Development of an integrated rehabilitation pathway for individuals recovering from COVID-19 in the community

J Rehabil Med. 2020 Aug 24;52(8):jrm00089. doi: 10.2340/16501977-2727.


Objective: COVID-19 is a multisystem illness that has considerable long-term physical, psychological, cognitive, social and vocational sequelae in survivors. Given the scale of this burden and lockdown measures in most countries, there is a need for an integrated rehabilitation pathway using a tele-medicine approach to screen and manage these sequelae in a systematic and efficient way.

Methods: A multidisciplinary team of professionals in the UK developed a comprehensive pragmatic telephone screening tool, the COVID-19 Yorkshire Rehabilitation Screen (C19-YRS), and an integrated rehabilitation pathway, which spans the acute hospital trust, community trust and primary care service within the National Health Service (NHS) service model.

Results: The C19-YRS telephone screening tool, developed previously, was used to screen symptoms and grade their severity. Referral criteria thresholds were applied to the output of C19-YRS to inform the decision-making process in the rehabilitation pathway. A dedicated multidisciplinary COVID-19 rehabilitation team is the core troubleshooting forum for managing complex cases with needs spanning multiple domains of the health condition.

Conclusion: The authors recommend that health services dealing with the COVID-19 pandemic adopt a comprehensive telephone screening system and an integrated rehabilitation pathway to manage the large number of survivors in a timely and effective manner and to enable the provision of targeted interventions.

Keywords: C19-YRS; hospital; long-term; telephone screening tool.

MeSH terms

  • Betacoronavirus*
  • COVID-19
  • Community Health Services / methods
  • Community Health Services / organization & administration*
  • Coronavirus Infections / rehabilitation*
  • Critical Pathways / organization & administration*
  • Delivery of Health Care / methods
  • Delivery of Health Care / organization & administration*
  • Humans
  • Pandemics
  • Patient Care Team / organization & administration*
  • Pneumonia, Viral / rehabilitation*
  • Referral and Consultation / organization & administration
  • SARS-CoV-2
  • State Medicine / organization & administration
  • Survivors
  • Telemedicine / methods
  • Telemedicine / organization & administration*
  • United Kingdom