Collaboration Care Pathway post-Covid Nijmegen

Corona patients who continue to have complaints long after the corona infection will receive a personal supervisor (case manager) from today who will guide them in the care process. It is part of the new aftercare in the Nijmegen region by general practitioners, paramedics and hospitals. Until now, people with long-term complaints after corona were seen at the aftercare clinics of the Radboudumc and Canisius Wilhelmina Hospital (CWZ).

Long (long-term) COVID, also called Post COVID, has caused many problems in recent years, including long-term staff absences. The Radboudumc and CWZ hospitals, NEO Huisartsenzorg and the physiotherapists of CFN have worked together in Nijmegen to reorganize care for these patients.

The patient will now receive care close to home, but supported by hospitals where necessary. A newly hired professional plays a central role in this process: the case manager. 'This is usually someone with a paramedical background, such as a physiotherapist or occupational therapist. This case manager maps out all of the patient's complaints through an extensive intake interview', says Joris Botman, physiotherapist and chairman of CFN. 'Then he or she determines which care providers need to be called in and ensures that the care is initiated and coordinated.'

People with Post-COVID were seen for two years at the aftercare clinics of the Pulmonary Diseases departments of Radboudumc and CWZ. In addition to providing explanations and recovery advice, patients were already being referred from the aftercare clinics of both hospitals to, among others, the physiotherapist, occupational therapist, speech therapist, dietitian, and psychologist; almost always primary care professionals close to home.

'Patients have a great need for recognition and explanation, but certainly also for guidance during recovery in which healthcare providers collaborate effectively,' says CWZ pulmonologist Jürgen Hölters. 'This requires innovative care; not provided by a medical specialist, but closer to the patient, primarily focused on paramedical expertise.' General practitioner Léon van Groenendael endorses this. “With the arrival of the case manager, the general practitioner is relieved of the burden of coordinating this aftercare, and collaboration between healthcare professionals is ensured.”

The aftercare clinics of Radboudumc and CWZ were the forerunner, the post-COVID care pathway is the sustainable solution. 'We actively transfer the knowledge gained from the aftercare clinic to the case managers and general practitioners', says Radboudumc pulmonologist Bram van den Borst. 'Of course, we as pulmonologists from the two hospitals remain available for the analysis of unexplained lung complaints after COVID-19. Radboudumc also continues to conduct scientific research into the post-COVID syndrome.'

The trial with this new care will start from 1 June 2022 in Nijmegen for a period of one year and will be financed by the health insurers VGZ and CZ. If successful, it could possibly serve as a national example. With the project financing via the VEZN funds received from VGZ and CZ, the Coöperatie Fysiotherapeuten Nijmegen (CFN) started as the main applicant and the project managers took over the implementation from the team of the Health Innovation Labs. All this in collaboration with the program council (representation from the Radboudumc, CWZ, NEO and CFN). The further monitoring and development of the project will be done with the program council. Alfons Olde Loohuis and Nanny Smits from C-support are involved in this development.