Innovative Care Delivery of Acute Rehabilitation for Patients With COVID-19: A Case Report

ABSTRACT Objectives The novel coronavirus 2019 (COVID-19) has impacted acute rehabilitation delivery by challenging the reliance on in-person care and the standard practice of delivering separate physical and occupational therapy services. Healthcare systems are rapidly developing innovative models of care that provide essential acute rehabilitation services while mitigating viral spread. We present two case reports to illustrate how we used technology and COVID-19 specific decision-making frameworks to deliver acute rehabilitation. Methods We iteratively developed two decision-making models regarding care delivery and discharge planning in the context of the challenges to delivering care in a pandemic. We leveraged use of video communication systems installed in all COVID-19 rooms to reduce the number of in-room providers and frequency of contact. Two patients were admitted to the hospital with symptomatic COVID-19 (males, ages 65 and 40 years). Results With the use of video communication system and the decision-making frameworks for care delivery and discharge planning, we avoided 7 in-person sessions. Both patients demonstrated functional gains and were discharged home. Conclusion The two case reports highlight the innovative use of a technology and COVID-19 specific decision-making processes to provide patient-centered care given the challenges to care delivery during the COVID-19 pandemic. Impact Statement The use of technology and decision-making models allows for delivery of safe acute rehabilitation care that minimizes contact, conserves personal protective equipment, and prepares for COVID-19 surges. The discussion points raised have applicability to patients without COVID-19 and other healthcare systems. Future research is needed to determine the effectiveness, costs, and downstream effects of our novel approach to acute rehabilitation for patients with COVID-19.

to delay, prevent, or recover the loss of function due to prolonged hospitalization. [1][2][3][4][5] The typical functional declines observed may be exacerbated during a COVID-19 hospital admission due to the necessary precautions to mitigate viral spread such as keeping patients confined to their rooms and minimizing contact with providers. As a result, PTs and OTs in the hospital setting are faced with daily challenges and complex decisions regarding how to deliver rehabilitation services efficiently. Prior to the pandemic, standard acute rehabilitation practice at our facility provided PT and OT services as separate sessions. A paradigm of separate PT and OT sessions no longer fits during the COVID-19 pandemic when effective rehabilitation service is needed to maximize function and facilitate discharge planning, while also mitigating viral spread through reduced provider-patient contact, and conserving personal protective equipment (PPE).
A solid literature base exists citing rehabilitation approaches effective for the treatment and management of patients with COVID-19. [6][7][8] However, answers to clinical decisions regarding how rehabilitation services should be delivered during hospitalized care of patients with COVID-19 is evolving and largely unknown. We present two case reports to illustrate how we used technology and developed COVID-19 specific decision-making processes for care delivery. Both patients signed forms regarding permission to release information and the information presented meets the Health Insurance, Portability, and Accountability Act requirements for disclosure of protected health information.

[H1] Overview of Infrastructure Changes to Treat Patients with COVID-19
The  Table. In Figure 1, we outlined our decision-making process for determining which rehabilitation providers are necessary for in-room sessions. The PT/OT team reviewed the chart and determined the patient was appropriate for evaluation. 9,10 Next, they reviewed nursing notes that indicated the patient was using an assist of one for out of bed mobility and determined that the OT would be in the room for the evaluation with the PT outside.  Outcomes are presented in the Table, and functional scores at discharge exceeded minimal clinically important differences. Given the complexities of discharging patients from the hospital to post-acute care facilities in the context of a pandemic, our discharge planning process has evolved. To address this, an interdisciplinary team, including rehabilitation, formed a consensus on criteria for admission to the newly created, on-site COVID-19 acute rehabilitation unit (CRU) ( Figure 2) to eliminate the need for transfer to an outside facility for further rehabilitation following hospitalization. At the time, these admission criteria were considered indicators of low viral load. 18,19 At evaluation, PT/OT recommended the patient in Case 1 discharge to CRU; however, by hospital discharge the patient met all but one intake criteria (not tolerating ≥2 hours of daily rehabilitation). The interdisciplinary team discussed the case and decided admission to CRU was appropriate because the patient was steadily improving his aerobic capacity and demonstrated adherence to daily activity recommendations (i.e., ambulation in the room with nursing three times per day at RPE <5/10). Patient rooms in the CRU had video communication capability, yet it was used less as viral load was considered lower. The patient discharged from the hospital after 24 days (7 days acute care, 17 days CRU) to his assisted living facility with prior services and a progressive home exercise program.

[H1] CASE 2 DESCRIPTION
A 40-year-old, male was admitted to the hospital with a positive COVID-19 test (Tab.). Based on our decision-making process (Figure 1), chart review revealed the patient required assist of one as he fatigued easily with minimal activity and, thus, for the evaluation, the PT was in the room and the OT remained outside.

[H2] INTERVENTION AND PLAN OF CARE
The plan of care is outlined in the Table. We used the ICF model to prioritize the patient's needs and determined a combined rehabilitation plan of care of 5 days per week (30-60-minute PT/OT treatment sessions). The team prioritized the list of problems and determined that the patient's decreased aerobic capacity-defined by an RPE ≥5/10 during basic mobility-indicated both PT and OT were weighted equally and would alternate days of service in-room versus via video communication (Fig. 1). The use of technology allowed rehabilitation clinicians to avoid 4 in-person sessions (2 PT, 2 OT).

[H2] CASE 2 OUTCOMES
Outcomes are presented in the Table and demonstrated improvement. We initially recommend the patient discharge to CRU due to fatigue with minimal in-room mobility (RPE ≥5/10) and difficulty weaning off supplemental oxygen (Fig. 2). However, he expressed a strong desire to return home. Based on the patient's medical and functional improvements the discharge recommendation changed to home with outpatient, virtual PT. The patient was issued a tablet after PT/OT agreed he was cognitively intact (determined by a combination of cognitive status, availability of social support, and clinical judgement) and familiar with the use of tablet devices. At the time the tablet was issued, the patient needed to call to schedule a virtual PT appointment after hospital discharge. In this case, the patient did not call to schedule a virtual PT appointment but did have a phone visit with his primary care physician. The patient discharged from the hospital to home after 17 days (11 days in the ICU).

[H2] Role of the Funding Source
The funder played no role in the design, implementation, analysis, or interpretation of results or the decision as to whether or where to publish papers.

[H1] DISCUSSION
The COVID-19 pandemic has challenged acute rehabilitation to move beyond traditional in-person sessions and embrace a different model of service across PT/OT disciplines to deliver essential care. The two case reports highlight a model of care that used technology and two COVID-19 specific decision-making processes to provide safe and patient-centered care. Both patients with COVID-19 demonstrated functional gains after 2-4 weeks of acute rehabilitation and discharged home.
To our knowledge, this case report is the first to outline how rehabilitation providers leveraged technology to deliver acute rehabilitation services. The use of in-room video communication system and PT/OT co-treatment strategies enabled patients to receive both PT and OT services, while concurrently conserving PPE and reducing provider contact.
Furthermore, the capability for virtual rehabilitation following hospital discharge allowed the rehabilitation team and patient to comfortably make an informed decision to discharge the patient from the hospital to home (Case 2). However, we experienced potential barriers (eg, scheduling difficulty) to successful adherence to recommended rehabilitation following hospitalization. Virtual rehabilitation is a new program at our facility, and we are currently revising the scheduling process and developing resources to facilitate improved transition of care. [20][21][22][23] To our knowledge, this case report is the first to outline a decision-making model used to inform the delivery of acute rehabilitation services. The complex decision-making integral to rehabilitation in acute care is intensified by the COVID-19 pandemic when PPE is scarce, minimal contact is recommended, and transfers to post-acute facilities is conservative. All the aforementioned factors greatly impact the delivery of acute rehabilitation services, which often require close patient contact, frequent interaction, and the need to make timely, patient-centered discharge recommendations. Thus, our decision-making model provided structured guidance and standardization to our clinical decisions in the context of providing acute rehabilitation during a pandemic.
While the changes in service delivery outlined in this case report were a practical necessity during a pandemic, a need exists to evaluate and determine what elements to maintain beyond the pandemic's end. First, the role of acute rehabilitation clinicians has traditionally served as a consultation service for discharge planning. 5 However, the increased hospital length of stays and difficulty discharging to outside post-acute rehabilitation facilities has expanded the role of acute PT/OT to providing rehabilitation models of care in our facility, 5 which has implications for changes in staffing structures. Second, the use of our collaborative decision-making models and technology appeared to remove PT and OT silos in our facility. By actively collaborating between disciplines, PTs and OTs gained greater insight into disciplinespecific approaches and integrated these elements to help patients progress synchronously towards both PT and OT goals. Third, the increased use of technology has the potential to expand options to deliver acute rehabilitation care in remote areas that serve our patient population and lack adequate rehabilitation workforces at our facility.
This case report is not generalizable. However, the two cases illustrate our rapid change to delivering acute rehabilitation services in the context of the COVID-19 pandemic. We believe the treatment delivered and discussion points raised have applicability to other patients with COVID-19 and other healthcare systems. A second limitation is the lack of formal satisfaction data regarding patient or clinician satisfaction with the technology and delivery of acute