Planning Care

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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.


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. To ensure people get the right care and support, 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. For many people with ongoing symptomatic COVID-19 and post-COVID-19 syndrome, this will mean referral to an integrated multidisciplinary assessment service for investigation, support to manage their symptoms and rehabilitation.

Prompt referral is needed to avoid delays in getting people the support they need. In the panel’s experience, the earlier people received help the more effective the interventions. The panel were also concerned that a lack of support could negatively affect people’s mental health. They agreed that referral should be offered to those who would benefit from these services from four weeks after the start of acute COVID-19.


After the holistic assessment, use shared decision making to discuss and agree with the person (and their family or carers, if appropriate) what support and rehabilitation they need and how this will be provided. This should include:

  • advice on self-management, with the option of supported self-management (see 'Self management and supported self management' section), and
  • one of the following, depending on clinical need and local pathways:
    • support from integrated and co-ordinated 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.

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

  • think about the overall impact their symptoms are having on their life, 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.
  This content is derived from the Scottish Government's Implementation Support NoteExternal link

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.


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