Welcome, everyone. Thanks so much for being here. We have such a great panel of speakers tonight, all of whom are authors on the paper ambulatory rehabilitation of patients hospitalized with cobit infections early pandemic experience in New York City and Boston. And that was recently just published in camera. So we'll have the opportunity to hear about the experience of developing to physiatry lead on medicine clinics in the early months of the pandemic. And so, as Brian mentioned, we'll first have our authors take us through a little bit of background on the project here a little bit about the results. And then we do have plenty of time for questions. So please do enter those questions into the chat. I know we have people joining us from all over the country. And so we'd love to hear what you'd like to know. So, my name is Sarah Smith. I'm a 3 at University of Washington and the resident liaison to the Academy's medical education committee. And I just want to quickly introduce all of our speakers here. We have Dr Hannes here. Dr. Ginger Polish from Boston and as well as Dr. Jeffrey Snyder and then the New York group. We have Dr. Alfred Gellhorn and Dr. Farah Hamid, and we'll go ahead and jump right in. It sounds like we're going to start by hearing a little bit about how did this even come together in the first place? And hopefully Dr. Gellhorn can maybe shed a little light on that and tell us how this collaboration even came about in the first place between the New York and the Boston institutions. Thanks, Sarah. That's a lovely introduction. I'm happy to chat about that. Hannah, did you actually want to talk about that? I think that you're sort of first on the list here. If not, I'm happy to jump in and chat about it. Yeah, I can definitely talk about it. And in our crew, Dr. Snyder was going to start with the origins, not to pass the buck again, but he was there a little bit before me, but I will certainly jump in. Sure, I can start a little bit about how things started in Boston, and then we can transition to how the collaboration between the Boston and New York groups developed. In the very first week of April, we started to realize that people who were surviving COVID-19 infection were having prolonged hospitalizations, who were really sick, and many of them were ending up in our rehab hospital in Boston. And we started to just foresee that there was going to be a large need for these people to be followed long-term, and that they would have needs long-term that we could potentially address. And I think we initially just thought of their physical impairments, cognitive issues, and also psychological impairments. And I think those issues were also compounded by the idea at the time that access to care was really impaired in our region, in the sense that a lot of outpatient facilities were closed, people couldn't go to routine outpatient care, outpatient therapy, even home care was affected. And even post-acute inpatient rehab was affected. People were being channeled to the rehab hospital in sort of different utilization patterns to really manage the high flow of patients, overwhelming the system with COVID-19. So we got together sort of quickly at the time and tried to organize sort of a post-COVID recovery clinic, which really started virtually, and saw all these patients by telemedicine to help address the needs of this population where we could help them. And in Boston, that started by really targeting patients who had been seen in the post-acute care setting in our system. So these are people who had initially very serious COVID infections and were hospitalized for usually a number of weeks. Most of them had been intubated for prolonged periods of time, and they were going home from a post-acute care setting to home. And those were sort of people we had initially targeted, and that evolved over time as the pandemic evolved. But in the early weeks and months, that's sort of how it started. And a lot of the interesting aspects that we could talk more about, too, is just how we even organized and did this. And we had sort of a very intense sort of group that got together on a regular basis over Zoom just to even talk about how we're going to manage this, because it was all new, and it was starting from scratch. And we were really just learning as we were going, especially in the very beginning. And still to this day, we're still learning about it as we're doing it. So we're happy to share our experience about that. How's that for a start for the Boston introduction? I don't know if you want to piggyback on that. Yeah, that's great. You know, there was a lot of similarities and some differences with New York. One of the main differences was some of the physiatry faculty were redeployed to the acute floors in our hospitals to take care of COVID patients. And that was, in many ways, sort of eye-opening and to be able to connect with the hospitalists in a way that we typically don't. And what that led to in a similar sort of way was this realization that as we were discharging patients, everyone was very aware that these patients were not well. They were not ready to go home to the life that they had before. And because I had made these sort of very intense relationships with the hospitalists over the time that I was there, they said, why don't you work on putting together a sort of a rehab program for these patients? Because that's clearly something that's going to be needed. And we all sort of agreed on that. One of the interesting parts of putting this together was it does turn out to be that that close relationship with the hospitalist teams was absolutely instrumental in making this fly from the beginning. And having those relationships in place was absolutely critical. But just as Jeff was saying, we sort of had a lot of questions about what we were going to be seeing. And we knew there were going to be impairments. We knew there was going to be pulmonary impairments. We knew there was going to be muscular deconditioning. We suspected there was going to be a lot of psychological comorbidities along with that. And so one of the main things that we wanted to do as we were putting this together was get the right team together, number one. And then number two, to get the right assessments in place as we were evaluating patients so that we could learn as we were going what exactly were the problems that these patients were facing and what kind of outcomes were we going to see with the program that we put in place. So a lot of similarities, a lot of differences. And then sort of in coming together, I think both sites were seeing such a large volume of this and knowing that we did not have a lot of answers about the best way to treat this. That was really the genesis of the collaboration when we said we need to share our data, we need to share our ideas, and all be collecting the same sort of data so that we can compare across the sites. So let me stop there and turn it over maybe to Dr. Hameed who can talk about how things might have been a little different at the Columbia site. Sure, yeah. So, you know, even within the New York sort of cohorts, we had sort of little differences in terms of getting patients in and getting this program started. So I wasn't necessarily redeployed as a hospitalist. However, I did make connections with some of the sort of post-discharge sort of follow-up that was taking place. So the hospital at Columbia basically sort of, and actually at Cornell as well, they looked a little different, sort of set up a post-discharge remote patient monitoring program. So with that, they basically actually redeployed the medical students that were no longer doing rotations because everything was sort of shut down. And the medical students then sort of started making daily phone calls to all of these patients that maybe weren't necessarily perfect for discharge. However, were discharged home because there was such a rapid influx of patients. So with that sort of influx of patients that was sort of coming into the hospital, people were being discharged and followed up. So with a phone call, basically these medical students were screening for appropriate rehab patients. So they were looking for people with shortness of breath or fatigue or muscle weakness, not allowing them to get back into their daily activities. And so with that, you know, that ended up sort of getting to be a really nice referral source that they ended up sort of sending us patients. And then we sort of took over. So that's sort of how we did it here. And not necessarily with that intense hospitalist relationship, we're still able to kind of develop a program and get something going. Great. Thank you, everyone. It sounds like things just got to start a little bit differently at each of these locations. Can you tell us a little bit about what you were actually assessing with the study? So you mentioned that a little bit already, Dr. Gellhorn. I don't know if you want to take that or whoever else wants to jump in there. Sure. Yeah. So there's a couple of things that we were thinking about as we were assessing. As Dr. Schneider mentioned, we were doing a lot of this virtually. And so it had to be tools that were, number one, validated and number two, able to be demonstrated and assessed over video. And so we spent a long time looking, sort of poring over the literature and finding tests that met those criteria. And we ended up with a few. So we wanted to assess, number one, for lower limb strength, which we felt was going to be impaired. And so we came up with the 30-second sit-to-stand test, which is, as it sounds, you have someone sitting and then you have them go to standing and see how many times they can do that in 30 seconds. Measuring endurance, we used the two-minute step test, which is simply having people stand and bring their knee up to sort of chest height as in a marching motion and do that for two minutes. And again, counting how many repetitions they can do. For depression and anxiety, we screened them with the PHQ-4, which is fairly easily delivered over video in, you know, a couple minutes. And so those were sort of the main tools that we were using to assess. And what we found was that we were able to complete an assessment in about 30 minutes. And we generally were finding that we were sending the majority of patients for a virtual PT or home PT, if that was available. And a minority of patients, and we'll talk about this a little bit more as we go into the data, a much smaller minority, surprisingly small minority for psychology and cognitive referrals. Great. Yeah, I'll leave the data for a minute and not ask you about what happened there because I know we're going to hear about that. I know we talked a little bit about the referral process already over in New York, establishing that relationship with the hospitalists themselves. Did anyone want to add anything else about how these referrals were generated? Because everyone was getting referrals a little bit differently depending on the site. Yeah, I can comment on that for the Boston site. So our providers were not deployed either. But fortunately, we have a couple of rehab hospitals that are in network. So there's a long-term care facility that's in network. And there's also an inpatient rehabilitation facility that's in network. And providers, physiatrists from each of those hospitals were involved in the clinic, including Dr. Schneider, who is at the inpatient rehab hospital. And we had, I mean, I think 20 people or so on our team, including case managers, care coordinators, who were really marketing this program to those two hospitals specifically, the rehab hospitals, as well as the acute care hospital. And that was sort of our initial marketing was for patients who had been hospitalized. And I'll go a little bit more into that data when we show the slides. So we got a lot of our referrals in network that way. We also connected with the home care services, PTOT speech, to get referrals that