key: cord-1006784-20vvq5qh
authors: Carpagnano, Giovanna Elisiana; Pierucci, Paola; Migliore, Giovanni; Minicucci, Anna Maria; Aricò, Maurizio; Marra, Maurizio; Carpagnano, Lucia Federica
title: Tailored post-acute care coordination for survivors of moderate to severe COVID-19 infection
date: 2021-12-17
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.12.014
sha: 8fddedb4ec966e99c67c3b78dc885159f8691690
doc_id: 1006784
cord_uid: 20vvq5qh

nan

The severe acute respiratory COVID19 pandemic has raised issues about its acute and chronic 2 management 1 . In particular for patients requiring respiratory support due to severe hypoxic acute 3 respiratory failure 2-3 , and presented with critical symptoms with persistence of radiological, clinical 4 and functional symptoms 4 . Thus, they need tailored follow-up during the so called 'chronic or long-5 phase' of the infection 5 . The common intention is to prospectively perpetuate a coordinated 6 patient's continuity in the care-line helpful for clinic and research purposes focused to reduce 7 unnecessary hospitalizations, to avoid unmotivated specialist follow-up, to promote multidisciplinary 8 approach, and most of all to confirm the patient centrality in the health-care system. The care-path 9

is usually structured to actively link three different parts: Managerial: relates to the management 10 offered to assist and support the hospital health-care organization; Clinical: includes all the 11 diagnostic and therapeutic services offered within the hospital; Global: includes all different 12 patient/person needs and not only clinical. 13 A few studies have already evaluated the post-COVID19 lung sequelae highlighting the need of post-14 discharge follow-up for patients' with more severe lung involvement (e-table) : hypoxic acute  15   respiratory failure and ARDS who presented with lung involvement persistence (ground glass  16 opacities, interstitial thickening, residual consolidation and various shades of Interstitial lung disease 17 (ILD)) 7 . Also, neurologic, dermatologic, immunologic, musculoskeletal and chronic fatigue features 18 have been extensively described in the literature 8 The Integrated patient management program agreed within the health-care system regional parts 26 was based on: 1. articulated and proactive treatment path, 2. personalized follow-up plan. The 27 logical-conceptual framework underlying Integrated management and coordinated proactive follow-28 up relates to "managed care" opposite to "usual care" and bases on a structured and collaborative 29 perspective health-care delivery model of integration among various multidisciplinary professionals 30 to improve patients' health status. 31

The respiratory physician acts as disease manager and links the discharged patient to the plan of 32 continuity of long term care ensuring that each patient requiring high and medium intensity of care 33 requiring various respiratory supports such as: proning, high flow nasal cannula (HFNC), non-invasive 34 ventilation (NIV), invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation 35 (ECMO) is included in the program, being responsible to monitor and to combine the acute-care 36 system to the activity of the out-patients clinic. In Table-1 

COVID-19 Does Not Lead to a "Typical

Acute Respiratory Distress Syndrome

Prolonged active prone positioning in spontaneously breathing nonintubated patients with Covid-19

Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of 90 COVID-19 patients

Post-COVID lung fibrosis: The tsunami that will follow the earthquake

COVID-19: Interim Guidance on Rehabilitation 96 in the Hospital and Post-Hospital Phase from a

Association of COVID-19 and other viral 101 infections with interstitial lung diseases, pulmonary fibrosis, and pulmonary hypertension: A narrative review 102

Long-104 COVID and Post-COVID Health Complications: An Up-to-Date Review on Clinical Conditions and Their Possible

Lung ultrasonography for long-term follow-up of COVID-19 107 survivors compared to chest CT scan

Use patient reported outcome measures (PROMs)

authors agreed to be accountable for all aspects of the present work. 71