interprofessional steering committee

© 2021 PRIME Education, LLC. All Rights Reserved. www.primeinc.org

Cheri Lattimer RN, BSNExecutive DirectorNational Transitions of Care CoalitionNorfolk, VA

Mark L Metersky, MD, FCCP, FACPProfessor of MedicineAssociate Chief of Service, Department of MedicineChief, Division of Pulmonary, Critical Care and Sleep MedicineDirector, Center for Bronchiectasis CareUniversity of Connecticut School of Medicine

Radu Postelnicu, MDAssistant Professor, NYU School of MedicineDivision of Pulmonary, Critical Care, and Sleep MedicineAssociate Director, Medical ICU/ BellevueAssistant Program Director, NYU PCCM Fellowship

James E Lett, II, MD, CMDFamily Medicine PhysicianMedical DirectorAvar ConsultingRockville, MDDirector of the National BoardNational Transitions of Care CoalitionNorfolk, VA

Jason F Okulicz, MDProfessor of Medicine, Uniformed Services University of the Health SciencesInfectious Disease Service, San Antonio Military Medical CenterChair, Tri-Service Infectious Disease Working Group, Defense Health Agency

This activity is provided by PRIME Education. There is no fee to participate.This activity is supported by an educational grant from Gilead Sciences, Inc.

Interprofessional Steering Committee

© 2021 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 2

LEARNING OBJECTIVES• Apply evidence-based and expert consensus

strategies for closing critical gaps in the care transitions and coordination of patients with COVID-19

• Describe current evidence and evolving guidance recommendations for the diagnosis, treatment, and management of patients with COVID-19

• Incorporate interprofessional strategies that support effective care coordination for patients with comorbidities, including communication and decision-making on continuing, withholding, or reinitiating concomitant medications

• Develop comprehensive hospital discharge plans that account for individual patient factors, including comorbidities and socioeconomic factors

• Apply interprofessional strategies for patient-centered COVID-19 care, including patient/caregiver education, shared decision-making, and promotion of self-management

Instructions to obtain credit:

1. Complete the activity in its entirety.

2. Visit PRIME®’s Credit Center at www.primeinc.org/credit.

3. Enter program code 54PR204.

4. Upon completion of the learner assessment tools, you will be able to print your certificate.

Release Date: February 26, 2021Expiration Date: February 25, 2022

CONTRIBUTING AUTHORSCheri Lattimer RN, BSNExecutive DirectorNational Transitions of Care CoalitionNorfolk, VA

Mark L Metersky, MD, FCCP, FACPProfessor of MedicineAssociate Chief of Service, Department of MedicineChief, Division of Pulmonary, Critical Care and Sleep MedicineDirector, Center for Bronchiectasis CareUniversity of Connecticut School of Medicin

Radu Postelnicu, MDAssistant Professor, NYU School of MedicineDivision of Pulmonary, Critical Care, and Sleep MedicineAssociate Director, Medical ICU/ BellevueAssistant Program Director, NYU PCCM Fellowship

James E Lett, II, MD, CMDFamily Medicine PhysicianMedical DirectorAvar ConsultingRockville, MDDirector of the National BoardNational Transitions of Care CoalitionNorfolk, VA

Jason F Okulicz, MDProfessor of Medicine, Uniformed Services University of the Health SciencesInfectious Disease Service, San Antonio Military Medical CenterChair, Tri-Service Infectious Disease Working Group, Defense Health Agency

The following individuals have identified relevant financial relationships with commercial interests to disclose:

Jason F Okulicz, MD (Contributing Author)Advisory Board or Panel – Gilead SciencesSpeakers Bureau or other Promotional Education – Gilead Sciences

The following individuals have no relevant financial relationships with commercial interests to disclose:

Cheri Lattimer, RN, BSN (Author)Mark L Metersky, MD, FCCP, FACP (Author)James E Lett, II, MD, CMD (Author)Radu Postelnicu, MD (Author)Mark A Rubin, MD (Reviewer)Annette Sophin, MSMM, PA-C (Planner)Joyce M Knestrick, PhD, CRNP, FAANP (Planner)Ayrin L Hnosko PhD, LCSW (Planner)

All PRIME staff participating in planning and content development have no relevant financial relationships with commercial interests to disclose.


CONTINUING EDUCATION

JOINT ACCREDITATION STATEMENTIn support of improving patient care, PRIME® is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

INTERPROFESSIONAL TEAMSThis activity was planned by and for the healthcare team, and learners will receive 2.0Interprofessional Continuing Education (IPCE) credits for learning and change.

PHYSICIAN CREDIT DESIGNATION STATEMENTPRIME® designates this Enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

PA CREDIT DESIGNATION STATEMENTPRIME® has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credits for activities planned in accordance with AAPA CME Criteria. This activity is designated for 2.0 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation..

NURSE PRACTITIONER ACCREDITATION STATEMENTPRIME Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 060815. This activity is approved for 2.0 contact hours (which includes 0.5 hour of pharmacology).

PHARMACY CREDIT DESIGNATION STATEMENTThis Application-based activity has been approved for 2.0 contact hours (0.2 CEUs) by PRIME® for pharmacists. The Universal Activity Number for this activity is JA0007144-0000-21-022-H01-P. Pharmacy CE credits can be submitted to the NABP upon successful completion of the activity by providing your NABP ID & DOB, which must be submitted within 60 days of completion. Pharmacists with questions can contact NABP customer service ([email protected]).

NURSING CREDIT DESIGNATION STATEMENTPRIME® designates this activity for 2.0 contact hours.

CASE MANAGER ACCREDITATION STATEMENTThe Commission for Case Manager Certification designates this educational activity for 2.0 contact hours for certified case managers. Credits for this program are pre-approved.

This activity is provided by PRIME Education. There is no fee to participate.This activity is supported by an educational grant from Gilead Sciences, Inc.


Table of Contents

INTRODUCTION .............................................................................................................................................................................................

PURPOSE AND SCOPE ........................................................................................................................................................

BACKGROUND ..............................................................................................................................................................................................

EPIDEMIOLOGY AND PATHOGENICITY ...............................................................................................................................

EPIDEMIOLOGY ............................................................................................................................................................................

PATHOGENICITY ...........................................................................................................................................................................

PATIENT PRESENTATION AND DIAGNOSIS ...............................................................................................................................................

ASSESSING SEVERITY OF ILLNESS AND RISK FACTORS FOR SEVERE DISEASE .............................................................................

EVALUATION FOR HOME MANAGEMENT OR HOSPITAL REFERRAL ...................................................................................................

INFECTION CONTROL AND PREVENTION ................................................................................................................................................

TREATMENT ............................................................................................................................................................................................

VACCINATION TO PREVENT RESPIRATORY ILLNESSES ........................................................................................................................

CONSIDERATIONS IN TRANSITIONS OF CARE ........................................................................................................................................

GUIDING PRINCIPLES IN TRANSITIONS OF CARE .............................................................................................................

HOME MANAGEMENT OF COVID-19 .........................................................................................................................................................

FROM HOSPITAL TO HOME .........................................................................................................................................................................

FROM HOSPITAL TO LONG-TERM CARE FACILITY (LTCF) .....................................................................................................................

HEALTH INEQUITIES AND ACCESS TO CARE ...........................................................................................................................................

LONG-TERM CONCERNS AFTER ACUTE COVID-19 ILLNESS ...............................................................................................................

ADDITIONAL TOOLS AND RESOURCES ...............................................................................................................................................

REFERENCES .................................................................................................................................................................................................

5

5

5

5

5

5

6

7

9

10

11

14

14

14

15

22

27

28

29

30

31

As clinical evidence and recommendations continue to evolve rapidly, recommendations from the Food and Drug Administration, Centers for Disease Control and Prevention, and other authorities should continue to be reviewed regularly. The tool is designed to be used in conjunction with such guidance, and should not supersede clinical judgment or updated evidence.


INTRODUCTIONPURPOSE AND SCOPE

This transitions of care (TOC) guide outlines pathways for patients with coronavirus disease 2019 (COVID-19). The purpose of the guide is to describe pathways, tools, and resources that enable multidisciplinary transitions of care across health care settings, as well as to identify and implement collaborative team-based approaches to COVID-19 management, from diagnosis and acute care through discharge and long-term follow-up. The guide, developed by an interprofessional steering committee that includes experts in infectious diseases, pulmonary/critical care, primary care, and case management, focuses on strategies and resources to support the following areas:

• Breaking down gaps and barriers associated with suboptimal care transitions• Promoting effective and timely referrals• Improving care coordination• Optimizing multidisciplinary transitions of care for COVID-19 patients across health care settings• Incorporating patients and caregivers as central team members

BACKGROUNDEPIDEMIOLOGY AND PATHOGENICITY

Epidemiology

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most recent coronavirus to emerge and elicit devastating consequences across the globe in the form of coronavirus infectious disease 2019 (COVID-19), a serious and contagious respiratory illness in humans.1,2,3 The virus spreads primarily through aerosol droplets and has infected people in more than 200 countries and territories.3 Approximately 80% of people infected have a mild course of disease. The remaining 20% progress to more serious illness.4 The number of people infected with SARS-CoV-2 across the US in 2020 was characterized by several peaks: one in the spring, a second that started in June and lasted through the early fall, and a third that began in November.5,6

Pathogenicity

COVID-19 is an enveloped RNA virus with four types of proteins involved in its pathogenicity.2,7,8 Structural proteins protect the virus and interfere with the host immune response, while nonstructural proteins coordinate the creation and assembly of new viruses.9

Table 1. SARS-CoV-2 Proteins

Protein Functions Notes

SpikeAttaches to host cells and allows the virus to fuse with host cell membrane

Viral attachment downregulates angiotensin-converting enzyme 2 (ACE2) expression, which triggers inflammation and injury

MembraneProtects the entire virus and neutralizes host antibodies

Determines how long the virus remains active

EnvelopeTethers the virus to host ribosomes to read and copy the viral genome

Other viral proteins hijack host cell machinery to produce new viral particles

NucleoproteinProtects viral RNA; helps assemble and package new viral proteins for release from the host

Contributes to the virulence, speed of replication, and mode of infection

This document contains point-of-care resources thatcan be printed separately for use in daily practice.


The virus selectively binds to angiotensin converting enzyme 2 (ACE2) receptors in human cells. Those receptors are particularly plentiful in the heart, epithelial cells, lungs, and kidneys.10 ACE2 binding disrupts several signaling pathways to induce inflammation, hypoxia, vasoconstriction, and fibrosis. Direct damage from viral invasion and indirect damage from inflammation can cause end organ injury.10,11 The leading causes of death from COVID-19 are acute respiratory distress syndrome (ARDS). COVID-19 can have systemic complications, and cardiac, liver, or renal failure can also contribute to death.12 In severe circumstances patients may progress to cytokine storm, increased T-cell death, and multi-system failure.3,13

The average time from SARS-CoV-2 exposure to onset of COVID-19 symptoms is 5 days, but symptoms may take up to 11 days to manifest.3 People aged 70 years and older generally have an incubation period of approximately 8 days.14 The onset and duration of infectious viral RNA shed-ding typically lasts 7 or 8 days15,16 but can last longer in some cases.17 After recovery from COVID-19, patients can continue to shed low concentrations of viral RNA for up to 3 months from initial symptom onset, though infectiousness is unlikely.18

PATIENT PRESENTATION AND DIAGNOSISThe most common early symptoms in infected patients include dry cough, dyspnea, and fatigue. Sudden loss of smell and taste are also common. Fever, myalgia, and gastrointestinal disturbances may occur but are less commonly reported.12

COVID-19 DIAGNOSIS

Diagnostic testing may be indicated for people who have been in close contact with someone infected with SARS-CoV-2. Testing may be advised for those with symptoms of COVID-19, and anyone with a pending diagnostic test should self-quarantine at home until results are known. Critical infrastructure workers, healthcare workers, first responders, and nursing home employees and residents may need additional testing in accordance with local guidance and reopening plans. As recommendations continue to rapidly change, the most recent guidance is listed on the Centers for Disease Control and Prevention (CDC) webpage.19

The landscape of diagnostic testing is continually evolving and encompasses a variety of platforms, including at-home testing and concomitant testing for SARS-CoV-2 with other common viral respiratory pathogens, including influenza. As testing supplies and capabilities vary significantly across the US, local and state-level recommendations can best guide testing prioritization and selection. SARS-CoV-2 infection can be diagnosed using either molecular or antigen testing, which have differing characteristics (Table 2). Time to results indicates test capabilities but may not reflect the actual time a patient may wait to receive test results, as this can be impacted significantly by test volumes at a given location. The type of sample needed varies per individual test; the test may require a nasal, nasopharyngeal, or mid-turbinate swab or a saliva sample. Owing to prolonged low-level viral shedding following recovery, re-testing is generally not indicated within 3 months of a positive test19 but may still be required for screening purposes prior to activities like visiting a nursing home or traveling internationally.


Table 2. SARS-CoV-2 Diagnostic Tests

Molecular Antigen

Detects Viral genetic material Viral protein

Setting Mostly laboratory tests, some point-of-care (POC) Mostly POC

Time to results Laboratory: Hours to daysPOC: < 1 hour

< 1 hour

Sensitivity High Moderate

Specificity High High

Serological antibody testing is also available to indicate a past infection, though the sensitivity of this test depends on the degree of immune response and how long after symptom resolution the test is done. Antibody testing alone is not indicated for diagnosis of acute SARS-CoV-2 infection.

ASSESSING SEVERITY OF ILLNESS AND RISK FACTORS FOR SEVERE DISEASEThe clinical presentation of COVID-19 can range from asymptomatic to severe or critical illness, and risk factors for severe disease have been identified.

Table 3. Classification of COVID-19 Severity of Illness

Asymptomatic/ Presymptomatic Infection Positive test but no symptoms

Mild Signs/symptoms but no dyspnea or abnormal chest imaging

Moderate Lower respiratory disease on clinical assessment/imagingand oxygen saturation (SpO2) ≥ 94%

SevereSpO2 < 94%, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) < 300 mmHg, respiratory rate > 30

breaths/min, or lung infiltrates > 50%

Critical Respiratory failure, septic shock, and/or multiple organ dysfunction

As understanding of the varied clinical presentations of COVID-19 continues to evolve, several patient characteristics and comorbid conditions have been identified as predisposing factors for serious illness. In addition to those listed in Table 4, men, patients aged 65 years or older, and patients of African American, Hispanic, and American Indian or Alaskan Native descent are more likely to progress to severe COVID-19, including hospitalization and death.20-22


Table 4. Risk Factors for Severe COVID-19

High-risk Underlying Conditions per Level of Evidence for Risk of Severe COVID-19 Outcomes

Significant association in ≥ 1 meta-analysis or systematic review

Association in cohort, case-control or cross sectional studies

• Cancer• Cerebrovascular disease• Chronic kidney disease• COPD • Diabetes mellitus, type 1 and 2• Heart conditions• Obesity (BMI ≥30 kg/m2)• Pregnancy and recent pregnancy• Smoking, current and former

• Children with certain conditions• Down syndrome• HIV• Neurologic conditions, including dementia• Overweight (BMI ≥ 25 kg/m2, but < 30 kg/m2)• Other lung disease • Sickle cell disease• Solid organ or stem cell transplantation• Substance use disorders• Use of corticosteroids or other

immunosuppressive medications

Association in ≥ 1 case series studies, or cohort or case-control studies with small sample sizes

