By Jeanie Davis

For hospitalized COVID-19 patients, surviving the infection is the first major hurdle — but it may not be the last. Their recovery may involve rehabilitation, depending on complications from ventilator-related immobility or damage from blood clots.

Rehabilitation facilities have updated their processes to accommodate these patients’ special needs, says Dina Walker, RN, MSN, ACM, RN-BC, National Director of Case Management for Encompass Health in Birmingham, AL.

“Patients may require inpatient rehabilitation as time spent immobile on ventilators or during a long acute care hospital stay leads to profound muscle weakness and deconditioning,” Walker explains. “If patients develop blood clots as a result of COVID-19, they may suffer a stroke or heart attack, potentially requiring physical, occupational, and even speech therapy.”

At Encompass Health’s inpatient rehab facilities, the electronic medical record was adapted to include COVID-19-related diagnoses, symptoms, and test results, including pending results. “We also updated our communication of COVID-related results and information to the post-discharge provider,” Walker says.

Weekly interdisciplinary conferences were relocated to accommodate social distancing. With limited visitation, larger spaces like the cafeteria and lobbies are available for these meetings. Staff members can also call in via WebEx, if necessary. A COVID-19 task force was created at Encompass Health’s main office to provide education and assistance to their 135 hospitals. They also published a frequently asked questions sheet and a regularly updated COVID-19 plan. Centers for Disease Control and Prevention (CDC) recommendations are followed closely.

Hospitals have had to adjust their therapy staffing, including staggering schedules, to accommodate smaller therapy groups among inpatients, maintaining social distancing and masking.

Leadership increased the frequency of cleaning in the facilities to ensure surfaces that patients and providers touch, including therapy gyms and equipment, are in compliance with CDC recommendations.

COVID-19 Discharge Planning Checklist

Walker advises Encompass Health’s case managers to refer to CDC guidance when preparing these patients for discharge home or for transfer to an assisted living or skilled nursing facility, available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html.

Other points to consider in discharge planning:

  • Address the patient’s quarantine isolation level and personal protective equipment (PPE) needs. Some patients go home and are not required to isolate; others are asymptomatic. Most patients require a mask, and the caregiver requires mask and gloves for some time.
  • Provide patients with discharge prescriptions for a 14-day supply or greater to allow for delay in primary care appointments or quarantine/isolation time.
  • Ensure the patient’s physician is available for follow-up appointment. “The biggest barrier we’re seeing is setting up follow-up visits with physicians in a timely manner,” Walker says. “Some have cut office hours or closed offices, cut back service lines, haven’t developed telehealth, or staff hasn’t come in, or they don’t have safe practices like distancing.”

She advises case managers to call physicians well in advance of discharge. “If the clinic is taking patients, are they using telehealth? If so, what platform are they using? Make sure the patient has the correct technology and the skills for a telehealth visit.”

This requires case managers to learn more about remote communications for patient engagement. “They will need to help patients and caregivers with the technology,” says Walker.

Also, assess PPE-related discharge needs for patient, caregiver, and family members:

  • Can the patient procure his or her own PPE?
  • Will the hospital provide PPE? What type, and how much?
  • How long will the patient and caregiver need to use PPE at home?

Identifying a facility to accept these patients has become increasingly difficult, Walker says. “Skilled nursing facilities [SNFs] and assisted living facilities [ALFs] are refusing to accept patients, even if the patient hasn’t been infected,” she says. “If they have been infected, it’s even more difficult.”

To simplify the transfer process, the Centers for Medicare & Medicaid Services waived patient choice of transfer facility as well as quality metrics of facilities.

However, the result has not been optimal for patients. “Sometimes, patients will only get accepted by one facility, even if it’s not their choice or preference,” Walker explains. “In some cases, we’re having to hold onto patients in the hospital, which increases their length of stay.”

In handling these difficult situations, case managers must educate patients and families about the options. “Inform them of each facility’s policies regarding accepting COVID-related patients,” she says. “Then, be prepared to translate that information to the patient and their caregiver.”

Walker’s team also has worked with SNFs and ALFs to dispel myths about COVID-19 infection. “We’re finding that some facilities require a patient to receive COVID-19 testing before they consider accepting the patient, and will only accept a negative test result,” Walker explains. “However, the COVID tests are so sensitive they’re detecting the viral RNA, which doesn’t necessarily mean the patient is infectious. We try to educate them as much as possible, but if that is their policy, there’s nothing else we can do.”

If the patient is discharged home, ask the physician to determine level of isolation, length of isolation/quarantine, and any PPE needs.

Identifying a home care agency has become difficult, Walker says. “Some home health agencies are experiencing staff shortages and may be limited in the services they are providing. We’re also seeing more families refusing to allow home health caregivers come into the home because they perceive risk of infection. If the patient has just gotten over COVID or hasn’t even contracted it, they don’t want someone bringing it in to their home.”

Case managers must learn what home health agencies are doing to prevent infection, she advises. Also, learn about a durable medical equipment provider’s protocols and communicate that to patients and families to alleviate those fears.

The hospital team should work closely to keep family members engaged remotely. Walker advises case managers to use whatever device or platform that works best for the family or caregiver, including WebEx, FaceTime, or Skype.

“We are providing our hospital care teams with iPads for that purpose, as FaceTime on a cellphone screen was just too small to be effective for remote education or training,” she says. “We provide teletraining for family caregivers using the iPads. We train them how to don and doff protective equipment. We provide them with gloves and masks to last during their remaining quarantine time.”

Home evaluations are necessary to determine if home modifications are needed to accommodate a patient’s functional limitations. These can be done by working with the family to take photos, measurements, and provide video e-tours of the home, says Walker.

“It’s certainly made us increase our technological knowledge and think outside the box to meet the needs of this special patient population,” says Walker.

Remember Non-COVID-19 Patients

As admissions to acute care facilities are slowly declining, this means that more post-acute services are being accessed, says Toni Cesta, PhD, RN, FAAN, owner and consultant with Case Management Concepts. “This is good news. Patients are moving out of hospitals, and fewer are being admitted. After a period, the same pattern should transition to the post-acute world, and the need for these levels also will begin to drop.”

Creative solutions are paramount, Cesta says. For example, some hospital systems are creating special temporary facilities to house the overflow of post-acute care patients. The most important thing to remember is that, as discharge planners, case managers must transfer patients to the least restrictive level of care possible. For example, patients who can manage at home should not be sent to a sub-acute unit.

“Things are improving overall, but we must remain diligent,” Cesta explains. “Do not forget the non-COVID-19 patients as you progress your patients through the acute care continuum. Keep lengths of stay as short as possible and move patients as quickly as possible.”