Building and Sustaining Organizational Capacity for the Rehabilitation Profession to Support Long COVID Care

Introduction

The number of people impacted by coronavirus 2019 (COVID-19) will affect quality of life, the workforce, and society for years to come. Estimates gather that upwards of 10–30% of persons infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will demonstrate prolonged symptoms after acute infection.^1,2 The persistent, multi-system sequelae of COVID-19 is identified by many terms including ‘long-COVID,’ ‘post-acute COVID-19 syndrome,’ ‘post-COVID condition,’ ‘post-acute sequalae of COVID (PASC),’ and ‘long hauler.’^3,4 Common, overlapping symptoms include fatigue, shortness of breath, sleep disorders, brain fog or cognitive dysfunction, depression, anxiety, and pain.^3,5 As such, multidisciplinary approaches appear necessary for comprehensive long-COVID care.^5–13 Rehabilitation providers are integral members of the long-COVID care team as many symptoms impact function, quality of life, and participation in society.^7,8,11,14,15

Healthcare systems are now realizing the emerging wave of persons with long-COVID could potentially overload an already taxed system.⁶ Current care pathways to outpatient rehabilitation for long-COVID care include pulmonary rehabilitation, cardiopulmonary rehabilitation, and general outpatient rehabilitation.^7,15 Emerging consensus garners that patients with long-COVID require lengthy outpatient rehabilitation (twice per week for greater than three months) similar to the frequency/duration of traditional cardiac or pulmonary rehabilitation.^7,15–18 This is consistent with symptom pathology, though much remains unknown regarding the impact of unique clusters of long-COVID symptoms on trajectories of functional recovery. While rehabilitation interventions for treating long-COVID are not entirely novel,^19–21 challenges exist to scaling of high volume, lengthy episodes of care for a large unforeseen population.

Health care utilization has been shown to be elevated in patients following COVID-19 illness for over 6 months post infection compared to non-COVID-19 controls.^22,23 Hentschel and colleagues,²⁴ explored factors related to outpatient rehabilitation utilization for Long COVID with results suggesting racial/ethnic disparities in utilization and higher likelihood of outpatient rehabilitation use if hospitalized with COVID-19 illness. However, to our knowledge, limited published data and findings exist on specific utilization of rehabilitation services in those who experienced COVID-19 illness compared to non-COVID-19 controls. Based on our clinical experience and literature suggesting patients following COVID-19 illness demonstrate elevated healthcare utilization, we anticipate health care systems and rehabilitation teams will need to consider long-term strategies and resources allocation to meet the rising need while reducing potential burnout.²⁵ Rehabilitation providers continue to be essential in providing care for return to patient-centered activities and participation.^26,27

Thus, the purpose of this commentary is to outline challenges in organizational capacity to scale long-COVID care to provide equitable, person-centered, and cost-effective care. We present these challenges and potential solutions through an illustrative example of long-COVID rehabilitation care provided at the XXX Health Care System (XXX).

The Impact of Organizational Capacity on Long-COVID Rehabilitation Care

Our perspective is guided by the Interactive Systems Framework,²⁸ which explores organizational capacity to scale and deliver appropriate services to patients. While evidence on long-COVID treatments is still emerging,^15,20 assessing and building organizational capacity for rapidly scaling rehabilitation is necessary to meet growing demand.¹⁰ Our focus is not on developing a clinical model^8–13 but rather understanding the organizational capacity that underpins whether (or not) and why models of long-OVID care are successfully enacted, embedded, and reach the right patients at the right time within a clinic or healthcare system. We outline a logic model (Figure 1)²⁹ to depict the interdependent relationships between understanding the contextual barriers and facilitators (i.e., determinants) of organizational capacity, strategies to build and enhance organizational capacity, and hypothesized multi-level outcomes of augmented organizational capacity. Figure 1 is constructed to provide a cyclical roadmap to implementing, evaluating, and scaling long-COVID care in the context of rehabilitation service capacity and evolving clinical guidance or evidence.

Figure 1.

Logic model to provide a roadmap to enhancing organizational capacity to develop and scale Long COVID rehabilitation services.

Contextual Determinants of Organizational Capacity

Contextual determinants of organizational capacity focus on barriers or facilitators that influence the successful (or not) implementation and scaling of long-COVID rehabilitation. While many determinant frameworks exist, we choose to use the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework³⁰ to simplify determinants of organizational capacity related to the clinical intervention, the recipients (e.g., providers, leaders, patients who engage in/receive the intervention), and the context in which the intervention is delivered (e.g., clinical setting or health system).