Mixed evidence

• Cystic fibrosis• Thalassemia

• Asthma• Hypertension• Immune deficiencies• Liver disease

PROGNOSTIC INDICATORS

An early sign of COVID-19 infection is the rise of acute-phase reactants, especially erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ferritin, and proinflammatory cytokines, which are also associated with disease progression and mortality.10,12 Predictive and prognostic biomarkers fall into three categories outlined in Table 5.10,12,23

Table 5. COVID-19 Predictive and Prognostic Biomarkers

Category Abnormal Labs Notes

Hematologic↑ WBC count↑ Neutrophil count↓ Lymphocyte count

Lymphopenia is the most reliable predictor of disease severity and prognosis12

Biochemical

Cardiac indicators:↑ Troponin I

Coagulation indicators:↑ Prothrombin time↑ D-dimer

↑ troponin highly suggests viral myocarditis23

↑ D-dimer predicts high disease severity and suggests potential for a thrombotic event 24,25

Inflammatory

↑ ESR ↑ CRP ↑ Ferritin↑ PCT ↑ cytokines

(procalcitonin)(interferons, TNF-alpha, interleukins—especially IL-6)

↑ CRP, ferritin, and IL-6 are strong indicators systemic inflammation

IL-6 is the most sensitive prognostic cytokine12

Collectively, these results can help guide decisions surrounding whether to admit or transfer a patient, and can alert providers to potential decompensation and future complications.


“LONG HAUL” SYMPTOMS

Past outbreaks of coronavirus illnesses left approximately a third of survivors with persistent symptoms including fibrotic lung disease, long-term cardiopulmonary complications, “brain fog,” altered glucose metabolism, and mental health challenges.26 Similar problems are surfacing with COVID-19.

In one study of hospitalized COVID patients, 87.4% reported one or more symptoms persisting ≥ 60 days after recovery.27 Outpatients with “mild” COVID-19 also experience prolonged symptoms. A University of Dayton study showed 51% of their infected students had lingering symptoms > 28 days after recovery.28 Additional studies confirm this problem, which is now called “LT-19,” or “long COVID.”26,29,30 To date, no treatment for LT-19 has been identified, and this remains an important area of continued study and concerted efforts for long-term monitoring and management after recovery from acute illness.

EVALUATION FOR HOME MANAGEMENT OR HOSPITAL REFERRALINDICATIONS AND CONSIDERATIONS FOR HOME MANAGEMENT

Patients with mild to moderate disease not requiring hospitalization may be instructed to recover from COVID-19 in the home setting. Plans for self-assessment and prompt communication of clinical deterioration should be established, along with the ability to adhere to infection control measures. Patients with risk factors for severe disease should be monitored more closely. Mechanisms for remote patient monitoring including telehealth, electronic symptom questionnaires, and home pulse oximetry testing may also be valuable tools to ensure safe recovery. Additionally, the home setting should be assessed, including caregiver capabilities, ages of other household members, and the likelihood of disease spread within in the home.

INDICATIONS FOR HOSPITAL OR INTENSIVE CARE REFERRAL

A low threshold for hospitalization should be maintained for any patient aged older 65 years and older and/or with comorbid conditions conferring increased risk for severe disease (see Table 4). Regardless of underlying risk factors, patients presenting with any of the following should be referred for hospital evaluation and possible admission for inpatient care:31

• Altered mental state• Shortness of breath• SpO2 < 94%• Respiratory rate > 30/min• Systolic blood pressure < 90 mm Hg• Other signs of shock or complications

Additionally, any of the following characteristics, either upon admission or during hospitalization, should prompt assessment for escalation to an intensive care unit:31

• Impending respiratory failure, life-threatening organ dysfunction, or shock• Need for intensive therapies such as mechanical ventilation• Need for intensive monitoring


INFECTION CONTROL AND PREVENTIONGENERAL UNIVERSAL PRECAUTIONS

For the general population in public environments:19

• Avoid high-risk exposures: being within 6 feet of another person for 15 minutes or longer, or any length

of exposure without a face mask

• Always wear face masks indoors

• Avoid crowds

• Wash hands frequently

• Avoid touching face, eyes, nose, mouth

For household members of persons infected with SARS-CoV-2:

• Wear a face mask while in close contact with an infected family member

• Disinfect high-touch surfaces daily (tables, doorknobs, light switches, toilets, faucets, etc.)

• Wash hands frequently

• Launder clothes using the highest temperature setting

In communal living, such as long-term care, in addition to state, county, and local protocols:32

Employees

• Always wear a mask and follow infectious disease protocols, utilizing face shields and personal

protective equipment (PPE) per your facility’s protocols

• Bundle resident care and treatment activities to minimize entries into resident rooms

• Dedicate space for isolating residents with COVID-19

Residents

• Encourage residents to wear a face mask whenever in communal settings

� Explore alternative infection control measures like physical dividers for residents who may be

intolerant of wearing face masks, such as those with COPD or dementia or other mental health

issues

In the hospital setting:

• Wear a surgical mask or N95 respirator (or N99 respirator or powered air-purifying respirator) and eye

protection as part of appropriate PPE33

• Minimize aerosol-generating procedures34

• If you must perform an aerosol-generating procedure, wear an N95 respirator along with PPE34


ISOLATION AND QUARANTINE

In contrast to isolation, which keeps a person known to have COVID-19 away from others, including household members, quarantine is used to separate someone potentially exposed to SARS-CoV-2 from others. Given the prolonged time from viral exposure to symptom onset, quarantining after exposure is an important way to prevent further spread of disease even before a potentially infected person develops symptoms or tests positive. A 14-day quarantine is recommended for anyone who has been in close contact with someone who has COVID-19, with some provisions for shorter quarantine duration listed below. Close contact with an infected individual is defined as any of the following, although there may be risk even without close contact:35

• Being within 6 feet for 15 minutes or longer

• Providing of home care to someone with COVID-19

• Direct physical contact (eg, hugging or kissing)

• Sharing eating or drinking utensils

• Contact with respiratory droplets (eg, being coughed or sneezed on by someone with COVID-19)

While 14 days remains the standard recommendation, the CDC has provided the following options to reduce the length of quarantine to lessen the personal, physical, mental, and economic burdens of prolonged quarantine, as dictated by individual circumstances and resources.36

Table 6. Options for Reduced Duration of Quarantine

Duration ConditionsResidual post-quarantine transmission risk

10 days • Symptom-free• No diagnostic testing performed

1%; upper limit 10%

7 days • Symptom-free• Negative diagnostic test confirmed

5%; upper limit 12%

TREATMENTThe first phase of COVID-19 is marked by viral invasion, followed by a robust inflammatory phase. Accordingly, antivirals may be most effective early in the disease process, whereas anti-inflammatory agents are more likely to confer benefit later on.34 However, many people don’t present to health care providers until the disease is severe, and questions remain surrounding how and when to treat mild cases of COVID-19.

Several medications still being investigated for efficacy against COVID-19 are available through Emergency Use Authorization (EUA) granted by the US Food and Drug Administration (FDA). Unlike formal approval, EUA for a given agent remains in place for only as long as the agent is expected to be beneficial during a public health emergency.37 Selected FDA-approved or emergency authorized treatments are summarized in Table 7.


