This briefing note examines research and jurisdictional reports on post COVID-19 condition pertaining to: 1) models of care and their reported outcomes; 2) waitlists for post-COVID-19 care; and 3) insurance assessments for post-COVID-19 care. In particular: 

This briefing note is an update of a Science Advisory Table’s (SAT) report on Understanding the Post-COVID-19 Condition (Long COVD) and the Expected Burden for Ontario (Sept 14, 2021). The literature search was limited to sources published from October 1, 2021 to April 2022; however, where applicable, information was included outside of this date range, if it was not present in the previously completed SAT report noted above.

• Most scientific and jurisdictional evidence on post-COVID-19 insurance assessments addressed the coverage and insurability of individuals diagnosed with COVID-19, rather than post-COVID-19 condition. As a result of the limited information on this topic, articles from various non-peer-reviewed sources (e.g., Financial Post, Texas Medical Association) were included.
• No information was identified on all topics of interest for Ontario. Limited information on post-COVID-19 care models from a CADTH report (Sept 2021) was identified for Canada, but no Canadian information on the other topics of interest was identified. 
• The clinical recommendations and/or methodological quality of most of the sources identified are unclear as the Research, Analysis, and Evaluation Branch does not have the expertise to make such assessments; methodological assessments published by other research groups are reported where available.

This section below summarizes scientific evidence and jurisdictional experiences on the assessment and treatment of post-COVID-19 condition.Jurisdictional information is presented from Canada, India, Italy, United Kingdom (UK), and United States (US).