First, clinical intervention determinants impacting organizational capacity comprise the elements of outpatient rehabilitation for long-COVID that differ from current, general outpatient rehabilitation. These factors specifically include the increased frequency and duration of rehabilitation due to the persistent nature of symptoms that may last more than 12 weeks.^6,15,20 The presence of chronic and post-exertional fatigue with long-COVID is an emerging issue and will require significant input from rehabilitation providers to determine safe thresholds for activity tolerance and slow, prolonged ramping of activity to prevent adverse effects.²⁰ Development of safe exercise thresholds for those with post-exertional fatigue, along with interventions like respiratory training, improvement of breathing mechanics, and strength training may require longer durations of care due to lower activity tolerance. As such, organizations must account for this shift in intervention delivery to accommodate a patient population that requires frequent and prolonged care.

Second, recipient determinants impacting organizational capacity focus largely on skills and process training for providers delivering long-COVID care. Skills training may be focused on cardiopulmonary assessment and treatment and maintaining current knowledge of best-practice interventions related to long-COVID care. Process training includes effective interdisciplinary communication, timely feedback on billing, current workflow for productivity, and scheduling and coordination of increased caseloads. Understanding organizational factors that support a provider’s ability to perform and deliver a large volume of services to a new, evolving condition is necessary to scaling long-COVID models of care.

Finally, contextual factors impacting organizational capacity include clinical resources (such as staffing, clinic space, and equipment), workplace culture, administrative infrastructure (e.g., clinic grid development, scheduling appointments or data analysis of program outcomes), internal processes & policies, and external policies such as reimbursement for healthcare services. Understanding organizational factors that support a provider’s ability to perform and deliver a large volume of services to a new, evolving condition is necessary to scaling long-COVID models of care. This increased time demand requires the organization to support both adequate clinical and administrative staff and space demands. Rehabilitation providers must be competent in their clinical and interpersonal skills, which may require increased training, especially in the context of a multi-system, novel disease process with dynamic and emerging evidence. Additionally, time is needed for communication with other team members (e.g., physician, mental health, social work) to ensure safe and effective management across disciplines. All of this must occur within the context of a healthcare system that has expectations for productivity, reimbursement, and meaningful deliverables to patients, providers, and the system.

To illustrate how intervention, recipient, and contextual factors impact our organizational capacity, we briefly describe our long-COVID clinic at the XXX. The long-COVID clinic is staffed by a rehabilitation physician (0.09 Full Time Equivalent [FTE]) and a physical therapist (0.25 FTE). Both professionals received informal training and extensive experience providing care for Veterans on an inpatient COVID-19 Rehabilitation Unit.³¹ The physician plan of care typically includes one clinic visit and follow-up every 8 weeks or until symptom resolution. The physical therapist’s plan of care typically includes 1–2 sessions per week for an average of 12–13 weeks. This clinic schedule and staffing allows a maximum of 4–5 patients per week. If clinic hours are not filled, the physical therapist is detailed to assist acute medicine physical therapy team and the physician fills in with other patients or administrative programmatic duties. These arrangements allow for continuity in staffing across other areas of the healthcare system. Communication between the physician and physical therapist consists of as-needed video or face-to-face meetings to discuss patient progress. The physician often presents during physical therapy sessions to allow brief verbal check-in with patients and interdisciplinary communication as needed. Currently, in the XXX, provider interdisciplinary communication related to long-COVID care is not captured via billing codes or accounted for in productivity metrics, which has implications for long-term sustainability.

Our long-COVID clinic was originally open only to Veterans who previously completed a stay on the COVID-19 Rehabilitation Unit [reference deidentified] as we initially identified these patients at the highest risk of experiencing long-COVID following severe COVID-19 illness. Prevalence of long-COVID vary widely with estimates of 13.5% of those with documented COVID-19 illness in the Veterans Affairs (VA) health care system.³² We observed a similar volume with ~15% of Veterans discharged alive from the COVID-19 Rehabilitation Unit receiving long-COVID care clinic services. Important to note, the Veteran population discharged from the COVID-19 Rehabilitation Unit is likely a small proportion of our XXX Veteran population who may be experiencing long-COVID; thus, we may be underestimating the prevalence. Variability in the prevalence of long-COVID estimated within and external to the VA health care system is likely due to the variety of populations studied, methods used to acquire data, disease definitions, and outcomes assessed.

