Long COVID Community Rehabilitation Support

Service Outline

Queensland has experienced an increase in the number of COVID-19 infections in 2022. Research indicates that one of the long-term clinical impacts of a COVID-19 infection can be the development of “Long COVID”.  This condition is defined as: 

• signs and symptoms that develop during or after an infection consistent with COVID-19,  
• continue for more than 12 weeks and  
• are not explained by an alternative diagnosis.   

Some of the common symptoms identified include fatigue, breathlessness, persistent cough, cognitive dysfunction and mental health impacts. Long COVID can have a debilitating impact on a person’s quality of life, with symptoms often continuing for many months post infection. 

The Long COVID community rehabilitation support model of care has been developed to provide a care pathway for consumers experiencing Long COVID.The service will be delivered across the Chronic Disease - Respiratory and Rehab@Home services of Community and Oral Health Services, MSH, in an inter-disciplinary care model that is holistic, flexible and patient centred.   
 

Are you referring to the right service?

• Adults 18 years and older.
• Long COVID/ suspected long COVID diagnosis by a medical professional.*
• Client would benefit from a short-term rehabilitation program.
• Resides within Metro South Health Catchment.
• Can be following a discharge from hospital or referred from community by GP, specialist, or health professional.

*Due to the generalised nature of Long COVID, medical governance via a GP should be part of the client’s management.

Minimum referral criteria (Does your patient meet the minimum criteria?)

Client has a change in level of function related to a COVID-19 infection  that will respond to time limited restorative care / rehabilitation. Their therapy needs are not available through existing services such as CHSP, Home Care Package, Disability funding, Chronic Disease Funding or Private Health Insurance.

If your patient does not meet the minimum referral criteria

• Find assessment and management information can be found on a range of conditions at SpotOnHealth HealthPathways
• If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested:
• Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc).
• Please note that your referral may not be accepted or may be redirected to another service.
   

Standard referral information (To be included in all referrals)

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary.

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• All conservative options that have been pursued unsuccessfully prior to referral
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes, BMI), noting these must be stable and controlled prior to referral
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use
• A comprehensive capture of information in relation to MSH Referral Criteria.

Clinical Modifiers

• The presence of clinical modifiers may impact the categorisation of the patient.
• Impact on employment
• Impact on education
• Impact on home
• Impact on activities of daily living functioning – low/medium/high
• Impact on ability to care for others
• Impact on personal frailty or safety
• Identifies as Aboriginal and/or Torres Strait Islander.

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral.

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner.

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.).

Essential referral information for Long COVID Community Rehabilitation Support (Referral will be returned without this)

• Reason for referral and change to client’s level of function.
• Client goals that are achievable within a time limited program.
• Medical History including results of investigations if any.
• Current medications.
• Allergies.
• Relevant past medical history, previous level of function.

Out of Scope Services

• Clients under 18 years of age
• Clients residing in residential aged care facilities/serviced apartment
• Does not reside within the Metro South Health catchment area
• DVA Gold card holders- refer to 1300 550 450
• People who have access to informal supports or other formal services that can meet their needs e.g., Home Care Package, DVA, NDIS, CHSP, Chronic Disease funding (Medicare EPC), post-acute funding or private health funds/Workcover/3rd party claims 
• Patients eligible for TCP 
• Conditions unrelated to COVID infection e.g., exacerbation of diabetes  
• Active clients of Palliative Care Services

Clinic Locations

Redland, Eight Mile Plains and Logan.

Eligible clients will be seen in their own homes or community health centre
Monday-Friday 0730-1630 hours excluding public holidays