By Melinda Young

EXECUTIVE SUMMARY

As many COVID-19 patients struggle with long, slow recovery, case managers can refer them to inpatient and outpatient rehabilitation services.

  • COVID-19 patients have varied rehab needs, including pulmonary, brain injury, and cardiac rehabilitation.
  • A first transition could be from acute care to inpatient rehab services, especially if patients are severely debilitated.
  • Loss of balance might require help from a physical therapist or occupational therapist.

After days, weeks, or even months of hospitalization with COVID-19, patients often need considerable help with their post-discharge recovery. This is especially true for people who need pulmonary, brain injury, or cardiac rehabilitation.

Hospital case managers can help patients recover by educating them about various rehabilitation services, says Gerard Francisco, MD, chair of physical medicine and rehabilitation at The University of Texas Health Science Center at Houston (UTHealth), and chief medical officer of The Institute for Rehabilitation and Research Memorial Hermann.

“COVID-19 patients’ rehab needs are varied. Many people who have this virus have a more protracted recovery,” he says. “Once patients are transferred out of the intensive care unit, some are sent out to the floors and others are discharged home. But many end up being at home for a long time, still convalescing, and they do not benefit from rehab — either because they don’t know about it, or are afraid to leave the house again.”

Most COVID-19 patients recover well, but others have symptoms that cannot be explained by anything else, he adds.

The SARS-CoV-2 virus or the person’s immune system reaction to the virus can cause symptoms ranging from signs of traumatic brain injury to heart disease, pulmonary disease, and musculoskeletal problems.

“Practically every organ system is involved,” Francisco says.

Traumatic brain injury units have seen fewer car accident injuries since the COVID-19 pandemic shut down the nation. But they have seen something new: COVID-19 patients with delirium, dizziness, memory problems, and strokes. (See story on COVID-19’s effects on the brain in this issue.)

“We’re seeing higher incidences of stroke in patients we wouldn’t normally think of being at high risk for a stroke,” he says.

There are many possible discharge plans that could work for COVID-19 patients. Case managers should ensure patients are aware of the rehabilitation options, says Katharine Seagly, PhD, director of the traumatic brain injury rehabilitation program, clinical neuropsychologist, and assistant professor at Michigan Medicine.

The first transition might be from acute care to inpatient rehab services. This is for patients with severe debilitation. It provides them with the most hours of physical therapy and other rehab services, Seagly notes.

“A neuropsychologist or psychologist on staff could help them manage the anxiety and depression or post-traumatic response that can arise when someone has been in the hospital for weeks or months and had to face their own mortality,” she says.

Emotional health issues are common, especially during the pandemic when patients were not permitted to have family members with them on the intensive care unit.

“That can be a very traumatic time,” Seagly says. “Being in the hospital facility for rehab makes sense, at least for the first few weeks, and it gives families time to plan.”

COVID-19 patients exhibit a wide range of physical symptoms. One of the most common post-discharge problems is physical weakness from prolonged immobilization, Francisco says.

“There appear to be some effects on the musculoskeletal system as well,” he adds. “Some people have a loss of balance that may require an expert, skilled physical therapist, or occupational therapist to work with them.”

Unlike patients who recover from the flu, many people who recover from COVID-19 will experience debilitating symptoms for weeks or months. For instance, a COVID-19 Survivors group on Facebook includes posts from survivors who list long-term issues with chest pain and abnormal ECG results, hair loss, leg pain, bloating, difficulty breathing, fatigue, heart problems, anemia, brain fog, and confusion. (View the posts at: https://www.facebook.com/Covid-19-Survivors-112669970366352/.)

Inpatient and outpatient hospital rehabilitation departments can offer COVID-19 patients programs geared to assisting their recovery. For instance, patients with ongoing pulmonary issues could benefit from a program designed to help them improve their lung function.

“We also know the virus affects the heart, causing inflammation. We thought chest pain was pneumonia-related, and now we think it’s because of the heart,” Francisco says.

Case managers can help COVID-19 patients prepare their homes for discharge, Seagly says. They can suggest ramps and moving a bed to the first floor if patients struggle to walk during their post-acute recovery period.

Transitions home also might include outpatient rehabilitation services. “That was a little tricky at first because nonemergent services were all closed, but, thankfully, things are opening back up. Many are using the hybrid model of some services virtually and some services in-person,” Seagly says.

Case managers can help patients transition to the best post-acute care services, including rehabilitation services, by asking them what they hope to do when they return home. If a patient has been away from work, then rehabilitation services can help them improve their work readiness.

“Let’s say the patient works in a factory. The physical therapist can help them go through the motions of the type of labor they were performing before,” Seagly explains. “If they had an office job, the occupational therapist can sit them at a computer and have them practice movements with their upper extremities and strengthen the muscles required for that.”

Rehab therapists also can help patients improve higher-level cognition and help them develop compensatory techniques like phone reminders and ensuring everything is well-organized, Seagly says.

“It’s figuring out what they want to get back to and letting them know what might be a barrier,” she adds. “We say, ‘Here’s what we can do with these services to get you back to the valued activities that make you feel better.’”

UTHealth offers a mini-program for rehabilitation care tailored to help patients with COVID-19 return to their new normal, Francisco says. Rehab professionals also can follow general principles for pulmonary rehabilitation, which is a common problem with COVID-19 patients.

“We have to pay more attention to the heart and lungs of a person as they may not tolerate one full hour of therapy,” he adds. “We may have to split it to three 20-minute sessions or two 30-minute sessions so the person can participate fully.”