Scientific Evidence

• Models of Care: Two post-COVID care models reported mixed findings on addressing post-COVID condition among patients in the UK and US.
  • Hybrid Care Model: Studies in the US (New York) highlighted hybrid care models that addressed post-COVID-19 condition. Most of the identified hybrid care models used inter/multidisciplinary teams and partnerships (e.g., physiatrist, physical therapist, neuropsychologist, clinical psychologist, pharmacy, social work, welfare support) to facilitate post-COVID rehabilitation. No reported outcomes were identified in these studies. Descriptions of the models’ inter/multidisciplinary teams are noted below. 
    • University of Texas Southwestern Medical Center COVID Recover Program (Dec 2021, US): To help post-COVID-19 patients restore muscle, lung, and brain function, as well as psychological wellbeing, this program uses the principles of multidisciplinary rehabilitation derived from clinical practices for cardiac and pulmonary rehabilitation, rehabilitation of complex medical issues including critical illness myopathy (i.e., disease affecting the muscles that control movement), and the management of persistent symptoms after concussions and mild traumatic brain injuries. Partnerships were developed with autonomic laboratory testing, pulmonology, cardiology, and psychiatry.
    • Centers for Excellence (Oct 2021, US): In addition to comprehensive primary care services, the Centers’ staff include mental health professionals, cardiologists, and pulmonologists. Diagnostic equipment is used for Post-acute Sequelae of COVID-19 (PASC) evaluation and general patient care, include pulmonary function testing, transthoracic echocardiograms, and chest radiography. Furthermore, the Centers can refer to acute hospital facilities as indicated for nephrology, hematology, and other subspecialties depending on a patient’s sequelae.
  • Care Models with Virtual Components: Hybrid care and post-COVID-19 clinic models with virtual components/modalities were identified from the UK and US. The identified studies reported mixed findings on the effectiveness of both care models.
    • Hybrid Care Models with Virtual Components: Three studies in the UK and US noted their models use an inter/multidisciplinary team to deliver treatment through virtual modalities. Mixed findings were reported on their effectiveness to address the post-COVID-19 condition. Noted strengths included streamlined resources, timely access to care, coordinated care, and strategically delegated responsibilities. Virtual modality limitations included difficulty establishing consistent and geographically equitable pathways of referral, as well as digital poverty and illiteracy hindering access to telemedicine appointments. For example:
      • Integrated Rehabilitation Pathway (Jan-Dec 2021, UK): This initiative implemented post-COVID-19 syndrome assessment clinics across England, supporting the medical assessment and rehabilitation of patients. The Pathway uses a three-tier service model, including a Specialist Multidisciplinary Teams (MDT) Service which brings together various disciplines with specialist skill sets to provide targeted virtual interventions such as virtual resources (e.g., Your COVID-19 recovery) to support self-management and virtual rehabilitation COVID-19 groups.
        • Strengths: Resources are directed where most appropriate and those with complex ongoing symptoms are seen by post-COVID specialists who have access to a medical MDT consultant. The tier system delegates responsibilities at each level, giving health care professionals working in general practitioner surgeries and hospitals clarity on which interventions to offer, and when referrals are necessary for post-COVID-19 MDT.
        • Limitations: A significant challenge is achieving consistent and geographically equitable pathways of referral and access across the city.
      • Multidisciplinary Care (Nov 2021, US/UK): A review of a multidisciplinary model that includes the key elements of multidisciplinary care (including physical medicine and rehabilitation, pharmacy, social work and welfare support, and primary care) and emphasizes the importance of achieving equitable provision of care identified the following:
        • Limitations: While telemedicine, which was rapidly adopted during the COVID-19 pandemic, can overcome transportation barriers, digital poverty and illiteracy can hinder access to telemedicine appointments. Hence, where possible, a hybrid model that incorporates both virtual and in-person clinic options are optimal.
    • Post-COVID-19 Clinics with Virtual Components: Three studies in the UK and US reported mixed findings on the effectiveness of specialized post-COVID rehabilitation that were delivered and/or included virtual modalities. A noted strength included improved patient ratings after post-COVID-19 rehabilitation. Virtual modality limitations included higher no-show rates to treatment programs, difficulty using telemedicine, longer wait times due to the need for translators, unintegrated electronic medical records, and patient inaccessibility to the internet and applications.
      • Virtual Rehabilitation Course (Dec 2021, UK): This pilot was a seven-week virtual rehabilitation course for people suffering from post-COVID-19 syndrome offered in October 2020. This course takes a whole-system approach to understanding COVID-19 and post-viral fatigue (PVF) and is delivered by an interdisciplinary team.
        • Strengths: The study examined 149 individuals who enrolled in the “Recovering from COVID” course and completed the EQ-5D-5L (i.e., self-assessed, health related, quality of life questionnaire) to assess health-related quality of life (HRQoL) across five dimensions (i.e., problems with mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Overall, 76 individuals who completed these measures at the end of the rehabilitation course demonstrated significantly improved patient ratings.
      • University of Texas Health San Antonio Program (Dec 2021, US): Adult and pediatric patients, including ethnic minority groups, were evaluated at a university clinic-based rehabilitation medicine outpatient practice and a community safety net clinic. Individuals who demonstrated functional impairments were referred to the virtual home-based COVID-19 physical therapy program for up to 12 weeks.
        • Limitations: The visits to the community safety net clinic demonstrated: higher no-show rates, difficulty using telemedicine, longer wait times due to the need for translators, and the assessments were not integrated into the electronic medical record. Barriers included patient inaccessibility to the internet, inability to download the patient portal, and communication barriers.
• Waitlists: The identified studies noted long waitlists (e.g., seven weeks) for treating post-COVID-19 condition in Italy and the UK. Studies noted the lack of established post-COVID-19 clinics and the lengthy triage care process contributing to long waitlists for care.
  • Limited Post-COVID Clinics (Italy): A research article (Jan 2022) on how Europe is approaching post-COVID-19 indicated that in Italy, no government funded clinics for post-COVID-19 have been established. Some hospitals have follow-up day clinics for patients who have had COVID-19; however, the waiting lists are high.
  • Lengthy Triage Care Process (UK): The Integrated Rehabilitation Pathway noted that the average timeframe from initial referral to receiving the completed screening questionnaire is four weeks. The majority of patients are placed on a waiting list for therapy for an average of seven weeks.
• Insurance Assessments: The identified studies noted post-COVID-19 condition insurance assessment barriers across three population types (low-income, marginalized [e.g., uninsured, undocumented immigrants, homeless, people of colour], and the general population) in India, the UK, and the US. To address these barriers, studies in the US noted the importance of government intervention (i.e., policy and Congress) advocating for the inclusion of post-COVID-19 condition in billing codes. Barriers are noted below:
  • Low-Income (UK/US): A review (Nov 1, 2021) on addressing PASC noted the importance of achieving equitable provision of care, including the implementation of care in low-income and middle-income countries. The review identified the following barriers and interventions:
    • Billing Infrastructure Barriers: In some health care systems, billing infrastructure – including inconsistent insurance reimbursement and billing codes – presents a significant barrier to the follow-up of services.
    • Government Intervention: A US Congressional hearing advocated for billing codes to capture PASC, allowing tracking of needs and services, and incentivizing the provision of services for low-income populations. Furthermore, the review indicated that addressing the barrier of inconsistent insurance reimbursement and billing codes requires changes in policy to reflect the extension of support for acute COVID-19 care to cover PASC.
  • Marginalized (US): A study (Jul 20, 2021) on planning for post-COVID syndrome noted that uninsured, lower-income, and minority patients have higher rates of underlying health conditions and obesity, all of which increase the probability of severe COVID-19 symptoms and long-term complications. Undocumented immigrants, people experiencing homelessness, and other marginalized groups (e.g., people of colour) may experience gaps in health coverage and forego needed care. The study identified the following barriers and interventions:
    • Classification of Health Condition Barriers: The study noted that COVID-19 should not be considered a “pre-existing condition,” and explained that the condition may be more difficult to obtain health coverage.
    • Government Intervention: Substantive policy changes at various levels can alleviate the potential burden of post-COVID-19 syndrome. Congress can enact additional legislation to direct national resources to clinics and community centres for mental health professionals, physical therapists, and primary care clinicians to care for individuals with post-COVID-19 condition.
  • General Population (India): A study (2022) on the impact of COVID-19 on the Indian health insurance sector and post-COVID-19 management identified two COVID-19 health insurance policies, Corona Rakshak and Corona Kavach, that cover medical expenses and the cost of personal protective equipment (PPE) kits, gloves, and masks among others during COVID-19 treatment.
    • Limited Clinical and Financial Information Barrier: Details on COVID-19 prognosis, morbidity, costs, and patient profiles are unavailable, making it difficult for insurance companies to decide who will qualify for COVID-19 treatment coverage. Until more information becomes available about COVID-19 treatments and prognoses, insurers will not have data on patients’ profiles, treatment, and cost.

International Scan

• Waitlists: The identified articles noted long waitlists (e.g., seven to nine months) for treating post-COVID-19 condition in the UK and US. The articles suggest that limited access to treatment and low staffing at post-COVID-19 clinics contribute to long waitlists for care.
  • Limited Access to Treatment (UK): An article (Mar 29, 2022) on addressing the long-term symptoms of COVID-19 identified recent data showing 40% of patients awaiting access to post-COVID services in England for more than three months from an initial assessment.
  • Low Staffing at Clinic (US): An article (Feb 3, 2022) on long-COVID patients and waitlists suggested that long waits are partly due to care centres/clinics only treating people who have a laboratory-confirmed COVID-19 diagnosis with limited staff. For example:
    • Stanford’s Post-Acute COVID-19 Syndrome Clinic: The article explained that each patient is examined by a physician at this clinic, and if necessary, is referred to a specialist. The article noted that while the clinic analyzes five or six new patients each week, it still has a months-long waitlist.
• Insurance Assessments: An article (Sept 28, 2021) on the denial of long-term disability benefits among those affected by post-COVID-19 condition noted that, long-haulers in the US, including those who contracted the virus in the first wave, remain unable to return to work in the same capacity as before they became ill. The article noted three insurance barriers that impact the working age population from recovering from COVID-19 and post-COVID-19 condition:
  • Limited Medical Evidence: Insurers frequently deny disability claims due to insufficient medical evidence, for example, the lack of a positive COVID-19 test, especially in the earlier waves of the pandemic, when testing was not widely available.
  • Asymptomatic COVID-19 Symptoms: Symptoms such as fatigue, brain fog, and depression are “invisible” or subjective symptoms, making it difficult for long-haulers to “prove” they are sick. Insurance companies use this ambiguity to deny or reject claims/coverage.
  • Unreliable Insurance Policies: If the symptoms experienced by a long-hauler meets the definition of a disability, as set out in an insurance policy, and there is medical evidence to support this, payouts should be guaranteed. However, it is noted that insurance companies continue to deny post-COVID disability claims.

