Advertisement

The Johns Hopkins Post-Acute COVID-19 Team (PACT): A Multidisciplinary, Collaborative, Ambulatory Framework Supporting COVID-19 Survivors

Published:January 11, 2021DOI:https://doi.org/10.1016/j.amjmed.2020.12.009

      Introduction

      The Coronavirus Disease 2019 (COVID-19) pandemic has rapidly shifted health care needs and delivery internationally, with about 1 in 5 people with COVID-19 requiring hospitalization, including in the intensive care unit (ICU), at pandemic onset.

      World Health Organization. Media statement: knowing the risks for COVID-19. Available at: https://www.who.int/indonesia/news/detail/08-03-2020-knowing-the-risk-for-covid-19, Accessed September 1, 2020.

      ICU survivors in general are at risk for impairments in mental, cognitive, and physical health, collectively known as post-intensive care syndrome;
      • Hosey MM
      • Needham DM
      Survivorship after COVID-19 ICU stay.
      ,
      • Needham DM
      • Davidson J
      • Cohen H
      • et al.
      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.
      similar challenges have been described post acute hospitalization (post-hospital syndrome).
      • Krumholz HM
      Post-hospital syndrome–an acquired, transient condition of generalized risk.
      Risks may be higher among COVID-19 survivors.
      • Hosey MM
      • Needham DM
      Survivorship after COVID-19 ICU stay.
      Given recognized acute pulmonary complications associated with COVID-19, pulmonary sequelae are a prominent concern,
      • Fraser E
      Long term respiratory complications of covid-19.
      • Spagnolo P
      • Balestro E
      • Aliberti S
      • et al.
      Pulmonary fibrosis secondary to COVID-19: a call to arms.
      • Raghu G
      • Wilson KC
      COVID-19 interstitial pneumonia: monitoring the clinical course in survivors.
      although COVID-19 has demonstrated an ability to impact multiple organ systems.
      • Gupta A
      • Madhavan MV
      • Sehgal K
      • et al.
      Extrapulmonary manifestations of COVID-19.
      Further, emerging scientific data describe a potential for lingering symptoms post-COVID-19 infection even among those who do not require hospitalization.
      • Yelin D
      • Margalit I
      • Yahav D
      • et al.
      Long COVID-19-it's not over until [e-pub ahead of print]?.
      ,
      • Tenforde MW
      Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network – United States, March-June 2020.
      The etiology and physiologic correlates of potential persistent symptoms require sufficient resource infrastructure for comprehensive supportive care and further insight into the natural history of COVID-19.
      We provide a description of early need recognition, resource redistribution, operational experience, and refined multidisciplinary clinic structure to support COVID-19 survivors: the Johns Hopkins Post-Acute COVID-19 Team (JH PACT).

      Available System Resources

      The first COVID-19 admission to the Johns Hopkins Hospital was reported in March 2020. Swiftly rising inpatient admissions drew heavily on inpatient resources, and Pulmonary and Critical Care Medicine (PCCM) providers were immersed in frontline care. Infection control efforts reduced availability of post-acute and ambulatory rehabilitation centers; provider resources were reallocated to augment in-hospital rehabilitation programs and support safe discharges. Non-COVID-19 research, outside of select clinical trials, was largely halted, and thus, clinical effort was expanded for many faculty members who traditionally serve in dual clinical and research roles.

