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Planning Care

Managing the long-term effects of COVID-19 (SIGN/NICE/RCGP)
Healthcare Improvement Scotland

Related information: Clinical case definitions

These recommendations are for healthcare professionals caring for people with ongoing symptomatic COVID-19 or post-COVID-19 syndrome who have been assessed in primary care or a multidisciplinary assessment service.

Rationale

To ensure people get the right care and support, the expert panel agreed that a tiered approach could be used in which everyone gets advice for self‑management, with the additional option of supported self‑management if needed. People can then also be offered care from different services to match the level of their needs. The recommendation applies to all age groups and therefore the panel updated the recommendation in November 2021 to allow for discussion with the family or carers of the person if appropriate.

There was not enough evidence to recommend specific criteria for referral and the panel agreed the right level of care would be agreed in shared decision making with the person after their holistic assessment.

The panel updated the recommendation for the November 2021 update to include more information about the decisions that people should be involved in about their care, including whether or not they are referred and when and how support will be provided. The panel agreed that the person should be central in planning their care. This was based on qualitative evidence of patient experience and expert testimony.

Recommendations

After the holistic assessment, discuss with the person (and their family or carers, if appropriate) the options available and what each involves. These should include:

  • advice on self-management, with the option of supported self‑management (see 'Self management and supported self management' section), and
  • one or more of the following, depending on clinical need and local pathways:
    • support from integrated and coordinated primary care, community, rehabilitation and mental health services
    • referral to an integrated multidisciplinary assessment service
    • referral to specialist care for specific complications.


Click here to view the Implementation Support flowchart.

Use shared decision making to agree what support and rehabilitation the person needs, including how and when it should be provided.

When discussing with the person the appropriate level of support and management:

  • take account of the overall impact their symptoms are having on their life and usual activities, even if each individual symptom alone may not warrant referral
  • look at the overall trajectory of their symptoms, taking into account that symptoms often fluctuate and recur so they might need different levels of support at different times.

For advice on working with people to make decisions about their treatment and care, see NICE's guidelines on shared decision making and decision-making and mental capacity and Healthcare Improvement Scotland's What Matters To You website. 
  This content is derived from the Scottish Government's Implementation Support Note.

Encourage patient involvement in referral decisions, taking into account opportunities for asynchronous consulting and/or Near Me and, in particular, self referral.

Where appropriate, appointed member / members of the primary and community care team should aim to act as a care and support co-ordinator to facilitate coordination across pathways and signposting to services – this could be the professional most appropriate for the person and could include the GP, GPN, AHPs, care worker or link workers according to patient need and local services.