29 June 2023

Long COVID team “trailblazing future rehabilitation modelling”

Earlier this month the Sussex Health and Care long COVID team was invited to Birmingham to speak at the National Long COVID Forum. They were able to share their learning as an Integrated Care System hosted team, which is considered to be a unique approach within the national modelling of long COVID services. The feedback from the conference delegates identified Sussex as leading a trailblazing approach for future rehabilitation modelling.

The team originally formed in 2020 following the distribution of national funding, with the trust collaborating with Sussex Community NHS Foundation Trust to provide a single approach to care across Sussex. Patients can be referred from primary and secondary care, following an initial assessment which promotes patient-centred and needs-based care. There are then four pathways for patients to follow; breathlessness, psychology, vocational rehab and fatigue.

We spoke to Karen Poole, Long COVID Co-Clinical Lead for Sussex Health and Care, to find out more.

“It has taken a lot of work to get here, negotiating to find the best care model and putting a lot of trust in each other to ensure we provide the best service possible,” says Karen.

“One of the aspects that makes this innovative is that within the pathways there is a stratified approach to care,” she explains. “This draws on a needs-based rather than diagnostic approach to care, where the patient’s own story and experience helps us to understand the level of clinical risk. We recognise that even though patients might be experiencing similar symptoms, the severity of these could differ greatly. Allowing the risk of the patient to be understood, helps us to tailor the rehabilitation offer for our patients. We offer supportive self-management with our care navigators, group-based programmes for those who need more support and one to one treatment for those with more complex needs.

‘This is the last year that national funding specifically for long COVID care, and support for people living with long COVID, will need to be provided within our existing community services. However the groundwork we have put in and learning gained from the last three years means we now have a really effective model to use going forward that can also be transferred to other services.”

The service is particularly efficient through its use of a workforce modelling approach that enables it to be responsive in flexing staff across the long covid pathway as demand fluctuated.

“By working this way, we have been able to meet the six-week national target from referral to assessment,” explains Karen. “We look where the bottleneck is in the process and that is where we direct the majority of our resources in order to resolve it as efficiently as possible.

“Obviously meeting the targets is great, but the real indication of the success of the services is the feedback we are getting from patients. 83% were extremely satisfied with the support they have received from us and made comments such as, ‘I feel heard and understood, which has helped me to realise my self-worth’, which make all the work worthwhile.”

Find out more about post COVID support services.