Canadian Scan

• Models of Care: A CADTH report (Sept 24, 2021) on an overview of post-COVID-19 condition noted three models of post-COVID care, including the strengths and limitations of each.
  • Primary Care Provider (PCP) Model: The PCP model carries out standardized assessments of symptoms, refers to and coordinates with specialists based on symptoms and needs, manages medications and comorbidities, and provides self-management support.
    • Strengths: PCPs are familiar with their rostered patients’ health and preferences. People affected by post-COVID-19 may feel more comfortable with their regular PCPs than going to a new clinic with unfamiliar care providers.
    • Limitations: PCPs may feel uncomfortable treating post-COVID-19 condition due to a lack of training or resources, especially for complex cases. Further, coordination and continuity of care across multiple specialists may be complex, which could lead to fragmented care (e.g., contradictory advice).
  • Hybrid Care Model: The hybrid model incorporates specialized clinics and primary care based on a person’s needs. For instance: 1) people with mild and typical symptoms being treated in primary care; 2) people who are hospitalized and/or have moderately complex needs being treated by community therapy teams; and 3) people with symptoms at three or more months and/or have complex needs being treated by a specialized clinic.
    • Strengths: The hybrid model may be more feasible and accessible than treating all cases of post-COVID-19 condition in specialized clinics. It also allows for people with complex needs to receive the intensive care that would be more difficult to receive in a primary care-based model.
    • Limitations: People with complex needs living far from specialized clinics may not be able to access needed care. Moreover, this model requires effective coordination of care across multiple providers.
  • Post-COVID-19 Clinics with Virtual/Online Care Components:
    • Specialized Care Model: These clinics have dedicated groups of health care providers, often multidisciplinary groups, to treat post-COVID-19 condition. These clinics have been set up in multiple countries, including Canada.
      • Strengths: This model may be an efficient way to develop expertise on treating post-COVID-19, as providers see a higher number of people affected by the condition and can learn the effectiveness of different treatment strategies. Further, coordination and continuity of care between multiple care providers may be smoother in dedicated teams.
      • Limitations: There is the potential for long waiting lists, difficulties training providers, accessibility issues for those who live far from clinics, and uncertainty about cost-effectiveness.
      • Virtual/Online Care Model: This model uses technologies, such as virtual visits, to help easily access multiple specialists, especially for people experiencing fatigue who may find it difficult to make multiple clinic visits.

Ontario Scan

• No information identified.

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following member of the Network provided an evidence synthesis product that was used to develop this Evidence Synthesis Briefing Note:

• Canadian Agency for Drugs and Technologies in Health (CADTH). (March 2022). Clinical Classification and Interventions for Post–COVID-19 Condition: A Scoping Review (Draft).
• Vu, T., & McGill, S. C. (2021). An Overview of Post–COVID-19 Condition (Long COVID). Canadian Journal of Health Technologies, 1(9).