      Anticipated Ambulatory Needs

      Potential ambulatory needs of COVID-19 survivors were extrapolated from other viral respiratory diseases, including severe acute respiratory syndrome (SARS) coronavirus, Middle East respiratory syndrome (MERS) coronavirus, and influenza;
      • Das KM
      • Lee EY
      • Singh R
      • et al.
      Follow-up chest radiographic findings in patients with MERS-CoV after recovery.
      • Lee SH
      • Shin H-S
      • Park HY
      • et al.
      Depression as a mediator of chronic fatigue and post-traumatic stress symptoms in Middle East respiratory syndrome survivors.
      • Lam MH-B
      • Wing Y-K
      • Yu MW-M
      • et al.
      Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up.
      • Zhang P
      • Li J
      • Liu H
      • et al.
      Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study.
      • Ahmed H
      • Patel K
      • Greenwood DC
      • et al.
      Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization of ICU admission; a systematic review and meta-analysis.
      data are notably limited. Patients developing acute respiratory distress syndrome (ARDS) were anticipated to be at risk for long-term respiratory complications,
      • Herridge MS
      • Cheung AM
      • Tansey CM
      • et al.
      One-year outcomes in survivors of the acute respiratory distress syndrome.
      and there were emerging reports of potential complications in multiple organ systems.
      • Gupta A
      • Madhavan MV
      • Sehgal K
      • et al.
      Extrapulmonary manifestations of COVID-19.
      Importantly, survivors requiring hospitalization, especially in the ICU, were anticipated to be at risk for markedly impaired strength/physical ability, worsened mood/anxiety/post-traumatic stress disorder symptoms, cognitive impairment, and increased use of health care resources.
      • Needham DM
      • Davidson J
      • Cohen H
      • et al.
      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.
      ,
      • Krumholz HM
      Post-hospital syndrome–an acquired, transient condition of generalized risk.
      ,
      • Ruhl AP
      • Huang M
      • Colantuoni E
      • et al.
      Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study.
      ,
      • Ruhl AP
      • Huang M
      • Colantuoni E
      • et al.
      Healthcare resource use and costs in long-term survivors of acute respiratory distress syndrome: a 5-year longitudinal cohort study.
      Importantly, aspects of the COVID-19 pandemic, including visitor restrictions, potential limitations on essential rehabilitation services, higher levels and longer duration of sedation during critical illness, and longer lengths of stay had the potential to further complicate recovery.
      • Hosey MM
      • Needham DM
      Survivorship after COVID-19 ICU stay.
      Hence, a multidisciplinary approach was needed to address the needs of a rising population of COVID-19 survivors.
      A rapidly developed solution was conceived to: 1) support the recovery of patients in the ambulatory setting, 2) prevent the additional burden of predicted readmissions on an already strained inpatient system, 3) understand the natural history of disease, and 4) funnel therapeutic opportunities to patients. A key consideration was the provision of ongoing care to uninsured and underinsured patients and collaboration with language translation services, given the disproportionate burden of COVID-19 in traditionally under-resourced populations.
      • Macias Gil R
      • Marcelin JR
      • Zuniga-Blanco B
      • et al.
      COVID-19 pandemic: disparate health impact on the Hispanic/Latinx population in the United States.
      • Chowkwanyun M
      • Reed AL
      Racial health disparities and Covid-19 – caution and context.
      • Raifman MA
      • Raifman JR
      Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income.

      Opportunity

      The procurement of a physical location for care delivery, which typically requires substantial justification within a formal business plan, can be a barrier to rapid implementation. Coordination for a multidisciplinary model requires harmonization of multiple providers and services in time and space. Rapid adoption of telemedicine on a broad scale, necessitated by infection control measures, overcame these barriers. Specifically, telemedicine allowed for appointments to be scheduled at the mutual convenience of patients and each of the multidisciplinary providers, circumventing the need for schedule alignment at a time of high clinical demand.

      Conception and Design

      The overall workflow targeted anticipated survivor streams, categorized by initial severity of illness and resultant health care utilization (Figure 1). Given predicted patient needs, the PCCM Division partnered with the Department of Physical Medicine and Rehabilitation (PM&R) to provide core assessments and direct services. Patients discharged from the ICU were eligible for JH PACT-ICU, prompting referral to both Pulmonary and PM&R (Figure 2). Patients who did not require ICU care for at least 48 hours could be referred to Pulmonary or PM&R (JH PACT-Base), depending on identified needs at the time of discharge. Patients who remained ambulatory but were identified by their primary care or another physician to have residual symptoms at 4-6 weeks post diagnosis were eligible for referral to JH PACT-Base. As an additional service, the Johns Hopkins Homecare Group Remote Patient Monitoring (RPM) team collaborated with the Office of Telemedicine and the PCCM Division to launch the COVID-19 RPM program for post-hospital discharges meeting specific, predefined criteria. Pulse oximeters were deployed at the time of discharge or later delivered to the patient's home. Oxygen saturation, heart rate, and symptoms were transmitted to dedicated clinical staff twice a day for 14 days, with the option of renewal if symptoms or vital sign abnormalities persisted. Clinical staff responded to alerts, contacted patients for abnormalities or missed check-in, and alerted a physician on call, staffed by Johns Hopkins PCCM via a dedicated pager line.
      Figure 1
      Figure 1Schematic of anticipated COVID-19 survivor streams. Simplified depiction of anticipated COVID-19 survivor courses captured for care in the JH PACT clinic. 1) Patients recovering from intensive care unit (ICU) admission for COVID-19. 2) Patient recovering from hospitalization for COVID-19. 3) Patients who remained in an ambulatory care setting but experienced prolonged, nonresolving symptoms post COVID-19 infection.
      Figure 2
      Figure 2Johns Hopkins Post-Acute COVID-19 Team (JH PACT) referral criteria for COVID-19+ hospital discharges. Patients requiring 48 hours or more in the intensive care unit (ICU) were eligible for referral to the JH PACT-ICU, consisting of evaluation by both the Physical Medicine and Rehabilitation (PM&R) and Pulmonary services. Patients requiring hospitalization but no hospital stay were referred to JH PM&R PACT-Base with additional Homecare referral for home physical therapy/occupational therapy services if necessary. Patient then assessed for ongoing pulmonary needs or qualification for remote patient monitoring, and could receive co-referral or independent referral to JH Pulmonary PACT-Base. Patients could also be individually referred to Remote Patient Monitoring without JH PM&R or Pulmonary PACT referral (not pictured). Patients who did not require hospitalization but had ongoing symptoms at 4-6 weeks post diagnosis could qualify for referral to either of the JH PACT-Base teams.
      Partnerships with key subspecialties (Figure 3) were formed early via grassroots communication with providers willing and interested in receiving referrals from JH PACT. This allowed for streamlined and timely referrals, established key providers for attendance at weekly multidisciplinary meetings, and allowed for development of a shared understanding of the challenges faced by COVID-19 survivors. The JH Pulmonary-PACT team further partnered with Radiology for dedicated, weekly rounds to review chest imaging, revealing typical and atypical findings and enhancing precision of clinical recommendations. Colleagues with a subspecialty focus in interstitial lung disease were invited to attend these rounds, and consulted ad hoc for complicated cases as recommended by the British Thoracic Society.

      British Thoracic Society. COVID-19: information for the respiratory community. Available at: https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/. Accessed September 15, 2020.

      ,

      George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia|Thorax. Available at: https://thorax.bmj.com/content/early/2020/08/24/thoraxjnl-2020-215314. Accessed September 15, 2020.

      Pharmacists completed medication reconciliation and provided recommendations via phone prior to clinic visits.
      • Najafzadeh M
      • Schnipper JL
      • Shrank WH
      • Kymes S
      • Brennan TA
      • Choudhry NK
      Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.
      Homecare teams provided nursing and essential therapy services (physical therapy, occupational therapy, speech-language pathology) to homebound patients. Co-management and communication with primary care physicians were prioritized. For patients without primary care, networks were developed with academic and community providers to facilitate establishment of care. Hospital social workers and a community health worker were critical components in light of disproportionate representation among vulnerable populations.
      Figure 3
      Figure 3Key services and staff of the Johns Hopkins Post-Acute COVID-19 Team (JH PACT) clinic. Patient flow and contributing staff members represented above. Green indicates participation in weekly multidisciplinary clinic meetings. Primary care is featured prominently as an essential collaboration and line of communication. Psychology consisted of partners in both neuropsychology and rehabilitation psychology. CHW = community health worker; PMR = Physical Medicine and Rehabilitation; RN = registered nurse.
      Concerns were initially raised about access to telemedicine among vulnerable populations and those at risk of marginalization. To address this, research and administrative support staff were trained and re-deployed in telemedicine support to proactively contact patients, assist with software download prior to clinic, and support connection on the clinic day. Nursing staff introduced new patients to the clinic structure and assisted in navigating follow-up testing, which often required repeat COVID-19 test coordination. Clinic workflows and resources (eg, subspecialty referral contacts) were stored in a central, secure drive accessible only by health care team members.

      Dissemination

      A referral form (Appendix) was disseminated via a collated Department of Medicine protocol for COVID-19+ discharges. Hospital and ambulatory referrals were accepted via a centralized e-mail monitored by a referral coordinator and supported by nursing and physician review for appropriate placement in JH PACT-ICU or PACT-Base. PCCM colleagues were engaged to refer patients at the time of ICU downgrade, and clinic information was disseminated among hospitalist staff and medicine residents. Johns Hopkins Health System partners across the state were engaged in providing care under variably adopted portions of the framework, including RPM, offering an enhanced structure for post-COVID-19 care at participating hospitals.
      The first JH PACT patient was seen on April 7, 2020, representing one of the earliest dedicated COVID-19 survivorship clinics in the nation. As of November 11, 2020, 265 unique patients have been seen in 530 visits by the JH PM&R or Pulmonary PACT. New patient JH Pulmonary PACT visits have generated an average of 1 (range 0-3) additional subspecialty referral per patient over the preceding month.

      Ongoing Mission

      The JH PACT clinic exemplifies the Johns Hopkins tripartite mission: patient care, research, and education. To optimize clinical care and ensure rigor and uniformity of evaluation across the dedicated staff in the clinic, we adopted standardized clinic templates. Assessments were standardized consistent with the Core Outcome Measurement Set for acute respiratory failure
      • Needham DM
      • Sepulveda KA
      • Dinglas VD
      • et al.
      Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study.
      (improvelto.com); Society of Critical Care Medicine Consensus Statement;
      • Mikkelsen ME
      • Still M
      • Anderson BJ
      • et al.
      Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.
      and COVID-19-specific recommendations by the European Respiratory Society/American Thoracic Society.
      • Spruit MA
      • Holland AE
      • Singh SJ
      • Tonia T
      • Wilson KC
      • Troosters T
      COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- and American Thoracic Society-coordinated international task force.
      Symptoms are assessed via validated questionnaires preclinic by telemedicine coordinators or via secure messaging and patient self-completion with incorporation into the medical record (Table).
      • Needham DM
      • Sepulveda KA
      • Dinglas VD
      • et al.
      Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study.
      ,
      • Zigmond AS
      • Snaith RP
      The hospital anxiety and depression scale.
      • Kroenke K
      • Spitzer RL
      • Williams JB
      The PHQ-9: validity of a brief depression severity measure.
      • Spitzer RL
      • Kroenke K
      • Williams JBW
      • Löwe B
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      • Hosey MM
      • Leoutsakos J-MS
      • Li X
      • et al.
      Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6).
      • Haley SM
      • Coster WJ
      • Andres PL
      • et al.
      Activity outcome measurement for postacute care.

      HealthMeasures. PROMIS. Available at: https://www.healthmeasures.net/explore-measurement-systems/promis. Accessed November 30, 2020.

      • Leidy NK
      • Rennard SI
      • Schmier J
      • et al.
      The breathlessness, cough, and sputum scale: the development of empirically based guidelines for interpretation.
      • Bestall J
      • Paul E
      • Garrod R
      • et al.
      Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.

      The Multi-Ethnic Study of Atherosclerosis (MESA). MESA overview and protocol. Available at: https://www.mesa-nhlbi.org/aboutMESAOverviewProtocol.aspx. Accessed November 30, 2020.

      • Fitzpatrick AL
      • Rapp SR
      • Luchsinger J
      • et al.
      Sociodemographic correlates of cognition in the Multi-Ethnic Study of Atherosclerosis (MESA).
      • Weintraub S
      • Besser L
      • Dodge HH
      • et al.
      Version 3 of the Alzheimer Disease Centers’ neuropsychological test battery in the Uniform Data Set (UDS).
      This approach allows for standardization of care, collation of clinical experiences, and description of the natural history of COVID-19 in the JH PACT population. Laboratory, pulmonary function testing, and imaging follow-up are obtained based on individual indications, though most consistent with British Thoracic Society recommendations.

      British Thoracic Society. COVID-19: information for the respiratory community. Available at: https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/. Accessed September 15, 2020.

      ,

      George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia|Thorax. Available at: https://thorax.bmj.com/content/early/2020/08/24/thoraxjnl-2020-215314. Accessed September 15, 2020.

      Research partnerships have proven synergistic in provision of clinical resources; we are pursuing additional funding to comprehensively characterize outcomes within this population. Further, trainees routinely rotate through the clinic, providing opportunities for clinical education and research. Importantly, trainees voice appreciation for the ability to see the postdischarge trajectory of patients they cared for in the hospital.
      TableStandardized Functional and Symptomatic Assessments
      DomainInstrumentSpecialtyVisit Type
      BaseICU
      Health-related quality of lifeEQ5DPulmonaryx
      PROMISƗPM&Rxx
      Mental health
       DepressionPHQ9
      Instruments differ from the core outcome measurement set for clinical research in acute respiratory failure survivors (see improvelto.com) due to licensing and cost associated with the Hospital Anxiety and Depression Scale (HADS).28 Telephone cognitive battery: Cognitive assessments are derived from the Multi-Ethnic Study of Atherosclerosis (MESA);36 battery has been successfully implemented in diverse patient populations and is available in both English and Spanish language translations.37,38
      Pulmonary and PM&Rxx
       AnxietyGAD7
      Instruments differ from the core outcome measurement set for clinical research in acute respiratory failure survivors (see improvelto.com) due to licensing and cost associated with the Hospital Anxiety and Depression Scale (HADS).28 Telephone cognitive battery: Cognitive assessments are derived from the Multi-Ethnic Study of Atherosclerosis (MESA);36 battery has been successfully implemented in diverse patient populations and is available in both English and Spanish language translations.37,38
      Pulmonary and PM&Rxx
       PTSDIES-6Pulmonaryx
      CognitionTelephone cognitive batteryPulmonaryxx
      PainEQ5D pain questionPulmonaryxx
      Physical functionAM-PAC surgical short formPM&Rxx
      Respiratory symptomsBCSS, mMRCPulmonaryxx
      Instruments are assessed at new and follow-up visits.
      AM-PAC = Activity Measure for Post-Acute Care;
      • Haley SM
      • Coster WJ
      • Andres PL
      • et al.
      Activity outcome measurement for postacute care.
      BCSS = Breathlessness Cough and Sputum Scale;
      • Leidy NK
      • Rennard SI
      • Schmier J
      • et al.
      The breathlessness, cough, and sputum scale: the development of empirically based guidelines for interpretation.
      EQ5D = EuroQol 5D;
      • Needham DM
      • Sepulveda KA
      • Dinglas VD
      • et al.
      Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study.
      GAD-7 = General Anxiety Disorder-7
      • Spitzer RL
      • Kroenke K
      • Williams JBW
      • Löwe B
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      ; ICU = intensive care unit; IES-6 = Impact of Event Scale-6
      • Hosey MM
      • Leoutsakos J-MS
      • Li X
      • et al.
      Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6).
      ; mMRC = modified Medical Research Council;
      • Bestall J
      • Paul E
      • Garrod R
      • et al.
      Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.
      MOCA = Montreal Cognitive Assessment
      • Needham DM
      • Sepulveda KA
      • Dinglas VD
      • et al.
      Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study.
      ; PHQ-9 = Patient Health Questionnaire-9
      • Kroenke K
      • Spitzer RL
      • Williams JB
      The PHQ-9: validity of a brief depression severity measure.
      ; PM&R = Department of Physical Medicine and Rehabilitation; PROMIS = Patient-Reported Outcomes Measurement Information System.

      HealthMeasures. PROMIS. Available at: https://www.healthmeasures.net/explore-measurement-systems/promis. Accessed November 30, 2020.

      low asterisk Instruments differ from the core outcome measurement set for clinical research in acute respiratory failure survivors (see improvelto.com) due to licensing and cost associated with the Hospital Anxiety and Depression Scale (HADS).
      • Zigmond AS
      • Snaith RP
      The hospital anxiety and depression scale.
      Telephone cognitive battery: Cognitive assessments are derived from the Multi-Ethnic Study of Atherosclerosis (MESA);

      The Multi-Ethnic Study of Atherosclerosis (MESA). MESA overview and protocol. Available at: https://www.mesa-nhlbi.org/aboutMESAOverviewProtocol.aspx. Accessed November 30, 2020.

      battery has been successfully implemented in diverse patient populations and is available in both English and Spanish language translations.
      • Fitzpatrick AL
      • Rapp SR
      • Luchsinger J
      • et al.
      Sociodemographic correlates of cognition in the Multi-Ethnic Study of Atherosclerosis (MESA).
      ,
      • Weintraub S
      • Besser L
      • Dodge HH
      • et al.
      Version 3 of the Alzheimer Disease Centers’ neuropsychological test battery in the Uniform Data Set (UDS).

      Conclusions

      Approaches to support COVID-19 survivors vary across institutions and continents.

      George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia|Thorax. Available at: https://thorax.bmj.com/content/early/2020/08/24/thoraxjnl-2020-215314. Accessed September 15, 2020.

      ,

      Geberhiwot T, Madathil S, Gautam N. After care of survivors of COVID-19—challenges and a call to action. JAMA Health Forum. Available at: https://jamanetwork.com/channels/health-forum/fullarticle/2770074. Accessed January 12, 2021.

      • O'Brien H
      • Tracey MJ
      • Ottewill C
      • et al.
      An integrated multidisciplinary model of COVID-19 recovery care [e-pub ahead of print].

      Mount Sinai Health System. Center for post-COVID care. Available at: https://www.mountsinai.org/about/covid19/center-post-covid-care. Accessed September 15, 2020.

      Penn Medicine News. What happens after COVID-19? Penn Medicine's new post-COVID recovery clinic offers support. Available at: https://www.pennmedicine.org/news/news-blog/2020/june/what-happens-after-covid19-penn-medicine. Accessed September 15, 2020.

      We have described a successful multidisciplinary approach grounded in a post-intensive care syndrome/post-hospital syndrome framework.
      • Needham DM
      • Davidson J
      • Cohen H
      • et al.
      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.
      ,
      • Krumholz HM
      Post-hospital syndrome–an acquired, transient condition of generalized risk.
      The rapid adoption of telemedicine, including ambulatory pulse oximetry monitoring, provided a unique opportunity to overcome traditional barriers and address disparities in care provision. While the American Thoracic Society and European Respiratory Society retain equipoise in recommendations for follow-up in a dedicated multidisciplinary clinic for post-COVID-19 care,
      • Bai C
      • Chotirmall SH
      • Rello J
      • et al.
      Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020).
      the present and future benefits to patients, the health system, and knowledge advancements through the JH PACT clinic are tangible. The comprehensive approach described here has proved successful in providing an enduring support network for COVID-19 survivors locally, alongside the provision of data that will inform our understanding of the natural history of COVID-19 in those requiring hospital-level care or with persistent symptoms in the ambulatory setting.

      Acknowledgments

      Administrative support: Laurie Neisser, MBA; Samuel Boadu, MPH; Andrew Byrd, BFin; Stephen Sisson, MD; Joyce Maygers, DNP, RN
      Advisory Board: Christian Merlo, MD, MPH; Dale Needham, MD, PhD; Megan Hosey, PhD; Peiting Lien, DPT, NCS; Jyotsna Supnekar, OTR, CHT, CLT; Amanda Gallagher, MA CCC-SLP; Kelly Daley, PT, MBA; Preeti Raghavan, MD
      Clinical Support: Arun Venkatesan, MD, PhD; Esther Oh, MD, PhD; Ashraf Fawzy, MD MPH; Alba Azola, MD; Jennifer Zanni, PT, DScPT, CCS; Laurie Fitz, PT; Norma Wright, RN; Denise Wagner, DT, PT; Jessica Engle, DO; Martin Bishop, PharmD, MS, BCACP; Jenna Blunt, PharmD, BCPS; Caitlin Down-Green, PharmD, BCPS, BCACP; Traci Grucz, PharmD; Erin VanMeter, PharmD, BCACP; Badia Faddoul, MS, RN
      Hospital System MD Partners: Carmen Salvaterra, MD; David Holden, MD; Steven Kariya, MD

