Post Covid Syndrome Referral Pathway - Information for GPs

This page contains: information for clinicians on what Post-COVID-19 syndrome is, national guidance, e-learning modules and resources for clinicians and patients.

What is Post-COVID-19 Syndrome?

What is Post Covid?

Acute COVID-19 is defined as signs and symptoms of infection for up to the first 4 weeks.

Ongoing symptomatic COVID-19 is defined as signs and symptoms of infection from 4–12 weeks.

Post-COVID-19 syndrome is defined as signs and symptoms of infection consistent with COVID-19 lasting longer than 12 weeks

 

What to look for:

Symptoms include but are not restricted to:

  • Generalized symptoms
    • Fatigue
    • Fever
    • Pain
  • Respiratory
    • Breathlessness
    • Cough
  • Cardiovascular
    • Chest tightness.
    • Chest pain.
    • Palpitations.
  • Neurological
    • Cognitive impairment such as loss of concentration and memory issues
    • Headache
    • Sleep disturbance
    • Peripheral neuropathy including paraesthesia and numbness
    • Dizziness
    • Delirium (in older people)
  • Gastrointestinal 
    • Abdominal pain
    • Nausea
    • Diarrhoea
    • Anorexia and reduced appetite (in older people)
  • Musculoskeletal
    • Joint and muscle pains
  • Psychological 
    • Depression and anxiety
  • Ear, nose, and throat
    • Tinnitus
    • Ear ache
    • Sore throat
    • Loss of taste and/or smell
  • Dermatological
    • Skin rashes

 

NICE, June 2021

Emerging Findings (July 2021)

  • There is growing evidence of the long term effects of COVID 19 in those who were admitted to hospital with COVID 19.
  • Studies also suggest that mental health problems may be common.
  • Four disease phenotypes have been identified with varying severities of physical, mental and cognitive health impairment.
  • Elevated rates of multi organ dysfunction with post discharge adverse events including: diabetes, major cardiovascular events and respiratory disease as well as increased risk of readmissions.
  • Risk was greater for those who were less than 70 years old and from ethnic minority groups.
  • Long term organ impairment, including impaired lung function at six months after infection, and persistent inflammation in the heart.
  • Occurrence in people who were never admitted to hospital and, in some cases, where initial symptoms were relatively mild.
  • The prevalence of Post COVID was higher in people aged 35 69, women, those from more deprived groups and amongst people with pre-existing health conditions.
  • Health and social care workers had a higher prevalence.
  • Some children and young people also appear to be affected with prolonged symptoms such as insomnia, respiratory problems, fatigue, muscle pain, and concentration difficulties, which were also seen in those with asymptomatic acute infection.
  • Care should be stratified, and management should be joined up across specialties within primary, community and secondary care and requires a multi professional workforce.

 

How to refer to NW London Post-Covid hospital and community services

How to refer

The referral form has been updated and embedded in both System One and EMIS. Please access it through these platforms.

Please note: GP/Clinicians are required to manually complete the fields highlighted in green on the form. All other fields will pull the information through from the patient’s records and auto-populate on the form,

 

The referral pathway

The following diagram illustrates the referral pathway [Download a version here]

Post Covid Pathway referral graphic ver 3.png

Who is suitable for this referral pathway?

The service is for all patients over 18 within NWL ICS believed to have post-Covid syndrome who:

  • require further clinical assessment and investigations related to suspected post-Covid syndrome

AND / OR

  • who need a programme of physical and/or psychological therapy


Exclusion Criteria

The Triage Team will unfortunately have to reject referrals in the circumstances as listed below:

  • Symptoms which are acute or life-threatening
  • Symptoms where alternative causes have not been ruled out
  • Where a standard face-to-face assessment – set out in this form as per London guidance - has not been completed by the Primary Care referrer
  • Patients under 18
  • Patients not registered to a GP practice within NWL
  • Patients with symptoms less than 12 weeks after Covid infection
  • Patients whose primary need is treatment of chronic conditions that existed prior to Covid infection (e.g. patients with a diagnosis of chronic fatigue syndrome/ME or fibromyalgia predating Covid infection) - in this case, please refer to the appropriate specialty
  • Patients with a single need requiring investigation or treatment - in this case, please refer to the appropriate specialty
  • Patients with symptoms resulting from Covid-19 vaccination

How to refer to IAPT services

Information to be added shortly

Services for Post-COVID-19 Syndrome in North West London

North West London Post-COVID-19 Syndrome Single Point of Access

This is the NWL post-Covid triage service, which will review the referral form, and if accepted will refer the patient on to either:

  • their local Post-COVID-19 syndrome assessment clinic (PCAC) if further medical investigations are required, who will assess the patient and refer the patient onwards for treatment
  • their local Post-COVID-19 syndrome Multidisciplinary therapy team who will assess the patient and deliver/coordinate a programme of physical and/or psychological therapy

 

Post-COVID-19 Syndrome Assessment Clinics

These clinics provide specialist assessment for patients with confirmed or suspected Post-COVID-19 syndrome. The clinic model is described below.

 

PCAC delivery model diagram.png

 

Post-COVID-19 Syndrome Community Multi Disciplinary Services

Improved access to Psychological Therapies Services

Should you wish to refer your patient directly to Improving Access to Psychological Therapy (IAPT) services there are several referral routes that can be followed:

  • Where there is diagnostic uncertainty as to whether ongoing physical symptoms are related to Covid 19, a pre-existing or new condition we would advise clarifying this prior to referral for psychological treatment
    • Refer to Acute Assessment clinic for diagnostic workup (this will be an assessment by a psychologist)
    • Acute Assessment clinic will agree care plan and refer for psychological treatment if indicated
  • Multiple needs are identified and community rehabilitation programmes may be indicated e.g. pulmonary, cardiac or neuro rehab and/or several services likely to be involved in treatment alongside IAPT
    • Refer to post Covid community MDT in order to assess rehab needs and coordinate treatment options. Psychologist embedded in MDT will assess and advise.
    • The community MDT can refer to IAPT directly if needed but will do so in the context of an agreed care plan and can monitor all services involved with patient’s care.
  • Straightforward presentation of anxiety and/or depression associated with some post Covid symptoms (single dominant need).
    • Direct referral to IAPT service as usual (referral form embedded for use in Systm1)

 

When to refer:

Referral indications for IAPT (common mental health problems, ongoing Covid symptoms and impact of Covid):

  • New or exacerbation of pre-existing anxiety / depression / relationship problems / adjustment difficulties
  • Anxiety and/or depression associated with the impact of Covid (e.g. bereavement, furlough, redundancy, lockdown restrictions, becoming a carer)
  • Anxiety and/or depression associated with ongoing Covid symptoms (e.g. fatigue, poor concentration, breathlessness)
    • No requirement for a positive Covid-19 test during acute phase of Covid
    • No requirement for a confirmed diagnosis of post-Covid syndrome or to wait 12 weeks after acute Covid infection
  • PTSD or other anxiety presentations associated with ITU admission and/or other medical interventions during management of acute

 

Times when a direct referral to IAPT services is unlikely to be appropriate:

  • Ongoing symptomatic Covid-19 symptoms requiring acute assessment or intervention (e.g. oxygen desaturation on exercise, severe lung disease, cardiac chest pain)
  • Diagnostic uncertainty as to whether ongoing symptoms are related to Covid-19, a pre-existing or new condition (e.g. requiring referral to post-Covid syndrome Acute Assessment clinics)
  • Where community rehabilitation programmes are indicated e.g. pulmonary, cardiac or neuro rehab or when referring to the post-Covid community MDT to co-ordinate rehab options
  • Diagnosis of severe and enduring mental health conditions or high risk/ significant self-harm requiring psychiatric review or multidisciplinary mental health interventions
  • Complex drug and/or alcohol use, or eating disorder, requiring specialist services
  • Immediately following a bereavement or traumatic event

 

Appointments offered:

IAPT services offer telephone, video and face to face appointments. In addition, some treatments are available using computerised CBT. The medium of consultation will depend on clinical need and patient choice. For face to face appointments infection control guidance will be followed.

Referral process:

GPs and primary care staff can refer to IAPT services using embedded referral forms within eRS

IAPT services also accept self-referrals and patients with post-Covid syndrome can use this route. However, we would recommend health professionals make a referral for any complex presentations to ensure IAPT clinicians have access to all relevant information.

Contact details for IAPT services are shown below:

Name of service

Geographical referral criteria

Service website

Main service telephone number and email address

Clinician overseeing Post-Covid work

Back on Track

Registered with Hammersmith & Fulham GP

www.backontrack.nhs.uk

0300 123 1156

wlm-tr.backontrack@nhs.net

Lucy Squire, CBT therapist

Hounslow IAPT

Registered with a Hounslow GP

www.hounslowiapt.nhs.uk

0300 123 1739

houccg.hounslowiapt@nhs.net

Connie Poon, Long-term conditions lead

Ealing IAPT

Registered with an Ealing GP

www.ealingiapt.nhs.uk

0203 313 5660

ealing.iapt@nhs.net

Alison Hopkins,

Long-term conditions lead

Westminster Talking Therapies Service

Registered with a GP who is part of Central London CCG.

www.talkingtherapies.cnwl.nhs.uk/westminster

030 3333 0000

westminster.iapt@nhs.net

Nebahate Ejupi,

Long-term conditions lead

Community Living Well –Talking Therapies

Registered with a Kensington and Chelsea GP or QPP area of Westminster – GP is part of West London CCG

www.communitylivingwell.co.uk

020 3317 4200

cnw-tr.clw@nhs.net

Nebahate Ejupi,

Long-term conditions lead

 

Post-COVID-19 syndrome coding

Enhanced Service Required Codes

The codes required are based on the requirements for identification and referral within the Enhanced Service 2021/22.