way, although we did not end up getting as many referrals from home care. But we were really targeting patients who had been hospitalized early on in our clinic. And we created, I don't know if we want to get into this now, but just briefly, we created a template and an order set through our EMR that providers could use to refer to the clinic. Yeah, I understand there was maybe some challenges that came up as you guys were deploying those electronic orders. Can we hear a little bit about that? I think Dr. Gellhorn, maybe? Yeah, that was a challenge. Yeah, that was a challenge. So we use Epic. And one of the things that we had wanted to do from the outset was to, as Hannah was saying, to sort of get this as easily electronically. And then at the time of discharge, patients are scheduled or given some sort of contact to make a follow-up with this post-COVID recovery clinic. And it seemed like a great idea. And we had a lot of people working on it. And it never happened. And it was one of the things where there were a lot of other electronic issues. The two campuses were merging electronic medical record systems at that time. Everyone was sort of in overdrive in a million different places with COVID anyway. And despite all of everybody's best intentions, it didn't happen. And, you know, I think it turns out that it wasn't a major detriment. I think we still got a huge number of referrals. And the program was very successful. It would have been nice to see that piece happen. And it's just one piece that did not come together for our system. It'll be great to hear how things evolved in the last couple of months. Before we get into that, Dr. Stewart, do you want to take us through some of the results of your study? Okay, so I can walk us through the Boston info here. And then I think Farrah was going to walk through New York. So we've looked at demographics of the patient. This is really what we're going to be going over now is the demographics of patients that we saw and where they were discharged to. So in our Boston cohort, this was through April-May time period. So we saw 36 patients in the clinic. And I think the other sort of important thing to know is that most of these patients were in the ICU for a pretty long period of time, so an average of 15 days. And the majority of them were also mechanically ventilated. And I'm going to come back to this slide for New York, but move ahead one here to show you discharge disposition. So here I think we were quite different from New York because most of our patients went to an LTAC facility. And the reason this happened, probably happened, is because the LTAC served as an extension of acute care per CMS, per their changes in rules during COVID. So the majority of our patients ended up going to an in-network LTAC hospital where they were really still being treated acutely and then stayed for rehab. So that's the Boston cohort. And I can go back for New York. Perfect. Thank you, Hannah. So when we were looking at New York, like we mentioned, we had Cornell and then Columbia, again, different patient populations. So not only did our referral sources come together a little differently, so did our patient mix. So generally, it was around a 50-50 split in terms of male and female, which is a little different than maybe what the literature says. I think when we look at specifics, Boston had a greater majority male, which may be something that we see in those sicker patients. So it sort of goes in line as we sort of talk through the disease course for these folks. In terms of demographic data, in terms of race, so when we break it down for Cornell, it's sort of, you know, if you think about it geographically in Manhattan, even though those are just a couple of miles apart, it's a very different patient mix. So there it was sort of a heterogeneous mix between sort of whites, Hispanics, blacks, and Asians, a pretty equal mix versus sort of the Columbia-Washington Heights population or patient mix, where it was really predominantly Hispanic. And so we definitely saw a greater sort of number of that sort of split in terms of the demographic and race. However, you know, when we look at the hospital stay and really the ICU stay and sort of those differences, really, I think this is where Boston and New York look very different. So for, you know, both New York programs generally, it was sort of less than a quarter of our patients were really ICU level of care versus, you know, Boston, where we sort of saw like more than, you know, more than half, actually two thirds of those patients were really a much higher level of care. And sort of, you know, when we think about the severity of COVID and we think about physiatry's role in that, right, I think this sort of highlights that even for those with a little bit more of a moderate disease course, right, they weren't necessarily hospitalized in the ICU, but they were still hospitalized. So there were, you know, sort of sick patients. There was still a really nice role for rehab and sort of, you know, a patient mix that might be really good to capture and think about as, you know, these, unfortunately, these COVID numbers are just continuing to surge elsewhere. So, you know, I thought that that was sort of a nice split in terms of, you know, what we sort of saw. And then obviously, you know, where maybe we could sort of still be helpful. Hannah, if you don't mind just advancing to the next one, we can sort of go to, you know, discharges disposition again. You know, you're sort of going to see that in the New York case mixes that we saw, it's really much higher, you know, straight to home discharges where we sort of tried to take over. And as an extension of sort of, you know, the hospital stay versus, you know, Boston, where really a majority of the patients were from the LTAC and sort of did that before they went home. And so that sort of, you know, was, again, another difference, but, you know, goes along with sort of a sicker patient population as well for