Alexandra Rendely is a physical medicine and rehabilitation physician at the University Health Network’s Toronto Rehabilitation Institute. Anjali Bhayana is a family physician and hospitalist in geriatric rehabilitation at the University Health Network’s Toronto Rehabiltiation Institute. Seema Marwaha is an internal medicine physician and editor-in-chief of healthydebate.ca.
Physicians and patients have both had to learn on the fly about what it means to really “recover” from COVID-19.
There have been more than 319,000 COVID-19 cases in Ontario, with more than 16,000 cases requiring hospitalization; about a third of those patients have required an admission to the intensive care unit (ICU). While some do recover without complications, the rest can be categorized into three main groups: those with severe disease who require intensive care, those with moderate disease who become hospitalized and those with a milder course. Any one of these patients can end up with profound and prolonged conditions including fatigue, “brain fog,” pain and breathlessness. There are also “long-haulers,” who comprise an estimated 10 to 20 per cent of recovered patients and for whom symptoms last longer than six months.
Rehabilitation is essential for helping patients who are no longer infectious return to their old self. This can take a long time with severe COVID-19 cases, because patients are on a ventilator for longer than the average ICU patient, causing a lot of muscle wasting and deconditioning. But it is crucial, especially because the coronavirus can attack more than just the lungs – it can affect the heart, liver, kidneys, gut and brain, as well.
Yet, many Canadians labelled as “recovered” are not currently receiving adequate rehabilitation and community support upon their discharge from hospital. Unlike in the U.K., where the National Health Service (NHS) is scheduled to open more than 80 post-COVID-19 multidisciplinary specialty clinics, Canada has only seven such in-person clinics, with just two in the country’s most populous province treating long-haulers. There appears to be no immediate plans to expand access.
More resources are needed to help our post-COVID-19 patients recover – especially among populations that have already been disproportionately affected.
It is no secret that racialized individuals, the elderly and those with a lower socioeconomic status face higher risks associated with COVID-19. Racialized persons make up 77 per cent of COVID-19 cases in Toronto and Ontario’s Peel region. And while the disease is more severe in older adults, the first large study in Canada of 1,000 hospitalized patients also showed that work-force aged adults under 50 accounted for 20 per cent of hospitalizations, with a third needing the ICU. More than half of hospitalizations have involved those from lower-income neighbourhoods.
These communities now also face unequal recovery resources, doubling down on the unjust impact of the virus. In Peel, for example, there are significantly fewer ministry-funded rehabilitation beds and less funding for home care services per capita than other regions in Ontario. Without adequate resources, people are being discharged with high care needs such as breathing and feeding tubes or long-term disabilities, forcing families to fill gaps in care or diminishing the likelihood of successful rehabilitation.
We need increased access to multidisciplinary rehabilitation programs, be it inpatient or outpatient, with guidance from rehabilitation physicians, specialists and therapists. We need better home care supports and greater access to community therapists after discharge from hospital – that is, publicly funded physiotherapy and occupational therapies for all adults. We also need a rehabilitation strategy for our homeless population, in light of recent outbreaks in shelters. As the province plans to transition to a model of care that will require more coordination and integration regardless of geographic location, the value of rehabilitation in this pandemic must not be lost.
A standardized pathway for COVID-19 rehabilitation must be instituted across our province, in every region. This should include equitable and rapid access to rehabilitation, timely and reliable home care, and multi-language virtual therapy support for discharged patients. And this should happen as soon as possible, as more infectious COVID-19 variants are here.
The individual consequences of suboptimal recovery from COVID-19 are substantial. But the societal consequences are equally as profound and lasting; there will be spiralling inequity and economic fallout if our work force aged long-hauler patients are unable to recover.
To fight this, we need to understand that strategic planning during a pandemic goes beyond emergency and hospital care. Those bearing the brunt of this pandemic should not have to also bear the brunt of enduring disability from it. Rehabilitation, after all, shouldn’t be seen as a privilege – it is a fundamental part of health care for everyone.
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