Table 2.

Identification and support of patients at risk of COVID-19 complications

Identification of risk and formation of individual management plan 1. Identify and flag patients at risk at clinical reviews and handovers on the basis of medical, socio-economic and psychiatric vulnerability 2. Discuss with multidisciplinary team (MDT) and line manager 3. Ensure MDT formation of a COVID-19 support plan 4. Maintain close monitoring of mental and physical health (on face-to-face reviews if scheduled; if required medical review triage and link in with general practitioner (GP) or liaise with emergency department) 5. Increase contact during high-risk periods for individual patients (such as concurrent medical illness, recent medical admission, increased social adversity, recent homelessness, family conflict, substance use or worsening of mental state) Connect those at risk with health supports 1. Ensure ongoing GP care and, if indicated, specialist care 2. Assist patients to form/revise their health care plan(s) with their GP 3. Encourage influenza vaccine and support to access government-funded vaccine if eligible due to chronic disease 4. Ensure reliable provision of medications. Connect those at risk with social supports 1. Identify risk (risk of homelessness, state of the home, food security, supplies, domestic violence) 2. Link in with social services such as COVID-19 support phone lines for those in self-isolation 3. Explore and support need for food/basic necessities for those without supports. Consider support funding via SA Health or link in to other appropriate services (such as non-government agencies) 4. Provide support for those at risk of or experiencing unstable accommodation and homelessness via social work in care coordination and/or link in to and liaison with non-government agencies 5. Ensure specific registration in electronic patient file and escalation in MDT, liaison with domestic violence supports and police (Family Safety Framework) for suspected or confirmed domestic violence 6. Extend cultural supports with community (via videoconference, phone) to reduce social isolation while maintaining social distancing; link in with support agencies and workers such as Aboriginal Liaison Officers Ongoing evaluation and re-evaluation 1. Re-evaluate ongoing need/risk at clinical review 2. Conduct regular senior CMH team clinician meetings/briefings (via videoconference with other sites and levels of leadership) to ensure strategies remain consistent and current