Your Guide to Post-COVID Patient Types and Recovery: Differences Between PICS and Long-Haulers

<p>Based on continued evaluation of the patients suffering from and recovering from COVID-19, a new subset of patients is emerging, formally called &ldquo;post-COVID". These patients experience long-lasting symptoms and typically fit into one of two categories:</p>
<ol>
<li>The sickest COVID patients who spent considerable time in the hospital (often the intensive care unit) and often developed <strong>post-intensive care syndrome (PICS)</strong> due to their extended hospital care</li>
<li>The COVID patients who did not require hospitalization originally but continue to experience symptoms, are becoming known in medical and recovering COVID communities as <strong>long-haulers</strong></li>
</ol>
<p><img src="https://www.kindredhealthcare.com/images/default-source/blog-images/the-kindred-continuum/covid-long-haulers-blog.jpg?sfvrsn=9c7d94ea_2" data-displaymode="Original" title="COVID PICS Patients are the sickest COVID patients who spent considerable time in the hospital (often the intensive care unit) and often developed post-intensive care syndrome (PICS) due to their extended hospital care. Vs COVID Long-Haulers who are The COVID patients who did not require hospitalization originally but continue to experience symptoms, are becoming known in medical and recovering COVID communities as long-haulers." /></p>
<p><strong>This guide explores some of the more common experiences of long-haulers, the need for research, the clinical conditions of PICS patients, and the positive role long-term acute care hospitals play in the care of PICS patients.</strong></p>
<p><strong>Post-COVID PICS Patients</strong></p>
<p>Patients who spend considerable time in an ICU are at risk of developing post-intensive care syndrome (PICS), which can have a long-lasting impact on patient well-being.</p>
<p>PICS has long been a known diagnosis for patients facing complex and prolonged medical treatment. According to the Cleveland Clinic, PICS is a result of a combination of factors, including receiving care in the ICU for serious medical conditions including respiratory failure or sepsis, the use of life-sustaining equipment such as ventilators, and the use of certain medications. Additionally, PICS can bring on ICU-acquired weakness, cognitive or brain dysfunction and other mental health disorders.</p>
<p>Hospitalized COVID-19 patients are receiving life-saving care in an ICU for much longer than the average stay of three to four days and are often reliant on a ventilator, both of which puts them at high risk.</p>
<p>Post ICU/CCU-level patients such as these often require the specialized, interdisciplinary care that is only available in LTAC hospitals. This is because these patients are significantly sicker &ndash; with a much higher case mix index &ndash; and benefit from care provided by a team who specializes in the care of medically complex patients and customized care pathways.</p>
<p><img src="https://www.kindredhealthcare.com/images/default-source/default-album/covid-long-haulers-blog2.jpg?sfvrsn=ee7d94ea_0" data-displaymode="Original" alt="Approximately 10% of people who were sick with COVID experience prolonged symptoms beyond three weeks. " title="Approximately 10% of people who were sick with COVID experience prolonged symptoms beyond three weeks." /></p>
<p><strong>Who Are COVID Long-Haulers?</strong></p>
<p>For those less severe COVID patients &ndash; the long-haulers &ndash; it is becoming clear that they may develop symptoms as a result of the SARs-CoV-2 infection. They have persistent myriad chronic symptoms that may continue for weeks and months after the patient has been declared virus-free.&nbsp;</p>
<p>According to a recent study in JAMA, approximately 10% of people who were sick with COVID experience prolonged symptoms beyond three weeks.</p>
<p>Jessica Dine, MD, a pulmonary specialist at the University of Pennsylvania, Perelman School of Medicine, noted that &ldquo;most of the patients I see who are suffering from [this], were not hospitalized.&rdquo; She noted that they were quite ill with COVID symptoms, but remained at home.<sup>1</sup>&nbsp;Another observational study from the United Kingdom also recognized that those post-COVID patients reporting a &ldquo;prolonged and debilitating course of illness&rdquo; were never admitted to a hospital.<sup>2</sup>&nbsp;It is important to note that these patients are very different from PICS patients, who spent considerable time in an ICU during their COVID treatment.</p>
