By Christopher Cheney
An extensive patient evaluation process is one of the distinguishing characteristics of a new long COVID clinic at Altamonte Springs, Florida-based AdventHealth.
There are coronavirus “long haulers” among COVID-19 patients who have experienced mild, moderate, and severe infections. In one study of COVID-19 patients hospitalized with severe acute respiratory infection, functional impairment was found in 53.8% of patients four months after hospital discharge. Long COVID symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, and fatigue.
AdventHealth opened the health system’s Post-COVID Clinic in March. Determining whether patients have long COVID and characterizing their symptomology requires an exhaustive evaluation process, says Dwayne Gordon, MD, an AdventHealth Medical Group internal medicine physician and lead physician of the Post-COVID Clinic, which is based at AdventHealth Orlando.
“These patients are universally difficult to diagnosis. You have to determine whether a patient has long COVID, which is not a crystal-clear condition. With long COVID, a patient can present in numerous ways. It can be weakness. It can be forgetfulness. It can be shortness of breath. It can be a chronic cough. It can be anxiety, depression, or insomnia. A key question is: Did your symptoms start before or after you had COVID? So, delineating the timeline is part of diagnosing long COVID. We try to determine whether someone has had onset of new symptoms or significant worsening of chronic symptoms after COVID. Some people had anxiety before they contracted COVID, but it can get significantly worse after COVID,” he said.
To qualify for care at the Post-COVID Clinic, a patient must have long COVID symptoms for at least three months.
The patient evaluation process at the clinic is conducted in two phases—an intake telephone call with a registered nurse followed by a 90-minute in-person evaluation, Gordon says. “We conduct an intake interview before patients come to the clinic. That intake includes getting basic information about when the patient was diagnosed with COVID, their initial symptoms, and their current symptoms.”
If the intake interview indicates a patient probably has long COVID, an in-person visit is scheduled, he says.
“For example, a patient could have been infected with COVID in 2020. We would ask about presenting symptoms, we would ask whether they were vaccinated before infection, we would ask whether the patient was hospitalized, we would ask whether they required oxygen, we would ask whether they required inpatient rehabilitation, and we would ask whether they required home oxygen. Then we would talk about their current symptoms. We also have a couple of forms for patients to fill out—the GAD-7 for general anxiety disorder screening and the PHQ-9 for depression screening. We get a SLUMS score to see whether there is evidence of memory loss or dementia. We screen all of our patients to see whether they have sleep-related disorders such as insomnia and obstructive sleep apnea. We go over their past medical history in detail, including medications and past surgeries. We also talk about their social history. Are they currently employed? Are they unemployed because of long COVID symptoms?”
The in-person evaluation also includes a complete physical therapy screening.
The evaluation process helps to establish a care plan, Gordon says. “After patients get evaluated by physical therapy, behavioral health, and myself, then we establish a comprehensive care plan. Many patients require physical therapy for generalized weakness. They might require occupational therapy because they are dropping things or are unable to do activities of daily living such as bathing, cooking, and dressing.”
Staffing, referrals, and research
It is crucial for long COVID clinics to have multidisciplinary care teams, Gordon says. “When it comes to being multidisciplinary, we have a primary care physician, a behavioral health team, and a physical therapist. Patients get a comprehensive evaluation by all three of those disciplines. We also partner with subspecialists who we can make referrals to—we have AdventHealth pulmonologists and cardiologists. We also have a registered nurse, who helps with social work, and a practice manager.”
Having a multidisciplinary clinic is a key to success, he says. “One thing we have learned, and we talk about regularly is the involvement of multiple departments—everything from marketing to research to behavioral health to primary care to physical therapy and beyond. We have all of these departments represented at a weekly meeting because long COVID is complex. You have to have a social worker, you have to have a nurse, you have to have medical assistants, you have to have doctors, you have to have your physical therapists. If you do not have those components, then you are going to fall short because these patients take a significant amount of time and resources.”
The Post-COVID Clinic is conducting research to increase the understanding of long COVID with the AdventHealth Transitional Research Institute. One study that is already underway is examining how long COVID affects patients with diabetes. Researchers will observe changes to organs, such as the heart, lungs, liver, kidney, pancreas, and spleen following a COVID diagnosis in people with and without diabetes to determine how COVID and any related inflammation may impact organ function in diabetics.
Behavioral health dimension
Behavioral health services are an important element of the Post-COVID Clinic, Gordon says. “Some people have significant anxiety and depression. They not only require counseling but also may require medications. They can get counseling from us, then we transition them to outpatient counseling for modalities such as cognitive behavioral therapy, where they get help coping with the stressors of long COVID.”
Insomnia is common among coronavirus long haulers, he says. “There can be multiple reasons for insomnia, including sleep disorders such as sleep apnea. They might get two or three hours of sleep per night. For these patients, we work on a medication regimen, and we work on sleep hygiene counseling that includes handouts for best practices to get a restful night.”
Insomnia contributes to brain fog among long COVID patients, Gordon says. “It is well known that if you have insomnia, then your ability to think clearly is going to be impaired.”
Forgetfulness and dementia are being observed in relatively young coronavirus long haulers, he says. “The majority of patients who are scoring for memory loss and dementia in the SLUMS evaluation are between 30 and 55 years old. It is highly unusual to see the scores that we are seeing in that age range. It is uncommon to do a SLUMS evaluation for people in this age range—this evaluation is typically done in the elderly population because that is when you tend to see forgetfulness.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.