Person-centred follow up

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Related information: Clinical case definitions

Rationale

There was a lack of evidence on monitoring, but the panel agreed it is important so that people’s support can be adapted if their symptoms or ability to carry out their usual activities change. The patient experience evidence highlighted the importance of follow up and ‘check ins’ to access further care. The panel did not want to limit monitoring to specific tests or symptoms, or to a particular timeframe, because people with ongoing symptomatic COVID-19 and post-COVID-19 syndrome have such a wide range of care needs. They decided it should be tailored to each person.

Recommendations

Agree with the person how often follow up and monitoring are needed and which healthcare professionals should be involved. Take into account the person’s level of need and the services involved.

Using shared decision making, offer people the option of monitoring in person or remotely depending on availability, the person’s preference and whether it is clinically suitable for them.

Tailor monitoring to people’s symptoms and discuss any changes, including new or worsening symptoms and the effects of these on the person’s life and wellbeing.

Rationale

In the panel’s experience, self monitoring at home can be useful and is used in practice. But it might not be suitable for everyone, and without the right information and support can cause unnecessary anxiety. People need good guidance to use equipment, interpret the results and understand when to contact a healthcare professional.

The panel discussed when a person should be discharged from rehabilitation and care. They agreed that a timepoint could not be specified, because this is dependent on the person's symptoms, the goals that were set, the progress made and the amount of social support the person has. However, they agreed that making a discharge plan with the person would support motivation, ensure the person gets the support they need and help to manage rehabilitation resources. The panel also agreed that transition to adult services should be considered in discharge planning for young people.

Expert testimony highlighted the importance of people being able to re-enter rehabilitation services after being discharged if their symptoms worsen. The panel recognised that symptoms may fluctuate and recur with patients needing to re-access support and services in the most efficient way possible. However, following shared decision making, local referral pathways would need to be followed because of variation in practice and funding.

Recommendations

Consider supported self monitoring at home, for example heart rate and blood pressure and pulse oximetry, if this is agreed as part of the person’s assessment. Ensure that people have clear instructions and parameters for when to seek further help.
Use shared decision making to discuss and agree plans for discharge from rehabilitation and care, taking into account the person’s preferences, goals and social support.

 

 

References

Full details of the evidence and the panel's discussion are in the evidence reviews on: