Information
This Pathway provides a combination of digitally enabled support, and 1:1 support from a Chest, Heart and Stroke Scotland (CHSS) health practitioner to help patients manage symptoms such as fatigue, breathlessness, pacing and anxiety, caused by Long Covid.
Following a Long Covid diagnosis, patients will be offered support through an App or web-based digital platform called Tailored Talks. Patients will receive personalised online written and video health information before being offered 1-12 weeks support from a CHSS health practitioner. A person-centred, goal-orientated approach will be implemented, offering a flexible service delivery model adapted to the patient’s need.
Tailored Talks is a secure web-based platform where patients are signposted to relevant medical information on symptom management. When the patient registers, they will be invited to complete a self-assessment questionnaire on the digital platform. Once the self-assessment questionnaire is completed, they will automatically be signposted to relevant Tailored Talks. Patients will be given the opportunity to request a CHSS call back. If the patient chooses to, CHSS will contact the patient within 5 working days of the self-referral.
The process is summarised in the following flowchart:
Support will focus on physiological recovery, as well as the psychological and social adjustment to the reality of living with Long Covid.
Aims of the pathway:
- Increase knowledge and understanding of Long Covid
- Advice on how to self-manage symptoms
- Building capacity and readiness to self-manage
- Signposting / referral onto other CHSS and/or community-based support
CHSS Advice Line Roles and Responsibilities
- Contact patient within 5 working days
- Provide an overview of the service aims, identify personal goals and document support plan
- Tailor intervention to the individuals need
- Undertake calls, reviewing and documenting the patient’s progress
- Implement a service discharge plan, titrating the intervention as required prior to service cessation
- Agree and undertake the final review, completing the outcomes record
- Secure data and store it for 12 months following discharge. Following that time, the data will be anonymised and retained for a period of 6 years.
Referrers can contact the team with general enquiries or for support with the pathway or referral process using the following email address
Contact email: loth.longcovid@nhslothian.scot.nhs.uk
C.W. & R.T/L.C. 17-07-23
Please see the flowchart below for detailed referral information
Who to refer:
- Confirmed diagnosis of Long Covid where alternative causes for symptoms have been excluded
- Discharged from hospital or diagnosis confirmed in the community
- Requiring physiological, psychological, and/or social support for Long Covid
- Patients with access to a telephone and who have an email address and can access the App or use the web-based version
Who not to refer:
- Patients unable to access a telephone, or who do not have an email address or cannot access the App or use the web-based version
- Patients requiring end of life care
- Patients with decreased cognition with significant decline in short-term memory
- Those with significant psychological/ psychiatric disorders requiring specialist support
- Anyone under the age of 18
Who can refer:
All GPs across Lothian
How to refer:
Please refer via electronic referral using SCIgateway.
SCIgateway: Lothian > Lothian Non-GP Locations/Providers > AAH > Rehabilitation Medicine > Long Covid > Long Covid (CHSS)
Before sending your referral, it is important to remove any irrelevant or sensitive information from the past medical and family history SCI gateway tab. This is to ensure that irrelevant personal information is not passed onto 3rd parties in the referral process. This is necessary as part of the Data Share Agreement.
Please do not send any attachments because they cannot be viewed.
Please ensure that the email address listed for the patient is correct and the patient has consented to sharing their information with 3rd parties before making the referral. If this is incomplete the referral will be rejected.
WHO PIL on self help after COVID 19 https://www.who.int/publications/m/item/support-for-rehabilitation-self-management-after-covid-19-related-illness
CHSS Advice Line: Chest Heart & Stroke Scotland Advice Line – Chest Heart & Stroke Scotland (chss.org.uk)
CHSS Long Covid Page: Long Covid – Chest Heart & Stroke Scotland (chss.org.uk)
Please click on the link to see a video with more information about the referral process: https://vimeo.com/tailored talks – long covid
