Related information: Clinical case definitions

Rationale

The panel agreed that multidisciplinary rehabilitation teams should work with people to make a plan for their rehabilitation once any symptoms had been investigated that could affect the safety of rehabilitation. Physical, psychological and psychiatric aspects of rehabilitation should be addressed, with fatigue management being a key component of this. The evidence showed that breathlessness, fatigue and ‘brain fog’ are among the most commonly reported long‑term symptoms, so support for these should be part of the person’s rehabilitation plan. See also the recommendations on multidisciplinary rehabilitation teams in Section 9.

Recommendations

  This content is derived from the Scottish Government's Implementation Support Note.
Working across the extended MDT to provide tailored support for people with long-term effects of COVID-19 to manage their condition, (seeking specialist advice where appropriate), should be the cornerstone of local service provision and be reflected in local pathways which support multidisciplinary and multi-agency collaboration.
Use a multidisciplinary approach to guide rehabilitation, including physical, psychological and psychiatric aspects of management. Ensure that any symptoms that could affect the person being able to start rehabilitation safely have been investigated first.  (See Section 9 for advice on the composition of multidisciplinary rehabilitation teams).

Rationale

A personalised rehabilitation and management plan records the person’s needs and how they will be met. In some settings a ‘rehabilitation prescription’ may be used to capture this information. The rehabilitation prescription is held by the person and includes an individualised description of rehabilitation needs or recommendations to inform the future planning and delivery of a person’s ongoing rehabilitation. The panel recognised that some people may need additional support, such as an interpreter or advocate, in developing the rehabilitation and management plan.

For the November 2021 update, the panel reviewed evidence that emphasised the fluctuating nature of ongoing symptomatic COVID-19 and post-COVID-19 syndrome. Based on this evidence, the panel agreed that it was key that a management plan should take into account that symptoms may fluctuate.

Recommendations

Work with the person (and their family or carers, if appropriate) to develop a personalised rehabilitation and management plan that is recorded in a rehabilitation prescription and should include:

  • areas of rehabilitation and interventions based on their assessment
  • helping the person to decide and work towards goals
  • how to manage and monitor their symptoms, taking into account that these may fluctuate, and what to do if symptoms return or change.

For people who may benefit from support during consultations, follow the recommendation on supporting access to assessment and care, including providing extra time or additional support (such as an interpreter or advocate).
Encourage people to keep a record of, or use a tracking app to monitor their goals, recovery and any changes in their symptoms (see also section 7).

Info box

Rehabilitation: a set of interventions designed to optimise functioning, health and wellbeing, and reduce disability in people with health conditions in interaction with their environment. In the context of ongoing COVID-19 symptoms, this may include providing information, education, supported self-management, peer support, symptom management strategies and physical rehabilitation. (Informed by the World Health Organization's fact sheet on rehabilitation.)

References

Full details of the evidence and the panel's discussion are in the evidence reviews on: