Full details of the evidence and the panel's discussion are in the evidence reviews on interventions, monitoring and referral, service models and views and experiences of patients, their families and carers.
Follow up, monitoring and discharge
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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‑COVID19 syndrome have such a wide range of care needs. They decided it should be tailored to each person's needs and preferences.
Use shared decision making to decide how often follow up and monitoring are needed, which healthcare professionals should be involved and whether appointments should be carried out in person or remotely. Take into account:
The evidence on when to refer was limited and based mostly on people who had been hospitalised, so it was not relevant to everyone. The panel agreed that healthcare professionals should be alert to any changes and that the recommendations in the assessment section would also apply to monitoring.
|Be alert to symptoms developing that could mean referral or investigation is needed, following recommendations in the section on assessment.|
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.
|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.|