................................... 37

WG4: Longitudinal Outcome Monitoring ............................................................................................... 41

Appendix 4: COVID19 PROVINCIAL PANDEMIC FLOWSHEET...................................................................... 50

Appendix 5: AHS COVID19 Rehabilitation Screening Tool (AHS-CRST) ....................................................... 52

Appendix 6: Rehabilitation Strategies Document ....................................................................................... 58

Glossary (*) ......................................................................................................................................... 60

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Introduction ........................................................................................................................................ 61

Care settings........................................................................................................................................ 61

Critical Care ..................................................................................................................................... 61

Hospital Units .................................................................................................................................. 62

Inpatient Rehabilitation .................................................................................................................. 63

Community and Outpatient Rehabilitation .................................................................................... 63

Patient Pathways ................................................................................................................................ 64

Critical Care Pathways ..................................................................................................................... 64

Acute Unit Pathways ....................................................................................................................... 64

Inpatient Rehabilitation Pathways .................................................................................................. 65

Community Rehabilitation Pathways .............................................................................................. 65

Supportive Living and Long Term Care ............................................................................................... 66

Self-directed recovery ..................................................................................................................... 66

Transition and Handover .................................................................................................................... 66

Other Recommendations .................................................................................................................... 68

Existing Resources that Support Discharge and Transition ................................................................ 68

Care Delivery Model: Virtual Health ................................................................................................... 68

Organizational Considerations for Implementation of Virtual Care in Alberta .............................. 68

Resource Prioritization .................................................................................................................... 68

Information Technology (IT) ........................................................................................................... 69

Human Resources ........................................................................................................................... 69

Advocacy ......................................................................................................................................... 69

Resources for Implementation of Virtual Care in Rehabilitation ........................................................ 69

Virtual Navigation ........................................................................................................................... 69

Considerations for Use .................................................................................................................... 69

Practice Support and Education .......................................................................................................... 71

Patient and Family Resources ......................................................................................................... 71

Clinician Resources ......................................................................................................................... 71

Current Support / programs that can be utilized................................................................................ 72

Special populations ............................................................................................................................. 72

Pediatrics ......................................................................................................................................... 72

Indigenous ....................................................................................................................................... 72

Elderly patients transitioning back to a facility ............................................................................... 73

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Incarcerated Populations ................................................................................................................ 73

Isolated and Rural Populations ....................................................................................................... 73

Supplement: Discharge and Transition ............................................................................................... 74

Clinician Resources ......................................................................................................................... 74

Patient and Family Resources ......................................................................................................... 75

Current Support/ Programs ................................................................................................................ 76

General COVID19 Information ........................................................................................................ 76

Critical Care, Acute Care and Non-Home Care Settings .................................................................. 76

Patients and Families ...................................................................................................................... 76

Rehabilitation .................................................................................................................................. 77

Nutrition .......................................................................................................................................... 78

Appendix 7: Post-COVID19 Rehabilitation Discharge & Transition Planning ............................................. 80

Appendix 8: AHS Post-COVID19 Longitudinal Monitoring Tool (AHS-PLMT) (BASELINE) ........ 84

Appendix 9: AHS Post-COVID19 Longitudinal Monitoring Tool (AHS-PLMT) (FOLLOW-UP) .... 93

Appendix 10: Longitudinal Monitoring & Tracking of COVID19 Rehabilitation Outcomes ...................... 102

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EXECUTIVE SUMMARY

BACKGOUND. The majority of persons with COVID19 survive, yet they are often left with multiple

physical, psychological, social and cognitive deficits that require rehabilitation [1–5]. Most

COVID19 sequelae would benefit from rehabilitation services support in hospital and community

settings. The breadth and diversity of these multiple sequelae is not typical of common

rehabilitation diagnoses. At present, variations in rehabilitation services are recognized across

the Zones and no provincial coordination addresses COVID19-related rehabilitation needs [6,7].

AIM. The Provincial Post-COVID Rehabilitation Taskforce (the Taskforce) was to develop a

provincial approach to timely, standardized and coordinated rehabilitation for adult patients post-

COVID19 across the care continuum.

APPROACH. The Taskforce examined key pathways and frameworks; conducted literature

reviews and environmental scans; and, consulted with local and international experts.

RECOMMENDATIONS & IMPLEMENTATION. The Taskforce presents 19 recommendations

that collectively enable timely, appropriate rehabilitation for adult patients with COVID19 across

the care continuum. The recommendations distinguish patients hospitalized due to COVID19

(Population 1 (hospitalized)) and patients who experienced COVID19 in the community

(Population 2 (community-only)). The following table overviews the number of recommendations,

and summarizes the content across these recommendations.

Focus

Overview of Recommendations

Screening

-Introduce screening questions and tools to recognize potential

rehabilitation needs and trigger focused discussion and assessment.

Rehabilitation

-Follow patient journey across care continuum.

-Provide direction on prioritizing rehabilitation activities.

-Use a principle-based approach in continuing care.

-Emphasize importance of educational resources and self-management.

Transition

Planning

-Detail a process to track and support patients with rehabilitation needs.

-Develop triage processes to standardize inpatient rehabilitation criteria.

-Develop education and communication processes to facilitate planning.

-Incorporate rehabilitation needs with existing COVID19 discharge

documents and pathways.

-Align with the work of existing discharge/transition coordinators.

Longitudinal

Follow-up

-Follow-up on rehabilitation needs at 3, 6 and 12 months.

-Align with telehealth services (like Health Link®/Rehabilitation Advice

Line (RAL)) for patient follow-up and communication with primary care.

-Align with Physicians’ Learning Program (PLP) for data analysis for

quality improvement.

An Implementation Committee will guide implementation and resource considerations. Existing

resources can be leveraged, including the Health Link®/RAL, PLP, MyHealth.Alberta, Community

Rehabilitation, Primary Health Care Integration Network, Health Professions Strategy & Practice,

and the Neurosciences, Rehabilitation and Vision Strategic Clinical Network

CONCLUSIONS. The long-term impacts of COVID19 are unclear, but early learnings suggest

widespread and diverse rehabilitation implications that require attention. The Taskforce

recommendations fit into existing care pathways and leverage existing resources and programs.

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INTRODUCTION & ACKNOWLEDGEMENTS

In Alberta, as of September 16, 2020, 16,274 people have contracted COVID19, of which 254

died and 750 have been hospitalized, of which 140 were admitted to an ICU [8]. Alberta has 1,134

active cases, with 46 patients with COVID19 in hospital [8]. Despite the many public health

measures such as social distancing, we continue to see new patients with COVID19 across all

five Zones, with the majority having unknown routes of acquisition [8]. COVID19 and its sequelae

remain a responsibility of Alberta Health Services (AHS), including that of rehabilitation services,

for the foreseeable future.

The majority of persons with COVID19 survive, yet they are often left with multiple physical,

psychological, social and cognitive deficits that require rehabilitation [1–5]. External jurisdictions

demonstrate that, as the COVID19 trajectory progresses, physical and psychosocial rehabilitation

are necessary parts of post-COVID19 care [1–5]. Emerging evidence shows that COVID19

produces longstanding medical, functional and psychological sequelae across many domains:

pulmonary (3-67%), neurological (30-84%), long-term fatigue (44%), neurocognitive impairment

and impaired consciousness (36-80%), hyper-coagulation (30-80%), cardiovascular (8-33%),

psychiatric (depression, anxiety, PTSD) (>48%), and post-intensive care syndrome and

weakness (70-80%) [5]. These sequelae often require support from rehabilitation services.

In-hospital isolation protocols leave hospitalized patients with COVID19 without the needed

rehabilitation (e.g. mobilization, cognitive stimulation, social interaction). The breadth of

COVID19-specific sequelae, combined with restricted movements, leave hospitalized patients at

risk of developing significant impairments (e.g. Post-ICU Syndrome) that continue well after

discharge [6,7]. International experts predict that COVID19 will lead to significant morbidity 3-6

months post-diagnosis, and continue to place pressure on routine medical and rehabilitation

services for 12 months and beyond [6].

Most of the COVID19 sequelae could be addressed by rehabilitation in hospital and

community. The breadth and diversity of these multiple sequelae is not typical of common

rehabilitation diagnoses. This requires a clear rehabilitation framework specific to COVID19 and

education of the health care providers. At present, variations in rehabilitation services are

recognized across the Zones and no provincial coordination or planning addresses COVID19-

related rehabilitation needs [6,7]. A sustainable, provincially-coordinated rehabilitation approach

could better target the spectrum of post-COVID19 rehabilitation needs; better support patients

recovering from COVID19; reduce demand on acute care; and, improve efficiency (Figure 1). This

approach must consider rehabilitation needs through the care continuum.

Figure 1. Intended Implications of a Provincially-Coordinated Rehabilitation Approach

A sustainable, provincially coordinated rehabilitation approach

Identifies and targets post-

COVID19 rehab needs

Better supports patients

recovering from COVID19

Reduces demand on acute

care services

Reduces redundancies of,

or gaps in, services

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APPROACH

Aims

The Provincial Post-COVID Rehabilitation Taskforce (the Taskforce) was established in May

2020 to develop a provincial approach to ensure timely, standardized and coordinated

rehabilitation for adult patients post-COVID19 across the care continuum.

A concomitant

system-level goal includes a long-term view of decreasing secondary complications from

COVID19, hence lowering health care utilization rates. The care continuum includes acute care

(e.g. ICU, acute medicine), inpatient and outpatient rehabilitation (e.g. Day programs, Choice

Program, Community Rehabilitation, Day Hospital), subacute care, continuing care (e.g. long-

term care, supportive living, and homecare), and primary care.

The Taskforce sought to develop a strategy based on the following guiding principles:

(a) Based on evidence and principles of patient-centred care

(b) Provincial in scope and engaging multiple disciplines across all Zones

(d) Ensures sustainability through leveraging available capacity, including existing pathways

(e.g. the Presumed/Confirmed COVID19 Positive Primary Care Pathway).

(e) Identifies patient flow across the care continuum

(f) Generates information on long-term rehabilitation needs to inform clinical care planning.

