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These recommendations are for healthcare professionals providing care for people with ongoing symptomatic COVID-19 or post-COVID-19 syndrome in any setting, including primary care and community settings, secondary care, or in multidisciplinary assessment and rehabilitation services.
There was evidence that people struggled to access appropriate care and some had experienced fragmented care. The panel agreed on the need to improve integration and co-ordination of care across different services. Having regular multidisciplinary meetings would help share information more efficiently and allow professionals to make decisions quickly about tests and referral. Sharing clinical records and care plans between services, with the agreement of the person, will help healthcare professionals provide integrated care, and avoid gaps in care or duplication of effort. In particular, sharing baseline measures is essential for monitoring as people move between services. The panel wanted to make sure that information is also shared with people using services so that they know what is happening with their care. The patient experience evidence also described how people could benefit from continuity of care, and the panel agreed this should always be an aim for well-integrated services.
|Ensure effective information sharing and integrated working by sharing clinical records and care and rehabilitation plans promptly between services and through multidisciplinary meetings, either virtual or in person.|
|Give people a copy of their care plans or records to keep, including their discharge letters, clinical records and rehabilitation plans and prescriptions.|
|Include baseline measures as well as ongoing assessments in information shared between services, including when the person is discharged from hospital. For example, resting oxygen saturation and heart rate, and the results of functional assessment.|
|Provide continuity of care with the same healthcare professional or team as much as possible, for example by providing a care co-ordinator or a single point of contact.|