Clinician Connect

Respiratory and Rehabilitation Networks

26 Oct 2021 Reading time approximately


  • In a collaborative effort, the COVID-19 Respiratory and Rehabilitation Communities of Practice have developed the Management of adults with COVID-19 in the post-acute phase model of care.
  • The model of care was informed by the Post-acute and subacute COVID-19 care evidence check from the NSW Health Critical Intelligence Unit and a group of subject matter experts, including representatives from the Intensive Care, Respiratory, Rehabilitation, COVID Care in the Community, Primary Care, Community Health and Palliative Care Communities of Practice. Input was also provided by pulmonary rehabilitation experts, Integrated Care and Allied Health.
  • The document provides guidance to acute care clinicians in planning for and delivering care to patients with COVID-19 in the first three months post-diagnosis, as they transition from the acute care environment into the community. The goal is the patient's safe and appropriate discharge and transition of care to the primary care provider, with specialist follow-up as required. This supports improved patient outcomes and patient flow.
  • A key focus of the model is clinical and functional assessment of a patient at each transition of care. This ensures patients are appropriately referred, for example to multidisciplinary rehabilitation services or pulmonary rehabilitation.
  • Follow-up work is planned to assist clinicians in assessing and managing patients with ongoing post-acute COVID-19 symptoms.
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