The Taskforce commissioned four Working Groups (WGs), each with clinical-operational co-Chair

dyads. These four WG addressed the following (Appendix 1 has detailed WG objectives):

1) Screening for rehabilitation needs (WG1)

2) Early rehabilitation assessment and treatment (WG2)

3) Discharge and transition planning for coordinated patient flow (WG3)

4) Criteria for longitudinal follow-up of patient functioning (WG4).

Governance

Taskforce co-chairs represented leadership from the Neurosciences, Rehabilitation & Vision

(NRV) Strategic Clinical Network

(SCN), Rehabilitation Operations, and Health Professions

Strategy and Practice (HPSP). The Taskforce and its WGs had broad representation from

provincial groups including Primary Care, Seniors Health, HPSP, Zone Operations, Connect Care

and operational rehabilitation managers (Allied Health, Continuing Care, Peter Lougheed Centre,

Red Deer Regional Hospital, Zone Medical Officer of Health), SCNs (Critical Care, NRV,

Respiratory Health), clinical specialists (clinical neurosciences, critical care, dietetics and nutrition

services, internal medicine, occupational therapy, physiatry, physiotherapy, pulmonary medicine,

public health, respiratory therapy, social work and speech language pathology), Physicians

Learning Program, Quality Improvement and researchers (nursing, pulmonary medicine,

rehabilitation). Appendix 2 contains the full membership for each WG. The Taskforce aimed to

deliver its recommendations by September 2020, to allow implementation to commence in early

Fall to support Albertans recovering from COVID19.

Rehabilitation approaches for pediatric patients may be addressed in a separate initiative in the future.

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September, 2020 v 5.0 8

Activities & Approach

Activities that informed the WG discussion and Taskforce recommendations included:

• Literature reviews and environmental scans to determine best practice, available services and

programs as well as relevant tools for screening, rehabilitation interventions, transitions and

long-term follow-up (Appendix 3 contains the evidence base of each WG)

• Alignment with key operational frameworks, pathways and documents to frame and inform

strategies consistently across the organization, such as the following:

o The Home to Hospital to Home (H2H2H) Transition Guidelines

o The provincial COVID19 Pandemic Flowsheet

o The Presumed/Confirmed COVID19 Positive Primary Care Pathway

o The Primary Care COVID19 strategy

o The AHS COVID19 Safe Discharge Checklist

o The Post-COVID Respiratory Clinics

• Consultation with clinical experts across Alberta, Canada and internationally to gather

advanced insights and comparable practices

• Discussions between WGs to ensure alignment, cohesiveness and no redundancies

Each WG refined its objectives based on group consensus and their described limitations and

assumptions (Table 1). All WG considered implications for implementation related to sustainability

and potential challenges.

Table 1. WG Limitations & Assumptions.

Limitations & Assumptions

• Recommendations were founded on core values: AHS Values, patient/family centred care,

quality and safety, quadruple aim, collaborative and professional practice.

• Recommendations recognize that rehabilitation requires a wide variety of professions: allied

health, nursing and medical.

• Three focal transition points were hospital to home or continuing care; home/community to

rehabilitation; and continuing care to rehabilitation.

• The primary aim of long-term follow-up is to identify clinical need for further rehabilitation. The

secondary aim considered data collection for quality improvement.

• Referrals triggered by rehabilitation screening are suggestions and do not replace individualized

assessment and clinical recommendations.

• Rehabilitation screening of hospitalized patients with COVID19 occurs in non-intensive care

settings. Unique considerations are required for patients in need of critical care [5].

• Comprehensiveness and feasibility must balance to recognize survey time burden and AHS’

evolving capacity of rehabilitation programs.

• By consulting key operational frameworks, there must also be alignment with key stakeholders

with existing COVID19 pathways, especially for implementation.

• The recommendations must be flexible. Rehabilitation needs post-COVID19 vary across

recovery stages, between patients, and amidst evolving program capacity.

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September, 2020 v 5.0 9

RECOMMENDATIONS

The Taskforce presents the following recommendations that would collectively enable timely,

appropriate rehabilitation for adult patients with COVID19 across the care continuum. The

recommendations are separate for Population 1 (hospitalized) and Population 2

(community-only) patients with COVID19. The differences in care trajectory, symptom severity

and possible manifestation of COVID19 sequelae support this separate approach [9]. Figure 2

summarizes the different points of transition for these two populations. While these

recommendations are specific to COVID19, the processes, infrastructure, staff awareness and

education that will be created will create benefits for other patient types beyond COVID19.

Figure 2: Points of Transition for Population1 and Population 2.

The recommendations for screening, rehabilitation, discharge/transition planning, and

longitudinal follow-up are depicted visually in Figures 3 and 4 for Population 1 (Hospitalized) and

Population 2 (Community-Only), respectively. These recommendations also align with specific,

existing care pathways, particularly the Presumed/Confirmed COVID19 Positive Primary Care

Pathway (Appendix 4).

•Home or community to acute care or Intensive care unit

(ICU)

•ICU to acute care

•ICU/acute care to home or continuing care

•Acute care or community to inpatient rehabilitation

•Inpatient rehabilitation to home or continuing care

•Home or facility-based continuing care to community

rehabilitation

Population 1:

Hospitalized

Patients

• Continuing care facilities to community

rehabilitation

• Home or community to community

rehabilitation

Population 2:

Community-

only Patients

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September, 2020 v 5.0 10

Figure 3: Population 1 (Hospitalized) Patient Flow & Taskforce Recommendations

Inpatient

Acute Care

COVID19

Positive

Patients

Screen patient for rehab

needs:

AHS COVID19

Rehabilitation Screening

Tool (AHS-CRST)

Inpatient Rehab

Discharge Planning/

Transition Home

• Discharge checklist

• Clear/concise

documentation

• Treatment choices/

rationale

Community Care

See “Community Care Flow” diagram

Emergency/

Critical Care

COVID19 Rehab: Acute Care Flow

Please Note:

This flowchart shows the

typical patient pathway,

however, the pathway is not

always uni-directional.

For example, patients may

go from inpatient rehab to

inpatient acute care, from

inpatient acute care to

critical care, or even

community care back to

acute care.

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Figure 4: Population 2 (Community-Only) Patient Flow & Taskforce Recommendations

Screening

Key recommendations:

1. Population 1 (hospitalized) patients with COVID19 will be screened for potential

rehabilitation needs at each transition of care using the AHS COVID19 Rehabilitation

Screening Tool (AHS-CRST), which is adapted from the COVID19 Yorkshire Rehabilitation

Screening Tool (C19-YRS).

2. Population 2 (community-only)

patients with COVID19 will be screened for potential

rehabilitation needs using four key screening questions (to be finalized)

that may be

incorporated into existing screening and assessment tools in primary care, and continuing

care (including home care and facility-based continuing care (long-term care and supportive

living)).

Community Care

Clinicians and Patients

consult RAL

Clinician Resources

• Education material

• Community of practice

• RAL

Patient Resources

• Discharge Package

• RAL

• Physician

• Pamphlets

• MyHealth.Alberta

Provided to Primary Care Physician

based on patient’s individual

needs:

• Specialized Rehab Services

• Home Based Rehab

• Virtual Care (or hybrid with

Home Care)

• TeleHealth

• Home Oxygen

• Community Rehab

• Private Rehab

• Self-Directed Rehab

If required refer patients

discharged from acute care

to Post COVID Respiratory

Clinic

Available Resources

Referral Recommendations

Hospital

Discharge

COVID Positive Patients

From

Community

Primary Care

(Following Primary Care

COVID Pathway)

Facility Based

Continuing

Care

Rehab Advice Line (RAL)

COVID19 Rehab: Community Care Flow

Rehab Wayfinding/Navigation

Acute Care Follow-Up

Follow-up conducted by RAL at 3, 6, and

12 months post-discharge (acute care) or

post-diagnosis (community) (consider

follow-ups at 1 and 24 months as well)

Collect PROMs:

• EQ-5D-5L

• AHS-PLMT

Follow-up may trigger

a letter to primary

care provider

Longitudinal Monitoring

Follow-ups to align with Medical Officer of

Health’s follow-up processes.

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The screening approach aims to provide information and advice to the care team to help them

identify patient needs and provide appropriate care, which may include detailed rehabilitation

assessment and management as appropriate with local rehabilitation services, the Rehabilitation

Advice Line (RAL) or specialist teams. Appropriateness means contextualization of the

rehabilitation plan, which is guided by the lead care team, the care setting (i.e. acute vs. primary

vs. supportive living/long-term care), as well as patient needs and goals of care.

Neither the literature nor consultation with experts yielded an established, gold-standard

screening or follow-up tool for rehabilitation needs. However, a frequently-acknowledged tool

was the C19-YRS from the UK National Health Service [10] for patients discharged from their

hospitalization due to COVID19. The C19-YRS has excellent face validity, is COVID19-specific,

and has relatively comprehensive coverage of functional domains. C19-YRS limits were exclusion

of nutrition and communication screening, uneven question framing, and exclusive focus on post-

discharge patients.

For Population 1 (hospitalized), the proposed AHS-CRST builds on the C19-YRS, while

addressing its limitations. The AHS-CRST screens for functional impairments related to breathing,

heart palpitations, mobility, communication, swallowing, cognition, mental health, nutrition, and

activities of daily living (Appendix 5). The tool asks patients to compare their functioning to pre-

COVID19 capacity. As the patient progresses through hospital settings, clinical judgment may

prioritize parts of the AHS-CRST over others to ensure flexibility, feasibility and appropriateness.

For Population 2 (community-only), four brief screening questions are proposed for direct

incorporation into existing screening and assessment tools (e.g. Presumed/Confirmed COVID19

Positive Primary Care Pathway). Two questions target rehabilitation needs and two target

respiratory needs (Figures 5 and 6). These questions are particularly planned for primary care

and facility-based continuing care teams to implement and use. These questions would be posed

by the provider tasked with administering the existing screening and assessment tool according

to the timing of the existing pathways (i.e. when patient reports feeling unchanged or better). As

above, positive responses to these screening questions will trigger further discussion and

appropriate rehabilitation referrals or assessments.

Figure 5. Rehabilitation Needs Screening Questions for Population 2 (Community-Only).

Are you experiencing any new symptoms or

problems since your COVID19 illness?

•Yes

•No

Are you back to doing your usual activities

(walking, self-care, work, school, hobbies)? If not,

what is preventing you from returning to those

activites?

•Yes

•No

•N/A

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Figure 6. Respiratory Needs Screening Questions for Population 2 (Community-Only).

Rehabilitation

Key recommendations:

3. Comprehensive rehabilitation assessments of identified issues should be completed at

every level of care where indicated by the rehabilitation screening. The assessments should

include multi-system assessments that build on screening results.

4. Many rehabilitation issues can, and should, be addressed by self-management, which must

be supported across the care continuum.

The Taskforce provides a detailed framework in the AHS COVID19 Rehabilitation Strategies

Document (ACRSD), including the types of rehabilitation issues to consider, the types of

assessment tools to use, and the many relevant, available AHS resources and programs

(Appendix 6). For Population 1 (hospitalized), the levels of care addressed are critical care, acute

care, inpatient rehabilitation, community and outpatient rehabilitation, and self-directed recovery.

For Population 2 (community-only experience), the levels of care addressed are community

and outpatient rehabilitation and self-directed recovery.

As demonstrated in the literature and by this Taskforce, standardized rehabilitation

assessments must consider the breadth of potential sequelae post-COVID19 including

evaluations of physical function, respiratory function, cognition, nutrition, communication,

swallowing, activities of daily living and psychosocial needs. The recommended screening

strategies above will improve efficiency by highlighting the functional domains that require full

assessment (and those that do not). Key rehabilitation resources include community

rehabilitation, telehealth resources (i.e. Health Link®/RAL, Provincial Mental Health Help Line,

MyHealth.Alberta), and virtual access to care wherever possible and appropriate.

The following highlights key rehabilitation recommendations specific to the care setting.

Population 1 Only: Hospitalized Patients

Critical Care

5. Priority assessments are required for patients in ICU who (a) require extended mechanical

ventilation, sedation and/or prolonged bedrest; (b) are over 65 years of age; or (c) with chronic

co-morbidities.

ICU teams should ensure continued best ICU rehabilitation practice including early and

progressive mobility, delirium prevention (i.e. the ABCDEF delirium management and prevention

Are you having more breathlessness than before

you were diagnosed with COVID19?

•Yes

•No

•N/A

Have you developed a cough, wheeze or chest

discomfort that is new since you were diagnosed

with COVID19?

•Yes

•No

•N/A

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September, 2020 v 5.0 14

practice bundle), airway management, musculoskeletal and skin management approaches, as

well as interventions for effective communication between patient/family and the providers.

Acute Care

6. Screening results direct rehabilitation assessments in acute care. These assessments may

target the following:

• Cognition (e.g. Saint Louis University Mental Status Exam)

• Physical function (e.g. 6-Minute Walk Test, Timed Up and Go Test)

• Activities of daily living (e.g. dressing, feeding, toileting assessments)

• Other outcomes (e.g. pulmo

nary function using spirometry, mental health using

Hospital Anxiety and Depression Screen (HADS)).

Inpatient Rehabilitation

7. Where patients have multiple diagnoses including COVID19, the diagnosis with the most

impairments

should determine the inpatient rehabilitation trajectory. Consultation with

physiatry may facilitate this process.

Population 1 (Hospitalized) and 2 (Community-Only Experience)

Long-term Care & Supportive Living

8. A principle-based approach has patients living in facility-based continuing care following

similar recommendations as those living in the community, but providers will customize based

on patient needs and goals of care, as well as resources.

Community and Outpatient Rehabilitation

9. All patients should have access to educational resources on

anticipated symptoms,

exercises, and self-management (e.g. MyHealth.Alberta contains resources like the COVID19

discharge checklist).

10. Appropriate rehabilitation programming for patients will vary

based on patient

functioning and goals, as well as resource availability. Existing pathways will direct patients

to community rehabilitation or home care based on eligibility and needs. Consideration of

hybrid models of virtual and in-person care may be appropriate.

Self-Directed Recovery (particularly for patients never hospitalized for COVID19)

11. Primary care

providers are the lead care providers of, and can share resources with,

patients who are directing their own recovery.

Existing educational resources can support

patients, such as Health Link®/RAL and MyHealth.Alberta.

Appendix 4 demonstrates recommended care for rehabilitation screening and assessment

can align with Presumed/ Confirmed COVID19 Positive Primary Care Pathway.

Discharge/Transition Planning

Key recommendations:

12. A process to track and support patients with rehabilitation needs post-COVID19

should align with the Medical Officer of Health direction, and should ensure rehabilitation

considerations in discharge documents, data monitoring, patient/family involvement,

appropriate triage processes, education, evaluation strategies and communication strategies.

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September, 2020 v 5.0 15

13. A central intake or transition and discharge coordinator should be embedded within

existing services (including Health Link®/RAL or institutions) to identify rehabilitation needs in

the community and support patients in wayfinding and transition.

14. Patient education resource and support packages should be compiled, particularly for

Population 1 (hospitalized), at transition to community. This should include basic exercises,

recommendations for recovery, strategies for well-being and mental health

, referrals to

appropriate community rehabilitation, as well as additional interventions (e.g.

resources on

smoking cessation

, addictions, and vaccination).

15. AHS Communications should be engaged to raise public awareness and to develop and

implement the communication strategies.

The process to track and support patients must consist of several facets around the

rehabilitation needs of adult patients post-COVID19. Provision of timely, appropriate rehabilitation

care post-COVID19 hinges on points of transition (Figures 2 and 7). Rehabilitation should be

consistently embedded and addressed in discharge documents and processes, especially those

specific to COVID19 (e.g. Patient Discharge handout, Discharge checklist). This will improve

recognition of rehabilitation needs. Rehabilitation concepts are consistent with patient and family

centred care. This embedding can be done in collaboration with CoACT/Collaborative Care,

Connect Care, and Primary Care (e.g. Patient Discharge handout, Discharge check list, Guideline

for monitoring patients in the community). These concepts complement the H2H2H Transitions

Guideline, which advances communication across the patient’s circle of care and the active

participation of patients, family and caregivers.

Data should be collected and monitored, particularly for those in community and continuing

care settings recovering from COVID19. Discharge and transition supports should focus on active

involvement of patient and family. Transition documentation of screening and functional

assessments should be shared between teams. Documentation for referral to community

rehabilitation should include information on medical stability, and any precautions,

contraindications or limitations for exercise. The appropriate triage processes should be in place,

particularly to identify which Population 1 (hospitalized) patients recovering from COVID19 may

require follow-up by outpatient respirology at 2-3 months post-hospital discharge (Post-COVID

Respiratory Clinics).

Patients should be made aware, at discharge and through primary care, of Health Link®/RAL

that offer direct access to rehabilitation professions and nursing, who can answer questions and

link to resources in a timely fashion. These telehealth teams should be clear on the pathways to

refer patients to more information (MyHealth.Alberta) and/or rehabilitation services (including

Community Rehabilitation), as well as Health Link® Dieticians. This will include strong links and

education to promote awareness. Education should be prioritized for the public, as well as

Populations 1 and 2. Transition and discharge coordinators with knowledge in rehabilitation will

be valuable, such as the Rehabilitation Navigators at the Glenrose Rehabilitation Hospital.

Communication strategies will be required to ensure patients recovering in the community and

continuing care settings are aware of potential functional impairments post-COVID19 and how to

access rehabilitation information and resources (Appendix 7). Some resources exist, but can be

expanded upon (e.g. Rehabilitation and COVID19 handbook, online resources especially on

MyHealth.Alberta). Expanded resources would be valuable in care planning, particularly if there

For example, for smoking cessation, AHS has handouts, summary of evidence, and quick reference tools for

clinicians https://healthcareproviders.albertaquits.ca/resources/covid-19

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 16

is a surge in COVID19 cases. Appendix 6 contains the ACRSD, which details the rehabilitation

resources and recommendations across the care continuum including the patient discharge

checklist including clinicians’ contact information, scheduled appointments, handouts, plans for

long-term follow-up, and when to seek medical help in case of emergency.

Consistent transition and referral criteria for rehabilitation services are required. These criteria

must consider special or marginalized populations that may have unique needs (e.g. pediatrics,

Indigenous populations, elderly patients, incarcerated populations, isolate and rural populations).

Mental health issues should be considered in collaboration with Addictions and Mental Health,

and referrals appropriate to Addictions and Mental Health services should be made (e.g. the

Mental Health Help Line).

Figure 7. Transitions of Care for Patients with COVID19.

Longitudinal Follow-up

Key recommendations:

16. A repeated-measures, longitudinal follow-up of all patients with COVID19 at 3, 6, and 12

months post hospital-discharge (Population 1) or post-diagnosis (Population 2) is

recommended for further rehabilitation assessment and management.

17. Two needs-assessment tools are recommended:

• EQ-5D-5L (a validated, AHS-approved, general quality of life tool)

• The proposed AHS Post-COVID19 Long-Term Monitoring Tool (AHS-PLMT), which is

also based on the C19-YRS.

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 17

18. Virtual telehealth services (e.g. Health Link®/RAL) will follow-up directly with patients to

identify unmet rehabilitation needs under the longitudinal follow-up approach.

• The telehealth clinicians will assess patients recovering from COVID19.

• Where the AHS-PLMT triggers further rehabilitation assessment, the clinicians will use

the Primary Care Referral Letters to engage primary care clinicians to follow-up and

determine appropriate clinical rehabilitation steps.

19. The Physicians’ Learning Program (PLP) will undertake the analysis of longitudinal data

for quality improvement and program planning purposes.

There is little consensus on which exact measures to use for long-term follow-up. Experts on

COVID19 and other pandemic diseases (e.g. SARS, H1N1) support the use of standardized

patient-reported outcome measures (PROMs), with additional validated health or functional

outcome measurements. There is also little consensus on the length of follow-up, but current

COVID19 registered clinical trials suggest follow-up for up to 2 years, at frequencies of 3-6 months

(Appendix 3). Most studies focus on patients from Population 1 (hospitalized). Most long-term

studies used numerous validated tools, rather than novel measurement instruments. The number

of tools required for the multiple potential functional sequelae of COVID19 are operationally

prohibitive.

The AHS-PLMT complements the AHS-CRST, with the same foundation (the C19-YRS) but

additional questions. This needs-assessment tool acknowledges the multi-system rehabilitation

needs of patients post-COVID19. Appendices 8 and 9 contain the baseline and follow-up versions

of the AHS-PLMT. Appendix 10 contains the protocol for implementing the longitudinal follow-up.

Telehealth clinicians (at Health Link®/RAL), with expanded capacity and leadership support,

could proactively determine the patients requiring follow-up, contact patients, complete the needs

assessment, and notify primary care as needed. Front-line clinicians will not be called upon to

complete longitudinal follow-up, which advances feasibility. The protocol suggests that all

Population 1 (hospitalized) patients be followed up with irrespective of timing of diagnosis, but

implementation discussions will balance feasibility with clinical needs to determine the appropriate

approach to follow-up with Population 1 (community-only) patients. The latter follow-up may

mobilize multiple platforms including online surveys on MyHealth.Alberta (especially for patients

out-of-window to the follow-up periods) and phone follow-up by Telehealth clinicians for a smaller

cohort of in-window patients (defined by randomization or a particular time period).

COVID19 is unprecedented and its long-term implications on the rehabilitation needs of the

Albertan population are unknown. Longitudinal follow-up is foremost directed at advancing patient

care, and ensuring continuity along the care continuum. The wealth of data to be collected can

advance understanding of the disease sequelae and the actual prevalence and nature of

rehabilitation needs post-COVID19, and inform planning for rehabilitation services accordingly.

The PLP currently collaborates internationally with the International Consortium of Healthcare

Outcome Measurement in designing the latter’s COVID19 Outcome set. This aligned interest on

standardized COVID19 data collection, and the PLP capacity and leadership support, would

ensure their success in data analysis and knowledge translation with key professions and groups

for quality improvement.

IMPLEMENTATION CONSIDERATIONS

Many existing resources and processes in AHS and Primary Care will advance

operationalization of these recommendations. The recommendations will be furthered with

recognition of potential challenges, mitigation strategies, budget and resource considerations. As

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 18

detailed below, the key mitigation strategy is the establishment of an Implementation Committee

in Fall 2020 to oversee and guide recommendation implementation. The Implementation Plan is

anticipated to be finalized by December 2020.

Opportunities & Resources

Current AHS resources fall into two categories to support Taskforce recommendations: (1)

pathways and tools that may be adapted; and, (2) resources that are readily available.

Adaptable Pathways and Tools

The following pathways and tools, which currently do not address rehabilitation, may be

adapted to include rehabilitation-specific requirements or activities. As these pathways and tools

are foundational to the AHS COVID19 response, it is critical that the Taskforce recommendations

align with them and vice versa. The work of alignment has begun (Appendix 4), and the Primary

Health Care Integration Network (PHCIN) has committed to incorporating rehabilitation

information into the Patient Transition Resources.

• H2H2H Transitions Guideline (Primary Care)

• Provincial COVID19 Pandemic Flowsheet: Admission to Acute (from Emergency Department,

Assessment Centre or Observational Unit)

• AHS COVID19 Provincial Pandemic Flowsheet: Patient Discharge from Hospital

• AHS COVID19 Safe Discharge Checklist

• My Discharge Checklist

• Presumed/Confirmed COVID19 Positive Primary Care Pathway

• COVID19 Assessment, Treatment & Stabilization in Place Guide (under development)

• Virtual Care Guidance for Allied Health Professionals

Readily-Available Resources and Programs

• Health Link®/RAL and the Mental Health Help Line could serve as telehealth resources for

patients with COVID19 as well as their care providers in the community (e.g. primary care,

community rehabilitation) or in continuing care settings (e.g. long-term care or supportive living

clinicians). One of these teams could also serve as the hub for longitudinal follow-up,

particularly patient needs assessment and communication with primary care.

• Community Rehabilitation services in Alberta, which can be found using the Community

Rehabilitation Directory. These teams will provide the in-person and virtual rehabilitation

care identified as necessary.

• MyHealth.Alberta team, could help ensure appropriate literacy of the AHS-CRST (screening)

and AHS-PLMT (long-term follow-up) measurement instruments, while the website currently

offers relevant educational resources (and could hold additionally developed resources). This

resource or AHS RedCap could be used to deliver some longitudinal follow-up surveys

electronically to complement the phone follow-up.

• Post-COVID19 Respiratory Clinics in Edmonton and Calgary will follow all hospitalized

patients with protracted respiratory needs post-COVID19 (consider at 2-3 months post-

discharge). Clinic medical leaders are supportive of referrals detected through the Taskforce

recommendations where patients have protracted respiratory needs post-COVID19.

• The PLP creates actionable clinical information and engages with physicians, teams, patients,

and partners to co-create sustainable solutions to advance practice. The PLP could support

audit and feedback of key outcome and process data to care providers and support them to

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 19

interpret this information, identify opportunities and plan practical and effective improvements

to patient care delivery for COVID19 patients.

• The PHCIN will help implement recommendations in primary care, including embedding

screening questions and rehabilitation concepts into Patient Transition Resources.

• Existing discharge and transition coordinators on teams could incorporate

recommendations and thus support the transition of patients in their post-COVID19 functional

recovery.

• The NRV SCN, in collaboration with key stakeholders, provides, and will continue to provide,

leadership and organizational support of the Taskforce and subsequent implementation

activities, respectively.

These resources and their connection to the recommendations herein to advance timely,

appropriate rehabilitation post-COVID reveal the relatively high feasibility of the

recommendations.

Challenges & Potential Mitigation Strategies

The feasibility of implementing these recommendations depends on the anticipation and

resolution of existing barriers and challenges.

Key Mitigation & Implementation Strategy:

• The establishment of an Implementation Committee will

guide implementation of the

aforementioned recommendations in a manner that can be sustained over time by AHS and

its partners across Alberta, and that will ensure consideration of mitigation strategies. The

Implementation Committee should include patient/family advisors,

frontline clinicians,

operational leaders across the Zones, content experts, NRV SCN leadership, SCN partners,

HPSP leadership, primary care, Medical Officer of Health, clinicians along the care

continuum, Health Link®/RAL, and data analytics.

• Data management for longitudinal follow-up will require discussion with stakeholders in

data analytics, the Medical Officer of Health, and Health Link®.

The expected tasks of the Implementation Committee are listed in Table 2, along with the

barriers that they address. The membership of this Implementation Committee will seek input

from key stakeholders early in the process to ensure building on their expertise, involving their

networks, and clarifying ongoing responsibilities. With respect to the data management plan, it

must ensure that the RAL can access necessary datasets to determine, retrospectively and

prospectively, when patients are at appropriate time-points. Data flow considerations must

enable independent, timely data collection by the RAL; available information for the health care

team including primary care; and available information for PLP for data analysis for quality

improvement.

Table 2. Mitigation Strategies & the Barriers They Address

Mitigation Strategy for Implementation Committee

Barrier at Issue

Workflow and capacity implications of these recommendations will

be clarified. Particular considerations include the following:

• What is required for the long-term (6+ months) sustainability

of currently-available resources (e.g. RAL, PLP)?

-Taskforce

recommendations

call for adoption and

adaption of current

resources and

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 20

• How can the proposed strategies (and their implications) be

realized in collaboration with primary care, long-term and

supportive care, Zone Rehabilitation Services, HPSP, AHS

Communications, MyHealth.Alberta, and other stakeholders?

• How can a seamless process be ensured for primary care

provider access to specialist resources and advice lines?

• Who will, and how can, identified programs (e.g. Rehabilitation

Navigators) and pathways (e.g. COVID19 Discharge

Checklist) be adapted to support the Taskforce strategies?

For example, who on the PHCIN will inform and embed

recommendations into existing tools and processes and how

can they reasonably be supported by their workflow?

• What will be the exact timing of (and who will be responsible

for) screening, assessment and longitudinal follow-up

activities to ensure balance between comprehensive care that

is not overly-burdensome to patients and clinicians? How will

the timing of implementation vary between Population 1

(hospitalized) and Population 2 (community-only) patients?

For longitudinal follow-up, should a random sample of

Population 2 (community-only) patients be followed to

determine patient population needs and appropriateness of

follow-up timing (as the current literature only informs long-

term sequelae for hospitalized patients post-COVID19)?

programs across four

areas. There could

be overlap or gaps

without careful, broad

oversight.

-Without public and

provider awareness

of the potential

sequelae of

COVID19 and the

available resources

at AHS, Taskforce

strategies will fall flat

from disuse.

The AHS-CRST and AHS-PLMT must be examined by key informant

groups and pilot tested for validity across care settings and for

different patient populations.

• Patient and family advisors will examine tools for acceptability

• MyHealth.Alberta staff will examine tools for literacy level

• Key experts from primary care, acute care, inpatient

rehabilitation, home care, continuing care, and the RAL will

give feedback on utility, feasibility and comprehensiveness.

• The longitudinal follow-up proposal (Appendix 10) contains

methods for a pilot study on AHS-PLMT reliability and validity.

-Taskforce proposes

novel tools that are

not validated.

-The feasibility of use

of these very

comprehensive tools

is unknown.

The scope, function and resourcing of the RAL must be clearly

identified and articulated. Further elaboration on the links between

the RAL and other programs must be clarified and confirmed (e.g.

continued support and platform from Health Link ®).

The RAL team

supports their broad

role across the

recommendations,

but the RAL long-

term sustainability is

unclear.

Further discussion and planning is required for populations with

diverse considerations affected by COVID19, and those communities

should be included in such discussion and planning. These

populations include continuing care, pediatric populations,

incarcerated populations, populations with low socioeconomic status,

cross cultural/immigrant populations, Indigenous populations, and,

Hutterite communities. Initial considerations were discussed briefly in

the ACRSD by WG2 (Appendix 6).

-Taskforce

recommendations do

not consider all

populations.

Confirmation is required on the suitability and required augmentation

of patient and provider educational resources. These resources will

-Taskforce

recommendations will

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 21

support transitions and self-management for patients with COVID19.

Particular considerations include the following:

• How to develop clear guidelines and materials (e.g.

infographics) to accompany the AHS-CRST to support

clinicians in operationalizing recommended screening

strategies and tools?

• Whether cost-effective, online exercise programs integrated

on MyHealth.Alberta are an appropriate investment?

• Whether, and what, further post-COVID19 rehabilitation-

related content is required on MyHealth.Alberta (e.g. videos,

podcasts, reliable internet resources for different levels of

health literacy and style of learning)?

require some

capacity to prioritize,

design and

disseminate

educational

resources.

-Introduction of new

tools and processes

requires concomitant

education and

support for effective

implementation.

Implementation strategies are required to enable fuller realization of

virtual care opportunities and strategies. HPSP has developed

guidance for allied health professionals in providing virtual care. The

provincial Virtual Health team is another key resource. These

resources support virtual care provincially, including that of

rehabilitation post-COVID19.

-Existing resources to

advance virtual care

in rehabilitation are

not fully

implemented.

BUDGET & RESOURCE IMPLICATIONS

The Taskforce recommendations emphasize feasibility and efficiency. Based on current

activities and discussions with stakeholders, the Taskforce anticipates in-kind contributions from

many key programs and teams who will be essential to implementation of the recommendations,

including the following:

• Data analytics and Health Link® (around the data management strategy)

• The PHCIN, Discharge and Transition Planning, MyHealth.Alberta, PLP as well as clinical

and programmatic teams in hospital and community (around development of educational

materials, and incorporation of recommendations into existing pathways and tools)

• AHS Communications (around communications plan)

As a whole, these recommendations are primarily revenue neutral. Only one of the 19

recommendations may implicate budgetary changes because it calls for a novel activity: the

proactive longitudinal follow-up at 3, 6 and 12 months. This strategy will first target Population 1

(hospitalized) within a few months, and then follow-up with all patients who tested positive for

COVID19 in Alberta. Recent findings from Italy that followed hospitalized patients with COVID19

reported that, at 2-months post-discharge, 32% of patients had 1-2 symptoms, 55% had three or

more symptoms, and only 12% of patients had no symptoms [11]. In longitudinal follow-up, it is

reasonable to expect around 10% attrition at each follow-up time-point as not all patients can be

reached due to patient mobility, disinterest and other causes [12].

Our understanding is that there may be potential capacity on the provincial Mental Health Help

Line operated by Health Link® to support implementation of long-term follow-up as this initiative

supports the psychosocial health needs of patients recovering from COVID19. Further discussion

by the Implementation Committee will be required to determine the actual logistics (including

frequency of calls, phasing of calls based on population types, professional discipline of follow-up

clinician, and appropriateness of a phone-online hybrid model of follow-up) and final staffing

required.

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 22

CONCLUSIONS

Literature reviews and expert consultations demonstrate that, locally and internationally, the

long-term rehabilitation needs of adult patients recovering from COVID19 can be diverse, wide-

spread, and of unknown duration. A global pandemic that remains unchecked around its long-

term consequences, particularly related to functioning and mental health, will introduce greater

population-wide morbidity, increased health service and pharmaceutical utilization, and

decreased productivity.

The development of a provincial strategy is needed to ensure timely, standardized and

coordinated rehabilitation for adult patients post-COVID19 across the care continuum. This

approach will ensure the identification, assessment and management of rehabilitation needs post-

COVID19 along the care continuum. The approach builds towards self-management, living well

in the community, reduced use of acute care, and a comprehensive, efficient nature.

The Taskforce strategy includes 19 recommendations. These recommendations (a) introduce

questions and tools for screening and long-term follow-up that will feedback to the care team to

support further discussions and assessments; (b) provide insight in how to prioritize rehabilitation

assessments and management across the care continuum; and, (c) strategize how discharge and

transition planning processes can advance care of rehabilitation needs post-COVID19. An

Implementation Committee should shepherd these recommendations into operational to forestall

the vast rehabilitation implications of COVID19 for Albertans.

These recommendations fit in existing care pathways and leverage existing resources and

programs, particularly the Health Link®/RAL, the Mental Health Help Line, PLP, Post-COVID19

Respiratory Clinics and MyHealth.Alberta. These existing pathways and resources, along with

their associated leadership and teams, demonstrate why AHS is well-positioned to implement this

strategy.

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 23

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Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 28

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 29

APPENDIX 1: WORKING GROUP OBJECTIVES

Working Group

Description

(Number, Name / Focus,

& Co-Chairs)

Objectives to Develop Scope

1. Screening

(Shayne Berndt &

Peter Sargious)

• Evidence-based systematic criteria for initial

identification of, or screening for,

rehabilitation issues / needs for persons with

COVID19

o Identify/develop screening tool

o Ensure tool is efficient and feasible

o Consider clinical recommendations and

guidelines for screening

o Consider pre-existing co-morbidities

o Capacity for tool to be completed by any

clinician and/or patient/family member

• Across care

continuum from

acute care to

community care

• Screening may

begin in acute care

settings and move to

community services

2. Rehabilitation

Strategies

(Carol McCarthy &

Christopher Grant)

• Setting-specific, evidence-based clinical

recommendations and guidelines for early

post-COVID19 rehabilitation assessment and

treatments

• Criteria / assessment tool for different levels

of care and clinical considerations for

specialty care

• Implementation recommendations for

rehabilitation interventions to prevent

unnecessary emergency department

utilization and hospital (re-) admission

• Across care

continuum from

acute care to

community care

3. Discharge &

Transition

(Laura Benard &

Mareika Purdon)

• Coordinated approach to patient flow through

acute care / rehabilitation / community

• Discharge and transition criteria specific to

rehabilitation needs for persons post-

COVID19 across the care continuum

• Provincial patient and family resources for

COVID19 rehabilitation

• Across care

continuum from

acute care to

community care

4. Longitudinal

Monitoring

(Elisavet

Papathanassoglou &

Cyndie Koning)

• Criteria for longitudinal monitoring of

functional independence of persons with

COVID19

• Evaluation framework to assess the impact of

the above strategies at the patient, clinician

and health systems levels

• Focus on post-

discharge monitoring

in the community

• Recommended to

start with patients

who received care in

acute care settings

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 30

APPENDIX 2: MEMBERSHIP

Overall Taskforce

Taskforce

Position

Name

Position

Department

Zone

Co-Chair

Catherine Hill

Acting Senior

Operating Officer

Glenrose Rehabilitation

Hospital

Edmonton

Co-Chair

Elaine Finseth

Associate Chief Allied

Health Officer,

AHPPE

Health Professions Strategy

& Practice

Central

Co-Chair

Petra O'Connell

Senior Provincial

Director

NRV & DON SCN

Calgary

SCN support

Brooke Blythe

Practice Lead

Critical Care SCN

North

Member

Carol Kirkland

Physiotherapy

Practice Lead

Red Deer Regional Hospital

Central

Member

Carol McCarthy

Program Manager

Rehabilitation & Allied

Health Services

Edmonton

Member

Chester Ho

Senior Medical

Director

NRV SCN

Edmonton

Member

Christopher Grant

Physiatrist

ICU Recovery Clinic

Calgary

Member

Cyndie Koning

Healthcare

Improvement

Specialist

Glenrose Rehabilitation

Hospital, Healthcare

Improvement Team

Edmonton

Member

Darren Ness

Director

Allied Health Calgary Zone

Calgary

Member

Doug Kremp

Respiratory Therapy

Clinical Lead, North

Zone

Respiratory

North

Member

Doug Pratt

Program Manager

Community Rehabilitation

(Adults) - Calgary Zone

Calgary

Member

Elisavet

Papathanassoglou

Scientific Director

NRV SCN

Edmonton

Member

Giovanni Ferrara

Respirologist

Pulmonary / Respiratory

Medicine

Edmonton

SCN support

Glenda Moore

Senior Consultant

NRV & DON SCN

Calgary

Member

Jason Daoust

Physical Therapy,

North Zone Clinical

Lead

Allied Health

North

Member

Jason Knox

Manager

Clinical Neurosciences

Calgary

Member

Jim Silvius

Senior Medical

Director

Seniors Health SCN

Calgary

Member

June Norris

Senior Practice lead

Physiotherapy

Health Professions, Strategy

& Practice

Edmonton

Member

Laura Benard

Senior Practice

Consultant

Allied Health Professional

Practice & Education

Calgary

SCN support

Jeanna Morrissey

Manager

Critical Care SCN

Calgary

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 31

SCN support

Kiran Pohar

Manhas

Assistant Scientific

Director

NRV SCN

Calgary

Member

Lindsay Stark

Manager

Allied Health

Edmonton

Member

Lisa Warner

Director

Community Rehabilitation

Edmonton

Member

Lisa Waselenchuk

Operations Manager

Facility & Supportive Living,

Allied Health & Specialty

Services

Edmonton

Member

Lois Ward

Senior Operating

Officer

Peter Lougheed Hospital

Calgary

Member

Mareika Purdon

Clinical Quality

Consultant - Patient

Flow

Integrated Quality

Management

Edmonton

Member

Nancy Fraser

Senior Provincial

Director

Critical Care SCN

Calgary

SCN support

Nicole McKenzie

Manager

NRV SCN

Calgary

Member

Patrick Mitchell

Respirologist

Respiratory / Pulmonary

Medicine

Calgary

Member

Peter Sargious

Senior Medical

Director

Internal Medicine, Calgary

Zone

Calgary

Member

Raiyan

Chowdhury

Intensivist, ENT

Specialist

Edmonton Zone Post-ICU

Follow-up Clinic, Critical

care, Otolaryngology - Head

& Neck Surgery

Edmonton

Member

Risa Olsen

Manager

Occupational Therapy

(South Zone-West)

