key: cord-0973879-v33worv3 authors: Brigham, Emily; O'Toole, Jacqueline; Kim, Soo Yeon; Friedman, Michael; Daly, Laura; Kaplin, Adam; Swarthout, Meghan; Hasselfeld, Brian; Lantz-Garnish, Melissa; Vannorsdall, Tracy; Agranovich, Anna; Raju, Sarath; Parker, Ann title: The Johns Hopkins Post-Acute COVID-19 Team (PACT): A Multidisciplinary, Collaborative, Ambulatory Framework Supporting COVID-19 Survivors date: 2021-01-12 journal: Am J Med DOI: 10.1016/j.amjmed.2020.12.009 sha: 8ddecccc645ec739d88b9aa2249345d00ec25437 doc_id: 973879 cord_uid: v33worv3 nan The COVID-19 pandemic has rapidly shifted healthcare needs and delivery internationally with about one in five people with COVID-19 requiring hospitalization, including in the intensive care unit (ICU), at pandemic onset. 1 ICU survivors in general are at risk for impairments in mental, cognitive and physical health, collectively known as post-intensive care syndrome (PICS); 2,3 similar challenges have been described post acute hospitalization (Post-Hospital Syndrome (PHS). 4 Risks may be higher among COVID-19 survivors. 2 Given recognized acute pulmonary complications associated with COVID-19, pulmonary sequelae are a prominent concern, 5-7 though COVID-19 has demonstrated an ability to impact multiple organ systems. 8 Further, emerging scientific data describe a potential for lingering symptoms post-COVID-19 infection even among those who do not require hospitalization. 9, 10 The etiology and physiologic correlates of potential persistent symptoms require sufficient resource infrastructure for comprehensive supportive care and further insight into the natural history of COVID-19. We provide a description of early need recognition, resource redistribution, operational experience, and refined multidisciplinary clinic structure to support COVID-19 survivors: the Johns Hopkins Post-Acute COVID-19 Team (JH PACT). The first COVID-19 admission to the Johns Hopkins Hospital was reported March 2020. Swiftly rising inpatient admissions drew heavily on inpatient resources, and Pulmonary and Critical Care Medicine (PCCM) providers were immersed in frontline care. Infection control efforts reduced availability of post-acute and ambulatory rehabilitation centers; provider resources were reallocated to augment in-hospital rehabilitation programs and support safe discharges. Non-COVID-19 research, outside of select clinical trials, was largely halted, and thus clinical effort was expanded for many faculty who traditionally serve in dual clinical and research roles. Potential ambulatory needs of COVID-19 survivors were extrapolated from other viral respiratory diseases, including severe acute respiratory syndrome (SARS) coronavirus, Middle East respiratory syndrome (MERS) coronavirus, and influenza; [11] [12] [13] [14] [15] data is notably limited. Patients developing acute respiratory distress syndrome (ARDS) were anticipated to be at risk for long-term respiratory complications, 16 and there were emerging reports of potential complications in multiple organ systems. 8 Importantly, survivors requiring hospitalization, especially in the ICU, were anticipated to be at risk for markedly impaired strength/physical ability, worsened mood/anxiety/posttraumatic stress disorder symptoms, cognitive impairment, and increased use of healthcare resources. 3, 4, 17, 18 Importantly, aspects of the COVID-19 pandemic, including visitor restrictions, potential limitations on essential rehabilitation services, higher levels and longer duration of sedation during critical illness, and longer lengths of stay had the potential to further complicate recovery. 2 Hence, a multidisciplinary approach was needed to address the needs of a rising population of COVID-19 survivors. A rapidly-developed solution was conceived to: (1) support the recovery of patients in the ambulatory setting, (2) prevent additional burden of predicted readmissions on an already strained inpatient system, (3) understand the natural history of disease and (4) funnel therapeutic opportunities to patients. A key consideration was the provision of ongoing care to uninsured and underinsured patients and collaboration with language translation services, given the disproportionate burden of COVID-19 in traditionally under-resourced populations. [19] [20] [21] Opportunity The procurement of a physical location for care delivery, which typically requires substantial justification within a formal business plan, can be a barrier to rapid implementation. Coordination for a multidisciplinary model requires harmonization of multiple providers and services in time and space. Rapid adoption of telemedicine on a broad scale, necessitated by infection control measures, overcame these barriers. Specifically, telemedicine allowed for appointments to be scheduled at the mutual convenience of patients and each of the multidisciplinary providers, circumventing the need for schedule alignment at a time of high clinical demand. The overall workflow targeted anticipated survivor streams, categorized by initial severity of illness and resultant healthcare utilization ( Figure 1 ). Given predicted patient needs, the PCCM Division partnered with the Department of Physical Medicine and Rehabilitation (PM&R) to provide core assessments and direct services. Patients discharged from the ICU were eligible for JH PACT-ICU, prompting referral to both Pulmonary and PM&R ( Figure 2 ). Patients who did not require ICU care for at least 48 hours could be referred to Pulmonary and/or PM&R (JH PACT-Base) depending on identified needs at the time of discharge. Patients who remained ambulatory but were identified by their primary care or another physician to have residual symptoms at 4-6 weeks post diagnosis were eligible for referral to JH PACT-Base. As an additional service, the Johns Hopkins Homecare Group Concerns were initially raised regarding access to telemedicine among vulnerable populations and those at risk of marginalization. To address this, research and administrative support staff were trained and re-deployed in telemedicine support to proactively contact patients, assist with software download prior to clinic, and support connection on the clinic day. Nursing staff introduced new patients to the clinic structure and assisted in navigating follow-up testing, which often required repeat COVID-19 test coordination. Clinic workflows and resources (e.g. subspecialty referral contacts) were stored in a central, secure drive accessible only by healthcare team members. A referral form (Appendix A) was disseminated via a collated Department of Medicine protocol for COVID-19+ discharges. Hospital and ambulatory referrals were accepted via a centralized email monitored by a referral coordinator and supported by nursing and physician review for appropriate placement in JH PACT-ICU or PACT-Base. PCCM colleagues were engaged to refer patients at the time of ICU downgrade, and clinic information was disseminated among hospitalist staff and medicine residents. Johns Hopkins Health System partners across the state were engaged in providing care under variably adopted portions of the framework, including RPM, offering an enhanced structure for post-COVID-19 care at participating hospitals. The first JH PACT patient was seen on April 7 th , 2020, representing one of the earliest dedicated COVID-19 survivorship clinics in the nation. As of November 11 th , 2020, 265 unique patients have been seen in 530 visits by the JH PM&R and/or Pulmonary PACT. New patient JH Pulmonary PACT visits have generated an average of one (range zero to three) additional subspecialty referral per patient over the preceding month. The JH PACT clinic exemplifies the Johns Hopkins tripartite mission: patient care, research, and education. To optimize clinical care and ensure rigor and uniformity of evaluation across the dedicated staff in the clinic, we adopted standardized clinic templates. Assessments were standardized consistent with the Core Outcome Measurement Set for acute respiratory failure 25 Approaches to support COVID-19 survivors vary across institutions and continents. 23,28-31 We have described a successful multidisciplinary approach grounded in a PICS/PHS framework. 3, 4 The rapid adoption of telemedicine, including ambulatory pulse oximetry monitoring, provided a unique opportunity to overcome traditional barriers, and address disparities in care provision. While the ATS and ERS retain equipoise in recommendations for follow-up in a dedicated multidisciplinary clinic for post-COVID-19 care, 32 the present and future benefits to patients, the health system, and knowledge advancements through the JH PACT clinic are tangible. The comprehensive approach described here has proved successful in providing an enduring support network for COVID-19 survivors locally, alongside the provision of data that will inform our understanding of the natural history of COVID-19 in those requiring hospital-level care or with persistent symptoms in the ambulatory setting. Patients requiring 48 hours or more in the ICU were eligible to referral to the JH PACT-ICU, consisting of evaluation by both PM&R and Pulmonary services. Patients requiring hospitalization but no hospital stay were referred to JH PM&R PACT-Base with additional Homecare referral for home physical therapy/occupational therapy services if necessary. Patient then assessed for ongoing pulmonary needs or qualification for remote patient monitoring, and could receive co-referral or independent referral to JH Pulmonary PACT-Base. Patients could also be individually referred to RPM monitoring without JH PM&R or Pulmonary PACT referral (not pictured). 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