LONG COVID care delivered through a multidisciplinary outpatient clinic was associated with fewer hospital visits and improved medication management. The findings highlight the potential benefits of coordinated follow-up for patients recovering from critical illness or COVID-19 hospitalization. Researchers evaluated a six-year clinical and educational model designed to address the physical, respiratory, cognitive, and psychological complications that can persist after hospital discharge.
The OPTIMAL Clinic, established in May 2020 at the University of California, San Francisco, provided integrated outpatient care to 1,539 patients between May 2020 and May 2026. Patients were recovering from COVID-19 hospitalization or an intensive care unit (ICU) stay, with most attending an initial consultation approximately one month after discharge. Follow-up appointments were offered at three, six, nine, and 12 months according to individual needs, allowing clinicians to support patients throughout their recovery.
The clinic combined in-person and virtual consultations involving physicians, pharmacists, nurse practitioners, physical therapists, occupational therapists, and social workers. Initial appointments brought physicians and pharmacists together to assess patients and develop coordinated treatment recommendations. Additional referrals addressed rehabilitation, respiratory symptoms, cognitive difficulties, and psychosocial concerns, while regular multidisciplinary case conferences supported complex clinical decision-making.
Across repeated evaluations, the multidisciplinary approach was associated with fewer emergency department visits and unplanned hospitalizations. Pharmacist involvement was also linked to improved medication optimization, including treatment adjustments and vaccination, alongside reductions in missed appointments. Although the report did not provide numerical effect sizes for these outcomes, the findings suggest that coordinated outpatient services may help address the complex needs of patients following critical illness.
Rehabilitation formed another central component of the model. Physical therapists supported patients experiencing deconditioning, while occupational therapists addressed cognitive rehabilitation, activity pacing, and sleep difficulties. Respiratory therapists contributed to pulmonary rehabilitation, and social workers provided emotional and psychosocial support. Integration of pharmacy and rehabilitation services also contributed to clinic revenue through billable activities, supporting the financial sustainability of the approach.
Alongside patient care, the clinic provided interprofessional training for 24 learners, including pharmacy students, medical students, and physician residents. Trainees reported favorable experiences with clinical supervision, collaborative decision-making, and professional development, suggesting that integrated clinics may offer opportunities to strengthen healthcare education while delivering coordinated care.
However, the authors acknowledged that variations in staffing, reimbursement, and clinical resources could limit the model’s generalizability. The descriptive evaluation also cannot establish whether the care model directly caused improvements in patient outcomes. Nevertheless, the findings highlight the potential value of multidisciplinary follow-up, medication management, and rehabilitation for patients recovering from long COVID or post-intensive care syndrome.
Reference
Bouajram R et al. A novel interprofessional experience caring for post-intensive care and long COVID patients: the optimal clinic experience. J Interprof Care. 2026; https://doi.org/10.1080/13561820.2026.2758239.
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