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Healthcare Improvement Scotland

Related information: Clinical case definitions

These recommendations are for healthcare professionals providing care for people with ongoing symptomatic COVID-19 or post-COVID-19 syndrome in any setting, including primary care and community settings, secondary care, or in multidisciplinary assessment and rehabilitation services.

Rationale

There was evidence that people struggled to access appropriate care and some had experienced fragmented care. The panel agreed on the need to improve integration and co-ordination of care across different services. Having regular multidisciplinary meetings would help share information more efficiently and allow professionals to make decisions quickly about tests and referral. Sharing clinical records and care plans between services, with the agreement of the person, will help healthcare professionals provide integrated care, and avoid gaps in care or duplication of effort. In particular, sharing baseline measures is essential for monitoring as people move between services. The panel wanted to make sure that information is also shared with people using services so that they know what is happening with their care. The patient experience evidence also described how people could benefit from continuity of care, and the panel agreed this should always be an aim for well-integrated services.

Recommendations

  Ensure effective information sharing and integrated working by sharing clinical records and care and rehabilitation plans promptly between services and through multidisciplinary meetings, either virtual or in person.
  Give people a copy of their care plans or records to keep, including their discharge letters, clinical records and rehabilitation plans and prescriptions.
 This content is derived from the Scottish Government's Implementation Support Note.
Discuss the referral with the specialist (via telephone, Consultant Connect or digital advice route) and, wherever possible, copy the patient into any correspondence.
  Include baseline measures as well as ongoing assessments in information shared between services, including when the person is discharged from hospital. For example, resting oxygen saturation and heart rate, and the results of functional assessment.
  Provide continuity of care with the same healthcare professional or team as much as possible, for example by providing a care co-ordinator or a single point of contact.
 This content is derived from the Scottish Government's Implementation Support Note.

Discuss the patient journey, in particular when there may be multiple symptoms, or the person may struggle with navigating the system. Facilitate system co-ordination where possible.

Emphasise support from local community resources, such as link workers, to facilitate access to services in the local community as well as specialist clinics.
  This content is derived from the Scottish Government's Implementation Support Note.

Practices should consider how they can share and signpost people to self-management resources – training and information to support care navigation, links to resources on practice websites, local links through practice patient groups can all support people living with long-term effects of COVID-19.

It should be recognised that many people may have multiple symptoms, and time over more than one appointment may be needed to assess a person’s physical, psychological and social concerns. Where possible continuity of care, and shared decision making which supports good care planning conversations (and anticipatory care plans where appropriate) will support positive therapeutic relationships, with the GP as the expert medical generalist working with the extended multidisciplinary team to support a person’s management across health and care.

References

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