the Boston cohort. It is really interesting to hear about this data from early on because I know things have changed quite a bit. And even with New York and Boston now, I'd love to hear your perspective on what exactly has changed. Is the disposition situation a little bit different? What are the clinics looking like now? Maybe we can have Dr. Stier start us off and talk a little bit about how things have changed in Boston. Sure. So Boston had, so that paper is from our initial peak or the first peak back in the spring. And then we did have a second peak this past winter, kind of over, you know, the holiday season. And our inpatient or our hospitalized patient consults went up again. But kind of throughout that time, after we saw the initial sort of set of patients who had been hospitalized, our referrals went down. And so we made the decision to open up the clinic to patients who were not hospitalized, because that's when we were also learning about this chronic COVID syndrome or, you know, what the long COVID, as some patients call it, long haulers. So we decided to open it up to patients with mild disease who had ongoing symptoms. And so we saw a pretty big uptick in patients who were coming from home and who had never been hospitalized. So to date, we've had a little over 300 referrals and about half of those have been scheduled. And most of them are coming from referral, internal referrals through Epic. And then there are some that are coming from direct calls from patients or providers who are not in network. How about things in New York, Dr. Gellhorn, do you want to take that? Yeah, one thing I might do, since we're sort of talking about, I was sort of talking earlier about the outcomes that we were collecting. Maybe I can actually share my screen and I can sort of go over some of the data and the way that shook out, because I think that that's helpful to think through too. Can you enable my screen sharing? You can go ahead. You should be able to do it now. Great. Thank you. So remember that the main outcomes, the sort of physical outcomes of interest that we were talking about, was the 30-second sit-to-stand performance for lower body strength and also the two-minute step test performance for endurance. And the data that we gathered was, this was on 106 patients, and we broke them into groups. One group that went to the virtual PT was more than half of them. Then 10 of them did home PT. Some of them, when we evaluated them at their first visit, we felt that they were actually doing well enough that we didn't feel that they needed to go to the virtual PT program. And we actually just provided them with a set of exercises and a pamphlet to do on their own. And then this none group here is interesting. Those are the patients that we felt needed the intervention. We sent them to the intervention, but they ended up not going. So they sort of served as a control group for us. I'm going to skip over the statistical analysis here. The baseline characteristics, we've sort of gone over here. So let me sort of move into the outcomes here. So at baseline, what we saw for these patients was that they were at very, very low levels of endurance and strength. So the normative data I have over here on the right part of this slide, which is the normative data for 30-second chair stand, this is on elderly adults in the community. And you can see that what I've circled here is where our patients ended up in their 30-second chair stand performance, which was about, in a group, the results you'd expect to see in sort of 80- to 90-year-olds. And so that was sort of the level of endurance that they had when we saw them initially. For the two-minute, I'm sorry, that's for the lower body strength. For the two-minute step test, similarly low levels of endurance. And so what I've circled here is that they sort of looked very similar to inpatient cardiopulmonary rehab patients. So when they started the program, this is where they were, quite low levels of endurance and quite low levels of strength. And remember, this is New York. This is in the beginning of everything. And so these were patients that we were simply sending home, whereas in any other situation, these are probably, this level of impairment is not a set of patients that you would just be discharging to home. So just to keep in mind that this was the situation we were dealing with. On the other hand, and this is one of the most surprising things, is that their baseline level of cognition and mental health was surprisingly good. So the mini-MOCA, I forgot to mention that we got that, but the mini-MOCA is just a version of the MOCA that you can administer remotely. It doesn't require any of the writing test part of the MOCA. And between all the groups, it was similar, and they all scored, on average, within the normal range. So we saw very, very low levels of cognitive dysfunction in this group. Similarly, the PHQ-4 screening for depression and anxiety was either normal or in the mild range, much, much less than I was anticipating from my own personal work on the inpatient units, where I saw a great deal of anxiety in patients. And I was expecting that that was just going to be a huge thing that we were dealing with, and it turned out not to be the case. And we can sort of talk about why that might be in the discussion. That means that we made psychology referrals only 8 percent of the time and OT and neuropsychology referrals in only 3 percent of the visits. Very, very low numbers. These are the outcomes. So when we followed patients up at two weeks, we measured them again in their sit-to-stand test scores. And you can see here, the most interesting thing is sort of the flat lining of the orange here, the group that got the sort of the none group, those that we felt should have the virtual PT intervention but didn't go. And so they didn't improve at all. So there's no significant, no change at all, whereas all of the other groups, the virtual PT, the home PT, and the independent exercisers have a significant improvement in their sit-to-stand test scores. You're going to see a very similar thing here with the step test scores, where sort of everyone is improving, but the none group is improving much, much less than the other groups. The last thing we wanted to know is whether or not this was clinically meaningful. And I think that's an important thing to define for any outcome. And what we did is we used data from the pulmonary rehab literature, and there's good data on both the sit-to-stand test and the two-minute step test. And so the clinically meaningful improvement for 30-second sit-to-stand is two or more steps, two or more reps. And for the step test, it's 25% more steps in two minutes. And if you look at the sort of the graphs that I have down here at the bottom for sit-to-stand, the percent in each group that met that clinically important difference, if that makes sense, was 65% in the virtual PT, 88% in the home PT, 50% in the independent exercises, and only 17% in the no exercise group. So two-thirds or more of the folks who are getting an exercise intervention were getting a clinically meaningful benefit from it at two weeks. Very similar for the two-minute step test. And in that one, the virtual PT group actually did significantly better than all of the other groups. So we felt that not only did we have some impressive statistically significant results with this intervention, it turns out that it's actually a clinically meaningful and important one, too. And that was sort of borne out as we would talk to patients in follow-up. They were very grateful and very happy. They felt that they had improved dramatically. So let me stop here. That's sort of the end of the data here that I would want to share from this and stop blathering on. And I can turn it back to you, Sarah. There was a couple of things when I was reading through this paper the first time that kind of surprised me. I'm sure everyone else who read this as well. I'd love to hear from you, though, as you were putting together the study, looking at the data, what actually surprised you the most? I'll give that back to Dr. Gellhorn first, but I'd like to hear from each of you. There were a number of things. I think the thing that stood out to me most in sort of what I've just presented also is the low levels that we saw of cognitive dysfunction and psychological distress. It wasn't zero, but it was much, much lower than I was anticipating. We actually put the team together at the beginning with heavy, heavy input from neuropsychology and our rehab psychologists because I was 100 percent sure that that was going to be, you know, everyone was going to be needing that. And so I was surprised. I'm very curious to hear from the Boston group and then from everybody else who's been treating COVID patients, you know, what their experience has been with this and if our experience in New York is abnormal in that way. So I would say from a mental health standpoint, our Boston team doesn't have any data to show yet, but just anecdotally, we talk amongst ourselves quite frequently. And I would say we see a range. It seems like most people are doing fairly well, but we certainly have a subsegment who are having ongoing sleep issues, anxiety, low mood. And it has been enough of an issue that we've been trying to build up our capacity to address the psychological needs of the post-COVID group. So we've recently had a psychologist join and is doing a patient support group. We've had another licensed clinical social worker offered to do one-on-one psychotherapy and counseling with our patient population. So, you know, I wouldn't say it's the majority by any means, but it's a sizable number. I would also say since our clinic has opened up to treat mild COVID cases, those who are not hospitalized, we do see a degree of anxiety in that group as well that we are working on and trying to address. One of the things I think that we learned is more process-oriented, which is that it surprised me and a lot of us thought a lot about this, which was how to access these patients was not so easy. And in spite of a lot of efforts that we put in in the first number of months, we met as a group twice a week to help move this forward and design this process. And we try to be very multidisciplinary. We had, you know, case managers and therapists and, you know, more administrative type people, physicians from different groups and from different hospitals in our system. And still, you know, it was hard to access all these patients in spite of a lot of efforts we put in to get them. I don't know if that speaks somewhat to the population itself being disadvantaged, the circumstances at the time where, you know, it was hard to access things and, you know, it's possible that we were not capturing everyone, you know, in spite of these efforts. I think that's sort of like something that we still think about and is a challenge in general with caring for this population. Yeah, I think going along with that is sort of the technology piece, right, as a potential barrier, which is sort of one thing. But the thing that actually surprised me was how useful it could be. You know, I had never done a virtual visit before in my entire life. You know, I've been practicing medicine now for a while, and I've never done that before. And so when we were sort of designing this and trying to, like, figure out how we would do this, our clinics are closed. There's like, you know, population health and infection control issues, right? We can't necessarily see these people as we normally do as clinicians, sort of, you know, hands-on, physiatrists. And then, you know, sort of trying to come up with a way to do this virtually and then actually sort of successfully do it virtually, I think, was really surprising and great, I think, in terms of thinking innovatively and thinking outside of the box and sort of thinking, you know, as physiatrists do, right, sort of creating on the spot. And so I really was pleasantly surprised about how technology was really helpful in this way. But also, you know, sort of understand that that was a big barrier. I think that we probably could have seen a lot more patience if we, you know, and I wonder if Boston sort of feels the same way, if it hadn't been so time intensive to get things set up and installed on your, you know, having a smartphone or having some sort of device, number one. Number two, sometimes language barrier was an issue. Number three, getting it installed appropriately, you know, sort of, you know, figuring out all the consent forms that you have to fill out to do a virtual visit, you know, all of those pieces sometimes may also be a barrier there as well. Yeah, and I would just say one more thing that surprised me in the Boston cohort was the racial makeup of the patients in our study. So two thirds of patients who we saw in the post COVID clinic were white. But that does not reflect the racial makeup of patients who were hospitalized acutely. There were more Hispanic patients, Latinx patients, Black patients, and we don't, you know, really know why exactly we didn't get that same sort of makeup in our clinic. We could imagine that there may be issues with access or as Farah mentioned, you know, language barriers. We all know that there are systemic disparities and racism at play in healthcare that are probably playing a role. But that is something that we have talked about and that we're curious about. And yeah, and that's just something I think that's really important to investigate with our patients. And a couple of you have now mentioned access to care. And as we are all getting off the ground with this with telemedicine right in the beginning, I know it was confusing for everyone. It's confusing for the doctors. It was confusing for the patients. And so I can I can see how accessing patients would be difficult, especially in that early stage. As people have kind of started to figure this out a little bit, things have at least gotten easier. At least from my perspective and in various clinics. And I'm wondering if that's changed at all for you all. Are you able to follow up with patients better? Are you still having those issues? Yeah, I guess I can start here. I think I've definitely had some issues throughout. I don't know if it's worse now or sort of the same. But this also goes for my telemedicine clinic that is not COVID related. I think that I've seen a lot of patients sort of fall off my schedule and and have a hard time reaching them. I would say to piggyback on what Farah mentioned is I've had a couple of patients who have limited English proficiency. And and I've had a difficult time trying to get a translator for those patients. Probably more difficult with telemedicine than than finding a translator in person. So that's something that I've definitely noticed. And I know Mass General is working on improving access to care and to language. Yeah, one one strategy that I sort of implemented because I'm not a Spanish speaker and a lot of the patients that we saw on the Columbia side were were was to actually have, if possible, you know, sort of call on like on on the landline with interpreter services. Sort of using that as sort of one mode of communication with a video visit on potentially another device or computer or something else. So sort of having having that sort of not seamlessly incorporated, but also sort of just trying to figure out how you can sort of put that together has been helpful. So, you know, or if a friend had a phone or a family member had another phone, then we sort of had two phone lines going. And that really made it a lot easier because otherwise I don't think I would have been able to see as many of the patients, at least on the Columbia side. Yeah, I think people have had to get really creative with this and try and figure out any way to make it work. So it'll be interesting to see how things continue to evolve. And hopefully someone can do a study out there and figure out what works best. So look out for that. I want to make sure that we have plenty of time to answer some questions because we have a couple rolling in already. So I've got the first question here. And I'll just leave it open ended if one of you feel like you're you can answer this question. Go for it. The first question here. Have you found a good number of patients with nightmares or hallucinations, either among those in rehab? So weeks out of ICU or outpatients among those who have had the long COVID? And if so, what interventions were utilized? So I can weigh in here. I'm happy to have anyone else jump in. So my clinical practice, I do mostly inpatient consultations and outpatient. So I might be missing the inpatient rehab part here. But certainly in the early stage during delirium, we see plenty of individuals who are having hallucinations as part of a hyperactive delirium. And we treat as we would any form of critical illness delirium. In the outpatient setting, I have personally not seen this in anybody that I've come across or heard from members of our group at this point that we've seen this. In terms of psychiatric comorbidities and those who are more mildly impacted, I tend to see much more anxiety. And in some cases, I've had a few individuals with panic symptoms. And I think in that population, it's extraordinarily difficult to kind of tease out what exactly are the contributing factors. To what extent is this related to COVID? To what extent is this related to maybe other difficulties in life? I know there's a lot of ideas kind of floating out there about how someone's pathophysiology might be impacted by mild COVID. And I think we're all trying our best to just follow the literature and make the best sense of it as we can without clear answers at this time. Great. Thank you. Next question. Were your efforts assisted by administrative structures in your health system? Or did you meet any barriers or resistance to this type of patient care? I'm happy to start with that one. And I think it'll be different for everyone. There were very little barriers, I think, is the short answer. And I think everyone really wanted to get on top of this and do what was best. Even regardless of insurance status, et cetera, we were sort of just seeing patients and getting them in as rapidly as we could. And everyone from the administration was very much on board with that. And a lot of the initial calls that I was on to set this up involved a lot of administrators in the medicine department and in the hospital. And I didn't get a single bit of pushback. I think what has happened a little bit subsequently as the volume went down dramatically after the first major peak in New York was that there were these other sort of silos that set up. So within the pulmonary department, they sort of put together their own post-COVID clinic. And they were sort of trying to get those patients and saying, well, we're the more reasonable people to follow this group of patients. And so there did become a little bit more of a – I mean, it was all still very amicable. But there were more people trying to sort of get those patients as the volume went down. And I think that that's going to be dependent on everyone else's situation. But from the very beginning, it was a very – we had very, very little resistance from the administration. I would just add that we had also a very supportive administration. And when we formed this sort of programmatic group that would oversee the clinical work, we included some administrative people like the head of outpatient care for the Spalding system was involved in that. And was really helpful in sort of helping us engineer access and reaching out to people, all the outpatient therapists in the system. And we actually put on a few educational lectures to our system, so informing the therapists or other providers about the work that we were doing in the patient population and sort of how to access the clinic. We similarly have had other departments within our hospital system, rightfully so, setting up clinics. And because we've had this programmatic group, which has been meeting not as frequently as we were in the beginning, but still at least once a month we've been meeting. We've recently even reached out and had a meeting with the head of outpatient cardiology at one of our main hospitals who's overseeing their COVID cardiology clinic. And clearly we have overlapping patients, but we don't want to be managing their cardiology problems. And I think they're happy to have us manage their rehab problems. So I think the collaboration there is really opportunities for us. And similarly, there's neurology services doing this as well. And there's neuropsychologists have created their own COVID neuropsychology clinic. And so, you know, part of this has been sort of for us has been navigating the whole hospital system and connecting with those different clinics and being part of a large hospital system. There's some, you know, natural challenges to finding all the right people. But I think that ultimately that's been helpful for us to connect with those groups. Yeah, I think it's a little bit of an internal problem that we face in psychiatry is not everyone understands our role. And so trying to explain to these other specialties what we can do for our patients can be a challenge. So it's interesting to hear how those discussions have gone in other places. We do have someone with their hand up. Stuart Weinstein, if you want to unmute yourself and ask your question, go ahead. Yeah, thank you. Listen, all of you, I really appreciate all the research you've done and publishing it. It's great for physiatry. You know, as the Academy president, I can tell you that the Academy is super interested in this information. And I think you're going to see a lot more to come from the Academy on COVID in the near future. A couple of comments and sort of a couple of questions. If we assume even 5 or 10 percent of the people who are COVID positive in this country end up with some kind of chronic issue, the numbers are just staggering. And in terms of capacity, I think this is a perfect population health model. Now, some of you already addressed this a little bit, but I'm curious, how are you planning in your own institutions looking at this as a population health issue to get the capacity? And secondly, can you comment on the role of physiatry, not just rehabilitation services, but how physiatry stays in the forefront and it's not just our therapy colleagues? Thanks for the question, Stu. I want to just throw a little curveball at it, which is believe it or not, there are people within our department who actually don't want this to be the main focus of our department. And I think, as you mentioned, the volume is potentially enormous here. The question then becomes, number one, can we support it, and if so, how? And then number two, does this sort of subsume the day jobs that we sort of are more trained for? A lot of the people in our department are sports medicine docs, and they are wondering, am I now a COVID doc or am I still a sports medicine doc? So I think that's another important part of this, is even though there's clearly a role for this and it shouldn't be derailed and we should have a big part in it, it has to fit into the framework of the providers in the department and figure out which providers it fits best for. And that hasn't always been obvious in our setting, where everyone was sort of just thrown into everything all at once. So that didn't completely answer your question, but I think it's another interesting thing to think about. Yeah, I would say that our group has had similar conversations. Just with this wide spectrum of illness, from where we started with seeing patients with what we thought was similar to post-ICU syndrome, and then we started seeing more patients with mild COVID with these persistent symptoms. I think that we've had a little bit of maybe an identity crisis in some ways, physiatrists