COVID-19: Post-Acute Rehabilitation
Original Editor - Wanda van Niekerk
- 1 Introduction
- 2 Benefits of Rehabilitation in COVID-19 Patients
- 3 Physiotherapy and the Post-Acute COVID-19 Rehabilitation Phase
- 4 COVID-19 Patient Presentation in the Rehabilitation Unit
- 4.1 Comorbidities
- 4.2 Severe COVID-19 Complications
- 4.3 Conditions that may arise from lengthy ICU-stays include:
- 4.4 Persistence of SARS-CoV-2 Virus
- 4.5 Sequelae after COVID-19 Infection
- 5 Procedures for Post-Acute Covid-19 Rehabilitation
- 6 Post-acute Rehabilitation Guidelines after COVID-19
- 6.1 General rehabilitation considerations in the post-acute phase
- 6.2 Respiratory rehabilitation
- 6.3 Functional rehabilitation
- 6.4 Multidisciplinary team involvement
- 7 Actions for Rehabilitation Service Providers
- 8 Resources
- 9 References
Countries all across the world are in various stages of the pandemic with many countries now entering the "day after" COVID-19 phase. Many people who have suffered from the effects of this disease might now be at risk of long-term impairment and disability. The extent of this impairment and disability is yet unknown, but it is clear from early research that these patients will be in need of rehabilitation in all phases of the disease - acute, post-acute and long-term. Rehabilitation is defined as "a set of interventions designed to reduce disability and optimize functioning in individuals with health conditions in interaction with their environment." Rehabilitation might very well be a key strategy to reduce the impact of COVID-19 on the health and function of people. Physiotherapists are essential to these rehabilitation efforts in all phases to facilitate early discharge, but even more to support and empower patients.
Benefits of Rehabilitation in COVID-19 Patients
- Optimizing health and functioning outcomes
- Rehabilitation can reduce Intensive Care Unit -admission related complications, such as Post Intensive Care Syndrome (PICS), Intensive care unit acquired weakness (ICUAW)
- The aim of rehabilitation is to improve recovery and reduce disability or the experience thereof
- Rehabilitation interventions address several consequences of severe COVID-19 such as:
- Physical impairments
- Cognitive impairments
- Swallow impairments
- Provision of psychosocial support
- It is evident that older people and people with pre-existing comorbidities are at higher risk for more severe illness. Rehabilitation can be beneficial in these populations to maintain their prior levels of functionality and independence.
- Early Discharge Facilitation
- During the pandemic, there is a high demand for hospital beds in countries worldwide, especially during the times when the pandemic reaches its peak in a country or area. This leads to patients being discharged sooner than would normally be the case. Rehabilitation is crucial in this scenario to prepare a patient for discharge, coordinating complex discharges and also to safeguard the continuity of care.
- Reducing the risk of readmission
- Rehabilitation is a key strategy to ensure that patients do not deteriorate after discharge and require readmission. During the COVID-19 pandemic, this is critical in the context of shortages of hospital beds.
- Physiotherapists as rehabilitation professionals are frontline healthcare professionals and should be engaged in the care of patients suffering from severe cases of COVID-19
- A patient who has severe COVID-19 will go through multiple phases of care – acute, post-acute and long term care. In the acute phase, care will most likely be provided in the ICU or critical care units. In the post-acute phase, care will most likely be provided in a hospital ward, or a step-down or rehabilitation facility. The long-term phase will be when patients return home and are still recovering and will receive rehabilitation at community level.
Physiotherapy and the Post-Acute COVID-19 Rehabilitation Phase
- Physiotherapists are instrumental in the rehabilitation of patients as they transition from the acute phase to the post-acute phase.
- The consequences of COVID-19 will be specific in each individual and their rehabilitation needs will be specific to these consequences such as:
- Long term ventilation
- Related impairments – respiratory, neurological, musculoskeletal
- COVID-19 patients will often present with pre-existing comorbidities and this must be taken into consideration in the rehabilitation plan for the patient. Physiotherapists working across various disciplines should work together and draw on the expertise of each other.
- The transition from the acute to the post-acute phase needs to be supported through service delivery pathways and the multidisciplinary team will be key to this.
COVID-19 Patient Presentation in the Rehabilitation Unit
Factors to consider in creating a rehabilitation plan for survivors of COVID-19 include:
- Direct lung trauma
- Injuries to other organs and systems due to COVID-19
There is clear evidence from across the world that the leading co-morbid conditions of people with COVID-19 include:
Considering that these conditions are often associated with ageing, it is most likely that survivors of COVID-19 are older people with pre-existing conditions such as cardiovascular and cerebrovascular disease. This will have an influence on rehabilitation needs as well as rehabilitation outcomes.
Severe COVID-19 Complications
Early complications of COVID-19 include:
- Acute respiratory distress syndrome (ARDS)
- Sepsis or septic shock
- Multi-organ failure
- Acute kidney injury
- Cardiac injury
These complications often lead to the person being admitted to an Intensive Care Unit (ICU).
Conditions that may arise from lengthy ICU-stays include:
Critical Illness Polyneuropathy (CIP)
- Critical Illness Polyneuropathy is a mixed sensorimotor neuropathy that may lead to axonal degeneration and studies have shown that patients hospitalised in ICU with ARDS may present with CIP. Critical illness polyneuropathy (CIP) causes several difficulties such as:
- Difficulty weaning from mechanical ventilation
- Generalized and symmetrical weakness (distal greater than proximal, but does also include diaphragmatic weakness)
- Distal sensory loss
- Decreased or absent deep tendon reflexes
- Critical Illness Polyneuropathy is associated with:
- Critical Illness Polyneuropathy is diagnosed through:
- Muscle biopsies
- Electromyographic testing
- Critical Illness Polyneuropathy is a mixed sensorimotor neuropathy that may lead to axonal degeneration and studies have shown that patients hospitalised in ICU with ARDS may present with CIP. Critical illness polyneuropathy (CIP) causes several difficulties such as:
Critical Illness Myopathy (CIM)
- This condition is present in 48 – 96% of patients in ICU with ARDS.
- It is a non-necrotising diffuse myopathy with fatty degeneration, fibre atrophy and fibrosis.
- CIM is associated with:
- exposure to corticosteroids, paralytics and sepsis.
- It has a similar clinical presentation to CIP but with more proximal weakness and sensory preservation.
Patients recover more completely from myopathies than polyneuropathies, but with both conditions, there are long term consequences to consider such as:
- Loss of function
- Loss of quality of life
- Poor endurance
Post Intensive Care Syndrome (PICS)
A distinct feature of COVID-19 is that, when necessary, acute and ICU care, as well as ventilator reliance, is often required for considerably longer periods. The aftershock as a result of this long ICU period will be felt for many months and years.
Characteristics of PICS include:
- Cognitive impairments
- Psychiatric Illness
- Physical Impairments
The neuromuscular complications from PICS often result in poor mobility, falls and even quadriparesis.
Risk factors for Post Intensive Care syndrome:
- Duration of ICU admission
- Duration of sedation
- Duration of mechanical ventilation
- Hypoxia and hypotension
- Glucose dysregulation
- Premorbid mental and physical comorbidity
Throughout the world, healthcare systems will be inundated with a cohort of post-ICU patients created by the COVID-19 pandemic. It is therefore important to have a coordinated rehabilitation response.
Persistence of SARS-CoV-2 Virus
Patients who have physically recovered and who have two negative tests after infection are considered to be cured and non-infectious. There are however reports of patients testing positive again at a later stage. Studies have also shown that the virus may persist in a persons’ oropharyngeal cavity and stools for up to 15 days after they have been declared cured. This needs to be considered when patients are being discharged to the ward or rehabilitation facilities as they still might be able to transmit the disease.
Sequelae after COVID-19 Infection
Studies have shown that hospitalised patients with COVID-19 also had associated cardiac injury. The mechanism of cardiac injury is uncertain, however. Patients with this associated cardiac injury presented with:
- Cardiac insufficiency
- Ejection fraction decline
- Troponin I elevation
- Severe myocarditis with reduced systolic dysfunction
The presence of cardiac injury, as well as other comorbidities, need to be considered for patients entering post-acute rehabilitation.
Numerous neurological symptoms have been reported in patients with COVID-19. The scoping review of the available literature on COVID-19 shows an increase in the risk of secondary neurological complications in patients hospitalised with COVID-19.
The symptoms include:
- Disturbed consciousness
- Absence of sense and smell
- Posterior reversible Encephalopathy syndrome
- Viral encephalitis
- Increased risk for acute cerebrovascular event
- Reports of Guillain-Barre Syndrome associated with COVID-19
Again, these neurological factors need to be considered when a patient is entering post-acute rehabilitation after COVID-19.
- Physical deconditioning
- Severe muscle weakness
- Reduced joint mobility
- Neck and shoulder pain (due to prone lying)
- Difficulty in verticalization
- Impaired balance and gait
- Impaired lung function
- Lung fibrosis as sequelae of pneumonia – patients showing respiratory insufficiency needing respiratory rehabilitation
- Tough secretions requiring specific physiotherapy techniques or technical removal
- Difficult awakening with long-lasting confusional state and psychological problems
- Delirium and other cognitive impairments
- Limitations of ADL
- Impaired swallow and communication
Patients with severe COVID-19 infection seem to have lengthy and longer than usual stays in ICU and many complications due to the long period of immobilisation and prone positioning. It is important to have a gradual progression from the weaning phase to transfer to a rehabilitation service – patients need to be monitored closely and accurately as they remain unstable for several days after extubation.
Procedures for Post-Acute Covid-19 Rehabilitation
Patients who have recovered from the acute respiratory effects of COVID-19 will still need further rehabilitation.
Guidance for rehabilitation physiotherapists
- Determine risk
- Consider the risk involved of a patient not receiving immediate rehabilitation on outcomes such as risk of hospitalization, extended hospital stay
- If the therapist continues with a rehabilitation assessment or treatment – point of care risk assessments should be done prior to each patient interaction
- Try and do as much as possible without patient contact
- Find other innovative ways to gather information without direct contact with patients in isolation. Consider telehealth methods to conduct a subjective assessment or a pre-treatment screening or discharge planning; to observe patient mobility, etc)
- Determine the type of Personal Protective Equipment (PPE) needed for patient contact
- Aerosol Generating Procedures (AGP’s)
- The type of oxygen therapy the patient is receiving and the type of procedure conducted will determine if a procedure is aerosol-generating
- Therapies that require airborne precautions:
- High flow nasal oxygen
- Non-invasive ventilation
- Nebuliser treatment
- Tracheostomy tubes with/without mechanical ventilation requiring open suctioning
- Sputum inducing procedures require airborne precautions
- Respiratory physiotherapy
- Activities resulting in expectoration of sputum – moving from lying to sitting, walking, bedside ADL's, prone positioning
- Other considerations before starting direct contact treatment
- It is critical to have a step-by-step process for donning and doffing PPE to avoid contamination
- Use the minimum amount of people required to safely administer a treatment session
- Careful consideration is needed with regards to equipment use. Be sure that it is line with infection control measures and that any equipment can be properly decontaminated. Avoid moving equipment between COVID-19 and non-COVID-19 areas. Opt for using single patient use, disposable equipment (i.e, Theraband instead of hand weights)
Suggestions for the design and procedures for an inpatient rehabilitation unit
These suggestions will need to be assessed based on the unique setting of each rehabilitation unit and the specific needs of the individual patient. Many of these suggestions are extrapolated from the experiences in China and Italy as well as from the SARS epidemic.
- A separate area or unit is necessary for the rehabilitation of post-COVID-19 patients
- Patients might be transferred from acute care earlier than is generally done, in order to clear beds for more patients in need of acute care
- Patients should stay in their rooms
- Therapy should be provided one on one
- group therapy and therapy in rehabilitation gyms should not be allowed
- Earlier discharge of patients (as soon as the family can take care of the patient) to free up space for incoming patients
- There might be difficulty in discharging patients to long-term care facilities and retirement homes as these facilities might not be taking in new residents during the pandemic
- Shared equipment should be decontaminated between patients
- Best to utilize single-use equipment where possible (Therabands instead of free weights)
- Special care and attention should be paid to the use of electrode sponges, heat packs, gels, topical lotions, etc
- Therapeutic activities should be planned to minimize the number of personnel needed (i.e. therapist with a gait/walking aid instead of a therapist and an assistant)
- Minimize the number of personnel in contact with a patient. Have a single staff member perform most of the care and duties for a patient
- Walking practice should be done in areas that are not commonly used
- Surgical masks should be worn by patients and therapists should be using the necessary PPE
- Patients should always practice social distancing among each other
Personnel considerations in a rehabilitation unit
- Frequent health checks for rehabilitation personnel
- Staff shortages may arise either due to illness, isolation or redeployment
- Changes in staff/patient ratio – more one on one sessions
- Guidelines and protocols will be changing as new evidence becomes available. Continuous staff training will be paramount
- Personnel should be trained and re-trained in the use of PPE
- Physiotherapists should use higher levels of PPE if they are at risk of exposure to aerosols from post-COVID-19 patients.
- Ongoing input from frontline staff is important to inform other healthcare professionals
- Other ways of providing non-required therapies and services should be considered such as telerehabilitation
- Work efficiency might be affected by the use of PPE and the time it takes to don PPE, as well as infection control measures
- Virtual staff meetings should be held if possible
Post-acute Rehabilitation Guidelines after COVID-19
The WHO and the PAHO have compiled a document on the rehabilitation considerations during the COVID-19 outbreak, and the WCPT has also compiled briefing papers in response to COVID-19. The second briefing paper specifically addresses rehabilitation and the vital role of physiotherapy.
Each patient in the post-acute rehabilitation unit should be assessed by all the relevant healthcare professionals. A suitable and manageable treatment plan should be created with input from the healthcare team and the patient. The direct impact of COVID-19 on the respiratory system and other systems, the sequelae of COVID-19 (such as a long period of ICU stay, mechanical ventilation) as well as the comorbidities involved will direct and inform the rehabilitation plan. Other factors that will affect the rehabilitation plan is the discharge destination and estimated discharge date.
Currently, there is limited evidence of the impact of rehabilitation after COVID-19. The information provided is based on evidence from countries such as China, Italy and other areas. This evidence is based on the experience and expert opinions of rehabilitation healthcare professionals from these regions.
General rehabilitation considerations in the post-acute phase
- Patients recovering from an acute COVID-19 event may present with a disability or functional damage (respiratory function, CIP, CIM, PICS), reduced participation and deterioration in their quality of life (short term as well as long term post-discharge)
- Variable recovery time – dependent on the degree of normocapnic respiratory failure, associated physical dysfunction (asthenia, muscle weakness), emotional dysfunction; the presence of other comorbidities
- Clinical parameter evaluating protocols are indicated on a daily basis – temperature, SaO2, Sp02/Fi02, cough, dyspnea, respiratory rate, thoraco-abdominal dynamics
- Simple and repeatable protocols to wean oxygen therapy should be used
- Reconditioning interventions are indicated in weaned patients and those with prolonged weaning from mechanical ventilation to improve physical status and effects of prolonged immobilisation
- Evaluate peripheral muscular strength with MRC scale, manual muscle testing, isokinetic muscle test; measurement of joint range of motion
- Exercise with gradual load increase and based on subjective symptoms can help to regain and maintain normal function
- Consider telehealth systems for patients that need rehabilitation but who are in isolation
- Balance function assessment is necessary as soon as possible (especially in patients who have been bedridden for a long period)
- Exercise capacity and oxygenation response during effort should be assessed
It is recommended to not begin with respiratory rehabilitation too early to avoid aggravating respiratory distress or dispersing the virus unnecessarily. Techniques such as diaphragmatic breathing, pursed-lip breathing, bronchial hygiene, lung expansion techniques (positive expiratory pressure), incentive spirometry, manual mobilisation of the ribcage, respiratory muscle training and aerobic exercise are not recommended in the acute phase. In the event of comorbidities such as bronchiectasis, secondary pneumonia or aspiration increasing secretions, postural drainage and standing (gradual increase in time) may help with secretion management.
- Thoracic activity
- Diaphragmatic activity and amplitude
- Respiratory muscle strength (maximal inspiratory and expiratory pressures)
- Respiratory pattern and frequency
Also include an assessment of their cardiac status
In the post-acute phase, the following respiratory rehabilitation may be included:
- Inspiratory muscle training if inspiratory muscles are weak
- Diaphragmatic breathing
- Thoracic expansion (with shoulder elevation)
- Mobilisation of respiratory muscles
- Airway clearance techniques (as needed)
- Positive expiratory devices may be added if needed
Be careful to not overload the respiratory system and causing respiratory distress!
A randomised controlled trial from China implemented a respiratory rehabilitation program consisting of 2 sessions of 10 minutes per week for 6 weeks post-discharge from acute care. The study results showed a significant improvement in respiratory function, endurance, quality of life and depression. The respiratory rehabilitation programme included respiratory muscle training with positive expiratory pressure device, cough exercises, diaphragmatic training, chest stretching and pursed-lip breathing.
Aspects to monitor closely in patients include:
- Shortness of breath
- Decreased SaO2 (<95%)
- Blood pressure (< 90/60 or > 140/90)
- Heart rate (>100 beats per minute)
- Temperature (> 37.2 C)
- Excessive fatigue
- Chest pain
- Severe cough
- Blurred vision
- Heart palpitations
- Loss of balance
Patients in post-acute rehabilitation can start a multidisciplinary team rehabilitation program. Concepts of pulmonary rehabilitation can be applied, but keep in mind that pre-rehabilitation assessments such as formal lung function and exercise testing is probably not feasible at the start and cannot be done in infectious patients. Exercise training may have to start with relatively simple graded functional and strengthening exercises, using no or minimal equipment.
Recommendations on functional rehabilitation from the European Respiratory Society include:
- Assessment of exercise and functional capacity
- Monitoring of pre-existing conditions
- Exercise training and/or physical activity coaching
Functional Rehabilitation aspects to assess:
- Muscle and joint range of motion
- Strength testing
- Exercise capacity – assess with the 6-minute walking test (continuous oxygen saturation monitoring included)
- Cardiopulmonary exercise testing
- Activities of Daily Living (ADL)
Clinical outcome measures
It is recommended to use easily applicable tests, as advanced equipment to assess the functional capacity of patients may not be available or safe to do during the pandemic. Clinical outcome measures that can be used:
- Patient Specific Functional Scale to identify perceived limitations in activities of daily living
- Monitor patient’s oxygen saturation and heart rate frequency before, during and after physical activity and exercises
- Use Borg Scale CR10 for shortness of breath and fatigue
- International Physical Activity Questionnaire to measure function and disability
- Physical Activity Scale for the Elderly to measure function and disability
- Berg Balance Scale
- 6 Minute Walking Test - to assess exercise capacity
- Barthel Index to measure ADL
- Short Physical Performance Battery
- 30 seconds sit to stand test
- Handgrip dynamometer test
- Manual muscle strength test
The multidisciplinary team should aim to use the same clinical outcomes for the same constructs to facilitate communication between team members and not burden the patient unnecessary.
Specific Physiotherapy Interventions
- Ways of early mobilisation include:
- Frequent posture changes
- Bed mobility
- Sit to stand
- Simple bed exercises
It is important to monitor the patient’s respiratory and hemodynamic state during rehabilitation!
- Active limb exercises should be followed by progressive muscle strengthening (suggested programs 8-12 RM load for 8 -12 repetitions, 1 to 3 sets with 2 minutes rest between sets, 3 sessions a week for 6 weeks)
- Neuromuscular electrical stimulation can be used to help with strengthening.
- Aerobic reconditioning can be achieved with walking, cycle or arm ergometry, NuStep cross trainer
- Keep aerobic activity less than 3 metabolic equivalents of task (MET’s) initially
- Progressive aerobic exercise can later be increased to 20 -30 minutes
- Education on energy conservation and behavior modification
Advice on exercise as medicine
- Gradual increase of daily living activities and physical functioning
- Provide patient with exercises that support recovery in daily function
- All activities should be well monitored especially in patients with PICS
- Perform exercises at low to moderate intensity and off limited duration. Keep in mind that patients who have been admitted to ICU and who show symptoms of PICS will have a very low capacity to perform activities and exercise.
- The activity levels of the patient prior to COVID-19 infection, the patient’s needs and the current physical abilities of the patient will determine the specific parameters for exercise prescription
- Recommendation of a maximum score of 4/10 on Borg Scale CR10 for shortness of breath and fatigue during the post-acute rehabilitation phase as patients have reduced lung function after COVID-19 infection and cardiac function may possibly be affected after COVID-19 infection.
- No maximal exercise testing is done after active COVID-19 infection - limitations due to pandemic. So there will not always be adequate clinical information to determine a patient's specific parameters for exercise prescription and also not possible to estimate the risk involved of physical training at a moderate/high intensity.
- Prescribe exercises with training parameters regarding frequency, intensity, time/duration and type
Multidisciplinary team involvement
Various members of the multidisciplinary team will be involved in the post-acute rehabilitation phase of survivors of severe COVID-19. Some of these team members include:
- Occupational therapists
- Focus ADL and instrumental ADL guidance
- Interventions to facilitate functional independence
- Help to prepare the patient for discharge
- Can address cognitive changes
- Speech and language pathologists/therapists
- Assess and treat dysphagia as a result of intubation
- Assess and treat voice impairments as a result of prolonged intubation
- Address communication issues
- Education on healthy lifestyle and the importance of participating in family and social activities should be provided to the patient.
- Psychological interventions should be provided where required for patients by occupational therapists, social workers or rehabilitation psychologists.
- Chinese medicine techniques (tai chi, Qigong, guided breathing) have been suggested by the Chinese
Actions for Rehabilitation Service Providers
These are actions that rehabilitation facilities, private practices and hospitals can take during the COVID-19 pandemic to improve and ensure quality service delivery.
- Stay informed on the outbreak status and regional and national guidelines regarding COVID-19
- Set-up communication links with all relevant COVID-19 coordination bodies and networks
- Source, disseminate and enforce COVID-19 guidelines and protocols
- Ensure frequent communication with patients and distribute important information
- Rehabilitation should be integrated into Infection Prevention and Control (IPC) measures and healthcare workers should use Personal Protective Equipment (PPE) appropriate to their risk exposure
- Have set protocols for IPC (to whom, when, and how these apply)
- Rehabilitation professionals like physiotherapists may engage in the delivery of Aerosol Generating Procedures (AGP's) and the essential PPE is required for this
- The rehabilitation workforce (and family members) should have priority access to COVID-19 testing
- IPC training is critical to all rehabilitation professionals
- Increase the rehabilitation workforce for the post-acute and long-term recovery phases after COVID-19
- Address workforce shortages
- Source rehabilitation professionals from areas such as retired workforce, trainees, academics, private practice
- Develop competency-based training and supervision for professionals who are rejoining the rehabilitation workforce or shifting their roles to provide support
- Ensure productivity of the existing workforce by implementing measures such as leave postponement, modifying shift structures, increasing part-time contract to full time
- Identify high-risk rehabilitation healthcare professionals and define clear and strict conditions for their practice
- The wellbeing of rehabilitation professionals can be supported by monitoring for and taking steps to prevent burnout, and guarantee access to psychosocial support
- Additional equipment
- Attain additional equipment needed for the surge in rehabilitation demand related to COVID-19 patients, such as pulse oximeters, rehabilitation equipment such as hoists, walking aids, equipment used during respiratory/pulmonary rehabilitation such as stationary bikes
- Attain additional assistive devices that can support early discharge, such as walking frames, commode chairs, mattresses and transfer products
- Rehabilitation clinical management for COVID-19 patients
- Implement clinical management guidelines and protocols of care related to COVID-19 patients based on best available evidence
- Adaptable rehabilitation resources for COVID-19 patients who experience ongoing respiratory and physical deconditioning should be available
- These may include:
- Exercise programs with graded exercises
- Pacing strategies
- Behavior modification
- Advice on positioning
- Recognition of red flags such as signs of medical deterioration
- Implement systems for tracking COVID-19 patients and remote-follow-up
- Implement referral pathways and develop contact lists for services required by COVID-19 patients
- Rehabilitation practices modification for Infection control
- Develop and implement protocols for the management of rehabilitation equipment and assistive devices to reduce infection risk
- Prepare rehabilitation professionals for the impact of PPE such as the time involved donning and doffing PPE and the impact it will have on patient rapport
- Plan for working in different teams to reduce therapist-patient exposure
- Amendments to the scope of practice and more interdisciplinary practice to minimize patient’s contact with multiple professionals
- Multidisciplinary teamwork will be more virtual meetings than face to face interactions
- Address barriers to telehealth such as technology, devices, network and costs
- Group patients beds and adjust the spacing to reduce the risk of infection
- Rehabilitation sessions should rather be done within a patient’s bed space in order to restrict the movement of patients within a rehabilitation facility
- Avoid the use of shared therapy spaces such as gyms
- Develop protocols for patient discharge to maximize bed availability and minimize the patient time in the rehabilitation facility
- Encourage and ensure access to psychosocial support for patients
- Increased levels of anxiety and depression as seen in COVID-19 patients. Ensure that patients have access to the support that they need during their rehabilitation process
- Be aware of patients’ normal family or support structure being disrupted due to the COVID-19 outbreak. Facilitate support such as communication with family members.
- Provide training and access to psychological first aid skills for rehabilitation professionals
- Implement peer support mechanisms
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