      Appendix

      References

      1. World Health Organization. Media statement: knowing the risks for COVID-19. Available at: https://www.who.int/indonesia/news/detail/08-03-2020-knowing-the-risk-for-covid-19, Accessed September 1, 2020.

        • Hosey MM
        • Needham DM
        Survivorship after COVID-19 ICU stay.
        Nat Rev Dis Primers. 2020; 6: 60
        • Needham DM
        • Davidson J
        • Cohen H
        • et al.
        Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.
        Crit Care Med. 2012; 40: 502-509
        • Krumholz HM
        Post-hospital syndrome–an acquired, transient condition of generalized risk.
        N Engl J Med. 2013; 368: 100-102
        • Fraser E
        Long term respiratory complications of covid-19.
        BMJ. 2020; 370: m3001
        • Spagnolo P
        • Balestro E
        • Aliberti S
        • et al.
        Pulmonary fibrosis secondary to COVID-19: a call to arms.
        Lancet Respir Med. 2020; 8: 750-752
        • Raghu G
        • Wilson KC
        COVID-19 interstitial pneumonia: monitoring the clinical course in survivors.
        Lancet Respir Med. 2020; 8: 839-842
        • Gupta A
        • Madhavan MV
        • Sehgal K
        • et al.
        Extrapulmonary manifestations of COVID-19.
        Nat Med. 2020; 26: 1017-1032
        • Yelin D
        • Margalit I
        • Yahav D
        • et al.
        Long COVID-19-it's not over until [e-pub ahead of print]?.
        Clin Microbiol Infect. 2020 Dec 11; https://doi.org/10.1016/j.cmi.2020.12.001
        • Tenforde MW
        Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network – United States, March-June 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 993-998
        • Das KM
        • Lee EY
        • Singh R
        • et al.
        Follow-up chest radiographic findings in patients with MERS-CoV after recovery.
        Indian J Radiol Imaging. 2017; 27: 342-349
        • Lee SH
        • Shin H-S
        • Park HY
        • et al.
        Depression as a mediator of chronic fatigue and post-traumatic stress symptoms in Middle East respiratory syndrome survivors.
        Psychiatry Investig. 2019; 16: 59-64
        • Lam MH-B
        • Wing Y-K
        • Yu MW-M
        • et al.
        Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up.
        Arch Intern Med. 2009; 169: 2142-2147
        • Zhang P
        • Li J
        • Liu H
        • et al.
        Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study.
        Bone Res. 2020; 8: 8
        • Ahmed H
        • Patel K
        • Greenwood DC
        • et al.
        Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization of ICU admission; a systematic review and meta-analysis.
        J Rehabil Med. 2020; 52: jrm00063
        • Herridge MS
        • Cheung AM
        • Tansey CM
        • et al.
        One-year outcomes in survivors of the acute respiratory distress syndrome.
        N Engl J Med. 2003; 348: 683-693
        • Ruhl AP
        • Huang M
        • Colantuoni E
        • et al.
        Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study.
        Intensive Care Med. 2017; 43: 980-991
        • Ruhl AP
        • Huang M
        • Colantuoni E
        • et al.
        Healthcare resource use and costs in long-term survivors of acute respiratory distress syndrome: a 5-year longitudinal cohort study.
        Crit Care Med. 2017; 45: 196-204
        • Macias Gil R
        • Marcelin JR
        • Zuniga-Blanco B
        • et al.
        COVID-19 pandemic: disparate health impact on the Hispanic/Latinx population in the United States.
        J Infect Dis. 2020; 222: 1592-1595
        • Chowkwanyun M
        • Reed AL
        Racial health disparities and Covid-19 – caution and context.
        N Engl J Med. 2020; 383: 201-203
        • Raifman MA
        • Raifman JR
        Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income.
        Am J Prev Med. 2020; 59: 137-139
      2. British Thoracic Society. COVID-19: information for the respiratory community. Available at: https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/. Accessed September 15, 2020.