South

Member

Shantel

Farncombe

Interim Manager

Integration, Innovation,

Provincial Primary Health

Care

South

SCN support

Selvi Sinnadurai

Executive Director

NRV SCN

Edmonton

Member

Shayne Berndt

Manager

OT South Zone-East: Stroke

Support Team &Home

Rehabilitation Team

South

Member

Sherri Kashuba

Executive Director

Critical Care SCN

Edmonton

Member

Tom Hufkens

Manager

Rural Allied Health

Calgary

Member

Tricia Miller

South Zone Manager

Speech Language Pathology,

Audiology, Children's Allied

Health

South

Member

William Tung

Professional Practice

Leader -

Physiotherapy

Rehabilitation Services,

Royal Alexandra Hospital

Edmonton

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 32

Working Group #1 - Screening

Position

Name

Position

Department

Zone

Clinical

Lead

Co-Chair

Peter Sargious

Senior Medical

Director

Internal Medicine, Calgary

Zone

Calgary

Operational

Lead Co-

Chair

Shayne Berndt

Manager

Occupational Therapy South

Zone-East: Stroke Support

Team & Home

Rehabilitation Team

South

SCN

Support

Glenda Moore

Senior Consultant

NRV SCN

Calgary

Member

Shantel

Farncombe

Interim Manager

Integration, Innovation,

Provincial Primary Health

Care

South

Member

Eileen Keogh

Senior Practice

Consultant

Allied Health Professional

Practice & Education

Edmonton

Member

June Norris

Senior Practice Lead

Physiotherapy

Health Professions, Strategy

& Practice

Edmonton

Member

Melani Gillam

Provincial Practice

Lead - Standards &

Practice

Nutrition Services

Calgary

Member

Shawna McGhan

Senior Planner

Primary Health Care

Edmonton

Member

Hilary Gray

Clinical Educator

Allied health

Calgary

Member

Doug Kremp

Respiratory Therapy

Clinical Lead, North

Zone

Respiratory

North

Member

Ashley Bissett

Health Educator -

Occupational Therapy

Allied Health & Specialty

Services

Member

Doug

Woodhouse

Medical Director

Physician Learning Program

Calgary

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 33

Working Group #2 – Rehabilitation Strategies

WG Position

Name

Position

Department

Zone

Clinical Lead

Co-Chair

Christopher

Grant

Physiatrist

ICU Recovery Clinic

Calgary

Operational

Lead Co-

Chair

Carol McCarthy

Program Manager

Rehabilitation & Allied

Health Services

Edmonton

SCN Support

Brooke Blythe

Practice Lead

Critical Care SCN

North

Member

Mike Stickland

Pulmonologist

EGH Respiratory Rehab /

UAH Pulmonary Division

Edmonton

Member

Marlis Atkins

Director

Adult & Seniors

Health/Patient Education

Resources & Documentation

Provincial Strategy,

Standards & Practice

Nutrition Services

Edmonton

Member

Stephanie Oviatt

Clinical Practice Lead

(PT)

Allied Health

Calgary

Member

Megan Terrill

Senior Practice

Consultant

Provincial Rehabilitation

Red Deer

Member

Nicole Morin

Occupational

Therapist

UofA Hospital

Edmonton

Member

Alison Foxford

Speech Language

Pathologist

Glenrose

Edmonton

Member

Melani Gillam

Provincial Practice

Lead - Standards &

Practice

Nutrition Services

Calgary

Member

Kristin

Christensen

Professional Practice

Lead

Covenant Health

Physiotherapy

Edmonton

Member

William Tung

Professional Practice

Lead

Physiotherapy

Edmonton

Member

Hilary Gray

Clinical Educator

Allied health - Calgary Zone

Calgary

Member

Laura Cunliffe

Social Worker

UAH / MAZ

Edmonton

Member

Lauren Singh

Physiotherapist

Community Accessible

Rehabilitation

Calgary

Member

Tracey Telenko

Professional Practice

Lead

Respiratory Services UAH,

MAHI & RAH

Edmonton

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 34

Working Group #3 - Discharge & Transition Planning

WG Position

Name

Position

Department

Zone

Operational

Lead Co-Chair

Mareika Purdon

Clinical Quality

Consultant - Patient

Flow

Integrated Quality

Management

Edmonton

Rehabilitation

Lead Co-Chair

Laura Benard

Senior Practice

Consultant

Allied Health Professional

Practice & Education

Calgary

SCN Support

Jeanna Morrissey

Manager

Critical Care SCN

Calgary

Patient &

Family

Advisor

Janice MacRae

Patient & Family

Advisor

N/A

Calgary

Patient

Advisor

Ron Bradley

Patient Advisor

N/A

Edmonton

Member

Raj Padwal

Professor of

Medicine & Co-

Director

Clinical Epidemiology,

Clinical Pharmacology &

General Internal Medicine

Professor of Medicine & Co-

Director, Hypertension

Dyslipidemia Clinic

Edmonton

Member

Jennifer Lee

OT, Senior Quality

Consultant

Seniors, Palliative &

Continuing Care

Calgary

Member

Shantel

Farncombe

Interim Manager

Integration, Innovation,

Provincial Primary Health

Care

South

Member

Mike Stickland

Pulmonologist

EGH Respiratory Rehab \

UAH Pulmonary Division

Edmonton

Member

Nicole Morin

Occupational

Therapist

UofA Hospital

Edmonton

Member

Lisa Waselenchuk

Operations Manager

Facility & Supportive Living,

Edmonton Zone, Allied

Health & Specialty Services

Edmonton

Member

Debbie Boudreau

CORE lead patient

access

Patient Access, Connect

Care - Clinical Operations

Calgary

Member

Catherine

Johansen

Manager

Respiratory Health &

Outpatient Cardiology

South

Member

Marlis Atkins

Director

Adult & Seniors Health/

Patient Education

Resources &, Nutrition &

Food Services

Edmonton

Member

Melissa Sztym

Team Lead

Covenant Health

Professional Practice Lead,

OT & Team Lead for Stroke

ESD Program

South

Member

Doug Pratt

Program Manager

Community Rehabilitation

(Adults) - Calgary Zone

Calgary

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 35

Member

Risa Olsen

Manager

Occupational Therapy,

South Zone-West

South

Working Group #4 - Longitudinal Monitoring & Tracking

WG Position

Name

Position

Department

Zone

Co-Chair

Elisavet

Papathanassoglou

Scientific Director

NRV SCN

Edmonton

Co-Chair

Cyndie Koning

Healthcare

Improvement

Specialist

Glenrose Rehabilitation

Hospital, Healthcare

Improvement Team

Edmonton

SCN Support

Kiran Pohar

Manhas

Assistant Scientific

Director

NRV SCN

Calgary

Member

Giovanni Ferrara

Respirologist

Pulmonary Medicine

Edmonton

Member

Katie Churchill

Senior Practice Lead

Health Professions Strategy

& Practice

Calgary

Member

Adalberto Loyola

Sanchez

Physiatrist

Assistant Professor Division

of Physical Medicine &

Rehabilitation Department

of Medicine Faculty of

Medicine & Dentistry

Glenrose Rehabilitation

Hospital

Edmonton

Member

Jia Hu

Zone Medical Officer

of Health

Medical Officer of Health

Calgary

Member

Elizabeth Mackay

Facility Medical

Director

Peter Lougheed Centre

Calgary

Member

Doug Woodhouse

Medical Director

Physician Learning Program

Calgary

Member

Jason Daoust

PT, North Zone

Clinical Lead

Allied Health

North

Member

Jo Harris

Senior Analytics &

Project Consultant

Critical Care Strategic

Clinical Network

Calgary

Member

Sue Buhler

Research &

Academic Lead

Nutrition Services

Edmonton

Member

Tom Briggs

Senior Program

Officer

Planning & Performance

Calgary

Member

Patrick Mitchell

Respirologist

Respiratory / Pulmonary

Medicine

Calgary

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 36

APPENDIX 3: DETAILS ON BACKGROUND FOR WG1, WG3 & WG4

The following provides more details on the background, and understanding of current practice,

which select Working Groups (WGs) developed in addressing their stated objectives. This

appendix is limited to WG1, WG3 and WG4 because WG2’s background is embedded in their

final report.

WG1: Screening

● Background: COVID191919 Scientific Advisory Group Rapid Evidence Report (May

19/20); Primary Care COVID191919 Management Pathways (Central & Calgary Zone)

including the Guideline for Monitoring and Managing COVID19 Patients in the

Community; COVID1919 19 Yorkshire Rehab Screen (C19-YRS) (1); EQ-5D-5L (2);

Canadian Nutrition Screening Tool (3); Dyspnea Breathlessness Scale (4) were

reviewed.

● Literature Review: British Society of Rehabilitation Medicine – Responding to COVID19

and Beyond (5), including the PICUPS tool (6) and PICUPS Plus Tool; The Stanford

Hall Consensus Statement for Post-COVID19 Rehabilitation; Poverty: A Clinical Tool for

Primary Care Providers (7)

● Grey Literature: AHS Connect Care-Social Determinants of Health Care Domains (8);

AHS Connect Care Functional Independence Adults Orders Decision Making Pathway

(9)

Current Practices or Strategies

● Patients admitted to hospital (acute care unit or ICU) for treatment of COVID19 are

currently being followed by a primary care provider or hospitalist physician, specialists

and/or multidisciplinary team based upon typical referral pathways. This same team is

responsible for the assessment, treatment and transition of this patient to community

healthcare professionals as part of the discharge plan. See, Provincial COVID19

Pandemic Flowsheet: Admission to Acute (from Emergency Department, Assessment

Centre or Observational Unit), AHS COVID19 Provincial Pandemic Flowsheet: Patient

Discharge from Hospital, AHS COVID19 Safe Discharge Checklist, Home to Hospital to

Home Transitions Guideline.

● Patients recuperating within the community are currently being followed up by their

primary care provider according to their COVID1919 pathway guidelines; referrals made

to homecare and other services as required. See Presumed/Confirmed COVID191919

Positive Primary Care Pathway, COVID191919 Assessment,Treatment & Stabilization in

Place Guide (under development)

● COVID19 clinics are under development in larger centres within Alberta Health Services

● Residents of continuing care facilities are also followed by their primary care provider but

access to rehabilitation services varies with each site; those providers can refer to

ambulatory rehabilitation services if the resident has a means of transportation to those

services

● AHS is in discussion with establishment of a COVID19 registry.

● Rehabilitation Advice Line went live (May 12, 2020) in the province to assist individuals

within the community with navigation of the healthcare system, specifically in regards to

rehabilitation services available to them.

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 37

WG3: Discharge & Transition Planning

What are the principles of a successful rehabilitation discharge and transition?

Home to Hospital to Home Guideline:

if-hp-phc-phcin-ht

hth-guideline.pdf

This guideline presents leading operational practices, change management, tools and

resources and information for 6 key components of successful transitions from home to

hospital to home:

• Confirmation of the Primary Care Provider

• Admit Notification

• Transition Planning

• Referral and Access to Community Supports

• Transition Care Plan

• Follow-Up to Primary Care

Rehabilitation discharge and transitions can be threaded throughout the H2H2H document

including community supports. Of note for rehabilitation transition planning are some core

concepts that align with key rehabilitation documents. These include: Preparing patients,

family and caregivers for their recovery at home is at the heart of transition planning. This

process should occur as early as possible after admission for all patients. Successful

planning requires the active participation and involvement of patients, family and

caregivers and the circle of care team. This step can help the patient navigate many of the

challenges associated with transitions in care.

There are a number of different factors required for effective transition planning, including an

individually tailored, easy-to-understand transition care plan. This plan provides a

comprehensive set of resources that will support a safe transition in care.

Key challenges:

1. lack of informational continuity between hospital and patients’ circle of care;

2. discrepancies in medication lists before and after discharge;

3. inadequate preparation with patients, family and caregivers prior to discharge.

These challenges can increase the burden of care, confuse patients, family and caregivers

and lead to undesirable outcomes (e.g. hospital readmissions, emergency department visit,

etc.).

Rehabilitation Model of care:

Rehabilitation MoC

Guide-Feb2019.pdf

R-

MoC-CR-Imp-Guide-

1. Safe Transitions

Primer Final.pdf

Safe Transitions are defined as: A process with defined standards, actions and resources to

ensure safe, streamlined and coordinated care at points of transition between healthcare

Post-COVID Rehab Task Force Final Report

September, 2020 v 5.0 38

providers, services or service sectors. Safe transitions are based on a customized care plan

that is co-created with patients, families and care teams. The care plan addresses patient

care needs and goals, utilizes available resources and incorporates self-care education

and strategies. From the initial visit, healthcare providers proactively plan with and support

patients & families through treatment and points of transition to ensure continuity of care.

Standards associated with safe transitions include:

1. Patients and families are engaged partners in all phases of care, including goal-setting,

care planning, treatment and transitions to the level and degree desired by the patient /

family.

2. Goal-setting and treatment planning begins during the initial visit, incorporates

previous care planning and includes proactive planning for care transitions.

3. Information transferred at care transition includes a customized care plan co-created

with the patient/family and healthcare providers - considering individual environment,

circumstances, family context and community context.

4. Healthcare providers use a standardized tool/s for documenting and transferring

information.

5. Standardized information for a safe and streamlined transition is up-to-date and complete,

documented, and presented in a way that is easily understood by the patient/family and

healthcare providers.

6. Communication occurs between the current healthcare provider/s and the receiving

healthcare provider/s.

7. Patient/family is aware of and understands the transition plan and has contact

information for the sending and receiving healthcare provider/s or service.

8. Patients/ families receive information and education required to make decisions and

use self-care strategies as applicable.

Rehabilitation Conceptual Framework:

tms-prs-prov-rehab

-conceptual-framew

The RCF enables teams to conceptualize, design and deliver rehabilitation services where

rehabilitation is guided by the philosophy of “enhancing function for meaningful living.” The

key principles and beliefs of rehabilitation include:

People are at the centre of rehabilitation in AHS

Services focus on ability - through capacity building, prevention, fostering resourcefulness,

and enhancing or restoring function

Rehabilitation contributes to wellness across the continuum of health, the lifespan and

generations - impacting the health and wellbeing of the whole person and their community

Rehabilitation enables and encourages people to identify, reach and maintain their cognitive,

communicative, emotional, physical, psychological, social and spiritual health goals

Rehabilitation services are planned and provided using a continuous learning process

People are matched to service options based on their needs at different times of life

Quality rehabilitation comes from professional practice that is person centred, wholistic,

integrated and guided by evidence

Client Advisor perspective:

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September, 2020 v 5.0 39

Acknowledge that we are still learning about COVID1919 and don’t know everything and that

new information may come available in the future.

Provide information about what might be needed.

Focus on building the patient’s ability to support themselves, build their confidence, self-

efficacy, and their ability to self-manage.

Human interaction is needed, patients need to feel safe and confident with the person they

are talking to. Limit the number of contacts a patient needs to make.

Family members or others in the patient’s home are important supports as well as the

patient’s primary care provider.

Lack of patient focused information.

Patient information should focus on wellness and be more collaborative rather than

directive using adult learning principles.

Client contracts can be used to further promote wellness and self-management.

Considerations –

• Embed rehabilitation concepts and language into transition documents across AHS

and primary care when new documents are created or when documents are open for

revisions. (e.g. H2H2H, COVID1919 D/C check list, COVID1919 patient discharge

handout) with a focus on active involvement of the client and family, information

sharing and communication.

• Discharge and transition supports should focus on active involvement of the client and

family including goal setting, information sharing and communication and enhancing

function including supporting self-care or self-management.

• Central place for COVID1919 patients to receive rehab care virtually.

• Patient education/resource materials also available on an accessible web page.

What existing resource are there that support discharge and transition? Or that can inform a

provincial approach to access across the province?

Home to Hospital to Home guideline

Rehabilitation advice line

Fracture liaison service

Rehab navigator role (GRH)

Virtual care resources

Virtual Hospital

COVID1919 discharge checklist

My discharge checklist

Ontario’s Rehabilitation Care Alliance Guidelines for Frail seniors in the context of

COVID1919.

RAAPID

Integrated Operations Centre (IOC) Edmonton Zone

Rehabilitation Model of Care

Community Rehabilitation Directory

Alberta Referral Directory

Guideline for monitoring COVID1919 patients in the community

211, 811 Health Link®

Early Supported Discharge (stroke)

AHS virtual care resources.

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September, 2020 v 5.0 40

Considerations:

• Leverage existing program information such as job descriptions, evaluation plans and

key performance indicators to develop a strong evaluation plan.

• Exercise caution to avoid duplication or overlap with existing services.

What are the transition points across the continuum of Care?

Rehabilitation transitions are not linear and often skip across the continuum of care. The

volume and variability of transitions across the continuum of care combined with the variability

of programs and services across Alberta make defining a consistent approach difficult. The

diagram below identifies the multiple areas of transition that exist across the continuum of

care. While the number of different types of transitions for rehabilitation patients is high an

approach that follows key principles of transition and focuses on key areas of transition for

patients with or recovering from COVID1919 is possible.

Specific transition points identified for COVID1919 patients:

Hospital to home/community -consider home care and community options, collaboration

with primary care.

Home/community to rehabilitation - consider home care and community options,

collaboration with primary care.

Continuing care – potential for change in function requiring rehabilitation, consider home

care and supportive living needs.

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September, 2020 v 5.0 41

WG4: Longitudinal Outcome Monitoring

RAPID LITERATURE REVIEW

In brief, a rapid literature review yielded 27 articles and 12 registered clinical trials that inform

what outcomes, measurement tools, and methodological strategies are used to longitudinally

follow-up persons with COVID19 (or other coronavirus illnesses). In what follows, we overview

the review methods, describe the overarching framework, and then synthesize the literature

around recommended outcomes, tools and methods for longitudinal follow-up of persons with

COVID19 in post-acute and community experience groups.

Rapid Review Methods

The rapid literature review commissioned for WG4 (and completed by Nicole Loroff, AHS

Knowledge Resource Services), involved three specific questions:

1) What outcomes and measurement tools are considered in the longitudinal follow-up of post-

acute COVID19 patients, particularly related to functional outcomes and independence?

2) What research methods are proposed, or being utilized, to longitudinally monitor the post-

acute outcomes of COVID19 patients?

3) What strategies have health systems used in post-pandemic settings to longitudinally

monitor the outcomes for persons who experienced the pandemic illness? Pandemics of

relevance include COVID19, SARS, MERS, and H1N1.

The concomitant search strategy included eight databases (MEDLINE (via Ovid), PubMed, TRIP

Pro, LitCOVID1919, WHO COVID19 Research Database, OTseeker, PEDro, Google Scholar,

and Clinical Trials.gov). Search terms related to the concepts of coronavirus, longitudinal follow-

up, rehabilitation and post-acute. There was no limit on study design, but only English-language

papers were included.

This search strategy yielded 77 peer-reviewed articles, four grey literature articles, and 13

registered clinical trial summaries. These 94 documents were screened by two reviewers at the

title-abstract level. Thereafter, 28 articles and 12 registered clinical trials were included for full-

text extraction. Data extracted from each article included country, pandemic illness of interest,

types of patients examined, multiple versus single domains of interest, types of outcomes, number

of outcome measurement tools used or proposed, tool names, whether mapped to the

International Classification of Functioning, Disability and Health (ICF) framework and

methodological details (e.g. duration and frequency of follow-up).

Framework of Approach

Research considering the current needs of COVID19 patients post-discharge suggests that

outcomes must be viewed from a framework that considers their mental health, physical health,

and their participation within their home, social, and work environments [13–16]. Longitudinal

monitoring of COVID19 patients within these parameters facilitates direct patient care that

improves quality of life. The ICF, produced by the World Health Organization, provides a

framework to examine the disabling effects of COVID19 by establishing the impairments, activity

limitations and participation restrictions that result from the interaction between the persons with

COVID19 and their environment [17].

While most screening and long-term measurement studies, both for COVID19 and other

disease pandemics such as SARS and H1N1, address areas of body function and structure (e.g.,

pain, immunological and respiratory systems, movement, mental health), fewer address more

than a few areas of activity and participation. Some notable gaps which may be considered would

include participation beyond engagement in work (employment) to include engagement in other

activities such as learning, interpersonal relationships, and community life. In addition, there also

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appears to be gaps in measurement related to personal and environmental factors impacting

rehabilitation, such as caregiver support, housing, or access to rehabilitation services.

Synthesis of the Literature & Registered Clinical Trials

Most published articles were from Hong Kong (n=8), with the rest originating from China (n=3),

international groups (n=3), the UK (n=4), Australia (n=2), Canada (n=2), USA (n=2), as well as

individual articles from Germany, Ireland, and Spain (two articles had unclear origins). These

articles focused on different pandemics: COVID19 (n=12), SARS (n=10), H1N1 (n=3), and

multiple pandemics (n=3).