Table 7. Selected Treatments for COVID-19

Agent IDSA39 NIH35 WHO40 Key Trial DataApproval status (FDA)

Dexamethasone or alternative

corticosteroids

Severe and critical COVID-19



Improved survival among

patients requiring supplemental

oxygen41,42

Available

Remdesivir


(including IMV and ECMO)

Severe COVID-19 only (not

for patients needing IMV

or ECMO)

Not recommended

for any severity of COVID-19

illness

ACTT-1: Shortened time to

recovery43

Solidarity: No impact on

mortality, IMV, duration of

hospitazation44

Real-world analyses

suggest benefit of remdesivir

across a range of baseline O2 requirements,

with the greatest benefit seen

among patients on low-flow O2

45–48

Approved 10/20/204

Tocilizumab

Severe or critical

COVID-19, in addition to

steroids

Severe or critical


steroids

Severe or critical


steroids

Improved survival among critically ill inpatients in

combination with corticosteroids50,51

EUA 06/24/2152

Remdesivir+ baricitinib N/A

Insufficient data

N/A

Reduced recovery time among

people on high-flow O2 and

NIMV53

EUA11/19/2054


Monoclonal antibodies†

Suggested for high-risk outpatients

Recommended for high-risk outpatients

N/A

Reduced hospitalization

for high risk patients;55,56,57,58

reduced mortality with casirivimab

/ imdevimab among

hospitalized patients

seronegative for baseline antibodies59

EUA 11/21/20 (updated 6/3/21),2/25/21 (paused 6/25/21),

5/26/2160,61,62,63

Convalescent plasma

(high titer only)

Recommend only in a

clinical trial Insufficient data N/A

May reduce disease

progression when administered

early in disease13-15

EUA08/23/20;16

revised 2/4/202117

†Monoclonal antibodies authorized for emergency use include casirivimab/imdevimab, and sotrovimab63 (bamlanivimab/etesevimab distribution paused per in vitro assays suggesting inactivity against the SARS-CoV-2 P.1 and B.1.351 variants69); IMV = Invasive Mechanical Ventilation; ECMO = Extracorporeal Membrane Oxygenation; NIMV = Non-Invasive Mechanical Ventilation.

Remdesivir, monoclonal antibodies, and convalescent plasma act on the virus itself, and most of the other drugs block an aspect of the inflammatory process. A comprehensive review of all available and investigative therapies is beyond the scope of this review; additional information can be found in COVID-19 resources provided by the Infectious Diseases Society of America (IDSA), the National Institutes of Health (NIH) and the World Health Organization (WHO).


VACCINATION TO PREVENT RESPIRATORY ILLNESSESThere are currently three COVID-19 vaccines authorized for emergency use70. One is a single dose that is 66% effective in preventing laboratory-confirmed infection, and the other two are given in 2 doses 3-4 weeks apart and are about 95% effective in preventing laboratory-confirmed infection.71,72 Reliable information to ensure safe vaccine uptake is important for all patients, particularly those with risk factors for serious illness. Comprehensive patient education should include the continued need for vaccination against pneumococcal pneumonia and seasonal influenza as well as COVID-19 and should dispel misinformation suggesting that receipt of one vaccine may render others unnecessary. Additionally, patients should receive education surrounding the sequence of vaccination for protection against respiratory diseases, namely the recommendation to separate COVID-19 vaccination from any other vaccine by at least 14 days. Additionally, patients with confirmed or suspected COVID-19 should defer vaccination until their symptoms resolve and their isolation period ends to alleviate diagnostic confusion between symptoms from disease or vaccination.73 However, patients treated with monoclonal antibodies or convalescent plasma should not be vaccinated until 90 days after treatment.73 Current guidance surrounding COVID-19 vaccination is offered through the CDC webpage: https://www.cdc.gov/vaccines/covid-19/index.html.

CONSIDERATIONS IN TRANSITIONS OF CAREGUIDING PRINCIPLES IN TRANSITIONS OF CARE

The National Transitions of Care Coalition (NTOCC) developed Seven Essential Intervention Categories (Figure 1) that align with key transitions of care policies crafted by national healthcare organizations, including the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, the American College of Emergency Physicians, and the Society of Academic Emergency Medicine.57

Figure 1. Seven Essential Intervention Categories for Designing Transitions Strategies

TransitionPlanning

Specialist

Home Health Palliative

CareSub-Acute

RehabAcute

Hospitalization

Post-Acute/Long-Term Care Facility

Diagnostic& Treatment Center

OutpatientTherapies

Hospice

CommunityAgencies

Case/Disease Management

Primary Care

Shared Accountability Across Providers &

Organizations

Assessment – including social determinants of health – conducted by a social worker or case manager;

Develop an educational plan, and share with the care team

Collaborative assessment and medication plan completed by a physician, pharmacist, advance

practice nurse, physician assistant, nurse, social worker,

or case manager

Collaborative team careplanning and implementing

patient shared decision-making; Use patient assessment, including

social determinants of health

Bidirectional communication (provider to provider) at the next level

of care; Provide communication to patient and family caregiver(s)

Ensuring timely access to medica-tions and key health care providers, and communicating importance to

patients and their family caregiver(s)

Information sharing between the collaborative care teams: physician,

pharmacist, advanced practice nurse, physician assistant, nurse, social

worker, case manager, allied health professional, community health workers, community agencies

Ensuring that a health care provider is responsible for the care of the patient at all times,

with clear and timely communica-tion of the patient’s plan of care

Specialist

Continuum of Care Health Health

Health Care Provider Engagement

Follow-UpCare

InformationTransfer

MedicationManagement

Patient and Family Engagement/

Education


HOME MANAGEMENT OF COVID-19Whether patients are diagnosed and managed exclusively on an outpatient basis or are transitioning from the hospital, most patients will complete their recovery from COVID-19 at home. Safe recovery from COVID-19 in the home setting requires mechanisms to monitor patients for clinical deterioration as well as education for patients and caregivers about when and how to access medical attention. Patient and caregiver willingness and ability to monitor and communicate symptoms can vary significantly, and these differences are compounded by inconsistent access to telehealth and varying levels of comfort in using telehealth or other electronic means of communication.

MONITORING FOR DISEASE PROGRESSION

As indications for hospital referral are similar between COVID-19 and other respiratory illnesses such as community-acquired pneumonia,58,59 identifying patients in need of acute escalation of care is not a unique challenge for frontline providers. However, additional needs specific to COVID-19 must be considered in determining suitability for home management, such as ability to isolate, self-monitor, and communicate any worsening of symptoms while at home. Additionally, patients with certain comorbid conditions are more likely to progress to severe illness and should be monitored carefully, even when clinically stable upon initial diagnosis with COVID-19. As such, a working knowledge of risk factors for disease progression along with a comprehensive medical history and assessment of the home environment are critical, but can be difficult to obtain due to limited time to collect a complete medical history and the evolving nature of evidence surrounding comorbid conditions and disease severity.

In addition to ensuring patient recovery, the significant burden posed by hospital readmission underscores the importance of continuing monitoring at home after hospitalization, particularly among patients at high risk of readmission. Readmission or return visits to the emergency department for COVID-19 are most common within 10 days of discharge and are associated with shorter initial lengths of stay, prior hospitalization within the last 3 months, COPD, hypertension, heart failure, diabetes, and chronic kidney disease.60,61,62

Strategies to support home recovery from COVID-19 include:

• Assess patients for risk factors for progression to severe COVID-19 (see Table 4)

• Assess home caregiver capabilities

• Refer to the NTOCC Point-of-Care Checklist for Transitions of Care Assessment and Coordination provided at below to assess social, environmental, and technological factors contributing to patient readiness for home management

• Create a checklist of items to review with patients/caregivers, or refer to the Checklist for Home Recovery from COVID-19 provided below, to support symptom monitoring and communication during home recovery from COVID-19

• Equip patients with or have patients purchase a pulse oximeter for home monitoring of oxygen saturation

� May be obtained at most pharmacies without a prescription for under $50

• Establish which health care provider patients should call if symptoms worsen

• Identify indications for patients or caregivers to seek urgent or routine medical attention


• Discuss situations that may not necessitate seeking urgent medical attention

� Lingering symptoms such as fatigue or loss of taste or smell may be expected

� Patients may have transiently worsened symptoms over the course of the day (eg, a worsened cough first thing in the morning) but are overall improving each day

� Tailor recommendations to each patient’s baseline status, goals, comfort and discernment

• Implement a telehealth system to promote patient assessment, such as daily symptom reporting through an electronic portal monitored by clinic staff

ADHERENCE TO INFECTION CONTROL MEASURES

Beyond widespread prevalence and substantial morbidity, the highly contagious nature of COVID-19 complicates management in the outpatient setting. Providers must assess and reinforce patient willingness and ability to self-isolate and alert recent close contacts of the need to quarantine.35 Confusion frequently exists surrounding the definitions and implications of isolation and quarantine in the context of a household member infected with COVID-19 and provisions to safely discontinue these measures.

Strategies to limit spread of disease during home recovery from COVID-19 include:

• Clarify “isolation”: separation from a known infected person from others, including household members, for a minimum of 10 days from symptom onset.63 Simply staying at home is not enough. Other may not come to that home and risk exposure.

� See Checklist for Home Recovery from COVID-19 for complete list of provisions to discontinue patient isolation

• Clarify “quarantine”: separation of a potentially exposed person from others for the expected time between exposure and onset of illness

� Recommended for 14 days, though shorter durations may be acceptable in certain situations (see Table 6)

� As the recommended duration of quarantine following exposure is longer than the recommended duration of isolation following infection, it is possible for someone known to be infected to leave isolation sooner than an exposed person will leave quarantine63

• Reinforce that SARS-CoV-2 vaccination may alter guidance for quarantine, but does not affect guidance for general prevention measures such mask wearing and avoiding close contacts with others

• Create a checklist of items to review with patients/caregivers, or refer to the Checklist for Home Recovery From COVID-19 below, to minimize spread of infection during home recovery from COVID-19

• Establish home hygiene protocols to limit further spread

• Establish provisions for discontinuing patient isolation


Point-of-Care Resource for Patient Education Printable Resource for Use in Daily Practice

This list should be used by providers to guide discussions with patients and their caregivers in preparation for recovery from COVID-19 in the home setting.

Monitoring symptoms at home Establish which health care provider should be contacted if symptoms worsen If possible, use a home pulse oximeter

• This can provide useful information in follow-up discussion with providers• Establish results that should prompt seeking medical attention

� May be one specific oxygen level concentration or a persistent decline, as determined per individual patient severity of illness and baseline status

Identify indications for patients or caregivers to seek medical attention, such as:• Progression or sudden worsening of symptoms, which may include:

� New, higher, or more frequent fever� Signs of a blood clot, such as new one-sided leg swelling, or suddenly increased

heart rate or shortness of breath� Persistently declining oxygen saturation as measured by home pulse oximeter, or

decline to a pre-established threshold concentration� Increasing shortness of breath

• If the home environment has changed and is not safe for isolation and recovery Discuss situations that may not necessitate seeking urgent medical attention

• To be personalized to meet each unique patient’s needs

Protecting household members Instruct close contacts of the infected person to quarantine for 14 days

• Shorter durations may be acceptable in certain situations (See CDC recommendations above)

The patient should be isolated from others, including household members• Patient should recover in a private bedroom• One bathroom should be designated for patient use only

� If the home has only one bathroom, disinfect after each use• Avoid unnecessary visitors to the home

All of the following must be met before discontinuing home isolation: • ≥ 10 days since symptom onset• ≥ 24 hours since last fever (without using fever-reducing medication)• Other symptoms have improved or resolved

Both the patient and caregiver should put on a mask before entering the patient’s room All household members should wash hands often and avoid touching their face Consider implementing measures to improve ventilation, as described by the CDC:

https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html Clean and disinfect surfaces frequently Do not share personal items like towels, bedding, dishes, silverware with the patient Consider alternative housing for extremely high risk household members

Checklist for home recovery from COVID-19


MANAGEMENT OF COMORBID CONDITIONS AND MEDICATION RECONCILIATION

In the US, adverse drug events are the most common post-discharge complication responsible for hospital readmission, and approximately half of medication errors leading to sentinel events reported to the Joint Commission could have been avoided through effective medication reconciliation.64,65 As patients who develop severe COVID-19 requiring hospitalization often have multiple comorbid conditions and are frequently prescribed new short-term medications at discharge,66 careful medication reconciliation is need to ensure uninterrupted care. Common barriers to medication reconciliation include varied patient ability to provide an accurate history, electronic health record integration between different systems, and time constraints.67 Regardless of whether hospitalization was required, continued management of comorbid conditions can be complicated when patients are recovering from COVID-19 at home. For example, the benefit of immunosuppressive medications used for autoimmune disorders must be weighed against potential risks during active infection with SARS-CoV-2.68,69,70

Additionally, scheduling routine specialist and preventive services can be difficult as providers balance the need for protecting themselves and other patients while ensuring continuity of care for patients recovering from COVID-19 at home. Patient reluctance to seek in-person care for indications unrelated to COVID-19 has also been observed, with more than 40% of respondents to a large CDC survey reporting having delayed or avoided medical care because of concerns about COVID-19.71 Strategies to support medication reconciliation and uninterrupted access to chronic and preventive care include:

• Continue and optimize existing medication reconciliation practices to include pharmacist support, medication list updates, and comprehensive patient interviews

• Develop a summary sheet of acute and chronic medical conditions and current medications, or refer to the NTOCC Health Management Tool provided below

• Communicate care plans with patients and providers in other settings• Avoid inadvertent long-term continuation of short-term prescriptions for acute COVID-19 treatment (eg,

corticosteroids) by ensuring prescriptions are not automatically refillable• Facilitate uninterrupted access to medication in case of the need to quarantine or self-isolate

� Engage family or significant others in transportation and/or payment coverage � Connect patients with mail-order pharmacy � Authorize 90-day prescriptions � Inquire about any difficulty accessing medications

• Access guidance specific to chronic diseases managed with immunosuppressive therapies through medical society recommendations, such as: � American College of Rheumatology72 � American Academy of Dermatology69 � American Gastroenterological Association73,74

• Develop a method to verify when patients who have recovered from COVID-19 have completed isolation and can safely return to in-person care, or refer to the COVID-19 Care Card provided on the following page.

REINFECTION, RETESTING AND IMMUNITY

The likelihood of reinfection after recovery from severe COVID-19 is not well understood and can be a source of confusion and misinformation for patients and providers alike. Patients should be counseled to avoid undergoing retesting within 3 months of initial symptom onset, as prolonged viral shedding may occur during this time.17 However, earlier repeat testing may be required in accordance with institutional guidelines prior to undergoing aerosol-generating procedures such as pulmonary function testing. Additional indications for earlier repeat testing in compliance with local or national regulations may include returning to work, performing certain procedures, or traveling out of state or internationally. As with any condition, new or worsening symptoms should prompt medical evaluation.


COVID-19 Care Card for Safe Return to In-Person CarePrintable Resource for Use in Daily Practice

This resource should be used to summarize patient COVID-19 history to help other providers verify when the patient is no longer infections and can safely be seen in person.

Summary of COVID-19 Tests, Symptoms, and Management

Today’s date: _______________________________Patient name: _______________________________

COVID-19 Testing HistoryDate of most recent COVID-19 test: _______________

TYPE OF TEST:

Antigen: _________________Molecular (PCM) _________Antibody _________________

Date of any previous COVID-19 test: ______________

Symptom History

Symptom Start date End date* Never had

Fever

Shortness of breath

Cough

Muscle pain or weakness

Fatigue

Upset stomach or diarrhea

* If symptom is continuing, say “current.”

Patient Isolation HistoryWhen did patient start enter isolation? Date: ___________________Last day of isolation (date completed or anticipated end date): ______________________________

Assessment of Return to In-Person CareIf patient continues to improve, he or she may be safely seen in person using standard COVID-19 precautions as early as ___________ [anticipated end of quarantine/infectious period].

Health care provider’s signature: ____________________________________________________________Health care facility (name; city/state) __________________________________________________________

COVID Care Card

Date of birth: ________________________________

_________ Result: Positive Negative

_________ Result: Positive Negative_________ Result: Positive Negative

Did not isolate:_______________


COVID -19 Health ManagementUse this tool as a guide in order to be active in taking care of your own health management or a loved one whom you care for.

When you are calling, emailing or having a telehealth visit with your health care professional ( a doctor, pharmacist, advanced practice nurse, nurse, case manager or social worker) use this questionnaire to discuss your symptoms, health status, concerns and to record actions you should take in managing your symptoms. You should also use the questionnaire when you or a loved one is leaving the hospital after you have been treated for COVID-19 to record important information about your health management and what you need to do when you get home.

Visit with: _______________________ Today’s Date: _______________________

BE SURE YOU KNOW THESE THINGS:

1. I am experiencing the follow symptoms (Check all that apply):Fever: ___ Chills: ___ Sore throat: ___ Fatigue: ___ Cough: ___ Trouble breathing: ___Headache: ___ Muscle/body aches: ___ New loss of taste or smell: ___ Congestion or runny nose: ___ Nausea or vomiting: ___ Diarrhea: ___

2. I have had contact with a person who has COVID-19 in the last 14 days? Yes ___ No ___

3. I have the following medical conditions:Heart disease: ___ Diabetes: ___ Chronic lung disease: ___ Autoimmune disorder: ___Additional medical conditions: _______________________________________________________

4. List all medicines you are currently taking on the back of this questionnaire, including any on the following list:

___ All prescription medications (can buy only with a prescription)___ Major side effects of these medicines I have experienced___ Over-the-counter medicine (can buy without a prescription)___ Vitamins, herbs, or supplements I take such as St. John’s Wort

IMPORTANT! Inform providers of allergies or sensitivities you have to any medicine

5. Should I be tested for COVID-19?______ Where should I go for the test? ______________________________________________________When should I expect the results? ___________________________________________________

6. What medication are you prescribing for me today? ____________________________________

7. Are there any side effects with this medication I should be aware of? __________________________________________________________________________________

8. Should I self-quarantine? ____ If so, for how long? _____________________________________

9. What do I need to do to protect my family? ___________________________________________

10. Be sure to tell your provider if in you have any of the following living in your home:____ Adults over 65____ An adult/child who has a chronic condition or their immune system is compromised

11. When should I do a follow up regarding my condition or any changes in my condition? __________________________________________________________________________________

12. Who should I call with any concerns about my condition or if I have additional questions? __________________________________________________________________________________

Name: ________________________________ Telephone #: _______________________________

Prevent the spread of COVID-19 in

7 STEPSSource: World Health

Organization

• Wash your hands frequently

• Avoid touching your eyes, nose and mouth

• Cover your cough using the bend of your elbow or a tissue

• Avoid crowded places and close contact with anyone that has a fever or cough

• Stay at home if you feel unwell

• If you have a fever, cough and difficulty breathing, seek medical care early - but call first

• Get your information from trusted sources

What you need to know

Anyone can have mild tosevere symptoms.

Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness.

Wear A Mask

Avoid Crowds

Stay 6 feet apart


COVID -19 Health ManagementUse this tool as a guide in order to be active in taking care of your own health management or a loved one whom you care for.

When you are calling, emailing or having a telehealth visit with your health care professional ( a doctor, pharmacist, advanced practice nurse, nurse, case manager or social worker) use this questionnaire to discuss your symptoms, health status, concerns and to record actions you should take in managing your symptoms. You should also use the questionnaire when you or a loved one is leaving the hospital after you have been treated for COVID-19 to record important information about your health management and what you need to do when you get home.

WHEN I GET UP, I TAKE:

Drug name-Brand name or

generic & DOSE

This looks like-Color, shape

Howmany?

How I take itI started

taking thison: ( date)

I stop takingthis on:(date)

Why I take it

Who toldme to take

it?(name)

Example:Lisinopril 10 mg

Round yellowpill

1By mouth

withbreakfast

June 3, 2018 Keep takingHigh blood pressure

Dr. Smith

IN THE AFTERNOON, I TAKE:

IN THE EVENING, I TAKE:

BEFORE I GO TO BED, I TAKE:

OTHER MEDICINES THAT I DO NOT USE EVERY DAY:

Trusted Information Sources:https://www.cdc.gov/coronavirus/2019-nCoV/index.html

https://www.who.int/emergencies/diseases/novel-coronavirus-2019https://www.ntocc.org/

https://www.usa.gov/state-health

MY MEDICINE LIST


LEVERAGING TELEHEALTH FOR ACUTE AND PREVENTIVE CARE

The COVID-19 pandemic has advanced the use of telehealth as a safe and efficient means of providing patient care which may have long-lasting utility. Telehealth is the use of electronic information and telecommunication technologies to provide care when the patient and provider cannot meet in person. In its simplest form, telehealth is an email, phone call, or video chat with a health care provider. More sophisticated forms involve real-time monitoring and clinical decision-making tools such as home vital signs uploaded from home devices or pacemaker data. Because patients vary in their levels of comfort and experience using such technologies, early support and education can facilitate the implementation of telehealth.75,76 During the COVID-19 pandemic, patient satisfaction with telehealth has been high and does not appear to pose a barrier to shifting away from traditional in-person clinic visits.77 Several considerations should be addressed by patients and providers prior to conducting telehealth medical appointments to ensure a positive and productive experience, such as:75,76

Equipment considerations (for patients and providers):• Ensure stable, secure internet connection• Establish a quiet environment to ensure confidentiality and minimize interruptions

Preparing your practice site for telehealth:• Schedule office staff to conduct remote patient intake• Establish clinical criteria to prompt in-person or emergent care• Assess ability to navigate speech, hearing, or language barriers

Preparing patients for a telehealth appointment:• Provide comprehensive and easy-to-follow instructional materials complete with visual aids like

screenshots to help patients access and navigate the telehealth platform• Notify patients in advance of any information they should have readily available

FROM HOSPITAL TO HOMEIn addition to considerations outlined in the section above for all patients recovering from COVID-19 in the home setting, patients transitioning home after being hospitalized may have additional needs, depending on the complexity of the inpatient course.

HOME OXYGEN THERAPY

Hypoxia is a key feature of lung involvement in severe COVID-19, and home oxygen therapy is among the most common post-discharge needs for patients continuing to recover in the home setting.66 One hospital protocol that provided home oxygen therapy to patients with mild to moderate COVID-19 with SpO2 between 90% and 92% but not requiring hospitalization contributed to the avoidance of 481 inpatient hospital days for 76 patients.78 While home oxygen therapy can promote healing and recovery from COVID-19 in the home setting, timely reassessment for continued need is important. Studies of patients with COPD have verified an association between prolonged home oxygen therapy and physical inactivity, which can lead to deconditioning.79,80 Unfortunately, fewer than half of patients are reevaluated for potential de-implementation of home oxygen therapy within 90 days of hospitalization for a COPD exacerbation.81

Strategies to support effective use and timely discontinuation of home oxygen therapy include:• Coordinate home delivery of supplies for home oxygen therapy• Designate key contacts and organize home health care including respiratory therapy as indicated• Establish a plan for evaluation of continued need for home oxygen therapy to support use of the

minimum volume and duration necessary for recovery


POST-DISCHARGE ANTICOAGULATION

Compared to patients with ARDS due to other causes, patients with COVID-19 are approximately twice as likely to develop any form of venous thromboembolism (VTE) and six times as likely to develop a pulmonary embolism (PE).82 Accordingly, national organizations consistently recommend VTE prophylaxis for both acutely ill and critically ill patients hospitalized for COVID-19. However, no estimates exist for VTE rates in ambulatory patients recovering from COVID-19 at home.25,83,84 Currently available guidance regarding extended post-discharge VTE prophylaxis varies, ranging from recommending inpatient prophylaxis only85 to considering home prophylaxis for patients at high risk for VTE,86 and all encourage careful assessment of potential risks and benefits.84-86

In the absence of a standardized approach to post-discharge VTE prophylaxis and the expectation that many patients will continue therapeutic anticoagulation upon discharge, either for pre-existing indications or for VTE developed during hospitalization, there is a need for careful planning, monitoring and communication, including:

• Agreement across the multidisciplinary team on the anticoagulant treatment or prophylaxis plan before discharge � Decisions should weigh potential risks against benefits and tailor regimens to unique patient

features such as renal impairment, drug interactions or bleeding risk � Discussion of duration of anticoagulant therapy and appropriate monitoring

• Clear explanation to patients, caregivers, and primary care providers of the indication and intended duration of anticoagulation

Discharge processes should be established to:

• Promote patient readiness for home recovery

� Verify support at home

� Assess patient functional status, including fall risk

� Implement follow-up plans, including home monitoring and duration and implications of patient isolation

• Review measures to protect household members from infection

• Optimize electronic information sources to support timely and accurate information transfer

• Support patient medication adherence to new and chronic medications

� Provide updated medication list summarizing changes

� Counsel patient and caregiver about medications prior to hospital discharge

� Communicate changes to pharmacy filling prescriptions

• Create a checklist for patients/providers or refer to the NTOCC Point-of-Care Checklist provided below to ensure that discharge is appropriately supported.

Discharge Management Protocols


NTOCC Point-of-Care Checklist for Transitions of Care Assessment and Coordination

m mYes No

Do the patient and the caregiver understand the COVID-19 diagnosis/illness?

m mYes No

Do the patient and caregiver understand their symptoms?

m mYes No

Has the patient received a reconciled medication list detailing medications to be taken following discharge?

m mYes No

Has the adherence assessment been completed?

m mYes No

Has an assessment for substance use disorder been completed?

m mYes No

Have the follow-up instructions for lab tests, follow-up PCP visits, consultations, x-rays, and other relevant tests results been completed with providers and patient?

m mYes No

Should a technology assessment be completed with the patient & family before providing a virtual visit or alternative communication interventions after discharge?

m mYes No

Do the patient and family know what they need to discuss in a follow-up virtual visit?

m mYes No

Review all prescribed medications, over-the-counter medications, and health/nutritional supplements:• Name of medication• Dose• Route• Frequency• Next refill

m mYes No

Can the patient or caregiver tell you the reason she or he is taking the medication?

m mYes No

Can the patient or caregiver tell you the effects of taking the medication?

m mYes No

Can the patient or caregiver tell you the symptoms or side effects of taking the medication?

m mYes No

Do they know who to call if they have a problem or question regarding their medications?

This NTOCC checklist is designed to enhance communication between providers, care settings, patients and caregivers. Adapt the checklist to address areas of concern that are relevant to individual patients, as well as to your specific care setting.

Assessment of Medical Issues:

Medication Assessment:

Printable Resource for Use in Daily Practice


m mYes No

Can the patient or caregiver tell you the next refill date for the medication?

m mYes No

Has the patient or caregiver been given information on how long she/he needs to remain on the medication?

m mYes No

Has all information regarding the need for and timing of COVID-19 vaccination and appropriate timing of the vaccination been provided to the patient and family prior to leaving the hospital or LTC?

Medication Assessment Continued:

m mYes No

Has the patient or caregiver’s health literacy been assessed with a formal tool?

m mYes No

Has the patient or caregiver been given easy-to-understand, clinically appropriate material in layperson’s language (written, digital, etc.) regarding COVID-19 management & vaccinations?

m mYes No

Has the patient or caregiver been provided materials and services in his/her preferred language?

m mYes No

Have clinical staff used graphic representations for a patient or caregiver with limited language proficiency or literacy?

m mYes No

Have clinical staff developed an educational plan based upon the patient’s or caregiver’s identified needs including hearing impairment, vision impairment and/or English as a Second Language?

m mYes No

Have all self-management of medications and procedures to be delivered been provided to the patient or caregiver with accurate communication using teach-back methods?

m mYes No

Have staff evaluated the caregiver’s capacity to understand and apply health care information in assisting the patient?

m mYes No

Have barriers (financial, transportation, resources) to accessing care and medications been assessed and solutions to ensure access been identified?

m mYes No

Have the patient’s or caregiver’s ability to perform activities of daily living and meet basic needs been evaluated?

m mYes No

Has the home environment been assessed for the ability to support patient isolation and COVID-19 care interventions, including the age and any chronic illness of additional people in the home?

m mYes No

Do the patient and family have access to internet and the ability to conduct a virtual visit with practitioners?

m mYes No

Have environmental barriers that may compromise the patient’s or caregiver’s ability to meet established treatment goals been assessed?

Health Literacy & Linguistic Factors:

Social Factor Assessment:


m mYes No

Has a formal and informal support system been identified for the patient or caregiver?

m mYes No

Has adequate and safe housing been established for the patient or caregiver?

m mYes No

Has adequate food security been determined for the patient or caregiver?

Social Factor Assessment Continued:

m mYes No

Does the patient have a primary care physician? Ensure assessment and discharge information is sent to PCP. Date completed

m mYes No

Does the patient have a specialist (eg, gastroenterologist)? Ensure assessment/discharge information is sent to specialist. Date completed

m mYes No

Does the patient have referrals for home care, DME, respiratory therapy and O2 management? Ensure assessment/discharge information is sent to each entity. Date completed

m mYes No

Is the patient being transitioned to post-acute services? Ensure assessment and discharge information is sent to facility. Date completed

m mYes No

Ensure all appointments, referrals and follow-up care has been completed and information has been provided to the patient or caregiver. Date completed

Continuity/Coordination of Care:

Adapted from the NTOCC original Transitions of Care Checklist - Elements of Excellence in Transitions of Care:http://www.ntocc.org/Portals/0/PDF/Resources/TOC_Checklist.pdf


FROM HOSPITAL TO LONG-TERM CARE FACILITY (LTCF)For the purposes of this pathway, the term “LTCF” is used to encompass all subacute care facilities, including rehabilitation centers, skilled nursing facilities, and similar care milieus. While beyond the scope of this review, each type of long-term care setting has unique barriers and opportunities that warrant individual attention. After being hospitalized for COVID-19, up to 30% of patients are expected to require transitional care in LTCFs.87 The strongest predictors of needing subacute care after hospitalization for COVID-19 are age (≥ 65 years), presence of comorbidities, cognitive deficits, and a score < 50% on the Short Physical Performance Battery (SPPB).88

HIGH DEMAND

The importance of LTCFs during the COVID-19 pandemic in alleviating hospital capacities and supporting continued patient recovery has been underscored by waivers issued by the Centers for Medicare & Medicaid Services (CMS) temporarily removing the requirement of a minimum 3-day hospitalization before post-acute care expenses may be covered.89 As needs for acute care beds and long-term support remain high, LTCFs and hospitals alike are challenged to balance these needs with safe and sustainable care.

To optimize use of LTCFs as essential resources while protecting new and existing residents and staff, the following practical approaches should be considered: 90,91

• Developing temporary specialized post-acute care facilities specifically for patients who are recovering from COVID-19 and may still be contagious, analogous to surge hospitals

• Routinely assessing and communicating vacancies to accept COVID-19 patients • Securing resources to safely care for COVID-19 patients, such as personal protective equipment,

negative-pressure rooms, separate units, and isolation measures • Establishing protocols for post-acute care of COVID-19 patients • Providing staff training and education on COVID-19 and infection control measures

INFECTION CONTROL

LTCFs and other communal living facilities are faced with a unique set of challenges to infection control. Residents often share a room or bathroom, which may limit their ability to maintain recommended physical distancing where they spend the most time, and there may be a high proportion of residents unable to tolerate wearing masks, such as those with dementia or COPD.

In addition to routine precautions like hand washing and social distancing, measures to support infection control in the LTCF setting include:

• Encourage residents to wear a mask in all social/communal situations where feasible • Implement other precautions for situations in which masks cannot be tolerated (such as physical

distancing, physical shields or dividers, extra ventilation, or open windows)• Review and follow facility protocols for infection prevention and control• Batch tasks to limit entries into patient rooms• For additional suggestions, see recommendations from the Society for Post-Acute and Long-Term

Care Medicine, available at https://paltc.org/COVID-19


TRANSFER OF INFORMATION

Patients transferred to LTCFs after hospitalization for COVID-19 may require a high level of post-acute care for continued recovery. These needs may differ from those of typical residents and may include medications, equipment, and specialist consultation other than those routinely provided at the receiving facility. Additionally, hospital and LTCF electronic health records are often not integrated with each other, complicating information sharing between facilities. To navigate and minimize these barriers, prospective communication from the hospital to the receiving LTCF should be initiated as early as possible to avoid delays in obtaining supplies and improve the timeliness of specialist follow-up.

The receiving facility should be contacted to discuss patient needs early enough to allow for procurement of any specialized equipment, medication, or other supplies that may be difficult or expensive to obtain. Strategies to support transfer of information include:

• Communicate patient information directly via telephone and specific instructions on transfer forms, rather than relying on the hospital discharge summary

• Call the admitting office or director of nurses to find out who the attending physician caring for the patient will be

• Coordinate realistic post-acute care plans with the receiving facility

• Determine sub-specialist availability and anticipated time to first consultation

• Establish plan to transfer care to providers who perform rounds at the facility, or to continue care with current providers via telehealth and later with transportation to clinics

• Clearly state orders for weaning patients from supplemental oxygen as well as orders for any physical or occupational therapy needed, assessment of fall risk, skilled nursing care needed, etc.

• Ensure the sending provider remains responsible for the patient’s care until the receiving provider acknowledges they can assume ownership over the continuum of care.92

Transfer of information from hospital to LTCF

HEALTH INEQUITIES AND ACCESS TO CAREThe COVID-19 pandemic has disproportionately impacted racial and ethnic minority groups and has highlighted longstanding health inequities across the US, particularly with respect to social distancing, isolation and quarantine measures to prevent spread of disease. Members of communities of color are more likely to be essential workers with inherently increased chances of exposure.93 In the event of an exposure or infection, ability to socially distance is impaired among groups residing in multigenerational homes, either due to physical space limitations, or inability to delegate household responsibilities elsewhere.93 Socioeconomic inequities can also preclude access to technology needed for telehealth, impeding timely connection to care for COVID-19 symptoms or for continued management of comorbid conditions during periods of limited in-person appointments.


Prior to discharge, patients should be assessed for social determinants of health – such as housing, food security, literacy, and occupational security – as well as their ability to socially distance to prevent further spread of disease. For example, providers should ask:

• Who lives at home with you?

• Are you able to basic needs like secure housing, utilities or food?

• Are you able to safely isolate in your home?

• Are you able to physically separate yourself from household members?

• Can someone else fulfill your usual household responsibilities?

• What is your employer’s stance on missed work due to COVID-19?

• What technology do you have available for remote follow-up care (smartphone, internet)?

Assessing Social Determinants of Health

The EveryONE project by the American Academy of Family Physicians offers resources for providers connecting patients to food, housing, transportation, legal, financial, and employment support, as well as a Social Needs Screening Tool to assess social needs for personal safety, available here: https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-form-sdoh.pdf. Additionally, CMS offers a screening tool for comprehensive assessment of social needs related to health care: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.

For situations where patients are unable to comply with a 14-day quarantine after a potential SARS-CoV-2 exposure, the CDC has offered provisions whereby a shorter quarantine may be acceptable, reviewed in Table 6 above. Other unique solutions may be considered, particularly in metropolitan areas such as the COVID-19 Hotel Program in New York City where patients with confirmed COVID-19 are offered the opportunity to self-isolate in a hotel free of charge.

LONG-TERM CONCERNS AFTER ACUTE COVID-19 ILLNESSRecognition, understanding, and care for patients experiencing long-term symptoms after recovery from initial illness with COVID-19 continues to evolve and can place significant burden on patients, caregivers, and the healthcare system.94,95 Long-term disease effects are described in the context of two populations which may be distinct or overlapping: (1) patients with mild initial illness that did not require hospitalization but then go on to develop long-term manifestations, sometimes referred to as “post-COVID-19 syndrome” or “long COVID-19”; and (2) patients recovering from prolonged hospitalization and intensive care.

Lung function can continue to decline after resolution of acute symptoms due to lasting interstitial fibrosis.96 Neurological manifestations include smell and taste impairment, headache, dizziness, acute cerebrovascular disease and impaired consciousness. Described musculoskeletal effects have included myalgia and back pain.97


These long-term symptoms are a source of fear and anxiety and challenge providers to manage patient expectations for recovery. Additionally, patients with prolonged symptoms and impaired function will require comprehensive long-term monitoring and follow-up care. Patients and caregivers should be made aware of possible chronic symptoms and provisions for self-monitoring at home, along with:

• Expectations for long-term recovery process following prolonged hospitalization, especially after intensive care and mechanical ventilation

• Determination of shared responsibilities for monitoring and follow-up• Indications to seek medical attention• Situations that may not necessitate seeking urgent medical attention (tailored to each patient’s clinical

status and abilities, as discussed previously)

Care models to support comprehensive long-term monitoring and follow-up care have been proposed,98 but the resources and infrastructure to offer multidisciplinary clinics for these manifestations of COVID-19 are still in the conceptual stages in the US. Additional information surrounding long-term COVID-19 symptoms and recovery can be accessed through the CDC and the Mayo Clinic:

• https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html• https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/

art-20490351

ADDITIONAL TOOLS AND RESOURCES

• CDC: COVID-19 Testing Overview

� https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html

• CDC: COVID-19 Vaccination

� https://www.cdc.gov/vaccines/covid-19/index.html

• American College of Rheumatology: COVID-19 Guidance

� https://www.rheumatology.org/Practice-Quality/Clinical-Support/COVID-19-Guidance

• American Academy of Dermatology Association: Coronavirus Resource Center

� https://www.aad.org/member/practice/coronavirus

• American Gastroenterological Association: COVID-19 Clinical Guidance

� https://gastro.org/practice-guidance/practice-updates/covid-19-clinical-guidance

• Society for Post-Acute and Long-Term Care Medicine COVID-19 Resources Page

� https://paltc.org/COVID-19

• CMS screening tool for social needs related to health care:

� https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

• American Academy of Family Physicians EveryONE Project Social Needs Screening Tool

� https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-form-sdoh.pdf

• CDC: Long-Term Effects of COVID-19

� https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html

• Mayo Clinic: COVID-19: Long-Term Effects

� https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351


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