Diagnosis codes: Ongoing symptomatic COVID-19 (4-12 weeks after infection); Post-COVID-19 syndrome (12 weeks plus)

  • 1325171000000109 Acute COVID-19 infection
  • 840539006 COVID-19 diagnosis (where not previously recorded)
  • 1325181000000106 Ongoing symptomatic COVID-19
  • 1325161000000102 Post-COVID-19 syndrome

Signposting and referral codes: Signposting to Your COVID Recovery when signposting patients to the publicly available Your COVID Recovery website (phase 1); Referral to post-COVID assessment clinic

  • 1325041000000104 Referral to Your COVID Recovery/ Living With Covid rehabilitation platforms
  • 1325021000000106 Signposting to Your COVID Recovery
  • 1325031000000108 Referral to post-COVID assessment clinic

Resolution code: Post-COVID-19 syndrome resolved: to be used at the patient and clinician discretion when all symptoms are fully resolved and there is no evidence of persisting organ impairment or if an alternative diagnosis has been made to account for all symptoms (code not available at time of publishing)

Coding of key clinical information in letters from post-COVID assessment clinics or other specialist services is also required

Assessment (optional)

  • 1325061000000103 Assessment using Newcastle post-COVID syndrome Follow-up Screening Questionnaire
  • 1325081000000107 Assessment using C19-YRS (COVID-19 Yorkshire Rehabilitation Screening) tool Primary Care Minimum Data Set (as at April 2021)

For ongoing symptomatic COVID-19 or post-COVID-19 syndrome in primary care

Data Category

Term

SNOMED CT code

COVID-19 diagnosis (where not previously recorded)

COVID-19

840539006 | Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder) |

 

Ongoing symptomatic COVID-19/post-COVID-19 syndrome diagnosis

Ongoing symptomatic COVID-19

1325181000000106 | Ongoing symptomatic disease caused by severe acute respiratory syndrome coronavirus 2 (disorder) |

 

Post-COVID-19 syndrome

1325161000000102 | Post-COVID-19 syndrome (disorder)

Red flag symptoms/signs

Peripheral blood oxygen saturation on room air at rest

866661000000106 | Peripheral blood oxygen saturation on room air at rest (observable entity) |

Peripheral blood oxygen saturation on room air on exertion

866681000000102 | Peripheral blood oxygen saturation on room air on exertion (observable entity) |

Respiratory disease

50043002 | Disorder of respiratory system (disorder) |

Cardiac chest pain

426396005 | Cardiac chest pain (finding) |

 

Diagnostics/investigations

Blood test

396550006 | Blood test (procedure) |

Assessment using 1-minute sit-to-stand test

1321911000000103 | Assessment using 1-minute sit-to-stand test (procedure) |

Lying blood pressure reading

163033001 | Lying blood pressure (observable entity)

Standing blood pressure reading

163034007 | Standing blood pressure (observable entity) |

Chest X-ray

399208008 | Plain chest X-ray (procedure) |

 

Management/referrals

Referral to paediatric service

306128002 | Referral to pediatric service (procedure) |

 

Mental health support

 

Referral to IAPT programme

380201000000109 | Referral to improving access to psychological therapies programme (procedure)

Referral to liaison psychiatry service

306136006 | Referral to liaison psychiatry service (procedure) |

Referral to mental health team

390866009 | Referral to mental health team (procedure) |

 

Specialist referral

 

Referral to respiratory medicine service

306114008 | Referral to respiratory medicine service (procedure) |

Referral to pulmonary rehabilitation

24461000000105 | Referral to pulmonary rehabilitation (procedure) |

Referral to cardiology service

183519002 | Referral to cardiology service (procedure) |

Referral to cardiac rehabilitation programme

704050007 | Referral to cardiac rehabilitation program (procedure) |

 

Referral to pain management service

306109009 | Referral to pain management service (procedure) |

Referral to gastroenterology service

183523005 | Referral to gastroenterology service (procedure) |

Referral to endocrinology service

306118006 | Referral to endocrinology service (procedure) |

Referral to neurology service

183521007 | Referral to neurology service (procedure) |

Referral to rheumatology service

306127007 | Referral to rheumatology service (procedure) |

Referral to dermatology service

183518005 | Referral to dermatology service (procedure) |

Referral to ENT service

183544005 | Referral to ear, nose and throat service (procedure) |

Referral to infectious diseases service

306124000 | Referral to infectious diseases service (procedure) |

 

Self-management/supported self-management

 

Signposting to Your COVID Recovery

1325021000000106 | Signposting to Your COVID Recovery (procedure) |

Provision of support for self-management

733810001 | Provision of support for self-management (regime/therapy)

Advised to self care

315241000000102 | Advised to self care (situation) |

Primary care management

737470001| Primary care management (procedure) |

Referral to social prescribing service

871731000000106 | Referral to social prescribing service (procedure) |

Community care management

781901000000106 | Community care management (procedure) |

 

Post-COVID assessment clinic

Referral to post-COVID assessment clinic

1325031000000108 | Referral to post-COVID assessment clinic (procedure) |

 

Outcome measure score (where available)

 

EQ-5D-5L - EuroQol five dimension five level index

736534008 | EuroQol five dimension five level index value (observable entity) |

EQ-VAS - EuroQol visual analogue score

736535009 | EuroQol visual analogue score (observable entity) |

  

Get in Contact

For more information about the post-covid referral pathway or any queries, please email clcht.nwlpcspa@nhs.net