Strategies to Build Organizational Capacity

Understanding determinants of organizational capacity is an essential starting point and, in the context of evolving long-COVID definitions and care, must be re-evaluated regularly. Decisions for maximizing patient care outcomes while being clinically efficient require strategic forethought. To do so, a strong need exists to create an infrastructure that networks within and across organizations to minimize duplication of work and solicits timely feedback from stakeholders. With this infrastructure, novel care-delivery methods can flourish and be malleable to meet the needs of patients and healthcare systems as evidence and knowledge of long-COVID emerges.

In the long-COVID program at XXX, a key strategy to build organizational capacity is measuring and reporting metrics important to organizational decision-makers. In our system the following outpatient metrics are tracked and influence the allocation of resources: clinic volume (total number of consults, unique patients and/or encounters), clinic utilization, access, community care referrals (non-VA), and modality (e.g., in-person, telehealth). Thus, to enhance the viability of the XXX long-COVID clinic, data is reported to Rehabilitation & Extended Care and the XXX executive team and in active outreach efforts to operational and clinical partners to enhance visibility of the program.

A second key strategy utilized at XXX is leveraging inter-organizational networks of stakeholders embedded in long-COVID practice, policy, and research. As such, the physical therapist (co-author XX) and Physical Medicine & Rehabilitation physician (co-author XX) are founding, active members of a long-COVID Community of Practice (led by author XXX). The Community of Practice was initiated in April 2021 and works collaboratively across the Veterans Health Administration to 1) solicit feedback from Veterans, providers, and leadership on access to and provision of long-COVID care, and 2) partner with external organization to create broader system networks to share lessons learned and co-create knowledge related to long-COVID care.^27,33 This multi-disciplinary community provides significant value to the XXX long-COVID team as the bi-monthly meetings facilitate development of best clinical practices across the VHA, integration of lessons learned from facilities experiencing similar and disparate challenges, and advocacy for local, regional, and national-level leadership engagement in advocating for reimbursement and policies that promote the visibility and sustainability of long-COVID care. While not an explicit goal of the Community of Practice, the infrastructure and connection to this multi-disciplinary team within a large healthcare system strategically builds organizational capacity through stakeholder feedback, collaborative networking, and standardized measurement and report of clinic metrics to operational leaders.

Mechanisms for Enhancing Organizational Capacity

The strategies outlined in Figure 1 and illustrated above may influence the scaling of long-COVID care in three keyways. First, ensuring long-COVID care aligns with the organizational vision, mission, and strategic goals will amass the support to sustain such an endeavor. Second, demonstrating the value and viability of long-COVID care provides data that enables leadership to allocate enduring resources to match demand. Third, developing interdisciplinary, interorganizational communication pathways allows for rapid knowledge synthesis and translation of best-practice into long-COVID care.

Potential Multi-Level Outcomes of Enhanced Organizational Capacity

Under our illustrative example, we are still identifying and evaluating potential outcomes from enhancing organizational capacity to provide long-COVID rehabilitation care. However, based on our understanding of leadership priorities, clinical experience, and lessons learned from other VA and non-VA systems, we preliminarily identified three areas of outcomes: organization, staff/providers, and patients/families. As outlined in Figure 1, by enhancing organizational capacity and support, there is the potential to reduce staff turnover, improve patient satisfaction, and foster a culture of continuous learning and flexibility at an organization level. At the level of providers and staff, we may observe reduced burn-out and higher job satisfaction because of improved organizational support. Finally, at the level of patients and their families, an enhanced quality of life (by returning to desired recreational or domestic activities) and increased connection and trust in the healthcare system may track with stronger organizational support for long-COVID care.

Call to Action

The lasting effects of COVID-19 on individuals, families, communities, and societies across the globe are just emerging with the potential to explode into the next public health crisis. Rehabilitation providers are critical members of the interdisciplinary care screening for, evaluating, treating, and managing long-COVID sequalae. However, current models of outpatient rehabilitation care, in combination with pulmonary and cardiopulmonary rehabilitation, may lack the capacity to effectively treat a large volume of patients at higher frequency and longer duration. This paper adds and expands upon previously cited literature on what type of models of long-COVID care are necessary to meet patient needs to a perspective and description of how organizational capacity facilitates or inhibits successful implementation and why. Strong grassroots efforts are needed by providers, staff, and leadership to advocate for and build organizational capacity to provide timely, equitable, and high-quality long-COVID care.