COVID-19 Positive Care Pathways

Information for GPs about the COVID-19 Positive Care Pathways program.

What is the pathway?

The COVID-19 Positive Care Pathways program provides clinical care, monitoring and support for all people who test positive for COVID-19 in the Monash Health catchment. The program ensures clients who are at risk of deteriorating are identified early and are transitioned to higher levels of care.

The program is delivered by Monash Health alongside community partners, Central Bayside Community Health Services (CBCHS). The South East Public Health Unit (SEPHU) are involved in patient allocation and consent at the beginning of the patient journey and in clearance from isolation and discharge at the end of the patient journey. This function is also performed for Peninsula Health and Alfred Health, who run their own local pathways using similar processes.

Once SEPHU has obtained consent and allocated a patient to Monash Health (based on the patient home postcode), CBCHS (or Monash Health) will perform an Intake Assessment. Each case is triaged into one of three pathways: low, medium, or high risk, based on clinical risk, severity of illness and social needs. Low risk patients remain under Primary Care with a General Practitioner, medium risk receive care from Complex Care with a mix of virtual care and home visits and high-risk patients are admitted to hospital for inpatient care. All pregnant women are considered medium or high risk.

The COVID-19 positive patient can be escalated or de-escalated between care pathways depending on their clinical condition. Refer to Appendix 1 for an overview of the program.

All people residing in the Monash Health catchment area who have tested positive for COVID-19 are eligible for the COVID-19 Positive Care Pathways program, excluding:

  • Residents of residential aged care facilities
  • Supported Residential Services and disability accommodation, where these facilities are receiving care through an outbreak management response team
  • Department of Justice detainees (prisoners)
  • People with COVID-19 in COVID-19 specific emergency accommodation where a service provides its own dedicated care and supports.

The Monash Health catchment includes people residing in the following postcodes:

3147, 3148, 3149, 3150, 3163, 3165, 3166, 3167, 3168, 3169, 3170, 3171, 3172, 3173, 3174, 3175, 3177, 3178, 3202, 3781, 3783, 3800, 3802, 3803, 3804, 3805, 3806, 3807, 3808, 3809, 3810, 3812, 3813, 3814, 3815, 3975, 3976, 3977, 3978, 3980, 3981, 3984

What is the GP role in the pathway?

Once a patient is allocated to the low severity pathway, CBCHS will contact their regular GP to ensure the GP is willing to accept care for their COVID positive patient. If the GP is not willing to provide care or if the patient does not have a GP, the local Primary Health Network (PHN) can assist to source a local GP who is willing to accept care for COVID positive patients.

GPs are expected to have telehealth appointments with their patients on day 2, 5, 8 and 11 at a minimum, and more often as required.

Patients will also receive daily text messages to self-enter their symptoms on COVID Monitor. Severe symptoms will trigger a response from the Complex Care COVID Team, operating 7 days a week. If patients elect not to receive text messages, the clinical care team will call patients daily and enter symptoms directly into COVID Monitor. GPs will be offered access to COVID Monitor by CBCHS as part of the initial contact call.

The role of the GP is to support patients by:

  • Providing regular telehealth assessment of COVID-19 symptoms to detect deterioration
  • Ensuring any co-morbid conditions remain stable
  • Providing reassurance, education, and advice
  • Ensuring isolation guidelines are adhered to
  • Ensuring social and welfare circumstances are stable

Telehealth consults should capture, at least, clinical information outlined in Table 1 below for consistent monitoring. A clinical features monitoring template can be found on the South East Melbourne Public Health Network webpage.

Table 1: Clinical features script

Clinical features script
Observations where availableHeart Rate
Respiratory Rate
Oxygen Saturation
Shortness of breath assessmentIs your breathing different from yesterday?
Can you walk at least half the distance you walked yesterday?
Can you lie flat without worsening shortness of breath?
Is your breathing disturbing your sleep?
Deterioration assessmentHow do you feel compared to yesterday?
Are you having fevers or chills?
Have you had any dizzy spells?
Do you have muscle aches and pains?
Do you have any lethargy?
AssessmentStable/deterioration/improvement
PlanContinue, Escalate, De-escalate

GPs are expected to consider escalation of care for their COVID positive patient should any of the following symptoms present:

  • New or increasing shortness of breath
  • Chest pain or tightness
  • Syncope or near syncope
  • Altered mental state
  • Severe weakness or lethargy
  • Haemoptysis
  • Consistently missing meals more than one day
  • Respiratory rate ≥ 30 breaths/min
  • Oxygen < 92% at rest

GPs should escalate to the areas listed in Table 2 as relevant.

Table 2: Key contacts for COVID-19 Positive Care Pathways

Urgency / FunctionTeam / RoleContact Details

Non-urgent:
Advice on community management, guidelines and support and services available

Complex Care

0404 084 273 (COVID Care Pathway Phone)

Monday – Sunday, 8am-8pm

Social and welfare support

 

Central Bayside Community Health(03) 8587 0359

Clinical deterioration:
Escalation to hospital level monitoring, consideration for non-urgent admission

COVID Adult Medical Lead or COVID Paediatric Medical LeadVia Monash Health switchboard (03) 9594 6666

Urgent:
For emergency assistance and urgent transfer to hospital

Ambulance Victoria

Call 000 and notify the COVID Care Pathway Phone 0404 084 273

 

Refer to the Resources section below for additional information to support management of COVID-19 positive patients.

How are patients discharged?

Release from isolation and discharge from the COVID Care Pathway occurs simultaneously.

Patients may be discharged from the pathway for reasons other than being cleared of COVID-19. These reasons may include: false positive result, transferred to hotel quarantine, withdrawal of consent or transfer to another health service’s pathway.

SEPHU are responsible for clearing the patients of COVID-19 and release from isolation. SEPHU will be aware of when patients are due for clearance, however GPs can request Clearance/Discharge via SEPHU.Trace@monashhealth.org.

GPs should continue to monitor their patients after being discharged from the COVID-19 Positive Care Pathways program as required. Long-term complications and prolonged recovery occur in a percentage of patients.

Resources

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