Following an outbreak at a local meatpacking plant, the University of Iowa Hospitals and Clinics treated a significant number of Covid-19 patients in its region. Several months after the initial outbreak, recovered patients began to reappear with unexpected and non-specific symptoms such as chronic fatigue. Patients did not have a place to seek treatment, and some were stigmatized in the community. Additionally, the novelty of the virus meant that primary care physicians and some specialists, including community pulmonologists and cardiologists, were ill-equipped to treat patients. To address these issues, a group of pulmonologists converted underutilized clinic space into the Respiratory Illness Clinic: a clinic specifically designed to treat recovered Covid-19 patients.

Overview of the patient journey

The Respiratory Illness Clinic provides a clear point of entry for referring physicians and patients seeking care for non-specific Covid-19 complications. Patients first see one of the four pulmonologist intensivists who take a standardized approach to patient evaluation. Patients are asked about their medical history (notable conditions, history of smoking, etc.) and then go through a comprehensive series of tests including a physical exam, pulmonary function test, spirometry, functional capacity evaluation, exhale nitric oxide test, expiratory and inspiratory CT scan, and blood work. After the evaluation, the patient is referred to the proper specialist. Depending on how the patient is progressing, the Respiratory Illness Clinic staff suggests either a three or six month follow-up.

Patient profiles

UIHC recommends that all patients experiencing symptoms 30 days after their diagnosis should make an appointment at the clinic for further evaluation. Patients have varied both in terms of age (20s to 70s) and severity of complications. Pulmonary and respiratory issues including asthma, airway diseases, and in more severe cases lung scaring and fibrosis, have been the most common ailments. However, several patients have exhibited non-specific cognitive issues such as brain fog or general fatigue.

Care coordination

Pulmonologists serve as the quarterback by managing the initial assessment of patients and coordinating follow-up care with needed specialists. The pulmonologists have created close referral relationships with psychology, physical therapy, and rehab departments. These specialists are not located on-site. While most patients treated at the clinic do not have a primary care physician, pulmonologists share visit notes with those that do have a regular PCP and make themselves available to answer questions.

Growth

In the first few weeks of opening, clinic volume was low—around 1 patient per week. However, as Covid-19 cases have risen, volume has risen to 6-7 patients per week. The health system launched a TV, press, and website advertising campaign to educate the community about the clinic. Hospitalists are also notified about the clinic upon patient discharge through EHR best practice advisory messages. There is now a two-week wait time to receive an appointment.

Evaluating success

The clinic does not yet have sufficient data to evaluate health outcomes. However, anecdotal feedback suggests that patients are grateful they have a place to receive care and are reassured to know definitively if they might have long-term damage to their lungs or other organs.

Plans for the future

UIHC will continue to monitor long-term health consequences of Covid-19 survivors to determine if they will grow the clinic’s capacity and make further investments in service offerings. With added funding, UIHC says the clinic would benefit from additional onsite ancillary personnel, such as a medical assistant, nurse, respiratory therapist, and physical therapist

Following a surge of Covid-19 in the region, Penn Medicine saw patients—not only those discharged from their ICU but also non-hospitalized patients—presenting to different specialists with lingering complications from Covid-19. The multi-system nature of complications made it challenging to address patients’ needs. To better coordinate care and connect patients to specialists with Covid-19 treatment expertise, Penn Medicine’s Department of Physical Medicine and Rehabilitation created the Post-Covid Recovery Clinic.

Overview of the patient journey

All patient interactions begin with an initial one-hour telehealth visit with physiatrists. During this visit, patients go through multiple screening measures to look for different ongoing sequelae of their initial Covid-19 infection. The standardized evaluation includes a comprehensive history of their COVID-infection, including any treatments they received. There is also a thorough review of systems. Standardized screening questions are used to evaluate for cardiopulmonary symptoms, pain levels, endurance, fatigue, and physical and community functioning. Standardized measures are used to evaluate for level of dyspnea, cognition, anxiety, depression and PTSD. Depending on their lingering symptoms, patients are provided self-management strategies, further testing is ordered, treatments are prescribed, or patients are referred to the appropriate specialists. To track progress, followups are generally scheduled for one to two months after the initial visit.

Patient profiles

Approximately 60% of patients seen in the clinic were never hospitalized for Covid-19. Most patients seen have been younger and middle-aged. While their complications range in severity, some symptoms include: persistent dyspnea, cough, chest pain, palpitations, anxiety, depression, fatigue, loss of endurance, and cognitive and memory issues.

Growth

Penn has seen approximately 50 patients in its first 10 weeks. In October 2020, the clinic has scheduled nearly 15 patients per week. Patients are often referred from their primary care physician or community pulmonologists and cardiologists. Other patients have self-referred after hearing about the clinic through internet searches and Facebook groups.

Care coordination

Even though initial evaluations are completed through Penn’s inpatient rehab department, many specialists are involved throughout the care journey, including pulmonologists, cardiologists, psychiatrists, and physical therapy specialists. Penn has selected a set of clinicians who will treat or oversee the management of recovering Covid-19 patients and has developed an expedited referral process for patients to see these clinicians.

Evaluating success

Penn is tracking patient progress on the standardized clinical indicators it collects during initial and follow-up visits. However, because many patients are traveling from outside of the Philadelphia region, this has posed some issues with insurance coverage and made in-person follow-up care difficult. Anecdotally, many patients have expressed appreciation that their symptoms are being recognized and addressed. However, some are frustrated about what is causing their ongoing symptoms when testing does not reveal answers.

Plans for the future

Penn is hopeful that the distribution of a vaccine will mitigate the necessity of a post-Covid-19 recovery clinic over time. However, they believe that many patients—particularly those that experienced serious illness—will experience symptoms for some time. Therefore, the clinic plans to operate indefinitely.

With added funding, Penn would invest in additional psychological services and research personnel. Penn is also considering broadening the scope of the clinic beyond just Covid-19 patients. In the future, Penn could offer the recovery clinic to patients that have just been discharged from the hospital or ICU and report ongoing symptoms that need to be addressed across several clinical specialties.