Occupational Therapy in Postacute Care for Survivors of COVID-19: Research Gaps We Need to Fill

At the time of this writing, more than 33 million Americans had been diagnosed with coronavirus disease 2019 (COVID-19; Centers for Disease Control and Prevention [CDC], 2021a). The COVID-19 Simulator Consortium has projected that despite the administration of vaccines, COVID-19 diagnoses will reach nearly 34 million by October 11, 2021 (MGH Institute for Technology Assessment, 2021), which the CDC estimates will result in a subsequent 2,500 to 9,300 hospitalizations per day (CDC, 2021b). As a result of disease complications or comorbidities, 60% to 88% of hospitalized COVID-19 patients have significant functional limitations, including self-care, motor, cognitive, and feeding deficits (Roberts et al., 2021), as well as activity-related fatigue (Halpin et al., 2021). Although these limitations resolve for some patients at the end of infection (Ceravolo, Arienti, et al., 2020), early reports indicate that these functional limitations persist well beyond the infection and posthospitalization periods and that an average of 46% of hospitalized COVID-19 patients will require postacute care (PAC) rehabilitation to overcome them (Ceravolo, Arienti, et al., 2020; Ferraro et al., 2021; Halpin et al., 2021; F. Negrini et al., 2021; Pincherle et al., 2020; Roberts et al., 2021; Wang et al., 2020).

As critically important members of PAC teams, occupational therapy practitioners must continue to play an important role in speeding patients’ recovery, optimizing their health and functional outcomes, facilitating discharge to appropriate PAC, and decreasing the risk of hospital readmission (Ferraro et al., 2021; Keeney, 2020; Pan American Health Organization [PAHO], 2020; Roberts et al., 2021; Simpson & Robinson, 2020). Because of the frequency of functional limitations in COVID-19 patients, the World Health Organization (WHO), PAHO, and Cochrane Rehabilitation REH-COVER (COVID-19 Evidence-based Response) have identified PAC rehabilitation as an essential component of health care planning and treatment and advised policymakers and health care planners to develop PAC rehabilitation preparedness plans to meet the needs of COVID-19 survivors (Ceravolo, de Sire, et al., 2020; PAHO, 2020; WHO, 2020).

Yet, the road map for how occupational therapists and other rehabilitation providers should deliver PAC rehabilitation—and for which patients—is far from established. Several challenges are complicating access to and the process of rehabilitation for COVID-19 survivors. Some health systems are using PAC facilities to offload COVID-19 patients from overwhelmed acute care hospitals, thus reducing rehabilitation beds (Gitkind et al., 2020; Keeney, 2020) and resulting in potentially hasty discharge before patients are truly ready for home (Sheehy, 2020). In other settings, rehabilitation interventions have been stalled by infection control policies (Spruit et al., 2020). Moreover, recent reports indicate that many health systems and facilities are underresourced to provide PAC rehabilitation (Gitkind et al., 2020; Korupolu et al., 2020), such that the usual continuum of PAC rehabilitation varies substantially across the United States (Keeney, 2020; Kim et al., 2020).

Occupational therapy practitioners and researchers can play a significant role in addressing two critically important issues in PAC rehabilitation. First, we must better understand factors that influence the type of PAC rehabilitation a survivor of COVID-19 will receive. Studies from before the COVID-19 pandemic demonstrated that key sociodemographic (e.g., marital status), health (e.g., comorbidity burden, functional status), and facility (e.g., hospital location) variables predicted PAC discharge destination in hospitalized patients (Hong et al., 2019; Kinney et al., 2021; Malcolm et al., 2021). However, COVID-19 survivors have rehabilitation needs related to several high-risk complications (e.g., acute respiratory distress syndrome, post–intensive care syndrome; Murk et al., 2021) that were not seen in such frequency and severity in prepandemic PAC populations. Thus, we must determine unique patient- and facility-level factors that influence whether and where a hospitalized COVID-19 patient receives PAC occupational therapy services. Doing so will inform occupational therapy practitioners and health systems about which patients are most likely to require certain types of PAC rehabilitation and may reveal the need for expanding the workforce and its preparedness.

Second, we must examine how wide variations in the delivery of PAC occupational therapy have affected important outcomes for survivors of COVID-19. Recent reports have described disruptions in the health care system that may affect rehabilitation access, utilization, and outcomes: Some overwhelmed hospitals are offloading patients to inpatient PAC, and some patients are prematurely discharged home without PAC (Ferraro et al., 2021; Gitkind et al., 2020; Keeney, 2020; Korupolu et al., 2020; S. Negrini et al., 2020; Sheehy, 2020). Given these disruptions in acute care and PAC for COVID-19 survivors, there is a high likelihood that some patients are not being discharged to the appropriate level of PAC rehabilitation, thus increasing their risk for poor outcomes such as fewer days living in the community, hospital readmission, higher mortality, and limitations in basic and instrumental activities of daily living (Bowles et al., 2021; Hong et al., 2019; Malcolm et al., 2019; Middleton, Downer, et al., 2018; Middleton, Graham, et al., 2018; Ottenbacher et al., 2014; Zhu et al., 2020). Documenting variations in these and other outcomes by PAC discharge setting is essential to understanding how disruptions in usual PAC occupational therapy and rehabilitation are affecting COVID-19 survivors and will help guide treatment and discharge practices that optimize outcomes.

To be sure, numerous accounts have detailed the creative and rapidly adaptive ways occupational therapy practitioners have provided PAC rehabilitation through telehealth and other virtual means. Clearly, much of our profession has applied a strong can-do attitude to modifying approaches to meet the rehabilitation needs of COVID-19 survivors. Now is the time to also apply that attitude to research examining the effects of modifications in PAC rehabilitation and issues of reduced access and disrupted continua of care on people hospitalized with COVID-19. The effects of COVID-19 on PAC will be studied for the next several years, but questions about which patients receive PAC, at which types of facilities, and to what effect (outcomes) require more immediate answers.

These questions align with the recently published COVID-19 Rehabilitation Research Framework (CRRF), which presents research priorities conceived through a joint effort of Cochrane Rehabilitation and the WHO Rehabilitation Program (S. Negrini et al., 2021). The CRRF lays out COVID-related rehabilitation research priorities in two parts: (1) scope of inquiry and (2) rehabilitation research areas (e.g., topics) and associated questions. Table 1 displays the CRRF priorities and ways occupational therapy researchers might contribute to each priority. The most recent rapid living systematic review by Cochrane Rehabilitation (de Sire et al., 2021), which applied the CRRF in reviewing COVID-19 rehabilitation studies published up to the end of 2020, noted that the level of evidence of research addressing the rehabilitation needs of COVID-19 survivors had increased; however, they also found that most studies still were case reports or series and that high-quality studies on rehabilitation efficacy and long-term monitoring had yet to emerge. Importantly, only 11 (20%) of the 54 studies assessed patient status or patient outcomes at the activity level (using, e.g., the Barthel Index, SF–36, or FIM^®).

Taken together, the state of existing research on rehabilitation related to COVID-19 suggests an opportunity for occupational therapy researchers to fill important gaps regarding the quality of studies and the need for activity and participation assessments and outcomes for COVID-19 survivors. We must endeavor to examine these questions with some urgency. Fortunately, deidentified electronic health record (EHR) data can provide rich information to examine PAC occupational therapy utilization and outcomes for survivors of COVID-19 at the health system level or, more broadly, the national level. Using EHR and other data sources, occupational therapy practitioners and researchers can help build the evidence base to support and guide PAC rehabilitation for COVID-19 survivors and perhaps for survivors of future pandemics.