<p>According to the patient-driven <a href="https://www.wearebodypolitic.com/bodytype/2020/8/16/covid-19-support-group-long-haul" target="_blank">Body Politic COVID-19 Support Group</a>, long-hauler symptoms &ldquo;include (but are by no means limited to) fevers that last for months, impaired short-term memory, poor proprioception (sense of body movement and position), brain fog, heat intolerance, orthostatic intolerance (difficulty standing), dramatic changes to blood pressure and heart rate, muscle pain, menstrual changes, tinnitus, persistent nausea, weight loss, hair loss, and newfound food sensitivities.&rdquo;<sup>3</sup> They note that these symptoms often persist for a month or more, may flare up unpredictably in different combinations, and can be debilitating enough to prevent the reestablishment of employment or household responsibilities.&nbsp;&nbsp;</p>
<p><strong>Challenges with Lack of Long-Haulers Research</strong></p>
<p>Our understanding of SARS-CoV-2 is still in its relative infancy. Consequently, there is a notable lack of validated research on the virulence of SARS-CoV-2 and how to prevent or provide long-term interventions for long-haulers.</p>
<p>In March 2020, Body Politic started the COVID-19 Support Group after its founder and key members became ill and discovered the lack of online content or resources for people suffering from COVID. In response, they launched a patient-driven survey with 640 respondents. They are now conducting a second, patient-reported survey to help understand long-term post-COVID symptoms and experiences.</p>
<p><em><a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30701-5/fulltext" target="_blank">The Lancet</a>&nbsp;</em>recently noted that the main limitation of current research is data reporting/fragmentation, a high risk of bias and no external validation. Specifically, the authors urged strong research to understand long-haulers, highlighting that &ldquo;participation of an international and interdisciplinary group of researchers is essential.&rdquo;</p>
<p><strong>Path Ahead</strong></p>
<p>Long-term acute care hospitals have the clinical expertise and a strong and lengthy history of providing vital intensive medical care and therapies often necessary to successfully support PICS&rsquo; patient recovery. These competencies include rehabilitative therapies to recover strengths and abilities, cognitive rehabilitation, and pulmonary rehabilitation to increase lung function.</p>
<p>LTAC hospitals deliver care for the most difficult-to-treat, critically ill and medically complex patients &ndash; such as patients with respiratory failure, septicemia, traumatic injuries, wounds or other severe illnesses complicated by multiple chronic conditions, many of which have been symptoms of post-COVID recovery.</p>
<p>On the contrary, due to the limited research on the prolonged treatment for long-haulers, a definitive and validated care path is not known at this time. By recognizing that most long-haulers do not access acute level care at a typical hospital, a specialized rehabilitation hospital or long-term acute care hospital, it is probable that acute medical and rehabilitation interventions may help COVID patients more fully recover and support longer-term stability and recovery.</p>
<p><strong>How Kindred Can Help</strong></p>
<p>Kindred&rsquo;s long-term acute care hospitals provide high-quality COVID and post-COVID interdisciplinary medical and rehabilitative care that supports a more complete recovery and return to independence.</p>
<p>Data demonstrates that during the pandemic, Kindred&rsquo;s LTAC hospitals cared for significantly sicker patients (higher case mix index), discharged a greater percentage of patients back to their home or community, and reduced rehospitalizations (during the LTACH stay) of Medicare patients to less than 7%.</p>
<p>The teams of skilled and caring clinicians in Kindred&rsquo;s long-term acute care hospitals can be the right partner for you in caring for your patients who have been in an ICU or a critical care unit, or who are chronically ill and readmit to the hospital frequently. Kindred has proven success in treating patients with pulmonary disease and respiratory failure, including a long history of liberating patients from mechanical ventilation and artificial airways. Kindred also has decades of experience treating post-intensive care syndrome (PICS).</p>
<p>Many Kindred hospitals have or are in the process of achieving disease-specific certification from The Joint Commission in key conditions such as respiratory failure and sepsis.</p>
<p><strong>If you have a post-COVID patient, or other patients in need of care after a hospital stay, call a Kindred Clinical Liaison for a patient assessment. Our experts will help you determine whether an LTAC stay is appropriate for your patient. If you are unsure of who your Kindred representative is, please feel free to contact us and speak with a Registered Nurse who can assist.</strong></p>
<hr />
<p>References</p>
<ol>
<li>Rubin R. <em>As Their Numbers Grow, COVID-19 &ldquo;Long Haulers&rdquo; Stump Experts.</em> JAMA. Published online September 23, 2020. doi:10.1001/jama.2020.17709</li>
<li>Rayner C, Lokugamage AU, Molokhia M. <em>COVID-19: prolonged and relapsing course of illness has implications for returning workers<br />
</em>https://blogs.bmj.com/bmj/2020/06/23/covid-19-prolonged-andrelapsing-course-of-illness-has-implications-for-returning-workers</li>
<li>https://www.wearebodypolitic.com/bodytype/2020/8/16/covid-19-support-group-long-haul, Body Politic COVID-19 Support Group, August 18, 2020
</li>
</ol>

Continued Care for COVID Recovery: How LTAC Hospitals Help Post-COVID Patients

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<br />
<p>The latest research findings are honing in on the clinical conditions associated with COVID-19, along with the specific care pathways needed for patients, once stabilized, to fully recover. Specialized care after the initial hospital stay is proving to play a critical role.&nbsp;</p>
<p>Hospitalized COVID-19 patients often experience significant pulmonary complications, including severe pneumonia and acute respiratory distress-like syndrome. Further, many physicians are reporting that patients are developing post-intensive care syndrome (PICS) due to an intensive care unit (ICU) stay measured in weeks rather than days. The virus is also resulting in strokes, and causing sepsis, which can lead to multi-system failure and leave a patient with lasting damage to the lungs and other organs.</p>
<p><strong>This brief details COVID-19 patient care management strategies and research on how the clinical expertise of LTAC hospitals is uniquely suited for post-COVID patients.</strong></p>
<h2><strong>New Research on Care Solutions for Post-COVID Patients: The Role of LTACHs</strong></h2>
<p>A growing body of evidence indicates that the specialized services delivered in long-term acute care hospitals play a unique and positive role in treating patients recovering from COVID-19.</p>
<p>A recent study in the <em>Journal of Rehabilitative Management</em> stated that: &ldquo;Early rehabilitation of the COVID-19 patients can enhance pulmonary, respiratory function, reduce complications, improve function, cognitive impairments and quality of life."<sup>1</sup></p>
<p>Hospitalized COVID-19 patients are receiving life-saving care in an ICU for much longer than the average stay of three to four days and are often reliant on a ventilator, both of which puts them at high risk of developing post-intensive care syndrome (PICS) &ndash; a condition that can include ICU-acquired weakness, cognitive or brain dysfunction and other mental health disorders. Specialized care interventions and rehabilitation are needed to address the short- and medium-term consequences of post-COVID patients experiencing PICS symptoms and recovering from extended mechanical ventilation.<sup>2</sup></p>
<p>Additionally, as published recently in <em>The Boston Globe<sup>3</sup></em>:</p>
<p style="padding: 0 50px;">Many recovering COVID-19 patients need to be weaned off of ventilators and slowly reintroduced to eating on their own. Some also require speech therapy, pulmonary therapy, and dialysis.</p>
<p style="padding: 0 50px;">&hellip;COVID-19 has reminded the world of the importance of facilities that occupy the middle ground of the critical care landscape.</p>
<p style="padding: 0 50px;">&ldquo;In a pandemic, you really do need that kind of intensive care,&rdquo; said Grabowski, who co-authored a paper advocating for the importance of long-term acute care hospitals. "For years, we said, &lsquo;Why do we need long-term care hospitals?&rsquo; And all of a sudden with COVID, we&rsquo;re saying &lsquo;Why don&rsquo;t we have more long-term care hospitals?&rsquo;&rdquo;</p>
<p>Lastly, a recently co-authored a post in <em>Health Affairs</em> highlighted the critical resource that LTAC hospitals can play during the COVID pandemic.<a href="#_ftn4" name="_ftnref4"></a><sup>4</sup> Specifically, the researchers suggest that <strong>the clinical expertise in LTAC hospitals with &ldquo;critical care nurses, respiratory therapists, and intensivists&rdquo; aligns with the ongoing needs of COVID patients. </strong>The experts conclude that, &ldquo;During this unprecedented international crisis, [LTAC hospitals] offer additional opportunities to prepare for and manage the surge of COVID-19 patients experiencing respiratory failure.&rdquo;</p>
<h2><strong>Unique Clinical Presentations Require Specialized Care</strong></h2>
<p>Due to the complex medical needs of post-COVID patients, long-term acute care (LTAC) hospitals are a key care setting. LTAC hospitals deliver care for the most difficult-to-treat, critically ill and medically complex patients &ndash; such as patients with respiratory failure, septicemia, traumatic injuries, wounds or other severe illnesses complicated by multiple chronic conditions, many of which have been symptoms of post-COVID recovery.</p>
<p>These specialty hospitals are unlike other post-acute care settings because they are licensed as a general acute care hospital by the state and certified by the Centers for Medicare &amp; Medicaid Services (CMS) as an LTAC hospital, and accredited by the Joint Commission under acute care standards. Additionally, care is provided in an interdisciplinary fashion, featuring daily physician visits and specialty physicians based on patient needs. Clinicians are specially trained for the critical care setting and are able to support prolonged recovery times.</p>
<h2><strong>LTACH Expertise in Pulmonary Care and Recovery</strong></h2>
<p>A patient&rsquo;s recovery and long-term lung health is directly dependent on the type and intensity of the care they receive. Distinct from all other post-acute settings, LTAC hospital clinicians are highly specialized in their ability to successfully liberate the most challenging ventilator patients, and LTAC hospitals feature hospital-level infection control, negative pressure rooms where needed and on-site laboratories and dialysis.</p>
<h2><strong>How Kindred Hospitals Can Help</strong></h2>
<p>We specialize in the treatment and rehabilitation of the post-intensive care and complex medical patient requiring continued intensive care, including specialized rehabilitation, in an acute hospital setting.</p>
<p>Our team of skilled and caring clinicians in our long-term acute care hospitals can be the right partner for you for your patients who have been in an ICU or a critical care unit, or who are chronically ill and readmit to the hospital frequently. We have proven success in treating patients with pulmonary disease and respiratory failure, including a long history of liberating patients from mechanical ventilation and artificial airways.</p>
<p>Many of our hospitals have or are in the process of achieving disease-specific certification from The Joint Commission in key conditions such as respiratory failure and sepsis.</p>
<p>We also have decades of experience treating post-intensive care syndrome (PICS). Under Kindred&rsquo;s expert interdisciplinary care, patients receive targeted services including:</p>
<ul>
<li>Daily physician oversight</li>
<li>Physician specialists</li>
<li>ICU-level care and staffing when necessary</li>
<li>24/7 respiratory therapy coverage</li>
<li>IV pain control management and narcotic/opioid weaning</li>
<li>Early mobilization of both ventilated and spontaneously breathing patients</li>
<li>Antimicrobial management to complete sepsis treatment and prevent antibiotic resistance</li>
<li>Interdisciplinary teams to clarify interventions and monitor progress</li>
<li>A patient-centered, goal-directed care plan addressing function, cognition and medical impairments</li>
<li>Family-focused discharge planning, whether directly to home or to less intense levels of post-acute care</li>
</ul>
<p><strong>If you have a post-COVID patient, or other patients in need of care after a hospital stay, call a Kindred Clinical Liaison for a patient assessment. Our experts will help you determine the most appropriate care setting for your patient&rsquo;s next stage of treatment. If you are unsure of who your Kindred representative is, please feel free to <a href="https://www.kindredhealthcare.com/our-services/transitional-care-hospitals/healthcare-professionals" target="_blank">contact us</a>&nbsp;and speak with a Registered Nurse who can assist.</strong></p>
<hr />
<p>References</p>
<ol>
<li><span style="font-size: 12px;">Fary Khan, MBBS, MD, FAFRM (RACP), Bhasker Amatya, DMedSci, MD, MPH, <em>&ldquo;Medical Rehabilitation in Pandemics: Towards a New Perspective,&rdquo;</em> Journal of Rehabilitative Management, Vol. 52, Issue 4, April 9, 2020</span></li>
<li id="ftn2">
<p><span style="font-size: 12px;">Stam HJ, Stucki G, Bickenbach J. Covid-19 and Post Intensive Care Syndrome: A Call for Action. J Rehabil Med. 2020;52(4):jrm00044. Published 2020 Apr 15. doi:10.2340/16501977-2677</span></p>
</li>
<li id="ftn3">
<p><span style="font-size: 12px;">Dasia Moore, "COVID-19 patients are recovering, but with nowhere to go," The Boston Globe, May 19, 2020</span></p>
</li>
<li><span style="font-size: 12px;"><em>&ldquo;How Can We Ramp Up Hospital Capacity To Handle The Surge Of COVID-19 Patients? Long-Term Acute Care Hospitals Can Play A Critical Role,&rdquo;</em> Health Affairs blog, April 13, 2020, DOI: 10.1377/hblog20200410.606195</span></li>
</ol>
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For Continued Acute Level Care, LTAC Hospitals May Be the Best Option

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<br />
<p>A patient&rsquo;s full recovery is only made possible when they have access to the right clinical expertise necessary to address their unique care needs. Choosing the right care path for critically, chronically ill patients is essential to achieving optimal outcomes for both patients and providers.</p>
<p>Long-term acute care (LTAC) hospitals deliver care for the most difficult-to-treat, critically ill and medically complex patients &ndash;including those with respiratory failure, septicemia, traumatic injuries, wounds or other severe illnesses complicated by multiple chronic conditions.</p>
<p><strong>Read this brief to learn about the LTAC hospital level of care, key indicators that your patient may benefit from this level of care, and how an early assessment by a post-acute care representative can provide care management solutions for referring hospitals and positively impact patient outcomes.</strong></p>
<h2>Continued ICU-Level Care: The Value of LTAC Hospitals</h2>
<p>Long-term acute care hospitals are in a unique position to effectively treat critically ill patients. Unlike other post-acute settings, long-term acute care hospitals can help patients who need to see a physician every day. Further, care is provided by several specialty physicians based on a patients&rsquo; needs, such as pulmonologists, cardiologists, neurologists and more. These specialists coordinate care with an interdisciplinary team made up of nurses, therapists, dietitians, pharmacists and other specialists.</p>
<p>These experts work together to determine the best treatment options and care plan for each and every patient. Most treatment plans involve many clinical disciplines, are complex, intensive, and evolving, and may require a length of stay measured in weeks.</p>
<p>While LTAC hospitals provide care for a very high-acuity, niche patient population, they play a vital role in helping patients recover more efficiently — including those who have a high risk of readmission due to their clinical complexity. By transitioning these challenging patients to a LTAC hospital, when it is the most appropriate site of care for their needs, referring hospitals can help to manage preventable rehospitalizations, and successfully avoid readmission penalties.</p>
<h2>Research Based Positive Outcomes for the Severely Ill</h2>
<p>LTAC hospitals have long been recognized for their strong performance in successfully weaning patients from ventilators. Additionally, recent research of non-ventilator patient populations found that for patients with three or more days in intensive care in a short term hospital, LTAC hospital care &ldquo;is associated with improved mortality and lower payments.&rdquo;&nbsp;<sup>1</sup> The study also concluded that the effects of LTAC hospital care tend to &ldquo;be more favorable for patients with either multiple organ failure or &ge;3 days in an ICU/CCU as compared with patients without these characteristics.&rdquo;&nbsp;<sup>2</sup></p>
<p><img alt="Chart text: for ventilated and non-ventilated patients with 3+ days in the ICU, LTAC care is associated with improved mortality and lower payments" data-displaymode="Original" src="https://www.kindredhealthcare.com/images/default-source/blog-images/the-kindred-continuum/194694-02-hd-topic-2-outcomes.jpg?sfvrsn=6f3282ea_4" title="LTAC Care Chart" /></p>
<h2>Identifying How Your Patient Would Benefit from Care in an LTAC Hospital</h2>
<ul style="list-style-type: disc;">
<li><strong>Extended stay (multiple days) in an ICU or critical care unit – </strong>During a patient’s stay in an ICU, the critical care team can generally tell if a patient will need extended care around days 3-7 of the stay. As reported in CHEST from a large Prolonged Mechanical Ventilation (PMV) Consensus Conference, &ldquo;While acknowledging that liberation from mechanical ventilation can be unpredictable, but recognizing that by as early as day 7, the need for a prolonged treatment is likely," the formal recommendation was made that clinicians &ldquo;begin consideration for PMV-focused care when tracheostomy is first considered.&rdquo;&nbsp;<sup>3</sup> As soon as it is determined a patient will need prolonged acute care, it is important for the clinical team to reach out to post-acute representatives to determine the best options or site of care.</li>
<li><strong>Higher case mix index than traditional hospital patients -</strong> Post ICU/CCU-level patients often require the specialized, interdisciplinary care that is only available in LTAC hospitals. This is because these patients are significantly sicker &ndash; with a much higher case mix index &ndash; than their acute hospital counterparts.
<ul style="list-style-type: circle;">
<li>On admission, LTAC hospital patients average nearly double the number of complications as STAC hospital patients</li>
<li>On admission, LTAC hospital patients average over 6 comorbidities.</li>
</ul>
</li>
<li><strong>The severity of the patient&rsquo;s conditions need daily physician oversight and acute, hospital-level</strong> <strong>care</strong> &ndash; common conditions treated within LTAC hospitals are respiratory failure, septicemia, pulmonary edema, advanced wound care, infectious diseases and cardiac care. Patients with multiple and severe conditions such as these require physician and clinical specialist oversight daily along with the acute care, hospital-based environment.</li>
</ul>
<h2>Benefits of Early Post-Acute Care Assessment</h2>
<p>Once it is determined that a current or former ICU/CCU patient will require prolonged care for a full recovery, it is important that discharge from the unit to the most appropriate level of care be done as soon as possible, because patients who experience a delay may experience adverse outcomes.</p>
<p>Early assessments by post-acute networks provide benefit to the patient and referring hospital:</p>
<ul>
<li>Improved patient experience through a smoother transition between facilities; better coordination, less disruption</li>
<li>Enhanced efficiency in case management &ndash; earlier identification that the care needs are exceeding the short-term facility&rsquo;s focus; potential to help in payment denial management</li>
</ul>
<h2>How Kindred Can Help</h2>
<p>Kindred LTAC Hospitals, also known as Transitional Care Hospitals, provide expert interdisciplinary care to meet the unique needs of each patient who can benefit from our level of care. Treatment is led by physician specialists, and supported by a full complement of clinical disciplines. Additionally, the hospitals feature ICU-level units, telemetry units with on-site pharmacy, radiology services and operating rooms.</p>
<p>The comprehensive team approach with condition-specific clinical programs facilitates improved outcomes and a greater chance of recovery.</p>
<p>Kindred Hospitals have an average length of stay of 29 days&nbsp;<sup>4</sup> and have a 30-day (all-cause, planned and unplanned) readmission rate of just 8.6%&nbsp;<sup>5</sup>, providing new strategies for referring hospitals to manage readmissions and effective care management. Additionally, our physician-led, interdisciplinary teams have a strong reputation for successfully weaning patients off mechanical ventilation.</p>
<p>As part of determining the most appropriate site for prolonged acute care, our Clinical Liaisons can provide patient assessments, and can help physicians and other attending clinicians determine if a patient is appropriate for LTAC hospital services.</p>
<p><strong>If you have a patient who needs more time to recover, </strong><a href="https://www.kindredhealthcare.com/our-services/transitional-care-hospitals/healthcare-professionals/make-a-referral">contact us</a><strong> and we will help determine if LTACH care is the most appropriate next step.</strong></p>
<hr />
<p>
References:<br />
<br />
<span style="font-size: 12px;">
1 Koenig, L., Demiralp, B., Saavoss, J., &amp; Zhang, Q. (2015). The Role of Long-term Acute Care Hospitals in Treating the Critically Ill and Medically Complex: An Analysis of Nonventilator Patients. Medical Care, 53(7), 582&ndash;590. http://doi.org/10.1097/MLR.0000000000000382<br />
</span><span style="font-size: 12px;">2,5 ibid
<br />
3 Management of Patients Requiring Prolonged Mechanical Ventilation; Report of a NAMDRC Consensus Conference. CHEST 2005;128: 3937-3954.
<br />
4 Quality and Innovation Report, Kindred Healthcare, 2018 outcomes</span></p>
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