trying to figure out, you know, what is our role here? How can we help these patients the most? We don't really, we always talk about, you know, we don't really own an organ. We really see the patient as a whole and help with function. And some of these other, you know, as you mentioned, Alfred, these silo clinics with neuro clinic and neuropsych clinic and cardiology clinic, you know, they sort of own their organ. And I think that by really communicating with those groups and making sure that the patient is on the right track in terms of, you know, their, I don't want to say their organ systems, but their health and making sure there's, you know, nothing sort of acute going on that's dangerous. And then trying to help them with function and providing structure in their life and helping with, you know, all the things that we do as physiatrists really addressing the patient in a holistic way with, you know, mental health services and cognitive services and sort of getting them connected with the people that they need to be connected with. And then we kind of quarterback those things. I think that that's sort of where some of us fall, but certainly there are other providers who really specialize in cognition or mental health. Like, you know, Ginger is one of our providers who really, who's really great at treating that specifically. So, yeah, I think it's ever adapting and changing, but I think that as physiatrists we are in a, you know, our education lends itself to seeing people as a whole person and helping them functionally, which a lot of people are struggling with. So this next question is a little bit related, so I'll jump to this. It sounds like these clinics were just PM&R and not founded as multidisciplinary at their inception. Is that correct? So in some ways they were multidisciplinary in the sense that we had a lot of therapies involved, right? We tried initially on the Columbia side to obviously have a neuropsychologist, a psychologist, you know, sort of anticipating what our needs would be. I will say on the Columbia side that did evolve in some ways, maybe not, again, sort of as an extension of this virtual clinic. We sort of had a virtual program in some ways where if I saw somebody that was having, you know, persistent oxygenation needs that I couldn't get them to wean from their oxygen, you know, sort of, you know, then I would sort of send them to a pulmonologist who was sort of happy to see these patients. And so I think organically it kind of did grow into that as we, so right when we implemented, we tried to anticipate and set up, you know, a team that could sort of manage what we thought would come in through the door. And then as we sort of started seeing these people, we sort of tried to figure out where to go next with that. So I do think that it evolved with time, but maybe from Boston, if you guys had some thoughts too. I would say it was, you know, fairly similar. It started as, you know, physiatry led. We had a number of physical therapists who were very active early on and learning and sharing information about how to bring pulmonary rehab techniques into what they do in physical therapy. Since then, we've kind of, same thing, organically. Now we have our psychology go-to, you know, our social work go-to. We recently made a collaboration with cardiology. We have a cardiology go-to. We have a few people who are a neurology go-to. So it's really maybe, you know, our home base is in physiatry, but we've really expanded over time to have a pretty cool web of individuals across a number of disciplines. Thank you both for sharing that. I want to be mindful of everyone's time because we just have a little bit of time left, a couple of minutes here, but we do have one more question. And for those of you who asked questions that we weren't able to get to tonight, we'll see if there's a way that we can try and coordinate getting those answers out to you. But for now, last question, can you please describe your face exercise program and how RPE was used to prescribe exercise? Sure. So we actually worked with three physical therapists to develop this. And the one that is, I think, mentioned in the paper is what we sort of delivered in this sort of packet of information that we gave to everyone who was leaving discharge. So as opposed to adding additional exercises, which is frequently what's done in physical therapy programs to progress, what our therapists felt was that that was going to be too cumbersome, that it was going to be too long of a packet for patients to wade through and they were just going to throw it away. So instead of doing that, they actually just increased the repetitions of the exercises. So I forget the exact numbers, but it started very slow. And then day by day, there was a little calendar that patients would keep and mark their progress on it. And they would just increase the number of repetitions that they did. And it turned out to be a very easy thing for patients to do, which I think coming out of the hospital in the craziness of the time was critically important. And so that worked very, very well. The other piece in terms of the RPE, we actually, ideally, and this was the case for most of our patients, instead of using RPE, we actually had pulse oximeters for the majority of patients. And so those were used both in our initial visits, the physicians were able to sort of monitor patients' O2 sats, and then also as they were progressing the exercise in the course of the virtual PT. So that was a very, very helpful way to follow them as well. All right. Thank you so much to all of our speakers for being here. It's just about 6 o'clock right now, so we will wrap it up. But thanks again, everyone, who is listening in. And we'll see you at our next National Grand Rounds next month.

ambulatory rehabilitation

COVID-19 infections

physiatry-led clinics

study results

rehabilitation interventions

cognitive dysfunction

implementation challenges

access to care

multidisciplinary approach