      3. George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia|Thorax. Available at: https://thorax.bmj.com/content/early/2020/08/24/thoraxjnl-2020-215314. Accessed September 15, 2020.

        • Najafzadeh M
        • Schnipper JL
        • Shrank WH
        • Kymes S
        • Brennan TA
        • Choudhry NK
        Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.
        Am J Manag Care. 2016; 22: 654-661
        • Needham DM
        • Sepulveda KA
        • Dinglas VD
        • et al.
        Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study.
        Am J Respir Crit Care Med. 2017; 196: 1122-1130
        • Mikkelsen ME
        • Still M
        • Anderson BJ
        • et al.
        Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.
        Crit Care Med. 2020; 48: 1670-1679
        • Spruit MA
        • Holland AE
        • Singh SJ
        • Tonia T
        • Wilson KC
        • Troosters T
        COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- and American Thoracic Society-coordinated international task force.
        Eur Respir J. 2020; 562002197
        • Zigmond AS
        • Snaith RP
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Spitzer RL
        • Kroenke K
        • Williams JBW
        • Löwe B
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Hosey MM
        • Leoutsakos J-MS
        • Li X
        • et al.
        Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6).
        Crit Care. 2019; 23: 276
        • Haley SM
        • Coster WJ
        • Andres PL
        • et al.
        Activity outcome measurement for postacute care.
        Med Care. 2004; 42: I49-I61
      4. HealthMeasures. PROMIS. Available at: https://www.healthmeasures.net/explore-measurement-systems/promis. Accessed November 30, 2020.

        • Leidy NK
        • Rennard SI
        • Schmier J
        • et al.
        The breathlessness, cough, and sputum scale: the development of empirically based guidelines for interpretation.
        Chest. 2003; 124: 2182-2191
        • Bestall J
        • Paul E
        • Garrod R
        • et al.
        Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.
        Thorax. 1999; 54: 581-586
      5. The Multi-Ethnic Study of Atherosclerosis (MESA). MESA overview and protocol. Available at: https://www.mesa-nhlbi.org/aboutMESAOverviewProtocol.aspx. Accessed November 30, 2020.

        • Fitzpatrick AL
        • Rapp SR
        • Luchsinger J
        • et al.
        Sociodemographic correlates of cognition in the Multi-Ethnic Study of Atherosclerosis (MESA).
        Am J Geriatr Psychiatry. 2015; 23: 684-697
        • Weintraub S
        • Besser L
        • Dodge HH
        • et al.
        Version 3 of the Alzheimer Disease Centers’ neuropsychological test battery in the Uniform Data Set (UDS).
        Alzheimer Dis Assoc Disord. 2018; 32: 10-17
      6. Geberhiwot T, Madathil S, Gautam N. After care of survivors of COVID-19—challenges and a call to action. JAMA Health Forum. Available at: https://jamanetwork.com/channels/health-forum/fullarticle/2770074. Accessed January 12, 2021.

        • O'Brien H
        • Tracey MJ
        • Ottewill C
        • et al.
        An integrated multidisciplinary model of COVID-19 recovery care [e-pub ahead of print].
        Ir J Med Sci. 2020; : 1-8https://doi.org/10.1007/s11845-020-02354-9
      7. Mount Sinai Health System. Center for post-COVID care. Available at: https://www.mountsinai.org/about/covid19/center-post-covid-care. Accessed September 15, 2020.

      8. Penn Medicine News. What happens after COVID-19? Penn Medicine's new post-COVID recovery clinic offers support. Available at: https://www.pennmedicine.org/news/news-blog/2020/june/what-happens-after-covid19-penn-medicine. Accessed September 15, 2020.

        • Bai C
        • Chotirmall SH
        • Rello J
        • et al.
        Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020).
        Eur Respir Rev. 2020; 29200287