App-supported care for Long Covid patients, optimising health care access

During the initial wave of Covid 19, the large volume of patients with Post-Covid health needs stretched NHS capacity to accommodate assessment, treatment and rehabilitation.

This was exacerbated by the limited understanding of Covid-19 at the time, post-Covid concerns and what is now called ‘Post-Covid Syndrome’ (Long Covid).

Patients presented with complex, multifactorial health concerns including fatigue, brain fog, breathlessness and anxiety. Long Covid currently has no cure, but with advice, education and support, patients gain confidence in self-management and many report improvement in symptoms. No pre-existing Trust services were equipped to take on these patients; a new service was required.

Rehabilitation is a journey, and traditional rehabilitative NHS services meet a patient at set points, offering advice and instruction, often with little flexibility to see the patient sooner, or support them if they forget what to do before their next appointment. Should their condition change, they may be unable to access a clinician familiar with their case, leading to frustration and a sense of distance from the healthcare provider. A patient who cannot recall how to do rehabilitation exercises correctly will likely make limited improvements, if any.

Traditional NHS services have a finite capacity. They are costly, require clinic space and are disrupted by unattended appointments. These issues were exacerbated by necessary adjustments to NHS services during the pandemic.

Situation

The Trust had approximately 4000 patients requiring some level of Post-Covid review following the first wave of Covid. This was a significant challenge magnified by the complex challenges of Covid on the NHS, including the closure of outpatient services and mass staff redeployment. Many of these patients required a supported period of rehabilitation with input from rehabilitation specialists, but often did not require regular hospital visits.

Aspiration

An ‘After Covid’ service and remote care/monitoring app, started in the Trust during the first wave of Covid, provided a viable approach to managing a large number of patients with rehabilitation needs in a responsive, patient-supportive manner.

Support resources could reach significantly more patients, providing rehabilitation in a more appropriate and accessible way. Patients could adjust treatment programmes reactively rather than waiting weeks until their next review, and those unsure what to do could message for advice, receiving a prompt response. The digital app enabled the team to rapidly update and expand the app as understanding grew, e.g. the addition and expansion of brain fog content, and creation of further treatment programs.

Solution and impact

An app was developed to facilitate a novel approach to the rehabilitative journey, with a minimum viable product (MVP) in use from August 2020. The app was produced by various expert health care specialists and provided by Living With Ltd. The app enabled patients to access educational material, work through treatment programmes, track progress with PROMS and message their team for support.

Health care professionals monitor patient outcomes on a live dashboard, as well as track progress, give bespoke advice and select patients who need accelerated input.

Patients were invited by the Trust to be screened for after-Covid needs, and were then referred to the app. One patient could be reviewed weekly in about 3 minutes via the app’s dashboard with RAG rated outcomes, tabulated PROM history and easy access to a range of patient facing tools. This enabled the clinician to track progress and communicate with the patient more regularly than the traditional rehab pathway; offering support, advice or escalating their next face-to-face review.

This resulted in a significant increase in capacity; one physiotherapist could manage a caseload of 100 patients in the equivalent time it would take to see around 10 patients face to face, expanding clinical capacity tenfold without the additional costs of face-to-face appointments.

Functionality

• Clinically-designed programmes for education and symptom tracking (fatigue, brain fog, breathlessness, stress and anxiety)
• Clinically validated ePROMS and additional symptom tracking.
• Self-management tools, fatigue diaries, medication tracking, patient information and secure two-way messaging.
• Registered clinical staff have secure access to the portal via a web browser, to view data and graphical trends.

Capabilities

• By using the smartphone app for ePROMS and patient messaging, the clinical team have a better idea how patients are on a day-to-day basis without having to call or see them face-to-face.
• The team can now triage patients to ensure those with the greatest clinical need are seen promptly and those doing well are not offered unnecessary appointments. This included triage of patients where needed for urgent face-to-face review.

Scope

• Patients were invited to the app by the Trust when they were screened for after-Covid needs.
• The app can be used by patients at home, work, or any location to record timely condition information.

Key learning points

• Implementation of a MVP with regular updates enabled a rapid start to clinical care, whilst allowing time to improve clinical understanding.
• App was planned via virtual meetings; the team could draw on expertise from multiple institutions.
• The need for this app was unique to the Covid climate, however the implementation of an app to support rehabilitation has been successful and provided learning points that can be applied to digital healthcare outside of the pandemic.

Digital equalities

• A small number of patients offered the app did not have a smartphone; relatives could support the app on their phone and the patient continued to utilise the app regularly.
• A carers module for the app has been developed, enabling carers to access and update the app for the patient, as well as sections being translated into different languages.

Key figures and quotes

• One physiotherapist could manage a caseload of 100 patients in the equivalent time it would take to see around 10 patients face to face.
• “As a physiotherapist, I am often limited to the structures of clinic timetables and traditional NHS pathways of care. [Living With] enables you to walk alongside patients in the journey of their rehabilitation, enhancing what you can offer them. You can track their progress and communicate with them regularly; offering support, advice or escalating their next face-to-face review if required. This provides excellent care for patients where they have a real sense of ongoing therapist support.” Hannah Hylton, Highly Specialist Respiratory Physiotherapist, Barts Health NHS Trust.
• ‘’This app has helped us manage the challenge of providing responsive, triaged support to patients recovering from Covid. The flexibility of the platform and ability to change content rapidly has allowed us to provide the best care we can to patients over the pandemic and having seen the advantages we plan to continue to provide this model of care for other conditions moving forwards.’’ Dr Paul Pfeffer, Respiratory Consultant, Barts Health NHS Trust

Key contact

Hannah Hylton — Highly Specialist Respiratory Physiotherapist, Barts Health NHS Trust

h.hylton@nhs.net

Chris Robson, CEO, Living With

chris.robson@livingwith.health