Most articles focused solely on persons discharged from the ICU (n=19) or hospital generally

(n=23). Seven articles considered the follow-up of non-hospitalized positive patients (i.e. the

community experience group). Seven studies focused on a single category of outcomes (e.g. only

psychological outcomes, only cardiac outcomes, or only pulmonary implications), while the

remaining studies considered multiple categories of outcomes (e.g. physical, psychological, and

pulmonary implications).

Measurement Tools

Of the 19 articles that clearly described measurement tools or strategies to longitudinally

follow pandemic survivors, the mean, median and mode number of tools described were 4.7, 3,

and 1 (minimum 0, maximum 18), respectively. Articles generally prescribed data collection using

patient-reported outcomes measures (n=24), diagnostic imaging (n=12), laboratory testing (n=4),

and health services utilization data (n=4).

WG4 prepared a more fulsome report that (a) details the conceptual focus of the measurement

tools described, how many tools within each conceptual focus, the total number of articles that

cite that tool, and the most frequently cited tool; and (b) lists all the specific tools by name. There

were 16 distinct conceptual focuses described, such as quality of life, physical function,

depression/anxiety, respiratory function, impact on caregiver, and COVID191919-specific tools

(Figure 1). For each focus, the mean (standard deviation) and median number of tools were 3.5

(2.42) and 3, respectively (minimum 1 and maximum 8). The focuses with the most tools

described included physical function (n=8), depression/anxiety (n=8), with exercise tolerance

(n=6) and fatigue (n=6) close behind.

For each focus, the mean (standard deviation) and median number of citations were 6.9 (6.85)

and 4.5, respectively (minimum 1 and maximum 20). The most frequently cited tools were the SF-

36 for quality of life (12 citations), the 6-minute walk test (12 citations), and the Hospital Anxiety

and Depression Scale (9 citations). Four papers proposed novel, COVID19-specific tools, which

each targeting a spectrum of potential sequelae. No pilot or validation data was offered for

COVID19 specific tools.

Methodology for Follow-up

Methodologically, there was great heterogeneity across the identified studies around the

methods, duration and frequency of data collection for longitudinal outcomes. Seven articles

include only high-level considerations for, not implementation of, longitudinal follow-up of

COVID19 survivors. In articles focused on the sequelae of SARS and H1N1 pandemics, (a) an

observational cohort design was used; (b) hospitalized pandemic patients were the focus; (c)

study duration was 1, 1.5, 2 or 4 years post-discharge; and (d) the frequency of follow-up ranged

from one time to every three months [18–29]. For the articles addressing the COVID19 pandemic,

some were focused on clinical follow-up, while others described the need for longitudinal research

without specifying methodology [13–17,30–36]. Frequency and duration of follow-up is described

in weeks (every 2, 3 or 4 weeks) and months (up to 2), respectively.

The full WG4 report lists the currently registered clinical trials focused on the long-term

outcomes of COVID19 survivors. Almost all clinical trials address either COVID19 positive

persons who received critical care or in-patient acute care. Most trials examine multiple potential

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September, 2020 v 5.0 43

sequelae. Methodologically, most studies are observational cohorts that prioritize patient-reported

outcome measures with monitoring duration and frequencies of up to 24 months and at 3-6 month

intervals, respectively. Most measurement tools have been used and validated previously. New

COVID19-specific measurement instruments are not proposed by these registered clinical trials.

Summary:

This review suggests that monitoring of post-COVID19 patients should address both disease-

related impairments and their impact on activities and participation in life. The literature supports

the use of standardized patient-reported outcome measures (PROMs), with additional specific

health/functional measurements. There is little consensus on which measures to use. Most

research does suggest inclusion of a health-related quality of life measure and a mental-health

measurement tool. There is little consensus on the length of follow-up, but current clinical trials

suggest follow-up for up to 2 years. Observational cohorts, which describe the patient population,

rather than compare them to other populations, appear to be the most frequently used

methodology.

CURRENT PRACTICE OR STRATEGIES

While a systematic longitudinal monitoring program is not in place in Alberta for COVID19

positive persons, there are planned programs and strategies, as well as current data repositories,

which relate to, and could advance, the longitudinal monitoring of post-discharge and community-

experience persons with COVID19.

Planned Programs & Strategies

Once persons are diagnosed with COVID19, four programs and strategies may relate to long-

term monitoring. First, the primary care pathway for COVID19 indicates that patients are called

every 1 or 2 days for at least 14 days upon diagnosis to assess symptoms and needs. For patients

who experience COVID19 and did not require hospitalization, follow-up stops at 14 days. If further

symptoms develop, primary care uses SpecialistLink to facilitate rapid access to specialists (e.g.

infectious disease, respiratory assessment and intervention, public health). On rare occasions,

community paramedics are available to perform wellness checks in person as required. Remote

patient monitoring using pulse oximetry is being considered.

Second, where patients with COVID19 are hospitalized in intensive care units, they may be

followed post-discharge by an ICU Recovery clinic (Foothills Calgary), a specialized clinic on

feeding and swallowing (Edmonton) or the dysphagia clinic (Calgary). Online resources are also

available (e.g. mental health, available rehabilitation resources, relevant websites). The post-ICU

clinic collects data on the symptoms and experiences of patients.

But, to date, the number of

post-COVID19 patients who have visited this clinic is low despite the number of ICU-

hospitalizations in Calgary Zone; and, the clinic cannot offer provincial longitudinal monitoring.

Third, newly-initiated post-COVID1919 clinics in Edmonton and Calgary intend to follow all

patients requiring long-term medical care for the respiratory sequelae of COVID19. The Edmonton

post-COVID1919 clinic is physician-led with support from respiratory therapists; referrals are

accepted upon discharge from hospital teams, from family physicians and all other specialty

physicians. The Calgary post-COVID1919 clinic is similar, but includes nursing and a link to

mental health support. The clinics will facilitate close monitoring, timely investigation and prompt

intervention for respiratory problems. Initial follow-up will be at 3 months unless earlier is deemed

necessary. A REDCap database has been developed to track process outcomes and collect

patient data (i.e. full pulmonary function tests, 6-minute walk test, blood work, chest x-ray, and

https://www.albertahealthservices.ca/info/Page15597.aspx

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September, 2020 v 5.0 44

several patient-reported outcome measures). Because the sequelae of COVID19 extend beyond

respiratory conditions to include other bodily systems and structures, the provincial longitudinal

monitoring of outcomes for post-acute (and post-community) recovered COVID19 patients should

link with, but extend beyond, the post-COVID1919 clinic dataset.

Fourth, the Rehabilitation Advice Line (RAL) was launched on May 12, 2020. This telehealth

line is housed under Health Link®; is operated by occupational therapists and physical therapists;

and offers education, self-management support and wayfinding for rehabilitation-related

questions. The RAL specifically targets the rehabilitation needs related to musculoskeletal,

neurological and COVID19 disability. Currently, the RAL involves clinicians answering calls

directly or performing call backs to callers to other lines (e.g. Health Link®) or after hours. RAL

clinicians are licensed allied health professionals who discuss past medical history, current

functional issues, social support and living arrangements, and community access. There is an

opportunity for, and RAL leadership interest in, the RAL clinicians using the call back feature to

implement follow-up longitudinal monitoring surveys with the post-discharge (Phase 1) and

community-experience (Phase 2) persons diagnosed with COVID19. The availability and in-kind

contribution of the RAL clinician time may promote the feasibility and sustainability of the

longitudinal monitoring of the functional outcomes of persons diagnosed with COVID19.

Data Repositories & Tools

A brief review of currently available databases and tools do not suggest that there is

systematic tracking of post-discharge and community-experience persons diagnosed with

COVID19. Tableau data demonstrates population-level understanding especially of the health

service utilization, but little systematically tracked data on functional outcomes.

For example, the Tableau data on patients discharged from ICU includes median Acute

Physiology and Chronic Health Evaluation Scores, Sequential Organ Failure Assessment, and

Clinical Frailty Score.

Another Tableau dashboard reveals types of care provided to persons who

had a critical stay within their hospital stay (e.g. duration of invasive ventilation, continuous renal

replacement therapy, delirium eligibility).

Linking these data with longitudinal outcomes would be

helpful both clinically and administratively in planning individual and population-level care. A

broader dataset on all persons diagnosed with COVID19 is available online, and includes active

cases by region, total deaths, and patient characteristics (e.g. age, gender, health care worker

location, number of co-morbidities, location of patients, laboratory testing, and rate of

hospitalization and ICU admission).

https://www.alberta.ca/stats/COVID19-alberta-statistics.htm

These datasets are

important building blocks to any longitudinal monitoring strategy.

The rapid literature review described above depicts the various measurement instruments

used in long-term follow-up of post-pandemic patients. In Alberta, further instruments currently in

use may be of value for longitudinal monitoring. For example, the Canadian Nutrition Screening

Tool (CNST) is a screening tool to assess if a patient is at risk for malnutrition. This is critical for

hospitalized patients, as the Canadian Malnutrition Task Force found that 45% of patients

hospitalized at acute care hospitals across Canada were malnourished or at risk for malnutrition

[37]. This two-question tool has demonstrated validity and reliability in Canadian hospitalized

patients. In Alberta, it is built into the Connect Care admission package, and it triggers a dietician

referral for further assessment. Weight loss and appetite changes and taste alterations are

associated with COVID19 infections. Malnourished patients have higher rates of complications

including re-admission within 30 days so it is imperative these patients are screened and followed

https://tableau.albertahealthservices.ca/#/views/CriticalCareCOVID19/Admissions?:showAppBanner=false&:display_count=n

&:showVizHome=n&:origin=viz_share_link&:iid=1

https://tableau.albertahealthservices.ca/#/views/CriticalCareCOVID19/DischargesTable?:showAppBanner=false&:display_coun

t=n&:showVizHome=n&:origin=viz_share_link&:iid=1

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September, 2020 v 5.0 45

up by a dietitian if found at risk [38]. Nutrition Services has developed two education resources

for persons diagnosed with COVID19 that could be provided as a first intervention, and referrals

to Health Link® Dietitians could facilitate more in depth assessment and follow up by outpatient

dietitians

REFERENCES: